Stone Oak Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review, the facility failed to ensure the MDS assessment accurately reflected the resident's status for three residents (Residents #2, #11 and #14) of thirty-two residents reviewed for MDS assessments. The Facility failed to note on Resident #2's admission MDS dated [DATE] he was taking a hypoglycemic medication. 2. The facility failed to ensure Resident #11's Quarterly MDS assessment was coded Not rated, resident had a catheter instead of Always incontinent for a resident identified to have a suprapubic catheter. 3. The facility failed to ensure Resident #14's quarterly MDS assessment was coded Yes regarding the resident was receiving antidepressant for his depression. These failures could place resident at risk for inadequate care due to inaccurate assessments.The findings included: 1.Record review of Resident #2’s electronic face sheet dated 07/23/2025 reflected he was a [AGE] year-old male who was admitted to the hospital facility on 05/28/2025. 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 observations, interviews, 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 #98) of 28 residents, 1 of 1 medication rooms, and 1 (500-hall nursing cart) of 5 med carts reviewed for pharmacy services. 1. There were three antibiotic solutions (Imipenem and cilastatin) for Resident #98 to be given via intravenous route that expired 07/22/2025 found inside the facility medication room on 07/24/2025. 2. There was one super sani-cloth germicide disposable wipe that expired 05/2025 found inside the facility medication room on 07/24/2025. 3. There was one bottle of Senna-Plus 8.6 mg that expired 06/2025 found inside the 500-hall nurse cart on 07/24/2025. This failure could place residents at risk of not receiving appropriate therapeutic effects of medication. The findings included: 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.

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. 1. The facility failed to store plastic cups and bowls to allow for air-drying in the dish room.2. The facility failed to ensure all prepared items in the walk-in refrigerator was labeled and dated with use by date. These failures could place residents at risk for food borne illness.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. 1. The facility failed to store wet insulated plastic dome plate covers to allow for air-drying by the steam table.2. The facility failed to ensure all prepared items in the walk-in refrigerator were labeled and dated with the use by date. These failures could place residents at risk for food borne illness. The findings included: Observation of the facility's kitchen on 07/22/2025 at 9:03 AM revealed two…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 (Resident #32) of twenty-eight residents reviewed for environment, in that: Resident #32's room air conditioning vents were visibly soiled. This deficient practice could result in residents living in an unclean and unpleasant environment.The findings were: Record review of Resident #32's face sheet, dated 07/25/2025, revealed the resident was an [AGE] year old male, originally admitted on [DATE], and re-admitted to the facility on [DATE] with the diagnoses of Alzheimer's disease (destroys memory and other important mental functions), heart failure (the heart does not pump blood enough), muscle weakness, muscle wasting and atrophy (loss of skeletal muscle mass), and dementia (loss of memory and thinking ability). Record review of Resident #32's quarterly MDS assessment, dated 07/02/2025, revealed the resident's BIMS score was 00 which indicated the resident was unable to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to encode and transmit required MDS information within 14 days after discharge for 2 of 32 residents reviewed for MDSs.1.Resident #24 was discharged on 01/29/25 and as of 07/24/25 he did not have a discharge MDS assessment. 2.Resident #84 was discharged on 03/14/25 and as of 07/24/25 did not have a discharge MDS assessment. This deficient practice affects residents who receive care at the facility and could result in negative impacts on discharge planning. The findings included: 1.Record review of Resident #24's electronic face sheet dated 07/25/2025 reflected he was an [AGE] year-old male who was admitted to the facility on [DATE] and discharged on 01/25/2025 to the hospital. His diagnoses included: congestive heart failure (a long-term condition that happens when the heart cannot pump blood well enough to give the body a normal supply, resulting in shortness of breath), peripheral vascular disease (refers to any disease or disorder of the circulatory…

