The Reserve At Richardson

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 of four residents (Resident #85) reviewed for feeding tube management. The facility failed to ensure LVN B checked Resident #85's gastric residual and g-tube placement before flushing and administering medications on 05/20/2026. This failure could place residents with g-tubes at risk for tube displacement, clogging, aspiration, and discomfort.Findings included: Record review of Resident #85's Face Sheet, dated 05/21/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with gastrostomy status (having done a surgical procedure that creates artificial opening into the stomach to provide nutritional support). Record review of Resident #85's Comprehensive MDS Assessment, dated 05/15/2026, reflected that the resident had severe impairment in cognition with a BIMS score of 00. 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 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 two of ten residents (Residents #46 and Resident #87) reviewed for respiratory care. 1.The facility failed to ensure Resident #46's nasal cannula was stored properly when not in use on 05/21/2026.2.The facility failed to ensure Resident #87's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) was stored properly when not in use on 05/20/2026. These failures could place residents at risk for respiratory infection and not having their respiratory needs met.Findings included: 1.Record review of Resident #46's Face Sheet, dated 05/21/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with shortness of breath. Record review of Resident #46's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one of ten residents (Resident #67) reviewed for pharmaceutical services. The facility failed to dispose of Resident #67's expired insulin on 05/21/2026. This failure could place residents at risk of not receiving the medication's full therapeutic benefits and not receiving medications as ordered resulting to adverse effects.Findings included: Record review of Resident #67's Face Sheet, dated 05/21/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with diabetes mellitus (high blood sugar). Record review of Resident #67's Comprehensive MDS Assessment, dated 04/01/2026, reflected that the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated…

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, in accordance with accepted professional standards and practices, the facility failed to maintain medical records on each resident that are complete; accurately documented; readily accessible; and systematically organized for for 2 (Resident #20 and Resident #66) of 5 residents reviewed for Advanced Directives. The facility failed to ensure that Resident #20 and Resident #66's OOH-DNR (Out of Hospital-Do Not Resuscitate) were completed correctly with both signatures not meeting the criteria for a qualified witness, making the forms invalid. This failure could affect all residents who have implemented an Advanced Directive and established their choice not to be resuscitated at the risk of receiving CPR (Cardiopulmonary Resuscitation) against their wishes.Findings included: Record review of Resident #20's face sheet dated [DATE] reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnosis included unspecified dementia, (a clear…

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 resident had a right to confidentiality of his or her personal and medical records for one (Resident #1's) of ten residents reviewed for privacy and confidentiality. The facility failed to ensure ADON A did not leave Residents #1's medical information exposed and unattended on top of the nurse's station countertop on 12/02/2025. This failure could place the residents at risk of their medical information being accessed by unauthorized individuals.Findings included: Record review of Resident #1's Face Sheet, dated 12/02/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with depression (persistent feeling of sadness or loss of interest). Record review of Resident #1's Comprehensive MDS (assessment used to determine functional capabilities and health needs) Assessment, dated 11/30/2025, reflected the resident was unable to complete the interview to determine the BIMS (screening…

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 store all drugs and biologicals in a locked cart or under direct observation of authorized staff in an area where residents could access it for one (Nurse Cart) of one cart reviewed for medication storage. The facility failed to ensure that LVN B locked the nurse cart before leaving it unattended on 12/02/2025. This failure could place the residents at risk of accessing/opening the cart causing accidental overdose, adverse reactions, or misuse of medications.Findings included: Observation on 12/02/2025 at 10:04 AM, revealed a nurse medication cart was parked outside the nurse's station unlocked. The cart and the drawers were facing the hallway, the drawers contained medications. It was observed that a resident in a wheelchair was sitting approximately ten steps from the open cart. During an observation and interview on 12/02/2025 at 10:06 AM, MA C saw the cart and locked it. She said the cart was used by the nurses, but she was not sure who was currently using it. She said the cart should always be locked…

