Ignite Medical Resort El Paso, LLC

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 two residents (Residents #1, and #2) of 4 residents reviewed for care plans.The facility failed to have a comprehensive person-centered care plan for Resident # 1 and #2 to address resident's wound vac.These failures could affect residents and put them at risk for not receiving care and services to meet their needs.Findings included: Resident #1Record review of Resident #1's admission record dated 10/27/2025 revealed a [AGE] year old male with an admission date of 09/22/25.Review of Resident #1's history and physical dated 09/23/2025 revealed resident had a left 5th toe amputation and the presence of a wound vac to distal lower leg.Review of Resident #1 's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that each resident received food that is palatable, attractive, and at a safe and appetizing temperature for 1 of 1 meal (7/30/25) tested for nutritive value, flavor, and appearance:The facility failed on 7/30/25 to serve and address the residents concerns regarding their meals not being at a safe and palatable temperature for residents who were served their meals in their rooms.The facility failed on 7/30/25 to serve a sample food tray for the surveyors at a safe and palatable temperature. The facility failed on 7/30/25 to serve meals at a safe temperature. This failure could affect the residents who ate food from the facility's kitchen by placing them at risk of poor food intake and/or dissatisfaction due to not providing appetizing temperature meals. The findings included:Record review of the facility's lunch menu for Wednesday July 30th, 2025, consisted of Beef Pepper Steak, Garlic Mashed Potatoes and Buttered Carrots. In an…

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

Based on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed in that:The facility's kitchen staff failed to thaw food properly.This failure could place residents who eat foods prepared in the kitchen at risk of cross contamination and food-borne illnesses.The findings include: In an observation on 7/29/25 at 8:13 AM in the kitchen, two packs of beef, approximately four pounds each, were thawing inside a large and clear plastic container. The container was observed next to the kitchen sink. Meat juice was visible outside of the bags containing the meat and a pool of juices was forming inside the container. In an observation on 7/29/25 at 8:25 AM in the kitchen, the same receptacle containing the meat had been moved to a different sink and was completely submerged in water below the faucet and the water was left running. In an interview on 7/31/25 at 9:53 AM with the Executive Chef, he stated that the procedure for thawing meat was 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 ensure each resident received services in the facility with reasonable accommodation of resident needs and preferences for 1 of 14 Residents (Resident #62) reviewed for accommodation of needs.The facility failed to ensure Resident #62's call light was in reach.This failure could affect the residents' dependent on staff for transferring in and out of their bed and/or wheelchair by causing feelings of isolation, frustration, hunger, and a diminished quality of life.Findings include:Record review of Resident #62's face sheet dated 07/30/25 revealed a [AGE] year-old female with an initial admission date of 12/18/24 and a re-admission date of 07/25/25. Record review of Resident #62's history and physical dated 07/27/25 revealed medical history of: Senile Degeneration of brain (decline of cognitive function impacting memory and reasoning), Anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something 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 ensure the resident's environment was as free from accident hazards as possible for 2 of 18 residents (Resident #2 and Resident # 49) reviewed for accidents. The facility failed to properly dispose of shaving razors in a sharps container in Residents #2 and 49's shared room. This deficient practice could place residents at risk of harm or injury and contribute to avoidable accidents. The findings included: Resident #2 Record review of Resident #2's face sheet dated 07/31/2025 revealed a [AGE] year-old male that was initially admitted to facility on 10/12/2022 and readmitted on [DATE]. Record review of Resident #2's history and physical dated 01/17/2025 revealed, Resident #2 was diagnosed with dementia (decline in mental ability). Record review of Resident 2's MDS assessment dated [DATE] revealed a BIMS score of 09 indicating moderate cognitive impairment. Record review of Resident #2's care plan reviewed on 04/24/25 revealed the Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not maintain an infection prevention 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 4 residents reviewed for infection control. (Residents #62)CNA A failed to perform hand hygiene after disposing of dirty briefs and before putting on new clean briefs for Resident #62.These failures could place the residents who required incontinent care at risk for cross contamination and infection.Findings include:Record review of Resident #62's face sheet dated 07/30/25 revealed a [AGE] year-old female with initial admission date 12/18/24 and re-admission date 07/25/25. Record review of Resident #62's history and physical dated 07/27/25 revealed medical history of: Senile Degeneration of brain (decline of cognitive function impacting memory and reasoning), Anxiety (a feeling of worry, nervousness, or unease, typically about an…

