Greenhill Villas

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 needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 2 of 6 residents (Resident #14 and Resident #51) reviewed for respiratory care and services. 1.The facility failed to cover the nasal cannula tubing with a bag on an oxygen concentrator machine that was not in use for Resident #14. 2.The facility failed to cover the bi pap mask with a bag that was not in use for Resident #51. These failures could place residents at risk for developing respiratory complications. Findings included: 1.Record review of Resident #14's face sheet, dated 06/17/25, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), dyspnea (labored breathing)…

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

Based on observation, interview, and record review, the facility failed to ensure all drugs and biological were stored in locked compartments for 1 medication cart of 3 (Medication Cart #3) reviewed for medication storage: The facility failed to ensure Medication Cart #3 was locked when unattended. This failure could place residents at risk of having access to unauthorized medications and/or lead to harm or drug diversions. Findings included: An observation on 6/19/2025 beginning at 10:04AM, revealed, Medication Cart #3 was unlocked and unattended with no nurse or medication aide at cart for 5 minutes. The staff member responsible for the medication cart returned to the unit at 10:06 AM. All other drawers could be opened, and medication and supplies could be easily accessed. The cart was observed to have prescribed medication blister packs, over counter medications, as well as a locked narcotic box. A resident was observed seated in a wheelchair with back of chair near the medication cart, 3 additional residents were sitting in their wheelchairs approximately 10 feet from 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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents reviewed for enhanced barrier precautions (Resident #1) infection control practices. 1. The facility failed to ensure LVN J donned a gown prior to administering feeding to Resident #1 via g-tube. Resident #1 was on enhanced barrier precautions. This failure could place residents at risk of exposure to communicable diseases, cross-contamination, and infections. Findings included: 1. Record review of Resident #1's face sheet dated 06/17/25, indicated she was a [AGE] year-old female that admitted [DATE] with diagnoses that included: epilepsy (a disorder in which nerve cell activity in the brain disturbed, causing seizures), gastrostomy status (opening allows for a tube to be inserted, providing 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 observation, interview, and record review, the facility failed to ensure residents could call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside for 1 of 20 residents (Resident #71) reviewed for resident call system. The facility failed to ensure Resident #71 had a call light that was functional. Resident #71's call light did not turn on when the button was pressed on 06/17/25. This failure could place residents at risk for a delay in assistance and decreased quality of life, self-worth, and dignity. Findings included: Record review of Resident #71's face sheet dated 06/17/25 indicated Resident #71 was an 80-years-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #71 had diagnoses including dementia (is a general term for a decline in mental ability severe enough to interfere with daily life), obesity, nontraumatic subacute subdural hemorrhage (is a collection…

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 the resident access personal and medical records pertaining to him or herself, upon an oral or written request, in the form and format requested by the individual, if it was readily producible in such form and format (including in an electronic form or format when such records were maintained electronically, or, if not, in a readable hard copy form or such other form and format as agreed to by the facility and the individual, within 24 hours (excluding weekends and holidays) and allow the resident to obtain a copy of the records or any portions thereof upon request and 2 working days advance notice to the facility for 1 of 2 residents (Resident #2) reviewed for access of records. The facility failed to provide Resident #2's legal representative copies of medical records after an oral request was voiced to the facility on [DATE]. This failure could place residents at risk of violation of their rights. Findings include: 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 interviews and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 of 6 residents (Resident #1) reviewed for pharmacy services. The facility failed to follow orders from 10/02/2024 to 10/06/2024 and administered to Resident #1, Aricept (Alzheimer medication), and Meloxicam (nonsteroidal anti-inflammatory medication) after the medications were discontinued. This failure could place residents at an increased risk for inaccurate drug administration and not receiving the care and services to meet their individual needs. Findings included: Record review of the face sheet, dated 11/09/2024, revealed Resident #1 was a [AGE] year-old female admitted on [DATE] for five day respite care and discharge date [DATE], with diagnoses of Alzheimer's disease (a brain disorder that gradually destroys memory and thinking skills), and unspecified osteoarthritis,…

