San Antonio North Nursing and Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, for 1 of 6 resident (Resident #1) reviewed for care plans. The facility failed to ensure the care plan included instructions necessary for implementing communication interventions with Resident #1 who was deaf and mute. This failure could place residents at risk of harm due to poor communication.The findings include: A record review of Resident #1's admission record revealed an admission date of 1/27/2025 with diagnoses which included deaf non-speaking, unspecified focal traumatic brain injury,…

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 store, prepare, distribute and serve food in accordance with professional standards for food service safety, for 1 of 5 residents medication carts (200-hall medication cart) reviewed for food safety. The facility stored resident's pudding and jelly in the Resident's medication cart without labels and dates to indicate if the foods were safe to serve. These failures could place residents at risk for food borne illnesses.Findings included: During an observation and interview on 4/3/2026 at 3:08 PM LVN D was at his medication cart preparing to administer medications for his assigned residents. The medication cart presented with a covered 1-gallon water pitcher filled with water. The water pitcher had no label to identify when the water was poured. LVN D demonstrated the first drawer where he stored a clear plastic cup with a lid which held approximately 2 ounces of pudding and another similar clear plastic cup with jelly. The containers had no labels and dates to indicate what the contents were or when they…

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, sanitary, comfortable, and homelike environment for 1 of 6 residents (Resident #1). The facility failed to ensure Resident #1's room was clean, sanitary and did not have a strong smell of urine. This failure could place residents at risk of living in unsafe, unsanitary, and uncomfortable conditions which could lead to a decline of mental and physical health and decreased social interactions. Findings included: Record review of Resident #1's admission Record, dated 02.13.2026, revealed Resident #1 was admitted to the facility on 10.03.2024 with diagnoses of Acute Kidney Failure, Chronic Kidney Disease, Muscle Weakness and the Need for assistance with personal care. Record review of Resident #1's MDS, dated 2.2.2026, revealed Resident #1 has a BIMS of 15. MDS also revealed that Resident #1 sometimes refuses care 1-3 days a week, and substantial assist to the toilet. Record review of Resident #1's Care Plan, last revision 2.2.2026, revealed Resident #1 suffers from incontinence related to impaired…

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 and interviews, the facility failed to provide a safe and homelike for 3 of 3 residents' rooms observed for electricity and 3 of 3 residents affected (Resident #1, Resident #2, and Resident #3).Rooms #10 (Resident #3), #11 (Resident #1), and #12 (Resident #2) had no over the bed lights and electrical issues with other electronics.This failure could place residents at risk a lack of comfort, risk for falls, and a diminished quality of life in the facility. The findings included: Record review of Resident #1's face sheet dated 1/7/2026 revealed a [AGE] year-old-male was admitted to the facility on [DATE] with the diagnoses: major depressive disorder, schizoaffective disorder, bipolar type, traumatic brain injury, and PTSD.Record review of Resident #1's Care Plan dated 12/3/2025 revealed he was care planned for PTSD, traumatic brain injury, and risk for falls.Record review of Resident #1's QMDS dated [DATE] revealed he had a BIMS score of 14, indicative of cognitively intact.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 interviews and record reviews, the facility failed to ensure the rights of the residents to be from from abuse for 3 of 3 residents reviewed for abuse.Resident # 6 was abused by LVN B.Resident #7 was abused by LVN B.Resident #8 was abused by LVN B.These failures could place residents at risk of more abuse and diminish their quality of life.Record review of Resident #8's face sheet dated 1.6.2026 revealed an [AGE] year-old female was admitted on 3.1.2019 with diagnoses: anxiety disorder, hypertensive heart disease without failure (high blood pressure that causes structural changes to the heart), and major depressive disorder.Record review of Resident #8's Care Plan dated 12.10.2025 revealed she was care planned for major depressive disorder, anxiety, and fall precautions due to dizziness and giddiness. Record review of Resident #8's AMDS dated 12.16.2025 revealed she had a BIMS score of 13, indicative of no cognitive impairment.Record review of Resident #6's face sheet dated 1.8.2026 revealed a 66…

