River Hills Health And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible, for 1 of 8 residents (Resident #18) reviewed for urinary catheters. The facility failed, for 10 consecutive days, to follow the physicians' order to flush Resident #18's urinary catheter twice a day. These failures could place residents at risk for a decline in their health status. The findings included: A record review of Resident #18's admission record dated 6/13/2025 revealed an admission date of 4/8/2025 with diagnoses which included neuromuscular dysfunction of bladder (no bladder control because of brain, spinal cord, or nerve problems), urinary tract infection, and Parkinson's disease (an illness that affects the part of the brain that controls movement, walk, talk, sleep, and thought). A record review of Resident #18's quarterly MDS assessment,…

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

Based on record reviews and interviews the facility failed to ensure the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, for 1 of 1 facility's reviewed for nursing staffing. The facility failed to have the services of an RN on 5/31/2025 and on 6/1/2025. These failures could have placed residents at risk of not having the critical skills of a RN. The findings included: A record review of the facility's census reports for the dates of 5/31/2025 and 6/1/2025 revealed a census of 101 residents daily. A record review of the facility's RN staff payroll hours for the period from 3/1/2025 through 6/10/2025 revealed no evidence for the services of an RN for 8 consecutive hours on 5/31/2025 through 6/1/2025. During an interview on 6/13/2025 at 10:00 AM ADON A stated she was not aware of the federal and state requirement to have at a minimum the services of an RN for 8 consecutive hours a day. ADON A stated she was aware to attempt to have the services of an RN daily but not the rationale for the attempt. ADON A stated she was responsible for 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 store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 2 medication storerooms and 3 of 10 medication carts reviewed for security and control, in that: 1. LVN L left the 100-hall medication cart unattended, unsupervised, and unlocked. 2. LVN Q left the 100-hall medication cart unattended, unsupervised, and unlocked. 3. LVN C left the medication room on the 100-200-hall unattended, unsupervised, and unlocked. These failures could place residents at risk of misappropriation of property, not receiving the therapeutic effects of medications, and or adverse effects of medications. The findings included: During an observation and interview on 6/10/2025 at 9:10 AM revealed the 100-hall cart located on the 100-hall unattended, unsupervised, and unlocked. Continued observations revealed residents and staff ambulating on the hall without observation of a nurse assigned to the medication cart. At 9:14 AM LVN G…

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 1 of 1 facility reviewed for food service safety, in that: 1. A fridge used to hold snacks and other food and drink items for residents was observed to contain an unlabeled and undated sandwich and a past best-by date gallon of milk. 2. A food storage bin had a scoop that was left in the bin. These failures could place residents who receive food and/or snacks from the facility at risk for food borne illness. The findings included: 1. Observation and interview on 06/12/2025 at 11:05 AM revealed a refrigerator with resident snacks revealed the following: *an unlabeled and undated item, appearing to be a sandwich. * a gallon of liquid, appearing and labeled as milk, with the best by date of Jun 10. MA E stated she regularly went through this refrigerator and threw anything away 2 days after its labeled date. MA E stated she was not sure why the sandwich was not labeled and that the milk should have been thrown away on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents had the right to personal privacy and confidentiality of his or her personal and medical records for 1 of 5 residents (Resident #13) reviewed for privacy, in that: The facility failed to ensure that MA (E) locked the computer after she walked away and left it unattended, which exposed Resident #13's morning medication list. This failure could place residents at risk of having their medical information exposed to others and cause residents to feel uncomfortable and disrespected. The findings include: Record review of Resident #13's face sheet dated, 6/12/25 reflected an [AGE] year-old female resident who was admitted to the facility on [DATE] with diagnoses which included: Anxiety disorder (a group of mental health conditions characterized by excessive, persistent, and uncontrollable feelings of worry and fear), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure. the resident has a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 1 of 4 community showers, 1 of 20 resident rooms, in that: 1. A community shower chair had brown substance at the bottom of seat. 2. 400 hall shower room was missing 1 tile. 3. room [ROOM NUMBER] door frame to bathroom was missing the frame on 1 side of the door frame. This failure could place residents at risk of lack of facility cleanliness and a homelike environment. The Findings were: 1. Observation on 6/11/2025 at 3:50 PM with CNA I and J in the 400-shower room revealed the shower chair had brown substance on the bottom of seat. CNA G and H stated the shower chair was to be cleaned after each use. Interview on 6/11/2025 at 3:51 PM with CNA's I and J stated the shower chair had brown substance and should be cleaned after each use. The CNA's stated 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 the interview and record review, the facility failed to ensure that residents are free from chemical restraints related to PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order, for 1 of 3 residents (Resident #62) reviewed for chemical restraint, in that: The facility failed to ensure Resident #62 was prescribed a psychotropic drug for anxiety, no longer than 14 days PRN (as needed). This deficient practice could place residents at risk of receiving unnecessary psychotropic medications. The findings were: Record review of Resident #62's face sheet, dated 6/13/25, revealed an [AGE] year-old female admitted to the facility on [DATE] with the diagnosis that included: anxiety (intense, excessive, and persistent worry…

