Sonterra Health Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that the resident's environment remained as free of accident hazards as was possible for 1 of 7 Residents (Resident #80) whose environment was reviewed for safety hazards. Nursing staff failed to remove 3 razors from Resident #80's bathroom. This deficient practice could affect residents exposed to the razors and could contribute to avoidable accidents. The findings were: Review of Resident #80's face sheet, dated 5/15/25, revealed he was admitted to the facility on [DATE] with diagnoses including Vascular Dementia and Visual Hallucinations. Review of Resident #80's MDS assessment, dated 3/27/25, revealed his BIMS was 8 of 15 reflective of moderate cognitive impairment. Review of Resident #80's Care Plan, revised on 1/2/25 revealed he was at risk for impaired cognitive function/dementia or impaired thought processes r/t Dementia. Interventions included COMMUNICATION: Identify yourself at each interaction. Face when speaking and make…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan for 1 of 6 Residents (Resident #80) whose records were reviewed for CPAP care. Nursing staff failed to store Resident #80's CPAP mask in a plastic bag and failed to clean it per facility policy. This deficient practice could affect residents with respiratory needs and could contribute to upper respiratory infections. The findings were: Review of Resident #80's face sheet, dated 5/15/25, revealed he was admitted to the facility on [DATE] with diagnoses including Vascular Dementia (according to microsoft [NAME]: type of dementia caused by problems in the blood supply to the brain, resulting from a cerebrovascular disease) and Obstructive Sleep Apnea (People with obstructive sleep apnea repeatedly stop and start breathing while they sleep). Review of Resident #80'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 assess the resident for risk of entrapment from bed rails prior to installation. Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for 2 of 6 Residents (Resident #21 and Resident #153) whose records were reviewed for the use of side rails. 1. Nursing staff failed to obtain physician orders, a consent, and did not make other efforts prior to the implementing the use of SRs for Resident #21. 2. Nursing staff failed to obtain physician orders and a consent for the use of SRs for Resident #153. These deficient practices could affect any resident and could contribute to unavoidable accidents. The findings were: 1. Review of Resident #21's face sheet, dated 5/15/25, revealed he was admitted to the facility on [DATE] with diagnoses including Metabolic Encephalopathy (according to Cleveland Clinic: it is a change in how your brain works due to an underlying…

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 each resident's drug regimen must be free from unnecessary drugs without adequate indications for its use for 1 of 6 Resident (Resident #151) whose records were reviewed. Nursing staff failed to obtain a consent from Resident #151's family representative for the use of Hydorxyzine (used for anxiety). This deficient practice could affect any resident who received psychotropic medications and could contribute to the use of unnecessary medications. Review of Resident #151's face sheet, dated 5/15/25, revealed she was admitted to the facility on [DATE] with diagnosis including unspecified Dementia. Review of Resident #151's physician orders for May 2025 revealed an order hydrOXYzine HCl Oral Tablet 25 MG (HydrOXYzine HCl) Give 1 tablet by mouth every 8 hours as needed for anxiety for 14 Days. Review of Resident #151's MAR for May 2025 revealed Resident #151 received HydrOXYzine from 05/12/25 to 05/15/25. Review of Resident #151's consent form 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.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biological were stored in locked compartments for 1 of 24 residents (Resident #150) reviewed for medications storage. During medications administration, LVN A left medications at bedside of Resident #150. This deficient practice could place residents at risk of misappropriation of medications or harm due to accidental ingestion of medications. The findings included: Record review of Resident #150's face sheet, dated 05/14/2025, revealed an admission date of 05/04/2025, with diagnoses which included: Cirrhosis of liver (permanent scarring that damages the liver and interferes with its functioning) , Dysphagia (Difficulty swallowing), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Hypertension (High blood pressure), Chronic kidney disease stage 3 (gradual loss of kidney function). Review of MDS log revealed Resident #150's admission assessment was not due yet. Review of BIMS assessment, dated 05/05/2025, revealed Resident #150 had a BIMS score of 9 and was…

