Huntington Health Care & Rehabilitation Center

Based on observation, interview and record review the facility failed to provide pharmaceutical services including procedures that assured the accurate acquiring, receiving, dispensing and administering for all drugs and biologicals to meet the needs of each resident for 1 of 12 months (May 2025).The facility failed to have a licensed pharmacist, 2 facility staff witnesses and sign the drug destruction log during drug destruction occurrence May 22, 2025.These failures could place residents at risk for misappropriation and drug diversion.Findings include:Record review of a Drug Destruction record, dated 5/22/25, indicated the attached sheets which contained the controlled substances were initialed only by the consultant pharmacist and contained no witness signatures.During an interview on 7/16/25 at 3:15 PM, the DON said if drugs were not destroyed appropriately and did not have the required witnesses, a drug diversion could happen. She said going forward, she would ensure the witnesses signed the attached sheets appropriately. Record review of the facility's policy titled Medication…

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, in accordance with State and Federal laws, all drugs and biologicals were in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 4 residents (Resident #23) reviewed for storage of medications and for 1 of 4 medication carts (Nurse Cart L) reviewed for pharmacy services.1.The facility failed to ensure Resident #23's 10 ml sterile normal saline prefilled syringe and intravenous site dressing were not kept at the bedside and was unable to be accessed by unauthorized personnel or residents on 07/15/25. 2.The facility failed to ensure expired Tresiba (insulin degludec) for Resident #30 was not on the nurse medication cart on 7/16/25. This failure could place residents at risk of unauthorized use of medication, accidental contaminations/use of an unprescribed medication, and adverse effects of medications. Findings include: 1.Record review of Resident #23's face…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and consumption for 1 of 2 resident personal refrigerators (Resident #57) reviewed for food safety. 1. The facility failed to ensure the refrigerator for Resident #57 was clean and contained food items that were labeled and dated. 2. The facility failed to ensure the refrigerator for Resident #57 did not contain expired milk or expired whipped cream. These failures could place residents at risk for food borne illnesses.Findings included: Record review of Resident #57's electronic medical record and face sheet, dated 7/16/2025, reflected a [AGE] year-old male resident who was admitted to the facility on [DATE]. His diagnoses included: cellulitis (bacterial infection of the skin and the deeper tissues beneath the skin), obstructive sleep apnea (sleep disorder where breathing repeatedly stops and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide documentation for transfer or discharge by resident's physician for 1 of 1 resident (Resident #1) reviewed for discharge requirements. The facility failed to provide a reason for Resident #1's discharge by the resident's physician and the specific resident needs the facility could not meet, the facility's efforts to meet those needs and the specific services the receiving facility would provide to meet the needs of the resident which could not be met at current facility. This failure could place residents at risk of not having the needed records when transferring care and services and causing a disruption in their care and/or services. Findings included : Record review of Resident #1's undated face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including Hodgkin lymphoma (a type of cancer that affects the lymphatic system), diabetes, (a condition that affects blood sugar levels), dementia, (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.

Based on record review and interviews the facility failed to ensure the arbitration agreement contained all the required elements for 1 of 1 facility reviewed for Arbitration Agreements. The facility did not ensure the arbitration agreement granted the resident or his/her representative the right to rescind the agreement within 30 calendar days of signing. The facility did not ensure the arbitration agreement allowed the resident or anyone else (e.g., resident's representative) to communicate with federal, state, or local officials such as federal and state surveyors, other federal or state health department employees, and representative of the Office of the State Long Term Care Ombudsman. This failure could place the residents or the residents' responsible parties in binding agreements not fully understood, have a loss of their legal rights, and cause negative psychological issues. Findings included: Record review of an undated admission Agreement page 9 titled Arbitration and page 18 titled Dispute Resolution Plan indicated the agreement did not grant the resident or his/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.

