Buena Vida Nursing and Rehab-San Antonio

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents have the right to be informed of and participate in their treatment, including the right to be informed in advance of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options, and to choose the alternative or option they prefer for 1 of 6 residents (Resident #35) whose records were reviewed for informed consent. The facility failed to obtain signed consent prior to administering the psychotropic medication Risperdal (an atypical antipsychotic indicated for the treatment of schizophrenia, bipolar I disorder with acute manic or mixed episodes, and autism-associated irritability) for Resident #35. This failure could place residents at risk of receiving medications without consent and without the option choose alternative treatment or decline treatment based on awareness of the risks and benefits of the medications.The findings included: Record review of Resident #35's admission sheet 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.

Based on observations, interview and record review, the facility failed to respect the residents' right to confidentiality in his or her personal and medical records for one (Laptop) of three medication cart computers reviewed for confidential medical records. The facility failed to ensure a laptop A was not left open with patient information on the screen. This failure could place residents at risk of resident-identifiable information being accessed by unauthorized persons. Findings included: Observation on 08/26/25 at 11:21 a.m. revealed laptop A was on top of a medication cart was left open in hallway displaying Resident #25's appointment information for a medical appointment with the date, time, and location for the appointment for anyone passing by to see. No staff was at the cart with laptop A and no staff returned to Laptop A before it timed out and turned off on its own. Interview on 8/29/25 at 1:05 p.m. the DON stated the laptop was used by all staff. The DON stated the computer should not be left on displaying patient information because it was a HIPPA violation and anyone…

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 coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort for 1 of 8 residents reviewed for PASRR (Resident #34). The facility failed to ensure Resident #34 had an accurate PASRR Level 1 Screening indicating diagnoses of mental illness and refer the residents to the state designated authority. This failure could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs.Findings included: Record Review of Resident #34's admission record, dated 8/26/25, revealed a [AGE] year-old female initially admitted [DATE] and readmitted on [DATE] with diagnoses including schizoaffective disorder (a mental health condition with a mix of schizophrenia symptoms such as hallucinations and delusions, and mood disorder symptoms, such as…

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 the resident environment remained as free of accident hazards as was possible for 1 of 4 hallways (hallway 2300) observed for accidents and hazards: The facility failed to ensure hallway 2300 did not have a capped lancet lying in the middle of the floor. This failure could place residents at risk of harm or injury and contribute to avoidable accidents and a decline in health. The findings included: During an observation on 8/28/2025 at 11:07 AM, a capped lancet was observed lying on the floor of hallway 2300. Twenty minutes later at 11:27 AM, the capped lancet was still observed lying on the floor of hallway 2300. Between 11:07 AM and 11:27 AM, Housekeeper A was observed walking up and down hallway 2300 past the capped lancet cleaning restrooms and resupplying rooms with soap and paper towels. Housekeeper A did not pick up the capped lancet or bring it to the attention of staff nurses during the observation period. During an interview with Housekeeper A on 8/28/2025 at 11:30 AM, Housekeeper A stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder and bowel received appropriate treatment and services to prevent urinary tract infections for 1 of 4 residents (Resident #34) reviewed for incontinent care: The facility failed to ensure CNA F did not wipe between Resident #34's gluteal folds from back to front in the wrong direction during incontinent care. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices. The findings included: Record Review of Resident #34's admission record, dated 8/26/25, revealed a [AGE] year-old female initially admitted [DATE] and readmitted on [DATE] with diagnoses including type 2 diabetes (high blood sugar levels, insulin resistance, and a relative loss of insulin), bacteremia (infection or bacteria in the blood), schizoaffective disorder (a mental health condition with a mix of schizophrenia symptoms such as hallucinations and delusions, 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 that residents who required dialysis received such services, consistent with professional standards of practice for 1 of 1 resident (Resident #4) reviewed for dialysis: The facility did not maintain communication, coordination, and collaboration with the dialysis facility for Resident #4. This failure could affect residents who received dialysis treatments and place them at risk for complications and not receiving proper care and treatment to meet their needs. The findings included:Record review of Resident #4's admission record, dated 8/29/25 with an initial admission date of 12/13/2017 and readmission of 7/31/25 revealed a resident [AGE] year-old male resident with diagnoses that included end stage renal disease (the final stage of and type 2 diabetes mellitus (high blood sugar levels, insulin resistance, and a relative last of insulin) without complications. Record Review of Resident #4's quarterly MDS assessment, dated 7/31/25, reflected…

