Whispering Pines Lodge

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide an ongoing program of activities in accordance with the comprehensive assessment to meet the interests and the physical, mental, and psychosocial well-being for 2 of 6 residents (Resident #2 and Resident #7) reviewed for activities. The facility failed to ensure quarterly activity assessments were completed for Resident #2. The facility failed to provide consistent and scheduled in-room activities for Resident #7 to meet her needs. These failures could place residents at risk for not having activities to meet their interests or needs and a decline in their physical, mental, and psychosocial well-being.Findings included: 1. Record review of a face sheet dated 01/08/2026 indicated Resident #2 was a [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included atherosclerotic heart disease (plaque buildup inside the arteries), malignant neoplasm of prostate (cancer tumor in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to store all drugs and biologicals in locked compartments for 1 of 4 medication carts reviewed. (Nurse medication cart for the B Hall) LVN D failed to securely lock the nurse medication cart for the B Hall. This failure could place residents at risk of not having their medications available as prescribed or possible drug diversions.Findings included: During an observation on 1/06/26 at 7:56 A.M. revealed the nurse medication cart sitting across the hall from room [ROOM NUMBER] was unlocked. The door was open to room [ROOM NUMBER] and the resident was in the room lying in bed. There was a resident standing at the nurse medication cart leaning on her walker. There were no staff present at the medication cart. The top drawer contained a tray of eye drops, lancets, alcohol pads, 3 insulin pens and a glucometer. The second drawer contained liquid G-tube medications, 34 cards of various medications (including Metoprolol, Metformin, Lisinopril,…

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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 22 residents (Resident #22), reviewed for infection control practices.1. The facility failed to ensure SNA B and CNA C wore a gown while providing direct care to Resident #22, who was on EBP (infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities), while performing a mechanical lift transfer and incontinent care on 1/05/2026.2. The facility failed to ensure LVN D wore a gown and gloves while providing direct care to Resident #22's feeding tube (medical tube delivering liquid nutrition) and PEG tube (soft tube inserted through the skin and abdominal wall directly into the stomach) 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 observations, interviews, and record reviews the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside, for 1 of 6 residents (Resident #12) reviewed for call lights.The facility failed to ensure Resident #12's call light was functioning properly. This failure could place residents at risk of possible falls, major injuries, hospitalization, and unmet needs. Findings include: 1.Record review of a face sheet dated 01/08/2026 revealed Resident #12 was [AGE] year-old male admitted on [DATE] with diagnoses including multiple sclerosis (chronic autoimmune disease where the immune system attacks the brain, spinal cord and optic nerves), hypertension (high blood pressure), and chronic pain. Record review of the quarterly MDS dated [DATE] revealed Resident #12 was understood by others and able to understand 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 observations, 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 5 of 25 residents (Resident's #1, #2, #3, #7, and #8) reviewed for infection control practices. 1. The facility failed to ensure facility staff followed infection control protocol during a COVID-19 outbreak at the facility. 2. The facility failed to ensure Residents #1, #2, and #3 had airborne isolation precaution signage outside their room door on 09/08/25. 3. The facility failed to ensure the staff had access to face shields or goggles on the PPE isolation carts on 09/08/25 and 09/09/25. 4. The facility failed to ensure LVN A, MA B, and CNA C wore the appropriate PPE (face shield or goggles and N-95 mask) into a COVID-19 positive room, when providing care and services on 09/08/25. LVN A and MA B continued 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 treat each resident with respect and dignity and care for each resident in a manner that promotes maintenance or enhancement of her quality of life for 1 of 25 residents (Resident #15) reviewed for resident rights. The facility failed to ensure LVN M spoke to Resident #15 in a respectful and dignified manner on 8/21/25. This failure could place residents at risk for decreased quality of life, quality of care, and self-esteem. Findings included: Record review of Resident #15's face sheet dated 9/8/25 indicated Resident #15 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #15 had diagnoses including fibromyalgia (is a long-term condition that involves widespread body pain), low back pain, major depressive disorder (a persistently low or depressed mood and a loss of interest in activities that you used to enjoy), and anxiety (intense, excessive, and persistent worry and fear about everyday situations).…

