Richardson Nursing and Rehabilitation

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 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 four of twelve residents (Residents #14, #15, #19, and #29) reviewed for care plans. 1. The facility failed to ensure Resident #14 was care planned for oxygen therapy. 2. The facility failed to ensure Resident #15 was care planned for congestive heart failure. 3. The facility failed to ensure Resident #19 was care planned for her AVAPS. 4. The facility failed to ensure Resident #29's care plan reflected an intervention for her bed to be in the lowest position for fall prevention and a plan of care for Enteral feeding. These failures could place the residents at risk of not receiving the necessary care and services. Findings…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure that residents' environment remained free of hazards as was possible for ten of eleven residents (Residents #4, #7, #10, #11, #24, #31, #34, #74, #91, and #96) and for two of four LVNs (LVN B and LVN I) reviewed for accident hazards.1. The facility failed to ensure Resident #31 had her fall prevention interventions which included a fall mat to each side of bed every shift for safety. 2. The facility failed to ensure Residents #4, #10, #11, #24, #34, #74, #91, and #96 were properly supervised while smoking in the smoking area of the facility and that Resident #4, #10, #24, #34, #74, #91, and #96 had quarterly smoking assessments completed.3. The facility failed to ensure that LVN B did not leave a container of germicidal wipes on top of her cart unattended on 03/10/2026. 4. The facility failed to ensure LVN I did not leave a container of germicidal wipes on top of his cart unattended on 03/10/2026.These failures placed 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 observation, interview 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 three of twelve residents (Residents #5, #6 and #15) reviewed for respiratory care. 1. The facility failed to ensure Resident #5's nasal cannula was stored properly when not in use on 03/10/2026. 2. The facility failed to ensure Resident #6's nasal cannula was stored properly when not in use on 03/10/2026. 3. The facility failed to ensure Resident #15's breathing mask was stored properly when not in use on 03/10/2026. These failures could place residents at risk of respiratory infection and not having their respiratory needs met.Findings included: 1. Record review of Resident #5's Face Sheet, dated 03/10/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with chronic pulmonary…

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 assess the resident for appropriateness and review the risks and benefits of grab/assist bars (smaller bars used by the person in bed to reposition themselves), with the resident or resident representative and obtain informed consent prior to installation for 4 (Resident #1, Resident #13, Resident #76, Resident #91) of 7 resident rooms observed and reviewed for grab/assist bars. The facility failed to have evidence of informed consents for Resident #1, Resident #13, Resident #76, and Resident #91 for grab/enabler bars to be placed on the bed. The facility failed to have evidence of assessments for Resident #1, Resident #13, Resident #76 and Resident #91, for risk of entrapment and ability to safely use the grab/enabler bars. These failures could affect residents who used grab/assist bars at risk of the resident/responsible party not being aware of the risks, informed consent not being obtained from the resident or responsible party, 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.

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure food items in the refrigerator were dated, labeled, and sealed appropriately. The facility failed to ensure the ice machine was thoroughly cleaned and sanitized. The facility failed to ensure the ice scoop holder was thoroughly cleaned and sanitized. The facility failed to ensure the ice chest on the 2500-hall was thoroughly cleaned and sanitized. The facility failed to ensure the tea dispenser was covered with a lid. The facility failed to ensure the rinse temperature on the dishwasher was at the manufacturers required operating temperature of 180 degrees. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination. Findings included: During Observation on 03/10/26 at 8:57 am, a tea dispenser in the facility kitchen was observed with tea in it…

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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three of fifteen residents (Residents #5, #29, and Resident #38) reviewed for infection control. 1. The facility failed to ensure CNA D and CNA E performed hand hygiene before transferring Resident #5 on 03/10/2026. 2. The facility failed to ensure LVN B wore a gown while administering Resident #29's medication via g-tube on 03/10/2026. 3. The facility failed to ensure CNA F performed hand hygiene and changed her gloves after touching the soiled draw sheet during Resident #38's incontinent care on 03/10/2026. These failures could place residents at risk of cross-contamination and development of infections.Findings include: 1. Review of Resident #5's Face Sheet, dated 03/10/2026, reflected a [AGE] year-old female…

