Advanced Health & Rehab Center of Garland

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure the resident free from physical restraints not required to treat the residents' medical symptoms as was possible for one of five residents (Resident #1) reviewed for physical restraints. The facility failed to ensure Residents #1 had physician orders or a physician assessment for the bolster mattress on her bed. This failure could place residents at risk of not having an environment that was free of restraints which could result in injury.Findings include: Record review of Resident #1's Face Sheet, dated 09/25/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included muscle weakness and unsteadiness on feet. Record review of Resident #1's Quarterly MDS assessment, dated 7/24/25, reflected she had a BIMS score of 00 (severe cognitive impairment). For ADL care, it reflected the resident required extensive assistance and an active diagnosis of muscle weakness. Record 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 Findings included: Record review of Resident #5's Face Sheet, dated 09/30/25, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included schizoaffective disorder (psychotic symptoms) and vascular dementia (memory loss). Record review of Resident #5's Quarterly MDS assessment, dated 9/194/25, reflected he had a BIMS score of 13 (intact cognitive response). Active diagnoses included schizophrenia and altered mental status. Record review of Resident #5's Comprehensive Care Plan, dated 8/19/25, reflected the resident required psychotropic medication. Record review of Resident #5's physician's orders, dated 9/30/25, reflected the resident was prescribed the following medication: Ativan Oral tablet 1 MG, give 1 mg by mouth every 8 hours as needed for agitation. Atorvastatin Calcium oral tablet 20 mg, give 1 tablet by mouth in the morning for high cholesterol. Divalproex Sodium oral tablet delayed release 500 mg, give 1 tablet two times a day for mood stabilizer. Ferrous…

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 establish and implement an admissions policy for one (Resident #1) of three residents reviewed for admissions.The facility did not provide Resident #1 and his RP with a written admission agreement, consent to treat, resident rights notification, Medicare/Medicaid information or disclosure of services and charges at the time of admission. This failure placed residents at risk of receiving care and services without informed consent, being uninformed of rights and financial obligations and not knowing how to exercise Medicare/Medicaid protections.Findings included:Record review of Resident #1's face sheet dated 08/26/25 reflected he was a 71 year old male admitted on [DATE]. His active diagnoses included nontraumatic intracerebral hemorrhage (bleeding within the brainstem), anxiety disorder (mental health condition causing agitation), colostomy status (surgical opening in the colon for stool elimination), urinary retention with catheter use (inability to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 5 of 34 (Residents #31, #49, #64, #17, and #107) residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #31, #49, #64, #17, and #107's rooms were in a position that was accessible to the residents. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency. The findings included: Resident #31 Record review of Resident #31's Face Sheet, dated 04/10/2025, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE]. Resident #31's diagnoses included congestive heart failure (a weakened heart condition that causes fluid buildup in body tissues) and difficulty in walking. Record review of Resident #31's Quarterly MDS (assessment used to determine…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 10 of 15 resident rooms in the memory care unit (Resident room [ROOM NUMBER], #2, #3, #4, #5, #6, #7, #8, #9, and #10) reviewed for environment. 1. The facility failed to ensure Resident room [ROOM NUMBER], #2, #3, #4, #5, #6, #7, #8, #9, and #10, in the memory care unit, were thoroughly cleaned and sanitized. This deficient practice could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life. Findings include: An observation on 04/08/25 at 10:24 AM of resident room [ROOM NUMBER] reflected the air condition unit in the room had thick black and brown dirt along and between the vents. The bathroom sink faucet had brownish stains along the base of the faucet. The floor of the shower area had brown…

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, distributed, and serve food in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food and nutrition services. 1. The facility failed to ensure the ice machine in the facility kitchen was thoroughly cleaned. 2. The facility failed to ensure kitchen cooking equipment was cleaned. 3. The facility failed to place a cover on top of the tea dispenser to avoid air borne contaminants. 4. The facility failed to ensure foods in the refrigerator was sealed from air-borne contaminants. 5. The facility failed to ensure the storage bins in the dry food area was clean and covered from air-borne contaminants. These failures could place residents at risk for cross contamination and other air-borne illnesses. Findings include: Observations on 04/08/25 from 9:08 AM to 9:15 AM in the facility's only kitchen revealed: The ice machine, located in the kitchen had white stains inside the walls of the machine and light brownish stains on the inside of the door.…

