Focused Care of Gilmer

Based on observation, interview and record review the facility failed to provide care and services in accordance with activities of daily living for hygiene-bathing, dressing, grooming, and oral care for residents a during a confidential interview for 13 of 13 residents (Unidentified Resident #1, Unidentified Resident #2, Unidentified Resident #3, Unidentified Resident #4, Unidentified Resident #5, Unidentified Resident #6, Unidentified Resident #7, Unidentified Resident #8, Unidentified Resident #9, Unidentified Resident #10, Unidentified Resident #11, Unidentified Resident #12, Unidentified Resident #13)reviewed for ADLs. The facility failed to ensure the residents had a sufficient number of towels in the facility for ADL care. This failure could place residents at risk of no showers, hand hygiene, not receiving services/care and decreased quality of life. Findings include:A record review of the facility in-service binder, no in-services were noted related to the facility not having towels available for the resident's hygiene needs. A record review of the facility invoice…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that residents who need respiratory care were provided with such care, consistent with professional standards of practices for 3 of 25 residents (Resident #14, Resident #35, and Resident #2) reviewed for respiratory care.The facility failed to ensure that oxygen filters were clean for Resident #14's oxygen concentrator.The facility failed to change the oxygen tubing for Resident #35's oxygen concentrator.The facility failed to ensure Resident #2's oxygen reservoir was changed weekly.These failures could place residents who receive respiratory care at risk of developing respiratory complications and a decreased quality of care.1. Record review of Resident #14's face sheet, dated 01/02/26 revealed a [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included Chronic Obtrusive Pulmonary Disease (a progressive, irreversible lung disease causing chronic, long-term breathing problems,…

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 store all drugs and biologicals in locked compartments for 3 of 23 residents reviewed for storage of drugs and biologicals (Resident #9, Resident #32, and Resident #30) and 2 of 4 medication carts (Medication Cart #2 and Treatment Cart #4) reviewed for medication storage. The facility failed to securely store wound care chemicals for Resident #9.The facility failed to securely store fluticasone propionate nasal spray 50 micro grams (a corticosteroid used to relieve seasonal and year-round allergy symptoms, including nasal congestion, runny nose, itchy nose, sneezing, and watery eyes), fluticasone propionate and Salmeterol powder 250/50 micrograms (a combination prescription inhaler containing a corticosteroid and a long-acting beta-agonist), and povidone-iodine 10% solution (a fast-acting, broad-spectrum topical antiseptic used to prevent infections in minor cuts, scrapes, and burns, as well as for preoperative skin preparation) 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 observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation in that:1. The facility failed to dispose of expired prepackaged green onions that were actively decomposing.2. The facility failed to label and date bread, butter, and baked items.These deficient practices could place residents who received meals from the kitchen at risk for food borne illness.The findings were:During an observation of the kitchen on 2/22/26 at 10:01 a.m. it was observed that bread was not dated or labeled sitting on top of a toaster. Bags of green onion were expired, dated 1/17/2026, and unlabeled. [NAME] onions were decomposing inside of the bag releasing black liquid. Blocks of margarine were undated and labeled with no expiration date listed on the packaging.During an interview on 2/25/26 at 9:13 a.m. with the Dietary Manager she stated that food should be labeled and dated. She said that food should be covered properly. She…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 3 of 16 residents (Resident # 17, Resident #52, and Resident #69) reviewed for resident rights.1. The facility failed to ensure Resident #17 was able to access her bedroom furnishings.2. The facility failed to ensure Resident #69 was able to access her call light.This failure could place residents at risk for unmet needs and decreased quality of life.Findings include:1. Record review of Resident #17's face sheet, dated 08/21/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #17 had diagnoses which included Paraplegia (impairment or loss of motor and sensory function in the lower extremities and sometimes the torso, resulting from spinal cord damage in the thoracic,…

