Sunflower Park Health Care

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for 1 of 8 residents (Resident #48) reviewed for PASRR Level I screenings and services.The facility failed to ensure the residents who were identified as PASRR positive on admission were assessed for appropriate services and care coordination in that Resident #48 was never evaluated for PASRR services that she was eligible for.This failure could place residents who had a mental illness at risk of not receiving individualized care, or specialized services to meet their needs. Findings included:Record review of Resident #48's face sheet dated 01/07/2026 revealed a [AGE] year-old female admitted [DATE] with diagnoses to included schizophrenia (a brain disorder causing distorted perceptions, thoughts, and emotions), pulmonary fibrosis (a lung disease where lung tissue becomes scarred, making it hard for oxygen to get into the 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 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 met professional standards of quality care within 48 hours of a resident's admission, including initial goals based on admission orders, physician orders, dietary orders, and social services for 2 of 16 (Resident #5, Resident #59) reviewed for baseline care plans.The facility failed to ensure a baseline care plan was completed within 48 hours from admission for Resident #5 and Resident #59.These failures could place residents at risk of not receiving care and services to meet their needs.The findings were: 1.Record review of Resident #5's face sheet, dated 01/06/2026, revealed Resident #5 was admitted on [DATE], with diagnoses which included: cerebral infarction (a stroke that occurs when blood flow to part of the brain is blocked, causing brain cells to die), anxiety disorder (mental…

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, based on the comprehensive assessment and care plan and the preferences of each resident, activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 2 of 8 residents (Residents #7 and #59) reviewed for activities, in that:1. Resident #7 was not taken to activities after she expressed an interest in them or provided in-room activities.2. Resident #38 was not provided with 1-on-1 activities.This deficient practice could affect residents who received in-room and out-of-room activities, and place them at-risk for lack of stimulation, boredom, and depression.The findings were:1. Record review of Resident #7's face sheet revealed an [AGE] year-old female admitted [DATE] and readmitted [DATE] with diagnoses that included: chronic kidney disease (a long term condition where the kidneys lose their function over time), osteoarthritis ( a degenerative joint disease leading…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 3 (Resident #1) residents reviewed for quality of care. 1. The facility failed to ensure the Treatment Nurse documented accurate skin assessments for Resident #1.2. The facility failed to ensure Resident #1 had was provided treatment for his wound to his great right toe. This failure could place residents at risk for not receiving appropriate care and treatment, a decreased quality of life, and pressure ulcers.Findings included: Record review of Resident #1's face sheet dated 01/06/26 indicated he was an [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses of dementia (condition characterized by progressive loss of intellectual functioning and memory impairment), major depression (a serious mood disorder causing persistent sadness, loss of interest, and life impairment), chronic heart failure(long term…