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

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for professional standards for food service safety. -Access to trash can next to handwashing sink was not hands free as the lid of the trash can was damaged. -The facility failed to ensure food items in the facility's only walk-in refrigerator were sealed and labeled appropriately. -The facility failed to ensure food items in the facility's only walk-in freezer were dated and stored appropriately. -The dishwashing and sanitization machine was dirty with dried caked on substance on top of the machine and streaking down the front of the machine. -The kitchen ice machine was dirty with dried caked on substance around the ice dispenser door. -Multiple vents observed with dust and debris over cooking prep areas. -Wall and ceiling observed with dried yellow splatter in a kitchen prep area. These failures could place residents at risk for food-borne illness, and food contamination.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure medical records were maintained on each resident that were complete and accurately documented for 1 (Resident #1) of 4 residents whose records were reviewed for accuracy and completeness. -The facility failed to document Resident #1's fall incident per policy in an incident report. This deficient practice could place residents at risk for improper care due to incomplete or inaccurate records. Findings included: Record review of Resident #1's admission Record dated 03/25/2025, revealed an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1's diagnoses included lack of coordination, weakness, and falls. Record review of Resident #1's MDS assessment dated [DATE], revealed a BIMS score of 11 indicating moderate cognitive impairment. Record review of Resident #1's Progress Notes dated 02/27/2025 at 3:28 p.m., reads in part notify MD and NP, patient found sitting on the floor by the toilet. Patient assessed and no injuries…

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 1 of 5 (Resident #3) r esidents reviewed for infection control in that: The facility failed to dispose of Resident #3's dirty brief and wipes smeared with feces that were left on the room floor wrapped in a linen. This failure could place residents at risk for cross contamination resulting in acquired infection. Findings included: Record review of Resident #3 's face sheet dated 07/19/24 reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnosis of dementia. Record review of Resident #3's annual MDS assessment dated [DATE] reflected her cognitive was severely impaired. During an interview on 07/12/24 at 4:09 pm, Resident #3's family member was at bedside and denied any concerns with care provided.…

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 conduct assessments that accurately reflected the resident's status for 4 of 12 residents (Residents #10, #15, #28, and #237) reviewed for resident assessments. The facility failed to ensure Resident #10's admission MDS Assessment accurately reflected her diagnosis of anxiety. The facility failed to ensure that Resident #15's admission MDS Assessment accurately reflected his skin status or diagnosis of anxiety/use of anti anxiety medication. The facility failed to ensure Resident #28's Medicare 5 Day MDS Assessment accurately reflected his diagnosis of Diabetes Mellitus. The facility failed to ensure Resident #237's admission MDS Assessment accurately reflected his diagnosis of chronic pain. These failures could place residents at risk of not receiving the proper care required to attain or maintain the highest practicable physical, mental, and psychosocial well being. The findings included: Resident #10 Review of Resident #10'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 Resident #15 Care Planning Copied from another care area: [NAME], [NAME] (26221) 06/04/24 02:23 PM No communicateion w VA as res believes documented Based on interviews 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, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well being for 3 of 6 residents (Residents #10, #15, and #28) reviewed for care plans. Resident #10 did not have a care plan to address her antipsychotic use. Resident #15 did not have a care plan to address CAA areas of vision, psychosocial status, urinary status, skin status, active diagnosis, or anti anxiety use. Resident #28 did not have a care plan to address his diabetic status or insulin use. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs. The findings included the following: 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 interviews and record review the facility failed to ensure that residents who have not used psychotropic drugs [NAME] not given these drugs unless the medication [NAME] necessary to treat a specific condition as diagnosed and documented in the clinical record for 3 (Residents #10, #21, and #137) of 5 residents reviewed for unnecessary medications., The facility failed to ensure Resident #10 had an appropriate diagnosis for the use of Seroquel (an antipsychotic used to treat schizophrenia and bipolar disorder). The facility failed to ensure Resident #21 was not given risperidone (an antipsychotic) without a diagnosis. The facility failed to ensure that Resident #137 did not receive an antipsychotic (Seroquel/Quetiapine Fumarate) that was not necessary to treat Dementia. These failures put residents at increased risk for adverse consequences such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status from receiving unnecessary antipsychotic…

