Harbor Valley Health and Rehabilitation

Based on interview and record review, the facility failed to store, prepare, distribute, and serve food for 1 of 1 kitchen in accordance with professional standards for food service safety. 1. The facility failed to maintain the temperature of walk-in refrigerator at or below 41 degrees F in November 2025.2. The facility failed to maintain the temperature of the milk refrigerator at or below 41 degrees F in December 2025.3. The facility failed to take temperatures for the cold foods (to include tossed salad on 12/03/25, milk and orange juice on 12/01/25, 12/02/25 and 12/04/25). These failures could place residents at risk for food borne illness.The findings included: Record review of Refrigerator Temperature-walk in, dated November 2025, reflected the following days had temperatures that were above 41 degrees Fahrenheit:(day: degrees Fahrenheit for morning and/or evening)6: evening 42 (signature unknown)7: evening 43 (signature unknown)15: evening 43 (signed by [NAME] I)19: morning 42 (signature unknown), evening 43 (signature unknown) Record review of Refrigerator Temperature-milk,…

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 5 residents (Resident #10) reviewed for infection control:The facility failed to ensure LVN K cleaned an insulin pen's rubber seal with an alcohol swab prior to insulin administration for Resident #10.This failure could place residents at risk for cross contamination and infection due to improper care practices. The findings included: Record review of Resident #10's face sheet dated 12/4/25 revealed a [AGE] year old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included type 2 diabetes (a chronic medical condition in which the body does not use insulin effectively and over time may also not produce enough insulin causing blood glucose levels to become too high), metabolic…

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 all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access for 3 of 5 Residents (Resident #1, #2, and #3) reviewed for medication storage:1. The facility failed to ensure Resident #1 did not have medication cups with cough syrup at the bedside.2. The facility failed to ensure Resident #2 did not have a jar of medicated mentholated ointment (a combination product that is used to relieve itching, minor muscle, or joint pain. This product may also be used as a chest rub to soothe symptoms associated with the common cold) at the bedside.3. The facility failed to ensure Resident #3 did not have a jar of medicated mentholated ointment (a combination product that is used to relieve itching, minor muscle, or joint pain. This product may also be used as a chest rub to soothe symptoms associated with the common cold) at the bedside.These deficient…

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

Based on observations, interviews and record reviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. The facility failed to ensure [NAME] A wore a beard net on 11/12/25. This failure could place residents at risk of contaminated food and illness.Findings include:During an observation of the kitchen on 11/12/25 at 12:20 p.m., [NAME] A had facial hair and was not wearing a beard net and was checking food temperatures before lunch meal service. During an interview on 11/12/25 at 12:24 p.m., [NAME] A stated he was most recently reeducated on the beard net policy one year ago by the former DM. He stated all kitchen staff were responsible for following the facility's beard net policy. He stated he put on a beard net before checking food temperatures and preparing and serving meals. He also said, It was OSHA compliant to not wear a beard net if a beard was no more than 2 inches long. He stated he was still required to wear a beard net regardless of the facial hair length. He stated 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 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 1 (Resident #1) of 6 residents reviewed for infection control. The facility failed to ensure staff wore PPE when entering Resident #1's room on 11/12/25 at 8:00 a.m. This failure could place residents at risk of cross-contamination and infection. Findings include: Review of Resident #1's admission Record, dated 11/14/25, reflected she was an [AGE] year old female who was admitted to the facility on [DATE]. She had medical diagnoses including dementia (a set of symptoms that cause a significant decline in cognitive abilities like memory, thinking, and reasoning, to the point that it impairs daily life), weakness and COVID-19. Review of Resident #1's Quarterly MDS Assessment, dated 11/03/25, reflected she had 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 interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 (Resident #2) reviewed for care plans.CNA L and CNA X failed to follow the care plan for Resident #2 and transferred Resident #2 without a mechanical lift on 08/16/2025. This deficient practice could place residents who are transferred at risk for injury.The findings included:Record review of an undated face sheet revealed Resident #2 was an [AGE] year-old female who admitted to the facility for hospice respite on 08/13/2025 with diagnoses that included Alzheimer's Disease (a progress disease that affects memory and other important mental functions) and Hypertension (high blood pressure). Record review of a facility form titled, Facility Order Form,…