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 2 of 16 residents (Resident #16, Resident #41) reviewed for accidents and hazards, in that: Resident #16 had an unsecured oxygen cylinder in his room. Resident #41 was utilizing a wheelchair with an unsecured seat backrest resulting in a fall. These deficient practices placed residents at risk for injuries.The findings included: 1. Record review of Resident #16's face sheet dated 01/06/26 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses of fracture of left femur, high blood pressure, diabetes mellitus (disease where the body is unable to make insulin causing high blood sugars), and atrial fibrillation (most common type of irregular heartbeats). Record review of Resident #16's admission MDS assessment dated [DATE] indicated she was able to understand others, and she was able to make herself understood.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents requiring respiratory care were provided such care, consistent with professional standards of practice for 1 of 3 residents reviewed for respiratory care (Residents #26). The facility failed to ensure Resident #26's suction machine yankauer was bagged. The facility failed to ensure Resident #26 had a physician order for the use of the suction machine. The facility failed to ensure Resident #26 had the use of the suction machine included on her care plan. This failure could place residents who require respiratory care at risk for respiratory infections and exacerbation of respiratory disease. Findings Included: Record review of Resident #26's face sheet dated 01/06/26 indicated she was a [AGE] year-old female who re-admitted to the facility on [DATE] with the diagnoses of chronic kidney disease (gradual loss of kidney function to where kidneys cannot filter waste effectively), high blood pressure, and bipolar disorder…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary medications. An unnecessary medication is any medication used: In excessive doses; or for excessive duration; or without adequate monitoring; or without adequate indication for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued for 1 of 8 residents (Resident #41) reviewed for unnecessary medication. The facility failed to ensure Resident #41's protein pump inhibitor (PPI) Omeprazole had been decreased according to pharmacy recommendations and physician's approval. This failure could place residents at risk for adverse drug reactions (unintended, harmful events attributed to the use of medication) and providing medication without physician's knowledge.The findings included: Record review of Resident #41's admission record, dated 01/06/2026, revealed an [AGE] year-old admitted on [DATE] and readmitted on [DATE] with diagnoses that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel, and labeled and dated correctly for 1 of 27 residents (Resident #26) observed for medication storage. 1. The facility failed to ensure Resident #26 did not have a bottle of normal saline, a bottle of wound cleanser spray, a tube of zinc oxide protectant, and 2 tubes of zinc oxide silicone cream (medications used for wound care and barrier cream used for wound prevention) in a mauve basin on top of her personal refrigerator in her room. These failures could place residents at risk for obtaining injury or harm from misuse.Findings include: Record review of Resident #26's face sheet dated [DATE] indicated she was a [AGE] year-old female who re-admitted to the facility on [DATE] with the diagnoses of chronic kidney disease (gradual loss of kidney function to where kidneys cannot filter waste effectively), high blood pressure, and bipolar disorder…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 4 residents (Resident #44) reviewed for hospice services. The facility failed to obtain Resident #44's most current Form 3071 Texas Medicaid Hospice Program Individual Election/Cancellation/Update, Form 3074, Physician Certification of Terminal Illness, Hospice Nurses' Notes, and Hospice Physician Orders. This deficient practice could place residents who receive hospice services at risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. Findings included: Record review of a face sheet dated [DATE] indicated Resident #44 was a [AGE] year-old-male…

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 interviews and record review, the facility failed to ensure each resident was free from abuse, neglect, exploitation, and misappropriation of resident property for 1 of 3 residents (Resident #1), reviewed for drug diversion . The facility failed to prevent the misappropriation of Resident #1's Ondansetron. (Ondansetron is commonly used to prevent nausea and vomiting). This failure could place residents at risk for not receiving their prescribed medications. Findings include: Record review of Resident #1's face sheet, dated 9/30/21, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included Contractures (In pathology, a contracture is a shortening of muscles, tendons, skin, and nearby soft tissues that causes the joints to shorten and become very stiff, preventing normal movement), Dysphagia (Difficulty swallowing foods or liquids, arising from the throat or esophagus, ranging from mild difficulty to complete and painful blockage) and Dementia (a broad term…

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 store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility did not ensure: 1. Food items were labeled and dated. 2. Hair restraints were worn correctly. 3. The juice machine spigot was free from a red/orange gooey substance where the juice was dispersed. 4. Ice scoops were stored in a container. 5. Can opener blade was free from debris. 5. Dietary Manager TT washed her hands after touching her nose. These failures could place residents at risk for foodborne illness. Findings included: During the initial tour observation and interview with Dietary Manager SS on 10/28/24 beginning at 10:26 a.m., the following was revealed: 1. 2 ice scoops was stored on top of the ice machine uncovered. 2. The juice machine spigot with a thick gooey red/orange substance. 3. [NAME] UU and Aide H hairnets were not covering their entire head. There was loose hair sticking…