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 utilize nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required for 1of 1 facilities.The facility failed to ensure Staff Member A had an MA certificate from [DATE] to [DATE] for a total of 88 shifts and passed medications to residents.This failure could place residents at risk of medication errors, inaccurate assessment, and illness.The findings were: Record review of the staff roster provided by the facility on [DATE] revealed Staff Member A's title was LVN. Record review of Staff Member A's employee file revealed a hire date of [DATE] as a MA. Review of the Texas…

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 attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it for 1 of 7 residents (Resident #1) reviewed for pharmaceutical services. The facility failed to document review and response to irregularities identified in Resident #1's medication regimen in August and September 2025. This failure could result in unintended effects of medications and/or illness. Findings included: Record review of Resident #1's face sheet dated 10/08/2025 reflected a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included intentional self-harm by unspecified firearm discharge and other chronic pain. Record review of Resident #1's quarterly MDS, submitted 8/5/2025, reflected a BIMS score of 15, which indicated intact cognition. Section N0415 reflected Resident #1 was taking opioid medication. Section N2001 (did a complete drug…

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 two of seven residents (Resident # 41 and Resident #2) reviewed for privacy. 1.The facility failed to ensure MA B locked the computer, after he walked away and left the computer unattended, which exposed Resident #41's morning medication list. 2.The facility failed to ensure the privacy curtains in Resident #2's room were able to completely close around his bed to provide Resident #2 privacy during wound care. These failures could place residents at risk of having medical information exposed to others and of loss of personal privacy, causing residents to feel uncomfortable and disrespected. The findings include: 1.Record review of Resident # 41's face sheet dated 07/30/25 revealed an [AGE] year-old male admitted to the facility on [DATE]. Resident # 41 had diagnoses that included: Schizophrenia (is a severe and chronic…

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 residents had a right to a safe, clean, comfortable, and homelike environment for 2 (Residents #52 and #87) of 30 residents reviewed, in that: 1. The bathroom door facing the interior of the bathroom used by Resident #52 had scrape marks and the lower section of the door was unpainted. 2. The entrance to the bathroom used by Resident #87 had a 3inch rust area on the left door post and the toilet was not secured to the floor base. These failures could result in residents not having a safe, clean, homelike environment which could result in low self esteem and a diminished quality of life. The findings included:1. Record review of Resident #52's face sheet, dated 7/29/25, revealed the [AGE] year resident was originally admitted to the facility on [DATE] with diagnoses including: expressive language disorder( a condition that affects a person's ability to use language), essential hypertension( a condition characterized by high…

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

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 facility in that: 1. The facility failed to replace dirty overhead ceiling tiles in the main kitchen area. 2. The facility failed to replace a light bulb fixture in the main kitchen area. 3. The facility failed to clean an overhead ceiling vent in the dish room. 4. The facility failed to repair a wall penetration and broken floor molding in the employee bathroom in the main kitchen area. These failures could place residents at risk for food borne illness. The findings included: Observation on 07/28/25 from 9:15am until 9:35am with the Food Service Director revealed the following: a. There were 6 ceiling tiles which each measured approximately 2x2 ft in the main kitchen area that had dirt particles on the surface and were stained.b. There was a missing florescent light bulb in a overhead ceiling light fixture which measured approximately 4x2 ft in length in the main kitchen area.c. There 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 interview and record review, the facility failed to maintain clinical records that were complete and accurately documented for 1 (Resident #11) of 25 residents reviewed for clinical records, in that: Resident #11's Medication Administration Record, dated July 2025, had blank spaces on July 5, 2025 rather than documentation. This deficient practice could cause miscommunication among the resident's caregivers and result in improper care.The findings were: Record review of Resident #11's face sheet, dated 07/31/2025, revealed the resident was admitted on [DATE] with diagnoses including: Essential Primary Hypertension, Generalized Anxiety Disorder, and Type 2 Diabetes Mellitus. Record review of Resident #11's Quarterly MDS, dated [DATE], revealed a BIMS score of 15 which indicated intact cognition.Record review of Resident #11's care plan, revised 05/17/2024, revealed [Resident #11] receives anti-anxiety medications r/t anxiety. Administer ANTI-ANXIETY medications as ordered by physician. Observe for side…

