Landmark of Plano Rehabilitation and Nursing Cente

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure that a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for two (Residents #54 and #79) of three residents reviewed for pressure ulcers. The facility failed to provide appropriate treatment to Residents #54 and #79 on 08/24/25. This failure placed residents at risk for decline in quality of life and the wounds being infected or deteriorating. Findings include: Review of Resident #79's face sheet dated 08/26/25 revealed she was a [AGE] year-old male, he was originally admitted on [DATE]. Admitting diagnoses included, Type 2 diabetes, muscle weakness,…

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 environment remained as free of accident hazards as possible for 1 (Resident #73) of 6 residents reviewed for accidents and hazards. The facility failed to ensure Resident #73 did not have access to disposable razors. This failure could place residents at risk of injury or harm, as well as contribute to avoidable accidents.Findings included: Record review of Resident #73's Face Sheet, dated 08/26/25, reflected he was an [AGE] year-old male, who was admitted to the facility on [DATE], with diagnoses including dementia (a group of symptoms affecting memory, thinking and social abilities), abnormalities of gait and mobility (deviations from a normal walking pattern, impacting how a person moves and their ability to maintain balance and coordination), and need for assistance with personal care (when a person requires help with daily activities like bathing, dressing, or toileting due to a chronic health issue, physical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #80) of 4 residents reviewed for oxygen administration. The facility failed to follow Resident #80's physician order for continuous oxygen. This failure could place residents at risk of receiving incorrect or inadequate oxygen support and could result in a decline in health.Findings included: Record review of Resident #80's Face Sheet, dated 08/26/25, reflected she was an [AGE] year-old female, who originally admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease with (acute) exacerbation (a sudden worsening of chronic obstructive pulmonary disease symptoms including shortness of breath), respiratory arrest (a serious medical condition caused by apnea or respiratory…

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, in accordance with State and Federal laws, ensure all drugs were stored in locked compartments under proper temperature controls, and permit only authorized personnel to have access to these drugs for 1 (Resident #73) of 5 residents reviewed for medication storage. The facility failed to ensure Resident #73 did not have unsecured multivitamins in his room. This failure could place residents at risk of not being monitored for their medications, adverse reactions, and drug diversion.Findings included: Record review of Resident #73's Face Sheet, dated 08/26/25, reflected he was an [AGE] year-old male, who was admitted to the facility on [DATE], with diagnoses including dementia (a group of symptoms affecting memory, thinking and social abilities), abnormalities of gait and mobility (deviations from a normal walking pattern, impacting how a person moves and their ability to maintain balance and coordination), and need for assistance with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 6 residents (Residents #79 and #2) reviewed for infection control. 1. RN B failed to complete hand hygiene while providing wound care and incontinent care to Resident #79. 2. CNA C failed to complete hand hygiene while providing incontinent care to Resident #2. This failure could place residents at risk for infections and cross contamination. Findings included: Review of Resident #79's face sheet dated 06/26/25 revealed he was a [AGE] year-old male, he was originally admitted on [DATE]. Admitting diagnoses included hypertensive heart disease with heart failure, Type 2 diabetes, muscle weakness, dementia, and abnormalities of gait and mobility. Review of Resident #79's care plan initiated on 04/11/25…

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 safe, clean, comfortable, and homelike environment for one (Resident #1) of six residents reviewed for decent living environment. 1. The facility failed to ensure Resident #1 had access to her bathroom. This failure could place residents at risk for diminished quality of life due to a lake of a well-kept environment. Findings included: Record review of Resident #1's face sheet, dated 07/18/25, reflected a [AGE] year-old female, with an initial admit date of 03/28/25, and a readmit date of 05/16/25. Resident #1 had diagnoses of Frontotemporal Neurocognitive Disorder (brain disease that leads to significant changes in behavior, language abilities, and personality), Dementia (Decline in memory, thinking, and social abilities), Muscle Weakness, Bipolar Disorder (Extreme Mood Swings), Depression (disorder causing feelings of sadness, anger, or loss), Manic Disorder (causes periods of extreme changes in mood or emotions and energy…