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 effectively 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 5 of 7 (Resident's #49, #1, #2, #209 and Resident #42) residents and 1 of 1 linen carts reviewed for infection control. 1.The facility failed to ensure CNA C provided proper incontinent care to Resident #49. 2.The facility failed to ensure CNA C wore PPE prior to entering Resident #1's room. 3. The facility failed to ensure LVN A performed hand hygiene after checking blood sugar on Resident #2. 4. The facility failed to ensure CNA K provided proper incontinent care to Resident #209. 5. The facility did not ensure the DON and NA QQ don (on) their PPE prior to entering Resident #42's room. 6. The facility did not ensure Laundry Aide RR covered the clean personal cart while passing out the resident's clothing 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 review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 3 of 4 residents (Resident's #28, #32, #37) reviewed for dignity. 1. The facility failed to ensure Resident #32 was treated with dignity and respect when the Administrator called her big girl on 10/22/24. 2. The facility failed to ensure Resident #32 was treated with dignity and respect when CNA GG and MA HH told her washing her hair was too time consuming on 10/30/24. 3. The facility failed to ensure Resident #37 was treated with dignity and respect when CNA MM told her to shut up. 4. The facility failed to ensure Resident #28 was treated with dignity and respect when CNA MM put pressure on Resident #28 to clean herself and walked out of the room with her pants still pulled down. These failures could place residents at an increased risk of embarrassment and a diminished quality of life. 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 interview and record review, the facility failed to consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life and failed to demonstrate their response and rationale for such response for 16 of 16 confidential residents reviewed for resident council. The facility failed to ensure there was documentation of the facility's efforts to resolve concerns collected at the resident council meetings on 05/22/2024, 06/26/2024, 07/25/2024, 08/29/2024, 09/26/2024, and 10/15/2024. This failure could place residents at risk of not having their concerns and grievances followed through and a diminished quality of life. Findings included: Record review of the Resident Advisory Council Minutes for 05/22/2024 indicated the call lights were not being answered timely. Record review of the Resident Advisory Council Minutes for 06/26/2024 indicated the call lights were not being answered timely. Record review of the Resident Advisory Council Minutes for 07/25/2024 indicated the call lights…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 4 of 23 residents (Resident #9, Resident #30, Resident #42, and Resident #47) reviewed for care plans. 1. The facility failed to ensure a care plan was developed and implemented for Resident #47's in and out self-catheterization (procedure used to empty the bladder by inserting a catheter, small tube, into the bladder to drain urine and immediately removed). 2. The facility failed to ensure Resident #30's care plan reflected her history of trauma. 3. The facility did not ensure that Resident #42's care plan included treatment for a wound on the right medial (toward the middle or center) thigh, which required wound care three times per week. The facility did not ensure that Resident #42's care plan included treatment for wound on the right distal (away from the center 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 interview and record review, 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 completed a training course approved by the State for 1 of 1 facility reviewed for Activity Director qualifications. The facility did not ensure the Activity Director was qualified to serve as the director of the activities program. This failure could place residents at risk of not receiving a program of activities that meets their assessed activity needs. Findings include: Record review of a Personnel File Review Sheet, undated, indicated the Activity Director was hired on 10/14/2024. During an interview on 10/29/2024 at 12:12 PM, the Activity Director said she started as the activity director on 10/17/2024, and she was not certified. The Activity Director said the Administrator had given her six months to obtain her activities certification. The Activity Director said Medical Records, the DON and ADON had been helping her schedule activities, but they were not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to establish a system of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and determine that drug records are in order and that an account of all controlled drugs were maintained and periodically reconciled for 1 of 1 storage area reviewed for expired and discontinued medications. The facility failed to keep a record of the receipt of controlled medications awaiting disposition to allow accurate and periodic reconciliation. This failure could place residents at risk for loss of prescribed medications and drug diversion. Findings included: During an observation and interview on [DATE] at 3:47 p.m., the following unlogged medications were observed in the controlled medications storage area waiting to be disposed of: *Morphine/Diazepam supp 10mg/10mls-12 Supp, *Diazepam 5mg/0.5ml - 30 tablets, *Diazepam gel 10mg/1ml - 10 syringes, *Diazepam 5mg/0.5ml - 7 syringes, *Hydrocodone/APAP 7.5/325mg…

