The Hillcrest Of North Dallas

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to provide pharmaceutical services including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all routine and emergency drugs and biologicals for 3 residents (Resident #1, Resident #2, and Resident #3) of 5 residents reviewed for pharmacy services. 1. The facility failed to ensure Resident #1's Hydrocodone-Acetaminophen were ordered and administered according to physician's orders, causing the resident to miss 3 doses in May 2025. 2. The facility failed to ensure Resident #2's Hydrocodone-Acetaminophen were ordered and administered according to physician's orders, causing the resident to miss 2 doses in April 2025. 3. The facility failed to ensure Resident #3's Oxycodone HCL were ordered and administered according to physician's orders, causing the resident to miss 2 doses in May 2025. These failures could place residents at risk for not receiving therapeutic dosages of their medications as ordered by 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 interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate dispensing and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #1) of 2 residents reviewed for Pharmacy Services. 1. The facility failed to ensure LVN A administered medications per the Physician's Orders on 05/05/25 for Resident #1. 2. LVN A filled out a wasted form when the medication was not wasted. 3. MA B signed the wasted form even though she did not witness LVN A waste the medication. This failure could place residents at risk for worsening of their medical conditions by not receiving the therapeutic effects of medications prescribed for them, medication error, and drug diversion. Findings included: Record review of Resident #1's face sheet, dated 05/23/25, revealed Resident #1 was a [AGE] year-old male admitted on [DATE] and readmitted on [DATE]. Resident #1's diagnoses included: transient cerebral ischemic attack (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 ensure residents were free of any significant medication errors for one (Residents #1) of two residents reviewed for medications. 1. The facility failed to ensure LVN A administered medications per the Physician's Orders on 05/05/25 for Resident #1. 2. LVN A filled out a wasted form when the medication was not wasted. 3. MA B signed the wasted form even though she did not witness LVN A waste the medication. This failure could place residents at risk for worsening of their medical conditions by not receiving the therapeutic effects of medications prescribed for them, medication error, and drug diversion. Findings included: Record review of Resident #1's face sheet, dated 05/23/25, revealed Resident #1 was a [AGE] year-old male admitted on [DATE] and readmitted on [DATE]. Resident #1's diagnoses included: transient cerebral ischemic attack (a temporary interruption of blood flow to the brain, causing symptoms similar to a stroke but with the symptoms…

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 develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Resident #1) of six residents reviewed for care plan. The facility failed to ensure Resident #1's care plan was revised to reflect person centered interventions for pain and physical therapy. This failure could place the resident at risk of current needs not being met. Findings included: Record review of Resident #1's admission Record dated 5/1/25 reflected a [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE]. Record review of Resident #1's Quarterly MDS assessment dated [DATE] reflected he had a BIMS score of 15 indicating he 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility for one resident (Resident #1) of three residents reviewed for discharge planning. -The facility failed to provide or document sufficient preparation for an orderly discharge of Resident #1. This failure could place residents at risk of not receiving care and services to meet their needs upon discharge, which could cause physical and emotional harm. Findings included: Record review of Resident #1's face sheet, dated 04/04/2025, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] and discharged on 03/13/2024 with diagnoses that included: cerebral ischemia (a condition where the brain does not receive enough blood flow, resulting in a lack of oxygen and nutrients. This can lead to brain damage.), Generalized Anxiety Disorder (a mental health condition characterized by excessive,…

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 observation, interview and record review the facility failed ensure that a resident that needed tracheostomy care was provided such care consistent with professional standards of practice for 1 of 4 residents (Resident #1) reviewed for tracheostomy care. The facility failed to ensure Resident #1's tracheostomy tubing was changed out within a seven-day period upon observation on 11/07/2024 at 4:13 PM. These failures could place residents at risk of cross-contamination and the development of infection. Findings include: Record review of Resident #1's face sheet, dated 12/07/2024 at 5:41 PM, reflected a [AGE] year-old resident who was admitted to the facility on [DATE]. Resident #1 had relevant diagnoses which included Moyamoya disease (blood vessel disorder that reduces blood flow to the brain,) cerebral infarction (blood supply to the brain is blocked or reduced) and tracheostomy status (hole in front of the neck into the windpipe to keep open for breathing.) Record review of Resident #1's Comprehensive…

