Castle Hills Rehabilitation and Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #1) of 3 residents reviewed for assessments. Resident #1's admission MDS assessment, dated 02/03/2026, identified the resident did not have pressure ulcer. This failure could place residents at risk for inadequate care due to inaccurate assessments. The findings included: Record review of Resident #1's face sheet, dated 02/22/2026, revealed the resident was a 65-years-old female and admitted to the facility on [DATE] with diagnosis of pressure ulcer of sacral region (wound that from as a direct result of pressure over a bony prominence to the buttock area). Record review of Resident #1's admission MDS, dated [DATE], revealed the resident's BIMS score was 11 out of 15, which indicated the resident had moderate cognitive impairment, and in Section M (Skin conditions), it was coded that Resident #1 did not have one or more unhealed pressure ulcers/injuries. 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 interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs that were identified in the comprehensive assessment, and described services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #1) of 3 residents reviewed for care plans. The facility failed to ensure Resident #1's care plan reflected her unhealed stage pressure ulcer to her left and right buttock area. This failure could place residents at risk for not receiving proper care and services.The findings included: Record review of Resident #1's face sheet, dated 02/22/2026, revealed the resident was a 65-years-old female and admitted to the facility on [DATE] with diagnosis of pressure ulcer of sacral region (wound that from as a direct result of pressure over a bony…

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 maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #1) out of 3 residents reviewed for medical records. Facility nurses did not document their initials on Resident #1's treatment administration record after giving wound care to the resident on 02/01/2026, 02/07/2026, and 02/08/2026. This failure could place residents at risk for missed treatment and medications which could result in decline in healing and well-being.Findings included: Record review of Resident #1's face sheet, dated 02/22/2026, revealed the resident was a 65-years-old female and admitted to the facility on [DATE] with diagnosis of pressure ulcer of sacral region (wound that from as a direct result of pressure over a bony prominence to the buttock area). Record review of Resident #1's admission MDS, dated [DATE], revealed the resident's BIMS score was 11 out of 15, 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.

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 the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for one (1) of seven (7) residents (Resident #1) reviewed for pharmaceutical services. RN A failed to administer Resident #1's cefazoline sodium injection solution (an antibiotic) at the rate confirmed through the pharmacy during administration on 01/15/2026. This failure could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects. The findings included: Record review of Resident #1's admission Record, dated 01/16/2026, revealed a [AGE] year-old male admitted on [DATE]. Record review of Resident #1's Diagnosis Report, dated 01/16/2026, revealed diagnoses including bacteremia (the presence of bacteria in the bloodstream), methicillin resistant staphylococcus aureus infection (MRSA, a type of antibiotic-resistant bacterial…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (1) of seven (7) residents (Resident #2) reviewed for infection control. The facility failed to ensure Resident #2's foley catheter (a tube inserted into the bladder used to drain urine from the bladder) bag was not touching the floor. This failure could place residents at risk of infection and cross contamination.The findings included: Record review of Resident #2's admission Record, dated 01/14/2026, revealed a [AGE] year-old male admitted on [DATE] and re-admitted on [DATE]. Record review of Resident #2's Diagnosis Report, dated 01/16/2026, revealed diagnoses including cerebral palsy (a disorder that affects a person's ability to move and maintain balance and posture), profound intellectual disabilities (a limitation 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.

Based on observation, interview, and record review, the facility failed to store, prepare, and distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen observed for food service sanitation. The kitchen was dirty. This failure could place residents who eat meals from the kitchen at risk for spread of infections, food contamination, and food borne illness. During an observation on 10/2/25 from 10:45 AM to 11:10 AM, the kitchen reflected a need for sanitation, cleanliness and safety Observation reflected: dirt, crease build-up, and debris under the juice table, pantry floor, steam table, and cooking table. During an interview on 10/2/25 at 11:00 AM, the FSS stated that he had no explanation for the dirty kitchen. The FSS added that he was up all last night trying to clean the kitchen and had no help. During an interview on 10/2/25 at 11:05 AM, the Dietician A stated: the kitchen needed to be kept cleaned and sanitized. The Dietician had not explanation for the dirty kitchen.During an interview on 10/2/25 at 11:07AM, Dietician B…

