Stillhouse Rehabilitation And Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with state law through established procedures for 3 of 22 residents (Resident #23, Resident #32, and Resident #47) reviewed for abuse. 1.The facility failed to report abuse timely to the state agency on behalf of Resident #32. 2. The facility did not report to HHSC…

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 assessments accurately reflected the resident status for 2 of 22 residents (Residents #23 and #27) reviewed for MDS assessment accuracy. 1. The facility failed to interview Resident #23 regarding his mood on his 04/18/25 quarterly MDS assessment. 2. The facility failed to accurately reflect Resident #27's active diagnoses to not include a diagnosis of depression (a mood disorder characterized by persistent feelings of sadness and loss of interest or please in activities) on his 04/19/25 quarterly MDS assessment. These failures could place residents at risk for not receiving care and services to meet their needs. Findings included: 1. Record review of Resident 23's face sheet dated 05/27/25, reflected Resident #23 was a [AGE] year-old male, readmitted to the facility on [DATE] with a diagnosis which included recurrent depressive disorders. Record review of Resident #23's quarterly MDS assessment, dated 04/18/25, reflected Resident #23 made himself…

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 develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs, for 1 of 8 (Resident #29) residents reviewed for the care plans. The facility failed to ensure Resident #29's fall mat was beside her bed on 05/20/25. This failure could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. Findings included: Record review of Resident #29's face sheet, dated 05/22/25, indicated she was a [AGE] year-old female re-admitted to the facility on [DATE] with diagnoses which included dementia (loss of memory), stroke, and history of falling. Record review of Resident 29's admission MDS assessment, dated 1/28/25, indicated Resident #29 understood and by others. Resident #29's BIMS score was 08, indicating her cognition was moderately impaired. 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 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 1 of 22 residents (Resident #68) reviewed for ADL (activities of daily living) care. The facility failed to provide nail care by removing black material from under fingernails for dependent female Resident #68 on 05/19/2025 and 05/20/2025. This failure could place residents at risk of not receiving care and services to meet their needs. Findings included: Record review of the face sheet, dated 05/19/2025, revealed Resident #68 was a [AGE] year old female with diagnoses which included type 2 diabetes mellitus without complications (person's blood sugar levels are high, indicating diabetes, but they haven't experienced any long-term health problems like kidney disease, nerve damage, or heart disease), essential (primary) hypertension (high blood pressure where no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 of 22 residents (Residents #13) reviewed for pharmacy services. The facility did not ensure Resident #13 was given Tylenol (pain medication) 650 mg after a fall with complaints of lower back pain. This failure could place the resident at risk of not receiving medications as ordered. Findings included: Record review of Resident #13's face sheet, dated 05/27/25, reflected Resident #13 was a [AGE] year-old female, readmitted to the facility on [DATE] with a diagnosis which included muscle weakness, history of falling, and generalized osteoarthritis (degeneration of joint cartilage and the underlying bone). Record review of Resident #13's quarterly MDS assessment, dated 05/04/25, reflected Resident #13 made herself understood, and understood others. Resident #13's BIMS score 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 ensure all drugs were stored in a locked compartment, only accessible by authorized personnel for 1 of 22 resident (Resident #22) reviewed for storage and labeling of medications. The facility did not ensure Resident #22's eye drops was properly secured. This failure could place residents at risk for misuse of medication, overdose, drug diversions, adverse reactions of medications, and not receiving the therapeutic benefit of medications. Findings included: Record review of Resident #22's face sheet, dated 05/27/25, reflected Resident #22 was a [AGE] year-old male, readmitted to the facility on [DATE] with diagnoses which included acute and chronic respiratory failure with hypercapnia (too much carbon dioxide in the bloodstream), and dry eye syndrome of bilateral lacrimal glands (tear glands). Record review of the order summary report dated 05/22/25 reflected an active physician order for Olopatadine HCl Ophthalmic Solution 0.2%: instill…