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 proper treatment and assistive devices to maintain hearing abilities for 1 of 8 residents (Resident #37) reviewed for hearing. The facility failed to ensure Resident #37 received appropriate services to assess for maintaining or improving hearing abilities. This failure could place residents at risk for unmet needs and diminished quality of life related to communication. The findings included: Record review of Resident #37's face sheet, dated 06/13/2025, reflected an [AGE] year-old resident initially admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe) and pneumonia (infection that inflames air sacs in one or both lungs, which may fill with fluid). Record review of Resident #37's Quarterly MDS Assessment, dated 06/06/2025, reflected that Resident #37 had a BIMS of 13, indicating the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review failed to ensure the resident environment remains as free of accident hazards as is possible for 1 of 8 (#33) residents in the 400 halls, in that: Resident #33's fall matt was not in place. This failure could place residents at risk for injuries. The Findings were: Record review of Resident #33's admission Record dated 6/13/2025 revealed she was admitted on [DATE], re-admitted on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infraction affecting right dominate side (a person is experiencing weakness or paralysis (hemiplegia) or weakness alone (hemiparesis) on the left side of their body due to a stroke affecting the right side of their brain, which typically controls the left side of the body. ), acute kidney failure, cognitive communication deficit, Alzheimer's, and seizures. admission record was documented she was on hospice services. Record review of Resident #33's Quarterly MDS was dated 5/ 28/2025, was documented BIMS score was 3/15…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure residents were free from any significant medication errors, for 1 of 6 residents (Resident #9) reviewed for medication errors, in that: LVN C administered Resident #9's meropenem (an intravenous antibiotic used to treat a variety of bacterial infections) antibiotic intravenously at the wrong infusion rate and effectively administered the medication in half of the intended time, over 30 minutes instead of 1 hour. This failure could place residents at risk of not administering medications as prescribed and increasing adverse effects. The finding included: A record review of Resident #9's admission record dated 6/12/2025 revealed an admission date of 5/20/2025 with diagnoses which included osteomyelitis (a serious bone infection that can occur due to bacteria) left ankle and foot; chronic kidney disease stage 4 severe (severe, irreversible damage to the kidneys. At this stage, the kidneys are functioning at only 15-29% of their…

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 The personal refrigerators in residents' Room # 203 A contained food items which were unlabeled and undated. This deficient practice could place residents at risk of foodborne illness due to consuming foods which are spoiled. The findings were: Observation on 06/10/2025 at 9:20 a.m. revealed the personal refrigerator in resident room [ROOM NUMBER]A contained a container of mole and fideo, which was unlabeled and undated. Observation in room [ROOM NUMBER] A on 06/11/2025 at 10:45 a.m. revealed a container with mole and fideo was still present. During an interview with LVN L on 06/11/2024 at 12:55 a.m., LVN L confirmed the personal refrigerator in resident Room # 203 A contained a container with mole and fidelo which was unlabeled and undated. During an interview with the DON on 06/12/2025 at 10:27 a.m., the DON confirmed perishable food and drinks in residents' personal refrigerators should be labeled and dated to prevent residents from consuming spoiled foods. The DON stated the night shift nursing assistants…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for 1 of 6 residents reviewed for infection prevention protocols, in that: LVN KR administered Resident #9's antibiotic intravenously while placing the entire medication cart into Resident #9's room and then removing the cart, without sanitization, with intentions of continuing medication administration with peer residents. This failure could place residents at risk for harm by infections by cross contamination. The finding included: A record review of Resident #9's admission record dated 6/12/2025 revealed an admission date of 5/20/2025 with diagnoses which included osteomyelitis (a serious bone infection that can occur due to bacteria) left ankle and foot; chronic kidney disease stage 4 severe (severe,…

