Arbor View Nursing & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were free from significant medication errors for 2 of 2 residents (Residents #8 and #20) reviewed for unnecessary medications. The facility failed to ensure Resident #8 received a hypertension medication based on the physician's order for the specific medication. The facility failed to ensure Resident #20 received a hypertension medication based on the physician's order for parameters for the specific medication (metoprolol). These failures could result in unintended side effects or residents not receiving the intended therapeutic effects of the medication regimen. The findings included: 1.Record review of Resident #8's face sheet, dated 7/23/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included essential hypertension (high blood pressure) and hypertensive heart disease without heart failure. Record review of Resident #8's quarterly MDS, submitted 7/22/2025, reflected a BIMS score of 09,…

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 all drugs and biologicals in locked compartments under proper temperature controls for 2 of 4 medication carts (200 hall medication cart and 300 hall treatment cart) reviewed for medication storage. The facility failed to ensure 2 medications requiring refrigeration (promethazine suppositories and Latanoprost eye drops) were stored in the refrigerator. The facility failed to ensure the 300 hall medication cart was locked when not in use. These failures could lead to residents not receiving the intended therapeutic effects of medication or unintended access to medications and ingestion. The findings were: 1. In an observation of the 200-hall medication cart on 7/24/2025 at 11:35 AM, the medication Latanoprost 0.0005% ophthalmic solution was observed in a drawer. The medication was labeled with a blue sticker that indicated refrigeration was required for storage. A second medication, promethazine 25mg suppositories, was also observed being stored in a drawer with a blue label indicating refrigeration 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 observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 (Resident #69) out of 8 residents reviewed for environmental concerns. Resident #69's window blind was broken, and it could not cover the window fully. This failure could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe. The findings were: Record review of Resident #69's admission record, dated 07/31/2025, revealed the resident was a [AGE] year-old, initially admitted [DATE] and re-admitted to the facility on [DATE] with diagnoses to include insomnia (a common sleep disorder that can make it hard to fall asleep or stay asleep), major depressive disorder, and generalized anxiety disorder. Record review of Resident #69's quarterly MDS assessment, dated 07/17/2025, revealed the resident's BIMS score was 09 out of 15, indicating moderate cognitive…

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

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 must be free from unnecessary drugs without adequate indications for its use for 1 of 3 Resident (Resident #46) whose records were reviewed for unnecessary medications. Resident #46 had an order for a psychotropic medication (Buspirone HCl) without adequate indications for its use. This failure could place residents at risk for adverse drug consequences and receiving unnecessary medications. The findings included: Record review of Resident #46's admission Record, dated 07/25/2025, reflected a [AGE] year-old resident initially admitted on [DATE] with diagnoses which included alcoholic cirrhosis of liver with ascites (advanced scarring of the liver caused by excessive alcohol use) and hepatitis C (an infection caused by a virus that attacks the liver and leads to inflammation). Record review of Resident #46's Quarterly MDS, dated [DATE], reflected Resident #46 had a BIMS score of 7, indicating severe cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to, in response to allegations of abuse or neglect, have evidence that all allegations are thoroughly investigated and to report 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 is verified appropriate corrective action must be taken, for 2 of 5 residents (Residents #23 and #44) investigated for abuse and neglect. The facility failed to investigate an incident of witnessed abuse from Resident #23 on 5/25/25.The facility failed to investigate an incident in which Resident #44 sustained an injury of unknown source on 7/23/25. These failures could lead to abuse and/or neglect of residents and decreased quality of life. The findings included: 1. Record review of Resident #23's face sheet, dated 7/22/2025, reflected a [AGE] year-old female…

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 assessments accurately reflected the residents' status for 2 of 18 residents (Residents #19, #46) reviewed for assessments. The facility failed to ensure Resident #19's MDS accurately reflected the known diagnosis of PTSD.The facility failed to ensure Resident #46's MDS assessment accurately reflected the known diagnoses of depression and anxiety. These failures could place residents at risk of improper or incorrect care and services as necessary for their physical, mental, and psychosocial well-being. The findings included:1.Record review of Resident #19's face sheet, dated 7/22/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included anxiety disorder (excessive worry), vascular dementia (a progressive disorder that impairs thought processes, such as memory, reasoning, and decision making), and post-traumatic stress disorder (a mental health condition resulting from the experience of…

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

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1of 16 Residents (Resident #70) reviewed for comprehensive person-centered care plans. The facility failed to revise Resident #70's comprehensive care plan to reflect the resident's ADL self-care performance. This failure placed all residents at risk of not receiving the care and services to maintain their highest practicable physical, mental, and psychosocial well-being.The findings were: Record review of Resident #70's quarterly MDS assessment, dated 05/25/2025, reflected resident had a BIMS score of 04 out of 15, indicating severely impaired cognition. It reflected Resident #70 needed supervision for eating, partial/moderate assistance for oral hygiene, partial/moderate assistance for toileting hygiene, substantial/maximal assistance for…

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 were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 8 residents (Resident #79) reviewed for personal hygiene. Resident #79 received 1 shower from the time of his admission on [DATE] to 07/24/2025. This failure could place residents who require assistance from staff for personal hygiene at risk of not receiving care and services contributing to overall poor hygiene, risk of experiencing a diminished quality of life, and possible skin infections. The findings included: Record review of Resident #79's admission Record, dated 07/24/2025, reflected a [AGE] year-old resident with an initial admission date of 07/12/2025. No diagnoses were listed on Resident #79's admission Record. Record review of Resident #79's Comprehensive Person-Centered Care Plan, dated 07/24/2025, reflected no interventions or focus areas…

