Lavaca Bay Nursing And Rehabilitation Center

Based on interviews and record review, the facility failed to provide required training on restraints for 5 of 25 (Activity Director, CNA Q, PTA O, CNA N, and the Speech Therapist) staff sampled for licensure and training. The facility failed to ensure that the Activity Director, CNA Q, PTA O, CNA N, and the Speech Therapist had completed their mandatory restraints training. This failure could place residents at risk of being cared for by untrained staff. The findings included: Review of the facility's training log, undated, showed no evidence of training for restraints for the Activity Director, CNA Q, PTA O, CNA N, and the Speech Therapist. During an interview on 12/18/24 at 10:55 AM with the Regional HR Manager, regarding licensure and training, it was noted that several sampled employees were missing required federal or state trainings. During an interview on 12/18/24 at 1:30 PM with the acting HR Coordinator, regarding licensure and training, it was noted that the Activity Director, CNA Q, PTA O, CNA N and the Speech Therapist were missing training for restraints. The facility…

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 interviews and record review, the facility failed to provide required Quality Assurance Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program, for 10 of 25 (Housekeeper P, MA R, CNA S, Food Service Director, RN T, LVN U, Speech Therapist, Social Worker, Occupational Therapist, and LVN E) staff sampled for licensure and training. The facility failed to ensure that Housekeeper P, MA R, CNA S, Food Service Director, RN T, LVN U, Speech Therapist, Social Worker, Occupational Therapist, and LVN E had completed their mandatory QAPI training. This failure could place residents at risk of being care for by untrained staff. The findings included: Review of the facility's training log, undated, showed no evidence of training for QAPI for Housekeeper P, MA R, CNA S, the Food Service Director, RN T, LVN U, the Speech Therapist, the Social Worker, the Occupational Therapist, and LVN E. During an interview on 12/18/24 at 10:55 AM with the Regional HR Manager, regarding licensure and training, it was noted that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to provide required training on behavioral health for 2 of 25 employees sampled for licensure and training. The facility failed to ensure that 2 of 25 staff reviewed for behavioral health training (RN V and the Physical Therapist) had completed this mandatory training. This failure could place residents at risk of not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being due to lack of staff training. The findings included: Review of the facility's training log showed no evidence of training for behavioral health for RN V and the Physical Therapist. During an interview on 12/18/24 at 10:55 AM with the Regional HR Manager, regarding licensure and training, it was noted that several sampled employees were missing required federal or state trainings. During an interview on 12/18/24 at 1:30 PM with the acting HR Coordinator, regarding licensure and training, it was noted that 2 of 25 employees sampled for licensure…

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 and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 6 resident units (300 unit) reviewed for dignity. Laundry Aide X walked into several resident rooms in the 300 unit without knocking. This failure could place residents at risk for diminished quality of life, loss of dignity and self-worth. The findings included: During an interview on 12/17/24 at 8:17 a.m., Resident #75, who resided on the 300 unit revealed sometimes staff had entered her room without knocking and it bothered her because it was an invasion of privacy. Resident #75 stated, what if they come in and I'm naked or something? Record review of Resident #75's most recent quarterly MDS assessment, dated 9/18/24 revealed the resident was cognitively intact for daily decision-making skills. Observation on…

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

Based on interview and record review, the facility failed to promote the residents' right to receive mail, for all facility residents: Facility staff did not distribute mail received on Saturdays to the residents. This deficient practice could result in residents not receiving mail in a timely manner and a diminished quality of life. The findings were: During a confidential resident group meeting on 12/17/24 at 3:00 p.m., 3 of 10 members of the resident group stated they never received mail on Saturdays because the Receptionist was off on the weekends. During an interview on 12/17/24 at 5:11 p.m., the Receptionist acknowledged she worked as the receptionist Monday through Friday and did not work on the weekends. The Receptionist revealed, during the week she collected the mail from the mailbox and the local post office. The Receptionist revealed, once she collected the mail, it was placed in a small nook labeled Activities behind the receptionist area. The Receptionist revealed, the Activity Director or the Activity Aide would then collect the mail from the small nook and distribute…

