Greenville Gardens

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 2 of 5 residents (Resident #2, and Resident #3) reviewed for abuse. The facility failed to protect Resident #2 from Resident #1, when Resident #1 pulled Resident #2's hair, which resulted in Resident #2's fall, and Resident #2 having to go to the ER for evaluation on 04/30/2024. The facility failed to protect Resident #3 from Resident #1, when Resident #1 hit Resident #3 on the chest on 05/10/2024. These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: 1. Record review of a face sheet dated 06/19/2024 indicated Resident #1 was a [AGE] year-old male originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included schizoaffective disorder (a condition that can make you feel detached from reality and can affect our mood)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, for 2 of 5 residents (Resident #2, and Resident #3) reviewed for abuse. The facility failed to implement their policy on reporting abuse when Resident #1 pulled Resident #2's hair which caused Resident #2 to fall and be sent to the ER for evaluation on 04/30/2024. The facility failed to implement their policy on reporting abuse when Resident #1 hit Resident #3 on the chest on 05/10/2024. The facility failed to implement their abuse policy to prevent Resident #1 from pulling Resident #2's hair on 4/30/2024, and hitting Resident #3 on the chest on 5/10/2024 These failures could place residents at risk of unreported abuse, neglect, exploitation, and a decreased quality of life. Findings included: Record review of the facility's policy titled, Abuse Prevention and Prohibition Program, revised 10/24/2022, indicated, .Each resident has the right to be free…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source were reported immediately, but no later than 2 hours after the allegation was made, for 2 of 5 residents (Resident #2, and Resident #3) reviewed for abuse and neglect reporting. The facility failed to report to HHSC when Resident #1 pulled Resident #2's hair which caused Resident #2 to fall and be sent to the ER for evaluation on 04/30/2024. The facility failed to report to HHSC when Resident #1 hit Resident #3 on the chest on 05/10/2024. These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: 1. Record review of a face sheet dated 06/19/2024 indicated Resident #1 was a [AGE] year-old male originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included schizoaffective disorder (a condition that can make you feel…

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 were permitted to remain in the facility, and not transfer or discharge the resident from the facility unless the transfer or discharge was necessary for the resident's welfare and the resident's needs could not be met in the facility and failed to ensure a resident was not transferred or discharged for 1 of 3 residents (Resident #1) reviewed for discharge requirements. The facility failed to allow Resident #1 to return to the facility after being sent to the behavioral hospital for treatment. This failure could place residents at risk for inappropriate discharge from the facility and cause psychological harm. Findings included: Record review of a face sheet dated 06/19/2024 indicated Resident #1 was a [AGE] year-old male originally admitted to the facility on [DATE], re-admitted on [DATE], and discharged on 05/16/2024 with diagnoses which included schizoaffective disorder (a condition that can make you feel detached from reality 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 each resident on the secured unit met the criteria for the unit and was not provided with the access codes or other information for independent egress for 5 of 18 residents (Resident #'s 35, 23, 38, 18, and 47) reviewed for seclusion. The facility failed to ensure Resident #35 met the facility's criteria to reside on the secured unit based on her elopement risk assessment dated [DATE] indicating no risk. The facility failed to ensure Resident #23 met the facility's criteria to reside on the secured unit based on her elopement risk assessment dated [DATE] indicating she was not a risk to elope. The facility failed to ensure Resident #38 met the facility's criteria to reside on the secured unit based on his elopement assessments on 1/10/2024 indicating he was a moderate risk to elope. The facility failed to ensure Resident #18 met the facility's criteria to reside on the secured unit based on her elopement assessments on 12/29/23 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 interviews and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary psychotropic drugs (without adequate behavior or side effect monitoring) for 3 of 8 (Resident # 54, Resident # 64, and Resident # 3) residents who were reviewed for psychotropic medication. 1. The facility failed to ensure Resident #54 had behavior monitoring (monitor activities and mood) for his prescribed Venlafaxine (an antidepressant used to treat major depression) for the months of May and June 2024. 2. The facility failed to ensure Resident #64 had behavior monitoring (monitor activities and mood) and side effects (unwanted undesirable effects that are possibly related to a drug) for his prescribed Lexapro (an antidepressant used to treat depression) for the months of May and June 2024. 3. The facility failed to ensure Resident #3 had behavior monitoring (monitor activities and mood) for her prescribed Duloxetine (an antidepressant; that is used to treat depression and anxiety) 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 ensure adequate monitoring of cigarettes to prevent accidents or hazards for 1 of 3 residents reviewed (Resident #54) and the facility failed to ensure 1 of 1 unit environment remained free of accident hazards for 1 of 18 residents (Resident #38) reviewed for accidents and hazards. 1. The facility did not ensure Resident # 54 did not have his cigarettes which were left out on his bedside table. 2. The facility failed to ensure Resident #38's personal disposable razor was disposed of or stored properly after use to prevent accidents. These failures could place residents at risk for injury. Findings included: 1.Record review of Resident #54's face sheet, dated 06/05/24, indicated Resident #54 was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #54 had diagnoses which included anxiety (a feeling of fear, dread, and uneasiness), Insomnia (when you are not sleeping as you should), depression(sadness), and high blood…