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 ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 2 of 5 medication carts (Treatment Cart and Hall C Nurse Cart) and 1 of 1 medication room refrigerator reviewed for drugs and biologicals. 1. The facility failed to ensure the Treatment Nurse secured the facilities only treatment cart. 2. The facility failed to ensure Resident #12's Humalog (fast-acting insulin to control high blood sugar) insulin was dated when opened on Hall C's nurse cart. 3. The facility failed to ensure Resident #4's Lantus (Long-acting insulin that regulates blood sugar levels at a stable rate throughout the day) was dated when opened on Hall C's nurse cart. 4. The facility failed to ensure Resident # 14's Combivent Respimat inhaler (which is used to prevent bronchospasm (tightening and narrowing of the airways) in people with chronic obstructive pulmonary, was dated when opened on Hall C's nurse cart. 5. The facility failed to ensure Resident # 9's Albuterol…

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, attractive, and at a safe and appetizing temperature for 16 of 16 confidential residents reviewed for food and nutrition services. The facility failed to ensure dietary staff provided food that was palatable and had an appetizing temperature on 10/29/24. This failure could place residents at risk of decreased food intake, hunger, and unwanted weight loss. Findings included: During a confidential resident group meeting 16 residents stated the food was bland and always cold. During an observation and interview on 10/29/24 at 11:59 a.m., the lunch tray was sampled by Dietary Manager SS and four surveyors. The sampled tray consisted of buttered noodles, which were lukewarm, carrots which were cool, and pork shank which tasted lukewarm. Dietary Manager SS stated the buttered noodles and pork shank tasted lukewarm and the carrots were cool. Dietary Manager SS puckered his lip when he tasted the honey roll, he stated the roll had a vinegary taste. During an interview on 10/31/24 at 2:55 p.m.,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure assessments accurately reflected the resident status for 1 of 23 residents (Resident # 47) reviewed for MDS assessment accuracy. The facility failed to ensure Resident # 47's in and out self-catheterization (procedure used to empty the bladder by inserting a catheter, small tube, into the bladder to drain urine and immediately removed) was coded accurately on the Quarterly MDS Assessment with an ARD of 08/01/2024. These failures could place residents at risk for not receiving care and services to meet their needs. Findings included: Record review of a face sheet dated 10/20/2024 indicated Resident #47 was a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included lumbar spina bifida without hydrocephalus (birth disorder involves the incomplete development of the spine), hemiplegia (one-sided paralysis or weakness), paraplegia (paralysis of the legs and lower body caused by 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 residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 2 of 23 residents (Resident #42 and Resident #51) reviewed for quality of care. 1. The facility did not ensure that LVN A and LVN OO followed physician orders for wound care on Resident #42's right distal (away from the center of the body) medial (toward the middle or center) calf. 2. The facility failed to ensure CNA N and Student NA Z reported to the charge nurse after Resident #51 had an unwitnessed fall on 10/16/24. This failure could place residents at risk for decreased quality of care and injury. Findings included: 1. Record review of Resident #42's face sheet, dated 10/30/24, indicated Resident #42 was originally admitted to the facility on [DATE] with diagnoses which included PVD (narrowed blood vessels reduce blood flow to the limbs) and infection…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of the bladder and had an indwelling urinary catheter received appropriate treatment and services for 1 of 2 residents (Resident #47) reviewed for urinary catheters. The facility failed to ensure Resident #47 was provided proper supplies to perform in and out self-catheterization (procedure used to empty the bladder by inserting a catheter, small tube, into the bladder to drain urine and immediately removed). This failure could place residents at risk of urinary tract infections and a decreased quality of life. Findings included: Record review of a face sheet dated 10/20/2024 indicated Resident #47 was a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included lumbar spina bifida without hydrocephalus (birth disorder involves the incomplete development of the spine), hemiplegia (one-sided paralysis or weakness), paraplegia (paralysis 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 observation, interview, and record review, the facility failed to ensure that licensed staff were able to demonstrate the specific competencies and skill sets necessary to care for resident's needs for 1 of 5 staff (CNA K) reviewed for competencies. The facility failed to ensure CNA K was competent in infection control and providing incontinent care on 10/29/2024. This failure could potentially affect residents by placing them at an increased and unnecessary risk of exposure to staff who lack the appropriate skills and competencies to provide safe care and minimize infections. Findings included: Record review of a face sheet dated 10/30/2024 indicated Resident #209 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included malignant neoplasm of unspecified ovary (ovarian cancer) and chronic obstructive pulmonary disease (chronic inflammatory lung condition that affects the respiratory system). Record review of Resident #209's electronic medical record on 10/30/2024…

