The Suites Pasadena

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 (Resident #1) of 4 residents reviewed for resident rights. -The facility failed to honor Resident #1's request of wearing a mask before entering her room on 02/21/25. This failure could place residents at risk for a lack of self-determination and quality of life. The findings included: Record review of Resident #1's admission Record, dated 02/21/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnosis included multiple sclerosis (autoimmune disease resulting in damage to the insulating covers of nerve cells in the brain and spinal cord), bipolar disorder (mental health condition that causes extreme mood swings), and muscle weakness. Record review of Resident #1's MDS Quarterly…

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 reviews, the facility failed to provide food that accommodates resident allergies, intolerances, and preferences for 1 (Resident #1) of 4 residents reviewed for dietary services. -The facility failed to honor Resident #1's food preference according to her meal ticket by serving her pork, which her meal ticket reflected she disliked. This failure could place residents at risk for possible weight loss, and a diminished interest in meals and quality of life. The findings included: Record review of Resident #1's admission Record, dated 02/21/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included multiple sclerosis (autoimmune disease resulting in damage to the insulating covers of nerve cells in the brain and spinal cord), bipolar disorder (mental health condition that causes extreme mood swings), and muscle weakness. Record review of Resident #1's MDS Quarterly Assessment, dated 12/08/24, revealed a BIMS score of 13,…

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

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 for 1 kitchen. Food item was not sealed in the facility pantry . This deficient practice could place 25 residents who received meals from the main kitchen at risk for food borne illness. Findings included: Observation on 10/29/24 at 08:57 am revealed one 13.7-quart clear full-size container of brown sugar was left open to air. In an interview with the Dietary Manager on 10/30/2024 at 10:00 am, she said she noticed the brown sugar lid and the plastic wrapping was not covered on the container. She said when the workers leave the brown sugar uncovered it could cause the sugar to get hard and go bad fast. She said when the workers leave the container of brown sugar uncovered anything can crawl inside of it. She said anything at the top shelf can fall into the sugar which can cause cross contamination. She said she expected her workers to follow policy and procedures. In an interview with the [NAME]…

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 inform residents in advance of the risks and benefits of proposed care and treatment for 1 of 5 residents (Resident #19) reviewed for resident rights. The facility failed to obtain a signed consent for antipsychotic medication, Wellbutrin XL Oral Tablet Extended Release 24-hour 150 MG, administered to Resident #19. The failure affected residents who received psychoactive medications without informed consents and placed them at risk of receiving treatments without informed consent. Findings included: Record review of Resident # 19's face sheet provided by the facility on 10/31/2024 revealed that Resident # 19 [NAME] a 61 -year-old male who admitted to the facility on [DATE] and had an active diagnosis of bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) with an onset documented as of 09/05/2024. Record review of the comprehensive MDS assessment revealed Resident # 19's Brief…

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 coordinate assessments with the Preadmission Screening and Resident Review (PASRR) program to the maximum extent practicable for 1 of 5 residents (CR #236) reviewed for PASRR. The NF was notified and instructed to submit a NFSS Request by a specific deadline but failed to do so. The NFSS Request submittal was denied and there was not a follow up submittal to ensure the request was approved to provide specialized services for PASRR for the CR #236 This failure could place residents requiring PASRR services at risk of not having their special needs assessed and met by the facility. Findings included: Record review of CR # 236's face sheet provided by the facility on 10/28/2024 revealed that CR # 236 [NAME] a 45 -year-old female who admitted to the facility on [DATE] and had an active diagnosis of Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) with an onset documented as 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 observations, interviews, and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 12 residents (Resident #132) reviewed for significant medication errors. The facility failed to ensure Metoprolol Tartrate (a blood pressure (BP) medication given to lower (high blood pressure) and treat heart failure) was administered on 10/28/2024 and 10/29/2024 to Resident #132 as ordered on 10/25/2024 by the physician. This failure could place residents at risk of not receiving desired therapeutic outcomes, increased side effects, or a decline in health. Findings included: Record review of Resident #132's admission face sheet, undated, reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: hypertension (high blood pressure), heart failure (a chronic condition in which the heart not pumping blood as well as it should), and respiratory failure. Record review of Resident #132's baseline care plan dated 10/25/2024…

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.

