Harker Heights Nursing & Rehabilitation

Based on observation, interview and record review, the facility failed to ensure drugs were stored properly and only authorized persons had access for 1 (MC #1) of 3 med carts reviewed for drug storage and labeling. The facility failed when MC #1 was in an unsecured location, unlocked, and was accessible to staff, residents and passers-by. This failure could place residents at risk of ingesting medications that was not prescribed to them leading to sickness.During an observation of MC #1 on 2/28/26 at 10:00 AM, revealed it was unattended, unlocked and accessible to staff, residents, and passers-by in the main lobby area. The locking mechanism was protruding outward on the medication cart. Neither the RN, nor the LVN saw the surveyor open the drawers and take pictures. During an interview with the RN on 02/28/26 at 10:23 AM, she stated the cart belonged to the LVN who was working the 300 hall. The RN stated staff were trained a couple of weeks ago on med cart storage. She stated residents could get into the cart and take medications that were not intended for them, leading to harm or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure the right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility was changed for 1 of 3 residents (Resident #1) reviewed for room or roommate changes.The facility failed to ensure Resident #1, and her RP received written notice prior to moving Resident #1 to another room. This failure could place residents at risk of having their resident rights violated and being moved into another room without notice.Findings include:Observation on 10/15/25 at 10:45 AM revealed Resident #1 was sitting up in her wheelchair in her room. She was clean and well-groomed, and dressed appropriately for the day. Resident #1's RP was also in her room placing items in her closet. Review of an undated face sheet for Resident #1 reflected an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included idiopathic normal pressure hydrocephalus (a neurological disorder primarily…

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 policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that also took into account nonsmoking residents for 1 (Resident #1) of 25 residents reviewed for smoking.The facility failed to implement their policy that smoking for team members was permitted only in approved designated areas. This failure could place residents at risk of an unsafe smoking environment, accidents, harm and long-lasting health concerns centered around secondhand smoke. Findings include:Record review of Resident #1's face sheet, dated 01/16/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had the following diagnoses which included normal pressure hydrocephalus (cerebrospinal fluid builds up in the ventricles), Alzheimer's(a progressive disease that destroys memory and other important mental functions), adult failure to thrive…

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 that the resident environment remained safe, clean, comfortable, and homelike including keeping the facility comfortable and safe temperature levels. Facilities initially certified after October 1, 1990, must maintain a temperature range of 71 to 81 F; for 1 of 1 memory care unit.The facility failed to maintain comfortable and safe temperature levels in the memory care unit when the local temperatures were at 97 Degrees Fahrenheit (F) and the temperature inside the memory care unit was 93 degrees (F) on 08/09/2025. An IJ was identified on 08/09/2025. The IJ template was provided to the facility on [DATE] at 8:47pm. While the IJ was removed on 08/11/2025, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because (e.g.) all staff had not been trained on temperatures and hydration.This failure could affect…

