Wurzbach Nursing And Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments for 2 of 20 residents (Residents #46 and #238) reviewed for storage. 1. Resident #46's insulin Lantus Solos Flex Pen for diabetes had no open date, found inside B-wing nursing cart on 06/11/2025. 2. Resident #238's insulin Novolog Flex Pen for diabetes had no open date, found inside B-wing nursing cart on 06/11/2025. These failures could place residents at risk of having not therapeutic effects by using old insulins. The findings were: 1. Record review of Resident #46's face sheet, dated 06/13/2025, revealed Resident #46 was a [AGE] year-old male and admitted to the facility 12/04/2020 and re-admitted to the facility 05/31/2024 with diagnoses of dementia (a group of thinking and social symptoms that interferes with daily functioning), type 2 diabetes mellitus (body does not insulin properly, resulting in high blood sugar levels), hypokalemia (low potassium level in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #16) of 20 residents reviewed for medical records. The facility failed to ensure facility nurses documented Resident #16's mechanically altered diet correctly on 06/08/2025's Weekly Swallowing/Nutritional Status. This failure placed resident at risk for missed treatment and care which could result in decline in health and well-being. Findings included: Record review of Resident #16's face sheet, dated 06/13/2025, revealed the resident was a [AGE] year old male and originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses of pneumonitis due to inhalation of food and vomit (complication of pulmonary aspiration or the inhalation of food, liquid, or vomit inti the lungs), chronic obstructive pulmonary disease (common lung disease causing restricted…

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, implement, and maintain an effective training program for all new and existing staff for 5 of 27 (Cook K, Dietary Aide L, CNA M, CNA N, and LVN O) employees reviewed for training requirements. The facility failed to implement and maintain a training program that ensured [NAME] K, Dietary Aide L and CNA M received required trainings upon hire. The facility failed to implement and maintain a training program that ensured CNA N and LVN O received required trainings annually. This failure could place residents at risk of being cared for by staff who have been insufficiently trained. Findings were: Record review of personnel record for [NAME] K revealed hire date of 03/25/2025. Review of training log provided by human resources revealed [NAME] K did not complete required trainings upon hire. Record review of personnel record for Dietary Aide L revealed hire date of 04/07/2025. Review of training log provided by human resources revealed Dietary Aide L did not complete required trainings upon hire. 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.

Based on interview and record review, the facility failed to ensure annual communications training for 2 of 27 (CNA N, and LVN O) employees reviewed for training requirements was completed. The facility failed to ensure communication training was provided CNA N and LVN O annually. This failure could place residents at risk of being cared for by staff who have been insufficiently trained. Findings were: Record review of the personnel records for CNA N revealed a hire date of 01/01/2020. Review of training log for the previous 12 months provided by human resources revealed no evidence that CNA N received annual communication training. Record review of the personnel records for LVN O revealed a hire date of 01/01/2020. Review of training log for the previous 12 months provided by human resources revealed no evidence that LVN O received annual communication training. Interview with HR Representative on 06/13/2025 at 1:40 PM revealed she was new to the facility. HR stated the facility uses an online training program that emails the employee and their supervisor of assigned trainings. HR…

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 annual rights of the resident training for 2 of 27 (CNA N, and LVN O) employees reviewed for training requirements was completed. The facility failed to ensure resident rights training was provided CNA N and LVN O annually. This failure could place residents at risk of being cared for by staff who have been insufficiently trained. Findings were: Record review of the personnel records for CNA N revealed a hire date of 01/01/2020. Review of training log for the previous 12 months provided by human resources revealed no evidence that CNA N received resident rights training. Record review of the personnel records for LVN O revealed a hire date of 01/01/2020. Review of training log for the previous 12 months provided by human resources revealed no evidence that LVN O received annual resident rights training. Interview with HR Representative on 06/13/2025 at 1:40 PM revealed she was new to the facility. HR stated the facility uses an online training program that emails the employee and their supervisor of assigned…

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 annual abuse, neglect and exploitation training and dementia training for 2 of 27 (CNA N, and LVN O) employees reviewed for training requirements was completed. The facility failed to ensure abuse, neglect and exploitation training and dementia training was provided CNA N and LVN O annually. This failure could place residents at risk of being cared for by staff who have been insufficiently trained. Findings were: Record review of the personnel records for CNA N revealed a hire date of 01/01/2020. Review of training log for the previous 12 months provided by human resources revealed no evidence that CNA N received abuse, neglect and exploitation training or dementia training. Record review of the personnel records for LVN O revealed a hire date of 01/01/2020. Review of training log for the previous 12 months provided by human resources revealed no evidence that LVN O received annual abuse, neglect and exploitation training or dementia training. Interview with HR Representative on 06/13/2025 at 1:40 PM revealed 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.

