Ignite Medical Resort San Antonio, LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Number of residents sampled: Number of residents cited: Based on observation, interview, and record review the facility failed to ensure for a resident who enters the facility with an indwelling catheter or subsequently receives one had a clinical condition that demonstrates catheterization is necessary for 1 of 3 residents (Resident # 50) reviewed for indwelling urinary catheterization necessity, in that: Resident #50 did not have a physician's order for an indwelling catheter. This deficient practice could affect residents in the facility who have an indwelling or external catheter and place them at risk for infection and improper care. The findings were: Record review of Resident #50 face sheet revealed a [AGE] year-old female admitted on [DATE] with diagnosis that included: Urinary retention (refers to the inability to empty the bladder),Congestive heart failure (a condition where the heart muscle is weakened or stiffened), and Hypertension (is a condition where the force of blood against the artery walls is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 1 residents (Resident #108) reviewed for respiratory care. The facility failed to ensure Resident #108's long-term indwelling chest catheter, known by the brand name PleurX, was drained per physician order and by competent staff. These failures could result in infection and/or complications to a resident's respiratory or cardiovascular systems. Findings included: Record review of Resident #108's face sheet, dated 9/21/2025, reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Relevant diagnoses included resistance to vancomycin related antibiotics, malignant pleural effusion [a fluid collection in the space surrounding the lung], and secondary malignant neoplasm of unspecified lung…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure a medication error rate below 5%, for 25 medication administration opportunities with 2 errors resulting in a 8% medication error rate, for 2 of 8 residents (Resident #25 and Resident #126) reviewed for medication administration. 1. LVN K administered to Resident #126 his prescribed insulin aspart after breakfast contrary to the physician's orders. 2. ADON LVN A attempted to administer Resident #25 his prescribed insulin aspart after breakfast contrary to the physician's orders. These failures could place residents at risk for not receiving the therapeutic effects of their medications. The findings included: 1 A record review of Resident #126's admission record dated 9/24/2025 revealed an admission date of 9/15/2025 with diagnoses which included type II diabetes with hyperglycemia (a disease where excess sugar accumulates in the bloodstream and could contribute to infections) and infection of right knee prosthetic (artificial…

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 ensure all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access, for 1 of 6 medication carts (200-hall medication cart), reviewed for security. LVN G left the 200-hall west medication cart unattended and unlocked. This failure could place residents at risk for having their medications accessible to unauthorized people. The findings included: During an observation and interview on 9/23/2025 at 10:43 AM revealed the 200-hall west medication cart parked in the 200-hall west hallway unlocked and unattended. Further review revealed staff and residents ambulated nearby in the hallway. During an interview on 9/23/2025 at 10:45 AM ADON J stated the cart was assigned to LVN G. ADON J stated the expectation was for the medication carts to be locked when not attended. During an interview on 9/23/2025 at 10:49 AM LVN G stated he was in a resident's room assessing their blood sugar. LVN G stated he could not see his medication…

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 all mechanical, electrical, and patient care equipment in safe operating condition for 2 of 2 elevators reviewed for essential equipment. The facility failed to ensure elevators #1 and #2 were functioning properly. This failure could place residents at risk of not having functional and safe mode of travel from floor to floor. The findings included: Record review of Elevator #1's Texas Department of Licensing and Regulation revealed last known annual inspection was 7/24/2024 and the hydraulic elevator passed inspection. Record review of Elevator #2's Texas Department of Licensing and Regulation revealed last known annual inspection was 7/24/2024 and the hydraulic elevator passed inspection. Record review of elevator service calls documented [elevator repair company portal] from 5/21/2024 to 5/15/2025 revealed a total of 25 service calls of which 4 were related service calls: -5/15/2025 3:54 pm (after surveyor intervention) elevator 1, Jumping very hard 1 of 2 with resolution documented as checked…

