The Villages Of Dallas

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents with pressure ulcers received care and treatment consistent with professional standards of practice to promote healing and prevent further development of skin breakdown and infection for one (Resident #45) of four residents reviewed for pressure ulcers (open wound on the skin caused by prolonged pressure to bony prominences). The facility failed to ensure that LVN A cleaned Resident #45's wound to right 5th toe from inside to outside on 02/05/2025. This failure could place the residents with pressure ulcers at risk for worsening of existing pressure ulcers and infection. Findings included: Record review of Resident #45's Face Sheet, dated 02/05/2025, reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with sepsis (infection of the blood stream) and muscle weakness. Record review of Resident #45's Comprehensive MDS Assessment, dated 11/01/2024, reflected the resident had a severe…

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 observations, interviews, and record review, the facility failed to ensure residents who were incontinent of bowel and bladder received appropriate treatment and services to prevent urinary tract infections for one (Resident #42) of three residents observed for Incontinent Care. The facility failed to ensure that CNA D did not wipe Resident #42's perineal (area between the legs) area from back to front while providing incontinent care on 02/05/2025. This failure could place the residents at risk of cross-contamination and development of urinary tract infections. Findings included: Review of Resident #42's Face Sheet, dated 02/05/2025, reflected the resident was a [AGE] year-old female admitted on [DATE]. The resident was diagnosed with acute kidney failure. Review of Resident #42's Comprehensive MDS Assessment, dated 01/22/2025, reflected the resident was cognitively intact with a BIMS score of 14. The Comprehensive MDS Assessment indicated Resident #42 was always incontinent for bladder and bowel. Review…

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 that one (Resident #59) of five residents was provided medications and pharmaceutical services, including the accurate administering of all drugs, to meet their needs. The facility failed to ensure MA did not leave Resident #59's medications inside the resident's room and failed to monitor the administration of the medications on 02/04/2025. This failure could place the residents at risk of chocking or not receiving medications as ordered by the physician. Findings included: Record review of Resident #59's Face Sheet, dated 02/05/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with hypertension (high blood pressure), gastro-esophageal reflux disease (stomach acid repeatedly flows back into the tube connecting your mouth and stomach), cerebral infarction (insufficient oxygen in the brain causing stroke). Record review of Resident #59's Quarterly MDS Assessment, dated…

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 including but not limited to receiving treatment and supports for daily living safely for 6 (room [ROOM NUMBER], #2, #3, #4, #5, and #6) of 10 resident rooms reviewed for cleanliness and sanitization. The facility failed to ensure that Resident Rooms #1, #2, #3, #4, #5, and #6 were thoroughly cleaned and sanitized. This deficient practice could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life. Findings included: An observation on 09/24/24 at 12:57 PM of Resident room [ROOM NUMBER] reflected the bathroom floor had built up dirt particles along the walls. The base that the toilet sat on, had thick brownish stains along the front and sides. The air condition unit in the resident's room had dirt stains along the top of the unit and thick black dirt between the vents. The mini fridge in the room had a thick…

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 observations, interviews, and record review, the facility failed to 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 five (Resident #1, Resident #3, Resident #4, Resident #5, and Resident #9) of eleven residents observed for Infection Control. 1. The facility failed to ensure that CNA B changed her gloves and performed hand hygiene while providing incontinent care to Resident #1. 2. The facility failed to ensure that LVN A would not bring a plastic container containing push button lancets (small, sharp needle used to prick the skin and draw blood), a container of test strips, and alcohol wipes inside Resident #3, Resident #4, and Resident #5's room when she checked the residents' blood sugar. 3. The facility failed to ensure that CNA D and CNA E changed gloves and performed hand hygiene while providing incontinent care to Resident #9. These…