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 ensure each resident receives and the facility provides food that accommodates residents' food preferences for 1 of 22 residents (Resident #10) reviewed for food preferences and the accommodation of resident's meal choices. The facility did not honor Resident #10's preference for chocolate health shake. This failure could result in a decrease in resident choices, diminished interest in meals, and weight loss. Findings included: Record review of Resident #10's face sheet, dated 05/27/25, reflected Resident #10 was a [AGE] year-old female, readmitted to the facility on [DATE] with a diagnosis which included diabetes mellitus without hyperglycemia (chronic condition that affects the way the body processes blood sugar) and protein-calorie malnutrition. Record review of Resident #10's annual MDS assessment, dated 04/25/25, reflected Resident #10 made herself understood, and understood others. Resident #10's BIMS score was 15, which indicated her…

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 food was prepared in a form designed to meet individual needs and as prescribed by the physician for 1 of 22 residents (Resident #10) reviewed for therapeutic diets. The facility did not ensure Resident #10 was given double protein portion as ordered by the physician. This failure could place residents at risk for poor intake, weight loss, unmet nutritional needs, and a loss of dignity. Findings Included: Record review of Resident #10's face sheet, dated 05/27/25, reflected Resident #10 was a [AGE] year-old female, readmitted to the facility on [DATE] with a diagnosis which included diabetes mellitus without hyperglycemia (chronic condition that affects the way the body processes blood sugar) and protein-calorie malnutrition. Record review of Resident #10's annual MDS assessment, dated 04/25/25, reflected Resident #10 made herself understood, and understood others. Resident #10's BIMS score was 15, which indicated her cognition was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain medical records for 1 of 22 residents (Residents #43). The facility failed to ensure the care plan was updated to reflect the discontinuation of Resident #43's fall mat. This failure could place residents at risk of not receiving appropriate interventions meet their current needs. The findings include: Record review of a face sheet dated 05/21/2025 indicated Resident #43 was a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included chronic kidney disease (a progressive condition where the kidneys gradually lose their ability to filter waste and excess fluid from the blood), end stage renal disease (a condition where the kidneys are no longer able to function effectively, leading to the buildup of waste and excess fluid in the body), acute respiratory failure with hypoxia ( occurs when the lungs are unable to deliver enough oxygen to the blood, leading to low oxygen levels 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 establish policies regarding smoking areas, and smoking safety for 1 of 1 smoking area. 1. The facility did not ensure cigarettes were not discarded in the trash can designed for the disposing of trash. 2. The facility did not ensure trash was not discarded in the red trash can designed for the disposing of cigarettes. These failures could place residents who smoke at risk of physical harm and lead to an unsafe smoking environment. Findings Included: During an observation and interview on 05/20/25 at 10:30 a.m., there was a red can with trash observed inside the can located in the designated smoking area. CNA B stated the trash observed inside the can was the foil wrapper part of the cigarette box when you first open the box. CNA B stated the wrapper should be disposed in the trash can. CNA B stated whoever took the residents out to smoke should check the red can for trash. CNA B stated this failure could potentially cause a fire. During an observation on 05/20/25 at 10:38 a.m., a cigarette butt was observed…

