San Antonio West Nursing and Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were free of any significant medication errors for 2 of 5 residents (Residents #95 and #89) reviewed for medication administration. The facility failed to ensure Resident #95 received his anti-seizure medication as ordered by the physician on 4/9/2026. The facility failed to ensure Resident #89 received the correct dose of insulin on 4/10/2026. These failures could result in residents not receiving the intended therapeutic effects of medications, including seizures or low blood sugar levels.Findings included: 1. Record review of Resident #95's admission Record reflected a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included epilepsy, unspecified, not intractable, without status epilepticus [a chronic neurological disorder characterized by unprovoked seizures caused by abnormal electrical activity in the brain; the seizures are able to be treated with medication and are not continuous].…

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 reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one (1) of one (1) kitchen (Kitchen 1) reviewed for food safety requirements. 1. Food service staff failed to ensure an internal thermometer was present in the reach-in refrigerator #1. 2. Food service staff failed to ensure a facility contracted food supplier representative wore hair restraints while in the kitchen during meal preparation. 3. The facility failed to ensure a package of pork ribs was labeled and dated in the walk-in freezer. 4. [NAME] P failed to ensure the walk-in freezer temperature log was filled out for the morning of 04/07/2026. These failures could place residents at risk for the spread of infections, food contaminations, food-borne illnesses, and diminished quality of life. The findings included: During an observation and interview on 04/07/2026 at 10:47 a.m., an internal thermometer for the reach-in refrigerator #1 could not be located. [NAME] P and Dietary Svr were…

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 effective pest control program so that the secured unit in the facility was free of pests and rodents. The facility failed to ensure the building was free of insects. This failure could lead to contamination and/or decreased quality of life. Findings include:In an observation on 4/7/2026 at 12:35 PM, approximately 10 small flying insects that resembled gnats were observed flying in the dining area and hallway adjacent to the dining area during lunch. In an observation on 4/9/2026 at 12:14 PM, revealed Resident #44 received lunch during an interview in the dining room. Approximately 5 small flying insects that resembled gnats were flying above his food. He was observed swatting the flies away from his food as he ate lunch. In an observation and interview on 4/10/2026 at 11:21 AM, LVN E stated the flying insects observed in the secured units nursing station were gnats. She stated that issues with gnats have been ongoing and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of needs and preferences for one (1) of seven (7) residents (Resident #77) reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #77's room was in a position accessible to the resident on 04/07/2026. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.The findings included: Record review of Resident #77's admission Record, dated 12/30/2025, revealed a [AGE] year-old female admitted on [DATE] and re-admitted on [DATE]. Record review of Resident #77's Diagnosis Report, dated 04/08/2026, revealed diagnoses including cerebral infarction (a disruption in the brain's blood flow), legal blindness, and repeated falls. Record review of Resident #77's Quarterly MDS, dated [DATE], revealed Resident #77 was rarely/never…

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 coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid incorporating the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's care planning for 1 of 3 residents (Resident #16) reviewed for PASARR services. The facility failed to ensure Resident #16's PASRR Level 1 Screening was completed accurately with mental illness diagnosis to secure a Level 2 Evaluation by the Local Authority. This deficient practice could place residents at risk of not receiving services identified by the local authority.The findings included: Record review of Resident #16's admission Record, dated 04/10/2026, revealed a [AGE] year-old female admitted on [DATE] and re-admitted on [DATE]. Resident #16 was not listed as her own responsible party with her [friend] listed as Emergency Contact #1.Record review of Resident #16's Medical Diagnoses, undated and accessed…

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 used in the facility must be labeled in accordance with currently accepted professional principles for 1 of 3 medication carts (A- hall medication cart) reviewed for medication storage.The facility failed to ensure a vial of insulin was labeled with the expiration date. This failure could result in residents receiving expired medications.Findings included: In an observation and interview on 4/10/2026 at 7:46 AM, a vial of insulin (a medication used to treat elevated blood sugar levels) was observed in the top drawer of the A-hall medication cart without an expiration date. LVN C was unsure when the vial had been opened. She said all insulin vials and pens should be labeled with the date they are opened and the date they expire to ensure residents do not receive expired medications. In an interview with the DON on 4/10/2026 at 10:00 AM, she said the facility policy is to label all insulins with the date they are opened and the date they expire, and the nursing staff was primarily…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents received therapeutic diets that were prescribed by the attending physician for 1 of 21 residents (Resident #2) reviewed for therapeutic diets.The facility failed to ensure Resident #2 received large protein portions instead of large portions at every meal per RD recommendations, which were approved by Dr. Q.This failure could place residents at risk for poor intake, weight loss, unmet nutritional needs, and a loss of dignity.Findings Included: Record review of Resident #2's admission record, dated 04/07/2026, reflected resident was a [AGE] year-old male, initially admitted [DATE] and re-admitted [DATE] with diagnoses to include type 2 diabetes mellitus with hyperglycemia (elevated blood sugar levels due to the body's inability to self-regulate levels), onset date 01/29/2026. When Resident #2 was first admitted on [DATE], Type 1 Diabetes (a condition in which the body no longer produces the enzyme to reduce blood sugar levels) was not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician and others participating in the provision of care for one (1) of one (1) residents (Resident #14) reviewed for hospice services. The facility failed to maintain the current hospice plan of care to ensure Resident #14 received adequate end-of-life care. This failure could place residents at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs. The findings included: Record review of Resident #14's admission Record, dated 04/09/2026, revealed Resident #14 was initially admitted the facility on 01/12/2024 and readmitted on [DATE]. Resident #14 was noted to be [AGE] years old and received hospice services.…