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

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles for 2 of 5 medication carts (the 2200/2500 hall medication aide cart and the 2300/2400 hall medication aide cart) assessed for medication storage and labeling. The facility failed to ensure all medications located inside the 2200/2500 hall medication aide cart and the 2300/2400 hall medication aide cart were stored in labeled containers. This failure could place residents at risk of receiving inadequate treatments or ingesting medications for which they were not prescribed. The findings included: During an observation of the 2200/2500 hall medication aide cart on 8/28/2025 at 8:14 AM, two dosing cups with pills were discovered sitting in the top drawer of the cart. During an interview with Medication Aide B on 8/28/2025 at 8:14 AM, Medication Aide B stated if pills are left in dosing cups in the medication cart, they could be mistaken for someone else's pills and be given to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure medical records were kept in accordance with professional standards and practices and were complete and accurately documented for 1 of 6 residents (Resident #35) reviewed for accuracy of records. The facility failed to ensure Resident #35's diagnosis of bipolar disorder was documented on the resident's active diagnosis list, the MDS assessment, and the care plan. This failure could place residents at risk for improper care due to inaccurate records. The findings included: Record review of Resident #35's admission sheet dated 7/01/2025 documented a [AGE] year-old male resident with diagnoses including dementia with behavioral disturbance, benign prostatic hyperplasia (enlarged prostate leading to difficulty urinating), and hypothyroidism (when the thyroid gland does not produce enough thyroid hormone). Record review of Resident #35's MDS dated [DATE] documented a BIMS score of 14 indicating intact cognition and recorded the use of antipsychotic,…

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 allegations involving abuse, neglect, and misappropriation were reported immediately, but no later than 2 hours after the allegation was made to the State Survey Agency for 1 of 8 residents (Resident #1) reviewed for abuse and neglect. The facility did not report to the State Survey Agency (HHSC) an alleged romantic relationship between Resident #1 and LVN A, as reported by Resident #1 to the DON, and LVN A to the ADON. This failure could place residents at risk for abuse/neglect and could lead to a diminished quality of life and psychosocial harm. The findings included: Record review of Resident #1's admission record, undated, reflected a [AGE] year-old resident with an initial admission of 02/03/2025 and diagnoses including acute respiratory failure with hypoxia (a condition where the lungs cannot adequately oxygenate the blood) and quadriplegia (paralysis of all four limbs). Record review of Resident #1's BIMS Assessment 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 interview and record review the facility failed to ensure that the comprehensive person-centered care plan described services that are furnished to maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Resident #1) reviewed for care plans in that: 1. Resident #1's care plan did not indicate that Resident #1 was noncompliant with the facility smoking policy and did not indicate effective interventions for the noncompliance. 2. Resident #1's care plan did not indicate that Resident #1 had verbally disruptive and aggressive behaviors toward staff and others and did not indicate effective interventions for the behaviors. This deficient practice could affect residents with behaviors and/or residents who smoke due to these conditions not being identified in the care plan and not indicating effective interventions to the behaviors in the care plan. The findings were: Record review of Resident #1's undated face sheet revealed Resident #1 was a [AGE] year…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures that assured accurate administering of all drugs to meet the needs of residents for 1 of 3 residents (Resident #1) reviewed for medication regimen. 1. LVN B did not administer Resident #1's Hydrocortisone gel to his face within the parameters of the scheduled administration time on 11/15/2024. 2. MA A documented that MA A administered medications to Resident #1 on 11/15/2024 that had not been administered. 3. MA A prepared Resident #1's medications, placed the medications in unlabeled cups and stored the medications in the top drawer of MA A's medication cart on 11/15/2024. 4. MA A was administering Lidocaine 4% patches for Resident #1 instead of Lidocaine gel as ordered. 5. LVN A did not administer Resident #1's Hydrocortisone gel to his face within the parameters of the scheduled administration time on 11/18/2024. These failures could place residents who receive medications…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 7 (Resident #1) residents reviewed for quality of care. 1. The facility failed to schedule an ENT appointment for Resident #1 per a physician's order. 2. The facility failed to schedule a Vascular appointment for Resident #1 per a physician order. This failure could affect resident who were referred for services with outside providers and could result in a decline in physical condition. The findings were: Record review of Resident #1's undated face sheet revealed Resident #1 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included Cerebral Infarction (a disruption in the brain's blood flow), Hemiplegia (paralysis of one side of the body) and Depression. Record review of Resident #1's quarterly MDS assessment, dated 08/17/2024, revealed Resident #1 had a BIMS score of 15, indicating no cognitive…