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 electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS fiscal year 2024 for the first quarter (October 1, 2023, to December 31, 2023) reviewed for administration. The facility failed to transmit RN hours for: 11/18/2023, 11/19/2023, 12/02/2023, 12/03/2023, 12/16/2023, 12/17/2023, and 12/30/2023. This failure could place residents at risk for personal needs not being identified and met. Findings included: Record review of the CMS PBJ report for the first quarter of 2024 (October 1, 2023, through December 31, 2023) indicated there were no RN hours for the following dates: 11/18/23 (SA), 11/19/23 (SU), 12/02/23(SA), 12/03/23 (SU), 12/16/23 (SA), 12/17/23 (SU), and 12/30/23 (SA). Record review of the DON's punch detail report for November and December 2023 indicated RN hours on 11/18/2023, 11/19/2023, 12/02/2023,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, 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 3 of 23 residents (Resident #63, Resident #25, and Resident #42) reviewed for comprehensive person-centered care plans. 1. The facility failed to ensure Resident #63's grab bar was included on the care plan. 2. The facility failed to ensure Resident #25's comprehensive care plan addressed that he received an anticoagulant medication and that he required the use of assist/grab bars. 3. The facility failed to ensure Resident #42's care plan was person-centered to include his lack of triggers and unwillingness to discuss his history of trauma. These failures could place residents at risk of unmet care needs, not receiving necessary medications, 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 that it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 17.95 % based on 7 errors out of 39 opportunities, which involved 3 of 6 residents (Resident #'s 172, 16, and 17) reviewed for medication administration. The facility failed to ensure LVN A administered Resident #172's Levetiracetam (medication used to treat seizures) timely. The facility failed to ensure LVN A administered Resident #66's midodrine (medication to treat blood pressure), Eliquis (medication to coagulation of blood), and levothyroxine (medication for thyroid disease) timely. The facility failed to ensure MA B administered Resident #17's tramadol (medication for pain), levothyroxine (medication for thyroid disease), and Protonix (medication for gastric upset) timely. These failures could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. Findings…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents were free of significant medication errors for 3 of 10 residents (Resident's #172, #66, and #17) reviewed for pharmacy services. 1.The facility failed to ensure LVN A administered Resident #172's Keppra (medication used to treat seizures) timely. 2.The facility failed to ensure LVN A administered Resident #66's midodrine (medication to treat blood pressure), and Eliquis (medication to coagulation of blood timely. 3. The facility failed to ensure MA B administered Resident #17's tramadol (medication for pain), timely. This failure could place the resident at risk of medical complications and not receiving the therapeutic effects of their medications. Findings Included: 1) Record review of a face sheet dated 3/27/2024 indicated Resident #172 was an [AGE] year-old female who admitted on [DATE] with the diagnosis of high blood pressure, malnutrition, and arthritis. Record review of an admission MDS assessment 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 observations, interviews, and record review the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition for 1 of 6 residents (Resident #16) reviewed for quality of life. The facility did not ensure Resident #16 was provided assistance with eating during the lunch meal on 03/25/2024. This failure could place residents at risk for decreased food intake, weight loss, and a decreased quality of life. The findings included: Record review of the face sheet, dated 03/27/2024, revealed Resident #16 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, late onset (type of gradually progressive brain disorder that causes problems with memory, thinking, and behavior), need for assistance with personal care, and unspecified protein-calorie malnutrition (occurs when an individual does not consume sufficient protein and calories, leading to adverse effects 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 observation, interview and record review, the facility failed to follow their own established smoking policy for 1 of 6 residents reviewed for quality of care (Resident #3). The facility did not provide a smoking apron per their smoking assessment for Resident #3. The failure could place residents at risk of an unsafe smoking environment and burns. Findings included: Record review of a face sheet dated 03/27/2024 indicated Resident #3 was a [AGE] year-old female originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Paranoid Schizophrenia (pattern of behavior where a person feels distrustful and suspicious of other people and act accordingly) Dementia (loss of cognitive functioning thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life), other lack of coordination ( problems with movement). Record review of the care plan last reviewed 07/17/2023, indicated Resident #3 was a smoker and would wear a smoking apron…

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 1 of 2 residents (Resident #2) reviewed for quality of care. The facility failed to ensure Resident #2's urinary (foley) catheter was properly secured to his leg. 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: Record review of a face sheet dated 03/27/2024 indicated Resident #2 was a [AGE] year-old male originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Hemiplegia and Hemiparesis following cerebral infraction affecting the right dominant side (indicates paralysis on the right side of the body), Hemiplegia unspecified affecting left dominant side (indicates paralysis on the left side of the body),…

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, interview, and record reviews, the facility failed to attempt to use alternatives prior to installing a side or bed rail, obtain informed consent prior to installation, ensure correct installation, use and maintenance of bedrails for 2 of 2 residents (Residents #63 and #25) reviewed for quality of care. 1. The facility failed to ensure informed consent for the use of Resident #63's bed rails were obtained prior to installation. 2. The facility failed to follow Resident #63's bed rail assessment, which did not recommend the use of bed rails. 3. The facility failed to document the attempt of alternatives used prior to installation of Resident #25's bed rails. 4. The facility failed to ensure an informed consent for the use of Resident #25's bed rails were obtained prior to installation. These failures could place residents at risk for entrapment with serious injury and even death. Findings included: 1. Record review of the face sheet, dated 03/27/2024, revealed Resident #63 was a [AGE]…

