Oasis at Pearland

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure 1 of 4 sampled residents (CR #3) were admitted with physician orders for immediate care, in that: The facility failed to have physician's orders that indicated CR #3's need for dressing to healing tracheostomy. This failure places residents with medical needs at risk for a decrease in their quality of care. Findings included: Record review of CR #3's face sheet, dated 08/25/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and was diagnosed with anoxic (without oxygen) brain damage and chronic respiratory failure with hypoxia (lack of oxygen). Record review of CR #3's care plan, not dated, revealed no mentioning of resident's trach status or post trach status. Record review of CR #3's MAR, dated 08/25/2024, revealed there were no orders for trach site care. Record review of CR #3's MDS, dated [DATE], reflected resident was not documented to receive tracheostomy care. Record review of CR #3's nurses notes, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record and interview the facility failed to provide a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 6 of 6 residents reviewed for environment. 1-The facility did not have an adequate supply of linen as multiple rooms #103, #108, #109, #117, #124, #125 were observed with no sheets on the beds. 2-The facility did not have linen readily available to meet residents' needs. This failure could cause residents to have skin breakdown, infections and dignity issues. Findings included: Observation of resident rooms on 6/27/2024 at 11:02am, revealed #103, #108, #109, #117, #124, #125 revealed there were no sheets on the beds. Observation on 6/27/2024, and 6/28/2024 of supply carts on Dove, Swan and Flamingo halls did not have sheets on the cart. Record review of linen order placed on 6/24/24 revealed 5 dozen of flat sheets were ordered. Further review of linen order revealed on 4/1/2024 25 dozen of towels, 5…

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 one (Resident #1) of six residents observed for pleasure feedings. The facility failed to ensure that Resident #1's received pleasure feeding as ordered by the physician. These failures could place residents at risk for weight loss and further decline in health status. Findings included: Resident #1 Record review of Resident #1's admission face sheet revealed he was [AGE] year-old male that was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. His diagnoses included volvulus (twisting or knotting of the gastrointestinal tract), constipation (difficult having a bowel movement), vascular disorder of mail genital organs (disorder that affect the blood flow of the penis), unspecified protein calorie malnutrition (lack of protein and calories to meet nutritional need), cerebral palsy(abnormal…

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 have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing care to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 3 of 6 residents (Resident #1, Resident #2 and Resident #9) reviewed for sufficient staffing. -The facility failed to ensure there were sufficient staff per the facility assessment and failed to provide repositioning for Resident #1 and Resident. -The facility failed to provide Incontinent care to Residents #1 and Resident #2 and Resident #9. with bowel/bladder incontinence on 6/27/2024 and 6/28/2024. These failures could place residents at risk of their needs not being met, skin breakdown, and loss of dignity. Findings Included: Record review of the facility assessment tool dated April 2024 through April 2025 revealed Staffing plans is was based on your population and their needs for care and support, facility general approach to staffing 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.

Based on observation, interview and record review, the facility failed to provide food that was palatable, and at a safe and appetizing temperature for of the 1 (Dove Hall) of 4 halls for residents who receive room trays from the facility's kitchen. The facility did not maintain proper temperatures for room service trays for lunch on Dove hall. These failures could affect all residents who eat in their rooms and residents who received pureed meals by placing them at risk of weight loss, altered nutritional status and diminished quality of life. Findings included: Observation on 6/27/24 at 12:42pm, Dove hall food trays were in a warmer. Two plates observed inside that were covered with saran wrap. The food warmer was opened. There were no doors. In an interview on 6/27/2024 at 4:32pm, Resident #8 stated the food was cold and it was probably because his hall was served last every day. He said they do not have closed food warmer but the CNA's are serving them when they can. He said they only have one CNA on his hall, and this could be the issue why the food was cold. He said the…

