South Dallas Nursing & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two of fifteen residents (Resident #34 and Resident #42) reviewed for infection control. 1. The facility failed to ensure CNA E performed hand hygiene during Resident #34's incontinent care on 12/15/2025. 2. The facility failed to ensure CNA D performed hand hygiene and changed her gloves during Resident #42's incontinent care on 12/15/2025. 3. The facility failed to ensure CNA F did not walk down the hallway wearing a gown and gloves on 12/15/2025. These failures could place residents at risk of cross-contamination and development of infections.Findings included: Record review of Resident #34's Face Sheet, dated 12/16/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 2 (Halls 100 and 600) of 4 halls reviewed for environmental concerns. 1.The facility failed to ensure rooms' electrical outlets were covered in room [ROOM NUMBER] on hall 600. 2. The facility failed to ensure rooms were free from holes in the walls in room [ROOM NUMBER] on hall 600. 3. The facility failed to ensure windows were in a good state of repair in room [ROOM NUMBER] on hall 100. These failures could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant and unsafe.During an observation on 12/14/25 at 9:15 a.m., room [ROOM NUMBER] on hall 600 had an outlet that did not have a cover, no wires exposed . During an observation on 12/14/25 at 9:22 a.m., in room [ROOM NUMBER] on hall 600, there were two holes found in the walls. One hole was located at the bottom right of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for one (Resident #23) of eight resident reviewed for quality of care. The facility failed to ensure that LVN A used the proper procedures when providing wound care to Resident #23's diabetic ulcer on his right heel on 12/15/2025. This failure could place the residents with wounds at risk for infection or worsening of existing wounds.Findings included: Record review of Resident #23's Face Sheet, dated 12/16/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with non-pressure chronic ulcer (skin injuries that occur without the influence of pressure) of right posterior (back) heel. Record review of Resident #23's Quarterly MDS Assessment, dated 11/27/2025, reflected the resident was cognitively intact (resident capable of normal cognition and needed little support) with a BIMS score of 14.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys for one (Resident #43) of sixteen residents reviewed for medication storage. The facility failed to ensure Resident #43 did not have a bottle of nasal spray on his side table on 12/14/2025. This failure could place the residents at risk of accidental overdose, misuse of medications, not receiving the medication's full therapeutic benefits, and possible side effects.Findings included: Record review of Resident #43's Face Sheet, dated 12/16/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with asthma (lung disorder caused by narrowing of the airways). Record review of Resident #43's Comprehensive MDS Assessment, dated 10/03/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had asthma.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews and record review the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for four of five dietary staff members reviewed for qualified dietary staff.The facility failed to ensure four (Cook A, [NAME] B, [NAME] C and Dietary Aide G) dietary staff members had their Texas Food Handler's License.This failure could place residents at risk of not having met their nutritional needs and place them at risk of foodborne illnesses.Findings included: A request for food handlers' licenses was made for all kitchen staff via email to the Administrator on 10/14/2025 at 3:10 p.m. and they were not provided. Record reviews of the four dietary staff members (Cook A, [NAME] B, [NAME] C and Dietary Aide G) personnel files on 10/15/2025 at 11:30 a.m. revealed all four dietary staff did not have a Food Handler's Certificate. All four dietary staff had been employed longer than 30 days.A request for job description was made for job description for kitchen staff members sent via email…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review of the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food and kitchen safety.1. The facility failed to ensure both handwashing sinks were in proper working order.2.The facility failed to ensure drainage in the dishwashing room was in working order.3. The facility failed to ensure the kitchen remained free of bugs and insects (pests).These failures could place residents at risk for food-borne illness and cross contamination.Findings included:Observations of the Kitchen on 10/14/2025 at 09:30 a.m., with [NAME] A revealed the following: -Handwashing sink #1 /eyewash station leaked from a pipe beneath the sink. There was a large black rectangular basin there beneath the sink to catch the water.-Handwashing sink #2 was non-functioning. There was no running water that came from the faucet when the handle was turned on the hot or cold side.