Rockwall Nursing Care Center

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 reside and receive services with reasonable accommodate of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 3 of 4 residents (Residents #1, #3 and #4) reviewed for accommodation of needs. The facility failed to place Residents #1, #3 and #4's call-lights within reach. This failure could place residents at risk of not having their needs and preferences met and a decreased quality of life.Findings include: 1. Record review of Resident #3's face-sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included: Unspecified dementia with agitation (a person experiencing memory loss and mental decline alongside significant emotional or physical restlessness) Record review of Resident #3's quarterly MDS, dated [DATE], revealed the resident had minimal difficulty hearing, functional limitations…

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 housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 2 of 4 residents (Resident #2 and #4) reviewed for resident rights. The facility failed to keep the privacy curtain for Resident #2 and Resident #4 in clean and sanitary condition. This failure could place residents at risk of an unsafe, unsanitary, non-homelike environment and decreased quality of life.Findings include: Record review of Resident #4's face-sheet revealed a [AGE] year-old female who was admitted to facility on 11/25/2016. Her diagnosis included: Alzheimer's Disease (a progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and eventually the ability to carry out simple tasks), Anxiety disorder (a mental health condition characterized by persistent, excessive, and uncontrollable worry or fear that interferes with daily life). Record review of Resident #4's quarterly MDS, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to 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 infection for 2 of 4 residents (Residents #1 and #2) reviewed for infection control. 1. LVN A failed to change gloves when going from dirty to clean task during perineal care of Resident #1's incontinent care. 2. LVN A failed to sanitize his hands after removing his dirty gloves and before donning clean gloves during Resident #2's incontinent care. 3. LVN A failed to sanitize the bedside table and change covering linen when moving the table from Resident #1's room to Resident #2's room. These deficient practices could place residents at risk for cross contamination and/or spread of infection. Findings include: 1. Record review of Resident #1's face-sheet revealed a [AGE] year-old male who was admitted to facility on 09/01/2022.…

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

Based on observation, interview and record review the facility failed to maintain an effective pest control program so the facility was free of pests and rodents for one (Hall 300, the male secure unit) and two of two rooms (Resident #1 and Resident #2's rooms located in Hall 300 male secured unit) reviewed for pest control. The facility failed to ensure Hall 300 to include Resident #1 and #2's rooms were free from gnats. This failure could place residents at risk for the potential spread of infection, cross-contamination, food-borne illness, and a diminished quality of life.Findings include: Observation and interview on 03/13/26 at 12:40 PM to 12:50 PM revealed gnats in Resident #1's room, LVN A and CNA A, both stated gnats were present in the room and stated they called pest control to evaluate the issue, last pest control visit was 03/04/26. Observation and interview on 03/13/26 at 12:55 PM to 1:10 PM revealed gnats in Resident #2's room, LVN A and CNA A, both stated gnats were present in the room and stated they called pest control to evaluate the issue. Interview on 03/13/26 at…