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 1 of 6 residents (Resident #89) reviewed for infection control. The facility failed to ensure LVN C utilized proper PPE when administering insulin to Resident #89. This failure could result in the spread of infection. Findings included: Record review of Resident# 89's admission Record dated 4/10/2026 reflected a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included type 2 diabetes mellitus with hyperglycemia [when the body develops resistance to insulin, leading to elevated levels of blood sugar]. Record review of Resident #89's significant change MDS submitted 3/17/2026 reflected a BIMS score of 08, which indicated moderately impaired cognition. Record review of Resident #89's Order Summary Report…

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 personal privacy during personal care for 1 of 6 Residents (Resident #1) who were reviewed for care. CNA A failed to ensure Resident #1 was not exposed to anyone passing his room when she opened Resident #1's door during care. This deficient practice could place residents at risk for feeling embarrassed and compromise the resident's dignity. The findings were:Review of Resident #1's admission MDS assessment, dated 1/23/26, revealed he was admitted to the facility on [DATE] with diagnoses of malnutrition, cerebral infarction (stroke) due to occlusion or stenosis (blockage/narrowing) of small artery, dysphagia (trouble swallowing) following cerebral infarction, encounter with attention to gastrostomy (enteral feeding) and cognitive communication deficit (condition where cognitive impairments, rather than language or speech problems, disrupt a person's ability to communicate effectively). Further review revealed Resident #1's BIMS…

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 provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s) and If necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments for 1 of 1 Resident (Resident #2) who was reviewed podiatry care. Nursing staff failed to ensure they cut Resident #2's toenails and/or that they referred Resident #2 to a podiatrist for care as needed. This failure could place residents at risk of experiencing pain when wearing footwear or poor hygiene. The findings were: Review of Resident #2's face sheet, dated 2/13/26, revealed he was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia (condition that affects how people think, feel and behave. It may result in a mix of hallucinations, delusions, and disorganized thinking and behavior) 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, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and environment to help prevent the development and transmission of communicable diseases and infections for 1 of 1 Resident (Resident #1) who was reviewed for infection control. CNA A failed to wear a mask and gown while providing Resident #1, who was on EBP, with peri-care. This deficient practice could place residents at risk for contracting infectious diseases. The findings were:Review of Resident #1's admission MDS assessment, dated 1/23/26, revealed he was admitted to the facility on [DATE] with diagnoses of malnutrition, cerebral infarction (stroke) due to occlusion or stenosis (blockage/narrowing) of small artery, dysphagia (trouble swallowing) following cerebral infarction, encounter with attention to gastrostomy (enteral feeding) and cognitive communication deficit (condition where cognitive impairments, rather than language or speech…

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 was possible for 1 of 1 Resident (Resident #3) reviewed for smoking. The facility failed to ensure Resident #3 smoked in the facility designated smoking area. Resident #3 was smoking in the front patio area of the facility. This deficient practice could place residents at risk of avoidable accidents. The findings were:Review of Resident #3's quarterly MDS, dated [DATE], revealed she was admitted to the facility on [DATE] with diagnoses including bi-polar disorder, depression, anxiety, schizophrenia and post-traumatic stress disorder. Further review revealed Resident #3 had a BIMS score of 15 of 15 reflective she did not have cognitive impairment. Review of Resident #3's initial smoking evaluation, dated 3/21/25, revealed she did not have any deficits preventing her from smoking independently and unsupervised. Further review revealed staff had reviewed the smoking policy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs that are identified in the comprehensive assessment, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 of 9 residents (Resident #1, Resident #2, Resident #3, and Resident #4) reviewed for care plans. 1. The facility failed to ensure Resident #1's care plan included his having exhibited physical aggression toward another resident. 2. The facility failed to ensure Resident #2's care plan included his having experienced physical aggression from another resident. 3. The facility did not have Resident #3's care plan after the resident had a resident-to-resident physical altercation on 08/17/2025. 4. The facility did not have Resident #4's care plan after 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 Observation, interviews, and record reviews, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #5) of 9 residents reviewed for medical records. The facility failed to ensure Resident #5's electronic medical diagnosis list accurately indicated the resident had dementia with anxiety on the list, but the physician note indicated, the resident had dementia with anxiety. This failure could place residents at risk for missed treatment and medications which could result in a decline in health and well-being.Findings included: Record review of Resident #5's face sheet, dated 01/08/2026, revealed the resident was a [AGE] year old male, admitted [DATE] and re-admitted [DATE] with diagnoses of hyperlipidemia (too many lipid or fats such as cholesterol), cerebral infarction (blood flow to the brain is blocked), encephalopathy (a disease in which the functioning of the brain is affected by some…

