Port Arthur Nursing and Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received an accurate assessment, reflective of the resident's status for 1 of 23 residents reviewed for accuracy of assessments. (Resident #s 14) The facility did not accurately complete the MDS assessment to indicate Resident #14 did not have a restraint/ side rail. This failure could place the residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being. Findings included: Record review of a face sheet dated 06/23/25 indicated Resident #14 was a [AGE] year-old female readmitted on [DATE]. Her diagnoses included dementia (group of thinking and social symptoms that interfere with daily function) and bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Record review of the most recent quarterly MDS assessment dated [DATE] indicated Resident #14 was severely impaired of cognition and needed supervision for sit…

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 accurately submit a PL1 (PASRR Level 1 Screening) screening when a resident admitted with a diagnosis of Mental Illness, Intellectual Disability or Developmental Disability for 1 of 5 residents reviewed for PASRR screenings. (Resident # 29) The facility failed to submit a new PL1 screening when Resident #29 was readmitted from mental health hospital on [DATE] . This failure could place residents at risk of not receiving specialized services. Findings included: Record review of Resident #29's face sheet dated 06/25/25 was a [AGE] year-old-female admitted on [DATE] and readmitted on [DATE] . She had diagnoses of convulsions (uncontrolled jerking, loss of consciousness and other symptoms caused by abnormal electrical activity in the brain), and stroke. Record review of Resident #29's annual MDS dated [DATE] indicated she was not PASRR positive and had a BIMS score of 00 indicated severely impaired with cognition. The assessment indicated she had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 of 1 resident reviewed for tracheostomy care. (Resident #317) LVN A did not change Resident #317's outer tracheostomy cannula on 05/11/25 as listed on the May 2025 MAR. This failure could place residents with a tracheostomy at risk for infections to the tracheostomy site. Findings included: Record review of a face sheet dated indicated Resident #317 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included injuries of the head, quadriplegia (a loss of motor function in all four limbs), and tracheostomy status (an opening in the neck in order to place a tube into a person's windpipe so they can breath). Record review of physician orders for May 2025 indicated Resident #317 had an…

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 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 one (Resident #117) of seven residents and one of five medication carts(Hall 400 cart) reviewed for pharmacy services. The facility failed to ensure all of Resident #117's medications was administered as ordered by the physician resulting in the incorrect dose of Vitamin C administration. The facility failed to ensure three insulin pens of aspart insulin were removed from use. Aspart insulin (rapid acting insulin used to lower blood sugar), with open date of 04/25/25, had been expired for 31 days, open date of 05/19/25, had been expired for 9 days, and open date of 05/23/25, had been expired for 5 days. This failure could place residents at risk of not receiving medications as ordered by their physicians and exacerbations of their medical conditions.…

