Las Colinas Of Westover

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, 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 32 residents (Resident #75) reviewed for accuracy of medical records. The facility failed to ensure Resident #75's oxygen therapy was documented on her MAR. This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care and treatment. The findings included: Record review of Resident #75's electronic face sheet dated 09/30/2025 reflected she was an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included: Alzheimer's disease (progressive brain disorder that causes memory loss, confusion, and other cognitive decline), dysphagia (difficulty swallowing foods and liquids), anxiety disorder (mental health condition characterized by excessive worry, fear, and nervousness that can interfere with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 residents (Resident #57 and #88) of 32 residents observed for infection control. 1. CNA D failed to change her gloves and sanitize her hands between soiled and clean items when she performed incontinent care for Resident #57. 2. CNA C failed to change her gloves and sanitize her hands between soiled and clean items when she and CNA B performed incontinent care for Resident #88. These failures could affect residents and place them at risk for infection. The findings included:1.Record review of Resident #57's electronic face sheet dated 10/02/2025 reflected she was a [AGE] year-old female who was readmitted to the facility on [DATE]. Her diagnoses included: senile degeneration of brain (progressive deterioration…

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 a safe, functional, and sanitary environment for 2 (Resident #37's room and Resident #8's room) out of 8 Residents' rooms reviewed, in that: 1. In Resident #37's restroom, the floor of the shower area was wet because the shower head was leaking water. 2. In Resident #8's restroom, there were human feces on the floor of the restroom. This deficient practice could result in residents living, staff working, and families visiting in an unsafe, unclean, and unpleasant environment. The findings were: 1. Record review of Resident #37's face sheet, dated 10/03/2025, revealed the resident was a [AGE] year-old female, originally admitted on [DATE], and readmitted to the facility on [DATE] with diagnoses of fracture of unspecified part of neck of left femur Chronic obstructive pulmonary disease (common lung disease causing restricted airflow and breathing problems), muscle weakness, and obstructive and reflux uropathy (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.

Based on observation, interview, and record review, the facility failed to ensure the residents' right to a safe, clean, comfortable and homelike environment for 1 of 1 Beauty Shop, in that:The facility Beauty Shop was found unlocked on 11/25/25 and contained potentially harmful items.This deficient practice could result in residents living in an unsafe environment.The findings were:Observation on 11/25/2025 at 10:32 a.m., revealed the facility Beauty Shop was unlocked and unoccupied, and contained containers of potentially harmful materials including: hairspray labeled flammable, hair dye labeled can cause allergic reaction and may cause skin irritation, sanitizing wipes labeled flammable and avoid contact with eyes, hair setting solution labeled keep out of reach of children', and nail dryer labeled flammable.During an interview with the Administrator on 11/25/2025 at 10:40 a.m., the Administrator confirmed the Beauty Shop should have been secured so that residents would not come into contact with potentially harmful materials. He stated the shop was usually secure and the door…

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 medical records that were complete and accurately documented for 1 of 15 (Resident #1) residents reviewed, in that: Resident #1's diagnoses of Primary Osteoarthritis Left Shoulder, Primary Osteoarthritis Right Shoulder, and Polyneuropathy Unspecified were not listed on his face sheet. This failure could result in inadequate care due to incomplete and inaccurate medical records. The findings were:Record review of Resident #1's face sheet, dated 11/25/2025, revealed he was admitted on [DATE] with diagnoses including: Chronic Respiratory Failure with Hypoxia, Unspecified Protein-Calorie Malnutrition, and Unspecified Combined Systolic (Congestive) and Diastolic (Congestive) Heart Failure. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 15 which indicated intact cognition. Record review of Resident #1's care plan, dated 09/21/2025, revealed Pain related to Immobility. Record review of a provider note from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes enhancement of his or her quality of life, recognizing each resident's individuality for 3 of 7 Residents (Resident #71, Resident #101 and Resident #64) who were observed for ADL care. 1. LVN A stood while feeding Resident #71 her lunch meal on 9/24/24 and on 9/25/24. 2. LVN A stood while feeding Resident #101 her lunch meal on 9/25/24. 3. LVN B held the door open while a CNA was talking to him about Resident #64 exposing him to anyone walking down the hallway on 9/26/24. These deficient practices could affect dependent residents and contribute to feelings of shame or feeling uncomfortable. The findings were: 1. Review of Resident #71's face sheet, dated 9/27/24, revealed she was admitted to the facility on [DATE] with diagnosis including Dementia, Schizoaffective Disorder and Major Depressive Disorder, all dated 4/17/23.…

