The Lev At San Antonio

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each Resident for 1 of 8 residents (Resident # 47) reviewed for pharmacy services. LVN H did not document an SBAR to Resident #47's physician in which Resident #47 had dislodged her intravenous access and had not received her 1 dose of the prescribed antibiotic. LVN H administered Resident #47's physician ordered antibiotic without documenting the physician's order. This failure could place residents at risk for harm due to not receiving pharmacy services as ordered. The findings included: A record review of Resident #47's admission record dated 9/10/2025 revealed an admission date of 1/4/2022 with diagnoses which included schizophrenia (a chronic mental health condition characterized by a persistent disruption in thoughts, perceptions, and behaviors),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure a medication error rate below 5%, for 28 medication administration opportunities with 2 errors resulting in a 7.14% medication error rate, for 1 of 8 residents (Resident #57) reviewed for medication administration errors. Medication Aide J administered to Resident #57 his prescribed:Metoclopramide (a prescription medication used to treat and prevent nausea and vomiting, and to manage certain gastrointestinal issues.)Gabapentin (a prescription medication used to treat nerve pain and epilepsy.)Late by 51 minutes. These failures could place residents at risk for not receiving the therapeutic effects of their medications. The findings included: A record review of Resident #57's admission record dated 9/10/2025 revealed an admission date of 6/26/2025 with diagnoses which included diabetes mellitus with diabetic neuropathy (nerve damage related to high blood sugar levels) and gastro-esophageal reflux (a condition where stomach…

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 an infection prevention and control program with written standards, policies, and procedures for standard and transmission-based precautions to be followed to prevent spread of infections for 1 of 3 residents (Resident #7 and Resident #28) reviewed for disinfecting the glucometer in between Residents. LVN G did not disinfected the glucometer after assessing Resident #28's blood sugar level and then attempting to assess Resident #7's blood sugar level. This failure could place residents at risk for blood borne pathogens and infections. The findings included: Resident #28A record review of Resident #28's admission record dated 9/10/2025 revealed an admission date of 8/8/2025 with diagnoses which included type II diabetes, infectious gastroenteritis (common stomach flu), and sepsis (a life-threatening condition that occurs when the body's immune system overreacts to an infection.) A record review of Resident #28's Quarterly MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 1 of 5 (Resident #1) residents reviewed for medical records. The facility failed to obtain Resident #1's hospital records and a hospital discharge summary on 7/5/2025 and when the resident returned to the facility and the computerized medical record on 8/13/2025 and 8/14/2025 revealed no evidence of a hospital record or hospital discharge summary from Resident #1's hospital discharge. This failure placed residents at risk for delayed or inaccurate information of hospital history which could result in lack of continuity of care and missed history of treatment. The findings included: Record review of Resident #1's face sheet dated 8/12/2025 revealed an [AGE] year-old female, admitted on [DATE] with diagnoses which included: Type 2 diabetes mellitus, dementia with agitation and chronic kidney disease. Record review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to document a resident's discharge to ensure that appropriate information is communicated to the receiving health care provider for 1 or 6 residents (resident #1) reviewed for transfer or discharge. The facility failed to ensure that: 1.Resident #1 did have a documented discharge order written by the resident's physician for the resident's discharge from the facility. 2. Resident #1 did have a documented discharge summary written by the resident's physician or nurse for the resident's discharge from the facility. This deficient practice could affect resident's planned discharge destination by contributing to a discharge from the facility that was not properly documented. The findings included: Record review of Resident #1's face sheet, dated 04/01/25, revealed a [AGE] year-old resident initially admitted on [DATE] with diagnoses including autistic disorder (a neuro-developmental disorder of repetitive patterns of behavior), trisomy 21-mosaicism (a genetic…