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 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 infection for one of six residents (Resident #1) reviewed for infection control.The facility failed to ensure CNA B wore a gown while providing incontinence care for Resident #1, who was on enhanced barrier precautions (use of gown and gloves during high contact resident care), on 01/07/2026. This failure could place residents at risk of cross-contamination and development of infections.Findings include: Record review of Resident #1's Face Sheet, dated 01/09/2026, reflected a [AGE] year-old female who admitted on [DATE]. Resident #1 had diagnoses which included cervical spina bifida (the spine and spinal cord do not form properly) and paraplegia (loss of ability to move the lower half of the body). Record review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for two (Resident #1 and Resident #2) of 10 residents reviewed for abuse and neglect.The facility failed to ensure Resident #1 was free from abuse when Resident #2 slapped her on the face on 09/20/2025. This failure could place residents at risk of abuse and emotional stress.The findings include: Record review of Resident #1's Face Sheet, dated 09/26/2025, reflected the resident was an [AGE] year-old female who admitted on [DATE]. Resident #1 had diagnoses which included dementia (decline in cognitive function that interferes with daily life), cognitive communication deficit (impacts how a person processes and conveys information), and the need for assistance with personal care. Resident #1 resided in the memory care unit. Record review of Resident #1's Quarterly MDS (tool used to assess health status) 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 observations, interviews, and record review, the facility failed to implement written policies and procedures that prohibited and prevented abuse for 2 (Resident #1 and Resident #2) of 10 resident reviewed for abuse and neglect. The facility failed to implement their policies and procedures to ensure Resident #2 did not slap Resident #1 on the face on 09/20/2025. This failure could place residents at risk of continued abuse and neglect. Findings included: Record review of Resident #1's Face Sheet, dated 09/26/2025, reflected the resident was an [AGE] year-old female who admitted on [DATE]. Resident #1 had diagnoses which included dementia (decline in cognitive function that interferes with daily life), cognitive communication deficit (impacts how a person processes and conveys information), and the need for assistance with personal care. Resident #1 resided in the memory care unit. Record review of Resident #1's Quarterly MDS (tool used to assess health status) Assessment, dated 08/26/2025, 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 ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for two of ten residents (Residents #1, and #2) reviewed for call systems access. The facility failed to ensure the call light system in Resident #1, and #2's rooms was in a position that was accessible to the residents on 10/21/25. 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 include: 1. Record review of Resident #1's Face Sheet, dated 10/21/25, reflected she was an [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included fracture of left femur (thigh bone) and muscle weakness. Record review of Resident #1's Quarterly MDS assessment, dated 10/01/25, reflected a BIMS score of 11,…

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 care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for four of seven residents (Residents #1, #3, and #4) reviewed for respiratory care. The facility failed to ensure Residents #1, #3, and #4 nasal cannulas and breathing devices were properly stored in a bag when not in use on 10/21/25. This failure could place residents at risk for respiratory infection and not having respiratory needs met.Findings include: 1. Record review of Resident #1's Face Sheet, dated 10/21/25, reflected she was an [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included Supraventricular Tachycardia (irregular heartbeat). Record review of Resident #1's Quarterly MDS assessment, dated 10/01/25, reflected a BIMS score of 11, a moderate cognitive impairment. For ADL care, 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 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 (Resident #10, Resident #11, and Resident #12 ) of twenty-two residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #10, #11, and #12's rooms were in a position that was accessible to the residents 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: Resident #10 Record review of Resident #10's Face Sheet, dated 06/17/2025, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE]. Resident #10 had diagnoses which included dementia (decline in cognitive function that interferes with daily life) and cognitive communication deficit (impacts how a person processes and conveys information).…

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 each resident receives adequate supervision and assistance devices to prevent accidents for four (Residents #19, #39, #15, and #10) of 12 residents reviewed for essential equipment. 1. The facility failed to maintain wheelchairs for Residents #19, #39, #15, and #10. These failures could place residents at risk for using equipment that is in unsafe operating condition, that could cause injury. Findings included: Record review of Resident # 19's face sheet dated 01/14/2025 reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included: Dementia (condition characterized by loss of brain functions such as memory loss), muscle weakness (muscle deterioration), and abnormalities of gait and mobility (unable to walk safely). Record review of Resident #19's MDS assessment dated [DATE] revealed he had a BIMS score of 10 which indicated moderate impairment. ADL care reflected resident is totally…

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, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety. 1. The facility failed to ensure food items were labeled and dated with the received or expiration date. 2. The facility failed to ensure expired whipping cream was disposed. 3. The facility failed to discard open items stored in the refrigerator that were not sealed. These failures could place residents at risk for food-borne illness and cross contamination. Findings Included: Observation of drink dispenser on 01/14/2025 at 9:14am revealed the following: -1 3 gallon drink dispenser of unidentified yellow liquid drink. There was no label description or preparation date. Observation of refrigerator #1 on 01/14/2025 at 9:22 am revealed the following: -2 quarts of heavy whipping cream with use by date 01/08/2025 . Observation of refrigerator #3 on 01/14/2025 at 9:28am revealed the following: -1 large zip top bag of ham dated 01/12/2025 exposed 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.