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

Based on observation, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 2 of 5 residents (Resident #23 and #150) reviewed for infection control, in that: 1. While administering medications for Resident #23, MA B did not sanitize the mobile blood pressure machine. 2. While Administering medications for Resident #150, LVN A did not sanitize of wash her hands between change of gloves. LVN A did not change her gloves prior to start care on Resident #150 These deficient practices could place residents at-risk for infection due to improper care practices. These findings included: 1. Record review of Resident #23's face sheet, dated 05/14/2025, revealed an admission date of 12/21/2021, and a readmission date of 09/22/2024, with diagnoses which included: Dementia (decline in cognitive abilities), Major depressive disorder (mental disorder characterized by at least two weeks…

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 prepare a comprehensive care plan that included to the extent practicable, the participation of the resident and the resident's representative(s) and failed to review and revise resident care plans after each assessment, for 2 of 4 residents (Resident #1 and #2) reviewed for care plan revision/timing. The facility failed to ensure Resident #1 had quarterly care plan reviews in February 2024 and May 2024 (2 out of 5), and Resident #2 had quarterly care plan reviews in March 2024, June 2024 and January 2025 (3 out of 6). This failure could affect residents care/services and may cause a delay in treatment and/or decline in health. Findings included: Record review of Resident #1's admission Record, dated 04/23/25, reflected a [AGE] year-old female initially admitted [DATE] with diagnoses to include muscle wasting and atrophy, personal history of urinary (tract) infections, and mild cognitive impairment. Record review of Resident #1's 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure medical records were kept in accordance with professional standards and practices and were complete and accurately documented for 1 of 6 residents (Resident #1) reviewed for accuracy of records. The facility failed to ensure Resident #1 had documented weekly skin evaluations per the facility policy on 6 out of 7 occasions (08/24/24, 08/31/24, 09/07/24, 09/14/24, 09/21/24, 09/28/24) from 08/21/24 to 10/05/24. This failure could place residents at risk for improper care due to inaccurate records. Findings included: Record review of Resident #1's admission Record, dated 04/23/25, reflected a [AGE] year-old female initially admitted [DATE] with diagnoses to include muscle wasting and atrophy, personal history of urinary (tract) infections, and mild cognitive impairment. Record review of Resident #1's quarterly MDS assessment, dated 03/25/25, revealed the resident had a BIMS score of 7 out of 15, indicating severely impaired cognition. Record review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources are reported immediately to the administrator of the facility and to other officials, including to the State Survey Agency in accordance with State law through established procedures, for 1 of 3 Residents (Resident #1) reviewed for Neglect, in that: The facility did not report an allegation of neglect per facility policy to the State Survey Agency (HHSC) when a medication error for Resident # 1 occurred. This deficient practice could affect any resident and could contribute to further neglect. The findings were: Record review of Resident # 1's face sheet dated 3/20/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included dependence on renal dialysis (an illness where kidneys don't function, and a machine is required to filter blood through an artificial kidney), diabetes type 1 ( Illness…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observations, interviews, and record reviews, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys, for 1 of 4 medication carts (400 hall medication cart) reviewed for drug security. The 400 Hall nurse's medication cart was left unattended with a blister package of medication Tamulosin HCL for Resident #4 on top of the cart. This failure could place residents at risk for misappropriation of property and could place residents at risk for accidents, hazards, and not receiving therapeutic effects. The findings included: Record review of Resident #4's admission Record (face sheet), dated 9/14/24, revealed he was admitted to the facility on [DATE] with diagnoses which included Benign Prostatic Hypertrophy (an enlarged prostate) and history of lung cancer. Record review of Resident #4's Physician Order Summary, dated 09/14/2024, revealed an order for Tamulosin HCL capsule 0.4 mg give 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.

