Fort Worth Transitional Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status for one (Resident #28) of ten residents reviewed for nutrition. The facility failed to ensure Resident #28 maintained an acceptable weight causing her to trigger a -7.75 percent weight loss. The facility failed to provide weekly weight checks for Resident #28 beginning 12/19/24 with missing dates of 12/19/24, 12/26/24, 01/02/25, 01/09/25, 01/17/25, 01/23/25. These failures placed residents at-risk for weight loss and inadequate nutrition. Findings included: Review of Resident #28's quarterly MDS assessment, dated 12/11/24 revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #28 had a BIMS score of 6 which indicated severe cognition impairment. The resident's diagnoses included Anemia (not having enough red blood cells to carry oxygen), High Blood Pressure (pressure inside arteries are higher than 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 that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for 2 of 3 residents (Residents #44 and #54) reviewed for oxygen. 1. The facility failed to have accurate physician orders for Resident #44's oxygen use. 2. The facility failed to ensure Resident #54, who was ventilator dependent, was repositioned every two hours to assist the resident in expectorating secretions. This failure could place residents who received oxygen therapy at risk for inadequate or inappropriate amounts of oxygen delivery and possible infection. Findings included: 1. Review of Resident #44's admission Record dated 01/08/25 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident #44's quarterly MDS, dated [DATE], revealed the resident was not able to completed the BIMS due to cognitive impairment. The resident's diagnoses…

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 ensure any drug regimen irregularities reported by the Pharmacist Consultant were acted upon, for one resident (Resident #56) of five residents whose medications were reviewed. The facility's Pharmacy Consultant recommended the physician should consider a gradual dose reduction for Resident #56's Duloxetine (used to treat depression) and Zolpidem (used to treat insomnia) on 08/19/24. The facility failed to ensure this was communicated to the resident's primary care physician regarding the recommendation. This failure could place residents receiving medications at risk for adverse consequences and could cause a decline in their physical, mental, and psychosocial condition. Findings included: Review of Resident #56's admission Record, dated 01/30/25, reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Review of Resident #56's Quarterly MDS Assessment, dated 12/03/24, reflected she had a BIMS score of 13…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews, the facility failed to ensure residents who use psychotropic drugs receive gradual dose reductions unless clinically contraindicated, in an effort to discontinue these drugs for 1 (Resident #56) of 3 residents reviewed for unnecessary medications/ gradual dose reduction. The facility failed to ensure a gradual dose reduction (GDR) was attempted or to document contraindication for a gradual dose reduction for Resident #56's ordered Duloxetine (an antidepressant used to treat depression) and Zolpidem (a sedative-hypnotic used to treat insomnia). This failure could place residents at risk for possible psychotropic medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications. Findings included: Review of Resident #56's admission Record, dated 01/30/25, reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Review of Resident #56's Quarterly MDS Assessment, dated 12/03/24, reflected…

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

Based on observations and interviews, the facility failed to ensure the menus were followed for 1 (the lunch meal on 01/28/25) of 2 meals reviewed for menus. The facility did not serve the posted lunch menu of roast beef, red cabbage, dill potatoes, or ice cream on 01/28/25. This failure could affect all residents in the facility, who eat from the kitchen, by placing them at risk of not knowing what was going to be served for that meal. Findings included: Observation on 01/28/25 at 12:00 PM of the monthly menu posted near the dining room reflected for Tuesday, January 28th the following: Roast Beef, Dill Potatoes, Red Cabbage, Wheat Bread, Margarine, Ice Cream, Coffee or Tea, Garnish Parsley Sprig. Observation on 01/28/25 at 12:17 PM revealed an unknown dietary aide brought the daily menu posting to the 3rd floor dining room area which listed the following: beef tips, season potatoes, cabbage, roll with butter, and pears. Interview on 01/28/25 at 12:22 PM with Resident #22 revealed the menu was not usually posted or followed. Resident #22 said she never knew what was going to be…