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 all drugs and biologicals in locked compartments for 3 of 4 medication carts reviewed for medication storage and security. Medication Carts 100, 200, and 300 were left in the hallway unlocked and unattended. These failures could place clients at risk for drug diversion or accidental ingestion. Findings included: Observation on 06/04/24 at 08:57 AM revealed the hall 100 medication cart was unlocked and unattended in front of a resident's room. Staff moved it to in front of the nurse's station facing outward still unlocked and unattended, facing outward (anyone passing by have access to the drawers), and walked away from it. At 9:02 a.m. staff returned to the cart, set up medication and then left, again leaving the cart unlocked and unattended. The staff continued to leave the cart unlocked and unattended until surveyor left at 9:11 a.m. Observation on 06/04/24 at 08:38 AM LVN C walked away from the 300 Hall Medication Cart leaving it unlocked, unattended, and facing outward. At 8:42 AM the 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.

Based on observations and 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. The facility failed to ensure stored foods were properly stored, labeled, and dated. This failure could place residents who received prepared meals from the kitchen at risk for food borne illness and cross-contamination. The findings included: Observation on 6/4/24 at 8:45 AM of the walk-in refrigerator revealed a large plastic tub on the bottom rack of shelving that contained a large, torn open, plastic bag of raw, pre-cut white meat. The bag containing the meat had no label or date. The plastic tub had approximately 0.5 inch of bloody liquid collected in the bottom where it had leaked out of the open bag of meat (no spillage was noted outside of the tub). Observation on 6/4/24 at 8:50 AM of the walk-in freezer revealed one 5-pound bag of frozen, sliced, yellow-colored vegetables with no label and no date. In an interview on 6/5/24 at 12:20 PM, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to 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 disease and infections for 4 (Resident #137, #8, #15, #87 ) of 6 reviewed for incontinent care and 3 of 4 residents reviewed for infection control practices. The facility failed to ensure that CNA D performed proper hand hygiene and glove changes while providing incontinence care to Resident #137. The facility failed to ensure residents were identified for enhanced barrier control for Residents #8, #15, #87. This failure could place residents at risk for the spread of infection. Findings included: Incontinent Care Review of Resident #137's face sheet dated 06/06/24, revealed a 69- year- old male admitted to the facility on [DATE] with diagnoses including Pulmonary embolism and diabetes mellitus. Review of Resident #137'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 observations, interviews, and record review, the facility failed to ensure residents received parenteral fluids administered consistent with professional standards of practice and in accordance with physician orders for 1 of 2 residents (Resident #237) reviewed for peripheral intravenous care. The facility failed to ensure Resident #237's midline dressing was changed after becoming soiled on 6/2/24. This failure could place residents at risk of developing an infection. The findings included: Review of Resident #237's admission Record, dated 6/5/24, revealed he was a [AGE] year old male admitted to the facility on [DATE]. Review of Resident #237's admission MDS Assessment, dated 5/23/24, revealed a BIMS score of 15 (indicating he was cognitively intact) with no signs or symptoms of delirium. He had diagnoses of multi drug resistant organism and septicemia. He received insulin, antibiotic, diuretic, and opioid medications. He received IV medications and had IV access. Review of Resident #237's Progress…

