Hunters Pond Rehabilitation And Healthcare

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 includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 8 residents (Resident #1) reviewed for care plans: The facility failed to develop a person-centered care plan with interventions that addressed Resident #1's need for 2 staff to assist with bed mobility. This failure could place residents at risk for not having their needs and preferences met. The findings were: Record review of Resident #1's admission record, dated 1/8/25, admitted on [DATE] revealed a [AGE] year-old female with diagnoses that included encephalopathy (any brain disorder or disease that affects the brain's structure or function), gastrostomy status (a surgical procedure that creates an opening in the abdomen and into the stomach. 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 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 disease and infection for 2 of 8 residents (Resident #14 and Resident #16) reviewed for infection control 1. The facility failed to ensure CNA D used appropriate hand hygiene between glove changes when providing incontinent care to Resident #14. 2. The facility failed to ensure Resident #16's catheter bag was not laying on the floor. These deficient practices could place residents at-risk for infection due to improper care practices. The findings included: 1. Record review of the admission Record, dated 1/8/25, reflected Resident #14 was a [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included morbid severe obesity due to excess calories, chronic kidney disease stage 3 (the kidneys are moderately…

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 residents who required dialysis received such services, consistent with professional standards of practice for 1 of 4 residents (Resident #1) reviewed for dialysis. Resident #1's did not have vital signs checked prior to leaving for dialysis on 10/4/24. This deficient practice could affect residents who received dialysis treatments and could result in inadequate care of dialysis treatment. Findings included: Record review of Resident #1's admission Record, dated 10/22/24, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Acute Kidney Failure (condition in which kidneys suddenly are unable to filter waste from blood), Type 2 Diabetes (condition in which the body has trouble controlling blood sugar and using it for energy), and Hypertension (high blood pressure). Record review of Resident #1's Order Summary, dated 10/22/24, revealed an order for dialysis treatment on 10/4/24. Further review revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure assessments accurately reflected the resident's status for 2 of 6 Residents (Resident #95 and Resident #104) whose MDS records were reviewed for accuracy. 1. The facility failed to ensure Resident #95's Quarterly MDS assessment dated [DATE] documented that Resident #95 received hospice services. 2. The facility failed to ensure Resident #104 Discharge MDS assessment dated [DATE] documented Resident #104 was discharged home. 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 #95's face sheet dated 07/10/24, revealed Resident #95 was admitted to the facility on [DATE] with diagnoses that included Type 2 diabetes mellitus with hyperglycemia (chronic health condition that affects how body turns food into energy), sepsis, unspecified organism, (body's extreme response to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort for 1 of 8 residents reviewed for PASRR (Resident #24). The facility failed to ensure Resident #24 had an accurate PASRR Level 1 Screening indicating diagnoses of mental illness and refer the residents to the state designated authority. This failure could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs. Findings included: Record Review of Resident #24's admission record, dated 7/11/24, revealed a [AGE] year-old male initially admitted [DATE] and with diagnoses including depression and insomnia. Record Review of Resident #24's quarterly MDS assessment, dated 5/16/24, reflected Resident #11 had intact cognition for daily decision making and had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a comprehensive care plan for 1 (Resident #39) of 21 residents reviewed for comprehensive care plans, in that: Resident #39's care plan was missing diagnoses and treatment information. This deficient practice could place residents at risk of receiving inadequate care and could result in a decline in health. The findings were: Record review of Resident #39's face sheet, dated 07/12/2024, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Paraplegia, complete; Hypotension; and Gastro-Esophageal Reflux Disease without Esophagitis. Record review of Resident #39's clinical record, as of 07/12/2024, revealed the resident was re-admitted to the facility on [DATE]. Record review of Resident #39's Quarterly MDS Assessment, dated 06/30/2024, revealed a BIMS score of 15 which indicated intact cognition. Record review of Resident #39's care plan, revised 07/05/2024, revealed the care plan did not address the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 8% based on 2 out of 25 opportunities, which involved 2 of 4 Residents (Residents #52 and Resident #69) reviewed for medication administration, in that: 1. The facility failed to ensure CMA A administered Resident #52's isosorbide mononitrate (medication use to prevent chest pain (angina) in patients with certain heart conditions). 2. The facility failed to ensure LVN B administered Resident #69's insulin aspart (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) 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 #52's face sheet, dated 7/12/24 revealed a [AGE]…

