River Oaks Health And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that drugs and biologicals were stored in locked compartments and accessed only by authorized personnel for 1 of 4 residents (Resident #1) reviewed for medication storage. Resident #1 had two unidentified pills on his bedside table on 06/17/25 and did not self-administer his own medications. This failure could place residents at risk of inadequate therapeutic outcomes or decline in health. Findings included: Record review of Resident #1's face sheet dated 6/17/25 revealed a [AGE] year-old male admitted on [DATE]. His diagnoses included type 2 diabetes (the body has trouble controlling blood sugar and using it for energy), chronic kidney disease (a disease characterized by progressive damage and loss of function in the kidneys), heart failure (a chronic condition in which the heart doesn't pump blood as well as it should). Record review of Resident #1's annual MDS assessment dated [DATE] revealed a BIMS score of 8 out of 15 which…

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 allegations of abuse were reported to the State Survey agency and the administrator of the facility, immediately but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse for 1 of 1 resident reviewed for abuse and neglect for one (Resident #1) of 1 resident reviewed for abuse. The facility did not report immediately to the State Survey agency when Resident #1 accused LVN A touched him inappropriately on 03/08/25 and LVN A did not report the allegation immediately to the Administrator. These failures could place residents at risk for abuse, neglect, and exploitation. Findings included: Review of Resident #1's Face Sheet dated 04/24/2025 indicated a [AGE] year-old male readmitted on [DATE], with initial admission on [DATE]. Admitting diagnoses included Cerebral Infarction Unspecified (a blood vessel supplying blood to the brain has been blocked, leading to brain tissue damage. the cause 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 develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet residents' medical, nursing, mental and psychosocial needs, for 1 Resident (Resident #2) of 1 resident reviewed for care plans. The facility did not provide interventions as outlined in Resident #2's comprehensive person-centered care plan to address Resident #2's weight loss issues with not interventions including nutritional supplements to improve weight. These failures could place residents identified at risk for weight loss at risk for their medical, physical, and psychosocial needs not being met. The findings were: Record review of Resident #2 Face Sheet, dated 04/24/2025, revealed a [AGE] year-old admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #2's diagnoses included Other Sequelae Following Cerebrovascular Disease (long -term consequences 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 a resident maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range unless the resident's clinical condition demonstrated that this was not possible for 1 (Resident #2) of 1 resident reviewed for weight loss. Resident #2 had a 9.37% weight loss in 8 months between 8/6/24 and 4/9/25 with no documentation from the Dietitian on nutritional concerns or recommended interventions to address Resident #2's weight loss. This failure could place residents at risk of not having needs addressed and/or met r/t weight loss. The findings were: Record review of Resident #2 Face Sheet, dated 04/24/2025, revealed a [AGE] year-old admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #2's diagnoses included Other Sequelae Following Cerebrovascular Disease (long -term consequences and complications that can result from a stroke or other cerebrovascular issues, including impaired movement,…

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 prepare food by methods that conserve nutritive value, flavor, texture and appearance for 3 or of 5 (Residents #4,# 12 and #18) residents reviewed for regular diets. The facility failed to ensure that regular diets served were prepared by methods that conserve nutritive value, flavor, texture, and appearance. This failure could place residents on regular diets at risk for a decrease in quality of life and possible weight loss. Findings included: Review of Resident #4's admission Record reflected she was a [AGE] year-old woman, admitted on [DATE], with a primary diagnosis of Atrial Fibrillation (irregular heart rhythm). Review of Resident #4's Care Plan dated 11/25/2024 reflected Intervention provide diet as ordered. Review of Resident #4's MDS dated [DATE] reflected Resident #4's BIMS score was 15 (cognitively intact). Review of Resident #4's Order Summary Report reflected Resident #4 is on a regular diet, regular texture, regular…

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 measure designed to provide a safe, sanitary environment to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #21) during medication administration, and 3 of 16 residents (Residents #27, #32, #40) reviewed for infection control in that: 1.MA A attempted to perform hand hygiene in another resident's room after measuring blood pressure on Resident #21 who was on Enhanced Barrier Precaution (EBP). 2.MA A did not sanitize blood pressure machine after it was used to measure blood pressure for Resident #21. 3. LVN D failed to ensure EBP procedure was followed throughout the wound care treatment and dressing change for Resident #27. LVN D did not put on his gown for PPE when he returned to complete wound care on Enhanced Barrier Precautions. LVN D failed to ensure two used towels with blood on them were handled with care and in a bag…

