Paradigm at Katy

Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 6 residents (Resident #71) reviewed for pharmacy services. -Resident #71 had Ipratropium .02% solution with 22 plastic vials (respiratory treatment), Ipratropium .02% nebulizer solution with 15 plastic vials, and Budesonide inhalation (respiratory treatment for Crohn's and asthma) suspension of .5mg/ml in medication cart A, even though Resident #71 had discharged from the facility. The failure of not disposing of discharged residents' medications could potentially cause a decline in their health condition and further injury if they were accidentally administered another resident's medication. Findings included: Observation on 5/1/2025 at 11:49 am of LVN G on Cart A, revealed Resident #71 had medications labelled Ipratropium .02% solution with 22 plastic vials, Ipratropium .02% nebulizer solution with 15…

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 label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 2 carts (Cart B) reviewed for medication labelling. - LVN V's cart (cart B) had one undated Lidocaine vial (used to treat pain) with injection marks in the seal. These failures could cause medications to be given past their expiration date, potentially leading to ineffective therapeutic effect. Findings included: Observation of LVN V's medication cart B on 5/1/25 at 11:27am, revealed there was one bottle labelled Lidocaine Hydrochloride injection 88 1/0 with injection marks on the seal with no date on it. In an interview with LVN V on 5/1/2025 at 11:27am, she said if she had opened and used the Lidocaine vial she would have taken it out from the cardboard box, and written the date on the side before using it. She was not the person who opened it. In an interview on 5/1/2025 at 11:34pm…

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 dispose of garbage and refuse properly for 1 of 1 facility dumpsters observed for proper garbage disposal -Dumpster A's side door was observed open with trash inside on 4/27/2025. This failure could place residents at risk of contact with pests and associated diseases. Findings included: Observation on 4/27/2025 at 1:04pm, revealed the left-side sliding door Dumpster A was open. The dumpster appeared half-full of trash inside. In an interview on 4/27/2025 at 1:04pm with the DS, she saw the side door was open and slid it closed. She said it should have been closed. She said all the departments used that dumpster. If it was left open, animals and pests could get into it. In an interview on 4/27/2025 at 3:04pm with the DM, she said the dumpster should not be left open. A potential risk to the facility and residents from leaving the dumpster door open would be in attracting rodents from overflow, or people can get in it. In an interview on 4/28/2025 at 4:10pm with the HK Supervisor, she said housekeeping staff…

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 2 (Resident #19 and Resident #13) of 14 residents reviewed for infection control. - The facility failed to ensure Resident #19 foley catheter tubing was off the floor. - The facility failed to ensure Resident #19's floor mat was free from his foley catheter tubing. - - Resident #13's room had two bottles of hair products with other resident's names on them on the dresser on [DATE]. These failures placed residents, staff and visitors at risk for cross contamination, unwanted infections, and decease in quality of life. Findings: Resident #19: Record of Resident #19's Facesheet revealed he was a [AGE] year-old male who readmitted on [DATE] with diagnosis that included but were not limited to functional quadriplegia (complete…

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 adequate supervision to prevent accidents for 1 of 6 (Resient #1) reviewed for supervision in that: -The facility failed to ensure CNA A did not improperly reposition Resident #1 by pulling his arm on 03/24/25. This failure could place residents at risk of being injured, bruised, or have fractured limbs . Findings Include: Record review of Resident #1's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included acute and chronic respiratory failure (when the lungs cannot properly exchange gases, causing abnormal levels of oxygen and carbon dioxide in the blood), end stage renal disease (a condition in which the kidneys lose the ability to remove waste and balance fluids), tracheostomy (a surgical procedure where an opening is created in the neck to allow air to enter), essential hypertension (a chronic disease that cause abnormal high blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to 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 met professional standards of quality care for 1 of 10 residents (CR #1) reviewed for comprehensive Person-Centered Care Planning. The facility failed to develop a baseline care plan for CR #1 that addressed his communication status/needs, tracheostomy/ventilator status/needs, and his nighttime anxiety. This failure placed newly admitted residents at risk of not receiving the care and services specific to their needs. Findings include: Record review of CR #1's face sheet dated 09/10/2024 revealed he was an [AGE] year-old male who was admitted to the facility on [DATE]. CR #1 was diagnosed with non-pressure chronic ulcer (a non-healing wound) of the skin, acute and chronic respiratory failure with hypoxia (absence of enough oxygen in the tissues to sustain bodily functions),…

