Avir at Lubbock

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored properly for 3 of 5 medication carts (1 nurses medication cart for memory care on Station 2, 1 nurses medication cart for Station 2 and 1 medication aide cart for Station 1), reviewed for medication storage.The facility failed to maintain proper medication storage after the following was found:The nurse medication cart located on Station 2 contained medication Lorazepam (2MG/ML; dated 8/11/25) that required refrigeration for Resident #4. The nurse's medication cart for Memory care located on Station 2 contained medication (2MG/ML; dated 8/03/25) that required refrigeration for Resident #6. The medication aide cart for Station 1 contained medication Lorazepam (unable to see the dose) that required refrigeration for Resident #5. This failure could place residents at risk of not receiving prescribed medications that are not effective or that could expire faster than the printed date.Findings included: An observation of Station II memory medication cart was conducted…

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 review and revise resident's comprehensive care plans by the interdisciplinary team after each assessment for 1 (Resident #8) of 12 residents reviewed for comprehensive care plans. The facility failed to update or add interventions to Resident #8's care plan regarding aggressive and physical behaviors toward other residents that occurred on 08/05/25 and 08/29/25. These failures could result in residents not receiving the care that they need.Findings Included:Record review of Resident #8's face sheet, dated 09/03/25, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include dementia (memory loss), psychotic disturbance (mental health condition characterized by loos of touch with reality), mood disturbance (significant change in a person's emotional state), anxiety (increased worry), cognitive communication deficit (Difficulty communicating), depressive episodes (periods of significant low mood or loss…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure each resident's drug regimen be free from unnecessary drugs without adequate indications for its use for 2 of 12 (Resident #4 and Resident #6) reviewed for unnecessary medications.The facility failed to ensure that Resident #4 PRN orders for psychotropic drugs (Lorazepam (2MG/ML) were limited to 14 days and or provide a physician's rationale indicating that it was appropriate for the PRN order to exceed the 14 day stop date.The facility failed to ensure that Resident #6 PRN orders for psychotropic drugs (Lorazepam (2MG/ML) were limited to 14 days and or provide a physician's rationale indicating that it was appropriate for the PRN order to exceed the 14 day stop date.This failure could lead to residents being prescribed medications without indication and place residents at risk of unnecessary side effects and a decline in overall health.Findings included:Resident #4 Record review of Resident #4's face sheet, dated 09/0325, revealed a [AGE]…

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 ADL (Activities of Daily Living) care to a resident who is unable to carry out activities of daily living and receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 of 5 residents (Resident#1, #2, and #3) observed for ADL care to ensure they were receiving appropriate hygiene in that: The facility failed to provide showers for Residents #1, #2, and #3 on their scheduled shower days. This failure could place the residents at risk of not receiving the care and services to maintain their highest practicable physical, mental, and psychosocial well-being. The findings included: Resident #1: Record review of Resident #1's face sheet revealed an [AGE] year-old female with an admission date of 03/09/2023 with diagnoses that included: Dementia in other diseases classified elsewhere (mental decline that affects thinking, memory, reasoning, personality, mood and behavior), Urinary tract…

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 its medication error rate was less than 5 percent. The facility had a medication error rate of 9.38% based on 3 errors out of 32 opportunities, which involved 2 of 7 residents (Resident #6 and Resident #10) reviewed for medication administration. 1. LVN A failed to administer Resident #6's Certizine medication according to physician orders, resulting in Resident #6 receiving the medication late. 2. LVN A failed to verify the dosage on Resident #6's Simethicone 125 mg medication order prior to administering the medication, resulting in Resident #6 being underdosed. 3. LVN A failed to verify the dosage on Resident #10's vitamin D3 125 mcg medication order prior to administering the medication, resulting in Resident #10 being underdosed. These failures could place residents at risk of incomplete therapeutic outcomes, increased negative side effects, and decline in health. Findings included: Resident #6 Record review of 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.

