El Paso Health & Rehabilitation Center

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 1 (Resident #1) of 7 residents reviewed for care plans. -The facility failed to follow the comprehensive person-centered care plan for Resident #1's fall risk, by failing to have a fall mat in place next to bed while resident was lying down in bed. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services as indicated in their comprehensive person-centered plans developed to address their needs. Findings include: Review of Resident #1's admission Record dated 09/13/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE].…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to review and revise Resident Care Plans after each assessment for 1 (Resident #1) of 8 residents whose records were reviewed. -Resident #1's Care Plan was not updated to reflect discontinuation of padding the wall. These deficient practices could lead to errors in treatment and services provided based on incorrect information. Findings included: Resident #1: Review of Resident #1's admission Record dated 09/13/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1's diagnoses included cerebral palsy (congenital disorder of movement, muscle tone, or posture), depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), muscle weakness, lack of coordination, intellectual disability (deficits in theoretical thinking/learning), seizures (uncontrolled jerking, loss of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 (Residents #1) of 7 residents reviewed for assistance with ADLs. -The facility failed to ensure Residents #1's fingernails were trimmed and cleaned. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk of infection, and decreased quality of life. Findings include: Review of Resident #1's admission Record dated 09/13/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1's diagnoses included cerebral palsy (congenital disorder of movement, muscle tone, or posture), depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), muscle…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who are fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 (Resident #3) of 4 residents reviewed for gastrostomy tube management quality of care. -The facility failed to ensure Residents #3 was provided with the correct feeding through gastrostomy tube (g-tube, feeding tube) as ordered per physician. This failure could place residents who received feedings by gastrostomy tube at risk for decline in health and weight loss. Findings included: Review of Resident #3's admission Record dated 09/13/2024, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3's diagnoses included cerebral infarction (lack of oxygen to the brain causing damage to brain tissue), unspecified protein-calorie malnutrition, dysphagia (swallowing difficulties), and gastrostomy status (a feeding tube that delivers nutrition to your stomach). 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 maintain a safe, sanitary and comfortable environment for 2 (Resident #2 and Resident #5) of 4 residents and 1 (room [ROOM NUMBER]B) of 3 rooms reviewed for environment. The facility failed to ensure Resident #2's blue face of the feeding pump machine had white unknown substance. The top of the feeding pump machine was dirty with a brown-ish substance. Resident #5's feeding pump machine was greasy and dirty. The pole the feeding bag was hung from, and the feeding pump machine was hooked up too had brown-ish substances all around the pole and the black power cord. The Face of the feeding pump machine also on the left side had a reddish substance. The right side of the feeding pump machine had some black smeared substance. Underneath the feeding pump machine was a brown-ish substance. The facility failed to ensure the feeding pump machine in room [ROOM NUMBER]B was not covered with an unknown brown-ish substance. This deficient practice…

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 a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 (Resident #3 and Resident #6) of 5 residents reviewed for quality of life. The facility failed to ensure Resident #3 and Resident #6's fingernails were trimmed and cleaned. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk of infection, and decreased quality of life. Findings include: Resident #3 Record review of Resident #3's face sheet dated 08/05/24, revealed, admission on [DATE] to the facility. Record review of Resident #3's outside facility history and physical dated 05/31/24, revealed, an [AGE] year-old male diagnosed with muscle wasting, lack of coordination, Type 2 Diabetes Mellitus, and anxiety. Record review of Resident #3's quarterly MDS assessment dated [DATE], revealed severely impaired…