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 respiratory care was provided in accordance with professional standards of practice, the comprehensive care plan, or the residents' goals and preferences for one of one resident reviewed (Resident #69) reviewed for respiratory care. RT P failed to listen to all lobes in Resident #69's lungs prior to the administration of a respiratory medication (albuterol inhaler). This failure placed residents at risk of improper assessment, inaccurate identification of concerns with the respiratory system, and hospitalization. Findings included: Record review of Resident #69's admission Record, dated 7/25/25 reflected a [AGE] year-old female with an original admission date of 06/20/2024 and a current admission date of 11/01/2024. Record review of Resident #69's Diagnosis Report, dated 07/25/2025 reflected diagnoses including other specified interstitial pulmonary disease and unspecified systolic (congestive) heart failure. Record review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that are complete and accurately documented for 2 of 6 residents (Residents #44 and #79) reviewed for clinical documentation and medical records accuracy. 1.The facility failed to ensure Resident #44's skin assessment accurately reflected staples to the resident's forehead 3 days after they were placed. 2.The Electronic Health Record for Resident #79 did not reflect any medical diagnoses. This failure could place residents at risk for incomplete or inaccurate clinical records, which could lead to miscommunication, a delay in services, or a potential decline in the resident's health. The findings included: 1.Record review of Resident #79's admission Record, dated 07/24/2025, reflected a [AGE] year-old resident with an initial admission date of 07/12/2025. No diagnoses were listed on Resident #79's admission Record. Record review of Resident #79's Comprehensive…

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 they established and maintained an infection prevention 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 out of 6 (Residents #46 and #33), reviewed for infection control, in that: 1.LVN N put a pill back in Resident #46's pill cup after it fell into her bare hand and gave them to the resident. 2.CNA O cleaned/wiped Resident #33's penis towards the urinary opening (from dirty to clean) during peri care. These failures placed residents at risk of transmission of communicable diseases and infections, a decline in overall health, and hospitalization. Findings included: 1.Record review of Resident #46's admission Record dated 07/25/2025 reflected a [AGE] year-old female with an admission date of 04/14/2025. Record review of Resident #46's Diagnosis Report dated 07/25/2025 reflected diagnoses including alcoholic…

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 had suitable, nourishing meals and snacks outside of scheduled meal service times for 3 of 4 residents (Resident #1, Resident #3, and Resident #5) reviewed for snacks. The facility failed to ensure Resident #1, Resident #3, and Resident #5 were offered snacks at bedtime as prescribed by the physician. This failure could affect residents who received meals/snacks served from the facility's only kitchen by placing residents at risk for, unplanned weight loss, and inadequate nutrition status. The findings included: 1. Record review of Resident #1's face sheet dated 6/11/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included muscle wasting and atrophy (loss of muscle mass), diabetes with ketoacidosis (condition characterized by high blood glucose levels and elevated levels of ketones in the blood or urine), adult failure to thrive, and limitation of activities due to disability.…

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 clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 3 of 3 residents (Residents #1, #3 and #5) reviewed for accuracy of medical records: 1. The facility failed to ensure Resident #1's prescribed high protein snack order was documented on the TAR as ordered by the physician. 2. The facility failed to ensure Resident #3's prescribed health shake snack order was documented on the TAR as ordered by the physician. 3. The facility failed to ensure Resident #5s prescribed snack order and health shake was documented on the TAR as ordered by the physician. These failures could affect residents whose records are maintained by the facility and could place the residents at risk for errors in care and treatment. The findings included: 1. Record review of Resident #1's face sheet dated 6/11/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with…

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 treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 3 residents reviewed for dignity. The facility failed to ensure Medication Aide A did not enter Resident #1's room in the 300 unit without knocking. This failure could place residents at risk for diminished quality of life, loss of dignity and self-worth. The findings included: Record review of Resident #1's face sheet dated 6/11/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included depression, muscle wasting and atrophy (loss of muscle mass), and limitation of activities due to disability. Record review of Resident #1's most recent quarterly MDS assessment dated [DATE] revealed the resident was moderately cognitively impaired for daily decision-making skills. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 1 of 10 residents (Resident #2) reviewed for accidents and hazards: The facility failed to ensure Resident #2 did not have disposable razors in his room. This failure could place residents at risk of harm or injury and contribute to avoidable accidents and a decline in health. The findings included: Record review of Resident #2's face sheet dated 6/11/25 revealed a [AGE] year old male admitted to the facility on [DATE] with diagnoses that included anxiety disorder (mental health condition characterized by excessive, persistent worry or fear that is difficult to control and interferes with daily life), lack of coordination, difficulty in walking, dementia (general term for a decline in cognitive function that interferes with a person's daily life and activities), and post-traumatic stress disorder (mental health condition that can develop after 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 interview and record review, the facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care, and the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment required for 1 of 1 facility reviewed for qualified dietary staff. 1. The facility failed to ensure the DM had the appropriate certification, education, or qualifications to serve as the Director of Food and Nutrition Services. These deficient practices could place the residents who consume food prepared from the kitchen at risk of food borne illness and not receiving adequate nutrition. The findings included: 1. During an interview on 6/11/25 at 1:14 p.m., the Administrator stated he had hired the DM but was not forthcoming about the DM's required qualifications. During an interview on 6/11/25 at 4:26 p.m., The DM stated she was hired as the Dietary Manager, 2 ½ maybe 3 weeks ago and had experience as 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 interview, and record review the facility failed to employ sufficient staff with the appropriate competencies, skills set and accreditations to carry out the functions of the food and nutrition service department for 1 of 10 kitchen staff (Dietary Aide E) reviewed for qualified dietary staff. The facility failed to ensure the Dietary Aide E met the requirements for food handling by obtaining a current and valid Food Handler's Certificate. This failure could place residents at risk of not having their nutritional needs met and placing them at risk for food born illnesses. The findings included: During an interview on 6/11/25 at 6:33 p.m., Dietary Aide E stated he had worked in the facility for the past 6 months and initially worked as a housekeeper. Dietary Aide E stated he currently worked as the cook in the facility kitchen and did not have his Texas Food Handler's certification because he had not had time to complete the course. Dietary Aide E stated, they (the facility) were just looking for staff to work the kitchen. Dietary Aide E stated he had worked in commercial…

