Highland Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that all alleged violations of abuse, neglect, and exploitation are thoroughly investigated, and the results of the investigation are reported to the SSA within five working days for 1 of 7 residents (Residents #3) reviewed for abuse, neglect, and exploitation.The facility failed to have evidence of an investigation of alleged exploitation of Resident #3.This failure could result in continued mistreatment of residents or lack of oversight.Findings included: Record review of the facility document titled Resident Master Information dated 4/02/3035 reflected Resident #33 was a [AGE] year-old male admitted to the facility on the 3/02/2022. Relevant diagnoses included bipolar disorder (a mental health disorder characterized by significant mood swings) and dementia (a progressive neurological disorder affecting memory and judgement). Record review of Resident #3's quarterly MDS submitted 2/9/2026 reflected a BIMS score of 06, which indicated severely…

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 Comprehensive Care Plans, A comprehensive care plan must be to the extent practicable, the participation of the resident and the resident's representative. An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not to be practicable for the development of the resident's care plan for 2 of 8 (#2,#16) residents in that:Resident #2 and 16 Resident/Families were not offered to attend their care plan meetings. This could affect residents and could cause residents to decrease self-esteem. The Findings: 1. Record review of Resident #2's admission Record (no date) revealed she was admitted on [DATE] and readmitted on [DATE] with diagnoses with depressive disorder, diabetes II, anxiety, and bipolar disorder. Record review of Resident #2's Quarterly MDS dated [DATE] revealed her BIMS score was 15/15 (cognitively intact), impairment on one side of upper extremity,…

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 routine dental services for 1 of 2 residents (Resident #3) reviewed for dental services. The facility failed to ensure Resident #3 received routine dental care in 2025 and 2026. This failure could result in tooth decay or loss, infection, and decreased quality of life. Findings included: Record review of the facility document titled Resident Master Information dated 4/02/3035 reflected Resident #3 was a [AGE] year-old male admitted to the facility on the 3/02/2022. Relevant diagnoses included bipolar disorder (a mental health disorder characterized by significant mood swings) and dementia (a progressive neurological disorder affecting memory and judgement). Resident #3's insurance was identified as Medicaid.Record review of Resident #3's quarterly MDS submitted 2/9/2026 reflected a BIMS score of 06, which indicated severely impaired cognitive status. Section L of the MDS (oral/dental status) was not assessed. 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.

Based on observation and interviews, the facility failed to ensure the resident received care and services safely and that the physical layout of the facility maximized resident independence and did not pose a safety risk, with housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior and adequate and comfortable lighting levels in all areas; for 2 of 2 shower rooms (A hall shower and B hall shower) reviewed for trip hazards and lighting. 1. The facility failed to have adequate safe lighting for the showers as evidenced by the B Hall shower having a shower stall with no light fixture within the shower stall and the A hall shower stall having no functioning light bulb in the fixture within the shower stall. 2. The facility failed to ensure there was no trip hazard in the A hall shower room as evidenced by the A hall shower stall had an inclined ramp up to the shower stall with a tile bump atop of the ramp. These failures could place residents at risk for injuries by not having adequate lighting and trip hazards. The findings included:…

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 Resident #6 FTag Initiation 01/10/25 03:31 PM Initiate F700 & F656 initiated d/t order for abdominal binder and fact that abdominal binder is not identified in the care plan and use of 1/2 side rail for positioning (not appropriate need for this resident). Resident #33 FTag Initiation 01/10/25 10:39 AM Thorazine consent not signed, wrong resident and theo [NAME] res was not on thorazine vns check was not on mar,

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure a medication error rate below 5%, for 27 medication administration opportunities with 15 errors resulting in a 55.56% medication error rate, for 4 of 4 residents (Residents #6, #7, #22, and #30) reviewed for medication administration. 1. LVN D administered Resident #6's medications by her gastronomy tube (often called a G tube, is a surgically placed device used to give direct access to a person's stomach for supplemental feeding, hydration, or medicine), contrary to professional standards by administering all the medications together rather than one by one, and late by 11 minutes. 2. LVN D administered Resident #30's medications by her gastronomy tube contrary to professional standards by administering all the medications together rather than one by one, and late by 50 minutes. 3. Medication Aide I did not administer Amlodipine 5mg to Resident #7 as prescribed by her physician. 4. Medication Aide I did not administer…

