Navasota Nursing & Rehabilitation

Based on observation, interview, and record review the facility failed to ensure residents had the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal for five of six residents (confidential residents) reviewed for grievances. The facility failed to post the grievance procedure in a prominent and accessible locations throughout the facility; provide residents with access to grievance forms, and instruction on how to file an anonymous grievance. This failure could place residents at risk by limiting their access to the grievance process, which may result on unresolved concerns that impact their well-being and overall quality of care. Findings include: Observation on June 4, 2025, at 10:38 AM, revealed the facility's grievance procedure posted in the first hallway near the front entrance. The notice was affixed approximately nine feet above the floor, which made it difficult to read. The height rendered it inaccessible to residents who use wheelchairs or those who…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 3 of 11 residents (Residents # 11, #17, and #32) reviewed for ADLS . 1. The facility failed to ensure Resident #11's fingernails were cleaned, trimmed and filed. 2. The facility failed to ensure Resident #17 received baths per her care plan and her request and failed to ensure her nails were trimmed. 3. The facility failed to ensure Resident #32 had clean clothing, failed to ensure she received baths three times a week and failed to ensure her nails were trimmed and filed. These failures could place residents at risk for a decline in health, skin breakdown, loss of self-esteem, a diminished quality of life and health-related issues from lack of hygiene . Findings include: 1. Record review of Resident #11's, undated, face sheet reflected a [AGE] year-old male who 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, based on the comprehensive assessment of a resident, the resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one of six residents (Resident #39) reviewed for quality of care. The facility failed to take vital signs daily for 58 of the last 68 days per the QAPI initiated physician orders for Resident #39. This failure could place residents at risk of not receiving necessary medical care and lead to an unacknowledged change in condition and possible hospitalization. Findings include : Record review of Resident #39's face sheet reflected a [AGE] year-old, female who was admitted to the facility on [DATE]. Resident #39 had diagnoses which included, Dementia, severe with agitation (damage or loss of nerve cells in the brain resulting in behavior changes), Essential Hypertension (high blood pressure), and Generalized Anxiety…

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 the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure a hair net was worn by Dietary Aide . These failures could place residents who ate food served by the kitchen at risk of food-borne illness. Findings included: An observation on 06/04/2025 at 10:49 AM, a Dietary Aide was observed in the kitchen prepping dessert and washing dishes without a hair restraint on. In an interview on 06/05/2025 at 9:08AM with Dietary Aide , she stated she had worked in the kitchen for 1 year and she knew a hair net should be always on. She stated she found a hair net on the floor in the kitchen but did not realize her hair net had fallen off. She stated she was trained by a previous Dietary Manager to always wear a hair net and she also had her food handler certificate . She stated some consequences for not wearing a hair net could be food getting into the food and causing contamination . 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 observation, 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 for one of two medication carts (RN medication cart) reviewed for medication safety. The facility failed to ensure that a loose Tramadol pill (controlled medication) in RN Medication Cart was secured, administered, and/or disposed of based on facility policy. The failure puts residents at risk for not receiving their prescribed medication and risk of possible drug diversion. Findings include: Observation of the RN Medication Cart for Station II and III on 6/4/2025 at 03:10 PM with RN A revealed one loose pill on the bottom of the drawer within the locked drawers of the medication cart. It was a small, white circular pill AN 627. Medication identified by RN A as Tramadol 50 mg. The medication was put into a cup and taken to the RCN and DON. The RCN and Traveling DON were notified of the loose medication in the cart. The RCN and Traveling DON 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 or obtain from an outside source dental service to meet the needs of 1 of 4 residents (Resident #33) reviewed for dental services. The facility did not assist Resident #33, who had missing teeth and pain when she ate , with a dental service consult. This failure could place residents at risk of oral complications, pain, difficulty eating, and diminished quality of life. Findings included: Record review of Resident #33's face sheet showed a 69 -year-old woman, who was admitted on [DATE]. Diagnoses included: Parkinson's disease (neurodegenerative disorder that affects movement), Protein - calorie malnutrition (inadequate intake of food (as a source of protein, calories, and other essential nutrients). Rhabdomyolysis (muscle tissue break down ). Record Review of Resident #33 's quarterly MDS assessment dated [DATE] , reflected a BIMS score of 10 which indicted moderately impaired cogntition. MDS section L- Oral / dental status…