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

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services. (1) The facility failed to ensure food was labeled and dated. (2) The facility failed to ensure that equipment was cleaned. (3) The facility failed to ensure that the dish machine sanitizer was working properly. (4) The facility failed to ensure that staff were properly trained to do they duties. (5) The facility failed to ensure that food on the steam was at the correct holding temperature. (6) The facility failed to ensure staff maintained proper hygienic practices. (7) The facility failed to ensure refrigerator maintain 41 degrees or below. These failures could place residents who ate meals prepared by the kitchen at risk for food contamination and foodborne illness. Findings included: In an interview with Dietary Aide B on 6/27/24 at 11:35am, she said she had to do dishes with very little cleaning material. She said they usually purchase from Company…

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 3 of 6 residents (Resident #1, Resident #2 and Resident #9 ) reviewed for facility administration in that: -The facility Administrator and DON failed to ensure the facility had sufficient staff to ensure timely incontinent care and/or repositioning were provided for (Resident #1, Resident #2, and Resident #9). -The facility Administrator failed to ensure the facility had adequate linen, towels, briefs and wipes to care for the facility residents in a timely manner. -The facility DON failed to supervise CNAs to ensure they were providing timely incontinent care and repositioning as ordered. This failure could place all residents who were dependent on staff for ADL care at risk of having skin breakdown, infection, and loss of dignity.…

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, based on the comprehensive assessment of a resident, 1 resident (Resident #3) of 3 residents reviewed for pressure sores received the necessary treatment and services consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing. 1-Resident #3 had a large pressure sore that was not properly dressed. 2-The Charge Nurse and Treatment Nurse were not aware that the dressing was not on the wound. 3-The facility had no documentation of measurements of the pressure sore since admission. The failure placed this resident at risk for worsening of the pressure ulcer and/or possible infection. Findings included: Record review of the admission Record (copied 07/02/24) for Resident #3 reflected she was [AGE] years old, and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, pressure ulcer of the sacral region, pressure induced deep tissue…

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 record review and interview, the facility failed to conduct and document a facility wide assessment to determine the resources necessary to competently care for residents during day-to-day and emergency operations for 1 of 1 facility in that: -The Facility Assessment Tool was not completed. This failure could affect residents by not having the necessary resources to ensure appropriate care is provided. Findings included: Record review of the Facility Assessment Tool revealed read in part: .Date(s) of assessment or update 1/16/2024. Date(s) assessment reviewed with QAA/QAPI committee 1/23/2024. Disclaimer: Use of this tool is not mandated by the CMS, or does it ensure regulatory compliance 12/13/2022. Facility Assessment Tool reviewed had previous Administrator and DON listed. Further review of the facility assessment revealed the assessment was missing the following: Resident profile, Services and care offered, and facility resources needed. Record review and interview on 4/24/24 at 2:10 p.m., with the Corporate RN. Surveyors reviewed the facility assessment presented by…

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 a private meeting space for the residents' monthly council meetings for 11 of 11 confidential residents reviewed for resident council. -The facility failed to provide a private space for resident council meetings. This failure could place residents, who attended resident council meetings, at risk of not being able to voice concerns due to a lack of privacy. Findings included: Interview on 4/23/24 at 10:11a.m., Activities Director stated that Resident Council was held in the dining room. When asked if it was private, she stated that she could post a sign and request staff to stay out of that area. Observation of Dining room on 4/24/24 at 11:00a.m., revealed multiple staff, visitors (nursing students), dietary staff, Maintenance director and other residents (using vending machine) going in and out of the dining room from both sides. Observation and interview on 4/24/24 at 11:10 a.m., during a confidential resident group meeting with 11 residents, revealed the resident council meeting were held once a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. -The facility failed to ensure foods were properly stored, labeled, and dated. This failure could place residents who ate food served by the kitchen at risk of food-borne illness. Findings included: Observation of the kitchen and interview on 04/23/2024 between 8:22a.m., and 9:10 a.m., with [NAME] A revealed the following: Refrigerator: A clear container with Puree pumpkin pudding dated 4/18/24 with no used by date. A clear gallon sized zip log bag with Salad mix dated 4/18/24 with no used by date. A clear gallon sized zip log bag with Croissants dated 4/10/24 with no used by date. A clear gallon sized zip log bag with bagels dated 4/8/24 with no used by date. A clear gallon sized zip log bag with pancakes dated 4/4/24 with no used by date. The Condiment refrigerator or Cook'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 interview, and record review, the facility failed to inform residents in advance of the risks and benefits of proposed care and treatment for 1 of 5residents (Resident #58) reviewed for resident rights, in that: The facility failed to obtain a signed consent for antipsychotic medication, Olanzapine was administered to Resident #58. The failure affected residents who received psychoactive medications without informed consents and placed them at risk of receiving treatments without informed consent. Findings include: Record review of Resident #58's face sheet dated 02/12/24 revealed he was a [AGE] year-old female who admitted to the facility on [DATE], with diagnoses of unspecified dementia, without behavioral disturbance psychotic disturbance, mood disturbance, and anxiety (group of symptoms that affects memory, thinking and interferes with daily life), anxiety disorder (group of mental illnesses characterized by intense anxiety and fear). Record review of the comprehensive MDS assessment revealed…