Based on interview and record review, the facility failed to ensure annual QAPI training for 2 of 27 (CNA N, and LVN O) employees reviewed for training requirements was completed. The facility failed to ensure QAPI training was provided CNA N and LVN O annually. This failure could place residents at risk of being cared for by staff who have been insufficiently trained. Findings were: Record review of the personnel records for CNA N revealed a hire date of 01/01/2020. Review of training log for the previous 12 months provided by human resources revealed no evidence that CNA N received QAPI training. Record review of the personnel records for LVN O revealed a hire date of 01/01/2020. Review of training log for the previous 12 months provided by human resources revealed no evidence that LVN O received annual QAPI training. Interview with HR Representative on 06/13/2025 at 1:40 PM revealed she was new to the facility. HR stated the facility uses an online training program that emails the employee and their supervisor of assigned trainings. HR stated it was the responsibility 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.

Based on interview and record review, the facility failed to ensure annual infection control training for 2 of 27 (CNA N, and LVN O) employees reviewed for training requirements was completed. The facility failed to ensure infection control training was provided CNA N and LVN O annually. This failure could place residents at risk of being cared for by staff who have been insufficiently trained. Findings were: Record review of the personnel records for CNA N revealed a hire date of 01/01/2020. Review of training log for the previous 12 months provided by human resources revealed no evidence that CNA N received infection control training. Record review of the personnel records for LVN O revealed a hire date of 01/01/2020. Review of training log for the previous 12 months provided by human resources revealed no evidence that LVN O received annual infection control training. Interview with HR Representative on 06/13/2025 at 1:40 PM revealed she was new to the facility. HR stated the facility uses an online training program that emails the employee and their supervisor of assigned…

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 annual ethics training for 2 of 27 (CNA N, and LVN O) employees reviewed for training requirements was completed. The facility failed to ensure abuse, neglect and exploitation training was provided CNA N and LVN O annually. This failure could place residents at risk of being cared for by staff who have been insufficiently trained. Findings were: Record review of the personnel records for CNA N revealed a hire date of 01/01/2020. Review of training log for the previous 12 months provided by human resources revealed no evidence that CNA N received ethics training. Record review of the personnel records for LVN O revealed a hire date of 01/01/2020. Review of training log for the previous 12 months provided by human resources revealed no evidence that LVN O received annual ethics training. Interview with HR Representative on 06/13/2025 at 1:40 PM revealed she was new to the facility. HR stated the facility uses an online training program that emails the employee and their supervisor of assigned trainings. HR stated it…

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 CNA received the required minimum 12 hours annual in-service 1 of 27 (CNA N) employees reviewed for training requirements was completed. The facility failed to provide the required 12 hours of annual training to CNA N. This failure could place residents at risk of being cared for by staff who have been insufficiently trained. Findings were: Record review of the personnel records for CNA N revealed a hire date of 01/01/2020. Review of training log for the previous 12 months provided by human resources revealed evidence of less than 12 hours per year of required in-service training being provided annually. Interview with HR Representative on 06/13/2025 at 1:40 PM revealed she was new to the facility. HR stated the facility uses an online training program that emails the employee and their supervisor of assigned trainings. HR stated it was the responsibility of the employee to complete their trainings and human resources responsibility to ensure trainings were completed. HR stated the facility relies on the on-line…