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 the transfer or discharge was documented in the resident's medical record for one (Resident #105) of three residents reviewed for transfers and discharges.The facility failed to accurately document Resident #105's discharge on [DATE].This failure could prevent the resident or their caregivers from receiving necessary information about the resident's support needed for further care.Findings included:Review of Resident #105's Face Sheet, dated 03/11/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with heart failure and Type 2 Diabetes (high blood sugar levels). Record review of Resident #105's 's MDS Assessment, dated 02/17/26, reflected the resident's BIMS indicated an intact cognitive response. The MDS Assessment reflected the resident had active diagnoses of heart failure and Type 2 Diabetes.Record review of Resident #105's progress notes on 02/19/26 revealed Resident left AMA.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to transmit encoded, accurate, and complete MDS data to the CMS System for 2 of 11 residents (Resident #1 and Resident #65) reviewed for MDS transmission. Residents #1 and #65 Quarterly MDS assessments were completed but not transmitted within 14 days of completion. This failure could place residents at risk of not having assessments completed and submitted in a timely manner as required. The findings were: Record review of Resident #1's admission Record, dated 3/11/2026, revealed a [AGE] year-old female who initially admitted to the facility on [DATE]. Resident #1 had a primary diagnosis of Metabolic Encephalopathy (syndrome of brain dysfunction caused by systemic illness, organ failure, or toxin accumulation affecting consciousness, cognition and motor function) and other diagnoses including Adult Failure to Thrive, Acute Kidney Failure, Cognitive Communication Deficit, Bipolar II Disorder (chronic mental health condition characterized by a pattern of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 7 residents reviewed for wound care (Resident #14). The facility failed to follow the facility's wound cleaning protocol for Resident #14's right heel dressing change. This failure put Resident #14 at risk of not receiving necessary treatments and a worsening of their wound.Findings included: Record review of Resident #14's face sheet revealed an [AGE] year-old admitted to the facility initially on 10/23/2025 and again on 02/16/2026 with the following diagnoses: Pressure ulcer of sacral region (The sacral region refers to the area at the very base of the spine, located just above the buttocks and directly between the two hip bone), Cognitive communication deficit, Lack of coordination, Weakness. Record review of Resident #14's MDS dated [DATE] revealed that the resident had a BIMS score of 6 ( indicates severe cognitive impairment).…

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 the necessary treatment and services, based on the comprehensive assessment and consistent with professional standards of practice, to prevent development of pressure injuries for 1 of 7 residents reviewed for pressure injuries. (Resident #31) The facility failed to apply foam boots to bilateral heel to prevent pressure ulcer for Resident #31. This failure can place the residents at risk for new development pressure injuries and could result in a decline in health. Findings included: Record review of Resident #31's face sheet dated 03/10/26 revealed an [AGE] year-old admitted to the facility initially on 12/13/2010 with the following diagnoses: Type 2 Diabetes ((high blood sugar levels), Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills), Convulsions (sudden, uncontrollable shaking or jerking of the muscles), Epilepsy (recurrent, unprovoked seizures caused by temporary, abnormal electrical…

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 ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infection and to restore continence to the extent possible for one of five residents (Resident #44) reviewed for catheter care. The facility failed to ensure Resident #14 had orders for her catheter. This failure could place residents with catheter at risk for urinary tract infection and other catheter- associated complications.Findings included: Record review of Resident #14's Face Sheet, dated 03/10/2026, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with neuromuscular disfunction of the bladder (the muscles and nerves that control the bladder do not work properly due to illness). Record review of Resident #14's Comprehensive MDS Assessment, dated 01/29/2026, reflected that the resident had a severe impairment in cognition with a BIMS score of 06. The Comprehensive MDS…

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

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 receiving enteral feeding received appropriate care and services to prevent complication of enteral feeding for 1 out of 7 residents (Resident #31) reviewed for enteral feeding. Resident #31 was not provided with an abdominal binder for G-tube site protection as ordered. This failure could place residents with a G-tube at risk of increased risk for infection and complications. Findings included: Record review of Resident #31's face sheet dated 03/10/26 revealed an [AGE] year-old admitted to the facility initially on 12/13/2010 with the following diagnoses: Type 2 Diabetes ((high blood sugar levels), Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills), Convulsions (sudden, uncontrollable shaking or jerking of the muscles), Epilepsy (recurrent, unprovoked seizures caused by temporary, abnormal electrical activity in the brain). Record review of Resident #31's MDS dated [DATE] revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 1 of 8 residents (Resident #39) reviewed for administration of all drugs. The facility failed to ensure Resident #39's morning medications were recorded on the resident's MAR once administered to the resident on 03/03/26. This failure could place residents at risk of receiving duplicate medication and being overly medicated.Findings included: Record review of Resident #39's Face Sheet, dated 03/11/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #39 had a diagnosis of heart disease. Record review of Resident #39's MDS Assessment, dated 01/08/26, reflected the resident's BIMS indicating an intact cognitive response. The MDS Assessment reflected the resident had active diagnoses of hypertension (high blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for one of twelve residents (Resident #90) and one (Medication Aide's Cart) of three carts reviewed for medication storage. 1. The facility failed to ensure Resident #90 did not have any medications inside her room on 03/10/2026. 2. The facility failed to ensure probiotics were refrigerated as per instruction of the manufacturer on 03/11/2026. These failures could place the residents at risk of accidental overdose, misuse of medications, not receiving the medication's full therapeutic benefits, and possible adverse reactions.Findings included: 1. Record review of Resident #90's Face Sheet, dated 03/10/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with dementia (a condition characterized…