Based on observation, interview, and record review, the facility failed to provide food that was palatable, attractive and at a safe and appetizing temperature for 3 of 3 food forms (Regular, Mechanical Soft, and Pureed) for 1 of 1 meal reviewed for palatability. 1) The facility failed to provide food that was palatable, attractive and at appetizing temperatures for 3 of 3 food forms served (Regular, Mechanical Soft, and Pureed) at 1 of 1 meal observed (03/12/2025 lunch). These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. The findings included: During confidential individual interviews, 3 of 5 residents voiced concerns related to food palatability and temperature. One Resident stated, this morning I didn't eat my breakfast because it had no taste. Another Resident stated, it's the lunch and the dinner that's not always good, the flavor, the food is cold sometimes. One other Resident stated that the other food was cold, the scrambled eggs, I just ate my oat meal and that was it. During the confidential Resident Council interviews…

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

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 7 of 12 residents (Residents #3, #28, #46, #40, #62, #6 and #10) reviewed for infection control. 1. MA A failed to sanitize the blood pressure cuff between resident use for Resident #3 and Resident #28. 2. LVN B failed to utilize hand hygiene between glove changes during wound care on Residents #46, #40, and #62. 3. LVN B failed to utilize enhanced barrier precautions during wound care for Residents #46, #40 and #62. 4. LVN A failed to utilize hand hygiene between residents during medication administration for Resident #6 and Resident #10. These failures could place residents at risk for cross contamination and infection. The findings include: During a medication administration observation on 3/12/2025 at 7:34 AM, MA A used the blood pressure cuff to take Resident #3's 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 inform residents in advance of the risks and benefits of proposed care and treatment for 2 of 24 resident reviewed for resident rights. (Resident #40 and Resident #32) 1. The facility failed to obtain consent from Resident #40 or the responsible party for Lorazepam (medication used to treat anxiety disorders). 2. The facility failed to obtain consent from Resident #32 or the responsible party for Lorazepam (medication used to treat anxiety disorders). This failure could place residents at risk for receiving psychoactive medications without consent and knowledge of side effects. The findings include: Record review of Resident #40's undated face sheet revealed a [AGE] year-old male originally admitted to the facility on [DATE]. Resident #40 had a medical history of paranoid schizophrenia (a chronic mental illness characterized by disruptions in thought, perception, emotion, and behavior), rhabdomyolysis (serious condition where damaged skeletal 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 interview and record reviews the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days for 2 of 24 residents reviewed for unnecessary medications (Resident #40 and #32). 1. The facility failed to ensure a PRN order for Lorazepam (medication used to treat anxiety disorders) dated 11/28/2024 and Lorazepam (medication used to treat anxiety disorders) dated 12/18/2024 had a stop date to ensure the medication did not extend beyond 14 days for Resident #40. 2. The facility failed to ensure a PRN order for Lorazepam (medication used to treat anxiety disorders) dated 12/16/2024 had a stop date to ensure the medication did not extend beyond 14 days for Resident #32. This failure placed residents with PRN psychotropic drugs at risk for side effects of psychotropic drugs and placed residents at risk for receiving unnecessary medications. Findings include: Record review of Resident #40's undated face sheet revealed a [AGE] year-old male originally admitted to the facility 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.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored properly for 2 of 4 medication carts (Station 1 medication cart and Station 2 medication cart), reviewed for medication storage. The medication cart assigned to Station 1 contained loose pills. The medication cart assigned to Station 2 contained loose pills. This failure could place residents at risk of not receiving prescribed medications as ordered and place the facility at risk of drug diversions. The findings included: On 03/12/25 at 9:23 AM, an observation of the medication cart for Station 1 was conducted with LVN A. Two loose pills were found in the bottom drawer of the medication cart. LVN A placed the pills in a dispensing cup and took them to ADON A for identification. ADON A identified the medication as Buspirone 10 mg (2 tablets). LVN A destroyed the loose pills by placing them in the sharps container on the medication cart. During an interview on 03/12/25 at 9:25 AM, LVN A stated there should not be loose pills on the medication cart. She stated she…

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

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services, in that: The facility failed to ensure foods were processed and pureed under sanitary conditions. These failures could place residents at risk for food contamination and foodborne illness. The findings included: The following observations were made on 03/11/25 at 11:00 AM during observation of puree meal preparation: After pureeing new potatoes, the DM took processor bowl, lid, and blade to 3 compartments sink and cleaned all 3 parts shaking liquid off all 3 parts. The DM took all 3 parts back to processor base and assembled. The bowl had liquid in bottom and lid was dripping liquid. The DM prepared puree bread then took processor bowl, lid, and blade to 3 compartments sink and cleaned all 3 parts shaking liquid off all 3 parts. The DM took all 3 parts back to processor base and assembled. The bowl had liquid in bottom and lid and blade was dripping…

