Harmony Care At Floresville

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 2 (Residents #188 and #195) of 8 residents reviewed for baseline care plans. 1. The facility failed to include Resident #188's risk for falls and epilepsy in his baseline care plan. 2. The facility failed to include Resident #195's oxygen therapy and wound care in his baseline care plan This failure could result in residents not receiving needed care and treatment. Findings Included: 1. Record review of Resident #188's face sheet dated 03/21/2025 revealed he was a [AGE] year-old man who was admitted to facility on 03/06/2025 with diagnoses which included: Epilepsy (a disorder where nerve cell activity in brain is disturbed causing seizures); alcoholic cirrhosis of liver (chronic liver damage leading the scarring and liver failure)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to a meet resident's medical, nursing, mental, and psychosocial needs for 1 of 6 residents (Resident #36) reviewed for care plans, in that: The facility failed to develop a comprehensive person-centered care plan to address Resident #36's indwelling catheter care requirements. This deficient practices could affect residents who require an indwelling catheter by not having their needs met and putting them at risk of being inappropriately cared for. The finding were: Record review of Resident #36's face sheet, dated 03/21/2025, revealed the resident was admitted to the facility on [DATE] and, readmitted [DATE] with diagnoses that included: Dementia (decline in cognitive abilities), Anxiety disorder (A group of mental illnesses that cause constant fear and worry), Major…

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 who need respiratory care were provided such care consistent with professional standards of practice for 1 (Resident #195) of 3 residents reviewed for respiratory care. The facility failed to ensure Resident #195's used oxygen tubing and nasal cannula were disposed of and not left in the resident's room. This failure could place residents on respiratory therapy at risk for respiratory compromise and infection. Findings included: Record review of Resident #195's face sheet dated 03/18/2025 revealed a [AGE] year old man admitted to the facility on [DATE] with diagnoses which included: Congestive Heart Failure (a chronic condition in which the heart doesn't pump blood as well as it should); and COPD (Chronic Obstructive Pulmonary Disease; a chronic inflammatory lung disease that causes obstruction of airflow to the lungs with symptoms that include shortness of breath, chronic cough, wheezing and excess mucus production…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments and permit only authorized personnel to have access to the keys for 1 (Resident #195) of 8 residents reviewed for Medication storage. 1. The facility failed to ensure Resident #195 did not have a jar of mentholated ointment (a topical analgesic and decongestant) at the bedside. This deficient practice could place residents at risk of medication misuse or drug diversion. The findings included: 1. Record review of Resident #195's face sheet dated 03/18/2025 revealed a [AGE] year old man admitted to the facility on [DATE] with diagnoses which included: Congestive Heart Failure (a chronic condition in which the heart doesn't pump blood as well as it should); and COPD (Chronic Obstructive Pulmonary Disease; a chronic inflammatory lung disease that causes obstruction of airflow to the lungs with symptoms that include shortness of breath, chronic cough, wheezing and excess mucus…

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 and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed, in that: 1. Access to the handwashing sink was blocked by two rolling carts. 2. There was a sand-like substance on top of the dish sanitizing machine. These deficient practices could result in residents consuming meals and/or snacks prepared in an unsanitary manner. The findings were: Observation on 03/18/2025 at 10:25 a.m. revealed that the hand-washing sink in the kitchen was blocked by a rolling cart with plate covers in front of the sink and a rolling cart with food trays next to it. During an interview with the Dietary Manager on 03/18/2025 at 10:27 a.m., the Dietary Manager stated the rolling carts should not have been stored in a manner which blocked access to the handwashing sink. The Dietary Manager further stated that kitchen staff moved the carts prior to washing their hands, and then put the carts back in front of and beside the sink. Observation on 03/21/2025 at 10:28 a.m.,…