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 provide notification of a resident's discharge to ensure that appropriate information is communicated to the Office of the State Long-Term Care Ombudsman for 1 or 6 residents (Resident #1) reviewed for transfer or discharge. The facility failed to ensure that: 1. Resident #1's discharge notification was sent to the Office of the State Long-Term Care Ombudsman. This deficient practice could affect resident's safe discharge planning by missed notification to the proper authorities. The findings included: Record review of Resident #1's face sheet, dated 04/01/25, revealed a [AGE] year-old resident initially admitted on [DATE] with diagnoses including autistic disorder (a neuro-developmental disorder of repetitive patterns of behavior), trisomy 21-mosaicism (a genetic condition in which there is a mixture of two types of cells-Down's syndrome), and type 2 diabetes with hyperglycemia (a condition in which the body does not produce enough insulin). Record…

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

Based on observation, 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 reviewed for kitchen sanitation, in that: 1. The facility failed to ensure cases of cookies, shortening, and coffee filters were stored off the floor in the dry storage room. 2. The facility failed to ensure disposable condiment cups of salsa and butter were covered in the reach in cooler. 3. The facility failed to ensure a pan of cake, a bag of sliced turkey breast, a container of whipped topping and a bag of boiled eggs were covered/sealed and labeled with a use-by date in the walk-in cooler. 4. The facility failed to ensure two bags of food, contents unknown, were properly sealed and labeled with a use-by date in the walk-in freezer. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: 1. Observation on 08/25/2024 at 10:48 AM revealed two 9 lb. cases of bulk cookies, one case stacked on top of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to develop policies and procedures to ensure that before offering the influenza immunization, each resident or the resident's representative received education regarding the benefits and potential side effects of the immunization and each resident was offered an influenza immunization during October 1 through March 31 annually, for 3 of 70 residents (Resident #10, #22, and #28) reviewed for the influenza vaccine offered. The facility failed to provide education to Residents #10, #22, and #28 regarding the benefits and potential side effects of the influenza immunization. The facility failed to offer an influenza immunization to Residents #10, #22, and #28, during October 1, 2023, through March 31, 2024. These deficient practices could place residents at risk for harm, by contracting and spreading influenza. The findings included: Resident #10: A record review of Resident #10's admission record dated 08/25/2024 revealed an admission date of 10/19/2021…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure that the resident's needs and choices for how he spends time outside the facility, were not supported and accommodated, including making transportation arrangements, for 1 of 8 resident (Resident #54) whose care was reviewed, in that: Resident #54's requested help with transportation for a non-medical appointment to explore benefits he may qualify for due to his diagnoses of blindness, including help with medical appointments. This deficient practice could place residents with the ability to make choices at risk of having their rights violated, diminished quality of life and unmet needs. The findings were: Record Review of Resident #54's admission Record, dated 08/28/24, reflected a [AGE] year-old male admitted [DATE] with diagnoses to include blindness in one eye, low vision in the other eye, and glaucoma (group of eye conditions that damage the optic nerve) in right eye. Record Review of Resident #54's quarterly MDS assessment, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure residents' rights to voice grievances to the facility or other agencies or entities that heard grievances without discrimination or reprisal and without fear of discrimination or reprisal for 1 of 8 residents (Resident #16) reviewed for grievances: 1. The facility failed to ensure Licensed Vocational Nurse A (LVN A) initiated a grievance report on behalf of Resident #16's grievance on 08/23/2024. 2. The facility failed to ensure Medication Aide O (MA O) and the ADON initiated a grievance report on behalf of Resident #16's grievance on 08/25/2024. This failure could place residents at risk by denying their right to make and have grievances heard and contributed to ill feelings of not being heard and unresolved issues. The findings included: 1. Resident #16 A record review of Resident #16's admission record dated 08/27/2024 revealed an admission date of 05/26/2024 with diagnoses which included Chronic Obstructive Pulmonary Disease…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents drug regiment was free from unecessary drugs (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 14 (Resident #1) residents reviewed for pharmacy services. The facility failed to monitor Resident #1's side effects and behaviors regarding the resident's olanzapine (antipsychotic medication) for schizoaffective disorder, busPIRone (antianxiety medication) for anxiety disorder, and Sertraline (antidepressant) for depression related to schizoaffective disorder from 11/17/2023 to 08/08/2024. This failure placed the residents at risk of side effects and adverse reactions to the medications as ordered by the physician and a delay in treatment and worsening of their condition. Findings included: Record review of Resident #1's electronic face sheet, dated 08/08/2024, reflected the resident was admitted 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 interviews and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #3) of 14 residents reviewed for accuracy and completeness of clinical records. LVN C administered Resident #3's hydrocodone-acetaminophen 5-325 mg one tablet on 5/14/2024, 5/15/2024, 5/17/2024, and 5/23/2024 as ordered and documented the dates on Resident #3's narcotic counting sheet but did not document them on Resident #3's medication administration record. This failure placed facility residents at risk for incorrect medication administrations due to misinformation by incomplete and inaccurate medical record. Findings included: Record review of Resident #3's electronic face sheet, dated 08/09/2024, reflected the resident was admitted to the facility on [DATE] with diagnoses included: type 2 diabetes mellitus (trouble controlling blood sugar), atherosclerotic heart disease of native…