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 each resident had the right to be free from misappropriation of property and exploitation for 1 of 4 residents (Resident #3) reviewed for misappropriation of property. The facility failed to prevent the misappropriation of Resident #3's Hydrocodone (Norco) (a combination medicine that is commonly taken for severe pain). This failure could place residents at risk for uncontrolled pain. Record review of Resident #3's face sheet, dated 2/24/2026, indicated Resident #3 was an [AGE] year-old male who was readmitted to the facility on [DATE]. Resident #3 had diagnoses which included chronic venous hypertension with ulcers to bilateral lower extremities (occurs when veins in the lower extremities fail to efficiently return blood to the heart ), Sepsis (a life-threatening condition caused by the body's extreme response to an infection), diabetes mellitus (a condition in which the body has trouble controlling blood sugar and using it for energy), 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 the resident rights, that included medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 6 residents (Resident #35) reviewed for care plans. The facility failed to implement the comprehensive person-centered care plan for Resident #35 by not documenting resident's need for oxygen therapy. This failure could place residents at risk of not having individual needs met, a decreased quality of life, and cause residents not to receive needed services Findings include:Record review of Resident #35's face sheet, dated 12/28/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #35 had diagnoses which included Acute and Chronic Respiratory Failure with Hypercapnia (occurs when a patient with underlying chronic respiratory insufficiency suffers a sudden, severe decline in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 of 5 residents (Resident #16 and Resident 64) reviewed for skin integrity. The facility failed to ensure Resident #16 and Resident 64's pressure- redistribution mattress (is designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) was on the correct settings. This failure could place residents at risk for developing pressure ulcers and could contribute to developing avoidable pressure ulcers. Findings include: 1.Record review of Resident #16's face sheet, dated 2/24/26, indicated a [AGE] year-old male initially admitted to the facility on [DATE]. Resident #16 had diagnoses which included cellulitis of buttocks (a bacterial infection of the deep skin layers), morbid (serve)…

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 had an indwelling catheter with a drainage bag had a securing device for 1 of 5 residents (Resident #18) reviewed for catheter care. The facility failed to ensure Resident #18's indwelling foley catheter (drains urine from your urinary bladder into a bag outside your body) had a catheter securement device to anchor the catheter to her leg. This failure could place residents at risk for friction, pulling, pain and trauma.Findings included: Record review of Resident #18's face sheet dated 2/23/26 reflected a [AGE] year-old female who was initially admitted on [DATE] and was readmitted to the facility on [DATE]. Resident #18 had diagnoses which included: neuromuscular dysfunction of the bladder (the loss of normal bladder control due to nerve damage), retention of urine (the inability to fully empty the bladder) and need for assistance with personal care. Record review of Resident #18's MDS assessment, dated 2/20/26,…

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 2 of 16 residents (Resident #18 and Resident #36) reviewed for infection control practices. 1. The facility failed to ensure CNA B removed her gown when she entered the hallway to get gloves while providing incontinent care and catheter care for Resident #18 on enhanced barrier precautions on 2/22/26. 2. The facility failed to ensure Resident #36's feeding tubing port was capped and off the floor. These failures could place residents at risk for cross contamination and the spread of infection. Findings include: Record review of Resident #18's face sheet dated 2/23/26 reflected a [AGE] year-old female who was initially admitted on [DATE] and was readmitted to the facility on [DATE]. Resident #18 had 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 ensure residents could call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside for 1 of 3 residents (Resident #52) reviewed for resident call system. The facility failed to ensure Resident #52 had a call light button attached to the call light system. Resident #52 did not have a call light available from 2/22/26 until 2/24/26. This failure could place residents at risk for a delay in assistance and decreased quality of life, self-worth, and dignity. Findings include: Record review of Resident #52's face sheet, dated 2/23/26, reflected a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #52 had diagnoses which included: chronic systolic (congestive) heart failure ( where the left ventricle weakens and cannot pump enough blood), chronic gout due to renal impairment (high…