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 reside and receive services in the facility with reasonable accommodation of resident needs and preferences for one (Resident #01) of four residents reviewed for reasonable accommodations. The facility failed to provide a different mattress to help alleviate Resident#1 pain due to his diagnoses and physical condition. Resident #01 was admitted to the facility on [DATE] and was provided with a low air loss mattress. Resident transferred to Long-term care on 11/13/24 and transferred rooms on 11/22/24 and he was provided with a pressure relieving mattress instead. This failure could place residents at risk of not being able to have their needs met. Findings included: Record review of Resident#1 admission MDS assessment, dated 09/17/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included: malignant neoplasm of unspecified part of unspecified bronchus or lung (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 provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs for two (Residents #1 and Resident #2) of three residents reviewed for pharmacy services. 1. The facility failed to give Resident #1 Acidophilus Lactobacillus Oral Capsule every 12 hours as ordered. 2. The facility failed to give Resident #2 Gabapentin every 12 hours as ordered. This failure could affect residents by placing them at risk for a delay in medical treatment or worsening in condition. Findings included: Record review of Resident #1's face sheet, dated 08/29/24, reflected a [AGE] year-old female, with an initial admission date of 03/23/23. Resident #1 had a diagnosis of Acute Respiratory Failure (shortness of breath), Cellulitis of lower left limb (bacterial infection in the skin and underlying tissue), Type 2 Diabetes (high blood sugar), Neuromuscular Dysfunction…

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 maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 3 residents (Resident #1) observed for accuracy of medical records. The facility failed to document Resident #1's bed bath refusals on the same day for each refusal. This deficient practice could place residents at risk for errors in care and treatment. The findings were: Record review of Resident #1's face sheet, dated 08/29/24, reflected a [AGE] year-old female, with an initial admission date of 03/23/23. Resident #1 had a diagnosis of Acute Respiratory Failure (shortness of breath), Cellulitis of lower left limb (bacterial infection in the skin and underlying tissue), Type 2 Diabetes (high blood sugar), Neuromuscular Dysfunction of Bladder (nerves that control the bladder do not work properly), Morbid Obesity (body mass index of 40 or higher), Muscle Weakness, Hemiplegia and Hemiparesis following 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents who were unable or required assistance to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene, for 1 of 2 residents (Resident #1 and Resident #2) reviewed for ADLs. The facility failed to provide bed baths for Resident #1 on a Monday, Wednesday, and Friday schedule. The facility failed to wash the hair of Resident #1 on a Monday, Wednesday, or Friday schedule. This failure could place residents who required assistance with showering and maintaining good personal hygiene at risk for not receiving care and services to meet their needs and avoid ADL decline. Findings include: Record review of Resident #1's face sheet, dated 08/29/24, reflected a [AGE] year-old female, with an initial admission date of 03/23/23. Resident #1 had a diagnosis of Acute Respiratory Failure (shortness of breath), Cellulitis of lower left limb (bacterial infection in the skin and underlying tissue), Type 2…

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 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 one (Resident #4) of three residents reviewed for infection control. The ADON failed to do hand hygiene while providing wound care to Resident #4. This failure could place residents at increased risk of infection. Findings included: Review of Resident #4's Significant Change MDS assessment dated [DATE] revealed the resident was an [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included heart failure, end stage renal disease, and diabetes. Her cognitive status was intact. Review of Resident #4's Physician Orders reflected: 07/17/24 Wound of the left buttock: Cleanse with wound cleanser, pat dry, apply collagen powder, Anasept gel, and cover with dry dressing every shift. 07/17/24 Wound 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, interviews, 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 1 (Resident #1) of 2 residents reviewed for pharmacy services. On 08/02/24, LVN A failed to complete documentation on Resident #1's controlled medication count sheet after 2 Acetaminophen - Codeine 300 - 30 mg [Generic for Tylenol with Codeine #3] oral tablets ([white, round tablet] a controlled combination medication used to relieve moderate to severe pain) were removed from the medication blister pack for administration. As of 08/02/24, the facility failed to remove Resident #2's controlled medications from the Hall 400 medication cart after [Resident #2] discharged from the facility on 07/17/24. On 08/02/24, LVN A removed 2 white, round tablets from Resident #2's (discharged from facility on 07/17/24) medication blister pack ([Fioricet…

