St. Teresa Nursing & Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #3) reviewed for Enhanced Barrier Precautions. The facility failed to implement their policy on Enhanced Barrier Precautions during high contact resident care activities for Resident #3 who had a wound and indwelling medical device. This failure could place residents at risk for healthcare associated cross-contamination and at risk of the transmission of multi-drug-resistant organisms (MDROs). The findings included:Record review of Resident #3's admission Record revealed Original admission Date 07/22/21 and re-admission Date 04/12/25. Record review of Resident #3's History & Physical dated 04/14/25 revealed [AGE] year-old female with past medical history of frequent UTIs (a common…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents were provided services with reasonable accommodation of needs and preferences for 3 of 12 residents (Residents #84, Resident #88 and #67) reviewed for call lights.This failure placed residents at risk of having their needs unmet when they are unable to contact staff.Findings included: Resident # 84. Record review of Resident #84's admission record dated 9/14/25, revealed he was admitted on [DATE]. Record review of Resident #84's health and physical dated 5/28/25, revealed he was an [AGE] year-old male with diagnoses of unspecified dementia, acute kidney failure, benign prostatic hyperplasia (a non-cancerous enlargement of the prostate gland that commonly occurs in older men a non-cancerous enlargement of the prostate gland that commonly occurs in older men) with lower urinary tract symptoms, dysphagia (difficulty swallowing) and repeated falls. Record review of Resident #84's quarterly MDS dated [DATE] revealed the resident…

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

Based on 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.-The facility failed to maintain a one-gallon bottle of sweet and sour sauce free from dried drippings in the pantry on 09/14/2025.-The facility failed to maintain a one-gallon bottle of mustard free from dried drippings inside of the walk-in refrigerator on 09/14/2025.These failures could place all residents who received meals from the main kitchen at risk of food borne illnesses.Findings included:During observations on 09/14/2025 that started at 8:10 AM in the kitchen, a couple of bottles with dry drippings were discovered. At 8:26 AM in the dry storage area, a one-gallon bottle of sweet and sour sauce was found on the top shelf with dried drips that ran from its cap all the way down to the bottom. At 8:32 AM, a one-gallon bottle of mustard was found at the top shelf inside the walk-in refrigerator. It was also spotted with dried, smeared drippings of mustard on it. In an interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for two residents (Residents #1, and #4) of twelve residents reviewed for care plans.The facility failed to have a comprehensive person-centered care plan for Resident # 1 to address resident's Tracheostomy care.The facility failed to have a comprehensive person-centered care plan for Resident #4 to address resident's psychotropic medication prescriptions, Trazadone and Buspirone.These failures could affect residents and put them at risk for not receiving care and services to meet their needs.Findings Include:Resident #1 Record review of Resident #1's admission record dated 09/17/2025 revealed a [AGE] year-old male with an admission date of 08/21/2025. Review of Resident #1's history and physical dated 08/13/2025 revealed a diagnosis of tracheostomy (surgical process 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide ADL care for 1 of 16 residents (Resident # 99) reviewed for ADLs.The facility failed to ensure Resident #108's nails were clean and trimmed.This failure could place residents at risk of not having their personal hygiene needs met and cause low self-esteem.Record review of Resident #108's face sheet dated 09/16/25 revealed a [AGE] year-old female with an admission date 05/06/25 and re-admission date 09/09/25.Record review of Resident #108's quarterly MDS dated [DATE] revealed BIMS was not completed since resident was rarely or never understood. Quarterly MDS revealed Resident #108 was Dependent for personal hygiene, meaning the helper does all the effort while the resident does none of the effort to complete the activity.Record review of Resident #108's health and physical dated 05/12/25 revealed a medical history of Acute Ischemic Stroke (the blood supply to part of the brain is blocked or reduced which prevents brain tissue from…