Based on observations, interviews, and record review, the facility failed to ensure that drugs and biologicals used in the facility were secured properly for two residents (Resident# 14 and Resident #18) of five residents reviewed for pharmacy services. -The office of the ADON was open and accessible to staff and residents. There were two blister pack cards of controlled medications. Staff were within sight of the open door. The deficient practice placed the facility at risk for drug diversion. Findings included: Observation on 10/31/24 at 3:25 p.m. revealed the DON and the ADON left the ADON's office. They walked down Hall 300 and exited the facility. Observation revealed the office was adjacent to the nurses' station. Observation on 10/31/24 at 3:30 p.m. revealed there were five unidentified staff within sight of the open door. Continued observation from outside of the doorway revealed there was an over-bed table just inside the office. On the over-bed table was a laptop computer and two medication cards with count sheets secured around them with rubber bands. There was no 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 interviews and record review, the facility failed to ensure residents had the right to be free from any physical or chemical restraints imposed for the purpose of discipline or convenience for one (Resident #1) of five residents reviewed for chemical restraints. 1. The DON changed the medication order from Seroquel Oral Tab 100 MG to be administered at bedtime to be administered in the morning. Resident #1 slept all day until 7-8pm for 3 days. 2. The DON failed to attain verbal consent from a physician or Resident #1, who was her own responsible party. This failure could place 21 residents who receive medications at the facility at risk for adverse medication effects and potential harm. Findings included: Record review of Resident#1's face sheet dated 03/28/24 revealed a [AGE] year-old woman who was admitted to the facility on [DATE]. Her admitting diagnoses were bipolar disorder (extreme mood swings), multiple sclerosis (immune system attacking the brain and spinal cord-central nervous system),…

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 treatment and care in accordance with the comprehensive person-centered care plan and in accordance with professional standards of practice for two (Resident #1 and Resident #2) of five residents reviewed for quality of care. 1. The DON falsified documentation that wound care was given to Resident #1 on 03/15/24 and 03/18/24. 2. LVN B failed to provide wound care services to Resident #2 everyday per physician orders. These failures could place 2 residents who receive wound care at risk for infections, healing regression, and pain. Findings included: 1.Resident #1 Record review of Resident#1's face sheet dated 03/28/24 revealed a [AGE] year-old woman who was admitted to the facility on [DATE]. Her admitting diagnoses were bipolar disorder (extreme mood swings), multiple sclerosis (immune system attacking the brain and spinal cord-central nervous system), insomnia (cannot sleep), anemia, obesity, lymphedema (swelling due to build up of lymph…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for one (Resident #2) of two residents reviewed for wound care. Licensed Vocational Nurse (LVN B) failed to properly wash or sanitize her hands in between glove changes when providing wound care to Resident #2. This deficient practice could place 2 residents who received wound care at risk for cross contamination and/or spread of infection. Findings included: Record review of Resident #2's facesheet revealed a [AGE] year-old woman who was admitted to the facility on [DATE]. Her admitting diagnoses were type 2 diabetes (affects your body's ability to use insulin and causes high blood sugar levels), heart failure, morbid (severe) obesity, chronic kidney disease, and peripheral vascular disease (a condition that narrows the arteries and reduces blood flow to the arms or legs). Record review of Resident #1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure services provided by the facility, as outlined by the comprehensive care plan, met professional standards of quality for two (Resident #2, CR#1) of three residents observed for gastrostomy tube feedings. The facility failed to ensure that LVN B turned off Resident #2's feeding as ordered by the physician. The facility failed to ensure that CNAs notified the nurses to turn off CR#1's feeding pump when providing care. These failures could place residents at risk for aspiration, and abdominal discomfort. Findings included: Resident #2 Record review of Resident #2's admission face sheet revealed he was [AGE] year-old male that was admitted to the facility on [DATE]. His diagnoses included type 2 diabetes (high blood sugar), dysphagia (difficulty swallowing), oropharyngeal phase (movement of food through the oral cavity by the tongue), lack of coordination, major depressive disorder (mental illness), insomnia (difficulty sleeping),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 2 of 5 Residents (Resident #2 and, Resident #3) reviewed for medical records accuracy, in that: Resident #2's and Resident #3's January 2024 Medication Administration Record (MAR) did not reflect documentation for medications given or not given. This failure could affect residents whose records are maintained by the facility and could place them at risk for errors in care, and treatment. Findings Included: Resident #2 Record review of Resident #2's admission face sheet revealed he was [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included type 2 diabetes (high blood sugar), dysphagia (difficulty swallowing), oropharyngeal phase (moving of food or, lack of coordination, major depressive disorder (mental illness), insomnia (difficulty sleeping), essential hypertension (high blood…