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 maintain medical records that were complete and accurately documented for 2 (Resident #1 and Resident #2) of 20 residents reviewed for clinical records, in that: 1. Resident #1's psychiatric provider notes included diagnoses not listed on the facility's list of diagnoses for the resident. 2. Resident #2's psychiatric provider notes included diagnoses not listed on the facility's list of diagnoses for the resident. These deficient practices could result in in errors in care and treatment. The findings were: 1. Record review of Resident #1's facesheet, dated 02/27/2025, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Alzheimer's disease, Cerebral Infarction and Vascular Dementia Unspecified Severity Without Behavioral Disturbance. Record review of Resident #1's annual MDS, dated [DATE], revealed a BIMS score of 07 which indicated severe cognitive impairment. Record review of Resident #1's care plan, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the residents' right to personal privacy and confidentiality of his or her personal and medical records for 3 of 3 (Resident #1, #2 and #3) residents reviewed for privacy and confidentiality, in that: The facility failed to prevent LVN A from having access and reviewing electronic medical records for Resident #1, #2, and #3's on [DATE] after she was removed from working from the facility on [DATE]. These failures placed residents at risk for having personal medical information disclosed and placed them at risk for misuse of the information. The findings included: Record review of Resident #1's face sheet (undated) revealed an admission date of [DATE] and readmission date of [DATE] with diagnosis which included: unspecified dementia, epilepsy, and hallucinations. Record review of Resident #2's face sheet (undated) revealed an admission date of [DATE] and a readmission date of [DATE] and a discharge date of [DATE] (expired) with…

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 each resident had a right to a dignified existence in a manner and in an environment that promotes enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 4 Residents (Resident #1) reviewed for dignity, in that: The facility failed to ensure a visitor, not related to Resident #1, did not record, and publish a video to social media, that could be taken out of context and in a manner than was distressing for family. This deficient practice could affect dependent residents and their families and contribute to feelings of shame and loss of dignity. The findings included: Record review of Resident #1's face sheet (undated) revealed an admission date of 3/25/2020 and readmission date of 3/14/2023 with diagnosis which included: unspecified dementia, epilepsy, and hallucinations. Record review of Resident #1's quarterly MDS dated 8/12/2024 revealed a BIMS SCORE that could not be assessed because the resident was unable to complete the interview. The assessment 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.

Based on observation, interview, and record review, the facility failed to store, prepare, and distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen observed for food service sanitation, in that: The kitchen was dirty and un-sanitary. This failure could place residents who eat meals from the kitchen at risk for spread of infections, food contamination, and food borne illness. The findings were: Observation on 3/12/24 from 2:30 PM to 3:00 PM of the kitchen revealed there was grease, dirt and debris under the two refrigerators. There was grease, dirt and debris under the ice chest. In the pantry foods were stored of the floor and in sealed containers. There was mice droppings on the floor near a wall adjacent to the pantry. Observations on 3/13/24 at 10:00 AM and 3/14/24 at 9:00 AM revealed the kitchen was closed for cleaning and sanitation. The facility ordered catered meals for the residents both days, 3/13/24 and 3/14/24. During an interview on 3/12/24 at 3:01 PM, the FSS stated that she was hired three weeks ago and had been…

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

Based on observation, interviews, and record review, the facility failed to dispose of garbage and refuse properly for 2 of 3 dumpsters, in that: The drain plug was missing from Dumpsters #1 and #2. This failure could place residents at risk for exposure to germs and diseases carried by vermin and rodents. The finding were: Observation on 3/13/24 at 11:30 AM with the Maintenance Director of the dumpster site revealed 2 out of 3 dumpsters were missing plugs. The dumpster lids were closed. The bottom of the dumpsters had no holes or metal rot. Only one dumpster had one garbage bag. All three dumpsters dumpster had been empty that morning. There were no pests, vermin and/or animals around the dumpster site. During an interview on 3/13/24 at 11:31 AM, the Maintenance Director stated he was hired three weeks ago and had not checked on the dumpster plugs. The Maintenance Director stated that the plugs were necessary so that liquids formed inside the dumpsters did not drip into the environment attracting pests, vermin and/or animals. The Maintenance Director stated that checking 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.

