The Plaza At Richardson

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately for 1 of 4 residents (Resident #1) reviewed for reporting, in that: The facility failed to report the allegation of neglect for Resident #1 to the State Agency within required reporting timeframes. This failure could place residents at risk ongoing abuse or neglect. Findings included: Review of Resident #1's face sheet dated 05/13/2025 revealed an [AGE] year-old female admitted to the facility on [DATE] with a readmission on [DATE]. Admitting diagnosis of other fracture of lower end of the left femur, subsequent encounter for closed fracture with routine Healing (bone breaks, but there is no break in the skin over the injury; cast change or removal of external or internal fixation device, medication adjustment, other aftercare, and follow-up injury…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility for 3 residents (Resident #1, Resident #2, and Resident #3) of 4 residents reviewed for discharge planning. -The facility failed to provide or document sufficient preparation for an orderly discharge of Resident #1 to a private residence and Resident #2 and Resident #3 to a nursing facility. This failure could place residents at risk of not receiving care and services to meet their needs upon discharge, which could cause physical and emotional harm. Findings included: Record review of Resident #1's face sheet, dated 09/27/24, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] and discharged on 09/16/24 with diagnoses that included: vascular dementia (loss of memory and thinking caused by a stroke), depressive episodes (mood disorder), heart disease, cerebral infarction (stroke),…

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 develop and implement an effective discharge planning process that focused on a resident's discharge goals and allowed the resident to be an active partner in the transition and development of a discharge plan for 3 residents (Resident #1, Resident #2, and Resident #3) of 4 residents reviewed for discharge planning. - The facility failed to prepare and involve Residents #1, #2, and #3 and responsible parties in an effective discharge planning process. This failure could place all residents at risk of not being an active part in their goals and discharge planning process, which could result in an unsafe discharge, and decreased quality of life. Findings included: Record review of Resident #1's face sheet, dated 09/27/24, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] and discharged on 09/16/24 with diagnoses that included: vascular dementia (loss of memory and thinking caused by a stroke), depressive episodes…

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 identify a Grievance Official who was responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions, and leading any necessary investigations by the facility for 1 of (Resident #1) of 3 residents reviewed for grievances. 1. The facility failed to ensure the Grievance Official was aware of a grievance for Resident #1. The Grievance Official failed to investigate a grievance for Resident #1. The facility's failure could place the residents at risk for concerns not being reported and addressed. Findings included: Review of Resident #1's MDS quarterly assessment, dated 07/26/24, reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Her BIMS score was 3. Her cognitive status was severely impaired. Her diagnoses included Non-Alzheimer's Dementia (decline in cognitive abilities that can affect a person's ability to think, remember, and make decisions). Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, 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 (Resident #35) of 8 residents reviewed for pharmacy services. The facility failed to obtain the routine scheduled pain medication for Resident #35, who was to receive it every 4 hours, from her hospice company. Resident #35 missed 7 doses of her scheduled pain medication placing her at risk for unnecessary pain. The medications were received after surveyor inquiry. This failure could place residents who require pain medication at risk of suffering pain due to lack of medication availability. Findings included: Record review of Resident #35's admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #35's Quarterly MDS assessment dated [DATE] revealed her diagnoses included…

