Park Village Healthcare and Rehabilitation

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 24 hours after the allegation was made, if the events that caused the allegation involve abuse to the administrator of the facility and to other officials including to the State Survey Agency in accordance with State law through established procedures for 2 of 8 residents (Resident #1 and Resident #2) reviewed for abuse and neglect.The facility did not make a report to local law enforcement or State Survey Agency (HHS) of an allegation on 11/05/25 when Resident #1 was found in the dining room massaging the breast of Resident #2 after he had taken off her adult brief. This failure could place residents at risk harm to include sexual abuse and could lead to diminished quality of life and psychosocial harm.Record review of Resident #2's face…

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 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 (Resident #1 and Resident #2) of five residents, reviewed for infection control. 1. The facility failed to ensure LVN A wore the appropriate PPE and performed hand hygiene during wound care for Resident #1. 2. The facility failed to ensure CNA C and CNA D performed hand hygiene during incontinence care for Resident #2. This failure placed residents at risk for healthcare associated cross contamination and infections. Findings included: 1. Review of Resident #1's Quarterly MDS Assessment, dated 06/24/25, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His cognitive skills for daily decision making were moderately impaired. His diagnoses included high blood pressure. 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.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen safety. 1. The cook failed to sanitize the thermometer between checking breakfast food on 06/20/25. 2. The cook failed to check the temperature of the cinnamon rolls, biscuits and fried eggs before they were served to the residents, These deficient practices could affect residents who received meals and/or snacks from the facility's only kitchen by placing them at risk for cross contamination and other food-borne illnesses. Findings included: Observation on 06/20/25 at 6:48 am to 7:40 am, the [NAME] checked the temperature of the scrambled eggs and wiped the thermometer off with a rag that was seating on the cart beside her. The [NAME] checked the temperature of the oatmeal, grits, puree sausage and puree eggs and did not sanitize the thermometer between checking each item. The [NAME] did not check the temperatures of the cinnamon rolls, biscuits, and fried…

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 residents, staff, and the public for 2 (Halls 100 and 400) of 3 halls reviewed for environmental concerns. 1. The facility failed to lock 2 Hoyer lifts , bed with mattress, bed frame in the hallway on 06/19/25 could be a fall risk and injury concern and issue for residents. 2. The facility failed to lock 1 Hoyer lift, bed frame and left pallet seating upright by the storage supply closet on 06/20/25 could be a fall risk and injury concern and issue for residents. This deficient practice could place residents at risk of falls, injuries, and decreased quality of life. The findings included: Observation on 06/19/25 at 10:40 am on hall 100 revealed there was an unlocked bed and unlocked bed frame on hall 100. Observation on 06/19/25 at 10:50 am on hall 400 revealed there was an unlocked Hoyer lift and unlocked bed frame. Interview on 06/19/25 between 1:00 pm to 1:40 pm, CNA D, CNA E and CNA F stated the nursing staff were responsible to lock…

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 store all drugs and biologicals in locked compartments and permit only authorized personnel to have access for one (Hall 400) of three medication carts reviewed for pharmacy services. On 06/19/25, LVN A failed to ensure medication cart was locked when not being used at the nursing station on Hall 400. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversion. Findings included: Observation on 06/19/25 at 11:10 am revealed the medication cart was unlocked in front of the nurse's station. The drawers faced the hallway, and no staff was in sight. LVN A walked by the medication cart and pressed the lock closed and left 400 Hall with a resident. The medication cart was left unlocked for approximately 5 minutes and no residents and visitors were in the area at that time. Interview on 06/19/25 at 11:20 am, LVN-PRN B stated the medication cart should be locked when not in use because residents could take medications out of the cart and take…