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 foot care and treatment, or assist the resident in making appointments with a qualified person for 2 (Resident #3 and Resident #6) of 5 residents reviewed for quality of life. The facility failed to ensure Resident #3 and Resident #6's toenails were trimmed and cleaned, or podiatry appointments scheduled. This failure could place residents at risk of infection or mobility issues. Findings include: Resident #3 Record review of Resident #3's face sheet dated 08/05/24, revealed, admission on [DATE] to the facility. Record review of Resident #3's outside facility history and physical dated 05/31/24, revealed, an [AGE] year-old male diagnosed with muscle wasting, lack of coordination, Type 2 Diabetes Mellitus, and anxiety. Record review of Resident #3's quarterly MDS assessment dated [DATE], revealed severely impaired cognition to be able to recall and make daily decisions as evidence by a BIMS score of 4. ADLs for personal hygiene…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure that the assessment accurately reflected the resident's status for 1 (Resident #7) of 5 resident reviewed for accuracy of MDS assessment, in that: The facility failed to ensure Resident #7's quarterly MDS accurately reflected the residents' history of falls. This deficient practice could affect residents at the facility who had been assessed for risk of falls and could contribute to inadequate care. Findings included: Record review of Resident #7's face sheet dated 08/01/24, revealed, admission on [DATE] and re-admission on [DATE] to the facility. Record review of Resident #7's facility history and physical dated 05/29/24, revealed, an [AGE] year-old male diagnosed with Alzheimer's Disease, difficulty in walking, muscle wasting, muscle weakness, Dementia, lack of coordination, unspecified fall. Record review of Resident #7's quarterly MDS dated [DATE], revealed severely impaired cognition to be able to recall or make daily decision with a BIMS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 (Resident #7) of 5 residents reviewed for care plans in that: The facility failed to develop a comprehensive person-centered care plan for Resident #7's history of falls needing to have a fall mat placed when in bed as per physician orders. 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 include: Record review of Resident #7's face sheet dated 08/01/24, revealed an admission on [DATE] and re-admission on [DATE] to the facility. Record review of Resident #7's facility history and physical dated 05/29/24, revealed, an [AGE] year-old…

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 and assistance devices to prevent accidents for 1 (Resident #7) of 4 residents reviewed for accidents. The facility failed to follow the physicians order to place a fall mat on the floor when Resident #7 remains in bed. This failure could place residents in the facility at risk of not receiving the necessary care of services as ordered by the physician to address their needs, resulting in accidents, falls, and potential harm. Findings include: Record review of Resident #7's face sheet dated 08/01/24, revealed, admission on [DATE] and re-admission on [DATE] to the facility. Record review of Resident #7's facility history and physical dated 05/29/24, revealed, an [AGE] year-old male diagnosed with Alzheimer's Disease, difficulty in walking, muscle wasting, muscle weakness, Dementia, lack of…

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

Based on 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 sanitation and food storage. The facility failed to keep refrigerator and dry storage free of moldy foods. The facility failed to keep the freezers clean. The facility failed to store food in sealed containers. The facility failed to keep one plastic container stored on a metal rack clean and free of dried food residues on its side. The facility failed to keep one plastic bag with 2 bottles of liquid caramel stored on a metal rack clean and free of food drippings. The caramel stored inside the bag had leaked to the floor. The facility failed to properly store cleaning chemicals. This failure could affect residents by placing them at risk of food borne illness. Findings include: Observation and interview with DM N on 06/18/2024 at 8:26 AM, revealed a pink stain of frozen liquid at the bottom of the freezer #2. DM N said that it looked like strawberry drippings and that…

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

Based on observation, interview and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 kitchen reviewed for safe operating equipment in safe operating condition. -The facility failed to maintain the stove in operational condition. -The facility failed to maintain the freezer in operational condition. This failure could place residents at risk of foodborne illnesses; and potential for injury to residents and staff by not maintaining essential equipment in safe operating condition. Findings include: Observation and interview on 06/18/24 at 8:22 AM, with the DM N revealed that freezer #2 had condensation inside and that the bottom was frozen and had a thick layer of ice. In the ice, there were pieces of cardboard from the boxes stored at the bottom of the freezer and food particles that were stuck in the ice. DM N said he would place a work order with the maintenance department so they could repair the freezer The Surveyor asked DM N what was the procedure that he needed to follow to place a work…

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 the resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 5 of 18 residents (Resident #7, #8, #14, #51 and Resident #65) reviewed for activities of daily living., received reasonable accommodation of needs. The facility failed to place Residents #7, #8, #14 and #51's call lights within reach. The facility failed to ensure Resident #65's room door was closing properly. This deficient practice could affect all residents who need assistance with activities of daily living of not having needs met. Findings included: RESIDENT #7 Record review of Resident #7's face sheet dated 06/18/2024 revealed he was [AGE] years old, was initially admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #7's History and Physical dated 10/13/2023 revealed he had diagnoses including cerebral palsy and seizures. Record review of Resident…