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 maintain an effective pest control program so that the facility was free of pests and rodents for 1 of 1 facility observed for pest control. 1. The facility failed to follow the instructions from the pest control company to have multiple holes fixed in the facility that rodents potentially used for access into the building between 1/10/2025 and 2/25/2025. The noncompliance was identified as PNC . The noncompliance began on 1/10/2025and ended on 3/3/2025. The facility had corrected the non-compliance before the survey began. These failures could place residents at risk for the spread of infection, cross-contamination, and decreased quality of life. Findings included: Record review of facility's document titled Service inspection Report dated 1/10/2025 revealed: After speaking with [Maintenance Man A] and [ADM ], there is a good plan for getting all the holes fixed which ultimately will fix the mouse issue. Spoke with ADM and taking a day to focus on getting the holes fixed and also mentioned hiring a contractor…

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 maintain medical records on each resident that are complete and accurately documented for 1 of 5 residents (Resident #1) reviewed for ADL care in that: 1. The facility failed to accurately document ADL services for Resident #1. This failure could place the residents at risk of not receiving the care and services to maintain their highest practicable physical, mental, and psychosocial well-being. The findings include: Record review of Resident #1's undated face sheet revealed a [AGE] year-old male originally admitted to the facility on [DATE]. Resident #1 had a medical history of cerebral infarction (a condition where blood flow to the brain is interrupted, causing brain cells to die), muscle weakness, and reduced mobility. Record review of Resident #1's admission MDS revealed Section C- Cognitive patterns a BIMs score of 0 which indicated resident is rarely/never understood. Section GG- Functional Abilities revealed resident 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 observations, interviews, and record review, it was determined the facility failed to provide ADL (Activities of Daily Living) care for 7 of 7 residents (Resident#1, #10, #11, #12, #13, #14, and #15)) observed for ADL care to ensure they were receiving appropriate hygiene in that: The facility failed to provide showers for Residents #1, #10, #11, #12, #13, #14, and #15, on a routine basis. This failure could place the residents at risk of not receiving the care and services to maintain their highest practicable physical, mental, and psychosocial well-being. The findings include: Resident #1: Record review of an admission Record dated for Resident #1 shows a [AGE] year-old female with an original admission date of 12/18/2024 and a readmission date of 1/6/2025 with diagnoses of transient ischemic attack (TIA) (mini stroke), and cerebral infarction (stroke), Paranoid schizophrenia , Metabolic encephalopathy (a problem with the brain caused by a chemical imbalance in the blood), Urinary tract infection,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure that each resident has a right to personal privacy and confidentiality of his or her personal medical records for 1 of 1 resident was reviewed for privacy (Resident #8). 1. LVN B left Resident #8's information up on the screen while her computer cart was on the other side of the nurse's station, and she was at the nurse's station. The computer screen was left up with Resident #8's information up and residents were walking by, putting Resident #8's information at risk. This failure could place residents at risk of having medical information exposed to others and misuse of personal information. Findings Included: Resident #8: Record review of an admission Record review for Resident #8 showed a [AGE] year-old male with an original admission date of 7/21/2022 and a readmission date of 11/23/2024 with diagnoses of end stage renal disease, fluid overload, atrial fibrillation, insomnia, lesions of oral mucosa, muscle spasm, edema,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours if the alleged violation involved abuse or neglect and resulted in bodily injury, to other officials (including the State Agency) and the Abuse Coordinator for 3 of 6 residents (Resident #1, #2, and #3) reviewed for abuse. A. The ADM failed to follow the facility's abuse policy by not reporting the allegation of abuse to HHSC regarding Resident #1 being hit by an unknown nighttime staff on 11/23/24. B. The ADM failed to follow the facility's abuse policy by not reporting the resident-to-resident altercation (Resident #1 attempted to pull Resident #2 out of bed) that occurred on 11/14/24 between Resident #1 and Resident #2 to HHSC. C. The ADM failed to follow the facility's abuse policy by not reporting the resident-to-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 record reviews the facility failed to have evidence all allegations of abuse, neglect or mistreatment were thoroughly investigated for 3 of 6 residents (Resident #1, #2, and #3) reviewed for abuse. A. The ADM failed to investigate Resident #1's allegation of abuse made against an unknown nighttime staff on 11/23/24. B. The ADM failed to investigate a resident to resident altercation (Resident #1 attempting to pull Resident #2 out of bed) that occurred on 11/14/24. C. The ADM failed to investigate a resident-to-resident altercation (Resident #1 grabbed Resident #3 in the face) that occurred on 11/14/24. These failures could place residents as risk for abuse and neglect by not investigating allegations of abuse, neglect, exploitation, or mistreatment. Findings included: Resident #1 Record Review of Resident #1's face sheet, dated 11/22/24, revealed an [AGE] year-old male that was admitted to the facility on [DATE], with a diagnosis of dementia (memory loss). Record Review of Resident #1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 10 residents (Resident #1) reviewed for comprehensive care plans. The facility failed to ensure Resident #1's care plan (problem, goal, and approach) was updated to reflect his increasingly ongoing incident of physical and verbal aggressive behaviors. This failure could place residents at risk of not receiving appropriate interventions to meet their current needs. The findings included: Record review of Resident #1's face sheet, dated 11/22/24, revealed an [AGE] year-old-male was admitted to the facility on [DATE] with diagnosis to include unspecified dementia (impaired ability to remember), with other behavioral disturbance (behavior concerns), other frontotemporal neurocognitive disorder (damage to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 3 residents (Resident #1) reviewed for pain management. The facility failed to ensure Resident #1 received Hydrocodone-Acetaminophen-Schedule III 300-30 mg tablet every 6 hours-as needed (PRN) for pain on 10/30/24 from 6 A.M. to 1:50 P.M. This failure placed the resident at risk of increased pain and decreased quality of life. Findings included: Review of Resident #1's Face Sheet dated 10/31/24 reflected she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. This report included Resident #1's diagnoses as unspecified pain, atherosclerosis of native arteries of extremities with rest pain to right leg (severe burning pain in your legs and feet that continues even when you're…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Interviews and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse and neglect for 1 of 6 residents reviewed for abuse. A. The ADM failed to follow the facility's abuse policy when Resident #1 reported allegations of abuse involving Resident #2 on an unknown date. B. The ADON failed to follow the facility's abuse policy when CNA A reported that Resident #1 alleged that CNA A was involved in abusing Resident #2 on 09/26/24. This failure could place residents as risk for abuse and neglect. Findings included: Record review of the facility policy, Abuse, Neglect, and Exploitation, revised May 2023 revealed: Policy The facility will provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, and exploitation and misappropriation of resident property. Reporting/Response The facility will have written procedures 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 that all alleged violations involving abuse, neglect, exploitation or mistreatment, injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or result in serious bodily injury to the administer of the facility and to other officials including the State Survey Agency in accordance with State law through established procedures for 2 of 6 residents (Residents #1 & 2) reviewed for abuse and neglect. A. The ADM failed to report an allegation of abuse involving Resident #2 that was reported to him on an unknown date by Resident #1. B. The ADON failed to report an allegation of abuse involving Resident #2 that was reported to him by CNA A on 09/26/24. These failures could place residents at risk for abuse/neglect and could lead to a diminished quality of life and psychosocial harm. Findings included:…