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 all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported no later than 2 hours if the events that caused the allegation did involve abuse or serious bodily injury to HHS, for 1 of 1 resident (Resident #1) reviewed for abuse, neglect, exploitation, or mistreatment. The facility failed to report to HHS within two hours, when a staff member reported CNA A spoke rudely and pushed Resident #1 down the memory care hallway on 07/05/25. This failure could place residents at risk of abuse or mistreatment. Findings included: Record review of Resident #1's face sheet, dated 07/18/25, reflected a [AGE] year-old female, with an initial admit date of 03/28/25, and a readmit date of 05/16/25. Resident #1 had diagnoses of Frontotemporal Neurocognitive Disorder (brain disease that leads to significant changes in behavior, language abilities, and personality), Dementia (Decline in memory, thinking, and social abilities), 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 observations, interviews and record review, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for three (Resident #1, Resident #2 and Resident #4) of seven residents reviewed for treatment/services for pressure ulcers. 1. The facility failed to ensure Resident #2, who had a pressure ulcer on his coccyx, had a low air loss mattress pump with the correct settings for appropriate pressure redistribution on 06/18/25. 2. The facility failed to ensure Resident #3 and Resident #4 had a functioning low air loss mattress available to use to promote healing of their sacral wounds on 06/18/25. 3. The facility failed to ensure Resident #3 wound dressing was changed daily as per orders. These failures placed residents at risk of developing new or worsening pressure ulcers. Findings included: 1. Record review of Resident #2's Face Sheet…

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 acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for two (Resident #2 and Resident #5) of seven residents reviewed for medications and pharmacy services. 1. The facility failed to administer Resident #2's blood pressure medication Carvedilol in accordance with physician orders, by not obtaining his blood pressure prior to administering the medication on nine occasions from 06/03/25 through 06/18/25. 2. The facility failed to administer Resident #5's blood pressure medication Midodrine in accordance with physician orders, by not obtaining his blood pressure prior to administering the medication on four occasions from 06/07/25 through 06/10/25. These failures could place residents at risk for not receiving therapeutic dosages of their medications as ordered by the physician and a potential for decreased…

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, in accordance with accepted professional standards and practices, the facility failed to maintain medical records on each resident that are complete; accurately documented; readily accessible; and systematically organized for three (Residents #2 , #3 and #7) of seven residents reviewed for resident records. 1. The facility failed to document if wound care was provided for Resident #2 in June 2025 on four occasions: 06/10/25, 06/14/25, 06/16/25 and 06/17/25. 2. The facility failed to document if wound care was provided for Resident #3 in June 2025 on three occasions: 06/10/25, 06/15/25 and 06/16/25. 3. The facility failed to document if wound care was provided for Resident #7 in May 2025 on four occasions: 05/05/25, 05/07/25, 05/21/25 and 05/26/25. These failures could place residents at risk of not receiving wound care, wounds worsening and a lack of oversight of their clinical records by the nursing staff and nursing management. Findings included: 1. Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living, received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 of 6 residents (Residents #1, #2, and #3) reviewed for ADL care. The facility failed to ensure Residents #1, #2, and #3 were provided their showers as scheduled for the month of May 2025. This failure could place residents at risk of not receiving services or care, decreased quality of life, and decreased self-esteem. Findings included: Record review of Resident #1's admission Record dated 5/28/25 reflected a [AGE] year-old female originally admitted to the facility on [DATE]. Record review of Resident #1's Quarterly MDS assessment dated [DATE] reflected she had a BIMS score of 15 indicating no impaired cognition. Her diagnoses included hypertension (high blood pressure); type 2 diabetes, stroke, amputation, and progressive neurological conditions. Review of 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 observations, interviews, and record reviews, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 (Resident #1) of 6 residents reviewed for quality of care. The facility failed to ensure Resident #1 received treatment immediately after she complained of having symptoms of a urinary tract infection. This failure could place residents at risk for a delay in treatment or diagnosis, a decline in the resident's condition, harm and/or the need for hospitalization and prolonged treatment. Findings included: Record review of Resident #1's admission Record dated 5/28/25 reflected a [AGE] year-old female originally admitted to the facility on [DATE]. Record review of Resident #1's Quarterly MDS assessment dated [DATE] reflected she had a BIMS score of 15 indicating no impaired cognition. Her diagnoses included hypertension (high blood pressure); type 2 diabetes,…