Based on record review and interviews the facility failed to ensure the Arbitration Agreement contained all the required elements for 1 of 1 facility reviewed for Arbitration Agreements. The facility failed to ensure the arbitration agreement included provision of a neutral arbitrator. The facility failed to ensure the arbitration agreement contained a section indicating the provision of a convenient venue. These failures could place the residents or the residents' responsible parties in binding agreements not fully understood, have a loss of their legal rights, and cause negative psychological issues. Findings included: Record review of an undated admission Agreement page 9 titled Arbitration and page 18 titled Dispute Resolution Plan indicated the agreement did not ensure the provision of a neutral arbitrator and did not ensure the Arbitration Agreement contained a section indicating the provision of a convenient venue. During an interview on 05/29/24 at 9:17 AM the administrator said that he was responsible for the admission agreements and was not aware of the requirements of the…

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

Based on observations, interviews, and record review, the facility failed to follow established policy regarding smoking areas, and smoking safety for 1 of 1 smoking area reviewed. The facility failed to empty ash trays and keep trash out of the ash trays in the designated smoking area on 5/29/2024. This failure could place residents who smoke at risk of physical harm and lead to an unsafe smoking environment. The findings included: During an observation on 05/29/24 at 8:25 AM the designated smoking area had 2 ash trays present. One ash tray was overflowing with cigarette butts and the other ash tray had a paper towel that had presence of burn marks . During an interview on 05/29/24 at 8:29 AM HSK A said the maintenance director was responsible for maintaining the smoking area and she would empty the trash. She said that in her training she was taught that residents were to be supervised during the smoke break to ensure they did not put their cigarettes in the trash can or keep a lighter. She said that paper in the ash trays and excessive butts could cause a fire. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible for 3 of 12 residents reviewed for quality of care. (Resident #3, #33, and #38) The facility failed to remove worn and damaged mechanical lift slings from service. This deficient practice could result in a loss of quality of life due to injuries. Findings included: Record review of a facility face sheet dated 5/29/24 for Resident #3 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: dysphagia, muscle weakness, and dementia. Record review of a quarterly MDS assessment dated [DATE] for Resident #3 indicated that he had a BIMS score of 15 which indicated that he was cognitively intact Section GG (Functional Abilities and Goals) indicated that he required substantial/maximal assist for transfers. Record review of a comprehensive care plan dated 12/30/23 for Resident #3 indicated that he required 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 observations, interviews, and record review the facility failed to ensure that residents requiring respiratory care are provided care, consistent with professional standards of practices for 3 of 7 residents reviewed for respiratory care (Residents #15, #29, and #1). The facility failed to ensure the external filters of Resident's #15, #29, and #1 oxygen concentrators were free of dust buildup on 5/28/2024. These failures could place residents who require respiratory care at risk for respiratory infections, breathing in dust and allergens, decreased effectiveness of oxygen concentrators, and exacerbation of respiratory distress. Findings included: 1.Record review of a face sheet dated 5/29/2024 for Resident #15 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of acute respiratory failure (lungs cannot release enough oxygen into the blood), Parkinson's disease (a chronic disorder that causes difficulty moving, tremors, and stiffness), COPD (a group of lung disease…

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

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the only kitchen. Temperature logs for the dishwasher, refrigerator 1, refrigerator 2, freezer 1, and freezer 2 were missing recorded temperatures. This failure could place residents who ate from the kitchen at risk of foodborne illness. Findings included: During an observation on 5/28/2024 at 9:20 AM, temperature log located at the dishwashing station with May 2024 on top of page had temperature checks missing from 05/20/2024 thru 05/27/2024. Temperature logs with May 2024 at heading for freezer 1 had recorded temperatures missing for 05/13/2024 thru 05/25/204, freezer 2 missing recorded temperatures for 05/14/2024 thru 05/25/2024, refrigerator 1 recorded temperatures missing for 05/14/2024 thru 05/25/2024, and refrigerator 2 recorded temperatures missing for 05/14/2024 thru 05/27/2024. During a record review of temperature logs dating from January 2024 thru April 2024, no missing recorded temperatures noted. During an interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #116) and 3 of 8 staff (MDS nurse, CNA E, and CNA F) reviewed for infection control. MDS nurse failed to perform hand hygiene between residents during noon meal service on 5/28/2024. CNA E and CNA F failed to follow enhanced barrier precautions (EBP) when they provided foley catheter (a tube inserted into the bladder) care and incontinent care to Resident #116 on 5/28/2024. These failures could place residents at risk of exposure to communicable diseases and infections. Findings included: 1.During an observation on 05/28/24 at 12:15 PM the MDS nurse was observed passing lunch trays in the main dining room. She was observed handling resident wheelchairs and other items in the dining…