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 maintain all mechanical, electrical, and patient care equipment in safe operating condition 1 of 1 kitchen observed for food service sanitation and safety. The kitchen had numerous overhead ceiling lights were not functioning. This failure could place residents who eat meals from the kitchen at risk for food contamination, and food borne illness.During an observation on 10/2/25 from 10:45 AM to 11:10 AM, the kitchen reflected lack for safety, 3 ceiling lights were not functioning over the 3-sink area, 2 lights over the cooking table, and 2 lights not functioning in the pantry. During an interview on 10/2/25 at 11:00 AM, the FSS stated that he had no explanation for the overhead lights at numerous ceiling fixtures not working. The FSS stated he did not have a work order for the replacement of the lights not working in the kitchen.During an interview on 10/2/25 at 11:05 AM, the Dietician A stated: overhead lighting was required in the kitchen to allow staff to better see and perform kitchen staff duties. 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 that all licensed staff possessed the appropriate competencies, and skill sets necessary to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 2 of 13 nursing staff (RN A and LPN B) reviewed for competencies. The facility failed to ensure that RN A and LPN B obtained current basic life support (CPR and AED) program certifications upon hire. This failure could affect and diminish the resident's quality of life by potentially placing the residents at risk of not receiving competent and skilled care to assure resident safety and maintain the highest practicable physical, mental, and psychosocial well-being of each resident.The findings included: Record review of an untitled and undated facility document, provided by the DON on [DATE], revealed a list with facility employees, their department, position, hire date, primary phone number, and designated if 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 observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for nutrition services.The facility failed to ensure the kitchen and refrigeration areas were free from dirt and debris. The facility failed to ensure food stored in the dry storage and refrigeration areas were labeled properly with the contents and dates prepared/opened. These failures could lead to contamination and foodborne illness. Findings included:On 11/14/2025 at 11:55 AM the following was observed in the facility's only kitchen:Multiple flying insects were present in the food preparation and distribution areas.A layer of white and brown debris coating the floor as well as multiple items of trash behind the freestanding refrigerator in the central food preparation areaMultiple broken tiles on the wall near the freestanding refrigerator, exposing broken drywall/cracked wood and dirty, white and black debris. A wet, black substance surrounding the plumbing of 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 observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility is free of pests for 1 of 1 dining area and 1 of 4 (Resident #1) resident's rooms reviewed for physical environment. The facility failed to ensure Resident #1's room was free from flying insects. The facility failed to ensure the communal dining area was free from flying insects. These failures could lead to contamination and/or decreased quality of life. Findings included:1.Record review of Resident #1's face sheet dated 11/13/2025 revealed a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included end-stage renal disease (when the kidneys are badly damaged). Record review of Resident #1's quarterly MDS, submitted 9/25/2025, reflected a BIMS score of 15 which indicated intact cognition. In an observation and interview on 11/13/2025 at 3:15 PM, flying insects were noted in Resident #1's room. Resident #1 said he consistently had flies in his 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 ensure the menu was followed in 1 of 1 kitchen.The facility failed to follow the recipe for the main entree to ensure there was enough for residents in the dining room and failed to update a substitution on the posted menu in the dining room.This failure could place resident at risk of frustration and a decreased quality of life. The findings were: During a resident group meeting on 9/11/25 at 10:30 a.m. the residents stated the facility often ran out of the main meal being served and they were stuck with the alternate meal or a sandwich. The residents could not elaborate on exactly when this happened and stated, all the time. The residents stated the alternate was usually chicken tenders. The residents stated they were frustrated and had complained to many people about it but could not state who they had complained to. During an observation on 9/11/25 at 12:00 p.m. residents were seated in the dining room waiting for lunch service. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. The facility failed to ensure dietary staff used facial hair restraints properly during meal preparation. The facility failed ensure proper hand hygiene was performed or changed gloves when touching other items that are not being used for serving or the clean serving area. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: Observation on 09/11/2025 at 10:50 a.m. [NAME] EE and [NAME] FF were observed not wearing beard restraints or facial hair guards with both cooks having mustache and goatees. The mustache hair being approximately over an inch long and the goatee (chin) hair longer. [NAME] EE preparing the beverage carts with pitchers of beverages. [NAME] FF was preparing the puree prep area to puree the food for the puree…

