Richland Hills Rehabilitation and Healthcare Cente

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure the menu was followed for one of one meal (lunch on 02/26/2025) reviewed for food and nutrition services. The facility failed to ensure the menu was followed for the lunch meal by leaving out the dinner roll with margarine for all diet types on 02/26/2025. This deficient practice could place residents at risk of dissatisfaction, poor intake, and/or weight loss. Findings included: Observation on 02/26/25 at 11:30 AM of the kitchen's steamtable (foods are kept at a warm temperature) revealed the following items: chicken fried steak, peas with onions, mashed potatoes, and gravy. No dinner rolls were observed, and none were placed on the residents' trays to serve to the residents. Interview on 02/26/25 at 3:50 PM with the Dietary Supervisor revealed that the dinner rolls were not served because the Dietary Supervisor could not locate them. The Dietary Supervisor said she was not aware that the delivery truck did not deliver the rolls 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.

Based on observation, interview, and record review, the facility failed to prepare foods according to the established food preparation practices and safety techniques in 1 of 1 kitchen reviewed for appropriate sanitation, as evidenced by: The warewasher (dish machine) sanitizer was not dispensing sanitizer, leaving the dishes used for the afternoon meal, of 02/24/25 through afternoon meal of 02/26/25, unsanitized. This failure could place residents at risk of infection. Findings included: Observation on 02/24/25 at 6:14 PM revealed the Dishwasher ran the warewasher and then used a test strip to test the sanitizer strength. The test strip showed no sanitizer at all in the warewasher. The Dishwasher repeated the test three times. Each time the test strip showed no sanitizer. Further observation revealed the sanitizer did not appear to be coming through the tubing from the bucket of solution to the warewasher. Observation and interview on 02/25/25 at 9:30 AM revealed the warewasher was not repaired and the facility was waiting on the repairman. The Dietary Supervisor revealed that she…

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 with wounds receives necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection for 3 of 3 residents (Residents #25, #30 and #107) reviewed for wound care. 1. The facility failed to ensure Resident #25 and Resident #107 received wound care everyday as per physician orders on 02/25/25. 2. LVN A failed to update physician wound care orders in the MAR when Resident #30 was seen by the Wound Care Physician on 02/17/25. These failures placed residents at risk for infection and delay in healing of existing wounds. Findings included: 1. Record review of Resident #25's admission MDS dated [DATE] reflected the resident was a [AGE] year-old female. Resident admitted to the facility on [DATE]. Her diagnoses included Peripheral Vascular Disease (a condition that affects the blood vessels outside the heart and brain). Resident #25 had a BIMS of 4 indicating her…

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 2 of 2 residents (Residents #56 and #107) reviewed for intravenous fluids. The facility failed to ensure Resident #56 and Resident #107 Midline/PICC line (used to deliver medications and other treatments directly to the large central veins near heart) dressing change was completed and the change date was documented on the dressing. Resident #56 and Resident #107 were observed without change dates and initials on 02/24/25. The failures could affect residents by placing them at risk for infections and cross-contamination due to not knowing when the dressing was last changed. Findings included: Record review of Resident #56's entry MDS assessment, dated 02/12/25, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. The resident had diagnoses which included: Pneumonia, (lung infection that causes the air sacs in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored securely for 2 of 2 residents (Resident #15 and Resident #40) reviewed for medication storage. 1. The facility failed to ensure Resident #40's 1 bottle of nitroglycerin 0.4 mg was stored in a secured place when they were stored in her room on her bed side table on 02/24/25. 2. The facility failed to ensure Resident #15's 1 bottle of 100 mg/Stool Softener with stimulant, 2 bottles of Clear Eyes .5 ounces each, 1 bottle of 190 heartburn relief tablets, 100 capsules allergy relief 25 mg, 1 bottle of Linzess prescription with the label peeled for whom it was prescribed to, and 1 bottle of acetaminophen 325 mg was not stored at the resident's bedside table. These failures placed residents at risk of receiving medications that were not prescribed by the doctor, overdose and reactions with other medications. Findings included: 1. Record review of Resident #40's quarterly MDS assessment, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to permit the resident to remain in the facility, and not transfer or discharge the resident from the facility unless the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility for 1 of 2 residents (Resident #199) reviewed for facility-initiated discharges. The facility failed to permit Resident #199 to remain in the facility and discharged the resident from the facility. Resident #199 was not allowed to return to the facility following a neurologist's appointment on 12/18/24 due to the facility having the resident sign an AMA form before she left for the appointment. After refusing Resident #199 to enter back into the facility, the facility called EMS who took her to a hospital for an evaluation. The failure could affect residents by placing them at risk of not having access to adequate care in a nursing home facility. Findings included: Record review of Resident #199's MDS Nursing assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide an ongoing program of in-room activities in accordance with the comprehensive assessment to meet the interests and the physical, mental, and psychosocial well-being of 1 of 18 (Resident #46) residents reviewed for activities. The facility did not provide Resident #46 ongoing individualized in-room activities for a minimum of fifteen minutes three times per week for the period between 02/25/25 to 02/27/25. This failure could place residents who required in room activities at risk for not having activities to meet their interests or needs and a decline in their physical, mental, and psychosocial well-being. Findings included: Record review of Resident #46's quarterly MDS, dated [DATE], reflected Resident #46 was a [AGE] year-old male with an initial admission date of 06/14/24. Resident #46's MDS reflected active diagnoses of anxiety disorder, depression, schizophrenia, profound intellectual disabilities, cognitive communication…