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 it was free from a medication error rate of 5 percent or greater. The facility had a medication error rate of 5.26 %, based on 2 errors out of 38 opportunities, which involved 2 of 4 residents (Resident #12 and #2) reviewed for medication administration. 1. The facility failed to ensure LVN B administered insulin correctly for Resident #12. 2. The facility failed to ensure LVN A administered insulin correctly for Resident #2. These failures could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders. Findings included: Record review of Resident #12's face sheet dated 10/31/24, indicated a [AGE] year old female who admitted to the facility on [DATE] with diagnoses which included congestive heart failure (a serious condition that occurs when the heart can't pump enough blood to meet the body's needs), diabetes mellitus type 2 (also…

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 laboratory services were obtained to meet the needs of 2 of 8 residents (Resident #9 and Resident #49) reviewed for laboratory services. 1. The facility did not obtain a physician's ordered A1C (used to measure average blood sugar over the past three months) for Resident #9. 2. The facility failed to ensure Resident #49's potassium level (Potassium is a mineral and electrolyte that helps maintain the body's water and electrolyte balance. It is also important for nerve and muscle function) was drawn on 07/23/24. These failures could place residents at risk of not receiving lab services as ordered and not managing medications at a therapeutic level. Findings included: 1. Record review of Resident #9's face sheet, dated 10/30/24, indicated Resident #9 was originally admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar) with diabetic…

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 liquids consistent with the resident's needs, for 2 of 3 (Resident #49 and Resident #44) residents reviewed for liquid inconsistency, in that: 1. The facility failed to ensure staff served Resident #49 nectar-thickened tea during her lunch meal on 10/28/24. 2. The facility failed to ensure LVN D checked the lunch tray appropriately for Resident #44 who required nectar thick liquids. This failure could place residents who have dysphagia at risk for aspiration. Findings included: 1.Record review of Resident #49' face sheet dated 10/31/24, indicated a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included Angelman syndrome (a genetic disorder that mainly affects the nervous system), protein-calorie malnutrition (protein calorie deficiency), severe intellectual disabilities (neurodevelopmental condition that affects cognitive and adaptive functioning, and begins before age [AGE]), eating disorder,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received therapeutic diets that were prescribed by the attending physician for 1 of 3 residents (Resident #49) reviewed for therapeutic diets. The facility did not ensure Resident #49 was given fortified food as ordered by the physician. This failure could place residents at risk for poor intake, weight loss, unmet nutritional needs, and a loss of dignity. Findings Included: Record review of Resident #49' face sheet dated 10/31/24, indicated a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included Angelman syndrome (a genetic disorder that mainly affects the nervous system), protein-calorie malnutrition (protein calorie deficiency), severe intellectual disabilities (neurodevelopmental condition that affects cognitive and adaptive functioning, and begins before age [AGE]), eating disorder, intermittent explosive disorder (impulse-control disorder characterized by sudden episodes of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure residents could call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside for 1 of 8 residents (Resident #1) reviewed for the ability to call for staff assistance. The facility failed to ensure Resident #1 had a call button. This failure could place resident at risk for a delay in assistance and decreased quality of life, self-worth, and dignity. Findings included: Record review of Resident #1's face sheet, dated 10/31/24 indicated Resident #1 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included seizures, Basal Cell Carcinoma (the most common form of skin cancer), Contractures of the left hand, and Dementia (memory loss). Record review of Resident #1's annual MDS assessment, dated 09/20/24, indicated that she was rarely understood and rarely understood by others. Resident #1 had…