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 provide residents the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 (Resident #23) of 24 residents reviewed for accommodation of needs. The facility failed to have Resident #23's soft touch call pad within reach for 2-days. The soft touch pad was located on Resident #23's nightstand out of reach. This failure could place residents at risk of not being able to communicate their need for assistance and result in unmet needs. The findings included: Record review of Resident #23's electronic face sheet, dated 09/09/2025, reflected a [AGE] year-old male who admitted on [DATE]. His diagnoses included: spastic diplegic cerebral palsy (form of cerebral palsy (a lifelong group of neurological disorders resulting from brain damage or abnormal brain development that affects a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure the MDS assessment accurately reflected the resident's status for two residents (Resident #25 and Resident #33) of 8 residents reviewed for MDS assessments.The facility failed to ensure Resident #25's resistive to care was coded on her Quarterly MDS Assessment.The facility failed to ensure Resident #33's nutritional status was coded accurately. These deficient practices could place residents at risk of missed or inappropriate care. The findings included:1. Record review of Resident #25's face sheet dated 09/12/2025, revealed Resident #25 was admitted [DATE], readmitted to the facility on [DATE] with diagnoses that included: Alzheimer's disease (a brain condition that gradually destroys memory and cognitive skills, ultimately interfering with daily tasks), secondary Parkinsonism (conditions that cause movement-related symptoms similar to those seen in Parkinson's disease), unspecified, Schizophrenia (a serious mental health condition that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, 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 2 (Residents #2 and #23) of 16 residents reviewed for comprehensive care plans.1.The facility failed to ensure Resident #2's care plan included his being a smoker. 2. The facility failed to reflect Resident #23 required a soft touch pad instead of a call light in his care plan.This facility failure could place residents at risk of inappropriate care or increased safety issues. The findings included: 1.Record review of Resident #2's face sheet, dated 09/12/2025, revealed he was admitted on [DATE] with diagnoses which included: essential (primary) hypertension (high blood pressure), malignant neoplasm of colon, and hypotension (low blood…

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 resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 (Resident #23) of 24 residents reviewed for grooming.The facility failed to perform nail care for Resident #23 who was observed with long ragged fingernails.This facility failure could place residents at risk of injuries or decreased self-esteem. The findings included:Record review of Resident #23's electronic face sheet dated 09/09/2025 reflected he was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included: spastic diplegic cerebral palsy (form of cerebral palsy (a lifelong group of neurological disorders resulting from brain damage or abnormal brain development that affects a person's ability to control movement, balance, and posture) that affects the legs most severely, causing stiff muscles and scissoring gait, though it…

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

Based on observation, interviews and record review, the facility failed to ensure 1 medication cart (Hallway 4 medication cart) of 4 medication carts was left unlocked and unattended.LVN A did not secure hallway #4's medication cart when she went to provide a resident medication.This facility failure could place residents at risk of misappropriation of drugs or misuse. The findings included: Observation during medication pass on 09/11/2025 at 09:45 am, LVN A left the medication cart insecure when she went into a resident's room to administer his G-tube medications. She closed the door behind her and the medication cart was left unlocked in hallway 4. During an interview on 09/11/2025 at 09:50 am, LVN A stated she should have secured the cart because others would have access to the medications and it could result in misappropriation or misuse leading to harm.During an interview on 09/12/2025 at 10:40 am, the DON stated LVN A needed to secure the medication cart when she left it so others could not have access to medications and other biological substances that could cause harm. She…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (Residents #69 and #23) of 3 residents reviewed for incontinent care.CNA C failed to change gloves and sanitize hands between soiled and clean items when she performed incontinent care for Resident #69. 2. CNA C failed to wear a gown or change gloves and sanitize hands between soiled and clean items when she performed incontinent care for Resident #23 who was on EBP.This failure could place residents at risk of UTI's or spread of an MDRO. The findings included: 1. Record review of Resident #69's electronic face sheet dated 09/09/2025 reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: cerebral infarction due to embolism of right middle cerebral artery (type 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 follow their own established smoking policy for 1 of 1 resident reviewed for smoking. (Resident #2) The facility failed to ensure to complete a Resident Safe Smoking Assessment for Resident #2. This failure could place residents at risk for injury or harm. Findings included: Record review of Resident #2's face sheet, dated 09/12/2025, revealed he was admitted on [DATE] with diagnoses which included: essential (primary) hypertension (high blood pressure), malignant neoplasm of colon, and hypotension (low blood pressure), unspecified. Record review of Resident #2's Quarterly MDS assessment, dated 08/07/2025, revealed the resident's BIMS score 15 for intact/borderline cognition. Record review of Resident #2's Social History, dated 08/08/2025, revealed Resident #2 was a Current smoker. Record review of Resident #2's EMR revealed he not been assessed for smoking safety. During an interview on 09/12/2025 at 4:45 p.m. the DON stated activities…