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 a resident with urinary incontinence, based on the resident's comprehensive assessment, who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for 1 (Resident #1) of 7 residents reviewed for Urinary Tract Infection (UTI), in that: The facility failed to ensure physician's orders were in place for care and management of a female external urinary collection system or implement a Urinary Toileting Program(s). These failures could put residents at risk of poor personal hygiene, impaired skin integrity, and decreased feelings of self-worth and dignity (how the reasonable person would react under such circumstances). Findings Included: A record review 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 observations, interviews, and record review, the facility failed to update and notify residents that menu changes were made prior to serving the meal. For the lunch meal on 5/30/2024 residents were served ground beef with sauce, baked rice with peas and carrots, steamed vegetables, a deep-fried egg roll, strawberry cake with shredded pineapple on top instead of the posted lunch menu of Mongolian Beef, Fried Rice, Stir Fry Vegetables, Egg roll, and Pineapple Upside cake. The Dietary Manager did not document or make any changes to the listed menu. These deficient practices could affect 92 residents who receive meals from the facility kitchen in that they would not receive the meal that was on the menu listing. The findings were: Record review of Resident #42's admission Record dated 5/31/24 revealed he was a [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE]. Record review of Resident #42's Quarterly MDS assessment dated [DATE] revealed he had severe cognitive…

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 medical records on each resident that were accurately documented, for 2 (Resident #35 and Resident #82) of 6 residents reviewed for clinical records. Resident #35's prescription medication of Pimozide Tablet 2MG was written as being indicated for psychosis; however, Resident #35 did not have a history of psychosis. Resident #82 had active physician's orders for weekly laboratory work including CBC, BMP, and ammonia levels. Resident #82's physician indicated these orders should have been previously discontinued. These failures could place residents at risk of receiving inaccurate services based on their comprehensive assessments. Findings included: 1.) Review of Resident #35's Face Sheet, dated 05/31/24, reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Review of Resident #35's annual MDS Assessment, dated 03/15/24, reflected she was cognitively intact. She had diagnoses including depression (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 observations, interviews, and record review, the facility failed to ensure residents who were incontinent of bladder or had a urinary catheter received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 Residents (Resident #2) reviewed for incontinent care. The facility failed to ensure Resident #2 had the foley catheter inserted with a physician orders. This failure could affect residents by placing them at increased risk of discomfort, skin ulcerations, and improper medical treatment. Findings included: Record review of Resident #2's face sheet, dated 05/31/24, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include hypertension, Alzheimer's, chronic pain, anxiety, bipolar disorder, and delusional disorder. Record review of the comprehensive quarterly MDS assessment dated [DATE] revealed Resident #2 had a BIMS score of 13, indicating no cognitive impairment. Resident #2 was always…

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 store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys, for 1 of 24 residents (Resident #25) reviewed for medication storage. The facility failed to appropriately store Resident #25's medication; Unisom and Ketoconazole that were left at the resident's bedside table. These deficient practices placed residents at risk for harm by misappropriation of property and not receiving the therapeutic effects of their medications. The findings included: Record review of Resident #25's face sheet dated 05/31/24 reflected the resident was a [AGE] year-old female. Resident #25 was admitted to the facility on [DATE] with diagnoses including, hypertension, vascular dementia, anxiety, major depressive disorder, insomnia, and lack of coordination. Record review of Resident's #25's Quarterly MDS assessment, dated 05/10/2024, reflected Resident #25 had a BIMS…