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 had the right to be free from misappropriation of property for 1 of 2 residents reviewed for misappropriation of property. (Resident #15) The facility failed to prevent a drug diversion (misappropriation) of Resident #15's Oxycodone 10 MG on 8/15/25. This failure could place residents at risk for decreased quality of life, unrelieved pain, misappropriation of property, and dignity.Findings included:Record review of Resident #15's face sheet dated 9/8/25 indicated Resident #15 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #15 had diagnoses including fibromyalgia (is a long-term condition that involves widespread body pain), and low back pain.Record review of Resident #15's quarterly MDS assessment dated [DATE] indicated Resident #15 had clear speech, adequate hearing and vision. Resident #15 was understood and had the ability to understand others. Resident #15 had a BIMS score of 15…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure all allegations of abuse and neglect had evidence that all alleged violations were thoroughly investigated and prevent further potential for 2 of 20 residents (Resident #15 and Residents #9) reviewed abuse, neglect and misappropriation. 1. The ADM and DON, failed to thoroughly investigate allegation of misappropriation of property, when LVN E documented an extra administration of Resident #15's oxycodone on 8/15/25. Resident #15 denied receiving an extra dose on 8/15/25. The ADM and DON, failed to provide evidence that Resident #15's incident on 8/15/25, with allegation of misappropriation of property, Oxycodone 10 MG, was thoroughly investigated. The facility failed to protect Resident #15 from potential further misappropriation of property after the allegation. LVN E continued to work from the date of the incident until suspension on 8/18/25. 2. The facility failed to protect Resident #9, after not thoroughly investigating Resident #15…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure each resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 10 residents (Resident #1) reviewed for reasonable accommodations. The facility failed to ensure Resident #1 was allowed to use his personal motorized wheelchair during his stay at the facility. This failure could place residents at risk for a loss of independence, decreased quality of life, self-worth, and dignity. Findings included: Record review of Resident #1's face sheet, dated 04/15/25, indicated he was a [AGE] year-old male, admitted to the facility on [DATE], and discharged on 02/24/25. His diagnoses included spastic quadriplegic cerebral palsy (a severe form of cerebral palsy that affects all four limbs, leading to paralysis and muscle stiffness), and chronic kidney disease (a long-term condition where the kidneys are damaged and can't filter blood as effectively, leading to a buildup 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 that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 10 residents (Resident #2) reviewed for accidents and supervision. The facility failed to ensure an oxygen cylinder found in Resident #2's room was properly stored. This deficient practice could place residents at risk of injury. Findings included: Record review of Resident #2's face sheet, dated 04/14/25, indicated he was an [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included pleural effusion (a condition where excessive fluid builds up in the space between the lungs and chest wall), heart failure (occurs when the heart can't pump enough blood to meet the body's needs), and end stage renal disease (the most severe stage of chronic kidney disease where the kidneys can no longer adequately filter waste from the blood). Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents could call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside for 1 of 10 residents (Resident #4) reviewed for the ability to call for staff assistance. The facility failed to ensure Resident #4 had a call light that was functional. Resident #4's call light did not turn on when the button was pressed. This failure could place residents at risk for a delay in assistance and decreased quality of life, self-worth, and dignity. Findings included: Record review of Resident #3's face sheet, dated 04/15/25, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (a condition caused by damage to the airways or other parts of the lung). Record review of Resident #3's admission MDS assessment, dated 04/11/25, indicated she had a BIMS…

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 Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for 4 of 8 residents (Resident #15 #16, #49, and #52) reviewed for PASRR Level I screenings. 1. The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #49. The PASRR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnosis (Post Traumatic Stress Disorder, a mental health condition that can develop after a person experiences or witnesses a traumatic event with an onset date of 08/01/21) was present upon Resident #49's re-admission date on 11/16/23. 2. The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #15. The PASRR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnosis (Major depressive disorder with an onset date of 06/28/22) was present upon Resident #15's admission date on 06/28/22. 3. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities in accordance with the comprehensive assessment to meet the interests and the physical, mental, and psychosocial well-being for 1 of 1 memory care unit reviewed for activities. The facility failed to provide meaningful activities for dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) residents on the memory care unit on 9/30/24-10/1/ 24. This failure could place residents at risk for not having activities to meet their interests or needs and a decline in their physical, mental, and psychosocial well-being. Findings included: During an observation on 09/30/24 at 9:32 a.m., the dining area had a large television playing a television show in the dining area of the memory care unit. Approximately 20 residents were in the dining area. During an observation on 09/30/24 at 10:50 a.m.-11:55 a.m., the dining and sitting area nor hallways had any…