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 psychotropic medications were not given unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 5 residents (Resident #58) reviewed for unnecessary medications. The facility failed to have an appropriate diagnosis or indication for the use of Resident #58's Olanzapine (antipsychotic medication used to treat severe agitation associated with certain mental/mood conditions schizophrenia, bipolar mania). The facility's failure could place residents at risk for psychotropic medication side effects, adverse consequences, decreased quality of life, dependence on unnecessary medications; and could increase the risk of death in older adults with mental health problems related to dementia. Findings include: Record review of Resident #58 's face sheet dated 02/12/24 revealed he was a [AGE] year-old female who admitted to the facility on [DATE], with diagnoses of unspecified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to 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 infection for 1 of 5 residents (Resident #19) reviewed for infection. -The facility failed to ensure CNA I performed hand hygiene during incontinent care on Resident #19. This failure could lead to the spread of infection to residents, resident illness, and/or resident distress. Finding include: Record review of the admission sheet (undated) for Resident #19 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included dementia (a group of thinking and social symptoms that interferes with daily functioning), other abnormalities of gait and mobility (weakness of the hip and lower extremity muscles commonly cause gait disturbances) and other lack of coordination (impaired balance or…

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 one resident (Resident #1) of three residents reviewed for tracheostomy care and tracheal suctioning was provided care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. -RT A did not utilize a pulse-ox to monitor Resident #1's tolerance of the suctioning procedure. -RT A did not hyper-oxygenate Resident #1 prior to suctioning. -RT A contaminated a sterile field and required surveyor intervention to have her obtain a new sterile field. -RT A did not wear a sterile glove when she picked up the inner cannula and inserted it into the trachea. -RT A was not able to determine the difference between a sterile glove and a clean glove. The deficient practice placed Resident #1 at risk for respiratory infection and respiratory distress. Findings include: Record review of the admission Record for Resident #1 (dated 04/03/2024) revealed she was [AGE] years…

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 residents are free of significant medications errorsfor for 2 of (Resident #1 and Resident #2) of 6 residents reviewed for medications errors. The facility failed to ensure that Resident #1's medications were given as ordered by the physician. The facility failed to ensure that Resident #2's, medication Metoprolol for high blood pressure was given as ordered by the physician. This failure placed all resident who received medications at risk of not getting their medications as ordered which could result in resident not receiving the therapeutic benefits of the medication including increased pain, blood pressure and decreased quality of life. Findings included. Resident #1 Record review of Resident #1's admission face sheet dated 11/7/2023 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE] and discharged on 10/21/2023. His diagnoses included essential hypertension (high blood pressure),…

