Highland Pines Nursing Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure residents received care, consistent with professional standards of practice, to prevent pressure ulcers based on the comprehensive assessment for 3 of 6 Residents (Resident #21, Resident #51, and Resident #79) whose records were reviewed for skin integrity. The facility failed to ensure Resident #21, Resident #51, and Resident #79's pressure-relieving mattresses (is designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) were on the correct settings. The facility failed to ensure Resident #79 received and/or documented wound care on 10/05/24, 10/06/24, 10/07/24, 10/10/24, 10/11/24, and 10/13/24. These failures could place residents at risk for developing pressure ulcers and could contribute to developing avoidable pressure ulcers. Findings included: 1. Record review of Resident #21's face sheet dated 10/14/24 indicated Resident #21 was a 69-years-old female 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 ensure that each resident who was incontinent of bowel/bladder and each resident with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections, for 3 of 7 residents (Resident #52, Resident #79, and Resident #88) reviewed for indwelling urinary catheters. The facility failed to ensure Resident #52, Resident #79, and Resident #88's indwelling catheter (drains urine from your bladder into a bag outside your body) had a catheter securement device to anchor catheter to their legs on 10/14/24, 10/15/24, and 10/16/24. The facility failed to ensure Treatment Nurse M did not place Resident #79's catheter bag on the bed during wound care on 10/15/24. Theses failures could place residents at risk for urinary tract infections. Findings included: 1. Record review of Resident #52's face sheet dated 10/17/24 indicated Resident #52 was a 77-years-old male admitted on [DATE] with diagnosis including…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 3 of 5 residents (Resident #25, Resident #16, and Resident #15) reviewed for respiratory care and services. 1. The facility failed to obtain a physician's order for Resident #25's oxygen, prior to surveyor intervention. 2. The facility failed to ensure Resident #25's oxygen concentrator was clean and free of gray/black debris. 3. The facility failed to ensure Resident #15's CPAP mask was stored in bag and oxygen concentrator had a filter on 10/14/24-10/17/24. 4. The facility failed to ensure Resident #16's oxygen concentrator filter was free from gray, fuzzy particles on 10/14/24-10/16/24. These failures could place residents who receive oxygen at risk for developing respiratory complications. Findings included: 1. Record review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 5 of 24 resident personal refrigerators reviewed for food safety (Resident #42, Resident #49, Resident #51, Resident #72, and Resident #81). 1.The facility failed to ensure the refrigerator for Resident #72 was cleaned, clutter free and free from meat with green mold. 2.The facility failed to ensure Resident #42, Resident #49, Resident #51, and Resident #81's refrigerator temperature was checked and logged daily. These failures could place resident at risk for food borne illnesses. The Findings were: 1.Record review of Resident #72's face sheet, dated 10/14/24 revealed a [AGE] year old male admitted on [DATE] with diagnoses that included chronic respiratory failure with hypoxia (a serious, long-term condition that makes it difficult to breathe and exchange oxygen and carbon dioxide in the body), unspecified protein-calorie malnutrition (a condition that occurs when…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 6 of 24 residents reviewed for infection control practices (Resident #'s 2, 7, 37, 39, 91, and 100), 1.The facility failed to ensure CNA C changed her gloves and performed hand hygiene appropriately while providing incontinent care to Resident #2. 2. The facility failed to ensure Resident #7 had enhanced barrier precautions sign posted on door with storage container for PPE on 10/14/2024 for resident with a feeding tube. 3. The facility failed to ensure Resident # 37 had enhanced barrier precautions in place with proper PPE storage containers available to care for foley catheter and wound care. 4. The facility failed to ensure Resident # 39 has enhanced barrier precautions in place with PPE containers available…