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 had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 3 of 8 residents (Resident #6, #7 and #8) reviewed for reasonable accommodation of resident needs, in that:. 1. The facility failed to ensure Resident #6 had access to his call light which was wrapped up in a basket on his nightstand outside of the resident's reach. 2. The facility failed to ensure Resident #7 had access to his call light which was attached to his bed outside of the resident's reach. 3. The facility failed to ensure Resident #8 had access to his call light which was tucked inside of his closed nightstand drawer out of the resident's reach. These deficient practices could place residents at risk of not maintaining and/or achieving independent functioning, dignity, and well-being. Findings…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to ensure that the MDS assessment accurately reflected the resident's status for 1 of 12 (Resident #3) whose MDS assessments were reviewed in that: Resident #3 had 1 of 2 falls inaccurately coded on the MDS assessment. This deficient practice could place residents at risk for inadequate care and services to meet their needs based on inaccurate MDS assessments. The findings were: Record review of Resident #3's undated face sheet revealed Resident #3 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included Dementia (loss of cognitive functioning) and Osteoporosis (bone disease characterized by decreased bone density and mass). Resident #3 had a date of discharge listed on the face sheet of 04/23/2025. Record review of Resident #3's discharge MDS assessment, dated 02/17/2025, revealed Resident #3 had short term and long-term memory deficits and a BIMS test was not completed. Section J revealed Resident #3 had 1 fall…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide or obtain laboratory services to meet the needs of its residents for 1 of 2 residents (Resident #2) reviewed for laboratory services, in that: The facility did not obtain a UA C&S (a medical test that combines a urinalysis with a culture and sensitivity test to diagnose and treat urinary tract infections) for Resident #2 as ordered by a physician. This deficient practice could place residents at risk for a delay in identifying or diagnosing a problem, adjusting medications, and ensuring treatment needs were identified and addressed. Findings included: Record review of Resident #2's face sheet, dated 02/04/2025, revealed an admission date of 09/26/2022 and a readmission date of 07/19/2024, with diagnoses that included: Raynaud's syndrome without gangrene (a condition that causes decreased blood flow to the extremities but doesn't always lead to dead tissue), essential primary hypertension (persistently elevated high blood pressure), depression…