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 on each resident that were-accurately documented for 1 of 8 residents (Resident #24) reviewed for accurate medical records in that: The facility failed to document Resident #24's medical diagnosis of Major Depressive Disorder (MDD) in his medical record. The deficient practices could affect residents who have medical records and could result in misinformation about professional care provided. The findings included: Record Review of Resident #24's admission record, dated 7/11/24, revealed a [AGE] year-old male initially admitted [DATE] and with diagnoses including depression and insomnia. Record Review of Resident #24's quarterly MDS assessment, dated 5/16/24, reflected Resident #24 had intact cognition for daily decision making and had depression. Record review of Resident #24's a physician's order dated 7/11/24 indicated Resident #24 took venlafaxine for depression. Record review of Resident #24's medical records from 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 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: 1. The facility failed to ensure LVN B cleaned a rubber stopper on an insulin pen prior to insulin administration for Resident #69. 2. The facility failed to ensure LVN C changed gloves while providing nephrostomy care to Resident #39. These deficient practices could place residents at-risk for infections. The findings included: 1. Record review of Resident #69's face sheet, dated 7/12/24, revealed a [AGE] year-old female, admitted on [DATE] with diagnosis of type 2 diabetes and hemiplegia and hemiparesis following cerebral infarction affecting left non dominate side (Hemiparesis is a common after-effect of stroke that causes weakness on one side of the body). During an observation 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 promote and maintain the residents' right to be treated with respect and dignity for 2 of 8 residents (Residents #2 and #3) reviewed for dignity and respect, in that: 1. The facility failed to provide Resident #2 assistance with eating his 03/21/24 lunch service for at least 10 minutes while he was waiting with food that was in front of him and other residents were able to eat. 2. The facility failed to allow Resident #3 to receive her food preferences and Resident #3 felt upset because she was not being heard or accommodated by the facility. This deficient practice could place residents at risk of psychosocial harm due to diminished self-image and could place residents needing assistance at risk for diminished quality of life, loss of dignity, and self-worth. The findings included: 1. Record review of Resident #2's admission record revealed an admission date of 02/23/2024 with diagnoses which included unspecified lack of coordination 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 observations, interviews, and record reviews 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 and psychosocial needs that are identified in the comprehensive assessment for 2 of 8 residents (Resident #1 and #5) reviewed for care plans. The facility failed to care plan Residents #1 and #5 allergies to lactose. This failure could have placed residents at risk of not having their needs identified and met. The findings included: 1. Record review of Resident #1's admission record revealed an admission date of 02/08/2024 with diagnoses which included gastrointestinal hemorrhage (gastrointestinal bleeding) and gastro-esophageal reflux disease with esophagitis (stomach acid repeatedly flows back into the tube connecting your mouth and stomach). Record review of Resident #1's annual MDS assessment dated [DATE] revealed Resident #1 had a BIMS of 05 out of 15…

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 each resident received and the facility provided food that accommodated resident allergies, intolerances, and preferences for 2 of 2 residents (Resident #1 and #4) reviewed for dietary services, in that: 1. The facility failed to ensure that Resident #1's breakfast meal on 03/21/24 did not include any products with lactose as was read on her meal tray ticket. 2. The facility failed to ensure that Resident #4's lunch meal on 03/21/24 did not include mixed vegetables as was reflected on his lunch meal tray ticket. This deficient practice could affect residents with preferences/dislikes, and place them at-risk by contributing to poor intake and/or weight loss. The findings included: 1. Record review of Resident #1's admission record revealed an admission date of 02/08/2024 with diagnoses which included gastrointestinal hemorrhage (gastrointestinal bleeding) and gastro-esophageal reflux disease with esophagitis (stomach acid…