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 one (Resident #3) of ten residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #3's room was in a position that was accessible to the resident on 06/17/2025. 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: Record review of Resident #3's Face Sheet, dated 06/17/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with paraplegia (paralysis of the legs and lower part of the body) and weakness. Record review of Resident #3's Quarterly MDS (assessment used to determine functional capabilities and health needs) Assessment, dated 05/14/2025, reflected the resident had a severe impairment 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 secure confidential and personal medical records for one (Residents #4) of one resident reviewed for privacy and confidentiality. The facility failed to ensure LVN A closed, locked, or minimized her laptop's monitor when she left her cart on 06/17/2025 and Resident #4's medical information was visible. This failure could place the residents at risk of exposure of their personal and medical information to unauthorized individuals. Findings included: Record review of Resident #4's Face Sheet, dated 06/17/2025, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with neuromuscular dysfunction of the bladder (the muscles and nerves that control the bladder do not work properly due to illness). Record review of Resident #4's Comprehensive MDS Assessment, dated 03/14/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 00 (requires significant…

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 #3) of one resident reviewed for feeding tube (a way of providing nutrition directly to the stomach). The facility failed to ensure that Resident #3's, who had a g-tube (gastrostomy tube: a tube inserted through the abdomen that delivers nutrition directly to the stomach), head of the bed was raised on 06/17/2025. This failure could place residents with g-tubes at risk for reflux and aspiration. Findings included: Record review of Resident #3's Face Sheet dated 06/17/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with dysphagia (difficulty in swallowing). Record review of Resident #3's Comprehensive MDS Assessment, dated 05/14/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 03. The Comprehensive MDS Assessment indicated the 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 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 six (Residents #1 and #2) of six residents reviewed for respiratory care. 1. The facility failed to ensure Resident #1's breathing mask (used to receive medications by breathing in mist through nose and mouth) was properly stored when not in use on 06/17/2025. 2. The facility failed to ensure an Oxygen in Use sign was placed outside of Resident #2's room when she was admitted to the facility on [DATE]. These failures could place residents at risk for respiratory infection and not having their respiratory needs met. Findings included: 1. Record review of Resident #1's Face Sheet, dated 06/17/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with respiratory failure…

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 ensure that drugs and biologicals were stored properly in locked compartments for one medication (wound cleanser solution) of one medication reviewed for storage of drugs and biologicals. The facility failed to ensure that the wound cleanser solution was not left inside Resident #3's bedside. This failure could place the residents at risk of accidental consumption or misuse of medications. Findings included: Observation on 06/17/2025 at 9:46 AM revealed Resident #3 was in her bed with her eyes closed. It was observed that there was a bottle of wound cleanser solution on the resident's bedside table. Observation and interview on 06/17/2025 at 9:53 AM, LVN A said the wound cleanser was not supposed to be inside any resident's room. She said she did not notice the wound cleanser inside Resident #3's room when she did her morning rounds. She said she did not know who left the wound cleanser and if it was used for the resident because as far as she knew the resident did not have any wounds that needed cleansing.…

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 coordinate assessments with the pre-admission screening and resident review (PASRR) to the maximum extent practicable for 1 (Resident #1) of 2 residents reviewed for PASRR. The facility failed to follow up with more information request after receiving notification from PASRR between 11/25/2024 and 12/01/2024, which led to a denial of physical therapy services for Resident #1. This failure could place all residents identified as mentally, intellectually and/or developmentally disabled at risk of not receiving specialized services and equipment to meet their needs. Findings included: Review of Resident #1's Face Sheet dated 03/25/2025 at 2:24 PM revealed she was a [AGE] year-old female re-admitted from an acute care hospital on [DATE]. Relevant diagnoses included quadriplegia (loss of function of all four limbs,) unspecified intellectual disabilities, paranoid personality disorder, cognitive communication deficit, major depressive disorder, and urinary…

