DFW Nursing & Rehab

Based on observation, interview, and record review, the facility failed to maintain safe and functional essential kitchen equipment in the facility's only kitchen. The facility failed to ensure the gas stove top oven had all turn knobs, did not leak grease, and was safe to touch when operating.The facility failed to assure the wall plug sockets were free of food and grease particles, and in safe operating condition. The facility failed to ensure the toaster oven was in safe operating condition. These failures could place residents at a risk for facility essential equipment not being maintained in working order. Findings included: An observation on 07/29/2025 at 8:52AM of the gas stove top oven revealed a small pile of white cloth towels with grease on them under the left front corner of the oven.An observation on 07/30/2025 beginning at 11:50AM of the facility's kitchen revealed:- A toaster over with electrical tape around its power cord- 2 wall sockets with black burn-like appearance- 2 wall sockets covered with food particles and grease- Food particles and grease build up on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to provide a clean, safe, and functional environment for 6 of 10 rooms (Rooms 1, 2, 3, 4, 6, and 8) reviewed for environment. 1. The facility failed to repair the window in room [ROOM NUMBER].2. The facility failed to have baseboards, holes in the wall, and tile repaired in shared resident restrooms. 3. The facility failed to have soap and paper towels available in resident shared restrooms.4. The facility failed to repair the window, and repair holes in the wall and baseboards in room [ROOM NUMBER]. These failures could place residents at risk of living in an unsanitary, unsafe environment and a diminished quality of life. Findings included: Observation on 07/29/2025 at 10:22 am, revealed dirt, grime and peeling paint on the windowsill in room [ROOM NUMBER]. A disposable under pad was stuffed between a small gap between the window and window seal. Observation on 07/29/2025 at 10:33 am, revealed all baseboards loose in the restroom, 3…

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 develop, prepare, and periodically update menu items to meet residents needs and preferences. The facility failed to utilize and follow dietitian approved recipes for pureed food items.The facility failed to prepare an alternate menu in advance. The facility failed to ensure alternate menus were reviewed and approved to ensure it met the residents nutritional needs by the facility's dietitian.The facility failed to make reasonable efforts to develop a menu based on resident complaints about the lack of variety in food options. These failures could result in an adverse effect to resident's physical and psychosocial well-being.Findings included: During an observation on 07/29/2025 at 9:30AM, this surveyor asked the dietary assistant for a regular and alternate menu for the next 3 days. The dietary assistant was able to provide a regular menu of the meal being served that day, but not an alternate menu. She explained the alternate menu item was chosen the day of and there was not an official alternate menu. An…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an effective pest control program for two of the three hallways reviewed for pest control and the facility's only kitchen. The facility failed to ensure Resident #36 and Resident #28's room was free of flies on 7/29/25 and 7/30/25.The facility failed to ensure Resident #56 and Resident #28's room was free of flies on 7/30/25. This failure could lead to pest infestation and place residents at risk of insect transmitted diseases.Findings included: Review of Resident #36's face sheet reflected he is a [AGE] year-old male admitted on [DATE]. Review of Resident #28s face sheet reflected he is a [AGE] year-old male admitted on [DATE]. Review of Resident #56's face sheet reflected he is a [AGE] year-old male admitted on [DATE]. Review of Resident #29's face sheet reflected he is a [AGE] year-old male admitted on [DATE]. Review of Resident #36's Quarterly MDS dated [DATE] reflected a BIMs score was not done as resident was rarely/never…

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 the resident's right to be free from abuse for one (Resident #65) of 5 residents reviewed for abuse, in that: On 7/27/25 the facility failed to ensure that Resident #65 was not slapped in the face by Resident #21 resulting in a bruise to the area of the right eye. This failure could result in resident abuse and injuries.Findings include: Review of Resident #65's Face Sheet reflected he is a [AGE] year-old male admitted to the facility on [DATE]. Review of Resident #65's Quarterly MDS dated [DATE] reflected in part diagnoses including seizure disorder, traumatic brain injury, depression, and bipolar disorder (mental health condition causing extreme mood swings). A BIMS score of 11 indicated moderate cognitive impairment. Review of Resident #65's Care Plan dated 7/12/25 reflected Resident #65 was at risk for bleeding and bruising due to taking aspirin. Review of Resident #21's Face Sheet reflected he is a [AGE] year-old male…