Based on observations, interviews, and record reviews the facility failed to post the following information on a daily basis: Facility name, the current date, the total number, and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: Registered nurses, Licensed practical nurses, Certified nurse aides, and Resident census. For 1 of 1 daily nursing staff posting. The facility failed to coordinate the generation and posting of the nursing daily staffing report. This deficient practice could deny residents and visitors nurse staffing information readily available in a readable format at any given time. The findings included: During an observation on 06/13/2024 at 01:00 AM revealed the facility's Daily Nursing Care Hours public posting hung on the wall behind the nurse's station. Further observation revealed the posting was dated Tuesday 06/11/2024. During an interview on 06/13/2024 at 01:30 PM the ADON stated the posting should be daily. During an interview on 06/14/2024 at 06:00 PM the…

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

Based on observations, interviews, and record reviews the facility failed to ensure all drugs and biologicals were stored in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys, for 3 (100 Hall medication aide cart, nurse medication cart, and treatment cart) of 8 medication and treatment carts reviewed for drugs and biologicals were stored in locked compartments. The 100-hall medication aide cart, the nurse medication cart, and the treatment cart were unlocked and unsupervised. This failure could place residents at risk for harm by unsecured and uncontrolled medications. The findings included: During an observation on 06/13/2024 at 12:51 AM revealed the 100-hall nurse LVN A seated at the nurses' station documenting at the computer. Further observation revealed the medication aide cart, nurse medication cart, and treatment cart positioned at the near end of the 100-hall. All 3 carts were observed to be out of LVN A's line of sight. All 3 carts were unattended and unlocked. 1 of the 3 medication carts had approximately…

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 10 snacks reviewed for preparation, distribution, and storage. The facility prepared and distributed sandwiches without labeling the sandwiches with the dates they were prepared and the dates the foods should not be served and thrown out. This deficient practice could place residents at risk for food borne illnesses. The findings included: During an observation on 06/13/2024 at 01:10 AM revealed a sandwich wrapped in clear plastic cling wrap stored at room temperature on a plastic tray on a wheeled shelf table. Further observation revealed the sandwich was not labeled in any fashion. During an interview on 06/13/2024 at 01:15 AM CNA B stated sandwiches were prepared and delivered to the hallway snack carts by kitchen staff. CNA B stated the sandwich on the snack cart was not labeled with any information. CNA B stated the sandwich was not safe to serve due to the lack of information. She…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to ensure the assessment accurately reflected the resident's status for 5 (Residents #6, #17, #19, #53 and #67) out of 24 residents reviewed for MDS assessments. 1. Facility failed to ensure Resident #6's quarterly MDS assessment with an ARD of 03/23/2024 reflected resident receiving hospice services. 2. Facility failed to ensure Resident #17's significant change MDS assessment with an ARD of 03/12/2024 reflected resident receiving hospice services. 3. Resident #19's quarterly MDS assessment with an ARD of 04/01/2024 inaccurately reflected her pressure sore status, interventions, and treatments as none when she had a Stage 3 (full thickness tissue loss) pressure sore to her sacrum (a shield shaped bony structure located at the base of the spine and connects the pelvis (the area of the body below the abdomen that contains the hip bones, bladder and rectum)), with interventions and treatment. 4. Resident #53's quarterly MDS assessment with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, 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 includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 3 residents (Residents #19, #53 and 127) of 24 residents reviewed for care plans. 1. Facility failed to implement Resident #19's care plan which reflected she required a floor mat beside her bed as a fall prevention. 2. Facility failed to ensure Resident #53's bowel and bladder incontinence was reflected in his comprehensive care plan with a revised date of 12/11/2023. 3. Facility failed to ensure Resident #127's hospice services were reflected in his comprehensive care plan with a revised date of 02/18/2024. These deficient practices could affect residents who required specific care, services and interventions by placing them at risk of 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.