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 two of twelve (Resident #97 and Resident #102) residents reviewed for infection control. 1. The facility failed to ensure RN C removed her gloves and performed hand hygiene before using the laptop on the medication cart outside of Resident #97's room on 04/08/2025. 2. The facility failed to ensure Medication Aide F removed her gloves and performed hand hygiene before using the laptop on the medication cart outside of Resident #102's room on 04/09/2025. This failure could place residents at risk of cross-contamination and development of infections. The findings included: 1. Record review of Resident #97's Face Sheet, dated 04/10/2025, reflected the resident was a [AGE] year-old male who was admitted to the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for one (Resident #17) of six residents reviewed for Care Plans. The facility failed to ensure Resident #17's treatment for Dermatitis was care planned. This failure could place the resident at risk of not receiving the necessary care and services needed. Findings included: Record review of Resident #17's Face Sheet, dated 04/09/25, reflected she was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included skin changes, Alzheimer's (memory loss), and Basal Cell Carcinoma of skin (skin cancer). Record review of Resident #17's Quarterly Minimum Data Set (MDS) assessment, dated 03/15/25, reflected she had a BIMS score of 15…

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 all drugs and biological were stored in accordance with currently accepted professional principles for 1 (hall 200 medication cart) of 4 medication carts reviewed for medication storage. The facility failed to dispose of one bottle of Magnesium Oxide (vitamin supplement), which expired January of 2025, from the Hall 200 medication cart on 04/09/2025. This failure could place residents at risk of receiving medications which might not provide the full therapeutic benefits of the medication or possibly cause side effects. The findings included: During an observation and interview 04/09/2025 at 11:15 AM, a bottle of expired Magnesium Oxide 400 milligrams was in the medication aide cart on hall 200. The expiration date printed on the bottle was 01/2025. Medication Aide F stated she was not aware the bottle of medication on the cart was expired. Medication Aide F stated no resident on her hall currently had an order for the medication. She stated expired medication should not be given to residents because 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 interview and record review the facility failed to immediately inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident representative when there was a significant change in the resident's physical, mental, or psychosocial status that was, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications for 1 of 5 residents (Resident #1) reviewed for Notification of Changes. The facility failed to notify Resident#1's durable power of attorney for healthcare when Resident#1 missed a scheduled dialysis appointment on 03/07/25. This failure could place residents at risk of not receiving treatment when there was a change in their condition, which could lead to worsening of conditions and serious injury or harm. Findings include: Record review of Resident#1 face sheet, dated, 03/12/25, revealed an 84 -year-old male, originally admitted to the facility on [DATE] and readmitted on [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 who acts as the fiduciary of the residents' fund, failed to hold, safeguard, manage and account for the personal funds of the resident deposited with the facility, to include the right to know, in advance, what charges a facility may impose against a resident's personal funds for one (Resident #3) of three residents reviewed for trust fund management. The facility failed to ensure Resident #3's trust fund account was spent down to avoid being over the amount allowed to have Medicaid Insurance benefits. These failures could place residents whose funds were managed by the facility at risk of losing their Medicaid insurance benefits and placed the residents' funds at risk of being misappropriated and residents/RP's not being aware of the residents' financial situation. Findings Included: Record review of Resident #3's Face Sheet (dated 09/06/24) reflected he was [AGE] year old male admitted to the facility on [DATE]. Resident #3's active 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 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 two (Residents #7 and #9) of eight residents reviewed for medications and pharmacy services. 1. The facility failed to take Resident #7's blood pressure and administer her medication in accordance with the physician orders. Resident #7 was not administered Metoprolol Tartrate (beta blocker to treat high blood pressure) on 08/20/24, 08/21/24 and 08/28/24 due to her blood pressure being out of parameters. However, there was no documented evidence to indicate her blood pressure was taken in her clinical record to validate the medication was not warranted. 2. The facility failed to take Resident #9's blood glucose and administer his sliding scale insulin Novolin in accordance with the physician orders. Resident #9 was did not have his blood glucose checked…

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, in accordance with accepted professional standards and practices, the facility failed to maintain medical records on each resident that are complete; accurately documented; readily accessible; and systematically organized for two (Resident #4 and Resident #5) of four residents reviewed for pressure ulcers and non-pressure wounds. 1. The facility failed to document wound care was provided for Resident #4 in August 2024 on 29 occasions. 2. The facility failed to document wound care was provided for Resident #5 in August 2024 on 36 occasions. The facility failure could place residents at risk of not receiving wound care, wounds worsening and a lack of oversight of their clinical records by the nursing staff and nursing management. Findings included: 1.Record review of Resident #4's Face Sheet dated 08/29/24 reflected he was a [AGE] year old male who admitted to the facility on [DATE]. Resident #4's active diagnoses included in part, quadriplegia (paralysis of all four limbs),…

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 complete a discharge summary that included, (i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results; (ii) A final summary of the resident's status; (iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter) for one (Residents #6) of two residents reviewed for discharge planning. The facility failed to complete a discharge summary for Resident #6 when she had a planned discharge home. This failure could place residents at risk of a recapitulation of the stay being unavailable to help ensure continuity of care once they went back home. Findings included: Record review of Resident #6's quarterly MDS assessment dated [DATE] reflected she was a [AGE] year old female who admitted to the facility on [DATE]. Resident #6 had no hearing, speech or…