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 laboratory services to meet the needs of its residents, for 1 of 3 (Resident # 136) residents reviewed for laboratory orders. The facility failed to follow physician orders on 05/29/24 that required obtaining a lab and provide needed treatment for Resident #136. This failure could place residents at risk for untreated medical issues and diminished quality of care. Findings included: Record review of Resident # 136's face sheet dated 06/06/2024 reflected a [AGE] year old female admitted on [DATE] with a diagnoses of acute embolism (blocked artery), thrombosis (blood clot), difficulty in walking, and weakness. Record review of Resident #136's admission MDS assessment dated [DATE] reflected Resident #136 had a BIMS score of 15, which indicated intact cognition. Resident #137 did not have any behavioral or mood issues. She was continent of bowel and bladder. Resident #137 ambulated by self and required limited assistance with most…

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 receive treatment and care in accordance with professional standards of practice, and the comprehensive person-centered care plan for 1 (Resident #3) of 6 residents reviewed for repositioning. The facility failed to ensure Resident #3 was repositioned every 2 hours. This failure could affect others by placing them at risk of potential medical complications related to changes in condition. Findings included: Record review of Resident #3's face sheet dated 09/13/2023 revealed an [AGE] year-old female who was re-admitted on [DATE] with diagnosis of failure to thrive (general state of decline in elderly patient) and muscle weakness. Record review of Resident #3's MDS quarterly assessment dated [DATE] revealed she could not complete BIMS interview, she was severely cognitive impaired. Required extensive assistance with 2-person physical assistance for bed mobility and was at risk for pressure ulcer/injury risk with no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY FACILITY Medication Administration 04/11/23 04:28 PM Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 resident (Residents #247) of 3 reviewed for medication administration. The facility failed to ensure LVN D administered Resident # 247 medications according to the physician ' s order. This deficient practice could place residents with g-tubes at risk of not receiving their medication in accordance with the physician ' s order. Findings included: Record Review of Resident #247 face sheet dated 4/14/2023 Resident #247 was a 70 yr. old female admitted on [DATE]. Record Review of Resident #247 ' s History and Physical dated 03/16/23 revealed a diagnosis of Alzheimer ' s dementia, cva (stroke), and dysphagia (difficulty swallowing). Record Review of MDS assessment dated [DATE] 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 FACILITY Kitchen 04/11/23 08:02 AM Culinary Director [NAME] - in refrigerator open bag with three hotdog buns with no label. unlabeled open container of chocolate syrup with Exp date of 11/04/2022. Risk - don't know when opened so don't know how long it will be good. Possible a threat to the safety of the product for residents to consume. Residents could have stomach issues, diaharrea. 04/11/23 11:10 AM CD [NAME] and cook [NAME] - issues with gloving in process of doing Puree - Puree OK but issues with infection control - uses same gloves to wash blender parts and then in preparation of pureed vegetables without glove change or hand washing. Wash water seen dripping from inside right hand glove onto surface of blender while in the process of blending the vegetables. When asked about gloving she states without prompt that she should have changed gloves and washed hands , re-gloved after washing the blender parts. That there is a risk of contamination of the food due to the failure, that resident could get sick. -…

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 Resident #23 Advance Directives [DATE] 10:44 AM [DATE] 02:37 PM on [DATE] - DNR order on Facility Record - No document in Documents file. Review of hard chart reveals no DNR document and front page states Full Code. [DATE] 03:03 PM interview and record review with RN Licely [NAME] - reviews [NAME] electronic chart for code status and states he is a DNR. Reviews hard chart and states that there is a sticker that says full code. Reviews resident chart and states she is unable to find a copy of the TX OOH DNR. Reviews residetn IDt admission Evaluataion with Baseline Care plan and states that it indicates no Advance Directives - . Says that this puts residetn at risk of delayed response to emergency sitatuaion. States she is not able to find the completed DNR form in the residetn's chrat. [DATE] 09:47 AM [NAME], LBSW - Resident - admissions asks if ADs are in place - Family will provide information regarding status all ADs including DNR. Full code is default - and some ay not have documents in place. DNR if wanted -…