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 environment remains as free of accident hazards as was possible for 2 of 5 residents (Resident # 110 and # 113) reviewed for accidents.The facility failed to properly recover and dispose of a shaving razor left inside the shared bathroom for Resident # 110 and # 113.The deficient practice could place residents at risk of harm and injury and contribute to avoidable accidents.The findings include:Resident #110.Record Review of Resident #110's face sheet date 09/17/2025 revealed an [AGE] year-old male that was initially admitted to the facility on [DATE].Record Review of Resident #110's quarterly MDS dated [DATE] revealed the resident has a BIMS score of 09 which means he is moderately cognitively impaired.Record Review of Resident #110's physical and history dated 07/16/2021 revealed the resident was diagnosed with Non-ST Segment Elevation Myocardial Infarction (NSTEMI), which is a type of heart attack; Hypertensive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident and failed to ensure drug records were in order and that an account of all controlled drugs was maintained for 1 (Resident#33 ) of 6 reviewed for medication administration. The facility failed to ensure Licensed Staff Registered Nurse E signed the individual control drug record for Resident #33's after administering controlled medication on 09/16/2025. This failure could place residents at risk for not receiving the intended therapeutic response of prescribed medications and drug diversion of controlled substances. The findings include:Record review of Resident #33's admission record 09/17/2025 revealed a [AGE] year-old female with an original admission date of 07/25/2025 and a readmission date of 08/13/2025. Review of Resident #33's history and physical 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 who are fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 (Resident #1) of 6 residents reviewed for gastrostomy tube management quality of care. -The facility failed to ensure Residents #1 was provided with the correct feeding through gastrostomy tube (g-tube, feeding tube) as ordered. This failure could place residents who received feedings by gastrostomy tube at risk for weight gain and decline in health. Findings included: Record review of Resident #1's admission Record dated 02/03/2025, revealed a [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident # 1's History and Physical dated 01/15/2025, revealed diagnoses of nutritional deficiency, unspecified (lack of essential nutrients in the body without specifying which particular nutrient is deficient), and 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 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 complete and accurately documented for 1 of 4 residents (Resident #3) reviewed for medical records. The facility failed to ensure Resident #3's inventory record accurately documented items for the resident during her stay at the facility. This failure could place residents at risk of lost, missing or stolen items. Findings include: Record review of Resident #3's face sheet, dated 01/06/24, revealed admission on [DATE], re-admission on [DATE] and most recent re-admission on [DATE] to the facility. Record review of Resident #3's history and physical, dated 04/12/24, revealed an [AGE] year-old female with a diagnosis which included Dementia (neurological conditions that cause a person to lose the ability to think, remember, and reason to the point that it interferes with their daily life). Record review of Resident #3's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to develop and implement 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 #3) of 8 residents reviewed for care plans. -The facility failed to develop and implement a comprehensive person-centered care plan for Resident #3's use of a BiPAP machine. 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 #3's admission Record dated 10/15/2024, revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #3's diagnoses included acute and chronic respiratory failure 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 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 2 (Residents #16, and #17) of 8 residents reviewed for assistance with ADLs. -The facility failed to ensure Residents #16 and #17, who required assistance with ADLs, did not have long and dirty fingernails. These failures could affect residents who were dependent on assistance with ADLs and could result in poor care, lack of dignity, infection, and skin tears due to long nails. Findings include: Resident #16: Review of Resident #16's admission Record dated 09/20/2024, revealed a [AGE] year-old male, with initial admission date of 06/16/2014 and readmission date of 06/20/2022. Resident #16's diagnoses included: dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), hemiplegia (total or partial paralysis of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that a resident who is fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for one (Resident #11) of 11 residents reviewed for quality of care. The facility failed to ensure that Resident #11's enteral feeding formula was properly labeled. This failure put residents at risk of not receiving adequate nutrition by way of enteral feeding. Findings included: Record review of Resident #11's face sheet dated 8/26/24 revealed a [AGE] year-old male who was re-admitted to the facility on [DATE] with diagnoses of gastro-esophageal reflux disease (frequent acid reflux or reflux of nonacidic content from the stomach), protein-calorie malnutrition, and gastronomy status (surgical formation of an opening through the abdominal wall into the stomach). Record review of Resident #11's quarterly MDS assessment dated [DATE] revealed a BIMS score of 09 indicating his cognition was moderately…

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 #97 Advance Directives 07/23/24 12:27 PM DNR per electronic record - no DNR document scanned into miscellaneous documents. 07/25/24 02:44 PM Socual worker [NAME] - adult Som requested DNR. Did requrest for DIN and in itniated DNR request - CUfrrent status is pendin MD signature on the DNR docuemtn. Her compliance nrusing team that if they makde a rfeuest in house to honor the client's desired so - have to get TX OOH DNR - Valid DNR for in house. No completed hospital DNR. It is a catch 22. 07/25/24 03:51 PM DON - if a resident requests refer to SW Resident #259 Advance Directives 07/24/24 08:44 AM Appears that OOH DNR is not signed by MD. Social worker [NAME] - this is not a valid completed - The facity strated the enactment process, DNR and was scanned in . She did revie with [NAME]. Did not notice - will put it up [NAME] for MDs sicnatur and slooks like medical records grabbed it before the MD signed it. The DNR came in 2/21/24 - The faamiy did sign a resquest fo do not recuscutate. DOe htave it .…

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 were not given psychotropic drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for three (Residents #27, #93, and #255) of 5 residents reviewed for unnecessary medications. The facility failed to ensure Resident #27 did not receive Risperidone, an anti-psychotic to treat Delusional disorder. The facility failed to ensure Resident #93 did not receive Aripiprazole, an antipsychotic to treat depression. The facility failed to ensure Resident #255 did not receive Quetiapine, an antipsychotic to treat dementia. These failures could place residents at risk for adverse consequences such as impairment or decline in an individual's mental, physical or psychosocial status from receiving unnecessary antipsychotic medications. Findings included: Resident #27 Record review of Resident #27's face sheet dated 07/25/2024 revealed he was [AGE] years old, was initially admitted…

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 #4 Urinary Catheter or UTI Resident #23 Urinary Catheter or UTI Resident #33 Urinary Catheter or UTI Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 5 residents (Residents #4, #33, #73, and #155) reviewed for infection control. The facility failed to ensure airborne precautions were followed for Resident #155 who had Shingles. The facility instructed staff to follow contact precautions. The facility failed to ensure Residents #4, #33, and #73's urinary catheters were not on floor. This failure could affect residents by placing them at an increased risk of exposure to communicable diseases and infections. The findings included: Resident #155 Review of Resident #155 admission Record, dated 7/24/24, revealed she was an [AGE] year-old female admitted 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 FACILITY Environment 07/25/24 03:40 PM DON regarding oxygen filters - get Rt arersponsible o makding [NAME] ethat oxyven macings are functionion gprooperlly. should be checking the filters. Risk to residednt not ereceiving desired effect of the oxygen. Not Getting enough oxygen, increase risk of infection.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that residents were free from physical restraints that were not required to treat the resident's medical symptoms for 1 (Resident 259) of two residents reviewed for physical restraints. The facility failed to assess whether Resident #259's concave mattress was a restraint before placing it on her bed. This failure put residents at risk of the use of equipment that might restrict their movement. Findings included: Record review of Resident #259's face sheet dated 7/25/2024 revealed she was [AGE] years old and was admitted to the facility 02/13/2024. Record review of Resident #259's quarterly MDS dated [DATE] revealed she had a BIMS of 14 (cognitively intact). She had no potential indicators of psychosis or behavioral symptoms. She had functional limitations in her range of motion on one arm and one leg. She required partial to moderate assistance to move around in bed, to sit up, sit on the side of the bed, stand up and transfer…