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 or obtain laboratory services to meet the needs of its residents and failed to be responsible for the quality and timeliness of the services for one (Resident #1) of eight residents reviewed for labs. The facility failed to complete Resident #1's lab order for C-diff (a bacterium that can cause diarrhea and inflammation of the colon, also known as colitis) as ordered by the physician. The failure could place residents at risk for delays in the provision of treatment for laboratory abnormalities and acute exacerbation of clinical conditions. Findings included: Record review of Resident #1's Face Sheet dated [DATE] reflected he a [AGE] year old male who admitted to the facility on [DATE] and re-admitted after a brief hospital stay on [DATE], and then died on [DATE] in the facility. Resident #1 had active diagnoses which included sepsis (onset date of [DATE]) (a life-threatening condition that occurs when the body has an extreme response to an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #2) of eight residents reviewed for infections. The facility failed to ensure COVID positive Resident #2, was appropriately isolated for 10 days per their facility COVID policy. On 09/03/24, Resident #2 was on day 7 of 10 in her isolation when she was in the communal dining room eating lunch at a table with residents nearby who were not wearing a mask and at risk of contracting the virus. The facility failure placed residents at risk of contracting COVID-19, which could lead to a decline in their health. Findings included: Record review of Resident #2's Face Sheet (dated 09/03/24) reflected she was a [AGE] year old female admitted to the facility on [DATE] with active diagnoses which included…

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 and homelike environment for five of ten residents (Resident #4, Resident #51, Resident #76, Resident #97, Resident #107) surveyed for environment. The facility failed to ensure the privacy curtains were in clean and in good condition/repair for Resident #4, Resident #51, Resident #76, Resident #97, and Resident #107. These failures could place residents at risk for not living in a safe, clean, and homelike environment. Findings included: Record review of Resident #4's Face Sheet revealed she was an [AGE] year-old female re-admitted to the facility on [DATE]. Relevant diagnoses included heart failure (dysfunction of the heart where it does not pump enough for one's body needs,) schizophrenia (mental disorder characterized by delusions, hallucinations, and disorganized thoughts), bi-polar disorder (mental disorder characterized by extreme mood swings,) and dementia (group of symptoms that affect memory and cognition.)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review the facility failed to ensure that the resident had the right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition for 1 of 8 resident (#54) whose care was reviewed in that: Resident #54 was not provided sufficient modes of communication. This deficient practice could affect residents with a communication/language barrier by contributing to low self-esteem and unmet needs. The findings were: Record review of Resident #54's face sheet, dated 03/12/24 revealed that the resident was a [AGE] year-old male. He was admitted to the facility on [DATE] with diagnoses of vascular dementia, cognitive communication deficit, major depressive disorder, primary open-angle glaucoma, unspecified glaucoma, altered mental status, and essential primary hypertension. Spanish was listed as the resident's primary language. Record Review of Resident #54's 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 provide the necessary services for residents who were unable to carry out activities of daily living to maintain good grooming and personal hygiene for two (Resident #24 and Resident #29) of eight residents reviewed for ADLs. 1. The facility failed to ensure Resident #24 received incontinence care every two hours. 2. The facility failed to ensure Resident #29 had his fingernails cleaned and trimmed. These failures could place residents who were dependent on staff for ADL care at risk for skin breakdown, infections, and a decreased quality of life. Findings include: 1. Record review of Resident #24's annual MDS assessment, dated 02/02/24, reflected she was an [AGE] year-old female with an admission date of 02/16/21. The resident's cognition was intact. The resident required substantial/maximal assistance with toileting. She was always incontinent of urine and stool. Her diagnoses included stroke. Record review of Resident #24's care plan,…