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

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 reviewed for food and nutrition services. 1. The facility failed to ensure foods in the refrigerator, freezer, and dry storage were properly stored, labeled, and dated. These failures could place residents at risk for food borne illness. Findings included: Observation of the facility's only kitchen on 05/07/24 at 8:37 AM, revealed the following: -1 opened jar of barbeque sauce in dry storage that had instructions to refrigerate after opening, -1 opened and exposed 25-pound bag of brown sugar, -1 plastic cup filled with peaches in the reach-in refrigerator that was covered but was not labeled or dated, -4 tomatoes in the walk-in refrigerator that appeared to be rotten with visible bruising and open holes in the flesh, -1 opened jar of jalapenos in the walk-in refrigerator that had a black substance around the lid and had a written expiration date of 11/2023, -1 opened container 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 the resident environment remained as free of accident hazards as possible for one (Resident #42) of six residents reviewed for accidents and hazards. The facility failed to ensure Resident #42 did not have access to a disposable razor. This failure could place residents at risk of injury or harm, as well as contribute to avoidable accidents. Findings included: Review of Resident #42's Face Sheet, dated 05/09/24, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. Review of Resident #42's MDS Assessment, dated 04/13/24, reflected she had diagnoses including stroke (damage to the brain from interruption of its blood supply), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Resident #42 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for one of five residents (Resident #32) reviewed for infection control. CNA C failed to perform hand hygiene while providing incontinence care to Resident #32 and between resident rooms. This failure could place the residents at risk for infection. Findings included: Record review of Resident #32's admission Record dated 05/09/24 revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. Record review of Resident #32's Quarterly MDS assessment dated [DATE] revealed he had severe cognitive impairment, he had impaired range of motion of his arm and leg on one side and required maximum assistance with toileting and personal hygiene. The MDS Assessment reflected his diagnoses included hypertension (high blood pressure); peripheral vascular disease or peripheral arterial disease (reduced blood flow to arms and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure each resident was treated with respect, dignity, and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for two (Residents #25 and #218) of eighteen residents reviewed for resident rights and dignity. 1. The facility failed to treat Resident #218 with dignity and respect during the discharge process from the facility to the resident's home. 2. The ADON failed to ensure Resident #25 was provided with a dignified dining experience, when she stood over him as she was assisting him in eating a lunch meal service. This failure could place residents at risk for a loss of dignity, decreased self-worth, and decreased self-esteem. Findings included: 1. Review of face sheet dated 05/10/24 documented Resident #218 was a [AGE] year-old female previously admitted on [DATE] and currently admitted on [DATE] with diagnoses of Alzheimer's disease, Anemia, Type 2 Diabetes Mellitus with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, but no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury to the administrator of the facility and to other officials, including to the State Survey Agency, in accordance with State law through established procedures for one of one resident (Resident #1) reviewed for abuse. The facility failed to report an allegation of sexual abuse of Resident #1 that occurred on 03/23/24 by CNA A, to the State Survey Agency within 2 hours of being notified. This failure could place residents at risk of abuse. Findings included: Record review of Resident #1's face sheet, dated 03/28/24, reflected Resident #1 was a [AGE] year-old male, who was admitted to the facility on [DATE]. Resident #1 had diagnoses of Parkinson's Disease (brain disease that causes uncontrollable…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurableobjectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 4 residents, (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1's care plan was updated to reflect the resident's diagnosis of prostate cancer. This failure could place the residents at risk of not receiving adequate care. Findings included: Record review of Resident #1's face sheet, dated 03/28/24, reflected Resident #1 was a [AGE] year-old male, who admitted to the facility on [DATE]. Resident #1 had a diagnoses which included Parkinson's Disease (brain disease that causes uncontrollable and unintended movements), Dysphagia (difficulty swallowing), Cognitive Communication Deficit (difficulty with talking and language…

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 menus were followed for 10 of 10 residents (Resident #5, #17, #24 #27, #34, #42, #46, #43, #45, and #48) reviewed for menus meeting resident needs. 1. The facility failed to ensure the menu was followed and residents (Resident #5, #17, #24 #27, #34, #42, #46, #43, #45, and #48) were served pork sausage, scrambled eggs and waffles for breakfast instead of a choice of cereal, bacon, scrambled eggs and toast as indicated on the breakfast menu . 2. The facility failed to ensure the menu was followed and residents (Resident #5, #17, #24 #27, #34, #42, #46, #43, #45, and #48) were served turkey with gravy, green beans, cornbread and frosted orange cake, instead of red beans and sausage, steamed rice, mixed greens, cornbread and frosted orange cake as indicated on the lunch menu . These deficient practices could place residents at risk by contributing to dissatisfaction, poor intake, and/or weight loss. The findings were: 1. Record review of the menu matrix, dated September 15, 2022, signed by the registered…

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 (1 of 1) kitchen where all facility food was prepared. The facility failed to ensure food was dated and not expired in their kitchen. This failure could place residents at risk for food contamination and food-borne illness. Findings include: Observation on 03/20/23 at 9:22AM of the walk in refrigerator in the kitchen revealed 6 bags which contained 12 hamburger buns in each bag with no expiration date, 2 bags of honey wheat bread with no expiration date and 14 bags of hotdog buns with 12 hot dog buns in each bag with no expiration date. Observation on 03/21/23 at 9:30 AM of the walk-in refrigerator revealed 14 bags of hot dog buns, 6 hamburger bun bags and 2 loafs of bread which were not dated with expiration dates. Interview at 9:43 AM on 03/20/23 with the Dietary Manager, who stated today was his first day and he did not know what he had walked into. The Dietary Manager stated it was no…