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 and follow accepted national standards for one of six residents reviewed for infection control practices. (Resident #52). The facility failed to ensure that LVN B used gloves to open a capsule prior to medication administration on 6/4/2025. This failure could place the resident at risk for cross contamination. Findings include: Review of Resident #52's Face sheet reflected a [AGE] year-old, female admitted on [DATE]. Diagnoses included Dementia, severe with other behavioral disturbance, Essential Hypertension (high blood pressure), and Cognitive Communication Deficit (problem with communication caused by cognition rather than a language or speech deficit). Review of the MDS assessment for Resident #52 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 provide services by sufficient numbers of nurse aides and licensed nurses on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans for 6 of 8 shifts (04/19/25 06:00 AM-06:00 PM, 04/19/25 06:00 PM-06:00 AM, 04/20/25 06:00 AM-06:00 PM, 04/20/25 06:00 PM-06:00 AM , 04/21/25 06:00 AM-06:00 PM , and 04/22/25 06:00 AM-06:00 PM) reviewed for sufficient nurse staffing. The facility failed to schedule nurse aides and licensed nurses in numbers consistent with the posted nurse staffing during the following shifts: 04/19/25 06:00 AM-06:00 PM, 04/19/25 06:00 PM-06:00 AM, 04/20/25 06:00 AM-06:00 PM, 04/20/25 06:00 PM-06:00 AM , 04/21/25 06:00 AM-06:00 PM , and 04/22/25 06:00 AM-06:00 PM. This failure placed residents at risk of not having their needs for assistance with activities of daily living and their medical needs met. Findings included: Review of the posted nurse staffing for 04/20/25, 04/21/25, 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 observations, interviews, and record reviews, the facility failed to ensure residents received services in the facility with reasonable accommodations of each resident's needs for 3 of 6 residents (Residents #1, #2, & #3) reviewed for resident rights in that: Residents #1, #2, & #3 's call lights was not within reach on 01/30/2025. This failure could affect residents who needed assistance with activities of daily living and could result in needs not being met. Findings included: 1.Record review of Resident #1's admission record dated 01/30/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 diagnosis of Alzheimer's Disease (a brain disorder that causes memory and thinking skills to decline over time. Record review of Resident #1's Quarterly MDS assessment, dated 01/22/2025, revealed the resident had a BIMS score of 03, which indicated severe impairment. The MDS also revealed Resident #1 was dependent in the areas of toileting hygiene, shower/bathe self, lower…

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, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 6 residents (Resident #3) reviewed for comprehensive care plans. Resident #3's comprehensive care plan did not reflect Resident #3's received psych service. This deficient practice could place residents at risk for not receiving proper care and services due to inaccurate care plans. Findings include: A record review of Resident #3's face sheet dated 01/30/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3's diagnoses included: unspecified dementia (a condition that cause a decline in thinking, memory, and reasoning abilities), major depressive disorder (mood disorder that causes a persistent feeling of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 of 6 residents (Resident #4) reviewed for care plans. The facility failed to ensure Resident #4's care plan was updated to reflect the resident's recent falls on 12/20/2024, 01/24/2025 & 01/25/2025. This failure could place residents at risk of not receiving appropriate care to meet their current needs. Findings include: Record review of a facility face sheet for Resident #4 dated 01/30/2025, reflected a [AGE] year-old male who was re-admitted to the facility on [DATE]. Resident #4's diagnoses included: unspecified dementia ((a condition that cause a decline in thinking, memory, and reasoning abilities), repeated falls (falling multiple times, usually within a short period), lack of coordination (not being able to move different parts of your body smoothly together), and muscle weakness (when your muscles don't have the strength…