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 residents who were unable to carry-out activities of daily living received necessary services to maintain personal hygiene for three of four (Resident #1, Resident #2, and Resident #3) residents reviewed for ADL care. 1. The facility failed to shave the underside of Resident #1's chin hair that was approximately 1 cm in length.2. The facility failed to shave the underside of Resident #2's chin hair that was approximately 1 cm in length.3. The facility failed to shave the underside of Resident #3's chin hair that was approximately 1 cm in length.This deficient practice could place residents at risk of a decline in self-confidence, isolation, low self-esteem, general happiness, and satisfaction, and feeling undignified. 1.Review of Resident #1's face sheet dated 7/1/2025, reflected a [AGE] year-old female re-admitted to the facility on [DATE] with diagnoses including cerebrovascular disease (disrupted blood flow to brain), 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.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for food labeling and storage in that: The facility failed to ensure the foods were labeled and dated in the kitchen refrigerator. This deficient practice could place residents at risk of foodborne illness. An observation on 7/02/2025 at 9:17 AM of the facility's only refrigerator revealed the following: - Salad greens in a metal container covered with clear, plastic wrap did not have a label containing the opened on and discard by dates. - Pasta noodles in a metal container covered with tinfoil did not have a label containing the opened on and discard by dates. - A yellow, non-opaque liquid, with chunks (like creamed corn) in a metal container covered with tinfoil did not have a label containing the opened on and discard by dates. During an interview on 7/02/2025 at 9:18 AM the DM stated, Those containers should have been labeled and dated and everyone 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 interviews and record reviews, the facility failed to maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized for 1 (Resident #1) of 5 residents reviewed for pain recognition and management. The facility failed to ensure staff accurately assessed Resident #1's pain levels after falls in January and February 2025. Staff used a numerical pain scale instead of a pain ad assessment on Resident #1, who was unable to verbalize his pain level. This deficient practice could place residents at risk of serious injury, pain, being misdiagnosed, receiving improper care and services, not treated timely, effectively, and consistently. Findings included: Review of Resident #1's admission Record, dated 02/14/25, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had medical diagnoses that included unspecified cerebral infarction (a medical condition where blood flow to the brain is disrupted, causing brain…

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 determine that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled (a system of recordkeeping that ensures an accurate inventory of medication by accounting for controlled medications that have been received, dispensed, administered, and/or, including the process of disposition) for )4 of 6 Narcotic Count Sheets reviewed for Change of Shift Narcotic Counts. The facility failed to ensure all controlled medications were accurately reconciled at the start and end of each shift. This failure could place residents at risk of misappropriation by drug diversion and could result in diminished health and well-being. Record Review of the Change of Shift Narcotic Counts for the 100 Hall on 02/05/2025 at 2:20pm, of the Change of Shift Narcotic Counts for the 100 Hall revealed missing documentation for 02/04/2025 for the night shift. Record Review of the 200/300 Hall count sheet on 02/05/2025 at 2:20PM revealed missing documentation for night shift on 02/03/2025…

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 care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality and failed to protect and promote the rights of the residents for 4 of 10 (Resident # 30, Resident #50, Resident #108, and Resident #190) residents observed for dignity. 1. The facility failed to ensure Resident #30, Resident #50, and Resident #108 were assisted with feeding in a dignified manner. 2. The facility failed to promote Resident #190's dignity while dining when staff did not serve her lunch tray for approximately 45 minutes after tablemate was served. These failures could place residents at risk of experiencing humiliation, degradation, and a decreased quality of life. The findings included: 1. Resident #30 Review of Resident #30's face sheet, dated, 02/05/2025, reflected a [AGE] year-old female 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure each resident received and the facility provided food and drink that was palatable, attractive and at a safe and appetizing temperature for residents who consumed foods orally from the only kitchen in the facility in that: 1. a) The test tray of the lunch meal on 02/06/25 was lukewarm, unappetizing in appearance (no seasoning observed, and soggy roll on the plate), not cooked well (related to beef and pasta noodles) and lacked seasoning and flavor. b) The facility failed to provide palatable food that was attractive or appetizing to residents' who complained the food did not look or taste good. 2. The facility failed to follow the puree diet recipe. The puree scramble eggs recipe required three tablespoons and one teaspoon of food thickener. There was not a recipe for oatmeal. This failure could place residents at risk of decreased food intake, hunger, unwanted weight loss, and diminished quality of life. The findings include: 1.…