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 with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for 1 of 5 residents (Resident #9) reviewed for restorative care. The facility failed to apply splint to Resident #9's left hand to reduce the risk of further loss of range of motion on 02/25/25 and 02/26/25. This failure placed ten residents on with devices for contractures at risk for decline in range of motion, decreased mobility, and worsening of contractures. Findings included: Record review of Resident #9's admission Record dated 02/27/25 reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE]. Record review of Resident #9's quarterly MDS assessment dated [DATE] reflected his diagnoses included unspecified dementia, stiffness of left shoulder, stiffness to left elbow, stiffness to left hand, muscle weakness, cognitive communication…

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 are complete and accurately documented for 2 of 2 residents (Residents #25 and #107) reviewed for wound care administration. 1. The facility failed to ensure staff accurately documented on Resident #25 and #107's MAR/TAR after performing wound care on 02/26/25. This failure could put residents at risk for treatment errors and errors in care. Findings included: 1. Record review of Resident #25's admission MDS assessment dated [DATE] reflected the resident was a [AGE] year-old female. Resident admitted to the facility on [DATE]. Her diagnoses included Peripheral Vascular Disease (a condition that affects the blood vessels outside the heart and brain). Resident #25 had a BIMS score of 4, indicating her cognition was severely impaired. Record review of physician's orders dated 02/24/25 revealed Resident #25 had a skin tear to right lateral ankle. The order…

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 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 1 resident (Resident #31) reviewed for infection control. The facility failed to ensure LVN B put on a gown before providing g-tube medication to Resident #31, who was on Enhanced Barrier Precautions. This failure could place residents at risk of contracting an infection from residents on Enhanced Barrier Precautions and cross contamination, which could result in infections or illness. Findings included: Record review of Resident #31's quarterly MDS assessment, dated 12/22/25, reflected his diagnoses included cerebral palsy (a group of non-progressive neurological disorders that affect movement, posture, and balance) and dysphagia following cerebral infarction (difficulty swallowing that occurs after a stroke). Resident #31's BIMS score was not completed due to the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a centralized staff work area, for 1 of 54 residents (Resident #29) reviewed for call lights. The facility did not adequately equip Resident #29 with a call light to allow the resident to call for assistance. This failure could place residents who rely on the call light system to have a delayed response or no way to contact staff to meet their needs. Findings included: Record review of Resident #29's admission Record dated 02/27/25 reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #29's significant change in status MDS assessment dated [DATE] reflected her diagnoses included malignant neoplasm (cancer) of liver, dysphagia (difficulty swallowing), anxiety disorder, repeated falls. Chronic obstructive pulmonary…