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, consult with the resident's physician and notify, consistent with his or her authority, the representative when there was a significant change in the resident's physical, mental, or psychosocial status for one (Resident #1) of four residents reviewed for resident rights. The facility failed to ensure Resident #1's MD was notified after she experienced swelling in her left arm. Resident #1 complained of pain 11/16/2024, the Medical Doctor was not informed. On 11/20/2024 the Medical Doctor assessed the resident and ordered an X-ray which showed no significant findings on 11/21/2024 of which the MD was not notified. On 11/26/2024 the resident requested to go to the emergency room where she was diagnosed with a ruptured left bicep tendon with instructions to keep arm elevated and free of compression. This failure could place residents at risk of illness, injury, uncontrolled pain, and a decreased quality 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 interviews, observations, and record review, the facility failed to ensure residents who were trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice, and accounted for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization for 1 (Resident #1) of 1 resident reviewed for trauma informed care. The facility had Resident #1 in a shared room with Resident #2, when his care planning for Post-Traumatic Stress Disorder (PTSD) documented that having roommates triggers his PTSD. This failure could place residents at increased risk for psychological distress due to re-traumatization. Findings included: Review of Resident #1's Face Sheet dated 07/17/2024 reflected a [AGE] year-old male initially admitted to the facility on [DATE] with the following diagnoses: chronic / acute post-traumatic stress disorder (mental health condition that can affect anyone who has experienced a traumatic event,…

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 provide a private space for residents' monthly resident council meetings and the confidential resident group meeting during survey for five of five confidential residents reviewed for resident council. The facility did not provide a private space for resident council meetings. The failure could place residents, who attended resident council meetings, at risk of not being able to exercise their rights of being able to voice their grievances in a private space without uninvited staff being present. Findings Included: Interview on 05/07/2024 10:10 AM, the Administrator stated the residents would be in the dining area that it was located next to the nurses' station which was an open room with no doors for privacy. After speaking with the administrator, the meeting was then moved to the Activity Directors office. A confidential resident group meeting held in the Activity Director's office on -05/08/224 at 10:30 AM with 5 residents. The residents in attendance of the resident group meeting stated they normally meet in the dining…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 5 of 10 residents (Resident #3, Resident #4, Resident #20, Resident #46, and Resident #61) reviewed for ADL's. A) The facility failed to ensure assistance was provided for repositioning and incontinent care every 2 hours for Resident #4, and Resident #20. B) The facility failed to ensure Resident #3, Resident # 46 and Resident #61's nails were cleaned. These failures placed residents at risk for a decline in health, skin breakdown, loss of self-esteem, and a diminished quality of life and could result in health-related issues from lack of hygiene. Findings Included: A) Review of Resident #4's face sheet dated 05/07/2024 reflected a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with the following diagnoses Dementia (A group of symptoms that affects memory, thinking…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to provide, based on comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choices of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interest of and support the physical, mental, and psychosocial well-being of each resident, encouraging interaction in the community for 4 of 8 residents (Resident #4, Resident #20, Resident #21, and Resident # 61) reviewed for activities. Residents #4, #20, #21, and Resident #61 were not receiving one-on-one activities or involved in group activities during the months of February, March, April, and May of 2024. This failure could place residents at risk for a decline in social, mental, psychosocial well-being, and a diminished quality of life. Findings included: 1. Record review of Resident #4's face sheet, dated 05/07/2024, revealed Resident #4 was an [AGE] year-old…

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 prepare puree food by methods that conserve nutritive value, flavor, and appearance for 1 of 1 kitchen observed for puree preparation. The facility failed to follow the puree diet recipes. The puree diet meatloaf was mixed with water instead of thickener or a broth with nutrient value. This failure could affect residents on puree diet at risk of receiving inadequate diet that could affect their health. Findings included: Observation on 05/06/2024 at 12:08pm revealed [NAME] M pureed the meatloaf with water instead of the thickener on the counter. [NAME] M did not have any recipes out for the pureed food. Observation of [NAME] N pureeing food on 05/07/2024 at 10:41am did not have recipes out for the pureed food. An interview with [NAME] N on 05/07/2024 at 2:08pm revealed that [NAME] N had been trained on puree. She stated that when pureeing meat, broth or thickener was supposed to be used. She stated that when adding thickener or broth, a little at a time was added until the meat was at the proper texture.…