Based on interview, and record review, the facility failed to ensure the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility, reviewed for registered nurse coverage. RN 8-hour coverage was not available for 7 days in the period 11/04/23 to 12/15/23. This deficient practice had the potential to affect all residents in the facility by leaving staff without supervisory coverage of an RN. The findings included: Record review of facility's RN hour time sheets from November 2023 to March 2024 revealed no 8 hours of RN coverage on the following days: 11/04/23=0 hours 11/05/23=0 hours 11/18/23=0 hours 11/19/23=0 hours 11/25/23=0 hours 11/26/23=0 hours 12/07/23=0 hours 12/15/23=0 hours Interview with DON on 4/19/24 at 12:45PM revealed the facility had a scheduler that was responsible to ensure RN coverage of at least 8 hours per day. The DON stated she worked Monday to Friday 8 hours a day and covered weekends if RN hours were not covered. The DON also stated she was on-call when there was no RN on duty. The DON confirmed that there 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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen observed for kitchen sanitation. The facility failed to ensure [NAME] I prepared the pureed pasta salad in a sanitary fashion. The facility failed to ensure insulated plate lids and insulated plate bases were air dried prior to stacking them with water droplets and meal prep. These failures could place resident who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: Observation on 04/18/2024 at 9:47 a.m. revealed DA J take the washed insulated plate lids and insulated bases after coming out of the dish washing machine and stacked them on top of each other on a 3-tiered cart without allowing them to air dry with water droplets visible on both. Observation on 04/18/2024 at 11:30 a.m. revealed the insulated plate lids and insulated bases had been moved to the serving…

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 review and revise the comprehensive person-centered care plan for one (Resident #56) out of 24 residents reviewed for comprehensive care plans. Resident #56's comprehensive care was not revised to reflect he was on an LCS/NAS regular texture diet. This deficient practice could affect residents placing them at risk for not receiving necessary care. The findings included: Record review of Resident #56's electronic face sheet dated 04/17/2024 reflected he was admitted to the facility on [DATE]. His diagnoses included: dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), syncope and collapse (fainting and passing out), dysphagia (difficulty swallowing) and weakness (lack of strength). Record review of Resident #56's quarterly MDS assessment with an ARD of 01/03/2024 reflected he scored a 04/15 on his BIMS which signified he was severely cognitively impaired. He could understand 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 ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 2 resident (Residents #53) reviewed for incontinent care.: While providing incontinent care for Resident #53, CNA C did not return Resident #53's foreskin to the original position. This deficient practice could place residents at-risk for infection, paraphimosis (urologic emergency in uncircumcised males) and skin break down due to improper care practices. The findings were: Record review of Resident #53's electronic face sheet dated 04/18/2024 reflected he was originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included: epilepsy (a neurological disorder marked by sudden episodes of sensory disturbance, loss of consciousness or convulsions associated with abnormal electrical activity in the brain), unsteadiness on feet (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure personal privacy during personal care for 1 of 5 resident (Resident #1) observed for personal privacy in that: While performing the incontinent care for Resident #1, CNA A and CNA B did not ensure Resident #1's personal privacy. This deficient practice could affect residents and could result in loss of dignity and low self-esteem. The findings were: Record review of Resident #1's face sheet, dated 3/20/24, Resident #1 was admitted to the facility on [DATE] with diagnoses of muscle wasting and atrophy [shrinking of muscle or nerve tissue], not elsewhere classified, multiple sites, unspecified speech disturbances, history of falling, and cognitive communication deficit [difficulty communicating due to injury to the brain]. Record review of Resident #1's quarterly MDS, dated [DATE], revealed Resident #1's BIMS score was 6, signifying severe cognitive impairment. Observation on 3/19/24 at 1:39 p.m. revealed CNA A and CNA B entered…