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 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, which must include, at a minimum, the following elements: A. Standard and transmission-based precautions to be followed to prevent spread of infections, and B. The hand hygiene procedures to be followed by staff involved in direct resident contact; for 2 of 2 residents reviewed for incontinent care and medication administration (Residents #6 and #30) reviewed for standard and transmission-based precautions for infection control and prevention. 1. On 1/9/2025, CNA A and CNA J assisted Resident #6 with incontinent care and failed to change gloves with hand hygiene in between glove changes after touching handling Resident #6's soiled linens and supplies prior to touching handling Resident #6's clean linens and supplies. 2. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY FACILITY Environment 01/09/25 02:35 PM poor lighting in shower rooms. a and b, resident little stated she used shower and she could use a better light, and could be warmer, the heater in a and b were not working. 01/09/25 05:36 PM pm [NAME] stated laundry door gap ok, ok for concern and no tag for door gap, shower curtain in between dirty and clean, and toilet on pedestal, Resident #19 FTag Initiation 01/10/25 01:31 PM no light in shwr and bump on ramp.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and observation, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 12 residents [Resident #6] reviewed for care plans. The facility failed to develop the appropriate care plan intervention of implementing an abdominal binder to prevent Resident #6 from pulling out her feeding-tube per physician's order. This deficient practice could place resident at risk of trauma or injury. The findings include: Record review of Resident #6 face sheet dated 9/20/24 revealed an [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE]. Relevant diagnosis included Dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life)…

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.

Resident #6 FTag Initiation 01/10/25 03:31 PM Initiate F700 & F656 initiated d/t order for abdominal binder and fact that abdominal binder is not identified in the care plan and use of 1/2 side rail for positioning (not appropriate need for this resident).

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 (the medication aide cart) reviewed for supervision and security. The Medication cart was left unsupervised and unsecured for 25 minutes by an unknown staff member. This failure could place residents at risk for harm by not receiving the therapeutic effects of their medications. The findings included: During an observation on 1/9/2025 at 10:30 AM revealed the medication cart was left unsupervised and unsecured and positioned in the A hall by Resident #4's room. Continued observation from 10:30 AM until 10:55 AM revealed Resident #4 and Resident #20, housekeepers, and CNAs walked freely in the hallway back and forth past the unattended and unsecured medication cart. During an observation and interview on 1/9/2025 at 10:56, LVN D was alerted to the unsecured and unattended medication cart. LVN D was observed to lock the cart and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews, it was determined the facility failed to ensure each resident was provided the right to a dignified existence, self-determination, for 2 of 6 residents reviewed for Resident rights (Resident #1 and #2). The facility failed ensure Resident #1 and #2's guardian the right to choose Hospice Company C to evaluate these residents for their eligibility for hospice; instead of Hospice Company D. This failure could place residents at risk of their responsible party not being involved in their medical care and treatment. Findings included: 1. Record review of Resident #1's clinical record , date not legible, revealed Resident #1 was an [AGE] year-old female who was admitted to the facility on [DATE], with diagnoses to include dementia (a loss of cognitive functioning that interferes with daily life and activities) without behavioral disturbances. It further revealed Resident #1's guardian was Guardian A. Record review of Resident #1's BIMS, dated 09/24/2024, revealed…

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

Based on record review and interview, the facility failed to include as part of its QAPI program, mandatory training that outlined and informed staff of the elements and goals of the facility's QAPI program, for 9 of the 16 staff members (the AADM, the DON, LVN C, LVN D, CNA E, CNA F, CNA G, CNA H, CNA I) reviewed for mandatory training, in that: Nine staff members (the AADM, the DON, LVN C, LVN D, CNA E, CNA F, CNA G, CNA H, CNA I) reviewed for mandatory training had not received training regarding the facility's QAA-QAPI program. This failure could place residents at risk of receiving inadequate care from staff who are unfamiliar with the facility's QAPI program. The findings included: Record review of employee files reflected the following employees had not received training regarding the QAPI program: -AADM was hired on 11/20/1986 -DON hired on 10/16/2023 -LVN C, hired on 8/22/2011 -LVN D, hired on 06/27/2016 -CNA E, hired on 04/25/2017 -CNA F, hired on 03/17/2016 -CNA G, hired on 11/20/1986 -CNA H, hired on 05/04/2005 -CNA I, hired on 01/19/2016 Interview 11/30/2023 at 3:16 PM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to assess each resident quarterly using the Minimum Data Set form specified by the state and approved by CMS for 3 of 16 residents (Resident #12, #26, and #28) reviewed for quarterly assessments, in that: Resident #12, #26, and #28's quarterly MDS Assessment was not completed within 92 days of the previous quarterly assessment. This failure could place residents at-risk of not having their assessments completed timely. The findings were: Record review of Resident #12's face sheet reflected an [AGE] year-old resident with an original admission date of 01/17/2019 and a primary diagnosis of schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania.) Record review of Resident #12's most recent MDS Assessment, dated 7/31/2023, reflected the due date of the next Quarterly MDS Assessment was to be completed on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 2 of 12 residents (Residents #4 and #20) reviewed for accidents and hazards in that: 1. The facility failed to ensure Resident #4 received supervision while using a needle point needle and scissors. 2. The facility failed to ensure Resident #20 received supervision while using a flat iron to style her hair. This failure could place residents at risk of harm or injury and contribute to avoidable accidents. The findings included: 1. Record review of Resident #4's face sheet, dated 9/6/23 revealed a [AGE] year old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included dementia with behavioral disturbance, hypertension (high blood pressure), angina pectoris (condition marked by severe chest pain caused by inadequate blood supply to the heart), heart failure, glaucoma (a condition of increased pressure within 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 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 1 of 4 medication carts (Treatment/Medication Cart) in that: The facility failed to ensure expired mediations were not found on the Treatment/Medication cart. This deficient practice could affect residents who received medications or treatments and could result in less potent or adverse effects. The findings included: Observation on 11/29/23 at 10:54 a.m. of the inspection of the Treatment/Medication Cart with LVN B revealed the following: - 1 open tube of moisturizing wound hydrogel with expiration date 3/29/2022 - 2 open packages of Oil Emulsion Non-Adherent Dressings with expiration date 11/2022 - 1 open box of anti-diarrheal 2 mg tablets with expiration date 9/2023 - 2 open tubes of antimicrobial skin and wound gel with expiration date 5/11/2023 - 1 bottle of sterile saline 0.9% with expiration date 1/28/2023…