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 physician orders for the resident's immediate care, at the time each resident was admitted for one (Resident #1) of one resident reviewed for admission physician orders. The facility failed to have Physician orders to provide wound care for Resident #1 who admitted on [DATE] until five days later on 03/27/24. This failure could place residents at risk for delayed wound healing and wound infection. Findings included: Review of Resident #1's undated admission record dated 03/2024 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included peripheral vascular disease (Reduced circulation of blood to a body part due to a narrowed or blocked blood vessel.) and osteomyelitis (Bone infection). Review of the Resident #1's nursing admission assessment dated [DATE] revealed the resident was alert, cognitively intact, occasionally incontinent of bowel/bladder and admitted with a surgical wound to the right foot.…

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 the necessary care and services to attain or maintain the highest, practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care for one (Resident #1) of four residents reviewed for wound care. The facility failed to ensure Resident #1's physician ordered wound care was provided on 03/25/24 and 03/26/24. This failure could place residents at risk for delayed wound healing and wound infection. Findings Included: Review of Resident #1's undated admission record dated 03/2024 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included peripheral vascular disease (Reduced circulation of blood to a body part due to a narrowed or blocked blood vessel.) and osteomyelitis (Bone infection). Review of the Resident #1's nursing admission assessment dated [DATE] revealed the resident was alert, cognitively intact, occasionally incontinent…

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 maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for one (Resident #1) of 4 residents reviewed for accuracy of medical records. Findings included: 1. The facility failed to ensure staff transcribed Resident #1's wound care orders in the clinical record. 2. The facility failed to ensure staff documented the administration of Resident #1's IV (Intravenous- giving medicines or fluids through a needle or tube inserted into a vein) antibiotic on 03/23/24 and 03/24/24. These failures could place residents at risk for medication and /or treatment errors and omissions in care. Findings included: Review of Resident #1's undated admission record and physician's orders dated 03/2024 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included peripheral vascular disease (Reduced circulation of blood to a body part due to a narrowed 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 treat each resident with respect, dignity, and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for two (Residents #1 and #2) of thirteen residents reviewed for dignity. LVN A failed to maintain Resident #1 and #2's dignity and respect by standing between the residents while feeding both of them. The failure could negatively affect the mental and psychological well-being of all residents who required the assistance of staff with eating. The findings were: Record review of Resident #1's face sheet dated 02/28/2024 reflected, she was an [AGE] year-old female initially admitted to the facility on [DATE] with primary diagnosis of Alzheimer's disease with early onset (most common type of dementia), lack of coordination, dysphasia (language disorder marked by deficiency in the generation of speech), and cognitive communication deficit (difficulty thinking and how…

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 assistance devices to prevent accidents for one (Resident #3) of thirteen residents reviewed for accidents. CNA B failed to have assistance from another staff member when transferring Resident #3 via a mechanical lift. This failure place residents at risk for accidents and injuries. Findings included: Review of Resident #3's face sheet, dated 02/28/2024, reflected a [AGE] year-old female originally admitted to the facility on [DATE] with diagnoses which included transient cerebral ischemic attack (blood clot blocks the blood supply to part of the brain), dysphasia (impairment in the production of speech), need for assistance with personal care, and hyperlipidemia (an elevated level of lipids in the blood). Review of Resident #3's quarterly MDS assessment, dated 11/05/2023, reflected a BIMS score of 3 indicating a severe cognitive deficit. Resident #3 required substantial/maximal…

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, 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 two of two (Medication Cart A and Medication Cart B) medication carts reviewed for medication storage. The facility failed to ensure Medication Cart A and Medication Cart B were locked when unattended. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversion. Findings included: In an observation and interview on 10/13/23 beginning at 2:45 PM, Medication Cart A and Medication Cart B were parked next to each other in the 100 hallway, and Medication Cart A and Medication Cart B were unlocked and unattended. MA A was observed as she walked away from the unlocked medication carts, down the hall, and to a room behind the nurse station. Residents and other staff were observed as they walked in the area near the unlocked…

