Normandy Terrace Nursing & Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments and permit only authorized personnel to have access to the keys for one (1) of twelve (12) residents (Resident #4) reviewed for medication storage. The facility failed to ensure Resident #4 did not have two (2) velphoro oral tablets (a phosphate binder, a medication used to control phosphorus levels in the blood) at the bedside. This deficient practice could place residents at risk of medication misuse or drug diversion.The findings included: Record review of Resident #4's admission Record, dated 02/20/2026, revealed a [AGE] year-old male admitted on [DATE] and re-admitted on [DATE]. Record review of Resident #4's Diagnosis Report, dated 02/23/2026, revealed diagnoses including end stage renal disease (the final stage of chronic kidney disease, where the kidneys lose nearly all their ability to filter waste in the blood), and dependence on renal dialysis (condition where…

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 a sanitary, orderly, and comfortable interior by housekeeping and maintenance services, which were necessary to maintain a sanitary, orderly, and comfortable interior for 1 of 8 residents (Resident #3) reviewed for homelike environment. The facility failed to maintain Resident #3's bathroom with dry clean drywall without damage and without stains. This failure could place residents at risk for diminished self-worth.The findings included: A record review of Resident #3's admission record dated 1/13/2026 revealed an admission date of 8/29/2025 with diagnoses which included mid back spine fractures at T7-T8 and T11-T12 (spine fractures), bladder cancer, and muscle weakness. A record review of Resident #3's quarterly MDS assessment dated [DATE] revealed Resident #1 was a [AGE] year-old male admitted for long term care supports for activities of daily life (ADLs). Resident #1 was assessed with the need for assistance with hygiene…

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 the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart, for 1 of 8 residents (Resident #2) reviewed for misappropriation of property, in that: Housekeeper F (HK F) took Resident #2's money to purchase herself meals. This failure could place residents at risk for harm by exploitation which could result in psychosocial harm and mistrust of the staff. The findings included: Record review of the facility's undated Freedom from Abuse Notice to Employees Resident / Patient Abuse, Neglect, and Mistreatment of Belongings policy revealed, Gratuities and Loans . gratuities and gifts are any type of denomination of currency, items, of monetary value or could be exchanged for monetary value, services that are typically of monetary value, and items that have been designated to an individual that may have monetary value. It is the policy of the facility not to accept…

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 basis for discharge was documented in the resident's medical record for 1 out of 3 residents (Resident #1) reviewed for inappropriate discharges. 1.The facility failed to provide and document sufficient preparation and orientation for Resident #1 to ensure safe and orderly discharge from the facility to another facility. 2.The facility failed to develop and implement an effective discharge planning process and involve Resident #1 and the resident representative in the development of the discharge plan and inform Resident #1 and resident representative of the final plan. 3.The facility failed to have a discharge summary that included a post-discharge plan of care for Resident #1 that was developed with the participation of the resident representative(s), which would assist the resident to adjust to his or her new living environment. These failures could place residents at risk of diminished continuity of care and unsafe and/or improper…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 residents (Resident #2 and Resident #3) reviewed for infection control. The facility failed to ensure RN A followed infection control policy/procedures during wound care for Resident #2 and Resident #3. This deficient practice could place residents at risk for infection. Findings included: Record review of Resident #2's admission Record, dated 10/23/25, revealed the resident was admitted to the facility on [DATE] with diagnoses which included: right femur fracture, Alzheimer's Disease (disease affecting memory and other important mental functions) , Dementia (group of thinking and social symptoms that interferes with daily functioning). An interview was attempted on 10/22/25 at 2:06 pm, Resident #2 did not respond 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, interview, and record review, the facility failed to respect the residents right to personal privacy for 2 of 2 residents (Resident #2 and Resident #3) reviewed for privacy/dignity. The facility failed to ensure residents' privacy/dignity was maintained during wound care on (2) occasions. This failure could place residents at risk for poor self-esteem, decreased self-worth, and quality of life. Findings included: Record review of Resident #2's admission Record, dated 10/23/25, revealed the resident was admitted to the facility on [DATE] with diagnoses which included: right femur fracture, Alzheimer's Disease (disease affecting memory and other important mental functions), Dementia (group of thinking and social symptoms that interferes with daily functioning). Record review of Resident #2's comprehensive MDS assessment, dated 9/5/25, revealed the resident's cognitive skills for daily decision making were severely impaired. An interview was attempted on 10/22/25 at 2:06 pm, Resident #2 did…