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 residents received meals at regular times comparable to normal mealtimes in the community or in accordance with resident needs and preferences for one meal (the lunch meal on 01/28/25) of three meals reviewed for frequency of meals. The facility failed to ensure residents received meals at regularly scheduled times for lunch on 01/28/25. This failure could place residents who eat from the facility's kitchen at risk of increased hunger. Findings included: Review of a piece of paper provided by the facility, titled [Facility Name] Meal Service Time are as Follows .Lunch: 12:00 pm-1:00 pm . Interview on 01/28/25 at 12:22 PM with Resident #22 revealed lunch was served late often and they did not have a choice because they could not get food anywhere else. Resident #22 said she was getting very hungry having to wait for them to start serving lunch. Observation on 01/28/25 at 12:40 PM of the 3rd floor's satellite kitchen's steamtables revealed the dietary staff began taking the temperatures of the food. One…

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 the 3rd floor's satellite kitchen. 1.The facility failed to ensure drinks leaving the 3rd floor's satellite kitchen were covered before being put on the hall cart to be delivered to residents eating in their rooms. 2.The facility failed to ensure the five steamtable compartments on the 3rd floor's satellite kitchen were clean and free of debris before food was placed in them. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination. Findings included: 1.Observation on 01/28/25 at 1:45 PM of the lunch tray cart on the 3rd floor revealed there were 21 resident's trays on the cart. Each tray on the cart had a drink on it filled with liquid but was not covered with anything. Interview on 01/28/25 at 1:45 PM with CNA I and CNA H revealed they never knew that the drinks on the trays were…

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 an effective pest control program to keep the facility free of pests for 1 of 2 dining rooms (Third Floor dining room) reviewed for pest control. The facility failed to ensure the Third Floor dining room was free of roaches. This failure could affect residents by placing them at risk for the potential spread of infection, cross-contamination, food-borne illness, and decreased quality of life. Findings included: Observation and interview on 01/28/25 at 12:54 PM revealed there were two roaches along the baseboards in the dining room on the Third Floor while residents were waiting to be served lunch. According to Resident #22, there were roaches all over the facility. Resident #22 stated there were roaches in her room as well. Resident #22 said that roaches have been present for a long time and she did not feel whatever was being done was effective. Resident #22 stated there has been several times she has found roaches in her personal items and tried to kill them. In a confidential interview on 01/29/25…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to ensure each reaident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #194) reviewed for supervision. CNA A failed to safely transfer Resident #194 on 01/15/25, which resulted in the resident having to be lowered to the floor. The failure placed residents at risk of injury. Findings included: Record review of Resident #194's Face Sheet dated 01/31/25 reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. Record review of Resident #194's quarterly MDS dated [DATE] reflected Resident #194 was cognitively intact with a BIMS score of 15. Functional limitation in range in motion indicated there was no impairment for upper and lower extremities and a mobility device of a wheelchair. Resident #194 was dependent on 2 or more staff for chair/bed-to-chair transfers, sit to lying, lying to sitting on side of the bed, toilet transfer, and tub/shower…

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 attempt to use alternatives prior to installing a side or bed rail, obtain informed consent prior to installation, ensure correct installation, use and maintenance of bedrails for 1 (Resident #22) of 3 residents reviewed for bedrails. The facility failed to obtain a bed rail assessment and physician's order prior to the installment of Resident #22's bedrails. This failure could place residents at risk of entrapment or injury. Findings included: Review of Resident #22's admission Record, dated 01/31/25, reflected he was a [AGE] year-old male who admitted to the facility on [DATE]. Review of Resident #22's admission MDS Assessment, dated 01/08/25, reflected he had a BIMS score of 03, indicating severe cognitive impairment. His active diagnoses included non-Alzheimer's disease, malignant neoplasm of prostate, and diabetes mellitus. His MDS did not address that he was receiving hospice services or utilized bed rails. Review of Resident #22's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 5 residents (Residents #194) reviewed for clinical records. The facility failed to ensure LVN B documented on Resident #194's clinical record that he had a fall. This failure could affect residents that required assistance with transferring with the use of a mechanical lift device by placing them at risk of having inaccurate or incomplete clinical records. Findings included: Record review of Resident #194's Face Sheet reflected the resident was a [AGE] year-old male was admitted to the facility on [DATE]. Record review of Resident #194's quarterly MDS dated [DATE] revealed Resident #194 was cognitively intact with a BIMS score of 15. Functional limitation in range in motion indicated there was no impairment for upper and lower extremities and a mobility device of a wheelchair. Resident #194 was…

