Edgemere Estates

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident receives care to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates they were unavoidable and a resident with pressure ulcers receives necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing for 1 (Resident #3) of 5 residents reviewed for pressure ulcers/wounds. The facility failed to provide wound care for Resident #3's pressure ulcer stage 3 to the left buttock on 02/01/25 and 02/02/25. This deficient practice could place residents at risk for worsening pressure injuries, pain, and a decline in health. Findings include: Resident #3 Record review of Resident #3's face sheet dated 02/05/25, revealed, admission on [DATE] to the facility. Resident #3 discharged on 02/04/25 Record review of Resident #3's hospital history of physical dated 03/22/24, revealed, a [AGE] year-old male diagnosed with Type 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 interview and record review the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care within 48 hours of a resident's admission for 1 of 6 residents (Resident #3) reviewed for baseline care plan. Resident #3 did not have a baseline care plan developed within 48 hours of admission that addressed his services that were being provided. This failure could place newly admitted residents at risk of not receiving the care and services and continuity of care. Findings include: Record review of Resident #3's face sheet dated 02/05/25, revealed, admission on [DATE] to the facility. Record review of Resident #3's hospital history of physical dated 03/22/24, revealed, a [AGE] year-old male diagnosed with Type 2 Diabetes Mellitus and pressure ulcer. Record review of Resident #3's admission MDS dated [DATE], revealed, no impairment in cognition…

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 an effective discharge planning process for 1 (Resident #3) of 3 residents reviewed for discharges. The facility failed to ensure Resident #3 had a safe discharge when he left AMA to his home. This failure could place residents at risk of inappropriate transfers and diminished continuity of care. Findings included: Record review of Resident #3 ' s face sheet dated 02/05/25, revealed, admission on [DATE] to the facility. Record review of Resident #3 ' s hospital history of physical dated 03/22/24, revealed, a [AGE] year-old male diagnosed with Type 2 Diabetes Mellitus and pressure ulcer. Record review of Resident #3 ' s admission MDS dated [DATE], revealed no impairment in cognition with a BIMS score of 13 and the resident was able to recall and make daily decisions. Resident #3 was coded for risk of pressure ulcers and unhealed pressure ulcers. Resident #3 was coded for stage 3 pressure ulcer. Resident #3 was to have pressure…

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 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 (Residents #3) of 4 reviewed for medication administration. The facility failed to administer on 02/01/25, to Resident #3's medication of Ciprofloxacin HCL oral tablet 500 mg which to given two times a day for infection and was not given in the morning. The facility failed to administer on 02/01/25, to Resident #3's medication of Sulfamethoxazole-Trimethoprim oral tablet 800-160 mg by mouth two times a day for infection and was not given in the morning. The facility failed to administer on 02/01/25 and on 02/02/25, to Resident #3's medication of Spironolactone oral tablet 25 mg by mouth one time a day for prophylaxis for both days. This deficient practice could place the residents at risk of not receiving medications as ordered by the physician.…

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 of 3 residents (Resident #3) reviewed for medical records. The facility failed to ensure Resident #3's was having incontinence care was documented by the facility. This deficient practice could place residents at risk of not receiving needed services although services are stated they are being provided. Finding included: Record review of Resident #3's face sheet dated 02/05/25, revealed, admission on [DATE] to the facility. On 02/04/25, Resident #3 was discharged from the facility. Record review of Resident #3's hospital history of physical dated 03/22/24, revealed, a [AGE] year-old male diagnosed with Type 2 Diabetes Mellitus and pressure ulcer. Record review of Resident #3's admission MDS dated [DATE], revealed, no impairment in cognition with a BIMS score of 13 and the resident was able to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and time frames to meet a resident's medical and nursing needs and described the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 (Resident #3, Resident #8, and Resident #13) of 3 residents reviewed for care plans. The facility failed to develop a comprehensive person-centered care plan regarding oxygen therapy for Resident #3, #8, and #13. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services. Findings include: Resident #3: Record review of Resident #3's admission Record, dated 01/29/2025, reflected a [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE]. Record review of Resident # 3's History and Physical dated 03/16/2023, revealed diagnoses to include dementia…