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 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 (Resident #1) reviewed for Nursing Facility Specialized Services. The facility failed to ensure a request to the State Agency was submitted for Resident #1 within the 20th day timeframe so the resident could benefit from a DME customized wheelchair. This failure could place residents at risk for not receiving the benefits of the recommendations from the LIDDA. The findings included: A record review of Resident #1's admission record dated 8/15/2025 revealed an admission date of 3/21/2025 with diagnoses which included cerebral palsy (a group of disorders that affect movement and muscle coordination caused by brain damage or abnormal development, usually occurring before, during, or shortly after birth.)A 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 interviews 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, were 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 5 residents (Residents #1) reviewed for reporting allegations of abuse and neglect.Administrator failed to report an incident of suspected abuse, from 06/18/2025, to the State Survey agency (HHSC) within the required 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 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 2 of 3 residents (Resident #1 and Resident #2) reviewed for pharmacy services. The facility failed to ensure antibiotics dispensed for Resident #1 and Resident #2 were administered by the staff member who dispensed the medication. This failure could place residents at risk of medication errors. The findings included: 1a. Record review of Resident #1's face sheet dated 9/12/2024 revealed an admission date of 1/05/2024 and a readmission date of 7/30/2024 with diagnoses which included: calculus of kidney (kidney stone). Record review of Resident #1's Care Plan last revised on 8/01/2024 revealed the resident had sepsis/osteomyelitis of vertebra lumbar region (lower spine) with interventions which included administer antibiotic as per MD orders.…

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 1 of 4 residents (Resident #1) reviewed for infection control, in that: 1. The facility failed to ensure CNA A changed her gloves when moving from a dirty to clean task and failed to use appropriate hand hygiene between glove changes when she provided incontinent care to Resident #1 on 09/10/2024. 2. The facility failed to ensure CNA A and CNA B wore gowns during incontinent care on 09/10/2024 for Resident #1 who had been identified as requiring enhanced barrier precautions (EBP). These deficient practices could place residents at-risk for infection due to improper care practices. The findings included: 1. Record review of Resident #1's face sheet dated 9/10/2024 reflected an admission date of 9/30/2023 and a readmission date 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 interviews and record reviews, the facility failed to ensure the assessment accurately reflected the resident's status for 3 of 14 residents (Residents #8, #14, and #26) whose assessments were reviewed, in that: 1. Resident #8 was a smoker, but Resident #8's annual MDS, dated [DATE], reflected the resident did not use tobacco. 2. Resident #14 was taking Plavix (Antiplatelet) for cerebral infarction, but Resident #14's annual MDS, dated [DATE], reflected the resident was taking anticoagulant. 3. Resident #26 did not take any anticoagulant, but Resident #26's annual MDS, dated [DATE], reflected the resident was taking anticoagulant. This failure could place residents at-risk for inadequate care and services due to inaccurate assessments. The findings were: 1. Record review of Resident #8's face sheet, dated 08/23/2024, revealed an admission date of 10/21/2022 with diagnoses that included: Schizoaffective disorder (mental disorder characterized by abnormal thought processes and an unstable mood),…

