Sorrento

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were free of any significant medication errors for 1 of 8 residents (Resident #79) reviewed for medication administration. The facility provided Resident #79 with the medication Hydralazine HCl outside of physician parameters. This failure could place residents at risk for not receiving the therapeutic effects of their prescribed medications. The findings included: Record review of Resident #79's admission Record, dated 04/04/2025, reflected an [AGE] year-old resident with diagnoses including muscle wasting and atrophy, chronic obstructive pulmonary disease, type 2 diabetes, and hypothyroidism . Record review of Resident #79's quarterly MDS assessment, dated 08/06/2025, reflected Resident #79 was assessed with a BIMS score of 15, indicating the resident was cognitively intact. Record review of Resident #79's Comprehensive Person-Centered Care Plan, dated 08/21/2025, reflected Resident #79 had hypertension with interventions including,…

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 all drugs and biologicals were stored and locked in compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 7 medication carts (800 hall medication cart) reviewed for safe and secure drug storage. The facility failed to ensure the 800-hall medication cart was secured and locked when LVN L utilized it and left it unlocked and unattended. This failure could place residents at risk for harm by accessing medications not prescribed for them, misappropriation, and not receiving the therapeutic effects of the medications as prescribed by their physicians. The finding included: During an observation on 8/19/2025 at 12:16 PM revealed the 800-hall medication cart was in the 800-hallway by a resident's room with a closed door. The medication cart was unattended and out of line of sight by the nurse who was assigned the cart. The drawers of the medication cart were able to be…

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 establishment and maintenance of 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 8 [KA1] (Resident #139) residents reviewed for infection isolation protocols. HK S failed to wear a N95 FFR while providing housekeeping services for Resident #139. This failure could place residents and staff at risk for harm by contracting and spreading the Covid-19 virus. The findings included: A record review of Resident #139's admission record dated 8/22/2025, revealed an admission date of 8/15/2025 with diagnoses which included Covid-19 (a contagious disease caused by the coronavirus SARS-CoV-2.) A record review of Resident #139's admission MDS dated [DATE] revealed Resident #139 was an [AGE] year-old male admitted for covid-19 recovery. A record review of Resident #139'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, in accordance with accepted professional standards and practices, maintain medical records on each resident that were complete and accurately documented for 1 of 3 residents (Resident #1) reviewed for medical records. The facility failed to document all medications administered or withheld in the July 2025 MAR for Resident #1. This failure could place residents at risk of medication errors.Findings included: Record review of Resident #1's face sheet, dated 7/15/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Diagnoses included bipolar disorder (a mental health condition causing mood swings), type 2 diabetes mellitus (a condition resulting from the body's resistance to insulin), and hypertension (high blood pressure). Record review of the quarterly MDS submitted 5/6/2025 reflected a BIMS score of 14, which indicated intact cognition. Record review of Resident #1's July 2025 MAR, printed 7/15/2025, revealed 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 develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #6) reviewed for care plans 1. The facility failed to ensure CNA D and CNA E implemented Resident #6's care plan when they used a gait belt instead of a mechanical lift to transfer the resident. 2. The facility failed to ensure Resident #6 had her oxygen tubing on as care planned. These failures could place residents at risk of a decrease in independence and injury. The findings include Record review of Resident #6's admission Record, dated 07/15/2025, 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 review the facility failed to ensure the resident environment remains as free of accident hazards as is possible for 1 of 2 (#6) residents in the 500 hall in that: Resident #6 was not transferred with Mechanical lift (Hoyer) during a transfer as care planned. This could affect all residents with Hoyer transfers and could result in accidents/injury. The Failures included: Record review of Resident #6's admission Record, dated 07/15/2025, she was [AGE] year documented a female resident who was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #6 had diagnoses which included acute respiratory failure with hypoxia (a condition where the body, or a region of the body, is deprived of adequate oxygen supply.), history of pneumonia, cognitive communication deficit, limitation of activates due to disability, dementia (a general term for a decline in mental ability severe enough to interfere with daily life), shortness of breath, muscle weakness,…