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 each resident's drug regimen was free of unnecessary medication for 1 of 23 residents reviewed for unnecessary medication. (Resident #22) The facility failed to hold two of Resident #22's blood pressure medications when the blood pressure and/or heart rate was outside the prescribed parameters. This failure could place the residents at risk for adverse consequences and decline in health. Findings included: Record review of Resident #22's face sheet reflected a [AGE] year-old female admitted on [DATE] with diagnosis of hypertension (high blood pressure). Record review of Resident #22's quarterly MDS assessment, dated 03/21/25, indicated a BIMS score of 13 indicating Resident #22 was cognitively intact. Hypertension was included as one of Resident #22's diagnoses. Record review of Resident #22's care plan dated 03/06/2025 indicated a diagnosis of hypertension. Interventions included Give anti-hypertensive medications as ordered. Record 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 interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported, immediately but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or bodily injury, to the administrator of the facility and to other officials, including the State Survey Agency in accordance with State law through established procedures for 1 of 10 residents (Resident #4) reviewed for reporting allegations of abuse. The admission Coordinator failed to ensure allegations of abuse were reported to the Abuse Coordinator immediately. Resident #4 reported allegations to the admission Coordinator on 05/26/25 that an un-named CNA was verbally aggressive, physically aggressive and he feared for his safety. This failure could place residents at risk of abuse, neglect, and exploitation. Findings included: 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 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 to help prevent the development and transmission of communicable diseases and infections for 2 out of 3 (Resident #2 and Resident #3) residents reviewed for enhanced barrier precautions (EBP) and the wound care process for infection control practices. LVN B failed to follow enhanced barrier precautions while providing wound care for Resident #3. The facility failed to ensure LVN C followed appropriate infection control during wound care treatment for Resident #2. The failures could place residents at risk for cross contamination and the spread of infection. The findings included: Record review of Resident #3's admission Record, dated 06/04/25, indicated she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including migraine, essential hypertension, and local infection of the skin. 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 interview and record review, the facility failed to investigate and report the findings of the investigation to the State Survey Agency within 5 working days of the incident for 2 of 7 residents (Residents #6 and #7) reviewed for abuse. The facility failed to investigate and submit the results of their investigation within 5 days after Resident #6 slapped Resident #7 on 05/20/24. These failures could place residents at risk of abuse, physical harm, mental anguish and emotional distress. Findings included: 1. Record review of Resident #6's face sheet dated 02/20/25 indicated she was a [AGE] year old female admitted on [DATE] and her diagnoses included cerebral infarction (stroke), hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided muscle weakness) affecting right dominant side, aphasia (a language disorder that prevents effective communication), anxiety (fear, dread and other symptoms that are out of proportion to the situation), and schizoaffective disorder (mental health…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to consult with the resident's physician when there was a need to alter treatment for 2 of 24 residents (Residents #68 and #71) reviewed for notification of changes. The facility failed to ensure the physician was notified of a change in condition when Resident #68's blood pressure was SBP>160, and DBP>90. (Systolic blood pressure refers to the amount of pressure experienced by the arteries while the heart is beating. Diastolic blood pressure refers to the amount of pressure in the arteries while the heart is resting in between heartbeats) The facility failed to ensure the physician was consulted regarding holding Resident #71's medication when vital signs were outside the prescribed parameters. This failure could place residents at risk of not receiving appropriate medical treatments, which could result in severe illness or hospitalization. Findings included: 1. Record review of face sheet dated 05/15/24 indicated Resident #68 was a [AGE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the rights of residents to be free from abuse or neglect for 2 of 18 residents reviewed for abuse or neglect. (Residents #s 16 and 28) The facility failed to ensure Resident #16 was free from verbal abuse by a staff member. The facility failed to ensure Resident #28 was free from physical abuse when his roommate grabbed his arm causing redness. The failure could place residents at risk for abuse/neglect, humiliation, intimidation, fear, shame, agitation, and decreased quality of life. Findings included: 1. Record review of a face sheet dated 05/13/24 indicated Resident #16 was a [AGE] year-old female, admitted [DATE]. Her diagnosis included schizoaffective disorder. (A mental health disorder that is marked by a combination of schizophrenia symptoms such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania) Review of a quarterly MDS assessment dated [DATE] indicated Resident #16 had a BIMS of 15…

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 their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 3 of 18 residents (Resident #s 16, 28 and 72) reviewed for abuse. The facility failed to ensure Resident #16 was free from verbal abuse from CNA A. The facility failed to ensure Resident #28 was free from physical agression. The facility failed to ensure Resident #72 was free from physical aggression from Resident #72 who grabbed his arm while standing over him resulting in redness to his forearm. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: Record review of the Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated April 2021 indicated Policy Statement Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes freedom from…

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 of residents were reported immediately to the administrator and to HHSC within the 2-hour period for 3 of 18 residents (Resident #16, #28, and #72) reviewed for abuse. The facility failed to ensure allegations of resident-to-resident altercations and resident and staff altercations were reported immediately to the administrator and to the State Agency no later than 2 hours after the incident occurred or was suspected. The facility failed to report an allegation of verbal abuse to the administrator and to the State Agency within 2 hours when Resident #16 was involved in verbal altercation with CNA. The facility failed to report an allegation of physical abuse within 2 hours to the State Agency when Resident #72 grabbed Resident #28. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: 1. Record review of a face sheet 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, interview, and record review, the facility failed to ensure assessments accurately reflected the status for 2 of 18 residents reviewed for assessments. (Residents #21 and #40). The facility failed to complete an accurate resident assessment for Resident #21. Resident #21's resident assessment did not indicate she received special treatments, procedures, and programs of tracheostomy care. The facility failed to complete an accurate resident assessment for Resident #40. Resident #40's resident assessment did not indicate he received special treatments, procedures, and programs of dialysis. This failure could place residents at risk of not having individual needs met and a decreased quality of life. Findings included: 1. Record review of a face sheet dated 05/14/24 indicated Resident #21 was a [AGE] year-old female readmitted on [DATE]. Her diagnoses included quadriplegia (a symptom of paralysis that affects all a person's limb and body from the neck down) and tracheotomy status (has a hole in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain grooming, and personal and oral hygiene for 1 of 18 residents reviewed for ADLs. (Resident #20) The facility failed to ensure Resident #20's fingernails were trimmed. The resident had contractures to the left upper fingers and thumb. This failure could place the residents at risk of not receiving the care and services to maintain their highest level of physical, mental and psycho-social well-being. Findings included: Record review of physician orders dated May 2024 indicated Resident #20, admitted [DATE], was [AGE] years old with diagnoses of hemiplegia/hemiparesis (a condition that causes paralysis or weakness on one side of the body) and a stroke. Record review of the most recent quarterly MDS dated [DATE] indicated Resident #20 had a BIMs of 5 (severe cognitive impairment), had a decrease in ROM to one side of his upper…