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

Based on interview and record review the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facilities reviewed for nursing services. The facility did not have RN coverage for 24 days on 10/5/24, 10/12/24, 10/13/24, 10/20/24, 10/26/24, 10/27/24, 11/16/24, 11/17/24, 11/23/24, 11/24/24, 11/30/24, 12/1/24, 12/7/24, 12/8/24, 12/14/24, 12/15/24, 12/21/24, 12/22/24, 12/28/24, 12/29/24, 1/4/25, 1/5/25, 1/18/25, and 1/19/25. This failure could place the residents at risk of not receiving needed care and services. The findings were: Review of the facility RN timesheets revealed there were no RN hours for Saturdays on 10/5/24, 10/12/24, 10/26/24, 11/16/24, 11/23/24, 11/30/24, 12/7/24, 12/14/24, 12/21/24, 12/28/24, 1/4/25, and 1/18/25. Review of the facility RN timesheets revealed there were no RN hours for Sundays on 10/13/24, 10/20/24, 10/27/24, 11/17/24, 11/24/24, 12/1/24, 12/8/24, 12/15/24, 12/22/24, 12/29/24, 1/5/25, and 1/19/25. In an interview on 1/31/25 at 9:58 a.m. the DON stated the facility did not currently…

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 receive reasonable accommodation of resident needs and preferences that would not endanger the health or safety of the residents for 1 of 6 residents (Resident #5) reviewed for reasonable accommodations of needs and preferences, in that: The facility failed to ensure Resident #5's call light was within reach. This failure could place the residents at risk of failing to achieve or failing to maintain independent functioning, dignity, and well-being. Findings included: Record review of Resident #5's face sheet, dated 1/31/2025, revealed a [AGE] year old female was admitted on [DATE] with a readmission date of 7/25/2024 with diagnoses that included: anxiety disorder, dementia, and hypertension. Record review of Resident #5's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 7 which was indicative of severe cognitive impairment. Record review of Resident #5's Care Plan, 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 had the right to personal privacy and confidentiality of his or her personal and medical records for one of five residents (Resident # 2) reviewed for privacy. The facility failed to ensure Medication aide B locked the computer, which exposed Resident #2's morning medication list after she walked away and left the computer unattended. This failure could place residents at risk of having medical information exposed to others and cause residents to feel uncomfortable and disrespected. The findings include: Record review of Resident #2's face sheet dated 01/29/25 revealed a [AGE] year old female admitted to the facility on [DATE]. Resident #2 had diagnosis that included: Multiple sclerosis (is a disease that causes breakdown of the protective covering of nerves), Hypertension (is when the force of blood against the artery walls is persistently too high), and Depression (is a mood disorder that causes a persistent feeling 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 develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 6 residents (Resident #5) reviewed for comprehensive care plans, in that: Resident #5's call light was not within reach according to one of the resident's care plan interventions for falls. This failure could place the resident at risk of inadequate care that may cause severe injury for the resident. The findings included: Record review of Resident #5's face sheet, dated 1/31/2025, revealed a [AGE] year old female was admitted on [DATE] with a readmission date of 7/25/2024 with diagnoses that included: anxiety disorder, dementia, and hypertension. Record review of Resident #5's Quarterly MDS, dated [DATE], revealed the resident had a BIMS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 2 residents (Resident #3) reviewed for gastrostomy tube management., in that: 1. LVN A failed to check the placement of Resident #3's PEG tube prior to administering flushes and medications. 2. LVN A failed to check Resident #3's gastric residual volume prior to administering flushes and medications via Resident #3's PEG tube. 3. LVN A failed to follow Resident #3's order for flushes when administering flushes and medication via Resident #3's PEG tube. 4. LVN A failed to administer medications and flushes via Resident #3's PEG tube using gravity. These failures could place residents with gastrostomy tubes at risk of aspiration, medical complications, and a decline in health due to inappropriate gastrostomy tube care and management. The findings included: 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.