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 kitchen sanitation in that: The facility failed to obtain pasteurized eggs for the purpose of serving undercooked eggs for residents. These failures could place residents at risk for cross-contamination and foodborne illness. The findings included: Observation and interview on 11/29/2023 at 3:51 PM revealed four (4) cartons of unpasteurized eggs stored in the reach-in refrigerator in the kitchen. The DM stated five (5) of the thirty-three (33) residents eat fried and/or over-easy eggs for breakfast. The DM stated she was aware of the presence of the unpasteurized eggs and the risks associated with serving them undercooked to residents such as foodborne illness. The DM stated she did not have a precise reason the facility had purchased only unpasteurized eggs. Interview on 11/29/2023 at 4:12 PM, the ADM stated that he had spoken with the DM. The ADM stated he was aware 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.

Based on record review and interview, the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation for 1 of 14 staff (the DOR) reviewed for background screenings, in that: The facility had failed to complete an Employee Misconduct Registry search for the DOR. This failure could place residents at risk for abuse, neglect, exploitation, and misappropriation of property. The findings included: Record review of the facility Key Personnel roster, dated 11/28/2023, reflected an unknown hire date for the DOR. Record review of the DOR's Personnel File reflected no evidence of a completed Employee Misconduct Registry search. Interview on 11/30/2023 at 2:40 PM, the ADM stated the DOR was contracted with the facility and provided services onsite to the residents as a Physical Therapist. The ADM stated he was not aware that contracted staff were required to also be searched on the employee misconduct registry and stated he understood the risk associated with not searching frequent visitors providing health services on the employee…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that all alleged violations involving resident neglect, are reported immediately, but not later than 24 hours after the allegation is made for 2 of 16 residents (Residents #8 and #17) reviewed for, reporting neglect, in that: The facility failed to report an incident to the State Survey Agency (HHSC), when Residents #8 and #17 were observed in the dining room to be using profanity toward each other after Resident #17 threw a liquid-filled cup at Resident #8. This failure could place the residents at risk for unreported allegations of abuse, neglect, and injuries. The findings were: Record review of Resident #8's face sheet reflected a [AGE] year-old female with an original admission date of 10/16/2015 and a primary diagnosis of Type 2 Diabetes Mellitus Without Complications. Record review of Resident #17's face sheet reflected a [AGE] year-old female with an original admission date of 05/04/2016 and a primary diagnosis of Type 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 ensure that all alleged violations involving resident neglect are investigated for 2 of 16 resident (Residents #8 and #17) reviewed for reporting neglect, in that: The facility failed to investigate an incident when Resident #8 and #17 were observed in the dining room to be using profanity toward each other after Resident #17 threw a liquid-filled cup at Resident #8. This failure could place the residents at risk for uninvestigated allegations of abuse, neglect, and injuries. The findings were: Observation on 11/29/2023 at 10:41 AM revealed Resident #17 yelling in the dining room toward Resident #8 calling Resident #8 a [expletive] and a [expletive] before throwing a cup of liquid toward her. Further observation revealed Resident #8 responded by calling Resident #17 a [expletive]. Following this, the Assistant AD and LVN B were observed to separate the residents and attempt to deescalate the situation. Resident #8 was observed stating I…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to assess each resident annually using the Minimum Data Set form specified by the state and approved by CMS for 1 of 16 residents (Resident #26) reviewed for annual assessments, in that: Resident #26's Annual MDS Assessment was not completed within 366 days of the previous annual assessment. This failure could place residents at-risk of not having their assessments completed timely. The findings were: Record review of Resident #26's face sheet reflected a [AGE] year-old resident with an original admission date of 02/08/2019 and a primary diagnosis of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side (paralysis of partial or total body function on one side of the body). Record review of Resident #26's last annual MDS assessment reflected a completion date of 10/26/2022. The proceeding MDS assessment was due dated 10/27/2023, however it was dated opened on 11/20/2023. Interview on 11/29/2023 at 2:41…