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 an acceptable parameter of nutritional status was maintained for 3 of 3 residents (Resident # 36, #42 and #61) who was reviewed for nutritional status, in that: 1. The facility failed to ensure Resident #36, #42 and # 61 had sufficient fluid intake to maintain proper hydration and health as evidence by Resident #36 said on 10/1/2024 he had dry mouth, on 9/30/2024 Resident #42's said he had to ask for water and ice and on 10/1/2024 Resident #61 did not have any ice and water in his cup . This failure could place residents at risk for dehydration and decline in health due to insufficient fluid intake. Finding included: 1. Record review of Resident #36's face sheet dated 10/2/2024, indicated he was a [AGE] year-old male who was admitted on [DATE]. His diagnosis included multiple sclerosis (A disease that affects central nervous system. The immune system attacks the myelin, the protective layer around nerve fibers and causes…

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 administering of all drugs and biologicals, to meet the needs of 4 of 19 residents reviewed for pharmacy services. (Residents #18, Resident #23, Resident #34, and Resident #68) The facility failed to ensure Resident #18's Niacin-50 (is one of the water-soluble B vitamins), Ativan (is used to treat anxiety) 1 mg, and Nicotine Patch (helps you quit smoking by reducing cravings for nicotine. Nicotine is an addictive substance in tobacco) were available for administration on 08/20/24, 08/21/24, 08/22/24, 08/23/24, 08/24/24, and 08/25/24. The facility failed to ensure Resident #23's Aspirin EC (is used to reduce fever and relieve mild to moderate pain from conditions such as muscle aches, toothaches, common cold, and headaches) 81 mg Delayed Release was not crushed. The facility failed to ensure Resident #34's Lorazepam Oral Tablet 1 MG (treats anxiety) was 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 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 61.76%, based on 21 errors out of 34 opportunities, which involved 4 of 4 residents (Resident #15, Resident #20, Resident #53, and Resident #73) reviewed for medication administration. 1. MA O administered Buspirone 10mg (is commonly used to treat anxiety disorders), Lorazepam 1mg (treats anxiety), and Tramadol 50mg (a pain relief medication, specifically indicated for moderate-to-severe pain) at 10:49 a.m.-11:21 a.m. instead of 8:00 a.m. as ordered on 09/30/24 for Resident #53. 2. MA O administered Divalproex 250mg (is used to treat certain types of seizures (epilepsy)), Senna-Plus (is used to treat constipation), Levetiracetam 500mg (is a medicine used to treat epilepsy), and Sertraline 100mg (used to treat depression, obsessive-compulsive disorder, panic disorder, anxiety and more) at 10:49 a.m.-11:21 a.m. instead of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure that residents were free of significant medication errors for 2 of 5 residents (Resident #23 and Resident #34) reviewed for pharmacy services. The facility failed to ensure Resident #23's losartan (blood pressure medication) was not administered when her blood pressure (is a measure of how forcefully your blood goes through your arteries) and heart rate (is how many times your heart beats in 60 seconds) was outside of the ordered parameters on 09/01/24, 09/02/24, 09/09/24, 09/17/24, and 09/26/24. The facility failed to ensure Resident #34's losartan (blood pressure medication) was not administered when her blood pressure was outside of the ordered parameters on 9/08/24, 9/09/24, 910/24, 9/17/24, 9/26/24, and 9/30/24. These failures could place residents at risk of medical complications and not receiving the therapeutic effects of their medications. Findings included: 1. Record review of Resident #23's face sheet dated 09/30/24 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 ensure the baseline care plan that included the instructions for resident care needed to provide effective and person-centered care was completed and provided to the resident and/or their representative for 1 of 5 residents reviewed for new admissions (Resident #34). The facility failed to provide Resident #34's RP a copy of the summary of the baseline care plan. This failure could place residents at risk of not receiving care and services to meet their needs. Findings included: Record review of Resident #34's face sheet dated 09/30/24 indicated Resident #34 was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis including dementia (a group of thinking and social symptoms that interferes with daily functioning) with psychotic disturbance (severe mental disorders that cause abnormal thinking and perceptions), paranoid schizophrenia (is a mental disorder characterized by disruptions in thought processes, perceptions, emotional…

