Granbury Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to make sure that the comprehensive care plan was prepared by an interdisciplinary team that included a nurse aide with responsibility for the resident for 8 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, and Resident #8) of 8 residents reviewed for care plans. The facility failed to ensure the nurse aides with responsibility for the residents were invited and attended the resident care plan conferences. These failures could place the residents at risk for not receiving the care and services to meet their needs.The findings included: Resident #1: Record review of Resident #1's Facesheet, dated 07/03/2025, revealed Resident #1 was a [AGE] year-old female, with an admission date into the facility of 09/08/2023. Diagnoses included Unspecified Dementia (diagnosis given when a person's cognitive impairment was not clearly categorized into a specific type of dementia). Record review of Resident #1's Quarterly MDS,…

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, interview, and record review the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, that were complete and accurate for 3 (Resident #1, Resident #3 and Resident # 7) of 7 residents reviewed for resident records. The facility failed to ensure weekly skin assessments were documented in the medical record for Resident #1, Resident #3, and Resident # 7. This failure could place residents at risk of having errors in care and treatment. The Findings included: Resident #1 Record review of Resident #1's face sheet dated 05/02/2025 revealed a [AGE] year-old-female admitted on [DATE], with the most recent admission on [DATE] and with the following diagnoses: Alzheimer's disease, respiratory failure, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (weakness and partial paralysis of left side following a stroke). Record review of Resident #1's Significant Change 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 the resident environment remained as free from accident hazards as was possible and each resident received adequate supervision and assistive devices to prevent accidents for 2 of 5 residents (Resident #1 & Resident #2) reviewed for accidents and supervision. 1. The facility failed to ensure Resident #1, and Resident #2 were properly supervised during smoke break to prevent agitation and altercations. These failures could place the residents at risk of injury. Findings included: Record review of Resident #1's electronic health record revealed a [AGE] year-old female, admission date 11/04/2021, Diagnoses: hypertension (high blood pressure), unspecified dementia (brain degeneration) chronic obstructive pulmonary disease (group of lung diseases that block airflow and make it difficult to breathe), major depressive disorder (persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities). Record review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 to help prevent the development and transmission of communicable disease and infections for one (Resident #1) of three residents reviewed for infection control practices. The facility failed to ensure CNA A performed proper hand hygiene and glove changes while providing incontinence care to Resident #1. This failure could place residents at risk for the spread of infection. Findings included: Review of Resident #1's face sheet dated 01/10/25, revealed a 67- year- old female admitted to the facility on [DATE] with diagnoses including frequency of micturition (urinating), constipation, muscle weakness and Alzheimer's disease (neurological disorder). Review of Resident #1's Quarterly MDS assessment dated [DATE] revealed Resident #1 required substantial/maximal assistance with most activities of daily living (ADLs). Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure residents/resident's representative had the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he/ she preferred for 2 of 26 residents (Resident #50 and Resident #114) reviewed for antipsychotic consents. 1. The facility failed to ensure Resident #50's HHSC Form 3713 for Ziprasidone (also known as Geodon an antipsychotic medication used to treat bipolar 1 disorder and schizophrenia) was signed by Resident #50 or Resident 50'ss responsible party. 2. The facility failed to ensure Resident #114's HHSC Form 3713 for Seroquel (an antipsychotic medication used to treat mental health disorders, such as schizophrenia) was signed by Resident #114 or Resident #114's responsible party. This failure could affect residents who received antipsychotics by placing them at risk 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, interviews, and record review, the facility failed to refer residents for PASRR screening and evaluation, with a newly evident mental disorder or related condition for level II PASRR review, 1 of 3 residents (Resident #107) in that: Resident #107 was not referred to the state-designated authority for PASRR re-evaluation upon evidence of past history significant for depression, anxiety, and PTSD when admitted to the facility on [DATE] with a negative PL1. This failure placed residents at risk of not receiving adequate services or care related to mental illnesses. Finding include: Record review of Resident #107's Facesheet, dated 12/03/2024, revealed Resident #107 was a [AGE] year-old male, with an admission date into the facility on [DATE]. Record review of Resident #107's Diagnosis Report, dated 12/03/2024, revealed Resident #107's admission primary diagnosis was Bipolar disorder, unspecified, effective 09/12/2023. Other diagnoses included Generalized Anxiety Disorder, which was dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles and included the appropriate accessory and cautionary instructions for 2 of 6 medication carts (Hall B nurse medication cart & Hall A-D nurse medication cart) reviewed for medication labeling and storage. The facility failed to ensure Schedule II-V medications subject to abuse were stored so that shortage of medication was readily detectable for 1 of 2 medication rooms (Hall G-H medication room) reviewed for medication labeling and storage. 1. The facility failed to dispose of expired medications from Hall A-D nurse medication cart. 2. The facility failed to have pharmacy labels on 2 insulin flex pens from Hall B nurse medication cart. 3. The facility failed to have medication count sheets with controlled substances from Hall G-H medication room. These failures could place residents at risk of misappropriation 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 provide food and drink that was palatable, attractive, and at a safe and appetizing temperature for 4 of 26 Residents (Residents #8, #9, #120, and #376) and one (1) of one (1) kitchen. 1. Residents #8, #9, #120, and #376 voiced concerns of cold food, flavor, and/or texture. 2. One (1) of the three (3) foods sampled on the meal tray was cold. These failures could affect the residents by placing them at risk for malnutrition due to residents' decline in consumption in food, dissatisfaction of meals served, and residents to have unwanted weight loss. Findings include: Record review of Resident #120's Facesheet, dated 12/04/2024, revealed Resident #120 was a [AGE] year-old male, with an admission date into the facility of 09/12/2024. Diagnoses included Parkinson's disease (a progressive neurological condition that affects the brain and causes movement and non-movement issues) with dyskinesia (a range of movement disorders that involve…