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 a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 4 of 6 resident rooms (room [ROOM NUMBER], #2, #3, and #4) and all the facility hall floors reviewed for environment. 1. The facility failed to ensure resident rooms #1, #2, #3, and #4 were thoroughly cleaned and sanitized. 2. The facility failed to ensure the facility hallway floors were cleaned and sanitized. These deficient practices could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life. Findings include: An observation on 02/18/25 at 08:19 AM of the facility hallways revealed large dark stains on the carpet areas and dark brown and black stains on the tiles, especially along the edges of the floor, near the walls. An observation on 02/18/25 at 08:20 AM of resident room [ROOM NUMBER]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure the resident had the right to be treated with respect and dignity for 1 of 4 residents (Resident #1) reviewed for dignity. The facility failed to ensure staff properly fed Resident #1 breakfast, while she was lying in bed. This deficient practice could place the resident at risk of not feeling as if they were being treated with dignity and respect while being fed. Findings include: Record review of Resident #1's face sheet, dated 02/19/25, revealed a 62 -year-old female who was admitted to the facility on [DATE]. Resident #1's relevant diagnoses included Cerebrovascular Disease (cognitive impairment), and contracture of muscle (shorten muscles). Record review of Resident #1's Minimum Data Set, dated [DATE] revealed she had a BIMS score of 12, which indicated cognitively intact and for ADL care it stated, For feeding, the resident required a one-person physical assist. Record review of Resident #1's Care plan, dated 01/25/25, revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to treat residents with respect and dignity for one (Resident #1) of seven residents reviewed for resident rights. The facility failed to ensure LVN A did not stand over Resident #1 while assisting the resident with her meal in the dining room on 01/15/25. This failure could affect residents who require assistance with activities of daily living and place them at risk of feeling rushed to eat or not interested in eating, which could result in weight loss and decreased psycho-social well-being of anguish or frustration. The findings include: Review of Resident #1's admission MDS assessment dated [DATE] revealed a [AGE] year-old female who admitted [DATE] with a staff assessment BIMS score of 03 (Severely impaired). She had partial to moderate assist with eating and active diagnosis of other neurological conditions. She was diagnosed with anemia, hypertension, renal insufficiency, diabetes mellitus, thyroid disorder, malnutrition, and anxiety.…

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 observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two of eight residents (Resident #77 and Resident #199) reviewed for Infection Control. 1. The facility failed to ensure CNA E changed her gloves and performed hand hygiene while providing incontinent care to Resident #77 on 12/10/2024. 2. The facility failed to ensure CNA D changed her gloves and performed hand hygiene while providing incontinent care to Resident #199 on 12/10/2024. 3. The facility failed to ensure that RN B would not bring the whole container of test strips used for checking blood sugar inside Resident #77's room on 12/11/2024. These failures could place residents at risk of cross-contamination and development of infections. Findings include: 1.Observation on 12/10/2024 at 10:01 AM revealed CNA E was about to do incontinent care for Resident #77. She prepared the things…

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 2 of 12 residents (Resident #49 and Resident #77) reviewed for Respiratory Care. 1. The facility failed to ensure Resident #49 had an order for oxygen administration. 2. The facility failed to ensure Resident #77's BiPAP (bilevel positive airway pressure - normalizes breathing by delivering pressurized air into the upper airway leading into the lungs) mask was properly stored. These failures could place residents at risk for respiratory infection and not having their respiratory needs met. Findings include: 1. Review of Resident #49's Face Sheet, dated 12/10/2024, reflected a [AGE] year-old female who initially admitted on [DATE] and the most recent admission date was 08/06/2023. Resident #49 admitted with chronic obstructive…

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 ensure that one of two (Resident #86) residents were provided medications and/or biologicals and pharmaceutical services to meet their needs. The facility failed to ensure LPN C flushed the g-tube (a tube inserted through the abdomen that delivers nutrition directly to the stomach) before and after each medication on 12/10/2024. This failure could place the residents at risk of not receiving medications as ordered by the physician. Findings include: Record review of Resident #86's Face Sheet, dated 12/11/2024, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #86 was diagnosed with gastrostomy (medical procedure where a tube is inserted into the stomach) status. Record review of Resident #86's Quarterly MDS Assessment, dated 11/22/2024, reflected the resident was unable to complete the interview to determine the BIMS score. The resident was on tube feeding (delivery of nutrition through a tube inserted 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 and interviews, the facility failed to maintain all patient care equipment in the laundry room in safe operating condition. The facility failed to ensure one (the washer located near the back wall) of two washing machines in the laundry room was maintained. These failures could place residents at risk of contamination and improper laundering of items. Findings Included: An observation and interview 12/11/24 at 08:22 AM revealed sudsy water running from the door of a front-loading washer in the laundry room onto the floor below. The drain was directly in front of the washer. A trash bag was twisted and looped through the handle of the washer door and tied to a handle on the washer panel, just above the door. There was lime buildup along the front of the washer below the door and on the side of the washer. The laundry employee stated they had used the trash bag for 2 days to secure the washer door. Review of the maintenance log on 12/11/24 revealed there was no pending work order for the washer. During observation and interview 12/12/24 at 09:20, the Housekeeping…

