Broadway Nursing & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure were seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 thereafter for 4 of 7 Residents (Resident #2, Resident #3, Resident #4, Resident #5) reviewed for physician visits. The facility failed to ensure Resident #2's, Resident #3's, Resident #4's and Resident #5's were visited by their physician at least every 60 days after their 90-day admission period. This deficient practice could place residents at risk for not having an MD assessing their health status. The findings were:1.Review of Resident #2's face sheet, dated 3/27/26, revealed he was admitted to the facility on [DATE] with diagnoses including Dementia (decline in cognitive function severe enough to interfere with daily life) in other diseases classified elsewhere mild, with agitation (indicating dementia as a symptom of an underlying condition) and other stimulant abuse with stimulant induced anxiety disorder (misuse 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 immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 7 residents (Resident #1) whose records were reviewed. LVN A failed to notify Resident 1, Resident 1's physician or NP and Resident 1's emergency contact when LVN A received a critical CO2 lab result (A CO2 blood test measures the amount of carbon dioxide in your blood, primarily in the form of bicarbonate (HCO3). This test is often part of a broader electrolyte panel or comprehensive metabolic panel (CMP), which helps evaluate your body's acid-base balance and overall metabolic function). This deficient practice could place residents at risk of not having…

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 all alleged violations involving abuse or mistreatment were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse for 1 of 7 Residents (Resident #2) whose records were reviewed for abuse. The ADM failed to report an allegation of abuse when Resident #2 threw a plastic cup at Resident #3 causing a skin tear over his left eyebrow within two hours after the allegation was made. This deficient practice could place residents at risk of further abuse. The findings were:Review of Resident #2's face sheet, dated 3/27/26, revealed he was admitted to the facility on [DATE] with diagnoses including Dementia in other diseases classified elsewhere mild, with agitation (indicating dementia as a symptom of an underlying condition) and other stimulant abuse with stimulant induced anxiety disorder (misuse of stimulants leads to the development of anxiety disorders).…

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 in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete and accurately documented for 1 of 7 Residents (Resident #1) whose records were reviewed. LVN A and LVN B failed to document what they did in response to Resident #1's critical lab, CO2 for value of 42, This deficient practice could place residents at risk of not having their medical records reflecting the care and services the residents received. The findings were:Review of Resident #1 progress note dated 3/3/26 at 1:14 AM read Resident (1) has critical lab results for C02 at 42 (reference range 21-31) informed NP and DON. Resident stable at this time. Review of progress note for Resident #1 dated 3/3/26 at 06:52 AM read Night nurse (LVN A) stated he sent results to NP pending response. Review of Resident #1's progress notes revealed no other documentation related to Resident #1's critical lab was entered by LVN A. Review of Resident #1's assessments for March 2026 revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments to reflect the current condition for 2 of 14 residents (Resident #8 and # 1) reviewed for care plan revisions. 1. The facility failed to ensure Resident #1's care plan was comprehensive and reflected Resident #1's history of hospitalization for suicidal ideation on 05/14/2025 and had attempted to injure herself on 08/14/2025.2. The facility failed to ensure Resident #8's care plan was comprehensive and updated to reflect Resident #8 used a geriatric chair (a large, padded chair with wheeled bases, designed to assist seniors with limited mobility) as a fall prevention. This deficient practice could place residents at risk of not receiving appropriate interventions to meet their current needs. Findings include: 1. Record review of Resident #1’s admission record…

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 convey within 30 days the resident's funds upon discharge for 1 of 3 residents (Resident #9) reviewed for personal funds. The facility failed to ensure Resident #9's personal funds were conveyed within 30 days of the resident's self-initiated discharge from the facility. This failure could result in loss of personal funds or decreased quality life to residents. Findings included: Record review of Resident #9's face sheet, dated [DATE], revealed an [AGE] year-old male admitted to the facility on [DATE] and discharged home on [DATE]. Record review of Resident #9's discharge MDS, dated [DATE] revealed a BIMS score of 15, indicating no cognitive decline. Record review of Resident #9's HHSC Form 3618, dated [DATE] and printed on [DATE], revealed Resident #9's notification to the state of discharge home (return not anticipated) was processed and accepted by HHSC and the Texas Medicaid and Healthcare Partnership on [DATE]. Record review of Resident #9'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 interviews and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result 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 resident (Resident #1) of 8 residents reviewed for abuse and neglect. The DON failed to notify the Administrator that Resident #1 intentionally cut herself on her right wrist with a shaving razor on 08/14/2025 in an attempt to inflict self-harm, and the Administrator failed to report the self-inflicted injury to the state agency. These failures…