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 annual behavioral health training for 2 of 27 (CNA N, and LVN O) employees reviewed for training requirements was completed. The facility failed to ensure abuse, neglect and exploitation training was provided CNA N and LVN O annually. This failure could place residents at risk of being cared for by staff who have been insufficiently trained. Findings were: Record review of the personnel records for CNA N revealed a hire date of 01/01/2020. Review of training log for the previous 12 months provided by human resources revealed no evidence that CNA N received behavioral health training. Record review of the personnel records for LVN O revealed a hire date of 01/01/2020. Review of training log for the previous 12 months provided by human resources revealed no evidence that LVN O received annual behavioral health training. Interview with HR Representative on 06/13/2025 at 1:40 PM revealed she was new to the facility. HR stated the facility uses an online training program that emails the employee and their supervisor 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 ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, are reported immediately but no later than 2 hours after the allegation is made, for 1 of 6 Residents (Resident #1), reviewed for freedom of abuse. The facility did not report to local law enforcement an allegation of sexual abuse involving Resident #1 by a CNA. This failure could result in law enforcement not investigating an allegation of sexual abuse and subjecting residents to other acts of sexual abuse, psychosocial and physical harm, and a diminished quality of life. The findings included: Record review of Resident #1's face sheet, dated 5/14/25, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: dementia (a decline in mental ability), Alzheimer's disease (a progressive disease that destroys memory and other mental functions), and cognitive deficits (difficulties in…

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 had the right to be free of misappropriation of resident property and exploitation for 2 of 4 residents (Resident #5 and Resident #6) reviewed for misappropriation and exploitation. The facility failed to ensure Resident #5 and Resident #6's pain medications were secured and not lost. These failures could place residents who received pain medications at risk of decreased quality of life, misappropriation of property and distress. The findings included: 1. Record review of Resident #5's face sheet dated 3/9/25 revealed an [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included osteomyelitis (infection of the bone usually caused by bacteria that can cause pain, selling and redness throughout the affected area), peripheral vascular disease (condition in which the blood vessels become narrowed or blocked and affects the blood flow to the legs, feed and sometimes arms),…

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 all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, to other officials (including to the State Survey Agency in accordance with State law through established procedures) for 2 of 2 residents (Resident #3 and Resident #4) reviewed for Freedom from Abuse, Neglect, and Exploitation: The facility failed to report to the state survey agency Resident #4 hit Resident #3 on the head on 9/27/2024. This failure could place residents at risk for abuse, diminished quality of life, physical, and psychosocial harm. The findings were: Record review of Resident #3's face sheet dated 03/07/2025 revealed a [AGE] year-old male admitted to the facility 08/30/2024 with diagnoses that included: dementia, hypertension, and major depression disorder. Record review of Resident #3's QMDS dated [DATE] revealed a BIMS score of 2- indicative of a severe cognitive impairment. Record review of Resident'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 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 2 of 5 residents (Resident #5 and #6) reviewed for pharmacy services. 1. The facility failed to ensure Resident #5's pain medications were acquired and dispensed per physician's orders. 2. The facility failed to ensure Resident #6's pain medications were acquired and dispensed per physician's orders. This failure could place residents at risk of not receiving their prescribed medications and a decreased quality of life. The findings included: Record review of the facility provider investigation report written by the facility administrator, dated 3/6/25, reflected: A drug diversion has been identified. Review of the facility provider investigation report revealed a medication audit identified Resident #5 and Resident #6 had narcotic medications missing. 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 provide pharmaceutical services, including procedures that assure the accurate acquiring, dispensing, and administering of all drugs and biologicals to meet the needs of 3 (Resident #1, Resident #2, and Resident #3) of 3 residents reviewed for pharmacy services. 1. The facility failed to ensure MA A accurately documented on Resident #1's Controlled Substance Administration Record the administration time for scheduled pain medication, Tramadol HCl Oral Tablet 50mg. 2. The facility failed to ensure MA A accurately documented on Resident #2's Controlled Substance Administration Record the administration time for scheduled pain medication, Tramadol HCl Oral Tablet 50 mg. 3. The facility failed to ensure MA A accurately documented on Resident #3's Controlled Substance Administration Record the administration times for scheduled pain medication, Tylenol with Codeine #3 Tablet 300-30 mg, and for a scheduled anti-anxiety medication, Diazepam Oral…

