Maverick Nursing and Rehabilitation Center

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food storage safety. 1.The kitchen had an unsealed cheese bag dated 12/4/2025 in the fridge,2.The kitchen had an unsealed cilantro bag dated 12/5/2025 in the fridge.3.The kitchen had an unsealed pizza dough bag dated 10/26/2025 in the freezer.4.The kitchen had an undated macaroni container in the pantry5.The kitchen had a tomato that appeared to be spoiled in the fridge. This deficient practice could place residents who eat food from the kitchen at risk of foodborne illnesses.The findings include:During an observation on 12/09/2025 at 10:46 a.m. of kitchen refrigerator, the following items were unsealed: cheese bag date 12/04/20205, cilantro bag dated 12/05/2025. Observation of the kitchen refrigerator noted a spoiled tomato. During an observation on 12/09/2025 at 10:46 a.m. of kitchen freezer a pizza dough bag dated 10/26/2025 was observed unsealed. During 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 observations, interviews, and record review, the facility failed to ensure that residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents, for 1 of 7 residents (Resident # 1 ) reviewed for call light. The facility failed to ensure Resident # 1's call light was within reach. This failure could place residents at risk of not achieving independent functioning, dignity, and well-being. Findings include: 1.Record review of Resident #1 's face sheet dated 12/9/25 revealed a [AGE] year-old male admitted to the facility 11/19/25.Resident # 1 had diagnoses that included diabetes mellitus, [is a chronic metabolic condition marked by high blood sugar levels], Dependence on renal dialysis [means your kidneys have failed requiring a machine to filter waste, extra fluid, and balance minerals in your blood for survival], and Myopathy[is a broad term…

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 refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 1 of 2 residents (Resident #68) reviewed for PASARR accuracy.1. The MDS Case Manager did not refer Resident #68 for a level II resident review upon newly evident serious mental health disorder.This deficient practice could place the residents at risk of not receiving the necessary care and services.The findings included:Record review of Resident #68's face sheet, dated 12/10/2025, revealed a [AGE] year-old male admitted to the facility on [DATE], with a primary diagnosis type 2 diabetes Mellitus with diabetic chronic kidney disease (condition caused by the way the body regulates and uses sugar as fuel). Record review of Resident #68's MDS, dated [DATE], revealed the resident's BIMS score a 4 out of 15 which suggested the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the 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 for 1 resident (Resident # 83) of 24 residents reviewed for comprehensive person-centered care plans. The facility failed to ensure Resident #83's care plan included Contact Isolation which was ordered to prevent spread of her infection C-diff and EBP for her infected wound which required treatment and a dressing. Resident #83's comprehensive person-centered care plan did not reflect the use of PPE as an intervention. This deficient practice affects residents with contagious infections and could result in increased transmission of the bacteria. The findings included: Record review of Resident #83's electronic face sheet dated 12/10/2025 reflected…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice for 1 resident (Resident #30) of 3 residents reviewed for oxygen therapy. Resident #30's oxygen concentrator left side black foam filter was gray from being covered with air particles and dust. This deficient practice affects residents who receive oxygen therapy and could result in hypoxia (low oxygen) and difficulty breathing.The findings included: Record review of Resident #30's electronic face sheet dated 12/10/2025 reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: epilepsy (chronological neurological disorder characterized by recurrent seizures), anoxic brain damage (damage to the brain due to a lack of oxygen), respiratory failure with hypoxia (a condition where the body does not receive enough oxygen leading…

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 and ensure safe and sanitary storage of residents' food items for 1 (refrigerators in resident room [ROOM NUMBER]-B) of 5 residents' refrigerators reviewed in that: The personal refrigerator in resident's room [ROOM NUMBER] B contained unlabeled, undated food items. This deficient practice could place residents at risk of foodborne illness due to consuming foods which could be spoiled. The findings were: Observation on 12/10/2025 at 9:05 a.m. revealed that the personal refrigerator in resident room [ROOM NUMBER]-B contained an ice-cream pint, opened, with an expiration date of 03/15/26, which was unlabeled and undated. Observation on 12/11/2025 at 08:50 a.m. revealed the personal refrigerator in resident room [ROOM NUMBER]-B contained an ice-cream pint, opened, with an expiration date of 3/15/2026, which was unlabeled and undated. Further observation on 12/11/2025 at 12:54 p.m. revealed that the ice cream was still present in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 residents (Resident #36 and #83) who were reviewed for infection control. The findings included: 1. The facility failed to post a sign which indicated enhanced barrier precautions (EBP) for Resident #36 who had an open wound with treatment. 2. The facility failed to post signs on Resident #83's door that indicated she was on contact isolation for C-Diff. and required EBP for having an open wound which required a dressing. This deficient practice affects residents with infections and wounds and could result in increased transmission or cross contamination. The findings include: Record review of Resident #36's face sheet, dated 12/10/2025, revealed a [AGE] year-old male and admitted to the facility on [DATE],…