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

Based on observation, interview, and record review, the facility failed to establish a system of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and determine that drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 1 of 1 storage area reviewed for pharmacy services The facility failed to keep a record or receipt of controlled medications awaiting disposition to allow accurate and periodic reconciliation. This failure could place residents at risk for loss of prescribed medications, resident's safety, and drug diversion. Findings included: During an observation and interview on 03/26/2024 at 10:05 AM, the following medications were observed in the controlled medication storage cabinet with no medication log of the medications awaiting to be disposed: *Clonazepam 2 milligrams-30 RX# 501363197 *Tramadol 50 milligrams - 23 RX# 501380719 *Alprazolam 1 milligram-57 RX# 501380727 *Tramadol 50 milligrams 11 RX# 501344987 *Oxycodone 5 milligrams 58 RX# 501371736…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents' drug regimen was adequately monitored and free from unnecessary drugs for 2 of 5 residents (Resident #25 and Resident #42) reviewed for pharmacy services. 1. The facility failed to monitor Resident #25 for side effects/adverse reactions for the use of Xarelto (an anticoagulant medication- blood thinner). 2. The facility failed to ensure Resident #42's edema was monitored while taking furosemide. (Medication given to remove fluid and reduce swelling.) These failures could place residents at risk of swelling, bruising, and bleeding . Findings included: 1. Record review of Resident #25's face sheet dated 03/26/2024, indicated a [AGE] year-old male who initially admitted to the facility on [DATE] with diagnoses which included hemiplegia (paralysis of half of the body) and hemiparesis (weakness of one entire side the body) following cerebrovascular disease (stroke) affecting left non-dominant side, diabetes mellitus (a group of diseases…

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 food was prepared in a form designed to meet individual needs for 1 of 6 residents (Resident #16) reviewed for nutrition. The facility failed to ensure Resident #16 received her health shake with her lunch meal as ordered by the physician. This failure could place residents at risk for poor intake, weight loss, and unmet nutritional needs. The findings included: Record review of the face sheet, dated 03/27/2024, revealed Resident #16 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, late onset (type of gradually progressive brain disorder that causes problems with memory, thinking, and behavior), need for assistance with personal care, and unspecified protein-calorie malnutrition (occurs when an individual does not consume sufficient protein and calories, leading to adverse effects on their health). Record review of the quarterly MDS assessment, dated 02/10/2024,…

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 observation, interviews, and record review, the facility failed to implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 3 of 22 residents reviewed for care plans. (Resident #18, Resident #49, and Resident #51). 1. The facility failed to ensure Resident #18 had a person-centered care plan to accurately reflect Resident #18's actual pressure wound. 2. The facility failed to ensure Resident #49 had a person-centered care plan to accurately reflect Resident #49's required one on one activities. 3. The facility failed to ensure Resident #51 had a person-centered care plan to accurately reflect refusal of care for ADLs. These failures could place the residents at increased risk of injury or infection and not having their individual needs met. The findings included: 1. Record review of Resident #18's order summary report, dated 01/24/2023, revealed he was a [AGE] year-old male who 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure respiratory care was provided with professional standards of practice for 3 of 6 residents (Residents #36, #40, and #3) reviewed for respiratory care and services. 1. The facility failed to ensure Residents #36 and #40's oxygen concentrator filters were free of grey, fuzzy material. 2. The facility failed to administer oxygen at 2 via nasal cannula as prescribed by the physician for Resident #3. These failures could place residents who receive respiratory care at risk for developing respiratory complications. Findings include: 1. Record review of Resident #36's order summary report, dated 01/25/2023, indicated Resident #36 was a [AGE] year-old male, originally admitted to the facility on [DATE] with a diagnosis which included COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs), chronic respiratory failure with hypoxia (low levels of oxygen in your body tissues), essential hypertension (force of…