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 its medication error rates were not 5 percent or greater. There were 3 errors out of the 58 opportunities, resulting in a 5.17 percent medication error rate involving 2 out of 5 residents reviewed for medication errors. (Residents #6 and #35) 1. The facility failed to ensure Resident #6's MiraLAX (laxative) was administered as ordered on 06/04/24. 2. The facility failed to ensure Resident #35's fluticasone (nasal spray that treats allergy symptoms) and guaifenesin (medication used to relieve chest congestion) were administered as ordered on 06/04/24. These failures could place residents at risk of not receiving the therapeutic outcomes and possible negative outcomes. Findings included: 1. Record review of Resident #6's face sheet dated 06/05/24, indicated a [AGE] year-old female who admitted to the facility on [DATE], and readmitted on [DATE]. Resident #6 had diagnoses of type 2 diabetes mellitus (a long-term condition 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 store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 3 nurse medication carts and 2 of 23 residents reviewed in sample (Residents #69 and #43). 1. The facility failed to ensure Resident #69 did not have prescribed medication Prostat AWC oral liquid (medication used to aid in wound healing) left at bedside on 06/04/24. 2. LVN D failed to ensure the 400 hall nurse medication cart was locked when it was left unattended on 06/04/24 when she went to wash her hands. 3. The facility failed to ensure LVN D properly secured Resident #43's insulin pen inside the nurse's medication cart on 06/04/24. These failures could place residents at risk of injury. Findings included: 1.Record review of Resident #69's face sheet dated 06/04/24 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] and re-admitted on [DATE] with 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.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety requirements. The facility failed to ensure 3 muffin tins were free from carbon build-up, rust, and food particles on 6/03/24. This failure could place residents at risk of foodborne illness, and food contamination. Findings included: During an observation of the facility's kitchen on 06/03/24 and interview at 11:33 AM, three muffin tins were observed at the bottom of the steam table. The three muffin tins were black, had carbon build up, rust and light-yellow food particles. The Dietary [NAME] said they had been using the muffin tins. When asked if the muffin tins appeared clean, she said No. The Dietary [NAME] said it could get in the resident's food and cause them to get sick. During an interview on 06/03/24 at 11:36 AM, the Dietary Manager said he did not believe the carbon build up or rust could get in the resident's food since it was 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 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 4 residents (Resident #43) reviewed for infection control. The facility failed to ensure LVN D performed hand hygiene during Resident #43's insulin administration on 06/04/24 . This failure could place residents and staff at risk for cross-contamination and the spread of infection. Findings included: Record review of Resident #43's face sheet dated 06/05/24, indicated a [AGE] year-old male who admitted to the facility on [DATE] and readmitted [DATE]. Resident #43 had diagnoses type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), metabolic encephalopathy (problem in the brain caused by chemical imbalance in the blood), cerebral infarction (stroke),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a centralized staff work area, for 1 of 23 residents (Resident #69) reviewed for physical environment. The facility failed to ensure Resident #69 had a working call light in the room on 06/04/2024. This failure could place residents at risk of not being able to get assistance when needed. Findings included: 1.Record review of Resident #69's face sheet dated 06/04/24 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] and re-admitted on [DATE] with the diagnoses of partial traumatic amputation of left foot, Dementia (a disease in which causes a decline in a person's cognitive ability to perform day to day activities, Schizophrenia (mental disorder characterized by episodes of psychosis generally misperceptions of real life), Diabetes Mellitus (disease in which it causes too much…

