Duncanville Healthcare and Rehabilitation Center

Based on observation, interviews, and record review the facility failed to ensure that medications were secure and inaccessible to unauthorized staff and residents for three (one medication cart for Hall 400 and one medication cart for Hall 200, one medication cart for Hall 300) of seven medication carts reviewed for medication storage. The facility failed to ensure medication supplies were all stored in locked compartments and permit only authorized personnel to have keys, when LVN A's one medication cart for Hall 400 were left unlocked and unattended by LVN A. The facility failed to ensure medication supplies were all stored in locked compartments and permit only authorized personnel to have keys when LVN B's two medication carts for Hall 200 and one medication carts for Hall 300 were left unlocked and unattended by LVN B. This failure could result in resident access and ingestion of medications leading to a risk for harm and possible drug diversion. Findings included: An observation on 08/12/2025 at 4:30 a.m., revealed LVN B's one medication cart were left at the nursing station…

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 promptly notify the physician of laboratory results in accordance with facility policy and procedures for notification for 1 of 5 residents (Resident #306) reviewed for laboratory services.The facility failed to send Resident #306's weekly labs to the infectious disease doctor while the resident resided at the facility from 11/27/24 to 12/20/24.This deficient practice placed the residents at high risk of not receiving treatment, and/or developing complications.Findings included:Review of Resident 306's MDS dated [DATE] reflected the resident was [AGE] year-old female admitted to the facility on [DATE] and discharged on 12/20/24. Her diagnoses included diabetes and anxiety disorder. Resident #306 had a BIMS of 6 indicating her cognition was severely impaired. The MDS also reflected the resident had a stage 4 pressure ulcer.Review of Resident #306's care plan effective on 11/28/24 reflected the resident had pressure ulcers to her right heel, unstageable…

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 foods in accordance with the professional standards for food service safety in the facility's kitchen. 1. The facility failed to ensure food items in the refrigerator, freezer and dry storage room were labeled and stored in accordance with the professional standards for food service.2. The facility failed to ensure stored canned goods, had an uncompromised seal, free from dents.3. The facility failed to discard items stored in refrigerator, freezers or dry storage that were not properly labeled or past the 'best buy', consume by or expiration dates.These failures could place residents at risk for food-borne illness and cross contamination. Findings Included:Observation of the walk-in food storage room on 08/12/2025 at 5:15 a.m., revealed the following:- 1 Box of graham cracker crumbs in unsealed zip top bag. 5 lbs., date was written by facility 5.13.2025.- 12 slices of white bread in an unsealed, unlabeled bag.- 1 opened 24oz ketchup bottle, 1/2 full, BB date: 9.28.2026.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for five (Resident #74, #46,#5, #73, and #29) of eight residents observed for infection control in that: CNA C failed to wear a gown, change her soiled gloves and wash hands during incontinent care to Resident #74. LVN D failed to clean off the overbed table prior to and after usage, while replacing tubing on Resident #46' G-tube. LVN E failed to disinfect the blood pressure cuff, in between vital sign checks for Resident #5, and Resident #73. LVN E failed to disinfect the glucometer (machine used to check blood sugar) in between usage on Resident # 29 and Resident #5. LVN E failed to change her soiled gloves and wash hands during tracheostomy care to Resident #5Findings included:1.Review of Resident #74's quarterly MDS assessment,…