Based on observation, interview, and record review, the facility failed to ensure the residents' right to personal privacy and confidentiality of his or her personal and medical records for 1 of 1 facility reviewed for privacy and confidentiality, in that: The confidential information of various residents was left in 3 clear plastic trash bags outside of the Medical Records office, and was left on top of a printer in area accessible to all staff, residents, and visitors. The findings included: 1. Observation on 8/6/24 at 9:45 a.m. revealed there were 3 clear trash bags outside of the Medical Records office. During an interview with LVN A on 8/6/24 at 9:45 a.m., at the same time as the observation, LVN A looked inside of each clear trash bag and confirmed that each clear trash bag contained confidential resident information. 2. Observation on 8/6/24 at 9:48 a.m. revealed there was a stack of papers were observed on top of a printer located in a T.V. lounge directly across from the Medical Records office. Further observation revealed a visitor was noted sitting in the lounge. During…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals, in accordance with State and Federal laws, were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 1 of 2 residents (Resident #5) reviewed for storage of drugs, in that: The facility failed to ensure Resident #5's medications were secured when LVN C left Resident #5's room prior to administering medications. This failure could place residents at risk of medication misuse and diversion. The findings included: Record review of Resident #5's Comprehensive MDS assessment, dated 6/22/24, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: acute respiratory failure, congestive heart failure (condition in which the heart can't pump blood well enough to meet the body's needs) bradycardic (week pulse), deep vein thrombosis of left upper arm (a blood clot in a deep vein), atrial fibrillation…

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 all alleged violations involving abuse, neglect, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 2 (Resident #s 1 and 2) of 5 residents reviewed for abuse, neglect, and misappropriation of property, in that; 1. The facility failed to report Resident #1's 5/7/2024 elopement to HHSC. 2. The facility failed to report Resident #2's 5/2/2024 elopement to HHSC. This failure could place residents…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the residents' records were complete and accurate for 3 of 32 residents (Resident #5, #73, and #82) reviewed for clinical records, in that: 1. Resident #5's clinical record included a progress note which was inaccurate and appeared to have been written about a different resident. 2. Resident #73's diagnosis of Bipolar Disorder was not included on her face sheet. 3. Resident #82's colostomy care was completed by the resident not nursing staff, but nurses were signing off on the TAR as if they were completing care. These deficient practices could result in inadequate care due to incomplete and inaccurate medical records. The findings were: 1. Record review of Resident #5's face sheet, dated 02/15/2024, revealed the resident was admitted to the facility on [DATE] with diagnoses including Hypertensive Heart Disease Without Heart Failure, Other Developmental Disorders of Scholastic Skills, and Anxiety Disorder. Record review of Resident #5'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 ensure the recommendations from the PASARR level II determination and the PASARR evaluation report were included into a resident's assessment, care planning, and transitions of care for 1 (Resident #5) of 3 residents reviewed for PASARR services, in that: Resident #5 did not receive specialized PASRR services as agreed upon during his Interdisciplinary Team meeting. This failure could place residents with a positive PASRR evaluation at risk for the loss of opportunity to reach their highest level of functioning and could contribute to a decline in physical, mental, and psychosocial well-being. The findings were: Record review of Resident #5's face sheet, dated 02/15/2024, revealed the resident was admitted to the facility on [DATE] with diagnoses including Hypertensive Heart Disease Without Heart Failure, Other Developmental Disorders of Scholastic Skills, and Anxiety Disorder. Record review of Resident #5's Quarterly MDS, dated [DATE], revealed a BIMS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure each resident with a mental disorder was screened prior to admission for 1 of 3 of (#2) residents reviewed for PASRR: The facility did not correctly identify Resident #2 on the PASRR Level 1 Screening Form as having Mental Illness and did not submit a request to correct their PASRR negative screening. This failure could affect residents with mental illness that was not considered to be a Positive PASRR and could result in a decrease in services. The Findings were: Record review of Resident #2's Face sheet, dated 02/14/2024, revealed an [AGE] year-old, admitted on [DATE] and was diagnosed with schizoaffective [a condition where symptoms of both psychotic and mood disorders are present together during one episode], bipolar [causes extreme mood swings that include emotional highs (mania or hypomania) and lows] and [Type two Diabetes] health condition that affects how your body turns food into energy. Record review of Resident #2's Quarterly MDS…

