Advanced Rehabilitation & Healthcare Of Live Oak

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder and bowel received appropriate treatment and services to prevent urinary tract infections for 1 of 5 residents (Resident #66) reviewed for incontinent care: The facility failed to ensure CNA K provided incontinent care to Resident #66 in the order of cleanest to dirtiest, performed hand hygiene between glove changes, and CNA L changed her gloves and performed hand hygiene after touching soiled linen. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices. Findings Included: Record review of Resident #66 admission record, dated 5/23/25, revealed an [AGE] year-old female resident admitted on [DATE] with diagnoses including dementia, enterocolitis due to clostridium difficile (a highly contagious bacterium that causes diarrhea), bacteremia (bacteria in bloodstream), and stage 3 chronic kidney disease (mild to moderate 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 maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 3 residents (Resident #3) reviewed for accuracy of records, in that: The facility failed to ensure RN B and LVN C documented when they contacted the physician for Resident #3's high blood glucose levels (continuously over 200) for 5 days (1/25/25, 1/26/25, 1/27/25, 1/28/25, 1/29/25) and the physician's recommendations for Resident #3 who was not prescribed any insulin. This failure could put residents at risk due to inaccurate documentation and lead to missed or delayed diagnosis and treatment. The findings were: Record review of Resident #3's admission Record (face sheet), dated 4/15/25, revealed a [AGE] year-old female resident was admitted to the facility on [DATE] and discharged on 1/30/25 to a hospital with diagnosis which included sepsis unspecified organism (refers to a serious medical 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.

Based on record review and interview, the facility failed to ensure all written grievance decisions included the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued and to maintain evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision for 1 of 30 residents (Resident #1) reviewed for grievances in that: Resident #1 verbally complained about his food being discarded, and a grievance form was not filled out on 02/12/2025. This could affect all residents at the facility who could voice grievances by preventing their concerns from being addressed and resolved. The findings were: Record review of Resident #1's facesheet, dated 04/17/25, revealed…

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 all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours if the alleged violation involved abuse or neglect and resulted in bodily injury, to other officials (including the State Agency) and the Abuse Coordinator for 1 (Resident #2) of 3 residents reviewed for exploitation. The facility failed to report to the state agency when Resident #2 alleged her ID card, social security card, bank cards were stolen from her wallet. Resident #2 also alleged her monthly social security check was moved to another account with out her knowledge. This failure could place residents at risk of Exploitation/Misappropriation of Property and financial distress. Findings include: Record review of Resident #2's admission record, dated 4/16/25, revealed a [AGE] year-old female resident was admitted on [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide drinks, including water and other liquids consistent with resident needs and preferences and sufficient to maintain resident hydration for 6 of 8 residents (Resident #1, #2, #5, #6, #7 and #8) reviewed for hydration, in that: The facility failed to ensure Residents #1, #2, #5, #6, #7 and #8 had access to water and/or beverages in their rooms between meals and failed to ensure 16 ounces of fluid was offered with meals. These deficient practices could affect resident's hydration and lead to discomfort, dehydration, and/or a diminished quality of life. The findings included: 1. Record review of Resident #1's face sheet dated 2/11/2025 revealed an [AGE] year-old with an admission date of 07/01/2021 and readmission [DATE] with diagnoses which included: Alzheimer's disease, vascular dementia with behavioral disturbance and anxiety disorder. Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMs score of 3 which…