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 record reviews and interviews the facility failed to send a copy of the residents' discharge notice, prior to discharge, to the representative of the Office of the State Long-Term Care (LTC) Ombudsman of the residents' transfer or discharge and the reasons for the move, for 1 of 5 residents (Resident #8) reviewed for notifying the LTC Ombudsman of the residents' discharge.Resident #8 was discharged on 07/01/2025 without a notice to the LTC state ombudsman.This failure could place residents at risk of not knowing their rights or receiving the services of the state LTC Ombudsman.The findings included:A record review of Resident #8's admission record dated 7/3/2025 revealed diagnoses which included Secondary Parkinsonism (similar to Parkinson disease caused by certain medicines, a different nervous system disorder or another illness), Muscle Weakness, Unspecified Lack of Coordination, Calculus of Ureter (kidney stone that has traveled into the ureter, the tube connecting the kidney to the bladder), Calculus in Bladder (bladder stones), Unsteadiness on Feet, Abnormal Weight…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs residents for one (Resident #5) of three residents reviewed for medication review. LVN E failed to ensure Keppra (a medication given to prevent seizures) was administered to Resident #5 appropriately. LVN E did not hold the G-tube feeding an hour before and one hour after the medication was given. This failure could place residents at risk for not receiving medications as ordered by their physician and not receiving the intended therapeutic benefit of the medications.Findings included:Review of Resident #5's 30-day MDS assessment, dated 07/30/2025, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with the following diagnoses: hypertension (high blood pressure), seizures (abnormal brain waves), diabetes (high blood sugar), and acute…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the nursing staff were licensed for 1 of 4 staff (RN E) reviewed for competencies. The facility failed to ensure RN E was permitted to practice as a licensed vocational nurse. RN E registered nurse license was expired, the facility failed to ensure RN E was permitted to practice as a registered nurse. Confirmed through board of nursing RN E's nurse license was expired. The findings were: During an interview with the ADM on [DATE] at 10:00 AM requested license for RN E. During an attempted phone interview with (RN E) on [DATE] at 1:39 PM yielded no answer. A voicemail requesting return call was left. RN E did not return call for an interview. During a phone interview on [DATE] at 8:43 AM a request for RN E's nursing license verification was requested from the ADM. An email was sent to the ADM on [DATE] at 9:35 AM requesting RN E's nursing licensing verification for RN E. ADM did not respond to the email request. Record review of the website 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 observation, interview, and record review the facility failed to ensure a safe and decent living environment for one (Dining Hall) of one dining halls reviewed for decent living environment. The facility failed to ensure ten dinner trays from 05/05/25 were removed from the dining hall before breakfast on 05/06/25. This failure could place residents at risk for diminished quality of life due to the lack of a well-kept environment. Findings included: In an observation on 05/06/25 at 7:45 AM, reflected ten dinner trays with food and trash on the tables and on a cart in the dining hall. There were about 8 residents observed as they sat in the dining hall awaiting breakfast. In an interview on 05/06/25 at 8:30 AM, Resident #1 stated he saw the dinner trays still out from last night when he walked into the dining hall. He stated the dinner trays from the night before were left out every now and then. Resident #1 stated he did not like clutter and stated clutter brought critters to the place like bugs and anything crawling. Resident #1 stated he did not like critters. In an…

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

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. 1. The facility failed to ensure food stored in the refrigerator, freezer, and pantry were labeled, dated, and sealed. 2. The facility failed to ensure there were no dented canned goods in the pantry. 3. The facility failed to ensure there were no spoiled foods in the refrigerator or freezer. These failures could place residents at risk for food contamination and food-borne illness. Findings included: Observation on 05/06/25 beginning at 7:46 AM reflected the following items: Refrigerator: 1. One box of about 20 sweet potatoes with green and white mold circles 2. One box of about 15 cucumbers with white, furry mold and mushy ends 3. Large, clear container of mixed fruit in juice, not labeled or dated, with loose-fitting plastic wrap, not fully covering the top 4. Chopped chicken pieces in a plastic storage bag, no labeled or dated, with a torn open hole in the plastic, not closed…

