Ambrosio Guillen Texas State Veterans Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to immediately notify and consult with the resident's physician when a significant change in a residents physical, mental, or psychosocial status (that was a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 (Resident #1) of 3 residents reviewed for change in condition.The facility failed to immediately inform the NP/MD on 12/10/25 of Resident #1's new diagnosis of osteomyelitis (bone infection).This failure could place residents at risk of serious decrease in health related to delayed treatment. Findings include:Record review of Resident #1's admission Record dated 02/03/26, revealed an [AGE] year-old male with an admission date of 02/27/25 to the facility and a discharge date of 01/25/2026.Record review of Resident #1's discharge MDS dated [DATE], revealed, no BIMS score. Section C- Cognitive Patterns revealed Resident #1's Cognitive Skills for Daily Decision Making coded at a 2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews, the facility failed to ensure that the assessment accurately reflected the resident's status for 1 (Resident #1) of 5 residents reviewed for accuracy of MDS assessment, in that: Resident #1's Discharge MDS dated [DATE] did not accurately reflect the residents' diagnosis of Osteomyelitis (infection of the bone).This failure could place residents at risk of not receiving necessary care . Findings included:Record review of Resident #1's admission Record dated 02/03/26, revealed an [AGE] year-old male with an admission date of 02/27/25 to the facility and a discharge date of 01/25/2026.Record review of Resident #1's local hospital history and physical dated 02/12/25, revealed, a medical history of open wound of foot, open wound of left great toe and diabetes mellitus with hyperglycemia (elevated blood sugar). Per assessment plan, Resident was referred to local hospital on 12.12.25 due to concern of osteomyelitis in the left foot. MRI imaging was consistent with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure medical records were maintained on each resident that were complete and accurately documented for 1 of 1 (Resident #1) resident reviewed for accuracy and completeness of medical records.-The facility failed to document notification to NP/MD of osteomyelitis for Resident #1 on 12/10/25.These failures could place residents at risk of not receiving needed services.Findings included: Record review of Resident #1's admission Record dated 02/03/26, revealed an [AGE] year-old male with an admission date of 02/27/25 to the facility and a discharge date of 01/25/2026. Record review of Resident #1 's local hospital history and physical dated 02/12/25, revealed, a medical history of open wound of foot, open wound of left great toe and diabetes mellitus with hyperglycemia (elevated blood sugar). Per assessment plan, Resident was referred to local hospital on 12.12.25 due to concern of osteomyelitis in the left foot. MRI imaging was consistent with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure that all allegations involving abuse, neglect, exploitation or mistreatment, includinginjuries of unknown source, were reported immediately to the State Survey Agency, for 1 of 4 residents (Resident #1) reviewed for abuse/neglect. The nursing facility failed to report Resident #1's allegation of abuse, alleging LVN B squeezed her left-hand, on 10/01/25 to the state survey agency within 2 hours of learning of the allegation. This failure could place residents at risk for abuse and neglect and result in increased risk of abuse andneglect not being reported within 24 hours to the State Agency to ensure appropriate investigation and corrective actions were taken.Findings includeRecord review of Resident #1's face-sheet dated 10/27/25 revealed she was an [AGE] year-old female with admission date 10/06/23.Record review of Resident #1's history and physical dated 10/10/25 revealed the resident's following medical history: Venous Insufficiency (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.

Based on interview and record review, the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation for 2 of 10 employees (CNA A and CNA B) reviewed for annual employee misconduct registry and nurse aide registry screenings, in that: The facility had failed to complete annual employee misconduct registry and annual nurse aide registry screenings for CNA A and CNA B. This failure could place residents at risk for abuse, neglect, exploitation, and misappropriation of property. The findings included:-Record review of facility's policy undated on Abuse, Neglect and Exploitation revealed, Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The components of the facility abuse prohibition plan include Screening-Potential employees will be screened for a history of abuse, neglect, exploitation, or…