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 had the right to a safe, clean, comfortable, and homelike environment, which included but not limited to receiving treatment and supports for daily living safely for one of six residents (Resident#1) reviewed for environment. 1. The facility failed to properly clean and maintain a sanitary and comfortable environment free of foul odors for Resident#1 room. 2. The facility failed to maintain a safe environment for Resident#1 room. These failures could place residents at risk for a diminished quality of life due to the lack of a well-kept, home-like environment. Findings include: Record review of Resident#1's face sheet dated 12/20/24, reflected; Resident#1 was a [AGE] year-old female admitted to the facility on [DATE]. Resident#1 was diagnosed with paranoid schizophrenia (a type of psychosis, which means your mind doesn't agree with reality), bipolar disorder (A serious mental illness characterized by extreme mood…

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, based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable for 1 of 4 resident (Resident # 1) reviewed for activities of daily living. The facility failed to ensure Resident #1 was provided care and services for hygiene. This failure could place residents at risk for poor self-esteem, infections, socialization, ADL decline and diminished quality of life. Findings included: Record review of Resident#1's face sheet dated 12/20/24, reflected; Resident#1 was a [AGE] year-old female admitted to the facility on [DATE]. Resident#1 was diagnosed with paranoid schizophrenia (a type of psychosis, which means your mind doesn't agree with reality), bipolar disorder (A serious…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 4 residents (Residents #1), reviewed for pharmaceutical services, in that: The facility failed to ensure Resident #1 took olanzapine 10 mg tablet that was ordered to be taken: 1 tablet by mouth twice a day. DON B found 28 of what appeared to be Olanzapine tablets in 3 drawers of Resident#1 bedside nightstand. This failure could place residents at risk for not receiving medication as ordered. The findings included: Record review of Resident#1's face sheet dated 12/20/24, reflected; Resident#1 was a [AGE] year-old female admitted to the facility on [DATE]. Resident#1 was diagnosed with paranoid schizophrenia (a type of psychosis, which means your mind doesn't agree with reality), bipolar disorder (A serious mental illness characterized by extreme mood…

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 assured the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals, to meet the needs of each resident for 2 of 4 Residents (Resident #3 and Resident #4) reviewed for pharmacy services. The facility failed to administer Resident #3's PRN pain medication and Resident #4's routine pain medication due to not ordering medications timely. These failures could place residents at risk of not receiving the therapeutic benefit of the prescribed medication. Findings include: 1. Record review of Resident #3's admission Record, dated 12/11/2024, reflected a [AGE] year-old male who admitted to the facility on [DATE]. Resident #3 had primary diagnosis which included Alcoholic Cirrhosis of liver with ascites, other diagnoses included major depressive disorder, post-traumatic stress disorder, and type 2 diabetes mellitus . Record review of Resident #3's Quarterly…

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 safety in the facility's only kitchen. 1. The facility failed to ensure food stored in the refrigerator, freezer, and pantry were labeled, dated, and sealed. These failures could place residents who at risk for food contamination and food-borne illness. Findings included: Observation on 02/06/24 beginning at 9:55 AM revealed the following items: Refrigerator: 1. Cooked bacon and sausage patties in a gallon sized storage bag, not labeled or dated 2. Sausage patties in opened plastic packaging, not labeled or dated, or completely sealed 3. Cooked green beans in a metal bowl, not labeled or dated, with loose fitting plastic wrap, not completely sealed 4. Tuna salad in metal bowl, not labeled or dated, with loose fitting plastic wrap, not completely sealed 5. Red sauce in white plastic bowl, not labeled or dated, with loose fitting plastic wrap, not completely sealed 6. Ground meat in metal bowl, not labeled or dated,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized work area for 1 of 27 (Resident #1) observed for call lights. The facility failed to ensure Resident #1 had a call light installed in his room so Resident #1 could communicate to staff he needed assistance. This failure put residents at risk of not receiving ADL assistance and medical attention when needed. Findings include: Record review of Resident's #1 face sheet dated 1-18-2024, showed a [AGE] year-old male with an original admission date of 10-25-2023. Resident #1 has a primary diagnosis of epilepsy, and secondary diagnosis of gangrene (death of body tissue), sepsis, and acute respiratory failure. Record Review of Resident #1's Care Plan dated 11-10-2023, indicated Resident #1 has impaired visual function, has a seizure disorder, and is a fall risk. One of the Care…

