Castro County Nursing & Rehabilitation

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 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 #27)) of 4 residents observed for infection control. -CNA C did not wash her hands while performing incontinent care for Resident #27. This deficient practice has the potential to affect residents in the facility receiving incontinent care by exposing them to care that could lead to the spread of infections, tissue breakdown, and feelings of isolation related to poor hygiene. Findings include: Record review of Resident #27's face sheet revealed she was an [AGE] year-old female resident admitted to the facility originally on 11/14/23 and readmitted on [DATE] with diagnoses to include dementia (a group of thinking and social symptoms that interferes with daily functioning), schizoaffective disorder (a mental health…

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 and interviews, the facility failed to ensure corridors were equipped with firmly secured handrails on each side for 1 (A Hall) of 6 halls reviewed for handrails. The handrail between room A8 and A10 was loose. This deficient practice has the potential to place residents at risk for injuries related to falls that could result in bruising, skin tears, wounds, fractures, and decreased quality of life. Findings include: During an observation on 05/12/25 at 10:39 AM an approximate 10-foot section of handrail between room A8 and A10 was noted to have the middle section loose and this surveyor was able to move the handrail back and forth approximately ½ inch. The handrail was secured on each end and in the middle by brackets with two screws. Both screws in the middle bracket were loose. During an interview on 05/14/25 at 08:18 AM the MS noted that the handrail between room A8 and A10 was loose and that the screws had loosened. The MS reported that he makes rounds everyday as part of what the facility calls Angel Rounds and that he had missed the loose rail on his…

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 report an alleged violation of abuse or neglect immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involved abuse or result in serious bodily injury, to officials in accordance with State law, including to the State Survey Agency for 19 (Resident #53, #56, #58, #47, #46, #49, #44, #4, #73, #32, #15, #72, #70, #71, #50, #1, #3, #41 and #14) of 19 residents reviewed for abuse/neglect. 1. The facility failed to report Resident #58 groped a Resident #41 on 03/27/2025. 2. The facility failed to report Resident #58 slapped another resident on 03/29/2025. 3. The facility failed to report Resident #44 was pushed to the floor by Resident #46 and sustained a broken hip on 10/27/2024. 4. The facility failed to report Resident #53 had a physical altercation with Resident #71 on 01/23/2025. 5. The facility failed to report Resident #53 took his shoe and slapped Resident #3 with it on 03/12/2025. 6. 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 establish and follow a written policy on permitting residents to return to the facility after being hospitalized for 1 resident (Resident #73) of 19 residents reviewed for transfer/discharge. The facility did not allow Resident #73 to return to the facility after evaluation and treatment at a Psych Hospital. This deficient practice could place residents at risk of being discharged and not allowed to return to the facility causing a disruption in their care and services and potential decline in health. Findings included: Record review of Resident #73's face sheet, dated 04/17/2025, revealed that Resident #73 was an [AGE] year-old male resident who was admitted to the facility on [DATE] with the diagnoses of Alzheimer's disease with late onset (a progressive neurodegenerative disorder that primarily affects the brain, causing a gradual decline in cognitive function, including memory and thinking skills), dementia in other diseases classified elsewhere (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment 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 1 (Resident #1) of 5 residents reviewed for care plans. The facility failed to develop a comprehensive person-centered care plan based on assessed needs to address Resident #1's bipolar disorder, anxiety and depression and their interventions. This failure could place residents at risk of not receiving desired and necessary care and treatment. Findings Included: Record review of Resident #1's admission record dated 03/18/2025 revealed a [AGE] year-old female admitted to the facility on [DATE] 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.