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

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for service safety, in that: 1. The facility failed to ensure staff wore effective hair restraints. 2. The facility failed to ensure staff practiced appropriate hand hygiene during meal prep. These failures could place residents at risk of food borne illness and cross contamination. During an observation on 12/02/2024 at 10:45 a.m., [NAME] G cut a large sheet cake with no gloves on. [NAME] G had white tipped acrylic nails on her fingertips approximately ¼ inch in length. [NAME] G touched the cake with her left thumb on the left bottom of the pan as she held the pan to steady to cut. [NAME] G then wiped her left hand on the front of her left pant and pick up a knife and spread cool whip frosting over half of the sheet cake. [NAME] G picked up a permanent marker from a rolling cart that contained a bag of frozen bananas and wrote on a empty zip lock bag. [NAME] G the pushed then…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs, 1 of 5 residents (Resident #1) reviewed for comprehensive care plans. The facility failed to develop a comprehensive care plan for Resident # 1 that included the edema in his lower extremities and resisting care. This failure could place the resident at risk for a decline in health and providers not having the most current information for the Resident's plan of care. Findings included: Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed he was a [AGE] year-old male who was admitted on [DATE], with the following diagnoses: Downs syndrome (a genetic disorder caused by an extra set of chromosomes), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and aortic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure the medical record was complete and accurately documented for 1 of 5 residents (Resident #1) reviewed for resident records. The facility failed to ensure LVN A and documented accurate skin assessments for Resident #1. These failures could place residents at risk of new or worsening pressure injuries, and not receiving required treatments and medications as ordered by the physician. Findings included: Record review of Resident #1's discharge MDS assessment dated [DATE] revealed he was a [AGE] year-old male who was admitted on [DATE], with the following diagnoses: Downs syndrome (a genetic disorder caused by an extra set of chromosomes), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and aortic valve insufficiency (a condition in which a heart valve doesn't properly close, causing blood to flow backwards into the heart instead of pumping out). His BIMS score 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to immediately inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident representative when there was an accident involving the resident which resulted in injury and had the potential for requiring physician intervention, a significant change in the resident's physical, mental or psychosocial status, or a decision to transfer or discharge the resident from the facility for 1 (Resident #1) of 4 residents reviewed for notification of changes. The facility failed to ensure Resident #1's POA/resident representative was immediately notified when the resident had a change in condition that required her to be transported via ambulance to the hospital. The non-compliance was identified as PNC. The noncompliance began on 07/26/2027 and ended on 07/27/2027. The facility corrected the noncompliance before the survey began. This failure placed residents at risk of not having the comfort and company 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 interview, and record review, the facility the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, which were complete and accurately documented for 1 (Resident #1) of 4 residents reviewed for documentation. RN B failed to accurately document the notification of Resident #1's resident representative when Resident #1 had a change in condition and was sent via ambulance to the hospital. This failure could place residents at risk of inaccurate documentation in residents' records and decreased confidence in the facility staff. Findings include: Record review of Resident #1's Face Sheet, dated 07/29/2024, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Unspecified Dementia (symptoms affecting memory, thinking, and social abilities), severe, without behavioral, psychotic, mood disturbances, or anxiety, Hypothyroidism (underactive thyroid), unspecified, Depression…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 2 (Resident #3 and Resident #7) of 6 residents reviewed who required working call lights for quality of care. The facility failed to ensure the call light in Resident #3 and Resident #7's room was in good working order. The string to activate call light was long enough to be within reach of residents in room. This failure could place residents at risk of not being able to alert staff to their room. Findings include: Record review of MDS dated [DATE] reflected . Resident #3 Female [AGE] years old, admitted on [DATE]. BIMS of 0, severe cognitive impairment. Medical Diagnosis of Alzheimer's (neurodegenerative disease). Resident's Care Plan dated 5/2/24 states the resident has a communication problem r/t impaired cognitive status, ensure/provide a safe environment: Call light in reach. Record review of MDS dated [DATE] reflected . Resident #7,…