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 alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources are reported immediately but not later than 2 hours to the administrator of the facility and to other officials, including to the State Survey Agency in accordance with State law through established procedures, for 1 of 1 Residents (Resident #1) reviewed for Neglect, in that: The facility did not report an allegation of Neglect to the State Survey Agency (HHSC) within the 2 hours time frame of Resident #1's elopement from the facility This deficient practice could affect any resident and could contribute to further neglect. The findings were: Review of Resident #'s 1 face sheet dated 8/17/25, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included: multiple sclerosis (a condition in which nerve damage affects the communication between the brain and body), type 2 diabetes mellitus (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, interviews and record reviews, the facility failed to ensure the resident had the right to be informed of, and participate in, his or her treatment, including: The right to be informed in advance of the care to be furnished and the type of care giver or professional that will furnish the care, and the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives, or treatment options and to choose the alternative or options he or she preferred, for 1 (Resident #70) of 8 residents reviewed for resident rights. The facility failed to obtain signed consent from Resident #70 to receive care under secured conditions. This failure could place residents at risk of receiving care under secured conditions without their or their responsible party's prior knowledge or consent, placing residents at risk of inability to make decisions regarding their plan of care. Findings included: 1. 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 observation, 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 6 residents (Residents #66 and #56) reviewed for infection control, in that: 1. While providing incontinent care for Resident #66, CNA E failed to use proper infection control. 2. While providing incontinent care for Resident #56, CNA F failed to use proper infection control. These deficient practices could place residents at-risk for infection due to improper care practices. The findings were: 1. Record review of Resident #66's face sheet, dated 07/24/2025, revealed an admission date of 04/01/2024, and, a readmission date of 02/19/2025, with diagnoses which included: Alcoholic cirrhosis of liver (Damage to the liver due to alcohol consumption), Dysphagia (Difficulty swallowing), Sepsis (Body's response to infection…

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 resident's dignity for 1 (Resident #10) of 25 residents reviewed for dignity, in that: Resident #10's wheelchair was visibly soiled with dust and food particles. This deficient practice could result in psychosocial harm due to feelings of embarrassment. The findings were: Record review of Resident #10's face sheet, dated 07/25/2025, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Abnormal Posture, Unspecified Lack of Coordination, and Muscle Wasting and Atrophy. Record review of Resident #10's Quarterly MDS, dated [DATE], revealed a BIMS score of 14 which indicated intact cognition. Record review of Resident #10's care plan, revised 07/22/2025, revealed The resident has an ADL self-care performance deficit. Observation on 07/25/2025 at 1:45 p.m. revealed Resident #10 utilized a motorized wheelchair for ambulation. Further observation revealed Resident #10's wheelchair was…

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 had the right to personal privacy and confidentiality of his or her personal and medical records for one of five residents (Resident # 66) reviewed for privacy. The facility failed to ensure MA C locked the computer, which exposed Resident #66's morning medication list after she walked away and left the computer unattended. This failure could place residents at risk of having medical information exposed to others and cause residents to feel uncomfortable and disrespected. The findings include: Record review of Resident #66's face sheet, dated 07/24/25, revealed an [AGE] year-old male admitted to the facility on [DATE]. Resident #66 had diagnoses that included: Hypertension (is when the force of blood against the artery walls is persistently too high), and Depression (is a mood disorder that causes a persistent feeling of sadness and loss of interest), and Dementia (decline in cognitive function, impacting memory,…

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 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 resident (Resident #66) reviewed for incontinent care, in that: While providing incontinent care for Resident #66, CNA E used a back to front motion to clean Resident #66's buttocks. 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 #66's face sheet, dated 07/24/2025, revealed an admission date of 04/01/2024, and, a readmission date of 02/19/2025, with diagnoses which included: Alcoholic cirrhosis of liver (Damage to the liver due to alcohol consumption), Dysphagia (Difficulty swallowing), Sepsis (Body's response to infection causes injury to its own tissues and organs), Dementia (Decline in cognitive abilities), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Hypertension (High 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.