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 resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 3 of 19 residents reviewed for care plans. (Resident #62, Resident #53, and Resident #34) 1. The facility failed to ensure that Resident #62's care plan dated 08/15/24 addressed her psychotropic medications that she was prescribed by the physician on 08/02/2024. 2. The facility failed to ensure Resident #34's CAA of behavioral symptoms were on the 08/27/24 care plan. 3. The facility failed to ensure Resident #34's behaviors of incontinence on her and other resident's property was on the 08/27/24 care plan. 4. The facility failed to ensure Resident #53's CAA of limited range of motion of her upper and lower extremities were on the 07/11/24 care plan. 5. The facility failed to ensure Resident #53 activity preference of listening to music and type of preferred music…

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 3 of 5 residents reviewed for ADLs (Residents #25, #42, and #61). The facility failed to provide baths as scheduled for Resident #25, #42, and #61. 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. Findings included: 1. Record review of Resident #25's face sheet, dated 10/01/24, indicated he was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included cerebral palsy (a group of conditions that affect movement and posture), and heart failure (occurs when the heart muscle does not pump blood as well as it should). Record review of Resident #25's quarterly MDS assessment, dated 08/06/24, indicated he was able to make himself understood and he was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that residents who need respiratory care are provided with such care, consistent with professional standards of practices for 1 of 22 residents (Resident #49) reviewed for respiratory care. The facility failed to replace the oxygen filter that was damaged for Resident #49. This failure could place residents at risk for of respiratory infections. Findings included: Record review of Resident #49's face sheet, dated 11/16/23 revealed a [AGE] year old female admitted on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD - a common lung disease that causes breathing problems and restricted airflow), Chronic Systolic Heart Failure (a condition where the left ventricle of the heart is unable to contract properly, resulting in less blood circulating throughout the body), Hyperlipidemia (a condition where there are abnormally high levels of lipids or fats in the blood.) Record review of Resident #49's quarterly…

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 safe and sanitary storage of residents' food items for 2 of 12 resident personal refrigerators reviewed for food safety (Resident #37 and Resident #38). 1. The facility failed to ensure the refrigerator for Resident #37 did not have expired protein drinks. 2. The facility failed to ensure the refrigerator for Resident #38 was cleaned and free from a brown and black substance with black dead gnats. This failure could place resident at risk for food borne illnesses. Findings include: 1. Record review of Resident #37's face sheet, dated 3/2/21 revealed an [AGE] year old male admitted on [DATE]. He was most recently re-admitted on [DATE]. The face sheet revealed diagnoses that included Cerebral Infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), Essential Hypertension (abnormally high blood pressure that's not the result of a medical condition), Insomnia (a sleep…

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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #40) reviewed for Covid-19 infection control practices. 1. The facility failed to ensure MA S wore an N95 mask when entering a Covid positive resident room. 2. The facility failed to ensure MA S changed her mask after leaving a Covid positive resident room. 3. The facility failed to ensure MA S wore proper PPE (Personal Protective Equipment) in Resident #40's room on 10/2/2024. Resident #40 was COVID-19 positive. MA S wore surgical mask only when entering and exiting Resident #40's Covid-19 positive room. These failures could place residents at risk of exposure to communicable diseases, cross-contamination, and infections. Findings included: 1. Record review of Resident #40'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 interview 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 is verified appropriate corrective action must be taken for 2 of 11 residents (Resident #1 and Resident #2) reviewed for abuse and neglect. The facility failed to ensure the provider investigation report was turned into the state survey agency (HHSC) within 5 working days of the reported incident between Resident #1 and Resident #2. This failure could place residents at risk for abuse and neglect. Findings included: 1. Record review of Resident #1's face sheet, dated 09/04/24, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included dementia (a decline in cognitive abilities that can affect a person's ability to perform everyday 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 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 3 of 23 residents (Resident # 53, Resident #25, Resident # 26) reviewed for infection control. 1. The facility failed to ensure LVN A used proper infection control measures when performing wound care for Resident #53. 2. The facility failed to ensure that personal protection equipment storage boxes at Resident # 25 and Resident # 26's rooms were free from cross contamination. These failures could place residents at risk for cross-contamination and the spread of infection. Findings included: 1. Record review of Resident #53's face sheet, dated 5/30/23, revealed he was an [AGE] year-old female, who was admitted to the facility on [DATE] with the diagnoses which included non-pressure chronic ulcer of buttock with necrosis of muscle…

