The Mildred & Shirley L. Garrison Geriatric Educat

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure residents were free of any significant medication errors for 1 (Resident #1) of 6 residents reviewed for medication administration. 1. The facility failed to ensure furosemide (Lasix) (used to treat conditions involving fluid retention) administered to Resident #1 as ordered from 5/9/2025-5/20/2025 (12 days). This failure could place residents at risk for not receiving medications as ordered by their physician. The findings include: Record review of Resident #1's undated face sheet revealed an [AGE] year-old female originally admitted to the facility on [DATE]. Resident #1 had a readmission date of 5/09/2025. Resident #1 had a medical history of cellulitis (a common bacterial skin infection) of right lower limb, essential hypertension (high blood pressure), and infection and inflammatory reaction due to internal fixation (infection and inflammation from a surgical procedure used to stabilize and heal fractures by using metal implants). Record…

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

Based on observation, interview, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 12 of 30 confidential residents. The facility failed to ensure 12 of 30 confidential residents were provided, through postings in prominent locations; the Grievance Procedure, were provided access to the Grievance form, were provided information regarding who the facility grievance officer was, their contact information, and how to file an anonymous grievance. This failure could place the residents at risk of unresolved grievances and decreased quality of life. Findings include: Interviews during Resident Council on, 05/05/2025 at 2:00pm, 12 confidential residents, stated they did not have access to the Grievance form following the facility's remodel. The residents did not know they could file a Grievance anonymously, the Grievance procedure had never been discussed in Resident Council, and they had not observed a posting of the Grievance procedure in prominent locations. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Observations, Interviews, and Record Review the facility failed to ensure residents were free from involuntary seclusion for 5 of 32 (Residents #8, #24, #59, #89, and #96) residents reviewed for involuntary seclusion. The facility failed to obtain a physician order, documenting the clinical criteria met for placement in the secured/locked unit for Residents #8, #24, #59, #89, and #96. There was no update to the Care Plan for Resident #96 for placement in the secure/locked unit. This failure could place residents at risk of isolation, decreased quality of life, and psychosocial harm. Findings included: Resident #8 Record review of the face sheet, dated 05/05/2025, revealed Resident #8 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included the following: Alzheimer's disease (progressive, irreversible brain disorder), Chronic obstructive pulmonary disease (COPD (ongoing lung condition caused by damage to the lungs), cognitive communication deficit (difficulties 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.

Based on observations, interviews, 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. The facility failed to properly store, label. and date foods stored in the refrigerator and freezer. The facility failed to properly store, label, and date perishable food items stored in the dry storage. These failures could place residents at risk for food contamination and foodborne illness. The findings included: The following observations and interviews were made on 05/04/2025 beginning at 10:15 AM during the initial observation of the kitchen: Observation on 05/04/2025 at 10:15 AM of the dry storage, in the kitchen, revealed two 20 ounce bottles of Welch's grape jelly. The two bottles were observed to be opened and half-filled. According to the manufacturer's label, the bottles should have been refrigerated after opening. One of the two bottles of jelly did not contain a date to indicate when the bottle had been received by the facility. During…

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, 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 communicable diseases for 3 of 4 residents (Resident #32, Resident #35, Resident #67, and Resident #90) and 5 of 6 staff (LVN A, LVN D, CNA D, CNA E, and CNA F) reviewed for infection control. 1. LVN A failed to follow facility policy and procedure for handwashing while providing wound care for Resident #32, during observations of wound on 05/05/2025 at 2:33 PM. 2. CNA D and CNA E failed to follow facility policy and procedure for handwashing while providing incontinent care for Resident #35, during observations of incontinent care on 05/05/2025 at 10:34 AM. 3. The facility failed to provide an enhanced barrier precautions sign for Resident #67 while having a wound. LVN D, CNA D, and CNA E all provided direct care without PPE due to an enhanced barrier precaution sign not being posted. 4.…