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 safety in the facility's only kitchen. 1. The facility failed to ensure the oven and stove were maintained in a clean and sanitary manner. 2. The facility failed to ensure hot dog buns that had grown mold were not kept in the panty. These failures could place residents who receive food from the kitchen, at risk for food contamination and food-borne illness. Findings included: Observation on 12/05/23 at 8:47 AM revealed the conventional oven had grease and grime that was the color of dark brown on the window of the oven. Observation on 12/05/23 at 8:48 AM revealed the side of the gas stove and the top of the stove had grease and grime that was the color of dark brown and black. Observation on 12/05/23 at 8:50 AM revealed the pantry floor was sticky, and cereal was sprinkled on the floor throughout the pantry. Observation on 12/06/23 at 11:30 AM revealed 9 packs of hot dog buns with 12 hot dog buns each with green and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 8 residents (Residents #16, #17, #20, and #24) reviewed for infection control. MA B failed to sanitize a re-useable blood pressure cuff between blood pressure checks on Residents #16, #20, and #24. This failure could place residents at risk of contracting or spreading an infection. Findings included: Review of Resident #16's undated admission Record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included emphysema, high blood pressure, and history of COVID. Review of Resident #16's quarterly MDS, dated [DATE], revealed a BIMS score of 15, indicating he was cognitively intact. His Functional Status indicated he required limited assistance with his ADLs. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to assure full visual privacy for residents in 3 (Resident #4, #5, and #35) of 6 rooms reviewed for visual privacy. The facility failed to provide privacy curtains at the foot of B beds in 6 rooms. This failure could place residents at risk of loss of dignity and decreased feelings of self-worth. Findings included: Review of Resident #4's undated admission Record revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included seizures, diabetes, and morbid obesity. Review of Resident #4's quarterly MDS assessment, dated 10/14/23, revealed a BIMS score of 14 indicating she was cognitively intact. Her Functional Status indicated she required assistance with all of her ADLs. Review of Resident #4's care plan, dated 10/10/23, revealed she had a self-care deficit, was a high fall risk, and incontinent of urine and stool. Review of Resident #5's undated admission Record revealed he was a [AGE] year-old…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who are unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 8 residents (Residents #5 and #345) reviewed for ADL care. The facility failed to ensure Residents #5 and #345 were bathed and shaved on a regular basis. This failure could place the residents at risk of developing skin issues, and a decreased sense of worth. Findings included: Review of Resident #5's undated admission Record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of stroke affecting his right side, seizures, and dementia. Review of Resident #5's quarterly MDS assessment, dated 11/21/23, revealed a BIMS score of 10, indicating moderate cognitive development. His Functional Status indicated he required assistance with all of his ADLs, bathing required extensive assistance by staff. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 residents (Resident #15) reviewed for dialysis. The facility failed to ensure that Resident #15 had a current order for dialysis after readmission to the facility. This failure could place residents at risk of not receiving the appropriate care as ordered by the physician. Findings included: Record review of Resident #15's quarterly MDS assessment dated [DATE] reflected the resident was a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident #15's active diagnoses included Type 2 diabetes, legal blindness, major depressive disorder, anxiety, anemia, epilepsy, muscle weakness, thrombocytopenia which is a condition that occurs when the platelet count in your blood is too low, myoclonus…

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 its medication error rate was less than 5%. MA B had two medication errors out of 39 opportunities resulting in an error rate of 5.13%. This failure could place residents at risk of not receiving the intended therapeutic effects of medications or receiving the wrong medication. Findings included: Observation on 12/06/23 at 8:30 AM revealed MA B administered Hydrocodone 7.5-325 mg orally to Resident #20. Observation on 12/06/23 at 8:49 AM revealed MA B administered Enteric Coated Aspirin 81 mg orally to Resident #24. Review of Resident #20's physician orders revealed an order for Hydrocodone 10-325 mg written on 12/15/22. Review of Resident #20's MAR for November and December revealed he was being provided Hydrocodone 7.5-325 mg Review of Resident #24's physician orders revealed an order for Aspirin 81 mg to be chewed. Interview on 12/06/23 at 11:30 AM with MA B revealed he did not have chewable aspirin on his cart, only enteric coated aspirin. MA B stated he did not know how Resident #20 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.

Based on observation, interview, and record reveiw, the facility failed to ensure all drugs were stored in locked compartments with access by authorized personnel only for 1 of 4 carts (South Station Nurse Cart) reviewed for storage of drugs and biologicals. RN C failed to secure her medication cart before she stepped away from it. This failure could place residents at risk of accessing medications not prescribed for them. Findings included: Observation on 12/06/23 at 1:10 PM revealed the nurse medication cart for South Hall was unlocked, all drawers were able to be opened by the surveyor. Observation on 12/06/23 at 1:15 PM revealed RN C returned to the nurses' station from another hall. She did not notice her cart was unlocked until made aware by the surveyor. Interview on 12/06/23 at 1:16 PM with RN C revealed she initially stated the cart was unlocked because she was going to medicate a resident. When the surveyor pointed out that the cart had been unlocked while she was away from it and on another hall while residents were sitting in wheelchairs nearby, RN C stated she 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.