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, record reviews, and interviews, the facility failed to protect and promote the rights of the resident in an environment that promoted maintenance or enhancement of his or her quality of life for 4 of 18 residents (Resident #69, Resident # 52, Resident # 78 and Resident # 54) reviewed for resident rights. The facility failed to protect and value Resident #69, Resident # 52 and Resident #78's quality of life and provide a peaceful atmosphere when facility staff engaged in unprofessional and obscene behavior with family members of residents. The facility failed to ensure staff knocked prior to entering Resident #54's room. This failure could place residents at risk for decreased quality of life, increased anxiety, and increased stress. Findings included: 1. Record review of Resident #69's admission Record indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Alcohol Induced Dementia (a type of alcohol-related brain damage), Tremors (causes…

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 6 of 10 residents (Resident # 6, Resident # 23, Resident #20, Resident #25, Resident #59, and Resident #63) reviewed for reasonable accommodations. The facility failed to ensure Resident # 6, and Resident # 23 could choose between taking a bath and having a sponge bath. The facility failed to ensure Resident #20's call light was in reach while in bed. The call light cord for Resident #20 was lying on the over the bed light and not within reach of Resident #20. The facility failed to ensure Resident #25's call light was in reach while in bed. The call light cord for Resident #25 was lying on the floor behind the dresser and not within reach of Resident #25. The facility failed to ensure Resident #59's call light was in reach while in bed. The call light cord for Resident #59 was lying on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 3 of 12 residents (Resident # 64, Resident #6, and Resident #54) reviewed for comprehensive person-centered care plans. 1.The facility failed to develop a care plan for Resident # 64's diagnosis of post-traumatic stress disorder (PTSD). 2.The facility failed to implement the care plan intervention to document Resident #6 meal intake. 3.The facility failed to update Resident #54's from at risk for falls to actual fall on his care plan. 4.The facility failed to update Resident #54's fall care plan interventions. Findings included: 1.Record review of a face sheet dated 09/12/2023, indicated Resident #64 was a [AGE] year-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 residents who were unable to carry out activities of daily living received the necessary services to maintain bathing were provided for 2 of 12 residents reviewed for ADLs (Residents # 64 and Resident # 48). The facility did not provide 10 of 16 scheduled showers for Resident #64 in August of 2023 and 6 of 6 scheduled showers from September 1st to Septermber 13th 2023. The facility did not provide 8 of 13 scheduled showers for Resident #48 in August of 2023 and 3 of 5 scheduled showers from September 1st to September 13th 2023. These failures could place residents at risk of not receiving services/care and decreased quality of life. Findings Include: 1.Record review of a face sheet dated 09/12/2023, indicated Resident #64 was a [AGE] year-old female admitted on [DATE] with the diagnoses of cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), PTSD (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 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 failed to ensure a certified Activity Directory was employed for the facility. This failure could place residents at risk of not receiving a program of activities that met their assessed activity needs. Findings included: Record review of the undated Personnel File Review of Staff Members indicated no information for the Activity Director. Record review of a hiring website, reviewed on 09/13/23, did not reveal a job posting for certified AD for this facility. During an interview on 09/12/23 at 09:30 a.m., the ADM said the facility had an assistant activity director and she was about to start her training. The ADM said she was in nursing school in the mornings and then came to the facility for afternoon activities. She said she did not know…