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 reviews the facility failed to ensure all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access, for 1 of 6 medication carts (300-hall medication cart), reviewed for security. LVN B left the 300-hall medication cart unattended and unlocked. This failure could place residents at risk for having their medications uncontrolled. The findings included: During an observation and interview on 9/17/2025 11:28 AM revealed the 300-hall nurse cart was stationed at the end of the 300-hall and was unattended and unlocked. LVN A locked the cart and stated the cart was assigned to LVN B. During an interview on 9/17/2025 at 11:32 AM LVN B stated she had left the 300-hall medication cart unattended and unlocked while she stored a bottle of enteral feeding formula in the facility's resident pantry. LVN B stated she could not visualize the 300-hall medication cart from within the resident pantry. During an interview on 9/17/2025 at 11:45 AM the Administrator and the…

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

Based on observations, interviews, and record reviews the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety, for 1 of 1 residents pantry refrigerators reviewed for food safety. The facility stored resident's foods in the Resident's pantry refrigerator without labels and dates to indicate if the foods were safe to serve. These failures could place residents at risk for food borne illnesses.The findings included:During an observation and interview on 9/17/2025 at 11:34 AM revealed the facility's Resident's Pantry room had a refrigerator. The refrigerator presented with signage which read, Resident Food Storage . food should have a name, room number, and a date when placed into storage . refrigerator will be checked daily and disposed of not labeled food . LVN B stated the refrigerator had unlabeled containers of food which included berries, various desserts stored in small foam containers, 1 - 1/2 sandwich, and 1 cookie, which all did not have and labeling to reveal if the foods were safe to serve. During 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 service safety for 1 of 1 kitchen, in that: The facility failed to ensure three packets of bread, observed in the freezer on 09/08/2024, were labeled and dated, and that one of packets was not opened in the freezer because the plastic bag was torn. This failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: Observation on 09/08/2024 at 9:59 a.m. in the kitchen revealed there was one freezer in the dry storage room, and inside the freezer there were three packets of bread. Two packets were covered in plastic bags but not labeled and dated. The other packet was French toasted bread, covered in a plastic bag, but the packet was opened because the plastic bag was torn. The packet of French toasted bread was also not labeled and dated. Interview on 09/08/2024 at 10:01 a.m., Kitchen Supervisor-N saw the three packets of bread inside the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, 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 disease and infection for 2 of 6 residents (Residents #83 and #63) reviewed for infection control, in that: 1. The facility failed to ensure CNA AD used the proper technique to sanitize her hands while providing incontinent care for Resident #83. 2. The facility failed to ensure CNA-AD and CNA-AE wore a gown while performing incontinent care for Resident #63 who was on EBP (Enhanced Barrier Precautions) on 09/10/2024. These deficient practices could place residents at-risk for infection due to improper care practices. The findings included: 1. Record review of Resident #83's face sheet, dated 09/10/2024, revealed an admission date of 01/17/2024 and, a readmission date of 06/21/2024 with diagnoses which included: Dementia (decline in cognitive…

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

Based on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 1 of 6 residents (Resident #17) reviewed for resident rights, in that: The facility failed to ensure CNA AD and CNA AE completely closed Resident #17's privacy curtain while providing incontinent care. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy. The findings include: Record review of Resident #17's face sheet, dated 09/10/2024, revealed an admission date of 07/01/2022 and, a readmission date of 01/06/2023, with diagnoses which included: Dementia (decline in cognitive abilities), Major depressive disorder (mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure), Hypertension (High blood pressure), Chronic kidney disease (gradual loss of kidney function)and, Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood). Record review of Resident #17's Quarterly MDS assessment, dated 08/07/2024, revealed the resident had a BIMS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to ensure the assessment accurately reflected the resident's status for 2 of 18 residents (Residents #40 and #9) whose assessments were reviewed, in that: 1. The facility failed to ensure Resident #40's quarterly MDS, dated [DATE], correctly documented the resident as receiving an anticoagulant medication. 2. The facility failed to ensure Resident #9's, who was a smoker, annual MDS, dated [DATE], did not reflect the resident did not use tobacco. These failures could place residents at-risk for inadequate care and services. The findings were: 1. Record review of Resident #40's face sheet, dated 09/10/2024, revealed an admission date of 03/09/2018 and, a readmission date of 05/12/2024 with diagnoses that included: Type 2 diabetes mellitus (high level of sugar in the blood), Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills), Heart failure (impairment in the heart's ability to fill with and pump blood), Major…