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 any significant medication errors for one of five (Resident #1) residents reviewed for medication administration. -Resident #1 received a dose of 100units of insulin glargine instead of the prescribed 11units on the evening of 02/16/2025 in error. This failure could place residents who receive insulin medications at an increased risk for complications such as decreased blood glucose levels, change in cognition, and an exacerbation of symptoms and disease process. The noncompliance was found to be Past Non-Compliance (PNC). The noncompliance began on 02/16/2025 and ended on 02/17/2025. The facility corrected the noncompliance before the investigation began. Findings include: Record review of Resident #1's most recent face sheet revealed a [AGE] year-old female resident who was admitted to the facility on [DATE] with diagnoses that included, but not limited to, congestive heart failure, hypothyroidism, type 2 diabetes…

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 inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative when there was a significant change in the resident's physical, mental, or psychosocial status in either life-threatening conditions or clinical complications and a decision to transfer or discharge the resident from the facility for 1 (Resident #1) of 5 residents reviewed for notification. LVN D failed to notify Resident #1's family and physician when Resident #1 was found unresponsive in his room and sent to the hospital via ambulance. This failure could cause residents to feel alone and/or abandoned by their family members in times of crisis. Findings Included: Record review of Resident #1's admission record dated 01/25/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified dementia with other behavioral disturbance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of resident and misappropriation of resident property for 1 (Resident #1) of 5 residents reviewed for abuse. The facility failed to implement their policy titled Abuse, Neglect and Exploitation when CNA A failed to report bruising to Resident #1's ribcage she found on 01/24/25 during a brief change. This failure could place residents at risk of abuse/continued abuse. Findings Included: Record review of Resident #1's admission record dated 01/25/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified dementia with other behavioral disturbance (breakdown of thought process causing disruptive behavior), psychotic disorder with delusions (severe mental illness including distorted beliefs), generalized anxiety disorder (inability to control constant worrying),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed, in accordance with accepted professional standards and practices, to maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized for 1 (Resident #1) of 5 residents reviewed for accuracy of medical records. The facility failed to list the correct behavioral hospital on Resident #1s admission Record. The facility failed to perform a skin assessment on Resident #1 for three days (01/18/25, 01/19/25, and 01/20/25) following his admission skin assessment, as per their Skin Assessment policy. The facility's failure to ensure medical records on each resident were complete, accurately documented, and readily accessible, placed all residents requiring care at risk for incorrect or omitted treatment, duplicated treatments, and a failure to ensure continuity of care. Findings Included: Record review of Resident #1's admission record dated 01/25/25 revealed a [AGE] year-old male admitted 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.

Based on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment requirement for 1 of 1 kitchen staff (Dietary Manager) reviewed for qualifications. The Dietary Manager failed to have the appropriate license, certification, or qualifications to function as the Director of Food and Nutrition Services. This failure could place residents who consume food prepared from the kitchen at increased risk of food borne illness and not receiving adequate nutrition. Findings included: Record Review of a current facility employee roster including hire date, indicated the DM's date of hire was 04/30/2024. During an interview on 12/12/24 at 7:14 AM, the DM stated she had been employed at the facility since April , 2024 but had been the DM since June , 2024. When asked for her…

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 send a copy of the discharge notice to the Office of the State Long-Term Care Ombudsman for 1 (Resident #1) of 5residents reviewed for transfer/discharge. The facility failed to provide a notice of discharge to the facility's Ombudsman as soon as practicable when Resident #1 was discharged on 12/11/24 to a locked unit at another facility due to the current facility not being able to meet Resident #1's needs. This failure could place residents at risk of being discharged and not having access to available advocacy services, discharge/transfer options, and appeal processes. Findings included: Review of Resident #1's face sheet dated 12/12/2024 reflected the resident was an [AGE] year-old female, with admission date of 12/26/2023 and then discharged to another facility on 12/11/2024. The resident had diagnoses which included but not limited to: Alzheimer's disease (memory loss), anxiety disorder, muscle weakness, and wandering. Review of Resident #1'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, interview, and record review the facility failed to ensure the resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States for 11 (Resident #2, Resident # 3, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, and Resident #13) of 54 residents reviewed for resident rights. The facility failed to ensure 11 residents (Resident #2, Resident # 3, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, and Resident #13) were able to vote in the election of 2024. This failure could place residents at risk of feeling unheard and devalued. Findings Included: 1. Record review of Resident #2's admission record dated 11/06/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, hemiplegia (partial paralysis) affecting right dominant side, muscle weakness, 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 ensure each resident had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 2 (Resident #1 and Resident #4) of 6 residents and 3 (Room A2, Room A7, and Room A9) of 8 rooms on the locked unit reviewed for environment. 1. The facility failed to ensure Resident #1 had a sink in his bathroom for approximately a week. 2. The facility failed to ensure Resident #4 had a sink in her bathroom for an undetermined period of time. 3. The facility failed to ensure the sinks in the bathrooms of Room A2, Room A7, and Room A9 were securely attached to the wall. These failures could place residents at risk of injury, infection, and feeling ill at ease in their living environment. Findings Included: 1. Record review of Resident #1's admission record dated 11/06/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that…