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 #93 Dementia Care 07/24/24 04:44 PM LOS - 6/25/2024 7/23/2024 Care plan for dementia not in place. BIMS of 13 on 5-day MDS Diagnosis - Receiving Apriprazole for depression MDS 5 day Jun 28, 2024 shows DX - non-Alzheimer's dementia, Depression - no other psych/mood disorder shown. Care Plan - requires antipsychotic - monitor for side effects. Resident #97 Position, Mobility 07/23/24 09:32 AM Resident states they are not doing anything to address her range of motion of arms or legs. MDS Jun 11, 2024 - 5-day - Dependent for Toileting, dressing, Showering did not occur Substantial/maximal assistance - Roll right and Left, sit to lie, sit to stand, transfers. OT - 95 minutes over three days stating 6/7/24 PT - 98 mins over three days starting 6/7/24 No time recorded for Restorative. Order: PT eval completed this date. PT recommends 5X4 weeks to address deficits with the use of ther ex, ther act, NM re-ed, manual therapy, and gait training as tolerated to maximize rehab potential. 05/31/2024 Discontinued…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for one (Resident #97) of 17 residents reviewed for comprehensive person-centered care plans. The facility failed to ensure that Resident #97's comprehensive care plan included interventions to address urinary tract infection, shortness of breath, hypotension (low blood pressure), impaired cognitive function, cellulitis (skin infection), potential nutritional problem, mood problem, and depression. The facility failed to ensure that Resident #97's comprehensive care plan for a self-care deficit specified which areas of function were to be maintained or improved (such as bed mobility, transfers, or toilet use). This failure could put Resident #97 at increased risk of not having her care needs met. Findings included: Record review of Resident # 97'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 observations, interviews, and record review the facility failed to provide necessary services to maintain good grooming and hygiene for a resident who was unable to carry out activities of daily living for 2 (Residents #26 and #29) of 12 residents reviewed for services to maintain good grooming and hygiene. The facility failed to provide personal hygiene for Resident #26 and #29 by not trimming their fingernails. This deficient practice placed residents at risk of poor hygiene and decline in residents' self-esteem. Findings included: Record review of Resident #26 's Face Sheet dated 7/25/2024 revealed he was initially admitted on [DATE] and readmitted on [DATE]. He was [AGE] years old. Record review of Resident #26 's history and physical dated 9/4/2018 revealed he had diagnoses of hypertension, cerebral infarction (stroke), respiratory failure with hypoxia (not having enough oxygen in the blood) and needed for assistance with personal care. Record review of Resident #26 's quarterly MDS assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one (Resident #97) of 3 residents reviewed for treatment and services to increase range of motion and/or to prevent further decrease in range of motion. The facility failed to provide Resident #97 with treatment and services to address her limited range of motion. This failure could put Resident #97 at increased risk of contractures and impaired skin integrity. Findings included: Resident #97 Record review of Resident # 97's face sheet dated 07/25/2024 documented she was [AGE] years old was initially admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #97's 5-day MDS assessment dated [DATE] revealed she had a BIMS score of 8 (Moderate Cognitive impairment). She had diagnoses including chronic obstructive pulmonary disease (lung condition…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 resident reviewed for accident hazards/supervision. (Resident #23). The facility failed to ensure HA H and NA I demonstrated appropriate transfer techniques while using the mechanical lift for Resident #23. These failures could place residents at risk for injuries. Findings included: Review of Resident #23's admission Record, dated 7/24/24, revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including paralysis following a stroke. Review of Resident #23's Annual MDS Assessment, dated 4/10/24, revealed: She scored an 8 of 15 on her mental status exam (indicating she was moderately cognitively impaired). She had upper and lower range of motion impairment on one side and used a wheelchair. She was completely dependent on staff for transfers. Active diagnoses included stroke. Review of Resident #23'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 #97 Urinary Catheter or UTI 07/23/24 09:36 AM cath bag in privacy bag resting on fall mat 07/23/24 09:33 AM Interview observation with [NAME] - Cath bag on floor - photo taken. 07/23/24 09:58 AM [NAME], LVN - adjust bed so bag is not on fall mat. States bag is touching because of fall mat, should not be on the floor for infection control reasons. 07/25/24 03:22 PM DON - regarding cath bag o nthe floorit doses have a privacy bag. Doe nto know policy as to wehtehr the bag is sufficient protection. IF the bag is not sufficient protection there is a risk for intection - CNAs asll clinical staff responsible fo thei .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that a resident who needs respiratory care is provided such care consistent with professional standards of practice for two (Residents #256 and #38) of 7 residents reviewed for provision of respiratory care. The facility failed to ensure that Resident #256's oxygen concentrator filter was free of accumulations of dust. The facility failed to ensure that Resident #38's oxygen concentrator filter was free of accumulations of dust. This failure put residents at increased risk of inhaling dust and germs. Findings included: Record review of Resident #256's face sheet dated 7/25/2024 revealed [AGE] years old and was admitted to the facility 06/27/2024. Record review of Resident #256's hospital history and physical dated 06/25/2024, revealed she had diagnoses including stroke. She received supplemental oxygen through a nasal cannula (a thin plastic tube) while in the hospital. Record review of Resident # 256's admission MDS 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 pharmaceutical services including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 (Residents #210) of 12 residents and for 2 of 5 medication carts reviewed for pharmaceutical services. LVN A did not administer Resident #210's scheduled multivitamin with minerals as indicated by the physician orders. The medication cart used for hall 400 and 500 had insulin pens that had expired as indicated by the manufacturer's instructions. These failures could place residents at risk of not receiving medications as prescribed or the therapeutic benefit of medications or at risk of receiving medications that were expired and not produce the desired effect and under dosed. The findings were: Record review of Resident #210's admission Record, dated 07/24/2024, indicated she was admitted to the facility on [DATE] with diagnoses of nutritional deficiency 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 FACILITY Medication Administration During an interview