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, in accordance with accepted professional standards and practices, the facility failed to maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized for 5 of 5 residents (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) reviewed for reviewed for administration. 1. The facility failed to document wound care was provided for Resident #1 on five (5) occasions on Resident #1's September Treatment Administration Record (TAR). 2. The facility failed to document skin treatment was provided for Resident #2 on six (6) occasions on Resident #2's September TAR. 3. The facility failed to document wound care was provided for Resident #3 on thirty-four (34) occasions on Resident #3's September TAR. 4. The facility failed to document wound care was provided for Resident #4 on two (2) occasions on Resident #1's September TAR. 5. The facility failed to document wound care was provided for Resident #5…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to immediately inform the resident's physician when there was a significant change in resident's physical, mental, or psychosocial status for 1 of 5 residents (Resident #1) reviewed for resident rights. The facility failed to consult with Resident #1's physician and provide all necessary details, when Resident #1 complained of a worsening wound on 09/22/2024. This failure could place the resident at risk for delay in treatment and a decline in the resident's health and well-being due to the physician not being notified of changes in the resident's condition in a timely manner. The findings include: Record review of Resident #1's Administration Record, dated 09/24/2024, indicated Resident #1 was admitted on [DATE] and she was [AGE] years old. Resident #1 was noted to have discharged on 09/23/2024 to an acute care hospital. MD A was noted as Resident #1's attending physician. NP B was noted as one of Resident #1's nurse practitioners (NP). 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 interviews and record reviews the facility failed to immediately inform the resident and notify, consistent with his or her authority, the residents' representative(s) when there is a significant change in the resident's physical, mental, or psychosocial status and or a need to alter treatment significantly, for 1 of 3 residents (Resident #1) reviewed for being informed of their health status. The facility failed toensure they reported to Resident #1's Representative on 08/14/2024 of Resident #1's change of condition (episodic high blood pressure) to include new orders for anti-high blood pressure and anti-nausea / vomit medication. This failure could place residents at risk for harm by not reporting a residents health status and the opportunity for consent of care . The Findings included: A record review of Resident #1's admission record dated 09/11/2024 revealed an admission date of 03/20/2024 with diagnoses which included dementia (a group of symptoms affecting memory, thinking and social abilities.…

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 were free of any significant medication errors for 1 of 8 residents (Resident #28) reviewed for medication administration. Resident #28 was provided a medication, Midodrine, 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 #28's face sheet, dated 4/25/2024, reflected a [AGE] year-old female resident with an initial admission date of 3/3/2017 and diagnosis including Huntington's disease (an inherited condition in which nerve cells in the brain break down over time). A record review of resident #28's quarterly MDS assessment, dated 2/8/2024, revealed Resident #28 was assessed with a BIMS score of 2 out of a possible 15 which indicated severe cognitive impairment. A record review of resident #28's Care Plan dated 3/1/2024, revealed the resident had hypotension 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 observations, interviews, and record review the facility failed to, in accordance with State and Federal laws, ensure all drugs and biologicals were stored properly in the medication cart for 1 (Station A) of 3 medication treatment carts observed for drug storage. The facility failed to ensure 5 insulin pens were dated when opened. This failure could result in harm due to resident received expired medications. The findings were: Record review Resident #4's face sheet dated 04/24/24 revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included dementia (cognitive loss), diabetes (high blood sugar), and major depressive disorder (mental illness, feeling of sadness). Record review of Resident #4's quarterly MDS assessment, dated 02/22/24 revealed a BIMS score of 12, which indicated cognition was moderately impaired. Section N - medications reflected Resident #4 had received insulin injections during the last 7 days. Record review of Resident #4's care plan 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.

Based on interview and record review the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 5 (CNA E) CNAs in that: CNA E did not have a current EMR/NAR check. This could place residents at risk of abuse, neglect, and exploitation. The Findings: Record review of the staff list dated 4/23/2024 revealed that CNA E was hired on 4/21/2024. Record review of CNA E's personnel file revealed there was not a current EMR/NAR. CNA E's last EMR/NAR check was on 3/17/2023. Interview on 4/26/2024 at 12:33 PM the Administrator stated she would search for the EMR/NAR for CNA E. The Administrator did not provide evidence before exit. ADM stated they did not have HR (Human Resources) staff in the building. ADM searched and provided the information for licensure. ADM stated she was not able find CAN E's EMR/NAR. Record review of policy Abuse, Neglect and Exploitation Program, dated April 2021 revealed Residents have the right to be free from abuse, neglect,…

