The Park in Plano

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on , interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to attain or maintain the resident's highest practicable mental nad psychosocial well-being for 1 of 5 residents (Resident #53) reviewed for care plans. The facility failed to ensure Resident #53 was care planned for the weekly psychological services being received based on physician orders dated 11/24/2024. This failure could place residents at risk of not receiving the necessary care and services needed. Findings include: Record review of Resident #53's face sheet, dated 01/28/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #53 was diagnosed with Post Traumatic Stress Disorder (stressful event). Record review of Resident #53's Quarterly MDS Assessment, dated 11/20/2024, reflected the resident had a severe cognitive impairment in cognition…

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 incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible for one of three residents (Resident #5) reviewed for Incontinent Care. The facility failed to ensure CNA D used proper technique to clean Resident 5's perineal area (area between the legs) on 01/29/2025. This failure could place residents at risk of cross-contamination and development of urinary tract infections. Findings include: Record review of Resident #5's face sheet, dated 01/30/2025, reflected an [AGE] year-old female who was admitted on the facility on 06/03/2024. Resident #5 had a diagnosis which included generalized muscle weakness. Record review of Resident #5's Comprehensive MDS Assessment, dated 12/24/2024, reflected the resident had a moderate impairment in cognition with a BIMS score of 11. The Comprehensive MDS Assessment indicated Resident #5 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for one (Resident #52) of two residents reviewed for feeding tube (a way of providing nutrition directly to the stomach). The facility failed to ensure LVN A cleaned the syringe and flushed the g-tube during Resident #52's medication administration through gastrostomy tube (G-tube: a tube inserted through the abdomen that delivers nutrition directly to the stomach) on 01/28/2025. These failures could place residents with G-tubes were at risk for infection, dehydration, and drug-to-drug interaction. Findings included: Record review of Resident #52's Face Sheet dated 01/28/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with dysphagia (difficulty in swallowing). Record review of Resident #52's Comprehensive MDS Assessment, dated 12/13/2024, reflected the resident had a severe impairment in cognition 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 ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #18) of twelve residents reviewed for Respiratory Care. The facility failed to ensure Resident #18's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) was properly stored when not in use on 01/28/2025. This failure could place residents at risk for respiratory infection and not having their respiratory needs met. Findings included: Record review of Resident #18's Face Sheet, dated 01/28/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #18 was diagnosed with coronary heart disease (the blood vessels supplying blood to the heart get blocked). Record review of Resident #18's Comprehensive MDS Assessment, dated 12/04/2024, reflected 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 review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for two (Resident #1 and Resident #20) of eight residents reviewed for Care Plans. 1. The facility failed to ensure Resident #1 was care planned for oxygen administration. 2. The facility failed to ensure Resident #20 was care planned for oxygen therapy (oxygen delivered through a flexible tube to the nose through two prongs) and droplet precautions (prevent infection with germs that can be spread by speaking, sneezing, or coughing). These failures could place the residents at risk of not receiving the necessary care and services. Findings included: 1. Record review of Resident #1's Face Sheet, dated 12/18/2024, reflected…

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 the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for two (Resident #1 and Resident #5) of twenty residents reviewed for Reasonable Accommodation of Needs. The facility failed to ensure the call light was in reach and accessible for Resident #1 and Resident #5 on 11/05/2024. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency. Findings included: Review of Resident #1's Face Sheet, dated 11/05/2024, reflected the resident was a [AGE] year-old male admitted on [DATE]. Resident #1's pertinent diagnoses included metabolic encephalopathy (changes in how the brain works due to underlying conditions) and history of falls. Review of Resident #1's Quarterly MDS Assessment, dated 09/02/2024, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The 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 interviews and record reviews the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 (Residents #4) of 4 residents reviewed for (ADLs) care provided to dependent residents. The facility failed to ensure Resident #4 received scheduled bed baths reviewed from October 1, 2024 - October 31, 2024. This failure placed the resident at risk of not receiving necessary services to maintain good personal hygiene, skin breakdown, and decreased self- esteem. Findings included: Record review of Resident #4's Face Sheet, dated 11/06/2024, revealed she was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses included muscle weakness, history of falling, and unsteadiness on feet. Record review of Resident #4's Quarterly Minimum Data Set (MDS) dated [DATE] revealed, she had a Brief Interview for Mental Status (BIMS) score of 12 (moderate impairment) and for ADL…

