Harmony Care at Giddings

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute food under sanitary conditions in accordance with professional standards for food service safety for 1 of 1 kitchen.1. The facility failed to label and date all food items located in the walk-in refrigerator, freezers and in the dry food pantry area on 7/15/2025, and 7/16/2025. 2. The facility failed to clean and sanitize its food storage areas, to include the shelves and 1freezer in storage room. on 7/15/2025, and 7/16/2025.3. The facility failed to clean and sanitize its dining area on 7/15/2025, 7/16/2025, and 7/17/2025. These failures could place residents who receive meals from the kitchen and dine in the facility's dining room at risk for foodborne illnesses.Observation during the initial tour of the kitchen on 7/15/2025 beginning at 09:30 AM, the following was observed:Dry Food Pantry area: 18 cans of diced red peppers, not labeled and dated 6 cans of Thick it, not labeled and dated 2 gallons…

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, including hand hygiene, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 7 (Resident #5, Resident #8, Resident #22, Resident #27, Resident #15, Resident #39, and Resident #42 of 11 residents reviewed for infection control practices, in that: The facility failed to:1. Ensure CNA B and Medication Aide A practiced proper hand hygiene while serving and assisting residents #22, #27, and #42 during the lunch meal on [DATE].2. Ensure CNA C changed dirty gloves when handling clean items while providing peri care to Resident #8.3. Ensure Medication Aide A sanitized blood pressure monitors in between Resident #15 and Resident #39 while obtaining blood pressures. 4. Ensure LVN F washed his hands before and after the wound care on Resident #5 and changed dirty gloves when handling…

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 be treated with respect and dignity for one of five residents (Resident #14) reviewed for dignity. The facility failed to speak to Resident #14 in a way that promoted her dignity and self-worth. This failure could place residents at risk of a decline in their sense of dignity, level of satisfaction with life, and feeling of self-worth.Findings include: Record review of Resident #14's face sheet, dated 07/17/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #14 had diagnoses which included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a condition where a person exhibits symptoms of dementia, but the specific type of dementia was not identified, and the severity had not been specified. Dementia- a loss of thinking, remembering, and reasoning to such an extent that it interferes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two of eight residents (Resident# 12 and Resident #16) reviewed for ADL care. The facility failed to ensure Resident #12, and Resident # 16's nails were cleaned, and did not have rough edges. This failure could place residents at risk of not receiving services or care, diminished quality of life, and decreased self-esteem. Findings include: 1. Record review of Resident #12's face sheet, dated 07/17/2025, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #17 had diagnoses which included Type 2 diabetes mellitus without complications (a disorder where the body either does not produce enough insulin or cannot properly use the insulin it produces, leading to high blood sugar levels), lack of coordination (the inability to smoothly and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review, the facility failed, to provide an ongoing activities program to support residents in their choice of activities, both facility sponsored group and individual activities, and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for two of five residents ( Resident # 15 and Resident #25) reviewed for activities. The facility failed to provide Resident #15 and Resident #25 in room activities on the dates of 07/01/2025 thru 7/17/2025. This failure could place residents at risk for boredom, depression, and diminished quality of life. Based on interview, observation and record review, the facility failed, to provide an ongoing activities program to support residents in their choice of activities, both facility sponsored group and individual activities, and independent activities, designed to meet the interests of 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 dispose of garbage properly in 1 of 1 kitchen.On 07/15/2025 at 9:30 AM, 1 of 2 facility garbage containers were observed with no lids attached or on them and they had waste inside. This failure has the potential to affect residents in the facility, staff, and visitors by placing them at risk of infection for exposure to germs and diseases carried by pests and rodents. In an interview with Dietary Supervisor on 07/16/2025 at 3:15 PM, Dietary Supervisor stated that trash cans should always have lids and should remain closed when not in use. Dietary Supervisor stated not keeping the lids closed could lead to cross contamination, placing residents at risk of illness.In an interview 07/17/2025 at 9:51 AM with Dietary Aide D, she stated that she has been employed at the facility for six years and has worked in the kitchen for the past four years. She reported that she has been trained on all kitchen policies. Dietary Aide D stated that trash cans should be kept always closed with a lid. She explained that if a trash…