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 post a notice of the availability of such reports (surveys, certifications, and complaint investigations) in areas of the facility that are prominent and accessible to the public for 3 of 4 days observed for required postings. The facility did not post a sign providing the location of the survey results binder. This deficient practice could affect any resident and result in residents not being informed of the survey results. The findings were: Interview with 8 residents during a group meeting on 09/26/24 at 01:37 PM revealed they were not familiar with the survey results and where they were stored. All 8 residents stated they had not seen a sign or a binder labeled survey results. Observation on 09/26/24 at 02:18 PM in the facility lobby area revealed a group of binders on the shelf on the right-hand side. Amongst the binders there was 1 binder labeled Survey Results; it was not easily visible. Further observation revealed there was not a sign letting the residents and the public know of the location of the…

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

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for 1 of 1 kitchen observed for food service. The facility failed to ensure that items stored in the walk-in in refrigerator were labeled. The Dietary Manager and Dietary Aide failed to wear beard restraints while working in the kitchen. Cook and Dietary Aide did not properly wear hair restraints in a way that covered all their hair. This failure could place residents who receive food prepared in the facility's only kitchen by placing them at risk for food-borne illness and food contamination. The findings were: Observation of the facility's kitchen on 09/24/2024 at 8:40 AM revealed Dietary Manager not wearing beard restraint over his facial hair while in the kitchen. Observation of the walk-in refrigerator on 09/24/2024 at 8:44 AM revealed 13 trays of pre-portioned drinks, cakes, and bowls of cereal and unlabeled. Observation of the facility kitchen on 09/26/2024 at 10:24 AM revealed Cook's hair restraint not covering all…

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 for 2 of 5 residents (Residents #69, #90) and 1 of 1 rooms (room [ROOM NUMBER]), reviewed for infection control. 1. Resident #69 was provided wound care without EBP being used 2. Resident #90 was provided wound care from supplies that were open and kept in the same baggie, the staff made direct contact with the and gloves were not changed after, and the padding in the soiled brief contacted the wound when applying the dressing, and after the wound care was completed, the wound dressing was covered with the soiled brief while turning the resident. 3. Nursing staff failed to ensure the shower chair in room [ROOM NUMBER] was cleaned and sanitized when soiled with feces. These failures could place residents at risk of cross…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility is free of pests for 1 of 1 facility reviewed for physical environment. Multiple gnats were observed on resident food containers and flying around the facility. This failure places residents at risk of frustration, anxiety, and could result in the resident's not having a safe, sanitary environment. The findings were: In an observation of room [ROOM NUMBER] A on 9/24/24 at 9:45 a.m. on a bedside table next to bed held a tumbler and on top of the tumbler was a small snack sized Styrofoam bowl of fruit, possibly diced pears or peaches sealed with plastic wrap. On top of the plastic wrap was 8 to 10 gnats, and multiple flying around the tumbler and around surveyor's head at doorway. There was no loose food or open containers were observed. In an observation of room [ROOM NUMBER] A on 9/24/24 at 9:25 a.m. revealed a sticky fly trap tape hanging from the light above the bed 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 interviews and record reviews, the facility failed to ensure all Pre-admission Screening and Resident Review (PASARR) Level 1 residents with mental illness were provided with a PASARR Level II Evaluation and Assessment for 1 of 3 residents (#71) reviewed for PASARR services. The facility failed to identify Resident #71 as having diagnoses indicative of Mental Illness including Schizoaffective Disorder and Major Depressive Disorder on the PASARR screening which would require a PASARR Level II assessment. This deficient practices could place residents at risk to a diminished quality of life related to not receiving or benefiting from specialized services. Review of Resident #71's face sheet, dated 9/27/24, revealed she was admitted to the facility on [DATE] with diagnosis including Dementia, Schizoaffective Disorder and Major Depressive Disorder, all dated 4/17/23. Review of Resident #71's quarterly MDS assessment, dated 7/25/24, revealed her BIMS was 0 meaning she was unable to complete the Brief…