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 reviews, the facility failed to ensure that residents' environment remained free of accident hazards as was possible for 1 ( unknown Resident) of 68 residents at the facility reviewed for accident prevention . The facility failed to secure a coffee station on 11/06/24 that allowed for residents to self-serve coffee, which could result in skin burns. This failure could prevent residents from having an environment that was free and clear of accidents and hazards. Findings included: In an observation on 11/06/24 at 8:25 AM, an unknown resident was observed walking to a cart in front of the nurse's station, which contained hot coffee, and poured herself a cup of coffee (no lid) and walked away. The coffee at the station was poured into a cup for a temperature check using the index finger and withdrawn within seconds because of the heat. The coffee was not Lukewarm. In an interview and observation on 11/06/24 at 8:27 AM, Staffing Coordinator/CNA R stated the cart with the hot coffee had been placed there for resident to self-serve since 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 observations, interviews, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two (Resident #2 and Resident #6) of twelve residents reviewed for Respiratory Care. 1. The facility failed to ensure that Resident #2's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) was properly stored on 11/05/2024. 2. The facility failed to ensure that Resident #6's oxygen concentrator (machine that produces oxygen) had a humidification bottle (adds moisture to reduce nasal irritation) connected to it on 11/05/2024. These failures could place the residents at risk for respiratory infection and not having their respiratory needs met. Findings included: 1. Review of Resident #2's Face Sheet, dated 11/05/2024, reflected the resident was a [AGE] year-old female admitted on [DATE].…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure that one (Resident #3) of five residents were provided medications and/or biologicals and pharmaceutical services to meet their needs. The facility failed to ensure LVN A did not leave Resident #3's medications inside the resident's room on 11/05/2024. This failure could place the residents at risk of not receiving medications as ordered by the physician. Findings included: Review of Resident #3's Face Sheet, dated 11/05/2024, reflected the resident was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included type 2 diabetes mellitus and pain to right and left arm. Review of Resident #3's Quarterly MDS Assessment, dated 09/19/2024, reflected resident was cognitively intact with a BIMS score of 15. The Quarterly MDS Assessment also indicated Resident #3 had type 2 diabetes mellitus (high blood sugar) and pain to right and left arm. Review of Resident #3's Comprehensive Care Plan, dated 10/30/2024, reflected 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 observations, interviews, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #4) of eight residents reviewed for Infection Control. The facility failed to ensure that CNA D changed her gloves and performed hand hygiene while providing incontinent care to Resident #4 on 11/06/2024. This failure could place the residents at risk of cross-contamination and development of infections. Findings included: Review of Resident #4's Face Sheet, dated 11/06/2024, reflected the resident was a [AGE] year-old female admitted on [DATE]. Resident #4 was diagnosed with need for assistance with personal care. Review of Resident #4's Comprehensive MDS Assessment, dated 08/29/2024, reflected the resident had a severe impairment in cognition with a BIMS score of 03. Resident #4's Quarterly MDS Assessment…

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 from significant medication errors for one (Resident #1) of three residents reviewed for medication errors in that: The facility failed to administer Resident #1's blood pressure medications as ordered by the physician. This failure could place residents at risk of medical complications and a decrease in therapeutic dosages of their medications as ordered by the physician. Findings included: Review of Resident #1's electronic face sheet dated printed 08/21/2024 revealed a 90 year- old female initially admitted to the facility on [DATE] and re- admitted [DATE] with diagnosis that included but not limited to metabolic encephalopathy(a group of neurological disorders that cause brain dysfunction due to chemical imbalances in the blood), Venous insufficiency(a condition that occurs when veins in the legs have trouble pumping blood back to the heart), hypertension( high blood pressure) Review of Resident's care plan last reviewed…

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 treat residents with respect and dignity for 1 of five (Resident #2) residents reviewed for dignity in that: The facility failed to ensure staff did not stand over Resident #2 while assisting the resident with her meal in the dining area on 08/21/2024 This failure could affect residents who require assistance with activities of daily living and placed them at risk for psychosocial harm due to a diminished quality of life. The findings were: Review of Resident #2's electronic face sheet printed 08/22/24 reflected a [AGE] year-old-female admitted on [DATE] with diagnoses including but not limited to senile degeneration of brain (cognitive decline in older people, particularly memory loss), dysphagia oropharyngeal phase (difficulty swallowing), and unspecified lack of coordination. Review of Resident #2's Quarterly MDS assessment, dated 06/09/2024 reflected the BIMS score was not completed. Review Resident #2's MDS section GG functional…