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 residents with personal privacy and confidentiality of his or her personal and medical records for 1 of 1 (Resident #1) resident reviewed for resident rights. The facility did not ensure the treatment nurse used a secure telephonic device to communicate with the wound nurse NP. This failure could place residents at risk for diminished quality of life, loss of dignity and self-worth. Findings included: Record review of Resident #1's face sheet, dated 09/09/24, indicated Resident #1 was originally admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar), and laceration without foreign body (an object originating outside the body if an organism), right lower leg. Record review of the quarterly MDS assessment, dated 07/08/24, indicated Resident #1 made herself understood and usually understood others. Resident #1's BIMS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, for 1 of 3 (Resident #1) residents reviewed for abuse. 1. The facility failed to implement the abuse and neglect policy and procedure regarding reporting an injury of unknown origin. 2.The facility did not implement their policy on reporting neglect for laceration of unknown origin for Resident #1 to the abuse coordinator (Administrator) or HHSC. These failures could place the residents at increased risk for abuse and neglect. Findings included: Record review of the facility policy for Abuse/Neglect revised 03/29/2018, indicated, The resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation as defined in this subpart. This includes but was not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident'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 observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source were reported immediately, but no later than 2 hours after the allegation was made, for 1 of 3 (Resident #1) residents reviewed for abuse and neglect. The facility failed to report Resident #1's laceration to right lower leg, an injury of unknown origin, timely to HHSC. This failure to report could place the residents at risk for abuse. Findings included: Record review of Resident #1's face sheet, dated 09/09/24, indicated Resident #1 was originally admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar), and laceration without foreign body (an object originating outside the body if an organism), right lower leg. Record review of the quarterly MDS assessment, dated 07/08/24, indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to have evidence that all alleged violations were thoroughly investigated for 1 of 3 (Resident #1) residents reviewed for abuse and neglect. The facility failed to conduct a thorough investigation when Resident #1 obtained a laceration to her right lower leg. This failure could place residents at risk of abuse and neglect. Findings included: Record review of Resident #1's face sheet, dated 09/09/24, indicated Resident #1 was originally admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar), and laceration without foreign body (an object originating outside the body if an organism), right lower leg. Record review of the quarterly MDS assessment, dated 07/08/24, indicated Resident #1 made herself understood and usually understood others. Resident #1's BIMS score was 5, which indicated her cognition was severely…

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

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 food and nutrition services. 1. The facility failed to ensure all food items were properly dated and labeled in Refrigerator #1, Refrigerator #2, and Freezer #2. 2. The facility failed to ensure all food items were properly sealed in Freezer #1. 3. The facility failed to ensure Dishwasher E properly wore a facial hair cover while in the kitchen. These failures could place residents at risk of foodborne illness and food contamination. Findings include: During an observation on 05/19/24 at 9:14 a.m., revealed in Refrigerator #2 there were 2 small plastic bowls with lids which contained a thick, yellow food item with a creamy appearance that was not dated or labeled. There were 3 small plastic bowls with lids which contained round purple food items with no date or label. There was 1 small plastic bowl with red food items with no date or label. There was a sign on the door 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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 18 residents (Resident #17) reviewed for infection control. 1. The facility failed to ensure CNA G changed her gloves after providing incontinent care to Resident #17 prior to touching Resident #17's clean brief, shoulder, hip, gown and her blanket. 2. The facility failed to ensure CNA G handled dirty linen appropriately. 3. The facility failed to ensure CNA G performed appropriate hand hygiene prior to handling Resident #17's bed remote, drinking cup and bedside table. 4. The facility failed to ensure CNA A followed the Enhanced Barrier Precautions (interventions to prevent spread of infection in high-risk residents) to wear a gown while performing incontinent care for Resident #17 who had a urinary catheter…

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 comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 2 of 18 residents (Resident #25 and Resident #34), reviewed for care plans. 1. The facility failed to revise Resident #25's care plan after returning from the hospital with a urinary catheter (tubing inserted to the bladder to drain urine). 2. The facility failed to revise Resident #25's care plan to indicate he refused to have his urinary catheter removed 3. The facility failed to revise and update Resident #34's comprehensive care plan to reflect the resident was placed on hospice. These failures could place residents of the facility at risk of not addressing their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental and psychosocial outcome. Findings included : 1. Record review of Resident #25'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 observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 18 residents (Resident #49) reviewed for accidents and supervision. The facility failed to ensure CNA A performed a safe mechanical lift transfer for Resident #49. This failure could place residents at risk of injury. Findings include: Record review of Resident #49's face sheet dated 5/21/24 indicated he was [AGE] years old and admitted to the facility on [DATE]. Resident #49 had diagnoses which included osteoarthritis left shoulder (degenerative disease of the shoulder joint), chronic pain, depression (persistent sadness), hemiplegia and hemiparesis (unable to move or weakness to one side of the body) following cerebral infarction (blood disruption to the brain causing brain tissue to die) and 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 ensure a resident with urinary incontinence, based on the resident's comprehensive assessment, received appropriate treatment and services to prevent urinary tract infections (UTI) for 2 of 4 residents (Residents #17 and Resident #25) reviewed for catheters. 1. The facility failed to ensure Resident #17 had an indwelling urinary catheter (tube inserted into the bladder to drain urine) securement/anchor device (used to secure an indwelling urinary catheter). 2. The facility failed to ensure Resident #25 had orders for care of his indwelling urinary catheter. These failures could place residents at risk for indwelling urinary catheter dislodgement, urethral (empties urine from the bladder and out of the body) damage, pain, urinary tract infections, and not receiving needed care. Findings included: 1. Record review of Resident #17's face sheet dated 5/21/24 indicated Resident #17 was [AGE] years old and was initially admitted to the facility…