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 has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for one (Resident #3) of four resident reviewed for misappropriation. The facility failed to ensure Resident #3 was free from exploitation when Resident #3 reported that $611.00 was taken from her. This failure could place the residents at risk of unresolved and unreported allegations of misappropriation. Findings included: Record review of Resident #3 face sheet dated 04/30/2025 revealed a [AGE] year-old female readmitted to the facility on [DATE] with an initial admission on [DATE]. Resident #3 discharged from facility on 01/10/2025. Resident #3's Diagnosis included Atherosclerosis of Native Arteries of Other Extremities with Ulceration (a form of peripheral arterial disease (PAD), which affects the blood supply to the limbs); Type 2 Diabetes Mellitus without Complications (the blood sugar levels are being managed effectively,…

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 in response to allegations of abuse, neglect, exploitation, or mistreatment, failed to report immediately 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 Texas law no later than two hours after the allegation is made, for 1 of 5 residents reviewed for abuse and neglect (Resident #1): The Administrator, who is the Abuse Coordinator, failed to immediately report (within 2 hours) an allegation of abuse that Resident #2 hit the arm of Resident #1. This failure could place residents at increased risk for abuse and neglect. Findings Include: Review of Resident #1's Quarterly MDS dated [DATE] reflected a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses in part including hemiplegia (paralysis on one side of the body) and cerebrovascular accident (stroke). The MDS reflected Resident #1 had a BIMS score of 15,…

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, record reviews and interviews, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for one (Resident #5) of five residents reviewed for accidents. The facility failed to update interventions for falls or accidents on Resident #5's care plan from 10/31/24 to 12/03/24. Resident #5 had two falls on 11/10/24 and 11/23/24, no interventions were entered on Resident #5's care plan. This failure could place residents at risk of not addressing individualized needs and services. Findings included: Record review of Resident #5's face sheet dated 10/31/24 revealed Resident #5 was a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of Unsteadiness on Feet. Record review of Resident #5's MDS dated [DATE] revealed Resident #5 had a BIMS score of 15, indicating intact cognition. Resident #5 was required extensive assistance in toileting, transfers and bed mobility requiring the assistance of at least…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for three (Resident #1, Resident #2, and Resident #3) of seven residents reviewed for pharmaceutical services. 1. LVN A failed to follow physician orders for administering medications (Carafate, amlodipine, aspirin, folic acid, losartan, pantoprazole DR, vitamin D3, finasteride, multivitamin, Potassium ER, and sertraline) by mouth to Resident #1 and administered the medications via Resident #1's gastrostomy tube (abdominal feeding tube). 2. LVN A failed to ensure proper placement of Resident #1's gastrostomy tube prior to administering medications. 3. LVN A failed to identify medications that should not be crushed for administration. LVN A crushed Potassium ER and pantoprazole DR and administered these medications to Resident #1. 4. LVN 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 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 four residents (Resident #1, #2, #3, and #4) reviewed for infection control procedures. The facility failed to ensure CNA A performed hand hygiene after direct contact with Residents #1, #2, #3, and #4 while serving meals on Hall 300. This failure could place residents at risk for healthcare associated cross contamination and infections. Findings included: Record review of Resident #1's 5-day [in progress] admission MDS assessment, dated 11/21/24, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: anemia (low iron levels), hypertension (high blood pressure), and heart failure (heart does not pump blood like it should). Resident #1's cognition was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of three residents reviewed. The facility failed to send Resident #1 to the hospital when he requested to be transported to the hospital. This failure could place residents at risk of a change in condition and not receiving proper treatment and care in a timely manner. Findings included: Record review of Resident #1's face sheet, dated 10/16/24, reflected a [AGE] year-old male with an admission date of 09/12/24. Resident #1 had a diagnosis of Hypertensive Heart and Kidney Disease with Heart Failure and with Stage 5 Chronic Kidney Disease (damage to heart and kidneys due to prolonged high blood pressure), End Stage Renal Disease (kidneys no longer function properly), Type 2 Diabetes (body cannot produce enough insulin or process it), Sepsis (body responds…