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

Based on observation, interview and record review, the facility failed to ensure the meals served met the nutritional needs of residents for 1 of 1 meals (the lunch meal), as evidenced by: The facility failed to ensure [NAME] C followed the recipe for pureeing the country fried steak and California blend vegetables. The facility failed to ensure [NAME] C used a #6 scoop to serve the country fried steak. The facility failed to ensure [NAME] C used a #12 scoop to serve the California blend vegetables. These failures could place residents at risk for weight loss, not having their nutritional needs met, and a decreased quality of life. Findings included: During an observation and interview on 01/23/23 starting at 10:07 AM, [NAME] C pureed the California blend vegetables. [NAME] C poured from a pot the California blend vegetables and water from the vegetables into a canister to puree them and added salt, no measurements used. After this, [NAME] C pureed the country fried steak. [NAME] C put 2 country fried steaks in the puree canister and added beef broth without measuring. [NAME] C said…

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 food that was palatable and served at an appetizing temperature for 5 of 22 residents (Resident #36, Resident #41, Resident #46, Resident #50, and Resident #59) reviewed for dietary services. The facility failed to provide palatable food served at an appetizing temperature or taste to residents' who complained the food was not hot and did not taste good. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. Findings included: During a resident interview on 01/22/2023 at 10:36 AM, Resident #50 stated the food was disgusting. Resident #50 stated the food was not hot and the gravy was too watery. During a resident interview on 01/22/2023 at 10:41 AM, Resident #59 stated the food was bland. During an interview on 01/22/23 at 10:44 AM Resident #36 stated the food was bland. During a resident interview on 01/22/2023 at 11:14 AM, Resident #46 stated the food was bland. During an interview on 01/22/23 at 11:28 AM,…

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. The facility failed to ensure: o food items were dated, labeled, and sealed appropriately. o expired food items were discarded. o the vent hood was clean. o the juice dispenser nozzle was clean. o the juice drain on the floor was clean. o the toaster was free of food debris. o the ice machine was clean. o a food cart was clean. o a fan on the floor in the kitchen was clean. o the floor was clean. These failures could place residents at risk for foodborne illness. Findings included: During an observation on 01/22/23 starting at 09:02 AM, Reach in refrigerator: 1 gallon of dill pickle relish with no open date 1 16 oz package of beef bologna with no open date Kitchen shelf: 1 11 oz container of parsley flakes use by date 12/17/22 1 18 oz container of Hungarian style paprika use by date 3/26/22 1 28 oz container…

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 safe and sanitary storage of resident's food items for 3 of 22 residents reviewed for personal food safety. (Resident #16, Resident #63, and Resident #59) The facility did not implement the personal food policy related to personal refrigerators for Resident #16, Resident #63, and Resident #59. This failure could place the residents at risk for food borne illnesses. The findings included: 1. Record review of Resident #16's order summary report, dated 01/25/2023, revealed she was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of Alzheimer's disease (progressive disease that destroys memory and other important mental functions), osteoarthritis (degeneration of joint cartilage and the underlying bone), and type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar). Record review of the MDS assessment, dated 10/19/2023, revealed Resident #16 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for (Residents #18, Resident #4, Resident #25 and Resident #69) reviewed for infection control. 1.The facility did not ensure Resident #4 utilized appropriate PPE use throughout the facility. 2.The facility failed to ensure CMA H disinfected the wrist blood pressure monitor between Resident #25 and Resident # 69. 3.The facility failed to ensure NA K changed her gloves and performed hand hygiene during incontinent care provided to Resident #18. These failures could place residents and staff at risk for cross-contamination, spread of infection and could potentially affect all others in the building. Findings include: 1.Record review of Resident #4's face sheet (01/25/23) indicated she was a [AGE] year-old female that was admitted to…

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 provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 2 of 22 residents (Resident #15 and Resident #49) reviewed for resident rights. 1. The facility failed to ensure NA K provided privacy for Resident #15 while providing incontinent care. 2. The facility failed to ensure NA K and CMA L treated Resident #49 with dignity and respect by referring to her as a feeder. These failures could place residents at an increased risk of embarrassment, isolation, and diminished quality of life. The findings included: 1. Record review of Resident #15's order summary report, dated 01/25/2023, revealed he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance (loss of memory, language, problem solving and other thinking abilities that were severe enough to…