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 treat each resident with respect and dignity and care in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality, for 2 (Residents #29 and #68) of 4 D-Hall residents reviewed for dignity. The facility failed to ensure MA B and LVN C treated Residents #29 and #68 with dignity and respect when they referred to the residents' as feeders. This failure could place residents at risk for psychosocial harm due to diminished self-esteem and quality of life. Findings included: Record review of Resident #29's face sheet dated 01/22/2025 revealed she was a [AGE] year-old-woman with an admission date of 09/03/2016 and with diagnosis which included: Cerebral Palsy (movement disorder caused by damage or lack of development to brain areas that control muscle movement) and Dementia (general term for loss of memory, language and other thinking abilities). Record…

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 residents' right to request, refuse, and/or discontinue treatment for 2 (Residents #38 and #20) of 14 residents reviewed for informed consent, in that: 1. The facility failed to ensure Resident #38's right to informed consent for treatment with the psychotropic medication Sertraline was provided. 2. The facility failed to ensure Resident #20's right to informed consent for treatment with the psychotropic medication Sertraline was provided. These failures could place residents at-risk of receiving treatment without having been informed of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options, and to choose the alternative or option he or she prefers. The findings included: 1. Record review of Resident #38's face sheet dated 01/22/2025 revealed he was an [AGE] year-old man with an admission date of 04/18/2024 and diagnoses which included: Metabolic Encephalopathy (brain condition that occurs…

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, in that: 1. Boxes of food were stored on the floor in the dry goods pantry. 2. Frost and ice accumulated on two boxes of food in the freezer. 3. An open container of jelly, labeled refrigerate after opening, was left out of the refrigerator. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings were: 1. Observation on 01/23/2025 at 11:24 a.m., in the dry goods pantry, revealed a four stacks of food items were in the floor and had not been placed on the pantry shelves. During an interview with the Dietary Manager on 01/23/2025 at 11:48 a.m., the Dietary Manager confirmed that stacks of food items were in the floor, had not been placed on the pantry shelves, and should have been. She stated that a delivery had recently been received and staff had not had time to properly store the food items. 2.…

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 disease and infection for 2 of 6 residents (Residents #45 and #23) reviewed for infection control, in that: 1. LVN A did not wear a gown and gloves while performing an accu-check (process of testing blood glucose level using a lancet to prick a finger to draw blood and analyze with a glucometer), and administering medication to Resident #45 who had been placed on contact isolation precaution. 2. LVN A did not wear gloves while performing an accu-check on Resident #23. These deficient practices could place residents at-risk for infection due to improper care practices. The findings include: 1. Record review of Resident #45's face sheet dated 01/23/2025 revealed he was a [AGE] year old man, initially admitted to the facility on [DATE], and re-admitted on…

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

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public, in that: The lobby area of the secure unit smelled strongly of urine. This deficient practice could result in residents living in, staff working in, and the public visiting in an unpleasant environment. The findings were: Observation on 01/24/2025 at 10:32 a.m. revealed the lobby are of the secure unit smelled strongly of urine. Further observation revealed no obvious cause for the smell and observations of the unit's residents revealed all appeared to be clean and well-groomed with no personal odors. During an interview with LVN C on 01/24/2025 at 10:32 a.m., LVN C confirmed the lobby are of the secure unit smelled strongly of urine and stated the smell resulted in an unpleasant environment for staff and residents. During attempted interviews with residents at various times on 01/24/2025, none were able to be interviewed. During an interview with a resident's visitor on 01/24/2025 at 10:48 a.m., the visitor…