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

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 timeframes to meet a resident's medical and nursing needs identified in the comprehensive assessment for two (Resident #59 and Resident #61) of 23 residents reviewed for comprehensive resident-centered care plans. The facility failed to include care plans to address Resident #59's limited range of motion of his upper and lower extremities. The facility failed to include care plans to address Resident #61's limited range of motion of his upper and lower extremities. This failure put residents at increased risk of being unable to maintain their highest practicable physical well-being. Findings included: Resident #59 Record review of Resident #59's face sheet dated 06/19/2024 revealed he was [AGE] years old and was admitted to the facility on [DATE]. Record review of Resident #59's admission MDS dated [DATE] revealed he 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 all residents were provided, based on the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility sponsored activities and individual activities, designed to meet the interests and support the physical, mental, and psychosocial well-being of each resident for 2 of 9 (Resident #65 and Resident #51) residents reviewed for activities. The facility failed to provide regular, individualized activities to Resident #65 and Resident #51. This failure placed residents at risk of decreased physical, mental, and psychosocial well-being. Findings included: Resident #51 Record review of Resident #51 ' s face sheet dated 06/18/24 revealed an [AGE] year-old male who was admitted to the facility on [DATE]. Record review of Resident #51 ' s history and physical dated 07/11/23 revealed a diagnoseis of weakness, pain, history of falls, cerebral edema, and concussion with loss of consciousness…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the resident's medical records were complete and accurately documented in accordance with accepted professional standards and practices for 5 (Resident #1, #57, #59, #61 and #65) of 23 residents reviewed for advance directives. The facility failed to ensure that Resident #1, #57, #59, #61, and #65's Texas OOH DNR were completed correctly. This failure put residents at risk of not having their health care wishes honored, such as receiving unwanted resuscitative measures. Findings included: Resident #57 Record review of Resident #57's face sheet dated [DATE] revealed he was [AGE] years old, was initially admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #57's History and Physical dated [DATE] revealed he had diagnoses including severe traumatic brain injury, Tracheotomy status (tube into the neck for breathing), Gastrostomy status (tube into the stomach for nutrition), Encounter for palliative care (care focused…

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 of 7 Resident #8) residents reviewed for abuse. The facility failed to implement their abuse policy when they failed to immediately suspend the Driver after Resident #8 ' s allegation of mistreatment was reported. This failure could place residents at risk of potential continued mistreatment and abuse. Findings included: Record review of Resident #8 ' s face sheet dated 06/19/24 revealed an [AGE] year-old female who was admitted to the facility on [DATE] and she was her own responsible party. Record review of Resident #8 ' s history and physical dated 11/07/23 revealed diagnoses of diabetes mellitus type 2, kidney stones, chronic pain, restless leg syndrome, physical debility, and depression. Record review of Resident #8 ' s quarterly MDS assessment dated [DATE] revealed a BIMS score of 10, indicating her cognitive was intact. Record review of Resident #8 ' s nursing progress note 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 observation, interview, and record review the facility failed to ensure residents are given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living (ADLs) for 1 of 7 residents (Resident #26) reviewed for meal assistance. The facility failed to encourage Resident #26 often during her meal per her care plan. This failure could place residents that needed encouragement to eat to maintain ADL independence at risk of possible weight loss and avoid ADL decline. Findings included: Record review of Resident #26 ' s face sheet dated 06/19/24 revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #26 ' s history and physical dated 05/20/24 revealed a diagnosis of Alzheimer's disease, anorexia, cognitive communication deficit, and unspecified dementia. Record review of Resident #26 ' s annual MDS assessment dated [DATE] revealed a BIMS score of 04, her cognitive was severely impaired and required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 7 residents (Resident #15) reviewed for nail care. The facility failed to trim Resident #15 ' s fingernails. This failure could place residents at risk of cross contamination and skin scratches that could result in infection. Findings include: Record review of Resident #15 ' s face sheet dated 06/19/24 revealed an [AGE] year-old male who was admitted to the facility on [DATE]. Record review of Resident #15 ' s history and physical dated 08/02/23 revealed a diagnosis of anemia, type 2 diabetes mellitus, Alzheimer ' s dementia, and hypertensive heart disease. Record review of Resident #15 ' s annual MDS assessment dated [DATE] revealed a BIMS score of 04, his cognitive was severely impaired and required substantial/maximal assistance with hygiene. Record review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that residents did not receive psychotropic drugs on a PRN basis for more than 14 days for one (Resident #61) of three residents reviewed for PRN psychotropic medication orders exceeding 14 days. The facility failed to ensure that Resident #61 did not have a PRN order for Lorazepam (antianxiety medication) for more than 14 days. This failure could place residents at risk of side effects from receiving unnecessary psychotropic medications. Findings included: Record review of Resident #61's face sheet dated 06/19/2024 revealed he was [AGE] years old, was initially admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #61's Progress Note dated 02/07/2024 revealed he had a diagnosis of anxiety disorder. Record review of Resident #61's History and Physical dated 03/22/2024 revealed no diagnosis of anxiety disorder. Record review of Resident #61's quarterly MDS assessment dated [DATE] revealed he was receiving…

