Brentwood Terrace Healthcare And Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of practice for 1 of 12 residents (Resident #132) reviewed for oxygen therapy. The facility failed to ensure Resident #132 had a physician's order in her chart for oxygen. This failure could place residents who receive respiratory care at risk for developing respiratory complications and a decreased quality of care. Findings Included: Record review of Resident #132's face sheet, dated 06/04/25, reflected Resident #132 was a [AGE] year-old female, admitted to the facility on [DATE] with a diagnosis which included COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of the MDS assessment, accessed on 06/04/25, reflected Resident #132's admission MDS had not been completed yet. Record review of Resident #132's comprehensive care plan initiated on 05/24/25 reflected Resident #132…

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 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 4 of 5 residents (Resident #5, Resident #7, Resident #10, and Resident #58) reviewed for resident rights. The facility failed to ensure CNA A treated Resident #5, Resident #7, Resident #10, and Resident #58 respectfully when she failed to speak to them while providing care. This failure could place residents at risk of embarrassment, feelings of worthlessness, decreased self-worth, loss of dignity, and a diminished quality of life. Findings included: 1. Record review of Resident #5's face sheet dated 01/08/2025 indicated Resident #5 was an [AGE] year-old female initially admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung condition that affects the respiratory system). Record review of the 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.

Based on interview and record review, the facility failed to consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility and failed to demonstrate their response and rationale for such response for 6 of 6 confidential residents reviewed for resident council. The facility failed to ensure there was documentation of the facility's efforts to resolve concerns about call light response times collected at the resident council meetings on 07/15/2024, 08/22/2024, and 09/20/2024. This failure could place residents at risk of not having their concerns and grievances followed through and a diminished quality of life. Findings included: Record review of the Resident Advisory Council Minutes for 07/15/2024 indicated the call lights were not being answered timely. Record review of the Resident Advisory Council Minutes for 08/22/2024 indicated the call lights were not being answered timely. Record review of the Resident Advisory Council Minutes for 09/20/2024 indicated the call…

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: 1. The microwave was clean and free of food debris. 2. The deep fryer was clean and free of food debris. 3. Three sheet pans were free from encrusted black colored grease buildup coating on the outside and the inside surface. These failures could place residents at risk for foodborne illness. Findings include: During an initial tour observation in the kitchen on 01/05/2025 at 10:20 a.m., there was brown flakey debris in the microwave, dark brown grease with brown flakey debris floating in the deep fryer, and three sheet pans with encrusted black colored grease buildup coating on the outside and the inside surface. During an interview on 01/05/2025 at 11:00 a.m., [NAME] H stated the microwave was used during breakfast and had not been cleaned out. [NAME] H stated the deep fryer was cleaned weekly on Thursdays. [NAME] H stated they had fried fish…

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 right to formulate an advanced directive for 1 of 20 residents (Residents #9) reviewed for advanced directives. The facility did not ensure Resident #9's OOH-DNR included the physician's printed name. This failure could place residents at risk of not receiving care and services to meet their needs. Findings included: Record review of Resident #9's face sheet, dated 01/08/25, indicated Resident #9 was a [AGE] year-old female, originally admitted to the facility on [DATE] with diagnoses which included dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life). Record review of Resident #9's physician order summary report, dated 01/08/25, indicted an active physician's order for code status: DNR with an order date 05/28/19. Record review of Resident #9's quarterly MDS, dated [DATE], indicated Resident #9 sometimes made herself understood, understood others. 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 observations, 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 includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 24 (Resident #43) residents reviewed for care plans. The facility failed to update Resident #43's care plan after she no longer required a fall mat on last revision date 11/26/2024. This failure could place Resident # 43 at risk of not having their individualized needs met and a decreased quality of life. Findings Included: Record review of Resident # 43's face sheet dated 1/07/2025, revealed Resident # 43 was an [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnoses of dementia (memory loss), muscle weakness (decreased ability of muscles to generate force or power), reduced mobility ( person has difficulty…

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 all drugs were stored in a locked compartment, only accessible by authorized personnel for 2 of 20 residents (Resident #34 and Resident #59) reviewed for medications at their bedside. 1. The facility failed to ensure the nebulizer medication for Resident #34 was not left at the bedside on 01/05/2025 and 01/06/2025. 2. The facility did not ensure Resident #59's Lamisil (medication used to treat fungal infections of the skin), Cortizone-10 (medication used to treat swelling, itching and redness of the skin), and Flonase (medication used to relieve seasonal and year-round allergic and non-allergic nasal symptoms) were properly safe and secured. These failures could place residents at risk for misuse of medication and overdose, drug diversions, adverse reactions of medications, and not receiving the therapeutic benefit of medications. The findings included: 1. Record review of the face sheet, dated 01/07/2025, reflected Resident #34…