Based on observations, interviews and record reviews the facility failed to ensure that CNAs were able to demonstrate competency in skills and techniques necessary to care for residents' needs for 1 of 6 residents (Resident #66) by 1 of 6 CNAs (CNA E) reviewed for competent staff, in that: The facility failed to ensure CNA E used the right technique to clean Resident #66 while providing incontinent care. 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 #66's face sheet, dated 07/24/2025, revealed an admission date of 04/01/2024, and, a readmission date of 02/19/2025, with diagnoses which included: Alcoholic cirrhosis of liver (Damage to the liver due to alcohol consumption), Dysphagia (Difficulty swallowing), Sepsis (Body's response to infection causes injury to its own tissues and organs), Dementia (Decline in cognitive abilities), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Hypertension (High blood pressure), Major depressive disorder…

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 drugs and biologicals were stored in accordance with currently accepted professional principles for, 1 of 3 (Hall 300 Nurse cart) medication carts observed, in that: The Nurse Medication Cart in the 300-hall contained five loose medication pills. This failure could place residents who receive medications at risk for not receiving the intended therapeutic effects of medications. The findings were: The findings were: Observation on 07/24/2025 at 7:45 p.m. of the 300 Hall Nurse Medication Cart revealed there were five loose medication pills inside one of the drawers. During an interview with MA C on 07/24/2025 at 7:50 p.m., MA C confirmed there were five loose medication pills inside a drawer of the Nurse Medication Cart. MA C stated the pills must have dropped at some point during a medication pass and she had not had a chance to clean the medication cart today. During an interview with the DON on 7/24/2025 at 8:20 p.m., the DON stated medication carts should not have loose medications. The DON stated…

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

Based on observation and interview, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 ( Resident # 86 ) of 5 resident refrigerators reviewed in that: The personal refrigerator for Resident # 86 contained food items that were unlabeled and undated. This deficient practice could place residents at risk of foodborne illness due to consuming foods which are spoiled. The findings were: Observation on 07/22/2025 at 10:37 a.m. revealed Resident #86 personal refrigerator contained a plastic bowl with lid containing menudo (Mexican tripe soup) without an expiration date, which was unlabeled and undated. Further observation on 07/22/2025 at 1:30 p.m. revealed the plastic bowl in Resident # 86's personal refrigerator was still present without an expiration date, which was unlabeled and undated. Interview on 7/22/25, at 2:00 p.m. CNA B, said the refrigerator in Resident #86's room contained a plastic bowl with lid containing menudo without an expiration date. CNA B said the bowl was unlabeled and undated. CNA B stated it was 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 interview and record review, the facility failed to maintain clinical records that were complete and accurately documented for 1 (Resident #66) of 25 residents reviewed for clinical records, in that: Resident #66's diagnoses of insomnia and aggressiveness /combativeness were not listed in his diagnosis list and Resident #66's physician order for psychotropic medication erroneously read supervised self-administration. This deficient practice could cause miscommunication among the resident's caregivers and result in improper care. The findings were: Record review of Resident #66's face sheet, dated 07/25/2025, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Generalized Anxiety Disorder and Major Depressive Disorder. Record review of Resident #66's Quarterly MDS, dated [DATE], revealed a BIMS score of 03 which indicated severe cognitive impairment. Record review of Resident #66's care plan, revised 08/10/2024, revealed, The resident has a behavior problem r/t dementia…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse, to the administrator of the facility and to other officials including to the State Survey Agency where state law provides for jurisdiction in long-term care facilities in accordance with State law through established procedures for 7 of 12 residents (Residents #2, #3, #4, #5, #7, #8, and #9), reviewed for freedom from abuse, neglect, and exploitation. 1. The facility failed to report when Resident #2 physically attacked Resident #3 for 2 days after the incident. 2. Facility failed to report an incident of suspected abuse, from 12/23/2024 when Resident #5 pushed Resident #4 down until 02/24/2025. 3. DON failed to report an incident of suspected abuse, from Saturday 04/19/2025 when Resident #7 accused staff hurting her, until Monday 04/21/2025. 4. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide the necessary care and services to a resident who [NAME] unable to carry out activities of daily living for 1 of 7 residents (Resident #2), reviewed for activities of daily living in the area of incontinent care. Resident #2 was not provided with incontinent care by a nursing staff member on 6/7/24 in a timely manner. This failure could result in residents experiencing a diminished quality of life. Findings included: Record review of Resident #2's admission Record, dated 6/11/24, revealed Resident #2 the resident was originally admitted to the facility on [DATE] with the most recent readmission on [DATE]. , Resident #2 hadwith diagnoses that included: Parkinson's Disease (A disorder of the central nervous system that affects movement, often including tremors) , acute kidney failure (condition in which kidneys suddenly are unable to filter waste from blood) , schizophrenia (a disorder that affects a person's ability to think,…