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 licensed staff were able to demonstrate the specific competencies and skill sets necessary to care for resident's needs for 1 of 4 staff (CNA-K) reviewed for competencies. The facility failed to ensure CNA-L had competencies to care as evidence by CNA-L did not clean the resident's genital area when CNA-L was providing incontinent and indwelling urinary catheter care to Resident #74 on 12/18/2024. This failure could potentially affect residents by placing them for cross contamination and infections due to staff who lack the appropriate skills and competencies to provide minimize infections. Findings included: Record review of Resident #74's face sheet, dated 12/19/2024, revealed the resident was [AGE] years old male and admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with the diagnosis of dementia (impairment of brain functions), peripheral vascular disease (reduced blood flow to the limbs),…

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 {including procedures that assure accurate acqyuiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of residents for one of four carts reviewed for accuracy. 1. Resident #64 had 2 missing hydrocodone (NARCO)tablets that were not documented as given and could not be accounted for during November 27, 2024. These failures could place residents who received medications, including narcotics at risk for not receiving the intended therapeutic effects of their prescribed medications and experiencing unintended and harmful effects of medications prescribed to others and place the facility at risk for drug diversion. The findings included: Record review of Resident # 64's face sheet, dated 12/18/24 reflected a male age [AGE]. The resident was admitted on [DATE] with diagnoses that included: joint replacement, cancer, and pain. RP was listed as: resident. 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 record review and interview, the facility failed to ensure any drug regimen irregularities reported by the Pharmacist Consultant were acted upon, for two residents (Residents #34 and #59) of five residents whose medications were reviewed. 1. The facility's Pharmacy Consultant recommended the physician should consider a gradual dose reduction for Resident #34's Mirtazapine for depression on 11/25/2024. However, the facility failed to ensure communicating to the resident's primary care physician regarding the recommendation. 2. The facility's Pharmacy Consultant recommended adding Do Not Crush to Resident #59's medication administration record for the resident's Diltiazem for hypertension (high blood pressure) on 10/22/2024. However, the facility failed to ensure adding the recommendation to the medication administration record. The failures could place residents receiving medications at risk for adverse consequences and could cause a decline in their physical, mental, and psychosocial condition. The…

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

Based on observation, interview and record review, the facility failed to ensure that drugs and biologicals used in the facility were secured and distributed properly for one of four nurse medication carts (Hall 200 nurse medication cart and Hall 300 medication cart) reviewed for drug storage and use, as evidenced by: 1. The nurse medication cart for the 300-hall contained 5 loose pills. These failures could place residents who received medications, including narcotics at risk for not receiving the intended therapeutic effects of their prescribed medications and experiencing unintended and harmful effects of medications prescribed to others and place the facility at risk for drug diversion. The findings included: 1. During an observation and interview on 12/17/24 at 9:15 AM of the nurse cart for the 300 hall with LVN F, revealed 5 loose pills in the bottom of the cart drawers that held the blister packs. When asked what could happen if loose pills are left in the cart, LVN F stated anything could happen if the pills were consumed by a resident for whom they were not prescribed. LVN…

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 collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 1 resident (Resident #36) reviewed for hospice services, in that: The facility failed to monitor hospice aide and nursing visit per the hospice plan of care and keep the correct visit log sheet in Resident #36's hospice binder. This failure could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. The findings were: Record review of Resident #36's face sheet, dated 12/19/2024, revealed the resident was a [AGE] year old female, admitted to the facility on [DATE] and re-admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 1 (Residents #74) of 18 residents reviewed for infection control. CNA-L touched the new and clean brief with old and dirty gloves while providing incontinent and indwelling urinary catheter care to Resident #74 on 12/18/2024. This failure could place residents at risk for cross contamination and infections. The findings included: Record review of Resident #74's face sheet, dated 12/19/2024, revealed the resident was a [AGE] year old male, admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses of dementia (impairment of brain functions), peripheral vascular disease (reduced blood flow to the limbs), neuromuscular dysfunction of bladder (lack of bladder control), urinary tract infection (bladder infection),…

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 interviews and record review, the facility failed to provide mandatory effective communications training to 1 of 25 (RN V) staff sampled for licensure and training. The facility failed to ensure that RN V had completed effective communications training. This failure could place residents at risk of being care for by untrained staff. The findings included: Review of the facility's training log, undated, showed no evidence of training for effective communications for RN V. During an interview on 12/18/24 at 10:55 AM with the Regional HR Manager, regarding licensure and training, it was noted that several sampled employees were missing required federal or state trainings. During an interview on 12/18/24 at 1:30 PM with the acting HR Coordinator, regarding licensure and training, it was noted that RN V was missing training for effective communications. The facility was provided time to locate and verify the missing trainings. During a second interview on 12/18/24 at 3:30 PM with the acting HR Coordinator, verified RN did not receive the effective communications trainings.…