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 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 for 1 of 5 Residents (Resident #1) reviewed for dignity. Nursing staff failed to greet Resident #1 upon entering her room; failed to engage with Resident #1 while she was attempting to talk with them in Spanish and failed to request the assistance from other staff who could understand Resident #1 so they could determine if she needed assistance. Resident #1 was Spanish speaking only. This deficient practice could affect any Resident who did not speak English and could result in the Residents needs not being met and contribute to feelings of unworthiness. The findings were: Review of Resident #1's face sheet, dated 1/12/25, revealed she was admitted to the facility on [DATE] with diagnosis of unspecified Dementia (according…

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 unable to carry out activities of daily living received the necessary services to maintain good nutrition for 1 of 5 Residents (Resident #1) who needed assistance with meals. Nursing staff failed to set up Resident #1's meal tray to include raising the head of the bed, opening up condiments, ensuring the meat was cut when served and ensuring the bedside table was close to Resident #1 and in a position where she could reach the food on the meal tray. This deficient practice could affect any Resident who required set-up assistance during meals and could result in the resident having difficulties reaching the food and it could discourage the resident to eat their meal. The findings were: Review of Resident #1's face sheet, dated 1/12/25, revealed she was admitted to the facility on [DATE] with diagnosis of unspecified Dementia (according to Mayo Clinic Dementia is a term used to describe a group of symptoms affecting…

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 each resident received assistance devices to prevent accidents for 2 of 2 Residents (Resident #2 and Resident #3) who were observed during mechanical lift transfers. 1. CNA F failed to lock the mechanical lift while raising and lowering Resident #2 during a transfer. He failed to widened the base of the mechanical lift which resulted in the wheelchair getting stuck between the legs while lifting Resident #2. CNA F failed to widened the base when transferring Resident #2 from the wheelchair to the bed while suspended in the air and when lowering Resident #2 onto the bed. 2. CNA I failed to lock the base of the mechanical lift while raising and lowering Resident #3 during a transfer. CNA H reached behind CNA I and locked the base of the mechanical lift with her left foot while CNA I was lowering Resident #3 into the bed. These deficient practices could affect any resident who was transferred via mechanical lift and could 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 ensure the residents' right to formulate an advance directive for 1 of 8 residents (Resident #192) reviewed for advanced directives, in that: The facility failed to ensure Resident #192's desire to formulate an advanced directive was properly documented in his electronic medical record. This failure could place residents at-risk of having their end of life wishes dishonored, and of having CPR performed against their wishes. The findings included: Record review of Resident of #192's face sheet, dated 8/30/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included lack of coordination, type 2 diabetes mellitus (chronic health condition that affects how body turns food into energy), hypertension (high blood pressure), atrial fibrillation (Atrial fibrillation (AFib) is an irregular and often very rapid heart rhythm.), and chronic kidney disease stage 4 severe (the last stage before kidney failure). 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 assessments accurately reflected the resident's status for 1 of 8 Residents (Resident #42) whose MDS records were reviewed for accuracy. 1. The facility failed to ensure Resident #42's Annual MDS assessment dated [DATE] was updated when the resident's insulin was discontinued on 12/15/2023. This failure could place residents at risk of improper or incorrect care or services necessary for their physical, mental, and psychosocial well-being due to inaccurate assessments. The findings included: 1. Record review of Resident #42's face sheet dated 08/28/24, revealed Resident #42 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included metabolic encephalopathy (change in how your brain works due to an underlying condition. It can cause confusion, memory loss and loss of consciousness), Type 2 diabetes mellitus with diabetic neuropathy (chronic health condition that affects how body turns food into energy) 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 observation, interview, and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible for 1 of 8 Residents (Resident #86) and 2 of 4 storage closets (Hall 100 and Hall 200) reviewed for accident hazards in that: 1. The facility failed to remove a potential hazard for Resident # 86's room. 2. The facility failed to ensure the storage clostes on Halls 100 and 200, which contained potential hazard items, were locked. This deficient practice could place residents at risk of remaining in an environment that was not free of accident hazards. The finding included: 1. During an observation and interview on 8/28/24 at 10:17 a.m. in Resident #86's room by his bedside was a basin with a disposable razor in it. Resident #86 was laying in bed. He stated staff would bring supplies for a bed bath and assist him with shaving. Resident #86 stated he did not noticed the razor next to his bed and was unsure how long it had been there. 2. During an observation on 8/28/24 at 4:08 p.m. a closet on hallway 200 and a closet on hallway…