Based on observation, interview and record review, the facility failed to maintain an effective pest control program to keep the facility free of pests for 1 of 1 kitchen in that: Mice and rats were seen in the facility's kitchen in the past. This deficiency practice could affect residents who receive meals from the kitchen and could place them at risk of contracting food borne illnesses. The noncompliance was identified as PNC(past noncompliance). The noncompliance began on 12/29/23 and ended on 2/12/24. The facility had corrected the noncompliance before the survey began. The findings included: Observation on 3/12/24 from 2:30 PM to 3:00 PM of the kitchen revealed there were 13 dried mouse droppings near the pantry area underneath a metal cabinet. Two sticky mouse traps were present on the floor near the pantry. There was a live mouse trap in the ceiling of the kitchen near the ceiling leading to the pantry. As the Maintenance Director removed the ceiling tile near the pantry, five dried vermin droppings fell on a kitchen counter top. There were no fresh droppings in the food…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews a facility must coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort. Coordination includes, Incorporating the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care for 1 of 1 (Resident #1) resident with PASARR recommendations in that: Resident #1 NFSS for therapy services was not submitted timely. The Failures could affect residents with PASSR services and could result in residents not receiving the PASSR recommended services. The findings included: Record review of Resident #1's admission record dated 3/7/2024 was admitted on [DATE], re-admitted on [DATE] with diagnoses of Quadriplegic Cerebral Palsy, Schizophrenia, Severe intellectual disabilities, and Muscle Weakness. Record review of Resident #1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours to the administrator of the facility and to other officials (including to the State Survey Agency) in accordance with State law through established procedures for 7 of 7 residents (Resident #'s 1-7) reviewed for neglect, in that: Resident #'s 1-7 were occupying rooms in 100 Hall (Male Secured Unit) and 200 Hall without functioning HVAC/Heating Systems which resulted in these residents being subjected to enduring cold temperatures during cold winter weather. The facility did not report this to the state agency. This deficiency placed residents at risk for harm by a diminished quality 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, record reviews, and interviews, the facility failed to maintain essential equipment in safe operating condition for 2 of 2 HVAC Heating Units reviewed for safe operating equipment: 1. The HVAC Heating Unit for Hall 100 (Male Secured Unit) was not functioning during cold winter weather 2. The HVAC Heating Unit for Hall 200 was not functioning during cold winter weather This failure placed residents at risk for harm by a diminished quality of life, specifically, sleep deprivation and cold-related injuries (hypothermia). The findings included: Observation on 01/17/24 at 2:15 PM, when entering the facility, revealed it was noticeably cold and residents/staff were still wearing winter clothing (jackets/gloves/scarfs/ski caps) while in the building. Record review of website: Past Weather in [city] Texas, USA - Yesterday or Further Back (timeanddate.com) of the air temperatures for [city], Texas revealed the following air temperatures and corresponding dates for the city this facility was located:…

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 utilize the services of a registered nurse for at least eight consecutive hours per day, seven days per week for 73 days out of 110 (9/1/23 - 9/13/23, 9/19/23 - 9/23/23, 9/27/23 - 10/6/23, 10/10/2023 - 10/12/23, 10/21/23 - 10/30/2023, 11/2/23 - 11/5/23, 11/9/2023 - 11/12/23, 11/17/23 - 11/19/2023, and 11/23/23 - 12/10/23) reviewed for nursing services, in that: The facility did have a registered nurse for at least eight consecutive hours per day, seven days per week on the following dates: 9/1/23 - 9/13/23, 9/19/23 - 9/23/23, 9/27/23 - 10/6/23, 10/10/2023 - 10/12/23, 10/21/23 - 10/30/2023, 11/2/23 - 11/5/23, 11/9/2023 - 11/12/23, 11/17/23 - 11/19/2023, and 11/23/23 - 12/10/23. This deficient practice could place residents at risk of not receiving adequate care. The findings included: Record review of the facility's Daily Nursing Staffing Sheets revealed the following: 9/1/23: 1 RN for the A.M. shift, 0 RNs for the P.M. shift, and 0 RNs for the overnight shift. 9/2/23 - 9/3/23: 0 RN for the A.M. shift, 0 RNs for the 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 observation, interview, and record review, the facility failed to ensure nurses had the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, for 2 out of 9 LVNS (LVN G and LVN H) reviewed for the administration of medications via and caring for a central line. As of 12/08/2023, 2 LVNs (LVN G and LVN H) operated outside their scope of practice by administering medications via Resident #1's PICC. These failures could place residents at risk for adverse outcomes to resident care and/or services and may also include the potential for physical and psychosocial harm. Findings included: Record review of Resident #1's Face Sheet, dated 12/08/23, revealed the resident was admitted on [DATE] with the following diagnosis: Acute hematogenous osteomyelitis (infection in the bone caused by bacteria), left tibia (anterior bone of the lower leg) and fibula…

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 determine that drug records were in order and that an account of all controlled substances was maintained and periodically reconciled for 4 out of 4 (Resident #13, Resident #14, Resident #15, and Resident #16) resident records reviewed in that: The facility failed to ensure the administration and count of controlled substances were reconciled. This deficient practice could affect residents whose records were maintained by the facility and place them at risk for drug diversion. The findings included: Resident #13 Record review of Resident #13's face sheet dated 12/06/2023 revealed the resident was re-admitted on [DATE] with diagnoses that included: Pain and Fibromyalgia (condition defined by widespread pain). Record review of Resident #13's MDS assessment, dated 10/25/2023, revealed the resident had a BIMS score of 9 (suggesting moderate impairment). Record review of Resident #13's care plan dated 7/18/22, revealed Resident is at risk for…

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 all drugs and biologicals were stored in locked compartments in 3 medication carts of 6 medication carts (Nurse's Cart 300-hallway, Treatment Cart 300-hallway, and Treatment Cart 200-hallway) reviewed for medication storage, in that: The facility failed to ensure the Nurse's Cart 300-hallway, Treatment Cart 300-hallway, and Treatment Cart 200-hallway were locked when left unattended in the hallway. This deficient practice could place residents at risk of medication misuse or drug diversion. The findings included: During an observation on 12/06/2023 at 2:02 p.m., the nurse's medication cart on the 300-hallway was unlocked and unattended. There were ambulatory residents in the immediate vicinity and there were no nurses at the nurses' station. CMA B arrived at 2:03 p.m., she locked the cart. During an observation on 12/08/23 at 7:16 a.m., the nurse's medication cart on the 300-hallway was unlocked and unattended. 2 CNAs were at the nurses' station, there were no nurses and there were ambulatory residents…