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, observation, and record review, the facility failed to ensure that an allegation of abuse was reported immediately to Health and Human Services for one (Resident #30) of three residents reviewed for abuse and neglect reporting. The facility failed to make a timely report of Resident #30's allegation that a staff member kicked a shoe at her, hurting her leg, on 07/19/25. This failure could place residents at risk of being abuse and lack of oversight by a state agency. Findings included: Review of Resident #30's face sheet, dated 07/31/25, reflected she was a [AGE] year-old female, admitted on [DATE], and having diagnoses of Alzheimer's disease, dementia in other disease (dementia associated with another health condition) with behavioral disturbance, bipolar II (a less severe form of bi-polar than bi-polar I), major depressive disorder, and an anxiety disorder. Review of Resident #30's quarterly MDS assessment, dated 06/05/25, reflected Resident #30 had adequate hearing and clear speech, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to provide evidence that all an allegation of abuse was thoroughly investigated for three residents (Resident #30, Resident #15, and Resident #81) of three residents reviewed for abuse and neglect reporting. 1. The facility administrator failed to provide evidence of a thorough investigation of an allegation of abuse by Resident #30 on 07/19/25, in which she alleged a staff member kicked a shoe at her and hurt her foot.2. The facility administrator failed to provide evidence of a thorough investigation of an allegation of abuse between Resident #15 and Resident #81 where there was a physical altercation between the both of them. This failure could place residents at risk of being abused and lack of oversight by a state agency. Findings included: 1. Review of Resident #30's face sheet, dated 07/31/25, reflected she was a [AGE] year-old female, admitted on [DATE], and having diagnoses of Alzheimer's disease, dementia in other disease (dementia…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observation, and record review, the facility failed to implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and mental and psychosocial needs in order attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one resident (Resident #30) of 24 residents reviewed for care plans. The facility failed to create a care plan addressing Resident #30's trauma history on 05/07/25, when her trauma screening assessment reflected her history of trauma. This failure could affect residents by placing them at risk for not receiving care and services to meet their needs.Findings included: Review of Resident #30's face sheet, dated 07/31/25, reflected she was a [AGE] year-old female, admitted on [DATE], and having diagnoses of Alzheimer's disease, dementia in other disease (dementia associated with another health condition) with behavioral disturbance, bipolar II (a less severe form of bi-polar than bi-polar…

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 provide or obtain laboratory services only when ordered by the physician; physician assistant; nurse practitioner or clinical nurse specialist in accordance with State Law, including scope of practice laws and promptly notify the ordering physician of the results for one (Resident #1) of two residents reviewed for labs. 1. Nursing staff did not ensure that labs (CBC, CMP, lipid, Valproic acid) were drawn every six months for Resident #1. 2. Nursing staff did not ensure that labs (Hgb and A1C) were drawn every three months for Resident #1. These failures could place residents at risk of a delay in receiving the necessary interventions to treat their medical condition. Findings included: Review of Resident #1's face sheet dated 06/18/25 revealed a [AGE] year-old male with an admission date of 12/15/2023. Diagnoses included: metabolic encephalopathy (condition when brain dysfunction occurs), severe protein-calorie malnutrition (condition of inadequate…

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, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for two of six residents (Resident #1 and Resident #2) reviewed for care plans. 1. The facility failed to identify Resident #1 had physical and/or verbal behaviors on his admission MDS assessment dated [DATE] or develop a care plan to address the behavior. 2. The facility failed to develop a care plan to address Resident #2's substance abuse . This failure could place residents at risk of not receiving appropriate care and services. Findings include: 1. Record review of Resident #1's face sheet, dated 5/20/25, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: dementia (brain disorder…

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 all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury to the administrator of the facility and to other officials including to the State Agency in accordance with State law through established procedures, for two of eleven residents (Resident #1 and Resident #2) reviewed for abuse, neglect and exploitation . 1. The facility failed to report to the state agency when Resident #1 exhibited sexually inappropriate behaviors to prevent further abuse or neglect towards Resident #1 and others. 2. The facility failed to report to a law enforcement entity and the state agency when Resident #2 obtained and used nonprescription drugs at the facility, was found…