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

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #32) observed for infection control. RN M failed to wear a gown and gloves while providing care for a resident on enhanced barrier precautions (EBP). This failure could lead to the resident being exposed to infections from other residents. Findings included: Observation on 01/29/25 at 7:24 AM of Resident #32's room revealed posting on the outside notifying staff and visitors the resident was on EBP, and it was required to wear a gown and gloves with all direct care of the resident. Observation on 01/29/25 at 7:24 AM revealed RN M administered seven medications via Resident #32's gastric tube, and one medication via subcutaneous injection while wearing gloves but no personal protective equipment (PPE) which included gown and gloves. Interview on 01/29/25 at 7:35 AM with RN…

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 conduct pre-employment nurse aide registry check to determine if the individual met competency evaluation requirements for 1 of 3 nurse aides (CNA A) whose personnel files were reviewed for registry verification. The facility failed to conduct a pre-employment nurse aide registry (NAR) check on CNA A. This failure could place residents at risk of being exposed to staff with histories of misconducts that were unemployable, increasing the risk for abuse or neglect. Finding included: Record review of CNA A's employee file reflected a hire date of 11/18/2024. A Texas Criminal History Registry check was completed on 12/09/24 and EMR and NAR checks were completed on 12/13/24. Record review of CNA A's time sheet dated 11/16/24-11/30/24, reflected the aide's first effective work day was on 11/18/24, and she worked a total of 60 hours during this time period. Record review of the facility's document titled Daily Nursing Assignment, dated 11/18/24, reflected CNA A was assigned to work Hall 200 from 3:00 PM-10:00 PM. In an interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 of 6 residents (Resident #3) reviewed for enteral nutrition. 1. The facility failed to ensure Resident #3's head was elevated while his tube feeding was infusing. 2. The facility failed to date and time when Resident #3's bottle of liquid nutrition was hung. These failures could place residents at risk of aspiration (inhaling stomach contents into the lungs) and receiving nutrition fluid that is expired. Findings included: Record review of Resident #3's undated admission Record reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included brain tumor, 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 ensure parenteral fluids were administered consistent with professional standards for 1 of 2 residents (Resident #1) reviewed for intravenous medications. 1. The facility failed to ensure the dressing on Resident #1's PICC line (used to deliver medications and other treatments directly to the large central veins near heart) was changed timely. Resident #1 went without a dressing change for 10 days. 2. The facility failed to have orders for PICC line dressing changes and flushes. The failures could affect residents by placing them at risk for infections and cross-contamination. Findings included: Record review of Resident #1's entry MDS assessment, dated 10/22/24, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE]. The resident had diagnoses which included: other acute osteomyelitis, right tibia, and fibula, (a bone infection of the two long bones located in the lower leg that develops quickly, usually…

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 1 of 8 residents (Resident #4) reviewed for infection control. CNA D failed to wear the appropriate PPE while providing care to Resident #4 who was on Enhanced Barrier Precautions. This failure could place residents at risk of being infected by staff in contact with other residents with infections. Findings included: Record review of Resident #4's undated admission Record reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included cerebral palsy, seizures, cognitive communication deficit, and difficulty swallowing. Record review of Resident #4's admission MDS, dated [DATE], reflected a BIMS score not calculated due to the resident's medical conditions. His…