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 and interview, the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for 2 of 8 resident rooms (Resident #8 and Resident #234) reviewed for clean and sanitary environment. The facility failed to ensure Resident #8 and Resident #234's rooms did not have gnats. This failure could put all residents at risk of not having a clean, sanitary, and comfortable environment. Findings included: Record review of Resident #8's face sheet, dated 06/10/24, indicated Resident #8 was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #8 had diagnoses which included Atrial fibrillation {A fib} (an irregular and often very rapid heart rhythm), Depression (sadness), and Dementia (forgetfulness). Record review of Resident #8's quarterly MDS assessment, dated 05/06/24, indicated Resident #8 understood and was understood by others. Resident #8's BIMS score was 10, which indicated she was cognitively moderately 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents were free of significant medication errors for 1 of 2 residents (Resident #1) reviewed for pharmacy services. The facility failed to ensure MA R administered Resident#1's oxycodone 10 milligrams timely as scheduled on 3/10/2024 at 7:30 a.m. and 11:30 a.m. The facility failed to ensure MA R administered Resident #1's Lasix 40 milligrams timely as scheduled on 3/102024 at 8:00 a.m. The facility failed to ensure MA R administered Resident #1's Gabapentin 300 milligrams timely as scheduled on 3/102024 at 8:00 a.m. The facility failed to ensure MA R administered Resident #1's Aldactone 100 milligrams timely as scheduled on 3/102024 at 8:00 a.m. This failure could place the resident at risk of medical complications and not receiving the therapeutic effects of their medications. Findings Included: During an interview on 4/09/2024 at 10:17 a.m., Resident #1 said on 3/10/2024 his morning medications were administered after…

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 treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 3 of 19 residents reviewed for resident rights. (Resident #36, Resident #56, and Resident #58) 1. The facility failed to ensure Resident #56's pants were well-fitted and did not fall to expose her brief. 2. The facility failed to ensure MA G treated Resident #36 with dignity and respect by referring to her as a feeder. 3. The facility failed to ensure CNA L fed Resident #58 while sitting down. These failures could place residents at an increased risk of embarrassment, isolation, and diminished quality of life. The findings included: 1. Record review of Resident #56's face sheet, dated 03/01/2023, revealed Resident #56 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of unspecified dementia with other behavioral disturbance (deterioration of memory, language,…

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 coordinate assessments with the PASARR program to the maximum extent practicable to avoid duplicative testing and effort for 3 of 19 residents (Resident #8, Resident #23, and Resident #44) reviewed for PASARR. The facility failed to coordinate IDT meetings to discuss specialized services with the Local Mental Health Authorities/Local Behavioral Health Authorities for Resident #8 and Resident #44. The facility failed to ensure the correct PASARR Screening was submitted to the local authority for Resident #23 who had MI diagnosis upon admission. These failures could place residents with positive PASARR at risk of not receiving specialized services which would enhance their highest level of functioning and could contribute to residents decline in physical, mental, and psychosocial well-being. Findings included: 1. Record review of a face sheet dated 03/01/2023 revealed, Resident #8 was a [AGE] year old male initially admitted on [DATE] and readmitted 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 provide an ongoing program of activities in accordance with the comprehensive assessment to meet the interests and the physical, mental, and psychosocial well-being for 1 of 1 secured unit and 3 of 19 residents reviewed for activities on the secured unit. (Resident's #53, #55, #62) The facility failed to ensure activity care plans and quarterly activity assessments were completed for Resident's #53, #55, and #62. This failure could place residents at risk for not having activities to meet their interests or needs and a decline in their physical, mental, and psychosocial well-being. The findings included: 1. Record review of Resident #53's face sheet, dated 02/27/2023, revealed Resident #53 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of schizoaffective disorder (mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder…