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 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 4 residents (Resident #2) reviewed for accuracy of medical records.Resident #2 did not have foley catheter orders in Resident #2's November 2025 administration orders when he readmitted from the hospital with a foley catheter on 11/03/2025. This deficient practice could affect residents whose records were maintained by the facility and could place them at risk for errors in care and treatment. Findings included:Record review of Resident #2's undated face sheet revealed Resident #2 was a [AGE] year old male who admitted to the facility on [DATE] with diagnoses that included retention of urine (inability to empty the bladder completely), schizophrenia (a chronic mental illness characterized by delusions, hallucinations, and disorganized thinking) and profound intellectual disabilities (a severe…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents had the right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility was changed for one of one resident (Resident #1) reviewed for room change. The facility did not provide Resident #1's guardian with a written notice prior to a room change or the right to refuse on 06/16/2025. This deficient practice could place residents at risk of being displaced without notice and/or reason to accommodate other individuals.The findings included: Record review of Resident #1's admission Record, dated 10/07/2025, revealed an [AGE] year-old male admitted on [DATE]. Resident #1 had a listed guardian as his only contact. Resident #1's room assignment noted as 012-B. Record review of Resident #1's Diagnosis Report, dated 10/07/2025, revealed diagnoses including vascular dementia (a change in thinking and memory that occurs when the brain experiences a disruption in blood flow), 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 consult with the resident's physician and notify the representative when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for one of eleven residents (Resident #2) reviewed for quality of care. The facility failed to notify Resident #2's resident representatives of Resident #2's increase of exit seeking behavior with refusal for redirection resulting in police intervention observed on 10/03/2025. This failure could place residents at risk of unmet physical and psychosocial needs, physical harm and a decrease in quality of life and could result in the family or representative not being aware of conditions that may require them to make medical decisions. The findings included: Record review of Resident #2's admission Record, dated 10/07/2025, revealed a [AGE] year-old…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for two of eleven residents (Resident #1 and Resident #3) reviewed for care plans. 1. The facility failed to update or add interventions to Resident #1's care plan regarding behaviors that impact his safety, stripping the bed and the suspected behavior of repeatedly pulling on the privacy curtain resulting in pulling the curtain track down from the ceiling. 2. The facility failed to update or add interventions to Resident #3's care plan regarding reported suicidal ideation that occurred on 10/05/2025. These failures could place residents at risk of not receiving the necessary services or having the appropriate interventions to meet their current needs. The findings included: 1. Record review of Resident #1's admission Record, dated 10/07/2025, revealed an [AGE] year-old male admitted on [DATE]. Record review of Resident #1's Diagnosis…

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 assist in offering nutrition and hydration based on the residents comprehensive assessment. The facility failed to ensure the resident was offered a therapeutic diet and prepare and serve food in a form to meet individual resident's needs for 1 of 6 residents (Resident #1) reviewed for dietary requirements.The facility failed to ensure residents received their prescribed therapeutic diet.This deficient practice could result in residents losing weight, feeling abnormally hungry or weak and a reduced quality of life.Findings included:Record review of Resident #1's admission record dated 10/01/2025 reflected an [AGE] year-old female who was admitted to the facility on [DATE] with the following diagnoses: Parkinson's Disease without Dyskinesia (Parkinson's Disease without involuntary, erratic body movements), without mention of fluctuations, Gastro-Esophageal Reflux Disease, without Esophagitis (stomach contents flow back into the esophagus…

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 medical records that were compete and accurately documented for 1 of 3 residents (Resident #1) reviewed during the complaint investigation. The facility failed to ensure that Resident #1's treatment administration record noted treatments on 8.13.2025, 8.18.2025, and 8.24.2025 as required by the orders noted on the electronic medical record. This failure could place residents at risk of not receiving necessary care and services or receiving care and services more often than ordered.Findings include: During an observation and interview on 09022025 at 1:00 PM, Resident #1 was observed with bandages on her right leg covering a below the knee amputation. She stated, they are supposed to change her amputation wound daily but they don't always do it daily. Record review of Resident #1's admission record, dated 09.02.2025, reflected a [AGE] year-old female who was readmitted to the facility on 07.21.2025 with diagnoses of other…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 2 of 5 residents (Resident #1 and #2), reviewed for functional environment. The facility failed to provide Resident #1's room with a functional overhead light fixture and an unbroken window blind. This failure could lead to residents experiencing a diminished quality of life.The findings included: Record review of Resident #1's face sheet, dated 8/15/25, reflected resident was a male age [AGE] re-admitted on [DATE] with diagnoses that included: CVA (stroke), COPD (chronic lung disease), DM (diabetes), and dementia (decline in mental ability). The RP (responsible party) was listed as: self.Record review of resident #1's MDS dated [DATE] indicated Resident 1's BIMS score was 15 which indicated no impairment in cognition.Observation and interview on 8/15/25 at 2:50 PM, Resident #1 was in his room, in bed watching TV, alert and…