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 normal transportation for residents to medical services outside of the facility for 1 of 6 residents (Resident #1) reviewed for transportation. The facility failed to provide transportation for Resident #1 to a doctor's appointment on 10/14/25. This failure could place residents at risk of possible adequate evaluation, hospitalization and unmet needs.Findings include: Record review of Resident #1's face sheet, dated 10/28/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: paraplegia (a condition characterized by the loss or impairment of motor sensory functions in both lower limbs), gastro-esophageal reflux disease (a condition where stomach contents flow back up into the esophagus, causing irritation and various symptoms) and flatulence (the release of gas from the digestive tract through the anus). Record review of Resident #1's quarterly 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 observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment for 1 of 11 residents (Resident #3) reviewed for the physical environment. The facility failed to ensure Resident #3's room was clean and free of strong urine odors. This failure could place residents at risk for a decreased quality of life and an unsanitary environment. The findings included: Record review of the face sheet, dated 11/25/25, reflected Resident #3 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of hypertensive heart disease with heart failure (long-term condition caused by high-blood pressure, which resulted in heart failure), paraplegia (weakness or paralysis of the lower legs), and spinal stenosis (narrowing of the spinal canal). Record review of the quarterly MDS assessment, dated 9/18/25, reflected Resident #3 had clear speech, was understood by others, and was usually able to understand others. Resident #3 had a BIMS score 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 observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 2 residents (Resident #1 and Resident #2) reviewed for incontinent care. 1.The facility failed to ensure CNA A changed gloves and performed proper hand hygiene before going from dirty to clean during Resident #1's catheter and incontinent care on 11/25/25. 2. The facility failed to ensure CNA B performed hand hygiene before applying new gloves and changed gloves before going from dirty to clean during Resident #2's incontinent care on 11/25/25. These deficient practices could place residents at risk for decreased quality of life, infection, and skin breakdown due to improper care practices. The findings included: 1.Record review of Resident #1's face sheet, indicated she was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 residents reviewed for infection control practices (Resident # 7). 1.The facility failed to ensure CNA A and CNA B wore personal protective equipment while providing incontinent care for Resident #7 who was on EBP with a Foley catheter (a thin, flexible tube inserted through the urethra into the blader to facilitate urine drainage), Gastrostomy tube (is a feeding tube that delivers nutrition to your stomach) and a wound on 11/1/2025. These failures could place residents at risk of exposure to communicable diseases, cross-contamination, and infections. Findings included:Record review of the face sheet dated 11/7/2025 indicated Resident #7 was a [AGE] year old male who was re-admitted on [DATE] with…

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 3 of 5 residents (Resident #1, Resident #41 and Resident #206) reviewed for pharmaceutical services. The facility failed to ensure Physician Ordered medications were ordered and available for administration for each of the 3 residents (Resident #1, Resident #41 and Resident #206). 1. MA E did not administer Resident #1's Pepcid (used to treat gastroesophageal reflux) 20 milligrams medication during a medication pass on 12/03/2024 as ordered by the physician on 06/24/2022. 2. MA E did not administer Resident #41's Pepcid (used to treat gastroesophageal reflux) 20 milligrams medication during a medication pass on 12/03/2024 as ordered by the physician on 09/30/2024. 3. MA E did not administer Resident #206's Pepcid (used to treat…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure the medication error rates were not 5 percent or greater. The facility had a medication error rate of 15.22%, based on 7 errors out of 46 opportunities, which involved 4 of 5 (Resident #1, Resident #17, Resident #41 and Resident #206) residents and 1 of 1 medication aide (MA E) and 1 of 1 LVN reviewed for medication errors. 1. MA E did not administer Resident #1's Pepcid during the medication pass as ordered by the physician on 12/3/24 due to medication not available. 2. MA E failed to administer the correct dose of vitamin C to Resident #17 on 12/03/2024 as ordered by the physician and mixing a medications and protein supplement (polypharmacy) together instead of preparing them individually. 3. MA E did not administer Resident #41's Pepcid during the medication pass as ordered by the physician on 12/3/24 due to medication not available. 4. MA E did not administer Resident #206's Pepcid or Paxil during the medication pass as ordered…

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

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure food stored in the kitchen refrigerator was labeled, dated and not expired. 2. The facility failed to ensure food stored in the kitchen dry storage area was not expired. These failures could place residents at risk for foodborne illness. Findings include: During an observation on 12/02/2024 at 09:25 AM, revealed the #2 refrigerator contained a clear plastic bag of black olives with an opened date of 11/13/24 that was 1/3 full and a tray of what appeared to be 2 heads of lettuce covered with a clear plastic wrap that was not labeled or dated. During an observation on 12/02/2024 at 09:25 AM of the dry storage area revealed a clear plastic bag of [NAME] cracker crumbs, 5-pound bag that was approximately 1/3 full with an open date of 9/23/24 and a use by date of 10/23/24, 10 packages of flour tortillas 12 count package with…