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 file grievances anonymously for 1 (Resident #1) of 3 residents reviewed for grievances. 1. The facility failed to ensure Resident #1 had access to file a grievance anonymously. The facility's failure could place the residents at risk for concerns not being reported and addressed. Findings included: Record review of Resident #1's MDS admission assessment, dated 02/19/25, reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Her BIMS score was 12. Her cognitive status was moderately impaired. Her diagnoses included stroke and diabetes. Record review of the Facility Grievances for April 2025 and May 2025 reflected there were four grievances completed for Resident #1, but none of them were filed anonymously. An interview on 05/28/25 at 11:00 AM with Resident #1 revealed she had a personal notebook that she wrote her complaints in. She said she would have a nurse make a copy of the document 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 observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 3 (Resident #14, Resident #64, Resident #69) of 6 residents reviewed for ADLs. The facility failed to ensure: 1- Resident #14 had his fingernails trimmed on 03/18/25. 2- Resident #64 had her fingernails cleaned and trimmed on 03/19/25. 3- Resident #69 had her fingernails cleaned and trimmed on 03/19/25. These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Findings include: 1-Review of Resident#14's Quarterly MDS assessment dated [DATE] reflected Resident #14 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses included cerebral infarction (a condition where blood flow to the brain is interrupted, causing brain tissue to die), muscle wasting, and 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 observation, interview and record review the facility failed to assist residents in obtaining routine and 24-hour emergency dental care for 1 of 8 residents (Residents #36) reviewed for dental services. The facility failed to provide timely dental services for Resident #36 when he started having tooth pain on 02/11/25. This failure could place residents at risk of oral complications, dental pain, and diminished quality of life. Findings included: Record review of Resident #36's Quarterly MDS dated [DATE] revealed he was a [AGE] year-old male admitted to the facility on [DATE]with the diagnoses of stroke, cognitive communication deficit, and unspecified pain. His BIMS score was a 13 (intact cognition). Record review of Resident #36's care plan revealed a focus area communication problem due to expressive aphasia and slurring. Interventions included encouraging resident to continue to state his thoughts if he was having difficulty, assist with finding words as needed/appropriate, and monitor/document for…

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, record review and interview, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior environment for one residents' room (room [ROOM NUMBER] 301 ) of 6 residents' rooms reviewed for clean and sanitary environment. The shared bathroom in resident room [ROOM NUMBER] 301 had a water leak coming from underneath the toilet seat crossing in front of the sink and going to the shower drain. These failures could affect residents by placing them at risk of not having a clean, sanitary, and comfortable environment. Findings included: 1. Observation of Resident #69, and Resident#32's shared bathroom on 03/18/2 at 10:41 AM showed a water leak coming from underneath the toilet seat crossing in front of the sink and going to the shower drain. Observation/Interview with Maintenance Director on 03/19/25 at 09:02 AM he looked at the bathroom floor in room [ROOM NUMBER] 301 and stated it may have a leak somewhere. He flushed 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 protect the residents right to be free from physical abuse by Resident #60 for 1 resident (Resident #6) of 24 residents reviewed for abuse and neglect. On 01/25/25, Resident # 60 swung at Resident #6 and hit Resident # 6's right eye. Resident # 6 sustained bruising under the right eye. This failure placed the facility's residents at risk for abuse and neglect. Findings included: Record review of Resident #6's annual MDS, dated [DATE], reflected she was an [AGE] year-old female originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses that included dementia (loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), hypertension (elevated blood pressure), and diabetes mellitus (elevated blood sugar). Resident#6 has a BIMS score of 02/15 indicating severe cognitive impairment. Record review of the Resident#60…

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 immediately report an alleged act of abuse to the State Survey Agency, for 2 residents (Resident #6 and 60) of 24 residents reviewed for abuse and neglect. The facility failed to immediately report an allegation of physical abuse. This failure placed the facility's residents at risk for abuse and neglect. Findings included: Record review of Resident #6's annual MDS, dated [DATE], reflected she was an [AGE] year-old female originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses that included dementia (loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), hypertension (elevated blood pressure), and diabetes mellitus (elevated blood sugar). Resident#6 has a BIMS score of 02/15 indicating severe cognitive impairment. Record review of the Resident#60 Quarterly MDS, dated [DATE], reflected she was [AGE] years…

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 and administering, of medications for 2 (Nursing Medication cart hall 100 North and nursing medication cart 300 hall) of 3 medication carts reviewed for pharmacy services. The facility failed to ensure prompt identification of potential diversion of controlled medications when CMA B did not report a damaged blister pack of Clobazam 20 mg (controlled medication) and LVN D C did not report a damaged blister pack of Tylenol with Codeine#4 oral tablet 300-60 mg (controlled medication). This failure could place residents at risk of not having their medication available due to possible drug diversion and at risk of not receiving the intended therapeutic benefit of the medication. Findings included: Record review of Resident #31's Quarterly MDS assessment, dated 01/12/25, reflected he was a [AGE] year-old male with admission date of 08/30/24. Resident #31's…