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 the facility's only kitchen, reviewed for food safety. 1. The facility failed to ensure the ice machine chute guard was clean. 2. The facility failed to ensure food items in the refrigerators, freezer and dry storage room were labeled with the item description (handwritten or manufacturer's label), had the received by date, the opened date and or the consume by or expiration by dates (if opened, 72 hours per the facility's policy or the manufacturer's expiration date); stored in accordance with the professional standards for food service. 3. The facility failed to discard opened items stored in refrigerator, freezers and dry storage that were not properly labeled with the opened or prepped by date and or past the 'best buy', consume by or manufacturer's expiration dates. 4. The facility failed to ensure multiple food items stored in a bin/container were each clearly identifiable. 5. The facility…

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

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 #19) of 5 residents reviewed for ADLs. On 07/08/24 at 9:47 AM the facility failed to ensure Resident #1 had his fingernails cleaned and trimmed. 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 included: A review of Resident # 19's face sheet dated 06/04/24 reflected a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted to the facility on [DATE], with the following diagnosis: Dementia (impaired ability to remember, think, or make decisions), and Anxiety. A review Resident #19's Quarterly Minimum Data Sheet (MDS), dated [DATE] reflected Resident #19 was assessed to with a Brief Interview for Mental Status (BIMS) score of 04 indicated…

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 received treatment and care in accordance with professional standards of practice for 1 of 5 residents (Resident #19) reviewed for quality of care when: A. On 07/08/24 at 9:47 AM CNA J failed to note that Resident #19 had superficial scratches to his forehead that had been observed earlier that day. B. On 07/08/24 at 1:47 PM LVN H failed to assess he superficial scratches to Resident #19's forehead after being notified about the superficial scratches. This failure placed facility residents at risk for worsening stasis and venous ulcers, Cellulitis (skin infection), Osteomyelitis (infection of the bone), Sepsis (infection of the blood) severe pain, and loss of limbs. Findings included: A review of Resident # 19's face sheet dated 06/04/24 reflected a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted to the facility on [DATE], with the following diagnosis: Dementia (impaired ability to remember, think,…

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 all drugs and biologicals were stored in accordance with currently accepted professional principles in locked compartments and permit only authorized personnel to have access to the keys for 1 (Resident #28) of 3 reviewed for storage of drugs, in that: LVN A failed to lock unattended medication cart outside of a resident room. The facility failed to ensure Resident #28's medications were stored properly prior to administration by LVN A. This failure could place residents at risk of medication misuse and diversion. The findings included: Record review of Resident #28's undated face sheet reflected Resident #28 was initially admitted to the facility on [DATE] with diagnoses to include: Quadriplegia (paralyzed to lower body), anxiety, (anxious), constipation (inability to have a bowl movement), and Chronic pain (pain). Record review of Resident #28's quarterly MDS, dated [DATE], reflected a BIMs of 12 indicating the Resident #28 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure Food and drink that is palatable, attractive, and appetizing temperature for 1 (Residents #14) of 6 residents reviewed for food and nutrition. The facility failed to serve the resident food that was the appropriate temperature and fully cooked. This failure could place residents at risk for decreased quality of life. Findings included: Review of Resident #14's undated face sheet revealed she was a [AGE] year-old-female admitted to the facility on [DATE] with diagnoses that included: Cardiovascular accident (stroke), seizures (nerve disorder), depression (mental illness), diabetes (increased blood sugar), and bipolar disorder (mental illness). Also listed on the face sheet was the following: Allergen Milk, Chocolate, & Tomato. Review of Resident #14's quarterly MDS assessment, dated 05/21/24, revealed she had a BIMs score of 14: cognitively intact. The resident had the ability to understand, with clear speech, and required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferencesfor 1 (Residents #14) of 6 residents reviewed for resident rights. The facility failed to facility's failure to provide lactose free milk to Resident #14. The resident had an allergy to milk products and the facility failed to keep the product in the facility. The facility failed to serve the resident food that was the appropriate temperature and fully cooked. This failure could place residents at risk for decreased quality of life. Findings included: Review of Resident #14's undated face sheet revealed she was a [AGE] year-old-female admitted to the facility on [DATE] with diagnoses that included: Cardiovascular accident (stroke), seizures (nerve disorder), depression (mental illness), diabetes (increased blood sugar), and bipolar disorder (mental illness). Also listed on the face sheet was the following:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #19) of 5 residents reviewed for accuracy and completeness of clinical records. The facility failed to accurately document Resident #19 ' s superficial scratches on his forehead in his medical records. A. On 07/08/24 at 9:47 AM CNA J failed to note that Resident #19 had superficial scratches to his forehead that had been observed earlier that day. B. On 07/08/24 at 1:47 PM LVN H failed to assess he superficial scratches to Resident #19's forehead after being notified about the superficial scratches. C. On 07/09/24 at 1:41 PM CNA J revealed that she had been the CNA that gave Resident #19 a shower the previous day and that she that she had not noted any scratches on Resident #19. This failure placed facility residents at risk for worsening stasis and venous ulcers, Cellulitis (skin…