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 acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicated otherwise for 1 of 18 residents (Resident #66) reviewed for nutrition. 1. The facility failed to follow the dietician's recommended tubing feeding for Resident #66 to receive Glucerna 1.2 - 474 ml (2 cartons) four times a day for 2275 calories per day. 2. The facility failed to follow the facility's weight policy of weighing Resident #66 weekly times four weeks after readmission from the hospital on 4/02/24, did not follow up on Resident #66's 15 pound weight loss from admission on [DATE] to readmission on [DATE], and there was no weight obtained within 24 hours after readmission from the hospital on 5/11/24. These failures could place residents at risk for malnourishment, weight loss, skin…

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 the right to be free from abuse and/or neglect for 1 (Resident #1) of 15 residents reviewed for abuse and/or neglect. The facility failed to prevent CNA A from committing verbal abuse by telling Resident #1 to hush while he was upset. This failure could place residents at risk of emotional harm. Findings included: 1. Record review of Resident #1's face sheet, dated 05/08/24, indicated he was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included spastic hemiplegia affecting right dominate side (a condition in which the part of the brain controlling movement is damaged), neuromuscular dysfunction of bladder (a dysfunction of the bladder caused by nervous system problems), depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (a disorder that causes intense, excessive and persistent worry and fear about everyday situations), paraplegia…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 12 residents (Resident #2) reviewed for accidents and hazards in that: 1. The facility failed to ensure the back door on the memory care unit was monitored and secured while there was a malfunction with the doors locking. During this time Resident #2 eloped. 2. The facility failed to monitor and supervise resident in the memory care unit who was an elopement risk. 3. The facility failed to in-service staff on elopement response. These failures could place residents at risk for inadequate supervision and accidents. Findings included: 1. Record review of Resident #2's face sheet, dated 05/07/24, indicated she was a [AGE] year-old female, admitted on [DATE]. Her diagnoses included dementia with agitation(a term used to describe a group of symptoms affecting memory, thinking and social abilities), diabetes mellitus type 2 with diabetic neuropathy (a long-term…

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 unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene were provided for 3 of 6 (Resident #1, Resident #2, and Resident #3) residents reviewed for ADLs. The facility did not provide scheduled showers for Resident #1, Resident #2, and Resident #3. The facility did not schedule Resident #1 for a shower from February 18, 2024, through March 14, 2024 These failures could place residents at risk of skin irritation, skin infection, skin breakdown, not receiving services/care and decreased quality of life. Findings Include: 1. Record review of the face sheet dated 3/20/24 indicated Resident #1 was a [AGE] year-old male, re-admitted to the facility on [DATE] with diagnosis including diabetes, obesity, hypertension (elevated blood pressure), and osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bones wears down). Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure respiratory care was provided consistent with professional standards of practice for 4 of 7 residents (Residents #261, #13, #2, and #28) reviewed for respiratory care and services. 1. The facility failed to document and monitor Resident #261's use of oxygen. 2. The facility failed to administer oxygen between 1-2 liters per minute via nasal cannula as prescribed by the physician for Resident #261. 3.The facility failed to administer oxygen at 2 liters per minute via nasal cannula as prescribed by the physician for Resident #13. The facility failed to ensure Resident #13's oxygen concentrator had a filter in place. 4. The facility failed to ensure Resident #2 and Resident #28's oxygen concentrator filters were cleaned. These failures could place residents who receive respiratory care at risk for developing respiratory complications. Findings include: 1. Record review of Resident #261's order summary report, dated 03/29/2023,…