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 food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure DC K used proper hand hygiene during food preparation. 2. The facility failed to ensure DC L wore a beard guard when standing over food prep table. This failure could place residents who ate food from the kitchen at risk for foodborne illness. Findings included: 1. Observation on 02/07/2025 between 6:40 AM and 7:15 AM, DC K began to prepare puree meal. DC K did not wash her hands prior to preparing puree food. She did not wear gloves or wash hands when she was placing food in the puree equipment. DC K touched the following during the process of preparing puree food: her clothes, menu manual, an empty plastic bag, top of cardboard box, plastic container drawer where utensils were stored, surveyor shirt, and the right side of upper portion of her pants. DC K touched the top of blueberry muffins located on the steam table 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 observations, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two of eight residents (Resident # 30, and Resident #80) reviewed ADL care. 1. The facility failed to ensure Resident #30 and Resident #80 nails were cleaned, trimmed, and did not have any rough edges. This failure could place residents at risk for poor hygiene, dignity issues, and decreased quality of life. Findings included: 1.Review of Resident #30's face sheet, dated, 02/05/2025, reflected a [AGE] year-old female who was admitted on [DATE] and readmitted on [DATE]. Resident #30 had diagnoses which included Alzheimer's disease, unspecified (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), need assistance for personal care (assistance with basic daily activities like bathing, dressing,…

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 the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for 2 of 7 residents (Resident #400 and Resident #188). 1. ADON A observed Resident #400 sliding out of the bed and walked out without aiding the resident with bed mobility. 2. The facility failed to ensure a qualified staff fed Resident #188. These deficient practices could place residents at risk for injury, harm, and low sense of self-worth. The findings included: 1. Review of Resident #400's face sheet dated [DATE] reflected am [AGE] year-old female admitted to the facility on [DATE] with a diagnosis that included cerebral infarction (stroke- occurs when blood supply to part of the brain is blocked or reduced), acute pulmonary edema (condition caused by fluid in the lungs), acute kidney failure, history of falling, muscle weakness, unsteadiness on feet, 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, interviews and record reviews, the facility failed to provide food that accommodates residents' allergies, intolerances, and preferences for two (2) of ten (10) residents (Resident # 50 and Resident # 241) reviewed for food allergies. The facility failed to honor Resident #50's food preference according to her meal ticket and failed to ensure Resident #50 was not served beef, which her meal ticket reflected she disliked. The facility kitchen failed to honor Resident # 241's food allergies according to her meal ticket and served her products containing gluten (oatmeal, blueberry muffin, dinner roll, and egg noodles) which her meal ticket stated she had an allergy to gluten. This failure placed the resident at risk of consuming a food allergen and of receiving and consuming foods not of their preferred preference which could result in diminished health status. Findings included: 1. Review of Resident #50's face sheet, dated 02/06/2025, reflected a [AGE] year-old female who was admitted to 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, 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 3 residents (Resident #57) observed for infection prevention. The facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented and used when CNA-G and CNA-J provided perineal and catheter care for Resident #57. This deficient practice could place residents at-risk for spread of infection. Findings included: Record review of Resident #57's face sheet dated 12/09/2023 revealed she was a [AGE] year-old woman, with an initial admission date of 10/18/2021, with re-admission on [DATE] and with diagnoses which included: Type 2 Diabetes Mellitus (a chronic condition that affects how the body uses sugar (glucose) for energy), Neuromuscular Dysfunction of Bladder (a condition where the nerves controlling bladder…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to immediately notify the resident's RP when there was a significant change in the resident's physical status for 1 of 3 (Resident #1) reviewed for change in condition. The facility failed to ensure Resident #1's RP was notified when he was sent out to the hospital for low blood pressure on 01/27/2025 while at his dialysis treatment. This failure could place residents at risk of their responsible party not being involved in ensuring safety. Findings included: A record review of Resident #1's face sheet dated 02/01/2025 reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1's diagnosis was end stage renal disease(kidneys lose the ability to remove waste and balance fluids) and unspecified dementia(signs of memory loss but specific underlying cause cannot be identified. A record review of Resident #1's Quarterly MDS assessment, dated 11/13/2024, reflected the resident had a BIMS score of 1, which indicated severe cognitive…