and observation on [DATE] at 01:14 PM LVN [NAME] said she had given Resident #210 [NAME] the multi vitamin in the bottle which had the blue label that indicated High potency multivitamin supplement further inspection of the bottle revealed that it did not contain minerals as indicated on the supplement facts label. LVN [NAME] said she was aware of the resident ordered to have a multi-vitamin but was not sure if they had any of the one with minerals. LVN [NAME] then went to the medication room to look for vitamin with minerals and in the medication room was found some vitamin with minerals which she then took the place in the medication cart. LVN [NAME] said that earlier there were no vitamin with minerals bottles in the medication room. During an interview on [DATE] at 01:09 PM the DON [NAME] was made aware of the nurse administering the multi-vitamin without minerals to Resident #210. The DON said the nurse should have followed the physician order 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record reviews, the facility failed maintain medical records on each resident that were accurately documented for 3 of 12 residents reviewed for medical record accuracy. (Resident #97, #155 and #259) - The facility failed to ensure that Resident #97's a Texas Out of Hospital DNR was completed prior to documenting in the resident's chart that she had a DNR status - The facility failed to ensure Resident #155 who was listed as DNR (Do Not Resuscitate) had an Out-of-Hospital Do Not Resuscitate (OOH-DNR) form. - The facility failed to ensure that Resident #259's Texas Out of Hospital DNR had been signed by a physician prior to documenting in the resident's chart that she had a DNR status This deficient practice could place residents at risk of having their end of life wishes dishonored, and of having cardiopulmonary resuscitation (CPR) performed against their wishes. Findings included: Resident #97 Record review of Resident # 97's face sheet dated [DATE] documented she was [AGE] years 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 observation, interview, and record review the facility failed to ensure the prompt resolution of all grievances to include ensuring that all written grievances decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent finding or conclusions regarding the resident's concerns; a statement as to whether the grievance was confirmed, any corrective action or to be taken by the facility as a result of the grievance, and the date when the decision was issued for 1 of 10 (resident #22) reviewed for resident rights. The facility failed to initiate and complete a grievance for Resident #22's family who voiced concern of unidentified CNAs not closing the curtain when providing perineal care. This failure could place residents at risk for grievances not being addressed or resolved promptly. Findings included: Record review of Resident #22's face sheet dated 06/07/24 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 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 2 (Residents #19 and #20) of 7 residents reviewed for assistance with ADLs. -The facility failed to ensure Residents #19 and #20, who required assistance with ADLs, did not have long fingernails. These failures could affect residents who were dependent on assistance with ADLs and could result in poor care, lack of dignity, and skin tears due to long nails. Findings include: Resident #19: Review of Resident #19's admission Record dated 06/05/2024, revealed a [AGE] year-old male, with initial admission date of 04/11/2023. Resident #19's diagnoses included: Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), Tracheostomy status (an incision in the windpipe made to relieve an obstruction to breathing),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide reasonable accommodations of needs for 1 (Resident #19) of 15 residents reviewed for call light button placement. -The facility failed to ensure that Residents #19 call light was within his reach. These failures could place residents at risk of not being able to have their needs met. Findings included: Review of Resident #19's admission Record dated 06/05/2024, revealed a [AGE] year-old male, with initial admission date of 04/11/2023. Resident #19's diagnoses included: Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), Tracheostomy status (an incision in the windpipe made to relieve an obstruction to breathing), gastrostomy status (surgical procedure used to insert a tube through the abdomen and into the stomach), and dependence of respirator status (need for mechanical ventilation). Review of Resident #19's quarterly MDS dated [DATE], revealed the resident 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 to ensure personal privacy during personal care for 1 of 10 (resident #22) whose care was reviewed in that: The facility failed to close the curtain when providing perineal care to Resident #22. This deficient practice could place residents at risk of dignity, low self-esteem and diminished quality of life. Findings included: Record review of Resident #22's face sheet dated 06/07/24 revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of vascular dementia (caused by the lack of blood that carries oxygen and nutrient to a part of the brain, it causes problems with reasoning, planning, judgment, and memory), cerebral infarction (occurs when the blood supply to part of the brain is blocked or reduced, this prevents brain tissue from getting oxygen and nutrients), and tracheostomy status (a surgical airway management procedure which consists of making an cut on the front of the neck and opening a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure each resident recieves adequate supervision and assistance devices to prevent accidents for 1 (Resident #21) of 9 residents reviewed for care ADLs. -The facility failed to follow the comprehensive person-centered care plan for ADL self-care performance deficit requiring two-person participation for bathing. 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, accidents and potential harm. Findings include: Review of Resident #21's admission Record dated 06/06/2024, revealed at [AGE] year-old female who was originally admitted to the facility on [DATE]. Resident #21's diagnoses included the following: dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), seizures (uncontrolled jerking, loss of consciousness, blank…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 1 of 10 (resident #22) reviewed for oxygen therapy. The facility failed to replace Resident #22 tracheostomy ventilation circuit tubing that was seen with red/brownish particles for 2 days. This failure could place residents on oxygen therapy at risk of cross contamination resulting in acquired infection. Findings included: Record review of Resident #22's face sheet dated 06/07/24 revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of vascular dementia (caused by the lack of blood that carries oxygen and nutrient to a part of the brain, it causes problems with reasoning, planning, judgment, and memory), cerebral infarction (occurs when the blood supply to part of the brain is blocked or reduced, this prevents brain tissue from getting oxygen and nutrients), and tracheostomy…

