Treviso Transitional Care

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to consult with the resident's physician and representative when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 22 residents (Resident #61) reviewed for notification of change.The facility failed to notify the NP/MD of Resident #61's complaint of left foot pain on 8/21/25.This failure could place residents at risk of not receiving adequate and timely intervention and a decline in condition.Findings included: Record review of Resident #61's face sheet dated 8/26/25 indicated he was [AGE] years old and was admitted to the facility on [DATE]. Resident #61 had diagnoses which included cerebral infarction (stroke-disruption of blood flow to the brain causing tissue damage), hemiplegia and hemiparesis (paralysis (unable to move) and/or muscle weakness on one side of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the right to be free from any physical restraints imposed for purposes of convenience and not required to treat medical symptoms for 1 of 1 resident reviewed for restraint use (Resident #8).The facility failed to ensure Resident #8 was free from physical restraints in the form of seatbelt located on the wheelchair that Resident #8 was unable to remove independently. This failure could place residents at risk for a decreased quality of life, a decline in physical functioning and injury. Findings included:Record review of a face sheet printed on 8/24/2025 indicated Resident #8 was an [AGE] year-old, female and was readmitted on [DATE] with diagnoses including Chronic pain syndrome (a long-term condition characterized by persistent pain that last for months or years, significantly affecting daily life), hemiplegia affecting left nondominant side (partial or total paralysis on one side of the body), hypertension (occurs when 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 interviews and record review the facility failed to ensure assessments accurately reflected the resident status for 1 of 22 residents (Resident #3) reviewed for MDS assessment accuracy. The facility did not ensure Resident #3's quarterly MDS identified a diagnosis of Diabetes and use of insulin. These failures could place residents at risk for not receiving care and services to meet their needs.Findings included:Record review of the face sheet dated 8/25/2025 indicated Resident #3 was [AGE] year-old female who was readmitted [DATE] with diagnoses including fracture of lower end of left tibia (a break in the shinbone which is the larger bone in the lower leg), neuromuscular dysfunction of bladder (refers to a condition where the bladder's ability to store and release urine is impaired due to problems with nervous system), malignant neoplasm of uterus (a cancerous tumors that develop when cells in the lining of the uterus) and Diabetes (a group of diseases that affect how the body uses blood sugar).…

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 the resident and their representative with a summary of the baseline care plan for 2 of 6 residents (Resident #60 and Resident #114) reviewed for baseline care plans. The facility failed to provide Resident #60 and Resident #114, a copy of the summary of their baseline care plans. This failure could place residents at risk of not knowing their care and needs provided by the facility. Findings included:1. Record review of Resident #60's face sheet dated 8/26/25 indicated Resident #60 was a [AGE] year-old male admitted to the facility on [DATE]. Resident #60 had diagnoses including pneumonia (is an infection that inflames the air sacs in one or both lungs), type 2 diabetes (is a chronic condition that happens when you have persistently high blood sugar levels), and chronic obstructive pulmonary disease (is a chronic lung disease that causes inflammation and narrowing of the airways, leading to airflow obstruction). Resident #60 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 1 of 17 residents reviewed for ADLs (Residents #59.) The facility did not clean or trim Resident #59's fingernails.This failure 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.The findings were:Review of Resident #59's electronic face sheet dated 10/18/2024 revealed he was admitted to the facility on [DATE] with diagnoses of Dysphagia (difficulty swallowing), Parkinson's Disease (a progressive, chronic neurological disorder characterized by symptoms such as tremors, muscle stiffness, slow movement (bradykinesia), and impaired balance), Lack of Coordination (a neurological symptom characterized by awkward, clumsy movements affecting the whole body, limbs, or eyes, resulting 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 7 residents (Resident #3) reviewed for accidents and supervision. The facility failed to ensure CNA G performed a safe mechanical lift transfer for Resident #3.This failure could place residents at risk of injury.Findings include:Record review of Resident #3's face sheet dated 8/26/25 indicated she was [AGE] years old and admitted to the facility on [DATE]. Resident #3 had diagnoses which included history of left tibia (lower leg bone), diabetes (high blood sugar), history of falls, rheumatoid arthritis (chronic inflammation disorder usually affecting small joints in the hands and feet), hypertension (high blood pressure), and heart failure.Record review of Resident #3's quarterly MDS dated [DATE] indicated had a BIMS score of 14, 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 observation, interviews, and record review, the facility failed to ensure a resident with urinary incontinence, based on the resident's comprehensive assessment, received appropriate treatment and services to prevent urinary tract infections (UTI) for 1 of 2 residents (Residents #25) reviewed for urinary catheters. The facility failed to ensure Resident #25 had an indwelling (foley) catheter securement device on 8/25/25.The facility failed to ensure on 8/25/25, CNA D provided catheter care per the facility's policy and procedure on Resident #25.These failures could place residents at risk for indwelling urinary catheter dislodgement, urethral (empties urine from the bladder and out of the body) damage, pain, and urinary tract infections.Findings included:Record review of Resident #25's face sheet dated 8/26/25 indicated Resident #25 was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #25 had diagnoses including neuromuscular dysfunction of bladder (a person…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or others for 1 of 6 residents (Resident #1) reviewed for reasonable accommodations of needs . The facility failed to ensure Resident #1 had a functioning call light. This failure could place residents at risk of possible falls, major injuries, hospitalization, and unmet needs. Findings include: Record review of Resident #1's, undated, face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: Cerebral Infarction (a serious condition that occurs when blood flow to the brain is blocked, causing an area of dead brain tissue), Urinary Tract Infection (a bacterial infection that affects the urinary tract, which includes the bladder, ureters, kidneys, and urethra),…