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 and document sufficient preparation and orientation to residents to ensure a safe and orderly discharge from the facility for one resident (Resident #1) of six residents reviewed for discharge planning. SW A and MDS Nurse B failed to ensure Resident #1 filed her NOMNC appeal by 08/10/24 to continue to stay at the facility. SW A and MDS Nurse B failed to ensure Resident #1 was given the second option to appeal to her Medicare Health plan, before she discharged [DATE]. SW A failed to follow-up with the DME Provider on 08/14/24 to give them additional documents needed to process the delivery of Resident #1's wheelchair. SW A failed to ensure Resident #1's correct address was given to the Home Health Care provider to ensure they could provide services to the town she lived in. These failures could place residents at risk of being discharged home too soon and not having the appropriate healthcare services to meet their needs which could result in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident who is incontinent of bladder received appropriate treatment and services to prevent urinary tract infections based on the resident's comprehensive assessment for 2 of 3 residents (Residents #1 and #2) reviewed for urine incontinence/catheters. The facility failed to ensure Resident #1 and Resident #2's catheter urine collection bags were kept off the floor and failed to ensure the collection bags had privacy covers. This failure could place residents with catheters at risk for a loss of dignity, decreased self-worth and decreased self-esteem. Findings included: 1. Review of Resident #1's undated admission Record reflected the resident was a [AGE] year-old male, admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident #1's admission MDS assessment, dated 04/22/24, reflected the resident had moderate cognitive impairment with a BIMS score of 11. The resident had an indwelling catheter and required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent elopement for one (Resident #1) of five residents reviewed for elopements. The facility failed to ensure Resident #1, who had dementia and a history of wandering, had on a WanderGuard device as care planned to prevent elopement. This failure could place residents at risk of elopement or injury. Findings included: Record review of Resident #1's face sheet, dated 04/25/23, revealed the resident was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included dementia (the loss of cognitive functioning that interferes with daily life and activities), muscle weakness, lack of coordination, and unsteadiness on her feet. Record review of Resident #1's admission MDS assessment, dated 02/25/24, revealed Resident #1's BIMS score was 8 indicating moderate cognitive impairment. The assessment reflected Resident #1 had no wandering behavior that had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 (Resident #3) of 5 residents reviewed for clinical records. The facility failed to ensure staff accurately documented on Resident #3's April 2024 Skilled Administration Record that she was being monitored for her behaviors. This failure could affect residents and place them at risk of inaccurate or incomplete clinical records. Findings included: Review of Resident #3's admission record, dated 04/25/24, reflected the resident was a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included dementia (the loss of cognitive functioning that interferes with daily life and activities). Review of Resident #3's quarterly MDS assessment, dated 02/20/24, revealed she had a BIMS score of 05 indicating severe cognitive impairment. Further review revealed Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide 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 for one (Resident #5) of five residents reviewed for call lights. The facility failed to ensure Resident #5's call light was accessible. This failure could place the residents at risk of falling, further injury, and unnecessary pain from not being able to call for help. Findings included: Review of Resident #5's admission Record, dated 04/25/24, revealed the resident was a [AGE] year-old male who originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included unspecified intellectual disabilities (a disorder with onset during the developmental period that includes both intellectual and adaptive functioning deficits), cognitive communication deficit (problems with communication that have an underlying cause in a cognitive deficit rather…

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 all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately to the Administrator for two (Residents #3 and #4) of four residents reviewed for abuse. The facility failed to ensure CNA Z immediately reported an allegation of abuse, on 02/03/24, when she observed Residents #3 and #4 were seen touching each other inappropriately, to the Administrator. This failure could place residents at risk of emotional, physical, and mental abuse. Findings included: Review of Resident #3's admission record, dated 04/25/24, reflected the resident was a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included dementia (a term for a range of conditions that affect the brain's ability to think, remember, and function normally). Review of Resident #3's quarterly MDS assessment, dated 02/20/24, reflected she had a BIMS score of 05 indicating severe cognitive…

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 a baseline care plan within 48 hours of admission for 3 of 7 residents (Residents #12, #31, and #132) reviewed for baseline care plans. The facility failed to ensure Residents #12, #31, and #132 had a baseline care plan, or conversely a comprehensive care plan, within 48 hours of admission. These failures could place the residents at risk of having their needs and preferences met. Findings included: Review of Resident # 12's undated admission Record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included sick sinus syndrome (irregular heart beats and arrhythmia) requiring pacemaker placement, respiratory failure, and kidney failure. Review of Resident #12's admission MDS, dated [DATE], revealed a BIMS score of 5, indicating severe cognitive impairment. His Functional Status indicated he required assistance with all of his ADLs. Review of Resident #12's baseline care plan revealed it was…