-Dishwasher - water would not drain. In the center of the dishwasher room,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to maintain the kitchen equipment in good repair for 1 of 1 range hood reviewed for safe operating equipment.The facility did not ensure the range hood in the kitchen was in good repair.This failure could place the staff and residents at risk of a fire and not having safe operating equipment.Findings included:During an observation and interview on 10/14/18 at 9:30 a.m., [NAME] A tried to turn on the range hood and the range hood did not come on. He stated the range hood had not worked since he had been working there for a month and half. [NAME] A did state that the kitchen there had been times when the kitchen was smokey if someone cooked on high. During an interview on 10/14/2025 at 9:45 a.m., the DM stated she had been at the facility for nine days and there was a quote for the range hood to be replaced. The DM stated that to her knowledge a company had come out and stated that the motors had gone out on the range hood and needed to be replaced and the facility was quoted roughly $4,000 so they needed another…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for 1 of 1 kitchen reviewed for pest.The facility failed to ensure the kitchen was free of gnats and rodent droppings on 10/14/2025, 10/15/2025 and 10/16/2025.These failures could place residents at risk for insect borne illness, not having a home free of pests and a comfortable environment in which to live. Findings include:In an interview on 10/14/2025 at 9:30 a.m., [NAME] A revealed he saw rats and/or mice in the kitchen of the facility many times. [NAME] A stated he had seen pest droppings in the kitchen. [NAME] A stated that there are gnats in and near the hand washing sink. Observation on 10/14/2025 at 10:00 a.m. there was pest droppings (small black pellets) in all three sections of a nonfunctioning dish washing sink on back wall near the fridge, another nonfunctioning sink in the back of the kitchen and on the floor beneath that sink. Additionally, there was five gnats in the nonfunctioning hand washing sink…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record reviews, the facility failed to ensure care plans were developed in consultation with the resident's representative for 1 of 4 residents (Resident #1) reviewed for Comprehensive Care Plan in that:The facility failed to ensure Resident #1, or the resident's representative were invited to participate in the resident's care plan meeting.This failure placed residents at risk for a loss of independence, psychosocial well-being, and the opportunity for them to participate in the planning of their care.Findings included: Record review of Resident #1's face sheet dated 10/15/2025, revealed a [AGE] year-old male admitted to the facility 09/11/2017. His diagnoses included Alzheimer's disease with late on set (memory and cognition issues, impaired judgment), heart failure unspecified (a condition where the heart is unable to pump enough blood to meet the body's needs, but the specific cause or type of heart failure is unknown), hypertension(condition where the blood pressure in the arteries…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to notify the resident's representative when there was an incident resulting in injury for 1(Resident #2) of 4 residents reviewed for notification of changes. The facility failed to notify Resident 2's representative when resident fell from his bed causing delayed swelling to his face and arm.This failure could place residents at risk of not receiving the support and advocacy of their families after an incident.Findings included: Record review of Resident #2's face sheet dated [DATE] revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included type 2 diabetes mellitus with foot ulcer, atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (artery that supplies blood to heart due to fatty deposits), congestive heart failure, and chronic kidney disease stage 3. Record review of Resident #2's MDS dated [DATE] reflected Resident #2's BIMS score of 9 which indicated moderate cognitive impairment.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to have evidence that all allegations of abuse, neglect, exploitation, or mistreatment, were thoroughly investigated for 1 of 5 residents (Resident #4) reviewed for abuse and neglect.The facility did not thoroughly investigate an incident in which Resident #4 made a grievance that a staff member was rough with her and did not stop perineal care when requested.This failure could place residents at risk for abuse/neglect and could lead to a diminished quality of life and psychosocial harm.Findings included: Record review of Resident #4's Face Sheet, dated 10/16/2025, reflected a [AGE] year-old resident with an initial admission date of 04/24/2024 and diagnoses including dementia (decline in cognitive functions, such as memory, thinking, reasoning, and problem-solving, severe enough to interfere with daily life), atherosclerotic heart disease (the buildup of fats, cholesterol and other substances in and on the artery walls), interstitial pulmonary disease (a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assist residents in obtaining routine and 24-hour emergency dental care for one (Residents #3) of four residents reviewed for dental services. The facility