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 group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life and failed to demonstrate their response and rationale for such response in a timely manner 3 (February, March, and April 2024) of 6 months reviewed for resident group response, in that: The documentation of the facility's effort to resolve resident grievances of medicine being left at bedside, not having their beds made, bedding not being changed on shower days, no snacks being provided, and the facility running out of toilet paper collected at Resident Council meetings on 02/01/2024, 03/21/2024, and 04/04/2024 were not made until between 05/07/2024 and 05/18/2024. This failure placed residents at risk of not having grievances addressed or provided a rational for facility decisions for issues identified in a timely manner. Findings included: Record review of Resident Council Meeting Forms dated 02/01/2024, 03/21/2024, and 04/04/2024 indicated the group council voiced…

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 Minimum Data Set (MDS) was electronically completed and transmitted to the CMS System within 14 days after completion for 4 of 32 residents (Resident #149, Resident #24, Resident #16, and Resident #5) reviewed for MDS transmittal. The facility did not ensure Resident # 149's quarterly MDS assessment dated [DATE] was completed and successfully electronically transmitted within 14 days The facility did not ensure Resident # 24's quarterly MDS assessment dated [DATE] was completed and successfully electronically transmitted within 14 days . The facility did not ensure Resident # 16's quarterly MDS assessment dated [DATE] was completed and successfully electronically transmitted within 14 days . The facility did not ensure Resident # 5's quarterly MDS assessment dated [DATE] was completed and successfully electronically transmitted within 14 days This deficient practice could place residents at risk of not having their assessments transmitted…

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 in 1 of 1 kitchen reviewed for food service safety. 1. The facility failed to store all cardboard boxes off the floor. 2. The facility failed to ensure the outside of the microwave and the wall next to the beverage table was clean and sanitary. 3. The facility ensure that all food items in the freezer and walk in cooler were properly dated and labeled. These failures could place residents at risk of foodborne illness and food contamination. Findings include: During an observation on 07/08/24 at 6:14 a.m., there were two (2) carboard boxes containing clear liquid frying oil sitting on the floor of the pantry. During an observation on 07/08/24 at 6:15 a.m., the microwave was sitting on a stainless-steel table. There was a brown buildup on the outside of the microwave. During an observation on 07/08/24 at 6:16 a.m., a coffee dispenser was sitting on a plastic bin with a white lid on the beverage table. The white lid and the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a resident assessment within the required time frame for 3 of 15 residents (Resident 24, Resident 16, Resident #5) reviewed for quarterly assessments. Resident #24's Quarterly MDS dated [DATE], was not completed until 7/8/24. Resident #16's quarterly MDS dated [DATE], was not completed until 7/5/24. Resident #5's quarterly MDS dated [DATE], was not completed until 7/5/24. This failure placed residents at risk of not having their assessments completed timely which could result in not having their individually assessed needs met. Findings included: 1. Record review of Resident #24's face sheet dated 01/27/24 indicated she was an [AGE] year-old female who admitted to the facility on [DATE]. Resident #24 had diagnoses including Acute Kidney Failure (A condition in which the kidneys suddenly can't filter waste from the blood), Parkinson's Disease (A disorder of the central nervous system that affects movement, often including tremors), and Anemia…