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 and prevention control program that included, at a minimum, a system for preventing and controlling infections for 1 of 3 (Resident #3) residents reviewed for medication administration. MA B failed to perform hand hygiene after administering medications to Resident #2 and before administering medications to Resident #3. This failure could place residents receiving medication at risk for cross contamination and/or spread of infection. The findings were: Record review of Resident #2's undated face sheet revealed Resident #2 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included Dementia (a general term for impaired ability to remember, think, or make decisions), Anxiety and Asymptomatic Human Immunodeficiency Virus Infection (a virus that attacks the body's immune system). Record review of Resident #2's admission MDS assessment, dated 09/25/2024, revealed Resident #2 had a BIMS…

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 housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior for 1 of 6 resident rooms, observed for housekeeping and maintenance, in that: 1. Resident #2's bed foot board was broken and hanging on the bedframe. 2. Resident #2 was sleeping in bed without linen. These failures could lead to resident injury and a diminished quality of life. The findings were: Record review of Resident #2'a face sheet, dated 11/1/24 reflected a male age [AGE]. The resident was re- admitted on [DATE] with diagnoses that included: dementia (primary). Record review of Resident's quarterly MDS dated [DATE] reflected resident's BIMS score was documented as 1 (severely impaired). B/B was documented as incontinent; and resident required one staff assistance for bathing. Resident was ambulatory with staff supervision. Record review of Resident #2's CP, undated, reflected the resident received ADL for transfer, mobility, 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, interviews, and record review, the facility failed to maintain medical records, in accordance with accepted professional standards and practices, that are complete; and accurately documented for 1 of 6 residents (Resident #1) reviewed for medical records. Resident #1's Nurse [NAME] for October 2024 for bathing was documented differently from the CNAs October 2024 POC (an electronic record system) documentation. This failure could result in residents not having an accurate overall view of their care and services. The findings were: Record review of Resident#1 's face sheet, dated 10/31/24 reflected a male age [AGE]. The resident was admitted on [DATE] with diagnoses that included: Nontraumatic intracranial hemorrhage (primary) (stroke), anxiety, cognitive deficits, and dysphasia following cerebral infarction (stroke). RP was listed as: family member. Record review of Resident#1's quarterly MDS, dated [DATE], reflected: the resident's BIMS score was 6 (moderate impairment). Resident'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 maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 2 of 3 residents (Residents #1 and #2) reviewed for accuracy of medical records in that: 1. The facility failed to ensure medications prescribed to Resident #1 were documented on the MAR for multiple dates in August 2024. 2. The facility failed to ensure medications prescribed to Resident #2 were documented on the MAR for multiple dates in August 2024. These failures could affect residents whose records are maintained by the facility and could place the residents at risk for errors in care and treatment. The findings included: 1. Record review of Resident #1's face sheet, dated 8/16/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), muscle weakness, lack of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents have a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 1 of 1 facility reviewed for safe, clean, comfortable environment, in that: 1. In room [ROOM NUMBER], there were loose tiles around the toilet, the bolt securing the toilet to the flood was rusted, there was an excessive accumulation of dust and debris on top of the mirror above the sink and paper towel dispenser, and the vent located on the wall across from the bathroom had a large accumulation of dust surrounding each opening. 2. A light above the sink in the Secured Unit shower room was not functioning. 3. In the bathroom of room [ROOM NUMBER], the toilet seat had a broken hinge. 4. In room [ROOM NUMBER], there were broken window blinds, there were large water marks on the ceiling panels of the bathroom, and the ceiling exhaust fan in the bathroom was separated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 10 of 24 residents (Residents #3, #4, #8, #11, #14, #19, #24, #33, #39, and #46) reviewed for the provision of routine and emergency drugs and biologicals, in that: 1. On [DATE] at 10:54 AM MA B administered Resident #3's baclofen 1 hour and 53 minutes late, and the resident's torsemide (a diuretic used to treat swelling), buspirone, and gabapentin (a medication to treat nerve pain) 53 minutes late. 2. On [DATE] at 10:46 AM MA B administered Resident #4's clonazepam (a medication used to treat anxiety) 1 hour and 46 minutes late. 3. On [DATE] at 11:18 AM MA B administered Resident #8's buspirone (a medication to treat anxiety) 2 hours and 18 minutes late. 4. On [DATE] at 11:22 AM MA B administered Resident #11's hydralazine 2 hours and 55…