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 biological's were stored properly in the cart for 1 (100 hallway med aide cart) of 2 medication carts reviewed, in that: The facility failed to ensure Resident #5's Lyrica (pregabalin), a DEA controlled substance, was stored appropriately in a double locked container. This failure could place residents at risk of not receiving prescribed medications as ordered and drug diversions. The findings included: During an observation of LVN B's medication cart for the 100 hallway on 5/15/2025 at 5:00 p.m., revealed one white capsule marked Z 14 and identified as Lyrica, a schedule V (5) controlled substance, was found in an unmarked medication cup that had been removed from the locked controlled substance box of the medication cart and left in the upper right drawer of the medication cart which did not have a separate locked compartment for controlled substances. During an interview on 5/15/2025 at 5:00 p.m., CNA B stated the white capsule marked Z 14 was a capsule of Lyrica meant for Resident #5.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #1) of 5 residents reviewed for medical records. The facility failed to ensure LVN A documented Resident #1's medication at the correct time the medication was administered. This failure placed resident at risk for delayed or inaccurate medication administration which could result in decline in health and well-being. The findings included: Record review of Resident #1's face sheet, dated 5/15/2025 revealed Resident #1 was a [AGE] year-old female admitted on [DATE] with diagnoses which included: displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing (fracture to left leg bone with surgical repair), benign neoplasm of cerebral meninges (non-cancerous tumor of the lining of the brain and spinal cord) and generalized muscle weakness. Record review…

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 protect the confidentiality of personal and medical records for 14 (Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, Resident #14, Resident #15) of 14 residents and involving one (LPN A) of six staff observed for confidentiality of records. The facility failed to ensure LPN A would not leave a Vital Signs Flow Sheet Report on a 200-East Hall medication cart exposing 200-East Hall residents' personal information. This failure could affect residents by placing them at risk for loss of privacy and dignity. The findings included: During an observation on 200-East Hall on 03/13/2025 at 09:18 a.m., revealed an unattended and visible Vital Signs Floor Sheet Report, dated 03/13/2025 for shift 6A-6P (06:00 a.m. to 06:00 p.m.). The staff identified on the document was LPN A, CNA B for 06:00 a.m. to 12:00 p.m., and CNA C for 12:00 p.m.…

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 develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of care within 48 hours of a resident's admission for three (Resident #1, Resident #2, and Resident #3) of four residents reviewed for baseline care plans. The facility failed to complete a baseline care plan within 48 hours of admission that addressed the services that were being provided for Resident #1, Resident #2, and Resident #3. This failure could place newly admitted residents at risk for not receiving the care, services, and continuity of care to meet their needs. Findings included: Record review of Resident #1's admission Record, dated 03/13/2025, reflected a [AGE] year-old female. She was admitted to the facility on [DATE] and discharged on 03/10/2025 to an acute care hospital. Record review of Resident #1's Medical Diagnosis EMR tab, undated and…