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 resident assessments accurately reflected the resident's status for 1 (Resident #13) of 12 residents reviewed for accuracy of resident assessments. The facility failed to ensure that Resident #13's MDS 05/05/2024 quarterly assessment accurately reflected the resident's history of falls. This failure put residents at increased risk of staff not being aware of resident needs due to inaccurate assessments. Findings included: Record review of Resident #13's face sheet dated 07/09/2024 revealed she was and 82-years-old female, admitted to the facility on [DATE]. She had diagnoses of Parkinson's Disease (chronic and progressive movement disorder that initially causes tremor in one hand, stiffness or slowing of movement), dysphagia (difficulty swallowing), and depression. Record review of the quarterly MDS assessment dated [DATE] indicated Resident #13 had a BIMS of 08, which indicated moderate cognitive impairment. The MDS also revealed Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and records reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to ensure the comprehensive care plan described the services and interventions to be used to attain and maintain the resident's practicable physical, mental, and psychosocial well-being for 2 (Resident #13 and Resident #44) of 10 residents reviewed for care plans. 1.The care plan for Resident #13 did not address the diagnosis and treatment for Parkinson's Disease. 2.The care plan for Resident #44 did not address a significant weight loss of greater than 10% in 180 days. These failures could place residents at risk of not having their individualized needs met, falls, weight loss and a decline in their quality of care and life. Findings include: 1.Record review of Resident #13's face sheet dated 07/09/2024 revealed she was and 82-years-old female, admitted to the facility on [DATE]. She had diagnoses of Parkinson's Disease (chronic and progressive movement disorder that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 2 of 13 residents (Residents #13 and Resident #44) reviewed for care plans. 1. The facility failed to revise and update Resident #13's nutrition care plan with the diet change of puree diet with honey thickened liquids. 2. The facility failed to revise and update Resident #44's comprehensive care plan about her discontinued IV medications, discontinued use of a foley catheter, healed DTI to left heel, tobacco use, antibiotic use, UTI diagnosis, hypnotic use, anticoagulation use, and healed pelvic abscess. These deficient practices could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. Findings included: 1. Record review of Resident #13's face sheet dated 07/09/2024 revealed she was and 82-years-old female, admitted to the facility on [DATE]. She…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that residents who need respiratory care are provided with such care, consistent with professional standards of practices for 1 or 8 residents (Resident #24) reviewed for respiratory care. The facility failed to change the oxygen tubing for Resident #24. These failures could place residents at risk for of respiratory infections. Findings included: Record review of Resident #24's face sheet dated 01/27/24 indicated she was an [AGE] year-old female who admitted to the facility on [DATE]. Resident #24 had diagnoses including Acute Kidney Failure (A condition in which the kidneys suddenly can't filter waste from the blood), Parkinson's Disease (A disorder of the central nervous system that affects movement, often including tremors), and Anemia (A problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues). Record review of Resident # 24's quarterly MDS assessment dated [DATE] indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 of 4 residents reviewed for pharmacy services (Resident #42) 1. The facility failed to keep a record receipt of Resident #42's-controlled medication Hydrocodone. The failures could place residents at risk of not having accurate records of medication administration which could result in diminished health and well-being. Findings included: 1.Record review of the undated face sheet for Resident #42 indicated he was a [AGE] year old male that admitted [DATE] with diagnoses that included: Displaced Mid-cervical fracture of left femur (fracture of the left hip), cervical disc disorder (degeneration of the cervical spine) with myelopathy (nervous system disorder that affects the spinal cord) , high cervical region, rheumatoid arthritis (chronic inflammatory disorder usually affecting…