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

Based on observation, interview, and record review the facility failed to provide each resident that receives food from the kitchen, food that is palatable, attractive and at a safe and appetizing temperature for 1 of 1 kitchen reviewed for safe and appetizing temperatures: The breakfast meal served on 8/15/25 did not have the required holding temperatures for the last meal trayed served from the kitchen. This failure could lead to a diminished quality of life and expose residents to food borne pathogens and illness. The findings included: Observation on 8/15/25 from 8:05 AM to 8:40 AM of kitchen reflected that the steam table did not operate. The staff attempted to heat the food by adding hot water to the steam table or keeping food items longer in the oven. Observation of food temperatures of food items on the steam table reflected the following readings[breakfast meal]: readings were taken by [NAME] A with temperatures taken at 8:07 AM (initial) and test tray temperature at 8:50 AM: Oatmeal 110 F to (not taken; no more oatmeal) Eggs 159 F (initial) to 92 F (test tray) Sausage…

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, and distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen observed for food service safety. The food temperature logs were incomplete. This failure could place residents who ate meals from the kitchen at risk for spread of infections, food contamination, and food borne illness. The findings included: Record review of facility's July Food Temperature log dated July 2025 reflected the lunch meal's temperatures not documented from 7/9/25 to 7/21/25 and 7/23/25 to 7/31/25. Further record review reflected the breakfast meal from 7/24/25 to 7/31/25 and the dinner meal from 7/30/25 to 7/31/25 were not documented. During an interview on 8/15/25 at 8:25 AM, The FSS stated that the July Food Temperature Log for the lunch meal from 7/9/25 to 7/21/25 and 7/23/25 to 7/31/25 were not documented. The FSS stated that the breakfast meal from 7/24/25 to 7/31/25 and the dinner meal from 7/30/25 to 7/31/25 were not documented. The FSS did not have an…

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

Based on observation, interview, and record review the facility failed to maintain dietary equipment that was in safe operation condition for 1 of 1 kitchen reviewed for steam table operation. The steam table was not operating. This failure could place residents who ate meals from the kitchen at risk for spread of infections, food contamination, and food borne illnessThe findings included: Observation on 8/15/25 from 8:05 AM to 8:40 AM of kitchen reflected that the steam table did operate. The staff attempted to heat the food by adding hot water to the steam table or keeping food items longer in the oven. Observation of food temperatures of food items on the steam table reflected hot foods were in the danger zone. During an interview on 8/15/25 at 8:15 AM, [NAME] A stated the steam table was not operating since Tuesday 8/12/25. [NAME] A stated that the food was cold on the steam table and served cold to the residents. [NAME] A stated efforts that were made to keep the food hot by regulation, 165 F at steam table and 135F when served by keeping the food on the stove until transferred…

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, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 2 of 4 residents (Resident #2 and Resident #3) reviewed for clinical records.1. The facility failed to ensure Resident #2's output was documented in his medical record on 6/9/25 and 6/19/25. 2. The facility failed to ensure Resident #3's output was documented in his medical record on 6/9/25 and 6/19/25. 3. The facility failed to ensure Resident #3's complete VS were documented in his medical record on 6/29/25. This failure could place residents at risk of not receiving the care and services needed. Findings included: 1.Record review of Resident #2's admission Record, dated 7/1/25, revealed the resident was readmitted to the facility on [DATE] with diagnoses that included: Acute Kidney Failure (condition in which kidneys suddenly are unable to filter waste from blood) , 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 observations, interviews, and record review, the facility failed to store, prepare, and distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen observed for food service safety. The facility failed to have two overhead ceiling light covers in the cooking area free from numerous dead brown insects. The facility failed to ensure the ceiling vent in the dishwashing area was free from a black substance throughout the vent. These failures could place residents who eat meals from the kitchen at risk for spread of infections, food contamination, and food borne illness. The findings included: During an observation on 4/30/25 at 10:30 AM of the kitchen reflected: two overhead ceiling lights with brown dead insects. Further observation of the kitchen reflected the overhead vent in the washing area had a black substance on the vent. During a joint interview on 4/30/25 at 10:42 AM, the Administrator stated, she saw the vent had a black substance and she saw brown spots on two light ceiling fixtures. The Administrator stated 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 a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 16 rooms, reviewed for functional environment. The facility failed to provide Resident #1 with functional bedside and overhead lights for a minimum of 30 days. This failure could lead to residents experiencing a diminished quality of life. The findings included: Record review of Resident #1's face sheet, dated 4/29/25, reflected the resident was a 75 -year-old male who was re-admitted on [DATE] with diagnoses that included: peripheral vascular disease (heart disease), chronic kidney disease, amputation of left BKA (below the knee amputation), and diabetes. The RP was listed as: the resident. Record review of Resident#1's admissions MDS, dated [DATE], reflected: BIMS score was 9, which indicated moderate cognitive deficits. Resident #1's ADLs included: catheter care, services for incontinence of bowel, and total assistance for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews the facility failed to ensure each resident was treated with respect, dignity, and care for 2 of 8 residents (Resident #18 and Resident #56) observed for resident rights. 1. The facility failed to ensure all residents were served at one table before serving the other tables, allowing all residents to eat at the same time at their respective tables. 2. Residents were served a fried chicken patty instead of fried chicken for 01/26/25 lunch meal. 3. Residents struggled to cut their fried chicken patty with a fork. These failures could place residents at risk of not being treated with dignity and respect. Findings included: Resident # 18 Record review of Resident #18's admission Record, dated 01/26/25, reflected Resident #18 was an [AGE] year-old initially admitted on [DATE]. It reflected Resident #18 had diagnoses to include dysphagia (difficulty in swallowing), lack of coordination, muscle weakness, cognitive communication deficit, and dementia (group of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews the facility failed to ensure and 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, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 5 of 8 (Residents #5, #22, #45, #67, #79) residents in that: 1.Resident #5 stayed in bed and had not observed activities program and activity assessment was not up to date. 2.Resident #22 she called bingo/loteria (Mexican bingo) and tried to get some activities for the other residents, since we don't have a full time Activity Director, since November 2024. The Activity Assessment was not up to date. 3. Resident #45 was bed bound resident with no in room activities. Activity assessment was blank.…