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 9 errors out of 36 opportunities, resulting in a 25 percent medication error rate for 2 of 7 residents reviewed for medication error. (Resident #6, Resident #24) The facility failed to ensure the following: 1. Resident #24 received clonazepam (antianxiety) at the prescribed time. 2. Resident #24 did not receive vitamin C after the prescribed 10 days. 3. Resident #24 received sucralfate (used to prevent ulcers in the intestines) at the prescribed time and on an empty stomach. 4. Resident #24 received ondansetron (used for nausea) at the prescribed time. 5. Resident #24 received 5 mg dose of Trintellix (antidepressant). 6. Resident #6 received Bactrim DS (antibiotic) at the prescribed time. 7. Resident #6's losartan, metoprolol, and amlodipine (blood pressure medications) were held due to physician parameters. These failures could place residents at risk for inaccurate drug…

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 were free of significant medication errors for 1 of 7 residents reviewed for medication pass. (Resident #6) The facility failed to ensure MA F held Resident #6's losartan, metoprolol, and amlodipine (blood pressure medications) when her blood pressure was below the parameters ordered by the doctor. This failure could place the resident at risk of medical complications and not receiving the therapeutic effects of their medications. The findings included: Record review of Resident #6's face sheet, dated 03/01/2023, revealed Resident #6 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus without complications (high blood sugar), hyperlipidemia (too much fat in blood), and atrial fibrillation (irregular and often very rapid heart rhythm (arrhythmia) that can lead to blood clots in the heart). Record review of Resident #26's order summary report, dated 03/01/2023,…

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 that all drugs and biologicals used in the facility were labeled in accordance with professional standards and were stored in a locked compartment and only accessible by authorized personnel for 1 of 19 residents (Resident #61) reviewed for medication storage and 2 of 4 medication carts (Hall 3 & secure unit) reviewed for drugs and biologicals. 1. The facility did not keep medication being administered under the direct observation of the person administering medications. Resident #61 had 1 bottle of Chlorhexidine Gluconate Solution (mouthwash) on his bedside table. 2. The facility failed to ensure multi-dose bottles of over-the-counter medications on the hall 3 and secured unit medication carts were dated when opened. 3. The facility failed to discard a bottle of expired docusate sodium 100 mg tablets (stool softener) on the secured unit medication cart. 4. The facility failed to discard a bottle of chest congestion relief DM…

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

Based on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 3 of 19 residents (Resident #8, Resident #18, and Resident #26) reviewed for dietary services. The facility failed to provide palatable food served at an appetizing temperature or taste to residents' who complained the food was not hot and did not taste or look good. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. Findings included: During an interview on 2/26/2023 at 9:11 AM, Resident #26 stated the food was bland and sometimes cold. During an interview on 2/26/2023 at 9:13 AM, Resident #18 stated the food looked and tasted nasty and was bland. During an interview on 02/27/2023 at 9:40 AM, Resident #8 stated, sometimes the food just don't taste good. During an observation and interview on 02/27/2023 starting at 12:48 PM, a lunch tray was sampled by the Dietary Manager and six surveyors. The sample tray consisted of a country fried…

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

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure: o food items were dated, labeled, and sealed appropriately. o expired food items were discarded. These failures could place residents at risk for foodborne illness. Findings included: During an observation on 02/26/23 starting at 8:35 AM: Refrigerator R-1: pint size bag of diced tomatoes with no date Ziploc bag with 2 opened blocks of cheddar cheese and a package of opened provolone cheese slices with no dates Ziploc bag with opened turkey bologna package dated 2/10 had thick, white slimy juices Freezer F-1: 3 unopened packages of frozen turkey bologna with no dates Ziploc bag with crunchy breaded fish unsealed, with no dates 5 logs of ground beef with no dates Freezer F-2: open box of frozen cookie dough open to air, unsealed dated 2/22/23 opened blue bunny sherbet bucket with no open date 5 packages of corn with no dates 2 pecan pies with no…

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 medical records were maintained in accordance with accepted professional standards and practices on each resident and accurately documented for 3 of 19 residents (Resident #11, Resident #53, Resident #62) reviewed for accuracy of medical records. 1. The facility failed to ensure Resident #62's responsible party signed the antipsychotic consent form after giving consent to administer the medication. 2. The facility failed to ensure Resident #53's responsible party signed the antipsychotic consent form after given consent to administer the medication. 3. The facility did not ensure Resident #11's OOH-DNR was dated by the physician. These failures could place residents at risk of not receiving care and services to meet their needs. The findings included: 1. Record review of Resident #62's face sheet, dated [DATE], revealed Resident #62 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnosis of Alzheimer's disease (a gradually…