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 failed to ensure the facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 of 18 (#6) residents with oxygen orders in that: Resident #6 was not wearing her oxygen tubing as ordered. This could affect all resident with Oxygen and could result in residents as ordered. The findings included:Record review of Resident #6's admission Record, dated 07/15/2025, she was [AGE] year documented a female resident who was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #6 had diagnoses which included acute respiratory failure with hypoxia (a condition where the body, or a region of the body, is deprived of adequate oxygen supply.), history of pneumonia, cognitive communication deficit, limitation of activates due to disability,…

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 special eating equipment and utensils for residents who needed them and appropriate assistance to ensure that the resident could use the assistance devices when consuming meals and snacks for 1 of 6 residents (Resident #7) reviewed for assistive devices. The facility failed to ensure Resident #7 had her 2 handed drinking cup as ordered. This failure could place residents at risk of a decrease in independence. The findings includeRecord review of Resident #7's [TF1] [RV2] admission record documented a female resident [AGE] years old, who was admitted to the facility on [DATE]. Resident #7 had diagnoses which included Hemiplegia and Hemiparesis following cerebral infarction affecting left non-dominate side (conditions affecting one side of the body. Hemiplegia is characterized by paralysis, while hemiparesis involves weakness, both impacting mobility and daily activities.), need for assistance with personal care, muscle weakness, low…

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, exploitation or mistreatment, including injuries of unknown source, are reported immediately, but not later than 2 hours after the event, if the events result in serious bodily injury, or no later than 24 hours if the events and do not result in serious bodily injury, 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 9 residents (Residents #6) reviewed for abuse and neglect, in that: 1. CNA D observed CNA G yank Resident #6 out of bed and overheard CNA G tell Resident #6 he was going to kill him in Spanish. CNA D did not report the allegation timely and did not report to the Administrator. 2. CNA M observed Resident #6 with wheelchair wheels tied together with plastic bags, restricting Resident #6's mobility, and CNA M did not report the incident to the DON or Administrator.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the residents had a right to be treated with respect and dignity, including the right to be free from any physical restraints imposed for purposes of convenience, and not required to treat the resident's medical symptoms and to use the least restrictive alternate for the least amount of time and document ongoing re-evaluation of the need for restraints for 1 of 9 residents (Resident #6) whose care was reviewed in that: CNA G restrained Resident #6 by tying trash bags around Resident #6's wheelchair wheels to reduce Resident #6's independent mobility in the facility. This deficit practice could potentially affect residents who required wheelchairs for mobility evidenced by restricting movement, a decline in ADL function and psychological distress. The findings were: Record Review of Resident #6's undated face sheet revealed Resident #6 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included a Nontraumatic…

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 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 (Resident #1) of 4 residents reviewed for pharmacy services. 1. The facility failed to ensure Resident #1's medications administered to him were consumed and were not left in the resident's room. 2. The facility failed to ensure Resident #1 received acetaminophen-hydrocodone 10/325 tablets as prescribed by a physician. These failures could place residents at risk for medication error and drug diversion. The findings included: 1. Record review of Resident #1's face sheet dated 5/21/2025 revealed a [AGE] year-old male admitted on [DATE] with diagnoses which included: metabolic encephalopathy (a condition where underlying health issues disrupts the brain's normal function), anxiety disorder and acute kidney failure. Record review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record 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 #1) of 5 residents reviewed for medical records. The facility failed to ensure LVN A documented Resident #1's acetaminophen-hydrocodone in the electronic medical record. This failure placed resident at risk for delayed or inaccurate medication administration which could result in decline in health and well-being. The findings included: Record review of Resident #1's face sheet dated 5/21/2025 revealed a [AGE] year-old male admitted on [DATE] with diagnoses which included: metabolic encephalopathy (a condition where underlying health issues disrupts the brain's normal function), anxiety disorder and acute kidney failure. Record review of Resident #1's 5-day admission MDS assessment dated [DATE] revealed a BIMS score of 14 which indicated the resident was cognitively intact with no symptoms of delirium.…