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's baseline Care Plan to include the minimum healthcare information necessary to properly care for a resident for 1 of 6 Residents (Resident #160) whose records were reviewed. Nursing staff failed to include Resident #160 used two 1/4 side rails while in bed for mobility. This deficient practice could affect residents who used side rails and could result in residents not receiving the equipment they needed for mobility. The frindings were: Review of Resident #160's face sheet, dated 9/27/24, revealed she was admitted to the facility on [DATE] with diagnoses including Other Malaise. Further review revealed Resident #160 had been in the facility 9 days. Review of Resident #160's EHR revealed an MDS had not been completed because it was not due until day 14 per RAI. Review of Resident #160's Baseline Care Plan, dated 9/18/24, revealed she was cognitively intact. Further review revealed under section H., Resident #160 did not…

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 received proper treatment and care to maintain mobility and good foot health, and provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s) and assist the resident in making appointments with a qualified person for 1 of 5 residents (Resident #52) reviewed for quality of care. Resident #52 did not see a podiatrist despite having thickened toenails and other foot concerns and the request of the resident's RP. This failure could place residents at risk of pain, difficulty wearing socks and or shoes, and could result in embarrassment, frustration, anxiety, and a decreased quality of life. The findings were: Record review of Resident #52's face sheet dated 9/27/24 revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with readmission on [DATE]. His diagnoses included cerebral infarction (also…

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 received appropriate treatment and services to prevent urinary tract infections for 1 of 4 residents (Resident #94), reviewed for quality of care. Resident #94's catheter care was not provided according to facility policy or standards of care. This failure could place resident's at risk of pain, anxiety, and could result in infection, illness, and a general decline in health. The findings were: Record review of Resident #94's face sheet dated 9/27/24 revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included retention of urine (a condition in which you are unable to empty all the urine from your bladder), hydronephrosis (a condition where one or both kidneys become stretched and swollen as the result of a build-up of urine inside them), obstructive uropathy (disorder of the urinary tract that occurs due to obstructed urinary flow and can be either structural or functional),…

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 needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 of 3 residents (Resident #79), reviewed for quality of care. Resident #79's oxygen nasal cannula was on the floor and not covered or protected from the elements. This failure could result in cross contamination and could result in infection, and illness. The findings were: Record review of Resident #79's face sheet dated 9/27/24 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with readmission on [DATE]. Her diagnoses included cerebral infarction (also known as a stroke-refers to damage to tissues in the brain due to a loss of oxygen to the area), acute cough, and wheezing. Record review of Resident #79's annual MDS assessment dated [DATE] indicated the resident had clear speech, understood 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 revealed the facility failed to ensure correct use of bed rails including but not limited to the following elements. Assess the resident for risk of entrapment from bed rails prior to installation and obtain informed consent prior to installation for 2 of 6 Residents (Resident #71 and Resident #160) whose records were reviewed. 1. Nursing staff failed to obtain an informed consent for the use of 1/4 bed rails for Resident #71. 2. Nursing staff failed to designate the reason for the use of the 1/4 bed rails on the bed evaluation for Resident #160 and failed to obtain an informed consent for the use the bed rails. These deficient practices could affect residents who used bed rails and could result residents not having required documentation in place for the use of bed rails. The findings were: 1. Review of Resident #71's face sheet, dated 9/27/24, revealed she was admitted to the facility on [DATE] with diagnosis including Dementia, Schizoaffective Disorder 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 interview and record review the facility failed to provide services that are furnished to maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 9 residents (#1 and #2) reviewed for care plans in that: 1. Resident #1's care plan did not indicate that she had a fall resulting in a shoulder fracture with interventions to include a sling to her left arm, fall mats and an orthopedic consult. 2. Resident #2's care plan did not indicate that she had a fall resulting in a finger fracture with interventions to include a finger splint. This deficient practice could place residents at risk of not having needs identified and interventions established. The findings were: 1. Review of resident #1's face sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease (a progressive disease that affects memory and other important mental functions) and Ataxic Gait (impaired balance or coordination). 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 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 16 residents (Resident #8 and Resident #10) reviewed for care plans in that: 1. Resident #8's comprehensive care plan did not address the residents past medical history of Diabetes Mellitus 2. (Type 2 diabetes is a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel. That sugar also is called glucose. This long-term condition results in too much sugar circulating in the blood. Eventually, high blood sugar levels can lead to disorders of the circulatory, nervous, and immune systems.) 2. Resident #10's comprehensive care plan's interventions were not implemented regarding the focus of Resident #10 being at risk…