Based on observation, interview, and record review, the facility failed to post the current week's menu in a convenient location so the residents may see it for 1 of 1 facility reviewed for menus, in that: There was no weekly menu posted in any location in the facility on 10/03/2023. This deficient practice could affect the residents who ate food from the kitchen and their right to make choices about their meals beyond the present day. The findings included: Observation on 10/03/2023 at 9:15 AM revealed there was no weekly menu posted in wall sleeve in North Hall. Observation on 10/03/2023 at 9:18 AM revealed there was no weekly menu posted in wall sleeve in South Hall. Observation on 10/03/2023 at 9:20 AM revealed there was November 2022 weekly menu posted in wall sleeve and an undated menu matrix posted on bulletin board in the dining room. In an interview and observation with the Executive Director (ED) on 10/03/2023 at 11:33 AM concerning the missing menu postings in the facility. He stated he knew there was a copy of the weekly menu in the dining room bulletin board, Let me…

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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed, in that: The facility failed to store a seven-day supply of non-perishable food staples. These failures could affect the residents who received their meals from the facility's only kitchen by placing them at serious risk due to a lack of enough food. Findings included: Observation on 10/03/2023 at 3:15 PM of the facility's food storage/pantry revealed about a one-day non-perishable food supply. The food supply included, but not limited to, noodles, canned goods, and boxed dry goods. During an interview on 10/03/2023 at 3:19 PM, the Dietary Director (DD) said, We had a food truck delivery today and we've had not had the chance to restock the shelves yet. When question about the food emergency reserves, she replied, I have to order food based on the budget for the month. I had already maxed out my budget for the end of September, now I will use the budget I have 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.

Based on observations, interviews, and record reviews, the facility failed to provide advance food that accommodates resident's preferences for one (Resident #2) of five residents reviewed for food preferences and the accommodation of residents' meal choices. The facility failed to provide Resident #2 with food preferences for breakfast and lunch on 10/17/2023. Resident #1 requested the salad of the day, creole potatoes, coleslaw, and a fruit plate with cottage cheese. Resident #1 received, red beans with pork sausage, rice, collard greens, cornbread, scalloped potatoes and fruit cocktail. This failure could affect residents that are provided daily meals by the facility, by placing them at risk for frustration, decreased meal satisfaction and/or weight loss. Findings included: In an observation and interview on 10/17/2023 at 12:20 PM of the lunch service distribution of meals to residents' rooms the investigator observed Resident #2 yelling at the DM for alternative meal for lunch. DM shared with him the alternative lunch options. Resident #2 was extremely distressed about 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 observation, interview and record review the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for three (Residents #4, #1, and #2) of four residents reviewed for accidents. The facility failed to provide a safe environment for 7 residents at risk of elopement by allowing other residents to have keypad access to exit doors. The failures placed residents with elopement at risk for accidents and injuries. Findings included: Record review of Resident #4's face sheet, dated 09/15/2023, revealed a [AGE] year-old male admitted on [DATE], with diagnoses that included dementia, abuse of other non-psychoactive substances, Wernicke's encephalopathy, and personal history of transient ischemic attack (TIA) and cerebral infarction without residual deficits Record review of Resident #4's care plan dated 8/15/23 revealed he had made verbal threats to leave the facility. He was at moderate risk for falls. His care plan indicated he was an elopement…

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, clean, comfortable, and homelike environment, for daily living for one of four residents (Resident #3) reviewed for environmental concerns. The facility failed to ensure Resident #3's room was cleaned daily. The facility failed to ensure Resident #3's wheelchair was clean and free of debris. These failures could place residents at risk for decreased quality of life. Findings included: Record review of Resident #3's face sheet, dated 09/14/23, revealed a [AGE] year-old-male admitted to the facility on [DATE] with diagnoses that included Transient Cerebral Ischemic Attack. Record review of Resident #3's most recent MDS, dated [DATE], revealed a BIMS score of 15 indicating intact cognition. Interview and observation on 09/14/2023 at 12:00 pm, Resident #3 stated he had seen roaches in his room by the television. Resident #3 stated his room was not cleaned this week. Resident #3's wheels on his wheelchair had accumulated dirt…

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 an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions for one (Resident #4) of one resident reviewed for discharge planning. The facility failed to follow their policy on AMA (against medical advice) protocol for Resident #4. Findings included: Record review of Resident #4's face sheet, dated 09/15/2023, revealed a [AGE] year-old male admitted on [DATE], with diagnoses that included dementia, abuse of other non-psychoactive substances, Wernicke's encephalopathy, and personal history of transient ischemic attack (TIA) and cerebral infarction without residual deficits. Record review of Resident #4's BIMS assessment, dated 08/24/2023, reflected a score of 11, indicating moderate cognitive impairment. Record review of Resident #4'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.