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 three (Residents #1, #2, and #3) of ten residents reviewed for Reasonable Accommodation of Needs. The facility failed to ensure the call light systems in Residents #1, #2, and #3's rooms were in a position that was accessible to the resident on 06/18/2025. 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: Resident #1 Record review of Resident #1's Face Sheet, dated 06/18/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness and lack of coordination. Record review of Resident #1's Quarterly MDS (assessment used to determine functional capabilities and health needs) Assessment, dated 05/27/2025, reflected the resident had a severe…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #6) of one residents reviewed for Respiratory Care. The facility failed to ensure Resident #6's breathing mask for his nebulizer (a medical device that turns liquid medicine into mist that could be inhaled through a face mask) was properly stored when not in use on 06/18/2025. This failure could place residents at risk for respiratory infection and not having their respiratory needs met. Findings include: Record review of Resident #6's Face Sheet, dated 06/18/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with asthma (lung disorder caused by narrowing of the airways) and shortness of breath. 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 observations, interviews, and record review, the facility failed to ensure that drugs and biologicals were stored in locked compartments for two (Resident #4 and Resident #5) of two residents reviewed for Storage of Drugs and Biologicals. The facility failed to ensure that no medications were inside Resident #4 and Resident #5's room. This failure could place the residents at risk of overdose or misuse of medications. Findings included: Resident #4 Record review of Resident #4's Face Sheet, dated 06/18/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with nasal congestion, rashes, and bipolar disorder (a mental health condition that causes extreme mood swings between emotional highs and lows). Record review of Resident #4's Comprehensive MDS Assessment, dated 05/06/2025, reflected the resident was cognitively intact (capable of normal cognition and needs little support) with a BIMS score of 15. The Comprehensive MDS Assessment indicated that 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 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 one (Resident #5) of 1 resident reviewed for Infection Control. The facility failed to ensure CNA D performed hand hygiene and changed her gloves while providing incontinent care to Resident #5 on 06/18/2025. This failure could place residents at risk of cross-contamination and development of infections. Findings included: Record review of Resident #5's Face Sheet, dated 06/18/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with diarrhea (loose bowel movement). Record review of Resident #5's Comprehensive MDS Assessment, dated 05/29/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated that 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 develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to attain or maintain the resident's highest practicable mental and psychosocial well-being for 3 of 8 residents (Resident #2, #74, and #182) reviewed for Care Plans. 1. The facility failed to ensure Resident #2 was care planned for oxygen administration. 2. The facility failed to ensure Resident #74 was care planned for condom catheter and hospice care. 3. The facility failed to ensure Resident #182 was care planned to use the call light to alert staff. These failures could place residents at risk of not receiving the necessary care and services needed. Findings include: 1. Record review of Resident #2's Face Sheet, dated 03/11/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with emphysema (a lung disease that damages the air…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 4 of 8 residents (Resident #2, #19, #39, and #67) reviewed for Respiratory Care. 1. The facility failed to ensure Resident #2 had an order for oxygen administration on 3/11/2025. 2. The facility failed to ensure Resident #19's mask for CPAP was stored properly on 3/11/2025. 3. The facility failed to ensure Resident #39's oxygen tubing was properly stored when not in use on 03/11/2025. 4. The facility failed to ensure Resident #67's CPAP mask, for the CPAP machine was placed in a sanitary bag to avoid contamination while not in use and had active physician orders for use of the CPAP machine. These failures could place residents at risk for respiratory infection and not…

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, distributed, and serve food in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food and nutrition services. 1. The facility failed to ensure the ice scoop for the ice machine in the facility kitchen was cleaned and not stored inside the ice machine. 2. The facility failed to cover a large trash can stored in the kitchen area. 3. The facility failed to ensure kitchen cooking equipment was cleaned. 4. The facility failed to place a cover on top of the tea dispenser to avoid air borne contaminants. These failures could place residents at risk for cross contamination and other air-borne illnesses. Findings include: Observations on 03/11/25 from 9:04 AM to 9:17 AM in the facility's only kitchen revealed: The ice machine, located in the kitchen, had the ice scoop stored inside of the machine with the ice and the ice scoop had brownish stains on it. One large trash can, which contained food and trash, in the kitchen area, was uncovered. One…