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 ensure the residents had the right to be informed of the risks, and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option she preferred, for 1 of 30 residents (Residents #65) reviewed for resident rights. The facility failed to obtain a signed informed consent based on information of the benefits, risks, and options available for Residents #65) prior to administering psychotropic medications (a psychoactive drug taken to exert an effect on the chemical make-up of the brain and nervous system). This failure could place residents at risk of receiving medications without their prior knowledge or consent, or that of their responsible party or being aware of the benefits and risks of the medications prescribed. Findings…

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 all residents had the right to formulate advance directives for 3 of 30 residents (Residents #12, #23, and #45) reviewed for advanced directives. The facility failed to ensure Residents #12, #23, and #45 who were listed as DNR (Do Not Resuscitate), had an Out-of-Hospital Do Not Resuscitate (OOH-DNR) form that did not have missed required information on the OOH-DNR. These failures could place residents at risk for not having their end of life wishes honored and incomplete records. Findings included: Resident #12 Record review of Resident #12's undated face sheet revealed a [AGE] year-old-female who was admitted to the facility on [DATE] and had diagnosis which included Dementia (irreversible that causes mental deterioration), Traumatic Brain Injury (brain dysfunction caused by an outside source), Asthma (inflamed, narrow airways that swell and make it difficult to breathe, Acute Cystitis (bladder inflammation), and Hypertension (the force 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 observations, interviews, and record reviews, the facility failed to ensure all residents had the right to personal privacy which included accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups for 3 of 3 residents (Resident #32, Resident #35, and Resident #90) reviewed for privacy. 1. LVN A failed to close the door, the curtain, the blinds, or provide a sheet or towel for coverage during wound care for Resident #32. 2. CNA D and CNA E did not close the door or close the curtain all of the way during incontinent care for Resident #35. 3. CNA F had provided peri care for Resident #90 and failed to close the blinds. This failure could place residents at risk of being exposed and cause residents to feel a loss of privacy, dignity, and decreased self-worth and self-esteem. Finding included: Resident #32 Record review of Resident #32s face sheet undated revealed an [AGE] year-old female with an admission date of 11/08/2023…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 1 of 32 residents (Resident #96) reviewed for care plans. The facility failed to develop an accurate, consistent, and completed care plan for Resident #96, specific to Resident #96 being placed in a secured/locked unit. This failure could place residents at risk of not receiving the care required to meet their individualized needs. Findings included: Resident #96 Record review of the face sheet, dated 05/05/2025, revealed Resident #96 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included the following: Encephalopathy (brain disease, damage, or malfunction), Schizoaffective disorder (mental health condition marked by…

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 (Sage medication cart and Oak medication cart), reviewed for medication storage. The medication cart assigned to Sage and Oak 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 05/05/2025 at 01:30 PM, an observation of the medication cart for Sage was conducted with LVN C. One loose pill (white round with 196 on one side) was found in the second drawer of the medication cart. LVN C identified the loose pill as clopidogrel (Plavix) 75 mg using her cell phone. LVN C destroyed the loose pill by placing it in the sharps container on the medication cart. On 05/05/2025 at 04:06 PM, an observation of the medication cart for Oak was conducted with LVN B. One loose pill (1/2 white oval) was found in the second drawer of the medication cart. LVN B was not able to identify the loose pill 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.

Based on observation, interviews, 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. 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 (05/05/2025 lunch). These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. The findings included: The following confidential responses were provided during the initial pool interview screening process on 05/04/2025: A resident stated, The food is always cold. A second resident stated the food was cold and he does not eat it most of the time. A third resident stated, Meals are always cold. Two of those three residents stated they ate in their rooms, and one stated they ate in the dining room. Record review of the Resident Council Minutes dated 11/12/2024 revealed resident comments related to the food served in the facility. It 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 personal privacy was provided for 4 of 4 shower rooms reviewed dignity. 1. The staff failed to provide privacy for Resident #1 and Resident #2 during showers by not having a shower curtain up or the shower curtain that was too small that it did not close all the way and exposing the resident. The failure could place residents at risk for diminished quality of life and loss of dignity and self-worth. The findings included: Resident #1: Record Review of Resident #1's face sheet revealed an [AGE] year-old female, who was admitted to the facility on [DATE] with a primary diagnoses of metabolic encephalopathy (an acute condition of global cerebral dysfunction in the absence of primary structural brain disease), acute cystitis (an infection of your bladder), hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone), type 2 diabetes (a condition in which the body has trouble controlling blood sugar…