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 refer all residents with newly evident or possible serious mental disorder for level II resident review for 1 (Resident #68) of 18 residents reviewed for resident assessments. The facility failed to refer Resident #68 for re-evaluation of PASARR level I review following a diagnosis of schizoaffective disorder-bipolar type, added on 01/05/2024. This failure could place residents at risk of not having their mental health needs met by the facility and could place all residents at risk of harm by mentally unstable residents. Findings Included: Record review of Resident #68's face sheet, dated 09/10/2024, revealed the resident was [AGE] years old male and an admission date of 11/08/2021 with diagnoses that included: cirrhosis of liver (scar tissue replaces healthy liver tissue), hypertension (high blood pressure), atherosclerotic heart disease (plaque buildup in artery walls), and schizoaffective disorder-bipolar type (chronic mental illness that causes…

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 comprehensive person-centered care plan for each that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs that are identified in the comprehensive assessment, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 18 residents (Resident #17) reviewed for comprehensive care plans, in that: The facility failed to ensure Resident #17, who was always incontinent of bladder and bowel, had a care plan regarding bowel incontinence care. This deficient practice could place residents at risk for not receiving proper care and services. The findings included: Record review of Resident #17's face sheet, dated 09/11/2024, revealed the resident was [AGE] years old female and an original admission date of 07/01/2022 and re-admission date of 01/16/2023 with diagnoses that included: Dementia (decline 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 observations, interviews, and record review, the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to prevent complications from enteral feeding for 1 (Resident #79) of 3 residents reviewed for quality of care. The facility failed to ensure Resident #79, who was receiving Glucerna at a rate of 55 ml/hour via tube feeding on 09/08/2024, coincided with the physician order that indicated providing Glucerna at a rate of 60 ml/hour to the resident. This failure could place residents at risk of not receiving the proper tube feeding requirements prescribed by the physician. Findings included: Record review of Resident #79's face sheet, dated 09/08/2024, revealed the resident was [AGE] years old female and an original admission date of 06/05/2023 and re-admission date of 12/23/2023 with diagnoses that included: Dementia (decline in cognitive ability), surgical aftercare following surgery on the digestive system, dysphagia (swallowing difficulties),…

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 needed respiratory care were provided such care, consistent with professional standards of practice, for 1 of 2 residents (Residents #63) reviewed for quality of care in that: The facility failed to ensure Resident #63's nebulizing mask and tubing, that were observed on 09/08/2024, were not covered in a plastic bag dated on 07/21/2024. This failure could affect residents who received nebulizing treatment and place them at risk for respiratory infections. The findings included: Record review of Resident #63's face sheet, dated 09/09/2024, revealed the resident was [AGE] years old female and an original admission date of 07/02/2021 and re-admission date of 02/15/2022 with diagnoses that included: Alzheimer's disease (damages memory and thinking skills), hypertension (high blood pressure), muscle wasting and atrophy (muscles to decrease in size and strength), dysphagia (swallowing difficulties), and cardiac…

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 record review and interview, the facility failed to ensure residents have the right to formulate an advance directive and determine the choice to receive or not receive CPR (cardiopulmonary resuscitation) for 1 of 6 residents (Resident #6) reviewed for advanced directives in that: Resident #6 did not have advance directives documented in the admission agreement or electronic medical record from the date of admission, [DATE], to discharge date , [DATE]. This deficient practice could affect residents admit to the facility and place them at risk of not having their wishes known, which could delay emergency treatment. Findings included: Review of Resident #6's face sheet dated revealed he was a [AGE] year-old male was admitted into the facility on [DATE] with diagnoses including Alzheimer's Disease. Review of Resident #6's consolidated orders for [DATE] revealed resident had an order for Full Code status, initiated [DATE]. Review of Resident #6's admission care plan, initiated [DATE], revealed the 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 for at least 8 consecutive hours a day, 7 days a week, on 5 days during the look back period from April 1, 2023, to August 8, 2023 (99 calendar days). The facility failed to maintain RN coverage on: April 1,2023, April 2, 2023, April 5, 2023, May 12, 2023, and May 13, 2023. This failure could affect all 82 residents of the facility by placing them at risk for not having their nursing and medical needs met. Findings included: Review of the 'Timecard Review (Department Report)' for all of the facility's RNs from 04/01/2023 - 08/08/2023 revealed there was no RN coverage on the following dates: April 1, 2023 April 2, 2023 April 5, 2023 May 12, 2023 May 13, 2023 During an interview on 08/11/2023 at 8:38 a.m. the Interim Administrator stated, I began my employment at this facility on July 13, 2023, I was not here on any of the days reported as not having the required RN coverage, I did check with the Regional Nursing Consultant to make sure she was not in the building and she was not. I…