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 residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation, which includes but not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms for 1 (Resident #1) of 3 residents reviewed for involuntary seclusion. The facility failed to ensure the ADON did not tip Resident #1's wheelchair forward, dump him onto his bed, remove his wheelchair from the room, and close the resident's door. This failure could place residents at risk of injury, falls from bed, and decreased sense of self worth. Findings included: Record review of Resident #1's undated admission Record reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which including stroke, history of falls, and depression. Record review of Resident #1's admission MDS, dated [DATE],…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure each resident was treated with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for two of eight residents (Residents #3 and #4) reviewed for dignity. 1. The facility failed to ensure the urinary collection bag for Resident #3's catheter was covered with a privacy bag. 2. The facility failed to ensure the urinary collection bag for Resident #4's catheter was covered with a privacy bag. These failures could place residents at risk for a loss of dignity, decreased self-worth and decreased self-esteem. Findings include: Record review of Resident #3's face sheet, dated 05/17/2024, indicated an [AGE] year-old male originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #3 had diagnoses which included, unspecified dementia with agitation (mild cognitive impairment easily agitated), cerebral ischemia (acute brain injury),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the residents had the right to personal privacy and confidentiality of his or her personal space for two of eight residents (Residents #1 and #2) reviewed for privacy. The facility failed to ensure there was a privacy curtain in Resident's #1 and #2's room since Resident #2's admission to the facility on [DATE]. This failure could place residents at risk for a loss of privacy, dignity, and decreased self-worth and self-esteem. Findings include: Record review of Resident #1's face sheet dated 05/17/2024 indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included, unspecified dementia (mild cognitive impairment), cognitive communication deficit (trouble understanding or responding to communication), depression (serious mood disorder), and chronic kidney disease (a gradual loss of kidney function over time). Record review of Resident #1's quarterly MDS Assessment, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure care plans were developed in consultation with the resident and the resident's representative for 3 of 13 residents (Resident #3, Resident #7, Resident #17) reviewed for Comprehensive Care Plan in that: The facility failed to ensure Resident #3, Resident #7, and Resident #17 or the resident's representatives were invited to participate in the residents' care plan meeting. This failure could place residents at risk for a loss of independence, psychosocial well-being, and the opportunity for them to participate in the planning of their cares. Findings include: Record review of Resident # 3's face-sheet dated 02/01/2024 revealed a [AGE] year-old female, re-admitted to facility on 01/19/2023. Her diagnoses included: Other Symptoms and Signs involving the musculoskeletal system (aching and stiffness & muscles twitches, pain), Heart Failure, Unspecified (Heart unable to pump enough blood), Type 2 Diabetes Neuropathy, Unspecified (a chronic condition…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident resided and received services in the facility with reasonable accommodation of resident needs and preferences for 3 (Resident #3, Resident #7, and Resident #27) of 13 residents reviewed for call lights. Staff failed to ensure Resident #3 and Resident #7's, and Resident #27's call buttons were within reach. This failure could place residents at risk for decreased quality of life, self-worth, and dignity. Findings included: Record review of Resident # 3's face-sheet dated 02/01/2024 revealed a [AGE] year-old female, re-admitted to facility on 01/19/2023. Her diagnoses included: Other Symptoms and Signs involving the musculoskeletal system (aching and stiffness & muscles twitches, pain), Heart Failure, Unspecified (Heart unable to pump enough blood), Type 2 Diabetes Neuropathy, Unspecified (a chronic condition that affects the way the body processes blood sugar). Review of Resident #3's Comprehensive Care Plan revised…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the medication error rate was not 5 percent (5%) or greater for 3 of 25 opportunities resulting in a 8 percent medication error rate for 1 of 10 residents observed for medication pass. Facility failed to ensure Resident #6 medications were administered as physician order. Facility failed to ensure Resident #6 medication were not crushed or mixed into a cocktailed without a physician order. Facility failed to ensure Resident #6 received chewable aspirin instead of safety coated aspirin that was crushed without a physician order. These failures could place residents at risk for significant medication errors and jeopardize the resident health and safety. Finding included: Review of Resident #6 's admission record, dated 01/25/2024, revealed a [AGE] year-old female admitted to facility on 04/07/2023 with diagnoses that included stroke, unspecified intellectual disabilities, difficulty communicating, dysphasia (difficult swallowing),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 6 (Residents #6, #39, #42, #43, #49, and #204) of 10 residents reviewed for infection control. The facility failed to implement an infection control and prevention that included wound care procedures and cross contamination for Resident #39 and #43 during wound care. The facility failed to ensure CMA C sanitized blood pressure cuff between use on Residents #6, #42, #49, and #204. The facility failed to ensure CNA F maintained a contaminate free clean linen for all residents in BACK HALL ODD and BACK HALL EVEN hallway from rooms 21 to room [ROOM NUMBER]. These failures could place residents at risk of infectious diseases, cross contamination, staph infection, and hospitalization. The finding included: Review of Resident #6 's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure clean, comfortable environment and maintenance services for one esident #30) of eight residents reviewed for clean and comfortable environment. The facility failed to maintain functional plumbing in the bathroom of Resident #30, causing her sink to not drain properly, to the extent she could not get hot water in her bathroom sink. These failures could place residents at risk for lack of hygiene, and a decreased quality of life. Findings included: Review of Resident #30's face sheet reflected she was a [AGE] year-old female, admitted [DATE], with diagnoses of unspecified dementia, severe, with behavioral disturbance, cerebral infarction (stroke), and bi-polar disorder. Resident #30 was listed as her own Responsible Party Review of Resident #30's quarterly MDS, dated [DATE], reflected she was able to understand others, and to be understood. Resident #30 had a BIMS of 11, indicating possible moderate cognitive impairment. The document…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents who received nutrition by enteral means received the appropriate treatment and services according to professional standards of maintenance for one (Resident #40) of one resident reviewed for enteral feeding. The facility failed to ensure Resident #40's g-tube water and enteral administration set (tubing attached to formula and water bottles for continuous g-tube feeding) was changed when his formula was changed, and failed to ensure the formula was dated when it was changed. This failure could place residents at risk of infection due to not following appropriate procedures. Findings included: Review of Resident #40's face sheet, dated 01/25/24 revealed he was an [AGE] year-old male, admitted on [DATE], and had diagnoses of Parkinson's (a progressive nervous system disorder, which affects the ability to move muscles), dysphasia (trouble swallowing) following a stroke, and gastronomy (g-tube or feeding tube) status,…