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 environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 (Resident #1) resident reviewed for accidents and hazards. The facility failed to provide a two-person mechanical lift transfer for Resident #1 on 2/11/2025. This failure placed residents at risk for falls and injury. The findings included: Record review of Resident #1's face sheet dated 2/11/2025 revealed an [AGE] year-old female with admission date of 07/01/2021 and readmission [DATE] with diagnoses which included: Alzheimer's disease, vascular dementia with behavioral disturbance and anxiety disorder. Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMs score of 3 which indicated a severe cognitive impairment. The MDS indicated Resident #1 function ability for moving from lying to sitting and sit to stand and for chair transfers was complete…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for 1 of 8 residents (Resident #2) reviewed for dietary services. The facility failed to ensure Resident #2 received their prescribed diet (mechanical soft with pureed meat texture) for evening meal service on 2/11/2025. This deficient practice could place residents, who were provided a mechanically altered diet, at risk of choking, aspiration (inhaling food,) and diminished quality of life. The findings included: Record review of Resident #2's face sheet dated 2/11/2025 revealed a [AGE] year-old female with an admission date of 6/20/2023 with diagnoses which included: cerebral infarction due to thrombosis of left cerebellar artery (stroke caused by a blockage of an artery leading to the brain), dementia with anxiety, dysphagia oropharyngeal phase (impairment in the ability to swallow which included difficulty with the mouth and throat). Record review of Resident #2'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 interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #1) of 4 residents reviewed for accuracy of assessments. The facility failed to ensure Resident #1 was coded on her Quarterly MDS for two falls without injury that occurred on 04/13/2024 and 04/22/2024. This failure could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. The findings included: Record review of Resident #1's admission Record, dated 09/12/2024, reflected Resident #1 was admitted on [DATE] and was [AGE] years old. Resident #1 was noted to be on hospice services. Record review of Resident #1's Diagnosis Report, dated 09/12/2024, reflected Resident #1 was diagnosed with diffuse follicle center lymphoma (a widely spread type of cancer that develops inside the lymph nodes), had a history of falling, muscle weakness, and shortness of breath. Record review of facility report,…

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 Facility requirements, The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless When the facility transfers or discharges a resident under any of the circumstance, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider. All other necessary information, and including a copy of the resident's discharge summary, for 1 of 2 (#1) resident that was discharged in that: Resident #1 was discharged from the facility, after not coming back from leave within 72 hours. Resident #1 notified the facility that she would be late due to having car issues, Resident was back in the facility the morning after. Resident #1 was told by ADM she was discharged and had her belongings packed and out of her room. Resident #1 was not allowed to re-enter…

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. 1. There were two plastic storage containers of food in the dry storage room that was not properly sealed. 2. There was a dented can of pineapples stored in the dry storage room. 3. There was a bag of brownie mix that expired on 3/20/24 stored in the dry storage room. 4. There was a container of disinfectant wipes on top of the ice dispenser. 5. The microwave was dirty and had old food particles inside. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: Observation on 04/02/2024 at 8:56 AM in the dry storage room revealed two clear 10-gallon food storage containers on a rack. The lids on the storage containers were not properly sealed onto the container, exposing the contents to the ambient air in the dry storage room and potential contamination by pathogens, bacteria and pests. There was 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 treat each resident with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, for five of nine anonymous residents reviewed for resident rights. Facility residents were not offered the right to vote in the March 5th election and did not have a plan in place to enable residents to vote in the May 28th or November 5th election. This deficient practice could place residents needing assistance at risk for diminished quality of life, loss of dignity, and self-worth. The findings included: Group interview on 04/03/2024 at 1:20 PM, five residents in a confidential resident group interview stated they have made concerns to the facility Social Worker and Administrator related to the ability to vote either by being transported to a polling site or by receiving mail-in ballots during the last election on March 5th. The resident group stated historically, the elections were coordinated by the Activity Director however as there had been a transition from…

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

Based on interview and record review, the facility failed to consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility for 7 of 9 anonymouse resident council residents. The facility failed to return resident's clothes after laundry service for at least six months after receiving individual and resident council grievances. This deficient practice could place residents needing assistance at risk for diminished quality of life, loss of dignity, and self-worth. The findings included: Record review of resident council minutes, dated October 18, 2023, reflected four council members experiencing lost clothes from the previous month (September 2023). Record review of resident council minutes, dated December 12, 2023, reflected four council members having a current concern of lost clothes. Record review of resident council minutes, dated January 9, 2024, reflecting a single council member having a current concern of lost clothes. Record review of resident council…