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 neglect, are reported immediately, but not later than 2 hours after the allegation is made, to HHSC for 1 (Resident #1) of 6residents reviewed for reporting. The facility's Abuse Coordinator failed to report to HHSC Resident #1's elopement incident that occurred on 08/27/2024. This failure could place residents at risk of continued neglect. Findings Included: Record Review of Resident #1's Face Sheet, dated 08/27/2024 revealed he was a [AGE] year-old male admitted to the facility 11/03/2019. Relevant diagnoses included dementia, major depressive disorder, generalized anxiety disorder, weakness, unsteadiness on feet, blindness in one eye, and macular degeneration (vision impairments.) Record review of Resident #1's Quarterly Minimum Data Set (MDS,) dated 06/21/2024 revealed he was moderately cognitively impaired with a Brief Interview of Mental Status (BIMS) score of 08. He was wheelchair bound and required…

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 neglect were investigated following reporting any alleged allegations to HHSC for 1 (Resident #1) of 6 residents reviewed for investigation. The facility's Abuse Coordinator failed to investigate to HHSC Resident #1's elopement incident that occurred on 08/27/2024. This failure could place residents at risk of abuse, neglect, and/or exploitation. Findings Included: Record Review of Resident #1's Face Sheet, dated 08/27/2024 revealed he was a [AGE] year-old male admitted to the facility 11/03/2019. Relevant diagnoses included dementia, major depressive disorder, generalized anxiety disorder, weakness, unsteadiness on feet, blindness in one eye, and macular degeneration (vision impairments.) Record review of Resident #1's Progress Note by LPN Y, dated 08/27/2024, revealed: Resident eloped from facility, found in parking lot in the front of the building. no s/s of distress noted, V/S are normal, noted 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 interviews and record review, the facility failed to ensure each resident received an accurate assessment, reflective of the resident's status for one (Resident #1) of six residents reviewed for accuracy of assessments. The facility failed to ensure Resident #1's Quarterly MDS assessment dated [DATE] accurately reflected that Resident #1 visual impairments. This failure could place residents at risk for not receiving care and services to meet their needs, diminished function of health, and regressions in their overall health. Findings included: Record Review of Resident #1's Face Sheet, dated 08/27/2024 revealed he was a [AGE] year-old male admitted to the facility 11/03/2019. Relevant diagnoses included blindness in one eye, and macular degeneration (vision impairments.) Record review of Resident #1's Quarterly Minimum Data Set (MDS,) dated 06/21/2024 revealed he was moderately cognitively impaired with a Brief Interview of Mental Status (BIMS) score of 08. Resident #1 was assessed as having adequate…

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 a safe, functional, sanitary, and comfortable environment for one of one facility reviewed for environment. 1. The facility failed to ensure the foundation, walls, and ceiling were in good repair in the hallway to the right of the secretary's desk. 2. The facility failed to ensure the carpets were clean and stain free throughout the facility. These failures could affect all residents, resulting in falls and cross contamination which could lead to a decline in the resident's health and physical functioning. Findings included: Review of the quarterly MDS assessment for Resident #1, dated 04/23/24, reflected he was an [AGE] year-old male admitted on [DATE]. His cognitive status was moderately impaired. His diagnoses included Alzheimer's Disease and heart failure. An observation on 05/21/24 at 9:25 AM revealed on the right side of the facility, close to the receptionist desk there were foundation problems. There was a downward slope…