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 all drugs and biologicals were stored in accordance with currently accepted professional principles in locked compartments and permit only authorized personnel to have access to the keys for 1 of 4 residents (Resident #2) reviewed for storage of drugs. LVN C left Resident #2's morning medications at bedside. This deficient practice could place residents at risk of medication misuse and diversion. The findings were: Record review of Resident #2's face sheet, dated 3/20/24, revealed Resident #2 was admitted to the facility on [DATE] with diagnoses of acute pulmonary edema [excess fluid in the lungs], chronic kidney disease, stage 3 unspecified, history of falling, and presence of cardiac pacemaker [a device that regular's the heart's beat]. Record review of Resident #2's BIMs score, dated 3/19/24, revealed Resident #2 had a BIMS score of 15, signifying no cognitive impairment. Record review of Resident #2's physician orders, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 4 residents (Resident #3) reviewed for accuracy of medical records in that: CNA D documented she gave Resident #3's clonazepam (a medication for seizures) on 2/20/24, which was after Resident #3 ran out of clonazepam on 2/19/24 and before the medication was restocked on 2/22/24. This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care and treatment. The findings were: Record review of Resident #3's face sheet, dated 3/19/24, revealed Resident #3 was admitted to the facility on [DATE] with diagnoses of cerebral palsy [a disorder that affects a person's ability to move and maintain balance and posture], unspecified, dysphagia [difficulty swallowing], unspecified, weakness, unspecified convulsions, and muscle weakness (generalized.)…

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 develop and implement a comprehensive person-centered care plan for each resident, which includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 of 4 Residents (Resident #1 and #2), reviewed for care plan development. 1. The facility failed to ensure Resident #1's comprehensive care plan included a plan of care for a diagnoses GERD (gastro-esophageal reflux disease, also known as acid reflux), eosinophilic esophagitis (inflammation of the esophagus) and history of GI (gastro-intestinal) bleeding. 2. The facility failed to ensure Resident #2's diagnoses of hypertension/hypotension and the resident's use of midodrine (medication used to increase blood pressure) that included physician ordered parameters for administration were addressed in the care plan. This failure could place residents at risk for lack of coordination of 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, 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 1 of 3 residents (Residents #2) reviewed for medication administration. The facility failed to ensure Resident #2 was administered midodrine (a medication used to increase blood pressure) by LVN C who had dispensed the medication. This failure could place residents at risk for a delay in medication administration and medication error and could result in a decline in health. The findings include: Record review of Resident #2's face sheet dated 12/01/2023 revealed an admission date of 7/18/2023 with diagnoses which included: unspecified dementia, malignant neoplasm of colon (cancer of colon), and hypertension (high blood pressure). Record review of Resident #2's physician order summary for November 2023 revealed an order for midodrine…

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 the resident's representative where there is a decision to transfer or discharge the resident from the facility for 1 of 6 residents (Resident #1) reviewed for notification, in that: The facility failed to contact Resident #1's emergency contact when the resident was transferred to the hospital. This deficient practice could place residents at risk of improper discharge planning and diminished quality of life. Findings included: Closed record review of Resident #1's undated face sheet revealed the resident was a [AGE] year old female admitted to the facility on [DATE] with diagnoses that included acute pulmonary edema (a condition caused by too much fluid in the lungs), congestive heart failure (a long-term condition whereby the heart can't pump blood well enough to supply the body a normal supply), and anxiety (the body's response to stress; a feeling of fear or apprehension about what's to come). Further review of this face sheet…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to maintain medical records on each resident that are complete; accurately documented; readily accessible; and systematically organized, for 1 of 6 residents (Resident #1) reviewed for accurate medical records, in that: Resident #1's electronic medical record revealed Resident #1's medical condition and subsequent transfer to the hospital were addressed via phone to a male family member when the resident did not have a male family member identified as an emergency contact or responsible party. This failure could cause confusion about the residents' diagnoses and care and place residents at risk for harm due to inaccurate records. The findings included: Closed record review of Resident #1's undated face sheet revealed the resident was a [AGE] year old female admitted to the facility on [DATE] with diagnoses that included acute pulmonary edema (a condition caused by too much fluid in the lungs), congestive heart failure (a long-term condition whereby 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 that the governing body appointed an administrator who was licensed by the State, where licensing is required; responsible for management of the facility; and reports to and is accountable to the governing body for 1 of 1 facility reviewed for the governing body, in that: The governing body did not appoint an administrator (Executive Director) who was licensed by the state. This deficient practice could result in the facility not being managed in a responsible manner, which could affect the health and safety of all residents. The findings include: Record review of the Executive Director's employee file revealed the Executive Director did not have a hire date with no license present. During an interview on [DATE] at 10:20 a.m. the ED introduced himself to the survey team and stated he did not have an administrator license, however there was an administrator who goes back and forth between some of the nursing facilities. During an interview 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.