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 under proper temperature controls, for 1 of 4 medication carts (100 hall cart) reviewed for storage. 1. The facility failed to ensure medications that required refrigeration were not stored on the 100 hall medication cart. This failure could place residents at risk for not receiving therapeutic effects of their medications. The findings included: 1. Observation on [DATE] at 4:13 p.m. revealed the 100-hallway nursing cart contained 9 separate glucometers stored in individual boxes. The boxes contained a log, to check if the meter was functioning properly with test control solutions, and serial numbers written on them to identify the meter that was tested. The logs had dates for testing of [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Four of the glucometers did not match the serial number documented on the log they were stored with. An insulin lispro pen with an open date of [DATE] was being used…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that its medication error rate was not 5 percent or greater. The facility had a medication error rate of 6.45% based on 2 out of 31 opportunities, which involved 1 of 5 Residents (Residents #36) reviewed for medication administration, in that: The facility failed to ensure LVN H administered Resident #36's insulin lispro (fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours) and insulin glargine (a long-acting insulin pen that lowers blood sugar levels in adults with diabetes) correctly. These failures could place residents at risk for not receiving the intended therapeutic effects of their medications and could contribute to possible adverse reactions. The findings included: 1. Record review of Resident #36's face sheet, dated 8/30/24 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included senile degeneration 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 collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 4 residents (Resident #30) reviewed for hospice services, in that: The facility failed to ensure Resident #30's most recent Physician Certification of Terminal Illness and Hospice election form were completed and part of the hospice documents. The most recent plan of care, list of hospice personnel involved in the care, and hospice physician orders were not available at the facility. This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. The findings were: Record…

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

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 to help prevent the development and transmission of infections involving 2 of 6 staff (LVN) reviewed for infection control, in that: The facility failed to ensure MA G cleaned the blood pressure cuff between resident #9 and Resident #80. These deficient practices could place residents at-risk for infections. The findings included: During an observation on 8/29/24 at 7:59 a.m. MA G was observed taking resident #9's blood pressure prior to administering medications to the resident. MA G return to her cart and place the blood pressure cuff on the cart. MA G did not sanitize the blood pressure cuff. MA G then went to resident number 80s room and took their blood pressure with the same cuff. MA G again return to her cart and place the blood pressure cuff on top of her cart. MA G again did not sanitize the blood pressure cuff. During an interview on 8/29/24 at 8:30 a.m. MA G stated she thought 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, record reviews, and interviews the facility failed to ensure resident rooms were equipped to assure full visual privacy for each resident for 1 (Resident #193's room) of 16 rooms reviewed for full visual privacy. The facility failed to provide Resident #193 with a privacy curtain. Resident #193's buttocks was visible from the hallway during incontinent care. This failure could cause a decrease in feelings of self-worth by being exposed during cares. Findings included: 1. Record review of Resident #193's face sheet, dated 8/30/24, revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: hypertensive heart (high blood pressure) and chronic kidney disease with heart failure and stage 1 through state 4 chronic kidney disease, reduced mobility, and Dysphagia (difficulty swallowing). Record review of Resident #193's comprehensive care plan, initiated on 3/27/24 revealed he had a peg tube and wounds. The care plan stated he had an ADL…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure each resident was free of any significant medication errors for 1 of 6 residents (Resident #4) reviewed for medications. The facility failed to prevent Resident #4 from being administered incorrect medications of Seroquel 50 mg PO and Ativan 0.5 mg PO. This deficient practice could result in a risk to the residents' health and complications which can lead to an infection, injury or death. The findings included: Record review of resident #4's Face Sheet, dated 8/06/2024, showed resident was admitted on [DATE] with diagnosis of chronic respiratory failure, type 2 diabetes and hypertension (high blood pressure). Record review of the Facility Incident Report, dated 3/15/2024, reflected MA failed to correctly identify Resident #4 prior to medication administration and Resident #4 was administered Seroquel 50 mg PO and Ativan 0.5 mg PO. Record review of Resident #4's doctors' orders, dated 3/12/2024 showed no medication orders for Seroquel or Ativan.…