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 with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 18 residents reviewed for range of motion. (Resident #20) The facility did not ensure Resident #20 had a splint to the left contracted hand as ordered. This failure could place the residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being. Findings included: Record review of physician orders dated May 2024 indicated Resident #20, admitted [DATE], was [AGE] years old with diagnoses of hemiplegia/hemiparesis (a condition that causes paralysis or weakness on one side of the body) and stroke. The orders indicated the resident was to receive a resting hand splint for left and wrist to treat and correct contracture dated 03/12/24. The orders indicated the resident was ordered physical therapy on 9/8/23 and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 of 18 residents reviewed for oxygen administration. (Resident #15) The facility failed to administer Resident #15's oxygen at 2 liters as ordered. This failure 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 physician orders dated May 2024 indicated Resident #15, readmitted [DATE], was [AGE] years old with diagnoses of atrial fibrillation (an irregular, often rapid heartbeat that commonly caused poor blood flow), morbid obesity and tobacco use. The order indicated the resident received oxygen at 2 liters nasal cannula continuously for shortness of breath active 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 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 to ensure the accurate administration of medications for 1 of 18 residents reviewed for medication administration. (Resident #40) The facility did not document blood pressure (BP) or heart rate (HR) for Resident #40 on the MAR, before administering medications with orders that included instructions to hold for prescribed parameters. This failure could place residents with prescribed medication parameters at risk of not receiving the desired therapeutic effects of their medications. Findings included: Record review of a face sheet dated 05/13/24 indicated Resident #40 was a [AGE] year-old male readmitted on [DATE] with diagnosis including hypertension (high blood pressure). Record review of an, Employee In-Service Record,dated 03/04/24 indicated The DON…

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 each resident's drug regimen was free from unnecessary drugs for 1 of 18 residents reviewed. (Resident #71) The facility did not hold Resident #71 metoprolol tartrate when the resident's heart rate was outside parameters set by the physician. This failure could place the residents at risk of adverse side effects from medications. Findings included: Record review of physician orders dated May 2024 indicated Resident #71, admitted [DATE], was a [AGE] year-old female with diagnosis including essential hypertension (high blood pressure). Resident #71 was prescribed Metoprolol Tartrate - give 12.5 mg by mouth twice daily for hypertension, hold for SBP below 100 or DBP below 60 or pulse below 60. Record review of the quarterly MDS assessment dated [DATE] indicated Resident #71 had a BIMS score of 15 which indicated cognition was intact. She had a diagnosis of hypertension and heart failure. Review of Resident #71's care plan revised on 04/24/24…

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 clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 4 of 12 residents (Resident #1, Resident #4, Resident #5, and Resident #6) reviewed for accuracy of medical records. The facility failed to document weekly wound assessment to Resident #1's inner left ankle trauma wound the week of 01/30/2024. The facility failed to document ordered wound care to Resident'#1's inner left ankle trauma wound on 01/25/2024, 02/02/2024, 02/08/2024, 03/29/2024 and 03/30/2024. The facility failed to document Resident #4, and Resident #5 wounds were assessed weekly, and care was performed as ordered. The facility failed to document weekly skin assessments to Resident #1, Resident #5, and Resident #6. This deficient practice could place residents at risk of having incomplete or inaccurate records and inadequate care. Findings included: 1. Record review of Resident #1's face…

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 behavioral health services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #2) reviewed for behavioral health services. The facility failed to ensure Resident #2 received behavioral health services after returning to facility following an inpatient stay at behavioral health hospital for a resident-to-resident altercation with behavioral symptoms occurred. This failure could place residents at risk for not receiving behavioral health services and a decline in Quality of life. Findings Included: 1. Record review of Resident #2's face sheet dated 04/14/2024 indicated he was [AGE] years old, initially admitted on [DATE] and readmitted [DATE] after an admission to behavioral hospital following a resident-to-resident altercation. Resident #2 with newly onset (02/22/2024) diagnoses including Major Depressive Disorder (mental illness that negatively affects how you…