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 residents' right to formulate an advance directive for 1 (Resident #54) of 14 residents reviewed for advance directives. The facility failed to ensure Resident #54's desire to formulate an advance directive OOH DNR was completed and part of the record. This failure could place residents at-risk of having their end of life wishes dishonored and of having treatments that go against their personal preferences. The findings included: 1. Record review of Resident #54's face sheet dated [DATE] revealed she was an [AGE] year-old woman with an admission date of [DATE] and diagnoses which included: Dementia (general term for loss of memory, language, problem-solving and other thinking abilities); End Stage Renal Disease (final stage of chronic kidney disease where kidneys can no longer function on their own); and Dependence on Renal Dialysis (requires dialysis treatment to survive). Further review of face sheet revealed under section Advance…

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 all drugs and biological were stored in locked compartments for 1 of 2 medication rooms (A-Hall medication room) reviewed for storage, in that: Controlled medications were not kept in a separate, permanently affixed compartment in the medication room. This deficient practice could place residents at risk of misappropriation of medications. The findings were: Observation in the A-Hall (secure unit) medication room on 01/23/2025 at 02:35 p.m. revealed a miniature refrigerator with a locked padlock on the outside of the door. The miniature fridge was not permanently affixed to the counter it was sitting on. Inside the miniature fridge was a small red lock box containing 2 containers of Morphine Sulfate 100mg in dark covers. The small red lock box was locked, but not permanently affixed inside the miniature refrigerator, and was able to be easily removed from the refrigerator. During an interview with the DON on 01/23/2025 at 05:08 p.m., the DON confirmed the small red lock box which contained 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 review, the facility failed to ensure resident medical records were kept in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete and accurately documented for 1 of 4 residents (Resident #4) reviewed for administration. 1. The facility failed to ensure Resident #4's EMR reflected unwitnessed falls on (2) occasions. 2. The facility failed to ensure Resident #4's EMR reflected behaviors requiring PRN medication on (2) occasions. These failures could place residents at risk for improper care due to inaccurate records. Findings included: 1. Record review of Resident #4's admission Record, dated 9/27/24, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Dementia (group of thinking and social symptoms that interferes with daily functioning), Muscle Weakness, Major Depressive Disorder (mental health disorder characterized by persistently depressed mood or loss 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 observations, 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 includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 4 residents (Resident #1) reviewed for care plans, in that: The facility failed to develop and implement a care plan related to monitoring for side effects of Resident #1's use of Aspirin (antiplatelet/blood thinner) and Ticagrelor (anti-platelet/blood thinner). This failure could place the residents at risk for delayed interventions and decline in health. Findings included: Record review of Resident #1's admission Record, dated 9/26/24, revealed the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included: Nontraumatic Acute Subdural Hemorrhage, Major Depressive Disorder (mental health…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and observation, the facility failed to assure that menus are developed and prepared to meet resident choices including their nutritional, religious, cultural, and ethnic needs while using established national guidelines. The facility had no existing method to inform residents of substitutions to the menu. This failure could place residents at risk for dissatisfaction, poor intake, and diminished quality of life. The findings included: Record review of the menu/alternate, always available menu reflected various items like sandwiches, salad, burgers, fries, soup that residents can get at any time and can be able to request, in addition to being posted outside of the dining room. Record review of Resident #14's face sheet, dated 02/23/2024, reflected a [AGE] year-old with an original admission date of 04/06/2020 and a primary diagnosis of Type-2 Diabetes (A long-term condition in which the body has trouble controlling blood sugar and using it for energy.) Record review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs for 2 of 6 residents reviewed for call light (Residents #13 and #19) reviewed for reasonable accommodations, in that: 1. Resident #16's call light was behind the headboard of the resident's bed and not within the resident's reach on 02/21/2024. 2. Resident #17's call light was on the floor on the resident's room and not within the resident's reach on 02/21/2024. This failure could place residents who used call lights for assistance in maintaining and/or achieving independent functioning, dignity, and well-being. Findings included: 1. Record review of Resident #16's face sheet, dated 02/21/2024, revealed an [AGE] year-old female admitted on [DATE] with diagnoses that included: chronic kidney disease, muscle weakness, cognitive communication deficit and muscle wasting and atrophy. Record review of Resident #16's admission MDS, dated [DATE], revealed a BIMS score of 03, which indicated 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 record review and interview, the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation for 2 of 6 staff (LVN A and CNA B) reviewed for employee misconduct screenings, in that: The facility had failed to complete an annual Employee Misconduct Registry search for LVN A and CNA B. This failure could place residents at risk for abuse, neglect, exploitation, and misappropriation of property. The findings included: Record review of the Abuse and Neglect policy, dated Revised April 2021, reflected Conduct employee background checks and not knowingly employ or otherwise engage any individual who has . had a finding entered into the state nurse aide registry concerning abuse, neglect, or exploitation, mistreatment of residents or misappropriation of their property . No further information related to completed recurring searched of the EMR were not located within facility policy. Record review of the facility staff roster, undated, revealed LVN A's hire date to be 06/11/2015, and CNA B's hire date to be 11/04/2021.…