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 right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 16 (Resident #10) residents reviewed in that: The facility failed to ensure that Resident #10's call light was within reach while she was in bed, on 12/05/2023 and 12/06/2023. This could affect residents who used their call light or desire to use the call light and place them at risk of not being able to notify staff of their needs. The findings included: Record review of Resident #10's admission Record, dated 12/05/2023 reflected a resident initially admitted to the facility on [DATE] and readmitted [DATE] with diagnosis including: generalized muscle weakness, other abnormalities of gait (a person's manner of walking) and mobility, repeated falls, age-related cognitive decline, and personal history of traumatic…

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 the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 16 residents (Resident #10), reviewed for care plan revisions, in that: The facility failed to ensure that Resident #10's care plan included an intervention, that was requested by Resident #10's Responsible Party (RP) to prevent further injury with falls. This deficient practice could place residents at risk for lack of coordination of services. The finding included: Record review of Resident #10's admission Record dated 12/05/2023 reflected a resident initially admitted to the facility on [DATE] and readmitted [DATE] with diagnosis including: generalized muscle weakness, other abnormalities of gait (a person's manner of walking) and mobility, repeated falls, age-related cognitive decline, and personal history of traumatic fracture. 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, interview, and record review, the facility failed to store prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen and one of two nourishment refrigerators. The facility failed to ensure food items were properly labeled and dated in one of one walk in refrigerator, one of one walk in freezer, one of one freezer portion of the nourishment refrigerator, the dry storage area and under the steam table. The facility also failed to have trash cans with foot pedals to ensure kitchen staff members were not touching items in the kitchen after they touched the trash can lid. These failures could affect Residents who received their meals from the facility's only kitchen and one of two nourishment pantries. Finding included: During an observation and interview in the facility kitchen on 07/25/2023 at 10:10 a.m. revealed the DM washing his hands and the removable lid to one of two large gray trash cans and then proceeding to touch items on the steam table. During the same observation and interview, the DM…

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 15 (Resident #2, Resident #4, Resident #13, Resident #22, Resident #24, Resident #29, Resident #35, Resident #39, Resident #44, Resident #47, Resident #48, Resident #49, Resident #62, Resident #92, Resident #152) of 15 reviewed for accuracy of medical records in that: Facility staff failed to accurately assess wounds and provide and/or document wound care for 15 residents with wounds. All 15 residents had blanks (not completed) on their treatment records (TAR) for physician wound care orders in the month of [DATE]. This deficient practice could affect residents requiring assistance from staff for wounds and could place them at risk for harm and not attaining the highest practicable well-being. The findings included: Record review of Resident #2's admission record, dated [DATE], revealed an admission date of [DATE].…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician and others participating in the provision of care for 3 of 3 residents (Resident # 11, Resident # 15, and Resident # 23) reviewed for hospice services in that: The facility failed to maintain required hospice forms and documentation to ensure residents received adequate end-of-life care. This failure could place the residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. The findings were: Record review of Resident #11's face sheet dated 07/28/2023 revealed a 79- year- old female who initially admitted on [DATE] with diagnoses that included but not limited 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 observation, interviews and record reviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 resident (Resident #155) observed for peri care and catheter care and 1 of 7 staff (MA OO) observed for infection control: 1. CNA H failed to follow infection control requirements while performing peri care for Resident #155. 2. MA OO failed to sanitized the blood pressure cuff between 3 residents (Resident #27, Resident #37, and Resident #65) during medication administration. This deficient practice could affect residents who receive peri care and medication administration and could result in cross contamination of germs and could result in a urinary tract infection (a painful infection of the urinary system, which includes the kidneys, bladder, urethra, and ureters) or other skin infections. The findings were: 1.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the nursing staff were licensed for 1 of 7 staff (LVN H) reviewed for competencies. The facility failed to ensure LVN H was permitted to practice as a licensed vocational nurse. This failure could place residents at the facility at risk of not receiving care and services from staff who are properly trained. The findings were: Record review of the staff list provided by the facility revealed LVN H, as an LVN, with a hire date of [DATE]. Record review of the employee file for LVN H, revealed that LVN H had no documentation of a permit to practice nursing. Record review of the website on [DATE] https://txbn.boardsofnursing.org/licenselookup revealed that LVN H was listed on the board of nursing as having an expired license as of [DATE]. Interview with LVN H by telephone on [DATE] at 12:03 p.m., LVN H stated, Yes, I have worked here about 2 years, on 200 hall Monday through Friday and helping out where I am able to help out. LVN H stated, his…

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.