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 follow their own established smoking policy for the facility's only smoking area and 1 of 7 residents (Resident #37) reviewed for smoking policies. 1. The facility failed to ensure Resident #37 wore a smoking apron during a supervised smoking break on 10/28/24. 2. The facility failed to ensure the smoking area was free of combustible materials on 10/28/24. These failures could place residents at risk of an unsafe smoking environment. The findings included: 1. Record review of the face sheet dated 10/31/24, reflected Resident #37 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of cerebrovascular disease (disorder that affect blood flow to the brain), Alzheimer's (a disease that destroys brain cells, causing a gradual decline in memory, thinking, and behavior), major depressive disorder (persistent feeling of sadness and loss of interest), and need for assistance with personal care. Record review 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 interview and record review the facility failed to ensure residents formulated an advance directive for 1 of 15 residents (Resident #16) reviewed for advanced directives. The facility did not ensure Resident #16's chart reflected the hospice OOH-DNR that was dated[DATE]. This failure could place residents at risk of not receiving care and services to meet their needs. The findings included: Record review of Resident #16's face sheet, dated [DATE], indicated Resident #16 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs), major depression (loss of interest in activities) and osteoarthritis (flexible tissue at the end of bones wear down). Resident #16's face sheet indicated he was a full code. Record review of Resident #16's order summary report, dated 1215/2021, indicated Resident #16 was a full code. Record review of the quarterly MDS dated [DATE], indicated Resident #16…