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 drug regimen was free from unnecessary medications (a medication used: in excessive doses (including duplicate therapy) for 1 of 6 residents (Resident #54) reviewed for unnecessary medications The facility failed to ensure Resident #54 did not receive duplicate medication therapy for metoprolol (blood pressure medication), venlafaxine (antidepressant), trazadone (antidepressant used as sleep aide), pantoprazole (acid-reflux medication), MiraLAX (laxative), and vitamin D3. This failure could place residents at risk for adverse drug reactions (unintended, harmful events attributed to the duplicate use of these medications) and receiving unnecessary medications. Findings included: Record review of Resident #54's face sheet dated 07/09/2024 indicated Resident #54 was an 85-years-old female, admitted to the facility on [DATE] with diagnoses including dementia (a group of thinking and social symptoms that interferes with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to store all drugs and biologicals in locked compartments for 1 of 5 medication carts (400/500 hall cart) reviewed for pharmacy services. 1. The facility failed to lock 1 medication carts for hall 400/500 medication cart. These failures could place residents at risk of not having their medications available as prescribed, a drug diversion, and an adverse reaction. Findings included: During an observation and interview on 7/10/2024 beginning at 9:36 AM, LVN B left the medication cart for hall 400 unlocked while administering medication to Resident # 285. During administration, it was observed LVN B leaving medication cart pulled facing the door and cart remaining unlocked. Resident #285 was requiring assistance and care prior to medication and the medication cart was out of LVN B sight. LVN B was observed going into the bathroom to wash her hands, leaving the cart out of visual observation. Observed cart unlocked from 9:36 AM to 9:43 AM with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate administering of all drugs and biologicals, to meet the needs of 2 of 6 residents reviewed for pharmacy services. (Resident # 1 and Resident #2) 1. The facility failed to administer 14 of 30 scheduled doses of the medication glipizide (used of treatment of diabetes mellitus type 2) 2.5 mg once daily before breakfast and omeprazole 20mg once daily before breakfast (used to treat GERD) timely for Resident #1 in January 2024. 2. The facility failed to administer 6 out of 21 doses of Synthroid (used to treat thyroid hormone imbalance) 100 micrograms daily in July 2023 for Resident #2. These failures could place residents at risk for inaccurate drug administration resulting in a decline in health and decreased quality of life or death. Findings included: 1.Record review of the face sheet dated 01/29/2024 indicated Resident #1 was an [AGE] year-old female admitted on [DATE] with…

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

Based on interview and record review, the facility failed to operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility for 1 or 6 employees (RN H) personnel files reviewed. -The facility failed to notify the Texas Board of Nursing as noted under employment requirements of the court order from the Texas Board of Nursing signed on 05/04/2016 of the employment of RN H. in August 2023. -The facility failed to submit a criminal background check for RN H prior to employment in August 2023. These failures placed the residents at risk of abuse, neglect, and exploitation. Findings included: Record review of the personnel file for RN H revealed a RN license through the state of Texas with court ordered stipulations related to charges involving misuse of narcotic medication signed 05/04/2016. Record review of the personnel file for RN H revealed she was hired on 08/16/2023. The file did not contain a notification…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure residents were free from abuse for 1 of 24 residents (Resident #5) reviewed for resident abuse. The facility failed to ensure Resident #5 was free from abuse, as a result Resident #5 was verbally assaulted by CNA A. This failure could place residents at risk of physical harm, mental anguish, and/or emotional distress. The findings included: Record review of Resident #5's face sheet, dated 1/29/24, revealed she was a [AGE] year-old female who was her own responsible party and she admitted to the facility on [DATE]. Resident #5 had diagnoses of chronic kidney disease, heart failure, dementia (progressive loss of intellectual functioning, especially with impaired memory), weakness, and needed assistance with personal care. Record review of Resident #5's quarterly MDS assessment, dated 12/12/23, revealed she had clear speech and was usually able to express ideas and wants. The MDS revealed Resident #5 usually understood others. The MDS 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 interview, and record review, the facility failed to ensure the right to be free from misappropriation of resident property for 2 of 24 residents reviewed for misappropriation of resident property. (Resident #3 and Resident #4) The facility failed to prevent CNA E from stealing a $25.00 gift card and some change from Resident #3. The facility failed to prevent misappropriation of property when CNA A took Resident #4's box of sodas. These failures could place residents at risk for decreased quality of life, misappropriation of property, and dignity. Findings included: 1. Record review of face sheet dated 01/29/24 indicated Resident #3 was [AGE] years old and was admitted to the facility on [DATE] with diagnoses of respiratory failure, chronic obstructive pulmonary disease (a chronic lung disease), depressive episodes and anxiety. The face sheet indicated Resident #3 was discharged on 08/13/23. Record review of an admission MDS assessment dated [DATE] indicated Resident #3 was understood and understood…