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, based on the comprehensive assessment and care plan, and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 08 of 10 residents (Residents #5, #17, #27, #34, #42, #43, #45, and #46 ) reviewed for activities. 1. The facility failed to provide activities to residents who resided in the facility. 2. The facility failed to provide activities to residents who resided on the facility's secured unit. These failures could place residents at risk for decline in social and mental psychosocial well-being due to the lack of ongoing activities. Findings include: 1. Observation on 3/20/23 revealed no activities took place in 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 interview and record review the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activity professional for one (the Activity Director) of one Activity Director reviewed for qualifications. The facility failed to ensure the Activity Director was a qualified therapeutic recreation specialist or an activities professional that met state licensing requirements. This failure could place residents at risk for a reduced quality of life due to lack of activities that were individualized to match the skills, abilities, and interests/preferences of each resident. Findings include: Observation on 3/20/23 revealed no activities took place in the common area or residents rooms between 9:00 AM to 3:00 PM . Observation on 03/21/23 at 2:45 PM revealed no March activity calendar posted in residents' rooms. Observation on 03/21/23 at 3:00 PM revealed no March activity calendar were posted in common areas. Observation on 3/21/23 revealed no activities in common area or resident's rooms took…

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 ensure, except when waived, they used the services of a registered nurse for at least eight consecutive hours a day, 7 days a week (for 26 days out of 90 days reviewed) and designate a registered nurse to serve as the director of nursing on a full-time basis (from 12/11/22 to 1/4/23 and 2/6/23 to 3/8/23). 1. The facility failed to designate a Registered Nurse to serve as the Director of Nursing on a full-time basis from 12/11/22 to 1/4/23 and 2/6/23 to 3/8/23. 2. The facility failed to employ a Registered Nurse to provide eight consecutive hours of RN coverage, seven days a week for 26 days between 12/01/22 to 03/19/23. These deficient practices could place residents at risk of leaving staff without supervisory coverage for RN specific nursing activities and for coordination of events such as emergency care and disasters. Findings include: 1. Record review of an undated and untitled sheet of paper, provided by the RNC, on 03/23/23, reflected the facility had a designated DON on the following dates: - DON Z 9/26…