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 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 4 days out of 5 days (11/19/24, 11/25/24, 11/27/24, and 12/11/24) reviewed for nursing services. The facility failed to ensure a registered nurse was scheduled for eight consecutive hours per day, seven days per week on the following dates: 11/19/24, 11/25/24, 11/27/24, and 12/11/24. This deficient practice could place residents at risk of not receiving adequate care. Findings included: Record review of the facility's Staffing Disclosure Sheets revealed the following: 11/19/24: Census - 111 o 1 RN for the day shift, 6 hours; 0 RN for the night shift 11/25/24: Census - 114 o 1 RN for the day shift, 6 hours; 0 RN for the night shift 11/27/24: Census - 111 o 1 RN for the day shift, 6 hours; 0 RN for the night shift 12/11/24: Census - 114 o 1 RN for the day shift, 6 hours; 0 RN for the night shift Record review of the facility's employee timesheets revealed RN G did not punch in on 11/19/24, 11/25/24, 11/27/24, or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care for 2 of 4 residents (Resident #1 and Resident #4) reviewed for baseline care plan. The facility failed to initiate a baseline care plan within 48 hours of the admission date for Resident #1 and Resident #4. This failure could affect newly admitted residents and place them at risk of not receiving continuity of care and communication among nursing home staff to ensure their immediate care needs were met. Findings included: Record review of Resident #1's admission Record, dated 11/14/24, revealed Resident #1 was initially admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses which included: malignant melanoma of skin (skin cancer), osteoporosis (weak/brittle bones), muscle weakness, gait/mobility abnormality, lack 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 interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident's rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 4 residents (Resident #1 and Resident #4) reviewed for care plans. The facility failed to develop a person-centered care plan with interventions that addressed: 1. Resident #1's ADL needs; risk for falls; cognitive deficits, dietary needs, therapy; and discharge planning. 2. Resident #4's ADL needs, cognitive deficits, dietary needs, hospice, medication side effects, treatments, and medications. This deficient practice could affect residents and place them at risk for not having their needs and preferences met. Findings included: 1. Record review of Resident #1's admission Record, dated 11/14/24, revealed Resident #1 was initially admitted to 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 observations, interviews, and record review, the facility failed to review and revise resident care plans after each assessment for 1 of 4 residents (Resident #1) reviewed for care plan revision/timing. The facility failed to ensure Resident #1's care plan was revised to reflect falls on (4) occasions. This deficient practice could affect residents the care/services and may cause a delay in treatment and/or decline in health. Findings included: Record review of Resident #1's admission Record, dated 11/14/24, revealed Resident #1 was initially admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses which included: malignant melanoma of skin (skin cancer), osteoporosis (weak/brittle bones), muscle weakness, gait/mobility abnormality, lack of coordination, cognitive communication deficit (difficulty with thinking and language), type 2 diabetes (chronic condition that affects the way the body processes blood sugar), memory deficit, frontal lobe and executive function deficit (damage to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to implement their written policies and procedures to report, prohibit, and prevent abuse for 2 of 2 residents (Resident #1 and #2) and 1 of 3 staff(CNA E) reviewed for developing and implementing abuse and neglect policies 1. The facility failed to develop and implement abuse policies for reporting abuse to the State Reporting Agency. 2. The facility failed to develop and implement abuse policies for review of an employee EMR and criminal history at least once every 12 months. These failures could place residents at risk of abuse, neglect, and misappropriation of property. The findings included: 1. Record review of a facility policy, titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program last revised [DATE] revealed the policy did not address reporting of incidents. Record review of Resident #1 face sheet dated [DATE] revealed an admission date of [DATE] with readmission date of [DATE] and discharge date of [DATE] with diagnoses…

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 all alleged violations involving abuse, and neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately but not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury to the State Survey Agency in accordance with State law through established procedures for 2 of 2 residents (Resident #1 and Resident #2) reviewed for reporting. 1. The facility failed to report to the State Survey Agency when Resident #1 had an unwitnessed fall and broke her neck. 2. The facility failed to report to the State Survey Agency when Resident #2 made allegations of being shaken by a staff member These failures could affect place residents by resulting in at risk of a delay of identification of abuse or neglect and lack of timely follow-up on recommended interventions to prevent harm, or impairment. The findings…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 3 residents (Resident #3) reviewed for pharmacy services. The facility failed to administer Resident #3's morning medications which included 7 medications within the facilities policy window for administration of medications. This failure could place residents at risk of not receiving the therapeutic effects of their prescribed medications. The findings included: Record review of Resident #3's face sheet dated [DATE] revealed an admission date of [DATE] and readmission date of [DATE] which included: systemic lupus erythematosus with organ or system involvement (systemic autoimmune disease with multisystemic involvement), pain in left hip and long term (current) use of systemic steroids. Record review of Resident #3's Care Plan last…