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 environment remained as free of accidents and hazards as possible, and each resident received adequate supervision to prevent accidents for 2 (Resident #2 and Resident #12) of 5 residents reviewed for quality of care.1. The facility failed to ensure the call light was within reach, assist bars were in place, and the bedside table was positioned away from Resident #2 on 8/28/25.2. The facility failed to ensure an PT/OT evaluation was completed for Resident #12, who required an assessment for assist bars to support bed mobility.These failures could place residents at risk for falls, injuries, loss of independence, and unmet care needs, which may result in a decline in overall health, safety, and quality of life. Findings included: 1. Record review of Resident #2's face sheet dated 9/11/25 revealed [AGE] year-old male was admitted to the facility on [DATE]. Record review of Resident #2's quarterly MDS assessment dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure sufficient nursing staff possess the competencies and skill sets necessary to provide nursing services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being for 1 of 1 staff member (RN C) reviewed for nursing services. 1. The facility failed to ensure RN C followed the facility's policy on blood sugar checks for Resident #6 by delegating the task to Certified Nurse Aide.2. The facility failed to ensure RN C administered injections according to the facility's policy and procedures to Resident #7.These failures could place residents at risk of being cared for not receiving nursing services by adequately trained and licensed staff, which could result in injury and infection. Findings included:Resident #6 -Review of Resident #6's admission Record, dated 09/10/25, revealed resident was admitted to the nursing facility on 06/06/25. -Review of History & Physical dated on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents are free of any significant medication errors for 1 (Resident #6) of 2 residents reviewed for pharmaceutical services.-The facility failed to administer insulin to Resident #6 according to physician orders.-The facility failed to ensure LVN D administered insulin to Resident #6 according to Manufacturer's Specifications. This deficient practice could place residents at risk of inadequate therapeutic outcomes, increased adverse side effects, and a decline in health.The findings include: -Review of Resident #6's admission Record, dated 09/10/25, revealed resident was admitted to the nursing facility on 06/06/25. -Review of History & Physical dated on 06/11/25 for Resident #6 revealed, [AGE] year-old male with history of dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), delusional disorder (is a type if mental health condition in which a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials, which included the state survey agency, in accordance with State law through established procedures for 1 of 3 residents (Residents #10) reviewed for misappropriation of property. The facility failed to report to the State Survey Agency when Resident #10 reported to the facility that his wallet that had his SS card, ID, approximately $180, and a check book was missing on 3/28/25. This failure could place residents at risk…

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 treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 7 of 15 residents reviewed for residents' rights, in that: -In the memory care unit, facility failed to serve 7 of 15 residents their meals at the same time as their tablemates, causing them to watch their tablemates eat while they waited up to 30 minutes for their meal. This failure could affect residents' self-esteem and dignity. The findings include: During an Observation on 1/27/25 at 11:30 AM, residents were observed sitting in dining area located in the memory care unit. The first meal cart containing the resident's lunch trays arrived at the memory care unit at 12:19 PM. The second meal cart containing the resident's lunch trays is observed to arrive to the unit at 12:27 PM. There are 2 of 4 residents observed in the first table not served while the other residents in table are…

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 residents were made aware of the grievance process for 5 of 12 Residents who were reviewed for their knowledge of the facility's grievance procedures and grievance resolutions during resident council meeting. The facility did not ensure residents or staff were aware of the facility's formalized grievance process. This deficient practice could place the residents at risk for decreased quality of life and feelings of hopelessness. Findings include: A confidential interview with the Resident Council Group revealed the residents did not know how to file a grievance with the facility or who was responsible for receiving, reviewing and attempting to resolve grievances voiced by the residents. Five residents who were in attendance stated they had not been explained the process on how to file a grievance during their admission. Record review of the Resident Council Minutes dated from August 2024 to January 2025 demonstrated they had not discussed grievances Policies and Procedures or resident rights for 6 months. During 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 a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 2 (Resident #68 and Resident #142) of 2 residents observed for oxygen management. -Resident #68 utilized oxygen in his room and did not have an oxygen sign posted outside of the room. -Resident #142 utilized oxygen in her room and did not have an oxygen sign posted outside of the room. These failures could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health and at risk of fire hazards by not posting oxygen signs outside the residents' rooms. Findings include: Resident #68 Record review of Resident #68's face sheet dated 01/31/25 revealed Resident #68 was admitted on [DATE] to the facility. Record review of Resident #68's History and physical dated 08/27/24 revealed an [AGE] year-old male diagnosed with unspecified dementia with unspecified severity,…