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 was made to the State Survey Agency for 1 of 8 residents (Resident #56) reviewed for abuse and neglect. The facility did not report to the State Survey Agency (HHSC) an incident in which Resident #56 had an unwitnessed fall a skin tear and a hematoma to her head. This failure could place residents at risk for abuse/neglect and could lead to a diminished quality of life and psychosocial harm. The findings included: Record review of Resident #56's Face Sheet, dated 4/26/2024, reflected an [AGE] year-old female resident with an initial admission date of 11/30/2020, with diagnoses including Alzheimer's disease (progressive disease that destroys memory and other important mental functions), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult 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 record review and interview, the facility failed to thoroughly investigate all alleged violations of resident abuse, neglect, exploitation, or mistreatment for 1 of 6 (Resident #56) residents assessed for reporting allegations. The facility failed to thoroughly investigate an incident in which a resident was found on the floor of their room with a skin tear to the right forearm and a hematoma to the top of the resident's scalp. This deficient practice placed residents at risk of abuse, neglect, exploitation, or mistreatment. The findings included: Record review of Resident #56's Face Sheet, dated 4/26/2024, reflected an [AGE] year-old female resident with an initial admission date of 11/30/2020, with diagnoses including Alzheimer's disease (progressive disease that destroys memory and other important mental functions), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), and that the resident was discharged on 04/17/2024. 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 ensure, before a resident was transferred to a hospital or the resident went on therapeutic leave, provided written information to the resident or the resident representative that specified the duration of the bed-hold policy, if any, during which the resident was permitted to return and resume residence in the nursing facility for 1 of 1 residents (Residents #89) reviewed for transfers, in that: The facility did not provide Resident #89 with a written bed-hold policy when the resident was transferred out to the hospital. This failure could place residents at risk for not receiving notice of the facility's bed hold policy before being transferred and at risk for of being improperly discharged and placed in unsafe conditions. The findings were: Record review of Resident #89's face sheet, undated, revealed an [AGE] year-old-female was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include respiratory failure, COPD…

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 each resident receives an accurate assessment for 1 of 9 (#77) that were reviewed in that: Resident #77 was discharged on 1/25/2024 and a discharge MDS was not completed. This could affect all residents and could result in residents' information not being accurate. The Findings: Record review of Resident #77's admission Record revealed she was admitted on [DATE], [AGE] year old female, and her diagnoses were Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs.), chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), adult failure to thrive, osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bone…

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 when the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, a recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results, a final summary of the resident's status to include items in paragraph, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative; reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over the counter) for 1 of 3 (Resident #77) resident reviewed for discharge in that: Resident #77 was discharged on 1/25/2024 and a discharge summary was not completed. This could affect all residents and could result in residents' information not being accurate. The Findings: Record review of Resident #77'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 observation, interview and record review, the facility failed to ensure that a resident, who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 1 of 20 residents reviewed for respiratory care. (Resident #240) The facility did not ensure Resident #240 had orders for the administration of oxygen. This failure could place the residents at risk of not receiving the care and services to maintain their highest level of well-being. Findings included: Record review Resident #240's face sheet dated 04/24/24 reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included hypertension (high blood pressure), atrial fibrillation (irregular heart beat), COPD (lung disease) and falls. Record review of Resident #240's EMR reflected he did not have a complete MDS assessment. Record review of care plan dated 04/22/24 reflected Resident #240 had…

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 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 (Resident #64) in that: Resident #64 was not administered her Tylenol and Senexon . This could affect all residents and could result in residents not administered medications can increase pain and constipation. The Findings: Record review of Resident #64's admission Record dated April 3, 2004 revealed she was admitted on [DATE], re-admitted on [DATE], she was [AGE] years old, with diagnoses of dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), diabetes II ( a disease that occurs when your blood glucose, also called blood sugar, is too high.), chronic pain, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of diseases for 1 of 3 (Residents #82) and 1 of 1 (LVN B) staff reviewed for infection control. LVN B failed to change gloves after removing a soiled dressing and failed to wash her hands or use ABHR after glove change. LVN B failed to wear proper PPE. These failures could place residents at risk for spread of infection and cross contamination. Findings include: Record review Resident #82's face sheet dated 04/24/24 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included diabetes (high blood sugar), hypertension (high blood pressure, heart failure, and Alzheimer's disease (cognitive loss). Record review of Resident #82's quarterly MDS assessment, dated 03/08/24 reflected no BIMS score, but indicated cognition was severely impaired. Section M…