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 have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption for three of twelve Residents (Resident #21, Resident #42 and Resident #23) reviewed for food and nutrition services. 1. The facility failed to ensure the refrigerator for Resident #21 was clean and contained food items that were labeled and dated. 2. The facility failed to ensure the refrigerator for Resident #42 did not contain expired broccoli cheddar soup. 3. The facility failed to ensure the refrigerator for Resident #23 did not contain expired peaches and pears. These failures could place residents at risk for foodborne illness. Findings include: 1. Record review of Resident #21's face sheet, dated 12/04/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #21 had diagnoses which included: chronic systolic heart failure (the heart does not…

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 4 of 7 residents (Resident #1, #17, #41, and #206) and 3 of 5 staff (MA E, CNA C, and CNA D) reviewed for infection control. 1. CNA C and CNA D failed to change gloves and perform hand hygiene during incontinent care for Resident #17 on 12/02/2024. 2. MA E failed to sanitize her hands while administering medications to Resident # 1, Resident #17, Resident #41 and Resident #206 on 12/03/24. 3. MA E failed to clean and disinfect the blood pressure cuff used on Resident #17 and Resident #41 after use during medication pass on 12/3/2024. These failures could place residents at risk of exposure to infectious diseases. Findings include: 1. Record review of Resident #17's admission Record, dated 12/3/2024, indicated a…

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

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 1 of 12 residents (Residents #30) reviewed for activities of daily living. The facility failed to ensure Resident #30 received nail care. This failure could place residents at risk of not having their needs met which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health. Findings include: Record review of Resident #30's facility face sheet, dated 12/03/2024, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #30 had a diagnosis which included atherosclerotic heart disease (buildup of plaque in the heart arteries). Record review of Resident #30's comprehensive care plan, dated 11/18/24, revealed Resident #30 had an ADL (activities of daily living) self-care 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 observation, interview, and record review the facility failed to be adequately equipped to allow residents to call for staff through a communication system which relayed the call directly to a staff member or to a centralized staff work area from toilet and bathing facilities for 2 of 18 residents (Residents #107 and #110) reviewed for call lights . The facility failed to ensure Residents #107 and #110's bathrooms had a call light pull cord on 12/02/2024 and 12/03/2024. This failure could place residents at risk of injury, pain, hospitalization, and a diminished quality of life. Findings include: 1. Record review of Resident #107's facility face sheet, dated 12/04/2024, revealed an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #107 had a diagnosis which included hemiplegia and hemiparesis following cerebral infarction (paralysis and weakness following a stroke). Record review of Resident #107's comprehensive care plan, dated 11/25/2024, revealed Resident#107 was high risk 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 interview and record review the facility failed to ensure as part of its QAPI program mandatory training that outlines and informs staff of the elements and goals of the facility's QAPI program for 2 of 15 employees (CNA G and CNA L) reviewed for training. The facility failed to ensure the quality assurance and performance improvement training was provided to CNA G and CNA L. This failure could place residents at risk for not being aware of facility programs, implementation, and monitoring. Findings include: Record review of CNA G's personnel file revealed CNA G was hired on 7/13/2017 and had not completed annual QAPI training . Record review of CNA L's personnel file revealed CNA L was hired on 2/06/2024 and had not completed QAPI training. During an interview on 12/05/2024 at 2:30 PM, the ADON said she was responsible for overseeing the on hire and annual trainings and was not aware of the required annual QAPI training not being completed for CNA G and CNA L. She stated she used a binder to manually record and keep track of required training. She said if staff were not…

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 be free from abuse, neglect, misappropriation of resident property, and exploitation for 2 of 9 residents (Resident #'s 1 and #2) reviewed for abuse. The facility failed to ensure CNA G did not verbally and physically abuse Resident #1 during incontinent care. The facility failed to ensure CNA G did not verbally and physically abuse Resident #2 during incontinent care. This failure could place residents at risk of abuse, humiliation, intimidation, fear, mental distress, depression, and decreased quality of life. Findings included: 1.Record review of the undated face sheet revealed Resident #1, a [AGE] year-old female, was admitted to the facility on [DATE] and readmitted on [DATE]. The face sheet revealed she had diagnoses that included: Nondisplaced fracture of coracoid process, left shoulder (broken shoulder), Paroxysmal atrial fibrillation (irregular and rapid heart rhythm), hypertension (pressure 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 observation, interview, and record review the facility failed to store, prepare, distribute, and serve food under sanitary conditions in 1 of 1 preparation kitchen. * The facility failed to ensure baking sheets did not have brown and/or black baked on build up and stacked together. * The facility failed to ensure muffin pans did not have brown baked on build up and stacked together. * The facility failed to ensure a scoop was not left in the bulk corn meal. * The facility failed to ensure the ice machine did not have a pink slimy substance in the drop chute. This failure could place residents who ate food from the kitchen at risk of foodborne illness. Findings included: During observations and interviews on 11/13/23, the following was noted in the kitchen: *at 08:35 a.m., on a storage shelf there were 3 small baking sheets with brown and/or black baked on residue were stacked together, 6 large baking sheets with brown and/or black baked on residue were stacked together, and 5 muffin pans with brown baked on residue were stacked together. The DM said she had difficulty…