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 1 (Resident #26) of 4 reviewed for medication administration; 4 (Halls 400-800) of 7medication carts reviewed for controlled substances; 1 of 2 medication room reviewed for storage of medications. 1. -The facility failed to ensure Licensed Staff H signed the Controlled Drugs-Audit Record form after counting and verifying that all controlled substances in the medication cart had been accounted for with the off- going nurse at the change of shift. 2.- -The facility failed to ensure Licensed Staff G signed the individual control drug record for resident #26 after administering controlled medication. 3. The facility failed to ensure licensed staff (6 am -2pm) signed the temperature log for vaccines/ medications after verifying correct refrigerator…

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 pharmaceutical services that assured the accurate acquiring, receiving, dispensing, safe and secure storage of medications for 4 of 7 nurse carts checked for medication storage; 1 of 1 treatment carts checked for storage of supplies. -The facility failed to ensure liquid medication stored in medication carts on three halls (300, 700 and 800) did not have dried drippings on the sides of the bottles. - The facility failed to ensure bottle of Betadine stored in the treatment cart was free of dried drippings. These failures could affect residents that received medications at the facility by placing them at of risk cross contamination. The findings include: Medication cart 800 Hall In an observation and interview on 01/29/25 11:35 AM with LVN G revealed the medication cart to have a bottle of ProStat with dried drippings on side of bottle. Per LVN H she states that she was trained to have bottles clean after each time she pours out medication. She stated the risk of having dirty bottles in the cart is…

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 foods which were palatable, attractive, and at an appetizing temperature for 1 of 1 meal observed for food preparation. (lunch 01/28/25) The facility did not serve food at an appetizing temperature for the lunch pureed, regular, and mechanical soft meals. The pureed diet fried zucchini and Albondiga (meatball) soup were below acceptable hot food temperature of 135 F or higher. The regular diet fried zucchini was below acceptable hot food temperature of 135 F or higher. The mechanical soft diet fried zucchini and Albondiga (meatball) soup were below acceptable hot food temperature of 135 F or higher. This failure could place residents who consumed food prepared in the kitchen at risk for reduced meal satisfaction and diminished nutritional intake. Findings included: During an observation and interview on 1/28/25 at 1:35 PM the CDM Interim stated he forgot his thermometer for temperature readings of sampling trays. At 1:38 PM CDM returned to conference room with thermometer and stated he forgot 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 observation, interview and record review the facility failed to ensure residents were provided services with reasonable accommodation of needs and preferences for 1 of 13 residents (Resident #24). Resident call lights were not kept within reach for 1 resident (Resident #24). This failure placed residents at risk of having needs unmet when they are unable to contact staff. Findings included: Record review of Resident #24's face sheet dated 01/29/25 revealed Resident #24 was admitted on [DATE] to the facility. Record review of Resident #24's History and physical dated 05/08/24 revealed an [AGE] year-old female diagnosed with generalized muscle weakness, unspecified abnormalities of gait and mobility, lack of coordination and failure to thrive. Record review of Resident #24's quarterly MDS dated [DATE] revealed an [AGE] year-old female diagnosed with coronary artery disease (a type of heart disease involving the reduction of blood flow to the cardiac muscle), hypertension, renal insufficiency (a condition…