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's Dietary Services failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. 1. The freezer in the kitchen had a packages of frozen foods that were opened and not sealed. 2. The ice machine had black substance that appeared to spread across in the area where ice was dispensed and hard water stains on the outside. 3. The ice machine in the nutrition room of the [NAME] Neighborhood had black substance on the hood of the unit where ice is dispensed. 4. The [NAME] neighborhood had food in the nutrition room in the freezer that was unlabeled. 5. In the dry storage area were gnats flying above the food. 6. There was a drainage trap with a plastic top for cups and paper near on the floor beneath the juice machines. This deficient practice could cause food borne illness for the residents that receive food from the kitchen. The findings included: During initial tour on 07/23/24 09:30 AM of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to immediately notify, consistent with his or her authority, the resident representative(s) 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 of 5 residents (Resident #96), reviewed for resident rights. The facility failed to notify Resident #96's resident representative of facility acquired pressure ulcers to his left foot, left lateral leg, left heel, right lateral knee, and left flank From 7/10/24 through 7/22/24 (12 days). This failure could place residents at risk of delays in decision making, and could cause anxiety, grief, and a poor quality of care and life. The findings were: Record review of Resident #96's undated face sheet revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] from an acute care hospital. His diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident#15) out of 24 residents reviewed for MDS assessments. Resident #15's quarterly MDS assessment with an ARD of 05/03/2024 inaccurately reflected he was ordered a therapeutic diet when he was ordered a regular diet. This failure could affect residents with MDS assessments and could result in inaccurate care. The findings included: Record review of Resident #15's EMR dated 07/25/2024 reflected he was admitted to the facility on [DATE]. His diagnoses included: anemia (a blood disorder that occurs when the body doesn't have enough red blood cells or red blood cells do not function properly), chronic kidney disease (kidneys are damaged and cannot filter blood the way they should), atrial fibrillation (a common type of irregular heart rhythm), and functional dyspepsia (a common gastrointestinal disorder defined by symptoms such as burning, pain and fullness). Record review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for 2 (Residents#35 and #71) of 24 residents reviewed for care plans. 1. Resident #35's supra-pubic (above the pelvic bone) indwelling urinary catheter (tube inserted into bladder through abdomen) was not reflected in her (current) (undated) comprehensive person-centered care plan. 2. Resident #71's PASRR services was not reflected in his (current) (undated) comprehensive person-centered care plan. These failures could affect residents who reside at the facility and require care and result in missed or inaccurate care. The findings included: 1.Record review of Resident #35's EMR reflected she was admitted to the facility on [DATE]. Her diagnoses included: dysphagia (difficulty swallowing), vascular dementia (a condition that affects the brain due to damaged blood vessels that disrupt blood flow and oxygen supply), and neuropathic bladder (lack of bladder control due to 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 observations, interviews, and record reviews the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments person-centered care plan to reflect the current condition for 2 of 12 residents (Resident #15 and Resident #70) reviewed for care plan revisions. 1.Resident #15's comprehensive person-centered care plan was not revised after his quarterly MDS assessment dated [DATE] to reflect he was ordered a regular diet instead of a therapeutic. 2.Resident #70's comprehensive person-centered care plan was not revised after his annual MDS assessment dated [DATE] to reflect he was on a therapeutic diet. This failure could affect residents with MDS assessments and could result in missed of required care. The findings included: 1. Record review of Resident #15's EMR dated 07/25/2024 reflected he was admitted to the facility on [DATE]. His diagnoses included: anemia (a blood…

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

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were secured properly within 1 of 4 medication carts (med cart in hall 100) observed for medication storage. RN B pre-poured medication for Resident #13 then stored it in the top drawer of the medication cart in hallway 100. This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications as ordered. The findings were: Observation of the medication cart on 100 hall on 07/26/2024 at 10:49 AM revealed a medication cup with one small yellow pill in the cup. Medication cup was not labeled and had no identifying markers to indicate what was within the cup. Medication cart was locked and secured. Interview with RN B on 07/26/2024 at 11:11 AM revealed RN B poured Resident #13's Eliquis 25 mg but when she attempted to pass the medication Resident #13 was sleeping. RN B stated she placed the medication in the medication cart planning to give the medication when the resident woke up for lunch at 11:30 AM. RN B stated that pre-pouring…