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 submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS fiscal year 2023 for 2 of 4 quarters reviewed for payroll data information. (Quarter 1 and Quarter 4) The facility failed to submit accurate staffing information to CMS for the 1st and 4th quarter of the fiscal year 2023. 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: Record Review of the facility's Civil Rights form (3761) dated 11/13/23 indicated the following: -6 RNs -9 LVNs -23 Direct Care Staff -6 Dietary -4 Housekeeping & Laundry -8 All Others Record review of the CMS PBJ Staffing Data Report (payroll-based staffing), CASPER Report (Certification and Survey Provider Enhanced Report)1705 D FY…

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 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 2 of 10 residents reviewed for comprehensive care plans. (Residents #6 and #42) The facility did not develop a care plan for Resident #6 addressing his smoking, behaviors, resistance to care, or his full code status upon readmission. The facility did not develop a care plan for Resident #42 addressing his bipolar disorder diagnosis, Factor 5 Leiden mutation diagnosis, or anticoagulant medication upon admission. This failure could place residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being. Findings included: 1. Record review of a face sheet dated 10/23/23 indicated Resident #6 was an [AGE] year-old male admitted on [DATE] 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 ensure a medication error rate of less than 5 percent. There were 2 errors out of 32 opportunities, resulting in a 6.25% percent medication error involving 1 of 6 residents (Residents #37) reviewed for medication pass. MA A failed to administer 2 scheduled doses of the medication Lyrica 50 mg (used to treat chronic pain) as ordered by the physician for Resident #37 on 11/13/23 beginning at 9:08 a.m. This failure could place residents at risk for inaccurate drug administration resulting in a decline in health and decreased quality of life. Findings included: Record review of the face sheet dated indicated Resident #37 was an [AGE] year-old female admitted on [DATE] with diagnoses included muscle spasms. She was readmitted [DATE] with diagnoses of fractures of 3 thoracic vertebra (backbone to which ribs are attached and her left tibia (the larger of the 2 bones in the lower leg) after a fall. Record review of an admission MDS assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure assessments accurately reflected the resident status for 1 of 12 residents (Resident #4) reviewed for MDS assessment accuracy. The facility did not accurately document Resident #4's weight and inaccurately indicated weight loss on her MDSs dated 10/07/22, 12/16/22, 02/07/23, 05/05/23, and 08/05/23. This failure could place residents at risk of not receiving care and services to meet their needs. Findings included: Record review of a face sheet dated 09/27/23 indicated Resident #4 was an [AGE] year-old female admitted on [DATE]. Her diagnoses included hypothyroidism (condition where the thyroid doesn't create and release enough thyroid hormone into your bloodstream), type 1 diabetes (chronic condition in which the pancreas produces little or no insulin) and obesity (overweight). Record review of the physician orders for November 2023 indicated Resident #4 had an order dated 07/31/22 for a carbohydrate controlled no added salt diet.…