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 interviews and record reviews, the facility failed to maintain the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, for 21 days of the 4-month review period, reviewed for RN coverage. The facility failed to ensure the facility maintained the services of a registered nurse for at least 8 consecutive hours a day on Saturdays and Sundays for 21 days of the four months (July 20023 - December 2023) reviewed. This failure placed residents at risk of receiving higher levels of patient care. Findings included: Review of the facility provided time sheets for Registered Nurses (RN) for the review period from July 2023 to December 2023, the facility failed to have the required RN coverage of at least 8 consecutive hours a day, for the following dates: 07/16/23 - (6.2 hours recorded) 07/22/23 - (2 hours recorded) 09/09/23 - (2 hours recorded) 09/30/23 - (2 hours recorded) 11/19/23 - (6.3 hours recorded) 11/25/23 - (2 hours recorded) 11/26/23 - (2 hours recorded) 12/03/23 - (0 hours recorded) 12/10/23 - (0 hours recorded) Interview on 12/14/23 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 ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for two (Resident #70 and Resident #46) of eight residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Residents #70 and #46's rooms was in a position that was accessible to the residents. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency. Findings included: Review of Resident #70's Face Sheet dated 12/12/2023 reflected resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included muscle weakness, lack of coordination, and cognitive communication deficit. Review of Resident #70's Quarterly MDS assessment dated [DATE] reflected Resident #70 had a severe cognitive impairment with a BIMS score of 00. Resident #70 required extensive assistance for bed…

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 provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for areas in the facility for 8 (Resident #'s 2, 10, 12, 31, 36, 38, 50, and 51's) of 27 resident rooms observed for a safe, clean, comfortable, and homelike environment. The facility failed to ensure that Resident #'s 2, 10, 12, 31, 36, 38, 50, and 51's rooms were cleaned, sanitized, and maintained, based on observations made on 12/12/23. This deficient practice could place residents at risk of infections and living in an uncomfortable environment leading to a decreased quality of life. Findings included: Observation of Residents #12 and #38's room on 12/12/23 at 11:22 AM revealed the wall alongside Resident's bed had light brownish stains going down the wall and there was a large circular scrap on the wall near the foot board. Both bed side tables in the room had dried-up brown stains and food crumbs in the drawer of the bed side tables. Observation of Residents…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to ensure the resident was free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for 4 of 8 (Resident #2, #26, #35 and #43) residents reviewed for restraints. The facility failed to ensure Residents #2, #26, #35 and #43 had physician orders as of 12/12/2023 for the bolster side rails on their mattress . These failures could unnecessarily inhibit the residents' freedom of movement or activity. Findings included: 1. Record review of Resident #43's MDS assessment, dated 08/25/23, reflected she was an [AGE] year-old female who admitted to the facility on [DATE]. Her cognitive status was moderately impaired. Her diagnoses included stroke and seizure disorder. Record review of Resident #43's December 2023 Physician Orders reflected there were no orders for the bolster side rails ( a barrier attached to the side of a bed used to limit the ability to get out 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 interviews and record reviews, the facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, which included both the comprehensive and quarterly review assessments for 3 of 6 residents (Resident #2, #38, and #59) reviewed for Care Plans. The facility failed to ensure Resident #2, #38, and #59's Care Plan was reviewed and updated quarterly, based on record reviews made on 12/13/23. This failure could place residents at risk of their needs not being met. Findings included: Record review of Resident #2's face sheet, dated 12/13/23, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included schizoaffective disorder (mood disorder), Diabetes (low insulin), and Stage 3 chronic kidney disease. Record review of Resident #2's Minimum Data Set (MDS) assessment, dated 11/25/23, revealed she had a BIM score of 00 (severe cognitive impairment), and required a two -person physical assist for all…

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 ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's only kitchen reviewed for kitchen sanitation. The facility failed to ensure foods in the facility's dry storage area, refrigerators, and freezer were labeled and dated according to guidelines and in a sanitary manner in the facility's only kitchen. The facility failed to ensure the kitchen was clean and sanitized. These failures could place residents at risk for cross contamination and other air-borne illnesses. Findings included: Observations on 12/12/23 from 09:10 AM to 09:20 AM in the facility's only kitchen revealed: The Ice Machine had dark black dirt stains along the inside door of the machine and along the inside walls of the machine. The lid of the ice machine hinges had rust and brownish dirt [NAME] in the springs of the door hinges. Just about the ice was a white panel that had black…