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 observations, interviews, and record review the facility failed to ensure that residents who require dialysis received such services, consistent with professional standards of practice for 3 of 3 resident (Resident # 41,#26, and #311) reviewed for dialysis. The facility failed to ensure nursing staff was checking Resident #41, #26, and #311's shunt (graft catheter aids the connection from a hemodialysis access point to a major artery) to left upper arm for bruit (sound heard through a stethoscope when held over the shunt) and thrill (vibration or buzz felt when fingers are laid on top of the shunt). This failure could place residents who receive dialysis at risk for complications and not receiving proper care and treatment to meet their needs. The findings were: 1.Record review of a face sheet dated, 3/29/2023, revealed Resident # 41 was a [AGE] year-old male initially admitted on [DATE] with diagnoses including chronic kidney disease, stage 4, severe (kidney failure), type 2 diabetes mellitus without…

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 served at an appetizing temperature for 12 of 17 residents (Resident #6, Resident #51, and 10 Residents in a confidential group) reviewed for dietary services. The facility failed to provide palatable food served at an appetizing temperature and taste to Resident #6, Resident #51, and 10 Residents in a confidential group. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. Findings included: 1. Record review of a face sheet dated 03/29/2023 revealed, Resident #6 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included hypertensive heart disease with heart failure (long-term condition with high blood pressure that affects the heart's ability to pump effectively), cardiomegaly (enlarged heart), and essential (primary) hypertension (high blood pressure). Record review of 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 store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure: o food items were dated and sealed appropriately. o expired food items were discarded. o the deep fryer was cleaned and oil changed. o a dented can was stored separately. o the ranch dressing and taco seasoning holder was clean. These failures could place residents at risk for foodborne illness. Findings included: During an observation on 03/27/2023 starting at 7:37 AM: Oil in the deep fryer was dark brown, and the deep fryer had crumbs all over and a burned French fry on the side Everything Freezer 1 opened box of biscuits unsealed no open date 1 opened box of sweet rolls unsealed no open date 1 opened box of cheesy garlic breadsticks unsealed no open date Cooking Freezer 1 opened box of pie shells with an open bag unsealed no open date Refrigerator 1 Bread and butter chips no open date 1 ziploc bag with 11 rolls not dated Freezer 2 1 opened box…

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

Based on interview and record review, the facility failed to maintain a quality assessment and assurance committee consisting at a minimum the required committee members for 6 of 6 meetings (October 2022, November 2022, December 2022, January 2023, February 2023, and March 2023) reviewed for QAPI. The facility did not ensure the Medical Director attended their QAPI meetings in October 2022, November 2022, December 2022, January 2023, February 2023, and March 2023. This failure could place residents at risk for quality deficiencies being unidentified, no appropriate plans of action developed and implemented, and no appropriate guidance developed. Findings include: Record review of the facility's QAPI Committee sign-in-sheets indicated the Medical Director did not sign in for their meetings from October 2022, November 2022, December 2022, January 2023, February 2023, and March 2023. An attempted telephone interview on 03/29/2023 at 8:01 a.m. with the Medical Director, was unsuccessful. During an interview on 03/29/2023 at 2:37 p.m., the Administrator stated per documentation it…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 3 residents (Residents #58 and #111) and 1 of 1 facility reviewed for infection control. 1. The facility failed to ensure Resident #111 was provided COVID-19 testing when she developed signs and symptoms. 2. The facility failed to ensure dirty linen bags were not tied to the clean linen carts. 3. NA P and Housekeeper U did not utilize appropriate PPE use throughout the facility. 4. LVN N did not wear gloves while checking Resident #58's blood sugar. 5. The facility did not ensure clean linen carts were covered. These failures could place residents and staff at risk for cross-contamination and the spread of infection. 1. Record review of Resident #111's face sheet, dated 03/29/2023, revealed Resident #111 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.