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

Based on interview and record review, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of all r esidents reviewed. -The Administrator failed to ensure the staff had gloves readily available to staff to provide care for the residents. This failure could cause residents not to receive care or delay of care resulting in an increase in infections and hygiene concerns . Findings include: In an interview on 7/19/24 at 10:00 a.m., the Central Supply Supervisor stated she ordered supplies every Monday and Wednesday. She stated she started working at the facility 4 months ago in March 2024 and the supply closets were full. She stated she was not having any problems with contracts for PPE. The Central Supply Supervisor stated she had a contract with Company C and she had no problems with her contracts with them. She stated she ordered supplies on Mondays and received supplies on Tuesdays. She stated for the storm they got notified 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.

Based on interview and record review the facility failed to have evidence that all alleged violations were thoroughly investigated and reported the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation was verified appropriate corrective action was taken for 6 of 6 Residents (Resident #7, #8, #9, #10, #11, #12) reviewed for allegations involving abuse, physical environment, and infection control. 1. The facility failed to complete a Provider Investigation Report for 3 of 3 intakes involving Resident #7, #8, #9, #10, #11, #12. These failures could place residents at risk for abuse, injury, and a diminished quality of life. Findings include: Record review of the facility Provider Investigation Reports reflected the facility did not have a PIR for Intake #493566, #503304 and #503492. Record review of TULIP (Texas Unified License Information Portal) system on 5/21/24 reflected the facility…

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 who needed respiratory care, including tracheotomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the 'residents' goals and preferences for one of two residents (Resident #1) reviewed for tracheotomy care. 1. The facility failed to ensure sterile technique when Resident #1 changed her inner cannula on 05/15/24. 2. The facility failed to ensure Resident #1's MD was notified Resident #1 changed her inner cannula on 05/15/24, per facility policy. These failures could place residents at risk for respiratory infections, hospitalizations, and a decline in overall quality of life. Findings include: Record review of Resident #1's face sheet, dated 05/23/24, reflected a female who was admitted to the facility on [DATE] with diagnoses which included Acute and Chronic Respiratory Failure with Hypoxia (not enough oxygen in 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 all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 3 call light systems (call light #2) reviewed in 1 of 2 shower rooms reviewed. The facility failed to ensure that call light #2 in shower room [ROOM NUMBER] was maintained in safe operating condition. These failures could place residents at risk of not receiving emergency care in a timely manner and at risk for fire emergencies. Findings include: The findings included: Record review of Resident #1's face sheet dated 04/25/2024 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including acute and chronic respiratory failure (difficulty breathing), polyneuropathy (nerve damage causing sensory malfunction), restless legs syndrome (irresistible urge to move legs), muscle weakness, encounter for attention to tracheostomy (procedure to assist with air reaching lungs through…