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 act upon the recommendations of the pharmacist report of irregularities for three residents (Residents #40, #37 and #26) of five residents reviewed for (DRR) Drug Regimen Review. 1. The facility failed to follow-up on a recommendation from the pharmacist regarding Resident #40's PRN psychotropic medications (Haldol [Haloperidol] and Lorazepam). 2. The facility failed to follow-up on a recommendation from the pharmacist regarding Resident #40's medications (lactobacillus, hyoscyamine, and baclofen) that were listed to be given orally although the resident was NPO. 3. The facility failed to follow-up on a recommendation from the pharmacist regarding Resident #37's Depakote and Risperidone when the diagnoses were not approved indications. 4. The facility failed to follow-up on a recommendation from the pharmacist regarding Resident #37's Risperidone and Depakote GDR's that were due. 5. The facility failed to follow-up on a recommendation from 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 interview and record review, the facility failed to ensure residents' drug regimens were free from unnecessary drugs for three (Residents #40, #37 and #2) of five residents whose records were reviewed for psychotropic drugs, in that: 1. Resident #40 had an order for the antianxiety medication lorazepam as needed on 08/10/22 and the order did not include an end date after 14 days. 2. Resident #40 had an order for the antipsychotic medication haloperidol as needed on 11/08/22 and the order did not include an end date after 14 days. 3. Resident #37 had an order for the antipsychotic medication Risperdal for a diagnosis of unspecified psychosis, which was not an appropriate indication for use. 4. Resident #37 had an order for the anticonvulsant medication Depakote for a diagnosis of unspecified dementia, which was not an appropriate indication for use. 5. Resident #2 had an order for the antianxiety medication lorazepam as needed on 12/06/22 and the order did not include an end date after 14 days. These…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that the medication error rate was not 5% or greater. The facility had a medication error rate of 27%, based on 18 errors of 66 opportunities, which involved two of six residents (Residents #12 and #14) and 1 of 2 staff observed during medication administration for medication errors. The facility failed to ensure the medications were administered per the physician orders for Residents #12 and #14. This failure could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. The findings include: 1. A record review of Resident #12's face sheet, dated 3/23/23, revealed an admission date of 7/22/19 with diagnoses which included Covid 19, hypertension, pain, anemia, anxiety, type 2 diabetes, major depressive disorder, and vitamin D deficiency. A record review of Resident #12's annual MDS assessment, dated 3/5/23, revealed Resident #12 was an [AGE] year-old male with 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 medical records on each resident that are complete, accurately documented and readily accessible for three (Residents #36,#34, and #40) of five residents reviewed for clinical records. 1. The facility failed to document on Resident #36's MAR/NAR that he had received his prescribed medications. 2. The facility failed to document on Resident #34's MAR/NAR that he had received his prescribed medications. 3. The facility failed to ensure that Resident #40's physician's orders for lactobacillus, hyoscyamine, and baclofen were written to be given NPO and not orally. This failure could place residents at risk of inaccurate medical records that could affect monitoring and medical services provided. Findings included: 1. Review of Resident #36's face sheet, dated 03/23/23, reflected he was a [AGE] year-old male who originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included seizures, osteomyelitis, 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 record review and interview, the facility with more than 120 beds, failed to employ a qualified social worker on a full-time basis for one of one Social Worker reviewed employment , in that: The facility, licensed for 124 beds, did not employ a full-time, qualified social worker since 02/28/23. This deficient practice could result in residents' social service needs not being met. The findings included: Record review of facility's license revealed the facility had a licensed capacity of 124 residents. Record review of the Facility Assessment, last revised 01/28/23, under Part 3: Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies reflected: 3.1 Identify the type of staff members, other health care professionals, and medical practitioners that are needed to provide support and care for residents .Administration (e.g., Social Services). Review of the facility's employee list revealed the SW's name crossed out with no longer here above that area. Review of the SW's personnel file revealed she was hired 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 observation, interview, and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for two (Residents #36 and #16) of eight residents observed for infection control. 1. The facility failed to ensure CNA B completed hand hygiene while performing incontinent care for Resident #16. 2. The facility failed to ensure LVN U performed hand hygiene while performing wound care for Resident #36. These failures could place the residents at risk for infection. Findings include: 1. Review of Resident #16's face sheet, dated 03/23/23, reflected she was an [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnosis included Alzheimer's, difficulty walking, type 2 diabetes, dementia, and muscle weakness. Review of Resident #16's most recent Quarterly MDS Assessment, dated 03/04/23, reflected he had a BIMS score of 00 indicating severe impaired cognition. The review further 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, interview, and record review the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity for one (Resident #34) of three residents reviewed for dignity in that: The facility failed to ensure Resident #34's urinary catheter drainage bag had a dignity/privacy cover. This deficient practice affected residents who had indwelling urinary catheters and placed them at risk for dignity. The findings include: Review of Resident #34's face sheet, dated 03/23/23, reflected he was a [AGE] year-old male who originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. His diagnoses included major depressive disorder, retention of urine, and generalized anxiety disorder. Review of Resident #34's most recent Significant Change in Status MDS assessment, dated 02/27/23, reflected a BIMS score of 15 indicating no cognitive impairment. Review of Resident #34's care plan did not address the use of a privacy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide pharmaceutical services to include procedures that assured the accurate dispensing and administering of all drugs to meet the needs of 1 of 5 residents (Resident #40) reviewed for medication administration in that: The facility failed to ensure medications via feeding tube were not crushed and mixed together when being administered to Resident #40. This deficient practice could affect residents and place them at risk of not receiving the therapeutic dosage and drug diversion. Findings included: Review of Resident #40's face sheet, dated 03/23/23, reflected he was a [AGE] year-old male who originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included anoxic brain damage, persistent vegetative state, and tachycardia . Review of Resident #40's physician's orders reflected: Enteral Feed Order every shift Isosource 1.5 continuous feed @ 60 ml/hr for 22 hours via g tube. Observation on 03/20/23 at 09:20…

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 interviews, the facility failed to assure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, for one (Resident #40) of five residents reviewed for labeling and storage, in that: The facility failed to ensure Resident #40's tube feeding formula was labeled with the correct resident's name on it. This deficient practice could affect residents prescribed medications in the facility and place them at risk for not receiving the correct medications. Findings included: Review of Resident #40's face sheet, dated 03/23/23, reflected he was a [AGE] year-old male who originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included anoxic brain damage, persistent vegetative state, and tachycardia . Review of Resident #40's physician's orders reflected: Enteral Feed Order every shift Isosource 1.5 continuous feed @ 60 ml/hr for 22 hours via g tube. Observation on 03/20/23 at 10:00 AM of Resident #40…

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 2 of 10 residents (Resident #45 and #43) reviewed with food prepared in a form designed to meet individual needs a physician ordered therapeutic diet. 1. The facility failed to follow Resident #43 physician ordered for no pork. 2. The facility failed to follow Resident #45 dietician ordered mechanical soft texture as ordered by the dietician. These deficient practices could place residents at risk of weight loss or other medical problems. Findings included: 1. Record review of Resident #43's face sheet, dated 03/23/23, revealed the resident was initially admitted to the facility on [DATE] and was readmitted on 06/2022 with diagnoses which included Type 2 diabetes (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel.) and gastroesophageal reflux disease without esophagitis (occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach) 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.