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 reviews, the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activities professional who was licensed or registered by the state for 2 of 2 Activity Director (AD) reviewed for qualified professionals, in that: The facility failed to have a qualified AD to serve as the director of the activities program. This failure could place residents at risk for reduced quality of life due to lack of activities that were individualized to match the skills, abilities, and interests/preferences of each resident. The findings included: Interview on 12/07/24 at 9:54 am the AD revealed she was just hired as an AD; she was previously a CNA. She stated she was enrolled in the AD certification and training program, but she was not certified. Interview on 12/08/24 at 10:57 am with the ADM revealed the facility currently did not have ADs who were certified qualified therapeutic recreation specialists or certified activity professionals. The ADM revealed 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 observations, interviews, and record reviews, the facility failed to notify the resident representative(s) when there was an accident involving the resident which results in injury and had the potential for requiring physician intervention for 1 (Resident #1) of 5 residents RP's reviewed for incidents. The facility failed to notify Resident #1's RP that staff observed Resident #1 had an injury of unknown origin. Staff observed Resident #1 had a black eye on 10/27/24 at 1:30 PM and didn't know how Resident #1 sustained the injury. Resident #1's RP was not notified until 10/27/24 at 7:39 PM. The facility failed to notify Resident #1's RP that an incident happened with Resident #1 on 10/25/24. Resident #1's RP wasn't notified of any incidents on 10/25/24 until 10/27/24 at 7:39 PM This deficient practice could place residents at risk of diminished quality of life, abuse, continuous incidents and accidents, and neglect. Findings included: Review of Resident #1's admission record, dated 10/29/24, reflected 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 observations, interviews, and record reviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 (Resident #1) of 5 residents reviewed for ADL care. The facility failed to ensure Resident #1's wheelchair was clean. This deficient practice could place residents at risk of neglect, infection, and a diminished quality of life. Findings included: Review of Resident #1's admission record, dated 10/29/24, reflected a [AGE] year-old female resident who was admitted to the facility on [DATE] with diagnoses including unspecified dementia, conversion disorder with seizures or convulsions, adjustment disorder with mixed anxiety and depressed mood, generalized muscle weakness, and other abnormalities of gait and mobility. Review of Resident #1's quarterly MDS assessment, dated 09/11/24, reflected she was dependent on staff assistance with her ADLs except eating, in which she was independent. Review of Resident #1's BIMS assessment, dated 10/29/24, reflected she had a BIMS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews , the facility failed to ensure that all alleged violations were reported immediately or not later than 24 hours for 1 (Resident #1) of 5 residents reviewed for incidents. The facility failed to report to the SA an incident where Resident #1 was found with a black eye on 10/27/24. This deficient practice could place residents at risk of abuse and/or neglect. Findings included: Review of Resident #1's admission record, dated 10/29/24, reflected a [AGE] year-old female resident who was admitted to the facility on [DATE] with diagnoses including unspecified dementia, conversion disorder with seizures or convulsions, adjustment disorder with mixed anxiety and depressed mood, generalized muscle weakness, and other abnormalities of gait and mobility. Review of Resident #1's quarterly MDS assessment, dated 09/11/24, reflected she had one fall with no injury, no skin issues, and was dependent on staff assistance with her ADLs except eating, in which she 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 observation, interview and record review, the facility must develop and implement a comprehensive person centered care plan for each resident. 1. The facility failed to ensure Resident #65's interventions encouraging wearing footwear to help prevent falls were in place. 2. The facility failed to ensure Resident #78 was encouraged to wear footwear to prevent falls during her behavior of continuous walking. Progress notes reflected a history of falls on 10/24/22 and 11/07/22 (no interventions listed to limit fall risk) These failures could place residents at risk of falls and of not receiving care according to their needs. These findings were: Review of the Face Sheet for Resident #65 reflected she was admitted on [DATE] with diagnoses of: Alzheimer's disease, HTN, Dementia, Generalized Anxiety disorder, edema, Psychotic disorder with delusions, Unsteady gait. Review of the Quarterly MDS assessment for Resident #65 dated 11/10/23 reflected a BIMS score of 4 indicating severe cognitive impairment. Her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on, interviews, and record reviews the facility failed to ensure that a resident who has a prosthesis is provided care and assistance, consistent with professional standards of practice, the residents' goals, and preferences, to wear and be able to use the prosthetic device for one (Resident #119) of seven residents reviewed for orthotic devices, in that: The facility failed to follow a physician's order, written on 8/22/2023 for Resident 119 to schedule an evaluation for a prosthesis. By the time the survey was being conducted the appointment had not been scheduled yet This failure could place residents at risk for health status decline, impaired mobility, without the support and therapeutic effects of prostheses devices. Findings include: Review of Resident #119 admission record, undated, reflected a [AGE] year-old female who was admitted on [DATE] with diagnosis of Peripheral vascular Disease (a disorder limiting blood flow in the arms and legs), Acquired Absence of the left leg below knee, unspecified…