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 liquids consistent with the resident's needs, for 1 of 23 (Resident #9) residents reviewed for liquid inconsistency. The facility did not ensure staff served Resident #9 her iced tea during her lunch meal on 01/05/25. This failure could place residents at risk for dehydration and loss of interest in eating. Findings included: Record review of Resident #9's face sheet, dated 01/08/25, indicated Resident #9 was a [AGE] year-old female, originally admitted to the facility on [DATE] with diagnoses which included dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life) and unspecified protein-calorie malnutrition (protein calorie deficiency). Record review of the order summary report dated 01/08/25 indicated Resident #9 had the following orders: *Regular diet ground meat texture, thin/regular consistency with an order start date of 03/31/23. Record review 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.

Based on observation, interviews, and record reviews, the facility failed provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service for 1 out of 1 kitchen reviewed for sufficient support personnel. 1. The facility failed to ensure the food temperatures for the chicken fried chicken patties, mechanical soft chicken fried chicken, pureed chicken fried chicken, pureed green beans and potatoes, and the mashed potatoes were held at a temperature outside the danger zone (135 degrees Fahrenheit or higher) while on the steam table. The facility did not reheat the food prior to serving. 2. The facility failed to ensure the lunch meal on 02/26/2024, 02/272024, and 02/28/2024 were served on time. There were 2 scheduled staff members each day. This failure could place residents at risks who consume food prepared in the kitchen at risk of foodborne illness. The findings included: Record review of the Meal Service Times, undated, revealed lunch meal was started at 12:00 PM for the secured unit, 12:15 PM for the dining room, and 12:20…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen reviewed for kitchen sanitation. The facility did not ensure: 1. Meat was thawing in the appropriate container and sink under constant flow of cool, running water during the initial tour on 02/26/2024. 2. The three-compartment-sink was properly used while preparing the pureed food for the lunch meal on 02/28/2024. 3. Unpasteurized eggs were used for sunny-side up and over easy eggs. 4. Food temperatures for the chicken fried chicken patties, mechanical soft chicken fried chicken, pureed chicken fried chicken, pureed green beans and potatoes, and the mashed potatoes were held at a temperature outside the danger zone (135 degrees Fahrenheit or higher) while on the steam table for the lunch meal on 02/28/2024. These failures could place residents at risk for cross contamination and food-borne illness. 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 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 5 of 11 residents (Resident #'s 44, 47, 52, 57, 179) reviewed for abuse and neglect reporting. The facility failed to report to the state agency when Resident #44's large bruise and fractured hip were found on 6/21/2024. The facility failed to report to the state agency when Resident #52 was cursed at and not allowed in his room by Resident #47 who had a history of verbal abuse. The DON was notified of this incident and failed to report the abuse. The facility failed to ensure the DON reported the abuse to HHSC within 2 hours, after LVN C reported abuse to her on 02/19/2024. The facility failed to report to the state agency when Resident #57 had shearing, hematoma, bruising, and a skin tear. The facility failed to ensure the DON reported…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 3 of 24 residents (Residents #'s 33, 130 and 4), reviewed for care plans. 1. The facility failed to revise and update Resident #33's comprehensive care plan when his antidepressant was discontinued. 2. The facility failed to revise Resident #4's care plan after she fell on 2/24/2024, 2/26/2024, and 2/27/2024. 3. The facility failed to revise Resident #130's care plan after he fell on [DATE] and 11/27/2023. These failures could affect residents of the facility by not addressing their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, and psychosocial outcome. Findings included: 1. Record review of Resident #33's face sheet dated 02/29/24, indicated a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE].…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure necessary services to maintain grooming and personal hygiene were provided for 7 of 9 residents reviewed for ADLs. (Resident #'s 9, 22, 36, 41, 57, 67, and 179) 1. The facility failed to ensure Resident #'s 9, 22, 36, 57, 67, and 179 were routinely showered/bathed. 2. The facility failed to ensure Resident # 41 was shaved. These failures could place residents at risk of not receiving services/care, decreased quality of life, and decreased self-esteem. Findings included: 1A. Record review of Resident #22's face sheet dated 02/29/2024, indicated an [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #22 had pneumonia (infection of the air sacs in one or both lungs), cerebral infarction (stroke), hemiplegia affecting left dominant side (left sided paralysis), open wound of unspecified buttock, and need for assistance with personal care. Record review of Resident #22's comprehensive…