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 all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 (Resident #1) of 6 residents reviewed for abuse and neglect. The facility failed to report to the State Survey Agency Resident #1's black eye within 24 hours of discovery of the injury. This failure could place…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review; it was determined the facility failed to ensure that in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete, accurately documented, and readily accessible for 1 of 6 residents reviewed for clinical records (Resident #1) in that: The facility failed to ensure Resident #1's concerns about the prior administrator were documented and addressed in social services notes. The facility's failure to ensure medical records on each resident were complete, accurately documented, and readily accessible, placed all residents requiring care at risk for incorrect or omitted treatment, duplicated treatments, poor self-esteem and self-worth, and a failure to ensure continuity of care. Findings included: Record review of Resident #1's face sheet dated 09/19/2024 reflected a [AGE] year-old-female admitted to the facility on [DATE]. Resident #1's current diagnoses included but not limited to diffuse…

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 coordinate assessments with the pre-admission screening and resident review program (PASRR) to the maximum extent practicable to avoid duplicative testing and effort for 1 of 7 (Resident #1) residents reviewed for PASRR. The facility contacted the HHSC PASRR Unit on 5-7-2024 for Resident #1 and no NFSS (Nursing Facility Specialized Services) form was provided to the HHSC PASRR Unit by the required date of 5-10-2024. This failure could affect residents with mental illnesses and placed them at risk of not being assessed to receive needed services. Findings included: Record review of Resident #1's clinical record face sheet printed 7-17-2024 revealed Resident #1 was a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include cerebral palsy (group of disorders that affect a person's ability to move and maintain balance and posture), major depression (mental illness causing sadness due to lack of chemicals in…

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, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure stored food was properly labeled and dated. This failure could put place Residents at risk for foodborne illness. Findings Included: Observation of shelved/refrigerated foods on 4/7/2024 at am revealed the following: 1. Observation of freezer 1 on 4/7/24 at 9:16 am revealed 1 bag of meat with no label or date. 2. Observation of freezer 1 on 4/7/24 at 9:18 am revealed 1 bag of squash in a plastic bag with no label or date. 3. Observation of freezer 1 on 4/7/24 at 9:18 am revealed 1 bag of green beans with no label or date. 4. Observation of refrigerator 1 on 4/7/24 at 9:25 am revealed 1 block of butter in a plastic bag with no label or date. 5. Observation of refrigerator 1 on 4/7/24 at 9:25 am revealed 1 cup of cream with no label or date. 6. Observation of kitchen counter on 4/7/24 at 9:26 am revealed 1open bag of corn…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a comfortable environment for 4 of 10 anonymous residents reviewed for environment and a homelike environment for 9 (Resident #2, #4, #21, #22, #27, #34, #36, #41, and #96) of 19 residents reviewed for environment. The facility failed to ensure during dining times that residents had comfortable sound levels that encouraged interactions. The facility failed to provide any furnishings to promote a homelike environment for 9 residents residing in the locked unit. This failure could place residents at risk for increased stress and affecting residents overall wellbeing. This failure could place residents at risk for diminished quality of life due to the lack of a well-kept environment. Findings included for comfortable sound levels: Record review of Resident #23's face sheet printed on 04/8/2024 revealed at [AGE] year-old resident admitted to the facility on [DATE] with diagnoses to include schizoaffective disorder (mental disorder),…