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, record review the facility failed to ensure that a resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain for 2 of 5 (Resident #9 and Resident #4) residents reviewed for urinary catheter. The facility failed to ensure Resident #9's urinary foley bag was placed below the bladder. The facility failed to provide catheter care for Resident #4 every shift. This failure could place residents with urinary catheters at risk of infection. Findings included: Resident #9 Record review of Resident #9's face sheet dated 4/24/24 revealed a [AGE] year-old male who was readmitted on [DATE] with diagnoses of quadriplegia (one affected with partial or complete paralysis of both the arms and legs especially as a result of spinal cord injury or disease in the region of the neck), tracheostomy (an opening surgically created through the neck…

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 #9) of 2 residents reviewed for perineal care and 1 (Resident #7) of 3 residents reviewed for infection control in that: Resident #7 was Covid-19 positive in January 2024, and the facility failed to record in the Infection Control Log for its Surveillance (a tool used to analysis data that can uncover an outbreak). CNA B failed to change gloves after cleaning Resident #9's BM and continued to provide ADL assistance with dirty gloves. These deficient practices could place residents at risk for infection due to improper care practices. Finding included: Resident #7 Record review of Resident #7's face sheet dated 04/25/24, revealed admission on [DATE] and re-admission on [DATE] to the facility. 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 interview and record review, the facility failed to ensure medical records on each resident were complete and accurately documentd for 1 (Residents #7) of 2 residents reviewed for physician orders in that: There were no physician orders for Resident #7 who was Covid-19 positive on 01/31/24 and placed in isolation. This deficient practice could place Covid-19 positive residents at risk of decline in psychological mental health. Findings included: Record review of Resident #7's face sheet dated 04/25/24, revealed admission on [DATE] and re-admission on [DATE] to the facility. Record review of Resident #7's hospital history and physical dated 01/11/24, revealed, a [AGE] year-old female diagnosed with Chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems). Record review of Resident #7's care plan dated 02/01/24, revealed, requiring isolation precautious specifically related to active Covid-19 infection. Please allow me to get some rest. Please…

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 the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 3 (Residents #1, Resident #2, and Resident #3) of 5 residents reviewed for call light button placement. The facility failed to ensure that Residents #1, #2, and #3 call lights were within their reach. This failure put residents at risk of not being able to call for assistance when needed. Findings included: Resident #1 Record review of Resident #1's face sheet dated 12/06/23 revealed admission on [DATE] and readmission on [DATE] to the facility. Record review of Resident #1's Mobile Med physician services history and physical dated 10/18/23 revealed a [AGE] year-old male diagnosed with chronic hypoxic (brain is starved of oxygen) respiratory failure with trach due to anoxic brain injury (brain was starved of oxygen), alcohol abuse, End Stage Renal Disease, seizure disorder, and hypothyroidism…

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 have a safe, clean , comfortable and homelike environment including but not limited to receiving treatmentand supports for daily livining safely for 1 (hall 300) of 4 hallways and 1 ( Residents #1's bathroom ) of 5 bathrooms reviewed for infection control in that: 1. PPE (Protective equipment such as gowns and gloves) were not disposed of properly in hallway 300. 2. Trash with briefs and bowel movement were not properly disposed and remained in a resident's bathroom. These deficient practices could place residents at risk for infection due to improper care practices. Findings included: Hall 300 Observation on 12/07/23 at 9:15 AM used gloves were seen on the side next to the wall across from a cleaning cart on the floor . Unknown Residents had already passed by the gloves going down the hall walking and being wheeled. During an interview on 12/07/23 at 9:45 AM Housekeeper J stated, the gloves on the floor of hall 300 should not have been on the floor and should have been thrown away in the trash. Housekeeper J…

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 implemment written policies and prodcueres that: Each covered individual shall report to the State Agency and one or more law enformecent entities for teh poltiical sibdivudsion in which the facility was located any reasonable suspicion of a crime against any indeividual who was a resident of or was receiving care from teh facility for 1 (Resident #4) of 5 residents reviewed for allegations of abuse. The DON and Administrator failed to immediately report to the state survey agency when Resident #4 claimed she was physically hit on her left arm and her left wrist by a nurse. This failure could place all residents at risk for abuse by not immediately reporting allegations of abuse to the proper authorities. Findings included: Record review of Resident #4's face sheet dated 12/07/23 revealed admission on [DATE] to the facility. A [AGE] year-old female diagnosed with anxiety disorder, end stage kidney disease, and Polyneuropathy (when multiple…