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 was provided equal access to care regardless of diagnoses, severity of condition, or payor source for two (Residents #1 and Resident #2) of seven residents reviewed for resident rights. 1) The facility failed to ensure Resident #1 was rescheduled for his colonoscopy (a procedure that uses a flexible tube with a camera to view the inside of the intestines) consultation when his appointment was cancelled on [DATE] due to a lapse in his Medicaid coverage. 2) The facility failed to ensure Resident #2 was scheduled for a timely Obstetrics and Gynecology (OBGYN--physician who cares for pregnant women and women's reproductive organs) consultation as recommended by her emergency room provider on [DATE] due to difficulties locating one within her Medicaid plan. Her appointment was not scheduled until after surveyor intervention. These failures placed residents at risk of delayed diagnostic studies necessary for their care 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 observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions for 01 of 01 kitchen reviewed for food and nutrition services. The facility did not check the temperature of the breakfast eggs on the holding table on 02/23/24 at 7:00 AM. The facility did not check and document the temperatures of breakfast, lunch, and dinner meals on 02/23/24. These failures could place residents who ate food from the kitchen at risk of foodborne illness. Findings included: In an observation in the kitchen on 02/23/24 at 7:00am revealed the cook did check the temperatures for boiled eggs, over easy eggs, and fried eggs before putting on the resident's plate. Record review of the temperature log for the month of February 2024 revealed, temperatures were not taken on 02/01/24, 02/02/24,02/03/24,02/05/24, 02/11/24, 02/12/24, 02/13/24, 02/14/24, 02/15/24, 02/16/24, 02/17/24, 02/18/24, 02/19/24, 02/20/24, 02/21/24 and 02/22/24 for breakfast, lunch, and dinner meals. Record review of food handlers certificates revealed that all…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 2 (Resident #1 and Resident #2) of 7 residents reviewed for resident rights. 1) The facility failed to ensure Resident #1 was rescheduled for his colonoscopy consultation when his was cancelled on [DATE] due to a lapse in his Medicaid coverage. No attempts were made by the facility staff to ascertain whether the Resident #1 had other payor sources available to him to proceed with his consultation. The Administrator was unaware Resident #1 was waiting for his Medicaid to be restored to proceed with his consultation. 2) The facility failed to ensure Resident #2 was scheduled for a timely Obstetric and Gynecology (OBGYN- physician who cares for pregnant women and women's reproductive organs) consultation as recommended by her emergency…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs for 2 (Resident #5 and Resident #7) of 10 residents reviewed for accommodation of needs. The facility failed to ensure Resident #5's and Resident #7's call light was placed within their reach. This failure could place dependent residents at risk of unmet needs. Findings included: Record review of Resident #7's admission Record dated 02/24/24 revealed she was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including other diseases of the biliary tract (organs and ducts that make and store bile); Type 2 diabetes; essential hypertension (high blood pressure); muscle weakness; lack of coordination; and abnormalities of gait and mobility (manner of walking). Record review of Resident #7's Quarterly MDS dated [DATE] revealed she had a BIMS score of 4 indicating…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain grooming, and personal hygiene for 2 (Resident #3 and Resident #5) of 5 residents reviewed for ADLs in that: Residents #3 was observed soaked in urine and feces in her bed. The urine had soaked through to her mattress. Resident #5 was observed laying in a soaked incontinence brief in her bed. The urine had soaked through to her pajamas and sheets. This failure could put residents at risk of impaired skin integrity, and decreased feelings of self-worth and dignity. Findings included: Record review of Resident #3's admission Record dated 02/24/24 revealed she was a [AGE] year-old female originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including encephalopathy (disturbance of brain function), cerebral infarction (stroke), dementia with agitation, and hemiplegia (loss of motor function) affecting…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to establish a system of records, receipts, and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and account for all controlled drugs for one resident (Resident #4) of one resident reviewed for destruction of narcotic pain patches in that: LVN G failed to document the removal and destruction of Resident #4's fentanyl pain patch in a manner to prevent the misappropriation of, or accidental or intentional exposure to, narcotic medications. This failure could place residents at risk of not receiving medications due to drug diversion and could place residents or staff at risk for intentional or accidental exposure to used narcotic pain patches still containing active medication. Findings included: Review of Resident #4's admission record, dated 02/23/24, reflected Resident #4 was a [AGE] year-old female, admitted on [DATE], with diagnoses of stroke (Damage to the brain from interruption of its blood…