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 right to retain their personal clothing for one of one resident, (Resident #4) reviewed for resident's rights. The facility failed to allow Resident #4 to exercise the right to retain and use personal possessions, including clothing. This failure placed residents at risk of for anxiety, frustration, and decreased quality of life who retain their personal clothing in their room. The Findings: Record review of Resident #4's admission Record dated 5/28/25 reflected a [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #4's Quarterly MDS assessment dated [DATE] reflected she had a BIMS score of 2 indicating severely impaired cognition. Her diagnoses included unspecified dementia, and anxiety disorder. Record review of Resident #4's Care Plan Report reflected impaired cognitive function/dementia or impaired thought processes- Dementia. Record review of Resident #4's progress notes dated 2/11/25 at 18:54 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 interview, observation and record review, the facility failed to provide a safe, clean, comfortable, homelike environment for 1 (Resident #2) of 4 reviewed for resident rights. The facility failed to: - make sure there were no black/brown stains on the tiles in Resident #2's shower and bathroom. - remove a stain on the ceiling in Resident #2's shower. - secure 3 tiles in front of Resident #2's bathroom sink. - tighten a loose toilet seat in Resident #2's bathroom. - replace missing tiles next to the floor on the right side of the toilet in Resident #2's bathroom. - replace an outlet in Resident #2's room which had half a missing plug-in and failed to place a cover on an outlet which had a half missing plug-in. - fix scratches and areas of missing paint on the walls in Resident #2's bedroom. - replace/paint a vent in Resident #2's room which had the paint chipped revealing black metal underneath. - replace 3 out of 4 light bulbs for wall lamps in Resident #2's room. These failures could place residents…

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

Based on observations, interviews, 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 two (Resident #1 and Resident #2) of four residents, reviewed for infection control. 1. The facility failed to ensure CNA B changed gloves and performed hand hygiene during incontinence care for Resident #1. 2. The facility failed to ensure CNA C performed hand hygiene during incontinence care for Resident #2. These failures placed residents at risk for healthcare associated cross contamination and infections. Findings included: 1. Review of Resident #1's Quarterly MDS Assessment, dated 01/05/25, reflected the resident had a BIMs score of 15 and was cognitively intact. The Resident had diagnoses which included hip fracture and diarrhea. The resident was always incontinent of bowel and bladder. The resident required maximum assistance with toileting. 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 residents unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 (Residents #1, #2 and #3) of five residents reviewed for ADL assistance. The facility failed to provide Residents #1, #2 and #3 with consistent showers/bed bath and timely incontinent care. The failures could place the residents at risk of resident's needs, safety and psychosocial well-being not being met. Findings Include: Review of Resident #1's face sheet dated 02/04/25 reflected the resident was a [AGE] year old female and she was admitted on [DATE]. The resident was admitted with the following diagnoses, local infection of the skin and subcutaneous tissue, need for assistance with personal care, diarrhea, abnormalities of gait and mobility, hypothyroidism, morbid (severe) obesity due to excess calories, hyperlipidemia, hypertension, and muscle weakness. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review the facility failed the have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident and determined by considering the number, acuity, and diagnoses of the facility's resident population with accordance with 3 (Residents #1, #2, #3) of 5 residents reviewed for sufficient staffing. The facility failed to ensure the facility had sufficient staffing to meet the needs of Residents #1, #2, #3. This failure could place the residents at risk of resident's needs, safety and psychosocial well-being not being met. Findings Include: Review of Resident #1's face sheet dated 02/04/25 reflected the resident was [AGE] years old female and she was admitted on [DATE]. The resident was admitted with the following diagnoses, local infection of the skin and subcutaneous tissue, need for assistance with personal care, diarrhea,…