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 that the residents had the right to have reasonable access to mail for four of nine anonymous residents reviewed for forms of communication. The facility did not provide residents with their Saturday mail, and instead it was provided on Monday. This deficient practice could affect any resident and result in access to communication being denied. The findings included: Group interview on 04/03/2024 at 1:20 PM, four residents in a confidential resident group interview stated they have made concerns in the last several months related to receiving their mail on Saturdays. The resident group stated they made verbal and written concerns to the Social Worker and Administrator related to the undelivered mail on Saturday but did not receive a resolution back. The resident group stated the paper grievance process included completing a paper grievance form and dropping it into one of the grievances boxed located by the Administrators and Social Worker's offices. The resident group stated they have observed administrative staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review, the facility failed to ensure the residents' right to a safe, clean, comfortable, and homelike environment for 21 (room [ROOM NUMBER], #314, #315, #316, #401, #403, #404, #405, #406, #407, #408, #409, #410, #411, #412, #413, #414, #415, #416, #417, #418) of 23 rooms reviewed for homelike environment: The facility failed to ensure resident bathrooms had hot water maintained at a comfortable temperature which was at least 100 degrees F. These failures could place residents at risk for living in an uncomfortable, and unhomelike environment which could cause a diminished quality of life. The findings included: Observations on 04/02/24 beginning at 10:12 a.m. revealed the following hand sinks had one handle. To turn the sink on you would raise the handle up and turn it to the left or right. The following temperatures were taken in both positions and read the same temperature by this surveyor. The bathroom sinks in the following resident rooms had temperatures 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 interviews and record reviews the facility failed to ensure 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 if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials, including to the State Survey Agency, for 8 of (Resident #17, #22, #33, #55, #70, #71, #87, and #92) 54 residents reviewed for allegations of abuse, neglect, exploitation, and mistreatment, in that: 1. The Administrator did not report to the state agency Resident #17's incident in December 2023, when it was reported she had missing rings. 2. The Administrator did not report to the state agency residents did not have access to hot water for an indetermined amount of time from at least 03/26/24 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 observation, interview, and record review, the facility failed to provide treatment and care in accordance with the comprehensive person-centered care plan and in accordance with professional standards of practice for 2 of 21 Residents (Resident #65 and Resident #47) reviewed for quality of care. 1. The facility failed to obtain medical information needed to monitor the parameters of the cardiac pacemaker for Resident #65. 2. The facility failed to obtain a physician's order for Resident #47 to treat diarrhea after twenty-three instances of loose bowel movements in the last thirty days. This failure could place residents at risk for not having care and services provided to meet their needs. The findings included: 1. Record review of Resident #65's face sheet, dated 04/05/2024 revealed a [AGE] year old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 4 of 21 residents (Resident #51, Resident #33, Resident #70 and Resident #71) reviewed for accidents and hazards in that: 1. The facility failed to ensure Resident #51 did not have a pair of scissors in his room. 2. The facility failed to ensure Resident #33, Resident #70, and Resident #71 did not have disposable razors left on their bathroom counters. This failure could place residents at risk of harm or injury and contribute to avoidable accidents. The findings included: 1. Record review of Resident #51's face sheet, dated 4/2/24, revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included atherosclerosis (disease of the arteries characterized by plaque deposit of fatty material on their inner walls) of bypass graft of bilateral legs, diabetes with neuropathy (chronic, long lasting condition that affects how 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 ensure that residents who required dialysis received such services, consistent with professional standards of practice for 2 of 2 residents (Resident #51, and Resident #82) reviewed for dialysis in that: The facility did not maintain communication, coordination, and collaboration with the dialysis facility for Resident #51 and Resident #82. This deficient practice could affect residents who received dialysis treatments and place them at risk for complications and not receiving proper care and treatment to meet their needs. The findings included: 1. Record review of Resident #51's face sheet, dated 4/2/24, revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included atherosclerosis (disease of the arteries characterized by plaque deposit of fatty material on their inner walls) of bypass graft of bilateral legs, diabetes with neuropathy (chronic, long lasting condition that affects how the body turns 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 review the facility failed to ensure that it was free of medication error rate of 5% percent or greater. The facility had a medication error rate of 32% based on 8 out of 25 opportunities, which involved 1 of 3 Residents (Residents #70) reviewed for medication administration, in that: The facility failed to ensure MA D administered 8 medications within acceptable parameters for safe medication administration to resident #70. This failure could place residents at risk for not receiving the intended therapeutic effects of their medications and could contribute to possible adverse reactions. The findings included: Record review of Resident #70's face sheet, dated 4/5/24 revealed a [AGE] year old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included cerebrovascular disease (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), dysarthria (difficult or unclear articulation…