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

Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for one of one kitchen reviewed for effective pest control.The facility had presence of mouse droppings on a shelf in the food storage room.This failure could place residents at risk for spread of infection, cross-contamination, and decreased quality of life.Observation on 07/15/2025 at 9:22 AM, in the facility's kitchen food storage room revealed several mouse droppings on the bottom shelf.In an interview with Dietary Supervisor on 07/16/2025 at 3:15 PM, she stated it looked like mouse droppings to her as well on the shelf. Dietary Supervisor stated the maintenance department was responsible for pest control. She stated the shelf would be cleaned that day.In an interview with the Maintenance Supervisor on 7/17/2025 at 9:44 AM, he stated that he began working at the facility on June 2, 2025. He reported that he has not personally seen any pests in the facility; however, some staff members have informed him that they have seen…

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 develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one resident (Resident #1) out of four residents reviewed for the development of the comprehensive care plans. The facility failed to ensure Resident #1 had a comprehensive person-centered care plan completed to reflect Resident #1's care needs for Catheter, Diabetes, Oxygen therapy, medications (antibiotics , anti-hypertensive, anticoagulant), and Cognition. This deficient practice places the resident at risk for not receiving the necessary and appropriate care. Findings included: Review of Resident # 1's face sheet dated 05/18/2025 reflected a [AGE] year-old male admitted on [DATE] with diagnoses that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, 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 infection for 2 of 5 residents (Residents #1 and #2) reviewed for infection control. The facility failed to ensure Resident #1 was placed on Isolation after she tested COVID-19 (Coronavirus 2019) positive in the hospital on [DATE]. The facility failed to have signage on Resident #1's door that reflected PPE was required for infection control. The facility failed to removed Resident #2 from a COVID-19 positive room even though she tested negative for COVID. These failures could place residents at risk for infection, or hospitalization. Findings included: According to the intakes received by HHSC, The facility is not practicing infection control. They are not quarantining the covid positive Residents. [Resident #3] is next door to [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 ensure each resident was treated with respect and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 (Resident #5) of 7 residents reviewed for resident rights. The facility failed to honor Resident #5's request of being assisted out of bed on 02/09/25. This failure could place resident at risk for depression, diminished quality of life and isolation. Findings included: Review of Resident #5's face sheet, dated 02/09/2025, reflected a [AGE] year-old female admitted to the facility on [DATE] with a diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (a condition that occurs when the right side of the brain is damaged, resulting in physical disabilities on the left side of the body), depression, unspecified (disorder than can impact your mood, thoughts and feelings, weight, sleeping habits, etc.) and pain. 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 immediately notify the resident's representative(s) when there was a significant change in the resident's physical and psychosocial status for one (Resident #4) of seven residents reviewed for changes in condition. 1. The facility failed to notify Resident #4's RP of Resident #4 being hit by a peer on 2/3/25. 2. The facility failed to notify Resident #4's RP of a visit to the ER after Resident #4 had a fall on 2/7/25 with an onset of increased confusion. These failures could put residents at risk of not having their care needs and health changes communicated and addressed with their responsible party. Findings included: Review of Resident #4's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease with early onset (a progressive disease that destroys memory, thinking and behavior, interfering with daily functioning), cognitive communication deficit (reduced ability…

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, in response to allegations of abuse, neglect or mistreatment, have evidence that all alleged violations were thoroughly investigated for two (Residents #4 and #7) of seven residents reviewed for abuse and neglect. The facility failed to investigate an allegation of abuse when Resident #7 hit Resident #4 on her face on 2/3/25. This failure placed residents at risk of further abuse, trauma, and psychosocial harm. Findings included: Review of Resident #4's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease with early onset (a progressive disease that destroys memory, thinking and behavior, interfering with daily functioning), cognitive communication deficit (reduced ability to communicate needs), and dementia (brain impairment of at least two brain functions). Responsible Parties are listed as Resident #4 and RP E. Review of Resident #4's 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 develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 7 residents (Residents #5 and #7) reviewed for care plans. 1. The facility failed to ensure the comprehensive care plan for Resident #5 included the need for a mechanical lift transfer with the assistance of 2 staff. 2. The facility failed to ensure Resident #7's comprehensive care plan included aggressive behaviors. These failures could affect residents by placing them at risk of not receiving appropriate physical and psychosocial care. Findings included: Review of Resident #5's face sheet, dated 2/9/2025, reflected a [AGE] year-old female admitted to the facility on [DATE] with a diagnoses of hemiplegia…