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 medical records were maintained on each resident that were complete and accurately documented for 2 (Resident #3 and Resident #12) of 14 residents reviewed for administration. -The facility failed to document in Resident #3's MAR/TAR medical records, a behavioral incident that was being tracked on the MAR/TAR. - The facility failed to document in Resident #12's MAR/TAR medical records, a behavioral incident that was being tracked on the MAR/TAR. These failures could place residents at risk of not receiving needed services or errors in treatment based on incorrect information. Findings included: Resident #3: Review of Resident #3's admission Record dated 11/18/2024, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Review of Resident #3's H&P dated 02/09/2024, revealed diagnoses of dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), mood affective disorder…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews, the facility failed to provide appropriate treatment and services to prevent urinary tract infections for one resident (Resident #3) of three residents reviewed for catheter care. -Resident #3's catheter drainage collection bag was lying on the floor. This deficient practice could affect residents with catheters and could result in cross contamination of germs and could result in a urinary tract infection (an infection in any part of the urinary system). The findings included: Review of Resident #3's admission Record dated 07/25/2024, revealed an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #3's diagnoses included: obstructive and reflux uropathy (disorder of the urinary tract that occurs due to obstructed urinary flow and can be either structural or functional), and benign prostatic hyperplasia with lower urinary tract symptoms (needing to urinate frequently, a weak urine stream, and leaking or dribbling of urine). Review 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 ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 1 (Resident #3) of 4 residents observed for oxygen management. Resident #3 was on oxygen and did not have oxygen signs posted outside his bedroom. This failure could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health; and place them at risk of an unsafe environment which could lead to accidents and injuries. Findings included: Review of Resident #3's admission Record dated 07/25/2024, revealed an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #3's diagnoses included: acute upper respiratory infection (contagious infection of upper respiratory tract), and obstructive sleep apnea (intermittent airflow blockage during sleep). Review of Resident #3's quarterly MDS dated [DATE], revealed the resident was rarely/never understood.…

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 medical records, in accordance with accepted professional standards and practices, were maintained on each resident that were accurately documented for 1 (Resident #3) of 8 residents reviewed for medical records. -The facility failed to ensure a physician's order for PRN oxygen for Resident #3 was documented. This failure could lead to errors in treatment based on incorrect information. Findings included: Review of Resident #3's admission Record dated 07/25/2024, revealed an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #3's diagnoses included: acute upper respiratory infection (contagious infection of upper respiratory tract), and obstructive sleep apnea (intermittent airflow blockage during sleep). Review of Resident #3's quarterly MDS dated [DATE], revealed resident was rarely/never understood. Review of Resident 3's progress notes dated 7/14/2024 at 5:35 a.m., written by LVN H reflected in part, chest x-ray…

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 assessments accurately reflected the resident's status for 2 of 16 residents (Resident #8 and Resident #16) reviewed for accuracy of assessments. The facility failed to ensure Resident #8's MDS accurately reflected his g-tube status. The facility failed to ensure Resident #16's MDS accurately reflected his behaviors. These failures could place residents at risk for not receiving care and services to meet their physical needs and promote feelings of well-being and quality of life. Findings included: Record review of Resident #8's face sheet dated 05/29/24 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnosis of altered mental status (change to your average mental function). Record review of Resident #8's quarterly MDS assessment dated [DATE] revealed a BIMS score of 11, indicating he was cognitively intact. The assessment did not account for enteral feeding. Record review of Resident #8's care…

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 implement care interventions in accordance with each resident's written plan of care for 1 of 16 residents (Resident #8) whose care was reviewed. The facility failed to implement behavior focused area and interventions for Resident #8's pulling on drainage. This failure could affect residents monitoring that could result in injury. Findings included: Record review of Resident #8's face sheet dated 05/29/24 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of altered mental status (change to your average mental function). Record review of Resident #8's quarterly MDS assessment dated [DATE] revealed a BIMS score of 11, indicating he was cognitively intact. Record review of Resident #8's care plan did not address behavior of pulling accordion drain. Record review of Resident #8's progress notes dated 04/21/24 read in part returned from being out on pass with [RP], reported resident was pulling on accordion drain,…