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 review the facility failed to ensure the activities program must be directed by a qualified professional who is a qualified therapeutic recreation specialist or an activities professional who- Is licensed or registered, if applicable, by the State in which practicing; and has completed a training course approved by the State for 1 of 1 facility in that: Operations Manager stated no full time Activity Director. No full time Activity Director since November 2024. This failure could result residents not having activities while residing in the facility. The Findings were: Interview on 1/26/2025 at 5:30PM with prn Activity Director (prn Activity Director) stated she was prn (as needed) Activity Director an comes in and does activities with Residents when she can. The prn Activity Director stated she calls different vendors from her house and comes to facility to do some activities, when she can. Interviews with the Resident Council stated they did not have an Activity Director and they try to figure out what to do for the day. Resident council…

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 with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection for 3 of 8 (Resident #67, #5 and #45 ) residents in that: 1. Resident #67 had a pressure ulcer on her heel and was not observed offloading her heels. 2. Resident #5 had a pressure ulcer on her heel and was not observed offloading her heels. 3. Resident #45 was not turned every 2 hours by staff. This could affect all residents with pressure ulcers and could result in wounds not healing. The Finding were: 1.Record review of Resident # 67's admission Record dated 1/27/2025 was documented she was admitted on [DATE], readmitted on [DATE] with diagnoses of diabetes II (a chronic condition where the body does not use insulin effectively or does not produce enough insulin.), and disorder of skin. Record review of Resident # 67's consolidated physician orders for January 2025 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 pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each Resident, for 8 of 16 residents (Residents #5, 20, #27, #38, #68, #69, #81, and #85) reviewed for pharmacy services. 1. On [DATE] Medication Aide E administered late medications to Resident #20 at 10:49 AM: a. Acetaminophen 325mg, (Tylenol) late by 1 hour and 49 minutes. b. Levetiracetam 500mg (a medication to treat seizures) late by 1 hour and 49 minutes. 2. On [DATE] Medication Aide E administered late medications to Resident #27 at 9:20 AM: a. Carvedilol 12.5mg (used to treat high blood pressure) late by 20 minutes. b. Divalproex 125mg (used to treat schizophrenia) late by 20 minutes. 3. On [DATE] Medication Aide E administered late medications to Resident #38 at 10:51 AM: a. Famotidine 20mg (used to reduce stomach acid) late by 1 hour and 51…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure a medication error rate below 5%, for 25 medication administration opportunities with 4 errors resulting in a 16% medication error rate, for 1 of 8 residents (Resident #62) reviewed for medication administration. 1. Medication Aide E administered Resident #62 his medication doxazosin (a medication to treat high blood pressure) 1 hour and 28 minutes late and his hydralazine (a medication to treat high blood pressure), carvedilol (used to treat heart failure with high blood pressure), and furosemide (used to treat swelling due to heart failure) late by 58 minutes. These failures placed residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. The findings included: A record review of Resident #62's admission record dated 1/30/2025 revealed an admission date of 5/25/2022 with diagnoses which included hypertensive chronic kidney disease with end stage kidney disease (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 observations, interviews, and record reviews the facility failed to have drugs and biologicals used in the facility labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable; and the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, for 1 of 1 nurse medication carts reviewed for security and supervision and for 3 of 8 residents (Residents #5, #81, and #85) reviewed for safe storage of insulins. 1. On [DATE] at 6:06 PM LVN J attended the nurse medication cart on the facility's D-hall and left the medication cart unsupervised and unlocked for 7 minutes while she left and provided care for a Resident. LVN J was out of line-of-sight with the nurse medication cart. 2. An inspection on [DATE] of the facility's treatment nurse medication cart revealed expired insulins for Residents #5, #81, and #85 as evidenced by the following: a.…