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

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for one (secure hall) of three halls reviewed for physical environment. The facility failed to ensure an exit door on the secured unit contained an alarm to alert staff if a resident exited the door. This deficient practice could place residents at risk of injury or harm. Findings included: Review of the facility Midnight Census report dated 2/9/25 revealed there were 7 residents listed as residing on the secure unit. Review of the facility IRs from 10/1/2025 through 2/9/25 revealed there were none related to unauthorized departure. During an observation and interview on 2/8/25 at 12:48 pm with CNA F revealed he believed that the exit door contained an alarm that went off when it was opened. CNA F was not certain how to turn the alarm off. He stated he would normally ask the Administrator, who was not at the facility on that day. CNA F stated he had not observed any residents trying to go out 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 ensure each resident was treated with respect and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 (Resident #1) of 4 residents reviewed for resident rights. The facility failed to honor Resident #1's request of being assisted out of bed between 8:30 and 9:00 AM on 09/12/2024. This failure could place resident at risk for depression, diminished quality of life and isolation. Findings included: Record review of Resident #1's face sheet, dated 09/12/2024, reflected a [AGE] year-old female admitted to the facility on [DATE] with a diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (a condition that occurs when the right side of the brain is damaged, resulting in physical disabilities on the left side of the body), depression, unspecified (disorder than can impact your mood, thoughts and feelings, weight, sleeping habits,…

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 that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Resident #1) reviewed for care plans. The facility failed to ensure the comprehensive care plans for Resident #1 included ADLs, behaviors, and diagnosis of mental illness on 07/25/2024. This failure could affect residents by placing them at risk of not receiving appropriate physical and psychosocial care. Findings included: Record review of Resident #1's face sheet , dated 09/12/2024, reflected a [AGE] year-old female admitted to the facility on [DATE] with a diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (a condition that occurs when 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 interview and record review, the facility failed to follow guidelines for mandatory electronic submission of staffing information based on payroll data in a uniform format. The facility failed to submit direct care staffing information on the schedule specified by CMS (Centers for Medicare and Medicaid Services), but no less frequently than quarterly for 1 of 4 quarters reviewed for payroll data information (Quarter 1 2024). The facility failed to submit PBJ staffing information to CMS for the 1st quarter ([DATE] to March 30) of fiscal year 2024. This failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment. Findings included: Review of the facility's Civil Rights Survey Report dated 05/28/2024 (Form 3761) indicated the following: 3 RNs 7 LVNs 9 Direct Care Staff 6 Dietary 4 Housekeeping & Laundry 7 All Others Record review of the CMS PBJ Staffing Data…

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 a safe, clean, comfortable, and homelike environment for 5 of 15 of Residents (Residents #27, #5, #13, #1 and #19), 1 of 1 outside facility grounds, and 1 of 1 shower rooms reviewed for homelike environment. A) The facility failed to ensure Resident #27's bathroom soap dispenser was attached to the wall on 05/28/2024 at 09:38 AM. B) The facility failed to ensure Resident # 5's remote control cord for her bed was intact and functional on 05/28/2024 at 09:40 AM. C) The facility failed to ensure Resident #13's window blinds were intact and not missing slats on 05/28/2024 at 09:40 AM. D) The facility failed to ensure Resident #1's window blinds were attached to the top of her window; the windowsill was attached securely to the window and the baseboard next to the window was attached to the wall on 05/29/2024 at 9:49 AM. E) The facility failed to ensure Resident #19's windowsill was attached securely to the wall and 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 that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents goals and preferences for 4 of 4 residents (Residents #88, #22, #19 and #24) reviewed for respiratory care. A. The facility failed to ensure Resident #80's CPAP mask was covered with a dated plastic bag on 05/28/2024 at 9:52 AM B. The facility failed to ensure Resident #22's nebulizer mask was covered with a dated plastic bag on 05/29/2024 at 2:33 PM. C. The facility failed to ensure Resident #19's oxygen tubing was dated on 05/28/2024 at 11:02 AM and failed to ensure her nasal cannula was covered with a dated plastic bag when not in use. D. The facility failed to ensure Resident #24's nebulizer mask was covered with a dated plastic bag on 05/29/2024 at 2:33 PM when not in use. These failures could place residents at risk for respiratory infections.…

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

Based on observation, interview and record review, the facility failed to ensure that all expired drugs and biologicals were removed and destroyed for 1 of 1 medication storage rooms reviewed for medications and failed to ensure 1 of 1 medication storage room refrigerators was free of contaminants. The facility failed to remove 7 bottles of expired medication from the medication storage room and 1 container of expired protective skin applicators when it was observed on 05/28/2024 at 3:45 PM. The facility failed to ensure the medication room refrigerator was free of contaminants including staff food and drinks when it was observed on on 05/28/2024 at 3:45 PM. This failure could place all residents at an increased risk of receiving expired and/or contaminated medications/supplements resulting in adverse health consequences. Findings included: Observation on 05/28/2024 at 3:45 PM in the medication storage room revealed one bottle of Aspirin 81 mg expiration date 08/2023, four bottles of Docusate Sodium expiration date 04/2024, one bottle of natural tear eye drops expiration date 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.