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 included measurable objectives and time frames to meet a residents medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Resident #6) reviewed for care plans in that: The facility failed to implement a comprehensive person-centered care plan for Resident #6's showering in a shower bed . 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 #6's face sheet dated 12/07/23 revealed admission on [DATE] and readmission on [DATE] to the facility. Record review of Resident #6's facility history and physical dated 06/08/23 revealed a [AGE] year-old female diagnosed with anoxic brain injury (brain starved of oxygen).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop and implement a baseline care plan for 1 of 6 residents (Resident #5) reviewed for accuracy of records. The facility failed to complete a baseline care plan for Resident #5's new seizure diagnosis. This failure could place residents at risk of not having accurate and complete information available to those providing their treatment and care. Findings include: Record review of Resident #5's face sheet, dated 10/25/23, reflected a [AGE] year-old female who was initially admitted on [DATE] and re-admitted to facility on 10/09/23 . Resident #5 had diagnoses which included traumatic subdural hemorrhage (significant bleeding inside the skull, and pressure against the brain is building rapidly) without loss of consciousness, fall, convulsions (body muscles contract and relax rapidly and repeatedly, resulting in uncontrolled shaking) and benign (not cancer) neoplasm of meninges (tumor that forms in your meninges, which are the layers of tissue 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 6 residents (Residents #1) reviewed for medication administration. The facility failed to ensure LVN A did not borrow Buspirone HCL from another resident to administer to Resident # 1 . This deficient practice could place residents at risk of not being administered medications according to physician's orders . Findings include: Closed record review of Resident #1's face sheet, dated 10/08/23, reflected a [AGE] year-old male initially admitted to the facility on [DATE] and discharged on 09/16/23. Record review of Resident #1's History and Physical, dated 09/15/23, reflected diagnoses which included schizophrenia(delusions [false beliefs], hallucinations [seeing or hearing things that don't exist], unusual physical behavior, and disorganized thinking 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 ensure resident has a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 2 of 5 (Resident #1 and Resident #2) residents reviewed for clean homelike environment. A.The facility did not ensure the air conditioners were maintained and cleaned for Resident #1 and Resident #2. These failures placed residents in an unsafe, unsanitary, and uncomfortable environment. Findings include: Resident #2 Record review of Resident #2's face sheet dated 08/23/2023 revealed a [AGE] year-old female who was admitted on [DATE] with diagnoses of dependence on ventilator and tracheostomy. Record review of Resident #2's MDS admission assessment dated [DATE] revealed a BIMS score of 99, she was not able to complete interview. During observation on 08/23/2023 at 8:46am, Resident #2 was in bed sleeping with tracheostomy in place. Air conditioner against the wall had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Resident #4) reviewed for care plans in that: The facility failed to implement a comprehensive person-centered care plan for Resident #4 addressing his tracheostomy. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed to address their needs. Findings included: Record review of Resident #4's face sheet dated 08/23/2023 revealed a [AGE] year-old male admitted readmitted on [DATE] with diagnosis of chronic respiratory failure and tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe (trachea) 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 assure that two (Resident #1 and #2) of five residents reviewed for enteral feeding, received appropriate treatment and services to prevent complications of enteral feeding. -The facility failed to ensure that Resident #1 and #5 feeding tube bags were labeled with time the administration begun to ensure residents maintain nutritional status within optimal parameters. This failure could affect residents by placing them at risk of not being provided enteral feeding care in a timely manner to prevent complications of enteral feeding. Findings included: Record review of Resident #1's face sheet dated 08/02/2023, revealed a [AGE] year-old female who was initially admitted on [DATE] and readmitted on [DATE]. Diagnosis included anoxic brain damage (brain is starved of oxygen), gastrostomy malfunction, tracheostomy status, asphyxiation due to hanging intentional self-harm (state or process of being deprived of oxygen), myoclonus (sudden, brief…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 1 of 5 (Resident #1) residents reviewed for care plans. -The facility failed to implement a comprehensive person-centered care plan interventions regarding ADL care bed mobility and toileting. This failure could affect residents by placing them at risk of not being provided with necessary care or services to address their specific needs. The findings included: Record review of Resident #1's face sheet dated 08/02/2023, revealed a [AGE] year-old female who was initially admitted on [DATE] and readmitted on [DATE]. Diagnosis included anoxic brain damage (brain is starved of oxygen), gastrostomy malfunction, tracheostomy status, asphyxiation due to hanging…