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 each resident was informed before or at the time of admission, and periodically during the residents stay, of services available in the facility and of charges for those services, which included charges for services not covered under Medicare/Medicaid or by the facility's per diem rate for 2 of 3 residents (Resident #274, and Resident #275) reviewed for Medicare/Medicaid coverage. The facility failed to ensure Resident #274, and Resident #275 were given a SNF ABN (a document that informs a Medicare beneficiary that Medicare will no longer pay for skilled services) when discharged from skilled services at the facility prior to covered days being exhausted. These failures could place residents at risk for not being aware of changes to provided services. Findings included: 1. Record review of Resident #274's face sheet, dated 10/15/24, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included embolism 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 interviews and record review, the facility failed to report the results of all investigations to the Administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation was verified appropriate corrective action must be taken for 1 of 7 residents (Resident #1) reviewed for abuse and neglect. The facility failed to ensure the provider investigation report regarding Resident#1's incident with Resident #26, dated 09/12/24 was turned into the state survey agency (HHSC) within 5 working days of the reported incident for Resident #1. This failure could place residents at risk for abuse and neglect. Findings included: 1. Record review of Resident #1's face sheet, dated 10/14/24, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included unspecified dementia (a group of symptoms that affect a person's memory, thinking, 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 interviews and record review, the facility failed to ensure assessments accurately reflected the resident's status for 2 of 24 resident reviewed for assessments. (Resident #49 and Resident #88) The facility failed to ensure Resident #49's MDS dated [DATE], was not inaccurately coded for being on an antipsychotic medication (are a class of psychotropic medication primarily used to manage psychosis). The facility failed to ensure Resident #49's MDS dated [DATE], was not inaccurately coded as having a diagnosis of bipolar (is a mental illness that causes extreme shifts in mood, energy, and activity levels) instead of mood disorder. The facility failed to ensure Resident #88's MDS dated [DATE] was coded for being PASRR (is a federally mandated review process, requiring all people seeking Medicaid-certified nursing facilities admissions to be screened for mental illness or intellectual and developmental disability regardless of funding source or age) positive for development disability/intellectual…

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 the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for 1 of 13 residents (Resident #97) reviewed for PASRR Level I screenings. 1. The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #97. This failure could place residents who had a mental illness at risk of not receiving a needed assessment (PASRR Evaluation), individualized care, or specialized services to meet their needs. Findings included: Record review of Resident #97's face sheet, dated 10/14/2024, revealed he was a [AGE] year-old male, who was readmitted to the facility on [DATE], with diagnoses which included hemiplegia and hemiparesis following cerebral infarction (symptom that involves one-sided paralysis after blood flow to the brain is blocked or reduced), obstructive and reflux uropathy (when your urine can't flow (either partially or completely) through your ureter, bladder, 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 notify the State Mental Health Authority to inform them of a significant change in mental condition for 1 of 5 (Residents #93) residents reviewed for Preadmissions Screening and Annual Resident Review (PASRR). 1. The facility failed to notify the SMHA to ensure Resident #93 received a new PASRR level 1 screening following identification of his diagnosis of post-traumatic stress disorder on 01/25/24. This failure could affect residents who may have a mental disorder diagnosis by placing them at risk for not receiving the necessary services that may benefit them daily. Findings included: Record review of Resident #93's face sheet, dated 10/14/24, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included post-traumatic stress disorder (a real disorder that develops when a person has experienced or witnessed a scary, shocking, terrifying, or dangerous event), encephalopathy (a broad term for any brain disease…

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 to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 1 of 24 residents reviewed for care plans. (Resident #25) The facility failed to ensure that Resident #25's care plan addressed his oxygen use. These failures could place residents at risk for not receiving the necessary care or having important care needs identified. Findings included: Record review of Resident #25's face sheet, dated 10/15/24, indicated he was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included chronic respiratory failure (a long-term condition that makes it difficult to breathe because the lungs can't exchange oxygen and carbon dioxide properly), heart failure (a serious condition that occurs when the heart can't pump enough blood and oxygen to meet the body's needs), chronic obstructive pulmonary disease (a common lung disease…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 2 of 5 residents reviewed for ADLs. (Resident #81 and Resident #88) The facility failed ensure Resident #81 was provided timely incontinent care on 10/15/24. The facility failed to ensure Resident #88 did not have yellow substance on his gum line and between his teeth on 10/14/24, 10/15/24, and 10/16/24. The facility failed to ensure Resident #88 was gotten or offered to get out of bed in October 2024. Theses failures could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, feelings of poor self-esteem, lack of dignity and health. Findings included: 1. Record review of Resident #81's face sheet dated 10/17/24 indicated Resident #81 was a 75-years-old female admitted on [DATE] and 08/07/22 with diagnoses including chronic respiratory failure (occurs when the body has low…