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

Based on observations, 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 1 kitchen reviewed, in that: 1. In a refrigerator, there were 2 bags of salad, 1 dated 01/25 and one not dated, and 1 bag of ham, dated 01/17, that did not reflect a discard date. 2. The facility's documents Three Compartment Sink Log and Milk Refrigerator Temperature Log for January 2025 reflected no entries were documented January 22-January 24. 3. Dietary Aide AG had a facial piercing and parts of her hair exposed while working in the kitchen. These failures could place residents who consumed meals and/or snacks prepared in the facility kitchen in danger of food-borne illness. The findings were: 1. During observation on 01/26/25 at 10:52 AM, there were 2 bags of salad, 1 dated 01/25 and one not dated, and 1 bag of ham, dated 01/17, that did not reflect a discard date. During an interview on 01/26/25 at 01:03 PM, the CDM revealed the salad bags and the bag of ham in the refrigerator 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 observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections; Standard and transmission-based precautions to be followed to prevent spread of infections; for 3 of 8 residents (Residents #45 and #69) and 3 of 3 staff (MA E, DON, LVN J) reviewed for infection prevention with Enhanced Barrier Precautions. 1. Resident #69 was diagnosed with a urinary tract infection (UTI), assessed with the need for infection prevention enhanced barrier precautions (EBP), and on 1/26/2025 at 11:52 AM the DON wore 1 glove for personal protective equipment (PPE) while attempting to administer an intravenous access for Resident #69. 2. Resident #69 was diagnosed with a urinary tract infection (UTI), assessed with the need for infection prevention enhanced barrier precautions, and on 1/28/2025 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 observations, interviews, and record reviews the facility failed to ensure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, for 1 of 1 secured yard reviewed for safety. 1.Daily intermittent observations, from 1/26/2025 to 1/30/2025, revealed the facility's secured backyard and smoking patio yard had a section of chain link fence a section of the chain link fencing was detached from the top rail and leaning down. 2. Daily intermittent observations, from 1/26/2025 to 1/30/2025, revealed the facility's secured backyard and smoking patio yard had several red fire rated trash cans, designated for cigarette butts, filled with non-cigarette butt trash. These failures could place residents at risk for elopement and/or fire risks. The findings included: A record review of Resident #24's admission record dated 1/30/2025 revealed an admission date of 12/17/2024 with diagnoses which included tobacco use, lack of coordination, and muscle weakness. A record review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review the facility failed to ensure the resident has a right to personal privacy and confidentiality of his or her personal and medical records for 3 of 9 (room [ROOM NUMBER], #47 and resident #76) incidences of privacy concerns in that: 1. LVN J did not knock on rooms [ROOM NUMBERS] before entering rooms. 2. LVN Z left her computer open with resident#76's personal information. This could affect and result in resident privacy being violated. The Findings were: 1. Observation on 1/26/2025 at 10:33 AM LVN J went into room [ROOM NUMBER] and did not knock on the door before entering room. Observation on 1/26/25 at 10:00 AM LVN J went into room [ROOM NUMBER] and did not knock on the door before entering room. Interview on 1/26/25 at 10:38 AM with LVN J stated she did not knock on the 2 doors, and she should have knocked before she entered. 2. Observation on 1/26/2025 at 12:11 PM to 12:19 PM revealed LVN Z had her computer screen open revealing Resident #76'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 observations, interviews, and record reviews the facility failed to ensure residents had a safe, clean, comfortable, and homelike environment, with adequate and comfortable lighting levels in all areas; for 2 of 8 residents (Residents #18 and #37) reviewed for adequate lighting in the dining room. On 1/26/2026 at noon and ongoing until 1/30/2025 the facility's dining rooms had malfunctioning fluorescent lamps and fixtures, which residents #18 and #37 had stated they wished for better lighting during their meals. These failures could negatively impact residents' morale and overall sense of self-esteem. The findings included: A record review of Resident #18's admission record dated 1/30/2025 revealed an admission date of 9/2/2021 with diagnosis which included dysphagia (difficulty swallowing), anxiety, and bipolar disorder (a serious mental illness characterized by extreme mood swings.) A record review of Resident #18's quarterly MDS assessment dated [DATE] revealed Resident #18 was an [AGE] year-old…

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 reviews the facility failed to ensure implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -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 8 (Resident #5) residents in that: Resident #5's code status in chart did not match the care plan. This failure could affect residents by not having their end of life met. The Findings were: Record review of Resident #5's admission Record dated 1/29/2025 was documented she was admitted on [DATE], readmitted on [DATE] with diagnoses of diabetes II (a chronic condition where the body does not use insulin effectively or does not produce enough insulin.), cognitive…

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 each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 5 resident wander guards (Resident #84) reviewed for accident hazards and supervision, in that: The facility did not ensure Resident #84's wander guard (a technology designed to prevent eloping from a facility) was working properly. This failure could place the residents at risk for elopement. Findings included: Record review of Resident #84's care plan, last reviewed 11/20/24, reflected a [AGE] year-old resident admitted [DATE]. It reflected Resident #84 had diagnoses to include need for assistance with personal care, muscle weakness, history of falling, cognitive communication deficit, lack of coordination, and difficulty walking. [Resident #84] is an elopement risk/wanderer as evidenced by impaired safety awareness, wanders aimlessly with intervention Wandergaurd as ordered, dated 09/27/24. Record review of Resident #84's January…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record reviews the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicated otherwise for 1 of 8 residents (Resident #71) reviewed for nutrition. The facility failed to follow Resident #71's care plan for weighing Resident #71 weekly and failed to follow the facility's policy for weight assessment and intervention when Resident #71 had a significant weight loss. These failures could place residents at risk for malnourishment, weight loss, skin breakdown, and decreased quality of life. Findings included: Record review of Resident #71's admission Record, dated 01/26/25, reflected Resident #71 was a [AGE] year-old initially admitted on [DATE]. It reflected Resident #71 had diagnoses to include depression, vitamin D deficiency, dysphagia, deficiency of other vitamins, vitamin B12 deficiency, iron…