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 review, the facility failed to ensure resident medical records were kept in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete and accurately documented for 1 of 7 residents (Resident #2) reviewed for clinical records. The facility failed to ensure Resident #2's vital signs were documented in the EMR on [DATE] and [DATE]. This deficient practice could place residents at risk for improper care due to inaccurate records. Findings included: Record review of Resident #2's admission Record, dated [DATE], revealed Resident #2 was originally admitted to the facility on [DATE] with the most recent readmission on [DATE], with diagnoses that included: Parkinson's Disease (A disorder of the central nervous system that affects movement, often including tremors), acute kidney failure (condition in which kidneys suddenly are unable to filter waste from blood), schizophrenia (a disorder that affects 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 interview and record review, the facility failed to promote the residents' right to receive mail, for all facility residents, in that: Facility staff did not distribute mail received on Saturdays to the residents. This deficient practice could result in residents not receiving mail in a timely manner and a diminished quality of life. The findings were: During a confidential group meeting on 05/30/2024 at 1:30 p.m., members of the resident group stated that they do not receive mail on Saturdays and stated they feel this practice is disrespectful. During an interview with the AD on 05/31/2024 at 3:15 p.m., the AD stated mail is not delivered to resident on Saturdays. During an interview with the ABOM on 05/31/2024 at 3:18 p.m., the ABOM stated she and BOM do not work on Saturdays, and that the mail received at facility on Saturdays was left for them to sort and is given to residents on Mondays. During an interview with the Weekend Receptionist on 05/31/2024 at 3:42 p.m., the Weekend Receptionist stated she receives the mail from the postman/woman on Saturdays and was…

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 provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities for 3 of 22 residents (Residents #14, #48 and #73) reviewed for activities in that: 1. The facility failed to provide Resident #14 activities designed to meet her interests and promote physical, mental, and psychosocial well-being. 2. The facility failed to provide Resident #48 activities designed to meet his interests and promote physical, mental, and psychosocial well-being. 3. The facility failed to provide Resident #73 activities designed to meet her interests and promote physical, mental, and psychosocial well-being. This deficient practice could affect residents at the facility who require assistance to activities to decline in mental acuity due to lack of stimulation, boredom, and depression. The findings included: 1. Record review of Resident #14's face sheet,…

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 residents had 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 8 residents ( Resident #21) reviewed for reasonable accommodations, in that: The facility failed to ensure Resident #21's call light was within reach. This failure could place residents at risk of not having their needs met Findings include: Record review of Resident #21's face sheet dated 5/28/24 revealed a [AGE] year-old male admitted to the facility 3/14/24 with diagnoses that included: End stage renal disease (disorder when kidneys no longer function on their own), Post Traumatic Stress Disorder (disorder that develops in some people who have experienced a shocking, scary, or dangerous event), and Diabetes Type II (disorder in which body doesn't produce enough insulin or does not use it properly,…