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 medications were stored in accordance with currently accepted professional principles for 1 (the medication room) of 2 medication storage areas reviewed for medication storage. The medication room refrigerator had medications that had been stored out of recommended storage temperatures. The facility's failure to ensure medications were stored in accordance with currently accepted professional principles could result in a resident receiving the incorrect medication or a medication that would be ineffective for their treatment resulting in exacerbation of the resident's condition and disease processes. Findings included: Record review of the medication room (the facility had one medication storage room) refrigerator log for April 2024 revealed the following documented temperatures: (-per merriam-webster.com: freezing point of water is 32 degrees Fahrenheit.) 4-1-2024-no temperature was noted. 4-2-2024- no temperature was noted. 4-3-2024-32 degrees Fahrenheit 4-4-2024-33 degrees Fahrenheit 4-5-2024-30…

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 all residents had the right to formulate an advanced directive for 1 (Resident #21) of 13 residents reviewed for advanced directives. Resident #21 had a DNR in his record that was missing information in the Two Witness's Section. The facility's failure to ensure the accuracy of a residents advanced directive such as a DNR (Do Not Resuscitate), recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care could place residents a risk for not receiving healthcare as per their or their legal representatives wishes. Findings included: Record review of Resident #21's face sheet printed 4-8-2024 revealed he was a [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), intermittent explosive disorder(repeated sudden outbursts 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 interview, and record review the facility failed to conduct a comprehensive and accurate assessment of each resident using the resident assessment instrument (RAI) specified by CMS for 1 (Resident #40) of 13 residents whose records were reviewed for assessments. Resident #40 was not listed as using tobacco on his 11-14-2023 admission MDS. This failure to ensure comprehensive and accurate assessments could affect residents by placing them at risk for inaccurate and incomplete MDS assessment which could result in residents not receiving correct care and services. Finding included: Record review of Resident #40's face sheet dated 4-8-2024 revealed a [AGE] year-old male resident admitted to the facility originally on 11-2-2023 and readmitted on [DATE] with diagnoses to include neuroleptic induced parkinsonism (a disorder of the central nervous system that affects movements to include tremors), hypertension (a condition in which the force of the blood against the artery walls is too high), stimulant…

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 the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish based on the comprehensive assessment and consistent with the resident's needs and choices for 1 of 12 residents (Resident # 23) reviewed for activities of daily living. The facility failed to assess Resident # 23's needs for a communication board to assist her to effectively communicate with staff. This failure could place residents at risk of not receiving services/care and decreased quality of life. Findings included: Record review of Resident #23's face sheet printed on 04/8/2024 revealed at [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include Schizoaffective disorder (mental disorder), anxiety disorder, cognitive communication deficit (problems with communication), Dysarthria(difficulty in speech due to weakness of speech muscles), anarthria (inability to produce clear speech),…

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 environment remained as free of accident hazards and each resident received adequate supervision as is possible for 2 of 12 residents (Resident #33 and Resident #40) reviewed for accidents and hazards. 1. The facility failed to ensure that a space heater was not being utilized in Resident #33's room. 2. The facility failed to ensure that Resident #33 did not have a lighter in his room. 3. The facility failed to ensure that Resident #40 did not have a Vape pen in his room. This failure could affect residents at the facility by placing them at risk for fire related injuries or ingesting unknown liquids from the Vape Pen. The findings were: Record review of Resident #33's face sheet dated 04/07/2024 revealed, a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, heart failure, intermittent explosive disorder, difficulty in walking, muscle weakness, 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 on interviews, and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 (02/11/2024) of the last 90 days reviewed. The facility did not have an RN working in the facility for 1 (02/11/2024) of the last 90 days reviewed. This deficient practice had the potential to affect residents in the facility by leaving staff without supervisory coverage for coordination of events such as hospice care, emergency care and disasters such as with flooding, power outage, tornado, fire, etc. Findings included: Record review of the facility's last 90 days (11/26/2023-04/07/2024) of RN coverage provided by the Administrator revealed the facility had no RN working in the facility for the following date: 02/11/2024. During an interview on 04/08/2024 at 3:17PM the DON verified that the facility did not have an RN working in the facility for 1 out of the last 90 days. The DON stated that on 02/11/2024 there was bad weather and that was the cause of not having a RN on shift that day as the RN that was supposed to be 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.