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, and interview the facility failed to ensure the call system was within reach of the resident, and accessible to a resident lying on the floor for 2 Residents' rooms bathroom (room [ROOM NUMBER] 302, room [ROOM NUMBER] 303) of 6 residents' rooms bathrooms reviewed for residents' call systems. - The facility failed to ensure the call light system was accessible to a resident lying on the floor in the residents' toilets located in the secured unit room [ROOM NUMBER] 302 - The facility failed to ensure the call light system string was not missing, and was accessible to a resident, including a resident lying on the floor in the residents' toilets located in the secured unit room [ROOM NUMBER] 303 This failure could place residents in the facility at risk of being unable to have a means of directly contacting caregivers. Findings included: room [ROOM NUMBER] 302 -Observation on 03/18/25 at 09:55 AM resident toilet call light pull string was entwined on grab bar fixture next to the toilet. 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 observations, interviews, and record review the facility failed to ensure the resident has the right to reside and receive services in the facility with accommodation of resident needs and preferences for one (Resident #1) of five residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system was within reach of the Resident #1 lying in bed. This failure could place residents in the facility at risk of being unable to have a means of directly contacting caregivers. Findings included: A record review of Resident #1's MDS assessment dated [DATE] reflected Resident #1 was a [AGE] year-old male with a BIMS score 00 of 15, indicating severe cognitive impairment. Resident #1 was originally admitted to the facility on [DATE], and readmitted on [DATE] with the diagnoses including, neurogenic bladder, multiple sclerosis, and hemiplegia or hemiparesis (Hemiplegia: paralysis of one side of the body) with left elbow, and left wrist contracture. The review further…

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 a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one (Resident #1) of one resident reviewed for catheter care. The facility failed to ensure Resident #1's urine catheter drainage bag kept off the floor when Resident#1 was lying in bed. This failure could place residents at risk for urinary tract infections. Findings included: A record review of Resident #1's MDS assessment dated [DATE] reflected Resident #1 was a [AGE] year-old male with a BIMS score 00 of 15, indicating severe cognitive impairment. Resident #1 was originally admitted to the facility on [DATE], and readmitted on [DATE] with the diagnoses including, neurogenic bladder ( urinary bladder dysfunction cause by nervous system conditions), multiple sclerosis, and hemiplegia or hemiparesis (Hemiplegia: paralysis of one side of the body). The review further reflected the resident had 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 observations and interviews, 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 1 (Resident #2) of 5 residents reviewed for infection control LVN A failed to wear appropriate PPE when providing suprapubic catheter care for Resident #2 who supposed to be on EBP ( Enhanced Barrier Precautions). This failure placed the residents at risk of exposure to possible infectious agents. Findings included: Record review of Resident #2's quarterly MDS, dated [DATE], reflected she was a [AGE] year-old female originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included cerebral palsy, neurogenic bladder, mild intellectual disabilities, and needs for assistance with personal care. Resident#2 has a BIMS score of 12/15 indicating moderate cognitive impairment. Her Functional Status…

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 provide a safe environment for five (Residents #1, #2, #3, #4, #5) of 12 residents reviewed for safe environment. The facility failed to ensure Residents #1, #2, #3, #4, #5's rooms were free from black ants from 08/04/24 to 08/26/24. Theses failures could place all residents at risk for ant bites, which could cause skin infections, allergic reactions, skin tears, scratches, scarring, and rashes resulting in pain and decline in health and psychosocial well-being. Findings included: 1) Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed, a [AGE] year-old male who admitted [DATE] with the ability to express ideas and wants, able to see in adequate light without corrective lenses. He had a staff assisted BIMS score of 01 (Modified independence cognition) and upper and lower one-sided weakness. He used a wheelchair and was diagnosed with anemia (low iron), renal insufficiency (kidney failure), Diabetes Mellitus,…