failed to promptly, within 3 days refer Resident #3 with lost or damaged dentures for dental services. This failure could affect residents by placing them at risk for oral complications, dental pain, and diminished quality of life.Findings included:Record review of Resident #3's face sheet dated 10/14/2025 revealed [AGE] year-old male admitted to the facility 09/30/2024. His diagnoses included Alzheimer's disease with late on set (memory and cognition issues, impaired judgment), chronic obstructive pulmonary disease (lung disease) and nontraumatic subacute subdural hemorrhage (bleeding near brain).Record review of Resident #3's MDS dated [DATE] reflected Resident #3's BIMS score of 7 which indicated severe impairment. Oral/dental status did not indicate no natural teeth or tooth…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations and record review, the facility failed to ensure 3 (Resident#1, Resident#2 and Resident#3) of 4 residents care plans included services provided to the residents The facility failed to provide Resident#1,2, and 3, with care plans that reflected the intervention of a wander guard for residents. This failure could affect how to meet the resident's needs.Findings included: Record review of Resident#1's face sheet, dated 10/09/25 reflected, she was a [AGE] year-old female who was originally admitted on [DATE] and diagnosed with unspecified Dementia (decline in cognitive function that cannot be definitively attributed to a specific type of dementia), psychotic disturbance (a mental health condition characterized by a significant loss of contact with reality), mood disturbance (a persistent change in a person's emotional state, going beyond typical ups and downs to affect their ability to function) and anxiety ( common mental health condition characterized by excessive worry, fear, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations and record reviews, the facility failed to ensure 2 out of 4 residents (Resident#1 and Resident#2) received adequate supervision and assistance devices to prevent incidents. The facility failed to ensure Resident #1 and Resident #2's wander guards worked properly. These failures could place residents at risk of elopement.indings included:Record review of Resident #1's face sheet, dated 10/09/25 reflected, she was a [AGE] year-old female who was originally admitted on [DATE] and diagnosed with unspecified Dementia (decline in cognitive function that cannot be definitively attributed to a specific type of dementia), psychotic disturbance (a mental health condition characterized by a significant loss of contact with reality), mood disturbance (a persistent change in a person's emotional state, going beyond typical ups and downs to affect their ability to function) anxiety ( common mental health condition characterized by excessive worry, fear, and nervousness), hypertension (a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the designated interdisciplinary team member was responsible for collaborating with hospice representatives and coordinating LTC facility staff participation in the hospice care planning process for those residents receiving these services and communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the patient and family for 1 (Resident #1) of 8 residents reviewed for hospice services. The facility failed to ensure a staff member was designated to communicate with a hospice agency. This deficient practice could place residents at risk of receiving substandard care due to miscommunication between their hospice and facility caregivers. The findings were: Record review of Resident#1's face sheet dated 05/28/25 revealed he was a [AGE] year-old male resident with an initial admission date of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for 3 of 3 resident rooms (rooms 603, 605 and 607) and 1 of 6 hallways (600 hallway) reviewed for environment. 1. The facility failed to ensure the main hallway was free of roaches on 06/07/25 at 1:30 PM. 2. The facility failed to ensure resident rooms 603, 605 and 607 were free of rodents on 06/05/25 at 10:04 AM. These failures could place residents at risk for insect borne illness, not having a home free of pests and a comfortable environment in which to live. Findings include: In an interview on 5/28/25 at 11:28 AM, Resident #6 stated he saw roaches in his room and around the facility many times. He stated the roaches were a lot worse a few months ago but he still saw roaches in his room. He stated he heard other residents talk about mice in the facility but he had not seen any. In an interview on 05/28/25 at 11:30 AM, Resident #9 stated he saw…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or result in serious bodily injury to the administrator of the facility and to other officials which included the State Survey Agency in accordance with State law through established procedures for 1 of 8 residents (Resident #1) reviewed for reporting allegations of neglect. The facility failed to ensure a report for an allegation of neglect was submitted within 2 hours to the State Agency after Hospice RN D reported a fall with possible injury to LVN E. This failure could place residents at risk of abuse, physical harm, mental anguish and emotional distress. Findings include: Record review of Resident#1's face sheet, dated 05/28/25, revealed a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for two residents (Resident #1 and Resident #2) of four residents reviewed for pharmaceutical services in that: 1. The facility failed to administer pain medications to Resident #1 as ordered upon admission after the resident requested pain medication on 1/23/2025. The facility also failed to return and administer Trazodone to Resident #1 as ordered on 1/24/2025. 