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 the required abuse training for all employees for 3 of 3 abuse incidents reviewed for abuse training, in that: The facility failed to address allegations of abuse for Resident #s 4, 5, and 3 by in servicing all staff on abuse definition and reporting. This failure could place residents at risk of abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life. Findings included: 1. Record review of Resident #5's Face Sheet, dated 12/08/2023 revealed Resident #5 was an [AGE] year-old male, initially admitted to the facility on [DATE] with diagnoses of dementia (a general term for impaired ability to remember, think, or make decisions), Alzheimer's disease (a progressive disease that affects memory and other important mental functions), and muscle wasting and atrophy (shrinking of muscle or nerve tissue). Record review of Resident #5's MDs, assessment date 09/21/2022 revealed Resident #5 had a BIMS score of 05 and was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that each resident had the right to be free from abuse for 3 of 3 (Resident #3, Resident #4, Resident #5) residents reviewed for abuse. 1. The facility failed to address allegations of abuse for Resident #4 and Resident #5 by in servicing all staff on abuse definition and reporting. 2. Resident #3 was verbally and mentally abused by LVN J. This failure could place residents at risk of abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life. Findings included: 1a. Record review of Resident #5's Face Sheet, dated 12/08/2023 revealed Resident #5 was an [AGE] year-old male, initially admitted to the facility on [DATE] with diagnoses of dementia (a general term for impaired ability to remember, think, or make decisions), Alzheimer's disease (a progressive disease that affects memory and other important mental functions), and muscle wasting and atrophy (shrinking of muscle or nerve tissue). 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure residents were informed before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/Medicaid or by the facility's per diem rate for 3 of 3 (Resident #57, #66, and #138) residents reviewed for Medicare/Medicaid services. 1. Resident #57 was not given a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) and Notice of Medicare Non-Coverage (NOMNC) when discharged from skilled services prior to her covered days being exhausted. 2. Resident #66 was not given a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) and Notice of Medicare Non-Coverage (NOMNC) when discharged from skilled services prior to her covered days being exhausted. 3. Resident #138 was not given a Skilled Nursing Facility Notice of Medicare Non-Coverage (NOMNC) when…

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 service safety for 1 of 1 kitchen, in that: 1. There were two reach-in freezers in the conference room that did not have temperature tracking logs and one freezer did not have a thermometer. 2. There was an opened 5 lb. container of cottage cheese that was past its use by date in the walk-in cooler. 3. There were two boxes of pasta and one box of thickened water on the floor in the dry storage room. 4. [NAME] B had facial hair and was not wearing a facial hair restraint while engaged in food preparation. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: 1. Observation on 04/23/2023 at 10:10 a.m. revealed there were two reach-in chest freezers in the facility's conference room. Neither freezer had a temperature log attached to it or on the wall indicating that the temperatures of the freezers had been recorded daily. Freezer…

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

Based on observation, interviews, and record review, the facility failed to dispose of garbage and refuse properly for 2 of 3 dumpsters (Dumpster #1 and Dumpster #2), in that: Dumpsters #1 and #2 did not have drain plugs for 4 of 4 days, and Dumpster #2 had trash pulled through the drain hole. This could place residents at risk for exposure to germs and diseases carried by vermin and rodents. The findings were: Observation on 4/25/2023 at 1:48 p.m. with [NAME] K revealed there were three Dumpsters, all blue in color, behind the facility. Dumpsters #1 and #2 did not have drain plugs. Observation on 04/25/2023 at 1:50 p.m. revealed Dumpster #2 had a torn trash bag and rag that were pulled from inside the dumpster through the drain hole to the ground outside the Dumpster. The rag was rusted in color and the trash bag was extended approximately 2' outside the dumpster. There was trash inside the trash bag and there were numerous pill bugs (aka roly poly) crawling underneath the trash bag. Interview on 4/25/2023 at 1:51 p.m. with [NAME] K revealed she observed that Dumpster #1 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to treat each resident with respect, dignity, and care for each resident in a manner and in an environment that promotes or maintains their quality of life for 1 of 7 residents (Resident #289) reviewed for dignity in that: Resident #289 was observed in their resident room wearing nothing but a disposable brief. The door to the resident's room was open, and the privacy curtain in front of the resident's bed was open. These failures could affect residents by contributing to poor self-esteem and decreased self-worth. The findings included: Record Review of Resident #289's Face Sheet reflected the resident was a [AGE] year-old male on hospice admitted to the facility on [DATE] with diagnosis that include alcoholic cirrhosis of the liver (chronic liver damage that causes liver failure), Hepatic encephalopathy (loss of brain function due to the liver not removing toxins from the blood), and osteoporosis (condition in which bones become weak 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 provide reasonable accommodation of resident needs and preferences involving the call light; in 1 of 81 residents reviewed for call light , Resident # 288 . Resident #288 had no access to his call light, as he was lying in bed, and the call light was on the floor. This deficient practice could affect 15 residents who used call lights for assistance in maintaining and/or achieving independent functioning, dignity, and well-being. Findings included: Review of Resident # 288's electronic face sheet dated 4/23/23 revealed a [AGE] year-old male admitted on [DATE] with a diagnosis of [Acute Respiratory Distress] when fluid builds up in the tiny, elastic air sacs in the lungs. [Muscle Weakness] Lack of muscle strength. [ Essential Hypertension] abnormally high blood pressure that's not the result of a medical condition. Review of Resident 288's admission MDS dated [DATE] revealed BIMS left blank, indicating resident # 288 could not complete 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 the assessment accurately reflected the resident's status for 2 of 38 residents (Residents #8, #57) whose assessments were reviewed, in that: 1. Resident #8's Annual MDS dated [DATE] incorrectly documented the resident was on an anticoagulant. 2. Resident #57 Quarterly MDS did not have depression listed under active diagnoses. This failure could place residents at-risk for inadequate care due to inaccurate assessments. 1. Review of Resident #8's face sheet dated 4/24/2023 revealed the resident was admitted to the facility on [DATE] and had diagnoses that included vascular dementia (problems with reasoning, judgement, memory and other thought processes caused by brain damage from impaired blood flow to the brain) with behavioral disturbance, mild protein-calorie malnutrition (inadequate of food as a source of protein, calories, and other essential nutrients occurring in the absence of significant inflammation, injury or another condition),…