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 the observation, interview, and record review, the facility failed to ensure that the residents environment remains free of accidents hazards as possible and each resident receives adequate supervision to prevent accidents for 1 (Resident #1) of 2 residents reviewed for accidents and supervision. The facility failed to ensure CNA B secured the brakes on a mechanical lift when lowering Resident #1 to bed. This failure could place residents at risk for falls or injury. The findings included: Record review of Resident #1's face sheet dated 1/2/25 revealed a [AGE] year-old female who was re-admitted to the facility on [DATE] with diagnoses of vascular dementia (common type of dementia that happens when there's decreased blood flow to areas of your brain), muscle weakness, and hemiplegia (paralysis on one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infraction (is a type of stroke that occurs when a blood vessel in the brain is blocked, causing damage to brain tissue).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet a resident's medical and nursing needs and described the services to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 2 (Resident #4 and Resident #7) of 8 residents reviewed for care plans. The facility failed to develop a comprehensive person-centered care plan for Resident #4 who required mechanical lift transfer. The facility failed to develop a comprehensive person-centered care plan for Resident #7 who no longer required a Hoyer lift transfer and was a 2 person assist transfer. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and not having personalized plans developed to address their needs. Findings included: Record review of Resident #4's face sheet 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 implement written policies that prohibit and prevent abuse for 1 (Resident #7) of 8 residents reviewed for abuse. The facility failed to implement their abuse policy when they failed to immediately suspend CNA B after Resident #7's RP reported a physical restraint allegation. This failure could place residents at risk of potential continued mistreatment and abuse. Findings included: Record review of Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating policy dated April 2021 read in part Investigating Allegations: 6- any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. Record review of Resident #7's face sheet dated 9/18/24 revealed a [AGE] year-old female re-admitted to the facility on [DATE] with diagnoses of anxiety and dementia. Record review of Resident #7's quarterly MDS assessment dated [DATE] revealed a BIMS score of 00, indicating she 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 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 1 (Resident #4 ) of 8 residents reviewed for transfers. The facility failed to ensure Lead CNA placed breaks on the mechanical lift when lifting Resident #4 from her wheelchair and lowering to her bed. This failure could place residents at risk for falls or injuries. Findings included: Record review of Resident #4's face sheet dated 09/18/24 revealed an [AGE] year old female who was re-admitted to the facility on [DATE] with diagnoses of muscle weakness, dementia, and other abnormalities of gait and mobility. Record review of Resident #4's history and physical dated 08/21/24 revealed [AGE] year-old female coming back from local hospital after being treated for bradycardia (slow heart rate), hypotension (low blood pressure), and right/ankle fracture. Record review of Resident #4's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 4 (Resident #5, #9, #10, and #11) of 6 residents observed for oxygen management. -Resident #5, Resident #9, Resident #10, and Resident #11 were on oxygen and did not have oxygen signs posted outside their bedrooms. These failures could place visitors, staff, and others at risk of not knowing oxygen was being used in the room and to not smoke. Findings included: Resident #5: Review of Resident #5's face sheet dated 07/19/2024, revealed a [AGE] year-old female who was admitted to the facility on [DATE], with diagnoses that included shortness of breath, chronic obstructive pulmonary disease (group of lung diseases that block airflow and make it difficult to breathe), and emphysema (lung condition that causes shortness of breath). Review of Resident #5's initial MDS assessment dated [DATE], revealed Resident #5 had 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 provide reasonable accommodations of needs for 1 (Resident #2) of 6 residents reviewed for call light button placement. -The facility failed to ensure that Resident #2's call light was within her reach. These failures could place residents at risk of not being able to have their needs met. Findings included: Review of Resident #2's Face Sheet dated 07/10/2024, revealed a [AGE] year-old female, with an admission date of 08/26/2016. Resident #2's diagnoses included: weakness, functional quadriplegia (complete immobility due to severe disability or frailty from another medical condition without injury to the brain or spinal cord), neuromuscular dysfunction of bladder (nerves and muscles don't work together very well causing lack of bladder control), depression (mood disorder that causes a persistent feeling of sadness and loss of interest), unsteadiness on feet, pain, and history of falling. Review of Resident #2'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care within 48 hours of the resident's admission for 1 of 5 residents (Resident #19) whose records were reviewed for baseline care plans. The facility failed to ensure Resident #1 had a baseline care plan developed and implemented within 48 hours upon admission on [DATE]. The facility failed to ensure Resident #1's baseline care plan addressed the resident as being a high fall risk. This failure could place the residents at risk for not receiving care and services required to meet their individual needs from the date and time they were admitted to the facility. Findings included: Record review of Resident #1's Face Sheet, dated 4/30/2024, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Alzheimer's disease,…