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 reasonable accommodation of resident needs and preferences for 3 (Resident #3, #6, and #8) of 54 residents who resided on A and B hall reviewed for call lights. In that: Resident #3 had no access to his call light which had been clipped to the privacy curtain at the foot of his bed. Resident # 6 had no access to her call light which was on the floor under the roommate's bed and on the floor next to her bed. Resident #8 had no access to her call light which was on the floor under the foot of her bed. This deficient practice could place residents not being able to use call lights for assistance in maintaining and/or achieving independent functioning, dignity, and well-being. Findings included: Record review of Resident's #3's face sheet, revealed he was a [AGE] year-old male, admitted on [DATE]. He had diagnoses that included: anxiety disorder and Epilepsy (a brain disorder that causes seizures). 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 observation, interview, and record review, the facility failed to provide food that accommodated the preferences for 2 of 13 residents reviewed for food preferences and the accommodation of resident's meal choices (Resident #'s 5 and 7). The facility did not honor Resident #5's allergy to foods and continued to serve her foods she was allergic to. The facility did not honor Resident #7's food preferences and continued to serve him foods he asked not to receive. This failure could place residents who report likes/dislikes and allergies at risk for dissatisfaction, poor intake, weight loss, and/or allergic reaction. Findings included: Record review of Resident # 5's face sheet revealed she was a [AGE] year-old female, admitted [DATE]. Resident #5's diagnoses include: anxiety disorder and Hemiplegia (paralysis of one side of the body) and Hemiparesis (muscle weakness of one side of the body) following a Cerebral Infarction (a disruption in the brain's blood flow). Record review of Resident # 5'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 observation, interview, and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 4 of 5 residents (Resident # 1, #2, #3, #4,) reviewed for infection control in that: 1. The facility failed to ensure LVN A, during the medication pass, performed hand hygiene after administering medications to Residents #1 and #2. 2. The facility failed to ensure LVN A, during the medication pass, sanitized the blood pressure cuff after taking Residents #1 and #2's blood pressures. 3. The facility failed to ensure LVN B, during the medication pass, sanitized the blood pressure cuff after taking Residents #3 and #4's blood pressures. These deficient practices could place residents at risk for cross contamination. The findings were: 1. Review of Resident #1's Electronic Record on 3/12/2024, revealed the resident was admitted to the facility on [DATE] with diagnoses which included Hypertension (heart problems caused by high 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to assure that all nursing staff had the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population for 1 of 5 residents (Resident #3) reviewed for continuity of nursing care, in that; The DON and LVN E failed to provide supervision and continuity of nursing care for Resident #3's infected left knee. Resident #3 was delayed by 2 days in receiving care for a red swollen infected knee. These failures placed Resident(s) at risk for harm by delayed care and increased infection. The findings included: A record review of Resident #3's admission record revealed an admission date of 12/2/2014 with diagnoses which included dementia [a range…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials, including to the State Survey Agency, for 1 of 5 residents (Resident #4) reviewed for injuries of unknown source, in that: The DON and LVN B did not report to the state agency and or investigate Resident #4's head injury of an unknown origin . This failure could place residents at risk for abuse. The findings included: A record review of Resident #4's admission record dated 12/01/2023 revealed an admission date of 04/03/2023 and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 3 secured courtyards (B wing courtyard) reviewed, in that: The facility failed to ensure that the B wing courtyard back door/fence was secured to prevent the public from coming into the facility and to prevent the residents from eloping. The non compliance was identified as past noncompliance. The noncompliance began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began. This deficient practice could place residents, staff, and the public at risk of exposure to potentially dangerous materials. The findings were: Record review of Resident #1's admission record, dated [DATE], reflected a male with an admission date of [DATE], and diagnoses which included paranoid schizophrenia (a mental illness characterized by delusions and hallucinations), unspecified dementia (decline in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews the facility failed to ensure residents had the right to and the facility had made prompt to resolve grievances the residents may have had, in accordance with identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations; As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated; for 2 of 5 residents(Resident #6 and Resident #17) reviewed for grievances, in that: 1. Resident #6 family made a grievance in reference to the bruise to Resident #6's chest, under arm, and back, were not consistent with her planned quality of care; for which the facility did not initiate a grievance…

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 and sanitary environment, and to help prevent the development and transmission of communicable disease and infections for 2 of 2 (Residents #12 and #67) observed for care in that: 1. CNA A failed to remove her gloves and perform hand hygiene before moving from a contaminated-body site to a clean-body site during care for Resident #12. 2. CNA A failed to remove her gloves and perform hand hygiene before moving from a contaminated-body site to a clean-body site during care for Resident #67. This failure can affect residents in the facility who received incontinent care and could result in spread of infections. The findings were: 1. Record review of Resident #12's admission Record (03/03/2023) revealed an admission date of 01/17/2023 with diagnoses of Irritable bowel syndrome (disorder that affects the stomach and intestines, also called the gastrointestinal tract) with Diarrhea and Cerebral Infarction, unspecified.…