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 to help prevent the development and transmission of communicable diseases and infections for 2 (Residents #47 and #63) of 18 residents reviewed for infection control in that: The facility failed to ensure CNA A wiped from front to back during incontinent care of Resident #47. The facility failed to ensure Resident #63's oxygen nasal cannula was bagged when not in use. These failures could place residents at risk for cross contamination and the spread of infection. Findings included: RESIDENT #47 Record review of Resident #47's admission record dated 06/19/2024 indicated she was admitted to the facility on [DATE] with diagnoses of heart failure, muscle wasting and atrophy. She was [AGE] years of age. Record review of Resident #47's MDS dated [DATE] revealed: BIMS = 13 indicating resident was cognitively intact. Bladder and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. The facility did not ensure the floors and ceilings were not stained, floor tiles were not broken/missing, restroom faucet(s) had running water, restroom(s) light bulbs were not out, there was not a strong urine smell in B-Hall, in a living area there was not trash on the floor, the wall under the medical records room/oxygen room did not have a huge hole, and hot water was available in C-hall, Room B105 had wet urine in the restroom and in the room, strong urine smell, there was wet pieces of toilet paper all over the room. Medical Records room had a hole in the wall, resident phone room had a hole in the wall, D-Hall had broken tile on the floor. These failures placed residents and staff at risk of living, working, and visiting in an unsafe, unsanitary, and uncomfortable environment. Findings include: Record review of Resident #3's face…

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, clean, comfortable, and homelike environment for 1 (Resident #10) of 6 residents reviewed for resident rights. -The facility failed to ensure Resident #10's bedroom was clean and comfortable based on a dead roach being inside the resident's bed light fixture. This failure could place the resident at risk of decreased quality of life due to the lack of a well-maintained environment. Findings included: Record review of Resident #10's face sheet dated 04/16/2024, revealed a [AGE] year-old male who was originally admitted on [DATE] and readmitted on [DATE]. Record review of Resident #10's H&P dated 06/25/2023, revealed Resident #10's diagnoses to include hypertension, gait abnormality/difficulty walking and depression. Record review of Resident #10's Quarterly MDS assessment dated [DATE], revealed a BIMS score of 15 indicating the person is intact cognitively. During an observation and interview on 04/09/2024 at 3:30 p.m.,…

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

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 includes measurable objectives and time frames to meet a resident's medical and nursing needs and the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Resident #1) reviewed for care plans in that: The facility failed to implement a comprehensive person-centered care plan for Resident #1 requiring wearing cushion boots (redistributing device for the prevention of heel pressure ulcers). 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 include: Record review of Resident #1's face sheet dated 04/11/24, revealed, admission on [DATE] to the facility. Record review of Resident #1's significant change in status MDS assessment dated [DATE],…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide the necessary treatment and services based on the comprehensive assessment and consistent with professional standards of practice to promote healing and prevent worsening of pressure injuries for 1 (Resident #3) of 3 residents reviewed for pressure ulcers. The facility failed to provide proper wound care for Resident #1's facility acquired pressure ulcers to the right outer heel. This deficient practice could place residents at risk for worsening pressure injuries, pain, and a decline in health. Findings include: Record review of Resident #1's face sheet dated 04/11/24, revealed, admission on [DATE] to the facility. Record review of Resident #1's significant change in status MDS assessment dated [DATE], revealed, he was cognitively intact to be able to make daily decisions and able to recall information with a BIMS (tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility)…