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 has a right to a dignified existence for 1 resident (Resident #2) out of 14 reviewed for rights to a dignified existence in that: Therapy Staff G told Resident #2 she should be working and not talking, and that tape would be put on her mouth if she continued to talk, leaving Resident #2 feeling embarrassed, and reluctant to talk to anyone while involved in therapy. This failure could result in residents feeling embarrassed, reluctant to talk and reluctant to engage in therapy, affecting their progress in achieving their goals for rehabilitation. Finding include: Closed record review of Resident #2's face sheet dated 03/27/2024 revealed that she was [AGE] years old, was admitted to the facility on [DATE] and discharged home on [DATE]. Closed record review of Resident #2's history and physical dated 02/22/2024 revealed she had a total left knee replacement on 02/15/2024 and had her gallbladder removed on 02/17/2024. Treatment…

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 provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public in four of four halls reviewed for condition of handrails. The facility failed to ensure that the handrails throughout the facility did not have the paint worn off them. This failure could put residents at risk of feeling a decreased sense of well-being, and at increased risk for splinters because of the poorly maintained condition of the handrails. Findings included: Handrails: Observation on 03/14/2024 at 2:30 PM of the handrails in the 100 and 200 halls revealed that the brown paint on all handrails was worn through and that the wood showed through the paint. Observation of the handrails at hall 300 on 3/13/2024 at 3:42 PM revealed that the brown paint on all handrails along the hallway was scraped and worn and wood showed through the paint. Observation of the handrails at hall 400 on 3/13/2024 at 3:46 PM revealed that the brown paint on all handrails along the hallway was scraped and worn and wood…

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 post in a form and manner accessible to residents, resident representatives contact information including telephone numbers for Long Term Care Ombudsman program for residents interviewed in a confidential group meeting. The facility failed to ensure the Ombudsman program information was posted in an area accessible for residents who required the use of wheelchair. This failure placed residents at risk of not being informed about the Ombudsman Program. Findings included: During a confidential group meeting on 3/12/24 at 9:30 am, residents who were wheelchair bound stated they did not know where to find the local Ombudsman information. During an observation and interview on 3/14/24 at 11:08 am, the Administrator stated the Ombudsman number was posted in the 100 hallway. The Administrator stated the Ombudsman number posting may have been too high for residents in wheelchairs to see. The Administrator stated he would move it down and stated the posting had been there for years and had not received complaints in…

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

Based on observation, interview and record review the facility failed to ensure that residents had the right to examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility; and were posted in a place readily accessible to residents, and family members and legal representatives of residents for residents interviewed in a confidential group meeting. The facility failed to have the survey manual readily accessible for the residents to view the survey. This failure could place residents at risk of not being able to fully exercise their rights to be informed of the facility's survey history. Findings included: During a confidential group meeting on 3/12/24 at 9:30 am, residents stated they did not know where or how to access the survey results in the facility. During an observation on 03/13/24 at 9:00 am, survey results were in the lobby area. Survey results signs were posted in hallways near the nurse's station where it said it was in nurses' station and lobby area. A Code 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 immediately notify and consult with the resident ' s physician when there was a significant change in a resident ' s physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 21 (Resident #283) residents reviewed for change in condition. The facility failed to immediately inform NP/MD of Resident #283 change in condition addressing her behaviors towards wearing her Prevalon boots as orderd by the physician for healing of pressure ulcers. This failure placed Resident #283 at risk of serious decrease in health related to delayed treatment of healing her pressure ulcers. Findings included: Record Review of Resident #283 face sheet dated 03/14/2024 revealed she was an [AGE] year old and was initially admitted to the facility on [DATE]. Record Review of Resident #283 quarterly MDS dated [DATE] revealed she has been accounted for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the prompt resolution of all grievances to include ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns, a statement as to whether the grievance was confirmed, any corrective action or to be taken by the facility as a result of the grievance, and the date when the decision was issued for 2 of 6 (Resident #383 and Resident #61 ) reviewed for resident rights. The facility failed to initiate and complete a grievance for Resident #383's family who complained of Resident #61. The facility failed to initiate and complete a grievance for Resident #61 who did not want to move rooms and room change notice was not provided. These failures could place residents at risk for grievances not being addressed or resolved promptly. Findings…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to implement their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 6 (Resident #61) residents reviewed for abuse. The facility failed to implement their abuse policy on reporting to State Office Resident #61's allegation of the Administrator slapping hand when forced out of her room. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings include: Record review of Resident #61's face sheet dated 3/14/24 revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #61's history and physical dated 01/17/2024 revealed diagnoses of anxiety, dementia, and other recurrent depressive disorders. Record review of Resident #61's quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, her cognitive was intact. Record review of Resident #61's care plan…

