The Plaza At Lubbock

Based on observations, interviews, and record review, the facility failed to provide an ongoing program to support residents in their choice of activities, both facility-sponsored group, individual activities, and independent activities, designed to meet the interest of and support the physical, mental, and psychosocial well-being of 7 of 18 residents (confidential residents) reviewed for quality of life. The facility: 1. Failed to engage in activities at scheduled times. 2. Failed to offer engaging activity replacement for scheduled activities that were cancelled or not completed. This failure could affect Residents of the facility by not addressing their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, and psychosocial outcome. The findings included: Observation and an interview of the dining room and the common area on 10/09/24 beginning at 10:10am, revealed the scheduled activity at 10:00am was Washer Toss. There were four confidential residents sitting in the common area and three confidential residents sitting…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1of 2 treatment carts observed for pharmacy services. The facility failed to ensure 1 tube of Medih [NAME] Gel and 1 tube of zinc oxide ointment were dated when opened. The facility failed to ensure that all medical supplies in the treatment cart were not past their expiration date. The facility failed to ensure single use open collagen packets were not stored in the treatment cart after being opened. This failure could result in harm due to resident received expired medical supplies, such as wound dressings, as well as those supplies not being maintained at their best therapeutic level. The findings were: During an observation on [DATE] at 11:00 AM during treatment cart inspection observed 1 tube of Med…

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. The facility failed to ensure food was accurately dated and labeled. These failures could place residents at risk for food contamination and foodborne illness. The findings included: The following observations were made during a kitchen tour on 10/9/24 that began at 10:00 AM and concluded at 11:40 AM: Observation on 10/9/2024 at 10:12 AM revealed the following unlabeled and undated items: Ziplock bag of 2 ounce mayonnaise and mustard cups, tray of approximately 15 sandwich halves, glass of white substance that was later identified by the KMGR as milk, stainless steel container of yellow substance that was later identified by the KMGR as egg salad, four 2 ounce cups of a red substance that was later identified as salsa, 8 serving flutes of juice, and a Ziplock bag of 2 ounce cups of a white substance later identified by the KMGR as tartar sauce. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 4 of 4 Residents and 5 of 5 staff members (LVN A, CNA A, CNA C, CNA E and CNA F) observed for infection control practices (Resident #7, #15, #87, and #257). in that: 1. CNA A failed to use proper hand hygiene before or after assisting with incontinent care for Resident #7. 2. CNA C failed to use proper hand hygiene before or after assisting with wound care for Resident #15. 3. LVN A failed to use proper wound care techniques and CNA D did not use proper hand hygiene before or after assisting with wound care for Resident #87 4. LVN A failed to use proper wound care techniques and CNA D did not wash hands before or after assisting with wound care for Resident #257. 5. CNA F failed to ensure using good hygienic…

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 1 of 1 residents reviewed for dignity. (Resident #257) 1. CNA D and LVN A failed to pull the privacy curtain while providing wound care for Resident #257. These failures could place residents at risk for diminished quality of life and loss of dignity and self-worth. The findings included: Resident #257: Record Review of Resident #257's face sheet revealed a [AGE] year-old female, who was admitted to the facility on [DATE] with a primary diagnoses of spinal stenosis lumbar region (narrowing of the spinal canal, compressing the nerves traveling through the lower back into the legs), acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood), urinary tract infection, type 2 diabetes mellitus with diabetic nephropathy, hyperlipidemia (a condition in which there are high levels of fat particles in the blood), major depressive disorder, and hypothyroidism (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure residents with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new pressure ulcers from developing for 2 of 2 residents (Residents #87 and Resident #257) reviewed for pressure ulcer care. 1. LVN A failed to use the correct wound techniques during wound care for Resident #87 and #257. These failures could place residents with wounds at an increased and unnecessary risk of complications such as pain, acquiring new pressure ulcers, worsening of existing pressure ulcers, and infection. Findings included: Resident #87: Record Review of Resident #87's face sheet revealed a [AGE] year-old male, who was admitted to the facility on [DATE] with primary diagnoses of fracture of unspecified part of neck of right femur, senile degeneration of the brain (loss of intellectual ability),Guillain-Barre syndrome (condition in which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to immediately inform the resident's physician when there was a significant change in resident's physical, mental, or psychosocial status for 1 of 7 residents (Resident #1) reviewed for physician notification of changes. 1. The facility failed to follow their policy on change of condition by not immediately notifying the physician, and DON of Resident #1's UTI symptoms on 8/9/2024. 2. The facility failed to consult with Resident #1's physician and provide all necessary details, when Resident #1 complained of feeling burning and discomfort when urinating on 8/9/2024. This failure could affect residents by placing them at risk for a delay in medical treatment, decline in health, and death. The findings include: Resident #1 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 medical history of acute kidney failure (kidneys no longer work on their…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident, who was continent of bowel and bladder, received appropriate treatment for a urinary tract infection, for 1 of 7 residents (Resident #1) reviewed for urinary straight catheters. 1. The facility failed to ensure Resident #1 had a physician order prior to performing a straight catheter procedure. 2. The facility failed to follow their policy on urine specimen collection by not determining the appropriate measurement method for urine collection. 3. The facility failed to follow their policy on physician orders by not receiving and transcribing physician orders for a UA recollection for Resident #1. 4. The facility failed to follow the physician order for Resident #1 by performing an invasive straight catheter procedure when the physician order did not specify what method of UA recollection was needed. These failures could place the residents at risk of unnecessary straight catheter procedures and risk for 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 interview and record review, the facility failed to provide or obtain laboratory services to meet the needs of its residents for 1 of 7 residents (Resident #1) reviewed for laboratory services in that: 1. The facility failed to follow physician standing orders for lab blood analysis, on facility admission of Resident #1. These failures could place residents at risk of not having laboratory services completed and cause delay in their care. Findings include: Resident #1 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 medical history of acute kidney failure (kidneys no longer work on their own), muscle weakness (lack of strength), and muscle wasting (thinning of muscle). Record review of Resident #1's MDS dated [DATE] Section C- Cognitive patterns revealed a BIMS score of 13 which indicates resident was cognitively intact. Section GG- Functional Abilities and goals- Admission, revealed resident required…