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 1 of 1 Maintenance and Housekeeping Office reviewed, in that: The Maintenance and Housekeeping Office, in which were stored tools and cleaning equipment, was observed with the door ajar and no staff in attendance. This deficient practice could result in residents, staff, or the public coming into contact with tools and cleaning equipment that were unsafe. The findings were: Observation on 05/21/2025 at 9:15 a.m. revealed the Maintenance and Housekeeping Office was located on the facility's second floor, was the first room of a hallway with resident room, was adjacent from the nurses' desk, and across the hall from a resident room. Further observation revealed the office door was ajar and no staff were in the office. Further observation revealed Housekeeper E was in the hallway between the Maintenance and Housekeeping Office and a resident's room. During an interview with Housekeeper E on 05/21/2025 at 9:15 a.m., Housekeeper E confirmed 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 ensure 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 6 residents (Resident #2) reviewed for incontinent care. The facility failed to ensure Resident #2 was not left sitting in urine in a chair in the dining room on the evening of 05/18/2025. This failure could place residents at risk of skin breakdown and infection. Findings include: Record review of Resident #2's admission Record dated 05/23/2025 revealed she was admitted [DATE] with diagnoses which included: Moderate Intellectual Disability (a condition that limits intelligence, defined as IQ between 36-51 and disrupts ability necessary for independent living) and Anxiety Disorder (a group of mental health conditions that cause fear, dread and other symptoms that our out of proportion to the situation). Record review of Resident #2's admission and baseline care plan…

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 resident medical records were kept in accordance with accepted professional standards and practices, maintaining medical records on each resident that are complete and accurately documented for 1 of 2 residents (Residents #1) reviewed for clinical records. The facility failed to ensure Resident #1's completion or refusal of prescribed wound care was accurately documented on her Treatment Administration Record (TAR) for 4 (4/11/2025, 4/18/2025, 4/29/2025 and 5/2/2025) of 14 treatment days between 04/01/2025 through 05/20/2025. This failure could place residents at risk of not receiving the care and services needed due to inaccurate or incomplete clinical records. Findings included: Record review of Resident #1's admission Record, dated 05/20/2025, revealed she was initially admitted on [DATE] and re-admitted on [DATE], with diagnoses which included: Chronic Systolic (congestive) Heart Failure (chronic condition where heart does…

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 all drugs and biologicals in locked compartments for 1 of 4 medication carts (Med Cart 1) reviewed for medication storage. The facility failed to ensure Med Cart 1 was locked while unattended on 5/11/25. This failure could place residents at risk of medication misuse and drug diversion. Findings included: Observation on 5/11/25 at 10:07 am revealed Med Cart 1 was in front of the nurses', across from the elevator on the second floor. Further observation revealed Med Cart 1 was unlocked and contained OTC medications and supplies in the first draw and resident medications in the second drawer. Further observation revealed one resident sitting in a chair close to the nurses' station, another resident walking past the nurses' station, five residents in the TV room located next to the nurses' station, the housekeeper, and CNA A. At 10:09 am a resident was observed as he wheeled himself in his wheelchair toward Med Cart 1 and placed his right hand on Med Cart 1 as he wheeled by it. During an interview and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews, the facility failed to assist residents in obtaining routine and 24- hour emergency dental care to meet the needs of 1 of 3 residents (Resident #1) reviewed for dental services in that: The facility did not assist Resident #1 with obtaining dental services when her top dentures were reported missing on 9/29/24 . This failure could place residents at risk of not having their oral health care needs met. The findings included: Record review of Resident #1's electronic medical record revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: Cerebral infarction (is a medical condition where blood flow to the brain is interrupted), kidney disease (is a condition where the kidneys are damaged and cannot function properly), and Dementia (condition that cause a progressive decline in cognitive function, memory, and behavior). Record review of Resident #1's inventory sheet, 9/10/24 , revealed Resident #1 had a top…