Based on observations, interviews and record reviews the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public for 2 of 12 rooms (Residents #43's and #61's rooms) and 1 of 4 halls (the 300 wing (secure unit) hallway). The facility failed to ensure that there was running water in the sinks, the sinks had functioning drains, safety grab bars were secure to the walls, tiles had no gaps between them exposing the porous flooring beneath and safety handrails had no exposed sharp metal protrusions. These failures could result in residents experiencing falls, skin tears and unable to perform handwashing. Findings included: An observation on 01/14/2025 at 4:07 PM in the bathroom of Resident #43 revealed43 revealed that the safety grab bar facing the toilet was loose from the wall and offered significant movement when pulled upon. The water barrier (a plastic based sheeting designed to repel liquids) next to the toilet had separated from the wall next to the toilet revealing a large gap (approximately 6 inches by 4 inches)…

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 protect the confidentiality of personal and medical records for one (LVN A) of three staff observed for confidentiality of records. The facility failed to ensure LVN A locked and closed the laptop during the medication pass exposing resident on the female locked unit's personal information. This failure could affect residents by placing them at risk for loss of privacy and dignity. The findings included: Observation on 12/19/2024 at 11:55AM revealed the computer on Medication Cart 1 was unlocked and unattended on the female locked unit which displayed resident medications that were being passed. The computer was unattended near the front door of the locked unit while LVN A assisted a resident to the dining table and went to another resident's room. LVN A also walked past the unlocked computer on Medication Cart 1 to assist another resident to a sitting area. Several residents walked past the unlocked computer on Medication Cart 1 which was facing toward the common area. Interview on 12/19/2024 at 11:57AM…

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 review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for accidents and hazards. The facility failed to ensure Resident #1's shoes were on properly to avoid falls. This failure could place residents at risk of their needs not being met. Findings included: Record review of Resident #1's electronic face sheet printed 12/19/2024 revealed an 85 year- old female admitted to the facility on [DATE] with diagnoses that included Alzheimer's (most common cause of dementia, causes brain cells to die over time and the brain to shrink), unspecified abnormalities of gait and mobility, and history of falling. Record review of Resident #1's care plan revised 12/11/2024 revealed focus: risk for falls with intervention that included anticipate needs, ensure footwear worn appropriately when ambulating or mobilizing in wheelchair. Record review of Resident #1's admission…

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 all drugs and biologicals in locked compartments for one (Medication Cart 1) of three medication carts reviewed for medication storage. The facility failed to lock Medication cart 1 leaving all medications on the cart accessible. These failures could place residents at risk for possible drug diversions. Findings included: Observation on 12/19/2024 at 11:55AM revealed the Medication Cart 1 was unlocked and unattended on the female locked unit. The Medication on Cart 1 was accessible to residents and staff on the unit due to the drawers being able to be pulled open. Medication Cart 1 was unattended near the front door of the locked unit while LVN A assisted a resident to the dining table and went to another resident's room. LVN A also walked past unlocked Medication Cart 1 to assist another resident to a sitting area. Several residents walked past unlocked Medication Cart 1 which was facing toward the common area. Interview on 12/19/2024 at 11:57AM with LVN A revealed she had worked in the facility off and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive assessment and quarterly review assessments for one (Resident #1) of four residents were reviewed for comprehensive care plans. The facility failed to ensure the interdisciplinary team revised and reviewed the care plan after each assessment. This failure could affect residents by placing them at risk for not having their individual needs met. Findings included: Record review of Resident #1's Face Sheet printed 11/01/2024, reflected a [AGE] year-old male who was admitted to the facility initially 10/14/2022 and readmitted on [DATE] with diagnoses to include but not limited to Dementia, unspecified severity without behavioral disturbance , psychotic disturbance, mood disturbance ( term used to describe a group of symptoms affecting memory, thinking and social abilities), acute kidney failure( a condition 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, observations, and record reviews the facility failed to obtain laboratory services to meet the needs of its residents for one (Resident #13) of three residents reviewed for laboratory services. The facility failed to collect a urine specimen for a UA for Resident #13 as ordered by the physician on 9/23/24. This failure could place residents at risk for urinary tract infections, renal failure, and pain. Findings included: Record review of Resident #13's quarterly MDS assessment dated [DATE] revealed the resident was [AGE] years old, was admitted to the facility on [DATE], and had a BIMS score of 03 (suggested severe cognitive impairment). The MDS also revealed Resident #13 was frequently incontinent and had a diagnosis of Alzheimer's disease. Record review of Resident #13's care plan, updated on 09/24/24, revealed Resident #13 was incontinent and should be monitored for symptoms of a UTI. Record review of Resident #13's physician order dated 09/23/24 revealed an order to obtain a UA. No other…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure each resident was treated with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality and protected and promoted the rights of the resident for two of five residents (Resident #1 and Resident#2) reviewed for resident rights. The facility failed to ensure Resident #1 was treated with respect and dignity when LVN A slammed her hand on the bedside table and yelled Sit at the resident as she walked passed him. This failure could place residents at risk of a diminished quality of life and loss of dignity and self-worth. Findings include: Record review of Resident #1's electronic face sheet, printed 05/17/2024, reflected Resident #1 was a [AGE] year-old male who was initially admitted to the facility on [DATE] and re admitted on [DATE]. Resident #1 had diagnoses which included dementia, unspecified severity with agitation (impaired…