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 prepare and provide food and drink that was palatable, attractive, and at a safe and appetizing temperature, for 7 of 28 residents (Resident #13, #15, #17, #25, #37, #54, and #61) reviewed for palatable and appetizing food, in that: 1. The facility served Resident #25 a breakfast meal 1 hour and 2 minutes after the kitchen delivered the meal, and the meal was cold and not palatable to the resident. 2. The facility served Resident #13 a breakfast meal 58 minutes after the kitchen delivered the meal, and the meal was cold and not palatable to the resident. 3. The facility served Resident #61 a breakfast meal 56 minutes after the kitchen delivered the meal, and the meal was cold and not palatable to the resident. 4. The facility served Resident #37 a breakfast meal 54 minutes after the kitchen delivered the meal, and the meal was cold and not palatable to the resident. 5. The facility served Resident #15 a breakfast meal 45 minutes after…

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, in that: 1. The facility failed to store an opened bag of cereal in a sealed container in the dry storage room. 2. The facility failed to ensure the chlorine sanitizer in the dish machine was at the minimum concentration necessary to sanitize dishes and utensils. These deficient practices could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings were: 1. Observation on 07/09/2024 at 10:41 AM in the dry storage room revealed a 35-oz. bag of corn flakes cereal. The cereal was stored in a zip-locked bag that was not sealed. During an interview on 07/09/2024 at 10:42 AM, the DM stated the zip locked bag should have been sealed to prevent the quality of the cereal from spoiling and potential contamination from rodents and pests. She further stated it was the responsibility of all dietary staff storing food in the dry storage room…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to honor residents' 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 1 of 24 residents (Resident #24) reviewed for needs and preferences, in that: On 07/09/2024 at 11:14 AM Resident #24 was left in her bedroom, in her bed with the call light button underneath her left back. Resident #24 was semi-paralyzed on her left side and could not reach the call light button. This failure could place residents at risk for harm by not honoring residents' individualized needs and preferences. The findings included: Record review of Resident #24's admission record dated 07/11/2024, revealed an admission date of 10/16/2023 with diagnoses which included left sided hemiparesis (left sided semi paralysis), contractures of left elbow and hand (a condition that causes one or more fingers to bend…

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 and permit only authorized personnel to have access to the keys for 1 of 2 medication rooms reviewed for medication storage, in that: The medication room on the second floor was left unattended and unlocked. This failure could place residents at risk for harm by not receiving the medications due to misappropriation. The findings included: Observation on 7/10/24 at 09:50 AM revealed the medication room on the facility's second floor, located at the beginning of the resident's hallway, was left unattended and unlocked. Further observation revealed multiple residents' medications which were stored inside the room. The medication room had a key latch door handle which was unlocked. During an interview on 07/10/2024 at 09:55 AM LVN A stated she was the nurse on duty for the second floor. LVN A stated she was busy serving Resident's breakfasts and was unaware the medication room was unattended and unlocked. During an interview on 7/10/24 at 10:00 AM MA B 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 a to dispose of garbage and refuse properly for 1 of 2 Dumpsters (Dumpster #2) reviewed for disposal of garbage, in that: The facility failed to ensure Dumpster #2's door was completely shut, had a drain plug, and was free of pests. These deficient practices could place residents at risk for exposure to germs and diseases carried by vermin and rodents. The findings were: Observation on 07/11/2024 at 11:50 AM revealed Dumpster #2 did not have drainage plug, the door was open, and there were ants present. During an interview on 07/11/2024 at 11:51 AM, the DM stated the door to Dumpster #2 was open and should not have been, as it presented an unsanitary condition and an opportunity for the proliferation of rodents. The DM also noted the presence of ants crawling on the rear side of the Dumpster. During an interview on 07/11/2024 at 12:15 PM, the Maintenance Director stated the drain plug was missing from Dumpster #2 and he would ensure it was replaced. The DM also noted the presence of ants and indicated he would…