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 1 of 1 kitchen observed for food service. The facility failed to ensure items stored in the reach in freezer, reach in refrigerator, dry storage, walk in refrigerator were labeled after opening. The facility failed to ensure strawberries stored in the walk-in cooler were free from mold. The facility failed to ensure food stored in the reach in refrigerator located in the kitchen were stored at or below 41 degrees. These failures could place residents at risk of food borne illnesses. The findings were: Observation of the facility's only kitchen on 08/20/2024 at 9:48 AM revealed four bags of open food stored in the reach in freezer unlabeled and undated, one tray of portioned out bowls of dry cereal covered and not labeled, one tray of cups with liquids in them covered and not labeled. Two 1-pound containers of strawberries had white fuzzy substance on the strawberries. Interview with the Dietary Manager on 08/20/2024 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure that residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences that would not endanger the health or safety of the residents for 1 resident 6 ( Resident # 22) reviewed for call lights. Resident #22's was in bed with the call light on the floor at the foot of the bed, out of reach for the resident. This failure could place residents at risk of achieving independent functioning, dignity, and well-being. The findings included: Record review of Resident #22's face sheet dated 8/22/2024 AT 10:15AM revealed the resident was admitted [DATE] with diagnoses that included: ESRD (End Stage Renal Disease), MDD (Major Depression Disorder), A-fib (Atrial fibrillation). Record review of Resident #22's Quarterly MDS dated [DATE] revealed a BIMS score of 13. Record review of the Care Plan dated 7/30/2024 revealed the resident was Care Planned for falls with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure that 1 of 4 residents (Resident #22) received treatment and care in accordance with professional standards of practice that would meet the resident's physical needs for 1 of 5 (Resident #22) residents reviewed for quality of care. Resident #22 was in a low bed with not fall mat next to the bed. This failure could place the resident at risk for injury by not following the person-centered Care Plan. The findings included: During an observation and interview on 08/22/24 at 10:30 AM Resident # 22 was asleep in bed, turned to her left side with her arm laying across the bedrail. She stated she had recently returned from dialysis, and she was very tired. There was no fall mat on the floor next to the bed. Record review of Resident #22's face sheet dated 8/22/2024 AT 10:15AM revealed the resident was admitted [DATE] with diagnoses that included: ESRD (End Stage Renal Disease), MDD (Major Depression Disorder), and A-fib (Atrial…

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 is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 resident (Residents #24) reviewed for incontinent care. While providing incontinent care on 08/22/2024 at 2:35 p.m. for Resident #24, CNA A did not return Resident #24's foreskin to the original position. This failure could place residents at-risk for infection, paraphimosis (urologic emergency in uncircumcised males) and skin break down due to improper care practices. The findings were: Record review of Resident #24's electronic face sheet dated 08/23/2024 reflected he was originally admitted to the facility on [DATE]. His diagnoses included: cerebral infarction (when blood flow to the brain is blocked), dysphagia (difficulty swallowing), need for assistance with personal care, hemiplegia and hemiparesis (weakness and paralysis on one side of the body),…

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 have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable, physical, mental, and psychosocial well-being for 1 of 5 (CNA A) nursing staff reviewed for competent nursing care. While providing incontinent care on 08/22/2024 at 2:35 p.m. for Resident #24, CNA A did not return Resident #24's foreskin to the original position. These failure affect residents who depend on nursing care and could place residents at risk for injury, infection, and harm. The findings included: Record review of Resident #24's electronic face sheet dated 08/23/2024 reflected he was originally admitted to the facility on [DATE]. His diagnoses included: cerebral infarction (when blood flow to the brain is blocked), dysphagia (difficulty swallowing), need for assistance with personal care, hemiplegia and hemiparesis (weakness and…

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

Based on observations, interviews, and record reviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring (monitoring for expiration dates), receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 3 medication carts (South unit medication aide cart). 1.South unit medication aide cart had thickened water for administering medications on 08/22/2024, and the thickened water was expired on 07/17/2024. This failure could place residents at risk for not receiving therapeutic effects of medication administration. The findings included: 1. Observation on 08/22/2024 at 10:06 a.m. indicated South unit medication aide cart had thickened lemon flavor water with high vitamin C, and the thickened water was expired on 07/17/2024. Interview on 08/22/2024 at 10:06 a.m. with medication aide A indicated one bottle of thickened lemon flavor water with high vitamin C was on the South unit medication aide cart, and the thickened water was expired on 07/17/2024. Further interview with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 3 medication carts (South unit medication aide cart) reviewed for drug security and 1 of 14 residents (Resident #3) reviewed for medications at the bedside. 1. Resident #3's 0.9% sodium chloride irrigation sterile water was left unattended and unsecured on the nightstand at the resident's bedside on 08/20/2024. These failures could place residents at risk for misappropriation of property and could place residents at risk for accidents, hazards, and not receiving therapeutic effects. The findings included: 1. Record review of Resident #3's electronic face sheet, dated 08/23/2024, reflected the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses included: hydrocephalus (fluid (CSF) builds up in the brain's ventricles, causing them…