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 policies, in accordance with applicable, Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that also took into account nonsmoking residents for one of four (Resident #3) residents reviewed for smoking. The facility failed to follow their policy regarding residents who smoke always being supervised When Resident #3 was observed smoking outside without staff supervision. This failure could place residents at risk for smoking-related injuries and fires in the facility. Findings include: Record review of Resident #3's electronic face sheet reflected a [AGE] year-old female who was admitted to the facility initially on 11/06/09 and re admitted [DATE]. Resident #3 had diagnoses which included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), Alzheimer's late onset (progressive mental deterioration that can occur in middle…

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 post on a daily basis information that included the facility name, the current date and the number and the actual hours worked by registered nurses, licensed practical nurses or licensed vocational nurses, certified nurse aides and the resident census for one of twenty -three days (05/17/24) reviewed for nursing services and postings. The facility failed to update the daily staffing information posting on 05/17/24. This failure could place residents at risk of not having access to information regarding staffing data and facility census. The findings include: Observation on 05/17/24 at 3:15 PM of the building revealed the daily nursing staff posting was posted near the front entrance nursing station with a date of 04/23/24. In an interview on 05/17/24 at 3:40 PM with the ADON revealed she was responsible for posting the staffing ratio daily. The ADON stated she usually printed the staffing ratio daily, however, she needed to make corrections to the posting for today (5/17/24). The ADON stated the staffing ratio…

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 right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for three (Resident #65, Resident #1, and Resident #31) of ten residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #65, Resident #1, and Resident #31's rooms was in a position that was accessible to the resident. This failure could place the residents at risk of being unable to obtain assistance when needed and not to get help in the event of an emergency. Findings included: Resident #65 Review of Resident #65's Face Sheet dated 11/14/2023 reflected that resident was a 78 -year-old female admitted on [DATE]. Relevant diagnoses included unspecified chest pain, atherosclerotic (the buildup of fats, cholesterol, and other substances in and on the artery walls) heart disease of native coronary artery without angina pectoris (chest pain), 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 observations, interviews, and record review 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 for 15 (Room#'s 2, 4, 8, 11, 13, 14, 17, 27, 28, 29, 35, 40, 42, 44, and 58) of 22 resident rooms observed for a safe, clean, comfortable, and homelike environment. The facility failed to ensure that resident room #'s 2, 4, 8, 11, 13, 14, 17, 27, 28, 29, 35, 40, 42, 44, and 58 were cleaned, sanitized, and maintained in accordance with the facility's policy on Facility Sanitation. This deficient practice could place residents at risk of infections and living in an uncomfortable environment leading to a decreased quality of life. Findings included: Observation of Resident #40's Room on 11/14/23 at 10:18 AM revealed, the floor had grayish and brownish stains all over the resident's floor and the floor was sticky. Between the resident's bed and the nightstand revealed a dark brownish stain on the floor along the wall. The wall in the same…