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 inform each resident periodically during the resident's stay, where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible for 1 of (Resident #70) of 8 residents reviewed for coverage notice. The facility failed to develop, implement, and practice appropriate billing practices, subsequently Resident #70's resident liability changed from $0 to $1,395.90 for 11/01/2023-12/31/2023, $1,427.70 for 01/01/2024-02/29/2024, and to $1,262.80 03/01/2024-Ongoing. The facility failed to notify Resident #70 in a timely manner about the change in Resident liability when they received a notice, dated 02/02/2024, from Texas Health and Human Service Commission about the new liability amount Resident #70 would be responsible for and resulted in a $8,502.60 bill on 04/01/2024. These failures could place residents 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 observations, interviews, and record review the facility failed to ensure the drugs and biologicals used in the facility must be labeled and stored in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions and the expiration date when applicable for 1 of 22 resident rooms (Resident #51's room): The facility failed to ensure Resident #51's medications were stored properly in the facility. This deficient practice could affect residents who received medications for treatments and could result in less potent or an adverse effects and drug diversion. The findings included: Record review of Resident #51's face sheet, dated 4/2/24, revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included atherosclerosis (disease of the arteries characterized by plaque deposit of fatty material on their inner walls) of bypass graft of bilateral legs, diabetes with neuropathy (chronic, long lasting condition that affects…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 Residents (Residents #62) reviewed for infection control. The facility failed to ensure LVN E used appropriate hand hygiene and did not wear a gown when providing medications through a feeding tube to Resident #62 who was on enhanced barrier precautions. This deficient practice could place residents at risk of infection for transmission of communicable diseases and a decline in health. The findings included: Record review of Resident #62's face sheet, dated 4/5/24, revealed a [AGE] year-old female, admitted to the facility on [DATE], with diagnoses that included protein-calorie malnutrition, chronic kidney disease, shortness of breath, dysphagia (difficulty or discomfort swallowing), heart failure and gastrostomy…

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 a functioning resident call system for one (Resident #1) of one resident in that: There was a non-functioning resident on-call system in room [ROOM NUMBER] in which Resident #1 resided. This failure could result in staff not being made aware of the resident's care needs. Record review of the face sheet dated 8/16/23 for Resident #1 revealed diagnoses including chronic kidney disease (a longstanding disease in which the kidneys fail to function properly), type 2 diabetes (a chronic condition that affects how the body processes blood sugar), and peripheral vascular disease ( a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Record review of the quarterly MDS assessment completed on 8/5/23 for Resident #1 revealed a BIMS score of 14 (a mental status test showing person is cognitively intact). Interview with Resident #1 on 8/15/23 at 1:40 p.m., stated that he had put his room call light on in…

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, in that: 1. The walk-in fridge had boxes of food stored on the floor. 2. The dry food storage area had boxes of food on the floor. 3. The dry food storage had containers of food with no lids. 4. The ice machine had a black residue inside above the ice. 5. The sanitizer test strip record was missing recordings. 6. 1 dishwasher sanitizer test strip bottle was expired. 7. A bag of squash had black spots on it and no label. A container of onions had black spots on them and no label. 8. A rack of food was left out from the night before. It had numerous gnats around it. 9. Food temperature was not taken to ensure meat entrée reached a safe temperature. Hot foods were not held at 135 degrees or higher at steam table. These deficient practices could place residents who ate food from the kitchen at risk for foodborne…

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 3 of 5 Residents (Resident #19, #61 and #311) reviewed for medication administration in that: 1. Resident #19 was observed with at least 9 pills in a medication cup at the bedside. 2. Resident #61 was observed with a jar of prescription ointment at the bedside. 3. LVN F administered Aspart (insulin) to Resident #311 without cleaning the rubber stopper and without priming the insulin pen (removing air bubbles from the needle) prior to administering. These deficient practices could affect residents who received medication and place them at risk of not receiving the appropriate amount of medication and could result in an adverse reaction or a decline in health. The findings were: 1. Record review of Resident #19's face sheet, dated 2/15/23…

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 have the right to formulate an advance directive for 1 of 22 residents (Resident #50) reviewed for advanced directives in that: Resident #50's OOHDNR order did not contain a printed physicians name, the physician's license number, and date which made the advance directive invalid. This deficient practice could place residents at risk of not having their wishes known, which could affect whether they receive emergency medical treatment. Findings included: Record review of Resident #50's admission record, dated [DATE], reveled an admission date of [DATE], with diagnosis of fracture (broken bone) and pain. Record review of Resident #50's MDS, dated [DATE], revealed severe cognitive impairment. Record review of Resident #50's order summary, dated [DATE], revealed an order for DNR with an order date of [DATE] and no end date. Review of Resident #50's clinical record revealed an OOHDNR form signed by Resident #50's Representative, two…