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 develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's mental, nursing, and psychosocial needs that were identified in the comprehensive assessment, for 2 of 38 Residents (Resident #55 and #57) reviewed for care plans, in that: 1. The facility failed to fully develop a comprehensive person-centered care plan that was specific for Resident #55 to address hospice information, details of hospice care provided and coordination of services. 2. The facility failed to fully develop a comprehensive person-centered care plan that was specific for Resident #57 to address the resident's diagnosis of depression and use of psychotropic medications. These failures could place residents at risk for not getting their medical, physical, and psychosocial needs met and not being provided with the necessary care or services and having…

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 care plan, the physicians' orders, and the residents' choices for 1 of 7 residents (Resident #7) reviewed for quality of care in that: The facility failed to provide Resident #7 with adequate and timely wound care to treat a wound to the resident's stomach. This failure could place residents at risk for not receiving appropriate care and treatment resulting in infection, delayed healing, and diminished quality of life. The findings included: Record Review of Resident #7's face sheet, dated 4/25/2023, reflected Resident #7 was a [AGE] year-old female admitted on [DATE] with diagnosis including Chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), Morbid obesity (excessive body fat that increases the risk of health problems), rash, and cellulitis 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, record review, and interview, the facility failed to ensure residents received proper treatment and assistive devices to maintain hearing abilities for that 1 of 7 residents (Resident #14) reviewed for hearing in that: The facility failed to ensure Resident #14 received appropriate services to assess for maintaining or improving hearing abilities. This failure could affect residents by placing them at risk for unmet needs and diminished quality of life. The findings included: Record review of Resident #14's face sheet dated 4/26/2023 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnosis that included Type 2 diabetes (chronic condition that affects the way the body processes sugar), post-traumatic stress disorder, and dementia (thinking and social symptoms that interfere with daily functioning). Record review of Resident #14 MDS dated [DATE] states Resident #14 can hear with minimal difficulty. Record review of Resident #14's Care Plan with a problem start 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 observations, interviews, and record reviews, the facility failed to ensure incontinent bladder residents received appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible for 2 out of 36 residents reviewed reviewed for indwelling catheters , (Resident # 12 and 41) The facility failed to ensure Resident # 12 and Resident # 41 indwelling catheter was attached to prevent pulling or tugging to the urethra. These failures could place residents at risk for discomfort, urethral trauma (injury to the duct in which urine is transported out of the body from the bladder), and urinary tract infections. Findings included: 1.Record review of Resident's # 12 face sheet dated 4/23/23 revealed an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with the diagnosis of [Dysphagia] Difficulty swallowing. [Dementia] impaired ability to remember, think, or make decisions that interfere with everyday activities. [Hypothyroidism] when…

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 record review, observations, and interviews, the facility failed to ensure residents who use psychotropic drugs, PRN orders for psychotropic drugs are limited to 14 days for 1 of 20 Residents , Resident (# 41) reviewed for unnecessary psychotropic medications. The Facility failed to address as needed order for Alprazolam that exceeded the 14-day limit for as-needed psychotropic medications. This deficient practice could affect 1 resident who receives Alprazolam in the facility and put them at risk for adverse consequences such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status. The findings were: Record review of Resident 41's face sheet dated 4/23/2023 revealed that a [AGE] year-old male was admitted on [DATE] and readmitted on [DATE] with a diagnosis of [paraplegia], impairment in motor or sensory function of the lower extremities. [Dysphagia] taking more time and effort to move food or liquid from your mouth to your stomach. [ Muscle wasting]…

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 are free of any significant medication errors and that accepted professional standards and principles which apply to administration were followed for 2 (Resident #288 and Resident # 4) of 15 Residents observed and reviewed for medication administration in that: 1. Resident # 288's medications were in a medicine cup in the top drawer of the medication cart. 2. Resident #4's medications were in the medicine cup in the top drawer of the medication cart. This deficient practice could affect residents who receive medications, resulting in needed medications not being taken and documented as taken. The findings were: 1.Review of Resident # 288's electronic face sheet dated 4/23/23 revealed he was admitted on [DATE] with a diagnosis of [Acute Respiratory Distress] when fluid builds up in the tiny, elastic air sacs in the lungs. [Muscle Weakness] Lack of muscle strength. [ Essential Hypertension] abnormally 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, record review, and interview, the facility failed to assist residents in obtaining routine dental care for 1 of 7 residents (Resident #14) reviewed for dental services in that: The facility failed to assist Resident #14 in obtaining dental services after assessments indicated the resident had mouth or facial pain, discomfort, or difficulty with chewing. These failures could lead to pain, and dental/gum problems. The findings included: Record review of Resident #14's face sheet dated 4/26/2023 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnosis that included Type 2 diabetes (chronic condition that affects the way the body processes sugar), post-traumatic stress disorder, and dementia (thinking and social symptoms that interfere with daily functioning). Record review of Resident #14's MDS assessment dated [DATE] indicated Resident #14 had mouth or facial pain, discomfort, or difficulty with chewing. Record review of Resident #14's MDS assessment dated [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to maintain medical records on each resident that are complete and accurately documented for 3 of 38 (Residents #55, #57, and #289) residents reviewed for complete and accurate medication administration records, in that: 1. Resident #55 had an order to be in isolation however she came off isolation over 2 months ago. 2. The facility documented Resident #289s admission note in Resident #57's electronic health record. These failures could place residents at risk for not receiving care and services necessary to achieve and maintain desired health outcomes and honor their advance directive preferences. The findings included: 1. Review of Resident #55's face sheet dated 4/24/2023 revealed the resident was admitted to the facility on [DATE] and had diagnoses that included vascular dementia (problems with reasoning, judgement, memory and other thought processes caused by brain damage from impaired blood flow to the brain) with behavioral disturbance, mild…