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 adequately equipped to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member or a centralized staff work area for 1 of 3 call light systems (call light #2) in 1 of 3 (shower stall #2) in 1 of 2 shower rooms (shower room [ROOM NUMBER]) reviewed for call lights. The facility failed to ensure shower stall #2's emergency call light system in shower room [ROOM NUMBER] had a cord enabling it to be reachable from the floor. The facility failed to ensure that call light #2 in shower room [ROOM NUMBER] was maintained in safe operating condition. This failure could place residents at risk of injury, pain, hospitalization, and a diminished quality of life. Findings included: Record review of Resident #1's face sheet dated 04/25/2024 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including acute and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for one of four resident halls (200-Hall) reviewed for resident call systems. The facility failed to ensure that the rooms on the 200-Hall had working call lights in the restrooms. This failure could place residents at risk of not being able to have their needs met and call for staff assistance when they needed it. Findings included: Observation on 4/6/2024 at 9:35 AM of the call light in the restroom of room [ROOM NUMBER] revealed that when the call light notification cord was pulled, the light on the exterior of the room did not activate. The restroom did have a bell attached to the call light pull cord. Observation on 4/6/2024 at 9:38 AM of the call light in the restroom of room [ROOM NUMBER] revealed that when the call light notification cord was pulled, the light on 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 ensure residents who are incontinent of urine received appropriate treatment and services to prevent urinary tract infections for 3 out of 3 residents (Resident #266, Resident #80 and Resident #92) reviewed for Foley catheter care. - The facility failed to ensure Resident # 266's foley catheter bag and privacy bag were not touching the floor while Resident #266 was in bed. - CNA B did not separate Resident #80's labia to clean during incontinent care, clean around the buttocks and did not perform appropriate hand hygiene with glove changes throughout the care. - C.NA E did separate Resident #92's labia to clean and clean the indwelling catheter from insertion site during catheter care in a circular motion and she did not clean the buttocks This deficient practice could place residents at-risk for infection due to improper care practices and decreased quality of life. 1. Record review of Resident #226's face sheet dated 03/13/24 revealed 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 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 2 of 4 medication carts (200 hall medication aide cart, and 400 hall nurse cart) reviewed for medication storage. - The 200-hall medication aide's cart contained the following discontinued medications: Centrum Silver Woman 50 plus, Calcium 200mg, PreserVision AREDS 2, and Garlique 60 capsules. -The 400-hall nurse's cart contained an insulin Lispro injection pen100 units/ML((U - 100)3ml prefilled pen that was not stored in its original packet and did not include the pharmacy label or administration instructions. These failures could place residents at risk of adverse medication reactions. Findings included: During observation on [DATE] at 4:00 p.m., for 200 hall medication aide cart check with MA F…

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 who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain nutrition, grooming and personal and oral hygiene for 1 of 5 residents (Resident #47) reviewed for ADLs. 1. The facility failed to ensure Resident #47 was provided personal grooming (fingernail care) by facility staff. This failure could place residents at risk for discomfort, and dignity issues. Findings included: 1. Record review of Resident #47's face sheet dated 03/14/24 revealed a [AGE] year-old female admitted to the facility initially on 06/16/23 and readmitted on [DATE]. Resident #47 had diagnoses which included: diabetes mellitus (the body does not control the amount of glucose in the blood), pleural effusion (fluid collection between the thin layers of the lung and the wall of the chest cavity), and tracheostomy (a hole that a surgeons make through the front of the neck and into the windpipe) Record review…

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 1 of 1 Activity Director (AD) reviewed, 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: Observation on 03/12/2024 at 09:20 a.m., Activities Aide (AA A) entered rooms on the 200 hall encouraging residents to come to the dining room for coffee. During an interview with the AA A on 03/12/2024 at 01:53 p.m., AA A stated she had only worked at the facility for just over a week. She stated she had been an AA A for an assistant living facility (ALF). She stated she was unsure if she wanted to obtain an AD certification as this was her first…