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 MDS assessments accurately reflected the resident's status for 1 of 14 Residents (Resident #1) whose MDS records were reviewed for accuracy. Resident #1's quarterly MDS assessment, dated 05/08/2024, reflected Resident #1 did not have physical behavioral symptoms directed toward others such as hitting, kicking, pushing, grabbing, and/or abusing others sexually. However, Resident #1's nursing note, dated on 05/03/24, indicated Resident #1 hit another resident's left arm on hallway 300. This failure could place residents at risk for inadequate care due to inaccurate assessments. The findings included: Record review of Resident #1's electronic face sheet, dated 08/08/2024, reflected the resident was admitted to the facility on [DATE]. Resident #1's diagnoses included: end stage renal disease (the kidneys lose the ability to remove waste and balance fluids), type 2 diabetes mellitus (the body has trouble controlling blood sugar and using it 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 all drugs and biological were stored in locked compartments for 1 of 1 medication room reviewed for storage, in that: The facility's narcotic box located inside a refrigerator in the only medication room was not permanently affixed compartment when Resident #2's Lorazepam was stored inside the narcotic box on 08/07/2024. This deficient practice could place residents at risk of misappropriation of medications or harm due to accidental ingestion of unprescribed mediations. The findings included: Record review of Resident #2's electronic face sheet, dated 08/09/2024, reflected the resident was admitted to the facility on [DATE] with diagnoses included: Alzheimer's disease (destroys memory and other important mental functions), muscle wasting and atrophy (decrease in size and wasting of muscle tissue), and anorexia (eating disorder causing people to obsess about weight and what they eat). Record review of Resident #2's physician order,…

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 assessments accurately reflected the resident's status for 1 of 4 Residents (Resident #22) whose MDS records were reviewed for accuracy, in that: Resident #22's Quarterly MDS assessment, dated 1/10/2024, was incorrectly coded that the resident did not have a fall since admission/entry or reentry or the prior assessment, whichever was more recent. This failure could place residents at risk for inadequate care due to inaccurate assessments. The findings included: Record review of Resident #22's face sheet, dated 2/15/2024, revealed the resident #22 was admitted to the facility 12/19/2023 with diagnoses that included: acute kidney failure, unspecified convulsions, aphasia, type 2 diabetes mellitus. Record review of Resident #22's Quarterly MDS, dated [DATE], revealed the resident did not have any falls since readmission to the facility on [DATE]. Record review of Resident #22's nursing notes, dated 12/29/2023 at 7:15 PM by LVN B, revealed in part,…