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 be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside, for 2 of 5 Residents (Resident #15 and Resident #18) reviewed for the ability to call for staff, in that: Resident #15 and Resident #18 presented with their call light on the floor away from their reach. This failure could place residents at risk for injury and diminished self-esteem, due to the inability to call for assistance. The findings included: A record review of Resident #15's admission record, dated 03/03/2023, revealed an admission date of 03/18/2022 with diagnoses which included Parkinson's disease [a chronic and progressive movement disorder that initially causes tremor in one hand, stiffness or slowing of movement], and severe intellectual disabilities. A record review of Resident #15's care plan, 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.

Based on observation, interview, and record review the facility failed to ensure 1 of 46 (Resident #67) sampled residents was treated with dignity during dining room observation. CNA A prevented Resident #67 to move freely by locking his wheelchair after he was finished with his breakfast. This failure could affect all residents in the facility and could result in residents not being treated with dignity. The findings were: Record review of Resident #67's admission Record (03/03/2023) revealed an admission date of 01/17/2023 with diagnoses of Hemiplegia and Hemiparesis following cerebral infarction, Cerebral Infarction, unspecified, and Irritable Bowel Syndrome with Diarrhea. Record review of Resident #67's care plan (02/14/2023) revealed he was at risk for falls due poor safety awareness and needed extensive assistance with activities of daily living with the assistance of two staff when combative. Further record review revealed Resident #67 propels short distances with his wheelchair. Record review of Resident #67's MDS (02/21/2023) revealed a Brief Interview for Mental Status…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source are reported immediately to the administrator of the facility and to other officials, including to the State Survey Agency in accordance with State law through established procedures, for 1 of 5 Residents (Resident #6) reviewed for injuries of unknown origin reporting, in that: Resident #6 was assessed with a large bruise from her chest to her under arm and continued to her back, which was not investigated and not reported to the state agency and Resident #6's Guardian as an injury of unknown origin. This failure could place Resident(s) at risk for harm by further exposure to injuries without proper investigation and reporting. The findings included: A record review of Resident #6's admission Record, dated 02/28/2023, revealed an admission date of 11/30/2018, with diagnoses which included Alzheimer's disease [causes the brain 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 must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following, The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 8 (#47) residents in the secured memory care unit in that: Resident #47 did not have a care plan for care in the secure memory care unit. This could affect residents in the secure unit and could result in residents not provided care while in the memory care unit. The findings included: Record review of Resident #47's admission Record dated March 2. 2023 revealed she was admitted to the facility on [DATE] with diagnoses of dementia, schizoaffective, adult failure…

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 has a prosthesis is provided care and assistance, consistent with professional standards of practice, the residents' goals and preferences, to wear and be able to use the prosthetic device for 1 of 5 (Resident #17) residents reviewed for orthotic devices, in that: Resident #17 needed a back brace as ordered by her neurosurgeon, and the facility failed to escalate their efforts to secure the back brace for Resident # 17. This failure could place residents at risk for health status decline without the support and therapeutic effects of prostheses devices. The findings included: A record review of Resident #17's admission record, dated 03/01/2023, revealed an admission date of 10/07/2022, with diagnoses which included wedge compression fracture of T11-T12 vertebra [thoracic area of the spine], age-related osteoporosis [a silent disease that weakens your bones and makes them break easily], spinal stenosis [can…

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 or obtain laboratory services only when ordered by a physician; physician assistant; nurse practitioner or clinical nurse specialist in accordance with State law, for 1 of 5 residents (Resident #238) reviewed for laboratory services, in that: Resident #238 was ordered a urinalysis which was not sent to the laboratory for 7 days. This failure placed residents at risk for health status decline related to denying the physician a prompt result from the ordered urinalysis. The findings included: A record review of Resident #238's admission Record, dated 2/28/2023, revealed an admission date of 02/16/2023 with diagnoses which included encephalopathy [a term for any disease of the brain that alters brain function or structure] and seizures [a seizure is a sudden, uncontrolled burst of electrical activity in the brain]. A record review of Resident #238's care plan, dated 03/01/2023, revealed, The Resident [Resident #238] uses mood…

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.