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 kitchen, in that: 1. The facility failed to ensure the reach in milk refrigerator was equipped with a temperature measuring device. 2. The facility failed to ensure utensils used for dispensing foods were stored to prevent contamination a. a metal scoop lying on the lid of a plastic container marked flour. b. a metal scoop lying in the plastic container marked sugar. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings were: 1. An observation and interview with the Dietary Supervisor on 02/21/2023 at 10:38 a.m., revealed there was no temperature measuring device in the reach in cooler for the milk. Further observation revealed a temperature log with recordings of measurements as recent as 8 am the same morning. The DS revealed the facility milk delivery comes every Tuesday morning and the thermometer had probably…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 6 Residents (Resident #260) whose records were reviewed for personal privacy. Staff failed to replace a window blind slat in Resident #260's room to provide privacy during personal care. This deficient practice could affect any resident and contribute to poor self-esteem and feelings of helplessness. The findings were: Review of Resident #260's face sheet, dated 2/24/23, revealed she was admitted to the facility on [DATE] with diagnoses including unspecified fracture of shaft of humerus right arm and Cognitive communication deficit. Review of Resident #260's admission MDS, dated [DATE], revealed her BIMS was 11 (out of 15) indicating some cognitive impairment and she required extensive to total care with most ADL's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to inform all adult residents concerning the right to at the resident's option formulate an advance directive for 1 of 6 residents (Resident #41) whose records were reviewed for advance directives. The SW did not complete a DNR, advance directive, per Resident #41 and Resident #41's family representative for almost 1 month. This deficient practice could affect any resident requesting a DNR, advance directive and could result in the residents wishes not being honored. The findings were: Review of Resident #41's face sheet, dated [DATE], revealed Resident #41 was admitted to the facility on [DATE] with diagnoses including fracture of one rib, right side and Cognitive communication deficit. Further review revealed Resident #41's advance directive was CPR/full code. Review of Resident #41's admission MD'S, dated [DATE], revealed Resident #41's BIMS was 12, indicating some cognitive impairment. Review of Resident #41's Care Plan, revised on [DATE], revealed he…