2. The facility failed to acquire, administer, and accurately document two scheduled doses of gabapentin on 1/24/25 to Resident #1 as ordered. 3. The facility failed to acquire and administer intravenous antibiotic medications to Resident #2 as ordered upon admission for the dose scheduled on 1/9/25. 4. The facility failed to obtain a pharmacy delivery receipt for Resident #2's medications…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure each resident had the right to make choices about aspects of his or her life in the facility that were significant to the resident for one (Resident #1) of seven residents reviewed for self-determination. The facility failed to promote Resident #1's self-determination by not honoring his choice to receive medications at a later time on 1/24/2025. This failure could place residents at risk for poor self-esteem and decreased self-worth due to their needs and preferences not being met. Findings included: Record review of Resident #1's MDS (type indicated option selected was none of the above) dated 1/23/2025 revealed Resident #1 was a [AGE] year-old male admitted to the facility on [DATE]. No BIMS score was listed on the assessment to indicate if the resident had any cognitive impairment. Record review of Resident #1's face sheet dated 1/28/2025 revealed Resident #1 had diagnoses of sepsis (infection that has spread to multiple organs),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that each resident received adequate supervision and assistive devices to prevent accidents for one (Resident #3) of 66 residents reviewed for assistive devices. A portable heater was found in use in Resident #3's room without direct supervision. This failure could place residents at risk for accidents or injuries. Findings include: Record review of Resident #3's Face sheet dated 01/28/2025 revealed that Resident #3 was a [AGE] year-old male that was initially admitted to the facility on [DATE] with diagnosis that included Diabetes Mellitus, Age-Related Cognitive Decline and Partial traumatic Amputation of left foot at Ankle Level. Record Review of Resident #3's Quarterly MDS Assessment and Care Screening dated 11/07/2024 revealed that Resident #3 had a BIMS score of 12 which indicated moderate cognitive impairment. The resident required the use of a wheelchair and required supervision or touching assistance for all transfers and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 (Resident #1) of 5 residents reviewed for quality of care. The facility failed to follow physician orders for daily fasting blood sugar checks for Resident #1 on 09/03/24, 09/04/24, 09/09/24, 09/10/24, 09/15/24, and 09/16/24. This failure could place the resident at risk of not receiving the care intended by the physician. The findings included: Record review of Resident #1's face sheet, printed on 09/17/24, reflected a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of legal blindness, chronic obstructive pulmonary disease (disease causing restricted airflow and breathing problems), diabetes mellitus due to underlying condition with diabetic neuropathy (a chronic disease that occurs when the body can't regulate blood sugar levels), other sequelae of cerebral infarction (Alteration of sensation following a stroke),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 (Resident # 8) of 5 residents' rooms and for 1 of 1 shower rooms reviewed for environment. 1. The facility failed to repair the wall in Resident #8's bathroom for at least a year. 2. The facility failed to ensure the shower room was sanitary, clean, free of foul odors, and in good repair. This failure could place 56 residents using the shower room and Resident #8 at risk of psychosocial harm and feeling uncomfortable due to living in an environment that was not homelike. Findings included: Record review of Resident #8's face sheet dated 9/09/2024 revealed Resident #8 was [AGE] years old and was admitted to the facility on [DATE] with diagnoses of major depressive disorder, generalized anxiety disorder, post-traumatic stress disorder, and mild cognitive impairment. Record review of Resident #8's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 13 (suggested…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for one sharps container in the shower room of Hall 300 of three sharps containers reviewed for accidents and hazards. The facility failed to ensure that residents did not have unsupervised access to used razors in the shower room on Hall 300, and that the sharps container was monitored and changed out before it became overfilled. This failure could place residents at risk of lacerations and injury from used sharps. Findings included: Observation on 09/08/24 at 09:00 a.m. revealed the door to the shower room on the 300 Hall was open and no facility staff were present in the shower room or the hallway. The sharps container on the wall of the shower room was overflowing past the Fill Line and five used blue plastic disposable razors were laying unsecured on the top of the sharps container. No residents were noted wandering the hall or entering the shower room. In an interview and observation with MA B on 09/08/24 at 09:10 a.m.,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to provide pharmaceutical services (including procedures that ensured drugs and biologicals were accurately acquired, received, dispensed, and administered) to meet the needs of each resident for 1 of 1 medication room reviewed for pharmacy services. The medication room contained: 1. 1 almost full opened box (quantity of 50) of IV administration sets with an expiration date of 6/05/2024. 2. 10 IV insertion cannulas with an expiration date of 02/28/2024. 3. 6 acetaminophen 650mg suppositories with a use by date of 12/11/2023 prescribed for Resident #30. This could place 1 (Resident #99) of 1 resident receiving IV medications and Resident #30 at risk for not receiving the intended therapeutic benefit of their medications and having possible adverse effects. Findings included: Record review of Resident #99's face sheet dated 9/10/2024 revealed the resident was [AGE] years old, was admitted on [DATE], and had a diagnosis of acute…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents and staff for 1 handwashing sink, 1 dishwashing sink and 1 dishwasher reviewed for essential equipment. 1.The facility failed to ensure the handwashing sink was in working order 2.The facility failed to ensure drainage in the dishwashing sinks was in working order. 3.The facility failed to ensure drainage in the dishwashing room was proper working order. These failures could affect all residents that eat meals from the kitchen and pose a possible risk for cross-contamination. Findings included: Observations of the Kitchen on 09/08/24 at 09:15 AM with the [NAME] G revealed the following: -Handwashing sink was non-functioning, there was no running water that comes from the faucet when the handle was turned on hot or cold side. -Dishwashing sink - water would not drain -Dishwasher - water would not drain - Near the center of the dishwasher room, there was a wet vacuum (designed to wet debris pickup), which had a long (an inch or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility was free from pests for one of one active shower rooms reviewed for pest control program. The facility had live small flies and roaches in the only active shower room in the facility. This failure could place residents at risk for spread of infection, cross contamination, and decreased quality of life. Findings included: An observation on 09/08/24 at 9:21 AM revealed a small fly was crawling on the door frame of the shower room on the 200 hall. In an interview on 09/08/24 at 12:22 PM MA G revealed that she had seen flies in the facility and that she had heard about roaches in the facility from residents. She stated that the staff were supposed to write pest sightings in the pest control book that was somewhere in the nurse's station. In an interview on 09/08/24 at 1:02 PM with Resident #53 he revealed that the shower room was always nasty, smelly, and dim. He stated that he…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced each resident's respect and dignity for 2 Resident's (Resident #49 and #57) of 5 residents reviewed for dignity. The facility failed to provide dignity and respect for Residents #49 and #57 by leaving the Residents' privacy bags off their foley bags exposing the full urinary bag to the doorways. This failure placed residents at risk for embarrassment and low self-esteem. Findings included: Record Review of Resident #49's Face Sheet revealed a [AGE] year-old male who had been initially admitted on [DATE] with diagnosis of cerebral infarction (Stroke), hemiplegia and hemiparesis affecting right dominant side (paralysis of one side of the body), and mid cognitive impairment. Record Review of Resident #49's quarterly MDS dated [DATE] revealed a BIMS score of 06 out of 15 indicating the resident was severely cognitively impaired. Resident #49 required…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure they had promptly notified the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders for 1 (Resident #28) of 10 residents reviewed for Keppra (antiseizure medication) lab levels and notifications. Resident #28 had abnormal Keppra lab results on 8/27/24, and the facility failed to follow up to ensure prompt notification was received by the ordering physician. This failure could result in the physician not being fully aware of the resident's clinical condition and response to Keppra for 10 residents currently prescribed Keppra. Findings included: Record review of Resident #28's Annual MDS dated [DATE], revealed the resident was [AGE] years old, admitted on [DATE], had a diagnosis of a seizure disorder, and a BIMS score…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for three of three residents (Residents #2 and #1) reviewed for ADL care. The facility failed to ensure Residents #2 and #1 bathed/showered three times a week as per their shower schedule. This failure could place residents at risk of skin breakdown, infection and loss of self-esteem. The findings include: 1. Record review of Resident #2's face sheet, printed on 05/17/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included sequelae of cerebral infarction (history of a stroke), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis of the right side), Type II diabetes, atrial fibrillation (irregular and rapid heart rhythm), cellulitis of lower limb and groin…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents had the right to personal privacy and confidentiality of his or her personal and medical records for one of five residents (Resident #2) reviewed for privacy. The facility failed to ensure LVN E locked the computer, which showed Resident #2's wound care information, after she walked away and left the computer unattended. This failure could place residents at risk of having medical information exposed to others, and cause residents to feel uncomfortable and disrespected. The findings include: Record review of Resident #2's face sheet, printed on 05/17/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included sequelae of cerebral infarction (history of a stroke), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis of the right side), Type II diabetes, atrial fibrillation (irregular and rapid heart rhythm), cellulitis…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for one of five residents (Resident #2) reviewed for storage of medication. The facility failed to ensure a 0.9% sodium chloride syringe was not stored at Resident #1's bedside table and failed to ensure it was secured in the medication cart or medication room. This failure could place residents at risk of medication misuse. The findings include: Record review of Resident #2's face sheet, printed on 05/17/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included sequelae of cerebral infarction (history of a stroke), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis of the right side), Type II diabetes, atrial fibrillation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for one of twelve rooms (room [ROOM NUMBER]) reviewed for pests. The facility failed to ensure an effective pest control program was implemented to prevent the presence of gnats in room [ROOM NUMBER]. This failure could place residents at risk for the potential spread of infection, cross-contamination and decreased quality of life. The findings include: Observation and interview on 05/17/24 at 11:37 AM in room [ROOM NUMBER] revealed Resident #1 was lying in his bed shaking his head back and forth. Resident #1 stated he was well, and his room was cleaned daily. When Resident #1 moved in his bed, 8 gnats flew off of him and Resident #1 began to shake his head again. Resident #1 stated yes when asked if he had a gnat and fly problem but could not specify how long he had the problem. Resident #1 stated he told staff about the gnats but could not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 16 of 30 days reviewed for RN coverage. The facility failed to ensure they had an RN on duty on. 02/05/24 (Monday); 02/06/24 (Tuesday); 02/07/24 (Wednesday); 02/08/24 (Thursday); 02/09/24 (Friday); 02/12/24 (Monday); 02/13/24; (Tuesday); 02/15/24 (Wednesday); 02/16/24 (Thursday); 02/17/24 (FR); and 03/07/24 (Thursday) This failure placed residents at risk of missed nursing assessments, interventions, care, and treatment. Findings included: Review of the RN staffing hours for February and March 2024 reflected zero hours worked by an RN on 02/05/24 (Monday); 02/06/24 (Tuesday); 02/07/24 (Wednesday); 02/08/24 (Thursday); 02/09/24 (Friday); 02/12/24 (Monday); 02/13/24; (Tuesday); 02/15/24 (Wednesday); 02/16/24 (Thursday); 02/17/24 (Friday); and 03/07/24 (Thursday). During an interview on 03/07/24 at 4:14 PM, the ADM stated the facility did not have a DON for around a month.The ADM explained it had been approximately the facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for three (Halls 100, 400 and 500) of six halls and one (main dining room) of two dining rooms and one of one kitchen and one (facility entrance) of one reviewed for environment. (A)The facility failed to ensure the exit door on the 100 hall and front of Resident #5's room door was clean and in good repair. The facility failed to ensure the floors on halls 100, 400 and 500 were clean and in good repair. The facility failed to ensure the flooring in the dining room next to the kitchen entrance and ice machine was clean and in good repair. The facility failed to clean or replace the two rusty panic bars on hall 100 and 2 rusty panic bars on hall 500. The facility failed to ensure Resident #9's room was cleaned thoroughly. (B) The facility failed to ensure the floor drainage system in the kitchen was not clogged up. The facility failed to ensure the front entrance of the facility was clean and in good repair. These failures could affect all…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for two (Residents #1 and #2) of six residents' rooms reviewed for Environment. The