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 maintain medical records, in accordance with accepted professional standards and practices that are complete; and accurately documented for 1 of 6 residents (Resident #1 ) reviewed for medical records. Resident #1's 2024 POC (an electronic record system) documentation for showers was not accurately documented by CNA's in October and November of 2024. This failure could result in residents not having accurate overall view of their care and services. The findings were: Record review of Resident #1's face sheet, dated reflected a female age [AGE]. The resident was admitted on [DATE]with diagnoses which included unspecified dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities.), Alzheimer's disease (most common of dementia affecting memory), Crohn's disease(inflammation of the digestive tract), Anxiety and depression(feelings on hopelessness and anxiousness). Record review of Resident #1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the resident and resident's representative of the discharge and the reasons for the move in writing and in a language and manner they understand, failed to update the recipients of the notice as soon as practicable once the updated information became available, and failed to send a copy of the notice to a representative of the Office of the State Long-Term Ombudsman for 1 of 5 residents (Resident #1) reviewed for discharge, in that: The facility failed to notify Resident #1's RP in writing and did not notify the State Long Term Care Ombudsman by phone or in writing of Resident #1's discharge due to safety concerns. This deficient practice could place residents at risk of being discharged and not allowed to return to the facility, causing a disruption in their care and services and potential decline in health. Findings included: Closed record review of Resident #1's undated face sheet revealed the resident was a [AGE] year-old male admitted 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 observations, interviews and record reviews, the facility failed to provide reasonable accommodation of resident needs for 3 of 3 (Resident #56, #74 and #77) residents reviewed for call lights in that: The facility failed to ensure Residents #56, #74 and #77's call light was within reach and placed for easy access. The deficient practice could place residents at risk of not receiving care or attention needed and falling. The Findings Include: Record review of Resident #56's face sheet, dated 10/26/2023, revealed the resident was admitted to the facility on [DATE] with diagnoses which included: Parkinson's Disease (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement, chiefly affecting middle-aged and elderly people), major depression, recurrent (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life.), paranoid schizophrenia (When a person experiences…

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 services as outlined by the comprehensive care plan to meet professional standards of quality for 3 of 3 (Residents #20, #32 and #48) residents observed for insulin injections in that: LVN E administered 9 Units of Aspart (brand name Novolog) insulin to Resident #20 without priming the flex pen before injection. LVN E administered 7 Units of Lispro insulin to Resident #32 without priming the flex pen before injection. LVN E administered 2 Units of Lispro insulin to Resident #48 without priming the flex pen before injection. This deficient practice could affect residents who received insulin by a flex pen in the facility by not receiving the intended therapeutic benefit of their medication. The Findings included: Record review of Resident #20's face sheet, dated 10/27/2023 revealed an admission date of 09/21/2020 with diagnoses which included cerebral vascular accident (CVA) (occurs as a result of disrupted blood flow to the brain…

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

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. The facility failed to ensure DA was wearing a beard restraint who had facial hair. These failures could place resident who received meals and/or snacks from the kitchen at risk for food borne illness. The findings were: Observation and interview on 10/26/2023 at 11:09 a.m. revealed the DA opening cans of diced peaches not wearing a beard restraint with approximately half inch hairs to his chin and hair to the sides of his upper lip. The DA stated he should have been wearing a beard guard. DA then walked over to the Interim DM then returned and stated the Interim DM told him there were none for him to wear. The DA then washed his hands and went back to preparing the diced peaches without wearing a facial hair net. The DA was observed putting diced peaches in souffle dishes. The DA stated during his food handlers training he did remember having been trained the use of hair nets,…