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 dispose of garbage and refuse properly to ensure the residents were free from pests and rodents and to live in a safe and clean evironment. Garbage was observed on the ground with used incontinent briefs and other debris on the ground around the dumpsters. This deficient practice could cause the facility to have pests and rodents in and around the facility preventing a clean and safe homelike environment for the residents. The findings included: During an observation 7/23/2024 9:40 AM there was garbage outside around the dumpsters in the back of the building through doors leading from the kitchen with incontinent briefs and plates and other debris on the ground. During an interview 7/23/2024 9:40 AM the NSD stated there was an overflow of garbage in the dumpsters and when the garbage truck dumped the garbage, it fell out on the ground. The NSD stated when she saw the garbage on the ground before the morning meeting that started at 8:00 AM and she did not clean it because she did not want to be late to 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, in accordance with accepted professional standards and practices, maintain medical records on each resident that were accurately documented for 1 of 5 residents (Resident #96), reviewed for administration. Wound assessments for Resident #96 were documented as the family was notified when they were not. This failure could result in confusion, decreased continuity of care, and result in anger, frustration, poor quality of life and a delay in decision making. The findings were: Record review of Resident #96's undated face sheet revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] from an acute care hospital. His diagnoses included stage 4 pressure ulcer to sacral region (area just above the tailbone with Full-thickness skin loss extends through the fascia with considerable tissue loss. There may be muscle, bone, tendon, or joint involvement.), Type 2 diabetes without complications (chronic condition that affects…

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 During observations, interviews, and record reviews, the facility failed to maintain an effective pest control program so that the facility is free of pests and rodents. In the dry storage area of the kitchen, about 5 gnats were observed flying around the food on the top shelf near packages of pasta and dry foods. This deficient practice could put residents at risks of food borne illness due infection control for the residents eating food from the kitchen. The findings were: During observation 07/23/24 09:30 AM gnats were in the dry storage room flying around foods on the top shelf. During an interview 07/23/24 09:30 AM the NSD stated ,oh no. I will take care of this right away because that is not clean to have bugs anywhere around food. She stated she had not requested for pest control services on the maintenance log for the gnats. During an interview 7/26/2024 at 10:03AM the NSD stated gnats may come because an area was not clean, maybe from the drains in the kitchen. She stated it would be due to improper…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents' right to formulate an advance directive for 1 of 5 residents (Resident #2) reviewed for advanced directives, in that: The facility failed to ensure Resident #2's Out-of-Hospital Do Not Resuscitate (OOH DNR) was honored. This failure could place residents at-risk of having their end of life wishes dishonored, and of having CPR performed against their wishes. The findings included: Record review of Resident #2's face sheet, dated [DATE] revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included hemiplegia following nontraumatic subarachnoid hemorrhage affecting the left non dominate side (partial or total paralysis on one side of the boday after a brain bleed), cerebrovascular disease, and seizures. The advanced directive was blank on the face sheet. Record review of Resident #2's admission MDS assessment, dated [DATE] revealed the resident was severely cognitively impaired for daily decision-making…

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 an admission policy was implemented for 1 of 5 Resident (Resident #2), in that: The facility failed to ensure Resident #2's RP was provided admission documents on admission. This deficient practice could place residents at risk who are not being informed of the admission requirements, services, and processes. Findings Include: Record review of Resident #2's face sheet, dated 7/19/24 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included hemiplegia following nontraumatic subarachnoid hemorrhage affecting the left non dominate side (partial or total paralysis on one side of the boday after a brain bleed), cerebrovascular disease, and seizures. The advanced directive was blank on the face sheet. Record review of Resident #2's admission MDS assessment, dated 7/16/24 revealed the resident was severely cognitively impaired for daily decision-making skills. Record review Resident #2's admission…