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 reasonable accommodation of resident needs and preferences for 3 of 37 residents (Residents #3, #6, and #8) reviewed for reasonable accommodations, in that: 1. Resident #3 had no access to her call light that was observed on the floor approximately four feet away from Resident #3. 2. Resident # 6 had no access to his call light that was observed on the floor behind the headboard of Resident #6's bed. 3. Resident #8 had no access to his call light that was observed on the floor approximately five feet away from Resident #8. This deficient practice could place residents not being able to use call lights for assistance in maintaining and/or achieving independent functioning, dignity, and well-being. Findings included: 1. Record review of Resident #3's undated face sheet revealed Resident #3 was a [AGE] year old female who admitted to the facility on [DATE] with diagnoses that included anoxic brain damage (occurs when your brain…

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 had the right to personal privacy during personal care for 1 of 3 residents (Resident #3) reviewed for privacy, in that: CNA E and CNA J did not maintain privacy while providing incontinent care for Resident #3. This failure could place residents who require assistance with incontinent care at risk of being exposed. Findings included: Record review of Resident #3's undated face sheet revealed Resident #3 was a [AGE] year old female who admitted to the facility on [DATE] with diagnoses that included anoxic brain damage (occurs when your brain loses oxygen and could cause serious, permanent brain damage), schizoaffective disorder (a chronic mental illness involving symptoms of schizophrenia and bipolar disorder and characterized by symptoms such as delusions, hallucinations, depression, and high-energy mood), bipolar disorder (a mental illness characterized by alternating periods of elation and depression), and depression…

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, observations, and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 11 residents (Resident #1) reviewed for accuracy of records, in that: The facility failed to ensure the treatment administration records (TAR) for Resident #1 accurately reflected the administration of the bilateral wound treatment on 01/03/2025 and 01/07/2025. This deficient practice could place residents receiving treatments at risk for not receiving appropriate care. The findings were: Record review of Resident #1's undated face sheet revealed Resident #1 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included congestive heart failure (a condition in which the heart doesn't pump blood as well as it should), type 2 diabetes (a condition that occurs when the body does not regulate or use sugar properly), bipolar disorder (a mental illness characterized…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and observation, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly discharge from the facility for 1 of 3 residents (Resident #1) reviewed for discharge rights, in that: The facility failed to ensure Resident #1's legal guardian was sufficiently prepared and oriented for Resident #1's transfer to hospital. This failure could place residents at risk of being discharged without preparation, causing a disruption in their care and services and denying them a voice regarding their treatment plan. The findings were: Record review of Resident #1's admission record, dated 06/29/24, reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include dementia (loss of thinking, remembering, and reasoning skills), schizoaffective disorder (a chronic mental illness that causes a person to experience dramatic changes in their thoughts, moods, and behaviors). Record review of Resident #1's 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 observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, for 2 of 3 the residents (Residents #4 and #56) reviewed for oxygen in that: The facility faield to ensure Residents #4 and #56 did not have an empty oxygen humidifier bottle on the oxygen concentrator dated 5/12/24 while in use. This deficient practice could place residents who received oxygen therapy at risk for an increase in respiratory complications. The findings were: 1. Record review of Resident #4's face sheet, dated 6/10/24, revealed a [AGE] year old male admitted to the facility on [DATE] with the diagnosis that included: Acute Kidney Failure (when your kidneys suddenly become unable to filter waste products from your blood), Respiratory Failure (a serious condition that makes it difficult to breathe on your own), and Atrial Fibrillation (an irregular and often very rapid heart rhythm). 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 observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 1 facility reviewed for environmental concerns. The facility failed to repair a broken electrical outlet in a Resident's room, fix a roof leak in a resident's room, repair a section of broken floor paneling in a resident hallway corridor, replace a damaged section of ceiling tile in a resident hallway corridor. This deficient practice could place residents at risk of not living in a safe, functional, sanitary, and comfortable environment. The findings included: During an observation on 06/10/24 from 10:10 a.m. to 10:55 a.m. revealed the following: 1. Resident room [ROOM NUMBER] had a broken electrical outlet that showed an open electrical connection without an outlet cover. 2. Resident room [ROOM NUMBER] had a roof leaf that involved a 3x3 section of roof panels with an active leak occurring which created a puddle of water 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 Observations, 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 2 of 2 residents (Residents #46 and #55) reviewed for call light. The facility failed to ensure Residents #46's and #55's call lights were within reach. This failure could place residents at risk of achieving independent functioning, dignity, and well-being. Findings include: 1. Record review of Resident #46's face sheet dated 6/11/24 revealed a [AGE] year old female admitted to the facility on [DATE] with a diagnosis that included: Schizoaffective disorder (is a mental health condition that is marked by a mix of hallucinations and mood disorder symptoms, such as depression, Dysphagia (difficulty swallowing), and Unsteady on feet (pattern of walking that is unsteady). Record review of Resident #46 Quarterly 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.