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 manage and maintain a system that assures a full, complete, and separate accounting, according to accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf, for 1 of 1 facility reviewed for management of resident funds. --facility failed to have a complete accounting of resident's trust fund activity for 2 months, failed to maintain adequate funds in the petty cash account, or have adequate management of facility funds for 2 months. These failures placed residents whose funds were managed by the facility at risk of losing their Medicaid insurance benefits and placed residents' funds at risk of being misappropriated. Findings include: Record review of facility Trust Fund Transaction History dated December 1, 2024 - December 30, 2024, and January 1, 2024 - January 30, 2024, revealed no documentation of credits or debits to resident trust fund accounts for 2 months. Record review of facility Trust Account Petty Cash document dated, 11/27/23, revealed the original funding…

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 resident who is incontinent of bladder received appropriate sized absorbent product for 1 of the 5 (Resident #7103) residents. The facility failed to provide reasonable accommodation of size 5X bariatric briefs for bariatric Resident #7103. This deficient practice placed residents at risk for not having their needs met. Findings included: Record review of Resident #7103 face sheet dated 01/17/2024 indicated he was a 76 -year-old female who admitted on [DATE] with primary diagnosis of Type 2 Diabetes Mellitus and a secondary diagnosis of morbid (severe) obesity. Interview with Resident #7103 on 01/17/2024 at 10:30am, revealed that she had resided at the facility for 3yrs. Resident #7103 stated that overall, she really liked the facility. She continued and stated that the facility had been struggling with keeping management over the past year. Resident stated that the facility was often time out of incontinent supplies (wipes 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.

Based on interview and record review the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population. The facility failed to ensure a qualified dietitian or other clinically qualified nutrition professional was employed either full-time, part-time, or on a consultant basis. This failure could place residents at risk of not having their nutritional needs met, weight loss, and an increased risk for wounds. The findings include: Interview on 7/18/2023 at 10:05 AM with MDS LVN, revealed she had been employed by the facility since 06/19/23. The MDS LVN said section K was completed by the dietary manager or dietician. Interview on 7/19/2023 at 3:20 PM with the CNO, she said the facility had reviewed and updated all the care plans for residents identified with unplanned or unexpected weight loss. The CNO said Resident #32's care plan was updated at…

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 be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest, practicable physical, mental, and psychosocial well-being of each resident for 2 of 35 residents (Resident #27 and Resident #31) reviewed for residents' administration. -LVN A failed to properly check Resident #27's gastrostomy tube placement as ordered prior to administration of any medications. -LVN A attempted to administer Resident #27's medications by plunger pushing them into his gastrostomy tube instead of administering to gravity. -LVN A failed to check Resident #27 for residual prior to administering medications. -The facility failed to ensure Resident #31's gastrostomy tube did not become dislodged twice after the discontinuation of his order for an abdominal binder. -The facility failed to ensure Resident #31 had a valid/accurate physician order for the discontinuation of Resident #31's gastrostomy tube…

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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 14 of 18 residents (Residents #6, #9, #12, #14, #18, #22, #28, #31, #86, #87, #88, #89, #90 and #91) reviewed for infection control and prevention. - The facility failed to track, observe trends, and/or monitor infectious diseases in the facility including pneumonia. This failure could place residents at risk of becoming infected with a preventable infections disease, becoming ill, and death. Findings include: 1. Record review Resident #6's admission record, dated 7/14/2023, revealed a [AGE] year-old male, with an original admission date of 8/21/2020, an initial admission date of 1/10/2023 and an admission date of 4/24/2023. Resident #6 had diagnoses which included quadriplegia (a symptom of paralysis that affects all 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.

Based on interview and record review the facility failed establish an infection prevention and control program (IPCP) that must include, at minimum, an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for 1 of 1 facility reviewed for an antibiotic stewardship program. The facility did not have an antibiotic stewardship program in place until June 2023. This failure could place residents at risk of being overmedicated, and/or the facility failing to observe an outbreak of an infectious disease which antibiotics had been prescribed. Findings include: Interview on 7/13/2023 at 4:35 PM with the CNO, corporate nurse representative, said the facility's antibiotic stewardship documentation was contained in the EHR. The CNO said the facility was able to monitor the antibiotic use in the facility for the last calendar year. The CNO said the system tracked the number of antibiotics prescribed, the prescriber, the length of time the prescription was utilized, and the diagnosis leading to the prescription . Interview on 7/16/2023 at…