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

Based on interview, and record review, the facility failed to implement its written polices, and procedures that prohibit abuse, neglect, and exploitation for 2 of 6 staff (RN H and CNA J) reviewed for neglect and abuse policies. The facility failed to conduct a criminal background check on RN H and CNA J in 2023. This failure could put residents at risk of receiving services from employees with a history of misconduct and/or were ineligible to provide services in this setting. Finding included: 01/29/2024 10:00 a.m. the employee files for RN H and CNA J were requested. Record review on 01/29/2024 at 3:30 p.m. of personnel files revealed the following staff did not have criminal background checks prior to or during employment: RN H and CNA J. During an interview on 01/31/2024 at 11:52 a.m., Human Resources (HR) stated she was responsible for completing all pre-employment checks. She stated she completed criminal background checks, checked employee misconduct registry, checked past employment references among other things. HR stated it was mandatory to conduct criminal background…

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 care plan to meet the medical, nursing, mental and psychosocial needs for 1 of 24 residents reviewed for care plans (Resident #6). The facility failed to implement 2-person assistance during transfers for Resident #6. This failure could place residents at an increased risk of injury during transfers, a decline in physical or functional well-being and care needs not being met. Findings included: 1. Record review of Resident #6's face sheet dated 1/29/24 indicated Resident #6 was a [AGE] year-old male and admitted on [DATE] and readmitted on [DATE] with diagnoses including sepsis (life threatening infection), brain bleed, difficulty swallowing following cerebral infarction (disruption of blood flow to the brain and parts of the brain die), high blood pressure, weakness, unsteadiness of feet, abnormalities of gait and mobility, lack of coordination, pain, and needs assistance with personal care. Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse/neglect were reported immediately, but no later than 24 hours of the event to the State Agency, in accordance with state law through established procedures for 1 (Resident #1) of 4 residents reviewed for neglect. The facility failed to report the elopement of Resident #1 to the State Agency in the allotted time frames set forth by the State Agency. This failure could place Resident #1 at risk for neglect. Findings included: Record review of a Face Sheet dated 11/4/23 for Resident #1 indicated she admitted to the facility on [DATE] and she was [AGE] years old with diagnoses of chronic obstructive pulmonary disease, cognitive communication deficit, type II diabetes mellitus, unspecified dementia, unspecified psychosis, abnormalities of gait and mobility, and lack of coordination. Record review of a care plan dated 10/4/2023 for Resident #1 indicated she was an elopement risk/wander and needed to be…

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 had the right to a dignified existence for 1 or 5 residents reviewed for rights (Resident #2.) Resident #2 was embarrassed due to being sent to the hospital ER with a hospital gown and a brief. The brief was showing from the back of the chair. This failure caused the resident embarrassment and did not promote a dignified existence. Findings included: Record review of Resident #2's face sheet indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were fracture of the left ankle, diabetes, anxiety disorder, bipolar disorder, depressive disorder, mild cognitive impairment. Record Review of an admission MDS dated [DATE] indicated Resident #2 did not have any cognitive impairment. The resident's functional status was she required limited assistance of one person for transfers. She required extensive assist of two people for toilet use and extensive assistance of one person for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision for 1 of 5 residents reviewed for supervision. (Resident #2) The facility did not supervise Resident #2 when staff dropped her off at a local emergency room alone and confused. This failure could place residents at risk of injury or harm. Findings included: Record review of Resident #2's face sheet indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were fracture of the left ankle, diabetes, anxiety disorder, bipolar disorder, depressive disorder, mild cognitive impairment. The face sheet listed the contacts. Record Review of an admission MDS dated [DATE] indicated Resident #2 did not have any cognitive impairment. The resident's functional status was she required limited assistance of one person for transfers. She required extensive assist of two people for toilet use and extensive assistance of one person for personal hygiene. Record…