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 implement their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 7 (Resident #1) residents reviewed for abuse. The facility failed to immediately suspend CNA B after CNA A reported suspected roughness when CNA B was providing care to Resident #1. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: Record review of Resident #1's face sheet dated 4/23/24 revealed an [AGE] year-old female who was admitted to the facility 08/07/2020 with diagnoses of dementia, Alzheimer's, acute pain due to trauma, and anxiety. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed her cognitive level was severely impaired and had behavior symptoms like verbal/vocal symptoms like screaming, disruptive sounds. Record review of Resident #1's care plan revealed…

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 ensure residents the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 3 (Residents #72, #200, and #54) of 26 residents reviewed for reasonable accommodation of resident needs. The facility failed to ensure that Residents #72, #200 and #54's call lights were where they could be reached by the resident. This failure put residents at increased risk of not having their needs met on a timely basis and at increased risk of falls. Findings included: Resident #72 Record review of Resident #72 ' s face sheet dated 12/01/2023 revealed he was [AGE] years old and was admitted to the facility on [DATE]. He was in the Memory Support unit. Record review of Resident #72 ' s history and physical dated 05/11/2023 revealed he had diagnoses including dementia, major depressive disorder, and history of malignant neoplasm of prostate (prostate cancer). Record review of Resident #72 ' 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 interview, and record review, the facility failed to develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 3 of 6 residents (Resident #18, Resident #106, and Resident #118) reviewed for care plans. - The facility failed to implement an accurate code status in Resident #18 ' s care plan. -The facility failed to implement COVID diagnosis protocols in Resident #106 ' s care plan. -The facility failed to develop and implement a comprehensive person-centered care plan for Resident #118 ' s behaviors of going into other residents' rooms and take their personal belongings. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed to address their needs. Findings included: Resident #18…

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 that assured the accurate acquiring, receiving, dispensing, safe and secure storage of medications for 3 of 4 medications carts (Hall 300, 400 and 600) reviewed for medication storage and 1 (#59) of 6 resident reviewed for medication administration . -The facility failed to keep medication drawer free of dust and paper particles in the 400 Hall. -The facility failed to store medications separately according to routes of administration in the 400 and 600 halls. -The facility failed to ensure liquid medication stored in medication cart did not have dried drippings on the sides of the bottles in the 300 Hall. -The facility failed to accurately document the prescribed dose in physician orders and medication administration for resident #59. The findings include: Medication Carts: 600 Hall An observation and interview on 11/30/23 at 5:29 PM with LVN L revealed a bottle of thickener was stored with external…

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 food was prepared in a form designed to meet individual needs for 8 of 8 residents reviewed with diet orders for pureed texture. -Cook #2 did not follow established facility recipes when preparing pureed foods. These failures placed residents who received pureed diets at risk of inadequate nutrition and weight loss. Findings include: During an observation and interview on 11/30/23 at 12:53 PM through 1:26 PM with [NAME] #2 revealed he was going to prepare pureed Food for 8 residents that were getting pureed Diets. The [NAME] did not measure eight portions of French Fries according to recipe. He poured 5 ½ cups of French Fries into blender, added heavy cream and hot water. [NAME] stated I just eyeball the amount of French Fries and liquid that I put into the blender to get an ice-cream texture. The [NAME] poured the French fries into a metal container, covered with saran wrap and foil paper and placed in the oven at 200 degrees Fahrenheit. The [NAME] had the recipe book opened but was not following 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 in 1 of 1 kitchen reviewed for kitchen sanitation and food storage. -The facility failed to store foods in walk-in refrigerator in sealed containers. -The facility failed to ensure pureed food were not prepared at 8:00 AM and kept in oven until meal service started. -The facility failed to maintain 3 large ingredient storage bins free of white powder residual, food particles and grease build-up. -The facility failed to keep the kitchen equipment clean and free of food particles. -The facility failed to ensure the three-compartment sink sanitizing chemicals were within acceptable range. -The facility failed to ensure the Dishwashing Machine ' s temperature was within acceptable range. These failures could affect residents by placing them at risk of food borne illnesses. Findings include: Walk-in Refrigerator: During an observation and interview on 11/28/23 at 8:12 AM with Dietary Director revealed 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 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 in 1 of 6 (500 Hall) hallways,1 soiled container (800 Hall) of 2 containers, and for 3 (Resident #74, #200 and Resident #128) of 29 reviewed for infection control. - The facility failed to ensure staff followed infection control practices when passing out meal trays during dining service. - The facility failed to ensure a soiled linen container was properly closed. - The facility failed to ensure that Resident #74 ' s urinary catheter was not touching the floor. - The facility failed to ensure that Resident #200 ' s urinary catheter was not touching the floor. -The facility failed to follow Standard Precautions related to use of personal protective equipment when administering nebulizer medication These deficient practices could…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that a resident who is fed by enteral means receives the appropriate treatment and services for 1 (Resident #43) of 2 residents reviewed for enteral feeding. -The facility failed to ensure that Resident #43 ' s HOB was maintained according to physician orders. This failure could place residents receiving enteral feedings at risk of aspiration (when food or liquid goes into the lungs or airway). Findings include: Record review of Resident #43 ' s face sheet dated 11/30/2023 revealed an [AGE] year-old male with an admission date to the facility of 03/12/2016. Record review of Resident #43 ' s History and Physical dated 11/06/2023 revealed a diagnosis of dysphagia (difficulty swallowing) with PEG (feeding tube) in place. Record review of Resident #43 ' s Quarterly MDS assessment dated [DATE] revealed the BIMS score could not be assessed due to Resident #43 not understanding the assessment. It also revealed a feeding tube was in place…