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 to include procedures that assured the accurate dispensing and administering of all drugs to meet the needs of 1 of 12 residents reviewed for pharmaceutical services. (Resident #72) Facility staff failed to remove Lidocaine patches 5% strength from Resident #72's personal refrigerator. These deficient practices could affect residents and place them at risk of not receiving the therapeutic dosage and drug diversion. The findings were: Record review of Resident #72's face sheet, dated 10/14/24 revealed a [AGE] year old male admitted on [DATE] with diagnoses that included chronic respiratory failure with hypoxia (a serious, long-term condition that makes it difficult to breathe and exchange oxygen and carbon dioxide in the body), unspecified protein-calorie malnutrition (a condition that occurs when a person does not get enough calories or the right amount of nutrients, such as proteins, carbohydrates, fats,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary medications (is a medication used: In excessive doses (including duplicate therapy); or For excessive duration; or Without adequate monitoring; or Without adequate indication for its use; or In the presence of adverse consequences which indicate the dose should be reduced or discontinued) for 1 of 5 residents (Resident #21) reviewed for unnecessary medications in that: The facility failed to ensure Resident #21 had documented diagnoses for the use of Atorvastatin (is used together with a proper diet to lower cholesterol and triglyceride (fats) levels in the blood), Furosemide (is a strong diuretic ('water pill')), Lasix (is a loop diuretic (water pill) that prevents your body from absorbing too much salt, causing it to be passed in your urine), Gabapentin (is a medicine used to treat partial seizures, nerve pain from shingles and restless leg syndrome), Melatonin (is used to combat jet lag…

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's PRN orders for psychotropic drugs were limited to fourteen (14) days for 1 of 24 residents selected for unnecessary medications review. (Resident #59). Resident #59 had a PRN order for Lorazepam, a psychotropic medication, for more than fourteen days without physician documentation re-evaluating the medication to continue it PRN or to become a scheduled medication. This failure could place residents who receive PRN psychotropic medications at risk of receiving unnecessary medications. Findings included: Record review of the undated face sheet indicated Resident #59 was an [AGE] year-old male that admitted on [DATE] and readmitted on [DATE]. Record review of the quarterly MDS dated [DATE] indicated Resident #59 had clear speech, was understood by others, and understood others. He had a BIMS score of 9 indicating moderate cognitive impairment. Record review of the care plan dated 8/29/24 indicated Resident #59 required psychotropic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 14.81%, based on 4 errors out of 27 opportunities, which involved 2 of 5 residents (Resident #39, Resident #90) reviewed for medication administration. 1. The facility failed to administer Resident # 39's [NAME] vitamin B-complex (contains essential vitamins such as B-complex, vitamin C, and folic acid, which help manage or prevent deficiencies common in individuals with compromised renal function.) and administered incorrect dose of Vitamin D3 25 mcg (a nutrient your body needs for building and maintaining healthy bones) on 10/15/2024. 2. The facility failed to administer Resident # 90's Oxybutynin (to treat an overactive bladder) and Protonix (a medication used to decrease the amount of acid produced in the stomach as ordered on 10/15/2024. These failures could place residents at risk for not receiving the intended…

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 that residents were free of significant medication errors for 1 of 10 residents (Residents #51) reviewed for pharmacy services. The facility failed to ensure Resident #51 received Acetaminophen-Codeine Oral Tablet 300-60mg (is used to help relieve mild to moderate pain; Tylenol #4 contains 60 mg of Codeine) as scheduled on 10/13/24 (8am and 3pm) and 10/14/24 (8am). This failure could place residents at risk of discomfort and pain. Findings included: Record review of Resident #51's face sheet dated 10/15/24 indicated Resident #51 was a [AGE] year-old female admitted on [DATE] and 12/08/20 with diagnoses including metabolic encephalopathy (is a brain dysfunction caused by a chemical imbalance in the blood that affects the brain), muscle wasting and atrophy (shortening), pain in left leg and hip, anxiety (is a mental illness that causes excessive and uncontrollable feelings of fear or anxiety that can significantly impair a person's daily life),…