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 professional staff were licensed, certified, or registered in accordance with applicable State laws for 1 of 8 staff (LVN A) reviewed for staff qualifications. The facility failed to ensure LVN A transferred her nursing license to Texas from Colorado within 60 days of establishing residency in Texas. This failure could place residents at risk of not receiving care and services from staff who were properly licensed. The findings included: Record review of LVN A's personnel file revealed a Texas Driver's license issues [DATE] with a local Texas address. Record review of Texas Board of Nursing license verification revealed LVN A's Texas nursing license was listed as inactive and had expired on [DATE]. Record review of LVN A's personnel file revealed a Colorado multistate license which expired [DATE]. During an observation/interview on [DATE] at 11:38 a.m., LVN A was observed working in the facility while passing medication. LVN 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 observations, interviews, 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. The overhead light in the kitchen storage room was not working. 2. A bag of 2 dozen hard boiled eggs in the refrigerator was not labeled or dated. 3. A bag of shredded cheese in the refrigerator was not labeled or dated. 4. A bag of 30 ham slices in the refrigerator was not labeled or dated 5. The temperature test strips for the dish machine were wet and could not be used. 6. The ceiling vent across from the dish machine had mold around the edges of the vent. 7. The grill vent above the dish machine hood cover was covered with dirt and grease. These deficient practices could place residents who received meals and snacks from the kitchen at risk for food borne illness from improper infection control, from a lack of food label date monitoring, from a lack of equipment maintenance, and improper sanitation in the kitchen area. The findings included: Observation on 04/16/24…

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 residents have a right to personal privacy for 1 of 5 residents (Resident #27) observed for nursing care and 8 of (Resident #36, Resident #41, Resident #56, Resident #58, Resident #66, Resident #80, Resident #91, and Resident #105) of 25 residents reviewed for privacy, in that: 1. The Treatment nurse did not close Resident #27's window curtain while providing wound care for the resident. 2. Shower sheets for Resident #27, Resident #36, Resident #41, Resident #56, Resident #58, Resident #66, Resident #80, Resident #91, and Resident #105 with the residents' names and details about their medical were found on a table on the 200 hallway. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy. The findings include: 1. Record review of Resident #27's face sheet, dated 03/21/2024, revealed an admission date of 11/29/2023 and, a readmission date of 03/28/2024, with diagnoses which included: Depression(mood disorder that causes a persistent feeling of sadness and loss 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 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. The findings were: Record Review of the Employee Service List, undated, revealed the Dietary Manager with a hire date of 04/17/2023. During an interview on 04/17/24 at 10:45 a.m., with the Dietary Director he revealed he had not taken a Dietary Manager Certification course and was unaware that he needed to complete this course He stated that his current position as a Dietary Manager was the only Dietary Manager position he had held. He stated that all of his previous positions working in kitchens, had been working in the capacity of a cook. During an interview with the Human Resources Director on 04/18/24…

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 designate an interdisciplinary team member responsible for collaborating and communicating with hospice representatives. This deficient practice could place residents who receive hospice services at risk of receiving substandard care due to miscommunication between their hospice and facility caregivers. The findings were: During an interview with the Social Worker on 04/18/2024 at 3:20 p.m., the Social Worker stated she was not the hospice liaison and did not know which facility staff member had been designated liaison. During an interview with the Medical Records Director on 04/18/2024 at 3:25 p.m., the Medical Records Director stated he was not the hospice liaison and did not know which facility staff member had been designated liaison. During an interview with the ADON on 04/18/2024 at 3:30 p.m., the ADON stated she was not the hospice liaison and did not know which facility staff member had been designated liaison. During an interview with the MDS Coordinator on 04/18/2024 at 3:35 p.m., the MDS Coordinator stated she…

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

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 1 of 5 residents (Resident #28) reviewed for infection control, in that: CNA B and CNA C failed to wash or sanitize their hands or change their gloves after touching the trash can and the privacy curtain before starting incontinent care. This deficient practice could place residents at-risk for infection due to improper care practices. The findings included: Record review of Resident #28's face sheet, dated 04/18/2024, revealed an admission date of 01/29/2024 with diagnoses which included: Parkinson's (Chronic degeneration of the central nervous system), Hypothyroidism (under active thyroid), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Hypertension (High blood pressure), Raynaud's syndrome (spasm of small arteries causes episodes of reduced blood flow to end…