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 who have authorized the facility in writing to manage any personal funds have access to those funds for 2 of 2 residents (Resident #4 and Resident #5) reviewed for personal funds. The facility failed to ensure Resident #4 and Resident #5 had access to their personal funds when requested. This failure could place residents whose funds are managed by the facility at risk of not receiving their personal funds deposited with the facility and not having their rights and preferences honored. Findings included: Record review of Resident #4's face sheet dated 1/19/2024 revealed an admission date of 10/18/2022 with diagnoses which included: schizoaffective disorder (a chronic mental illness involving symptoms of schizophrenia and characterized by symptoms such as delusions and hallucinations), hyperlipidemia (high fat levels in the blood), and type 2 diabetes mellitus (a condition that develops with the way the body regulates and uses sugar as…

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

Based on interview and record review the facility failed to ensure licensed nurses had the specific competencies and skill sets necessary to care for residents' needs, as described in the plan of care for 1 of 3 staff (RN A) reviewed for nursing competencies, in that: The facility failed to assess medication competencies for RN A prior to 1/06/2024 when RN A failed to follow physician orders for holding insulin glargine for a blood sugar less than 100. This failure could place residents at risk for not having medications accurately dispensed, not receiving the intended therapeutic effects of their medications and could contribute to possible adverse reactions. The findings included: Record review of RN A's Nursing Competency Skills Checklist dated 2/11/2023 and signed off by the DON revealed RN A was marked as competent to perform testing blood glucose, patient assessment, administering subcutaneous injections. Medication administration was not part of the competencies assessed. Record review of Resident #1's face sheet dated 1/11/2024 revealed an admission date of 12/27/2023 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 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 4 residents (Resident # 7) reviewed for accuracy of medical records in that: The facility failed to ensure RN A's signature matched her job title and nursing license. This deficient practice could affect residents whose records are maintained by the facility and could place improper identification of staff and role in the resident medical records. The findings included: Record review of the Texas Board of Nursing website at https://www.bon.texas.gov revealed: RN A's nursing license for registered nurse (RN was current with an expiration date of [DATE]. RN A's nursing license for LVN/LPN was delinquent and had expired on [DATE]. Record review of Resident #1's face sheet dated [DATE] revealed an admission date of [DATE] with diagnoses which included: type 2 diabetes mellitus with hyperglycemia (elevated 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 interview and record review, the facility failed to develop and implement a person-centered care plan that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 12 residents (Resident #2) reviewed for comprehensive care plans, in that: The facility failed to amend Resident #2's care plan obtained on [DATE] promptly to include the use of a weighted blanket when it was implemented in [DATE]. This deficient practice could affect residents and place them at risk for not receiving appropriate treatment and services or activities. The findings were: Record review of Resident #2's face sheet, dated [DATE], revealed Resident #2 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease [a progressive disease that affects memory and other important mental functions], unspecified, Type 2 Diabetes Mellitus with hyperglycemia [high sugar levels in the blood], mild protein-calorie malnutrition, gastrostomy status [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.

Based on observation, interviews, and record reviews, the facility failed to ensure food was prepared in a form designed to meet individual needs for 6 of 6 residents (Residents #2, #3, #4, #5, #6 and #7) reviewed for food meeting residents' needs, in that: Cook B did not ensure the pureed food placed on a plate was a pudding or mashed potato consistency as required for food served to residents who received a pureed diet. Cook B did not provide enough chicken for the 6 residents receiving pureed diets. This deficient practice could affect residents who received pureed meals from the kitchen by contributing to dissatisfaction, poor intake, choking, and/or weight loss. The findings included: Record review of menu for 11/29/2023 revealed the menu for the pureed meal for residents included pureed beef tips with gravy, pureed green beans, pureed egg noodles, apple sauce, and a beverage. Record review of the electronic health records dated 12/04/2023 revealed for Residents #2, #3, #4, #5, #6 and #7 they all had the following diet order: Regular diet, Pureed texture, Thin Liquids…

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, in that: The facility failed to ensure proper dating and labeling of dry foods and refrigerator items. The facility failed to ensure residents eating over easy eggs were given pasteurized eggs. This failure could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings were: Observation on 11/28/2023 at 11:45 a. m.- Spices- Found above the preparation area, on the shelf, 3 large containers of onion powder, parsley and cinnamon open but not dated. There were 9 small bottles of spice 16 oz to 21 oz open and not dated. There was ground cumin, dill weed, cayenne pepper, caldo de [NAME], 2 containers of chicken flavored base, 1 container of beef flavored base, 1 bottle of soy sauce not dated or labeled and 1- 16 oz spice container no date and the label was torn…

