Honey Grove Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety requirements. The facility failed to ensure the can opener blade was free of a black substance. The facility failed to ensure the steam table wells were clean and free of food debris. The facility failed to ensure the fryer was cleaned after use and free of food debris, and the fryer baskets free from hard cooked on food on the bottom of the baskets appearing to be French fries. The facility failed to ensure 3 skillets were free from carbon build up on the cooking surface of the pan. The facility failed to ensure the stove top was free from black burned on material in the burner wells. The facility failed to ensure a bag of [NAME] were dated and labeled in the walk-in cooler. The facility failed to ensure a large plastic container of pudding, and a large plastic container of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 (Resident #40 and #42) and 1 of 1 laundry cart reviewed for infection control practices. 1)The facility failed to ensure CNA F and RN G properly cleaned the perineal/genital areas for Resident #'s 40 and 42 during incontinent care . 2)The facility did not ensure Housekeeper H covered the clean linen cart while passing out clean linens on 09/23/2024. These deficient practices could place residents at risk for infection due to improper care practices. Findings included: 1)Record review of a face sheet dated 9/26/2024 indicated Resident #40 was a [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnosis of dementia (loss of memory). Record review of a comprehensive care plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment for 1 of 16 resident rooms (Resident #38) reviewed for environment. The facility failed to ensure Resident #38's door was properly functioning. This failure could place residents at risk for an uncomfortable, unhomelike environment, and a diminished quality of life. Findings included: Record review of a face sheet dated 09/24/2024, indicated Resident #38 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease with early onset (progressive disease that destroys memory and other important mental functions starting earlier in life) and heart failure (chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen). Record review of the Quarterly MDS assessment dated [DATE], indicated Resident #38 was able to make herself understood and understood others.…

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 assessments accurately reflected the resident status for 2 of 16 residents (Residents #42 and #43) reviewed for MDS assessment accuracy. 1. The facility did not ensure Resident #42's MDS assessment was accurately coded for wandering. 2. The facility failed to ensure Resident #43's antibiotic use was accurately coded. These failures could place residents at risk for not receiving care and services to meet their needs. Findings included: 1. Record review of Resident #42's face sheet, dated 09/26/24, indicated Resident #42 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's (progressive disease that destroys memory and other important mental functions). Record review of the admission MDS assessment, dated 06/14/24, indicated Resident #42 made himself understood and understood others. Resident #42's BIMS score was 4, which indicated his cognition was severely impaired. Resident #42 did not have disorganized thinking,…

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 implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 1 of 16 residents (Resident #1) reviewed for care plans. The facility failed to care plan that Resident #1 was PASRR positive for mental illness and an intellectual disability. These failures could place the residents at increased risk of not having their individual needs met and a decreased quality of life. Findings included: Record review of a face sheet dated 09/25/2024 indicated Resident #1 was a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included schizoaffective disorder, bipolar type (mood disorder that can involve delusions, hallucinations, depression, disorganized thinking and speech) and intellectual disabilities. Record review of the Comprehensive MDS assessment dated [DATE], indicated in Section A1510…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident received appropriate treatment and services to prevent urinary tract infections for 2 of 2 residents (Resident #40 and Resident #42) reviewed for incontinent care. The facility failed to ensure CNA F and RN G properly cleaned the perineal/genital areas for Resident #'s 40 and 42 during incontinent care. These failures could place residents at risk for urinary tract infections. Findings included: 1)Record review of a face sheet dated 9/26/2024 indicated Resident #40 was a [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnosis of dementia (loss of memory). Record review of a comprehensive care plan dated 11/10/2022 and revised on 7/05/2024 indicated Resident #40 was incontinent of bowel and bladder and was dependent for toileting. The goal of the care plan was Resident #40 would have a decreased likelihood of skin breakdown. The care plan interventions for Resident #40 included to monitor…

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 requiring respiratory care were provided such care, consistent with professional standards of practices for 1 of 1 resident (Resident #10) reviewed for respiratory care. 1. The facility failed to administer Resident #10's oxygen as ordered by the physician. 2. The facility failed to ensure Resident #10's oxygen flow meter on the oxygen concentrator was functioning properly and undamaged. These failures could place residents who receive respiratory care at risk for developing respiratory complications and a decreased quality of care. The findings included: Record review of the face sheet, dated 09/24/2024, revealed Resident #10 was an [AGE] year-old male who admitted to the facility on [DATE] with a diagnosis of COPD (term for certain types of irreversible lung and airway damage that block (obstruct) your airways and make it hard to breathe). Record review of the quarterly MDS assessment, dated 08/26/2024, revealed…