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 incorporate the recommendations from the PASRR level II determination and the PASRR evaluation report into a resident's assessment, care planning and transitions of care for 1 of 2 residents (Resident #1) reviewed for PASRR. The facility failed to submit NFSS forms timely to the TMHP Long Term Care Portal for Resident #1 to ensure payment for specialized services throught the PASRR program. This failure could place residents at risk for not receiving specialized services in a timely manner. Findings included: Record review of Resident #1's admission record, dated 07/19/24, revealed a [AGE] year-old male who admitted on [DATE] with diagnoses that included Down Syndrome (a genetic chromosome 21 disorder causing developmental and intellectual delays), hydrocephalus (a buildup of fluid in the cavities deep with the brain), contracture of muscle, left lower leg, muscle weakness, and mixed receptive-expressive language disorder (a communication disorder…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 of 1 newly admitted residents (Residents #2) reviewed for baseline care plan. The facility failed to ensure Resident #2's baseline care plan contained the correct code status. These deficient practices could place residents at-risk for decreased quality of life, improper care, and injury. The findings were: Record review of Resident #2's face sheet, dated [DATE] revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included hemiplegia following nontraumatic subarachnoid hemorrhage affecting the left non dominate side, cerebrovascular disease, and seizures. The advanced directive was blank on the face sheet. Record review of Resident #2's admission MDS assessment, dated [DATE] revealed the resident 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 interviews and record reviews, the facility failed to maintain medical records on each resident that are-accurately documented for 1 of 5 residents (Resident #2) reviewed for accurate medical records in that: The facility failed ensure Resident #2's emergency contacts were updated and accurate. The deficient practices place residents at risk of misinformation about professional care provided. The findings included: Record review of Resident #2's face sheet, dated [DATE] revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included hemiplegia following nontraumatic subarachnoid hemorrhage affecting the left non dominate side (partial or total paralysis on one side of the boday after a brain bleed), cerebrovascular disease, and seizures. The emergency contacts listed were family member A and family member B. Record review of Resident #2's admission MDS assessment, dated [DATE] revealed the resident was severely cognitively impaired for daily decision-making skills.…

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 notify the resident and the resident's representative/s of the discharge and the reasons for the move in writing and in a language and manner they understand, failed to update the recipients of the notice as soon as practicable once the updated information became available, and failed to send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 1 of 5 residents (Residents #1) reviewed for discharge. The facility failed to notify Resident #1's RP in writing and did not notify the State Long-Term Care Ombudsman by phone or in writing of Resident #1's discharge due to safety concerns. This deficient practice could place residents at risk of being discharged and not allowed to return to the facility, causing a disruption in their care and services and potential decline in health. Findings included: Closed record review of Resident #1's undated face sheet revealed the resident was a [AGE] year old female admitted…

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 establish and follow written policy on permitting residents to return to the facility after they were hospitalized for one (Resident #1) of five residents reviewed for transfer/discharge. The facility failed to readmit Resident #1 to the facility after she was sent to the hospital on [DATE]. This deficient practice could place residents at risk of being discharged and not allowed to return to the facility, causing a disruption in their care and services and potential decline in health. 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 spondylosis of the lumbar region (age-related degeneration of the vertebrae and disks of the lower back), vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to the brain) and borderline…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure the resident's environment remained as free of accident hazards as was possible for two of six residents (Resident #s 2 and 3), reviewed for accidents and hazards: The facility failed to ensure Resident #2 did not have 15 disposable razors stored in his restroom drawer and a pair of scissors. The facility failed to ensure Resident #3 did not have 5 disposable razors stored in his restroom drawer. These failures placed residents at risk of injury. The findings: Resident #2 Record review of Resident #2's electronic facesheet revealed Resident #2 was admitted to the facility on [DATE] and was [AGE] years of age. Further review revealed Resident #2's diagnoses included: vascular dementia with behavioral disturbance, anxiety disorder, cognitive communication disorder, and recurrent depression. Record review of Resident #2's MDS (Comprehensive), printed 6/14/2024, revealed Resident #2 had a BIMs Score of 9 which indicated moderate 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 interview and record review, the facility failed to ensure 30-day discharge notices included a statement of the resident's right to appeal which included the name, address (mailing and email), and telephone number of the entity which receives such requests: and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request and name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman for 3 of 3 residents (Resident's #1, #2, and #3) reviewed for discharge. The facility failed to include in 30-day discharge notices to Resident's #1, #2, and #3 the email or address for the State Long-Term Care Ombudsman or the email address and phone number of the agency in which to file an appeal or instructions or information on how to file the appeal. These failures could affect residents by placing them at risk of being discharged and not having access to available advocacy services, discharge/transfer options,…