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 oxygen therapy equipment in accordance with their policy. Residents #69, #2, #28, #195, #197, #12 and #98 had oxygen equipment and tubing in their rooms undated and unserviced . This failure could place residents at risk of exposure to infectious bacteria/viruses in the tubing because of unknown use. Findings include: Review of the Face sheet for Resident #12 reflected she was admitted on [DATE] with diagnosis of: Unspecified Dementia, High Blood Pressure, Hemiplegia following Cerebral Infarction, Unsteady gait, Depression, Metabolic Encephalopathy . Review of the annual MDS assessment for Resident #12 dated 9/28/23 reflected a BIMS score of 3 indicating severe cognitive impairment. Her functional assessment reflected she required extensive assistance of most ADLs except eating and moving in her wheelchair. No use of oxygen therapy was marked. Review of Resident #12's Care Plan reflected interventions were in place for: weight loss…

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

Based on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 3 of 4 medication carts (300/500 nurse med cart, 200/300 nurse med cart, and 100 treatment/nurse cart) reviewed for medication storage. The facility failed to properly label and date three insulin pens in the 300/500 nurse med cart. The facility failed to properly date one insulin pen in the 200/300 nurse med cart. The facility failed to properly label one insulin pen in 100 treatment/nurse cart. These failures could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications, not receiving prescribed drugs or contaminated medication. Findings included: Observation on 12/27/23 at 12:39 PM of the 300/500 nurse med cart revealed three opened insulin pens with no open date and one opened insulin pen with no 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.

Based on observations, interviews, and record reviews, the facility failed to store foods properly and maintain a sanitized food preparation area for the facility's only kitchen, which was reviewed for dietary services. 1. The facility failed to properly store, seal, and date food in the facility's walk-in refrigerator and freezer. These failures placed residents at risk of exposure to food borne pathogens. Findings include: During an observation of the kitchen on 12/27/2023, starting at 10:36 a.m., accompanied by the Dietary Manager the following observations were made: Refrigerator findings included the following Produce items were stored on the floor in the walk-in refrigerator. *1 Box of Bananas *1 Box of tomatoes *2 boxes of romaine lettuce *2 Boxes of cabbage *1 Box of mixed herbs Freezer findings included 2 boxes of opened, undated, golden potato patties were stored on the floor in a cardboard box, and undated. During an interview on 12/27/23 at 1:39 p.m., the Dietary Manager reported her expectation were when she inspects the walk-in freezer and refrigerator was that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 3 of 4 residents (Residents #59, Residents #68, and Residents #111) and 1 of 1 staff (MA Y) reviewed for infection control. The facility failed to ensure multi-use equipment was properly cleaned between each resident. This failure could place residents at risk for spread of infection and cross contamination during medication administration. Findings included: Review of Resident #59's undated face sheet reflected an [AGE] year-old female admitted to the facility initially on 08/09/19 and readmitted on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (a lung disease limiting air flow from the lungs), essential hypertension (high blood pressure), type 2 diabetes mellitus (a condition that affects the way 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 observations, interviews, and record reviews, the facility failed to treat residents with respect and dignity in a manner that promotes maintenance of his/her quality of life and recognized their individuality for two (Resident #1 and # 9) of 7 residents reviewed for resident rights in that: 1. The CTA fed Resident #1 while standing next to her. 2. LVN C referred to Resident #9 who requires assistance with feeding, as a feeder. These failures could place residents who needed feeding assistance at risk for lacking a dignified existence and unmet needs. Findings include: Review of Resident #1's admission record, undated, reflected a [AGE] year-old female who was admitted on [DATE] with diagnoses of anxiety, personal history of traumatic brain injury, dysphagia (difficulty swallowing), and other mental disorders due to known physiological condition. Review of Resident #1's MDS assessment, dated 10/21/23, reflected she had a BIMS score of 7, indicating severe cognitive impairment. Review of Resident #1's…