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 failed to ensure facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 of 8 (Resident #39) residents and 1 of 1 facility, in that: 1. The facility failed to maintain and or repair the 1 of 2 Heating Ventilation Air Conditioner systems [HVAC]. 2. The facility failed to maintain and or repair the call light system. 3. The facility failed to communicate and coordinate between nursing and dietary staff which resulted in Resident #39's physician ordered House supplement was not available. 4. The facility failed to maintain and or repair the ceilings. This could affect and could result in residents diminished quality of life, diminished self-esteem and not receiving supplements for interventions to prevent weight loss. The Findings were: 1. Observations between on [DATE] between 10:00 a.m. to 11:00…

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 be adequately equipped 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 and toilet and bathing facilities, for 1 of 1 facility's reviewed for a functioning call light system for 4 of the facility's 4 halls (Halls A, B, C, and D) reviewed for resident call system, in that: The facility failed to have a functioning call light system for the census of 69 residents who resided on the facility's 4 halls, Halls A, B, C, and D. This failure could place residents at risk for injuries or neglect. The findings included: During an observation on 11/14/2023 from 10:30 to 11:00 AM revealed the call light system on D Hall was not functioning as designed. During an observation on 11/14/2023 at 10:10 AM revealed the memory care unit presented with 19 residents (Residents #1, #4, #12, #14, #17, #19, #23, #25,…

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 make prompt efforts to resolve any grievances the residents may have for 11 of 30 grievances reviewed in that: The facility did not provide a response or written description of any action taken after receiving written grievances. This failure could affect residents who reside in the facility for unresolved grievances in a prompt manner. The findings included: During confidential interviews on 11/15/2023 at 10:05 AM, residents stated grievances were not always followed up on and they were concerned the grievances they wrote were not being addressed. Record review of the facility's grievance binder revealed 11 grievances written between 1/26/2023 and 2/23/2023 were left blank under the subsection of the grievance titled Grievance Official Follow-Up. Record review of document titled Grievance Form, dated 1/26/2023 revealed a grievance made by resident family members related to nursing services and assigned to the nursing department to investigate. The subsection Grievance Official Follow-Up, and Date Resolved were left blank…

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 all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials, including to the State Survey Agency, for 2 of 20 residents (Residents #12 and 47) reviewed for injuries of unknown source, and for 1 of 1 facility HVAC system not operating in that: 1. The DON and LVN V did not report to HHSC that Resident #47 had shoved Resident #12 against a wall on [DATE], causing Resident #12 pain. 2. The HVAC system was not operating for 8 months. This was not reported to HHSC state agency. a. Resident #54,…