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

Based on observations and interviews the facility failed to dispose of garbage and refuse properly for 2 (Dumpsters #1 and #2) of 2 dumpsters located outside of the facility. -Two dumpsters located outside the facility were open with their sliding doors open when not in use and trash was on the ground. These failures could place residents at risk of decreased quality of life due to an exterior environment which could attract pests, rodents, and other animals. Findings included: Observation on 04/11/2024 at 11:15 a.m., two dumpsters were observed outside the facility on the back of the property. Dumpster #1 was observed with the sliding door open. There were several pieces of trash on the ground outside of the dumpster. Dumpster #2 was observed with the sliding door open with trash reaching the height of the side door. Observation on 04/11/2024 at 12:59 p.m., two dumpsters were observed outside the facility on the back of the property. Dumpsters #1 and #2 were both observed with sliding doors opened. There were several pieces of trash on the ground outside of Dumpster #1. During an…

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

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 for 1 (Resident #11) of 6 residents reviewed for infection control. Resident #11's nasal cannula that was on the floor was placed back on Resident #11's nares (nostrils) without being replaced. This deficient practice could place residents at risk for infection due to improper care practices. Findings included: Record review of Resident #11's face sheet dated 04/11/2024, revealed a [AGE] year-old female who was originally admitted on [DATE] and readmitted on [DATE]. Record review of Resident #11's H&P dated 10/06/2023, revealed Resident #11's assessment included: Monitor O2 maintain adequate O2 saturation keep Sat>90%. Record review of Resident #11's MDS quarterly assessment dated [DATE], revealed a BIMS score of 00 indicating severe…

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, clean, comfortable, and homelike environment for 2 of 6 (Resident #1 and Resident #4) residents reviewed for resident rights. The facility failed to clean urine off the floor for Resident #1 and Resident #4, leaving a strong urine odor penetrating the shared room. This failure could place residents at risk at a diminished quality of life. Findings include: Record review of Resident #1's face sheet dated 10/10/23 revealed a [AGE] year-old female who was admitted on [DATE] with diagnoses of dementia. Record review of Resident #1's admission MDS assessment dated [DATE] revealed a BIMS score of 05; indicating severe cognitive impairment. Record review of Resident #1's care plan dated 09/09/23 revealed focus area for incontinence for bladder and bowel and goal was for resident to be clean and odor free through next review date. Record review of Resident #4's face sheet dated 10/10/23 revealed a [AGE] year-old female who 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 maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 (Resident #6) residents reviewed for infection control. The facility failed to ensure CNA D removed gown and gloves before exiting Resident #6 room, who was in isolation with contact precautions. This failure could place residents at risk of cross contamination which could result infections or illness. Findings include: Record review of Resident #6's face sheet dated 10/10/23 revealed a [AGE] year-old male who was readmitted on [DATE] with diagnoses of anxiety, Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), and metabolic encephalopathy (an alteration in consciousness caused due to brain dysfunction,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the resident's medical record included documentation that indicates the residents received education on the influenza immunizations for 1 of 6 (Resident #2) residents reviewed for immunizations. 1. The facility failed to document that Resident #2 or was provided education regarding the benefits and potential side effects of the influenza immunization and if the resident either receive the influenza immunization This failure could place residents at risk for contracting a viral disease and cause respiratory complications, and potential adverse health outcomes. Findings include: Record review of Resident #2's face sheet dated 10/10/23 revealed a [AGE] year-old male who was admitted on [DATE] with diagnoses of anxiety, hypertension (condition in which the force of the blood against the artery walls is too high), and atrial fibrillation (an irregular and often very rapid heart rhythm). Record review of Resident #2's 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 observation, interview, and record review the facility failed to maintain an effective pest control program so that the facility was free of rodents/insects for one of four halls. A. The facility failed to ensure an effective pest control program was in place to keep cockroaches out of the facility. This failure could affect all residents by placing them at risk of potential spread of infection, cross-contamination, food-borne illness, and decreased quality of life. Findings included: Observation on 08/12/23 at 3:12 PM in hall A with LVN A. The roach was crossing the resident's room A117 on the other side of the hall. Observation and interview on 08/12/23 at 4:31 PM with Administrator in room A102, which was being used to store bed frames had to pieces of large roach wings. Administrator stated the roaches were bad months ago, but it had got better since then with minimal sightings of roaches. Observation on 08/13/23 at 9:14 AM in hallway A revealed a roach that was dead on the floor near a resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, 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 6 residents (Resident #1) reviewed for medical records. The facility failed to ensure Resident #1's assessments for the change of condition were accurately documented clinical record. This failure could place residents at risk of inaccurate records with the potential for inadequate care and treatment. Findings included: Closed record Review revealed Resident #1's face sheet dated 08/12/23 listed initial admission on [DATE] and readmission on [DATE]. Record Review Resident #1's history and physical dated 01/04/22 revealed a [AGE] year-old female. Past medical history multiple sclerosis, neurogenic bladder with chronic urinary tract infections due to intermittent catheterization. Record Review Resident #1's quarterly MDS dated [DATE] revealed resident rarely made self-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 observation and interview 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 infection for the facility residents reviewed for infection control. The facility failed to remove linen from the facility and maintain in a sanitary condition until wash. The facility failed to maintain equipment in working condition to sanitize linens. This deficient practice could have placed residents at risk for cross-contamination resulting in acquiring infections. Findings included: Observation and Interview on 04/24/23 at 2:41 PM with laundry aide N revealed 8 gray linen plastic bins stored outside the facility that contained soiled linen were uncovered. Laundry aide N reported the facility has 2 commercial washing machines and only one is working at this time. The facility had 3 commercial dryers, only one dryer is working at this time. Laundry Aid…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment, including maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for two (Halls C and D) of four halls reviewed for maintenance services and failed to maintain a safe environment on two halls (Halls A and B) of four halls reviewed for safe water temperatures. 1. Halls C and D had numerous unaddressed environmental issues including holes in walls, water leaks, collapsed ceilings, lose faucets, windowsill boards broken or cracked, restroom light fixture covers missing, closet doors missing or broken. 2. The hot water in the bathroom sink in room B19 measured 129.9 degrees. 3. The hot water in the bathroom sink in room B18 measured 135 degrees. 4. The hot water in A/B hall shower, Shower Stall One measured 124.8 degree 5. The hot water in A/B hall shower, Shower Stall Two measured 132.2 degrees. These failures could put…