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 drugs and biologicals were stored in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 2 of 38 residents. (Resident #274 and Resident # 54) 1. The facility failed to ensure Santyl and Mupirocin ointment 2% was properly stored and locked in accordance with currently accepted professional standards for Resident # 54. 2. The facility failed to ensure Triamcinolone Acetonide Ointment 1% was properly stored and locked in accordance with currently accepted professional standards on [DATE] for Resident # 274. This failure could place residents at risk for adverse effects and reduced therapeutic effects of medication and supplies. Findings included: 1. Record review of Resident #54 s face sheet, dated [DATE], revealed he was an [AGE] year-old male, who was admitted to the facility on [DATE], with the diagnoses which included Type II Diabetes (Diabetes mellitus refers 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 develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 1 of 5 residents reviewed for care plans. (Resident #1) The facility failed to develop and implement the comprehensive person-centered care plan for Resident #1 by not documenting foley catheter changes. This failure could place residents at risk of not having individual needs met, a decreased quality of life, and cause residents not to receive needed services. Findings include: Record review of a face sheet dated 11/7/22 revealed Resident #1 was [AGE] years old and was admitted on [DATE] with diagnoses including Obstructive and Reflux Uropathy (A blockage in the urinary tract that prevents urine from flowing normally. This can cause urine to back up into the kidneys, which can damage them.), COPD (Chronic obstructive pulmonary disease is a chronic lung disease that makes it difficult to breathe),…

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 resident received adequate supervision to prevent accidents for 1 of 5 residents reviewed for accidents (Resident #14). The facility failed to ensure Resident #14 who was identified as high fall risk, confused, unable to be assessed for ability to sit to stand due to medical condition and safety concerns, and required wheelchair was monitored more closely to prevent falls or injury. This failure could place residents at risk for injury or harm. Findings included: Record review of Resident #14's face sheet dated 9/3/2024 indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were traumatic subdural hemorrhage with loss of consciousness of 30 minutes or less, subsequent encounter (a type of bleeding near the brain that can happen after a head injury), dementia (general term for impaired ability to remember, think, or make decisions that interferes with doing everyday activities), depression (mood…

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 that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours 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 1 of 7 residents (Resident #1) reviewed for neglect. Resident #1 was identified as confused and a wanderer and had increased confusion but was not monitored more closely. The facility did not report to HHSC when Resident #1 was discovered in traffic on a busy street on 7/27/24. This failure placed the resident at risk for harm. Findings included: Record review of Resident #1's face…

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 consult with the resident physician when there was a need to alter treatment for 1 out of 3 residents (Resident #61) reviewed for notification of changes. The facility failed to notify and consult with the physician about the changes in Resident #61's high blood sugar readings. This failure could place residents at the risk of not receiving appropriate medical interventions, which could result in severe illness or hospitalization. Findings included: Record review of Resident #61's face sheet, dated 09/05/23 indicated Resident #61 was an [AGE] year-old male admitted to the facility on [DATE] and re-admitted [DATE] with diagnoses which included stroke (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off), diabetes (a condition that happens when your blood sugar (glucose) is too high) and seizures (when too many of your brain cells become excited at the same…