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 be equipped to allow residents to call for staff through a communication system which relayed the call directly to a centralized staff work area for 1 of 12 residents (Resident #77) reviewed for call lights. The facility failed to ensure Resident #77's emergency call button in the bedroom was operating properly. This failure could place residents at risk of injury, pain, and hospitalization. The findings included: Record review of a face sheet dated 8/09/2024 for Resident #77 indicated he was a 94-year male admitted [DATE] with re-admission date of 3/18/2023 with diagnosis of dementia (the loss of cognitive functioning), atherosclerosis (thickening of the arteries caused by plaque), and cerebral ischemic attack (mini stroke that happens in the brain). Record review of a quarterly MDS dated [DATE] for Resident #77 indicated he had a BIMS score of 09 indicating moderate cognitive impairment and that he was dependent on staff with adl's.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to ensure residents were seen by a physician at least once every 30 days for the first 90 days after admissions, at least once every 60 days thereafter for 1 of 5 residents (Resident #1) whose care was reviewed in that: The facility failed to ensure Resident #1 was seen by her physician within 60 days. This deficient practice could affect residents and could lead to a decline in health status or untreated conditions. The findings were: Record review of Resident #1's face sheet, dated 3/29/24, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of unspecified dementia [a general term for impaired ability to remember, think, or make decisions], unspecified severity, without behavioral disturbance, psychotic disturbance [a disconnection from reality], mood disturbance, and anxiety, dysphagia [difficulty swallowing], unspecified, unsteadiness on feet, generalized anxiety disorder, and muscle weakness (generalized). Further record…

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

Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles in locked compartments for 1 of 1 medication cart (100 Hall medication cart) reviewed for storage of drugs. Agency LVN A left the 100 Hall medication cart unlocked. This deficient practice could place residents at risk of medication misuse and drug diversion. The findings were: Observation on 4/3/24 at 5:46 a.m. revealed Agency LVN A was at the nurses station. Agency LVN A left the nurses station to answer a call light in 200 Hall. The 100 Hall medication cart was unlocked and unattended. During an interview on 4/3/24 at 5:48 a.m., Agency LVN A stated she was working on the medication cart, then she went to her computer, then she went to check on a resident. Agency LVN A stated the medication cart should have been locked. Agency LVN A stated she was educated on medication security when she first oriented at the facility. During an interview on 4/3/24 at 10:51 a.m., the DON stated she, the ADON, medical…