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 the resident environment remained as free from accident hazards as was possible and each resident received adequate supervision and assistive devices to prevent accidents for 1 of 20 residents (Resident #1) reviewed for accidents and supervision. CNA A failed to ensure Resident #1 was properly transferred by two persons using a Hoyer Lift to prevent accidents. This failure could place the residents at risk of injury. Findings included: Record review of Resident #1's electronic health record revealed a [AGE] year-old male, admission date 09/06/2023, Diagnoses: muscle weakness, other lack of coordination, age-related physical debility, nondisplaced fracture of lateral end of unspecified clavicle (clavicle fracture), subsequent encounter for fracture with routine healing, and repeated falls. Record review of Resident #1's MDS Resident Assessment and Care Screening , Section G, Functional Status revealed Transfer: 3=Extensive assistance; Two+…

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 the assessment accurately reflected the resident's status for 2 (Resident #1 and Resident #3) of 10 Residents reviewed for accuracy of assessments. - The facility failed to ensure the Quarterly MDS dated [DATE] reflected falls and Significant Change MDS dated [DATE] reflected accurate number of falls for Resident #1. - The facility failed to ensure the Significant Change MDS dated [DATE] reflected accurate number of falls for Resident #3. This failure could place residents at risk of inaccurate assessments and not receiving appropriate care according to their status. Findings include: Resident #1 Review of Resident #1's electronic face sheet revealed a [AGE] year-old male admitted to facility on 08/24/2021 with diagnoses to include: dementia, depression, schizophrenia, and repeated falls. Review of Resident #1's Quarterly MDS assessment, dated 01/18/2024, revealed a BIMS score of 15 which indicated no impaired cognition. Section J Health…

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 and implement a comprehensive person-centered care plan based on assessed needs with measurable objectives that have the ability to be evaluated or quantified to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 (Resident #1, Resident #2, and Resident #3) of 10 residents reviewed for comprehensive person-centered care plans. The facility failed to develop care plans based on the assessed needs with measurable objectives and timeframes in areas such as impaired visual function, Seizure Disorder, and risk for falls for Resident #1. The facility failed to develop care plans based on the assessed needs with measurable objectives and timeframes in areas such as hypertension, Diabetes Mellitus, and risk for falls for Resident #2. The facility failed to develop care plans based on the assessed needs with measurable objectives and timeframes in areas such as Anticoagulant and Antiplatelet…

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, observation, and record reviews, the facility failed to ensure the comprehensive care plan were prepared by an interdisciplinary team, that included but not limited to, a nurse aide or a registered nurse with responsibility for the resident for 3 (Resident #1, Resident #2, and Resident #3) of 10 residents reviewed for care plans. The facility failed to invite and include the input of the nursing staff as members of the interdisciplinary team after the completion of the comprehensive assessment for Resident #1, Resident #2, and Resident #3. This failure could place the residents at risk for decreased quality of life and not having their needs met. Findings include: Resident #1 Review of Resident #1's electronic face sheet revealed a [AGE] year-old male admitted to facility on 08/24/2021 with diagnoses to include: dementia, depression, schizophrenia, and repeated falls. Review of Resident #1's Quarterly MDS assessment, dated 01/18/2024, revealed a BIMS score of 15 which indicated no impaired…

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 records review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to implement an appropriate action plan to address identified quality deficiencies for 1 of 1 facility. The QAPI committee failed to implement the corrective actions outlined on the Plan of Correction dated 12/13/2023 for deficient practice F657. This failure placed residents at risk for substandard quality of care due to the failure of the facility to take action on an identified problem affecting resident safety. Findings include: Review of a CMS 2567 dated 11/16/23 revealed that, based on observation, interviews, and record review, a deficient practice was cited at F657 (Care Plan Timing and Revision) during the 11/16/23 SSA recertification survey. Interviews and records revealed that the facility failed to invite and include the input of the nursing staff as members of the interdisciplinary team after the completion of the comprehensive assessment. Review of the facility's 12/22/23 Plan of Correction which was submitted in response to the 02/15/23 SSA…