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 implement written policies and procedures that prohibit and prevent resident abuse for 1 of 5 residents (Resident #1) of five residents whose records were reviewed for abuse. Facility staff did not implement facility policy and immediately notify administration when FM #1 reported on 6/23/24 to LVN A that CNA B was rough with Resident #1 during a transfer. This failure could affect residents by placing them at risk of abuse if the reportable allegations are not reported timely after they are discovered. Findings included: Record review of a face sheet dated indicated Resident #1 is an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease, unspecified (Primary, Admission), Pneumothorax, Cognitive communication deficit, Heart Disease, Chronic Obstructive Pulmonary Disease. Record review of a Resident #1's quarterly MDS assessment dated [DATE] indicated a BIMS of 4 which indicated severely impaired cognition.…

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 allegation of abuse was reported immediately but not later than 24 hours after the allegation was made for 1 of 5 residents (Resident #1) reviewed for reporting. The facility failed to ensure staff immediately reported an allegation of when FM #1 reported on 6/23/24 to LVN A that CNA B was rough with Resident #1 during a transfer. This failure could affect residents by placing them at risk of abuse if the reportable allegations are not reported timely after they are discovered. Findings included: Record review of a face sheet dated indicated Resident #1 is an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease, unspecified (Primary, Admission), Pneumothorax, Cognitive communication deficit, Heart Disease, Chronic Obstructive Pulmonary Disease. Record review of a Resident #1's quarterly MDS assessment dated [DATE] indicated a BIMS of 4 which indicated severely impaired cognition.…