Based on interviews and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents for 1 of 5 staff (LVN A) reviewed for abuse policies. The facility failed to implement their own written policy and procedure for screening by not completing a Criminal Background Check for LVN A until 1/11/2024, 8 days after her hire date on 1/3/2024. This failure could place residents in the facility at risk of Abuse, Neglect, or Exploitation. Findings included: Record Review of LVN A's employee file revealed she was hired on 1/3/24 with her last EMR/NAR completed 2/7/24 and Criminal History completed on 1/11/24. During an interview on 02/07/24 at 4:47 PM, the ADON reported that a possible negative outcome for not having an EMR/NAR and Criminal Background check at hire would depend on what is in the employees' background, but that it could cause the residents' harm. During an interview on 2/07/24 at 4:49 PM, the ADM stated that the reason so many things were not where they were supposed to be is because 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.

Based on observation, interview, and record review the facility failed to distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 dining rooms reviewed for dining room sanitation. The facility failed to ensure proper hand hygiene was practiced during the distribution and service of resident food trays. These failures could place residents at risk for transmission-based illness. Findings included: Observation of the luncheon dining service on 1/23/24 at 12:02PM revealed the following: LVN A, CNA C, the Maintenance Supervisor and Restorative Aide were delivering food trays to residents without performing hand hygiene before and after each tray. On 1/23/24 at 12:04PM, LVN A was observed with her right hand on the wall of the dining room, while waiting to pick up a resident tray for delivery. She then picked up the resident's food tray, delivered it to the resident and got back into the service line, without performing hand hygiene. The Restorative Aide was also observed delivering resident food trays in the dining room, without performing…

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

Based on interview and record review the facility failed to develop, implement, and maintain an effective training program for 5 of 5 (CNA D, CNA E, LVN Charge, LVN B and BOM (Business Office Manager) newly hired staff reviewed for nursing home training. The facility failed to ensure new employees were properly trained in the prevention of Resident Abuse, Neglect and Exploitation, HIV Policy and Procedures, Fall Prevention, Restraints, Emergency Procedures and Dementia. This failure could place residents at risk for a diminished quality of life and diminished psycho-social well-being, due to lack of training in essential Resident Care and Facility Practice. Findings included: Record review of employee records for the last 5 employees hired, revealed no training was conducted in Resident Abuse, Neglect and Exploitation, Blood-borne Pathogen Policy and Procedures, Fall Prevention, Restraints, Emergency Procedures and Dementia, prior to these employees interacting with residents. These employee records reflected the following: CNA D: Date of Hire: 1/17/24 Certificate number and Date of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to assess residents for risk of entrapment from bed rails prior to installation for 1 of 11 (Resident #1) residents reviewed for bed rails. The facility failed to ensure Resident #1 had (1) one-half bed rail, on the right side of his bed with no documentation of physician orders, consent, or safety assessment prior to installation. This failure could place residents at risk of injury, hinder residents from getting out of bed, and/or cause a decline in resident's ability to engage in activities of daily living. Findings included: Record review of Resident #1's Face Sheet revealed a [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses to include but not limited to, neuroleptic induced parkinsonism (irregular movements caused by use of antipsychotics), schizoaffective disorder (mental health disorder with symptoms of distorted reality), polyneuropathy (malfunction of many peripheral nerves throughout the body). Record…

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 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 of 1 facility reviewed for infection control. The facility failed to properly dispose of an insulin syringe and maintain a clean environment free of bloodborne pathogens. This failure could place residents at risk of communicable diseases, decline in health and mental status, and cause potential harm that may lead to injury. Findings include: An observation on 11/18/23 at 12:08 PM revealed a bandage on the floor by the emergency exit door on Unit A . An observation on 11/18/2023 at 12:50 PM revealed a dried red substance which appeared to be blood, a brown liquid that had dried, and trash located in Resident #3's room on the floor and in the bathroom. An observation on 11/18/2023 at 12:51 PM revealed a torn alcohol square wrapping, a used alcohol square, and a syringe with clear a cap…