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 a baseline care plan that provided effective and person-centered care of individualized resident care needs for 1 (Resident # 337) of 6 residents reviewed for person-centered care planning. 1. The care plan was initiated 8 days after Resident #337 was admitted . 2. The care plan only addressed activities; the care plan did not address goals, physician orders, dietary orders, therapy services, or social services. This failure could place newly admitted residents at risk for unmet needs. Findings include: Review of Resident #337's admission record, undated, reflected a [AGE] year-old female who was admitted on [DATE] with diagnoses that included dementia, overactive bladder, chronic pain, rhinitis, GERD, and history of falling. Review of Resident #337's admission MDS assessment, dated 12/27/2023, did not reflect Resident #337's diagnoses, functional status or treatments and services (as applicable). Review of Resident #337's care plan, initiated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure the resident environment remained as free of accident hazards as was possible for one out of three residents (Resident #74) reviewed for hazards in that: Resident #74 was observed to have disinfectant sprays and wipes on the counter of her sink in her room . Findings included: Review of the Face Sheet for Resident #74 reflected she was admitted on [DATE] with diagnoses of: Unspecified Dementia, Hyperlipidemia, HTN, Depression, unsteady gait, and Chronic Kidney disease. Review of the quarterly MDS assessment for Resident #74 dated 10/25/23 reflected a BIMS score of 4 indicating severe cognitive impairment. Her functional assessment reflected she was independent in most ADLs and needed one person assistance for mobilizing and bathing. She was assessed as occasionally incontinent of bowel and bladder. Review of the Care Plan for Resident #74 reflected interventions were in place for: independently ambulating with a cane, Dementia,…

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 who used psychotropic drugs received gradual dose reductions, unless clinically contraindicated, for 1 of 4 residents (Residents #8) reviewed for unnecessary medications. The facility failed to ensure Resident #8 received gradual dose reductions (GDR) for Buspirone and Zoloft. These failures could affect residents on psychoactive medications, by placing them at risk for possible adverse side effects, adverse consequences, and decreased quality of life. Findings included: Review of Resident #8's undated face sheet reflected a [AGE] year-old female admitted to the facility most recently on 06/14/22. Her diagnoses included chronic respiratory failure with hypoxia (not enough oxygen in the blood), generalized anxiety disorder (intense and excessive worry and fear), major depressive disorder (a mood disorder with persistent feeling of sadness and loss of interest), type 2 diabetes mellitus (a condition that affects the way the body processes…