Based on observation, interview, and record review, the facility failed to protect the residents' right to reside in a safe, clean, comfortable, and homelike environment for 2 residents (Residents #14 and #33), in that: 1. Barrels of soiled linens and trash were stored in the shower area of Resident #14's restroom. 2. Resident #33's shower chair and the floor of the shower area in her restroom were soiled with a dark brown substance which appeared to be mud or feces. These deficient practices could lead to diminished quality of life and psychosocial harm. The findings were: 1. Observation of Resident #14's restroom on 06/10/2024 at 1:00 p.m., revealed the presence of two wheeled barrels, one with soiled linen and the other with trash. During an interview with the Director of Housekeeping on 06/10/2024 at 1:04 p.m., the Director of Housekeeping confirmed the presence of two wheeled barrels, one with soiled linen and the other with trash in Resident #14's restroom and stated, I keep telling them not to do that. 2. Observation of Resident #33's restroom on 06/10/2024 at 1:12 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 observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 1of 6 residents (Resident #55) reviewed for accidents and hazards. The facility failed to ensure Resident #55 did not have access to an electronic cigarette. This failure could place residents at risk of injury or harm, as well as contribute to avoidable accidents. Findings included: Record review of Resident #55's face sheet, dated 6/11/24, revealed a [AGE] year-old male admitted to the facility on [DATE] readmitted on [DATE] with the diagnosis that included Muscle weakness (a decrease in muscle strength and the ability to move your body), Insomnia (a sleep disorder in which you have trouble falling and/or staying asleep) and Type II Diabetes (a disease that occurs when your blood glucose, is too high). Record review of Resident #55 Quarterly MDS assessment, dated 2/20/24, revealed a BIMS score of 14, indicating intact cognition. 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 interview and record review, the facility failed to ensure the resident was not given a psychotropic drug unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 3 residents (Resident #20) reviewed for unnecessary medications, in that: The facility failed to ensure Resident #20 was prescribed a psychotropic drug for anxiety no longer than 14 days PRN . This deficient practice could place residents at risk of receiving unnecessary psychotropic medications. The findings were: Record review of Resident #20's face sheet dated 6/11/24, revealed a [AGE] year-old female admitted to the facility on [DATE] with the diagnosis that included: Congestive heart failure (is a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply), Chronic Pain Syndrome (long-standing pain that persists beyond the usual recovery period), and Muscle Weakness (a decrease in muscle strength or a reduced ability…

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 and ensure safe and sanitary storage of residents' food items for 1 (refrigerator in resident room [ROOM NUMBER]B) of 3 residents' reviewed in that: The facilty failed to ensure the personal refrigerators in one residents' rooms contained food items which were unlabeled and undated. This deficient practice could place residents at risk of foodborne illness due to consuming spoiled foods. The findings were: Observation on 06/11/24 at 9:02 a.m. revealed the personal refrigerator in resident room [ROOM NUMBER] B contained open lunch meat undated. Further observation on 06/11/2024 at 10:36 a.m. revealed a container with lunch meat undated . During an interview with CNA A on 06/11/2024 at 10:45 a.m., CNA A confirmed that the personal refrigerator in resident room [ROOM NUMBER]B contained an open package of lunch meat which was unlabeled and undated. During an interview with the DON and ADON on 06/11/2024 at 1:47 p.m., the DON and ADON…