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 control program designed to prevent the development and transmission of infection for one of 8 residents (Resident #89) observed for infection control. CNA A failed to perform hand hygiene during while providing incontinence care to Resident # 89. This failure could place the residents at risk for infection. Findings include: Record review of Resident #89's face sheet dated 03/12/2024 reflected she was [AGE] years old female. She was admitted to the facility on [DATE] with the diagnoses of: Type 2 Diabetes Mellitus, (dementia (a progressive loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). Review of Resident #89's care plan date 12/21/2023 reflected . focus: Resident#89 has an ADL Self Care Performance Deficit and is at risk for not having their needs met in a timely manner, Performance deficit…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure resident rooms were 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 staff work area for one (Resident # 69) of 7 residents reviewed for resident call system. The facility failed to ensure the call light in resident room [ROOM NUMBER] A used by Resident #69 was always working. This failure could place residents at risk of being unable to obtain assistance for activities of daily living or in the event of an emergency. Findings included: Review of Resident #69's face sheet reflected an [AGE] year-old male with an admission date of [DATE]. admission diagnoses reflected fracture of unspecified part of neck of right femur (the part of the thigh bone, type 2 diabetes, end stage renal disease (a condition in which the kidneys lose the ability to remove waste and excess fluids from your blood) mild cognitive impairment.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to provide an environment that was free from accident hazards over which the facility has control and failed to provide supervision and assistive devices to each resident to prevent avoidable accidents for 1 of 3 resident (Resident #50) reviewed for accidents free of hazards. The facility failed to ensure Resident #50 did not elope from the facility on 08/23/23. The noncompliance was identified as PNC. The PNC began on 08/23/23 and ended 08/24/23. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of accidents, hazards, and improper supervision. Findings Included: Record Review of Resident #50's face sheet dated 09/19/23 revealed a [AGE] year-old male admitted on [DATE]. diagnoses included.: Acute Upper Respiratory Infection, Unspecified (J06.9), Generalized Anxiety Disorder (fears and uneasiness) (F41.1), Alzheimer's Disease, Unspecified (cognitive decline) (G30.9),…

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 an assessment accurately reflected a resident's status for 5 of 13 Residents (Resident #10 #20, #30, #40, and #50), reviewed for accuracy of MDS assessments. 1. The Quarterly MDS assessment of Resident #10 indicated that the resident had no psychotic behaviors or disorders. 2. The Quarterly MDS assessment of Residents #10, #20, #40, and 50 did not address resident mood, diagnosis, and behaviors associated with diagnosis. 3. The Quarterly MDS assessment for Resident # 30 did not document the resident's anxiety, and oxygen use. 4. The Quarterly MDS assess for Resident # 50 did not document resident, anxiety, history of wandering and elopement, as well as psychotropic medications, psychiatric conditions, medication use and oxygen use. These failures could affect the residents by placing them at risk of inaccurate and incomplete assessments which could result in residents not receiving care to meet their highest level of functioning…

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 comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 (Residents # 10, #20, and #50) of 9 residents reviewed for comprehensive care plans. The facility failed to develop and implement a comprehensive individualized care plan addressing resident's behaviors and interventions. These failures could place residents at risk for possible adverse side effects, adverse consequences, and decreased quality of life and care and worsening of contractures. Resident #10 A Record review of Resident #10's face sheet, dated 09/21/23, revealed [AGE] year-old female admitted on [DATE]. Her diagnoses include unspecified dementia with agitation restlessness and cognitive decline), repeated falls, and cognitive communication deficit, (difficult to understand), psychotic Disturbances, Mood disturbance without anxiety 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.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen. 1. The facility failed to ensure the proper labeling and dating of all foods stored in the refrigerator, freezer, and dry food storage areas. 2. The facility failed to ensure that staff was wearing the proper head and face coverings when serving food. These failures could place residents at risk for food-borne and transmission-based illnesses. Findings included: Observation on 01/24/23 at 12:25 PM in the facility's only kitchen revealed Interim Dietary Manager and Culinary Regional Dietary Manager, both having at least an inch of facial hair, were not wearing a beard covering. Also observed, was the cook wearing a chef's cap; however, he had at least two inches of hair hanging out the back of his chef cap. All three of them were plating food in the kitchen during lunch time. Observation of dry storage goods area on 01/24/23 at 10:00 am revealed two packages of hamburger…

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 develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights and that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 8 residents (Resident #27) reviewed for Care Plans. The facility failed to ensure Resident #27's fall mat was placed alongside the resident's bed per his care plan. This failure could place residents at risk of for needs not being met. Findings included: Review of Resident #27's face sheet dated 01/25/23 revealed he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Seizures and Convulsions (Shaking). Review of Resident #27's quarterly Minimum Data Set (MDS) dated [DATE], revealed he had a Brief Interview for Mental Status (BIMS) score of 0 (Severely Impaired Cognition). He required a two -person physical assist for all Activities of daily Living…

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 resident environment remained as free of accidents hazards as possible: and each resident recieved adequate supervision and assistance devices to prevent accidents for 1 of 8 residents (Resident #27) reviewed for accidents and hazards. The facility failed to ensure Resident #27's fall mat was placed alongside the resident's bed. This failure could place residents at risk of for needs not being met. Findings included: Review of Resident #27's face sheet dated 01/25/23 revealed he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Seizures and Convulsions (Shaking). Review of Resident #27's quarterly Minimum Data Set (MDS) dated [DATE], revealed he had a Brief Interview for Mental Status (BIMS) score of 0 (Severely Impaired Cognition). He required a two -person physical assist for all Activities of daily Living Assistance (ADL's), and used a wheelchair. Review of Resident #27's Care Plan dated…

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