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 one of one kitchen reviewed for kitchen sanitation The facility failed to ensure food was stored properly in the dry storage area and walk-in refrigerator. The deficient practice placed residents who were served from the kitchen at risk for health complications and foodborne illnesses. Findings included: During an observation of the kitchen dry storage area on 12/12/2023 at 11:04 am, four sealed zip bags container crackers, gelatin product and bottled water sitting on a tray. The zip bags were not labeled or dated, and the tray was not labeled or dated. There were two unsealed zip bags of dry cereal unlabeled and undated, an unsealed zip bag containing an open box of cereal product and an opened bag of flour product, an opened zip bag containing pasta products. Further observation revealed a scoop covered in a white powdered substance sitting on a wire shelf above the flour bin. During an observation of the walk-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 interview and record review, the facility failed to, in response to allegations of abuse, neglect or mistreatment, have evidence that all alleged violations were investigated, and the results of all investigations were reported to the State Survey Agency, within 5 working days of the incident for One (Resident #2) of six (6) residents reviewed, in that: The facility failed to report, within five days, the results of an investigation of an allegation of Misappropriation of Property by Resident #2 when her debit card was compromised. This failure placed residents at risk for continued abuse or neglect without appropriate corrective actions being taken. Findings included: Review of Resident #2's face sheet dated 12/13/2023 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of Chronic Obstructive Pulmonary Diseases, Fracture Right Femur (broken hip), Fracture of the Left Radius (broken wrist), Anxiety, Major Depressive Disorder and Chronic Kidney Disease. Review of Resident #2's 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 interview and record review, the facility failed to provide pharmaceutical services which includes the accurate acquiring and administering of medications to meet the needs for one (Resident #1) of six residents reviewed for pharmacy services, in that: The facility failed to reorder Resident #1's seizure medication three days prior to running out and failed to follow up on the order, causing her to miss one dose in the evening on 12/10/2023. This failure placed residents at risk for medical complications, decreased quality of life and hospitalization Findings included: Review of Resident #1's face sheet dated 12/13/2023 reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included: Seizures, Cerebral Infarction (stroke), Vascular Dementia (memory loss cause be circulation issues), Congestive Heart Failure, Type 2 Diabetes (Blood sugar regulation disorder), Hyperlipidemia (high cholesterol) and Hypertension (high blood pressure). Review of Resident #1's 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, interviews, and record reviews the facility failed to ensure residents received services in the facility with reasonable accommodations of each resident's needs for 1 of 7 residents (Resident #3) reviewed for call lights in that: Resident #3 was observed in their room with call lights not within reach. This failure could affect all residents who needed assistance with activities of daily living and could result in injury or needs not being met. Findings included: Review of Resident #3's Face Sheet dated 10/26/2023 reflected a [AGE] year-old female resident admitted on [DATE] with diagnoses that included Dementia, Hypertensions (high blood pressure), Type 2 Diabetes (blood sugar disorder), muscle weakness and other abnormalities of gait and mobility. Review of Resident #3's MDS dated [DATE], reflected resident had a BIMS score of 0 (zero) indicating severe cognitive impairment. Further review of resident's functional status in MDS section G, revealed resident needed extensive assistance…

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 13 of 18 residents (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12 and #13) reviewed for infection control. 1. The facility failed to isolate or test for COVID-19 for roommates (Residents #2, #4,and #6) of COVID-19 positive residents after the roommates were exposed to COVID-19. 2. The facility failed to ensure signs and symptoms of COVID-19 were documented for Residents #2, #4 and #6 during the period following exposure. 3. LVN C, HK D and CNA E failed to ensure they donned CDC-recommended PPE when they entered rooms of COVID-19 positive residents. These failures contributed to Residents #8, #9, #10, #11, #12 and #13 testing positive for COVID-19 and placed other residents at risk of infection,…

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 promote and facilitate resident self-determination through support of resident choices for 1 of 6 (Resident #3) residents reviewed for self-determination. The facility failed to honor Resident #3's Power of Attorney's request to change to a different Pharmacy. This failure could place residents who want to change pharmacies at risk for financial hardship, lack of self-determination, and unmet needs. Findings include: Review of Resident #3's Face sheet dated 9/1/2023 reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included: Type 2 Diabetes (blood sugar disorder), End stage renal disease (kidney disease), Hypertension (high blood pressure), Dysphagia (difficulty swallowing), and Cardiac Arrhythmia (Heart Rhythm disorder). The Face sheet reflected that Resident #3 had a Financial POA and reflected the pharmacy listed was the facility pharmacy and not the pharmacy request by the POA in July of 2023. 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.