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

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of infections for 1 of 7 staff (LVN D) reviewed for infection control, in that: LVN D did not sanitizer the scissors prior to cutting medical tape during wound care for Resident #7. LVN D did not change gloves, or sanitize her hands after touching her face mask, and continued wound care for Resident #7. These deficient practices could place residents who receive wound care at-risk for infections. The findings included: During an observation on 04/26/23 at 3:47 p.m. LVN D prepared wound care supplies to treat Resident #7's abdominal skin fold wound. LVN D put on clean gloves, cleaned the bedside table, removed the gloves, placed several bottles of sterile water on the table, placed calcium alginate pads on the table, removed scissors from the cart, did not sanitize the scissors, and placed them on table. LVN D then removed her gloves sanitized…

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 interviews and record reviews the facility failed to establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for 1 of 1 facility reviewed for antibiotic stewardship program, in that: The facility did not perform antibiotic stewardship for 4 consecutive months (October, November, December 2022, and January 2023. This deficient practice placed residents at risk for infections and ineffective antibiotic therapies. The findings: During an interview on 4/24/2023 at 1:33 p.m., ADON stated she was the facility's Infection preventionist starting February 2023. During an interview on 4/24/2023 at 1:45 p.m. with ADON stated she could not produce any documentation for the infection control or antibiotic stewardship surveillance and tracking for October, November, December 2022, and January 2023. ADON only provided antibiotic stewartship survelance for Febuary , March and April 2023 . During an interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to maintain an effective pest control program so the facility was free of pests for 1 of 124 residents (Resident #25), in that: There were gnats too numerous to count flying around Resident #25's head and body, and also gnats too numerous to count on the resident's mattress, pillows, water pitcher, bed frame, light fixture, and cord attached to the light fixture. This deficient practice could lead to the spread of diseases and have an adverse effect on the resident's mental health. The findings included: Record review of Resident #25's face sheet revealed the resident was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (disrupted blood flow to the brain which can cause parts of the brain to die off); aphasia (loss of ability to understand or express speech, caused by brain damage); gastroesophageal reflux disease (when stomach acid repeatedly flows back into the tube connecting the mouth and stomach),…

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

Based on observations, interviews, and record reviews the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access, for 1 of 1 Resident (#72) reviewed for medication storage, in that: RN H left Resident #72's medication unattended and unsecured at Resident #72's bedside. This deficient practice placed residents at risk for not receiving therapeutic effects of the medications as prescribed. The findings are: A record review of Resident #72's face sheet revealed an admission date of 9/15/2021 with diagnoses which included seizures, anxiety disorder, and paranoid schizophrenia [severe type, and a form of psychosis, paranoid schizophrenia is characterized by delusions and sometimes hallucinations]. A record review of Resident #72's Brief Interview for Mental Status score revealed 06 severe cognitive impairment. A record review of Resident #72's care plan, dated 1/26/2022, revealed, revealed, Death and dying issues related to terminal condition, as evidenced by: Hospice services…

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

Based on observations, interviews, and record reviews the facility failed to ensure the menu was followed for 1 of 1 kitchen reviewed for menus in that: The facility failed to ensure protion sizes were served according to the menu and recipe: 1. Residents who received a pureed diet were served ½ cup portion of Pureed Spaghetti with Pureed Meat Sauce instead of a 1 cup portion at the noon meal; and 2. Residents who received a regular diet were served one ½ cup portion of Caesar Salad instead of two ½ cup portions at the noon meal. These deficient practices could place residents at risk of dissatisfaction, poor meal intake, and/or unwanted weight loss. The findings were: Record review of the Diet Spreadsheet for Fall Winter 2021-2022 Extensions for Day 10 Tuesday revealed at the noon meal: 1. Residents who received a pureed diet were to receive two #8 scoops (two ½ cup portions to equal 1 cup) of Pureed Spaghetti with Pureed Italian Meat Sauce, and 2. Residents who received a regular diet were to receive two 4-ounce measuring utensil to equal 1 cup serving of Caesar Salad. 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 service safety for 1 of 1 kitchen, in that: 1. Employee A did not have a beard guard on to cover his facial hair during food preparation. 2. The handles of measuring utensils stored in the sugar, flour and rice bins touched the products stored in the bins instead of in an upright position. 3. Two and ½ cases of canned food (peaches, mashed potatoes, and sliced carrots) were stored on the floor in the dry storage room instead of 6 off the floor. These deficient practices could place all residents who received meals/snacks from the kitchen at risk for food borne illness. The findings were: 1. Observation on 1/23/22 at 9:08 a.m. revealed Employee A was standing by the 3-compartment sink washing pots and pans. Employee A had a beard about ¼-3/8 long and did not have a beard guard/restraint on. Employee A stated he was assisting in the kitchen because the dietary manager and several other dietary employees were out sick.…