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 with limited range of motion received appropriate treatment and services to prevent a decline in range of motion for 1 (Resident #80) of 3 residents. The facility failed to ensure Resident #80 had interventions in place for her right- hand contracture (A permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen and a decrease in ROM ( Range of motion) to prevent further decline of the range of motion in her right hand. This deficient practice placed residents with contractures at risk for decrease in mobility, range of motion, and could contribute to worsening of contractures. Findings Include: Review of Resident #80's face sheet dated 03/03/2024, reflected an [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: anoxic brain damage ( caused by a complete lack of oxygen to the brain), personal history of pulmonary embolism (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 observation, interview and record review, the facility failed to ensure the resident environment was as free of accident hazards as possible for 1 of 1 activities room reviewed for accident hazards, in that: The facility failed to prevent a long neck lighter from being found in 1 of 1 activities room. These deficient practices could result in residents coming into contact with dangerous materials which could place them at risk of injury or death. The findings were: Observation on 03/14/2024 at 08:01 a.m., revealed a long neck lighter on 1 of 3 bookshelves in the activities room sitting among games, puzzles, books, and crafts. During an interview with the AA A on 03/12/2024 at 01:53 p.m., AA A stated usually about 8 - 10 residents met in the activities room for resident council meeting, and they had met without staff present. During a confidential group meeting on 03/13/2024 at 02:49 p.m., residents indicated that they met monthly for resident council meetings in the activities room. They stated sometimes they met without staff present. They stated that the activities room…

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 the medication error rate was not five percent or greater. The facility had a medication error rate of 16% based on 4 errors out of 25 opportunities, which involved 3 of 8 residents (Resident #20, Resident #16 and Resident #269) reviewed for medication errors. 1-RN A left a substantial amount of acetaminophen/codeine 300mg/30mg and Sucralfate 1 gm on the portion cup after medication was administrated through g tube to Resident #20. 2-LVN C administered stool softener instead of Senna Syrup 8.8mg/5ml give 10 ml, to Resident # 16. 3-LVN D administered Prednisolone acetate drop, suspension 1%, to both eyes instead of one drop to the right eye to Resident #269 This failure could place residents at risk for increased negative side effects, and a decline in health. Findings included: 1 Record review of Resident #20's face sheet dated 03/14/24 revealed a [AGE] year-old male initially admitted on [DATE] and readmitted to the facility…

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 control program designed to prevent the development and transmission of infection for 3 of 8 residents (Resident #16, Resident #92 and Resident #107) observed for infection control. - RN B failed to clean around Resident #92's draining wound bed during sacral wound treatment. - Respiratory Therapy (RT) entered 2 isolation rooms without donning PPE. Resident #16 and Resident #107 This failure could place the residents at risk for infection. Findings include: Review of Resident #16's face sheet dated 03/01/2024, reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: anoxic brain damage ( caused by a complete lack of oxygen to the brain), seizure (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain), contact isolation due to carbapenem resistant and Serratia marcescen ( multidrug-resistant organisms- start…

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 a safe functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 2 entrance door to the facility by the laundry) The facility failed to ensure that stored 26 soiled biohazard boxes, syringes, insulin syringes, lancets, GTube formula bag outside by laundry services were not accessible to all staffs and visitors. Findings Included: During an observation on 03/13/2024 at 3:01 PM with Infection Preventionist (IP) the following observations were made: Observation outside the laundry room revealed 26 large biohazard boxes and an open trolley with the following items - A Diclofenac sodium topical Gel 1 tube - 2 Insulin syringes- - Open box of 60 mls Syringes - Lancets used to check blood sugar in the box - Novofine Auto cover 30 gm gauze in the box 100 needles - 60 mls (AMSure piston irrigation syringe) open box Lot number ( 2028-10-12) e - 5 GTube pump Ensure formula with flush bag1000ml Interview with IP on 3/13/24 at 4:30 PM she said she did not know who kept the boxes and 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 provide pharmaceutical services that include procedures to ensure accurate acquiring, receiving, dispensing, and administering of all drugs for 1 of 3 residents (CR #1) reviewed for medications. The facility failed to follow Physician's order to only discontinue insulin Lispro for CR #1, but facility discontinued all insulin (NPH and Lispro), leaving CR #1 with no insulin to administer for CR #1 while CR #1 was having high blood sugar for multiple days. The facility failed to notify the physician that CR #1 insulin NPH was discontinued when CR#1 was having high glucose readings for 6 days. CR#1 was sent out to the hospital on [DATE] and died in the hospital on [DATE]. These failures could place the residents in the facility at risk for not receiving needed medications to maintain optimum health, resulting in deterioration in their condition. Findings included: Record review of CR#1's face sheet revealed a [AGE] year-old female initially…