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 special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals for 2 of 2 (Residents #19 and #4) residents reviewed for special eating equipment and assistance when consuming meals. 1. The facility failed to provide Resident #19's physician ordered sippy cup with each meal tray. 2. The facility failed to ensure Resident #4 had a physician's ordered cup with lid and handles for drinking fluids. These failures could place residents at risk for harm by weight loss, diminished independence, and self-esteem. Findings included: 1. Record review of Resident #19's face sheet, dated 09/26/24, indicated Resident #19 was admitted to the facility on [DATE] with diagnoses which included encephalopathy (brain disease that alters brain function or structure). Record review of the quarterly MDS assessment, dated 08/20/24, indicated…

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 collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 3 residents (Resident #40) reviewed for hospice services. The facility failed to obtain Resident #40's most recent updated hospice plan of care. The facility failed to ensure Resident #40's hospice plan of care accurately reflect his medication regimen. The deficient practices could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs. Findings included: Record review of a face sheet dated 9/26/2024 indicated Resident #40 was a [AGE] year-old female who admitted on [DATE] and readmitted on [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents were free of any significant medication errors for 1 of 5 (Resident #1) residents reviewed for medication errors. The facility failed to ensure on 6/2/24 Resident #1 received 55 units of Lantus (long-acting insulin for diabetes) as ordered and instead was administered 55 units of Humalog (short-acting insulin for diabetes). The noncompliance was identified as PNC. The noncompliance began on 6/2/24 and ended on 6/3/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for receiving the incorrect medication and dosage resulting in adverse reactions. Findings Include: Record review of the face sheet dated 6/5/24 indicated Resident #1 was a [AGE] year-old female re-admitted to the facility on [DATE] with diagnoses including diabetes, aphasia (a language disorder caused by damage to parts of the brain that control speech and understanding of language), 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.

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 did not ensure: 1. An open bag of pre-cut chocolate chip cookies in the freezer had an open date or were stored properly. 2. A bag of an unknown ground meat substance, dated 07/21/23, was labeled and thawing properly in the refrigerator. 3. A container of white gravy, dated 07/24/23, had a discard by or use by date. 4. A container of brown gravy, dated 07/22/23, had a discard by or use by date. 5. An expired container of turkey, discard date of 07/23/23, was removed from the refrigerator. 6. A container of super pudding, dated 07/21/23, with no discard by or use by date. 7. 4 clear packages of a meat-like substance cut into strips were labeled in the refrigerator. 8. The deep fryer was clean and had clear grease. 9. The can opener was cleaned. 10. The dry storage area was clean and free of crumbs on the floor and dust on the storage containers of flour. These…

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 maintain an effective pest control program so that facility is free of pests and rodents for the facility's only kitchen and dry storage room. The facility did not maintain an effective pest control program to ensure the facility was free of flies in the kitchen and mouse droppings in the dry storage room. These findings could place residents at risk for an unsanitary environment and a decreased quality of life. The findings included: During an observation on 07/24/23 between 9:33 AM and 10:00 AM, the dry storage area had grimy and dirty floors with splotches of a black substance on the floor. Shoes were unable to easily move on the floor and stuck to the floor in some places. The right back corner of the dry storage room had a thick black dust build-up with 4 white, dry beans on the ground. There were multiple crumbs on the ground against the base boards and dark black splotches of a dried unknown substance. The container labeled flour…

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 the resident environment remains as free of accident hazards as is possible to prevent accidents for 2 of 6 hallways (Hall 2 and Hall 5) reviewed for accidents and hazards. The facility did not ensure the flooring on Hall 2 and Hall 5 were even, and free of cracked tiles. This failure could place residents at an increased risk for serious injury related to falls. The findings included: During observations between 07/24/23 at 10:43 AM and 07/28/23 at 9:38 AM the hallway at the end of Hall 2 had cracked tiles and uneven flooring that cratered for approximately 3 feet over four individually, squared tiles. Several observations included ambulatory residents frequently walking over the uneven area. During observations between 07/24/23 at 11:28 AM and 07/28/23 at 9:42 AM the hallway in the middle of Hall 5, near the fire extinguisher had cracked tiles and uneven flooring with deep ridges for approximately 4 feet over six…