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 6 residents (Resident #1) reviewed for foot care. The facility failed to ensure Resident #1 was provided with adequate foot care and access to podiatry services. This failure could place residents at risk of discomfort, poor foot hygiene, or a decline in residents' physical condition. The findings were: Record review of the admission Record, printed 6/04/2024, reflected Resident #1 was a [AGE] year-old female, originally admitted on [DATE]. Record review of the quarterly MDS, dated [DATE], reflected Resident #1 had a BIMS summary score of 4, indicative of severe cognitive impairment. Resident #1's primary medical condition category that best described the primary reason for admission was coded as medically complex conditions related to a diagnosis of paranoid schizophrenia. Other active diagnoses included Huntington's Disease. 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 observations, interviews, and record review, the facility failed to monitor based on the comprehensive assessment of a resident, residents who use psychotropic drugs for the efficacy and adverse consequences of prescribed psychotropic medications for 6 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6) of 12 residents reviewed for medication management. - The facility failed to monitor Resident #1 for side effects and observe for the behaviors of the antidepressant medication Sertraline HCl and the antianxiety medication Hydroxyzine HCl. - The facility failed to monitor Resident #2 for side effects and observe for the behaviors of the antianxiety medication Ativan, the antidepressant medication Citalopram, and the anticonvulsant medication Trileptal. - The facility failed to monitor Resident #3 for side effects and observe for the behaviors of the antidepressant medication Mirtazapine. - The facility failed to monitor Resident #4 for side effects and observe for 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 ensure that all allegations involving abuse, neglect, and misappropriation were reported immediately, but no later than 2 hours after the allegation was made to the State Survey Agency for 1 (Resident #1) of 13 residents reviewed for abuse and neglect. The facility did not report to the State Survey Agency (HHSC) an incident in which Resident #1 attempted suicide. This failure could place residents at risk for abuse/neglect and could lead to a diminished quality of life and psychosocial harm. The findings included: Record review of Resident #1's admission Record, dated 05/24/2024, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included dementia (a general term for impaired ability to remember, think, or make decisions), depression, and anxiety (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness) disorder. Resident #1 was noted as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to thoroughly investigate allegations of abuse and neglect for 1 (Resident #1) of 13 residents reviewed. The facility did not have evidence that a thorough investigation was completed for Resident #1 who had attempted suicide. This failure could place residents at risk of incidents not being thoroughly investigated. The findings included: Record review of Resident'#1's admission Record, dated 05/24/2024, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included dementia (a general term for impaired ability to remember, think, or make decisions), depression, and anxiety (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness) disorder. Resident #1 was noted as discharged on 05/02/2024 to an acute care hospital. Record review of Resident #1's State Optional MDS, dated [DATE], revealed the resident had a BIMS score of 8, which indicated the resident was mildly…

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 that the medication error rate was not five percent or greater. The facility had a medication error rate of 44% based on 11 errors out of 25 opportunities, which involved 1 (Resident #7) of 4 residents reviewed for medication errors. CMA H failed to administer medication as ordered to Resident #7 by administering Amlodipine (a treatment for high blood pressure), Buspirone HCl (a treatment for mood disorder), Calcium-Vitamin D supplement, Clonidine (a treatment for high blood pressure), Docusate Sodium (a treatment for constipation), Divalproex Sodium (a treatment for mood disorder), Furosemide (a treatment for edema or fluid retention), Metoprolol Tartrate (a treatment for high blood pressure), Multivitamin, Sodium Supplement, Spironolactone (a treatment for edema or fluid retention) over 1½ hours after the scheduled time. These failures could place residents at risk of not receiving the desired therapeutic effect of their…

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 to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 4 residents (Residents #2, #3, #1) reviewed for infection control, in that: 1. During wound care of Resident #3, LVN D made several passes in multiple directions with the same gauze to clean the wound; she made several passes in multiple directions to dry the wound, and when applying the ointment to the wound, she made several passes with the tongue depressor with ointment on it without discarding the used tongue depressor and using a new one with each new pass. 2. During incontinent care for Resident #2, CNA C washed her hands before starting care and dried her hands with one soaked paper towel for both hands; after washing her hands, she closed the privacy curtain; she donned gloves without using hand sanitizer. CNA F washed his hands…

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 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 one resident (#1) of four residents reviewed for infection control. CNA A did not change her gloves or sanitize her hands when she finished cleaning Resident #1's feces from his anus and placed a clean brief onto him This deficient practice could place residents at risk of developing a urinary tract infection. The findings were: Record review of Resident #1's electronic face sheet dated 09/07/2023 revealed a male resident who was admitted to the facility initially on 12/10/2022 and readmitted on [DATE]. Resident #1 had diagnoses which included cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels to the brain), pressure ulcer to right heel, stage 3 (affects the top two layers…