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 a safe, clean, sanitary, comfortable, and homelike environment 4 of 35 residents reviewed for environment. (Resident #34, Resident #73, Resident #23, and Resident #267) 1. The facility failed to ensure Resident #34 and Resident #73's portable air conditioning unit/filter was free of gray fuzz and dust-like particles. 2. The facility failed to ensure Resident #34's fan was free of gray fuzz and dust-like particles. 3. The facility failed to ensure Resident #23's bathroom was cleaned daily. 4. The facility failed to ensure Resident #267 did not have enteral feeding (also known as tube feeding, is a way of delivering nutrition directly to your stomach or small intestine) on the floor, IV pole, wall, and mattress. These failures could place residents at risk of an unsafe, unsanitary, or uncomfortable environment and a decrease in quality of life and self-worth. Findings included: 1.Record review of Resident #34's face sheet 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 interview, observation, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 2 of 7 residents reviewed for care plans. (Resident #72, Resident #98) The facility failed to implement the care plan intervention to document Resident #72 and Resident #98's meal intake. The facility failed to implement the care plan intervention for Resident #98 to receive his Frozen Nutritional Treats with meals. These failures could place residents at risk of not having individual needs met and cause residents not to receive needed services Findings included: 1. Record review of a face sheet dated 08/30/23 indicated Resident #72 was a [AGE] year-old male and admitted to the facility on [DATE] with diagnoses including Parkinson's (is a movement disorder. It causes tremors, stiffness, and slow movement), Alzheimer's (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 observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain personal hygiene were provided for 4 of 6 residents reviewed for ADLs (Resident # 79, Resident #98, Resident #66, Resident #90). 1. The facility failed to ensure Resident #79 received her scheduled bed bath. 2. The facility failed to ensure Resident #98 received his schedule bed baths. 3. The facility failed to ensure Resident #98 was offered to get out of bed. 4. The facility failed to ensure Resident #66 was routinely showered/bathed and shaved. 5. The facility failed to ensure Resident #90 was routinely showered/bathed. These failures could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health. Findings included: 1. Record review of a face…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of the bladder and had an indwelling urinary catheter received appropriate treatment and services for 3 of 4 resident (Resident #5, #79, and #89) reviewed for incontinence and urinary catheters. The facility failed to ensure Resident #5 had a physician's order for her indwelling urinary catheter with appropriate diagnosis for use. The facility failed to provide timely incontinence care to Resident #79 and Resident #89. These failures could place residents at risk for not receiving appropriate care, infections, skin breakdown and decreased quality of life. Findings included: 1. Record review of Resident #5's face sheet dated 08/30/23, indicated an [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia (memory loss), neuromuscular dysfunction of bladder (bladder dysfunction caused by nervous system conditions), diabetes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 7 of 35 residents reviewed for respiratory care. (Resident #4, Resident #26, Resident #34, Resident #56, Resident #67, Resident #73, and Resident #75). 1. The facility failed to ensure oxygen concentrator filters were free of gray fuzz, hair-like and dust-like particles for Resident #4, Resident #26, Resident #34, and Resident #73. 2. The facility failed to ensure Resident #75's oxygen concentrator was free of gray fuzz and dust-like particles in the slatted vent on the back of the oxygen concentrator. 3. The facility did not ensure oxygen concentrator filters were free from brown like substances for Resident #56 and Resident #67. 4. The facility failed to ensure Resident #26's oxygen tubing was changed weekly per physician orders. These failures could place residents at risk of respiratory infections. Findings included: 1. Record review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 4 of 6 residents (Resident #s 9, 68, 23, 79) reviewed for pharmacy services. ADON K failed to ensure she had a witness when wasting Resident #9's acetaminophen-codeine 300-60mg tablet (controlled medication used for pain). The facility failed to ensure Resident #68's Lorazepam (controlled antianxiety medication) was accurately reconciled. The facility failed to administer Resident #23 and Resident #79's scheduled medication per the facility's policy timeframe. These failures could place the residents at risk of not having medications available for use, not receiving medications, and drug diversion. Findings include: 1. Record review of Resident #9's face sheet dated 08/30/23, indicated a [AGE] year-old female who admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an 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 6 of 6 residents (Resident #s 5, 81, 32, 23, 79, and 98) and 4 of 4 staff (ADON K, LVN V, CNA A, CNA B) reviewed for infection control. The facility failed to ensure ADON K cleaned the glucometer after using it on a Resident #81. The facility failed to ensure ADON K performed hand hygiene during Resident #81's medication administration. The facility failed to ensure LVN V performed hand hygiene during Resident #5's medication administration. The facility failed to ensure CNA A provided proper incontinent care to Resident #32. The facility failed to ensure Resident #23 and Resident #79's water pitchers were cleaned regularly. The facility failed to ensure CNA A and CNA B followed contact isolation guideline for Resident #98.…

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 for 2 of 3 residents (Resident #98, Resident #267) reviewed for reasonable accommodations. The facility failed to ensure Resident #98 and Resident#267 call lights were within reach. The facility failed to ensure Resident #98, and Resident #267 had been assessed for the appropriate type of call light. These failures could place residents at risk for unmet needs. Findings included: 1. Record review of a face sheet dated 08/28/23 indicated Resident #98 was a [AGE] year-old male and admitted to the facility on [DATE] with diagnoses including Asperger's syndrome (a developmental disorder affecting ability to effectively socialize and communicate), muscle wasting and atrophy (is the wasting (thinning) or loss of muscle tissue), muscle weakness, slowness and poor responsiveness, limitation of activities…