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 resident environment remained as free of accident hazards as possible for five (Residents #1, #2, #3, #4 #5) of 12 residents reviewed for incident accidents. The Nursing staff failed to ensure black ants were not in Residents #1, #2, #3, #4 and #5's rooms and beds. These failures could place residents at risk of being bitten by ants causing skin irritation, skin infection and pain resulting in decreased health and psychosocial well-being. Findings included: 1) Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed, a [AGE] year-old male who admitted [DATE] with the ability to express ideas and wants, able to see in adequate light without corrective lenses. He had a staff assisted BIMS score of 01 (Modified independence cognition) and upper and lower one-sided weakness. He used a wheelchair and was diagnosed with anemia (low iron), renal insufficiency (kidney failure), Diabetes Mellitus, Cerebral Vascular…

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 in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that were accurately documented and must contain a record of the resident's assessment for five residents (Residents #1, #2, #3 #4 and #5) of 12 residents reviewed for Medical Records. The Nursing staff failed to ensure incident reports, skin assessments and Nurse progress notes were completed after reports of black ants were found in the rooms and beds of Residents #1, #2, #3, #4 and #5. These failures could affect all residents by placing them at risk of not being properly monitored and treated if documentation were not completed, accurate or missing which could result in decline in their health and psycho-social well-being. Findings included: 1)Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed, a [AGE] year-old male who admitted [DATE] with the ability to express ideas 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, observation, and record reviews the facility failed to Maintain an effective pest control program so that the facility is free of pests in Residents #1, #2, #3, #4, and #5's rooms reviewed for pest control. The facility failed to ensure Residents #1, #2, #3, #4, and #5's rooms were free from black ants from 08/04/24 to 08/26/24. Theses failures could place all residents at risk for ant bites, which could cause skin infections, allergic reactions, skin tears, scratches, scarring, and rashes resulting in pain and decline in health and psychosocial well-being. Findings included: Record review of the Facility's Pest Sightings log sheet in the Pest Control binder from 05/10/24 to 08/27/24 revealed, Ants: Resident #3 and Resident #4's was treated on 08/20/24 by Maintenance Assistant K. (There was no reports about ants in Residents #1, #2 and #5's rooms. Record review of the Facility's Electronic Maintenance Work order system from 05/01/24 - 08/28/24 revealed: 08/26/24: Ants in Resident #5's 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 store all drugs and biologicals in locked compartments and permit only authorized personnel to have access for one (Treatment Cart #1) of two treatment carts reviewed. The facility failed to ensure Treatment Cart #1 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 included: In an observation on 08/03/24 at 10:10 AM, Treatment Cart #1 was observed unlocked and unattended in the 100 Hall area. There were 4 residents in the immediate area, and no staff with visibility to the cart. The following items were observed in the cart: Hydrogen Peroxide Saline Alcohol Wipes Ketoconazole Shampoo Nystatin Topical Powder Zinc Oxide Ointment Hydrocortisone Cream In an interview on 08/03/24 at 10:15 AM, Nurse A stated she was the one responsible for Treatment Cart #1. She stated she had not used the cart since she started the shift this morning. She stated it must have been left unlocked by the nurse from…

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 routine and emergency drugs and biologicals to its resident for one (Resident #1) of three Residents reviewed for pharmacy services MA-A failed to administer all of Resident #1's medications. This failure could place the resident at risk of not receiving the full effects intended by the physician. Findings included: Record review of Resident #1's undated admission Record reflected he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included dementia, depression, and diabetes. Record review of Resident #1's quarterly MDS, dated [DATE], reflected a BIMS score not calculated. His Functional Status reflected he required assistance with all of his ADLs. Record review of Resident #1's care plan, dated 5/9/24, reflected he had impaired cognitive function related to Alzheimer's and has depression and takes Fluoxetine for it. Observation on 7/30/24 at 10:30 AM a pink and turquoise pill was found 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 observations and interviews, 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 one (Resident #2) of 6 residents reviewed for infection control CNA-B and CNA-C failed to wear appropriate PPE when providing care for Resident #2 who was on EBP. This failure placed the residents at risk of exposure to possible infectious agents. Findings included: Record review of Resident #2's undated admission Record reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included brain damage cause d by a lack of oxygen, cardiac arrest, and blood clot in the lungs. Record review of Resident #2's quarterly MDS, dated [DATE], reflected a BIMS score not calculated. Her Functional Status reflected she was totally dependent on staff for all of her ADLs. Record review of Resident #2's…