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

Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable environment for residents, staff, and visitors, in that: Two containers of cleaning fluids with hazardous material warning labels were found within the shower room of the facility's 200 hallway. This deficient practice could place residents at risk of coming into contact with hazardous materials. The findings were: Observation on 04/17/2024 at 10:42 a.m. revealed the resident shower room on the 200 hallway was not in use and was unlocked. Further observation revealed a container of cleaning wipes labeled, Danger and Keep Out of Reach of Children and a 32-ounce container of bathroom cleaner labeled, Danger, Do Not Drink, and May Cause Eye and Skin Irritation were found withing the shower room. Further observation at various times on 04/17/2024, 04/18/2024, and 04/19/2024 revealed no residents were inside the shower room without a member of staff, but residents were observed on the 200 hallway near the shower room throughout each day. During an interview with the AIT 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 interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 26 residents (Resident #13) whose assessments were reviewed, in that: Resident #13's Quarterly MDS assessment incorrectly documented the resident as not receiving an antidepressant. This failure could place residents at-risk for inadequate care due to inaccurate assessments. The findings were: 1. Record review of Resident #13's face sheet, dated 04/18/2024, revealed an admission date of 09/21/2018 and, a readmission date of 02/21/2024, with diagnoses that included: Multiple sclerosis (autoimmune disease affecting the nervous system), Type 2 diabetes mellitus(high level of sugar in the blood), Schizophrenia (mental disorder characterized by abnormal thought processes and an unstable mood), Depression(mood disorder that causes a persistent feeling of sadness and loss of interest), Anxiety disorder(A group of mental illnesses that cause constant fear and worry),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 (Resident #73) residents reviewed for comprehensive assessments. The facility failed to ensure that Resident #73's care plan documented interventions for the resident's weight loss of 13 pounds. This deficient practice could place residents at risk of not receiving proper care and services . The findings were: Record review of Resident #73's face sheet, dated 04/18/2024, reflected a [AGE] year-old female admitted to the facility on [DATE]. Resident #73 had diagnoses which included: Acute kidney failure (occurs when your kidneys suddenly become unable to filter waste products from your blood), Schizoaffective disorder (is a chronic 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 interview and record review, the facility failed to ensure the resident was not given a psychotropic drug unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 (Resident #102) of 7 residents reviewed for unnecessary medications, in that: Resident #102 was prescribed a psychotropic drug for anxiety without a documented diagnosis of anxiety in the clinical record. This deficient practice could place residents at risk of receiving unnecessary psychotropic medications. The findings were: Record review of Resident #102's facesheet, dated 04/18/2024, revealed the resident was admitted to the facility on [DATE] with diagnoses including: End Stage Renal Disease, Cerebral Infarction, and Hyperlipidemia. Further review revealed the listed diagnoses did not include Anxiety. Record review of Resident #102's Quarterly MDS, dated [DATE], revealed a BIMS score of 10 which indicated moderate cognitive decline. Record review of Resident #102's care…

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 was not 5% or greater. The facility had a medication error rate of 8%, based on 2 errors out of 25 opportunities, which involved (Resident # 15) and 1 of 2 staff (CMA D) reviewed for medication errors. The facility failed to ensure CMA D administered medications according to the physician's orders and per professional standards, which resulted in an 8% medication administration error rate. This deficient practice could place residents at risk of not receiving the therapeutic effects of their medications and possible adverse reactions. The findings were: Record review of Resident # 15's face sheet dated 4/17/24 revealed an [AGE] year-old female admitted to the facility on [DATE] with the diagnosis that included: Anxiety ( feeling of unease, such as worry or fear) , Dysphagia (medical term for difficulty swallowing) and Alzheimer's Disease (type of dementia that affects memory, thinking and behavior). Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 2 (refrigerators in resident room [ROOM NUMBER] and room [ROOM NUMBER]) of 5 residents' personal refrigerators reviewed, in that: The personal refrigerators in two residents' rooms contained food items which were unlabeled and undated. This deficient practice could place residents at risk of foodborne illness due to consuming foods which are spoiled. The findings were: Observation on 04/16/2024 at 10:02 a.m. revealed the personal refrigerator in resident room [ROOM NUMBER] contained a sandwich which was unlabeled and undated. Further observation on 04/17/2024 at 10:32 a.m. revealed the sandwich was still present. During an interview with CNA F on 04/17/2024 at 10:35 a.m., CNA F confirmed that the personal refrigerator in resident room [ROOM NUMBER] contained a sandwich which was unlabeled and undated. Observation on 04/16/2024 at 10:12 a.m. revealed the personal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a comprehensive care plan was developed within 7 days after the completion of the comprehensive assessment and failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment there was an update for 3 of 21 residents (Residents #5, #38 and #86) whose care plan was reviewed, in that: 1. The facility failed to update Resident #5's care plan when her order for Carbidopa/Levodopa was discontinued. 2. The facility failed to update Resident #38's care plan when she discontinued hospice services. 3. The facility failed to develop a comprehensive care plan for Resident #86 within seven days after completion of the comprehensive assessment. These deficient practices could place residents at risk of receiving the incorrect care and cause health complications with subsequent illness. The findings were: 1. Record review of the Resident #5's face sheet dated 3/3/2023, revealed the resident was an 87-…