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 an effective person-centered discharge plan that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 3 of 3 residents (Resident's #1, #2 and #3) reviewed for comprehensive care plans in that: 1. The facility failed to ensure Resident #1's care plan included discharge planning and goals. 2. The facility failed to ensure Resident #2's care plan included discharge planning and goals. 3. The facility failed to ensure Resident #3's care plan included discharge planning and goals. These failures could affect residents and place them at risk of their discharge wishes not being honored and not receiving appropriate treatment and services on discharge: The findings included: 1. Record review of Resident #1's face sheet dated 4/04/2024 revealed an admission date of 2/02/2023 with diagnoses which included: type 2 diabetes mellitus with complications, end stage renal…

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 professional staff were licensed, certified, or registered in accordance with applicable State laws for 1 of 8 staff (LVN A reviewed for staff qualifications. The facility failed to ensure LVN A renewed his nursing license before the expiration date in order to practice nursing in the State of Texas. This failure could place residents at risk of not receiving care and services from staff who were properly licensed The findings included: Record review of LVN A personnel file revealed a Texas LVN nursing license which had expired on [DATE]. Record review of the Texas Board of Nursing website license verification portal on [DATE] at 12:16 p.m. revealed LVN A Texas nursing license was listed as delinquent with a license expiration date of [DATE]. During an observation/interview on [DATE] at 10:10 a.m., LVN A was observed in the nursing facility with a name badge on. LVN A stated he was currently on duty as an LVN. He stated his license…

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 were permitted to remain in the facility, and not transfer or discharge the resident from the facility unless the transfer or discharge was necessary for the resident's welfare and the resident's needs could not be met in the facility and failed to ensure a resident was not transferred or discharged while the appeal was pending for 1 of 3 residents (Resident #3) reviewed for discharges, in that: The facility failed to wait to transfer Resident #3 to another facility until he was out of Medicaid pending status. These failures could result in residents being discharged without appropriate notice and while they were waiting for approval from Medicaid could place residents at risk being discharged against their wishes. The findings were: Record review of Resident #3's face sheet dated 4/04/2024 revealed an admission date of 4/11/2023 with diagnoses which included: heart failure, type 2 diabetes mellitus and generalized osteo-arthritis and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice for 1 of 5 residents (Resident #4) reviewed for respiratory care in that: The facility did not ensure Resident #4's oxygen nasal cannula tubing (a small, flexible tube that contains two open prongs intended to sit just inside the nostrils) was dated, as ordered by the physician. This deficient practice could affect residents who receive oxygen therapy and result in infection and respiratory compromise. The findings were: Record review of Resident #4's face sheet, dated 3/12/24, revealed resident #1 was admitted to the facility on [DATE] with diagnoses of: hypertensive heart and chronic kidney disease with heart failure and with stage five chronic kidney/end stage renal disease, type 2 diabetes mellitus, dependence on renal dialysis, and anemia in chronic kidney disease. Record review of Resident #4's comprehensive…