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 6 Residents (Resident #1 and Resident #2) reviewed for medical records accuracy, in that: Resident #1 and Resident #2 October 2023 MAR's and TAR's did not reflect documentation for medication and treatment done. Resident #1 and Resident #2 October 2023 nurse's notes did not why document reasons when medications were not given and why blood pressure medication was given. This deficient practice 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 #1 Record review of Resident #1's admission face sheet dated 11/07/2023 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE] and discharged on 10/20/2022. Resident #1's diagnoses included essential hypertension(high blood pressure), End…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #2) of 6 residents reviewed for comprehensive care plans. The facility failed to ensure Resident #2's comprehensive care plan included all care areas triggered on the assessment. This failure could place all residents at risk of not receiving proper care to develop and improve their mental, physical and psychosocial well-being. Findings included. Record review of Resident #2's admission face sheet dated 11/07/2023 revealed Resident # 2 was a [AGE] year-old female who was admitted on [DATE]. Resident #2's diagnoses included acute kidney failure (decreased kidney function), fever (temperature over 100 degrees) dysphagia (difficulty swallowing) anemia (having lower than normal healthy red…

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 were free of medications errors for (Resident #1) 1 of 6 residents' records reviewed of the MAR. Facility staff failed to follow the physician's orders for administering a narcotic (Norco) medication to R#1. This failure placed residents risk for not receiving the medications as ordered by the physician, which could cause excessive diarrhea. The findings included: Record Review of Resident #1's electronic face sheet revealed a [AGE] year-old female who entered the facility on 9/12/23 and re-entry dated 9/28/23. Record Review of Resident #1 Annual MDS dated 9.21.23 revealed a BIMS score of 10 (Moderate Cognitive Impairment). Record Review of Resident #1 Care Plan dated 9/28/2023 revealed diagnoses of acute and chronic respiratory failure (respiratory failure ), hypoxia or hypercapnia (low oxygen levels in blood and/or tissues), pneumonia (infection that inflames air sacs in one or both lungs), tracheostomy(a procedure to help air 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 immediately inform the resident, consult with the resident physician and notify the resident's representative when there was a significant change in the resident's physical mental or psychological status for 1 of 5 residents (Resident #1) reviewed for notification of change of condition. The facility failed to notify Resident #1's responsible party when there was lesion to the resident's nose which resulted in an open area on the nose bridge. This failure placed residents at risk of not being aware of any changes in their conditions and could result in the decline of the residents' health and well-being. Findings included: Record review of Resident #1's face sheet revealed a [AGE] year-old female who was admitted on [DATE]. Her diagnoses include diabetes type 11 (high blood sugar), hypertension (high blood pressure) Cerebrovascular, hyperlipidemia (high cholesterol) pain, iron deficiency anemia, hiatal hernia, GI Bleed traumatic brain…

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 transmit a resident assessment within the required time frame for 5 of 7 (CR #24, CR #60, CR #90, CR #94, and CR #96) discharged residents reviewed for data encoding and transmission in that: - The Facility failed to complete and transmit a discharge MDS for CR #24, CR #60, CR #90, CR #94, and CR #96. - The facility failed to complete an accurate discharge assessment for CR #24's death. This failure could place discharged residents at risk of not having their assessments transmitted timely. Findings included: CR #24 Record review of CR# 24's admission record dated [DATE] revealed a [AGE] year-old female was admitted to the facility on [DATE], re-admitted on [DATE] and discharged on [DATE] as death in the facility. CR #24 admitted with diagnoses that included asthma (a respiratory condition marked by spasms in the bronchi of the lungs, causing difficulty in breathing), muscle wasting and atrophy (Muscle wasting; Wasting; Atrophy of the muscles. Muscle…

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 correctly complete Level 1 assessments with the pre-admission screening and resident review program (PASRR) to the maximum extent practicable to avoid duplicative testing and effort for two (Resident #9 and Resident #14) of seven residents reviewed for PASRR. The facility failed to correctly complete a Level I PASRR Evaluation for Resident #9 and Resident #14. This failure could affect residents with a diagnosis of mental illness and could result in these residents not receiving needed services and or specialized care. Findings included: Resident #9 Record review of Resident #9's undated admission face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #9 had diagnoses which included major depressive disorder, recurrent, severe with psychotic symptoms (disturbed, confused, and disrupted patterns of thought), generalized anxiety disorder and Parkinson's Disease. Record review of Resident #9's annual MDS…