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

Based on observation, interview and record review, the facility failed to ensure the facility provided food that was palatable, for one of one observed meal reviewed for dietary services. The facility failed to serve food that had a palatable texture during the lunch meal on 12/13/23. This failure could affect residents by placing them at risk of weight loss, altered nutritional status, and a diminished quality of life. Findings included: Review of the facility's menu on 12/13/23 revealed the planned lunch consisted of crispy pork loin, orzo, buttered beets, wheat roll, margarine, baked pineapple, coffee or tea, and garnish carrot curl. Observation on 12/13/23 at 12:39 PM of the mechanical soft texture test tray with three surveyors, the Dietitian and Dietary Manager revealed the food was warm; however, the orzo (pasta) and pork loin were both bland and flavorless. A confidential interview with seven alert and oriented residents revealed the pasta and pork were both tasteless and most meals were being served that way. They stated the taste of the food was not getting any better even…

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 have a safe, clean, comfortable and homelike environment for 2 of 5 residents (Resident #37 and #49) reviewed for physical environment as evidenced by: The facility failed to ensure Resident #37 and #49's g-tube poles and floor were clean. These failures could place the three residents observed on g-tube feeding, at risk for the spread of infection and disease, a diminished quality of life and a diminished clean, homelike environment. Findings included: 1. Review of Resident #37's face sheet, dated 12/14/23, revealed the resident was a [AGE] year-old-female who admitted to the facility on [DATE] and readmitted on [DATE]. The resident's diagnoses included encounter for attention to gastrostomy (a surgical opening through the skin of the abdomen to the stomach), epilepsy (seizure disorder) and dysphagia (difficulty swallowing). Review of Resident #37's quarterly MDS assessment, dated 09/22/23, revealed her BIMS score was 0,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who was fed by enteral means received appropriate treatment and services to prevent complications for two (Resident #65 and #64) of four reviewed for feeding tubes. 1. The facility failed to follow physician's orders of providing Resident #65 with his 20 hours of feeding intake. 2. LVN F failed to provide Resident #64 her 10:00 AM bolus feeding as ordered by the physician. This failure could place residents at risk for a decline in health or adverse effects due to inappropriate management of G-tube care. Finding included: 1. Review of Resident #65's MDS dated [DATE] revealed he was a [AGE] year-old male admitted to the facility on [DATE]. The resident's diagnoses included anemia, quadriplegia, COPD, moderate protein calorie malnutrition, and encounter for attention gastrostomy (g-tube) a tube inserted through the belly that brings nutrition directly to the stomach. Resident #65 had a BIM of 3 (cognition severely…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate administering of drugs and biologicals to meet the needs of each resident for 1 of 5 residents (Resident #27) reviewed for insulin administration. LVN A failed to administer Resident #27's insulin according to physician's orders. This failure could place residents at risk for diminished quality of care. Findings included: Review of Resident #27's MDS dated [DATE] revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included heart failure, hypertension (high blood pressure), end stage renal disease, and diabetes mellitus. Resident #27 had a BIMS of 14 (cognition intact). Review of Resident #27's care plan initiated 05/22/23 revealed he had diabetes mellitus and interventions included to give diabetes medications as ordered by the doctor. Review of Resident #27's December 2023 Order Summary Report reflected an order 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 interview and record review, the facility failed to ensure residents were free of any significant medication errors for 1 of 5 residents (Resident #227) reviewed for medication errors. ADON G failed to communicate an order change, which resulted in Resident #227 missing two days of antibiotic therapy. This failure could place residents at risk of their infections worsening, and extending their length of stay in the facility. Findings included: Review of Resident #227's undated admission Record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included urinary tract infection, post kidney transplant status, and diabetes. Review of Resident #227's admission MDS, dated [DATE], revealed a BIMS score of 15, indicating he was cognitively intact. His Functional Status indicated he required minimal assistance with his ADLs. Review of Resident #227's care plan, dated 11/06/23, revealed he had a self-care deficit related to recent hospitalization, and had a…