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, 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 #50) of one resident reviewed for respiratory/tracheostomy care. The facility failed to ensure Resident #50's tracheostomy shield was changed per week per physician order. This failure could place the residents at risk for respiratory infection and not having their respiratory needs met. Findings included: Review of Resident #50's Face Sheet dated 05/21/2024 reflected he was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included chronic respiratory failure (condition where lungs cannot provide enough oxygen or remove enough carbon dioxide from the blood,) chronic obstructive pulmonary disease (persistent, progressive breathlessness and cough,) tracheostomy (surgical opening made through the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to provide a safe, clean, comfortable, and homelike environment for 15 of 30 resident rooms (Resident # 2, #3, #9, #12, #14, #16, #20, #21, #26 #28, #29, #38, #55, #94, and #200) , the handrails and the carpet throughout the facility observed for a safe, clean, comfortable, and homelike environment. The facility failed to ensure that resident rooms on multiple halls (100 & 200 halls) were free of diirt and stains on the floors, walls, mini friidges and air-condition units. The facility failed to ensure handrails on all resident halls were free of dirt particles, stains, and dust. These failures could place residents at risk of infections and living in an uncomfortable environment leading to a decreased quality of life. Findings include: Observation of Resident # 2 & #3 Room (on [DATE] at 10:40 AM revealed, the floor had a red circle stain near an Intravenous (IV) pole. The bottom of the (IV) pole had fluid stains all over it. 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 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 3 of 6 residents (Residents #35, #38, and #84) reviewed for ADLs care provided to dependent residents. The facility failed to ensure Residents #35, #38, and #84 received baths or showers consistently based on records reviewed from 9/1/2023 - 10/18/2023 referencing resident showers. This failure could place residents at risk of not receiving necessary services to maintain good personal hygiene, skin integrity, or decreased self- esteem. Findings Included: Record review of Resident #35's Face Sheet, dated 10/19/23, revealed she was a 75 -year-old female admitted on [DATE]. Relevant diagnoses included Muscle Weakness, Urinary Tract Infection, and Muscle Wasting. Record review of Resident #35's MDS dated [DATE] revealed she had a BIMS score of 15 (cognitively intact) and 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 that 4 (Resident #7, Resident 18, Resident 28, and Resident 31) of 10 residents were provided medications and/or biologicals and pharmaceutical services to meet the needs of the residents. The facility failed to ensure CMA Y re-ordered medications on a timely manner for Resident #7 (Eliquis 2.5 mg). The facility failed to ensure CMA Y re-ordered medications on a timely manner for Resident #18 (Sertraline HCL 50 mg). The facility failed to ensure CMA Y re-ordered medications on a timely manner for Resident #28 (Tramadol 50 mg). The facility failed to ensure CMA Y re-ordered medications on a timely manner for Resident #31 (Metoprolol Tartrate 50 mg, Buspirone HCL 10 mg, Gabapentin 100 mg, Finasteride 5 mg, and Amlodipine Besylate 5 mg). These failures placed the residents at risk of not receiving medications as ordered by the physician. Findings included: Resident #7 Review of 's Face Sheet dated 10/18/2023 reflected the resident 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.

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 stored, labeled, and dated. The facility failed to ensure expired foods were discarded. The facility failed to ensure kitchen equipment were clean and sanitary. These failures could place residents at risk for cross contamination and other illnesses. Findings included: Findings observed on 10/17/23 from 09:10 AM to 09:35 AM in the facility's only kitchen include: Ice Scoop for Ice Machine had greenish gray stains on the back side of the scoop. One large tray that contained of sliced onions, tomatoes, and lettuce.s. Also on the tray was a large piece of cucumber and a block of sliced cheese not properly sealed in the walk-in refrigerator. One small white container containing a white creamy substance was unlabeled 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 observations, interviews, and record review the facility failed to treat 1 of 6 (Resident #38) residents reviewed with dignity and respect. The facility failed to ensure Resident #38's room was clean and sanitized, the facility failed to ensure the resident received activities of daily living care, and the facility failed to ensure the resident was free of any hazards. This failure could prevent residents from attaining or maintaining the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. Findings include: Record review of Resident #38's Face Sheet, dated 10/19/23, revealed he was a 41 -year-old male admitted on [DATE]. Relevant diagnoses included Alzheimer Disease (memory loss), Dysfunction of Bladder, Urinary Tract Infection, and Schizophrenia (hallucinations and delusions). Record review of Resident #38's MDS on dated 09/01/23 revealed he had a BIMS score of 13 (cognitively intact) and for ADL care it stated,…