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 follow menus for 1 of 2 resident meals (dinner meal on 01/28/25) reviewed for menus in that: The facility failed to follow the menu for residents on soft bite sized and minced moist diets for the dinner meal on 01/28/25. This failure could place residents who consume food prepared by the facility kitchen at risk of not having their nutritional needs met and/or weight loss. The findings included: Record review of Week 3 Menu reflected Tuesday (Day 17) Dinner included Tomato Basil Soup and Pimento Cheese Sandwich. Record review of the recipes for Pimento Cheese Sandwich, undated, for the textures minced and moist and soft bite sized reflected recipe directions to include Grind 2 slice of bread 4-6 seconds to mince. Place prepared bread crumbs in a bowl and spray with vegetable pan spray until a more cohesive texture is achieved. Divide the prepared bread crumbs placing half of the crumbs as the first layer. Top with the #8 dip pimento cheese. Top with the other half of the minced prepared bread crumbs. 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.

Based on observation, interviews and record reviews, the facility's governing body failed to designate a person to exercise the administrator's authority when the facility did not have an administrator and secure a licensed nursing home administrator within 30 days. The facility terminated Licensed Administrator A on 11/08/2024; hired Employee B, who was not a licensed administrator 24 days later and served in the capacity of the administrator for 39 days. This failure could result in a decrease in the quality of care provided to the residents that could result in potential minimal harm to the resident. The findings were: Record review of the All Staff Active Listing, dated 1/4/2025, revealed Employee B was listed as the Administrator with a hire date of 12/02/2024. Record review of an Application for Employment, signed digitally by Employee B on 12/13/24, revealed she applied for the Administrator position, had previously worked at another nursing home as an AIT, did not list the school she attended and did not indicate she was a Licensed Nursing Facility Administrator. 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 interviews and record reviews, the facility failed to maintain documentation that an alleged violation was thoroughly investigated for 1 of 8 PIRs reviewed that involved (Resident #1 and Resident #2) for facility compliance to prevent further abuse from resident to resident altercations. The former Administrator A failed to investigate a resident to resident altercation (Resident #1 threw a cup and hit Resident #2 in the back of the head) that occurred on 07/21/2024. This failure could place residents at risk for abuse from altercations and could place the residents at risk of harm. The findings included: Record review of Resident #1's face sheet dated 1/6/2025 revealed a 56yr old male admitted to the facility on [DATE] with diagnoses that included: epilepsy, encephalopathy, opioid abuse, bipolar disorder, etoh (alcohol) abuse, and blindness of left eye. Record review of Resident #1's Care Plan dated 11/16/2024 revealed he was PASRR+ for developmental disorder, behavioral complex -physically 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 interviews and record reviews, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice for 1 of 2 residents (Resident #1) reviewed for dialysis. 1. The facility failed to ensure Resident #1 had a complete set of vital signs assessed prior to leaving for dialysis on (8) occasions. 2. The facility failed to ensure Resident #1 had a complete set of vital signs and access site assessed upon returning to the facility after dialysis on (9) occasions. These deficient practices could affect residents who receive dialysis treatments at risk for inadequate care and/or decline in health. Findings included: 1. Record review of Resident #1's admission Record, dated 12/5/24, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Chronic Kidney Failure (condition in which kidneys are unable to filter waste from blood), Type 2 Diabetes (condition in which the body has trouble controlling blood sugar…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to maintain an 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 7 of 8 residents (Resident #2, Resident #5, Resident #6, Resident #8, Resident #10, Resident #11, and Resident #15) reviewed for infection control. The facility failed to use proper infection control practices: 1. During skin assessment and wound care for Resident #2. 2. During skin assessments for Residents #5, #6, #8, #10, and #11. 3. During wound care for Resident #15. This failure could place residents at risk for infection and decline in health. Findings included: 1. Record review of Resident #2's admission Record, dated 12/2/24, revealed the resident was readmitted to the facility on [DATE] with diagnoses that included: Cellulitis (common bacterial skin infection), Lesions (Right Shoulder), and Type 2 diabetes (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, interviews, and record review, the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to prevent complications from enteral feeding for 1 (Resident #1) of 3 residents reviewed for enteral feeds, in that: The facility failed to ensure Resident #1's doctor's orders of administering water, before initiating feeding, were being followed. This failure could place residents at risk of not receiving the proper hydration requirements prescribed by the physician. The findings included: Record Review of Resident #1's admission record, dated 08/31/24, reflected a [AGE] year-old female initially admitted [DATE] with diagnoses to include dysphagia (difficulty in swallowing) following cerebral infarction (stroke) and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). Record Review of Resident #1's significant change in status MDS assessment, dated 07/22/24, reflected Resident #1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews the facility failed to ensure that nurses were able to demonstrate competency in skills and techniques to provide nursing and related services for 1 of 3 residents (Resident #1) by 1 of 1 nurse (LPN F) reviewed for competent staff, in that: LPN F failed to provide water flushes for enteral nutrition before enteral formula was administered as ordered for Resident #1. This failure could place residents at risk for not receiving nursing services by adequately trained and licensed nurses and could result in a decline in health. The findings included: Record Review of Resident #1's admission record, dated 08/31/24, reflected a [AGE] year-old female initially admitted [DATE] with diagnoses to include dysphagia (difficulty in swallowing) following cerebral infarction (stroke) and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). Record Review of Resident #1's significant change in status MDS assessment,…