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 immediately inform a resident's physician when there was a significant change in resident's physical, mental, or psychosocial status for 1 of 5 residents (Resident #1) reviewed for notification of changes in that: The facility did not notify Resident #1's physician (Physician F) prior to Resident #1's discharge on [DATE]. This deficient practice could place residents at risk of not having their physician notified of discharge resulting in a delay in continuity of care. The findings were: Record review of Resident #1's face sheet, dated 8/17/23, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy [a chemical imbalance in the blood that causes problems in the brain], thrombocytopenia [a low amount of platelets, which are blood cells that cause clotting, in the blood], unspecified, essential (primary) hypertension, muscle weakness (generalized), and dysphagia [difficulty swallowing], oral phase. Further…

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 did not ensure residents were permitted to remain in the facility, and not transfer or discharge the resident from the facility unless the transfer or discharge was necessary for the resident's welfare and the resident's needs could not be met in the facility and the facility also did not provide written records when a resident was discharged for 1 of 5 residents (Resident #1) reviewed for discharge rights, in that: The facility failed to have a valid circumstance to support discharging Resident #1 to the local homeless shelter on 8/15/23. The facility did not provide written records to the local homeless shelter upon discharging Resident #1. This failure could result in residents being discharged without appropriate reasons and documentation communicated to help with the transition of care and could place a medically compromised resident at risk of a decline due to changing clinical environments and care continuity. The findings were: Record review of 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 review, before the facility transferred or discharged a resident, the facility failed to notify the local Ombudsman of the transfer or discharge and failed to issue a notice of discharge to 1 of 5 residents (Resident #1) reviewed for discharge rights in that: The facility did not issue a discharge notice to Resident #1 at least 30 days prior to his discharge to the local homeless shelter on 8/15/23. The facility did not send a copy of the discharge notice to a representative of the Office of the State Long-Term Care Ombudsman. This failure could place the residents at risk of being discharged and not having access to available advocacy services, discharge/transfer options and appeal process, and being discharged without alternate placement. The findings were: Record review of Resident #1's face sheet, dated 8/17/23, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy [a chemical imbalance in the blood that causes problems in 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 ensure a resident had a discharge summary that included a final summary of the resident's status at the time of the discharge for 1 of 5 residents (Resident #1) reviewed for discharge in that: The facility failed to ensure Resident #1 had a discharge summary, medication reconciliation, information on Resident #1's permanent medical necessity (PMN) status, and a post-discharge plan of care at the time of his discharge to the local homeless shelter on 8/15/23. This deficient practice could place discharged residents at risk for a lack of continued care and services. The findings were: Record review of Resident #1's face sheet, dated 8/17/23, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy [a chemical imbalance in the blood that causes problems in the brain], thrombocytopenia [a low amount of platelets, which are blood cells that cause clotting, in the blood], unspecified, essential (primary)…

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 infections for 2 of 6 staff (Housekeeper D and Receptionist B) reviewed for infection control, in that: 1. Receptionist B was sitting at the entrance desk wearing a facemask inappropriately leaving nose uncovered. 2. Housekeeper D was observed wearing a facemask inappropriately down around her neck. These deficient practices could place residents at risk of illness from communicable diseases. The findings were: 1. During an observation on 08/01/2023 at 9:55 a.m. revealed, Receptionist B in the receptionist's desk Further observation revealed Receptionist B's facemask was not covering her nose. During an interview with Receptionist B on 08/01/2023 at the same time, Receptionist B confirmed she knew she was supposed to always have her facemask on. Receptionist B stated, I sometimes let my face mask…

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 in 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure stored food was properly labeled and dated. 2. The facility failed to ensure frozen foods were properly labeled and dated. 3. The facility failed to ensure expired foods were not in the pantry, refrigerator, and freezer. These failures could place residents at risk for food-borne illness. Findings include: Observations on 04/12/2023 at 9:40 AM until 10:25 AM revealed 1. A partially used 5 lb. bag of salad mix of red cabbage, romaine lettuce, and shredded carrots in clear plastic manufactures bag with plastic tied at the top to seal the package located in refrigerator 1. The white label on the outside of bag revealed, R 4/10/23, the only date on the package. There was not a use by date on the package the product was wet with moisture and the color of the lettuce was changing darker. 2. Three unopened clear plastic 5 lb.…