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 each resident with a diet that met his or her daily nutritional and special dietary needs for one (Resident #8) of 5 residents reviewed for diet needs. The facility failed to provide Resident #8 with a NAS diet as ordered by the physician. This failure could place residents with special dietary needs at risk of disease exacerbation and/or inadequate nutrition. Findings included: Record review of Resident #8's face sheet, dated 2/25/24, revealed she was a [AGE] year-old woman who was admitted to the facility on [DATE]. Record review of Resident #8's baseline care plan, undated, revealed her dietary/nutritional status section reflected she received a 2gm NA, regular diet, and thin liquids. Record review of Resident #8's physician orders, dated 02/25/24, revealed her diagnoses were edema, insomnia, and hypertension. Her diet order (dated 02/20/24) reflected 2 gm NA diet, regular texture, and thin consistency. Observation and Interview…

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 develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident, that meet professional standards of quality care for 1 (Resident #1) of 3 residents reviewed for care plans in that: The facility failed to ensure Resident #1 had a baseline care plan created within 48 hours after admission with goals and interventions. This deficient practice could affect residents who are newly admitted and could result in decreased quality of care. The findings included: Record review of Resident #1's face sheet, dated 02/07/24, reflected a [AGE] year-old male, with an admission date of 02/01/24. His diagnosis was not listed. Record review of Resident #1's baseline care plan dated 02/07/24, reflected an admission date of 02/01/24. The baseline care plan revealed the resident was not able to communicate well with staff, was dependent for eating, oral hygiene, toileting…