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 safe, clean, and comfortable homelike environment for 12 of 12 resident rooms (Room #s 302, 304, 306, 307, 311, 401, 403, 406, 502, 503, 505, and 510) reviewed for physical environment. The facility failed to ensure the air conditioning units were clean in 12 residents' rooms. There was unknown black substance coating the vents. This failure could place the residents at risk for decreased quality of life and infection due to unsanitary conditions. Findings included: Observations on 10/26/23 from 2:00 p.m. through 5:00 p.m., 10/27/23 from 9:00 a.m. through 4:30 p.m., 10/30/23 8:15 a.m. through 4:30 a.m., 10/31/23 from 8:15 a.m. through 2:00 p.m., and 11/01/23 from 9:00 a.m. through 4:00 p.m. indicated there were 12 rooms (Room #s 302, 304, 306, 307, 311, 401, 403, 406, 502, 503, 505, and 510) with air conditioning units with an unknown black substance coating the vents. During an interview on 10/31/23 at 10:48 a.m. HSK Y said she did not know why the vents were not properly cleaned and would have…

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 all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials (which included to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 11 of 27 residents (Resident #s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11) reviewed for abuse in that: 1. The facility failed to report to the state on 6/12/23, after LVN A was hit by Resident #5, LVN A assaulted Resident #5. She pushed Resident #5 hard against a wall, elbowed her in the face, and scratched her face. LVN A continued to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure the medical record of each resident was accurately documented in accordance with accepted professional standards and practices for 1 of 27 residents (Resident #12) reviewed for medical records. The facility failed to ensure Resident #12's fall on 10/09/23 was documented. This failure could place residents at risk for delayed care and appropriate interventions. Findings included: Record review of Resident #12's face sheet dated 11/06/23 indicated he was an [AGE] year old male, admitted on [DATE], and his diagnoses included Alzheimer's (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), lack of coordination (uncoordinated movement is due to a muscle control problem that causes an inability to coordinate movements), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and anxiety (a feeling of fear,…

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 prompt efforts were made to resolve resident grievances for 1 of 11 residents (Resident #1) reviewed for grievances. The facility did not immediately address concerns related to Resident #1's nutritional needs, feeding pump, possible weight loss, or room cleanliness. The facility did not address grievances from resident council meetings. This failure could place all residents at risk of unresolved grievances and decreased quality of life. Findings included: Record review of a face sheet dated 09/20/23 indicated Resident #1 was a [AGE] year old female admitted on [DATE] with the diagnoses head injury, aphasia (loss of ability to understand or express speech caused by brain damage), diabetes (a disease that occurs when blood glucose, also called blood sugar, is too high), pain, anemia (a low number of red blood cells), tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside…

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

Based on observation, interview, and record review, the facility failed to ensure the environment remained free of accident hazards for 1 of 1 unsecured chemical storage reviewed for environment. The facility failed to ensure chemicals were in a secured location. This failure could place residents, staff and visitors at risk of living, working or being in an unsafe environment. Findings included: During an observation on 09/20/23 at 11:28 a.m., the housekeeping storage room door adjacent to the common TV area was left open and unlocked. There were residents watching TV and passing by the storage room on their way to other areas of the facility. Observation on 09/20/23 at 11:28 a.m. of the storage room contents indicated the following cleaning and chemical products: Glass cleaner, Disinfectant #1, Disinfectant #2 (concentrate), Non-acid bowl and bathroom disinfectant cleaner, and Drain Fly-Odor-Waste Control. Record review of the glass cleaner safety sheet dated 01/24/23 indicated it may be harmful if swallowed, may cause skin irritation, inhalation of vapors or mist may cause…

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 and implement written policy to prhibit and prevent abuse, neglect,and exploitation of resident and misappropriation of resident property for 1 of 19 residents (Resident #87) reviewed for abuse. The facility failed to implement facility's written abuse policy to ensure the Housekeeping Supervisor did not verbally abuse Resident #87. This failure could place residents at risk for psychosocial harm and a diminished quality of life. Findings included: Record review of the facility policy titled Abuse -Prohibiting Policy, revised 11/2015, indicated The Administrator will ensure that the residents residing in the facility will remain free from verbal . abuse, . and misappropriation of resident property. Reporting abuse any person who suspects abuse, neglect or misappropriation . may have occurred must immediately report the alleged violation to their immediate supervisor or the Administrator of the facility, State Survey Agencies and Law Enforcement…