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 implement a comprehensive care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident # 2) of 8 Residents reviewed for comprehensive care plans. - The facility failed to identify and develop an intervention for Resident #2's behaviors of exposing his penis and urinating on the floor in the unit in Resident #2's comprehensive person-centered care plan. This failure could affect residents currently in the facility receiving care per comprehensive person-centered care plans resulting in resident no being able to attain or maintain their highest practicable physical, mental, and psychosocial well-being. Findings included: Record review of a face…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment for 2 of 8 residents (Resident #2, Resident #3) reviewed for staffing. The facility failed to have sufficient nursing staff in the memory care unit to provide supervision to assure resident safety. This failure could place residents at risk for not having their physical, mental, and psychosocial well-being met. Findings include: Record review of a face sheet dated 6/25/24 indicated Resident #2 is an [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses:…

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

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services. 1) The facility failed to ensure foods were processed, stored, and pureed under sanitary conditions. 2) The facility failed to ensure food and non-food contact surfaces were clean. 3) The facility failed to ensure staff stored personal items in a manner that prevented contamination. 4) The facility failed to ensure food was accurately dated and labeled. 5) The facility failed to protect foods from potential contamination. 6) The facility failed to ensure staff wore hair restraints in food areas. 7) The facility failed to ensure sanitizer were at recommended concentrations and used according to manufacturer recommendations, 8) The facility failed to rapidly reheat potentially hazardous hot food to 165 degrees F prior to placing on the steam table. 9) The facility failed to ensure that potentially hazardous cold foods were maintained at 41 degrees F or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure sure each resident had a right to a safe, clean, comfortable, and homelike environment in the facility and failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior in 6 of 22 resident rooms (2, 7, 8 ,9, 47, and 49) and 2 of 4 baths (Station 1 - Bath #1 and #2) , reviewed for environment. 1)The facility failed to ensure resident use equipment were safe and in good repair (Rooms 2, 7, 8, 9 and Station 1 - Bath #1 and #2). 2)The failed to ensure rooms #47 and #49 had running water available in the sinks in their rooms 3)The facility failed to ensure room [ROOM NUMBER] had an operating air conditioner/heater unit in the room. These failures could place residents at risk for living in an unsafe, uncomfortable, and unhomelike environment which could cause a decline in resident psychosocial well-being. The findings included: Observation on 2/6/24 at 5:58 PM in Bath #2, 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 record review and interviews, the facility failed to develop a comprehensive care plan to meet the highest practicable physical, mental, psychosocial well-being for two of 22 residents (Residents #18 and #69) reviewed for care plans. 1. The facility failed to develop a care plan for Resident #18 regarding dialysis. 2. The facility failed to develop a care plan for Resident #69 regarding insulin for treatment of the diagnosis of diabetes. These failures could place residents at risk of not receiving the care required to meet their individualized needs. Finding included: Resident #18 Record review of the undated face sheet for Resident #18 revealed that the resident was admitted to the facility on [DATE] and readmitted on [DATE]. The resident was [AGE] years old and had diagnoses of cerebral infarction, unspecified (stroke), unspecified inflammation of eyelid (history of), other specified glaucoma (vision disorder), palpitations (irregular heart beat), essential hypertension (high blood pressure),…

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 pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 of 22 residents reviewed for medications (#11 and #18 ). 1)The facility failed to accurately acquire and administer medications as ordered for two residents (Residents #11 and #18). Resident #11 missed doses of ordered Plavix (antiplatelet medication) and Resident #18 missed doses of hydralazine (blood pressure medication) and hydrocortisone eye ointment (anti-inflammatory medication). These failures could place residents at risk of experiencing missed medications which could result in the exacerbation of their medical conditions and a decline in health status. The findings included: Resident #18 Record review of the undated face sheet for Resident #18 revealed that the resident was admitted to the facility on [DATE] and readmitted on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review; the facility failed to ensure residents remained free of any significant medication errors for 1 of 1 resident reviewed for medication errors ( Resident #11). The facility failed to restart Resident #11's physician's ordered Plavix after a dental appointment. The resident was without her Plavix (blood thinner to treat stroke, heart attack, and other heart related disorders), for approximately 10 months (2/22/23 thru 12/19/23). This failure could result in residents having risk of heart attacks, strokes, blood clots, and risk of hospitalizations. Findings include: Resident #11 Record review of the current undated face sheet for female Resident #11 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of Atherosclerotic heart disease of native coronary artery without angina pectoris (heart disease), essential hypertension (high blood pressure), unspecified systolic (congestive) heart failure (heart failure),…