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 allegations involving abuse, neglect, and misappropriation were reported immediately, but no later than 2 hours after the allegation is made to the State Survey Agency for 1 of 4 residents (Resident #2) reviewed for abuse. The facility did not report to the State Survey Agency (HHSC) one incident of abuse following the allegation of CNA A providing Resident #2 with illicit drugs. This failure could place residents at risk for abuse and could lead to a diminished quality of life and psychosocial harm. The findings included: Record review of Resident #2's face sheet, dated 11/8/23, revealed the resident was admitted on [DATE] with diagnoses that included: Quadriplegia (paralysis of all limbs), Hypokalemia (low potassium in the blood), Anxiety Disorder, and Depression. Record review of Resident #2's Care Plan, dated 8/31/23, revealed: Resident #2 had an ADL self-care performance deficit r/t quadriplegia. Record review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY .Based on observation, interview and record review, the facility failed to provide a safe, clean, comfortable and homelike environment reviewed for safe water temperatures and homelike environment, in that; 1. Water temperatures at hand sinks and showers were out of safe parameters (100-110 degrees Fahrenheit) in public restrooms, resident restrooms and shower stalls, and in the communal shower room. 2. Cardboard screwed into air conditioning vent to prevent air flow in room [ROOM NUMBER]. 3. Rooms 409, shower water was 76.5/85.5 Degrees Fahrenheit, room [ROOM NUMBER] shower temperature was 85.5 Degrees Fahrenheit, and the 200 main shower water temperature was 75.7 Degrees Fahrenheit. This deficient practice could affect all residents, staff and visitors by placing them at risk for injury related to water temperatures exceeding safe parameters , or diminished quality of life by exposure to an uncomfortably low water temperatures during hand washing or showers and a non-homelike environment. 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 observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 facility, reviewed for infection control in that: 1.The DON exited a designated droplet transmission-based precautions room after doffing her N95 mask in the room. 2.The facility failed to ensure CNA F utilized appropriate infection control practices when entering a designated droplet transmission-based precautions room. 3.MA E did not sanitize bp cuff between residents. 4. CMA L did not have eye protection when entered a COVID positive room. This deficient practice could affect all residents, staff and visitors at risk for infection. Findings include: 1. In an observation and interview on 6/20/2023 at 5:45 PM, the DON was observed exiting room [ROOM NUMBER], a room designated droplet transmission-based…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observations, interviews and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public when water temperatures were below 100 degrees Fahrenheit or above 110 degrees Fahrenheit at hand sinks, shower stalls, communal shower room and public restrooms reviewed for environment: in that: 1. Water temperatures at hand sinks, shower stalls, communal shower room, and public restrooms were outside safe parameters between 100 to 110 degrees Fahrenheit. 2. A brown cardboard could be observed secured with screws into the air conditioning vent in the ceiling over Resident #42's recliner. 3. Resident #6s shower water was cold. This deficient practice could place the residents living in, staff working in, and visitors experiencing an environment that is unsafe, nonfunctional, unsanitary or uncomfortable and could impact the residents' ability to achieve or maintain their highest practicable physical, mental, and psychosocial…

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 each resident was treated with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility mustfailed to protect and promote the rights of the resident for 1 of 10 (Resident #57) residents in that: CNA J was standing up while assisting with feeding Resident #57 her meal. This could place residents at risk for diminished quality of life, loss of dignity and self-worth. The findings were: Record review of Resident #57's admission Record dated June 23, 20232023, revealed she was admitted on [DATE] with diagnoses of major depressive disorder, age-related physical debility, anxiety disorder anemia and dementia. Record review of Resident #57's Quarterly MDS dated [DATE], revealed section C cognition pattern,her BIMS score was 4/15 indicating she was (severely impaired), and section G…

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 complete an assessment which accurately reflected the resident's status for 2 of 8 (Resident #21 and #4) residents reviewed, in that: 1. Resident #21's diagnosis of Generalized Anxiety Disorder was not included in the resident's quarterly MDS assessment. 2. Resident #4 did not have his mobiliezed wheelchair with seat belt was not included in his in quaterly MDS assessment. This failure could result in inadequate care due to an incomplete assessment of her psychological condition. The findings included: 1.Record review of Resident #21's face sheet, dated 6/23/2023, revealed the resident was admitted on [DATE] with diagnosis including Type 2 Diabetes Mellitus, Heart Failure, and Recurrent Depressive Disorders. Record review of Resident #21's Quarterly MDS assessment , dated 4/19/2023, revealed a BIMS Score of 12, indicating moderate cognitive impairment. Record review of Resident #21's Physician Orders, dated 6/23/2023, revealed an order…