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 services of a Registered Nurse for at least eight consecutive hours a day, 7 days a week. The facility failed to ensure a Registered Nurse was present at the facility on: 01/08/2023, 01/21/2023, 01/22/2023, 02/11/2023, and 02/12/2023. This deficient practice could place residents at risk of receiving inadequate nursing care. The findings were: Record review of the staffing rosters for the six-month period preceding the survey revealed a Registered Nurse was not present at the facility on: 01/08/2023, 01/21/2023, 01/22/2023, 02/11/2023, or 02/12/2023. During an interview with the Administrator on 03/02/2023 at 10:18 a.m., the Administrator confirmed a Registered Nurse had not been present on site for the above listed dates. The Administrator stated a Registered Nurse was always available by phone and could drive to the facility in less than thirty minutes if needed. Record review of the facility's policy, Departmental Supervision, Nursing revised August 2022, revealed, A Registered Nurse provides services at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assured the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals) to meet the needs of each resident for 2 of 4 residents (Residents #46, and #201) reviewed for pharmacy services. 1. The facility failed to ensure Resident #46 was administered medications according to physician parameters. 2. The facility failed to ensure Resident #201 was administered medications according to physician parameters. These deficient practices could place residents at risk of not receiving the intended therapeutic benefit of the medications, could result in a worsening or exacerbation of chronic medical conditions, hospitalization and or a diminished quality of life. The findings were: 1. Record review of Resident #46's quarterly MDS dated [DATE], revealed, a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included medically…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys in 2 of 10 medication storage carts (Med Aide Cart and Nurses Treatment Cart) reviewed for medication storage. 1. The facility failed to ensure the Med Aide Cart was locked in the 100-hallway when it was left unattended. 2. The facility failed to ensure the Nurses Treatment Cart locked in the common, seating area near the 100-hallway Nurses station when it was left unattended. These deficient practices could place residents at risk of medication misuse and diversion. The findings were: In an observation on 3/01/2023 at 6:23 AM, the medication cart outside of room [ROOM NUMBER] was observed unlocked and unattended. The medication cart had prescription and over the counter medications in it. The medication treatment cart against the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, reviewed for kitchen sanitation. 1. The facility failed to ensure foods were properly sealed, labeled, dated and stored. 2. The facility failed to ensure equipment (the commercial toaster) was not soiled and the facility failed to ensure the walls were not soiled with any gummy substances. 3. The facility failed to ensure the commercial fryer did not contain murky oil and was clean. These deficient practices could place residents at-risk by contributing to foodborne illness, poor intake, and/or weight loss. The findings were: Observation on 03/01/2023 at 11:12 a.m. revealed an open container of beef broth on a shelf above the puree station. The container was undated. A manufacturer's date stamp read, best if used by 23 [DATE] . The last two digits of the year were smudged and illegible. The label read,…

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, based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for 1 of 23 residents (Resident #97) reviewed for quality of care, in that: Resident #97 hit her head during a fall and the facility failed to ensure four scheduled neurological assessments were completed following the fall. Resident #97 experienced two changes in condition within three days of her fall and her physician was not notified of the missing neurological assessments or of the changes in condition. The physician did not have the opportunity to assess the resident or to provide treatment, and no interventions were implemented on the resident's behalf. Resident #97 expired five days after she fell. This deficient practice placed residents at risk for health status decline and denied the physician opportunities to…

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.