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

Based on observation, interviews and record review the facility failed to ensure all drugs and biologicals used in the facility were stored in a locked compartment, only accessible by authorized personnel, and labeled, stored, and dated correctly for 2 of 4 medication carts (Hall 2 and Hall 5 medication carts) reviewed for storage of medications. 1.The facility failed to ensure Hall 2 and Hall 5 medication cart was secured and unable to be accessed by unauthorized personnel. 2.The facility failed to ensure 1 insulin pen (device used to administer insulin to residents with high blood sugars) on the Hall 2 medication cart was dated when opened. 3.The facility failed to ensure 3 Albuterol Sulfate Inhalation Solution (inhalation solution used to open the airways for breathing) on the Hall 2 medication cart were dated when opened. 4.The facility failed to ensure a bottle of liquid Ativan (a medication used for anxiety) was refrigerated. These failures could place residents at risk for not receiving drugs and biologicals as needed, not receiving the therapeutic benefits of medications,…

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

Based on observation, interviews, and record review, the facility failed to ensure the meals served to residents met the nutritional needs of residents for 1 of 1 meal (the lunch meal), as evidenced by: The facility did not ensure [NAME] Q followed the recipe for pureeing the breaded pork chop and the garlic buttered pasta during the lunch meal. These failures could place residents at risk for weight loss, not having their nutritional needs met, and a decreased quality of life. The findings included: Record review of the pureed recipe for the breaded pork chop, undated, revealed Combine beef base and water to make chicken broth. The recipe further revealed Gradually add broth; blend until smooth. Record review of the pureed recipe for the garlic buttered pasta, undated, revealed 1. Combine chicken base and water to make chicken broth. 2. Place prepared pasta in a sanitized food processor; gradually add prepared chicken broth and blend until smooth. 3. Add additional prepared broth if product needs thinning. During an observation on 07/25/23 between 11:15 AM and 12:06 PM, [NAME] Q…

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 4 of 15 residents (Resident's #9, #10, #23, and #25) reviewed for palatable food. The facility failed to provide palatable food served at an appetizing temperature or taste to Resident #9, Resident #10, Resident #23, and Resident #25 who complained the food was served cold and did not taste 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. The findings included: During an interview on 07/24/23 at 10:48 AM, Resident #10 stated the food was not very good. Resident #10 stated it was too dry, over seasoned, and cold. During an interview on 07/24/23 at 11:08 AM, Resident #23 stated the food was too salty or not salty enough. Resident #23 stated it just did not taste good. During an interview on 07/24/23 at 11:13 AM, Resident #25 stated the food was not always hot. During an interview on 07/24/23 at 11:25 AM, Resident #9 stated the food…

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 follow their own established smoking policy for the facility's only smoking area. The facility did not ensure a metal container with self-closing cover devices were available in the smoking area. This failure could place residents at risk of an unsafe smoking environment. The findings included: During a smoking observation on 07/25/23 at 8:31 AM, there was a plastic-lined, self-closing trash receptacle in the smoking area that had buttz can written on it. The trash receptacle had several different colored cigarette butts located inside. During an interview on 07/28/23 at 9:38 AM, the Maintenance Director stated the trash receptacles in the smoking area were plastic lined. The Maintenance Director stated he had been looking around online and in-stores for a metal trash can but had been unsuccessful. The Maintenance Director stated he was unable to provide documentation that attempts had been made. The Maintenance Director stated the plastic lined trash can was well-monitored because the residents did not smoke…

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 ensure residents have the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives and to choose the option he or she prefers for 1 of 5 residents reviewed for right to be informed. (Resident #23) The facility failed to ensure Resident #23 had signed psychotropic consent form for Paxil (antidepressant). This failure could place residents at risk for treatment or services without informed consent. The findings included: Record review of the face sheet, dated 07/27/23, revealed Resident #23 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD; an inflammatory lung disease that causes obstructed airflow from the lungs), bipolar disorder (mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania)…