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 the interview and record review, the facility failed to transmit the resident assessment within the required time frame for 1 of the 2 discharged residents (Resident # 89) reviewed for data encoding and transmission, in that: The facility did not submit a discharge not anticipated MDS for Resident #89. This failure could put residents discharged from the facility at risk of not having their assessments transmitted accurately. Findings included: Record review of Resident #89's face sheet, dated 5/31/2024, revealed a [AGE] year old male admitted to the facility on [DATE] and discharged on 3/12/24 with the diagnoses that included: Alzheimer's Disease (a brain disorder that gradually destroys memory, thinking, and learning skills), General Anxiety Disorder (is a condition that causes people to experience excessive, persistent, and unrealistic worry about everyday things), and Hypertension ( when the pressure in your blood vessels is too high (140/90 or higher). Record review of Resident #89's discharge MDS,…

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 all Pre-admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with a PASRR Evaluation assessment for 1 of 2 residents (Residents #21) reviewed for PASRR screening, in that: Resident #21's PASRR Level 1 assessment did not accurately capture the resident's diagnosis of mental illness. These failures could put residents with inaccurate PASRR Level 1 Evaluations at risk of not receiving care and services to meet their needs. The findings were: Record review of Resident #21's face sheet, dated 5/28/24, revealed a [AGE] year-old male admitted to the facility 3/14/24 with diagnoses that included: End stage renal disease (disorder when kidneys no longer function on their own), Post Traumatic Stress Disorder (a disorder that develops in some people who have experienced a shocking, scary, or dangerous event), and Diabetes Type II (disorder in which body doesn't produce enough insulin or does not use it…

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 received proper treatment and care to maintain mobility and good foot health for 1 of 1 resident (Resident #1) reviewed for foot care. The facility failed to provide Resident #1 with access to a podiatrist. The deficient practice placed residents at risk of discomfort, poor foot hygiene, and a decline in resident's physical condition. The findings were: Review of Resident #1's face sheet dated 05/28/2024 revealed an [AGE] year old female admitted on [DATE] and readmitted on [DATE] with diagnoses that included: Dementia (impaired ability to remember, think, or make decisions that interfere with doing everyday activities), rheumatoid arthritis (an autoimmune disorder that affects the lining of the joints, causing painful swelling), depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and diabetes mellitus (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 provide a safe, functional, sanitary and comfortable environment for residents, staff, and the public for 6 out of 12 resident rooms (Rooms #203, #207, #211, #213, #225 and #322) and 2 of 4 dining rooms (MC Dining room [ROOM NUMBER] and #3), 1 of 1 nurses' station (200 Wing), and 1 of 3 wings (300 Wing) reviewed for environmental conditions. 1. The ceiling tiles of the 300 Wing contained brown/black colored stains. 2. The floor in Memory Care dining room [ROOM NUMBER] had missing tiles on the floor. 3. The floor in Memory Care dining room [ROOM NUMBER] had debris and food crumbs throughout the floor and the floor was sticky. 4. There were brown colored stains on the ceiling of room [ROOM NUMBER] and #225. 5. The floors in resident rooms #203, #211, #213, and #225 had debris and food crumbs, including under and around beds and fixtures. 6. The floor in the 200 Wing nurses' station contained debris and food crumbs, including under and around…

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, record review and interviews, the facility failed to equip corridors with firmly secured handrails for 1 of 4 halls reviewed for environmental conditions. The facility did not ensure a handrail found in the Memory Care unit, across from the dining room was firmly affixed to the wall. This failure could place residents at risk for avoidable accidents and decreased quality of life due to environmental hazards. Findings included: An observation on 3/22/24 at 9:34 am revealed a handrail in the Memory Care unit across from dining rooms #1 and 2 was loose and partially detached from the wall. The handrail appeared to be resting on three brackets which was loosely attached to the wall. During an observation and interview on 3/22/24 at 11:43 am, the MD confirmed the handrail in the Memory Care unit across from dining rooms #1 and 2 was loose and partially detached from the wall and called another maintenance staff on the phone to fix the handrail. The MD said he was not aware that the handrail was loose and partially detached from the wall. An observation and interview…