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

Based on observation, interview and record review the facility failed to ensure sufficient space to accommodate dining and activities for 1 of 2 dining rooms observed. (Secured unit) The facility did not provide a dining room on the secured unit that accommodated all residents who wanted to eat in the dining room without causing resident crowding. This failure could place the residents at risk for injury, discomfort, and decreased quality of life. The findings included: During an observation on 02/26/2023 between 8:39 AM - 9:05 AM, 12 residents were eating in the dining room during breakfast meal. Four chairs were counted in the dining room, and all were occupied by the residents who ambulated with a walker. There were 2 recliners in the dining room were two of the residents were sitting with a meal tray on the bedside table in front of them. Resident #62 was sitting between a table and the wall. He required assistance to move his wheelchair away from the dining table because of the tight space. CNA L was standing up while feeding Resident #58. When mealtime was complete the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to provide respect, dignity, and care in a manner and in an environment that promoted maintenance or enhancement of quality of life and privacy and confidentiality of the medical records for 2 of 19 residents reviewed for resident rights. (Resident #27 and Resident #42) 1. The facility failed to ensure LVN O closed the EMAR of Resident #42 before entering her room to provide a blood glucose check and administer insulin. 2. The facility failed to ensure CNA U and CNA V provided privacy to Resident #27 while providing incontinent care. This failure could place residents at risk for a violation of resident's rights, diminished quality of life, and loss of dignity or self-worth. The findings included: 1. Record review of Resident #42's face sheet, dated 03/01/2023, revealed Resident #42 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of systemic lupus erythematosus or SLE (autoimmune disease, with systemic…

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

Based on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 of 1 secured unit observed for homelike environment. The facility served 12 out of 12 residents in the dining room, on the secured unit, on a serving tray. The facility posted signs on the secured unit doors that stated, Elopement and Wandering in Seniors. These failures could result in resident having poor self-esteem and decreased quality of life. The findings included: During an observation on 02/26/2023 between 8:39 AM - 9:05 AM, 12 out of 12 residents were sitting in the dining room with their breakfast meal served on the serving tray. There were two signs noted on the secured unit doors which stated, Elopement and Wandering in Seniors and had a picture of an elderly lady holding a cane walking toward a door. During an interview on 03/01/2023 at 4:11 PM, CNA Q stated meals were not always passed on the serving trays. CNA Q stated she was unsure why meals would have been served on the serving trays. CNA Q stated the signs on the secured…

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 an accurate MDS was completed for 2 of 19 residents (Residents #48 and #73) reviewed for MDS assessment accuracy. 1. The facility failed to accurately document smoking for Resident #48 on the MDS assessment. 2. The facility failed to accurately document discharge status for Resident #73 on the MDS assessment. These failures could place residents at risk for not receiving care and services to meet their needs. Findings included: 1. Record review of Resident #48's order summary report, dated 03/01/2023, indicated Resident #48 was a [AGE] year-old female, originally admitted to the facility on [DATE] with a diagnosis which included essential hypertension (high blood pressure), and schizoaffective disorder (a condition that can make you feel detached from reality and can affect your mood). Record review of Resident #48's annual MDS, dated [DATE], indicated Resident #48 understood others and made herself understood. The 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 interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 2 of 19 residents (Resident #4 and Resident #23) reviewed for care plans. The facility failed to develop and implement the comprehensive care plan from the triggered CAAs from the comprehensive MDS assessment for Resident #4 and Resident #23. This failure could place residents at risk of not having individual needs met and a decreased quality of life. Findings included: 1. Record review of Resident #4's face sheet, dated 02/27/2023, revealed Resident #4 was an [AGE] year-old male who admitted to the facility with diagnoses of Parkinson's disease (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), type 2…