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

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for residents who consumed food orally from 1 of 1 facility kitchen reviewed for dietary services in that: The facility failed to ensure [NAME] A used good hygienic practices while serving ready to eat food. Food contact equipment was not washed, rinsed, and sanitized in a sanitary manner. These failures could place residents at risk of foodborne illness. Finding include: During an observation on 12/18/24 at 11:30 AM, revealed [NAME] A walked away from the steam table and went to the back of the kitchen to the oven. He put an oven mitt on his right hand, over his disposable glove, and used his left hand to open the oven door with the disposable glove on his left hand. He removed a pan from the oven. He used his right hand with the oven mitt on it over the disposable glove. He used a food scoop to scoop food onto three plates, then returned the pan to the oven. He removed another pan from the oven 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.

Based on observation, interview and record review, the facility failed to prepare food in a form to meet individual needs in 1 of 1 kitchen reviewed for dietary services in that: The facility failed to ensure puree meat was prepared to a smooth uniform texture. This failure could place residents at risk for chocking. Finding include: During on observation on 12/18/2024 at 12:40 PM, the test tray sampled revealed the pureed meat had small pieces of meat in it and was not a smooth uniform texture. During an interview on 12/18/24 at 12:58 PM, the DM stated the pureed meat on the test tray look like mechanical altered meat. He stated the meat was not as smooth as it should be for a puree meal. He stated a resident that required a puree diet needed that type of diet so they could eat and not have food get stuck in their throat. He stated if a resident on a puree diet ate the meat from the test tray they could have choked. He stated [NAME] A was responsible for making the puree food because [NAME] A was certified in making puree food. He stated did not review the puree meal with [NAME] 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 Interviews and record review, the facility failed to implement their written policies and procedures to prohibit and prevent abuse and neglect for 2 (Resident #1 and Resident #2) of 7 residents reviewed for abuse and neglect. A. The facility failed to report and investigate the allegation of verbal abuse that was alleged by Family Member C on 08/31/24 involving Resident #1 and CNA A. B. LVN F failed to immediacy report an allegation of verbal abuse. C. The facility failed to report and investigate the allegation of exploitation that was alleged by CNA B on an unknown date in September 2024 involving Resident #2 and CNA A. This failure could place residents at risk of reoccurring abuse and exploitation. Findings Included: Resident #1 Record review of Resident #1's face sheet, dated 09/12/24, revealed an [AGE] year-old male was admitted to the facility on [DATE] with diagnoses that included cognitive communication deficit (language or speech deficit), depression (sadness), need for personal care 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 provide a safe, functional, sanitary, and comfortable environment for residents for 2 of 2 rooms Resident #1 and Resident #2) reviewed for safe environment, in that: 1. Resident #1 had a large number of mice droppings on the floor, including on the center of the floor by Resident #1's slippers, behind the recliner, and at the foot of the bed on the floor. 2. Resident #2 had mice droppings in his bedside table and a small number of mice droppings on the floor by the nightstand. The Findings include: Resident #1: Record review of Resident #1's undated face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #1 had a diagnosis of: Parkinson's Disease, muscle weakness, anxiety, hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone), hyperlipidemia (a condition in which there are elevated levels of fat particles in the blood), high blood pressure. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 in 2 of 2 resident rooms (Resident #1 and Resident #2) located on Bluebonnet Hall observed for pest control. 1. The facility failed to ensure rooms #101 A and #110 A did not have an infestation of mice. These failures could place residents at risk for infections and illness. The findings include: Resident #1: Record review of Resident #1's undated face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #1 had a diagnosis of: Parkinson's Disease, muscle weakness, anxiety, hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone), hyperlipidemia (a condition in which there are elevated levels of fat particles in the blood), high blood pressure. Record Review of Resident #1's annual MDS (Minimum Data Set) dated 08/19/2024, revealed Resident #1 had a BIMS score of 8 which indicates 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 review the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good personal and oral hygiene for 1 (Resident 1) of 10 residents reviewed for ADLs. The facility failed to ensure Resident #1's dentures were cleaned regularly. The failure was identified as past non-compliance as the facility had instituted adequate corrective measures to prevent reoccurrence of the non-compliance. This failure could place residents at risk of poor hygiene and grooming, bad breath, mouth sores and thereby decrease their quality of life. Findings Included: Record review of Resident #1's face sheet, dated 6/13/24, revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to: respiratory failure with hypoxia (inadequate oxygen), mild protein-calorie malnutrition (lack of proper nutrition), muscle weakness, lack of coordination, communication deficit, aphasia…