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 residents were seen by a physician for the resident's initial comprehensive visit for 1 of 5 residents (Resident #1) whose care was reviewed in that: Resident #1's initial comprehensive visit was not conducted by a physician. This deficient practice could affect residents and could lead to a decline in health status. The findings were: Record review of Resident #1's face sheet, dated 3/12/24, revealed Resident #1 was admitted to the facility on [DATE]. There was no diagnoses listed on this face sheet. Further record review of this document revealed Resident #1's attending physician was Physician F and Resident #1's care level was Skilled Care. Record review of Resident #1's care plan, dated 3/12/24, revealed Resident #1 had the following diagnoses: acute cholecystitis [an inflammation of the gallbladder], acute kidney failure, unspecified, anxiety disorder, unspecified, atypical atrial flutter [an abnormal heartbeat], and constipation. Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, 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 5 residents (Resident #3) reviewed for infection control in that: After cleansing Resident #3's perineal area, CNA D did not perform hand hygiene before applying Resident #3's clean brief. This deficient practice could affect residents and place them at risk for infection. The findings were: Record review of Resident #3's face sheet, dated 3/12/24 revealed Resident #3 was admitted to the facility on [DATE] with diagnoses of sepsis [a condition in which the body's extreme response to an infection become life-threatening], unspecified, urinary tract infection, diabetes mellitus with diabetic nephropathy [deterioration of kidney function due to diabetes], and essential (primary) hypertension. Record review of Resident #3'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 residents who were unable to carry out activities of daily living were provided with the necessary services to maintain good personal hygiene for 1 of 2 resident (Resident #1) reviewed for assistance with ADL care, in that: The facility failed to prevent Resident #1 from missing scheduled showers between 10/20/2023 and 11/02/2023. The noncompliance was identified as PNC. The noncompliance began on 10/20/2023 and ended on 11/02/2023. The facility had corrected the noncompliance before the survey began. This failure could place residents who require assistance from staff for personal hygiene at risk of not receiving care and services contributing to overall poor hygiene, risk of experiencing a diminished quality of life, and possible skin infections. The findings included: Record review of Resident #1's face sheet dated 11/8/2023 reflected a [AGE] year-old resident admitted on [DATE] with diagnosis of sepsis due to other specified staphylococcus…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the notice to residents was provided when changes in coverage were made to items and services covered by Medicare as soon as reasonable possible was provided to 2 of 2 residents (Resident#42, and Resident #76) reviewed for Medicare/Medicaid. The facility failed to give Resident #42 and Resident #76 a Skilled Nursing Facility advance Beneficiary Notice (SNF ABN) when discharged from skilled services at the facility prior to covered days being exhausted. This failure could affect residents who use skilled services and could place them at risk of not being aware of changes to provided services. The findings included: Record review of Resident #42's face sheet, dated 06/02/2023, revealed the resident was admitted [DATE] with diagnosis that included: cerebral infarction (stroke), altered mental status (change in mental function), hypertension (high blood pressure), Parkinson's disease (chronic and progressive movement disorder that initially causes…

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 a Minimum Data Set (MDS) assessment was electronically completed and transmitted to the CMS System within 14 days after completion for 2 of 2 Residents (Residents #50 and #54) reviewed for transmitting assessments. 1. Resident #50's quarterly MDS assessment was not completed and transmitted within 14 days of completion. 2. Resident #54's death in facility MDS assessment was not completed and transmitted within 14 days of completion. This deficient practice could place residents at risk of not having records completed and submitted in a timely manner as required. The findings included: 1. Review of Resident #50's face sheet, dated 06/01/2023 revealed an admission date of 06/15/2021 with diagnoses that included: acute on chronic diastolic (congestive) heart failure, type 2 diabetes mellitus with unspecified complications, hyperlipidemia, unspecified atrial fib, hypertension (high blood pressure), major depressive disorder recurrent psych symptoms, obstructive hydrocephalus, atrial flutter, and anxiety disorder. 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.

Based on observation, interview, and record review, the facility failed to establish and maintain an Infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 1 of 5 residents (Resident #47) reviewed for infection control, in that: CNA B failed to wash or sanitize her hands or change her gloves after touching the trash can and before starting catheter care. This deficient practice could place residents at-risk for infection due to improper care practices. The findings included: Record review of Resident #47's face sheet, dated 06/01/2023, revealed an admission date of 04/15/2023, with diagnoses which included: Urinary tract infection(an infection in any part of the urinary system), Chronic kidney disease(gradual loss of kidney function), Hypertension(High blood pressure), Hyperlipidemia(Elevated level of any or all lipids(fat) in the blood), Sepsis(blood poisoning) Record review of Resident #47's admission MDS assessment, dated 04/22/2023,…

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.