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 the necessary services to maintain good nutrition, grooming, personal and oral hygiene care for 2 (Resident #36 & Resident #43) of 20 residents reviewed for ADL care. The facility failed to ensure facility staff provided showers and personal grooming for Resident # 36 and Resident #43. This failure could place residents at risk of not receiving assistance with personal care which could cause pain, skin breakdown, and low self-esteem. Findings included: Resident #36 Record review of Resident #36's Face Sheet revealed admission on [DATE] and readmission on [DATE] to the facility. Record review of Resident #36's facility diagnosis report dated 04/27/2023 revealed a diagnosis dementia and lack of coordination. Record review of Resident #36's MDS quarterly dated 01/31/2023 revealed a brief interview mental status score of 7, ADLs of 3 extensive assistance with a one-person assistance with personal hygiene, diagnosis of Aphasia,…

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 a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 3 (Resident #1, Resident #59, and Resident #132) of 7 residents observed for oxygen management. The Facility failed to ensure Resident #1, Resident #59, and Resident #132 who were on oxygen therapy to post oxygen signs outside the entrance of their room doors. This failure could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support, decline in health, and expose them to oxygen hazards without oxygen signs being posted outside of their rooms. Findings included: Resident #1 Record review of Resident #1's Face Sheet revealed admission on [DATE] to the facility. Record review of Resident #1's MDS quarterly dated 02/05/2023, had a brief interview for mental status score of 07, diagnoses of non-Alzheimer's dementia, asthma, chronic obstructive pulmonary disease or chronic lung…

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 store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 (kitchen) of 1 reviewed for residents. 1. Food products in dry storage, freezer, 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 included: Observation and Interview on 04/24/2023 beginning at 8:15 AM Assistant Dietary Manager in dry storage revealed a 7 pound can of pudding that did not have a date, breadcrumbs in a sealed zip lock bag did not an expiration date, a tied bag of pasta that was opened did was not labeled with the date and name, a sealed bag of enriched quick creamy wheat did not have an expiration date, and thick n easy ensures that were not labeled and dated. Assistant Dietary Manager stated the Dietary Manager and himself oversee food items are being labeled and dated. Assistant Dietary Manager stated the risk of not labeling or dating or correctly labeling food…