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

Based on interviews and record reviews, the facility failed to complete the baseline care plan for 1 of 32 residents (Resident #153) reviewed for baseline care plans in that: The facility failed to complete (Resident # 153's) baseline care plan within the required time frame. This deficient practice could affect residents who receive care at the facility and could result in missed or inadequate care. The findings were: Record review of Resident #153's face sheet dated 02/15/24 with recent admission date of 2/2/24 and diagnoses which included: displaced fracture of the left femur (a left broken thighbone), type 2 diabetes (a condition in which the body has difficulty controlling blood sugar) and atherosclerotic heart disease (an illness in which the heart's arteries are damaged). Record review of Resident #153's MDS, completed on 2/10/24, revealed a BIMS score of 10, which indicated moderate cognitive impairment. Record review of Resident #153's Baseline Care Plan, shows a completion date of 2/7/24 with a locked finalization date of 2/13/24. In an interview with MDS Coordinator B on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 of 8 residents (Residents #82 and #92) reviewed for care plans, in that: 1. The facility failed to care plan Resident #82's self-care for colostomy. 2. The facility failed to ensure Resident #92's indwelling catheter was free of kinks; a dignity bag and anchor were used. These failures could have placed residents at risk of not having their needs met. The findings were: 1. Record review of Resident #82's face sheet, dated 2/13/24, revealed an admission date of 10/2/23 with the diagnosis that included: [Candidiasis] a fungal infection caused by a yeast, [colostomy status] An opening into the colon from the outside of the body which provides a new path for waste material to leave the body…

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

Based on interviews and record reviews, the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activities professional who was licensed or registered by the state for 1 of 1 Activity Director, reviewed in that: The facility failed to ensure the AD was qualified to serve as the director of the activities program. This failure could place residents at risk for reduced quality of life due to lack of activities that were individualized to match the skills, abilities, and interests/preferences of each resident. The findings were: Record review of staff roster, provided by the facility, undated, revealed the staff member was listed as Activities Director. Further review revealed the AD was hired on 09/21/23. During an interview with the Activities Director on 02/15/24 at 10:45a.m., she stated that she was hired on 9/21/23 as an Activity Director Assistant but became Director of the Activity Department on 12/1/23. She stated that she knows the position requires an Activity Director…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure incontinent bladder residents received appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible for 2 of 12 residents (Residents #82 and #7) reviewed for indwelling catheters and perineal/incontinent care, in that: 1. The facility failed to ensure Resident #82 indwelling catheter was attached to prevent pulling or tugging to the urethra. 2. The facility failed to ensure Resident #7's indwelling catheter was attached to prevent pulling or tugging to the urethra and failed to provide a dignity bag. These failures could place residents at risk for discomfort, urethral trauma (injury to the duct in which urine is transported out of the body from the bladder), and urinary tract infections due to improper care. The findings were: 1. Record review of Resident #82's face sheet, dated 2/13/24, revealed an admission date of 10/2/23 with the diagnosis that included: [Candidiasis]…

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 each resident's drug regimen was free from unnecessary medications (excessive dose and duplicative therapy) for 1 of 6 residents (Resident #6) reviewed for unnecessary medications, in that: 1. Resident #6 received Lorazepam 0.5 mg three times a day for general anxiety disorder. 2. Resident #6 received Buspirone 7.5 mg three times a day for general anxiety disorder This failure could place residents at risk for adverse drug consequences and receiving unnecessary medications. The findings were: Record review of Resident #6's Face sheet, dated 2/15/24, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: [Generalized anxiety disorder] involves a persistent feeling of anxiety or dread, which can interfere with daily life, [ Major depressive disorder] mood disorder that causes a persistent feeling of sadness and loss of interest, and [Heart failure] occurs when the heart muscle doesn't pump blood as well as 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 observation, interview, and record review, the facility failed to ensure all drugs and biologicals used in the facility were labled and stored in loccked compartments in 1 medication cart of 6 medication carts (Nurse's Cart 400-hallway) and one crash cart of 2, reviewed for medication storage, in that: 1. The facility failed to ensure the Nurse's Cart 400 hallway was left unlocked and unattended in the hallway. 2. The facility failed to ensure the irrigation solution in the crash cart for the south building was not expired. These deficient practices could place residents at risk of medication misuse or drug diversion. The findings included: 1. During an observation on [DATE] at 7:02 a.m., the nurse's treatment cart in the 400 hallway was unlocked and unattended. There were ambulatory residents in the immediate vicinity, and there were no nurses at the nurses' station. During an observation and interview on [DATE] at 7:18 a.m., the treatment cart in the 400 hallway remained unlocked; RN C was notified…