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 consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 (Resident #1) of 4 residents reviewed for resident rights. The facility failed to notify Resident #1's physician of her change of condition on 8/08/2024 when an injury of unknown origin developed into a hematoma [collection of blood outside of a blood vessel where it does not belong, may result in swelling, discoloration and warmth] at the back of her head. Resident #1 was subsequently sent out to the hospital on 8/09/2024 . This failure could affect residents by placing them at risk for a delay in medical treatment, decline in health, and death. The findings included: Record review of the admission Record, printed 8/10/2023, reflected Resident #1 was a [AGE] year-old female…

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 provide routine and emergency drugs and biologicals to its residents for 1 of 4 residents (Resident #1) reviewed for medication administration, in that: The facility failed to administer Keppra (a medication used to treat seizures) to Resident #1 on 5/10/2024 in a timely manner and within the facility's medication window for administration. This deficient practice could result in a risk to the residents' health and complications which can lead to seizures. The findings included: Record review of Resident #1's face sheet, dated 5/15/2024 revealed an admission date of 10/31/2018 with readmission date of 11/28/2021 with diagnoses which included: epilepsy, not intractable, without status epilepticus (a type of epilepsy that can be managed with medication), seizures and muscle spasms. Record review of Resident #1's quarterly MDS assessment revealed a BIMS score of 15 which indicated the resident was cognitively intact. Record review of Resident #1's care plan last revised on 10/09/2023 revealed Resident #1 had a behavioral…

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 records review, the facility failed to store, distribute, and serve food in a manner to prevent foodborne illnesses and food contamination for 1of 1 kitchen reviewed for: 1. Counters had an oily residue with a dark , oily substance on the edges and the crevices, and crumbs behind and underneath an appliance where food is prepared. 2. The stove had an oily black substance on and around the dials and black substance on the cooking surface, grill. 3. Desserts and cornbread were uncovered while waiting to be distributed, and while an insect was flying around the kitchen. 4. Two coffee carafes had dark brown substance inside the walls. 5. The floors had debris underneath the shelving units and underneath the sink there was a dead insect; and there was a very dark substance on areas of the floor and along the edges. 6. The bathroom off the kitchen area used by staff was cleaned by dietary staff. There was a black substance around the faucet and on the sink, there was a reddish- orange substance on the rim of the sink; the floor had debris and 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 observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 9 residents (Resident #61) reviewed for quality of care in that: Resident #61 did not receive a neurologist appointment as ordered after a standalone seizure event occurring on or about 5/13/2023. This failure could affect residents who receive care from the facility and place them at risk for worsening conditions. The findings were: Record review of Resident #61's face sheet, dated 12/14/23, reflected a [AGE] year-old male resident who was initially admitted to the facility on [DATE], with diagnoses of Cerebral Infarction [damage to tissues in the brain due to a loss of oxygen to the area], gastro-esophageal reflux disease without esophagitis [stomach acid repeatedly flowing back into the tube connecting your mouth and stomach without inflaming the esophagus], and hyperlipidemia [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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for 1 of 3 residents (Resident #50) reviewed for incontinent care in that: While providing incontinent care for Resident #50, CNA D did not clean Resident #50's meatus (duct by which urine is conveyed) working outward. This deficient practice could place residents at risk for infection and skin breakdown due to improper care practices. The findings were: Record review of Resident # 50's face sheet dated 12/14/23 revealed a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis that included: [Dementia] a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory. [Schizophrenia] is a severe mental illness that affects how a person thinks, feels, and behaves, and [ Depressive disorder] is a mood disorder that causes a persistent…

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 review, the facility failed to ensure residents' right to reside and receive services in the facility with reasonable accommodations of residents needs and preferences for 1 of 5 residents (Resident #4) reviewed for accommodations of needs in that: Resident #4's call light was clipped out of reach onto his privacy curtain. This deficient practice could place residents at risk of not receiving care or attention needed. The findings were: Record review of Resident #4's face sheet, dated 10/27/23, revealed Resident #4 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease [a progressive disease that affects memory and other important mental functions], unspecified, bullous disorder [a rare skin condition that causes large, fluid-filled blisters], unspecified, muscle weakness (generalized), contracture [a fixed tightening of muscle or tendons], right hand, and stiffness of right hip, not elsewhere classified. Record review of Resident #4's Quarterly…

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 implement a person-centered care plan that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 5 residents (Resident#4) reviewed for comprehensive care plans in that: The facility did not follow Resident #4's comprehensive care plan to ensure Resident #4's call light was within reach. This deficient practice could affect all residents and place them at risk for not receiving appropriate treatment and services or activities. The findings were: Record review of Resident #4's face sheet, dated 10/27/23, revealed Resident #4 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease [a progressive disease that affects memory and other important mental functions], unspecified, bullous disorder [a rare skin condition that causes large, fluid-filled blisters], unspecified, muscle weakness (generalized), contracture [a fixed tightening of muscle 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.