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 three (Resident #25, Resident #31, and Resident #44) of ten residents were provided medications and/or biologicals and pharmaceutical services to meet the needs of the residents. The facility failed to ensure MA A re-ordered medications in a timely manner for Resident # 25 (Buspirone 10 mg). The facility failed to ensure LVN S re-ordered medications in a timely manner for Resident #31 (Levothyroxine 25 mcg [microgram]) and Resident # 44 (Levothyroxine 25 mcg). This failure placed the residents at risk of not receiving medications as ordered by the physician. Findings included: Resident #25 Review of Resident #25's Face Sheet dated 11/15/2023 reflected resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included unspecified anxiety disorder and bipolar (a mental health condition that causes extreme mood swings between emotional highs and lows) type of schizoaffective disorder (a mental condition…

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 labeled and dated according to guidelines and in a sanitary manner. The facility failed to ensure kitchen staff were wearing the appropriated hair and/or beard cover while preparing and plating food in the kitchen area. The facility failed to ensure kitchen equipment were clean and sanitary. These failures could place residents at risk for cross contamination and other air-borne illnesses. Findings included: Observation on 11/14/23 at 09:10 AM revealed Kitchen Aide C working in the facility's only kitchen, and he was observed to have a beard that was approximately ¼ inch in length. Kitchen Aide C was observed not to have a beard covering on. Interview with the Dietary Manager on 11/14/23 at 09:10 AM, she was informed 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 observations and interviews, the facility failed to ensure the resident was free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for 1 of 6 (Resident #4) residents reviewed restraints. The facility failed to ensure Resident #4 had physician orders for the scoop mattress (the edges of the mattress are higher than the center of the mattress to keep the resident from rolling off the bed) she was observed laying on. This failure could unnecessarily inhibit the resident's freedom of movement or activity. Findings included: Record review of Resident #4's Face Sheet, dated 11/15/23, revealed she was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included unspecified convulsions, Cerebral Infarction Affecting Right Dominant Side (stroke), and Repeated Falls. Record review of Resident #4's MDS Quarterly assessment dated [DATE] revealed she had a BIMS score of 00 (severe cognitive impairment). 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 interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately for 1 of 3 residents (Resident #6) reviewed for reportable incidents. The facility failed to report Resident #6's elopement to the State Agency- Health and Human Service Commission in a timely manner. This failure could place residents at risk for abuse and/or neglect that could lead to serious injury, serious harm, serious impairment, pain, mental anguish, or death. Findings included: Review of Resident #6's Face Sheet on 11/16/2023 at 10:34 am revealed he was a [AGE] year-old male re-admitted to the facility 01/07/2022 from an inpatient psychiatric facility. Relevant diagnoses included Alzheimer's disease, Parkinson's Disease, Bipolar Disorder, Unspecified Psychosis (disconnection from reality,) Schizophrenia, Major Depressive Disorder, Type 2 Diabetes,…

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, in response to allegations of neglect, have evidence that all alleged violations are thoroughly investigated, prevent further potential abuse while the investigation was in progress, and report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident for 1 (Resident #6) of 3 residents reviewed for abuse and neglect. The facility failed to investigate, prevent, and report allegations of neglect when Resident #6 eloped on 11/05/2023. This failure could affect the residents at the facility by placing them at risk for abuse and/or neglect that could lead to serious injury, serious harm, serious impairment, pain, mental anguish, or death. Findings Included: Review of Resident #6's Face Sheet on 11/16/2023 at 10:34am revealed he was a [AGE] year-old male re-admitted to the facility 01/07/2022…

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 review, 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 #100) of 6 residents reviewed for revised Care Plan. The facility failed to ensure Resident #100's care plan was revised to reflect discontinued use of CPAP (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open)/BiPAP (bilevel positive airway pressure: normalizes breathing by delivering pressurized air into the upper airway leading into the lungs). This failure could place the resident at risk of needs not being met. Findings included: Review of Resident #100's Face Sheet dated 11/15/2023 reflected that resident was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included unspecified chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes…