facility failed to ensure Residents #1 and #2's bathroom floors and walls were in good repair and sanitary. These failures could place all residents at risk of falls which could result in injuries leading to a decreased quality of life and psycho-social well-being. Findings included: Record review of Resident #1's admission MDS assessment dated [DATE] revealed a [AGE] year-old male who admitted [DATE] with a BIMS score of 14 (no cognitive impairment) and impaired upper and lower one-sided extremities and used a wheelchair. He also needed partial to moderate assistance with toileting and had other neurological conditions. Interview and observation on 03/07/24 at 9:20 am, Resident #1's room had approximately 8 or 9 articles of clothing on the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for three (Halls 300 and 400 hall) of five halls and 1 (300-hall shower room) of 4 shower halls reviewed for pest control program. The facility had dead roaches and gnats in areas of the facility including the nurse's station, Halls 300, 400 and the shower room. This failure could place residents at risk for spread of infection, cross-contamination, and decreased quality of life. Findings Include: Observation 03/07/24 at 9:10 a.m., revealed 3-4 live gnats flying in the entrance of 300 hallway near the shower room. Observation on 03/07/24 at 9:18 a.m. 9-10 live gnats were observed in room [ROOM NUMBER] Resident bathroom, 1-3 live gnats were noted to be flying in the room . An interview on 03/07/24 at 9:20 a.m., Resident #6 revealed that he had seen many black small flies and roaches all over the facility. An interview on 03/07/24 at 9:24 a.m., Resident # 6…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to treat residents with respect and dignity for one (Resident #3) of six residents reviewed for Resident rights. The Nursing staff failed to ensure Resident #3 did not have food and drink stains on his shirt for over three hours on 03/07/24. This failure could affect residents who require assistance with meals, which could cause their food and drinks to fall onto their clothes, resulting in a sense of diminished self-worth and psycho-social well-being. The findings included: Review of Resident #3's Quarterly MDS assessment dated [DATE] revealed a [AGE] year-old male who admitted [DATE] with a BIMS score of 08 (Severe cognitive impairment), no behaviors, with upper and lower extremity impairments of both sides and used a wheelchair. He was partial/moderate assist with eating and substantial/maximum assist with mobility and had progressive neurological conditions. His diagnoses included anemia, neurogenic bladder, aphasia,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to thoroughly investigate an allegation of abuse for 1 resident (Resident #1) of 5 residents reviewed for abuse and neglect. The facility failed thoroughly investigate an allegation of abuse and neglect for Resident #1. This failure could place all residents at risk of abuse and neglect. Findings included: Record review of Resident #1's face sheet, dated 10/31/23, reflected Resident #1 was a [AGE] year-old male who was admitted to the facility on 09/0923 with diagnoses that included: type II diabetes, morbid obesity, atrial fibrillation (irregular heartbeat), muscle weakness, mild cognitive impairment (decline in thinking and memory), schizoaffective disorder (mood disorder), and contracture of unspecified joint. Record review of Resident #1's admission MDS Assessment, dated 09/16/23, reflected Resident #1: - understood others and could make himself understood, -was cognitively intact with a BIMS of 14, -did not exhibit physical, verbal, or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 5 (Residents #1, #7, #12, #17, and #20) of 38 residents observed for wheelchairs. The facility failed to properly maintain wheelchairs for Residents #1, #7, #12, 17 and #20. The wheelchair arm rest pads were torn and cracked with exposed interior foam. The arm rest pads could not appropriately be cleaned due to the cracked and exposed foam. These failures could place residents at risk for diminished quality of life and at risk for skin issues and discomfort due to the lack of a well-kept wheelchairs. Findings included: 1.Review of Resident #1's admission MDS assessment , dated 05/18/2023, reflected he was a [AGE] year-old male admitted to the facility on [DATE], with the following diagnoses: dementia without behavioral disturbance, type 2 diabetes mellitus, Alzheimer's disease with late onset, hemiplegia and hemiparesis following unspecified cerebrovascular disease cerebral…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 16 of 30 days reviewed for RN coverage. The facility failed to ensure they had an RN on duty on. 02/01/23 (WE); 02/02/23 (TH); 02/03/23 (FR); 02/06/23 (MO); 02/07/23 (TU); 02/08/23 (WE); 02/09/23 (TH); 02/10/23 (FR); 02/13/23; (MO); 02/14/23 (TU); 02/15/23 (WE); 02/16/23 (TH); 02/17/23 (FR); 02/20/23 (MO); 02/21/23 (TU); 02/27/23 (MO) This failure could place residents at risk of missed nursing assessments, interventions, care, and treatment. Findings included: Review of the RN staffing hours for February 2023 reflected zero hours worked by an RN on 02/01/23 (WE); 