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 had the right to be treated with respect and dignity, including the right to be free from any physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for 1 of 1 (Resident #74) resident observed for physical restraints in that: The facility failed to assess, care plan and obtain a consent for Resident #74 to be in a recliner which prevents rising on her own. This failure could place residents at risk for a decreased quality of life, a decline in physical functioning and injury. The findings included: Record review of Resident #74's face sheet dated 10/26/2023 revealed the resident was admitted to the facility on [DATE] with diagnoses which included: Alzheimer's disease (is a brain disorder that slowly destroys memory and thinking skills, and, eventually, the ability to carry out the simplest tasks), left side hemiplegia and hemiparesis following 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 interview and record review, the facility failed to ensure assessments accurately reflected the resident's status for 1 of 1 Resident #74) resident who's quarterly MDS was reviewed for accuracy in that: Resident #74's quarterly MDS assessment dated [DATE] incorrectly documented the resident had a restraint. This failure could place residents at risk for inadequate care due to inaccurate assessments. The findings included: Record review of Resident #74's face sheet dated 10/26/2023 revealed the resident was admitted to the facility on [DATE] with diagnoses which included: Alzheimer's disease (is a brain disorder that slowly destroys memory and thinking skills, and, eventually, the ability to carry out the simplest tasks), left side hemiplegia and hemiparesis following a stroke (hemiplegia is defined as paralysis of partial or total body function on one side of the body, whereas hemiparesis is characterized by one sided weakness, but without complete paralysis), depression recurrent (A mental health…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure individuals with mental disorders were evaluated and received care and services in the most integrated setting appropriate to their needs for 1 of 5 residents, (Resident #39) reviewed for Pre-admission Screening and Resident Review (PASRR) Level 1 screenings. The facility failed to identify on Resident #39's PASRR Level l that the resident had a diagnosis of a mental disorder. This deficient practice could affect all residents who had a mental illness and place them at risk for not receiving needed care and services to meet their needs. Findings include: Record Review of Resident #39's admission record revealed Resident #39 has a diagnosis of Post-Traumatic Stress Disorder (PTSD) prior to admission to the facility on [DATE]. Record Review of the admission PASRR Level I for Resident #39, dated 09/28/2023, revealed no was the response documented for the question: Is there evidence or an indicator this is an individual that has a Mental Illness?…

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 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 disease and infection for 1 of 6 residents (Resident #27) reviewed for infection control, in that: While providing incontinent care for Resident #27, the soiled brief came in contact with Resident #27's clean genitals and CNA A did not wash her hands after cleaning the resident and before touching the clean brief. These failures could place residents at-risk for infection due to improper care practices. The findings include: Record review of Resident #27's face sheet, dated 10/26/2023, revealed an admission date of 10/26/2021, with diagnoses which included: Cerebral infarction(Stroke), Chronic kidney disease(gradual loss of kidney function), Diabetes mellitus(high level of sugar in the blood), Hypertension(High blood pressure). Record review of Resident #27's MDS quarterly assessment, dated 08/11/2023, revealed the resident…

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 had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 14 residents (R#6) reviewed for misappropriation of resident property. The facility failed to ensure that R#6 was not subject to financial misappropriation by CNA A from the time period July 6, 2023, to August 8, 2023. CNA A misappropriated checking account funds from R#6 totaling $15,083. This was determined to be Past Non-Compliance from 07/06/23 until 08/08/23, due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could have the potential to affect the residents in the facility by placing them at risk for misappropriation of resident property. The findings included: Record review of R#'6s face sheet, dated 10/10/23, and EMR (electronic medical record) revealed, the resident was admitted on [DATE] and re-admitted [DATE] 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 interview and record review, the facility failed to review and revised the Comprehensive Care Plan for 1 of 12 residents (R#1 ) reviewed for revision of the Care Plan. R#1's Care Plan was not revised or documented new interventions after the resident was involved in four residents to resident altercations. This failure could denied the interdisciplinary team information on recommended interventions for dealing with resident to resident altercations. The findings included: Record review of Resident #1's face sheet, dated 10/10/23, and EMR (electronic medical record) revealed, the resident was re-admitted on [DATE] with diagnoses that included: fluid in the lung, emphysema, muscle wasting, dementia, delusional disorders, insomnia, anxiety, depression, and Alzheimer's disease. Resident was a male age [AGE]. RP (responsible party) was listed as: family member. Resident was housed in the secured unit of the facility. Record review of R#1's BIMS score dated 9/14/23 revealed a score of zero (severely…

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 (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, for 1 of 22 residents (R#8) reviewed for drug administration in that: Had this surveyor not intervened, CMA O would have administered R#8 her senna [a medication used to treat constipation] almost 12 hours before its scheduled timeframe. This deficient practice could affect residents who receive medication and place them at risk for not receiving a therapeutic effect. The findings were: Record review of R#8'S face sheet, dated 10/11/23, revealed R#8 was admitted to the facility on [DATE] with diagnoses of atherosclerotic heart disease of native coronary artery [buildup of fats in the arteries that supply blood to the heart muscle] without angina pectoris [chest pain], contact with and (suspected) exposure to COVID-19, ganglion [a noncancerous…

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.