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 each resident with respect, dignity, and care in a manner and environment that promoted maintenance or enhancement of his or her quality of life for one (Resident #58) of nineteen residents reviewed for Dignity. The facility failed to ensure CNA C pulled the privacy bag all the way down on Resident #58's catheter bag (collects urine from the urinary bladder) so the catheter bag and its content would not be visible during lunchtime on 03/11/2025. This failure could place the residents at risk of not having their right to a dignified existence maintained. Findings included: Record review of Resident #58's Face Sheet, dated 03/11/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with obstructive and reflux uropathy (a blockage in the urinary tract). Record review of Resident #58's Quarterly MDS Assessment, dated 01/27/2025, reflected the resident had a moderate 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 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 one of (Resident #19) eight residents reviewed for Revised Care Plans. The facility failed to complete a quarterly care plan for Resident #19. These failures placed residents at risk of needs not being met. Findings included: Record review of Resident #19's Face Sheet, dated 03/11/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with obstructive sleep apnea (a sleep disorder where breathing is interrupted repeatedly during sleep). Record review of Resident #19's Quarterly MDS Assessment, dated 01/30/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 01 (resident required significant assistance and support in daily life). The Quarterly MDS Assessment indicated that the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure that residents' environment remained free of accident hazards as was possible for 1of 6 residents (Resident #25) reviewed for accident prevention. The facility failed to ensure resident #25 had physician orders for the bolster pads that were applied to her mattress for fall prevention. This failure could prevent the resident from having an environment that was free and clear of accidents and hazards. Findings include: Record review of Resident #25's Face Sheet, dated 03/11/25, reflected she was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses included unsteadiness on feet, dementia (cognitive decline), and history of falling. Record review of Resident #25's Quarterly Minimum Data Set (MDS) assessment, dated 02/28/25, reflected she had a BIMS score of 00 (severe cognitive impairment). For ADL care it reflected for transfers, toileting, and bathing and the resident was totally dependent for assistance. 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 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 (Resident #74) two residents reviewed for Catheter Care. The facility failed to ensure that Resident #74's external catheter (non-invasive to collect urine from the bladder such as a condom catheter) had an order on 03/11/2025. This failure could place residents at risk of needs for catheter care not met. Findings included: Record review of Resident #74's Face Sheet, dated 03/11/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with unstageable pressure ulcer to the sacrum (unable to determine the depth of the pressure ulcer). Record review of Resident #74's Quarterly MDS Assessment, dated 01/26/2025, reflected the resident was cognitively intact with a BIMS score of 13 (resident capable of normal cognition…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure that one (Probiotics) of one medication reviewed for Medication Storage was stored properly. 1. The facility failed to ensure MA F administered Resident #26's probiotics that was properly stored. 2. The facility failed to ensure LVN E administered Resident #46' probiotics that was properly stored. These failures could place the residents at risk of not receiving the full benefit of the medications or supplement. Findings included: 1. Record review of Resident #26's Face Sheet, dated 03/12/2025, reflected a [AGE] year-old female admitted on [DATE]. The resident was diagnosed with constipation and nausea. Record review of Resident #26's Comprehensive MDS Assessment, dated 02/03/2025, reflected the resident had a moderate impairment in cognition with a BIMS score of 11 (assessment tool that provides insight into the resident's cognition). The Comprehensive MDS Assessment also indicated the resident had medically complex conditions.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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 one (Resident #34) of eight residents reviewed for Infection Control. The facility failed to ensure CNA B changed his gloves after touching the drainage tubing of Resident #72's Foley catheter (device that drains urine from the urinary bladder) during incontinent care on 03/11/2025. This failure could place residents at risk of cross-contamination and development of infections. Findings included: Record review of Resident #72's Face Sheet, dated 03/11/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with obstructive and reflux uropathy (a blockage in the urinary tract that cause the urine to flow back to the kidney). Record review of Resident #72's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for two (Resident #12 and Resident # 135) of three residents reviewed for wounds. 1) Resident #12's skin tear to her right forearm was not monitored after she received it on 02/06/24. 2) LVN E failed to treat Resident# 135's wounds on 02/11/24. This failure could place residents at risk for delays in treatment, developing infections and unidentified deterioration of their wounds. Findings included: 1) Review of Resident #12's MDS quarterly assessment, dated 01/03/24, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her cognitive status was moderately impaired. Her diagnoses included stroke and Parkinson's disease. Review of Resident #12's Progress Notes dated 02/06/24 at 6:09 PM written by LVN B reflected the: Resident skin is dry and warm to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to immediately notify, consistent with his or her authority, the resident representative(s) when there was an accident involving the resident which resulted in injury and had the potential for requiring physician intervention for one (Resident #12) of three residents reviewed for injuries. The facility failed to notify Resident #12's family after the resident was injured and sustained a skin tear to her right forearm that required ster-strips on 02/06/24. This failure could result in family members and resident representative's not receiving notification of resident injuries. Findings included: Review of Resident #12's MDS quarterly assessment, dated 01/03/24, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her cognitive status was moderately impaired. Her diagnoses included stroke and Parkinson's disease. Review of Resident #12's Progress Note dated 02/06/24 at 6:04PM written by LVN B reflected: Resident skin is dry and warm…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 2 of 4 residents (Resident #135 and Resident #77) reviewed for pressure injury. 1. LVN E failed to treat Resident #135's and Resident #77's wounds on 02/11/24. 2. The WCN failed to ensure Resident #77's head wound was not exposed to infection and contamination when she laid the resident's head on his pillow after cleaning the wound. These failures could place residents at risk for deterioration of wound. Findings included: 1. Review of Resident #77's quarterly MDS assessment, dated 02/03/24 reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His cognitive status was intact. His diagnoses included wound infection, and sacral pressure ulcer. Review of Resident #77's WCP notes, dated 02/07/24, 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.

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 that food items past their expiration date were discarded. This failure could place residents at risk for food borne illness. Findings included: Observation and interview with the Dietician on 02/13/24 at 10:30 a.m. while conducting a tour of the facility refrigerated storage area with Dietician, a 16-ounce container of Beef Bullion paste that had a date reading 11/07/23, no other date was observed on the container. The container was found to have been opened on an unknown date. Dietician explained that the date on the container was the date that the facility had received the Beef Bullion paste and that most pre-packaged containers were expected to be ok for consumption for 90 days after they have been opened. The Dietician immediately discarded the container in front of the investigator. In an interview on 02/15/24 at 2:12 PM with the Dietician she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 1 (Resident #3) of 8 residents reviewed for infection. 1. The facility failed to ensure CNA A performed hand hygiene during incontinence care for Resident #3. This failure could cause residents to suffer from infection. Findings included: 1. Review of Resident #3's Face Sheet dated 02/6/24, reflected she was a [AGE] year-old female admitted on [DATE]. Her diagnoses included dementia. An observation and interview on 02/14/24 at 2:26 PM revealed CNA A was preparing to perform incontinence care for Resident #3. CNA A washed his hands and put on gloves. The resident was in bed lying on her back. CNA A folded down the front of the brief and cleaned the peri-area. The resident was assisted to reposition to her right…

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.