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 observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #43 and Resident #55 ([NAME]) of 8 residents reviewed for infection control. 1. The facility failed to ensure the ADON performed hand hygiene while providing incontinence care to Resident #43. 2. The facility failed to ensure the WCN performed hand hygiene while providing wound care to Resident #55. This failure could place residents at risk of cross-contamination resulting in infections. Findings included: 1. Record review of Resident #43's MDS assessment, dated 08/25/23, reflected she was an [AGE] year-old female who admitted to the facility on [DATE]. Her cognitive status was moderately impaired. Her diagnoses included stroke and seizure disorder. Resident #43 required extensive assistance of two staff for…

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 treat each resident with respect and dignity for 1 of 8 residents (Resident #42) reviewed for resident rights. 1. The facility failed to ensure CNA A provided privacy to Resident #42 while transporting her to the shower room. This failure placed the residents at risk of not having their privacy respected. The findings included: 1. Record review of Resident #42's MDS assessment, dated 09/25/23, revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her cognitive status was moderately impaired, and her diagnoses included Alzheimer's disease. The resident was totally dependent on one staff for bathing. An observation and interview on 12/12/23 at 9:10 AM revealed Resident #42 was seated in a shower chair. CNA A pushed Resident #42 into the hallway from her room. Resident #42 had a sheet on her lap. The sheet did not cover the back of the resident. Part of the resident's buttocks and upper backs of her thighs were…

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 carryout activities of daily living received services to maintain grooming and personal hygiene for 1 of 8 residents (Resident #43) reviewed for quality of life. The facility failed to ensure CNA B provided Resident #43 with timely incontinent care. These failures could place residents at risk for a decreased quality of life and pressure ulcers. Findings included: 1. Record review of Resident #43's MDS assessment, dated 08/25/23, reflected she was an [AGE] year-old female who admitted to the facility on [DATE]. Her cognitive status was moderately impaired. Her diagnoses included stroke and seizure disorder. Resident #43 required extensive assistance of two staff for toileting. Record review of Resident #43's Care Plan, dated 06/29/21, reflected: The resident had urinary incontinence and the facility intervention clean peri-area with each incontinent episode. The resident had bowel incontinence 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 provide appropriate treatment and services to prevent complications of enteral feeding for one (Resident #45) of three residents reviewed for feeding tube. The facility failed to ensure LVN H would cap the tip of Resident #45's gastrostomy tube (G-tube-a tube inserted through the abdomen that delivers nutrition directly to the stomach) when not in use. This failure could place residents with G-tubes at risk of infection. Findings included: Review of Resident #45's Face Sheet dated 12/12/23 reflected Resident #45 was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included oropharyngeal phase dysphagia (difficulty in swallowing), dysphagia following cerebral infarction (insufficient oxygen in the brain causing stroke), and hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction. Review of Resident #45's Quarterly MDS Assessment reflected resident had 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, interviews, and record review, the facility failed to ensure that 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 one (Resident #67) of two residents reviewed for respiratory care. The facility failed to ensure Resident #67's oxygen concentrator had a humidifier. Findings included: Review of Resident #67's Face Sheet dated 12/12/2023 reflected resident was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses included unspecified chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and shortness of breath. Review of Resident #67's Quarterly MDS assessment dated [DATE] reflected Resident #67 had a moderately intact cognition with a BIMS score of 10. Resident #67's required limited assistance for bed mobility, transfer, and dressing. Review of Resident #67'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 that a resident who needs respiratory care was provided with such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 3 residents (Resident #1) reviewed for respiratory care. The facility failed to ensure Resident #1 had oxygen concentrator filters free of sediment and debris. This failure could place residents at risk of not receiving proper delivery of oxygen, cross contamination, respiratory compromise and/or infection and residents not having their respiratory needs met. Findings Included: Review of Resident #1's face sheet on 10/19/2023 revealed she was an [AGE] year-old female re-admitted to the facility on [DATE]. Relevant diagnoses included stroke, difficulty swallowing and speaking, muscle wasting, asthma, and dementia. Review of Resident #1's annual MDS assessment dated [DATE] revealed her cognition was severely impaired…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide an environment that was free from accident hazards over which the facility has control and failed to provide supervision and assistive devices to each resident to prevent avoidable accidents for 1 of 1 resident (Resident #1) reviewed for accidents free of hazards. The facility failed to ensure Resident #1 did not elope from the facility on 07/17/2023. The deficient practice was identified as past noncompliance (PNC). The facility provided sufficient evidence that all alleged violations were investigated, corrected, further elopements prevented, and was in substantial compliance after the exit date of the last standard recertification and before the abbreviated survey began. This failure placed residents at risk of accidents and hazards once outside of the facility borders. Findings included: Record review of Resident #1's Face Sheet, dated 08/30/23, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Relevant…

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.