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 MDS assessments accurately reflected the resident's status for one of 23 residents (Resident #11) reviewed for accuracy of assessments. The facility failed to ensure the Quarterly MDS dated [DATE] reflected a fall. This deficient practice could place the residents at risk of not receiving the necessary care and services. The findings included: A. Review of Resident #11's admission record revealed an admission date of 01/08/22 with a principal diagnosis of Unspecified fracture of shaft of right tibia (a break of the larger lower leg bone below the knee joint). Review of Resident #11's quarterly MDS dated [DATE] revealed a BIMS score of 12 (score indicated moderate cognitive impairment). Review of the Incidents by Incidents Type report print date 02/14/23 revealed Resident #11 had an unwitnessed fall on 11/12/22. Further review of Resident #11's quarterly MDS dated [DATE] revealed in part, J.1800. Any falls since admission/entry or reentry 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 observation, record review and interview, the facility failed to develop and implement a comprehensive person-centered care plan for 2 of 22 residents (Resident #6 and #82) reviewed for comprehensive person-centered care plans in that: 1. Resident #6's comprehensive care plan did not reflect the resident's use of oxygen therapy. 2. Facility failed to reflect Resident #82's choice to change her own oxygen rate. These deficient practices could affect residents who require care at the facility and result in missed or inadequate care. The findings were: 1. Record review of Resident #6's face sheet, dated 2/15/23 revealed an [AGE] year old female admitted on [DATE] and re-admitted on [DATE] with diagnoses that included COVID-19, morbid obesity due to excess calories, muscle weakness, lack of coordination, hypothyroidism (abnormally low activity of the thyroid gland resulting in slowing of metabolic changes in adults), dementia, cough, shortness of breath and hypertension (high blood pressure). 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 observation, interview, and record review, the facility failed to ensure each resident's environment remains as free of accident hazards as is possible for 1 of 22 residents (Resident #6) whose care was reviewed for accidents and hazards, in that: Resident #6's fall mat (used to prevent injury from fall) was not used while the resident was in the bed. This deficient practice could place residents who were at risk for falls at risk for avoidable accidents and could result in a decline in physical condition. The findings were: Record review of Resident #6's face sheet, dated 2/15/23 revealed an [AGE] year old female admitted on [DATE] and re-admitted on [DATE] with diagnoses that included COVID-19, morbid obesity due to excess calories, muscle weakness, lack of coordination, hypothyroidism (abnormally low activity of the thyroid gland resulting in slowing of metabolic changes in adults), dementia, cough, shortness of breath and hypertension (high blood pressure). Record review of Resident #6's most recent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care and services, including oxygen administration was provided such care, consistent with professional standards of practice for 1 of 2 residents (Resident #6) reviewed for respiratory therapy in that: The facility failed to ensure Resident #6 was receiving oxygen in a manner prescribed by a physician and the filter on the oxygen concentrator was covered with a white substance. These deficient practices could affect residents who received respiratory therapy and put them at risk for inadequate or inappropriate amounts of oxygen delivery. The findings were: Record review of Resident #6's face sheet, dated 2/15/23 revealed an [AGE] year old female admitted on [DATE] and re-admitted on [DATE] with diagnoses that included COVID-19, morbid obesity due to excess calories, muscle weakness, lack of coordination, hypothyroidism (abnormally low activity of the thyroid gland resulting in slowing of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident in 1 of 1 kitchen and 1 (Resident #310) of 22 Residents. Resident #310 was not served a breakfast tray. These failures could place residents who eat foods prepared in the kitchen at risk of cross contamination, food-borne illnesses, no food intake, weight loss, and not having their nutritional needs met. Findings include: Record review of Resident #310's admission record, dated 02/17/23, revealed diagnosis to include critical illness myopathy (muscle weakness occurring in critically ill patients and involving all extremities and the diaphragm [muscle involved in breathing]) and severe protein calorie malnutrition (condition where the body lacks enough protein and energy to function properly). Record review of Resident #310'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 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 2 residents (Resident #6) reviewed for infection control practices in that: LVN Treatment Nurse J failed to utilize appropriate infection control practices during wound care to Resident #6. This failure could place residents with wounds at risk for infection, slow wound healing and or a decline in health. The findings were: Record review of Resident #6's face sheet, dated 2/15/23 revealed an [AGE] year old female admitted on [DATE] and re-admitted on [DATE] with diagnoses that included COVID-19, morbid obesity due to excess calories, muscle weakness, lack of coordination, hypothyroidism (abnormally low activity of the thyroid gland resulting in slowing of metabolic changes in adults), dementia, cough,…

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.