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

Based on observations, interviews, and record reviews, the facility failed to ensure all drugs and biologicals were stored in locked compartments for three (Cart 200-East Hall, Cart 200-West Hall, and Cart 300-West Hall) of six reviewed for drug storage. The facility failed to ensure medication carts, 200-East Hall and 200-West Hall on the second floor and 300-West Hall on the third floor were secured when unattended on 03/12/2025. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm, drug overdose, or drug diversion. Findings included: During an observation and interview on 03/12/2025 at 03:07 p.m., a medication cart on 200-West Hall was observed to be unlocked and unattended. Facility staff and residents were not observed around the unlocked medication cart. At 03:08 p.m., RN G was observed coming out of a resident room. RN G confirmed the medication cart was his and that the cart was unlocked. He stated he had just gone to quickly administer a Tylenol to one of his residents. He stated the medication drawers that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure the residents received treatment and care in accordance with professional standards of practice for one (Resident #2) of four residents reviewed for physician orders for treatments. The facility failed to follow physician orders and obtain Resident #2's weight during night shift every Tuesday per physician order schedule. This failure could affect residents currently residing in the facility resulting in not receiving needed care to maintain optimum health and placing them at risk for injury and/or deterioration in their condition. The findings included: Record review of Resident #2's admission Record, dated 03/13/2025, reflected a [AGE] year-old male. He was admitted to the facility on [DATE]. Record review of Resident #2's Medical Diagnosis EMR tab, undated and accessed on 03/13/2025, reflected Resident #2 had diagnoses which included encounter for surgical aftercare following surgery on the digestive system, pneumonia (a lung…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure the residents received treatment and care in accordance with professional standards of practice, to promote healing, prevent infection, and prevent new pressure ulcers from developing for one (Resident #2) of four residents reviewed for pressure ulcers. In three observations over three days, the facility failed to follow physician orders and apply Prevelon boots (cushioned boots, also known as heel protectors, designed to lift the heel off the bed and help prevent heel pressure injures and provide pressure relief) as ordered for Resident #2. This failure could affect residents currently residing in the facility resulting in not receiving needed care to maintain optimum health and placing them at risk for injury and/or deterioration in their condition. The findings included: Record review of Resident #2's admission Record, dated 03/13/2025, reflected a [AGE] year-old male. He was admitted to the facility on [DATE]. Record review…

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 the kitchen. The facility failed to ensure osmolite (a tube feeding formula) was disposed of after its best-by date. The facility failed to ensure staffs facial hair was covered by a hair restraint. The facility failed to ensure trays, insulated plate lids, and insulated plate bases were air dried prior to stacking them with water droplets resulting in being wiped dry with a hand towel during meal prep. The facility failed to ensure dietary staff used proper hand hygiene during meal preparation. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: Observation on 08/12/2024 at 3:20 PM, revealed 4 8 fl. oz. closeable cartons of Osmolite with a best-by date on the top of the carton of 1FEB2024 in the 3rd floor nutrition fridge. Interview on 8/12/2024 at 5:00 PM, the DON stated that there should be no Osmolite 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 interviews and record reviews, the facility failed to deliver the necessary care and services to attain or maintain the highest practicable physical, mental, and psychological well-being for 3 of 30 Residents (Resident # 201, Resident # 67, and Resident # 203 who were reviewed for call light response in that: The facility failed to deliver timely call light response for Resident #201, Resident # 67, and Resident # 203. This deficient practice could affect residents who receive care at the facility and could result in missed or inadequate care. The findings were: Record review of Resident #201's face sheet dated 8/15/24 revealed Resident # 201 was admitted on [DATE] with diagnoses of fusion of spine (a surgical procedure to correct problems with the spine, type 2 diabetes mellitus (a condition in which the body has trouble controlling blood sugar), and adult T-cell lymphoma (a cancer of the immune system). Record review of Resident # 201's admission MDS assessment dated [DATE] revealed that Resident #…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to develop and implement baseline care plans that included the instructions needed to provide effective and person-centered care within 48 hours of admission for 8 of 25 residents (Residents #77, #99, #100, #102, #106, #149, #150, and #199) that were reviewed for baseline care plans in that: The facility failed to complete (Residents #77, #99, #100, #102, #106, #149, #150, and #199) baseline care plans within 48 hours. This deficient practice could affect residents who receive care at the facility and could result in missed or inadequate care. The findings were: Record review of Resident #77's face sheet, dated 08/15/2024, revealed Resident #77 was admitted to the facility on [DATE] with diagnoses which included: acute and chronic respiratory failure with hypoxia, COVID19, pneumonia due to SARS-associated coronavirus, chronic obstructive pulmonary disease, unspecified, acute bronchitis, pulmonary hypertension, unspecified, hypothyroidism, unspecified,…