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 implement their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 6 (Resident #61) residents reviewed for abuse. The facility failed to ensure Resident #61's allegation of the Administrator slapping hand when forced out of her room was thoroughly investigated. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings include: Record review of Resident #61's face sheet dated 3/14/24 revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #61's history and physical dated 01/17/2024 revealed diagnoses of anxiety, dementia, and other recurrent depressive disorders. Record review of Resident #61's quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, her cognitive was intact. Record review of Resident #61's care plan dated 1/16/24 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 interview and record review the facility failed to ensure that assessments accurately reflected residents ' status for 1 (Resident # 30) of 21 residents reviewed for accuracy of assessment. The facility failed to ensure that Resident #30 ' s MDS reflected her refusal to use her C-PAP machine (machine that uses air pressure to help breathing). This failure put residents at risk of poor sleep, increased incidence of sleep apnea (sleep disorder where breathing stops and starts). Findings included: Record review of Resident #30 ' s face sheet dated 03/14/2023 revealed she was [AGE] years old and was initially admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #30 ' s History and Physical dated 02/21/2023 reveled she had diagnoses including COPD (Chronic Obstructive Pulmonary disease - a condition where airways are narrowed, and breathing is difficult); Chronic respiratory failure with hypoxia (a condition where airways are narrowed or damaged and there is reduced oxygen…

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 resident with pressure ulcers received necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing for one (Resident #283) of five residents reviewed for treatment to address pressure ulcers. The facility failed to ensure that Resident #283 wore Prevalon boots while in bed as per physician ' s orders. This failure placed Resident #283 at risk of serious decrease in health related to delayed treatment of healing her pressure ulcers. Findings included: Record Review of Resident #283 face sheet dated 03/14/2024 revealed she was an [AGE] year-old and was initially admitted to the facility on [DATE]. Record Review of Resident #283 quarterly MDS dated [DATE] revealed she has been accounted for unstageable pressure ulcers. Record Review of Resident #283 ' s care plan dated 03/01/2024, revealed Resident #283 presents with an unstageable pressure wound of the right heel 2x2cm and ,.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with the comprehensive person-centered care plan, the residents' goals and preferences for one (Resident #30) of four residents reviewed for provision of respiratory care. Resident #30 was not assisted in putting on her CPAP mask every night as per physician ' s orders. This failure could result in residents having increased difficulty sleeping, decreased sleep quality, and increased instances of sleep apnea (a sleep disorder where breathing stops and starts). Findings included: Record review of Resident #30 ' s face sheet dated 03/14/2023 revealed she was [AGE] years old and was initially admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #30 ' s History and Physical dated 02/21/2023 reveled she had diagnoses including COPD (Chronic Obstructive Pulmonary disease - a condition where airways are narrowed, and breathing is difficult);…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, safe and secure storage of medications for 3 of 6 medications carts (Hall 200, 300 and 400) reviewed for medication storage and 4 (#283, #51, #29, & #30) of 14 residents reviewed for medication administration. -The facility failed to have physician ' s orders that documented prescribed amount of water for G-Tube flush before and after medication administration for Resident #283. -The facility failed to administer prescribed medications according to physician ' s orders for Resident #30. -The facility failed to administer Nebulizer Medications according to pharmacy policies and procedures for Resident #29. - The facility failed to administer prescribed medications according to manufacture specifications for Residents #40 and #51. - The facility failed to ensure Licensed Staff LVN O and LVN Q did not sign off on the Controlled Drugs-Count Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure that irregularities identified by reviews of resident's drug regimens by a licensed pharmacist were reported to the attending physician, the facility's medical director, and director of nursing, and that these reports were acted upon for 1 (Resident #40) of 14 residents whose drug regimens were reviewed. The consulting pharmacist failed to act upon the dispensing pharmacist recommendations to administer prescribed medications according to manufacture specifications. This failure placed residents at risk of not receiving medications according to manufacturer specifications placing them at increased risk of adverse drug effects and decline in their health status. The findings included: Resident #40 Observation on 03/13/24 3:20 PM during Medication Pass Observation with Medication Aide P stated she was going to administer Spironolactone 25 mg give one tablet by mouth bid. Pharmacy Label documented: Take with food or milk. Medication…