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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: 1. Dietary Aide A was not properly wearing a hair restraint. 2. A food item in the dry storage area was not properly dated and labeled. 3. A kitchen drawer had a drawer cover and a drawer surface area that were not cleaned. These deficient practices could place residents who received meals and snacks from the kitchen at risk for food borne illness from improper infection control, from a lack of food label date monitoring, and improper sanitation in the kitchen area. The findings included: Observation on 02/13/2024 from 9:50 a.m. to 11:00 a.m. during the kitchen tour revealed the following: a. Dietary Aide A was working in the kitchen wearing a hair restraint that did not fully cover the back of her head with visible exposed hair. b. There was a package of 24 blueberry muffins with a sealed plastic cover…

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 record review and interviews, the facility failed to maintain spaces of at least 80 square feet per resident for 14 of 15 Resident rooms (Resident rooms #101, 102, 103, 104, 105, 106, 107, 401, 403, 404, 405, 406, 408, and 409) inspected for resident room sufficient space for privacy and comfort, in that: The facility failed to ensure resident rooms #101, 102, 103, 104, 105, 106, 107, 401, 403, 404, 405, 406, 408, and 409 were maintained with at least 80 square feet of space per resident. This failure could place residents at risk of restricting their resident rights for comfort and privacy. The findings were: Record review of the Bed Classification Form 3740 dated 02/13/24 which was filled out by the Administrator indicated the capacity of the facility was 144 beds. In an interview with the Administrator on 02/16/24 at 10:55 a.m., revealed she was not aware of any room waivers for the facility. Review of the measurements provided by LSC, of the bedrooms which were measured and identified by the Maintenance Director indicated as follows: Bedroom # (allocated for 2 Beds 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.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public, for 1 of 6 halls (400 hall) reviewed for physical environment, in that: The facility failed to secure loose flooring on the 400 hall. This failure could place residents who reside in the facility at-risk of falls and further injuries due to an unsafe environment. The findings were: Observation on 02/15/2024 at 08:35 a.m. revealed the flooring on the 400 hall was loose. During an interview with the Maintenance Director on 2/16/2024 at 10:15 a.m., Maintenance Director confirmed there was loose flooring on the 400 hall. Record review of the facility's policy titled, Homelike Environment, revised February 2014, revealed, Residents are provided with a safe, clean, comfortable, and homelike environment .

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, in that: The janitorial closet on 600 hall was unlocked and accessible to residents. This deficient practice could place residents at risk of coming into contact with harmful substances. Observation on 12/07/2023 at 5:45 a.m. revealed the janitorial closet on 600 hall was unlocked and accessible to residents; stored within were a gallon container of bleach and four varied containers of cleaning fluids, each labeled with caution, keep out of reach of children and harmful if swallowed. During an interview with ADON A on 12/07/2023 at 5:45 a.m., ADON A verbally confirmed the janitorial closet on 600 hall was unlocked, accessible to residents, and stored within were hazardous materials. ADON A stated the closet should have been locked and did not know why it had not been locked. During an interview with the Administrator on 12/07/2023 at 7:00 a.m., the Administrator verbally confirmed that hazardous materials…

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.