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 a right to personal privacy and confidentiality of medical records for 2 (Resident #81 and Resident #5) of 7 residents reviewed for privacy and confidentiality. ADON K failed to ensure she closed the EMR of Resident #81 before entering his room to obtain a blood sugar check and administer medications. LVN V failed to ensure she closed Resident #5's EMR before entering the supply room and leaving the cart unattended. These failures could place residents at risk for low self-esteem, loss of dignity and decreased quality of life due to medication administration record being accessible to others. Findings included: 1. Record review of Resident #81's face sheet dated 08/30/23, indicated a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included quadriplegia (paralysis that affects all four limbs, plus torso), diabetes mellitus (a group of diseases that result in too much sugar in the blood),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team and the participation of the resident for 1 of 2 residents (Resident #82) reviewed for care plan timing and revision. The facility failed to ensure the IDT were in attendance to Resident #82's care plan meeting. This failure could place residents at risk of not being able to attain or maintain their highest practicable level of physical, mental, and psychosocial well-being. Findings included: Record review of Resident #82's face sheet dated 08/30/23, indicated a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included cerebrovascular disease (stroke), diabetes mellitus (a group of diseases that result in too much sugar in the blood), hypertension (high blood pressure), schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly), and bipolar disorder (disorder associated with episodes of mood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were offered sufficient fluid intake to maintain proper hydration and health for 3 of 4 resident (Resident #23, Resident #79, Resident #98) reviewed for hydration. The facility failed to ensure Resident #23, and Resident #79 received adequate hydration. The facility failed to ensure Resident #98 received thickened liquid for hydration between meals. The facility failed to implement the care plan intervention for Resident #98 to receive his Frozen Nutritional Treats with meals. These failures could place residents at risk for dehydration, electrolyte imbalance, and infections. Findings included: 1. Record review of a face sheet dated 08/30/23 indicated Resident #23 was [AGE] year-old female and admitted on [DATE] with diagnoses including type 2 diabetes (a chronic condition that affects the way the body processes blood sugar (glucose)), need for assistance with personal care, and abnormal weight loss. Record review of a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to 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 6 medication carts and 3 of 27 residents reviewed in sample (Resident #319, Resident #13 and Resident #81 ). The facility failed to have Resident #319's Arthritis hot pain cream stored and locked in an area not accessible to other staff, residents, or visitors. The facility failed to ensure Resident #13 did not have prescribed and OTC medications at bedside. ADON K failed to ensure the medication cart for hall 300 rooms 316-331 was locked when it was left unattended while giving Resident #81's medication. ADON K and LVN V failed to ensure the medication cart for hall 300 rooms 316-331 was locked when it was left unattended. These failures could place residents at risk of injury. Findings included: 1.Record review of Resident #319's face sheet dated 08/30/23 indicated she 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure safe and sanitary storage of resident's food items for 2 of 3 residents reviewed for personal food safety. (Resident #16 and Resident #34) The facility did not implement the personal food policy related to personal refrigerators for Resident's #16 and Resident #34. These failures could place the residents at risk for food borne illness. The findings included: 1. Record review of Resident #16's face sheet dated 8/30/23 indicated she was a 100year old female who admitted to the facility on [DATE] with the diagnoses of high blood pressure, breast cancer, heart failure, and need for assistance with personal care. Record review of Resident #16's MDS assessment dated [DATE] indicated that she had a BIMS score of 12 which meant she had moderately impaired cognition. The MDS also indicated that resident required extensive assistance of 2 staff for bed mobility, extensive assistance of 1 staff for transfers, toileting, dressing, 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 all patient care equipment was in safe operating condition for 1 of 1 resident (Resident#14) reviewed safe, functional equipment. The facility failed to ensure Resident #14 had an armrest cushion and secured side panel of her wheelchair. This failure could place residents at risk for skin issues, discomfort, and falls. Findings included: 1. Record review of a face sheet dated 08/30/23 indicated Resident #14 was a [AGE] year-old female and admitted on [DATE] with diagnoses including repeated falls, age-related physical debility (weakness or feebleness), lack of coordination and unsteadiness on feet. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #14 was understood and understood others. The MDS indicated Resident #14 had adequate hearing, clear speech, and impaired vision with corrective lenses. The MDS indicated Resident #14 had a BIMS score of 15 which indicated intact cognition. The MDS indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow their own established smoking policy for 1 of 3 residents (Resident #61) reviewed for smoking. The facility failed to ensure Resident #61 followed the facility's policy on smoking. the did not have a lighter and cigarettes on his bedside table. This failure could place residents at risk of unsafe smoking and injury. Findings included: Record review of Resident #61's face sheet, dated 09/05/23 indicated Resident #61 was an [AGE] year-old male admitted to the facility on [DATE] and re-admitted [DATE] with diagnoses which included stroke (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off), diabetes (a condition that happens when your blood sugar (glucose) is too high) and seizures (when too many of your brain cells become excited at the same time). Record review of Resident #61's quarterly MDS assessment, dated 08/04/23, indicated Resident #61 was…

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