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 assessment accurately reflected the resident's status for 2 of 12 residents (Resident #4 and #20) whose assessments were reviewed in that: 1. Resident #4's most recent Quarterly MDS assessment dated [DATE] did not accurately reflect the resident's oral/dental status and oxygen use. 2. Resident #20's most recent annual MDS assessment dated [DATE] did not accurately reflect the resident's ability to maintain personal hygiene. This failure could place residents at-risk for inadequate care due to inaccurate assessments. The findings included: 1. Record review of Resident #4's face sheet, dated 9/6/23 revealed a [AGE] year old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included dementia with behavioral disturbance, hypertension (high blood pressure), angina pectoris (condition marked by severe chest pain caused by inadequate blood supply to the heart), heart failure, glaucoma (a condition…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 12 residents (Resident #4 and #20) reviewed for comprehensive care plans in that: 1. Resident #4's comprehensive care plan did not address the resident's use of sewing needles and scissors. 2. Resident #20's comprehensive care plan did not address the resident's use of a flat iron used for styling hair. This deficient practice could place residents in the facility at risk of not being provided with the necessary care or services and having personalized plans developed to address their specific needs. The findings included: 1. Record review of Resident #4's face sheet, dated 9/6/23 revealed a [AGE] year old female admitted to the facility on [DATE] and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding for 2 of 2 residents (Resident #1 and #13) reviewed for enteral feeding tubes in that: 1. LVN A did not rinse or discard the medication syringe after administering medications into Resident #1's enteral feeding tube. 2. LVN A did not rinse or discard the medication syringe after administering medications into Resident #13's enteral feeding tube. These failures could place residents at risk for complications of enteral feeding. The findings included: 1. Record review of Resident #1's face sheet, dated 10/27/22 revealed a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included seizures/convulsions, anxiety, cerebral palsy (physical disability that affects movement and posture), osteoporosis (condition that causes bones to become weak and brittle).…

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 was provided with such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 residents (Resident #4) reviewed for respiratory care in that: The facility failed to ensure Resident #4 had an oxygen sign posted outside her bedroom. This deficient practice could place residents at risk for inadequate care. The findings included: Record review of Resident #4's face sheet, dated 9/6/23 revealed a [AGE] year old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included dementia with behavioral disturbance, hypertension (high blood pressure), angina pectoris (condition marked by severe chest pain caused by inadequate blood supply to the heart), heart failure, glaucoma (a condition of increased pressure within the eyeball causing gradual loss of sight),…

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 an interview and record review, the facility failed to ensure that the facility's infection preventionist attended the QAA/QAPI meetings, for 1 of 1 facility, reviewed for QAA/QAPI. The facility failed to ensure the infection preventionist attended their QAA and QAPI meetings for any month since the last annual survey (09/23/2022). This failure could place residents at risk for quality deficiencies being unidentified and a lack of appropriate plans of action developed or implemented. The findings included: Record review of the facility's QAA/QAPI standing members list reflected the infection preventionist was not a member. Interview on 11/30/2023 at 3:16 PM, the ADON stated the QAA/QAPI committee met quarterly and that LVN B, the Infection Preventionist, was not a part of these meetings. The ADON stated she was not aware that the Infection Preventionist was a required member of the committee. The ADON stated she understood the risk of not having the Infection Preventionist as a committee member as infection control concerns may not be brought to the committee. Interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made for 2 of 2 (Residents #1 and#2) residents. 1.The facility failed to report on 3 separate elopement incidents Resident #1 elopement from the facility, no injuries. 2. The facility failed to report and submit Resident #2's left knee fracture, intake #379566 allegation of unknown origin. These failures could place residents at risk for not having allegations of abuse or neglect reported to the State Agency to ensure that allegations are fully investigated. The findings were: 1. Record review of Resident #1's admission Record dated [DATE] revealed she was admitted on [DATE] with diagnoses of vascular dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially…

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.