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 in response to allegations of abuse, neglect, exploitation or mistreatment have evidence that all alleged violations were thoroughly investigated and prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress for two of eleven residents (Resident #1 and Resident #2) reviewed for abuse, neglect and exploitation. 1. The facility failed to investigate an alleged violation when Resident #1 exhibited sexually inappropriate behaviors to prevent further abuse or neglect towards Resident #1 and others. 2. The facility failed to investigate when Resident #2 obtained and used nonprescription drugs at the facility, was found exhibiting signs of an overdose, and was transported to the local hospital where he tested positive for marijuana . This failure could place all residents at an increased risk for abuse and neglect. Findings included: 1. Record review of Resident #1's face sheet, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to ensure the facility did not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion for 2 of 3 residents (Resident #1 and #2) reviewed for abuse, neglect, and or exploitation. for 2 of 3 residents reviewed for abuse. (Resident #1 and Resident #2) 1. The facility failed ensure Resident #1 and #2's were free from resident-to-resident abuse, which occurred on 04/05/25. These failures could place residents at risk for decreased quality of life, decreased self-esteem and increase anxiety. Findings included: Record review of an undated admission Record revealed Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with the diagnoses of Encephalopathy (broad term for any brain disease that alters brain function or structure), Bipolar Disorder and Unspecified Dementia, Unspecified Severity, with Agitation. Record review of Optional State Assessment Minimum Data Set, 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.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for food and nutrition services. The facility failed to ensure food items were kept away from potential airborne contaminants (leaking sinks, dust particle and grease). This failure could place residents at risk for food contamination and foodborne illness. Findings included: Observation on 04/08/25 at 8:00 AM, revealed behind the air fryer area had white and brown grease on the wall. Observation of the floor revealed brown grease behind the equipment that ran from the air fryer to the stove. Observation on 04/08/25 at 8:30 AM, revealed one white towel that had turned brown was wrapped around a pipe. Under the towel was a hole that the piping did not fit into, and water was running to the hole. Observation on 04/08/25 at 8:35 AM, revealed another white towel that had turned brown underneath the pots and pans sink. Interview on 04/08/25 at 9:00 AM, CK stated the pipes…