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 1 of 1 facility reviewed for environment. The facility failed to properly clean resident's rooms, maintain safe structure of the ceiling, provide a clean dining area, and ensure working order of sinks in the facility. This failure could place residents at risk of psychosocial decline, an increased institutional character setting, and spread of infections which could result in a decline in health. Findings include: An observation on 11/18/23 at 11:56 AM revealed a closet which contained trash liners, red and yellow plastic bags that were unidentifiable with approximately 5 empty boxes thrown in on the floor. An observation on 11/18/23 at 12:02 PM revealed a bowing ceiling in Unit A. An item which appeared to be a filter replacement latch was hanging approximate 1 inch from the right side while the left side was intact to the ceiling. A vent was protruding from the ceiling at approximately 1 inch all the way…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an effective pest control program for 1 of 1 facility reviewed for pests in that: Flies were observed in multiple areas of the facility. This failure could affect residents by placing them at an increased risk of exposure to pests and vector-borne diseases and infections. Findings included: An observation on 9/8/23 at 3:36 PM revealed a resident had 6 flies on a rolling table located in their room to which the resident swatted them away with her left hand. An observation on 9/8/23 at 3:45 PM revealed a fly attempting to land on a resident's face during an interview. An observation on 9/8/23 at 4:35 PM revealed 5 flies resting on a resident's face located in the lobby area of the facility. An observation on 9/8/23 at 4:50 PM revealed 9 flies on a substance located on the floor. An observation on 9/8/23 at 5:02 PM revealed 5 flies resting on a resident in the lobby. When waved off, 4 flies settled back on resident. An observation…

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 all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 (Resident #1) of 5 residents reviewed for abuse and neglect. The facility failed to report to the State Survey Agency an injury of unknown origin to Resident #1's brow resulting in a hospital visit and sutures…

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 an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interest of and support the physical, mental, and psychosocial well-being of 7 of 13 residents. The facility failed to: 1. Offer engaging activities in the Memory Care, secure unit This failure could affect residents of the facility by not addressing their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, and psychosocial outcome. The findings include: Observation of secure Memory Care Unit on 2/21/2023 at 10:00am five residents were sitting idle in the dining area of the unit staring at the walls. CNA B was sitting on the couch with one resident, there was no conversation with the residents while observation was occurring. Observation of the Memory Care Unit on 2/21/2023 at 11:30am six residents were sitting in the dining room area, the television was 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.

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 1 of 5 resident halls (Hall F) observed for bathroom sink water temperature in that: 6 resident rooms (F1, F3, F5, F6, F7 and F9) temperatures were not held between the state regulated water temperature of 100-110 Fahrenheit (F) degrees. This failure could place residents at risk for diminished quality of life, injury and burns. The findings included: Observation on 02/22/23 at 02:07 PM in Room F5 revealed the water temperature from the resident-use sink was 125 degrees F checked with surveyor's digital thermometer. Room F5 had no resident. Observation on 02/22/23 at 02:15 PM in Room F6 revealed the water temperature from the resident-use sink was 114 degrees F checked with surveyor's digital thermometer. Room F6 had no resident. Observation on 02/22/23 at 02:23 PM in Room F9 revealed the water temperature from the resident-use sink was 118 degrees F checked with surveyor's digital thermometer. 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 interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week in the facility for 7 (01/07, 01/08, 01/15, 01/21, 01/22, 02/18, and 02/19/2023) of 53 days reviewed for RN coverage. The facility failed to maintain RN coverage of eight hours a day (01/07, 01/08, 01/15, 01/21, 01/22, 02/18, and 02/19/2023). This failure could place residents at risk of not having their nursing and medical needs met and receiving improper care. Findings included: Record review of the facility's employee roster undated revealed there were two RN's employed at the facility. Record review of Payroll Detail Report undated revealed there was not an RN scheduled to work on (01/07, 01/08, 01/15, 01/21, 01/22, 02/18, and 02/19/2023). Interview with the BOM on 02/23/23 at 09:00 AM he stated the payroll detail report he printed was all the time punch for RN hours. Interview with the Admin on 02/23/23 at 09:10 AM he stated the DON and ADON are responsible for scheduling RN coverage. He stated they currently do…

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.