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 maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 7 residents (Residents #1) reviewed for accuracy of medical records in that 1. The facility failed to document communication between RN D and Resident #1 when Resident #1 reported feeling as if she had a UTI on 8/9/2024. 2. The facility failed to document Resident #1's change in condition when she reported to staff, she felt she had a UTI on 8/9/2024. 3. The facility failed to document communication between RN D and FNP when Resident #1 reported feeling as if she had a UTI and obtaining an order for the UA on 8/9/2024. 4. The facility failed to document communication between staff and FNP when a contaminated UA sample was reported to the facility on 8/10/24 at 8:30pm for Resident #1. 5. The facility failed to document when the FNP ordered a UA recollection order for Resident #1, and what time and staff member…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals) to meet the needs of each resident for 39 of 46 (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10,#11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, # 27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40 and #41) The facility failed to ensure MA F administered medications to (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10,#11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, # 27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40 and #41) accurately within the 2 hour window per physician orders. The facility failed to ensure Resident #6 did not receive another resident's medication during medication pass. The facility failed to reconcile narcotic sheets after MA F documented administering narcotic medications…

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 maintian residnet medical records in accordance with accepted professional standards and practicies. The facility must maintain medical records on each resident that are accurately documented. The facility failed to ensure staff documented medications given to residents in the Medication Administration Record for 41 of 46 ((Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10,#11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, # 27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40 and #41) ) reviewed for acurrate documentation. This failure could place residents at risk of receiving incorrect amounts of medication as prescribed by their physician Finding include: Record review of Resident #1 undated face sheet revealed an [AGE] year-old female. Resident #1 was originally admitted to the facility 07/22/2019 with the following diagnoses: Gastroesophageal reflux disease (condition in which the stomach contents move…

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(s) when there was a change in residents health status for 2 of 46 residents (Residents #6 & # 25) reviewed for notification of changes. This failure could affect all Residents by causing their physicians, and representatives to be unaware of changes in a Resident's condition. Finding include: Record review of Resident #6's undated face sheet revealed a [AGE] year-old male. Resident #6 was originally admitted on [DATE] with the following diagnosis: hyperlipidemia (elevated lipids in the blood), cerebral infarction (disrupted blood flow to the brain), protein-calorie malnutrition, and neuropathic bladder (lack of bladder control). Record review of Resident #6's annual MDS dated [DATE], Section C- Cognitive patterns revealed he had a BIMS score of 15 which indicated resident is cognitively intact. Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to 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 significant change in the resident's physical, mental, psychosocial status and when there was a need to alter treatment significantly for 1 of 5 resident (Resident #1) reviewed for notification of changes. The facility failed to immediately consult with the resident's responsible party when Resident #1 expired. This failure could place residents at the risk of not being aware/informed of residents' condition. Findings include: Record review of Resident #1's face sheet, dated [DATE], reflected an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 was discharged on [DATE]. Resident #1 had diagnoses which included: Alzheimer's disease (cognitive loss) and pain. Record review of Resident #1's comprehensive MDS. dated [DATE], indicated 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.