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 in one of one kitchen reviewed for a clean environment. The facility failed to keep a safe and sanitary kitchen environment (leaking sinks, dirt towels and open hole outside the kitchen that was not covered to control kitchen contamination). This failure could place the residents at risk of exposure to infectious material. Findings included: Observation and interview on 04/09/25 at 8:30 AM, the MD and AMD went outside behind the kitchen to view the hole the plumber dug two weeks ago to start repairs on the pipes for the kitchen. The MD stated the plumber will need to do the tunnel from outside to follow the piping under the building and will need to replace the PVC piping. Surveyor observed a large, uncovered hole behind the kitchen wall. Attempted to interview plumber on 04/09/25 at 9:00 AM, he stated to contact the MD at the facility, and he will be able to go over the details of the repair. Interview on 04/09/25 at 2:11 PM, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to notify the resident's representative and ombudsman of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood for 1 of 2 resident (Resident #1) reviewed for Discharge Rights. The facility failed to notify Resident #1's resident representative in writing of the transfer/ discharge of the resident to a behavioral hospital, the reason for the transfer/discharge, and the right to appeal. This failure could affect the residents at the facility by placing them at risk of being discharged and not having access to available advocacy services, discharge/transfer options, and appeal processes. Findings included: Resident #1's face sheet (undated) reflected she was a [AGE] year-old female readmitted to the facility on [DATE] with an initial admission on [DATE]. Resident #1 discharged to hospital for a behavioral evaluation on 02/10/2025. Resident#1 was transferred to the Behavioral hospital on [DATE] for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to immediately report failed to report abuse, neglect, exploitation, or critical incidents for 1 of 4 resident (Resident #1) reviewed for reporting. The facility failed to report an incident of resident to staff physical aggression/assault to HHSC. This failure could place residents at risk for abuse, neglect and incidents. Findings included: Record review of Resident #1's face sheet, dated 01/23/25, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included Schizophrenia (serious mental condition that affects how people think, feel and behave. It may result in a mix of hallucinations, delusions, and disorganized thinking and behavior) Type 2 Diabetes Mellitus with Diabetic, Unspecified Psychosis not due to substance or known major depressive disorder. Record review of Resident #1's Quarterly MDS assessment, dated 10/28/24, reflected Resident #1 had a BIMS of 12, which indicated cognition…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure complete and accurate incident/accident report for 1 (Resident#1) of 4 residents reviewed for incident reports. The facility failed to ensure Resident#1's incident report was completed on 01/22/25, which involved a verbal and physical altercation between Resident#1 and Administrator by LVN C. This failure could place residents at risk of inaccurate or incomplete information, resulting in the risk of abuse or neglect by staff. Findings include: Record review of Resident #1's face sheet, dated 01/23/25, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included Schizophrenia (serious mental condition that affects how people think, feel and behave. It may result in a mix of hallucinations, delusions, and disorganized thinking and behavior) Type 2 Diabetes Mellitus with Diabetic, Unspecified Psychosis not due to substance or known major depressive disorder. Record review of Resident #1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure each resident received an accurate assessment, reflective of the resident's status for 2 of 7 residents (Resident #1 and Resident #5) reviewed for Accuracy of Assessments. 1. Resident #1's discharge MDS assessment dated [DATE] did not accurately reflect his current and MD order for Hemodialysis treatment in Section O. 2. Resident #5's quarterly MDS assessment dated [DATE] did not accurately reflect his current MD order for continuous oxygen treatment in Section O. These failures could place residents at risk for not receiving care and services to meet their needs, diminished function of health, and regressions in their overall health. Findings included: Resident #1 Record review of Resident #1's face sheet dated 10/28/24 reflected he was a [AGE] year-old-male, admitted on [DATE] and readmission on [DATE]. Resident #1's DX included: Chronic Kidney Disease Stage 3 convulsions dependent on dialysis (kidney failure). Record review of Resident #1's…

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

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 the facility's only kitchen . The facility failed to ensure items found in the reach-in refrigerator, were labeled with the name of container contents and the use by date, expired by date in the facility's only kitchen. The facility failed to ensure items found in the reach-in refrigerator was covered, tabled and dated. This failure could place residents at risk for food-borne illness and food contamination. Findings include: Observation on 06/23/2024 at 9:01 AM revealed in the facility's only reach-in refrigerator the following items were not labeled or dated: Metal pot with shredded cheese covered with a ceramic plate. Styrofoam plate which contained potato chips and two sandwiches. Block of cheese covered in plastic wrap. Metal pan which contained meat pies covered with plastic wrap. Metal pan which contained sliced ham had no covering. Interview on 06/25/2024 at 03:42 PM with the Dietary Manager…

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 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 one of ten residents (Residents #19) reviewed for infection control. 1. The facility failed to ensure MA A performed hand hygiene and wore gloves when administering eye medication to Resident #19. 2. The facility failed to ensure MA A did not use his bare finger to remove Coreg 6.25 MG tablet out of Resident #19's. medication cup before administering her medications. These failures could place residents at risk of infectious diseases and cross contamination. Findings include: 1. Record review of Resident #19's face sheet, dated 06/25/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included generalized anxiety disorder a condition of severe, ongoing anxiety that…

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

Based on observation, interview and record review the facility failed to ensure the resident environment remained free of accident hazards as was possible for 1 of 1 smoking areas reviewed for accidents and hazards. The facility failed to ensure smoking residents were free of fire hazards, when a propane grill was stored on the smoker's court. The facility failed to ensure the smoking area was free of fire hazards. Findings include: Observation on 06/23/2024 at 1:00 PM of the resident smoking courtyard revealed residents sitting in patio chairs through the courtyard. Through the conference room window reflected a grill on the smoking court near the building . Observation on 06/23/24 at 1:13 PM, on the smoking courtyard, revealed a grill with 2 gas tanks outside in the courtyard one propane tank was attached to the grill and one was positioned behind the grill . Interview on 06/23/24 at 1:23 PM with the Activity Director revealed the residents sat all the way in the chairs in the courtyard. He said he did not do any cooking on the grill. He stated the maintenance man did the grilling…