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 a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 2 (Residents #20 and #64) of ten residents reviewed for incontinence care. 1. When CNA-A and CNA-B were providing peri care to Resident #20, CNA-A cleaned the resident's genital area without separating the labia. 2. When CNA-C and CNA-D were providing peri care to Resident #64, CNA-C did not clean the resident's suprapubic area (below the umbilical region), left groin area, and left buttock area and cleaned the resident's genital area with multiple passes with one wipe. This failure could place residents who required incontinence care at risk for cross contamination and the development of new or worsening urinary tract infections. The findings included: 1. Record review of Resident #20's face sheet, dated 07/25/2025, revealed the resident was an [AGE] year old female and admitted to the facility on [DATE]…

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 that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs for 2 of 10 residents (Residents #20 and #64) by 2 of 4 CNAs (CNA-A and CNA-C) reviewed for competent staff, in that: 1. When CNA-A was providing peri care to Resident #20, CNA-A cleaned the resident's genital area without separating the labia. 2. When CNA-C was providing peri care to Resident #64, CNA-C did not clean the resident's suprapubic area (below the umbilical region), left groin area, and left buttock area and cleaned the resident's genital area with multiple passes with one wipe. The failure could place residents at risk for not receiving nursing services by adequately trained staff and could result in a decline in health and infection. Record review of Resident #20's face sheet, dated 07/25/2025, revealed the resident was an [AGE] year old female and admitted to the facility on [DATE] with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 1 (Resident #64) of twenty-eight residents reviewed for infection control practices. When CNA-C was providing peri care to Resident #64, CNA-C changed gloves without sanitizing or washing his hands. This deficient practice could place residents at risk for cross contamination and infections.The findings included: Record review of Resident #64's face sheet, dated 07/25/2025, revealed the resident was a [AGE] year old male and admitted to the facility on [DATE] with the diagnoses of cerebral infarction (blood supply to part of the brain is blocked or reduced), muscle weakness, type 2 diabetes mellitus (the body has trouble controlling blood sugar and using it for energy), hypertension (high blood pressures), and hemiplegia and hemiparesis…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse, to the administrator of the facility and to other officials including to the State Survey Agency where state law provides for jurisdiction in long-term care facilities in accordance with State law through established procedures for 2 of 4 residents (Residents #2 and #3), reviewed for freedom from abuse, neglect, and exploitation. The facility failed to report the incident of suspected abuse on 6/5/25 when the visitor was noted pounding hard on the bed of Resident # 2 , yelling WAKE UP! . These failures could put the residents at risk of abuse, allegations of abuse not being reported immediately, and could result in physical and psychosocial harm. The findings were: Record review of Resident # 2's face sheet, dated 6/25/25, revealed an [AGE] year-old…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record reviews the facility failed to have evidence all allegations of abuse, neglect or mistreatment were thoroughly investigated and documented for 1 of 5 residents (Resident #2) reviewed for abuse. The facility failed to have evidence that a thorough investigation was conducted following the allegation Resident #2 was yelled at and had her bed pounded by a visitor. These failures could place residents at risk for abuse and neglect by not investigating allegations of abuse, neglect, exploitation, or mistreatment. The findings were: Record review of Resident # 2's face sheet, dated 6/25/25, revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: Alzheimer's disease (a neurodegenerative disease that destroys cells in your brain, causing loss of some brain functions, including memory and language), Anxiety ( a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome) and Hyperlipidemia (…

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 were complete, accurately documented, readily accessible, and were systematically organized, for 2 of 5 residents (Residents #4 and #5) reviewed for consents for accurate medical records. 1. The facility failed to document a discharge summary in Resident #4's electronic medical record on 01/24/25, when Resident #4 discharged . 2. The facility failed to document shower/bath for Resident #5 appropriately on 06/02/25. These failures could place residents at risk for inaccurate and unorganized medical records. The findings included: 1. Record review of Resident #4's admission record reflected Resident #4 was a [AGE] year-old male admitted on [DATE] with diagnoses to include senile degeneration of brain and major depressive disorder. It further revealed Resident #4 had an RP and was discharged on 01/24/25. Record review of Resident #4's quarterly MDS assessment, dated 01/12/25, reflected Resident #29 had a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews, the facility failed to ensure the assessment accurately reflected the resident's status for 1 resident (Resident #55) of 24 residents reviewed for MDS assessments. The facility failed to ensure Resident #55's quarterly MDS, dated [DATE], accurately reflected she does not have a feeding tube. This deficient practice could place residents at [NAME] of inadequate care. The findings included: Record review of Resident #55's face sheet on 06/19/2024 revealed resident to be a [AGE] year-old female originally admitted to the facility on [DATE]. Resident's diagnoses included Schizoaffective disorder (mental disorder characterized by abnormal thought processes and an unstable mood), major depressive disorder (mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure) and, feeding difficulties. Record review of Resident #55's care plan, dated 06/05/2024, did not identify Resident #55 as having a feeding…