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 Resident #96 Unnecessary Meds, Psychotropic Meds, and Med Regimen Review 04/12/23 11:16 AM Resident is in the Initial Pool. According to RR the resident takes an Antianxiety. Buspiron 10 mg TID According to RR the resident takes an Anticoagulant. - Lovenoz 30 MG Q AM According to RR the resident takes an Insulin. - she is not taking insulin - Actos 15 MG - for blood sugar but not insulin. According to RR the resident takes an Opioid. - Tramaol 50 MG Q 6 hrs PRN - Has not requested this According to RR the resident takes an Antidepressant. - Lexapro 20 MG Q day. Anticoagulant is on the MDS but not on either care plan baseline or comprehensive care plan. 04/14/23 11:17 AM DON - anticoagulans shouldb on base [NAME] care plan - If resident is h ere long enough woul be o n comprehansive. Staff standrd woul dlook for brusiing bleeding stool collor, Wouild be lok infor this because thins the bllo - increased tenedency to bleeding. Nursing practice is to monitor - it does not matter if it is ion the care plan or not.…

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 change midline dressing in accordance with physician orders and the comprehensive care plan for 1 (Resident #39) of 16 residents reviewed for quality of care The facility failed to change Resident #39 Midline dressing according to physician ' s orders. These deficient practices could have placed residents at risk for cross-contamination resulting in acquiring infections. Findings included: Record Review of Resident #39 ' s face sheet dated 04/14/23 revealed an [AGE] year-old male with an admission date of 03/24/23. Record Review of Resident #39 ' s History and Physical dated 03/14/23 revealed a diagnosis of Periprosthetic Joint infection, left shoulder and MRSA (Methicillin-Resistant Staphylococcus Aureus). Record Review of MDS assessment dated [DATE] revealed Resident #39 had a BIMS score of 15 indicating he was cognitively intact. In section I of the MDS assessment Resident #39 revealed active diagnosis of infection due to unspecified…

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 #8, Resident #5, and Resident #96) of 5 residents observed for oxygen management. 1. The Facility failed to change oxygen tubing for Resident # 8 according to physician's orders. 2. The facility failed to ensure Resident # 5's oxygen sign was posted on entrance door to resident's room. 3. The facility failed to store Resident #96 ' s respiratory treatment mask with a protective cover. These failures could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support, decline in health, and expose them to oxygen hazards. Findings included: Resident #8 Record review of the facility's Hospital Transfer/Discharge Report Sheet for Resident #8 revealed admission to nursing facility on 01/04/2023. Record review of History and Physical dated 01/06/2023 for Resident #8…

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 FACILITY Infection Control [DATE] 04:08 PM Resident [NAME] - 310 - [NAME] - worked for the state 1991 - worked as a case worker eligibility - Has been does not know. - Fell and has been here because of fractured tibia - Feels very lucid today - usually feels confused and asks that I call husband - they treat her very good. Bath room looks fine. Infection control concern the treatment mask is not bagged. [DATE] 09:04 AM Licely [NAME], RN - states that treatment mask should be in bag because of infection control concerns. Resident might breath in things that get in mask like germs. on her hospital paper work said Buspirone 2 5 MG pills - TID for anxiety. Mitirats a pin 7.5 MG at HS depression. escitaopran - 20 MG q day - Depression. admit date [DATE] [DATE] 11:15 AM DON - between treatments masks whold be stored in bags - for infecgtion prevention - risk to resident of infection. FACILITY Infection Control [DATE] 11:35 AM resident done with quarantine on [DATE] wound care cart observation red bag not being…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews, the facility failed to ensure food was prepared in a form designed to meet the individual needs for 1 (Resident # 246) of 2 residents reviewed for dietary services. The facility failed to ensure Resident #246's lunch meal was a thin liquid consistency diet as ordered by the physician. This failure could place residents at risk of choking and aspiration by not serving the prescribed liquid consistency. Findings included: Record review of facility Transfer/Discharge Report Sheet for Resident #246 revealed admission to facility on 09/27/22 and readmitted on [DATE]. Record review of Resident #246 History and Physical dated 03/31/2023 revealed an [AGE] year-old male with a diagnosis of Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). Record review of the baseline care plan dated 04/06/2023 for Resident #246 revealed dietary/nutritional status as…

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.