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 was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of changes for those services, which included changes for services not covered under Medicare/Medicaid or by the facility's per diem rate for 2 of 3 residents (Residents #23 and #33) reviewed for Medicare/Medicaid coverage. The facility failed to ensure Resident #23 and #33 was given a SNF ABN (is a notice given to beneficiaries in Original Medicare to convey that Medicare is not likely to provide coverage in a specific case) when discharged from skilled services at the facility at least 2 days prior covered days being exhausted. The facility failed to ensure Resident #23 and #33 was given a NOMNC (is a notice that indicates when your care is set to end from a home health agency (HHA), skilled nursing facility (SNF), comprehensive outpatient rehabilitation facility (CORF), or hospice) when…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 2 (Resident #54) residents reviewed for non-pressure wounds. The facility failed to treat Resident #54's non-pressure wound (is characterized by inflammation of the skin, occurring with or without erosion or secondary cutaneous infection) of the left buttock after readmission for 2 days. This failure could place residents of risk for not receiving appropriate care and treatment. Findings included: Record review of a face sheet dated 09/12/23 indicated Resident #54 was a [AGE] year-old male and admitted on [DATE], with a readmission on [DATE], with diagnoses including Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), and Type 2 diabetes (a chronic condition that affects the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure residents with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 4 residents (Resident #54) reviewed for pressure injury. The facility failed to treat Resident #54's unstageable sacrum pressure ulcer (is a term that refers to an ulcer that has full thickness tissue loss but is either covered by extensive necrotic tissue or by an eschar) after readmission for 2 days. This failure could place residents at risk for deterioration of wound. Findings included: Record review of a face sheet dated 09/12/23 indicated Resident #54 was a [AGE] year-old male and admitted on [DATE], with a readmission on [DATE], with diagnoses including Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), chronic obstructive pulmonary disease (a group of lung diseases 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 interview and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status for 1 of 4 residents (Resident #54) reviewed for nutrition/weight loss. The facility failed to obtain a readmission weight after Resident #54 readmitted from the hospital on [DATE] per the facility policy. The facility failed to consistently document Resident #54's meal intakes. These failures could place residents at risk for decreased nutritional and weight status and decline in health. Findings included: Record review of a face sheet dated 09/12/23 indicated Resident #54 was a [AGE] year-old male and admitted on [DATE], with a readmission on [DATE], with diagnoses including Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), and Type 2 diabetes (a chronic condition that affects the way the body processes 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 interview and record review, the facility failed to ensure, based on the comprehensive assessment of a resident, residents who had not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 5 residents (Resident #54) reviewed for unnecessary psychotropic medications. The facility failed to ensure Resident #54's Lorazepam (anti-anxiety) had an appropriate diagnosis for use. The facility failed to limit Resident #54's Lorazepam prn medications to 14 days and the prescribing practitioner did not provide a rationale for extended use. These failures could put residents at risk of receiving unnecessary psychotropic medications. Findings included: Record review of a face sheet dated 09/12/23 indicated Resident #54 was an [AGE] year-old male and admitted on [DATE], with a readmission on [DATE], with diagnoses including Alzheimer's disease with late onset (a progressive disease that destroys…

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

Based on observation, interview, and record review, the facility failed to ensure all drugs and biological were stored in locked compartments for 1 medication cart of 4 (Medication Aide Cart #1) reviewed for medication storage: The facility failed to ensure Medication Aide Cart #1 was locked when unattended. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversions. Findings included: An observation on 09/11/23 beginning at 3:40 p.m. revealed, Medication Aide Cart #1 was unlocked and unattended with no staff within eyesight of the nurse cart for 17 minutes. The keys were in the cart and the narcotic drawer was open. All other drawers could be opened, and medication and supplies could be easily accessed. The cart was observed to have prescribed medication blister packs, over counter medications, as well as a narcotic lock box. During an interview with Medication Aide AA on 9/11/2023 at 4:20 p.m., Medication Aide A stated, Oops, I left it unlocked while I went to help a CNA pull someone up in bed. Medication…

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 observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Residents #65) of 5 residents observed for infection control. Housekeeper DD failed to doff (take off) PPE while exiting isolation room and entered Resident #65's room wearing contaminated PPE. Housekeeper DD wore soiled gloves in the hallway. These failures could place residents at risk of cross-contamination and infections leading to illness. Findings included: Record review of Resident #65's admission Record dated 09/14/2023 indicated that resident was an 63-year- old female who admitted to the facility on [DATE] with diagnosis of non-pressure chronic ulcer of buttock with necrosis of the muscle (commonly occur in patients with arterial (ischemic) disease, venous disease, neuropathy, or a combination of these diseases),…

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 received adequate supervision and assistance devices to prevent accidents for 1 of 8 residents (Resident #1) reviewed for adequate supervision. The facility failed to properly transfer Resident # 1 in a wheelchair when they fell due to unlocked chair wheels. This failure could place residents at risk for injury, harm, and impairment or death. Findings included: 1. Record review of Resident #1's admission Record indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Alcohol Induced Dementia (a type of alcohol-related brain damage), Tremors (causes involuntary and rhythmic shaking), Muscle Wasting and Atrophy (the decrease in size and wasting of muscle tissue), Muscle Weakness (full effort doesn't produce a normal muscle contraction or movement), Communication Deficiency (an impairment in the ability to receive, send, process, and comprehend concepts or verbal, nonverbal and graphic…

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.