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 all drugs and biologicals were stored properly in the cart for 1 of 2 medication carts (med cart on South Hall). MA B had loose pills in the medication cart assigned to her on South Hall. This failure could place residents at risk of not receiving prescribed medications as ordered and drug diversions. The findings include: Record Review of Resident #42's face sheet reflected she was a [AGE] year-old female who was admitted to the facility on [DATE] with a diagnoses of: paralysis following stroke affecting right side, depression, anxiety, urgency of urination, allergic rhinitis, type 2 diabetes with high blood sugar, congestive heart failure, irritable bowel syndrome with constipation, cirrhosis (chronic liver damage from a variety of causes leading to scarring and liver failure) of the liver, muscle wasting and atrophy, high blood pressure, reduced mobility. Record Review of Resident #50's face sheet reflected he was a [AGE]…

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 menus were followed for 8 of 24 residents (Residents #4, 32, 35, 51, 67, 69, 70 and 75) reviewed during mealtimes. The facility failed to ensure Residents #4, 32, 35, 51, 67, 69, 70 and 75 received their meals according to the menu for 2 of 3 food forms (mechanical soft and puree) This failure could place residents at risk for unwanted weight loss and hunger. The findings included : Resident #4 Record review of the current undated face sheet for male Resident #4 revealed that the resident was admitted to the facility on [DATE] and re-admitted on [DATE]. The resident was [AGE] years old and had diagnoses of unspecified, focal traumatic brain injury with loss of consciousness, status, unknown, subsequent and encounter (brain injury), dysphasia, oral phase (swallowing disorder), sleep disorder, unspecified, and diabetes mellitus due to underlying condition without complications (blood sugar disorder). Record review of the current…

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

Based on observation, interview, and record review, the facility failed to provide food that was palatable, and at a safe, and appetizing temperature for 3 of 3 food forms (Regular, Mechanical Soft, and Pureed) for 1 of 1 meal reviewed for palatability. 1) The facility failed to provide food that was palatable for 3 of 3 food forms served (Regular, Mechanical Soft, and Pureed) at 1 of 1 meal observed (1/8/24 lunch). These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. The findings included: During confidential individual interviews 6 of 16 residents voiced concerns related to food palatability. One resident stated The food is always cold. It's all meals. Another resident stated, The foods are hard. One other resident stated, It sucks. It's not good. The hamburger buns are hard occasionally, and it has poor flavor. A resident stated that the food was so bad that she had to buy her food somewhere else. The resident added that the food was so bad that it made her throw up. Another resident stated, The food is cold and Does not taste…

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 residents had the right to formulate an advance directive for 1 of 22 residents (Residents #43) reviewed for advance directives. 1. Resident #43's Out-of-Hospital Do Not Resuscitate (OOH-DNR) and physician orders were not consistent. This failure could place residents at risk for not having their end of life wishes honored and incomplete records. Findings included: Record review of Resident #43's face sheet, dated 02/06/24, revealed a [AGE] year-old-male who was admitted to the facility on [DATE] with diagnoses to include paranoid schizophrenia (mental disorder), rhabdomyolysis (rare muscle injury) and pain. The face sheet also revealed Resident #43's advance directives were: Do Not Resuscitate. Record review of Resident #43's active physician order summary dated 02/06/24 revealed physician orders listed code status: full code with a start date of 09/27/23. Record review of Resident #43's Out of Hospital Do Not Resuscitate form revealed a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a comprehensive plan must be prepared by an interdisciplinary team to the extent practicable, the participation of the resident and the resident's representative(s)of the care plan conference for 2 of 22 residents (Resident #33 and Resident #43) reviewed for comprehensive resident centered care plans. The facility failed to invite Resident #33 and Resident #43 or the representatives to attend their care plan conferences. These failures placed the residents at risk for unmet care needs and a decreased quality of life. Findings included: Resident #33 Record review of Resident #33's face sheet, dated 02/07/24, revealed a [AGE] year-old male was admitted to the facility on [DATE] with diagnoses that included, but were not limited to Benign neoplasm of pineal gland (central nervous system tumors, which begin in the brain), Reduced mobility (unsteadiness while walking, difficulty getting in and out of a chair, or falls), Symptomatic epilepsy (a type…