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, observation, and record reviews, the facility failed to ensure the comprehensive care plan were prepared by a interdisciplinary team, that included but not limited to, a nurse aide with responsibility for the resident for 3 (Resident #5, Resident #6, and Resident #8) of 40 residents reviewed for care plans. The facility failed to invite and include the input of the nursing staff as members of the interdisciplinary team after the completion of the comprehensive assessment for Resident #5, Resident #6, and Resident #8. This failure could place the residents at risk for decreased quality of life and not having their needs met. Findings include: Resident #5 Record review of Resident #5's Face Sheet, dated 10/26/2023, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #5's diagnoses included Unspecified Dementia (mild memory disturbance due to known physiological condition), Unspecified severity, with agitation, Dysphagia (difficulty swallowing), Oral Phase, 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 drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 (Hall G medication cart and Hall E medication cart) of 6 medication carts reviewed for medication labeling and storage. The facility failed to ensure that insulin stored on Hall G and Hall E's medication cart were properly labeled and not past the medications' expiration date. These failures could place residents at risk of harm or decline in health due to lack of potency of medications/biologicals. The findings included: During an observation on [DATE] at 08:54 a.m., the G Hall medication cart located at the nurses station inspected for medication storage and labeling revealed: 1. Two insulin lispro pen injectors not labeled with an open date. 2. Two insulin glargine pen injectors not labeled with an…

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

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for 1 of 1 kitchen's reviewed for food service safety. The facility failed to properly label food items in the refrigerators, and freezers. The facility failed to discard food items after the use by date in refrigerators and freezers. The facility failed to seal items to protect them from freezer burn in freezers. The facility failed to discard expired food items in the dry food storage areas. The facility failed to maintain clean, refrigerators and freezers. The facility staff failed to practice good hand hygiene while preparing and serving food. These failures placed residents at risk of food borne illnesses that ate from the facility kitchen. Findings included: During an observation on 11/12/23 at 10:06AM of the facility's 1 kitchen: Bakery Freezer 1 bag small purple berries with the date of 10/24 on the package no label to identify what it was. Later DM said that it was blueberry and that the staff should have put 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 interview and record review, the facility failed to ensure an encoded, accurate, and complete MDS discharge assessment was electronically transmitted to the CMS System for 1 (Resident #84) of 3 residents records reviewed for closed records. The facility did not ensure the discharge MDS assessment was completed and electronically transmitted as required for Resident #84. This failure could place residents at risk of facility not providing complete and specific information for payment and quality of measure purposes. Finding included: Review of Resident #84's electronic face sheet, accessed 11/15/2023, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnosis to include: broken left leg, anxiety, and kidney disease. Further review of electronic face sheet revealed resident discharged home on [DATE]. Review of Resident #84's Discharge MDS dated [DATE], revealed assessment was not completed and had not been submitted. During an interview on 11/15/23 at 02:18 PM, the DON stated 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 interviews and record reviews, the facility failed to accurately reflect the resident's status on the Discharge MDS for 1 (Resident #134) of 3 residents reviewed for closed records. The facility failed to properly code Resident #134's Discharge MDS assessment a 04 for discharge to short-term general hospital instead of 01 for discharged home. This deficient practice could result in missed or inaccurate care. The findings included: Review of Resident #134's electronic face sheet accessed on 11/15/23 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: fusion of spine, heart failure, and kidney disease. Further review of electronic face sheet Resident #134 was discharged home on [DATE]. Review of Resident #134's Discharge MDS, dated [DATE] and transmitted 10/18/23, revealed: Section A- Identification Information discharge date [DATE] and discharge status 04 (short-term general hospital). Review of Resident #134's Discharge summary, dated [DATE], revealed 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 reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitization The facility failed to ensure that kitchen staff obtained food temperatures prior to serving meals on 09/04/2023, 09/14/2023,09/15/2023, 09/19/2023, 09/20/2023, 09/24/2023, 09/27/2023, 09/28/2023, 09/29/2023, 09/30/2023, 10/01/2023, 10/02/2023, and 10/03/2023. The facility failed to ensure plastic drinking cups were cleaned and sanitized properly. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. Findings included: During an observation on 10/03/2023 at 9:45 AM of the kitchen revealed blanks on temperature logs for the month of October 2023. During an interview on 10/03/2023 at 9:45 AM the DM stated the cook was to write the temperatures of food when it was cooked on the temperature log. The DM stated if the cook did not write the temperature on log, then there was no way to prove that 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.