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 ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record for 3 (Resident #65, Resident #24, and Resident #51) of 5 residents reviewed for unnecessary medications. Resident #65 was prescribed Seroquel/quetiapine (an antipsychotic) to treat depression. Resident #51 was prescribed Olanzapine (an antipsychotic) to treat major depression. Resident #24 was prescribed Seroquel/quetiapine (an antipsychotic) to treat restlessness and agitation. This failure put residents at unnecessary risk of side effects from psychotropic medications. Findings included: Resident #65 Record review of Resident #65 ' s face sheet dated 03/14/2024 revealed she was [AGE] years old, was initially admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #65 ' s History and Physical dated 05/24/2023 revealed she…

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 keep 2 bottles of Dessert Sauce stored on a metal rack in the dry storage room free of dried drippings around the lids. -The facility failed to keep a plastic bottle of Baking Soda free of white residual around sides of bottle. -The facility failed to keep a gallon of Vanilla, a gallon of Soy Sauce, a gallon of Worcestershire Sauce, and a gallon of Imitation Maple Syrup Sauce stored on metal storage rack in the dry storage room free of grease build up, white powder residual, and dried dripping on sides of containers. -The facility failed to discard perishable foods stored, in the dry storage area. Potatoes were wrinkled, soft to touch, mushy, and sprouting. -The facility failed to store an opened box of Corn Starch in a sealed container. -The facility failed to store foods in the refrigerator in sealed…

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 the observations, interviews, and record review the facility failed to dispose of garbage and refuse properly for 2 (Dumpsters #1, & #2) of 2 dumpsters reviewed for food safety requirements. -The facility failed to keep one of two plastic lids covered on Front Load Dumpster, making trash placed in dumpster visible. - The facility failed to keep the side metal door cover close on Side Load Dumpster, making trash placed in dumpster visible. This failure could place residents at risk of unsanitary conditions and risk for exposure to germs and diseases carried by insects and rodents. Findings included: Observation on 03/14/24 at 5:39 PM revealed Front Load Dumpster #1, half uncovered; there were cardboard boxes and plastic bags full of waste in dumpster; Side load dumpster was partially opened. Interview on 03/14/24 at 5:40 with the Maintenance Director revealed front door dumpster was used by the nursing department and side load dumpster was used by dietary staff. He stated that dumpsters should always be kept covered to prevent insects and rodents from getting into 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 interviews and record review the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 of 6 (Resident #61) of 6 reviewed for allegations of abuse. The facility failed to ensure the Administrator followed internal abuse policy, report allegations of abuse to State Office, and conduct thorough abuse allegation investigation. These failures could place all residents at risk of continued abuse by not immediately following the facility policy of abuse, neglect, exploitation, or misappropriation - reporting and investigating. Findings included: Record review of Resident #61's face sheet dated 3/14/24 revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #61's history and physical dated 01/17/2024 revealed diagnoses of anxiety, dementia, and other recurrent depressive disorders. Record…

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

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 3 (Resident #24, Resident #30, and Resident #61) of 21 residents reviewed for accuracy and completeness of clinical records. The facility failed to completely and accurately discontinue order provided to Resident #24 for puree diet. The facility failed to accurately document Resident #61 ' s allegation of a slap on the hand from the Administrator on her medical records. The facility failed to accurately document Resident #30 ' s use of her physician-ordered CPAP machine. These failures put residents at risk of not containing the proper nutrition's needed for a hospice patient, at risk of staff being unaware of resident ' s pattern of refusal of CPAP treatments, and at risk of staff being unaware of resident ' s allegations of abuse. Findings included: Resident #24 Record review of Resident #24 ' s…

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

Based on interviews and record review, the facility failed to maintain a quality assessment and assurance committee consisting at a minimum the required committee members for 13 of 14 meetings reviewed for QAPI. The facility did not ensure the MD, or a representative and Infection Preventionist attended QAPI meetings. This failure could place residents at risk for quality deficiencies being unidentified, no appropriate plans of action developed and implemented, and no appropriate guidance developed. Findings included: Interview on 03/14/24 at 10:23 AM, the DON revealed the facility held monthly QAPI meetings. The DON stated all department heads, and the Medical Director attended the QAPI meetings. The DON stated the Medical Director had only attended one QAPI meeting in 2023 and none in 2024. Record review on 03/14/24 10:28 AM with the DON of QAPI Signature Sheets for 2023 revealed the following: 02/16/23 Medical Director and/or designee did not attend QAPI meeting. 03/15/23 Medical Director and/or designee did not attend QAPI meeting; Infection Preventionist did not attend QAPI…