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 inform residents in advance of the risks and benefits of proposed care and treatment for 2 of 15 residents (Resident #9 and Resident #90) reviewed for resident rights, in that: -Resident #9 did not have a signed consent for psychoactive medication Quetiapine which he received. -Resident #90 did not have a signed consent for antidepressant medication Bupropion HCI (ER) XL which she received. These failures affected residents who received psychoactive medications without informed consents and placed them at risk of receiving treatments without informed consent. Findings include: Resident #9 Record review of Resident # 9's admission Record revealed he was a [AGE] year old male who admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included: bipolar disorder unspecified (a mental health disorder associated with episodes of extreme mood swings ranging from depressive lows to manic highs), anxiety disorder (a mental health…

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 manage the personal funds of the residents deposited with the facility for 2 of 16 residents (Resident # 6, #15) reviewed for trust funds. -The facility failed to ensure that Resident #6, and #14 trust fund accounts were spent down to avoid being over the amount allowed to have Medicaid Insurance benefits. -The facility failed to have a surety bond which would cover facility residents' trust funds. The facility's trust fund balance on 7/11/2023 was $57,003.25 and the surety bond at that time was $45,000. Resident #14 requested money from his trust fund, and it had not been provided to him timely. This failure could place residents whose funds are managed by the facility at risk of losing their Medicaid Insurance benefits and their personal funds not being accessible or mis-managed. Findings Included: Interview on 7/14/2023 at 11:52 am with the Corporate Business Officer, when asked about the individual amounts of resident trust funds, she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to convey resident funds within 30 days of the resident's discharge, eviction, or death, for 8 of 10 residents (CR#96, CR#97, CR#98, CR#99, CR#101, CR#102, CR#103 and CR#104) reviewed for conveyance of funds. -The facility failed to convey CR#96, CR#97, CR#98, CR#99, CR#101, CR#102, CR#103 and CR#104 funds within the timeframe as required after discharge. This failure could affect all residents and place them at risk for not receiving funds owed to them by the facility. Findings include: Interview on 7/11/23 at 9:30 am with Administrator A and DON A, the surety bond and trust funds balances were requested by surveyor., Administrator A said that he would contact corporate for the surety bond and trust fund balances. Administrator A said the facility has a corporate business office manager and the on-site business office manager left in June of 2023. Interview on 7/13/2023 at 9:.29 am with HHSC Trust Fund staff B, she confirmed that their unit is working 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.

Based on interview and record review, the facility failed to purchase a surety bond, or otherwise provide assurance satisfactory to the Secretary, to assure the security of all personal funds of residents deposited with the facility for 1 of 1 facility reviewed for surety bonds and security of personal funds, in that: -The facility's residents' trust fund account balance totaled $57,003.25. -The facility's Surety Bond totaled $45,000.00. This failure affected 13 residents that allow the facility to manage their funds at risk of the facility not being able to guarantee repayment to the resident. and placed any additional resident that choses to deposit funds in the facility trust fund at risk of their personal funds not being assured. Findings include: Interview on 7/11/23 at 9:30 am with Administrator A and DON A, the surety bond and trust funds balances were requested. Administrator A said that he would contact corporate for the surety bond and trust fund balances. Interview on 7/15/23 at 11:02 am with Administrator A and DON A., Administrator A confirmed the residents' trust fund…

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 were able to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that it was not possible or the resident preferences indicated otherwise for 3 of 18 (Residents #31, #32, and #89) reviewed for nutrition and hydration status and maintenance. 1. The facility failed ensure Resident #31, Resident #32, and Resident #89 did not sustain an unplanned and/or unexpected significant weight loss. 2. There was no evidence a registered Dietitian had addressed the unplanned weight loss, assessed the residents, or implemented interventions for residents that were experiencing unplanned weight loss since April 2023. 3. The facility failed to ensure residents #31, #32, and #89 were provided with dietitian evaluations and/or interventions. These failures could have led to a failure to maintain therapeutic…

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 resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 2 of 5 residents (Resident #27, Resident #31) reviewed for tube feeding management and restore eating skills, in that: -LVN A failed to properly check Resident #27's gastrostomy tube placement as ordered prior to administration of any medications. -LVN A attempted to administer Resident #27's medications by plunger pushing them into his gastrostomy tube instead of administering to gravity. -LVN A failed to give Resident #27 (5) ml's of water between each medication as ordered. -LVN A failed to check Resident #27 for residual prior to administering medications. -The facility failed to ensure Resident #31's gastrostomy…