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 manage the resident's funds for 1 of 1 resident (Resident #196) reviewed for Protection and Management of Personal Funds. The facility failed to manage the transfer of the Resident 196's Trust fund from the resident's prior living facility and the failed to manage the transfer of his Social Security funds from his prior living facility. This failure could place resident at risk of not being able or allowed to handle their personal affairs. Findings included: Record review of Resident #196's Face Sheet, dated 10/19/23, revealed he was a 72 -year-old male admitted on [DATE]. Relevant diagnoses included Major Depressive Disorder and Anxiety Disorder. Record review of Resident #196's MDS dated [DATE] revealed he had a BIMS score of 15 (cognitively intact). Interview with Resident #196 on 10/19/23 at 10:00 AM revealed he had been at the facility since July 10, 2023. He advised that he had been trying to get his $60 spending since he arrived at 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents had physician's orders for the resident's immediate care for two (Resident #41 and Resident #53) of six residents reviewed for admission orders. The facility failed to provide physician's orders for heel protectors as preventive measure for Resident #41 at the time of admission. The facility failed to provide physician's orders for oxygen supplement for Resident #53 at the time of admission. These failures could place the resident at risk of not receiving necessary care and services upon admission that could result to worsen condition. Findings included: Review of Resident #41's Face Sheet dated 10/17/2023 reflected that Resident #41was a 74 -year-old female admitted on [DATE]. Relevant diagnoses included unspecified dementia, unspecified lack of coordination, urinary tract infection, major depressive depression, and unspecified pain. Review of Resident #41's Quarterly MDS assessment dated [DATE] reflected 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 reviews, the facility failed to ensure each resident received an accurate assessment, reflective of the resident's status for 1 of 8 residents (Resident #83) reviewed for Accuracy of Assessments. The facility failed to ensure Resident #83's MDS accurately reflected Section I-Active diagnosis included I1700. Multidrug-Resistant Organism (MDRO). The resident had candida auris (highly contagious illness). This failure could place residents at risk for not receiving care and services to meet their needs, diminished function of health, and regressions in their overall health. Findings included: Resident #83 Record review of Resident #83's quarterly MDS assessment, dated 06/22/23, reflected she was a [AGE] year-old female re-admitted to the facility on [DATE]. Her cognitive status was severely impaired. Her diagnoses included seizure disorder, diabetes, Alzheimer's disease, respiratory failure. She had a tracheostomy. Record review of Resident #83's Face Sheet, dated 10/19/23, 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 observation, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for 4 of 8 sampled residents (Resident #41, Resident #50, Resident #53, and Resident #83) reviewed for Care Plans. The facility failed to ensure Resident #41's was care planned for heel protectors as a preventive measure. The facility failed to ensure Resident #50's was care planned for Hospice care. The facility failed to ensure Resident #53's was care planned for oxygen. The facility failed to ensure Resident #83's Care Plan reflected she was on contact precautions for candida auris (highly contagious infection). These failures could place residents at risk for not receiving care and services to meet their needs, diminished function of health, and regressions in their overall health. Findings include: 1 .Review of Resident #41's Face Sheet dated 10/17/2023 reflected that Resident #41was a 74 -year-old female admitted on [DATE]. Relevant diagnoses included unspecified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews, the facility failed to ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team for 1 (Resident #53) of 6 residents reviewed for revised Care Plan. The facility failed to ensure Resident #53's care plan was revised to reflect discontinued use of CPAP/BiPAP. This failure could place the resident at risk of needs not being met. Findings included: Review of Resident #53's Face Sheet dated 10/17/2023 reflected that resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included unspecified chronic obstructive pulmonary disease, acute (sudden onset) and chronic (an illness persisting for a long time or constantly recurring), respiratory failure, unspecified cardiac arrythmia (abnormal heart rhythm), chronic pulmonary edema, and hypoxemia (low blood oxygen). Review of Resident #53's Comprehensive MDS assessment 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 interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, including but not limited to standards of practice that will meet each resident's physical, mental, and psychosocial needs for 2 of 6 residents (Resident #43 and #45) reviewed for quality of care. The facility failed to record Residents #43 and #45's weekly weight on a as scheduled, utilizing a consistent method, for residents diagnosed with excessive weight loss. This failure could place residents at risk of experiencing unobserved and untreated excessive weight loss. Findings included: Record review of Resident #43's Face Sheet, dated 10/19/23, revealed she was a 90 -year-old female admitted on [DATE]. Relevant diagnoses included, Anorexia (eating disorder), Abnormal Weight loss, and Weakness. Record review of Resident #43's MDS dated [DATE] revealed she had a BIMS score of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to 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 1 (Resident #5) of 3 residents observed for infection control. The facility failed to ensure CNA A changed her gloves and performed hand hygiene while providing incontinence care to Resident #5. This failure could place residents at risk of cross-contamination and development of infection. Findings included: Review of Resident #5's Quarterly MDS assessment dated [DATE], reflected she was admitted on [DATE], and was a [AGE] year-old female and her cognitive status was moderately impaired. Her diagnoses included heart failure and seizure disorder. She was always incontinent of bowel and bladder. Review of Resident #5's Care Plan, dated 01/11/23, reflected: The resident had an ADL self-care performance deficit related 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 store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys for 1 resident (Resident #1) of 6 residents reviewed for pharmacy services. -The facility failed to ensure that Resident #1's prescribed Clotrimazole-Betamethasone was stored in a secured place. This failure could place all residents on the 2200 Hall at risk of drug diversion or misuse of medications. Findings included: Record review of Resident #1's face sheet, dated 10/04/23, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: depression, type II diabetes, psychotic disorder, and orthopedic aftercare following surgical amputation. Record review of Resident #1's care plan, dated 09/29/23, revealed the resident had impaired cognitive function with an intervention to cue, reorient, and supervise resident as needed. The care plan did not address self-administration of medications.…