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 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 three of three hallways and 1 resident (Resident #283) of 14 residents observed for infection control practices during enteral feeding. -The facility failed to store contaminated resident equipment in the designated storage area. -The facility failed to store reusable water containers off the floor in the Therapy Room. -The facility failed to store supply boxes off the floor in storage rooms. -The facility failed to prevent cross contamination was not storing clean and dirty equipment on separate racks. Findings included: Linen Rack; Linen Hampers: Observation on 03/11/24 at 9:29 AM, revealed clean linen cart cover had a hole on the right side approximately the size of a nickel. Observation on 03/11/24 at 9:30 AM, 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 the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for one (Resident #37) of 21 residents reviewed for safe operating condition of patient care equipment and for 1 of 1 kitchen reviewed for safe operating equipment. -The facility failed to ensure that the mechanical lift (Hoyer) sling used to transfer Resident #37 was in good working order, resulting in a sling strap tearing, and Resident #37 falling to the floor. -The facility failed to keep the ice machine in safe operating condition. This failure could result in residents fearing transfers using a mechanical lift, and serious injury, including fractures. This failure could place residents at risk of foodborne illnesses. Findings included: Record review of Resident #37 ' s face sheet dated 03/14/2024 revealed he was [AGE] years old and was admitted to the facility on [DATE]. Record review of Resident #37 ' s quarterly MDS dated [DATE] revealed he…

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 resident with urinary incontinence, based on the resident ' s comprehensive assessment, the facility must ensure that the resident receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 5 (Resident #32) residents reviewed for urinary catheter. The facility failed to ensure Resident #32 ' s subpubic catheter was properly secured. This failure placed residents at risk of possible pain and trauma due to the catheter not being properly secured on the leg. Findings included: Record review of Resident #32 ' s history and physical dated 11/23/2023 revealed diagnoses of UTI (urinary tract infection), dementia, suprapubic catheter. Record review of Resident #32 ' s quarterly MDS assessment dated [DATE] revealed he had a BIMS of 3 (cognitively severely impaired) and had a dwelling catheter. Record review of Resident #32 ' s care plan dated 12/05/2023 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 interview and record review, the facility failed to ensure the right to receive written notice of a room change before the change was made for 1 of 6 (Resident #61) residents reviewed for right to receive written notification. The facility failed to provide Resident #61 a written notice of a room change before the resident was moved. This failure could place all residents at risk of being displaced without notice and/or reason and decrease of quality of life being in a new environment. Findings included: Record review of Resident #61's face sheet dated 3/14/24 revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #61's history and physical dated 01/17/2024 revealed diagnoses of anxiety, dementia, and other recurrent depressive disorders. Record review of Resident #61's quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, her cognitive was intact. Record review of Resident #61's care plan dated 01/16/24 revealed Resident #61 had history 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 each resident received adequate supervision and assistance devices to prevent accidents for 1 of 6 (Resident #3) residents reviewed for wheelchair maintenance. The facility failed to ensure Resident #3 right brake on his wheelchair was locking properly. This failure could place residents dependent on wheelchair at risk for falls and/or injury. Evidence includes: Record review of Resident #3's face sheet revealed a [AGE] year-old male who was readmitted on [DATE] with diagnoses of history of falling and dementia. Record review of Resident #3's MDS admission assessment dated [DATE] revealed a BIMS score of 14, he was cognitive intact. Record review of Maintenance log for August 2023 revealed no written report on Resident #3 wheelchair. Observation and interview on 08/30/23 at 2:45 pm, Resident #3 was in bed, he was alert and oriented to person, place, time, and event. Resident #3's wheelchair was at bedside and right brake handle 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 observation, 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 1 of 5 residents (Resident #3) reviewed for care plans in that: The facility failed to implement a comprehensive person-centered care plan for Resident #3 addressing her lack of trunk support. 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: Record review of Resident #3's face sheet dated 8/8/23 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Alzheimer's disease and dementia. Record review of Resident #3's quarterly MDS dated [DATE] revealed a BIMS score of 1, she was severely…

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 maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #2) of 5 residents reviewed for accuracy and completeness of records. The facility failed to completely and accurately document an incident report and neurological checks provided to Resident #2 post unwitnessed fall. This was determined to be past non-compliance at isolated potential for more than minimal harm due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the inspection. This deficient practice could put residents at risk of not receiving needed services although services are documented as having been provided. Findings include: Record review of Resident #2's face sheet dated 8/8/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses of falls and disorientation. Record review of Resident #2's progress note…