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 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 infection for 2 of 11 residents (Residents #89 and #204) reviewed for infection control and for residents who eat in their rooms in halls, in that: 1. RN-E did not sanitize glucometer in between uses with Residents #204 and #89, or after leaving Resident's #89 room, who was on droplet precautions. 2. RN-E failed to wash or sanitize his hands between glove changes before administering medications to Resident #204 and Resident #89. RN-E failed to wash or sanitize his hands when entering or exiting Resident #89's room, who was on droplet precautions. 3. Server B during meal pass did not sanitize hands between trays when entering and exiting resident rooms. These deficient practices could place residents at risk for infection due to improper care practices. The findings include: 1. 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 observations, interviews, and record reviews the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside and toilet and bathing facilities, for 1 of 30 residents (Resident #79) reviewed for call light accessibility and functionality, in that: On 07/09/2024 at 01:00 PM Resident #79 utilized his call light which did not illuminate the nurse call light directly outside of and above of his room door. This failure could place residents at risk for harm by not receiving care and attention when their nurse call light system malfunctions and or is out of reach. The findings included: A record review of Resident #79's admission record dated 08/15/2024 revealed an admission date of 7/15/24 with diagnoses which included acute kidney failure (the kidney was not functioning correctly), type 2 diabetes mellitus (a condition in which the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to provide pharmaceutical services (including procedures that assist the accurate acquiring, receiving, dispensing ,and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 3 residents(Resident #1) reviewed for pharmacy services. The facility failed to acquire and administer Resident #1's scheduled dose of Dexamethasone (a corticosteroid that prevents the release of substances in the body that cause inflammation.) on 7/7/2024 and 7/8/2024. This failure could place residents at risk for pain and poor quality of life. The findings were: Record review of Resident #1's face sheet, dated 7/17/2024 revealed a [AGE] year-old female with an admission date of 6/27/2024 and diagnoses which included neoplasm of cerebral meninges, ( A meningioma is a tumor that grows from the membranes that surround the brain and spinal cord, called the meninges. A meningioma is not a brain tumor, but it may press on the nearby brain, nerves 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 review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 4 of 4 residents (Residents #1, #2, #3 and #4) reviewed for quality of care in that: The facility failed to ensure Residents #1, #2, #3 and #4 received their scheduled wound care as ordered by the physician. This deficient practice could place residents at risk for worsening skin conditions and infections. Findings included: Record review of Resident #1's admission Record, dated 1/19/24, revealed Resident #1 was admitted to the facility on [DATE], with the following diagnoses: Acute embolism (blockage in a blood vessel caused by a piece of material) and thrombosis (blood clot in an artery/vein) of right femoral vein, Type 2 Diabetes (chronic condition that affects the way the body processes blood sugar) , Hyperlipidemia (high levels of fat in the blood), Hypertension (high blood pressure), Peripheral Vascular Disease (circulatory…

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 ensure all drugs and biologicals were stored in locked compartments in 2 of 9 medication carts (third floor treatment cart and medication cart) reviewed for medication storage, in that: The facility failed to ensure the third-floor treatment cart and medication cart were locked when left unattended in the hallway. This deficient practice could place residents at risk of medication misuse or drug diversion. Findings included: During an observation on 1/19/24 at 11:30 a.m., the treatment cart on the third floor was unlocked and unattended. The treatment cart contained prescription and over the counter medications related to skin and wound care, and suture removal kits. There were visitors and non-nursing staff walking up and down the hallway and there were no nurses at the nurses' station or in the hallways. The treatment cart was again observed unlocked on 1/20/24 at 5:21 pm. The CNO was notified by the surveyor. During observation 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 baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care, for 2 of 8 Residents (Residents #236 and #238) reviewed for base line care plans, in that: 1. The facility failed to develop and implement a baseline care plan to support Resident #236's needs for hypotension, low blood pressure, with prescribed medications meant to raise blood pressure, oxygen use, prescribed opioid use for pain, and support interventions for a fractured hip. 2. The facility failed to develop and implement a baseline care plan to support Resident #238's needs for communication in Arabic. These failures could place residents at risk of not having their needs identified within the required timeframe, to provide person centered care. The findings included: 1. A record review of Resident #236's admission 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.