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 immediately consult with the resident's physician and notify, consistent with his or her authority, the resident representative when there is a significant change in the resident's physical status for 1 of 6 Residents (Resident #41) whose records were reviewed for change of condition, in that: ADON did not consult with Resident #41's doctor and the representative responsible party when Resident #41 experienced a significant weight loss. This deficient practice could affect any resident and could contribute to necessary parties not being able to assist with interventions contributing to the residents' health. The findings were: Review of Resident #41's face sheet, dated 2/24/23, revealed Resident #41 was admitted to the facility on [DATE] with diagnoses including fracture of one rib, right side and Cognitive communication deficit. Further review revealed Resident #41's advance directive was CPR, full code. Review of Resident #41's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 4 residents (Resident #1) reviewed for abuse, neglect. The facility failed to report an allegation of abuse, neglect, and mistreatment made by Resident #1 to the State Survey Agency. This failure could put residents at risk of abuse, neglect, and mistreatment. The findings included: Closed record review of Resident #1's face sheet dated 2/24/23 revealed the resident was a [AGE] year-old male with an admission date of 9/7/22. Diagnoses included unspecified fracture of first lumbar vertebra, subsequent encounter 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 interview and record review the facility failed in response to allegations of abuse, neglect, exploitation, or mistreatment, to have evidence that all alleged violations are thoroughly investigated for 1 of 4 residents (Resident #1) reviewed for abuse and neglect. The facility failed to complete an investigation of allegations made by Resident #1 for abuse, neglect, and mistreatment. This failure could place resident at risk of abuse, neglect, and mistreatment. The findings included: Closed record review of Resident #1's face sheet dated 2/24/23 revealed the resident was a [AGE] year-old male with an admission date of 9/7/22. Diagnoses included unspecified fracture of first lumbar vertebra, subsequent encounter for fracture with routine healing, unspecified lack of coordination, other abnormalities of gait and mobility, cognitive communication deficit (impairment in organization/thought organization, sequencing, attention, memory, planning, problem-solving), weakness, and type 2 diabetes mellitus…

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 person-centered comprehensive care plan for the resident, with no interventions to attain or maintain the resident's highest practical physical, mental and psychosocial well-being, for 2 of 12 residents (Resident #41, Resident #44) reviewed for comprehensive care plans, in that: 1. Nursing staff failed to update Resident #41's comprehensive care plan after experiencing a significant weight loss. 2. The facility failed to develop a comprehensive care plan that addressed Resident #44's communication language barrier in relation to being an Arabic speaker. These deficient practices could affect resident at the facility who require a care plan and place them at risk for not receiving the appropriate care and services needed to maintain optimal health. The findings included: 1. Review of Resident #41's face sheet, dated [DATE], revealed Resident #41 was admitted to the facility on [DATE] with diagnoses including fracture…

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 acceptable parameters of nutritional status, such as usual body weight or desirable body weight range for 1 of 6 residents (Resident #41) whose record was reviewed for weight loss. Nursing staff failed to implement their weight loss protocol and intervention measures when Resident #41 experienced a significant weight loss. This deficient practice could affect any resident and could result in residents' continued weight loss and decline in physical health. The findings were: Review of Resident #41's face sheet, dated 2/24/23, revealed Resident #41 was admitted to the facility on [DATE] with diagnoses including fracture of one rib, right side, Chronic Systolic (Congestive) Heart Failure, Malignant Neoplasm of Rectum and Cognitive communication deficit. Review of Resident #41's admission MDS, dated [DATE], revealed Resident #41's BIMS was 12 (out of 15), indicating some cognitive impairment and he required supervision and setup by 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, interview and record review to ensure that a resident who needs respiratory care is provided such care consistent with professional standards of practice and the comprehensive person-centered care plan for 1 of 6 Residents (Resident #261) whose records were reviewed for oxygen care. Nursing staff failed to ensure Resident #261's filter on the oxygen concentrator was clean and free of lint build up. In addition, the oxygen tubing and humidifier bottle were not dated on the date they were changed out. This deficient practice could affect residents who received oxygen therapy and could contribute to difficulty breathing; shortness of breath and ultimately a decline in physical condition. The findings were: Review of Resident #261's face sheet, dated 2/24/23, revealed she was admitted to the facility on [DATE] with diagnosis including acute and chronic respiratory failure with hypoxia (below-normal level of oxygen in your blood). Review of Resident #261's electronic medical record revealed her…

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 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 1 of 1 (Resident #31) reviewed for hospice services, in that: The facility failed to obtain Resident #31's most recent hospice Plan of Care, Hospice Consent and Election Form and Physician Certification of Terminal Illness. This failure could place the resident who received hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. The findings were: Record review of Resident #31's face sheet, dated 02/22/2023, revealed the resident was initially admitted to the facility on [DATE], and re-admitted on [DATE], with…

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