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 2 (Resident #16, and #58) of 24 residents reviewed for care plans. 1.Facility failed to develop and implement a person-centered care plan for Resident #16 to reflect she took an anticonvulsant medication daily. 2. Facility failed to develop and implement a person-centered care plan for Resident #16 to accurately reflect she was not on oxygen therapy. These deficient practices could places residents at risk of not receiving required specific care, services and interventions. The findings included: 1.Record review of Resident #16's electronic face sheet dated 06/18/2024 reflected she was admitted to the facility on [DATE]. Her 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 observations, interviews and record reviews, the facility failed to ensure a resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 (Resident #58) of 2 residents observed for gastrostomy tube (tube surgically placed through the abdomen to the stomach for feeding and medications) feeding and medication administration via the tube. The facility failed to ensure Resident #58's enteral feeding tube rate was set at 65cc's per hour as the physician ordered and medication flushes were not provided between medication administration as ordered. This deficient practice places residents with gastrostomy tubes for enteral feedings and medication administration at risk for malfunctioning of the tube, pain, and medication adverse reactions. The findings…

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 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 care plan, the resident's goals and preferences for 1 (Resident #16) of 3 residents observed on oxygen therapy. The facility failed to ensure Resident #16's oxygen was set at 2L/min as prescribed This deficient practice affects residents on oxygen therapy and could place them at risk for respiratory distress. The findings were: Record review of Resident #16's electronic face sheet dated 06/18/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: cerebral atherosclerosis (a disease that occurs when the arteries in the brain become hard and blood flow is decreased), refractory anemia (a genetic condition that is characterized by a low red blood cell count) and unspecified convulsions (rapid, involuntary muscle…

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 that nurses were able to demonstrate competency in skills and techniques to provide nursing and related services for 1 of 2 residents (Resident #58 ) by 1 of 2 nurses (LVN C) reviewed for competent staff, in that: LVN C failed to provide G-tube flushes before medications administration and between medication administration as ordered for Resident #58. These failures could place residents at risk for not receiving nursing services by adequately trained and licensed nurses and could result in a decline in health. The findings included: Record review of Resident #58's electronic face sheet dated 06/18/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: Dysphagia (swallowing difficulties), atherosclerotic heart disease (hardening of the arteries which results in lack of blood flow) and gastrostomy status (an opening into the stomach from the abdominal wall and a tube is inserted to allow air and fluid to…

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

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. CNA B picked up a resident's roll that had fallen off his tray onto the table with her bare hands and placed the roll onto the resident's dish at lunchtime. This deficient practice could affect residents who dine in the dining room and place them at risk for contamination of food. The findings included: Observation on 06/18/2024 at 12:30 PM during dining observations, CNA B dropped a roll from a resident's tray onto the table. She picked the roll up with her bare hand and placed it onto the resident's plate. Interview on 06/18/2024 at 12:32 PM with CNA B, she stated she should get the resident another rolls because she touched the roll with her hands and that was not sanitary. She did not get the resident at that time another roll, and he continued to eat. CNA B later returned with a roll. Interview on 06/21/2024 at 10:47 AM with the DON, she stated staff were trained to not touch resident's food 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, 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 disease and infection for 2 of 8 residents (Residents #41 and #58) reviewed for infection control, in that: 1. CNA B did not change gloves and sanitize or wash her hands before touching Resident #41's clean brief during incontinent care. 2. LVN C did not wear gloves to touch Resident #58's medication. These failures could place residents at-risk for infection due to improper care practices. The findings include: Record review of Resident #41's face sheet, dated 06/20/2024, revealed an admission date of 03/21/2023, and a readmission date of 04/29/2024, with diagnoses which included: Anemia (Blood has a reduced ability to carry oxygen), Mixed irritable bowel syndrome (Functional gastrointestinal disorder causing pain,bloating and loose stool) ,…