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 received services in the facility with reasonable accommodation of resident needs fo (Resident #3) reviewed for resident call system, in that. 1.Resident #3s call lights was on the floor and not within reach on 08/24/2024. This could place the residents at risk of not receiving the care and services to maintain their highest level of well-being. Findings included: Record review of Resident #3's electronic face sheet, printed on 08/26/24, revealed an [AGE] year-old male who was admitted to the facility initially 03/08/24 and readmitted on [DATE] with diagnoses that included but not limited to pressure ulcer of the sacral region, stage 4 and need for assistance with personal care. Record review of Resident #3's quarterly MDS, dated [DATE], revealed a BIMS score of 14, indicating the resident was cognitively intact. Record review of Resident #3 s care plan, dated 07/23/2024, reflected, the resident was a risk for falls and 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 protect the confidentiality of personal health care information for one of three (Resident #1) residents reviewed for confidentiality of records. The facility failed to ensure LVN A locked and closed the laptop during the medication pass exposing Resident #1's personal information to include some of his medications. This failure could affect residents by placing them at risk for loss of privacy and dignity. The Findings included: Review of Resident #1's electronic face sheet printed 08/26/2024 revealed a 87 year- old male admitted to the facility initially on 04/02/2024 and re admitted on [DATE] with diagnoses that included but not limited too acute combined systolic and diastolic heart failure(both types of left-sided heart failure that affect the heart's ability to pump blood), type 2 diabetes mellitus unspecified complication(chronic condition that causes high blood sugar levels due to a lack of insulin or insulin resistance and high…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide treatment and services to prevent complications of enteral feeding for one (Resident #1) of three residents reviewed for competent staff, in that: 1. CNA C was not competent in gastrostomy feeding tube nutrition and care. CNA C adjusted Resident #1's feeding pump without alerting a nurse that there was liquid leaking. This failure placed residents with feeding tubes at risk for complications to include aspiration, nausea, vomiting and/or diarrhea, residents who required two staff for bed mobility at risk for discomfort/injury and for residents not to receive needed nursing assessments. Findings included: Review of Resident #1's electronic face sheet printed 08/26/2024 revealed a 87 year- old male admitted to the facility initially on 04/02/2024 and re admitted on [DATE] with diagnoses that included but not limited to acute combined systolic and diastolic heart failure(both types of left-sided heart failure that affect the heart'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 maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 (Resident #1) of 4 residents reviewed for accuracy of medical records. The facility failed to ensure the physician visit were documented for the correct resident. Resident #1's file contained physician visit notes for the wrong resident. These failures could place residents at risk for medication and /or treatment errors and omissions in care. Findings included: Review of Resident #1's electronic face sheet printed 08/26/2024 revealed a 87 year- old male admitted to the facility initially on 04/02/2024 and re admitted on [DATE] with diagnoses that included but not limited to acute combined systolic and diastolic heart failure(both types of left-sided heart failure that affect the heart's ability to pump blood), type 2 diabetes mellitus unspecified complication(chronic condition that causes high blood sugar levels…

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 designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for one (Resident #1 ) of four residents reviewed for infection control. CNA C failed to use proper infection control prevention while tending to the G Tube for Resident #1 This failure could place residents at-risk of cross contamination which could result in infections or illness. Findings included: Review of Resident #1's electronic face sheet printed 08/26/2024 revealed a 87 year- old male admitted to the facility initially on 04/02/2024 and re admitted on [DATE] with diagnoses that included but not limited too acute combined systolic and diastolic heart failure(both types of left-sided heart failure that affect the heart's ability to pump blood), type 2 diabetes mellitus unspecified complication(chronic condition that causes…

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 adequately equipped to allow for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for one of three residents (Resident #3) reviewed for resident call system, in that. Resident# 3's call light was not working on 08/26/2024. These could place the residents at risk of not receiving the care and services to maintain their highest level of well-being. Findings included: Record review of Resident #3's electronic face sheet, printed on 08/26/24, revealed an [AGE] year-old male who was admitted to the facility initially 03/08/24 and readmitted on [DATE] with diagnoses that included but not limited to pressure ulcer of the sacral region, stage 4 and need for assistance with personal care. Record review of Resident #3's quarterly MDS, dated [DATE], revealed a BIMS score of 14, indicating the resident was cognitively intact. Record review of Resident #3 s care…

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' environment remained as free of accident hazards as was possible for 1 (Resident #17) of 11 residents reviewed accident hazards. The facility failed to ensure Resident #17's walker was repaired or replaced after it had been damaged during transport in February 2024. Resident #17 attempted to fix the walker himself utilizing zip ties, but the walker still malfunctioned and was described by Resident #17 as being scary to use. This failure could place residents at an increased risk of accidents, such as falls. Findings included: Review of Resident #17's Face Sheet, dated 07/11/24, reflected he was a [AGE] year-old male who admitted to the facility on [DATE]. Review of Resident #17's MDS Assessment, dated 04/09/24, reflected he was cognitively intact. He had diagnoses including cellulitis (a common and potentially serious bacterial skin infection), lymphedema (a chronic condition that causes swelling in the body due to 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 residents who are fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 1 resident (Resident #25) reviewed for gastrostomy tube management. The facility failed to ensure Resident #25 was provided with the correct water flushes before and after medication administration through a gastrostomy tube (g-tube, feeding tube). This failure could place residents who received medications by gastrostomy tube at risk for injury, aspiration into the lungs (fluid or food enter the lungs accidently), decreased quality of life, hospitalization and decline in health. The findings included: Record review of Resident #25's face sheet dated 7/11/24 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included type 2 diabetes (a chronic, long-lasting health condition that affects how your body turns food into energy), dysphagia oropharyngeal phase…