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 special eating equipment and utensils for residents who need them for 1 of 14 Residents (Resident #4) who were observed during meal service. The facility did not provide a built-up spoon to Resident #4 on 08/20/2024 at 12:40 PM. The meal ticket indicated Resident #4 needed to have a built-up spoon. This failure could affect residents who depended on assistive devices and infringe on the resident's dignity and feeding independence. The findings were: Record review of Resident #4's face sheet, dated 08/23/2024, revealed an original admission date of 08/04/2016 and re-admission date of 04/20/2023 with diagnoses that included: intracranial injury (brain injury), protein-calorie malnutrition (inadequate intake of food), type 2 Diabetes mellitus (high level of sugar in the blood), dysphagia (difficulty swallowing), and intellectual disabilities (limitation in cognitive functioning and skills). Record review of Resident #4's annual MDS assessment with an ARD of 08/12/2024 reflected the resident scored 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 maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 14 residents (Resident #8) reviewed for safe and functional equipment. Resident #8's bed headboard was loosed and swinging up and down. This failure could place residents at risk for skin tears, injury, falls and discomfort during transfers. Findings included: Record review of Resident'#8's face sheet, dated 08/23/2024, revealed an admission date of 10/21/2022 with diagnoses that included: Schizoaffective disorder (mental disorder characterized by abnormal thought processes and an unstable mood), hypothyroidism (A condition in which the thyroid gland do'sn't produce enough thyroid hormone), type 2 Diabetes mellitus (high level of sugar in the blood), chronic obstructive pulmonary disease (lung diseases that damage the airways and other parts of the lungs, making it difficult to breathe), and nicotine dependence (need nicotine and 'an't…

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 in accordance with accepted professional standards and practices, maintain medical records on each resident that are complete and accurately documented for 7 of 11 residents (Residents #1, #2, #3, #4, #5, #7, #8) reviewed for medical records, in that: Residents #1-#5's, and #7, #8's blood pressures and or vital signs were documented as the same on different shifts on the same day and on subsequent days. This failure could place residents at risk for inaccurate health assessments, medication administration errors, and could result in missed signs and symptoms of illness. The findings were: Closed record review of Resident #1's face sheet dated [DATE] revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included essential primary hypertension (abnormally high blood pressure that's not the result of a medical condition), and hypotension, unspecified (abnormally low blood pressure that can result 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 develop and implement a comprehensive resident centered care plan for 1 (Resident #9) of 11 residents reviewed for comprehensive resident centered care plans, in that: Resident #9's care plan was incomplete and did not accurately describe his care needs. This deficient practice could result in insufficient resident care. The findings were: Record review of Resident #9's facesheet, dated 03/12/2024, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Depression, Generalized Anxiety Disorder, Frontal Lobe and Executive Function Disorder, Personality Disorder, Schizophrenia, Bipolar Disorder, Acquired Absence of Right Leg Below Knee, and Acquired Absence of Left Leg Below Knee. Record review of Resident #9's Comprehensive MDS, dated [DATE], revealed a BIMS score of 15. Further review revealed the resident was dependent upon staff for toileting and required partial assistance with transfers into and out of a bath or…

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 resident's responsible party has the right to exercise the resident's rights for 1 of 9 residents (Resident #1) reviewed for resident representative rights in that: The facility failed to inform Resident #1's representative (RP) before asking Resident #1 to sign an application for Medicaid. This failure could place residents at risk of not having their preferred responsible party represent them in care decisions. The findings were: Record review of Resident #1's face sheet, dated [DATE], revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of unspecified sequelae [a condition following a previous disease or injury] of cerebral infarction [stroke], respiratory bronchiolitis interstitial lung disease [a syndrome of small airway passage inflammation and scarring of the lung tissue diseases occurring in people who smoke], front lobe and executive function deficit [the inability for a person to manage their own thoughts,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 9 residents (Resident #7, #8, and #9) reviewed for infection control in that: Housekeeper E did not perform hand hygiene between passing meals for Resident #7, Resident #8, and Resident #9. This deficient practice could affect all residents and place them at risk for infection. The findings were: Record review of Resident #7's face sheet, dated 12/21/23, revealed Resident #7 was admitted to the facility on [DATE] with diagnoses of senile degeneration of brain [loss of intellectual ability associated with old age], not elsewhere classified, unspecified protein-calorie malnutrition, type 2 Diabetes Mellitus without complications, edema [swelling caused by excess fluid trapped in the body's issues], unspecified, muscle…