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 assure residents who have authorized the facility in writing to manage any personal funds have ready and reasonable access to those funds for 1 of 15 residents (Resident #10) reviewed for personal funds. The facility failed to ensure Resident #10 had access to her personal funds when she requested it. This failure could place residents whose funds are managed by the facility at risk of not receiving their personal funds deposited with the facility and not having their rights and preferences honored. Findings included: Record review of a face sheet dated 07/28/2023, indicated Resident #10 was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included heart failure (chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), anxiety disorder (response that occurs when the mind and body encounter…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure the right to formulate an advance directive was provided for 1 of 15 residents (Resident #6) reviewed for advanced directives. The facility did not ensure Resident #6's OOH-DNR was signed by the responsible party and the notary. The facility did not ensure Resident #6's OOH-DNR was dated by the responsible party upon obtaining their signature. These failures could place residents at risk of not receiving care and services to meet their needs. The findings included: Record review of the of Resident #6's face sheet, dated 07/27/2023, indicated Resident #6 was an [AGE] year-old female, originally admitted to the facility on [DATE] with diagnoses which included myocardial infarction (heart attack), dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), and essential hypertension (high blood pressure). Record review of Resident #6's physician order summary report, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide a safe, clean, and comfortable environment for 1 of 15 residents (Resident #10) reviewed for environment. The facility failed to ensure Resident #10's door was in good repair. This failure could place residents at risk for an uncomfortable, unhomelike environment, and a diminished quality of life. Findings included: Record review of a face sheet dated 07/28/2023, indicated Resident #10 was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included heart failure (chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), anxiety disorder (response that occurs when the mind and body encounter stressful, dangerous, or unfamiliar situations), and essential primary hypertension (high blood pressure). Record review of the Comprehensive MDS assessment dated [DATE], indicated Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the completion of a significant change assessment for 1 of 7 residents reviewed for Significant Change Assessments. (Resident #23). The facility did not complete a significant change assessment for Resident #23 within 14 days of admitting to hospice services. This failure could place residents at risk of not receiving adequate services and reimbursement to meet their needs. The findings included: Record review of the face sheet, dated 07/27/23, revealed Resident #23 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD; an inflammatory lung disease that causes obstructed airflow from the lungs), bipolar disorder (mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression)), and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). Record…

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 implement a comprehensive person-centered care plan to meet resident's medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment for 2 of 15 residents (Resident #6, Resident #22) reviewed for care plans. The facility did not develop Resident #6's care plan related to self-inflicted injuries. The facility failed to ensure Resident #22's care plan indicated the correct code status. This failure could place residents at risk for injuries, inaccurate care plans and decreased quality of care. Findings include: 1.Record review of the of Resident #6's face sheet, dated [DATE], indicated Resident #6 was an [AGE] year-old female, originally admitted to the facility on [DATE] with diagnoses which included myocardial infarction (heart attack), dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), and essential hypertension (high…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that residents requiring respiratory care were provided such care, consistent with professional standards of practices for 1 of 3 residents (Resident #23) reviewed for respiratory care. The facility did not ensure Resident #23's oxygen was administered at 2 liters per minute via nasal cannula as prescribed by the physician. This failure could place residents who receive respiratory care at risk for developing respiratory complications. The findings included: Record review of the face sheet, dated 07/27/23, revealed Resident #23 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD; an inflammatory lung disease that causes obstructed airflow from the lungs), bipolar disorder (mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression)), and major depressive disorder (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 observations, interviews, and record review the facility failed to ensure safe and sanitary storage of resident's food items for 1 of 6 residents reviewed for personal food safety. (Resident's #41) The facility did not implement the personal food policy related to personal refrigerators for Resident's #41. These failures could place the residents at risk for food borne illness. The findings included: 1. Record review of Resident #41's face sheet, dated 08/02/2022, indicated Resident #41 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of idiopathic normal pressure hydrocephalus (a condition which accumulation of cerebrospinal fluid occurs in the brain), Urinary tract infection, schwannomatosis (a genetic disorder that causes the growth of benign tumors along the nerves of the body and in the skull, major depressive disorder, muscle weakness. Record review of the MINIMUM DATA SET (MDS) RESIDENT ASSESSMENT AND CARE SCREENING Nursing Home Quarterly (NQ) E., dated…

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

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 5 staff (CNA A, CNA B, LVN D) reviewed for infection control. 1.The facility failed to ensure CNA A and CNA B changed gloves and performed hand hygiene when providing incontinent care to Resident #44. 2.The facility failed to ensure LVN D cleaned the glucometer after using it on a resident. These failures could place residents and staff at risk for cross-contamination and the spread of infection. Findings included: 1. During an observation on 07/25/2023 at 8:10 AM, CNA A and CNA B provided incontinent care to Resident #44. CNA A and CNA B performed hand hygiene and put on gloves. CNA A unfastened Resident #44's dirty brief and CNA B tucked Resident #44's dirty brief underneath her from her side. CNA A and CNA B then turned Resident #44 on her side facing CNA B. CNA A cleaned Resident #44'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.