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 foods safety for 1 of 1 kitchen reviewed for food safety and sanitation. The facility failed to ensure food that was prepped was labeled and dated. The facility failed to maintain proper temperatures of food before putting on the steam table. This failure placed residents at risk of foodborne illness. Findings included: Observation of the kitchen on 05/06/2024 at 6:52am revealed inside the walking cooler with milk, apple juice, and orange juice were not dated or labeled with the date they were prepped. In the freezer there were two bags of round pieces of dough that were not sealed or dated as to when it was opened. There were also sausage patties that were not sealed or dated in the freezer. In the dry food storage area, there was a container of flour that did not have a date as to when it was opened. Observation of [NAME] M on 05/06/2024 at 12:08pm revealed the temperature of the pureed meatloaf was 120 degrees 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 observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 of 9 (Resident # 39) residents in 1 of 3 dining rooms. The facility failed to promote Resident # 39's dignity while dining when staff did not serve his lunch tray for 20 minutes after his tablemate was served. This failure could affect all residents who were eating in the dining room, by contributing to poor self-esteem, and unmet needs. Findings included: Record review of Resident #39's Face Sheet dated 05/08/2024 revealed a [AGE] year-old male admitted on [DATE] and re-admitted on [DATE] with diagnoses of intermittent explosive disorder (repeated, sudden bouts of impulsive, aggressive, violent behavior, or angry verbal outbursts), unspecified protein-calorie malnutrition ( a disorder caused by a lack of proper nutrition or an inability to absorb nutrients…

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 the residents received services in the facility with reasonable accommodation of each resident's needs for 2 (Resident #45 and Resident #46) out of 14 reviewed for call lights. The facility failed to ensure Resident #45 and Resident #46's call lights were within reach. This failure could affect all residents who needed assistance with activities of daily living and could result in needs not being met. Findings included: Record review of Resident #45's Face Sheet dated, 05/08/2024, reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of essential tremor ( a condition that affects the nervous system, causing involuntary and shaking or trembling), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety ( a mild cognitive impairment has yet to be diagnosed with no behaviors), repeated falls ( fall more than once 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 develop a comprehensive care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. for one resident (Resident #18) of eight reviewed for indwelling urinary catheters care plans, in that: The facility failed to ensure Resident #18's Comprehensive Care Plan reflected his use of an indwelling urinary catheter. These failures could place residents with indwelling urinary catheters at risk for urinary tract infections, change of condition and risk for not having their individually assessed needs met which could result in a diminished quality of care and staff being unaware of needed interventions. Findings included: Review of Resident #18's face sheet dated 05/08/2024 reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses dementia (A group of symptoms…

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 limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for two of five residents (Resident #4 and Resident #20), reviewed with limited range of motion. A) The facility failed to ensure Resident #4 had interventions in place for her bilateral hand contractures (A permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen and a decrease in ROM) to prevent further decline of the range of motion in her hands and failed to ensure her fingernails were trimmed. B) The facility failed to ensure Resident #20 had interventions in place for her right-hand contracture to prevent further decline of the range of motion in her right hand. This deficient practice placed residents with contractures at risk for decrease in mobility, range of motion, and contribute to worsening of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents who are incontinent of bladder receive appropriate treatment and services to prevent urinary tract infections for one of four residents reviewed for catheters. (Resident #18) The facility failed to ensure Resident #18 received care to prevent urinary tract infections when they stored his catheter bag on the floor and failed to ensure a catheter secure device was in place to prevent dislodgment. These failures could place residents with foley catheters at risk for urinary tract infections and change of condition. Findings included: Review of Resident #18's face sheet dated 05/08/2024 reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), Cerebrovascular disease (conditions that impact the blood vessels in your brain.), bipolar disorder (A serious mental illness…