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 a Minimum Data Set (MDS) was electronically completed and transmitted to the CMS System within 14 days after completion for 5 of 22 residents reviewed for MDS transmittal. The facility failed to transmit quarterly MDS assessments for Residents #51, #85, and #72 within 14 days of completion. The facility failed to transmit annual MDS assessments for Residents #65 and #21 within 14 days of completion. This failure could place residents at risk of not having their assessments transmitted timely. Findings included: 1. Record review of the quarterly MDS dated [DATE] revealed Resident #51 was a [AGE] year-old female with an admission date of 4/20/22. Her diagnoses included stroke (occurs when the supply of blood to the brain is reduced or blocked which prevents the brain tissue from receiving oxygen or nutrients); hypertension (high blood pressure), aphasia (difficulty communicating), hemiplegia or hemiparesis (weakness or paralysis of one side 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store drugs and biologicals used in the facility in accordance with currently accepted profession principles and assure that medications were secure and inaccessible to unauthorized staff and residents for 1 of 4 residents reviewed for use of insulin. (Resident #171) The facility failed to ensure 4 insulin pins were safely stored (Rx #'s 6361303, 6378274, 6376764, and 6377867). This failure could place residents at risk of ingestion of medications and/or risk of not receiving their prescribed medications. Findings included: Record review of the face sheet dated 02/01/2023 indicated Resident #171 was a [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses of respiratory failure, stroke, dependence on a ventilator, and loss of voice. Record review of the consolidated physician's orders dated 02/01/2023 indicated Resident #171 had Lantus Solo-star Solution Pen-injector 110 units per milliliter inject 12 units…

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 1 of 20 residents reviewed received reasonable accommodation of needs. (Resident #48) The facility failed to ensure Resident # 48 had a functioning call light. This failure could place residents at risk of injury that could lead to possible falls, major injuries, hospitalization, andfalls and unmet needs. Findings include: Record review of an undated face sheet indicated Resident #48 was an [AGE] year-old female admitted on [DATE] with diagnoses of muscle weakness, lack of coordination, dysphagia, aphonia, cognitive communication deficit, obesity, heart failure, and pain. Record review of the most recent quarterly MDS dated [DATE] indicated Resident #48 was understood and understood others. The MDS revealed Resident #48's BIMs (Brief Interview for Mental Status) score was a 06 indicating moderately impaired cognition. The MDS indicated Resident #48 required supervision with bed mobility, transfers, walking, dressing, eating,…

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

Based on observation, interview, and record review, the facility failed to provide a private space for residents' monthly council meetings for 7 of 7 confidential residents reviewed for resident council. The facility did not provide a private space for resident council meeting. This failure could place residents, who attended resident council meetings, at risk of not being able to voice concerns due to a lack of privacy. Findings included: During a confidential group interview and observation on 01/31/2023 at 10:56 a.m. held in the dining room, seven residents stated the resident council meeting was held in the dining room most of the time. The residents stated they do not have a private room since some of them have ventilators and extra equipment were needed. One resident said medications were brought to them, vital signs were taken and at times blood draws were obtained during the meeting. The residents stated they would like a more private area with no care interruptions, unless necessary, for more privacy and the ability to hear one another. During the meeting surveyor observed…