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 the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for two (Resident #6 and Resident #7) of ten residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #6 and Resident #7's rooms were in a position that was accessible to the residents. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency. Findings included: Resident #6 Review of Resident #6's Face Sheet, dated 09//25/2024, reflected that the resident was an [AGE] year-old female admitted on [DATE]. Resident #6 was diagnosed with muscle wasting, muscle weakness, and unsteadiness on feet. Review of Resident #6's Comprehensive MDS Assessment, dated 07/06/2024, reflected that Resident #6 had a moderate impairment in cognition with a BIMS score of 11. Resident #6 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 observations, interviews, and record review, the facility failed to ensure that all drugs and biologicals were accurately dispensed and administered to meet the needs of each resident when 1 (Resident #8) of 3 residents were reviewed for pharmaceutical services. Resident #8 had 1 oblong white pill in a medicine cup on the nightstand that Resident #8 had not taken. This failure could place residents at risk of not receiving their medications as ordered by their physician. Review of Resident #8's Face Sheet, dated 09/24/24, reflected that Resident #8 admitted [DATE] with chronic venous insufficiency (veins in legs are damaged and cannot pump blood back to the heart properly), chronic osteomyelitis (bone infection) in tibia and fibula (bones in lower leg) of left leg, and localized swelling, mass and lump, of left lower leg. Review of Resident #8's physician's order, dated 03/30/23, reflected an order for HYDROcodone-Acetaminophen Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth two…

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' right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 3 (Residents #1, #2, and #3) of 9 residents reviewed for call lights in reach. Resident #1's call pad was on the floor, under his bed, and not within reach, while he was in bed. Resident #2's call button was on the floor, under his bed, and not within reach, while he was in bed. Resident #3's call button was clipped to his pillow, and not within reach, while he was in his wheelchair at the foot of his bed. These failures could place residents at risk of not having their needs and preferences met and a decreased quality of life. Findings included: Record review of Resident #1's Face Sheet, 06/14/2024, reflected he was, and [AGE] year-old male originally admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included acute cystitis without hematuria (bladder infection), adult failure to…

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' environment remained as free of accident hazards as is possible; and residents received adequate supervision and assistance devices to prevent accidents, for one (Resident #1) of nine residents reviewed for accident hazards. The facility failed to ensure Resident #1's fall mat was on the floor, next to his bed. This failure could place the resident at risk of injuries from falls and a decreased quality of care. Findings included: Record review of Resident #1's Face Sheet, 06/14/2024, reflected he was, and [AGE] year-old male originally admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included acute cystitis without hematuria (bladder infection), adult failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function, and low cholesterol), lack of coordination, and dysphasia (speaks slowly…

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 the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for four (Resident #97, #49, and #60) of eight residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Residents #97, #49 and #60's rooms was in a position that was accessible to the residents. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency, or cause resident's unnecessary injuries. Findings included: Resident #97 Review of Resident #97's Face Sheet dated 12/21/2023 reflected resident was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included muscle weakness, lack of coordination, and cognitive communication deficit. Review of Resident #97's Quarterly MDS assessment dated [DATE] reflected Resident #97 had a moderate cognitive impairment with a BIMS score 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 provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for areas in the facility for 11 (Residents #1, 10, 18, 23, 28, 34, 48, 53, 71, 72, and 75's) of 27 residents observed for a safe, clean, comfortable, and homelike environment. The facility failed to ensure that Residents #1, 10, 18, 23, 28, 34, 48, 53, 71, 72, and 75's rooms were cleaned, sanitized, and maintained. This failure could place residents at risk of infections and living in an uncomfortable environment leading to a decreased quality of life. Findings included: Observation of Residents' #53 and #71's room on 12/19/23 at 11:09 AM revealed the wall alongside Resident's bed had brownish stains and there were a small scrap marks on the wall. The air-condition unit had dark dirt stains on the top of the into and in between the vents. A shelf near the window had a brown circular stain.…

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 that Residents, who needed respiratory care, was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for five (Resident #2, #23, #34, #41, and #99) of eight residents reviewed for respiratory care. The facility failed to ensure Resident #2 and #99's nebulizer mask was properly stored. The facility failed to ensure Resident #34 had a clear order for O2 administration. The facility failed to ensure Resident #23, and #41's tubing for their oxygen concentrators were changed weekly as scheduled. These failures could place the residents at risk for respiratory infection and not having their respiratory needs met. Findings included: Resident #2 Review of Resident #2's Face Sheet dated 12/19/2023 reflected resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included acute respiratory failure with hypoxia 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.