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 an accurate MDS was completed for 1 of 22 residents (Resident #43) reviewed for MDS assessment accuracy. The facility failed to accurately document Resident #43's tobacco use. This failure could place residents at risk for not receiving care and services to meet their needs. Findings include: Record review of Resident #43's order summary report, dated 01/25/2023, indicated Resident #43 was an [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis which included muscle wasting and atrophy (thinning or loss of muscle tissue), essential hypertension (high blood pressure), and dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life). Record review of Resident #43's admission MDS assessment, dated 09/16/2022, indicated Resident #43 usually understood others and made himself understood. The assessment indicated Resident #43 was moderately cognitive impaired…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 2 out of 22 residents (Resident #52 and Resident #70) reviewed for accident hazards. 1. The facility failed to ensure Resident #52's oxygen cylinder was securely stored. 2. The facility failed to ensure Resident #70 was free from an antiseptic agent containing alcohol. These failures could place residents at risk of injury. Findings included: Resident #52 Record review of the face sheet, dated 01/25/23, revealed, Resident #52 was a [AGE] year-old male initially admitted to the facility on [DATE] with diagnoses including malignant neoplasm of colon (colon cancer), malignant neoplasm of upper lobe, left bronchus or lung (lung cancer), and chronic obstructive pulmonary disease with (acute) exacerbation (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of the order recap report, dated 01/25/23, indicated Resident #52 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 (Resident #45) of 22 residents reviewed for pharmacy services. The facility did not ensure Resident #45 received her Lantus Solostar Solution (diabetic medication) and blood sugar checks as ordered by the physician. This failure could place the residents at risk of not receiving the intended therapeutic benefit of their medications and accidental exposure or drug diversion. Findings include: Record review of Resident #45's order summary report, dated 01/25/2023, indicated Resident #45 was an [AGE] year-old female, originally admitted to the facility on [DATE] with a diagnosis which included type 2 diabetes mellitus with diabetic nephropathy (chronic condition that affects the way the body processes blood sugar, progressive death of nerve fibers, which leads to deterioration 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, record review and interview, the facility failed to ensure that it was free of medication error rate of 5 percent or greater. 27 opportunities were observed with a total of 3 errors, resulting in a 11.11 percent medication error rate. Two (Residents #37 and Resident # 25) of five residents reviewed for pharmacy services. The facility failed to ensure Resident #37 received oxycodone-acetaminophen tablet 10/325mg to be administered at 6:00 a.m. CMA H administered the medication at 8:33 a.m. to Resident #37. The facility failed to ensure Resident #25 received Tramadol 50 mg at 6:00 a.m. and Protonix 40 mg at 6:30 a.m. The medications were administered at 8:51 a.m. These failures could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders. Findings included: 1.Record Review of Resident #37's face sheet (01/25/23) indicated he was a [AGE] year-old male that was admitted to the facility on [DATE]. 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 interview and record review, the facility failed to maintain a quality assessment and assurance committee consisting at a minimum the required committee members for 3 of 4 meetings (November 2022, December 2022, and January 2023) reviewed for QAPI. 1. The facility did not ensure the Administrator attended their QAPI meetings in November 2022, December 2022, and January 2023. 2. The facility did not ensure the Infection Preventionist attended their QAPI meeting in December 2022 and January 2023. This failure could place residents at risk for quality deficiencies being unidentified, infections, no appropriate plans of action developed and implemented, and no appropriate guidance developed. Findings include: Record review of the facility's QAPI Committee sign-in-sheets indicated the Administrator did not sign in for their meetings from November 2022 to January 2023. Record review of the facility's QAPI Committee sign-in sheets indicated the Infection Preventionist did not sign in for their meetings from December 2022 to January 2023. During an interview on 01/25/2023 at 9:38…

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 medical record included documentation that indicates the resident received education on the influenza and the pneumococcal immunizations of 2 of 5 residents reviewed for immunizations. (Resident #3 and Resident #10). 1 The facility failed to ensure Resident #3's medical record contained evidence of education on the pneumococcal immunization when the vaccine was administered to the resident. 2. The facility failed to ensure Resident #3's medical record contained evidence of education on the influenza vaccine when the vaccine was administered to the resident. The facility failed to ensure Resident #10's medical record contained evidence of education on the pneumococcal immunization when the vaccine was administered to the resident. The facility failed to ensure Resident #10's medical record contained evidence of education on the influenza vaccine when the vaccine was administered to the resident. These failures could place…

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.