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 store all drugs and biologicals in locked compartments and permit only authorized personnel to have access for one of four (Medication Cart #1) 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 and interview on 02/07/24 at 10:22 AM, Medication Cart #1 was observed in the 100 hall between rooms [ROOM NUMBERS], unlocked and unattended. The medication cart was unlocked for an additional three minutes before Nurse C came out of the resident room. She stated she was unaware she left the medication cart unlocked, and stated she knew better than to leave it unlocked. Nurse C stated the risk of leaving the medication cart unlocked was someone could take the medications off the medication cart. In an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs were provided for 2 (Resident #1 and Resident #2) of 5 residents reviewed for accommodation of needs. The facility failed to ensure Resident #1's and Resident #2's call light was placed within his reach. This failure could place dependent residents at risk of injuries and unmet needs. The findings included: Record review of Resident #1's face sheet, printed on 09/27/23, revealed Resident #1 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of chronic kidney disease, muscle weakness, dysuria (painful urination), unspecified protein-calorie malnutrition, osteoarthritis, vascular dementia (changes in memory thinking and behavior that affect the blood vessels in the brain), glaucoma, age-related osteoporosis, and other abnormalities of gait and mobility. Record 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 provide Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 3 (Rooms #108, #113 and #308) of 6 bedrooms reviewed for environment, in that: - The facility failed to ensure room [ROOM NUMBER]'s in-wall night light had a cover, exposing metal fixtures and a light bulb. - The facility failed to ensure the air condition units in Rooms #113 and #308 were free of damage and debris. These failures could place residents at risk of living in an unsafe, unsanitary, and uncomfortable environment. The findings included: Observation on 09/27/23 at 12:13 p.m., revealed room [ROOM NUMBER]'s air conditioning unit s had several broken circulation flaps with white, brown and green debris in the air vent. Observation on 09/27/23 at 12:18 p.m., revealed room [ROOM NUMBER] had a rectangular hole in the wall, to the left of the door. The hole exposed drywall, metal plates and a singular light bulb 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.

Based on observation, record review and interview, the facility failed to employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for 4 of 11 dietary support staff (DA B, DA C, DA D, and DA E) reviewed for competencies: The facility failed to ensure DA B, DA C, DA D, and DA E had a current Food Handling Certificate while working in the facility kitchen. This failure could place residents who consume food prepared in the facility kitchen at risk of foodborne illness due to being served by improperly trained staff. The findings included: Record review of the Food Handler certificate provided for DA B, indicated the certificate was issued on 08/24/2021 and was valid through 08/24/2023. Review of facility's active employee list indicated DA B had a hire date of 05/04/23. Record review of the Texas Food Handler Training certificate provided for DA C, indicated the certificate had a completion date of 06/25/2021 and indicated the certificate expired in two years (6/25/23). Review of the facility's active employee list…

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 for 1 of 1 kitchen, in that: - The facility failed to ensure food items stored in dry storage were labeled and dated. - The facility failed to ensure foods stored in the walk in cooler were stored in a sanitary manner. - The facility failed to ensure foods stored in the walk-in cooler were labeled and dated. - The facility failed to ensure cooler temperatures were monitored and recorded since 09/18/23 through 09/19/23 and 09/24/23 through 09/27/23. - The facility failed to ensure personal food items were not stored in the walk-in freezer. - The facility failed to ensure food stored in the walk-in cooler were not stored past the use by date. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: Observation of the facility's dry storage area, walk in cooler and walk in freezer on 09/27/23 from 9:59 a.m. to 10:09 a.m.,…

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

Based on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies, and skills set to carry out the functions of the food and nutrition service for 1 (DM) of 1 reviewed for competencies: The facility failed to ensure the DM met the requirements for a certified dietary manager. This failure could place residents who consume food prepared in the facility kitchen at risk of foodborne illness due to being served by improperly trained staff. The findings included: Record review of Texas Food Manager Certification Program certificate provided for the DM, indicated the certificate had an effective date of 08/19/2018. The certificate indicated the expiration date was 5 years from the effective date, 08/19/2023. Review of the facility's active employee list indicated the DM had a hire date of 03/31/2010. On 09/27/23 at approximately 3:35 p.m., the ADMIN and DON were notified of the expired certifications provided to surveyor. The ADMIN stated all dietary staff should have valid certifications and he would double check to ensure the surveyor…