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 record review and interview 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 one (Resident#19) of five residents reviewed for pharmaceutical services. The facility failed to specify blood pressure (BP) perimeters for Resident #19's order for Nifedipine 30 mg ER and Carvedilol 6.25 mg [both medications used to treat high blood pressure] when Resident #19's blood pressure reading was 105/72. MA A administered Nifedipine 30 mg and held Carvedilol 6.25 mg. These failures could place residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health. Findings Included: Record review of Resident #19's face sheet, dated 06/25/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included generalized anxiety disorder a condition of severe, ongoing anxiety…

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 all drugs and biologicals used in the facility are labeled in accordance with professional standards, including expiration dates and with appropriate accessory and cautionary instructions for one (Resident #38) of five residents reviewed for storage of drugs and Biologicals. The facility failed to ensure MA B administered Amiodarone 200 mg (a medication used to regulate and lower heat rate) without checking vital signs or heart rate for Resident # 38 even with warning reflected on the medication bubble card to hold if heart rate was less than 60 BPM. These failure could place residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health. Record review of Resident #38's face sheet, dated 06/24/24, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included metabolic encephalopathy (a condition of brain confusion due to chemical imbalance…

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 unable to carry out activities of daily living received necessary services to maintain grooming, and personal hygiene for 1 (Resident #1) of 5 residents reviewed for ADLs in that: The facility failed for provide Resident #1 with timely incontinent care. This failure could put residents at risk of impaired skin integrity, and decreased feelings of self-worth and dignity. Findings included: Record review of Resident #1's admission Record dated 05/30/24 revealed he was a [AGE] year-old male originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Insomnia (Disorder can make it hard to fall asleep and hard to stay asleep), major depressive disorder (mental disorder characterized by a persistent depressed mood-causing significant impairment in daily living), recurrent, Pseudobulbar affect (inappropriate involuntary laughing and crying due to a nervous system disorder), mild…

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 services to residents with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents by not providing a call light system within reach for 1 of 25 (Resident #2) observed for call lights. The facility failed to ensure Resident #2 had a call light within reach so Resident #2 could communicate to staff he needed assistance. This failure affected residents by placing them at risk for not getting their needs met and diminishing their quality of life. Findings include: Record review of Resident's #2s Face Sheet dated 3-5-2024 indicated a [AGE] year-old male admitted to the facility on [DATE]. Resident #2 had a primary diagnosis of Hemiplegia (paralysis) and Hemiparesis (loss of strength in limbs) following a cerebrovascular disease (condition affecting blood flow to the brain) affecting the right dominant side, unspecified visual loss, seizures,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for one of 5 residents (Resident #2) reviewed for comprehensive resident centered care plans. The facility failed to ensure the comprehensive resident centered care plan for Resident #2 was implemented by not putting a fall mat in Resident #2's room. This failure could place residents, that are at risk for falls, to be injured by not putting interventions listed in resident's care plan. Findings include: Record review of Resident's #2s Face Sheet dated 3-5-2024 indicated a [AGE] year-old male admitted to the facility on [DATE]. Resident #2 had a primary diagnosis of Hemiplegia (paralysis) and Hemiparesis (loss of strength in limbs) following a cerebrovascular disease (condition affecting blood flow 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 provide residents who were unable to carry out ADLs the necessary services to maintain good personal hygiene for 1 of 25 residents (Resident #1) reviewed for showers. The facility failed to ensure Resent #1 received showers/baths on scheduled shower/bath days. This failure affected residents by putting them at risk for a diminished quality of life, hygiene, and self-esteem. Findings include: Record review of Resident's #1 Face Sheet dated 3-5-2024, indicated a [AGE] year-old male, who was admitted to the facility on [DATE]. Resident #1 had a primary diagnosis of type 2 diabetes mellitus, morbid obesity due to excess calories, cerebral infarction (stroke), and osteoarthritis. Record review of Resident's #1 care plan dated 6-21-2023, revealed he required extensive/total assist with ADL's due to morbid obesity and late effect CVA (an interruption in the flow of blood to cells in the brain) with hemiplegia (Muscle weakness or partial paralysis…