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

Based on observation, interview, and record review, the facility failed to ensure all drugs and biological were stored in locked storage area and to limit access to authorized personnel for 1 of 1 medication rooms reviewed for medication storage;and 1of 4 medication carts reviewed for medication storage and handling of medications in accordance with manufacturers' specifications. -The facility failed to ensure nurses did not store their personal belongings in the medication room. -The facility failed to date Glucometer Normal/High Control Solutions and Glucose Test Strips when opened according to manufacturer recommendations in the 600 Hall. These failures could affect residents that received medications from the facility. The findings include: 600 Hall An observation and interview on 11/30/23 at 5:29 PM with LVN L revealed Glucometer Normal/High Control Solutions and Glucose Test Strips were not dated when opened according to manufacturer recommendations. The manufacturer box that contained Glucometer Normal/High Control Solutions revealed manufacturer's specifications on side 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 provide chopped meat for one (Resident #69) of 26 residents reviewed food prepared in a form to meet individual needs. 1. The facility failed to ensure Resident #69 was served chicken nuggets of the prescribed consistency. 2. The facility failed to ensure Resident #69 was assessed quarterly for changes in chewing and swallowing ability. These failures placed residents who received chopped foods at risk of inadequate nutrition and weight loss. Findings include: Resident #69 Record review of Resident # 69 ' s face sheet dated 12/01/2023 revealed he was [AGE] years old and was admitted to the facility on [DATE] and was residing in the Memory Support unit of the facility. Record review of Resident # ' 69 ' s history and physical dated 09/20/2023 revealed he had diagnoses including Alzheimer ' s disease, and legal blindness. He was 68 inches tall and weighed 159 pounds and appeared frail and cachectic (having loss of weight and muscle mass).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 2 (Resident #301 and Resident# 33) of 2 residents observed for environment. The facility failed to ensure Resident #301 and Resident #33, who were on oxygen in Rooms 808 & 409, had oxygen signs posted outside of their bedrooms. This failure could place residents on oxygen therapy at risk of harm and exposed to a fire hazard if staff and visitors are not aware of oxygen present. Findings include: Resident #301 Record review of Resident #301 ' s face sheet dated 11/30/23 revealed admission on [DATE] to the facility. Record review of Resident #301 ' s hospital history and physical dated 11/10/23 revealed a [AGE] year-old male diagnosed with chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), and shortness of breath. Record review of Resident #301 ' s admission MDS assessment dated [DATE] revealed intact…

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.