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 develop, implement, and maintain annually an effective training program for existing staff, consistent with their expected roles for 4 of 21 employees (LVN QQQ, LVN C, SW, and Housekeeping Supervisor) reviewed for required annual trainings. The facility failed to ensure LVN QQQ, LVN C, the SW, and the Housekeeping Supervisor received their restraint training annually. This failure could place residents at risk for the inappropriate use of restraints. Findings included: Record review of the employee files indicated the following staff had not completed their annual restraint training: *LVN QQQ (hire date 02/01/2023), *LVN C (hire date 02/01/2023), *the SW (hire date 02/01/2023), *the Housekeeping Supervisor (hire date 02/01/2023). During an interview on 03/02/2024 at 10:23 AM the Corporate HR Specialist said LVN QQQ, LVN C, the SW and the Housekeeping Supervisor had not completed the required annual restraint training. The Corporate HR Specialist said the last restraint training that LVN QQQ and LVN C was completed on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the resident's representative immediately when there was a significant change in the resident's physical, mental, or psychosocial status that is, a deterioration of health, mental, or psychosocial status in either life-threatening conditions or clinical complications for 1 of 24 residents ( Resident #57) reviewed for notification of changes. The facility failed to notify Resident #57's representative when the new areas of shearing, hematoma, bruising, and redness were found on Resident #57. This failure placed residents' caregivers at risk of not being aware of any changes in their conditions and could result in a delay in treatment and decline in residents' health and well-being. Findings included: Record review of Resident #57's face sheet dated 02/29/24, indicated an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included heart failure (progressive heart disease that affects pumping action of the heart…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of changes for those services, which included changes for services not covered under Medicare/Medicaid or by the facility's per diem rate for 1 of 2 residents (Resident #57) reviewed for Medicare/Medicaid coverage. The facility failed to ensure Resident #57 was given a SNFABN (SNFABN document that informs a Medicare beneficiary that Medicare will no longer pay for skilled services) when discharged from skilled services at the facility prior to covered days being exhausted. This failure could place residents at risk for not being aware of changes to provided services. Findings include: Record review of Resident #57's face sheet dated 02/29/24, indicated an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included heart failure (progressive heart disease that affects…

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 prompt efforts were made to resolve grievances for 1 of 6 residents (Resident #57) reviewed for grievances . The facility failed to appropriately resolve Resident #57's grievance when issues with receiving baths continued. This failure could place residents at risk for grievances not being addressed or resolved promptly. Findings included: Record review of Resident #57's face sheet dated 02/29/24, indicated an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included heart failure (progressive heart disease that affects pumping action of the heart muscles), atrial fibrillation (abnormal heart rhythm), weakness, protein-calorie malnutrition (not consuming enough protein or calories), and anxiety. Record review of Resident #57's comprehensive care plan dated 12/28/2023 and revised on 02/22/2024 indicated Resident #57 had an ADL self-care performance deficit with interventions she required one staff…

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 assessments accurately reflected the resident status for 1 of 24 residents (Resident #33) reviewed for MDS assessment accuracy. The facility inaccurately coded Resident #33's having received an antidepressant medication on his significant change in status MDS assessment dated [DATE]. This failure could place residents at risk for not receiving care and services to meet their needs. Findings included: Record review of Resident #33's face sheet dated 02/29/24, indicated a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #33's diagnoses included dementia (memory loss), unspecified protein calorie malnutrition (not consuming enough protein and calories), major depression, and bipolar disorder (serious mental illness characterized by extreme mood swings). Record review of Resident #33's comprehensive care plan dated 05/17/2019 and revised on 08/22/2019, indicated Resident #33 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 24 (Resident #70) residents reviewed for care plans. The facility failed to provide fall mat at bedside for Resident #70, as indicated on the care plan. These failures could place the residents at increased risk of not having their individual needs met, injury, not receiving necessary services, and a decreased quality of life. Findings Included: Record review of Resident #70's face sheet dated 03/02/2024, indicate Resident # 70 was a [AGE] year-old male admitted to the facility on [DATE], with a diagnosis which include unspecified Dementia (mild cognitive impairment has yet to be diagnosed as a specific type of dementia), muscle weakness (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide an ongoing program of activities in accordance with the comprehensive assessment to meet the interests and the physical, mental, and psychosocial well-being for 1 of 24 residents (Resident #179) reviewed for activities. The facility failed to provide consistent and scheduled in-room activities for Resident #179 to meet his needs. These failures could place residents at risk for not having activities to meet their interests or needs and a decline in their physical, mental, and psychosocial wellbeing. Findings included: Record review of a face sheet dated 03/02/2024 indicated Resident #179 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included quadriplegia (paralysis of all four limbs, and the trunk of the body), major depressive disorder recurrent (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks), and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident received appropriate treatment and services to prevent urinary tract infections for 2 of 2 residents (Resident #53 and Resident #179) reviewed for indwelling urinary catheters and incontinent care. 1. The facility failed to ensure Resident #179's urinary (foley) catheter was properly secured to his leg. 2. The facility failed to ensure Resident #53 was provided proper incontinent care. This failure could place residents with urinary catheters at risk for damage to the bladder, penis, or urethra (a hollow tube that lets urine leave your body), dislodging of the catheter, and urinary tract infections. Findings included: 1. Record review of a face sheet dated 03/02/2024 indicated Resident #179 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included quadriplegia (paralysis of all four limbs, and the trunk of the body) and neuromuscular dysfunction of the bladder (condition where a person…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for 1 of 8 residents reviewed for nutritional status (Resident #33). The facility failed to obtain Resident #33 weekly weights as ordered by the physician. This failure could place residents at risk for malnourishment, illness, skin breakdown, and decreased quality of life. Findings included: Record review of Resident #33's face sheet dated 02/29/24, indicated a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #33's diagnoses included dementia (memory loss), unspecified protein calorie malnutrition (not consuming enough protein and calories), major depression, and bipolar disorder (serious mental illness characterized by extreme mood swings).…