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 must ensure that the resident's environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 25 (Resident #2) observed for call lights. The facility failed to ensure Resident #2 had a call light within reach so Resident #2 could communicate to staff he needed assistance. The facility failed to enure Resident #2 had a fall mat next to the bed as indicated in Resident #2's care plan. This failure affected residents by placing them at risk for not getting their needs met and diminishing their quality of life. Findings include: Record review of Resident's #2's Face Sheet dated 3-5-2024 indicated a [AGE] year-old male admitted to the facility on [DATE]. Resident #2 had a primary diagnosis of Hemiplegia (paralysis) and Hemiparesis (loss of strength in limbs) following a cerebrovascular disease (condition affecting blood flow to the brain)…

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, observations and record review, the facility failed to ensure incontinent care was provided in accordance with appropriate treatment and service practices to prevent urinary tract infections and to restore continence to the extent possible for three (Residents #1, #2, and #3) of six residents reviewed for incontinent care and catheter care, in that: Residents #1, #2, and #3 had an indwelling urinary catheter (a catheter which is inserted into the bladder, via the urethra and remains in to drain urine) without a physician's order, regarding a valid rationale for the placement of an indwelling urinary catheter. This deficient practice could place residents at-risk for infection due to improper care practice. The findings included: Record Review of resident #1's face sheet, printed on 02/29/24, indicated Resident #1 was a [AGE] year-old male who admitted to the facility on [DATE]. Resident #1 had diagnosis of tracheostomy status (a procedure to help air and oxygen reach the lungs by creating an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment, for daily living for four of six residents (Resident #1, #2, #3, and #4) review for environmental concerns. The facility failed to clean restrooms in Resident #1, #2, #3 and #4's room. This failure could affect residents by exposing them to an unsanitary and unsafe environment. Findings included: In an observation and interview on 01/11/2024 at 12:36 p.m., revealed the door to shower room [ROOM NUMBER] was ajar, an attempt to open the door revealed the door and bathroom floor made contact requiring door to be opened with force. Observation reflected drag marks on the floor reflecting contact with the door and floor. The shower was clean. Observation reflected there was not an out of order sign on the door. Interview with the DON on 01/11/2024 at 12:37 p.m., reflected the shower is not working because of the door. We have someone coming out to repair the bathroom. The DON said all 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 that each resident received adequate supervision and interventions for 3 of 6 residents (Resident #1, Resident #3, and Resident #5) reviewed for supervision and interventions. 1.The facility failed to use a Hoyer sling that was in good condition for Resident #1. 2. The facility failed to ensure Resident #3's wheelchair was in good condition. 3. The facility failed to safely supervise and transport Resident #5 to the facility at admission. These failures could place residents at risk for accidents and injury. Findings included: 1. Record review of Resident #1's admission record, dated 01/12/2024, revealed a [AGE] year-old male who originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1's diagnoses included cerebral infarction (stroke), vascular dementia, mixed receptive-expressive language disorder (difficulty understanding and using language) and hemiplegia (one sided paralysis) and hemiparesis (one sided weakness)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide a safe, functional, sanitary and comfortable environment for 1 of 2 shower rooms reviewed for environmental concerns. The facility failed to ensure shower room [ROOM NUMBER] was functional. This failure could place residents at risk of not receiving showers and living in an unsafe and uncomfortable environment. Findings included: Observation and interview on 01/11/2024 at 10:45 a.m., of shower room [ROOM NUMBER], revealed the metal threshold of the shower room was loose and appeared dirty. The door did not open fully, and no signage was posted on the door. RN C stated residents did get showers in the room and RN C had to force open the door. Interview on 01/11/2023 at 12:39 p.m., CNA A stated the door to shower room [ROOM NUMBER] was hard to open. Interview on 01/11/2024 at 1:42 p.m., the Administrator stated residents do not use the tubs in their rooms, they go to the shower room. He stated the shower room on B Hall (shower room [ROOM NUMBER])…