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 and interview, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for four (Resident #11, Resident #12, Resident #13, and Resident #14) of ten residents reviewed for call lights. The facility failed to ensure the call light systems in Resident #11's, #12's, #13's, and #14's rooms were in a position that was accessible to the residents. Findings Included: Review of Resident #11's Face Sheet dated 09/25/2023 reflected that resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included type 2 diabetes mellitus without complications, unspecified dementia, major depressive order, epileptic seizures related to external causes, and hemiplegia (paralysis of one side of the body) affecting right dominant side. Review of Resident #11's Quarterly MDS dated [DATE] reflected that Resident #11 had a severe cognitive impairment with a BIMS score of 00. Resident #11 was totally dependent…

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, interviews, and record review, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for one of three (2600 Hall Treatment Cart) treatment carts reviewed for medication storage. The facility failed to ensure the 2600 Hall Treatment Cart was locked when unattended. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversion. Findings include: Observation on 09/14/23 at 10:20 AM, the 2600 Hall Treatment Cart unlocked which was determined by the lock not being pushed in. The 2600 Hall Treatment Cart was unattended in the hall and was not completely facing the resident room. LPN A exited a resident's room and took the soiled linens to the soiled linen closet and left the treatment cart unlocked. The Nurse Practitioner was near the cart and stated LPN A was working from the cart. Interview on 09/14/23 at 10:27 PM…

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 a right to personal privacy for 1 of 6 residents (Resident #1) reviewed for personal privacy. The Nurse practitoner and LPN A failed to provide privacy for Resident #1 during wound care and incontinent care. This failure could place residents at risk for low self-esteem, loss of dignity, and decreased quality of life due to a lack of privacy during their care . Findings included: Record review of Resident #1's electronic face sheet, undated, revealed the resident was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included hyperlipidemia (elevated level of lipids) and esophageal reflux disorder (when your stomach contents come back up into your esophagus). Record review of Resident #1's initial MDS assessment, dated 09/11/23, revealed Resident #1's BIMS score was 14, which indicated his cognition was intact. The initial MDS had not been completed regarding toileting. Record review…

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 a safe, functional, sanitary, and comfortable environment for 11 of 6 (Resident #2) residents' bathrooms reviewed for environment. The facility failed to ensure Resident #2's bathroom was clear of soiled linens This failure could place residents at risk of an unsafe or uncomfortable environment and a decrease in quality of life and self-worth. Findings included: Record review of Resident #2's electronic face sheet undated, revealed Resident #2 was a [AGE] year-old male, who admitted to the facility initially on 12/14/20 and re admitted on [DATE] with diagnosis of epilepsy (a chronic noncommunicable disease of the brain), Angina pectoris (chest pain or discomfort that keeps coming back), and metabolic encephalopathy (is caused by a chemical imbalance in the blood). Review of Resident #2 quarterly MDS assessment completed 06/27/23 revealed a BIMS score of 13 which indicated the resident was cognitively intact. Review of Section G…

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 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 (carpet throughout facility and rooms [ROOM NUMBER]) observed for a clean environment. The facility failed to ensure that the facility carpet and resident rooms were cleaned daily, and in accordance with the facility's Housekeeping Checklist. This deficient practice could negatively impact the facility's ability in preventing the spread of disease-causing organisms in residents' living areas and does not present a Clean Homelike Environment. Findings include: Observation on 08/29/23 at 09:00 AM revealed, the carpeted portion of the floors throughout the entire facility was heavily stained with dark dirt and grime. Observation on 08/29/23 at 11:14 AM of room [ROOM NUMBER] revealed the corners of the resident room floor had old dried-up dirt along the edges of the room…

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, 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 the Iced Tea dispenser, prepared for residents, was covered, and sealed from air-borne diseases. The facility failed to ensure the Ice machine, Ice Scooper, and Ice Scooper Holder was clean and sanitary. These failures could place residents at risk for cross contamination and other air-borne illnesses. Findings include: Observations on 08/29/23 at 12:30 PM in the kitchen include: Ice Machine was dirty on the inside of the ice machine and the machine was filled with ice. The top portion, over the ice, had dirt on the inner white plastic part of the machine that was over the ice and the Ice Machine door had a lot of old dirt particles in the springs of the door hinge. The Ice Machine Scoop was dirty, as it sat in the Ice Machine Scoop Holder, which was dirty on the inside and had a dark wet mud…

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.