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 regimens were free from unnecessary drugs for two (Residents #25 and #45) of five residents whose records were reviewed for psychotropic drugs, in that: 1. Resident #25 had an order for the antipsychotic medication Risperdal 3mg, per the pharmacy recommendations the medication order was changed to 2mg but had not been implemented 2. Resident #45 had an order for the antipsychotic medication lorazepam as needed used longer than the 14 days. These failures placed residents at risk for being over medicated or experiencing undesirable side effects and could cause a physical or psychosocial decline in health status. The findings included: 1. Review of Resident #25's face sheet, dated 05/17/23, revealed she was a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included Parkinson's diseases, anxiety, muscle weakness, bipolar disorder, severe depression and disorders of 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 a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two (Residents #25, #30) of five residents reviewed for ADL's. 1. Resident #25 did not receive shower per her shower schedule. 2. Resident #30 did not receive shower per her shower schedule. This failure could place residents at risk of not receiving the care they require to maintain their highest practical well-being, and could result in low self-esteem, anxiety, embarrassment, and a decline in their quality of life. The findings were: 1. Record review of Resident #25's face sheet, dated 05/17/23, revealed the resident was admitted to the facility 08/19/22 with diagnoses including: Parkinson's disease, muscle wasting and atrophy, muscle weakness, lack of coordination and chronic pain syndrome. Record review of Resident #25's quarterly MDS assessment dated [DATE],…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents who are fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for (Resident #8) reviewed for gastrostomy tube management. The facility failed to check the Resident #8's residual before administering medications via gastrostomy tube (G-tube: A tube directly inserted through the skin to the stomach to deliver nutrition). This failure could place residents who receive enteral feedings by G-tube at risk for injury, aspiration into the lungs (fluid or food enter the lungs accidently), decreased quality of life, hospitalization and decline in health. Findings include: Record review of Resident #8's face sheet dated 05/17/23 revealed a 78- year-old-male originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included acute and chronic respiratory failure (inability of the lungs to perform their basic task of gas exchange, the transfer of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, administering, and securing of medications for one medication carts (700/500 hall nurses' medication cart) of two medication carts reviewed for pharmacy services in that: The 500/700 hall medication cart had expired medications. The failure could place residents at risk for not receiving therapeutic dosages of their medications as ordered by the physician and a potential for decreased health status. Findings included: 1. Review on 05/16/2023 at 10:00 AM of nurse medication cart (Hall 700/500) reflected Hydrocodone/Acetaminophen 5-325 mg medications strip packaging with expiration date of 03/07/2023, 22 tablets left in the medication strip packaging of 60 tablets. Review of Resident #7's face sheet, dated 05/17/2023, reflected he was a [AGE] year-old male admitted originally to the facility on [DATE], and readmitted on [DATE]. His diagnosis 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 observation, interview, and record review the facility failed to ensure that the medication error rate was not 5% or greater. The facility had a medication error rate of 6%, based on 3 errors of 48 opportunities, which involved two residents of 10 residents observed (Residents #9 and #27) and 1 of 2 staff observed during medication administration for medication errors. The facility failed to ensure the medications were administered per the physician orders for Residents #9 and #27. This failure could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. The findings include: 1. A record review of Resident #9's face sheet, dated 05/17/2023, revealed an admission date of 12/23/2022 with diagnoses which included gastro-esophageal disease, angina pectoris, hypertension, lower back pain, anemia, type 2 diabetes, seasonal allergic rhinitis. A record review of Resident #9's annual MDS assessment, dated 3/20/2023, revealed Resident #9 was an [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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for three (Resident # 29, Residents#150, and Resident #200) of four Residents observed for infection control. The facility failed to ensure: 1-.CNA A completed hand hygiene while performing incontinent care for (Resident#150). 2. RN B completed hand hygiene while performing wound care for (Resident#29). 3. RN B completed hand hygiene while performing wound care for (Resident#200). 4. RN B prepared a clean field for the dressing change supplies while performing wound care for (Resident#29) 5. RN B prepared a clean field for the dressing change supplies while performing wound care for (Resident #200). These failures could place the residents at risk for infection. Findings include: 1. Review of Resident #150's face sheet, dated 05/17/2023, reflected she was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnosis…

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.