Based on observations, interviews, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 1 resident (Resident #17) reviewed for resident rights. The facility did not ensure CNA O and NA P treated residents with dignity and respect by referring to them as feeders. This failure could place residents at an increased risk of embarrassment, isolation, and diminished quality of life. The findings included: During an observation and interview on 03/27/2023 at 8:05 a.m., CNA O stated, I had to take a feeder back to the nursing station from the dining hall. When asked who she was referring to, CNA O stated Resident #17. CNA O was approximately 3 feet from several resident doors. CNA O stated it was not appropriate to refer to a resident as a feeder. CNA O stated she said the word feeder because she knew the surveyor would not know who she was talking about if she stated her name instead of saying feeder. CNA O stated referring to residents as feeder is…

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 coordinate assessments with the (PASRR) program to the maximum extent practicable to avoid duplicative testing and effort for 1 of 6 residents (Resident #33) reviewed for PASRR. The facility failed to indicate on the PASRR level 1 screening that Resident #33 had a mental illness. This failure could affect residents with mental illnesses and place them at risk of not being assessed to receive needed services. Findings Include: Record review of Resident #33's consolidated face sheet dated 03/29/23 indicated she was an [AGE] year-old female that was admitted to the facility on [DATE]. Resident #33 had a diagnosis of major depressive disorder (depressed mood or loss of interest in activities), chronic obstructive pulmonary disease (a chronic lung disease that blocks airflow and makes it difficult to breathe) and bipolar (mood swings ranging from depressive lows to manic highs). Record review of the MDS dated [DATE] indicated Resident #33 had a BIMS score…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish based on the comprehensive assessment and consistent with the resident's needs and choices for 1 of 1 resident (Resident #58) reviewed for activities of daily living. The facility failed to provide communication assistance to effectively communicate with staff for Resident #58. This failure could place residents at risk for decline and diminished quality of life. Findings included: Record review of Resident #58's order summary report, dated 03/29/2023, indicated Resident #58 was a [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis which included type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar), essential hypertension (high blood pressure), and hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure a resident who is unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 17 residents reviewed for activities of daily living. (Resident #38 and Resident #51) 1. The facility failed to provide facial hair removal for Resident #38 and Resident #51. 2. The facility failed to ensure Resident #51 was routinely showered and his fingernails were clean. These failures could place residents who were dependent on staff to perform personal hygiene at risk or embarrassment, decreased self-esteem, or decreased quality of life. The findings included: 1. Record review of Resident #38's face sheet, dated 03/29/2023, revealed Resident #38 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of hyperlipidemia (high cholesterol) and hemiplegia and hemiparesis following cerebral infarction affecting right dominant 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents received appropriate treatment and services to prevent further decrease of ROM for 1 of 2 residents reviewed for range of motion. (Resident #40) The facility did not ensure Resident #40 had a contracture prevention device in place for the treatment of his left contracted hand. This failure could place residents at risk for decrease in mobility and range of motion and contribute to worsening of contractures. The findings included: Record review of Resident #40's face sheet, dated 03/29/2023, revealed Resident #40 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of localization-related (focal) (partial) idiopathic epilepsy (these seizures are focal at onset-that is, emanating from a localized region of the brain) and cerebral palsy (group of disorders that affect movement, muscle tone, balance, and posture). Record review of the order summary report, dated 03/29/2023, revealed Resident #40 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 interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 2 of 2 residents (Resident #8 and Resident #261) reviewed for pharmacy services. The facility failed to reconciliate on the treatment administration record and the Individual Patient's Narcotics Record the administration of Resident #8's Tylenol with Codeine #3 (controlled medication used for pain) on 3/21/2023 on the 6 AM to 6 PM. The facility failed to reconciliate on the Individual Patient's Narcotics Record the administration of Resident #261's Alprazolam (controlled medication used for anxiety) on 03/24/2023 at 9 PM. These failures could place the residents at risk of not having medications available for use and drug diversion. Findings include: 1. Record review of Resident #8's face sheet dated 03/29/2023, revealed an [AGE] year-old female admitted on [DATE] with 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 observations, interviews, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled in accordance with professional standards for 1 of 4 medication carts (east nurse medication cart) reviewed for drugs and biologicals. The facility failed to ensure 2 insulin pens (device used to administer insulin to residents with high blood sugars) on the east nurse medication cart were dated when opened. This failure could place residents at risk of not receiving the therapeutic benefit of medications. Findings included: During an observation and interview on 03/27/2023 starting at 10:36 AM, 2 insulin pens on the east nurse medication cart were opened and not dated. LVN L stated the insulin pens should be dated when opened. LVN L stated it could be because the residents were new that the insulin pens were not dated when opened. During an interview on 03/28/2023 at 4:55 PM, LVN L stated insulin pens should be dated after opened because they were only good for 28 days after opening. LVN L stated she tried to go through her medication…

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