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 residents requiring respiratory care were provided such care, consistent with professional standards of practices for 2 of 4 residents (Resident's #6 and #227) reviewed for respiratory care. 1. The facility failed to ensure Resident #6's nebulizer mask was stored in a bag when it was not in use. 2. The facility failed to administer Resident #227's oxygen as ordered by the physician. These failures could place residents who receive respiratory care at risk for developing respiratory complications and a decreased quality of care. The findings included: 1. Record review of the face sheet, dated 03/02/2024, revealed Resident #6 was an [AGE] year-old female who re-admitted to the facility on [DATE] with a diagnosis of COPD (common, preventable, and treatable disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough). Record review of the quarterly MDS assessment, dated 02/21/2024,…

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 resident's drug regimen was free from unnecessary psychotropic drugs for 2 of 5 residents (Resident #52, and Resident #179) reviewed for unnecessary psychotropic drugs. 1. The facility failed to ensure Resident #179 was monitored for side effects and behaviors related to the use of Buspirone (anxiety medication), Clonazepam (anxiety medication), Lexapro (antidepressant), and Trazodone (used to treat depression) since his admission on [DATE]. 2. The facility failed to ensure Resident #52's PRN Clonazepam was administered with an adequate indication for its use on 02/23/24 and 02/24/24. These failures could place residents at risk of receiving unnecessary psychotropic medications with possible medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications. Findings included: 1. Record review of a face sheet dated 03/02/2024 indicated Resident #179 was a [AGE] year-old male admitted to 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 ensure all drugs were stored in a locked compartment, only accessible by authorized personnel, and labeled and dated correctly for 1 of 1 nurse treatment carts reviewed for drugs and biologicals and storage of medications. The facility failed to ensure Nurse treatment cart were secured and unable to be accessed by unauthorized personnel on 2/27/2024. This failure could place residents at risk of misuse of medications, drug diversions, and not receiving the therapeutic benefit of medications. Findings Included: During an observation and interview on 02/27/2024 at 11:45 P.M., LVN Q was observed walking down hall 100 away from the nurse's station leaving the nurse treatment cart unlocked. LVN Q stated the cart should be locked and the nurse should keep the key with them. LVN Q stated she did not know who the last person in the nurse treatment cart was. LVN Q stated it was important to keep the nurse treatment cart locked so residents do not get into it and get stuff out that was unsafe. LVN Q stated residents…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 help prevent the development and transmission of communicable disease and infections for 1 of 3 residents (Resident #53) reviewed for infection control practices. The facility failed to ensure CNA G performed hand hygiene and glove changes while providing incontinent care to Resident #53. These failures could place residents at risk for urinary tract infections, cross contamination, and the spread of infections. Findings included: Record review of a face sheet dated 3/06/2024 indicated Resident #53 was an [AGE] year-old female who admitted on [DATE] with the diagnoses of dementia, need for assistance with personal care, and kidney disease. Record review of the Quarterly MDS dated [DATE] indicated Resident #53 was usually understood and usually understood others. The MDS indicated Resident #53's BIMS score was 2…