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 an accurate MDS was completed for 1 of 15 residents (Residents #16) reviewed for MDS assessment accuracy. The facility failed to accurately code the ostomy status on Resident #16. This failure could place residents at risk for not receiving care and services to meet their needs. Findings included: Record review of Resident #16's face sheet, dated 09/19/2023, indicated Resident #16 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs), major depression (loss of interest in activities) and osteoarthritis (flexible tissue at the end of bones wear down). Record review of Resident #16's order summary report, dated 1215/2021, indicated Resident #16 had a foley catheter. The order summary did not indicate Resident #16 had an ostomy. Record review of the quarterly MDS dated [DATE], indicated Resident #16 understood others 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 develop, review, and revise a comprehensive care plan of each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 15 residents (Resident #43) reviewed for care plans. The facility failed to ensure Resident #43's care plan was updated and revised to reflect she was on PASRR services. This failure could cause the resident to not receive the correct care impacting the patient's health and/or serious illness. Findings include: Record review of Resident #43's face sheet dated 09/20/23 indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #43 had a diagnoses which included paraplegia (damage to the trunk, legs, and pelvic organs), hydrocephalus (fluid on the brain that causes damage) and lumbar spina bifida without hydrocephalus (spinal cord does not form properly). Record review of Resident #7's Comprehensive MDS dated [DATE] indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 15 (Resident #26) residents reviewed for accidents hazards and supervision. The facility failed to properly store wound cleanser leaving it on Resident #26's bedside table. The facility failed to properly store wound cleanser leaving it in Resident #'26's dresser. This failure could place residents at an increased risk for injury. The findings included: Record review of Resident #26's face sheet dated 09/21/2023 revealed, Resident #26 was a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of peripheral vascular disease (plaque buildup in the arteries), lumbago (low back pain) and unspecified diastolic congestive heart failure (heart muscle does not pump enough blood). Record review of Resident #26's Quarterly MDS 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 observation, interview, and record review the facility failed to ensure that a resident who is incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 (Resident #9) of 15 residents reviewed for urinary incontinence. The facility failed to provide timely treatment of Resident #9's Urinary Tract Infection. This failure could place residents with Urinary Tract Infections at increased risk of not receiving appropriate treatment, which could result in severe illness or hospitalization. Findings included: Record review of the undated face sheet indicated Resident #9 was a [AGE] year-old female admitted to the facility on [DATE]. Record review of the physician's orders dated 9/19/23 indicated Resident #9 had with diagnoses that included: Diabetes Mellitus 2 (a chronic condition that affects the way the body processes sugar, the body either does not produce enough insulin, or it resists insulin), Urinary Tract Infection (an infection in the urinary system,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent. There were 4 errors out of 33 opportunities, resulting in an 12% percent medication error involving 2 of 4 residents reviewed for medication administration (Residents #11and #36). MA A failed to verify the dose of eye drops to be administered and administered an inaccurate dose of 2 (two) drops instead of the ordered 1 (one) drop of Dorzolamide/Timolol eye drop solution (used to treat glaucoma by reducing pressure in the eye) to Resident # 36's right eye. MA A failed to administer 3 (three) scheduled medications including Isosorbide (used to prevent chest pain in patients with heart disease), Metformin (used to treat and manage high blood sugar levels), and Latuda (used to treat depression (a mental illness) to Resident #11 as ordered by the physician. These failures could place residents at risk for inaccurate drug administration resulting in a decline in health and decreased quality…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 4 residents (Resident #11) reviewed for significant medication errors, in that: MA A failed to administer 2 scheduled medication, isosorbide mononitrate (to high blood pressure and metformin (to treat high blood sugar). These failures could place the resident at risk of not receiving the therapeutic effect of the mediations and could result in declining health status. for a lower than desired blood pressure and/or pulse. Findings included: Resident #11 Record review of the face sheet dated 09/19/2023 indicated Resident #11 was a [AGE] year-old male who admitted to the facility on [DATE]. His diagnoses included hypertension (elevated/high blood pressure) and diabetes mellitus type 2 (chronic condition that affects the way the body processes blood sugar). During observation and interview on 09/19/2023 at 08:32 AM, MA A administered medications to Resident #11. MA 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 interview and record review facility failed to promptly notify the physician of laboratory results 1 of 15 residents reviewed for laboratory services (Resident #9). The facility did not notify Resident #9's physician about the results of her urinalysis. This failure could place residents with infections at risk of a delay in medical evaluation and treatment. Findings included: Record review of the undated face sheet indicated Resident #9 was a [AGE] year-old female admitted to the facility on [DATE]. Record review of the physician's orders dated 9/19/23 indicated Resident #9 had with diagnoses that included: Diabetes Mellitus 2 (a chronic condition that affects the way the body processes sugar, the body either does not produce enough insulin, or it resists insulin), Urinary Tract Infection (an infection in the urinary system, kidneys, bladder, or urethra), quadriplegia (a symptom of paralysis that affects a person's limbs and body from the neck down), dementia (impairment in memory and judgement). The…

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

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure food items were dated and labeled. These failures could place residents at risk for foodborne illness. Findings include: During an observation and interview with the Dietary Manager of the refrigerators on 09/18/2023 starting at 8:32 AM revealed 6 cartons of strawberries with no date, 3 cartons of mixed fruit with no label or date, a white container labeled chili beans dated 9/10/23 and the Dietary Manager stated it was peanut butter and jelly, and 1 bag of ham with no label or date. During an interview on 09-19-23 at 12:13 PM, the Dietary Manager stated whoever puts away the food items were responsible for dating and labeling the items. The Dietary Manager stated he was responsible for checking the refrigerator and freezer daily and making sure the items were labeled and dated. The Dietary Manger stated he does not work on the weekends, and it was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 2 of 3 residents (Resident #16 and Resident #28) reviewed for hospice services. The facility did not ensure Resident #16's hospice records were a part of their records in the facility. The facility did not ensure Resident #28's hospice records were a part of their records in the facility. The facility did not ensure Resident #16 had a physician order for hospice. This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. The findings included: 1.Record review of Resident #16's…

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