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 were informed before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/Medicaid or by the facility's per diem rate for 3 of 3 (Resident #13, #198, and #199) residents reviewed for Medicare/Medicaid services. 1. Resident #13 was not given a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) and Notice of Medicare Non-Coverage (NOMNC) when discharged from skilled services prior to her covered days being exhausted. 2. Resident #198 was not given a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) and Notice of Medicare Non-Coverage (NOMNC) when discharged from skilled services prior to his covered days being exhausted. 3. Resident #199 was not given a Skilled Nursing Facility Notice of Medicare Non-Coverage (NOMNC) when…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide housekeeping and maintenance services necessary to maintain a safe, sanitary, orderly, and comfortable interior in 2 of 3 resident rooms (Rooms #128 and #129) and for 2 of 6 Resident's (Resident #1 and #28) reviewed for environment, in that: 1. The facility failed to ensure Resident #1's personal refrigeration was clean and the temperature was monitored regularly including in the resident's room. 2. The facility failed to ensure the temperature was monitored regularly for the personal refrigerator in room [ROOM NUMBER]. 3. The facility failed to ensure the fan blades did not have built up dust on them for the fan in room [ROOM NUMBER]. 4. The facility failed to ensure the torn and cracked arm rests on Resident #28's wheelchair were changed out as needed. These deficient practices could affect any resident and place them at risk for not having a safe and sanitary homelike environment. The findings were: 1. Review of Resident #1'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 residents were free of any significant medication errors for 1 of 4 residents (Resident #37) reviewed for medications, that:. Resident #37's medication ordered for hypotension (low blood pressure) was administered when the resident's blood pressure was normal or high. This failure could place resident's at risk of medication complications. The findings were: Record review of Resident #37's face sheet undated revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (Weakness and paralysis of one side of the body, in this case the left side following a stroke), end stage renal disease (when the kidneys are no longer able to work at a level needed for day-to-day life), tracheostomy status (a surgically created hole (stoma) in your windpipe (trachea) that provides an alternative airway for breathing), gastrostomy…

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. 1. There was a zipper-sealed bag with four French toast sticks that did not have a label indicating a storage or use-by date. 2. The tabletop can opener blade, bar, and base were covered in sticky black and brown grime. 3. The ice machine scoop was stored inside the machine instead of in the holder affixed to the wall. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: 1. Observation on 07/11/2023 at 10:03 a.m. in the reach-in cooler revealed there was one zipper-sealed plastic bag containing four French toast sticks. There was no label on the bag indicating the date the French toast sticks were stored in the cooler or a use-by date. During an interview on 07/11/2023 at 10:05 a.m. the DM stated the bag of French toast sticks did not have a label indicating the date it was stored and a use-by…

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 comfortable environment for residents and staff for 4 of 4 (Residents #1, #19, #20 & #24), in the main dining room and in 8 of 8 resident rooms (#144, #142, #136, #133, #108, #114 and #128) in the facility reviewed for operation of the cooling system. The facility failed to maintain acceptable temperature parameters between 71 and 81 degrees for Residents #1, #19, #20 & #24, within the facility including in the main dining room and in rooms #144, #142, #136, #133, #108, #114 and #128. This deficient practice could affect any resident, make them feel uncomfortable and place residents at risk for heat exhaustion. The findings were: 1. Observation during initial tour on 7/11/23 at 10:46 AM of Resident #1's room revealed it was hot. Interview with Resident #1 revealed he complained the room was hot. He stated he had a fan on but it did not cool his room down and he felt uncomfortable. Resident #1 stated it had been hot for days.…