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 to ensure the accurate acquiring, receiving, dispensing, administering and securing of medications for two nurses medication carts (LVN A and Nurse cart 1, and LVN B cart 2) of 4 medication carts reviewed for pharmacy services. LVN A did not report and remove a damaged blister pack of Resident #7's Tramadol 50 mg tablet prescribed as needed every 6 hours for pain, 3 tablet slots perforated and taped over and not recorded as tampered by a facility nurse. LVN A did not report and remove a damaged blister pack of Resident #7's Oxycontin ER 10 mg tablet prescribed as needed every 12 hours for pain, I tablet slot perforated and taped over and not recorded as tampered by a facility nurse. LVN A did not report and remove a damaged blister pack of Resident #54's Clonazepam 0.5 mg tablet prescribed to be administered as ordered, ½ tablet (0.25 mg) at bedtime, 1 tablet slot perforated and taped over and not recorded…

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 licensed nurses had the appropriate competencies and skills sets to provide nursing services to provide resident needs and assure resident safety and attain or maintain the highest practicable wellbeing for 1 of 5 residents (Resident #196) reviewed and observed for medication management, in that: LVN C failed to administer Resident #196's ordered medication for two consecutive days. This deficient practice could place facility residents who require medication administration at risk for delayed treatments or not receive care needed, decreased quality of life. Findings included: The admission record dated 02/24/23 indicated Resident #196 was [AGE] years old with diagnoses of surgical aftercare fallowing surgery on the digestive system, diabetes mellitus type 2, and hypertension. Review of the consolidated physician orders dated 02/24/23 indicated Resident #196 was prescribed Enoxaparin Sodium (to reduce the risk of postoperative…

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 are free of any significant medication errors for 1 of 3 residents (Resident #196) reviewed for medication administration. The facility failed to provide an anticoagulant medication to prevent blood clots for two days for Resident #196 after she was admitted for a post abdominal surgery. This deficient practice could affect residents who received medication for different illnesses and place them at risk for a decline in health. Findings include: Record review of the admission record dated 02/24/23 indicated Resident #196 was [AGE] years old with diagnoses of surgical aftercare following surgery on the digestive system, diabetes mellitus type 2, and hypertension (high blood pressure.) Record review of the consolidated physician orders dated 02/24/23 indicated Resident #196 was prescribed Enoxaparin Sodium (to reduce the risk of postoperative (after surgery) blood clots) anticoagulant injection once a day as a preventative…

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 ensure that drugs and biologicals used in the facility were secured properly for one of four nurse medication carts (LVN A's second floor medication cart), reviewed for medication storage, as evidence by: An unlabeled alcohol whiskey bottle was on the second floor medication cart that was ordered to be secured in the medication room. This deficient practice places Resident's at risk for the unsafe administration and possibly not receiving properly prescribed doses of biologicals instructed and prescribed. The findings included: Record review of Resident #195's physician order dated 10/30/22 revealed the resident was allowed to have 15 ml of an alcoholic beverage of choice once a day, and the provisions noted were nurses had to keep the alcoholic beverage in the medication room and have the nurse account for the alcohol bottle each shift. An observation on 03/16/2023 at 8:50 AM of LVN A medication cart in hall 100 revealed an unlabeled alcohol whiskey bottle in the back of the narcotic medication bin. In an…

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 2 (Resident #85 and Resident #4) of 5 residents reviewed for infection control. The facility failed to ensure LVN A disinfected the blood pressure cuff in between blood pressure checks for Residents #85 and Resident #4. LVN A dispensed medications into a medication cup with his bare hands for Resident #85 and Resident #4 without sanitizing or washing his hands between administration of morning medications. This failure could place residents at-risk of cross contamination which could result in infections or illness. Findings included: Review of Resident # 85's Quarterly MDS dated [DATE], revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of Cerebral Vascular Accident (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.