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 a resident who is unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 19 residents reviewed for activities of daily living. (Resident #13 and Resident #60) 1. The facility failed to ensure Resident #60 was toileted and provided with a clean brief. 2. The facility failed to provide facial hair removal/shaving for dependent female Resident #13. This failure could place residents who were dependent on staff to perform personal hygiene at risk or embarrassment, decreased self-esteem, or decreased quality of life. The findings included: 1. Record review of Resident #60's face sheet, dated 02/27/2023, revealed Resident #60 was an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of acute and chronic respiratory failure with hypoxia (not enough oxygen in your blood), unspecified dementia without behavioral…

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 respiratory care was provided with professional standards of practice for 1 of 4 residents (Resident #38) reviewed for respiratory care and services. The facility failed to administer oxygen between 2-3 liters per minute via nasal cannula as prescribed by the physician for Resident #38 This failure could place residents who require respiratory care at risk for respiratory infections and exacerbation of respiratory distress. Findings include: Record review of Resident #38's order summary report, dated 03/01/2023, indicated Resident #38 was a [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis which included respiratory disorder (disease that affects the lungs that makes breathing difficult), essential hypertension (high blood pressure), and atrial fibrillation (irregular, often rapid heart rate). Further review of the order summary report, dated 03/01/2023, indicated Resident #38 received oxygen between 2-3…

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 that residents who require dialysis received such services, consistent with professional standards of practice for 1 of 1 resident (Resident #52) reviewed for dialysis. The facility failed to ensure nursing staff was checking Resident #52's shunt (vascular access used for hemodialysis) to left upper arm for bruit (sound heard through a stethoscope when held over the shunt) and thrill (vibration or buzz felt when fingers are laid on top of the shunt). This failure could place residents who receive dialysis at risk for complications and not receiving proper care and treatment to meet their needs. The findings were: Record review of a face sheet dated, 03/01/2023, revealed Resident #52 was a [AGE] year old female initially admitted on [DATE] and readmitted on [DATE] with diagnoses including end stage renal disease (kidney failure), unspecified dementia, unspecified severity without behavioral disturbance, mood disturbance, and…

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

Based on interview, and record review the facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service department for 2 of 9 dietary staff (Dietary Aide C and Dietary Aide D). The facility failed to ensure that dietary staff (Dietary Aide C and Dietary Aide D) serving in the kitchen maintained a current Food Handler Certificate. This failure could place residents at risk of not having their nutritional needs met and place them at risk for foodborne illnesses. Findings included: Record review of the food handler certificates provided by the Dietary Manager on 02/27/23 revealed: Dietary Aide C's Food Handler Certificate was issued on 02/23/2021, valid through 02/23/2023 Dietary Aide D's Food Handler Certificate was issued on 02/23/2021, valid through 02/23/2023. During an interview on 03/01/2023 at 8:56 AM, the Regional Dietician stated the food handler certificates were good for 2 years. The Regional Dietician stated the Dietary Manager was responsible for making sure the food handler…

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 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 2 staff (CNA U and CNA V) reviewed for infection control. The facility failed to ensure CNA U and CNA V performed hand hygiene between glove changes while providing incontinent care. This failure could place residents and staff at risk for cross-contamination and the spread of infection. Findings included: During an observation on 02/26/2023 at 11:10 AM, CNA U and CNA V provided incontinent care for Resident #27. During the incontinent care CNA U put on gloves and wiped Resident #27 buttocks. CNA U's gloves were soiled with feces, and she removed the gloves and applied a new pair of gloves. CNA U did not perform hand hygiene after removing her dirty gloves. CNA U continued and wiped Resident #27's buttocks, and gloves became soiled with feces. CNA U removed dirty gloves and applied a new pair…

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

Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 1 smoking area. The facility failed to ensure cigarette butts were disposed of appropriately. This failure could place the residents at risk for injury. Findings include: During an observation on 02/27/2023 at 3:30 p.m., the designated smoking area had numerous cigarette butts laying on the ground. During an observation on 02/28/2023 at 11:15 a.m., the designated smoking area had numerous cigarette butts laying on the ground. During an interview on 03/01/2023 at 9:16 a.m., the Activity Director stated the staff member supervising the residents during smoke breaks were responsible for ensuring cigarettes butts were disposed properly in the smoking area. The Activity Director stated cigarette butts should be disposed in the ash tray or in the red trash can. The Activity Director stated she did not notice the cigarette butts on the ground. The Activity Director stated, I didn't have on my glasses. The Activity Director stated this failure…

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.