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 each resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible, for 1 of 1 Residents (Resident #1) reviewed for perineal/incontinent care, in that: CNA A failed to clean between Resident #1's vaginal folds during incontinent/peri care. This deficient practice could place residents at risk of increased urinary tract infections and skin breakdown due to improper care. The findings included: Record review of Resident #76's face sheet, dated 9/22/23 revealed an [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included urinary tract infection, seizures, epilepsy (happens as a result of abnormal electrical brain activity, also known as a seizure, kind of like an electrical storm inside your head.), contracture (condition of shortening and hardening of muscles, tendons, or other…

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 the medication error rate was not five percent or greater. The facility had a medication error rate of 11% based on 4 errors out of 36 opportunities, which involved 2 of 6 residents (Resident #1 and Resident #2) reviewed for medication errors. - CMA A failed to administer medications as ordered to Resident #1 by administering Baclofen (a treatment for muscle spasms), Lithostat (a treatment for UTI), and Gabapentin (a treatment for nerve pain) 1 hour and 15 minutes after the scheduled time. - CMA A failed to administer a medication as ordered to Resident #2 by administering Protonix (a treatment for GERD) 1 hour and 23 minutes after the scheduled time. These failures could place residents at risk of not receiving the desired therapeutic effect of their medications and uncontrolled pain. Findings included: Resident #1 Record review of Resident #1's admission Record, dated 10/17/2023, revealed the resident was a…

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

Based on observation, interviews 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 and 1 of 3 food carts reviewed for kitchen sanitation in that: 1. The kitchen was soiled, dietary staff did not properly wash their hands, and food was not appropriately stored. 2. The 100-hall food cart had two lunch trays with food that was uncovered. These deficient practices could place residents who received meals from the main kitchen at risk for foodborne illness. The findings were: 1. Observation in the facility kitchen on 05/19/2023 between 11:45 a.m. and 12:10 p.m. revealed: *a container of powdered potatoes was located on a shelf above the sink in the food preparation are. The container was open and undated. *a buildup of a substance which appeared to be sand or dirt was located under the sink in the food preparation area. *caulking behind the sink and counter in the food preparation area was soiled and appeared black in color. *the frying station in the food preparation…

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 2 residents (Resident #44) reviewed for catheter/perineal care, in that: CNA F used multiple passes with the same wipe while providing catheter/perineal care to Resident #44. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices. The findings were: Record review of Resident #44's face sheet, dated 5/19/23 revealed a [AGE] year-old male admitted on [DATE] and re-admitted on [DATE] with diagnoses that included type 2 diabetes (a chronic, long-lasting health condition that affects how your body turns food into energy), heart failure, colostomy status (an opening created for the colon or large intestine through the abdomen wall) and urinary tract infection. Record review of Resident #44's most…

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 residents who required dialysis received such services, consistent with professional standards of practice for 1 of 2 residents (Resident #33) reviewed for dialysis in that: The facility did not maintain communication, coordination and collaboration with the dialysis facility for Resident #33. This deficient practice could affect residents who received dialysis treatments and place them at risk for complications and not receiving proper care and treatment to meet their needs. The findings were: Record review of Resident #33's face sheet, dated 5/19/23 revealed a [AGE] year old female admitted on [DATE] and re-admitted on [DATE] with diagnoses that included end stage renal disease (condition in which the kidneys cease functioning on a permanent basis), acute angle-closure glaucoma (an ocular emergency that results from a rapid decrease in intraocular pressure due to outflow obstruction), type 2 diabetes (a chronic, long-lasting…

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 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 2 residents (Resident #44) reviewed for infection control practices, in that: CNA F and CNA G failed to utilize appropriate hand hygiene and infection control practices during catheter/perineal care to Resident #44. These failures could place residents who required catheter/perineal care at risk for infection and or a decline in health. The findings were: Record review of Resident #44's face sheet, dated 5/19/23 revealed a [AGE] year-old male admitted on [DATE] and re-admitted on [DATE] with diagnoses that included type 2 diabetes (a chronic, long-lasting health condition that affects how your body turns food into energy), heart failure, colostomy status (an opening created for the colon or large intestine…

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.