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: The facility failed to ensure the bottle of eyewash solution was within its expiration date. These deficient practices could place staff at risk for injury. The findings were: Observation and interview on 4/3/24 at 8:01 a.m. revealed a bottle of eyewash solution above the handwashing sink had an expiration date of 11/2022. [NAME] B confirmed the eyewash solution was expired and did not know how frequently the eyewash solution was checked. Record review of a facility policy titled, Storage of Medications, dated April 2007, revealed the following: the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, 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 is made to the State Survey Agency for 1 of 3 residents (R #1) reviewed for sexual abuse. The facility did not report to the State Survey Agency (HHSC) two incidents of R #1 sexually abusing two other residents (R#6 and R#5) on two separate occasions (09/27/23 and 10/14/23). This failure could place residents at risk for sexual abuse and could lead to a diminished quality of life, and psychosocial harm The findings were: Record review of facility's Abuse and Neglect Policy dated 8/10/22 read: .Sexual abuse-is defined as non-consensual contact of any type with a resident .Any employee or individuals the facility engages with that witness, suspect, or received statements of abuse .must report to the Administrator .The Administrator, DON, or Designated Representative will be responsible to report…

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 1 of 5 residents (Resident #1) reviewed for accuracy of medical records in that: The facility failed to prevent Electronic Medical Records from having no documentation of Resident #1's transfer to the hospital. This deficient practice could affect Residents whose records are maintained by the facility and could place them at risk for errors in care and treatment. The findings were: Record review of Resident #1's face sheet revealed an admission on [DATE] with diagnosis of Alzheimer's Disease (A type of brain disorder that causes problems with memory, thinking and behavior. This is a gradually progressive condition.), muscle wasting and atrophy (Loss of muscle leading to its shrinking and weakening.), anxiety (is the mind and body's reaction to stressful, dangerous, or unfamiliar situations.), and hypertension (High…

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

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure food items in the dry storage were dated and labeled. This failure could affect Residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination. Findings included: Observations of the facility's dry storage area on 06/13/2023 at approximately 11:39 a.m. revealed the following items did not have an expiration date. - 2 large bags of expired cornflake type cereal (identified in name by the DM), labeled DELIVERED 07/07/2022 and no other visible dates. During the same observation, the following items were observed in the dry storage area passed the USE BY DATE: - 3 (46 ounce) containers of expired thickened liquids, each labeled USEBY: 03/09/2022. During an interview and observation on 06/13/2023 at 11:40 a.m., the DM said, the cornflakes and the thickened liquid were expired.…

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 fed by enteral means received appropriate treatment and services to prevent complications for 1 of 1 resident (Resident #3) reviewed for feeding tubes in that: The facility failed to ensure RN A properly checked for residual prior to administering medications to Resident #3's gastrostomy tube. This deficient practice could place residents who received medications via a gastrostomy tube at risk for medical complications or a decline in health. The findings included: Record review of Resident #3's face sheet, dated 6/16/23 revealed a [AGE] year-old female admitted on [DATE] and re-admitted on [DATE] with diagnoses that included dysphagia (difficulty swallowing), aphasia (a disorder that impacts speech and the ability to communicate) following cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) and gastrostomy status (a tube inserted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care and services, including oxygen administration was provided such care, consistent with professional standards of practice for 2 of 2 residents (Resident #45 and #43) reviewed for respiratory therapy in that: Resident #45's and #44's oxygen concentrator filters were covered in a white substance. This deficient practice could affect residents who received respiratory therapy and put them at risk for inadequate or inappropriate amounts of oxygen delivery. The findings included: 1. Record review of Resident #45's face sheet, dated 6/15/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses that included anxiety disorder, liver cell cancer, nicotine dependence in remission, and heart failure. Record review of Resident #45's most recent quarterly MDS assessment, dated 4/19/23 revealed the resident was cognitively intact for daily decision-making skills and received oxygen therapy.…

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 1 of 1 Resident (Resident #228) reviewed for infection control practices, in that: The facility failed to ensure CNA B utilized appropriate infection control practices when entering Resident #228's room who was on isolation for an infection. This failure could place residents on contact isolation for infection at risk for spreading the infection or a decline in health. The findings included: Record review of Resident #228's face sheet, dated 6/13/23 revealed an [AGE] year-old female admitted on [DATE] and re-admitted on [DATE] and 6/8/23 with diagnoses that included senile degeneration of brain (a decrease in cognitive abilities or mental decline), heart failure, cognitive communication deficit, and dementia.…

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.