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 in a manner and in an environment that promoted resident independence and dignity while dining for one (1) of 24 residents reviewed for meal service. (Resident #53). LVN B stood beside Resident #53 while she assisted the residents to eat. This failure could place residents who need assistance with eating at risk for weight loss and a decreased quality of life. Findings included: Review of the Face Sheet for Resident #53 indicated she was an [AGE] year-old female admitted on [DATE]. She had the following diagnoses: Hyperthyroidism (when the thyroid gland makes too much thyroid hormone), Alzheimer's disease (A type of brain disorder that causes problems with memory, thinking, and behavior), Anxiety disorder (mental illnesses that cause constant fear and worry), Chronic Kidney Disease (a condition where the kidneys gradually lose their ability to properly filter waste), and Hypertension…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review, the facility failed to ensure that the resident was free from physical or chemical restraints imposed for purposes of discipline or convenience and that were not required to treat the resident's medical symptoms for 1 of 10 residents (Resident #54) reviewed for physical restraints. The facility failed to obtain physician order and informed consent for Resident #54 before implementing a position change alarm. This failure could place residents in the facility at risk of decreased quality of life, injury and being subjected to restraints for purposes of convenience or discipline. Findings included: Record review of a facility face sheet dated 5/29/24 for Resident #54 indicated that she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: hypertension (high blood pressure), dementia, and kidney failure. Record review of a quarterly MDS assessment dated [DATE] for Resident #54 indicated that she had a BIMS score of 6, which indicated 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 interviews and record review, the facility failed to refer all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change of condition for 1 of 6 Residents (Resident #32) reviewed for PASSAR (Preadmission Screening and Resident Review Services). The facility failed to ensure Resident #32 had a new level 1 PASSAR completed with a new diagnosis of Post-Traumatic Stress Disorder (a mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback, and avoidance of similar situations) and major depressive disorder (persistent feeling of sadness and loss of interest that interferes with daily life). These failures could place residents at risk of not receiving the needed PASSAR services to meet their individual needs and could result in a decreased quality of life. The findings were: Record review of a face…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 2 of 8 residents (Resident #48 and #64) reviewed for baseline care plans. The facility failed to complete a baseline care plan within 48 hours of admission on Resident # 48 and provide a care plan summary to the resident or representative. The facility failed to complete a baseline care plan within 48 hours of admission on Resident # 64 and provide a care plan summary to the resident or representative. These failures could place residents at risk of not receiving correct and/or necessary care or treatment. Findings included: 1. Record review of a facility face sheet indicated Resident # 48 was a [AGE] year-old male and admitted to the facility on [DATE] with diagnosis of end stage heart failure. Record review of a quarterly MDS assessment…

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

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assures the accurate acquiring, receiving, dispensing, and administering of medications for 1 of 1 medication rooms reviewed for medication administration. The facility failed to dispose of expired medications from the medication storage room. These failures could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications, decreased quality of life, and hospitalization. Findings included: During an observation in the medication room on 5/29/2024 at 12:10 PM with MA C revealed the following: * 2 bottles of enteric coated aspirin with an expiration date of 4/24. During an interview on 5/29/2024 at 12:20 PM, MA C said she had been employed at the facility for 12 years. She said all nursing staff and medication aides were responsible for checking the medications and ensuring there were no expired medications stored in the medication room. She said she checked the medication room when she could. She…