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, based on a comprehensive assessment of a resident, residents who used psychotropic drugs received gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for 2 of 4 residents (Residents #11 and #28) reviewed for unnecessary medications. 1. The facility failed to ensure Resident #11 had documentation to show GDR related to Seroquel. 2. The facility failed to ensure Resident #28 had documentation to show attempted GDR despite pharmacist recommendations. These failures could place residents at risk from maintaining their highest practicable level of physical, mental, and psychosocial well-being, and adverse consequences related to medication therapy. Findings Include: 1. Record review of Resident #11's admission record, dated 7/11/2023 , revealed a [AGE] year-old woman admitted to the facility on [DATE]. Resident #11 had diagnoses which included Multiple Sclerosis (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5%. There were 4 errors out of 26 opportunities which resulted in a 15% error rate involving 3 of 3 residents (Resident #6, Resident #15, and Resident #27) and 2 of 2 employees (LVN A and MA A) observed during medication administration reviewed for medication error, in that: -LVN A omitted Resident #27's oral rinse that was prescribed for him after a dental procedure. -LVN A failed to give Resident #27 the correct multivitamin (MVI). -MA A failed to give Resident #6 his Sucralfate (antacid) as directed, which was before meals. -MA A failed to give Resident #15's delayed release aspirin (ASA) as prescribed. These failures could affect residents and put them at risk for not receiving the intended therapeutic benefit of their medication and or adverse outcomes. The findings were: Resident #27 Record review of Resident #27's admission Record on 7/13/23 at 11:00am revealed he was a [AGE] year old…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident's medical record included documentation that indicated the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal for 16 of 18 residnets (Residents #6, #7, #9, #12, #14, #18, #22, #25, #28, #31, #86, #87, #88, #89, #90 and #91) reviewed for influenza and pneumococcal immunizations, in that - The facility failed to ensure there was documentation related to the pneumococcal immunization for Residents #6, #7, #9, #12, #14, #18, #22, #25, #28, #31, #86, #87, #88, #89, #90 and #91). - The facility failed to ensure Resident #12 received a Pneumonia vaccine after it was requested by the resident. Resident #12 developed Pseudomonas Aeruginosa Pneumonia (PNA) (pneumonia) and was administered Levaquin 500mg tablet one tablet, once daily from January 9, 2023, to January 16, 2023. These failures could affect residents and place them at risk…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure the assessment must accurately reflect the resident's status for 1 of 18 (Resident #12) residents reviewed for accuracy of assessments, in that: 1. Resident #12's Annual MDS documented he was receiving dialysis treatment services although his dialysis treatment services had ended. This failure could place residents at risk of not receiving care and services needed to attain/maintain their highest practicable quality of life. Findings include: Record review of Resident #12's admission record dated 7/11/2023 revealed a [AGE] year-old resident admitted on [DATE]. The record documented his diagnoses included unspecified cerebrovascular disease (disorder resulting from inadequate blood flow in the vessels that supply the brain), hypertension (high blood pressure), atherosclerotic heart disease (condition where the arteries become narrowed and hardened due to buildup of fats in the artery wall), and unspecified nephritic syndrome (syndrome…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for 1 of 8 residents (Resident #26) reviewed for PASRR assessments. -The facility failed to ensure Resident #26 who had a diagnosis of mood disorder, had an accurate PASSR Level I assessment or received a PASRR Level II assessment or evaluation. This failure could place residents with a serious mental illness at risk of not receiving needed care and services to meet their individual needs. Findings included: Record review of Resident # 26's admission Record revealed he was a [AGE] year old male who admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included: epilepsy (a neurological disorder with sudden recurrent, unprovoked episodes of sensory disturbances, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain), mood disorder due 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 develop baseline admission care plan for each resident that included instructions needed to provide effective and person-centered care of the resident that met professional standard of quality care for 2 of 15 residents (Residents #89 and #91) reviewed for baseline care plans. The base line care plan was not developed within 48 hours of admission for Resident #89 and Resident #91. This failure could place residents at risk of not having their individual, medical, functional, and psychosocial needs identified and cause a physical or psychosocial decline in health. Findings include: 1. Record review of Resident #89's admission record, dated 7/14/2023, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident 89 had diagnoses which included: chronic obstructive pulmonary disease or COPD (refers to a group of diseases that cause airflow blockage and breathing-related problems. It includes emphysema and chronic bronchitis), Type I…

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.