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 ensure that its activities program was directed by a qualified professional. The Activity Director was not currently qualified to direct the activities program. This failure could result in not meeting the assessed activity needs of each resident. The findings were: Review of the staff roster on 08/11/2022 revealed the current Activity Directors hire date was 09/25/2015. Interview on 08/11/2023 at 03:25 p.m. with the Activity Director revealed the Activity Director had been in the current position since January 2022, stating I was the Activity Assistant before, when the Activity Director left I took over the position. The Activity Director stated, I am not a certified Activity Director, I haven't had any classes, they haven't ever told me that I need a certificate or anything, I do good at my job, and I don't think I need any training . The Activity Director further stated, if I need help I just as the Regional Nurse. Interview on 08/11/2023 at 03:29 p.m. the Interim Administrator stated, the facility does not have 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 ensure that residents who required dialysis received such services, consistent with professional standards of practice for 1 of 2 residents (Resident #44) reviewed for dialysis in that: The facility did not maintain communication, coordination, and collaboration with the dialysis facility for Resident #44. This deficient practice could affect residents who received dialysis treatments and place them at risk for complications and not receiving proper care and treatment to meet their needs. The findings were: Record review of Resident #44's face sheet, dated 8/11/23 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] and 7/17/23 with diagnoses that included hypoglycemia (low blood sugar), hyperlipidemia (elevated cholesterol), cognitive communication deficit, end stage renal disease (condition in which the kidneys cease functioning on a permanent basis) and dependence on renal dialysis. Record review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Residents have the right to formulate an advance directive for 1 of 9 resident (Resident # 73) reviewed for advanced directive in that: The facility failed to have the physician's signature recorded on the Out of Hospital Do Not Resuscitate (OOHDNR), which made the advanced directive invalid. This deficient practice could place residents at risk of not having their wishes known, which could affect whether they receive emergency medical treatment. Findings: Record review of Resident #73 face sheet, dated 08/10/2023, revealed the resident was admitted to the facility on [DATE] with diagnoses that included but not limited to the following: cerebral infarction (stroke) due to unspecified to occlusion or stenosis of right middle cerebral artery, acute respiratory failure with hypoxia, type 2 diabetes (high blood sugar), hyperlipidemia (high cholesterol), pneumonia, dysphagia following a cerebral infarction, muscle wasting and atrophy, lack 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 ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for 1 or 2 residents (#73). Resident #73's oxygens was administered at 2 Liters Per Minutes instead of 1 Liter Per Minute via nasal cannula as ordered by the physician. This deficient practice could affect 2 residents who received oxygen continuously and result in residents receiving incorrect or inadequate oxygen support and could result in decline in health. The findings were: Record review of Resident #73 face sheet, dated 08/10/2023, revealed the resident was admitted the facility on 06/29/2023 with diagnoses that included but not limited to the following: cerebral infarction due to unspecified to occlusion or stenosis of right middle cerebral artery, acute respiratory failure with hypoxia, type 2 diabetes (high blood sugar), hyperlipidemia (high cholesterol), pneumonia, dysphagia following a cerebral infarction, muscle wasting and atrophy, lack of coordination, and aphasia (loss 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 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 2 of 18 residents (Resident #55 and #64) reviewed for infection control practices, in that: During the medication pass, LVN B: -placed clean gloves in her pocket -did not perform hand hygiene prior to care and between glove changes -did not sanitize the digital wrist blood pressure cuff between resident use These failures could place residents at risk for infection, transmission for communicable diseases and/or a decline in health. The findings included: 1. Record review of Resident # 55's face sheet, dated 8/11/23 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included muscle wasting and atrophy (wasting or thinning of muscle mass), hypertension…

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.