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

Based on observations and interviews the facility failed to provide food that was palatable, and at a safe and appetizing temperature for residents interviewed for food temperature and taste. (Resident #168) The facility failed to serve hot and palatable foods. Resident #168 complained the food was served cold and did not taste good. These failures could place residents at risk for weight loss, altered nutritional status, and diminished quality of life. Findings included: During an interview on 05/28/2024 at 09:24 AM, Resident #168 said the food was served cold. Resident #168 eats in his room . During an observation on 05/29/2024, of the last meal cart for the residents that dine in their room left the kitchen at 12:55 PM and the test tray was served at 1:01 PM. The regular tray consisted of fettuccine alfredo with chicken, green beans, and mashed potatoes with gravy. The foods were bland and cool. The pork roast was cool and had small amount of chicken present. The green beans and mashed potatoes were cool. All food items were served cool. The dietary manager was present 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, interviews, and record review, the facility failed to be equipped to allow residents to call for staff through a communication system which relayed the call directly to a centralized staff work area for 2 of 12 residents reviewed for call lights. (Residents #44 & #55). The facility failed to ensure Resident #44's and Resident #55's emergency call lights in the bathroom were reachable from the floor. This failure could place residents at risk of injury, pain, hospitalization, and a diminished quality of life. Findings included: Record review of a facility face sheet dated 5/29/24 for Resident #44 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including dementia and history of falling. Record review of a quarterly MDS assessment dated [DATE] fore Resident #44 indicated that she had a BIMS score of 9 which indicated that she had moderate cognitive impairment. Section GG (Functional Abilities and Goals) indicated that she required supervision…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 3 medication carts (nurse cart 100 hall) and the medication storage room reviewed for labeling and storage. 1. The facility failed to remove expired insulin and glucose control solutions (high and low solutions) from the nurse medication cart on hall 100. 2. The facility failed to label and remove expired Tuberculin (TB) testing solution from the medication room refrigerator. These deficient practices could place residents at risk for improper glucose monitoring and could result in residents not receiving the intended therapeutic effects of their medications causing a health decline. Findings include: Record Review of physician order summary dated 3/27/23 reflected Resident #6 was an [AGE] year-old…

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 food was stored, prepared, and distributed under sanitary conditions in 1 of 1 kitchen reviewed for kitchen sanitation. Cook D had hair hanging out of the back of her hair net while washing dishes. The inside bin of the ice maker was dirty. Cook E laid the spoon used for stirring the pureed meat, on the three-compartment sink drainboard, then picked it up and continued to use it. These failures could place the residents at risk of foodborne illnesses. Findings include: During an observation and interview on 03/27/23 at 08:50 a.m., [NAME] D was washing dishes at the dish machine and her hair was hanging out of the back of her hair net. [NAME] D said she had worked at the facility since August 2022 and the previous Dietary Manager had taught her how to wear a hairnet. She said she was not aware her hair was hanging out of her hairnet in the back. She said not keeping her hair in the hairnet could cause hair to fall out into the food. During an observation and interview on 03/27/23 at 9:10 a.m., a paper…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs for 2 of 15 residents (Residents #14 and #25) reviewed for care plans. The facility failed to ensure Resident #14 and Resident #25's care plans accurately reflected residents' PASRR positive status. This deficient practice could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. Findings include: Record review of facility face sheet dated 03/28/2023 indicated Resident #14 was a [AGE] year-old female admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses iron deficiency anemia (low iron levels in the blood), intellectual disabilities (a condition characterized by significant limitations in both intellectual functioning and adaptive behavior that originates…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as is possible for 1 of 15 residents (Resident #43) reviewed for accident hazards. The facility failed to ensure an aerosol can of air freshener was not sitting on the bedside table of Resident #43's room. Label contained the phrase .KEEP OUT OF REACH OF CHILDREN AND PETS . This failure could place residents with dementia that may wander at risk of injury by ingestion or inhalation. Findings include: Record review of facility face sheet dated 3/29/23 for Resident #43 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: Parkinson's disease (body tremors), psychotic disorder with hallucinations, generalized anxiety disorder, and osteoporosis (decrease in bone density causing fragile bones). Record review of a quarterly MDS dated [DATE] for Resident #43 revealed that resident should not be interviewed for BIMS score due to rarely or never…

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 a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 2 of 13 residents (Residents #16 and #28) reviewed for respiratory care. The facility failed to ensure Residents #16 and #28's nasal cannula tubing on the wheelchair was changed every 7 days and labeled. This deficient practice could place residents at risk of developing respiratory infections and complications. Findings include: 1. Record review of Resident #16's face sheet, dated 03/29/2023, indicated Resident # 16 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included major depressive disorder, cough, and rash. Record review of the admission MDS assessment, dated 03/29/2023, indicated Resident # 16 required oxygen therapy and was cognitively intact with a BIMS of 14. Record review of…