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 a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 5 hallways (Hall 200) reviewed for safe environment, in that: The facility failed to ensure Hall 200 was free from pervasive foul odors. This failure could place residents at risk of a diminished quality of life and decline in self-worth. Findings include: Observation on 04/30/24 at 8:30 am, Hall 200 had a strong foul urine smell. Once past hall 200's double doors, there was a section of carpet that measured approximately 74 feet long by 23 feet wide. On the opposite end of this hall there was a section of carpet that measured approximately 68 feet long by 18 feet wide; and between these carpeted areas there was a dining area that was used by the residents for their meals, activities, therapy, or a place to sit throughout the day. Observation of Resident #2 on 04/30/24 at 8:30 am indicated she was sitting at a dining table receiving therapy with lingering foul odor. Resident #2 was asked questions…

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 immediately inform the resident, consult with the resident's physician, and notify consistent with his or her authority, the resident representative when there was a change in the resident's physical, mental, or psychosocial status for 1 resident (Resident #1) of 3 residents reviewed for notification of change of condition. The facility failed to notify Resident's #1 physicians, or representatives that Resident #1 had notified staff of feeling as if something was stuck in her throat, on 4/24/24. This failure could affect residents by causing their physician and representative to be unaware of changes in residents' condition. Findings include: Record Review of Resident #1's undated face sheet revealed a [AGE] year-old female, originally admitted on [DATE]. Resident #1 had a history of cognitive communication deficit, aphasia (inability to swallow), muscle wasting, cerebral infarction (disrupted blood flow to the brain), dysphagia (difficulty swallowing)…

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 contact surfaces were clean. 4) The facility failed to ensure staff stored personal items in a manner that prevented contamination. 5) The facility failed to protect foods from potential contamination. 6) The facility failed to ensure staff used good hygienic practices. These failures could place residents at risk for food contamination and foodborne illness. The findings included: - The following observation was made during a kitchen tour on 3/26/24 that began at 10:12 AM and concluded at 10:45 AM: The large slicer blade was soiled with dried food. - The following observations were made during a kitchen tour on 3/26/24 that began at 11:08 AM and concluded at 12:15 PM: Dietary staff B was about to place the beef…

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 (Mesquite Hall) of 4 medication carts (l) in that: 1. LVN A had an open medication cup with 5 medications belonging to Resident #21 that was supposed to have been administered to Resident #21 but was not. 2. LVN A had a loose medication belonging to Resident #57, identified as Xarelto 10 mg (a blood thinner). 3. LVN A had a loose medication belonging to Resident #99, identified as Gabapentin 100 mg (used for nerve pain and anticonvulsant). These failures could place residents at risk of not receiving prescribed medications as ordered and drug diversions. The findings include: Resident #21: Record Review of Resident #21's face sheet reflected he was a [AGE] year-old male who was admitted to the facility on [DATE] with a diagnoses of: anemia with chronic kidney disease, acid reflux, metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in 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 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 (3/27/24 lunch). These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. The findings included: During the confidential Resident Council interviews held on 3/26/24 1:47 PM, 5 of 12 residents voiced concerns related to food palatability, temperature and appearance. Residents stated bread and toast were wet because they were placed on top of or next to the foods with juices, same with toast. It was further stated the meals were cold, bread was soaking wet or hard as a rock. Residents stated pork chops and chicken were…