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 24 residents (Resident #25) reviewed for call light accessibility and functionality, in that: On 07/09/2024 at 01:00 PM Resident #25 utilized his call light which did not illuminate the nurse call light directly outside and above of his room door. This failurs could place residents at risk for harm by not receiving care and attention when their nurse call light system malfunctions and or is out of reach. The findings included: Record review of Resident #25's admission record dated 07/11/2024 revealed an admission date of 11/18/2022 with diagnoses which included left sided hemiparesis (left sided semi paralysis) and general anxiety disorder. A record review of Resident #25'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.

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 for 1 of 1 facility reviewed for environmental concerns, in that: The ceiling fan in the Soiled Utility Room on th 2300 Hallway had dust and dirt particles in the vent slats. This deficient practice could place residents at risk of not living in a safe, functional, sanitary, and comfortable environment. The findings included: Observation on the 500 Hall on 07/10/24 from 9:55 AM to 10:25 AM with the Maintenance Director revealed the soiled utility room on the 2300 resident hallway had a ceiling fan measuring approximately 2 x 2 feet that had dust and dirt particles in the vent slats. During an interview with the Maintenance Director on 7/10/24 at 10:15 AM he stated that he would repair all of the maintenance concerns revealed during the observation tour. The Maintenance Director stated that the repairs would improve resident safety and homelike environment. During an interview with the Administrator on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain medical records, in accordance with accepted professional standards and practices, which are complete, and accurately documented for 1 of 7 residents (Resident #3) reviewed for completeness and accuracy. The facility failed to transcribe Resident #3's order for Morphine correctly. This deficient practice could affect residents whose records were maintained by the facility and could place them at risk for errors in care and treatment. The findings were: Record review of Resident #3's face sheet, dated 6/20/2024 revealed, the resident was admitted initially on 7/132018 with readmission on [DATE] with diagnoses that included: chronic systolic heart failure(specific type of heart failure that occurs in the heart's left ventricle. The left and right ventricles are the bottom chambers of the heart. In a person with systolic heart failure, the heart is weak, and the left ventricle can't contract (squeeze) normally when the heart beats), chronic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident for 1 of 17 (Resident #29) in that: The facility failed to honor Resident #29's right to present when Administrator A entered the resident's room and misappropriated personal items and threw them away in the trash. This failure could result in residents experiencing a decline in self-worth and quality of life. The findings were: Record review of Resident #29's face sheet, dated 06/26/24, revealed a [AGE] year-old female resident who was re-admitted on [DATE] with diagnoses that included: end stage renal disease, anxiety, major depressive disorder, HTN (hypertension). Resident was her own RP. Record review of Resident #29's quarterly MDS dated [DATE] revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to treat residents with dignity and respect of personal possessions for 1 of 17 residents (Resident #17) reviewed for resident rights, in that: Hospitality Aide D turned off, on 12/23/23 at 3:44 PM, Resident #17's electronic monitoring device, a personal possession, without asking for permission to turn off the device. This deficient practice could affect residents who reside at the facility and result in a loss of personal property, frustration and loss of dignity. The findings were: Record review of Resident #17's face sheet, dated 6/27/24 revealed, a [AGE] year old male who was admitted on [DATE] and discharged [DATE] home with diagnoses that included: HEMIPLEGIA AND HEMIPARESIS ( paralysis of one side of the body), FOLLOWING CEREBRAL INFARCTION (stroke), DEMENTIA, and PARANOID PERSONALITY DISORDER. Resident was his own RP. Record review of Resident #17's quarterly MDS dated [DATE] revealed a BIMS score of 10 (moderately impaired). 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 interview and record review, the facility failed to ensure the right to be free from misappropriation of property was provided for 1 of 17 residents (Resident #29) reviewed for misappropriation and exploitation, in that: The facility did not prevent Resident #29's personal belongings from being lost when the former Administrator (A) without the resident's permission or the resident being present removed personal items from the resident's room. This failure could affect residents and their responsible party by preventing them from having access to their personal effects and belongings. The findings included: Record review of Resident #29's face sheet, dated 06/26/24, revealed a [AGE] year-old female resident who was re-admitted on [DATE] with diagnoses that included: end stage renal disease, anxiety, major depressive disorder, HTN (hypertension). Resident was her own RP. Record review of Resident #29's quarterly MDS dated [DATE] revealed BIMS score was 15 (cognitively intact). 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.