Based interviews and record reviews, the facility failed to maintain the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, for 5 days of the 6-month review period, reviewed for RN coverage. The facility failed to ensure the facility maintained the services of a registered nurse for at least 8 consecutive hours a day on Saturdays and Sundays for 5 days of the four months (July 2023 - December 2023) reviewed. This failure placed residents at risk of receiving higher levels of patient care. Findings included: Review of the facility provided time sheets for Registered Nurses (RN) for the review period from July 2023 to December 2023, revealed the facility did not have the required Registered Nurses coverage of at least 8 consecutive hours a day, for the following dates: 11/04/23: 3.4 hours recorded 11/25/23: 1.15 hours recorded 12/02/23: 1.18 hours recorded 12/09/23: 1.63 hours recorded 12/16/23: 2.47 hours recorded In an interview on 12/21/23 at 09:21 AM with the DON, she stated she that they had a CNA that created the Registered Nurses…

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 reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's main kitchen and the sub-kitchen, located in the skilled nursing area, reviewed for labeling and dating, and kitchen sanitation. The facility failed to ensure food in the facility's refrigerator, was labeled and dated according to guidelines and in a sanitary manner. The facility failed to ensure expired food was disgarded. The facility failed to ensure that the refrigerator, in the sub-kitchen was clean, sanitized, and did not contain staff foods. The facility failed to ensure the kitchen equipment in the main kitchen and sub-kitchen was clean and sanitized. These failures could place residents at risk for cross contamination and other air-borne illnesses. Findings included: Observations on 12/19/23 from 08:40 AM to 08:55 AM in the facility's only kitchen revealed: o One gallon container of sweet…

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 and 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 one (Resident #99) of 5 residents reviewed for dignity. The facility failed to treat Resident #99 with dignity and promote enhancement of her quality of life when the resident was not provided a privacy bag for her catheter bag. This failure placed residents at risk of not having their right to a dignified existence maintained and a decline in their quality of life. Findings included: Review of Resident #99's Face Sheet dated 12/19/2023 reflected resident was an [AGE] year-old female admitted on [DATE]. One of her diagnoses was encounter for fitting and adjustment of urinary device. Review of Resident #99's Quarterly MDS assessment dated [DATE] reflected Resident #99 was cognitively intact with a BIMS score of 15. The Quarterly MDS Assessment indicated 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 ensure each resident received adequate supervision and assistance devices to prevent accidents for one of eight residents (Resident #6) reviewed for accident hazards and supervision. The facility failed to properly maintain wheelchairs for Residents #6. This failure could place residents at risk for discomfort, pain, and injuries. Findings include: Resident #6 Record review of Resident #6's face sheet reflected a [AGE] year-old male with an initial admission date of 11/17/2023 and a diagnosis of hemiplegia and hemiparesis affecting the left side if the Resident's body (Paralysis of left side of body), Type 2 Diabetes Mellitus (Elevated blood sugar), and cerebrovascular accident (stroke). Record review of Resident #6 Quarterly MDS assessment dated [DATE] reflected Resident #6 had a BIMS score of 02 (severe cognitive impairment). Resident #6 required a 3 person assist for all transfers. Record review of Resident #6's care plan updated on…

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 was incontinent of bladder received services and assistance to prevent urinary tract infections for one (Resident #99) of two residents reviewed for urinary incontinence. The facility failed to prevent Resident #99's indwelling urinary foley catheter device from contact with the floor. These failures could place the resident with indwelling urinary catheter devices at risk for the development of new or worsening urinary tract infections. Findings included: Review of Resident #99's Face Sheet dated 12/19/2023 reflected resident was an [AGE] year-old female admitted on [DATE]. One of her diagnoses was encounter for fitting and adjustment of urinary device. Review of Resident #99's Quarterly MDS assessment dated [DATE] reflected Resident #99 was cognitively intact with a BIMS score of 15. The Quarterly MDS Assessment indicated resident had an indwelling catheter. Review of Resident #99's Comprehensive Care Plan dated…