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 one of six residents (Resident #1) reviewed for environment. 1. The facility failed to ensure Resident #1 had a sheet covering her bed. 2. The facility failed to ensure Resident #1 had a clean floor free of stains. These failures could place residents at risk of living in conditions that were not safe and decent. Findings include: In an observation and interview on 09/09/23 at 10:00 AM, revealed Resident #1 laid in her bed with no bed sheet that covered the mattress, and brown and tan, sticky stains on the floor and wall. The resident had a folded white sheet under her bottom. Resident #1's family member was in the room and stated she was not sure why the resident did not have a sheet that covered the mattress. She stated that she had an issue with no bed sheet in the past. The family member stated she had to bring full size sheet from home to cover the mattress at times. She stated one sheet was lost…

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, in accordance with state and federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the medications for one of one (Nurse Station #1) reviewed for medication storage. The facility failed to ensure medication was on a locked cart or in a medication storage area and not in an unlocked, open area. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversion. Findings include: In an observation on 09/09/23 at 5:51 AM, eight bubble packs of prescription medication and one box of lidocaine patches were seen sitting on the nurse's station counter. There were 2 residents in the immediate area, and there was also staff walking near Nurse Station #1. The following medication was on the counter at Nurse Station #1: Atorvastatin Calcium 40 MG (14 pills) Oxybutynin 5 MG (2 full bubble packs) Nifedipine ER 60 MG (one full bubble…

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 treat residents with respect and dignity and care for them in a manner and in an environment that promoted maintenance or enhancement of their quality of life for 4 (Residents #1, #2, #3, & #4) of 24 residents reviewed for resident rights. There was an allegation the facility staff failed to treat Residents #1, #2, #3, & #4, on the hallway with respect and dignity when they used inappropriate language (cussing) while walking down the hallway. This failure could place residents at risk for decreased quality of life, decreased self-esteem and increase anxiety. Findings included: Review of Resident #1's face sheet, dated 08/30/23, revealed she was a [AGE] year-old-female admitted to the facility on [DATE] with diagnoses that included: quadriplegia, seizures, depression, and anxiety. Review of Resident #1's quarterly MDS assessment, dated 08/09/23, revealed she had a BIMs score of 13: cognitively intact. The resident had the ability to understand, 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 observation, interview, and record review of the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen. 1.The facility failed to ensure food items in the refrigerator, freezer and dry storage room were labeled and stored in accordance with the professional standards for food service. 2. The facility failed to discard items stored in refrigerator, freezers or dry storage that were not properly labeled or past the 'best buy', consume by or expiration dates. 3. The facility failed to ensure only paper towels were placed in the handwashing sink garbage receptacle instead of gloves, product boxes and other forms of trash. 4. The facility failed to secure closed food items that were previously opened and stored in the dry storage room, refrigerator and freezer. These failures could place residents at risk for food-borne illness and cross contamination. Findings Included: Observation of the reach-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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 3 (Resident #82, Resident #83, and Resident #240) of 6 residents reviewed for infection control. The facility failed to ensure the Med Aide disinfected the blood pressure cuff in between blood pressure checks for Resident #82, Resident #83, and Resident #240. The facility failed to ensure the Med Aide used hand hygiene before and after contact with Resident #82, Resident #83, and Resident #240. These failure could place residents at-risk of cross contamination which could result in infections or illness. Findings included: Record review of Resident #82's admission MDS dated [DATE] revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Atrial Fibrillation (irregular heartbeat),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice for one (Resident #47) of six residents reviewed for nursing services. The facility failed to obtain a physician's order for Resident #47's dialysis treatment, AV shunt monitoring (permanent venous access site for dialysis to remove excess fluid), and AV shunt pressure dressing monitoring and change, after he was admitted to facility from the hospital on [DATE]. This failure could place residents at risk of not receiving dialysis treatment as ordered by their physician. Findings included: Record review of Resident #47's admission MDS dated [DATE] revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of Coronary Artery Disease, Hypertension (high blood pressure), hyperlipidemia (high cholesterol), and End Stage Renal Disease (kidney failure). He had a BIMS score of 13 (no…

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.