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 record review and interview, the facility failed to ensure, at the time of discharge, the communication of necessary information for a safe transition of care home for 1 of 1 (Resident #81) records reviewed for discharge planning. The facility failed to provide an accurate and complete plan of care for 1 of 3 closed records (Resident #43) with plans of services for home, a list of medications in laymen's terms submitted, or a sign receipt of plan of care. This failure has the potential to affect all residents and places them at risk of not receiving appropriate resources once discharged home. Findings included: Resident # 81 Record reviewed Resident # 81's face sheet revealed that the resident was[AGE] years old and admitted [DATE] with the following diagnoses: acid reflux dysphagia (difficulty swallowing), muscle wasting and atrophy (the decrease in size and wasting of muscle), type 2 diabetes with low blood sugar, nasal congestion, allergic rhinitis (allergic response causing itch, watery eyes,…

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, and the facility provided food prepared in a form designed to meet individual needs for 1 of 3 meals (2/06/24 - Supper) observed for 2 of 2 residents with orders for puréed and mechanical soft diets (Residents #32 and #75). The facility failed to provide food that was in a form to meet resident needs, 1 of 3 meals observed (2/06/24 - Supper) for 2 of 2 residents with orders for puréed diets (Resident #75) and mechanical soft diets (Resident #32). This failure could place residents at risk of decreased food intake and choking. The findings included: Resident #75 Record review of the current undated face sheet for female Resident #75 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (stroke with right weakness), aphasia (cognitive disorder), pain,…

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 control program designed to provide a safe, comfortable and sanitary environment to help prevent the development and transmission of diseases for 2 of 3 (Residents #66 an #73) and 2 of 2 (ADON B AND LVN C) staff reviewed for infection control. 1. ADON B failed to perform hand hygiene between glove changes when providing wound care for Resident #66 2. LVN C failed to perform hand hygiene between glove changes when providing wound care for Resident #73. 3. LVN C failed to keep dirty and clean supplies separated when providing wound care for Resident # 73. These failures could place residents at risk for spread of infection and cross contamination. Findings include: Resident #66 Record review of face sheet for Resident #66 revealed a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: symptomatic epilepsy (seizure disorder), hyperlipidemia (high levels of fat particles in the blood),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observation and record review, the facility failed to ensure all residents were treated with respect and dignity for 2 of 5 residents (Resident # 4 and Resident # 5) reviewed for dignity. CNA N made a video of Resident #5 yelling and cussing and posted it on a social media platform on 11/16/2023. Facility sent Resident # 4 to secondary provider day center on 11/21/2023 without a coat, shoes or wearing a bra. CNA B and LVN A failed to cover residents during wound care or incontinent care or provide privacy on 11/29/2023. This failure placed all residents at risk of psychosocial harm due to a diminished quality of life. Finding included: During an interview on 11/30/2023 at 5:05 PM, Resident #5's family member stated that family had noticed a video on snapchat that was title Resident #5's first name Chronicles and the video showed a table and in the background, they could hear Resident #5's voice. The family member stated they were not able to see Resident #5 only hear her yelling and cussing.…