Based on observations, interviews, and record review the facility failed to maintain an effective pest control program so that the facility was free of pests for 1 of 1 dining rooms and 1 of 1 shower room reviewed for environment. The facility failed to ensure the dining room was free of flies during the resident meal service on 05/28/2024 at 12:15 PM. The facility failed to ensure the shower room was free of roaches and water bugs on 05/29/2024 at 1:15 PM. These failures could place residents at risk for insect borne illness, not having a home free of pests and a comfortable environment in which to live. Findings included: Observation on 05/28/2024 at 12:15 PM revealed one resident swatting a fly off of her food. The fly landed in her dessert cup and was stuck on the inside. Another resident had a fly land on her drink cup several times. Observation on 05/29/2024 at 1:15 PM in the shower room of a small brown roach crawling toward the commode and a water bug (a large insect that can bite and prefers very wet environments) approximately one-inch-long crawling on the wall above 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 interview, and record review the facility failed to ensure that all alleged violations involving neglect were reported immediately to the state survey agency, for 1 of 1 resident (Resident# 25) reviewed for elopement. The facility did not report to the state survey agency when Resident #25 eloped from the facility on 05/14/2024 without facility knowledge and was found at the convenience store 0.4 miles away. This failure places residents at risk for elopement, accidents, and heat exhaustion due to lake of supervision. Findings included: Review of Resident #25's Face sheet dated 05/28/2024 reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses Dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), Vertigo (A sense of spinning experienced even when someone is perfectly still.), anxiety disorder, (Fear characterized by behavioral disturbances.) and lack of coordination. Review of Resident #25 Annual MDS dated [DATE] reflected…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that residents had orders and followed physician's orders for the resident's immediate care for 1 of 15 Residents (Resident #80) reviewed for admission orders. The facility failed to provide physician's orders for fingerstick blood sugar checks for Resident #80 who was admitted to the facility on [DATE]. The facility failed to check Resident #80's blood pressure per Physician's orders. This failure could place the resident at risk of not receiving necessary care and services upon admission that could result in a deterioration of her condition. Findings included: Record review of the undated Face Sheet for Resident #80 reflected she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of Type 2 Diabetes (long term condition in which the body has trouble controlling blood sugar and using it for energy) and Morbid Obesity (severely overweight). Record review of the Discharge Medications list 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 develop and implement a baseline care plan within 48 hours of admission that included the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care for 1 of 15 residents (Resident #80) reviewed for baseline care plans. The facility failed to ensure Resident #80's baseline care plan dated 05/28/2024 included instructions to address her admission diagnosis, Type 2 Diabetes (long term condition in which the body has trouble controlling blood sugar and using it for energy) and physician orders within 48 hours of admission. Resident #80 was admitted to the facility on [DATE]. This failure could place residents at risk of receiving inadequate care and services. Findings included: Record review of the undated Face Sheet for Resident #80 reflected she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of Type 2 Diabetes (long term…

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

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 5 out of 8 residents reviewed for comfortable and safe temperature levels. The facility failed to ensure the dining area was within 71-81 degrees Fahrenheit . This failure could place residents susceptible to loss of body heat and an uncomfortable setting. Findings included: Observation on 01/17/2024 at 10:50 a.m., revealed a personal use thermometer on top of a piano in the dining room, the temperature observed was at 67 degrees Fahrenheit. Further observations revealed no residents in the dining room. Observation on 01/17/2024 at 10:53 a.m., revealed dining room thermostat set at 73 degrees Fahrenheit, and temperature at 67 degrees Fahrenheit. Observation on 01/17/2024 at 12:01 p.m., revealed dining room thermostat set at 73 degrees Fahrenheit, and temperature at 68 degrees Fahrenheit while residents were eating lunch. Interview on 01/17/2024 at 10:43 a.m., Resident #1 stated that the dining room. Can be really cold, and that, it (dining room)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure the resident environment remains free of accidents and hazards for one (1) (Resident #1) of four (4) residents reviewed for accidents and hazards. The facility failed to properly supervise Resident #1 and as a result she had a cigarette lighter stored in her room. This deficient practice placed residents at risk for accidents resulting in injuries or hospitalization related to burns or fire. Findings include: Review of Resident #1's face sheet dated 1/3/2024 reflected a [AGE] year-old female admitted on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (a group of lung diseases that block airflow and make it difficult to breathe), Personal History of Lung Cancer, Muscle Wasting and Atrophy, Dementia (age related memory loss) and Paraplegia (partial paralysis). Review of Resident #1's MDS dated [DATE] reflected a BIMS of 11, indicating moderate cognitive impairment. Review of Section G, Functional 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.