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

Based on interview, and record review the facility failed to take reasonable steps to make residents and family members aware of upcoming meetings in a timely manner for four of four (January, February, March, and April 2023) resident group meetings reviewed for steps to make residents and family members aware upcoming meetings., The facility changed the date and/or the time of group meetings in January, February, March, and April 2023 on 4 occasions after posting the meetings on activity calendars distributed throughout the facility. This failure put residents and family members at risk of decreased opportunities to present grievances and recommendations. Findings include: In a confidential interview on 05/16/23 at 02:00 PM with 11 residents, four regular Resident Advisory Council participants said that although monthly calendars announcing group meetings (Resident Advisory Council) were posted around the facility, the group meetings never took place when they were scheduled. The group members said this made it difficult to know when the meetings would actually take place. Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 3 (Resident #86, Resident #76, Resident #99) of 10 residents observed for assistance with ADL's. The facility failed to ensure facility staff provided nail care for 3 residents (Resident #86, Resident #76, and Resident #99). This deficient practice could place residents who were dependent on assistance with ADLs at risk of not receiving assistance with personal care which could result in poor care, skin breakdown, and feelings of poor self-esteem. Findings include: Resident #86 Record review of Resident # 86's Face Sheet dated 5/18/23 revealed, a [AGE] year-old female who was originally admitted to the facility on [DATE] with a readmission date of 04/24/23. Record review of Resident #86's History and Physical dated 04/26/23 reflected in part that she had diagnoses of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that residents received care, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for three (Residents #48, #56, and #83) of five residents reviewed for pressure ulcer prevention and treatment. The facility failed to prevent the further development of a Stage 4 pressure sore for Resident #48 by failing to change the dressing as needed when soiled. The facility failed to change Resident #56's Stage 4 wound care dressing according to physician's orders. Resident #83 did not receive four treatments for Stage 4 pressure ulcers that were ordered by her physician. These failures could place residents at risk for developing new or worsening of existing pressure injuries. Findings include: Resident #48 Record review of Resident #48's Face Sheet dated [DATE] revealed an admission date of [DATE] and readmission on [DATE] to the facility. 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 ensure a resident was provided foot care and treatment, or provided assistance in making appointments for treatment for 1 Resident #74) of 10 residents observed for assistance with ADL's. Resident #74 wanted his toenails cut but had not received podiatry services. This deficient practice could place residents who were dependent on assistance with ADLs at risk of not receiving assistance with personal care which could result in poor care, skin breakdown, and feelings of poor self-esteem. Findings include: Record review of Resident #74's Face Sheet admission date 07/19/2022 and readmission on [DATE] to the facility. Record review of Resident #74's History and Physical dated 01/14/2023 revealed an [AGE] year-old male with a diagnosis of type 2 diabetes mellitus. Record review of Resident #74's quarterly MDS dated [DATE] revealed a brief interview for mental status score of 8 cognitive moderately impaired. ADLs of personal hygiene of extensive…

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 consistent with professional standards of practice and in accordance with physician orders for 2 (Resident #78 and Resident #56) of 2 residents reviewed for Midline (midline catheter inserted in the upper arm)/PICC (Peripherally Inserted Central Catheter) care. The facility failed to change Resident #56's and Resident #78's Midline line dressing according to physician's orders. This deficient practice could have placed residents at risk for cross-contamination resulting in acquiring infections. Findings included: Resident #56 Record review of Resident # 56's Face Sheet revealed, a [AGE] year-old male who was originally admitted to the facility on [DATE] with a readmission date of 05/10/23. Record review of Resident #56's History and Physical dated 05/15/23 reflected he had diagnoses of sepsis (body extreme response to infection), urinary tract infection, pneumonia, and infection in pressure…

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

Based on interview and record review the facility failed to ensure that there were sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident including licensed nurses and nurse aides for 5 of 11 residents who attended a confidential group meeting. Staff shortages on the weekends resulted in missed showers, missed, or delayed response to call lights, delayed medication administration, and delayed meals. These failures put residents at risk of decreased physical, mental, and psychosocial well-being. Findings included: Record review of Resident Advisory Council Minutes dated 01/18/2023 reflected in part that residents raised concerns about shortages of CNAs and Medication Aides on the weekends. The record reflected residents stated that on the weekends call lights were not answered in a timely manner and medications were not on time. Regarding Nutrition Services, meeting attendees stated that on…

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

Based on the observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for residents. 1. Foods in the dry storage, walk in refrigerator, and freezer were not dated or labeled properly. 2. Food containers and food bags were not properly sealed in the kitchen and in the Refrigerator. This failure could affect residents by placing them at risk of food borne illness. Findings include: Observation and interview on 05/15/2023 at 8:14 AM with the Dietary Manager in the walk-in refrigerator revealed a container of diced tomatoes that had no expiration date. A container of salsa had no expiration date. 2 sealed bags of potatoes were not labeled. A zip lock bag of deli salad had no expiration date. A metal pan of chicken soup was not sealed properly and did not have an expiration date. Cooked pork loin in a container did not have an expiration date. A container of tomato/onions had no expiration date. Cheese in a container had no expiration date 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 ensure that residents had the right to be free from any physical restraints not required to treat the resident's medical symptoms for one (Resident #98) of three residents reviewed for physical restraints. Resident #98 was placed in a Geri-chair (a specialized reclining chair ), the need for which he had not been evaluated, for which there was no doctor's order and for which representative consent was not obtained. This failure put residents at risk of being restrained without justification of the need for a restraint. Findings include : Record review of Resident #98's face sheet dated 05/17/2023 reflected he was [AGE] years old and was admitted to the facility on [DATE]. Record review of Resident #98's History and Physical dated 05/02/2023 reflected he had diagnoses including dementia with major depressive disorder and a fracture to his right lateral malleolus (broken ankle). Regarding his broken ankle he was to have weightbearing 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report immediately an alleged violation involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property to other officials including State survey and certification Agency in accordance with state law for 1 of 7 (Resident #203) reviewed for abuse. The Administrator failed to report to an injury of unknown origin that was reported to him on 04/19/23 by the local ombudsman to the State Agency with in the required time frames. The LVN Q failed to report bruising of unknown origin to the DON and or the Administrator immediately after assessing the resident. This deficient practice could place residents at risk for further endangerment if allegations of abuse, neglect, misappropriation and injuries of unknown origin are not thoroughly investigated. Findings Included: Record review of Resident # 203's face sheet dated 05/16/23 reflected Resident #203 was 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 ensure that resident received appropriate treatment and services to prevent physical trauma when providing care by failing to ensure the resident urinary catheter and tubing were secured in 1 (Resident #78) out of 4 residents reviewed for indwelling catheter. The facility failed to provide appropriate treatment to prevent physical trauma by not securing the urinary catheter and tubing. This deficient practice placed residents with an indwelling catheter at risk of obtaining physical trauma when receiving improper care. The Findings included: Record review of Resident # 78's face sheet dated 5/16/23 revealed a [AGE] year-old male who was originally admitted to the facility on [DATE] to the facility and readmitted on [DATE]. Record Review of Resident #78 History and Physical dated 10/4/22 reflected septic(body extreme response to infection) shock from urinary infection related to urinary catheter. Record Review of Resident's #78 admission…