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 consider the views of a resident group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility for 3 (01/27/23, 02/15/23 and 03/30/23) of 3 Resident Council meetings reviewed for resident group response. The facility failed to have an effective way to resolve the issues with the resident's meals being cold, late and not palatable to meet the resident's dietary needs and preferences. This deficient practice could place residents at risk for weight loss, food borne illnesses and decreased quality of life and psychosocial well- being. Findings Included: Review of the Facility's Meal Service Times revealed, Breakfast 7 am, Lunch 12 pm and Dinner 5 pm. Observation on 04/04/23 at 9:35 am, several residents were eating breakfast or just completed it and Resident #97 was eating breakfast in her room. Observation on 04/06/23 at 1:35 pm, the last lunch meal was served to a resident in their room on the 300 hall. Review of the Resident Council minutes dated…

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, sanitary, and comfortable environment for residents for one (Hall 100 memory care unit) of six halls and the dining rooms observed for environment, in that: The facility failed to ensure the shared bathrooms on Halls 100 (memory care unit) were clean, for Rooms 121,123, 122, 124, 128, 125, 110, 112, 115, 113, 106, 108, 102, 104 and the dining rooms. These failures could place residents at risk for diminished quality of life due to the lack of a well-kept environment and equipment. Findings included: An observation on 04/04/23 at 9:57 a.m. in resident's Rooms and 115 and 113's shared bathroom revealed there was a strong smell of urine with sticky floor tiles. The grout around the base of the toilet was black. The co-base in the bathroom is stained with a brown grimy substance. An observation on 04/04/23 at 10:20 a.m. in dining room on the right side of the hallway revealed handwashing sink with a grimy brown…

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

Based on observation, interview, and record review, the facility failed to provide food that was palatable, attractive and at a safe and appetizing temperature for eight (Residents #3, #18, #31, #37, #42, #70, #97, and #101) of nine residents reviewed for Palatable food. 1.The facility failed to provide food to the residents in a timely manner which resulted in the resident's food being cold. 2.The facility failed to ensure the resident's food was cooked thoroughly and not undercooked. These failures could place residents at risk for weight loss, food borne illnesses resulting in gastro-intestinal issues, diminished quality of life and psycho-social well- being. Findings included: Review of the Facility's Meal Service Teams revealed, Breakfast 7 am, Lunch 12 pm and Dinner 5 pm. Observation on 04/04/23 at 9:35 am Resident #97 was eating her breakfast and watching TV. Observation on 04/06/23 at 1:35 pm, the last resident on the 300 Hall received their meal. Interview on 04/04/23 at 9:37 am, Resident #97 stated the meals were late at times and was not sure why. Interview on 04/04/23 at…

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 designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for four (Residents #1, #36, #39, and #90) of six residents reviewed for infection control. LVN A failed to disinfect the glucometer machine (an instrument for measuring the concentration of glucose in the blood) between resident use, for resident #36 and #90. RN B failed to disinfect the blood pressure cuff in between blood pressure checks for Residents #1, #39, and unknown resident. This failure could place residents at-risk of cross contamination which could result in infections or illness. Findings included: Review on 04/05/23 of Resident #1's EHR revealed the resident was an [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses including Hypertension, (elevated blood pressure), and congestive heart…

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

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for two (smoke area and 300 hall) of 13 fire extinguishers, one (on 300 hall) of two portable ice machines, one (main) of two dining areas reviewed for environment. 1.The facility failed to ensure one fire extinguisher located in the patio smoke area and one fire extinguisher located at the end of the 300 hall exit were both fastened and mounted securely to their posts. 2. The facility failed to ensure one of their portable ice machines, the table it sat on and the flooring underneath it was clean that was located behind the 300 hall nurse's station. 3.The facility failed to ensure the facility's Auto floor scrubber was not stored in the main dining room, where the resident ate their meals. 4. The facility failed to ensure one kitchen door, one dishwasher door and the flooring of the kitchen and dishwasher room entrances were cleaned or replaced. These failures placed residents at risk of safety hazards and cross contamination which could…

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.