02/02/23 (TH); 02/03/23 (FR); 02/06/23 (MO); 02/07/23 (TU); 02/08/23 (WE); 02/09/23 (TH); 02/10/23 (FR); 02/13/23; (MO); 02/14/23 (TU); 02/15/23 (WE); 02/16/23 (TH); 02/17/23 (FR); 02/20/23 (MO); 02/21/23 (TU); 02/27/23 (MO) During an interview on 08/14/23 at 12:05 PM, the DON stated that she had just started at the facility two weeks prior. She stated that there was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews, and record review, the facility failed to ensure that medications were secure and inaccessible to unauthorized staff and residents for one of one treatment cart reviewed for prescribed treatment medication storage. The facility failed to ensure treatment supplies were secured or attended by authorized staff when RN D's and LVN E's treatment cart for the facility hallways 100, 200, 300, 400, and 500 was left unlocked. This failure could result in resident access and ingestion of prescribed treatment medications leading to a risk for harm and possible drug diversion. Findings included: An observation on 08/13/23 at 9:05 a.m. revealed the treatment cart was left in the hallway at the alcove of the nurses station unlocked, not in direct site of the LVN or the RN working in the facility. An observation on 08/13/23 at 9:50 a.m. revealed LVN E walked past the treatment cart at the nurse's station. The LVN did not observe the unlocked treatment cart; it remained unlocked and not in direct sight of the LVN. An observation on 08/13/23at 10:05 a.m. revealed RN…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for five (Residents #10, #12, #18, #40 and #44) of seven residents reviewed for infection control in that: LVN B failed to disinfect the blood pressure cuff in between blood pressure checks for Residents #10, #44. LVN C failed to disinfect the glucometer machine (an instrument for measuring the concentration of glucose in the blood) and the blood pressure cuff in between resident use, for resident #12, #18, and #40. This failure could place residents at-risk of cross contamination which could result in infections or illness. Findings included: Review on 08/15/23 of Resident #10's EHR revealed the resident was a [AGE] year-old male that was admitted to the facility on [DATE] with diagnosis including hypertension heart disease,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for three (Hall 100, 200, and 300) of five halls observed for environment. The facility failed to ensure resident's bathrooms on Halls 100, 200, and 300, were clean, safe, and in good repair. This failure could place residents at risk for diminished quality of life due to the lack of a well-kept environment and equipment. Findings included: An observation on 08/14/23 at 9:57 a.m. in resident's rooms [ROOM NUMBERS]'s shared bathroom revealed there were four floor tiles missing from in front of the toilet. The bathroom floor was saturated in a yellow substance and smelled of urine. An observation on 08/14/23 at 10:00 a.m. in resident's rooms [ROOM NUMBERS]'s shared bathroom revealed there was a sticky floor with a brown substance smeared on the top of the toilet seat and a large puddle of a yellow substance on the floor. An observation on 08/14/23 at 10:03 a.m.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an effective pest control program for 1 of 1 facility reviewed for pests in that: Flies and gnats were observed in multiple areas of the facility. This failure could affect residents by placing them at an increased risk of exposure to pests and vector-borne diseases and infections. Findings included: Observation on 08/13/23 at 9:17 a.m. revealed three gnats in the conference room crawling on the table. Observation on 08/13/23 at 9:39 a.m. revealed three gnats in the conference room flying round the surveyor. Observation on 08/13/23 at 9:40 a.m. revealed a fly crawling across the nurse's station. Observation on 08/13/23 at 9:45 a.m. revealed a fly flying down Hall 100. Observation and interview on 08/13/23 at 9:55 a.m. revealed a gnat crawling on the medication cart on Hall 200. Interview with RN D revealed that this time of the year was bad for gnats. RN D stated he did not see the pest control man at the facility. RN D stated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review of the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food and kitchen safety. 1. The facility failed to ensure items in the kitchen and dry storage were labeled and stored in accordance with the professional standards for food service. 2. The facility failed to ensure the handwashing sink#1 of 2 was free from leaking/running water. 3. The facility failed to ensure the kitchen remained free of bugs and insects (pests). 4. The facility failed to ensure both handwashing sinks were in working order. 5. The facility failed to ensure drainage in the dishwashing room was proper working order. 6. The facility failed to ensure that the 4-outlet plug in kitchen, over main prep area, were all 4 fully functional. There failures could place residents at risk for food-born illness and cross contamination. Findings included: Observations of the Kitchen on 08/13/23 at 09:24 AM with the Dietary Manager revealed the following:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.