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 individuals identified with MI, DD or ID were screened for 1 of 6 residents reviewed for PASRR (Resident #42) The facility did not have an accurate PASRR level 1 screening for Resident #42 upon admission, therefore a PASRR Evaluation was not conducted. This failure could place residents who have a diagnosis of mental disorder, developmental disability or intellectual disability at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs. Findings included: Record review of a face sheet dated 11/14/23 indicated Resident #42 was a [AGE] year-old male admitted [DATE] and readmitted [DATE]. He had diagnoses of depression (mental illness that negatively affects how you feel, the way you think and how you act), anxiety (persistent and excessive worry that interferes with daily activities), and bipolar disorder (mental disorder associated with episodes of mood swings ranging from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that residents receiving enteral feeding received appropriate care and services to prevent complication of enteral feeding for 1 of 2 residents (Residents #38) reviewed for enteral feeding. The facility failed to change Resident #38's enteral feeding set/bag every 24 hours on 11/12/23 and did not follow physician order to provide enteral feeding only 20 hours daily on 11/13/23. These failures could place residents receiving enteral nutrition at increased risk of not receiving the proper nutrition and infection. Findings included: Record review of Resident #38's face sheet dated November 2023 indicated he was [AGE] years old and admitted to the facility 02/17/22. His diagnosis included dysphagia (difficulty or discomfort in swallowing) and gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food). Record review of physician orders indicated he was to receive enteral feeding (a way…

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 medication error rate of less than 5 percent. There were 2 errors out of 32 opportunities, resulting in a 6.25% percent medication error involving 1 of 6 residents (Residents #37) reviewed for medication pass. MA A failed to administer 2 scheduled doses of the medication Lyrica 50 mg (used to treat chronic pain) as ordered by the physician for Resident #37 on 11/13/23 beginning at 9:08 a.m. This failure could place residents at risk for inaccurate drug administration resulting in a decline in health and decreased quality of life. Findings included: Record review of the face sheet dated indicated Resident #37 was an [AGE] year-old female admitted on [DATE] with diagnoses included muscle spasms. She was readmitted [DATE] with diagnoses of fractures of 3 thoracic vertebra (backbone to which ribs are attached and her left tibia (the larger of the 2 bones in the lower leg) after a fall. Record review of an admission MDS assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs when used without adequate monitoring for 1 of 13 residents (Resident #13) reviewed for unnecessary medication. The facility failed to monitor Resident #13 for side effects from 11/01/23 to 11/15/23 of the anticoagulant medication Eliquis (a blood thinning medication). This failure could place residents at risk for adverse consequences such as bleeding, bruising, and black colored stools related to the use of the anticoagulant medication. Findings included: Record review of Resident #13's face sheet, dated 11/13/23, indicated an [AGE] year-old male who was admitted to the facility on [DATE] with a diagnosis which included atrial fibrillation (an irregular and often rapid heart rhythm that can lead to blood clots in the heart and increases the risk of a stroke). Record review of physician orders dated November 2023, indicated Resident #13 was prescribed Eliquis 5 mg two times a day for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of diseases for 1 for 5 residents (Resident #3) reviewed for infection control during medication pass. The facility failed to ensure MA A did not touch medications with her bare hand on 11/13/23 at 9:50 a.m. This failure could place residents at risk for the spread of infection and cross contamination. Findings included: Record review of Resident #3's face sheet dated 11/14/23 indicated a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of multiple sclerosis (disease in which immune system damages protective covering of the nerves), fibromyalgia (widespread muscle pain and tenderness), and chronic migraine (moderate to severe and intense headache which happens more than half of a month for 3 months). Record review of Resident #3's annual 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 written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents and misappropriation of resident property for 2 of 4 residents (Residents #1 and #2) reviewed for abuse. The facility failed to implement their Abuse Policy and ensure all allegations of abuse were reported to HHSC within 2 hours of the allegation for Residents #1 and #2. This failure could place residents at risk of further abuse, physical harm, mental anguish, and emotional distress. Findings include: Record review of the facility's Abuse and Neglect policy, revision date 07/10/18, indicated .Procedure .Reporting/Investigation .All events that involve an allegation of abuse or involve a suspicious serious bodily injury of unknown must be reported immediately or within two hours of alleged violation Record review of Resident #1's face sheet, dated 10/23/23, indicated Resident #1 was an [AGE] year-old male who was admitted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury to the administrator or the facility and to other officials, including to the State Survey Agency, in accordance with State law through established procedures for 2 of 4 residents (Residents #1 and #2) reviewed for abuse. The facility failed to report allegations of abuse immediately, but not later than 2 hours to HHSC when Resident #1 was in Resident #2's room yelling at him. This failure could place residents at risk of verbal abuse, mental anguish, and emotional distress. Findings included: Record review of Resident #1's face sheet, dated 10/23/23, indicated Resident #1 was an [AGE] year-old male who was…

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