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 follow guidelines for mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must 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. The facility failed to submit PBJ staffing information to CMS for the 4th quarter of the fiscal year 2022. The facility's failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment. The findings included: Review of the facility's staff roster, undated indicated the following: 1 Administrator 9 RNs (included DON and 1 ADON) 27 LVNs (included 1 MDS Coordinator and 1 Treatment Nurse) 67 CNA/MA's 3 Maintenance Personnel 11 Housekeeping/Laundry Personnel 13 Dietary Personnel (included…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 24 hours after the allegation were made, to the administrator of the facility, other officials, including the State Survey Agency (SSA), for 1 (CR #50) of 7 resident reviewed for reporting. -RN H and CNA G failed to report an incident of abuse involving CR #50 to the facility's abuse coordinator and administrator immediately of knowing the abuse occurred on 07/19/2022. -The facility failed to report an incident to the SSA, Health and Human Service Commission (HHSC) immediately but not later than 24 hours of an incident of abuse on 07/19/2022 involving CR #50. This failure could place residents at risk for abuse by the facility not reporting such incidents to the Administrator and SSA within the mandated timeframes. Findings included:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care for 1 of 26 residents (Resident #14) reviewed for care plans, in that: -Resident #14 did not have a care plan until 25 days after she admitted . -Resident #14 did not have a baseline care plan to address her psychotropic medication use. These failures could affect all newly admitted residents to the facility by placing them at risk of not receiving the care and services for health promotion and continuity of care. Findings included: Resident #14 Record review of Resident #14's admission Record revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included major depressive disorder (persistently depressed mood and long-term loss of pleasure or interest in life), unspecified mood (affective) disorder (mental…

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 a comprehensive care plan within seven days after completion of the comprehensive assessment, for 1 Residents (Resident #14) of 24 residents reviewed for comprehensive care plans. The facility did not develop a comprehensive care plan for Resident #14 within seven days after completion of the comprehensive assessment. This failure could place residents at risk for not receiving the required person-centered care. The findings were: Resident #14 Record review of Resident #14's undated admission Record revealed she was a [AGE] year-old female who admitted to the facility on [DATE]. He diagnoses included major depressive disorder (persistently depressed mood and long-term loss of pleasure or interest in life), unspecified mood (affective) disorder (mental disorder characterized by a disturbance in mood which is abnormally depressed or elated), generalized anxiety disorder (mental condition characterized by excessive fear of or apprehension about…

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 dispose of garbage and refuse properly for 1 of 2 dumpsters (dumpster A) reviewed for garbage disposal. The facility failed to ensure the dumpster lid and door were secured. This failure could result in providing harborage and breeding areas for insects, rodents and other pests which could infest the facility. Findings included: An observation on 2/7/23 at 8:24 am., revealed 2 commercial-sized trash dumpsters with 2 lids on each dumpster, which were in the lot behind the dietary department. 1 (dumpster A) of the commercial-sized dumpsters had the right lid open, with garbage inside of it. Interview and observation on 2/7/23 at 8:24 am, with the Dietary Manager, she said that the dumpster lids must always be closed, to prevent infestation of pest and contamination. She said that the dumpsters were shared with all departments and all staff were responsible for making sure the dumpsters are always closed and monitoring. Interview on 2/7/23 at 10:00 am., with the Administrator, she said that the facility does not…

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 rooms were adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 1 of 4 halls (South Hall) reviewed for call systems. The facility failed to install a functioning call light system for Resident #10's room. This failure could place residents at risk for a delay in care and services, increased falls, excessive wait times, pain, and a decreased quality of life. Finding included: Resident #10 Record review of the face sheet for Resident#10 dated 02/09/2023 revealed a [AGE] year-old male admitted to the facility on [DATE] in room [ROOM NUMBER]. His diagnoses included sepsis, type diabetes mellites, acute kidney failure, heart disease, hypertension (high blood pressure), hyperlipidemia (high cholesterol), and right knee infective bursitis (inflammation of the knee). Record review of Resident#10's undated…

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.