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

Based on observation, interview and record review, the facility failed to maintain and effective pest control program to ensure the facility was free of pests for 1 of 2 resident rooms (Resident #3's room) reviewed for pests. The facility failed to ensure an effective pest control program was implemented to prevent gnats in resident rooms. This could place residents at risk of foodborne illness and/or disease spread by pests. Findings included: Observation and interview on 01/11/2024 at 12:56 pm in Resident #3's bathroom and bedroom revealed about 3-4 gnats flying around. Resident #3 stated he noticed the gnats and does swat at them. Interview on 01/11/2024 at 1:29 pm, the Maintenance Director stated he only goes into the resident bathrooms if the staff put something on the log that needs to be fixed. He stated if they put gnats, he logs that in the pest control book. Interview on 01/11/2024 at 1:50 pm, the Administrator stated he had been there since November and in the time here has no complaints about pest issues. He stated he had not actually seen with his own eyes any issues…

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

Based on observations, interviews, and record reviews the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 24 hours after the allegation is made for one (Resident #1) of 2 residents reviewed for reporting of allegations. The facility failed to report Resident #1's unwitnessed falls timely as required. This failure could place residents at risk of not having incidents reported as/when required. Findings included: Record review of Face Sheet for Resident # 1 revealed the resident initially admitted to facility on 04/10/2009 for long term care and enrolled with hospice on 01/06/2023 with admitting diagnosis of CVA (cerebrovascular accident; stroke). Resident #1 has an advanced directive on file with DNR. Resident #1 admission diagnoses information included essential (primary) hypertension; other encephalopathy (any disease that affects the whole brain and alters its structure or how it works, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that medical records were accurately documented for one (Resident #5) of three residents reviewed for accurate medical records, in that: The facility failed to ensure Resident #5's medical chart reflected nursing documentation of Resident #5 signing out of the facility and being pushed back into the facility by the local police because Resident #5's electronic wheelchair battery died. This deficient practice could result in errors in care and treatment. Findings included: A review of Resident #5's electronic face sheet reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Major depressive disorder (mental disorder[9] characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), Cerebral Infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), and Morbid obesity(…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents in 24 of 51 (1, 2, 5, 9, 10, 11, 15, 16, 17,18, 19, 21, 23, 24, 25, 26, 27, 38, 39, 40, 42, 43, 45, and 49 and four of four (North, South, East and West) corridors reviewed for environment. The facility failed to maintain all displaced, cracked, broken, and missing wall, floor, and ceiling tiles. The facility failed to repair rusted, worn, scraped, peeling and gouged paint on doors and door frames of the room bathrooms and corridors. The facility failed to maintain the buckled flooring in the therapy room in a safe manner. This deficient practice could place residents at risk of a diminished quality of life due to an unsafe and unmaintained environment. The findings were: Observations and interview with the Maintenance Assistant on 03/29/2023 between 1:18PM and 3:07PM revealed the ceramic tile walls of residents' bathrooms in bedrooms 1, 2, 9, 10, 11, 15, 16,…

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, the failed to provide a private meeting space for residents' monthly Resident Council Meeting for 7 of 10 confidential residents reviewed Resident Council. The facility failed to provide a private space area for the monthly Resident Council Meetings. This failure could place residents who attend the monthly Resident Council Meetings at risk of not being able to voice their concerns due to a lack of privacy. Findings included: In an interview on 03/29/2023 at 12:06 PM, the Activity Director revealed the monthly Resident Council Meetings were always held in the Dining Hall. The Activity Director revealed the Dining Hall was not closed for privacy and was open on one side. In an Interview on 03/29/23 at 1:57 PM, the Activities Director revealed the Resident Council Meeting on 03/29/203 would be held in a private area with a door. In an interview on 03/29/2023 at 2:00 PM during a confidential Resident Council Group Meeting with 7 residents present, each resident revealed in the meeting that their monthly Resident Council Meetings were held in the Dining…

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 assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #54) of five residents reviewed for pharmacy services. 1. The facility failed to ensure the MAR and TAR for Resident #54 was initialed immediately after administering their narcotic medication. This failure placed residents at risk of not having their MARs/TARs signed after receiving their medication which could lead to overdose of the medication. Findings included: Review of Resident #54's Face sheet, not dated, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of low back pain. Record Review of Resident #54's Order Summary Report, dated March 2023, reflected: Norco 5/325mg every 6 hours as needed for pain. Record review of Resident #54's narcotic count sheet, dated March 2023, reflected 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.