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 interviews and record reviews, the facility failed to ensure Quality Assurance and Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program was provided for 20 of 20 employees (the Administrator, DON, AD, DM, PT, OT, ST, SW, LVN B, LVN C, LVN D, RN E, CNA F, CNA G, CNA H, CNA I, CNA J, CNA K, and CNA L) reviewed for training. The facility failed to ensure that quality assurance and performance improvement training was provided to the Administrator, DON, AD, DM, PT, OT, ST, SW, LVN B (ADON), LVN C, LVN D, RN E, CNA F, CNA G, CNA H, CNA I, CNA J, CNA K, and CNA L. This failure could place residents at risk for injury or improper care due to a lack of training. The findings were: Review of Facility Staff Roster, undated, revealed: Administrator - date of hire - 07/05/2023 DON - date of hire - 04/03/2023 AD - date of hire - 06/13/2022 DM - date of hire - 08/03/2022 PT - date of hire - 04/10/2023 OT - date of hire - 03/09/2023 ST - date of hire - 03/09/2023 SW - date of hire - 05/01/2023 LVN B - date of hire…

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 Pre-admission Screening and Resident Review (PASARR) Level 1 Resident with a positive trigger for mental illness was provided with a PASARR Level II assessment for 1 of 1 Resident (Resident #1) reviewed for mental illness. The facility failed to provide a PASARR Level II assessment for Resident #1 after PASARR Level 1 assessment revealed the Resident triggered positive for mental illness. This deficient practice could place Residents who had a positive PASARR Level 1 evaluation at risk for not receiving care and services to meet their needs. The findings included: Review of Resident #1's face sheet, dated 7/14/23, revealed he was admitted to the facility on [DATE] with diagnoses including major depressive disorder (or clinical depression, affects how you feel, think and behave and can lead to a variety of emotional and physical problems), recurrent and mood disorder due to known physiological condition with mania [Bipolar disorder,…

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 develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's mental, nursing, and psychosocial needs that were identified in the comprehensive assessment, for 2 of 15 Residents (Residents #28 & #34) reviewed for care plans. 1. The facility failed to fully develop a comprehensive person-centered care plan that was specific for Resident #28 to address the resident's nutritional problem and use of supplemental oxygen therapy. 2. The facility failed to fully develop a comprehensive person-centered care plan that was specific for Resident #34 to address the resident's use of supplemental oxygen. These failures could place residents at risk for not getting their medical, physical, and psychosocial needs met and not being provided with the necessary care or services and having personalized plans developed to address their specific…

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 have a final summary of the resident's status at the time of the discharge that is available for release to authorized persons for 1 of 3 residents reviewed for discharge summary (Resident #46)). Resident #46 did not have a discharge summary sheet or documentation in her record. The facility failed to ensure all of Resident #46's necessary information was provided to ensure a safe and effective transition back home. This deficient practice could place any resident preparing to discharge at risk for not getting the necessary care and services to meet their physical and psychological needs. The findings were: Review of Resident #46's face sheet, dated 7/14/23, revealed she was admitted to the facility on [DATE] with diagnosis of Cerebral Infarction due to unspecified occlusion or stenosis of right middle cerebral artery (A middle cerebral artery (MCA) stroke occurs when blood flow from the largest artery of the brain is suddenly interrupted ( ischemia )…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan for 1 of 1 resident, (Resident #28) whose records were reviewed for nebulizer and oxygen therapy. Nursing staff failed to store Resident #28's incentive spirometer device in a plastic bag after use. These deficient practices could affect any resident receiving respiratory therapy and could contribute to the development of an infection. The findings were: Review of Resident #28's face sheet, dated 7/14/23, revealed she was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease and Pneumonia, unknown organism. Review of Resident #28's admission MDS assessment, dated 6/7/23, revealed her BIMS was 8 out of 15 indicating moderate cognitive impairment; she required extensive assistance with most ADL's; she had a diagnosis of Debility (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, interviews, and record review, the facility failed to dispose of garbage and refuse properly for 3 of 5 waste receptacles in that: There were three waste receptacles with their top lids completely open; of the three, two of the waste receptacles were overfilled with bags of trash past the opening of the receptacles. There was significant trash and debris in front and behind the row of waste receptacles. These failures could place residents at risk for exposure to germs and diseases carried by vermin and rodents. The findings included: Observation on 07/13/2023 at 10:45 a.m. revealed there were five waste receptacles (dumpsters) in a row outside the facility. Waste receptacles #1 and #2 could not be closed because the amount of waste in plastic bags inside the receptacles surpassed the top of the receptacles. Waste receptacle #3 had a cardboard box on the ground next to it. Waste receptacle #4's top lid was completely open. On the ground in front of and behind the row of waste receptacles there were disposable gloves, plastic utensils and other debris. There…

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.