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 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 one (Resident #31) of three residents reviewed for respiratory care. The facility failed to ensure Resident #31's humidifier for the oxygen concentrator was dated as per facility policy. This failure could place the resident at risk of not having their respiratory needs met. Findings included: Review of Resident #31's Face Sheet dated 11/14/2023 reflected resident was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included unspecified pneumonia and pain in unspecified joint. Review of Resident #31's Quarterly MDS assessment dated [DATE] reflected Resident #31 had a moderately impaired cognition with a BIMS score of 12. Resident #31 required extensive assistance for bed mobility, transfer, dressing, toilet use,…

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 one (Resident #31) of ten residents observed for infection control. The facility failed to ensure that the two prongs of Resident #31's nasal cannula (a device used to deliver supplemental oxygen to an individual. It consists of a lightweight tube on which one is connected to the oxygen source and the other end splits into two prongs and are placed in the nostrils) was on the floor. This failure could place the resident at risk of cross-contamination and development of infection. Findings included: Review of Resident #31's Face Sheet dated 11/14/2023 reflected resident was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included unspecified pneumonia (inflammation and fluid in the lungs caused by a bacterial,…

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 employ a qualified social worker on a full-time basis for one of one facility reviewed for social services. The facility of more than 120 beds, failed to employ a qualified Social Worker on a Full-time basis for all residents residing at the facility. This failure could place residents at risk of not receiving services the individual needs of the residents whenever needed. Findings included: Record Review of facility's Leadership credentials on 10/03/23 revealed the facility did not have a qualified Social Worker on record. Record review of facility's Facility Summary Report on 10/03/23 revealed their total licensed capacity was 192 beds, further divided up into 64 Title XVIII and 128 Title XVIII/XIX beds. Record Review of the facility census report on 10/03/23 revealed an in-house census of 73 residents. Interview with Administrator on 10/03/2023 at 12:45PM revealed the facility social worker position had been vacant for a few months; but she stated she was actively recruiting but stated was having a hard time filling 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 observation, interview, and record review, the facility failed to provide appropriate services to maintain the ability to carry out ADLs for 1 (Resident #1) of 5 residents reviewed for bed mobility. The facility failed to ensure Resident #1 maintained her ability to transfer herself independently, with the use of a motorized bed, following her move to a new room in the facility on 07/25/23. This failure could put residents at risk of having decreased functional ability and quality of life due to a loss of dignity, loss of mobility, and independence. The findings included: Record review of Resident #1's face sheet, printed on 09/20/23, revealed an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of acute respiratory failure with hypoxia (low levels of oxygen in your body tissues), type 2 diabetes mellitus, chronic obstructive pulmonary disease (restricted airflow and breathing problems), muscle weakness, unilateral primary osteoarthritis (cartilage degeneration without any…

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 (Hall 300) of 3 halls reviewed for environmental issues. The facility failed to ensure temperatures on resident halls did not rise above 81 degrees Fahrenheit. These failures increase the risk of residents experiencing decreased the comfort and affect the wellbeing of residents Findings included: Interview and observation on 08/01/23 at 2:20 PM with Resident #1 revealed he was in his room and it was hot in his room, and he had an oxygen concentrator that put out a lot of heat. Resident #1 stated it had been hot in his room for about two weeks. He stated he was offered to move rooms however he did not want to move because he liked his room. Resident #1 had no shirt on and he stated he did not have a shirt on because it was warm in his room and it helped him keep cool. Observation on 08/01/23 at 3:00 PM of the thermostat between rooms [ROOM NUMBERS] reflected 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 allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside for one (Resident #4) five reviewed for call lights. The facility failed to ensure Resident #4 always had the call light within reach. This failure placed the residents at risk of falling, injury, and unnecessary pain from not being able to call for help. Findings included: Review Resident #4's electronic face sheet dated 08/02/23 revealed an [AGE] year old male admitted to the facility 12/16/20 with diagnoses which included dementia with agitation (loss of cognitive functioning), endocarditis (inflammation of the inside lining of the heart chambers and heart valves), metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), acute kidney failure (a sudden episode of kidney failure or kidney damage that happens…

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.