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

Based on interview and record review, the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activities professional who completed a training course approved by the State for 1 of 1 facility reviewed for Activity Director qualifications. The facility did not ensure the Activity Director was qualified to serve as the director of the activities program. This failure could place residents at risk of not receiving a program of activities that met their assessed activity needs. Findings include: Record review of an, undated, Personnel File Review Sheet indicated the Activity Director was hired on 6/17/19. Record review of the Activity Director's payroll change notice, with an effective date of 10/24/22, indicated employee has been promoted from CNA to activity director. Record review of the N.A.P.T National Activity Professional Training Course enrollment form dated 05/16/23 indicated the Activity Director was enrolled in the course. During an interview on 05/17/23 at 2:28 PM, the Interim…

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 residents with food and drink that was palatable, attractive, and at a safe and appetizing temperature for five of six residents (Residents #29, #23, #37, #42 and #76) reviewed for palatable food. The facility failed to provide palatable food served at an appetizing temperature or taste to Resident #29, Resident #23, Resident #37, Resident #42, and Resident #76, who complained the food was served cold and did not taste good. This failure could place residents at risk of decreased food intake, weight loss, altered nutritional status, and a diminished quality of life. Findings included: 1. Record Review of Resident #29's face sheet, dated 05/16/23, indicated a [AGE] year-old female who was admitted to the facility on [DATE]. She had diagnoses which included acute kidney failure (a condition that occurs when your kidneys suddenly become unable to filter waste products from your blood), cerebral infarction (occurs as a result 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 an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 of 5 residents (Residents #35, #42, #45, #70 and #136) reviewed for infection control practices. The facility failed to ensure the proper disinfectant cleaner was used to clean Resident #42's isolation room with clostridium difficile (bacteria that causes infection in the large intestine). CNA N failed to handle Resident #70's dirty linen properly. CNA L failed to remove her dirty gloves and perform hand hygiene during Resident #136 incontinent care. The facility failed to ensure CNA N and CNA R performed hand hygiene while providing incontinent care for Resident #45 and Resident #35. These failures could place residents and staff at risk for cross contamination and the spread of infection. Finding include: 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.

Based on interview and record review the facility failed to develop, implement, and maintain an effective training program for all existing staff, consistent with their expected roles for 3 of 21 employees (Activity Director, Maintenance Supervisor and the Housekeeping Supervisor) reviewed for required trainings. The facility failed to ensure the Activity Director, Maintenance Supervisor and the Housekeeping Supervisor received restraint and HIV training annually. This failure could place residents at risk for inappropriate restraints and exposure to HIV. Findings include: Record review of an undated personnel file review sheet indicated hiring dates for the following staff members: *Activity Director was hired on 06/17/19 *Maintenance Supervisor was hired on 12/20/21 *Housekeeping Supervisor was hired on 03/4/19 Record review of the facility's in-service titled, annual required training on bloodborne pathogens, HIV, elopement management, compliance in ethics and restraints, dated 12/1/22, indicated the Activity Director, Maintenance Supervisor and the Housekeeping Supervisor did…