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

Based on observation, interview, and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for the lunch meal on 03/28/23 reviewed for food form and preparation. The facility failed to ensure the pureed turkey, prepared on 03/28/22 for the noon meal, was pureed to a smooth consistency without grainy, fibrous particles in it. This failure could place residents who received pureed or mechanically chopped meat at risk of consuming foods that could cause choking, decrease meal intake, and not having nutritional needs met. Findings included: During an observation and interview on 03/28/23 at 11:45 a.m., [NAME] E was preparing the pureed meat for the lunch meal. She said she had worked at the facility, this time, for a year and a half. She said the previous DM taught her how to puree. [NAME] E said she had two residents in the facility on a pureed diet, but she pureed extra just in case. She placed the turkey slices in the Robot Coupe and added ¼ cup of chicken broth and processed. She then poured the turkey into a serving pan to place…

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 and ensure safe and sanitary storage of residents' food items for 1 of 3 resident personal refrigerators reviewed for food safety (Resident #25). The facility failed to ensure the refrigerator for Resident #25 did not contain expired diced peaches and box of coffee creamer singles. This failure could place resident at risk for food borne illnesses. Findings include: Record review of Resident #25's face sheet, dated 3/28/23 revealed that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: cerebral palsy (a group of disorders that affect movement and muscle tone or posture), severe intellectual disabilities (noticeable motor impairment, severe damage to, or abnormal development of, their central nervous system, and generally having an IQ range of 20 to 34), and quadriplegia (condition in which both the arms and legs are paralyzed and lose normal motor function). During an observation and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to ensure services provided met professional standards of quality for 1 of 18 licensed staff (ADON) reviewed for valid nursing licenses. The facility failed to ensure the ADON's nurse license did not expire as of [DATE]. This failure could place residents at risk for not receiving nursing services by a licensed nurse. The findings include: Record review of a personnel file review for the facility indicated the ADON had been employed at the facility since [DATE] with a LVN nursing license. A copy of the Texas Board of Nursing license verification for ADON indicated her nursing license expired on [DATE]. Record review of a license search on the national licensure and disciplinary database with a report date of [DATE] at 10:34 AM indicated a search of the nursing license for the ADON. The report indicated the ADON's license was delinquent with an expiration date of [DATE]. Record review of the Texas Board of Nursing license verification dated [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 interviews and record reviews, the facility failed to maintain medical records on each resident that were complete and accurate, in accordance with accepted professional standards and practices for 3 of 6 residents (Resident #17, Resident #28 and Resident #38) reviewed for accurate records. The facility failed to ensure Resident #17, Resident #28 and Resident #38's executed (signed by MD and resident representative) Consent for Antipsychotic or Neuroleptic Medication Treatment (Form 3713) was placed in the medical record per facility policy. This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care and risk to safety. The findings included: Record review of Resident #17's order summary dated 3/27/23 revealed Resident #17 was [AGE] years old, was admitted to the facility on [DATE] with diagnosis of psychotic disorder (mental illness), anxiety and depression and received the services of Psychiatry. Resident #17 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.

Based on observation, interview, and record review the facility failed to maintain all mechanical, electrical, and patient care equipment, in safe operating condition, for 1 of 1 stove in the kitchen reviewed for food service. The facility did not ensure the gas stove was in working order. One of six gas stove burners did not light automatically, when the knob was turned. This failure could place residents who eat out of the kitchen at risk for injury and under cooked food. Findings include: During an observation and interview on 03/27/23 at 9:00 a.m. when the DM, turned the knobs on the gas stove, the front right burner did not light from the pilot. The DM then had to use a striker to light the burner. She said they had a work order out on the stove, that it had been that way for a while. She said the owner was trying to get them a new one. During an interview on 03/28/23 at 2:15 PM, the Maintenance Director said he did not have a work order on the stove prior to 03/27/23 when the DM told him the stove burner didn't light when the knob was turned. He said when the DM told him he…

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 be equipped to allow residents to call for staff through a communication system which relays the call directly to a centralized staff work area for 2 of 12 residents reviewed for call lights. (Resident # 30 and Resident #48) The facility failed to ensure Resident #30 and #48's emergency call light in the bathroom would reach the floor. The call light cord was coiled up in a bundle above the support bar. This failure could place residents at risk of injury, pain, hospitalization, and a diminished quality of life. Findings include: 1. Record review of a face sheet for Resident # 20 dated 3/29/2023 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of major depressive disorder (persistent feeling of sadness and loss of interest), dementia (not able to remember, think or make decisions in everyday activities), essential hypertension, and Alzheimer's disease (a disease that destroys memory and 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.