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 reviews the facility failed to dispose of garbage and refuse properly for 2 (Dumpster #1 & Dumpster #2) of 2 dumpsters reviewed for food safety requirements. 1. Two dumpsters outside in the back of the facility had trash around the dumpsters on the ground. 2. Two dumpsters were uncovered. This failure could affect residents by placing them at risk of illnesses, or be provided an unsafe, unsanitary, and uncomfortable environment. Findings included: Observation and Interview on 04/24/2023 beginning at 8:15 AM with Assistant Dietary Manager, revealed were two dumpsters in the back of the building near the kitchen door. Dumpster #1 nearest to the building had trash hanging off the side and from the front. The side door was not closed all the way exposing the trash inside and trash (napkins/BBQ sauce container) sat on the dumpster rail. On the ground were blue and clear medical gloves, a clear bag that had briefs in it, and next to it was an empty 5-gallon blue bucket lying on its side. There were pieces (medical gloves, spoons, napkins)…

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 filed to ensure resident records were readily accessible for two (Resident #31 and #131) of six residents reviewed for record accessibility. The facility failed to ensure that Resident #31 and #131's completed TX OOH DNR forms were in either their electronic or physical charts. This failure could result in staff having difficulty locating resident's TX OOH DNR forms and cause a delay in residents receiving desired treatment. Findings included: Record review of Resident #31's face sheet dated 4/26/2023 documented that she was [AGE] years old and was admitted to the facility on [DATE]. Record review of Resident #31's electronic diagnoses listing accessed 04/26/2023 documented that she had diagnoses including Alzheimer's disease. Record review of Resident #31's quarterly MDS dated [DATE] documented that she had a BIMS of 12 (Moderate cognitive impairment). Record review of Resident #31's care plan dated 05/20/2019 documented that Resident #31 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 maintain essential mechanical and electrical equipment in safe operating condition for 1 facility of 1 reviewed for essential equipment. 1. The facility did not provide necessary repairs for 1 industrial washing machines, 2 industrial dryers, 1 washer soap dispenser, and 1 washer bleach dispenser. 2. 2 of 10 Resident beds in C Hallway had head and foot boards that were broken. 3. Resident #36 was sitting in his wheelchair with a broken footrest that had parts to the chair with sharp edges. This failure could place residents who had their clothes laundered by the facility at risk no having sufficient linen available to meet residents needs and place residents who use sleep on facility beds at risk for injury from lose head or foot boards that may fall on them or screws/bolts that my scratch or puncture them as they are lying or sitting down. Findings included: Interview with the Maintenance manager on 04/27/23 at 9:11 AM, he stated that 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 interviews, observations, and record reviews the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced dignity and respect for 1 (Resident #43) of 6 residents reviewed for care that maintained or enhanced their dignity. The facility failed to maintain Resident #43 sense of dignity by not proving the resident with a bath according to his bath schedule and changing his clothing to promote proper hygiene. This failure could place residents who require assistance with bathing and changing their clothing at risk of decreased self-esteem affecting their dignity. Findings included: Record Review of Resident #43 face sheet dated 04/25/23 is a [AGE] year-old male admitted on [DATE]. Record Review of Resident #43 care plan dated 10/29/2019 revealed Resident #43 has an ADL self-care deficit related to a history of stroke, expressive aphasia, hemiplegia, and Parkinson's and required limited assistance x1 for bathing and changing. Record Review of Resident #43…

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 ensure residents received parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders for 1 (Resident #67) of 2 residents reviewed for Midline/PICC (Peripherally Inserted Central Catheter) care. The facility failed to ensure Resident # 67's midline (intravenous catheter) tubing was changed every 72 hours or sooner if contamination was suspected or integrity of system was compromised from 04/19/2023 to 04/27/2023. Resident 67's midline site was not changed as ordered by the physician, and care to the site was not completed every 24 hours. This failure placed residents at risk of developing an infection. Findings included: Record review of Resident #67's Face Sheet revealed admission [DATE] and readmission on [DATE] to the facility. Record review of Resident #67's MDS quarterly dated 04/06/2023 revealed a brief interview mental status score of 15, diagnosis of urinary…

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.