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 4 of 8 residents (Residents #48, #75, #92 and #99) and 4 of 6 (LVN A, LVN C, MA A and CNA A) staff reviewed for infection control in that: 1. LVN A failed to perform hand hygiene during medication administration for Resident #48. 2. MA A failed to perform hand hygiene during medication administration for Resident #75. 3. LVN C failed to perform hand hygiene between glove changes after performing wound care for Resident #92. 4. CNA A failed to perform hand hygiene between glove changes or use soap and water to wash hands when gloves became visibly soiled during incontinence care for Resident #99. These failures could place residents at risk for spread of infection and cross contamination. Findings include: Resident #48: Record Review of Resident #48's face sheet, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to respect the resident's right to personal privacy for 1 resident (Resident #81) reviewed for privacy issues in that: 1. MA A left the computer screen halfway up and unlocked with Resident #81's information on the screen when she walked away and left screen unattended. This failure could place residents at risk of having medical information exposed to others. This failure could cause residents to feel uncomfortable and disrespected. Findings Included: Record review of Resident #81's face sheet indicated Resident #81 was a [AGE] year-old female who admitted on [DATE] with the following diagnoses: liver failure, need for assistance for personal care, lack of coordination, muscle weakness, difficulty swallowing, high potassium, high blood pressure, pancytopenia (a condition in which there is a lower-than-normal number of red and white blood cells and platelets in the blood. Type 2 diabetes, acidosis (a buildup of acid in the bloodstream),…

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 incontinent of bladder or had a urinary catheter received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 Residents (Resident #99) reviewed for incontinent care in that: CNA A failed to properly clean the buttocks area and wash hands between all glove changes while providing incontinent care to Resident #99. This failure had the potential to affect residents by placing them at an increased risk of exposure to communicable diseases and infections. Findings include: Record review of the admission record for Resident #99, dated 03/28/24, revealed a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: hemiplegia and hemiparesis affecting right side (weakness or inability to move one side of the body), type 2 diabetes (blood sugar problems), major depressive disorder (mood disorder) and 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 each resident received, and the facility provided food prepared in a form designed to meet individual needs for 2 of 2 meals (3/26/24 - Lunch and Supper) observed for 5 of 5 residents with orders for puréed diets (Residents #36, 40, 63, 96 and 103). The facility failed to provide food that was in a form to meet resident needs for 2 of 2 meals observed (3/26/24 - Lunch and Supper) for 5 of 5 residents with orders for puréed diets (Resident #36, 40, 63, 96 and 103). This failure could place residents at risk of decreased food intake and choking. The findings included: Resident #36 Record review of the Order Summary Report dated 3/27/24, for female Resident #36 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of Mild Protein-Calorie Malnutrition (Malnutrition), Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure adequate supervision and assistive devices to prevent accidents for 1of 3 residents (R#1) reviewed for accidents. The facility failed to ensure R #1 was free of accident hazards, resulting in a fall on 09/14/23. This failure could lead to residents, who are at risk of falls, falling and sustaining an injury. The findings included: Record review of R#1's admission Record indicated R #1 was a [AGE] year-old-female admitted to the facility on [DATE] and readmitted on [DATE]. This report included R#1's diagnosis as major depressive disorder, single episode, severe with psychotic features, metabolic encephalopathy (a problem with the brain), need for assistance with personal care, unspecified lack of coordination, muscle weakness, muscle wasting and atrophy (waste away), other lack of coordination, difficulty in walking, cognitive communication deficit, vascular dementia (memory loss), unspecified severity, without behavioral disturbance, psychotic…

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 3 residents reviewed for medication errors (Resident #1). The facility failed to administer Resident #1's (R#1) medications 09/11/23 through 09/13/23. This failure could result in residents not receiving medications at the therapeutic level prescribed by their physician. Findings include: Record review of R #1's admission Record indicated R#1 was a [AGE] year-old-female admitted to the facility on [DATE] and readmitted on [DATE]. This report included R#1's diagnoses as major depressive disorder, single episode, severe with psychotic features, dehydration, urinary tract infection, metabolic encephalopathy (a problem with the brain), need for assistance with persona care, unspecified lack of coordination, muscle weakness, muscle wasting and atrophy (muscle wasting), dysphagia (difficulty swallowing), other lack of coordination, difficulty in walking, cognitive communication…

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.