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 who are fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for one (Resident #2) of one resident reviewed for gastrostomy tube management. The facility failed to ensure Resident #2 had a continuous feeding through a G-tube (A tube directly inserted through the skin to the stomach to deliver nutrition) as per ordered. The facility failed to ensure LVN M had the enteral feeding supplies needed to change the feeding formmula of Resident #2. The facility failed to ensure Resident #2 had a clear and complete order for the downtime. These failures could place residents who receive enteral feedings by G-tube at risk for infection, underfeeding or overfeeding. Findings include: Review of Resident #2's Face Sheet dated 12/19/2023 reflected resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included gastrostomy, and dysphagia. Review of 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 maintain medical records in accordance with accepted professional standards and practice for one (Resident #99) of 5 residents reviewed for pressure ulcers. The facility failed to document wound care treatments and pain assessment during wound care treatments. This failure could place resident at risks for incomplete medical records. Findings included: Resident #99 Review of Resident #99's Face Sheet dated 12/19/2023 reflected resident was an [AGE] year-old female admitted on [DATE]. One of her diagnoses was pressure ulcer of sacral region with unspecified stage. Review of Resident #99's Quarterly MDS assessment dated [DATE] reflected Resident #99 was cognitively intact with a BIMS score of 15. The Quarterly MDS Assessment also indicated resident had a pressure ulcer on the sacral region. Review of Resident #99's Comprehensive Care Plan dated 12/07/2023 reflected Resident #99 had pressure ulcer development to right buttock related to…

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 to 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 (Dietary Manager and CNA M) of five staff observed for infection control. The facility failed to ensure that CNA M changed her gloves and perform hand hygiene while providing incontinence care to Resident #49. The facility failed to ensure the Dietary Manager was wearing a face mask while in the kitchen area preparing food, when the facility required all staff to wear a face mask as a result of a COVID outbreak in the building. These failures could place the residents at risk of cross-contamination and development of infection. Findings included: Review of Resident #49's Face Sheet dated 12/19/2023 reflected resident was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included chronic respiratory failure with…

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 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 1one of 1 (3000 Medication Carts) medication carts reviewed for medication storage. The facility failed to ensure the 3000-medication cart was 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 include: In an observation and interview on 10/17/23 at 11:21 AM Medication Aide A passed medication to residents and left the 3000-medication cart unlocked and unattended while entering the resident room and closing the door behind her. There was no staff or residents observed on the hall near the 3000-medication cart. Interview with Medication Aide A stated she had worked in the facility PRN for one year. Medication Aide A stated she would typically lock the medication cart each time she left it unattended however she was nervous…

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 accommodate residents' food preferences for 1 of 2 residents (Resident #1) reviewed for preference. The facility failed to honor Resident #1's food dislikes. This failure could result in a decrease in resident choices, diminished interest in meals, and weight loss. Findings included: Record review of the electronic face sheet undated revealed an 81 year- old- female admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of acute and chronic respiratory failure (shortness of breath), Oropharyngeal dysphagia (swallowing problems occurring in the mouth and/or the throat). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #1 had a BIMS score of 15 which indicated intact cognition. Section GG regarding eating indicated setup or cleanup assistance needed. Record review of the care plan dated revised 10/11/23 indicated Resident#1 had potential for nutritional problems. Interventions included diet as…

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 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 3 of 4 residents (Resident #2, Resident #3 and Resident#4 ) reviewed for infection control practices, in that: The facility failed to ensure Medication Aide A performed hand hygiene between medication administration for Residents #3,#4 and #2, and sanitized the blood pressure cuff between use on Resident #3 and #2. These failures could place residents at risk for infection, transmission for communicable diseases and/or a decline in health. The findings included: 1. Record review of Resident #2's undated electronic face sheet revealed a 73- year-old female admitted to the facility on [DATE] and re admitted [DATE] with diagnosis of dementia without behavioral disturbances and type 2 diabetes mellitus without…

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 control program designed to prevent the development and transmission of infection for one of one resident (Resident #1) observed for infection control. Facility failed to ensure Wound Treatment LVN A performed hand hygiene while providing wound care to Resident #1. This failure could place the residents at risk for infection. Findings include: Record Review of Resident #1's Other MDS assessment dated [DATE] reflected Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of hypertension, Peripheral Vascular Disease (the reduced circulation of blood to a body part other than the brain or heart), diabetes, non-pressure chronic ulcer of right heel and midfoot, non-pressure chronic ulcer unspecified part of right and left lower legs. Resident #1 had a BIMS of 15 indicating she was cognitively intact. Resident #1 required limited to extensive assistance with ADLs. Observation on 09/16/23…

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.