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

Based on observations, interviews, and record reviews the facility failed to maintain an infection prevention and control program designed to provide a safe and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 halls (100 hall) in that: 1. Men's unit (hot zone)- CNA K and LVN L not wearing eye protection in the hot zone hall. a. CNA K walked from the hot zone to the cold zone to use the bathroom, without taking off her N95 mask. b. LVN L pushed the lunch cart from the hot zone to the cold zone, a door was separating the zones. Observation of lunch cart had 10 trays and 10 plate tops that were not sanitized. c. LVN L pushed the hydration cart with 3 tall plastic coffee pitchers, 3 1-gallon clear containers on 1st shelf, the 2nd shelf had a container with sugar, and the 3rd shelf had a metal wide container with ice and 3 resident plastic pitchers were not sanitized. This hydration cart was pushed from the hot zone to the cold zone. 2. Women's unit-LVN I was not wearing a N96 mask or eye protection when…

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 allegations of abuse were reported immediately, but not later than 2 hours after the allegation was made, or if the events that caused the allegation did not involve abuse or result in bodily injury not later than 24 hours, to the State Agency for 2 of 7 residents (#26 and #84) reviewed for abuse in that: The facility did not report to the State Survey Agency that Resident #26 reported she was going to give Resident #84 a blow job (oral stimulation of his penis) when the residents were found alone in the TV area. This deficient practice could place residents at risk for not having all allegations of abuse and neglect reported to the State Survey Agency in a timely manner. The findings were: Record review of Resident #26's face sheet dated 1/26/2022 revealed she was [AGE] years old, admitted to the facility on [DATE] and had diagnoses that included anoxic brain injury (complete lack of oxygen to the brain, resulting in death of brain cells), type…

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 coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort for 1 of 1 Resident (Resident #38) reviewed for coordination with the State Agency, in that; The facility did not submit the Nursing Facility Specialized Services (NFSS) form to the State Agency. This deficient practice placed the resident at risk for not receiving specialized services provided by the State Agency. The findings include: A record review of Resident #38's face sheet, dated 1/24/2022, revealed an admission date of 4/14/2021, with diagnoses which included moderate intellectual disabilities, cognitive communication deficit, and major depressive disorder. A record review of Resident #38's Brief interview for Mental Status (BIMS) score, dated 1/24/2022, revealed 03, severe intellectual disability. A record review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility to provide a safe and comfortable environment for residents, staff in 1 of 2 (women's unit) shower rooms in the 100 hall in that: In the Women's unit shower room, in the 100 hall, there was a tall plastic 3 shelf storage bin which contained 7.5 fluid ounces of peri-fresh spray, tray of razors 15 count, 3 24 fluid ounce body wash bottles, and a 16 ounce zinc oxide ointment container. Resident #58 was observed walking back and forth on the hall, but not in the shower room. The Findings were: Record review of Resident #58's face sheet dated 1/26/2022 revealed she was admitted on [DATE] with diagnoses of anxiety disorder, vascular dementia with behavioral disturbance, cognitive communication deficit, major depressive disorder and weakness. Record review of Resident #58's Quarterly MDS dated [DATE] in Section C-Cognitive Patterns revealed she had a BIMs of 5/15, severely cognitively impaired. Observation on 1/23/22 at 9:46 a.m. with CAN J, 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.

Based on observations, interviews, and record reviews the facility failed to provide quality laboratory services to meet the needs of its residents, for 1 of 1 glucometer reviewed for calibration, in that: The facility did not record the serial number of the glucometer being calibrated, the calibration solutions were not labeled with the opened date, and the glucometer was not calibrated daily. These deficient practices placed residents at risk for their blood sugar levels not being accurately assessed. The findings included An observation on 1/26/2022 at 4:22 pm of the facility's 100-hall glucometer [a device for measuring the concentration of glucose in the blood, typically using a small drop of blood placed on a disposable test strip, where a chemical reaction with glucose alters the electrical conductivity of the strip] revealed the facility utilized the [brand name] glucometer with the serial number (21)K008119H2721. A record review of the facility's Glucose Monitoring Quality Control Record for January 2022, revealed no serial number recorded for the glucometer being…

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 employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition services for 1 of 1 dietary manager reviewed for qualified dietary staff. The facility failed to employ a certified dietary manager as required. This failure could place residents who consumed food prepared by staff in the kitchen at increased risk of food borne illness and not receiving adequate nutrition. Findings included: Record review of the policy titled Food Services Manager, revised 12/2008, revealed The Food Services Manager is a qualified supervisor licensed by this state and is knowledgeable and trained in food procurement, storage, handling, preparation, and delivery. Record Review of an undated list of employees revealed Employee F was the Dietary Manager. Record review of the Dietary Manager's employee file revealed he was hired on 1/10/2022 as the Dietary Manager. Record review of the Dietary Manager's undated Employment Application revealed he did not have any certification or degrees. In an…

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

Based on interview and record review, the facility failed to maintain the required minimum of 12 hours annual in-service records for 2 of 2 CNAs (CNA C and CNA D) records reviewed for staff training. The facility failed to provide CNAs C and D with 12 hours in-service training per year. This failure could affect the residents by allowing them to be care for by untrained staff. Findings included: Record review of the following CNA's Individual Education Record (annual log of in-service hours) revealed the following: CNA C had a hire date of 7/18/2018 and had only completed 2 hours of annual training. CNA D had a hire date of 7/10/2020 and had only completed 2 hours of annual training. In an interview on 1/26/22 at 3:35 p.m., the Administrator revealed in-service training was conducted monthly. The Administrator stated the previous Human Resource employee would log employees in-service training on the Individual Education Record, but her employment ended in June 2021 and the Administrator has not had a chance to train the new Human Resource employee to record the in-services. 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.