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 have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population for 18 of 18 residents reviewed for memory care (Residents #1, #4, #12, #14, #17, #23, #25, #38, #40, #41, #47, #48, #52, #56, #60, #64, #66, and #67) reviewed for memory care and nursing services, in that: 1. CNA F failed to wait her her relief, CNA U, and left her assignment resulting in the 18 residents on the memory care unit being left unattended for one hour on the morning of 11/17/2023. 2. LVN V did not provide continuation of nursing services for Resident #12's incident of peer-to-peer aggression on 07/27/2023 by 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure a medication error rate below 5%. The facility error was 11.11% based on 3 errors out of 27 opportunities for 3 of 7 residents (Resident #13, #39, and #44) reviewed for medication administration: 1. LVN H administered expired insulin to Resident #39. 2. RN AW administered late medication for Resident #44. The medication was scheduled for administration any time between 08:00 AM and 10:00 AM. The medication was administered at 10:49 AM. 3. RN AW administered late medications for Resident #13. The medication was scheduled for administration any time between 08:00 AM and 10:00 AM. The medication was administered at 11:06 AM. These deficient practices placed residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. The findings included: 1. A record review of Resident #39's admission record, dated [DATE], revealed an admission date of [DATE] with diagnoses which included 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.

Based on observations, interviews, and record reviews the facility failed to Maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 facility in that: 1. Kitchen faucets had running water that could not be turned off by kitchen staff and caused a drip of water to be on floor on one of sinks in the kitchen. 2. There were ceiling lights with missing covers, broken, and missing lights in the kitchen and in the main dining room. 3. In the Laundry Room, there were 2 out of 3 washers and 3 out of 6 dryers were not working. These failures could affect residents and could result in residents not having clothes and light. The Findings were: 1. Observation on 11/14/2023 at 10:23 AM in the kitchen with the DM revealed a three compartment sink and a single compartment sink had running water that could not be stopped by the kitchen staff. At one of the sinks with running water was a big bucket in sink to catch water while the floor under sink had a small pool of water that dripped from the sink. Observation on 11/15/2023 at 9:50 AM with [NAME] T 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 interviews and record reviews the facility failed to ensure residents could request and formulate advance directives, for 1 of 8 (Resident #59) residents reviewed for formulation of advanced directives in that: Resident #59's medical record reflected conflicting physicians' orders for Resident #59's wishes for an advance directive. This failure could result in residents not having their end-of-life choices respected. Findings included: Record review of Resident #59's admission Record, dated [DATE], revealed the resident was admitted to the facility on [DATE], was re-admitted on [DATE], and had diagnoses of legal blindness, age-related physical disability, major depressive disorder, and end stage renal disease. Record review of Resident #59's consolidated physician orders print date [DATE], revealed the physician, on [DATE], ordered Resident #59 to be a Full Code. Record review of Resident #59's Significant change MDS, dated [DATE], revealed the resident had a BIMS of 15 (which indicated the resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure the facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required for 1 of 8 (Resident #49) residents reviewed for comprehensive care plans, in that: Resident #49's comprehensive care plan did not address the resident's use of a Trapeze bar for bed mobility or the use of a seatbelt on the resident's electric wheelchair. These deficient practices could affect all residents and could result in a decrease in care for residents. The Findings were: Record review of Resident #49's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure the care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 8 residents (Resident #65) reviewed for comprehensive care plans, in that: Resident #65's care plan was not revised to indicate significant weight loss after their Dietician Comprehensive Assessment in accordance with minimum standards. This failure could place residents at risk for not receiving appropriate interventions to meet their current needs. The findings included: Record review of Resident #65's face sheet, dated 11/17/2023, revealed an [AGE] year-old resident with diagnoses including chronic kidney disease (longstanding disease of the kidneys leading to renal failure), mild protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), and Alzheimer's disease (progressive disease 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 observation, interview and record review the facility failed to ensure the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 2 of 8 (Residents #50 and #59) residents reviewed for quality of care, in that: 1. The facility provided hospice services for Resident #50 without a physicians' order. 2. The facility supported and facilitated dialysis services for Resident #59 without a physicians' order. These failures could affect all residents with contracted services and could result with inappropriate care. The Finding were: 1. Record review of Resident #50's admission Record, dated 11/17/2023, revealed she was admitted on [DATE], age [AGE], primary payer was hospice, with diagnoses of Alzheimer's disease, dementia, cognitive communications deficit. Record review of Resident #50's admission MDS assessment, dated 11/6/2023, revealed Resident #50 was assessed with 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.