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 one of two ovens (oven #1 and oven #2) reviewed in the facility's only kitchen for essential equipment 1. The facility failed to ensure oven #2 was maintained, and the griddle grease can was properly cleaned in accordance with manufacturer's instructions. 2. The facility failed to ensure that one of the two ovens in the kitchen could be safely operated after the griddle grease can was welded to the oven and can't be removed. These failures could place residents at risk of not having their food send out timely. The findings include: Observation on 04/12/2023 at 9:40 AM revealed a Vulcan brand oven. The oven was one unit with two ovens side by side. The larger unit on the right had a griddle on the top and a grease can that caught grease below the griddle. The grease can was extended approximately 4 -6 inches from the front of the larger oven on the right that had the griddle on top. The grease can was frozen, it 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure each resident was provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care for three of eight residents (Residents #8, #54 and #48) reviewed for quality of life. 1. The facility failed to ensure the environment in and around Residents #8 and #54's room was free of unpleasant odors. 2. The facility failed to ensure Resident #48 was able to spend time outside per his preferences and care plan. These failures could place residents at risk of a diminished quality of life, indignity, and depression. Findings include: 1. Record review of Resident #8's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included cellulitis (bacterial skin infection), cerebral ischemia (brain injury from impaired blood flow) memory deficits,…

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 was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 5 of 5 residents (Residents #6, 8, 9, 14, and 27) reviewed for ADLS. The facility failed to ensure Residents #6, #8, #9, #14, and #27's fingernails were trimmed, smooth, and clean. This failure could place residents at risk of scratches, infection, and indignity. Findings included: 1. Record review of Resident #8's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included cellulitis (infection of the deeper layers of skin most commonly caused by bacteria that normally live on the skins surface), cerebral ischemia (impaired blood flow to the brain) memory deficits, need for assistance with personal care, type two diabetes mellitus (a chronic condition that affects the way the body processes blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 1 of 5 residents (Resident #58) reviewed for personal privacy and confidentiality of records. The facility failed to protect the personal healthcare information of Resident #58 which was visible on a computer screen in the hallway while MA D went into his room to administer medications. This failure could place residents at risk for loss of privacy and dignity. Findings included: Record review of the Resident #58's, undated, face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included Type 2 Diabetes without complications (a chronic condition that affects the way the body processes blood sugar), muscle weakness, lack of coordination, symptoms and signs involving cognitive (relating to conscious mental activities) functions and awareness, Chronic Kidney Disease…

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 was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 2 residents (Resident #10 and Resident #8) reviewed for incontinence care. 1. The facility failed to ensure Resident #10's urinary catheter bag was emptied and not backing up into the catheter tubing. 2. The facility failed to ensure Resident #8 received timely incontinent care, which led to a strong foul odor about her person. This failure could place residents at risk of urinary tract infections. Findings include: 1. Record review of Resident #10's, undated, face sheet reflected a [AGE] year-old male resident who was admitted to the facility on [DATE] with diagnoses which included Congenital and Developmental Myasthenia (inherited disorder that usually develops at or near birth and involves muscle weakness and fatigue), Type 2 Diabetes Mellitus (chronic…

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, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for one of two medication carts (2nd floor cart) reviewed for medication storage. The facility failed to ensure the Medication Aide cart for the 2nd floor was locked and supervised. This failure could place residents at risk of ingesting unprescribed and/or expired medications resulting in adverse health consequences. Findings included: Observation on 04/13/2023 at 7:16 AM revealed MA D left the medication cart unlocked while she administered medications to Resident #58. Interview on 04/13/2023 at 7:35 AM, MA D stated she had been a Medication Aide for 9 years but had worked at the facility for 1 ½ months. She stated she should not have left the medication cart unlocked and unattended as it was a safety issue and someone could come along and get into it, ingest the medications, and make them sick, or…

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.