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

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 one of one kitchen reviewed for food and nutrition services. Cook E failed to wear a hair restraint while in the facility's kitchen on 12/12/23. These failures could place residents at risk for food contamination and foodborne illness. Findings included: Observation on 12/12/23 at 8:40 AM revealed [NAME] E not wearing a hairnet while putting away food items. Observed [NAME] E's hair to be down and her hair length was approximately over her shoulder. Interview on 12/12/23 at 8:53 AM with [NAME] E revealed she had been employed for seven months. She stated the first thing the staff were required to do upon entering the kitchen was to put on a hairnet restraint. She stated she got busy and forgot to put on a hairnet, which was her reason she was not wearing a hairnet, while putting away food items. She stated the potential risk of not wearing a hairnet could be hair falling inside the food. Interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 5 residents (Resident #1) reviewed for clinical records. The facility staff failed to document Resident #1's vitals and an assessment in the resident's EHR after the family had concerns for a change in condition. This failure could place all residents at risk for an impact to their treatment and health. Findings included: Record review of Resident #1's face sheet, dated 11/30/23, revealed she was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included: disorder of calcium metabolism (abnormal calcium levels), type 2 diabetes, end stage renal disease (kidney disease), and congestive heart failure (heart disease). Record review of Resident #1's admission MDS assessment, dated 11/28/23, revealed she had a BIMs score of 15 which indicated her cognition was intact. Further…

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, in accordance with accepted professional standards and practices, maintain medical records on each resident that were complete, accurately documented and readily accessible for one of 5 residents (Resident #1) reviewed for clinical records. The facility failed to ensure funeral plans were documented in the EHR and accessible to staff at the time of Resident #1's death. This failure could place residents at risk for not having their decision for final rest and disposition honored. Findings include: Record review of Resident #1's face sheet, dated [DATE], revealed Resident #1 was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 was a DNR and suffered a cardiac arrest on [DATE] and expired on [DATE] at 7:45 PM. Record review of the Mortician Receipt/Death Report form, dated [DATE], revealed Resident #1 was released into the care of a funeral home selected by the facility. In an interview on [DATE] at 2:15 PM, ADON B…

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 residents who were unable or required assistance to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene, for 1 of 1 resident (Resident #1) reviewed for ADLs. The facility failed to provide a shower for Resident #1 on a Tuesday, Thursday, and Saturday schedule. This failure could place residents who required assistance with showering and maintaining good personal hygiene at risk for not receiving care and services to meet their needs and avoid ADL decline. Findings included: Record review of Resident #1's face sheet, dated 08/18/23, revealed a [AGE] year-old female, with an admission date of 08/15/23, and a diagnoses of Displaced Fracture of Base of Neck of Right Femur, Muscle wasting and atrophy, Abnormalities of Gait (manner of walking) and Mobility, Unspecified Lack of Coordination, Cognitive Communication Deficit, Need for Assistance with Personal Care, Depression (disorder 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 that drugs and biologicals used in the facility were secured properly for 1 of 1 nurse wound care/ treatment cart (Hall 300 nurse wound care/ treatment cart) reviewed for drug storage, as evidenced by; Nurse Wound cart/Treatment cart was left unlocked and unsupervised This deficient practice could place residents at risk for harm and place the facility at risk for possible drug diversion or physical harm. Findings included: Observation on 08/21/23 at 11:14 AM revealed an unlocked wound care/treatment cart was left unsupervised and parked in the 300 hall. There was no facility staff near the cart. There was no nurse in charge of the cart at the time of observation (LVN D) walked to the cart after seeing investigators documenting contents of Drawer #1 and Drawer #5. She left to find the keys for the cart. In an interview on 08/21/23 at 11:19 AM, LVN D returned with the cart key and locked the cart. She said she was starting her shift and stated the wound care carts are kept locked if unattended. She did…

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.