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 infection for 1 CNA of 7 employees observed during infection control observation. The facility failed to ensure CNA A properly removed his N-95 mask after exiting a COVID positive resident room. The facility failed to ensure CNA A disinfected his hands after removing his N-95 mask. These failures could place residents at risk of transmission of a communicable disease or infection. Finding included: Record Review of the facility CII report , dated 9/22/23 contained the following, COVID Outbreak Investigation Summary revealed that on 9/21/23 Resident A tested positive for COVID. During an interview on 9/29/23 at 10:30 a.m., the Administrator stated that the facility had 6 total residents on Hall 200 that tested positive for COVID and all had been cleared but Resident #1. Administrator stated 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 observation, interview and record review, the facility failed to provide food that was palatable, and at a safe and appetizing temperature 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 (8/23/23 lunch). These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. The findings included: During a confidential individual interviews, 5 of 17 residents voiced concerns with the palatability of foods served. On 8/22/23 at 10:29 AM, a resident stated that the food sucks. She stated there was not much taste to the food and was bland with no flavor. She stated that the lunch and the dinner were not good. On 8/22/23 at 10:36 AM, another Resident stated she did not like the food. She added the ham and cheese sandwiches did not have any mayonnaise and the bread was hard when she got it. On 8/22/23 at 2:57 PM, one other 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 store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services and 10 of 24 resident rooms (rooms 102, 109, 202, 205, 206, 211, 212, 213, 214 and 215), in that: 1)The facility failed to ensure foods were processed under sanitary conditions, 2) The facility failed to ensure Dietary staff dated and labeled foods as required, 3) The facility failed to ensure Dietary staff maintained quaternary sanitizer levels within acceptable ranges in wiping cloth solutions. 4) The facility failed to ensure Dietary staff ensured food contact surfaces were clean, 5) The facility failed to ensure foods were stored in a sanitary manner, 6) The facility failed to ensure Dietary staff used good hygienic practices, 7) The facility failed to ensure there were no unauthorized personnel in food areas, and 8) The facility failed to ensure the temperature 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 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 he or she preferred, for 7 of 29 residents ( Resident #9, #11, #14, #33, #92, #250 and #303) reviewed for resident rights . 1. The facility failed to obtain a signed informed consent based on information of the benefits, risks, and options available for Residents #9, #14, #92, #250 and #303 prior to administering melatonin (sleep aide). 2. The facility failed to obtain a signed informed consent based on information of the benefits, risks, and options available for Residents #11 prior to administering Lorazepam (anti-anxiety medication). 3. The facility failed to obtain a signed informed consent based…

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 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 4 of 4 common baths (100, 200, 300 and 400), resident transport van and 19 of 29 resident rooms (101, 102, 109, 110, 112, 113, 203, 204, 205, 206, 207, 209, 210, 211, 212, 213, 214, 215 and 216) reviewed for environment, The facility failed to ensure resident that use common areas and rooms were clean, safe and did not need repair. These failures could place residents at risk for living in an unsafe, unclean, uncomfortable, and unhomelike environment which could cause a decline in resident psychosocial well-being. The findings included: Observation on 8/23/23 at 5:08 PM in room [ROOM NUMBER], the laminated areas were missing on two of two chests of drawers, ranging from 1 x 12 strips and 1 x 1 areas.…