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, facility failed to provide necessary respiratory care consistent with professional standards of practice, for 1 (Resident # 22) of 4 residents reviewed for Oxygen therapy. Facility failed to ensure Resident #22 had a portable oxygen tank that was not depleted of consistent oxygen therapy. This failure could place resident at risk for difficulty breathing, anxiety, shortness of breath. Finding included: Review of Resident #22 's admission record, dated 01/25/2024, revealed a [AGE] year-old female admitted to facility on 05/12/2022 with diagnoses that included unspecified dementia, unspecified intellectual disabilities, difficulty communicating, dysphasia (difficult swallowing), anxiety, need for assistant with personal care, protein calorie malnutrition, localized swelling disorder, lack of coordination, heart failure, and difficulty catching a breath (Dyspnea). Review of Resident #22's annual MDS, dated [DATE], reflected Resident #22 had a BIMs (Brief Inventory…

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 1 (Resident #15) of 10 residents reviewed for storage of drugs and Biologicals. Facility failed to ensure insulin for Resident #15 was correctly labeled with the date it was opened. Finding included: Review of Resident #15 's admission record, dated [DATE], revealed a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included stroke, type 2 diabetes, high blood pressure, other viral pneumonia, muscle wasting, unsteady on her feet and lack coordination, stiffness of joints, falls, depression and insomnia. Review of Resident #15's order summary, dated [DATE], reflected NovoLIN R FlexPen Injection Solution Pen-injector 100 UNIT/ML (Insulin Regular (Human)) Inject as per sliding scale: if 0 - 150 = 0; 151 - 200…

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

Based on interviews and record reviews the facility failed to ensure they employed professional staff required to be licensed for 1 (Administrator) of 5 employees reviewed for licensure. The facility failed to ensure the Administrator had a valid LNFA license. This failure could place the residents at risk of not receiving care regulated by CMS. Findings included: Interview on 08/17/23 at 4:45 PM the Administrator stated he had completed the Licensed Nursing Facility Administrator course but had not passed the test. He stated he was eligible to re-take the test at the end of August. He stated he did not have a current LNFA license and did not know who's license he was operating under, but thought it might be the previous administrator. He stated he was appointed to the job with the anticipation he would pass his test. Review of information retrieved from TULIP Nursing Facility Administrator Public Registry on 08/28/23 revealed the Administrator's NFA License Status was listed as Prospective. The sections for License Number, License Issue Date, and License Expiration Date were all…

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.