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 an acceptable parameter of nutritional status was maintained for 2 residents (Resident #76 and Resident #10) of 10 residents reviewed for weight loss. The facility failed to monitor, document residents' weight's, care plan, and place interventions to prevent further weight loss for Resident # 76 and Resident #10 for significant weight loss. This failure could place residents in the facility at risk for compromised nutritional status, weight loss, and not being able to maintain their highest practicable level of health. Findings included: Resident #76 Closed record review of Resident # 76's Face Sheet dated 5/18/23 revealed, a [AGE] year-old female initially admitted to the facility on [DATE] with a readmission date of 04/25/23. Closed record review of Resident #76's History and Physical dated 04/25/23 reflected in part that she had diagnoses of diabetes, chronic hypoxic (having small amount of oxygen) respiratory failure 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, interviews, and record review the facility failed to ensure a resident who is fed by enteral means receives appropriate treatment and services to prevent complicantions for 1 (Resident #86) of 6 residents reviewed and 1 out 5 drugs/biologicals reviewed for labeling in that: The facility failed to ensure Resident # 86's enteral feeding bag was labeled with the resident's name, date, time feeding was hung, the rated order to infuse. This deficient practice could place resident who receive enteral feeding at risk of decline in health due to labeling errors. Findings included: Resident #86 Record review of Resident # 86's Face Sheet dated 5/18/23 revealed, a [AGE] year-old female who was originally admitted to the facility on [DATE] with a readmission date of 04/24/23. Record review of Resident #86's History and Physical dated 04/26/23 reflected in part that she had diagnoses of chronic respiratory failure with tracheostomy (incision on the front of the neck so a tube can be inserted to help…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 1 (Resident #30) of 10 residents observed for oxygen management. 1. Resident #30 was not receiving weekly changes of oxygen tubing and nasal cannula/mask according to physician's orders. This failure could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health. Findings include: Record review of Resident #30's Face Sheet dated 05/17/2023 admission date 06/16/2014 and readmission on [DATE] to the facility. Record review of Resident #30's History and Physical dated 09/04/2018 revealed a [AGE] year-old male with a diagnosis of hypoxemia (a low level of oxygen in the blood). Record review of Resident #30's annual MDS dated [DATE] revealed a brief interview for mental status score that was not mark ed, a diagnosis of hypoxemia (a low level of oxygen in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 #2) of 4 reviewed for medication administration. The facility failed to ensure that RN L administered Resident # 2's medications according to the scheduled medication time. This deficient practice could place residents on the 400 on the hall in the even shift at risk of not receiving their medication in accordance with the scheduled time. Findings included: Record Review of Resident #2 face sheet dated 5/18/23 revealed a [AGE] year-old male initially admitted on [DATE] with a readmission date of 03/01/23. Record Review of Resident #2 History and Physical dated 03/01/23 revealed a diagnosis of diabetes mellitus type 2 (condition where the body is unable to regulate the blood glucose). The document revealed a plan 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that each resident's drug regimen was free from psychotropic drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for one (Resident #98) of 5 residents reviewed for unnecessary medications. Resident #98 was prescribed an antipsychotic medication (Quetiapine Fumarate) for treatment of dementia with major depressive disorder. This failure puts residents at risk of medication side effects as a result of being administered unnecessary antipsychotic medications. Findings include: Record review of Resident #98's face sheet dated 05/17/2023 reflected he was [AGE] years old and was admitted to the facility on [DATE]. Record review of Resident #98's hospital discharge medication listing dated 04/03/2023 reflected in part that he was to continue receiving sertraline (an antidepressant) after his discharge from the hospital. He was also to receive Donepezil (improves mental function) 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.

Based on observation, interview, and record review the facility failed to ensure it was adequately equipped to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member or to a centralized staff work area for 1 (Resident #45) of 4 resident rooms reviewed for resident call systems. The facility failed to ensure 1 Resident #45 room had a workable outside door light. This failure could place residents at risk of being unable to obtain timely assistance for activities of daily living or in the event of an emergency. Findings include: Interview on 05/16/2023 at 8:54 AM Resident #45 stated she had pushed the call light on 05/15/2023 at around 12:00 AM and noticed the call light outside of the room was out. Resident #45 stated after some time the nurse finally came into her room and reported it to LVN J. Resident #45 stated LVN J informed her that he was going to place a work order to maintenance. Resident #45 stated LVN J did not mention any other means through which the residents could alert staff to their needs.…

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.