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 develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's mental, nursing, and psychosocial needs that were identified in the comprehensive assessment, for 1 of 10 Residents (Resident #123) reviewed for care plans, in that: a. The facility failed to fully develop a comprehensive person-centered care plan that was specific for Resident #123 to address code status information, details of care provided and coordination of services. b. The facility failed to fully develop a comprehensive person-centered care plan that was specific for Resident #123 to address Dialysis Service and Treatment, details of care provided and coordination of services. These failures could place residents at risk for not getting their medical, physical, and psychosocial needs met and not being provided with the necessary care or services and having…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 1 of 10 (Resident #4) residents in that: Resident #4 requested his beard be shaved and staff did not respond to him. This could result and could place risk for not receiving necessary care to maintain grooming. The Findings were: Record review of Resident #4's admission Record dated 6/23/2023 revealed he was admitted on [DATE], re-admitted on [DATE] with diagnoses of repeated falls, chronic kidney disease, cognitive communication deficit, lack of coordination and muscle weakness. Resident #4's picture on his admission Record revealed he had a mustache and no beard. Record review of Resident #4's quarterly MDS dated [DATE] was documented section C Cognitive Pattern, BIMS score was 10/15 (moderately impaired), Section G functional Status for transfers were required total…

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 residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Bbased on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices forresident for 1 of 4 (#123) residents on dDialysis in that: Resident #123 did not have an order for Ddialysis services. This could place residents at risk for not receiving appropriate care and treatment. The Findings were: Record Review of Resident #123's admission Record dated [DATE] revealed she was admitted to facility on [DATE] with diagnoses of end stage renal disease, dependence on renal dialysis and acute…

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

Based on observations, interviews, and record reviews the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, for 1 of 1 medication room refrigerator and freezer, reviewed for security and medication storage and labeling, in that: Medication room refrigerator and freezer did not have up to date temperature logs. This deficient practice could place residents at risk of adverse effects and ineffective therapeutic effects of their medications that require refrigeration. The findings included: In an observation , interview and record review, on 6/23/2023 at 6:45 PM, MA A unlocked and escorted this surveyor into the Medication Room for inspection. The Refrigeration Temperature Log, dated June 2023, which also included freezer temperatures, was missing entries for 6/22/2023 and 6/23/2023. CMA A stated staff on the overnight shift is responsible for checking the refrigerator and freezer temperatures and completing the log and should have had an entry for 6/23/2023 as they usually do it sometime after midnight and before the end 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 observations, interviews and record review the facility failed to ensure Food safety requirements. The facility must distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen in that: Administrative Assistance walked into and out of kitchen without a hairnet and delivered 2 ice bags to the freezer approximately 5 feet from the back door. This could place residents at risk for food contamination. The Findings were: Observation on 6/22/2023 at 2:19 PM with in the kitchen revealed dietary aid K opened the back door for Administrative Assistant she came into the kitchen with 2 ice bags in each hand and was not wearing a hairnet. Observation of Administrative Assistant had long loosened hair that was not contained. Observation of Administrative Assistant walked past the dietary manager's office and placed ice bags in freezer that was more than 5 feet from the back door. During an interview on 6/22/2023 at 2:21 PM with dietary aide K stated she did not notice Administrative Assistant was not wearing a hairnet. Dietary aide K…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain medical records that were complete and accurately documented for 1 of 8 (Resident #21) residents reviewed in that: Resident #21's diagnosis of Generalized Anxiety Disorder was not listed on her face sheet. This failure could result in inadequate care due to incomplete and inaccurate medical records. The findings included: Record review of Resident #21's face sheet, dated 6/23/2023, revealed the resident was admitted on [DATE] with diagnosis including Type 2 Diabetes Mellitus, Heart Failure, and Recurrent Depressive Disorders. Record review of Resident #21's Quarterly MDS assessment, dated 4/19/2023, revealed a BIMS Score of 12, indicating moderate cognitive impairment. Record review of Resident #21's Physician Orders, dated 6/23/2023, revealed an order beginning on 3/24/2023 for Buspirone HCl Oral Tablet 15 MG, three times daily, for Anxiety. Record review of Resident #21's psychological services progress note, dated 3/04/2023, revealed…

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.