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%. The facility error rate was 10.7% based on 3 errors out of 28 opportunities for 2 of 5 residents (Resident #256 and #257) reviewed for medication administration: 1. LVN M administered a late medication for Resident #256. The medication was scheduled for 07:30 AM administration, the medication was administered at 08:44 AM. 2. MA N administered late medications for Resident #257. The medications were scheduled for administration any time between 07:00 AM and 10:00 AM. The medications were administered at 11:54 AM. These deficient practices could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. The findings included: 1. Resident #256 A record review of Resident #256's admission record, dated 07/12/2023, revealed an admission date of 06/28/2023 with diagnoses which included diabetes mellitus type II [a deadly disease where the body…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure residents are free of any significant medication errors, for 2 of 5 residents (Resident #236 and Resident #256) reviewed for medication administration, in that: 1. MA N administered midodrine (a drug prescribed to raise blood pressure) while Resident #236 was experiencing high blood pressure. 2. LVN M administered Resident #256's insulin late. These failures could place residents at risk for not receiving therapeutic effects of their medications to include a diminished health status. The findings included: 1. Resident #236 A record review of Resident #236's admission record, dated 07/11/2023, revealed an admission date of 07/04/2023, with diagnoses which included hypotension [low blood pressure]. A record review of Resident #236's admission MDS, dated [DATE], revealed Resident #236 was an [AGE] year-old female admitted from the hospital and assessed with a BIMS of 15 out of 15 score indicating no mental cognition impairment. 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 observations, interview and record review revealed the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchens in that: The DM used a white towel from the sanitizer bucket under the holding food cart as a sanitizer thermometer testing in between food items. This failure could place residents at risk of cross contamination and food borne illness. The Findings were: Observation on 7/13/2023 at 4:08 PM in kitchen for food temperature, testing with the DM, he used a white towel from a small red bucket. This was labeled sanitizer bucket and was under the holding food cart, to wipe the food thermometer in between food items. Interview on 7/13/2023 at 4:09 PM the DM stated he always had used a towel from the sanitizer bucket to take the food temperature of food items. Interview on 7/13/23 at 4:10 PM [NAME] O stated he had just put a new bucket that was sanitizer and had not used, before the DM used it to take food item temperatures. [NAME] O stated he had not used the sanitizer towel for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls for 1 of 8 Residents (Resident #47) reviewed for storage of medications. Resident #47's triamcinolone cream [a cream used to treat the itching, redness, dryness, crusting, scaling, inflammation, and discomfort of various skin conditions], was stored in his room at his bedside. This deficient practice could place residents at risk for harm due to improper storage. The findings are: A record review of Resident #47's admission record, dated 07/13/2023, revealed an admission date of 06/28/2023, with diagnoses which included a rash. A record review of Resident #47's admission MDS, dated [DATE], revealed Resident #47 was a [AGE] year-old male, admitted from the hospital. A record review of Resident #47's physician's orders dated 07/10/2023 revealed Resident #47 was prescribed triamcinolone cream 0.1% topical apply to bilateral lower extremities topically…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents were provide the therapeutic diets as prescribed by the attending physician for 1 of 8 residents (#71) reviewed in that: Resident # 71 did not receive his sugar free health shake lunch meal as ordered by physician. This failure could affect residents with diet needs and could result in a decrease in calories and potential weight loss. The Findings were: Record review of Resident #71's admission Record dated 7/13/2023 revealed he was admitted on [DATE] with acute kidney failure, diabetes II and chronic kidney disease Record review of Resident #71's consolidated physician orders for July 2023 documented House Shake-Sugar Free three times a day with meals. Record review of Resident #71's admission MDS dated [DATE] revealed Section C: Cognitive Patterns BIMS score was 11/15 (moderately impaired). Record review of Resident #71's Care plan dated 6/13/2023 revealed Resident #71 for diet, controlled carbohydrate, regular texture,…

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.