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

Based on interview and record review, the facility failed to secure residents privacy and deliver mail unopened for 3 of 7 confidential residents reviewed for resident rights. The facility failed to ensure residents mail was delivered unopened. This failure could affect all the residents by placing them at risk of a decline in psychosocial well-being and diminished quality of life. Findings included: During a confidential group interview on 01/31/2023 at 10:56 a.m., three of seven confidential residents said they sometimes received their mail opened. They said the mail that was usually opened were the ones containing a check, social security, Medicaid/Medicare information and bank statements. They said they would like to be able to open the mail themselves and if it was something that needed to be provided to the facility then they could provide it. During an interview on 01/31/2023 at 11:51 a.m., the Activity director said the mail was received by the receptionist. The Activity director said the mail was sometimes mistakenly opened by the receptionist thinking it was a check 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 interview and record review the facility failed to ensure an accurate MDS was completed for 1 of 3 residents (Resident #120) reviewed for discharge MDS accuracy. The facility failed to accurately document #120's discharge. This failure could place residents at risk for not receiving needed care and services. Findings included: Record review of a nursing progress note dated 12/04/2022 indicated Resident #120 discharged home with his family at 4:40 p.m. The family requested a preferred home health to be set up by the social worker. Resident #120 was discharged with his belongings. Record review of a Discharge MDS dated [DATE] indicated in Section A2100 indicated Resident #120 discharged to an acute hospital. During an interview on 02/01/2023 at 11:43a.m., RN D indicated she was responsible for the accuracy of the MDS. RN D said the MDS inaccuracy could affect Resident #120 receiving needed community services. During an interview on 02/01/2022 at 2:06 p.m., the Administrator said he expected the MDS to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure respiratory care was provided consistent with professional standards of practice for 2 of 22 residents reviewed for respiratory care. (Resident #72 and Resident #103). The facility failed to provide oxygen concentrator filters for Resident #72. The facility did not ensure Resident #103's oxygen concentrator filter was free from gray like substances. These failures could place residents who required respiratory care at risk for respiratory infections. Findings included: 1. Record review of Resident #72's face sheet dated 02/01/23 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included sepsis (life-threatening complication of an infection), chronic obstructive pulmonary disease (lung disease that block airflow and makes it difficult to breathe), essential hypertension (force of the blood against the artery walls is too high), and hemiplegia and hemiparesis…

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 accurate acquiring, dispensing, receiving, and administering medications for 1 of 5 residents reviewed for pharmacy services (Resident #60). The facility failed to order Gentamicin 80mg IV for a urinary tract infection which resulted in Resident #60 missing 3 doses of a prescribed medications. This failure could place residents at risk for worsening health concerns. Findings included: Record review of the face sheet indicated Resident #60 was a [AGE] year-old male admitted to the facility on [DATE]. The face sheet indicated the resident had diagnoses of dependence of renal dialysis (when one has been depending on a dialysis machine for several months. During dialysis, the blood is detoxified, and excess water removed), dependence of a ventilator (ventilator dependence was defined as the failure to wean the patient from the ventilator while hospitalized in the intensive care unit or respiratory care center, in conjunction with continued use of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide or obtain laboratory services to meet the needs of 1 of 22 residents reviewed for laboratory services. (Resident #2) The facility failed to obtain valproic acid level (level must stay within a specific range for seizure medication to work properly) as ordered for Resident #2. This failure could place residents at risk of not having their medications at a therapeutic level, delays in treatment, and/or deterioration in condition. Findings included: Record review of Resident #2's face sheet dated 02/01/23, indicated he was a [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of seizures, anxiety, dementia with behavioral disturbance (memory loss with behaviors), and major depressive disorder (persistently depressed mood). Record review of Resident #2's quarterly assessment, dated 11/03/22, indicated he was usually understood and usually understood others. The MDS revealed Resident #2 had a BIMS score…

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 1 of 1 resident reviewed for infection control. (Resident #63) The facility failed to ensure CNA G and CNA H performed hand hygiene after changing gloves while providing incontinent care to Resident #63. This failure could place residents at risk for infection due to improper care practices. Findings included: Record review of Resident #63's face sheet, dated 02/01/23, indicated she was a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included type 2 diabetes mellitus (condition that affects the way the body processes blood sugar), heart failure (condition in which the heart does not pump blood as well as it should), anemia (lack of healthy red blood cells), and acute and chronic…

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.