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 receiving psychotropic medications had an approved diagnosis and PRN orders for psychotropic drugs were limited to 14 days unless the attending physician or prescribing practitioner believed, and documented, that it was appropriate for the PRN order to be extended beyond 14 days, for 4 of 29 residents (Resident #11, Resident #38, Resident #92 and Resident #250): Resident #11 continued to have a PRN order for Lorazepam 0.25mL after 14 days without an evaluation by the physician for continued treatment. Resident #38 was receiving Klonopin 0.5mg and Olanzapine 2.5mg without an adequate diagnosis. Resident #92 continued to have a PRN order for Hydroxyzine 25mg after 14 days without an evaluation by the physician for continued treatment. Resident #250 was receiving Sertraline 100 mg and Remeron 15 mg without an adequate diagnosis. These failures could result in residents receiving psychotropic and antipsychotic medications when…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure menus were followed for 1 of 3 food forms (puree) for 5 residents (Residents #1, 2, 32, 33 and 38) reviewed during mealtime. The facility failed to ensure Residents #1, 2, 32, 33 and 38 received their meals according to the menu. This failure could place residents at risk for unwanted, weight loss and hunger. The findings included: Resident #1 Record review of the Resident Consolidated Orders dated 8/24/23 for female Resident #1 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses listed as other cerebral palsy (motor disability), type 2 diabetes mellitus with hypoglycemia (blood sugar disorder) and dysphasia (swallowing disorder). Further record review of the orders revealed that the resident had a diet order dated 3/17/21 of Consistency Purée - Level 4. Resident #2 Record review of the current Resident Consolidated Orders for female Resident #2 revealed the 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, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 1 nonsmoking facility observed for safety and cleanliness in that: The facility failed to ensure that the facility was non-smoking and that staff adhered to the facility policy. The facility failed to dispose of cigarette butts safely. These failures place residents, staff, and visitors at risk of being in an unsafe environment. Findings included: On 08/23/23 at 3:53 PM, an observation of six cigarette butts on the ground on the facility's north side. No cigarette receptacle was observed at this time. On 08/23/23 at 3:57 PM, an observation of 3 cigarette butts along the northeast corner alongside the facility. No cigarette receptacle was observed at this time. On 08/23/23 at 4:00 PM, an observation of ten cigarette butts along the front of the facility near the front entrance. No cigarette receptacle was observed at this time. During an interview on 08/24/23 at 12:11 PM, the ADM said 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 observations, interviews, and record reviews, the facility failed to ensure each resident was treated with respect, dignity, and care for each resident in a manner and in an environment that promotes the maintenance or enhancement of their quality of life, recognizing each resident's individuality. The facility failed to protect and promote the rights of the resident for 1 of 29 (Resident #2) residents in that: Hospice CNA A provided Resident #2 personal care (bathing and brief change) with the privacy curtain not pulled, door open, and window blinds open. This could place residents at risk for diminished quality of life and loss of dignity and self-worth. The findings included: A record review of Resident #2's face sheet, dated 08/24/23, revealed an [AGE] year-old female was admitted to the facility on [DATE] with diagnoses to include paraplegia (paralysis in the legs) and need for assistance with personal care. Record review of Resident #2's Comprehensive Minimum Data Set, dated [DATE], revealed:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident who was incontinent of bladder, received appropriate treatment and services to prevent urinary tract infections for 2 of 2 resident with a urinary catheter (Resident #55 and #304); in that: 1. The facility failed to ensure catheter drainage bag was covered for privacy. 2. The facility failed to position the catheter tubing in a manner to prevent infections. These failures could place residents at risk for urinary tract infections. The findings included: Resident #55 Record review of Resident #55's face sheet, dated 08/24/23, revealed aan [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include stroke, diabetes (high blood sugar), congestive heart failure (fluid around heart), kidney failure and muscle weakness. Record review of comprehensive MDS assessment dated [DATE] revealed Resident #55 had a BIMS of 11 which indicated the resident's cognition was moderately impaired. The MDS further…

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 dispose of garbage and refuse properly in 1 of 1 refuse disposal areas which included 1 dumpster and 1 grease disposal container, in that: The facility failed to maintain the dumpster and the grease disposal container in a manner that effectively prevented the harborage and attraction of pest. These failures could result in providing harborage and breeding areas for insects, rodents and other pests which could infest the facility. The findings included: On 8/22/23 at 10:05 AM an observation was made of the dumpster area. The dumpster had one of two side doors open and was empty. The used grease bin, placed in the parking lot, was leaking from the bottom and the top lid was open. There was pooling grease on the ground that covered an approximate area of 1' x 1', 2' x 3' and 6 x 3'. On 8/22/23 at 12:48 PM and 8/23/23 at 12:01PM the grease bin was observed open, and the grease was pooling on the ground and was leaking from the unit. On 8/23/23 at 7:00 PM an observation was made of the dumpster and one of two side…

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 all mechanical, electrical, and patient care equipment in safe operating condition in 1 of 1 kitchen, in that: The facility failed to ensure the kitchen steamtable was maintained in safe operating condition. This failure could place residents at risk for receiving cold meals and at risk for fire emergencies. The findings included: On 8/22/23 at 10:54 AM the surveyor observed a bright flash at the steam table (electrical flash) and the lights on the steam table heating unit went out. During an interview with Dietary staff C on 8/22/23 at 10:54 AM, she stated this situation with the steam table had just now happened today (8/22/23). During an interview with Dietary staff F on 8/22/23 at 5:01 PM, she stated a repairman had replaced the steam table electrical plug last month when the steam table did the same thing (electrical flash) as it did today (8/22/23). Observation of the evening meal service on 8/22/23, beginning at 5:00 PM revealed the steam table was not operational and the stove and steamer…

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.