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 and interview, the facility failed to ensure each resident had a right to reside and receive services in the facility with reasonable accommodation of the residents needs and preferences for residents reviewed for accommodation of needs. The facility failed to provide a call light or call pad system to 2 resident rooms (19 and 21) observed during investigation process. During an observation made on 11/29/2023 at 11:59 AM. Observed Resident #3's face pad call light on the floor between the bed and nightstand. Resident #3 was unable to reach and get the call light off the floor. During an observation made on 11/29/2023 at 1:40 PM. Observed Resident #2's call light was on the floor on the right side of the head of the bed. During an observation made on 11/29/2023 at 1:42 PM. Observed Resident #1's call light was wedged at the end of suction machine on the nightstand on left side of the bed. During an observation made on 11/29/2023 at 1:45 PM. Observed Resident #3's face pad call light on the floor between the bed and nightstand. Resident #3 was unable to reach and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible in 2 of 6 resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) located on 1 of 2 nurse stations (Station 1) by not storing hazardous material properly. The facility failed to discard scalpel after debridement of wound and left on bedside table in room [ROOM NUMBER] on 11/29/2023. The facility failed to store hazardous material (1 disposable scalpel) and (1 bottle of Dermal Wound Cleaner) in a secure manner. These failures could place residents at risk for avoidable injuries and infections related to skin punctures. The findings included: During an observation on 11/29/2023 at 10:15 PM in room [ROOM NUMBER] revealed 1 disposable scalpel with a blue handle and clear plastic blade cover, located on the overbed table, and 1 bottle of Dermal Wound Cleaner located on the overbed table. The Dermal Wound cleaner label had a statement keep out of reach…

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 implement and maintain an infection prevention and control program designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 residents reviewed for infection control (Resident #1 and Resident #2). 1. LVN A failed to provide adequate infection control practices while cleaning a wound for Resident #1 on 11/29/202, by not washing hands. 2. LVN A failed to provide adequate infection control practices by incorrectly cleaning a wound from outer to inner wound and contaminating the wound. 3. CNA B failed to provide adequate infection control practices by not washing hands and placing a dirty wipe on the same bed as the Resident #2, behind his back during incontinent care. 4. The NP failed to dispose of used scalpel that was used to debris resident wound. This failure could affect residents and staff members by placing them at risk for the transmission 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 develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 2 (Residents #1 and #3) of 6 residents reviewed. The facility failed to implement a baseline care plan that included the minimum healthcare information necessary to properly care for Resident #1 and Resident #3. This failure could place newly admitted residents at risk for insufficient immediate care needs for the resident being met and maintained. Findings Included: Record review of Resident #1's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: Cerebral vascular accident (interruption in the flow of blood to cells in the brain), xerosis cutis (rough dry skin that may have scales or small cracks), hypo-osmolality (a condition were the levels of electrolytes, proteins, and nutrients 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 record review, interview, and observation the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timetables to meet residents' highest practicable physical, mental, and psychosocial needs for 1 of 6 residents (Resident #2) reviewed for care plans. The facility failed to develop a comprehensive care plan for Resident #2 within 7 days after the completion of the comprehensive assessment. This failure could place residents at risk of not receiving the care required to meet their physical, mental, and psychosocial needs to attain or maintain their highest practicable physical, mental, and psychosocial outcome. Findings include: Record review of Resident #2's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: rotator cuff tear of unspecified shoulder, pressure ulcer of sacral region, pain, postprocedural hematoma (blood clot) of skin and subcutaneous tissue…

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 remained free of any significant medication errors for 1 of 1 resident reviewed for medication errors (Resident #2). The facility failed to administer a dose of Resident #2's IV antibiotic scheduled for 8:00 PM on 09/01/2023. There was no adverse consequence to the missed dose. This failure could result in the resident's infection to relapse and increase of the risk of re-hospitalization. Findings include: Record review of Resident #2's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: rotator cuff tear of unspecified shoulder, pressure ulcer of sacral region, pain, postprocedural hematoma (blood clot) of skin and subcutaneous tissue following procedure, sepsis (body's extreme reaction to an infection), candida stomatitis (fungal infection of the mouth), nicotine dependence, anxiety disorder (persistent worry about everyday situations), and constipation. During an interview 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.

Based on observation, interview, and record review, the facility failed to ensure that drugs and biologicals used in the facility were secured in locked compartment in that, one medication cart was observed to be unlocked and unattended on Station 1 hallway. One medication cart was observed to be unlocked and unattened on 100 Hallway on intial observation rounds. This failure could result in the theft or misuse of medication, potentially could cause accidental poisoning. Findings include: During initial round observations on 09/02/2023 at 9:55 AM, there was an unattended 100 Hallway Medication Cart three rooms down from where MA was administering medications. Staff and residents were observed in the 100 Hallway. HHSC Investigator VII stood by cart for 5 minutes. When the MA returned, she stated, I never do this. I am so sorry, as she was locking her cart back. During interview on 09/02/2023 at 2:48 PM, the MA stated she had been working here for a month and had been a MA for 9 years. The MA apologized again, stating, I never do that, and I know better. The MA stated that residents…

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.