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 displayed or was diagnosed with dementia received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being, for one of 12 residents (Resident #18) reviewed for residents with dementia and behaviors. The facility failed to develop and implement a comprehensive person-centered care plan to address Resident #18's continuous behaviors regarding his indwelling catheter. This failure could place residents at risk for their medical, physical, and psychological needs not being met and placed residents with indwelling catheters at risk of urinary tract infections and traumatic removal of the catheter leading pain and injury. Findings included: Review of Resident #18's face sheet dated 05/08/2024 reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses dementia (A group of symptoms…

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 prevent the development and transmission of communicable diseases for two of four residents reviewed for infection control. (Residents #22 and #32) LVN A failed to sanitize the common glucometer, which is used during blood testing between resident blood sugar checks. This failure could lead to contamination of the nurse cart and potential resident exposure to blood-borne diseases. Findings Included: Review of Resident #22's face sheet dated 05/09/2024 reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses Diabetes Mellitus Type II (A condition results from insufficient production of insulin, causing high blood sugar.) and Sepsis due to Methicillin Susceptible Staphylococcus Aureus (an infection caused by a type of bacteria commonly found on the skin). Review of Resident #22's Quarterly MDS assessment dated [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid and incorporate the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care for 1 of 5 residents (Resident #3) reviewed for PASARR coordination. The facility failed to ensure specialized OT, PT and ST evaluations and therapies were effectively requested for Resident #3 within three business days of a PASARR IDT meeting on [DATE] in which the services were agreed to be necessary. This failure placed residents at risk of not attaining the highest practicable well-being possible. Findings included: Review of the undated face sheet for Resident #3 reflected a [AGE] year-old female admitted to the facility on [DATE]. Resident #3 had diagnoses which included mandibulofacial dysostosis (rare disorder of skull and facial development),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the completion of a significant change assessment for 1 (Resident #34) of 8 residents reviewed for Significant Change Assessments. The facility failed to ensure Resident #34 had a significant change assessment completed following the discharge from hospice service. This failure could place residents at risk of not receiving adequate services and reimbursement to meet their needs. Findings included: Review of Resident #34's face sheet dated 03/23/23 revealed Resident #34 was a [AGE] year-old female admitted on [DATE] with diagnoses including hepatic failure, unspecified without coma (loss of brain function occurs when the liver is unable to remove toxins from the blood), hypothyroidism, unspecified (type of disorder of thyroid gland, a condition in which the production of thyroid hormone by the thyroid gland is diminished), type 2 diabetes mellitus without complications (a chronic disease affecting blood glucose regulation), unspecified…

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 PASRR screening was completed for residents with a mental disorder or an intellectual disability for 1 of 6 residents (Resident #25) reviewed for PASRR Level I screenings. The facility did not ensure an accurate PL1 screening (a preliminary assessment completed for all individuals prior to admission to a Medicaid-certified nursing facility to determine whether they might have a mental illness or intellectual disability) was completed for Resident #25. This failure could place residents at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs. Findings included: Record review of Resident #25's face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #25 had diagnoses which included Bipolar Disorder, Anxiety Disorder, Hypertension, Cognitive Communication Deficit (Difficulty with thinking and how someone uses…

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 and prevention control program that included, at a minimum, a system for preventing and controlling infections for 1 of 3 residents (Resident # 64) reviewed for wound care. Facility failed to ensure the scissors were sanitized before using it to cut wound care supplies while providing wound care to Resident #64 This failure could place the residents at risk for cross contamination and infection. Findings included: Record review of Resident #64's face sheet on 03/22/23 reflected a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included Type 1 Diabetes Mellitus, Hypertension, Open Left and right Foot Wound, Depression, Hyperlipidemia (excess fat in blood), chronic kidney disease and Cerebral Infarction (stroke). Record review on 03/23/23 of Resident #64's quarterly MDS assessment dated [DATE] revealed a BIMS score of 99 out of 15 indicating the resident chose not to participate or 4 or more items…

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.