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, at the time each resident was admitted , there were physician orders for the resident's immediate care for 1 of 3 residents reviewed for admission physician orders. (Resident #70) The facility failed to ensure Resident #70 had a physician's order for the use of her life vest (personal defibrillator). This failure could place residents at risk of not receiving appropriate care and treatment services. Findings included: Record review of Resident #70's face sheet dated 05/18/2023 indicated she was a [AGE] year-old female who initially admitted on [DATE] and readmitted on [DATE] with the diagnoses of heart attack, diabetes, and heart failure. Record review of Resident #70's consolidated physician's orders dated 05/18/2023 indicated the physician's order for the life vest in place except with bath/showers for the diagnosis of heart attack, monitor Resident #70 to ensure wearing correctly, for emergencies call [PHONE NUMBER], and change…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial need identified in the comprehensive assessment for 2 of 3 residents reviewed for care plans. (Resident #70 and Resident #39) 1.The facility failed to schedule Resident #70 a cardiology appointment according to her discharge orders. 2.The facility failed to ensure Resident 39's care plan was updated to include psychotic medication of lorazepam (anxiety medication). These failure could place the residents at increased risk of not having their needs met and a decreased quality of life. Findings included: 1.Record review of Resident #70's face sheet dated 05/18/2023 indicated she was a [AGE] year-old female who initially admitted on [DATE] and readmitted on [DATE] with the diagnoses of heart attack, diabetes, and heart failure. Record review of Resident #70's hospital discharge orders and instructions dated 04/19/2023 indicated 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 interview and record review the facility failed to review and revise the person-centered care plan to reflect the current condition for 1 of 7 (Resident #39) residents reviewed for care plan revisions. The facility failed to ensure Resident 39's care plan to discontinued psychotic medication of Risperdal (mood disorder medication). This deficient practice could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. Findings included: Record review of a face sheet dated 05/18/23 revealed Resident #39 was a [AGE] year-old male admitted on [DATE] with diagnoses including anxiety, seizures, and chronic respiratory failure (condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body). Record review of Resident #39's quarterly MDS assessment, dated 04/19/23, indicated Resident #39 was usually understood and usually understood others. The MDS indicated Resident #39 cognition was severely…

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 necessary services to maintain grooming and personal hygiene were provided for 1 of 6 residents reviewed for ADLs. (Resident #1) The facility failed to ensure Resident #1 was routinely showered. This failure could place residents at risk of not receiving services/care, decreased quality of life, and decreased self-esteem. Findings included: Record review of Resident #1's face sheet dated 05/18/23, indicated he was a [AGE] year-old male who initially admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), paranoid schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), dementia (memory loss) without behaviors, and essential hypertension (high blood pressure). Record review of Resident #1's admission MDS assessment dated [DATE], indicated he was able to make himself…

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 was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents goals and preferences for 2 of 7 residents (Residents #37 and #56) reviewed for respiratory care. 1. The facility failed to ensure Resident #37 had a clean oxygen concentrator filter in place. 2. The facility failed to properly store the HHN tubing for Resident # 56. These failures could place residents at risk for respiratory infections and exacerbation of respiratory disease. Findings Include: 1. Record review of Resident #37's face sheet indicated a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included kidney disease (damage to kidney causing loss of function), high blood pressure, anemia (blood disorder), and generalized weakness. Record review of Resident #37's admission MDS, dated [DATE], indicated she had 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 ensure nurse aides were able to demonstrate competency in skills and necessary techniques to care for resident's needs, as identified through resident assessments and described in the plan of care for 1 of 4 CNAs (CNA L) reviewed for nurse aide competencies. The facility failed to ensure CNA L was proficient with hand hygiene and glove changes with incontinent care skills. This failure could place residents at an increased and unnecessary risk of exposure to staff who lack the appropriate skill competencies to provide incontinent care that was capable of minimizing urinary tract infections. Findings include: During an observation and interview on 05/17/2023 at 2:45 p.m., CNA L entered Resident #136's room and washed her hands. CNA L set up a towel on the bedside table and placed wipes and the brief on top of the towel. CNA L opened a trash bag and placed it at the foot of Resident #136's bed. CNA L cleansed Resident #136 peri-area using two wipes downward. The second wipe downward there was feces on the wipe. CNA L then…

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 all mechanical, electrical, and patient care equipment in safe operating condition for 2 of 6 residents (Resident #56 and Resident #78) reviewed for safe functional equipment. 1. The facility failed to ensure Resident #56 had a functioning wheelchair brake. 2. The facility failed to ensure Resident #78's wheelchair seat was not torn. These failures could place residents at risk for skin issues, discomfort, and falls. Findings include: 1. Record review of Resident #56's face sheet, dated 05/18/23, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included heart failure (develops when your heart does not pump enough blood for your body's needs), high blood pressure, obesity(overweight), and asthma (a disease that affects your lungs). Record review of Resident #56's quarterly MDS assessment, dated 03/10/23, indicated the resident was understood and understood others. Resident #56'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.