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 assist residents in obtaining routine dental services to meet the needs of 1 of 11 residents (Resident #27) reviewed for dental services, in that: The facility did not assist Resident #27 with obtaining dental services when her bottom dentures were reported missing. This failure could place residents at risk of not having their oral health care needs met. The findings included: Record review of Resident #27's electronic medical record revealed she was a 84 year -old female admitted to facility on 3/9/2023 with diagnoses which included: senile degeneration of brain (a decrease in the ability to think, concentrate, or remember.), adult failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity) abnormal weight loss, muscle wasting and atrophy( the wasting (thinning) or loss of muscle tissue.) and unspecified dementia with other behavioral disturbance (A person can have unspecified dementia(loss 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.

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: There was a tray of cheese sandwiches in the walk-in refrigerator without a use by date and beyond the 72 hours discard date. This failure could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings were: An observation and interview with the Food Service Supervisor on 04/25/2023 at 11:40 a.m., revealed a tray with cheese sandwiches, prepped for residents who would request a grilled sandwich, in the walk-in refrigerator. Further observation revealed the tray was labeled with a date of 04/21/2023 which the FSS stated was the prep date. The FSS confirmed there was no use by date on the tray of sandwiches however stated she followed her policy and the Food Code and she would need to discard the sandwiches if they were not used by end of day. The FSS then stated she was confused and thought the current date was 04/24/2023…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accommodate the needs of 3 of 8 residents (Residents #59, Resident #87, and Resident #93) reviewed for accommodation of needs. The facility failed to place Residents #59's, Resident #87's, and Resident #93's call-lights within reach. This failure could place residents at risk of not being able to obtain assistance as needed. Findings included: Record review of Resident #59's face sheet, dated 04/28/2023, revealed the resident was initially admitted to the facility on [DATE] with diagnoses which included: Alzheimer's disease (gradual decline in memory, thinking, behavior and social skills), muscle wasting and atrophy (muscles having become weaker and smaller), other lack of coordination, paroxysmal atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat), ataxic gait, and hypertension (high blood pressure). Record review of Resident #59's admission MDS, dated [DATE], revealed the staff assessment for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible and assistance devices to prevent accidents for 1 of 2 Residents (Resident #84) whose records were reviewed for falls. 1. Nursing staff failed to ensure Resident #84 wore non-skid socks when not wearing shoes. 2. Nursing staff failed to propel Resident #84 forward and safely while in his wheelchair. 3. A sharps (razor) was left on top of the vanity in Resident #84's restroom for 2 days; to ensure the water temperature did not exceed 110 degrees and that the aerator did not spray water out when the faucet was turned on. These deficient practices could affect residents at risk for falling, who used a wheelchair for mobility, and residents who wandered and could contribute to avoidable accidents. The findings were: 1. Review of Resident #84's face sheet, dated, 4/27/21, revealed he was admitted into the facility on [DATE] with diagnoses including Senile…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 12 residents (#41 and #84) reviewed for infection control practices, in that: 1. The door and door handle to Resident #41's room was visibly soiled with a brown sticky substance. 2. There were two handheld urinals (with visible yellow liquid in the urinals) hung on the safety bar in Resident #84's restroom for two days. The urinals were not secured in a plastic bag, labeled or dated per facility policy. These failures could place residents at risk related to the spread of communicable diseases and infections. The findings were: 1. Record review of Resident #41's face sheet, dated 04/27/2023, revealed an original admission date of 05/12/2022 with diagnoses that included: muscle wasting and atrophy (loss of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner that promotes enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 6 Resident (Resident #84) who was observed for dignity. Nursing staff was propelling Resident #84 backwards and preventing him from propelling forward freely in his wheelchair. This failure could affect any resident and contribute to feelings of frustration and dissatisfaction. The findings were: Review of Resident #84's face sheet, dated, 4/27/21, revealed he was admitted into the facility on [DATE] with diagnosis including Senile Degeneration of Brain and Unspecified Dementia. Review of Resident #84's quarterly MDS, dated [DATE], revealed his BIMS was 00 indicating severe cognitive impairment and he utilized a wheelchair for mobility. Review of Resident #84's Care Plan, revised 4/21/23, read: 'I have impaired cognitive function/dementia or impaired…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident's right to formulate an advance directive for 2 of 8 residents (Residents #50 and #74) reviewed for advanced directives. 1. Resident #50's OOH-DNR was invalid as it was not completed per requirements. 2. The facility failed to ensure Resident #74's OOH-DNR was completed correctly. These failures could place residents at risk of not having their end of life wishes followed and could result in CPR being performed against their wishes. The findings were: 1. Record review of Resident #50's face sheet dated [DATE] revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. The diagnoses included senile degeneration of brain (mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems thought to be related to old age due to cell death), muscle wasting and atrophy, multiple sites (wasting or loss of muscle tissue), and…