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 and interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. These services are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for four resident rooms (resident #327, #73, #16 and #11) of 24 resident rooms reviewed for clean and sanitary environment. 1. Resident #327's room had two nails on the floor, a plastic cup and the floor was dirty. 2. Resident #73's room had a hole behind the door at the entrance to the room. 3. Resident #16's room had broken blinds, a stain on the wall by the bathroom, and the toilet was running causing the pipes to make a loud whining noise. 4. Resident #11's room had broken blinds and a hole behind the door at the entrance to the room. These failures could affect all residents, staff, and the public by placing them at risk of not having a clean, sanitary, and comfortable environment. Findings included: 1. Observation of Resident #372's room on 2/6/24 at 9:58 a.m. showed two iron nails…

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 services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident #327) of 5 residents reviewed for ADLs. The facility failed to ensure Resident #327 had her fingernails cleaned and trimmed and was provided incontinent care for more than 4 hours on 2/7/24. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Findings include: Review of Resident #327's admission MDS assessment dated [DATE] reflected Resident #327 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses included hypertension (high blood pressure), peripheral vascular disease (circulation disorder caused by narrowing in a blood vessel), septicemia (blood poisoning by bacteria), and hyperlipidemia (high blood lipid levels). Resident #327 had a BIMS 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.

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 kitchen, reviewed for kitchen sanitation. The facility failed to ensure liquid Kool Aid stored in the facility's walk-in refrigerator was covered, labelled and dated. These failures could place residents at risk for cross contamination and other air-borne illnesses. Findings included: Observation on 01/06/2024 from 9:14 AM in the facility's kitchen revealed: 1. One jar pink liquid Kool Aid in the walk-in refrigerator was not covered, labelled, and dated. 2. One jar yellow liquid Kool Aid in the walk-in refrigerator was not labelled and dated. An interview with the Dietary Manager on 02/06/2024 at 11:39 AM, she stated her expectation of the kitchen staff was to keep the liquid Kool Aid in the refrigerator to be covered, labelled and dated. The liquid Kool Aid which was not covered was considered unsanitary, bugs could fall into the drink, and it had the potential 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 observations, interviews and record review, the facility failed to ensure resident rooms were adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for one (Resident #57) of 6 residents reviewed for resident call system The facility failed to ensure the call light in resident room [ROOM NUMBER] used by Resident #57 for dialysis treatment went to a centralized staff work area. This failure placed resident at risk of a delay in receiving assistance from facility staff and being unable to obtain assistance in the event of an emergency. Findings included: Review of Resident #57's MDS assessment dated [DATE] reflected Resident #57 was a [AGE] year-old male admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses of acute osteomyelitis (bone infection) of left ankle/foot, end stage renal disease, diabetes, stroke, hemiplegia and hemiparesis…

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 honor the resident right to choose his or her attending physician for 1 of 5 residents (Resident #1) reviewed for resident rights. The facility did not honor Resident #1's right to choose his primary care physician as his attending physician. This deficient practice could place residents at risk of decreased quality care and treatment due to their lack of free choice for their attending physician care while in the facility. Findings included: Record review of Resident #1's admission Record, revealed a [AGE] year-old male, who admitted to the facility on [DATE] from a short-term (acute) hospital with the following diagnoses: Acute on Chronic Systolic CHF (history of relatively stable HF, with a new diagnosis or active symptoms); CKD, Stage 3 (kidneys have mild to moderate damage); and T2DM. Record review of Resident #1's Comprehensive MDS admission assessment, dated 11/14/23, revealed Resident #1 had a BIMS of 11 which suggested moderately impaired…

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 assist the resident in making transportation arrangements to and from the source of service, if the resident needs assistance for 1 of 3 residents (Resident #1) reviewed for transportation services, in that The facility failed to ensure Resident #1 was provided transportation to services from outside entities on 12/07/23 and 12/15/23. This failure could result in missed appointments and delayed treatments. Findings included: Record review of Resident #1's admission Record, revealed a [AGE] year-old male, who admitted to the facility on [DATE] from a short-term (acute) hospital with the following diagnoses: Acute on Chronic Systolic CHF (history of relatively stable HF, with a new diagnosis or active symptoms); CKD, Stage 3 (kidneys have mild to moderate damage); and T2DM. Record review of Resident #1's Comprehensive MDS admission assessment, dated 11/14/23, revealed Resident #1 had a BIMS of 11 which suggested moderately impaired cognition. 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.