Based on observation, interview, and record review the facility failed to ensure that all drugs and biologicals were stored in locked compartments and inaccessible to unauthorized staff, visitors, and residents for two (Nurse medication cart and Nurse treatment cart) of four (4) medication carts reviewed for medication storage. The facility failed to prevent the Nurse's medication cart and Nurse's treatment cart from being unattended and unlocked. This failure could place residents, unauthorized staff and visitors access to medications that could cause physical harm and decreased quality of life . Findings include: An observation on 10/14/2023 at 11:07 am revealed the Nurse's medication cart and Nurse's treatment cart were unlocked and unattended at the nurse's station. There were three residents, one agency staff and 2 family members in the immediate vicinity of the two unlocked carts. There were no facility staff observed to be in the area. An observation on 10/14/2023 at 11:09 am revealed a nurse returning to the Nurse's station and sitting behind the station, out of the line 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 interviews and record reviews, the facility failed to review and revise the comprehensive person-centered care plan after each assessment, including comprehensive and quarterly review assessments, for 2 of 4 residents (Resident #1 and #2) reviewed for care plan timing, in that: 1. Resident #1's quarterly MDS assessment was completed on 08/08/23 and her most recent comprehensive person-centered care plan was revised and completed on 01/06/2023. 2. Resident #2's quarterly MDS assessment was completed on 07/20/23 and his most recent comprehensive person-centered care plan was revised and completed on 02/03/2023. This deficient practice could place residents at risk of not having their current preferences, goals, and needs met. Findings included: Review of Resident #1's face sheet, dated 09/29/2023, reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including unspecified dementia, personal history of COVID-19, unspecified muscle wasting and atrophy (a decrease in…

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

Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for four of 30 days reviewed for RN coverage. The facility failed to ensure they had an RN on duty on 03/05/23, 03/12/23, 03/19/23, and 03/25/23. This failure placed residents at risk of missed nursing assessments, interventions, care, and treatment. Findings included: Review of RN staffing hours for March 2023 reflected zero hours worked by an RN on 03/05/23, 03/12/23, 03/19/23, and 03/25/23. During an interview on 03/30/23 at 12:27 PM, the DON stated the facility census has been between 32 and 35 for over a year, and she has worked as the facility RN either Sunday or Saturday since she started. She stated she thought the rules about RN coverage were that if the census was low enough, they did not need an RN on duty every day. She stated she lived only a few minutes away from the facility and was on call 24/7 if there was an issue or a need for RN assessment or presence. The DON stated there was not an RN on duty the previous…

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 received treatment and care in accordance with professional standards of practice for two (Resident #25 and Resident #2) of 12 residents reviewed for quality of care. 1. The DON failed to ensure Resident #25's GI consult was scheduled in a timely manner. 2. Resident #2 was not wearing compression bandages as ordered on 3/29/2023 and 03/30/23 and did not receive monitoring for edema as ordered. These failures placed residents at risk of delayed care and services in accordance with professional standards of practice. Findings included: 1. A record review of Resident #25's face sheet dated 3/30/2023 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of metabolic encephalopathy (brain disorder), type 2 diabetes (uncontrolled blood sugar), Alzheimer's disease (memory loss), hypertension (high blood pressure), unspecified convulsions (irregular muscle movements), epileptic seizures (neurological disorder), major…

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 prevent the development and transmission of communicable diseases for two of four residents (Residents #11 and #12 and 1 of 1 LVN (LVN A) reviewed for fingerstick blood sugar checks. LVN A failed to sanitize the common glucometer, which is used during blood testing between resident blood sugar checks for Resident #11 and #12. This failure could place residents at risk of exposure to blood-borne diseases. Findings Included: Observation on 03/28/2023 at 10:59 AM, revealed LVN B preparing to perform a finger stick blook sugar (FSBS) test on Resident #12. LVN B removed the glucometer from the cart and placed the glucometer on the cart without cleaning the cart. LVN B without cleaning the glucometer took the glucometer into Resident #12's room along with her insulin pen and placed both items on her night stand without cleaning the night stand or putting down a barrier. LVN B then performed the FSBS test on Resident #12. After the FSBS…

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.