Based on observations, interviews, and record reviews the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys, for 1 of 1 medication aide medication cart, reviewed for security, in that, The Medication Aide J's medication cart was unattended and unlocked. This failure placed residents at risk for harm by misappropriation of property and not receiving the therapeutic effects of their medications. The findings included: During an observation on 11/14/2023 at 4:46 PM, revealed the facility's Medication Aide J's medication cart was unattended, and unlocked. The medication cart was observed to have the lock button unengaged and unlocked. An observation revealed the Medication Aide J [MA J] was down the hall in a resident's room. During an interview on 11/14/2023 at 4:52 PM MA J stated she was the facility's medication aide and the cart she had charge of was the medication aide medication cart. MA J stated she had gone down the hall to attend to a Resident and she had…

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 must provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 1 facility reviewed for safe, functional, sanitary and comfortable environment in that: The facility failed to maintain ceilings in the facility. This deficient practice placed residents at risk for harm by diminished health status and diminished self esteem. The Finding were: Observations during the building inspection tour on 11/14/2023 at 12:40 p.m. revealed a section of ceiling approximately 20 feet long was cracked and was separated from another piece of the ceiling. Further observation revealed the ceiling in the Therapy room was sagging and pieces of the gypsum in several areas were starting to peel and crack. During an interview at the time of the observations, the Maintenance Director stated the ceiling had been like that for a few months. The Maintenance Director stated he was aware that the ceiling needed to be repaired and that he notified management about the issue because it was unsanitary 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 resident's had the right to be free from abuse, neglect, misappropriation of resident's property, or exploitation, for 3 of 5 residents (Residents #2, #6, and #7) reviewed for abuse, in that: 1. The facility failed to ensure CNA A did not verbally abuse Resident #2 during interactions on 9/7/2023. 2. The facility failed to ensure Resident #7 was not hit by Resident #6 while sleeping, was not sent to hospital for an MRI afterward due to headaches, hearing and vision issues. Nurse assessment and progress notes did not indicate any issues with headaches or injuries from the incident. The incident was not reported to HHSC. This failure placed the resident at risk of decreased self-worth. The findings include: 1. Record review of Resident #2's face sheet, dated 11/3/2023, reflected a [AGE] year-old with an initial admission date of 12/7/2017. Resident #2's had diagnoses which included cerebral infarction (refers to damage to tissues 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 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 1 of 5 residents (Resident #4) reviewed for misappropriation of resident property. The facility failed to ensure Resident #4 was not subject to financial misappropriation of property by CNA G. CNA G misappropriated funds using the residents debit card totaling $477.54. This failure could place residents at risk for loss of money, possessions, and the feeling of loss. The findings include: Record review of Resident #4's face sheet, dated 11/2/2023, reflected a [AGE] year-old resident with an initial admission date of 8/21/2015. Resident #4 had diagnoses which included Congestive Heart Failure (A chronic condition in which the heart doesn't pump blood as well as it should), absence of left leg below knee, and type 2 diabetes. Record review of Resident #4's Quarterly MDS Assessment, dated 8/29/2023, reflected a BIMS score of 13, which…

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, interview and record reviews 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, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 2 (# 6) residents in that: Resident #6 revealed Resident #7 hit him over the head with a shoe while he was sleeping. Resident #6 stated he still had headaches, hearing and vision issues. Resident #6 stated…

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

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 take into account nonsmoking residents for 1 of 1 facility reviewed for smoking, in that: The facility failed to ensure unknown staff or unknown residents were not smoking in a non-smoking designated area. This failure could place residents at risk for smoking-related injuries and fires in the facility. The findings were: During an observation, in a middle courtyard area located by B hall, on 09/01/2023 at 11:05 a.m., revealed several smoked and used cigarette butts on the ground. Further observation revealed some of the cigarette butts were just outside the right side and out front of the doorway. Many more cigarette butts were all around a sitting area in the grass and/or dirt areas. During an observation, in a middle courtyard area by B hall, and interview on 09/01/2023 at 12:57 p.m., the MA observed and confirmed the several smoked and used…

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.