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 review, the facility failed to provide a therapeutic diet as prescribed by the attending physician for 1 of 7 residents(Resident #22 ) reviewed for therapeutic diets. The facility failed to ensure Resident #22 received mechanical soft and nectar thick diet and not receiving regular and thin liquids. This failure could affect residents who receive mechanical soft and nectar diets of aspiration and choking. Findings include: Record review dated 02/09/2023 at 1:05 p.m., of facility Face Sheet for a [AGE] year-old female Resident #22 who was admitted [DATE] and readmitted on [DATE]. Resident #22 is diagnosed with dysphagia (difficult or discomfort in swallowing). Observation on 02/07/2023 at 1:20 p.m , (Resident #22 family member called surveyor into Resident #22's room) Resident #22 was in her room laying in her bed elevated; turning red as she was trying to cough. Resident #22's eyes were closed. Residents' family member got up and began to pat her hard with her left…

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 the observations, interviews, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. 1. Food products in dry storage and in refrigerator were not correctly labeled, wrapped, or were expired. This failure could affect residents by placing them at risk of food borne illness. Findings include: Observation on 02/07/2023 at 8:10 a.m., in the dry storage was a 106 oz dented can of mixed fruits on the rollout shelve. - Dry storage area, a 16 oz clear bag enriched macaroni was sitting on the mid shelve inside a zip lock bag undated and opened. - In the back of the house kitchen prep area, the middle refrigerator inside on the top shelve was a 5.6 qt 6-inch-deep clear plastic container with salsa mid-way with a clear plastic wrap with its ends floating outwards and not gripping the container securing a closed hold. - In the back of the house kitchen prep area, 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 interview and record review the facility failed to ensure residents the right to formulate an advance directive for 2 (Resident #39 and Resident #69) of twenty-four residents reviewed for formulation of advance directives. Residents #39 and #69's medical records did not accurately reflect their Texas Out of Hospital Do Not Resuscitate (TXOOHDNR) orders. This failure could put residents at risk of not having their TXOOHDNR honored, resulting in receiving medical treatment they did not desire. Findings include: Resident #39 Record review of Resident #39's face sheet dated [DATE] documented she was [AGE] years old and was admitted to the facility on [DATE]. Record review of Resident #39's History and Physical dated [DATE] documented she was assessed for diagnoses including high blood pressure, hyperlipidemia (abnormally high concentration of fats in the blood) diabetes with complications, chronic kidney disease stage five, and functional quadriplegia (complete inability to move). Review of Resident #39'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 develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for one (Resident #72) of 8 residents reviewed for baseline care plans. Resident #72 physician's progress note dated 01/16/2023 indicated that she was being admitted to the facility for pain control, but her baseline care plan did not address pain management. This failure could put residents at risk of not receiving pain management. Findings include: Record review of Resident #72's face sheet dated 02/08/2023 documented that she was [AGE] years old and was admitted to the facility on [DATE]. Record review of Resident #72's physician's progress note dated 01/16/2023 documented that the resident had an acute compression fracture at T12 [a broken vertebrae]. She had mostly severe pain, 9-10 on pain scale, constant with slight variation .…

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 develop and implement a comprehensive person-centered care plan for a resident, consistent with the resident rights set forth 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 #44) of 8 residents reviewed for comprehensive care plans in that: -Resident #44's comprehensive care plan did not include ADL bathing needs for resident This deficient practice could affect residents by placing them at risk of not receiving care and services to meet their needs. Findings included: Review of Resident #44's Face Sheet dated 02/20/2023 documented an [AGE] year-old female with an initial admission date of 11/04/2022 and a re-admission date of 11/28/2022. Review of a History and Physical dated 11/04/2022 documented a history of right shoulder dislocation and anemia. Review of an admission 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 the observations, interviews, and record reviews the facility failed to ensure that the residents environment remains free of accidents hazards as is possible and each resident receives adequate supervision to prevent accidents for 1 (Resident #22) of 24 residents reviewed for accidents. 1. The facility failed to make sure the Diet Slips were being updated. Resident #22 was eating lunch that was regular texture rather than mechanical soft and began to have a choking episode. This failure could place residents at risk of aspiration and choking. Findings include: Record review of the Face Sheet indicated Resident #22 was a [AGE] year-old female who was admitted [DATE] and readmitted on [DATE]. Resident #22 is diagnosed with dysphagia (difficult or discomfort in swallowing). Record review of the Quarterly MDS (Minimum Data Set) dated 01/18/2023 for Resident #22 documented eating: self-performance 1. Supervision - oversight, encouragement or cueing. Eating: support provided 2. One-person physical assist,…