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 promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy and providing written rationale, by the provider, when an antibiotic was used despite criteria, to determine the appropriate the use of an antibiotic for 1 of 2 residents and reviewed antibiotic use. (Resident #5) 1. The facility did not ensure Resident #5 was assessed using the established and accepted criteria to determine if her UTI met the criteria for antibiotic use. 2. The facility did not ensure an SBAR was performed to indicate a change of condition when Resident #5 was exhibiting signs and symptoms of a UTI. These failures could place residents receiving antibiotics at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased antibiotic-resistant infections. The findings included: Record review of the order summary report, dated 02/28/2024, revealed Resident #5 was a [AGE] year-old female who admitted to the facility on [DATE] with a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs for 4 (NA A, NA B, NA C, and Hospitality Aide D) of 4 staff reviewed for demonstration of skills and techniques necessary for residents' needs. The facility failed to conduct competency assessments for NA A, NA B, NA C, and Hospitality Aide D. These failures could place residents at risk for not receiving the appropriate care and services to maintain their health and safety. Findings included: Record review of personnel file for NA A with hire date [DATE] indicated no evidence of skill competency checkoffs. Record review of personnel file for NA B with hire date [DATE] indicated no evidence of skill competency checkoffs. Record review of personnel file for NA C with hire date [DATE] indicated no evidence of skill competency checkoffs. Record review of personnel file for Hospitality Aide D with hire date [DATE] indicated no evidence…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, for 4 of 20 residents (Resident's #1, #2, #3 and #4) reviewed for abuse. 1. The facility did not implement their policy on reporting abuse for a resident-to-resident altercation that occurred on 01/12/2024 between Resident #1 and Resident #2. 2. The facility did not implement their policy on reporting abuse for a resident-to-resident altercation that occurred on 11/25/2023 between Resident #3 and Resident #4. These deficient practices could place residents at risk for abuse, neglect, and not having their needs met. 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,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source were reported immediately, but no later than 2 hours after the allegation was made, for 4 of 20 residents (Residents #1, #2, #3 and #4) reviewed for abuse and neglect. 1. The facility did not report the resident-to-resident altercation between Resident #1 and Resident #2 to the State Survey Agency within 2 hours of being notified. 2. The facility did not report the resident-to-resident altercation between Resident #3 and Resident #4 to the State Survey Agency within 2 hours of being notified. These failures to report could place the residents at risk for abuse. Findings included: 1. Record review of Resident #1's face sheet, dated 02/07/2024, indicated Resident #1 was a [AGE] year-old female, originally admitted to the facility on [DATE] with a diagnosis which included metabolic encephalopathy (problems with metabolism cause…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for 1 of 3 residents reviewed for nutritional status(Resident #1). The facility failed to ensure Resident #1 did not have a significant weight loss in 30 days. The facility failed to re-weigh Resident #1 after the Dietician recommended it on 10/21/23. This failure could place residents at risk for malnourishment, illness, skin breakdown, and decreased quality of life. Findings Include: Record review of the consolidated physician orders dated 11/20/2023 indicated Resident #1 was [AGE] years old, readmitted to the facility on [DATE] with diagnoses including unspecified dementia (a decline in cognitive abilities that impacts a person's ability to perform everyday activities) with other behavioral…

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 had the right to reside and receive services in the facility with reasonable accommodation of resident needs were provided for 1 of 4 residents reviewed for accommodation of needs (Resident #2). The facility failed to ensure ADL dependent Resident #2's call light was placed within his reach. This failure could place dependent residents at risk of injuries and unmet needs. Findings included: 1. Record review of the face sheet for Resident #2 indicated he was [AGE] years old re-admitted to facility on 7/29/22 with diagnoses including dementia, schizophrenia, shortness of breath, anxiety, muscle weakness and need for assistance with personal care. Record review of Resident #2's MDS assessment dated [DATE] indicated Resident #2 sometimes made himself understood and sometimes understood others. The MDS indicated Resident #2 had severe cognitive impairment (BIMS of 4). The MDS indicated he had no behavior of rejecting care. 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 ensure necessary services to maintain good grooming and personal hygiene for a resident who is unable to carry out activities of daily living were provided for 1 of 4 residents reviewed for activities daily living (Resident #1) The facility did not ensure Resident #1 was provided a bath or shower from 7/22/23 to 8/1/23. These failures could place dependent residents at risk of poor hygiene, infections, injuries and unmet needs. Findings included: 1.Record review of the face sheet for Resident #1 indicated he was [AGE] years old and re-admitted to the facility on [DATE] with diagnoses including history of stroke, hemiplegia/ hemiparesis affecting the left non-dominant side (muscle weakness or partial paralysis on one side of the body), reduced mobility, need for assistance with personal care, high blood pressure, and heart disease. Record review of Resident #1's MDS assessment dated [DATE] indicated Resident #1 made himself understood 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.