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

Based on interview and record review, the facility failed conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity within 14 days calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition for 1 of 8 residents (Resident #76) reviewed for Comprehensive Assessments and timing. The facility failed to ensure an MDS Assessment for Resident #76 was completed within 14 days after admission. This failure could place residents at risk for improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. Findings were: Record review of Resident #76's face sheet, dated 04/27/2023, revealed an admission date of 03/29/2023 and diagnoses that included: hypertensive heart disease with heart failure (high blood pressure that affects the heart), dyspnea (shortness of breath), hyperlipidemia (abnormally high levels of fats (lipids) in the blood, which include cholesterol and triglycerides), 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 refer all residents with newly evident or possible serious mental disorder for PASARR level II evaluation upon a significant change in status assessment for 2 of 5 residents (Resident #84 and Resident #81) whose PASARR records were reviewed. 1. MDS staff failed to submit a level II PASARR evaluation for over 6 months after Resident #84 was diagnosed with unspecified Psychosis. 2. Resident #81 did not have a PASRR level II evaluation with diagnoses of bipolar disorder, and schizoaffective disorder, bipolar type. These failures could place residents at risk for not receiving the specialized PASARR care and services required to meet their individual needs and could result in a decrease in quality of life. The findings were: 1. Review of Resident #84's face sheet, dated, 4/27/21, revealed he was admitted into the facility on [DATE] with diagnosis including unspecified Dementia and on 10/10/22 he was diagnosed with unspecified Psychosis. 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 interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and time frames to meet residents' mental, nursing, and mental and psychosocial needs for 1 of 8 residents (Resident #76) reviewed for care plans, in that: The facility failed to develop and implement a comprehensive person-centered care plan for Resident #76 within the required time frame. This failure could affect residents who have care areas not addressed by the care plan by not having their needs met and putting them at risk of not receiving appropriate care. The findings were: Record review of Resident #76's face sheet, dated 04/27/2023, revealed an admission date of 03/29/2023 and diagnoses that included: hypertensive heart disease with heart failure (high blood pressure that affects the heart), dyspnea (shortness of breath), hyperlipidemia (abnormally high levels of fats (lipids) in the blood, which include cholesterol and triglycerides), and atrial fibrillation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 2 of 3 (Resident #33 and #76) reviewed for hospice services. 1. The facility failed to obtain Resident #33's most recent hospice plan of care, signed hospice election form, and a physician's re-certification of the terminal illness. 2. The facility failed to obtain Resident #76's most recent hospice plan of care, signed hospice election form, and documentation by specific interdisciplinary hospice staff providing services. 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…

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.