Based on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access for one (Medication Cart #1) of three medication carts reviewed for pharmacy services. The facility failed to ensure Medication Cart #1 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 included: In an observation on 12/22/23 at 8:44 AM, revealed Medication Cart #1 was unlocked and unattended with no staff within eyesight of the medication cart for at least three minutes. All drawers could be opened, and all medications could easily be assessed. There was one resident observed in the immediate area. In an interview on 12/22/23 at 8:47 AM, PRN RN stated she wheeled a resident to the smoking area, because the resident was ready for a smoke break. PRN RN stated she did not realize she left the medication cart unlocked while unattended. She stated the risk of the unlocked medication cart…

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 resident/RP has the right to be informed of, and participate in, his or her treatment for one (Resident #1) of 22 residents reviewed for resident and RP rights. Resident #1's RP was not notified when the physician's order for glucose monitoring was entered as once-a-week monitoring the day after Resident #1 admitted to the facility. Prior to admitting to the facility, Resident's glucose was monitored twice daily. Resident #1's RP was not educated on the risks or benefits of testing glucose less frequently to make an informed consent to the change. The resident was hospitalized for 10 days with increased confusion, poor wound healing, hyperglycemia (high blood sugar), and septicemia (bacterial infection of the blood). This failure could place residents at risk for delayed interventions in treatment when glucose levels spike or drop due to underlining conditions e.g., sepsis, chronic kidney disease, infections, cancer, and diabetes. Findings…

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 were free of significant medications errors for one resident (Resident #1) of 22 residents reviewed for medication accuracy in that: The facility failed to hold antibiotic medication (Amoxicillin/Clavulanate) after orders were attached to Resident #1's hospital discharge documents until after 3 doses were administered 10/01/2023 to 10/02/2023. The facility failed to ensure Resident #1 was not administered medications that belonged to another resident that was a hospital patient. This failure could place residents at risk of receiving medications not ordered by their physician, which could cause exacerbate kidney disease, diarrhea, and nausea. Findings included: Record review of hospital notes, MDS, care plan and orders on 10/27/2023 at 9:30 AM for Resident #1 revealed, Resident #1 is an [AGE] year-old female with a medical history of dementia, cognitive communication deficits, hypertension, type 2 diabetes, chronic kidneys disease 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 observation, interview, and record review, the facility failed to immediately notify the resident's representative when there was a significant change in the physical status and consult with the resident physician for one of three residents (Resident #2) reviewed for notification of change in condition. LVN failed to notify Resident #2's resident representative of the significant change of condition of pain, notify the physician, and request for x-ray of the right knee on 10/08/23. This failure could place residents at risk for a delay in treatment and not receiving proper care due to failure to notify resident representative. Findings included: Review of Resident #2's face sheet dated 10/10/23 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of dementia, hypertension, difficulty in walking and age related physical debility. Review of Resident #2's care plan undated reflected Resident #2 had Condyle (A condyle is the round prominence at the end of 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 that alleged violations involving neglect were reported immediately but not later than 2 hours after the allegation is made if the event that caused the allegation resulted in serious bodily injury for 1 (Resident #1) of 5 residents reviewed for neglect. The Administrator failed to immediately report to HHSC within two hours after Resident #1 fell from a Hoyer lift during a transfer, which resulted in the resident sustaining a laceration to head requiring six staples at the hospital. This failure placed residents at risk of injury or worsening of their conditions. Findings included: Record review of Resident #1's face sheet revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] and re-entered on 08/20/23. Her diagnoses included Spastic Quadriplegic cerebral Palsy, muscle weakness, unspecified lack of coordination , need for assistance with personal care, Flexion Deformity, right elbow, age-related Osteoporosis…

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.