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 (Main Kitchen), in that: The facility failed to ensure opened items in the reach in refrigerators were dated or discarded correctly. This deficient practice could place residents who ate food from the kitchen at risk for foodborne illness. The findings were: During an observation and interview with the DM, in the refrigerator storage areas, on 05/30/2023 at 09:02 a.m., revealed an opened container of mushrooms (received 05/21/2022) with no opened date; an opened container of jalapenos (received 05/21/2022) with no opened date; an opened container of sour cream (received 05/17/2023) with no opened date; and an opened container of flavored sauce (received 10/12/2022 and opened 10/18/2022). The DM stated opened food items, per facility policy, were supposed to be discarded seven days after being opened. The DM also stated items were supposed to be dated after being opened. During an…

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 1 of 15 residents reviewed for call light: Resident # 214's call light was not placed within reach. This failure could place residents who used call lights for assistance at risk in maintaining and/or achieving independent functioning, dignity, and well-being. Findings included: Record review of Resident's # 214 face sheet dated, 6/2/23, revealed a [AGE] year-old male, admitted on [DATE] with diagnosis that included: Hemiplegia on Left side [loss of strength on left side arm and leg] Hyperlipidemia [abnormally high concentration of fats in the blood Hypertension [blood pressure that is higher than normal] Review of Resident # 214's admission MDS dated [DATE] revealed a BIMS score of 15, suggesting the patient was cognitively intact. Review of Resident #214's admission MDS dated [DATE] revealed that under section G, G0300, option # 2 was selected, stating the patient is unsteady on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents' right to formulate an advance directive for 1 of 8 residents (Resident #44) reviewed for advanced directives, in that: The facility failed to ensure Resident #44's Out-of-Hospital Do Not Resuscitate (OOH-DNR) was signed by the appropriate witnesses. This failure could place residents at-risk for residents' rights not being honored. The findings were: Record review of Resident #44's face sheet, dated 06/02/2023, revealed the resident was admitted on [DATE] with diagnoses that included: dementia, major depressive disorder, congestive heart failure, diabetes, and bipolar disorder. Record review of Resident #44's quarterly MDS assessment, dated 03/13/2023, revealed the resident had a BIMS score of 13, which indicated borderline/intact cognitive impairment. Record review of Resident #44's physicians orders, dated 06/02/2023, revealed an order entered on 04/14/2023 that read: DNR. Record review of Resident #44's care plan, undated,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain acceptable grooming and personal hygiene for 1 of 15 residents reviewed for ADLs (activities of daily living). Resident # 54 The facility did not ensure Resident #54 received grooming for their facial hair. This failure could place residents who required assistance with activities of daily living, and who were dependent on staff to perform personal hygiene at risk for embarrassment and or decreased self-esteem or decreased quality of life. Findings included: Record review of Resident #54's face sheet, dated 6/2/23, revealed a [AGE] year-old female with an admission date of 10/12/22 with diagnoses that included: Diabetes type II [is a condition that happens because of a problem in how the body regulates and uses sugar as a fuel]. Dementia [is a condition characterized by progressive or persistent loss of intellectual functioning] Mild Intellectual Disability [slower in all areas of conceptual…

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.