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 all alleged violations involving abuse, neglect, exploitation or mistreatment, which included injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury to the administrator of the facility and to other officials, which included the State Survey Agency, in accordance with State law through established procedures for 2 of 19 residents (Residents # 87 and #37) reviewed for abuse, neglect, and exploitation. 1. The facility's abuse/neglect coordinator failed to report an allegation of verbal abuse that occurred on 3/26/23 to HHSC timely for Resident #87. 2. The facility failed to report a potential allegation of misappropriation of property that occurred on 3/25/23 to HHSC timely for Resident #37. These failures could place residents at risk 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 ensure assessments accurately reflected the residents status assure that each resident received an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas and who are knowledgeable about the resident's status for 2 of 19 residents (Residents #4 and #63) reviewed for accuracy of assessments. (Resident #4 and #63) 1. The facility failed to accurately assess Resident #4 for smoking. 2. The facility failed to accurately assess Resident #63 for PASRR positive. This These failures could place the residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being. Findings included: 1. Record review of Resident #4's physician orders, dated March 2023, indicated Resident #4,the resident was admitted to the facility on [DATE] and, was 66- years -old male with diagnoses of which included cerebral infarction (damage to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes 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 2 of 19 residents (Residents #25 and #41) reviewed for comprehensive care plans. 1. The facility failed to ensure Resident #25 was care planned for Hospice services. 2. The facility failed to follow physician orders related to a blood pressure medication for Resident #41. These failures could place the residents at risk for not receiving the appropriate care and services to maintain their highest level of well-being. Findings included: 1. Record review of physician orders dated March 2023 indicated Resident #25, admitted [DATE], was [AGE] years old with diagnoses of hypertensive heart disease and a stroke. The resident was admitted to hospice…

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 maintained acceptable parameters of nutritional status, unless the residents clinical condition demonstrated that it was not possible or the residents' preferences indicated otherwise, based on a resident's comprehensive assessment for 1 of 19 residents (Resident #25) reviewed for weight loss. The facility failed to ensure Resident #25 received a health shake supplement as ordered for the noon meal on 03/28/23. This failure could place residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being. Findings included: Record review of physician orders dated March 2023 indicated Resident #25, , admitted [DATE], was [AGE] years old with diagnoses of stroke, hemiplegia (paralysis to one side of the body), and dysphagia (difficulty swallowing). An order initiated on 3/15/23 indicated the resident was to have health shakes with meals. Record review of a significant change…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure, based on a comprehensive assessment of a resident, to ensure residents' who used psychotropic drugs were adequately monitred and free from unnecessary drugs for 1 of 5 residents (Resident #48) whose records were reviewed for psychotropic drugsunnecessary medications. (Resident #48) The facility failed to monitor Resident #48 for side effects of antidepressant medication. This failure could place residents at risk for adverse drug reactions of psychotropic medications such as dizziness, fatigue and sleep disturbances. Findings included: Record review of a Resident #48's face sheet indicated Resident #48 was admitted to the facility on [DATE]., The resident was a [AGE] years old male with a diagnosis of which included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of a Resident #48's quarterly MDS assessment, dated 2/14/23, indicated Resident #48 had a BIMS score of 4,…

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 prepare food in accordance with professional standards for food safety for one of one kitchen reviewed for food service safety. The facility failed to ensure Tray Aide B [dietary staff] prepared food wore a hair restraint while in the kitchen. This failure could place residents at risk of cross contamination. Findings included: During an observation on 03/27/23 at 8:23 a.m., Tray Aide B stood in front of the steam table without a hair restraint covering his hair, which was approximately ¼ inch long, where the cook was plating, uncovered, breakfast foods (scrambled eggs, bacon, oatmeal, and toast) and handing them to Tray Aide B to load on a cart for delivery to residents. During an observation and interview on 03/27/23 at 08:24 a.m., Tray Aide B said he was not wearing a hair restraint or head covering because he forgot to put it on this morning. He said he was supposed to wear one while in the kitchen. He said he had received training on covering his hair while working in…

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

Based on observation, interview, and record review the facility failed to implement established policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that also took into account nonsmoking residents for 1 of 2 smoking areas (secured smoking area) reviewed for smoking safety. The facility failed to maintain the smoking area located outside the facility's secure unit. This failure could place smoking residents residing in the secure unit at risk of an unsafe smoking environment. Findings include: During an observation and interview on 03/27/2020 at 1:30 p.m., during smoke break outside the secure unit, revealed more than 100 partially smoked cigarettes covering the ground on both sides of a walkway where smokers sit to smoke. A metal ashtray was mounted in the smoking area that had a self-closing device so cigarette butts could be emptied into the depository below. The ashtray had cigarette butts piled on top of it leaving no room for any others to be added or cigarettes to be extinguished. Sticking…

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.