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 2 residents (Resident #14 and Resident #57) of 7 reviewed for medication administration and 1 of 1 medication room. -LVN H failed to administer insulin with meal per physician order for Resident #14. -LVN I administered Resident #57 medication through feeding tube without checking for residuals first. -Medication room had expired medications This deficient practice could cause a decline in health of residents due to incorrect medication administration or administration of expired medications. Findings included: Resident #14 Review of Resident #14's Face Sheet dated 02/10/2023 documented a [AGE] year-old female with an admission date of 12/07/18. Review of a History and Physical dated 06/29/2022 documented Resident #14 had a history of Type 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.

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 to the keys for 1 (100 Hall) of 4 medication carts reviewed for medication storage in that: -100 Hall Medication Cart was left unlocked with OTC medications inside. This deficient practice could place residents at risk of decline in health if medication was to be taken from opened medication cart. Findings included: Observations in the 100 Hall on 02/07/23 at 08:25 AM revealed that Medication Cart keys were found on top of the medication cart, where it was found to be open and unattended. The medication cart was located in the 100 hall where there were no residents at the time. Observation and interview with DON on 02/08/23 at 11:45 AM, revealed there were OTC medications in the 100 hall medication cart that had been left opened the day before. The DON stated since there were no residents in the 100 Hall at the time, the nurses had left the medication cart in the hallway. She said the nurses knew to close…

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 food was prepared in a form designed to meet individual needs for 1 of * resident reviewed for provision of food in a form designed to meet individual needs. The facility failed to ensure Resident #22 lunch meal was mechanical soft and nectar diet as ordered by the physician. This failure could place residents who received mechanical soft and nectar diets at-risk of choking and aspiration. Findings include: Record review of facility Face Sheet indicated Resident #22 was a [AGE] year-old female who was admitted [DATE] and readmitted on [DATE]. Resident #22 was diagnosed with dysphagia (difficult or discomfort in swallowing). Observation on 02/07/2023 at 1:20 p.m , (Resident #22 family member called surveyor into Resident #22's room) Resident #22 was in her room laying in her bed elevated; turning red as she was trying to cough. Resident #22's eyes were closed. Residents' family member got up and began to pat her hard with her left…

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 maintain medical records on each resident that were accurately documented for one (Resident #72) of 24 residents reviewed for accuracy of resident's medical records. A physician's order that the resident be observed on all rounds on every shift was entered into Resident #72's record incorrectly and documented that she was to be observed on all rounds every even- numbered day for Resident #72. This failure could put residents at risk of having undetected changes in their conditions resulting in delayed response to resident's medical care needs. Findings include: Record Review of Resident #72's face sheet dated 02/08/2023 documented that she was [AGE] years old and was admitted to the facility on [DATE]. Record review of Resident #72's physician's progress note dated 01/16/2023 documented that the resident was diagnosed with an acute compression fracture at T12 [a broken vertebrae]. Record review of Resident #72's electronic diagnosis listing accessed 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 interview and record review the facility failed to ensure that the facility's Binding Arbitration Agreement was explained to the resident and his or her representative in a form and manner that he or she understands, including in a language the resident and his or her representative understands; that the resident or his or her representative acknowledges that he or she understands the agreement; that the agreement explicitly granted the resident or his or her representative the right to rescind the agreement within 30 calendar days of signing it; or that the agreement explicitly stated that neither the resident nor his or her representative were required to sign an agreement for binding arbitration as a condition of admission to the facility for two (Residents #186 and #35) of three residents reviewed for facility compliance with requirements for binding arbitration agreements. The facility failed to adequately explain the intent of the binding arbitration agreement to Resident #186's representative.…

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 the facility's Binding Arbitration Agreement provided for the selection of a neutral arbitrator agreed upon by both parties; or that the agreement provided for the selection of a venue that is convenient to both parties for two (Residents #186 and #35) of three residents reviewed for facility compliance with requirements for binding arbitration agreements. The facility failed to ensure that it's Arbitration Agreement provided for the selection of a neutral arbitrator agreed upon by both parties for Residents #186 and #35. The facility failed to ensure that it's Arbitration Agreement provided for the selection of a venue that was convenient to both parties for Residents #186 and #35 . These failures put residents and their representatives at risk of being uninformed about their rights regarding binding arbitration and less able to defend their rights related to disputes, controversy or claims arising out of or related to the services to be…

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.