Mullican Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure assessments accurately reflected the resident status for 3 of 12 residents (Resident # 17, Resident #4, Resident 11) reviewed for MDS assessment accuracy. The facility failed to ensure Resident # 17's, Resident #4's, and Resident #11's, restraints were accurately coded. These failures could place residents at risk of not receiving care and services to meet their needs. Findings included: 1.Record review of Resident #17's face sheet, dated 03/10/24 indicated Resident #17 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included seizures, Bipolar (a mental illness that causes unusual shifts in a person's mood, and energy), Schizophrenia (severe mental disorder can result in hallucinations, delusions, and extremely disordered thinking disorder), and generalized anxiety (a feeling of fear, dread, and uneasiness). Record review of Resident #17's quarterly MDS assessment, dated 02/05/24, indicated Resident…

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

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, for 1 of 5 halls (C hall) reviewed for physical environment. The facility failed to ensure the flooring on the C hall was free from trip hazards. This failure could place residents who reside in the facility at-risk of falls and further injuries due to an unsafe environment. The findings were: During an Observation on 04/09/24 at 3:05 PM the flooring on the C hall was raised and split across the hallway. During an Observation and interview on 04/10/24 at 05:07 PM The ADON was shown the place on the floor that was raised, and she said she did not realize it had gotten worse. The ADON said she was not responsible for the floor but said she would notify the correct person to ensure it was addressed. She said the failure placed a risk for residents falling. During an observation and interview on 04/10/24 at 05:35 PM The DON She said she could see potential for someone to fall. The DON said she was not aware 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 refer all residents with possible serious mental disorder or a related condition for level II for 1 of 3 residents (Resident #17) whose records were reviewed for mental disorders. The facility failed to refer Resident #17 for a PASARR evaluation based on mental disorder diagnoses of Psychosis. This deficient practice could affect residents with mental illness and contribute to a delay in services needed. The findings included: Record review of Resident #17's face sheet, dated 03/10/24 indicated Resident #17 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included seizures, Bipolar (a mental illness that causes unusual shifts in a person's mood, and energy), Schizophrenia (severe mental disorder can result in hallucinations, delusions, and extremely disordered thinking disorder), and generalized anxiety (a feeling of fear, dread, and uneasiness). Record review of Resident #17's quarterly MDS assessment, dated 02/05/24,…

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 and implement a comprehensive person-centered care plan for each resident, 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 for 1 of 14 residents (Residents #2) reviewed for care plans. 1.The facility failed to include Resident #2's diagnosis and interventions for post-traumatic stress disorder (PTSD) in the care plan. This failure could have placed residents at risk for not having their needs met. The findings included: A record review of Resident #2's face sheet dated 04/10/24 indicated she was a [AGE] year-old female who originally admitted to the facility on [DATE] and last admission date of 03/27/24 with diagnosis PTSD (anxiety and flashbacks triggered by a traumatic event). A record review of Resident #2's significant change MDS assessment dated [DATE] indicated Resident #2 was rarely/never understood 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 review and revise the person-centered care plan to reflect the current condition for 3 of 3 (Resident #17, Resident #15, and Resident #25) residents reviewed for care plan revisions. 1.The facility failed to revise Resident #17's care plan to include he removed his Foley catheter leg strap (a device used to reduce the risk of tension or pulling on the catheter, which could cause some very unpleasant trauma within the bladder or urethra) as ordered at times. 2. The facility failed to revise Resident #15 care plan to remove her wander guard. 3. The facility failed to revise Resident #25 care plan to remove he was a smoker. These deficient practices could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. Findings included: 1.Record review of Resident #17's face sheet, dated 03/10/24 indicated Resident #17 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that residents requiring respiratory care were provided such care, consistent with professional standards of practice for 2 of 12 residents (Resident #8 and #31) reviewed for respiratory care. 1. The facility failed to ensure Resident #8 had oxygen orders. 2. The facility failed to ensure Resident #31 oxygen concentrator filters were cleaned. These failures could place residents who receive respiratory care at risk of developing respiratory complications and a decreased quality of care. The findings included: 1. Record review of Resident #8's face sheet, dated 04/10/24, indicated a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease (no airflow for breathing), high blood pressure, Dementia (impaired ability to remember, think, or make a decision) and Depression (feeling of sadness). Record review of Resident #8'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 on each resident that were complete and accurately documented, in accordance with accepted professional standards and practices, for 1 (Resident #17) of 4 residents whose records were reviewed for accuracy and completeness. The facility failed to maintain accurate documenation in the MAR for April 2024 for Resident #17. This deficient practice could place residents at risk of having incomplete or inaccurate records and inadequate care. Findings included: Record review of Resident #17's face sheet, dated 03/10/24 indicated Resident #17 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included seizures, Bipolar (a mental illness that causes unusual shifts in a person's mood, and energy), Schizophrenia (severe mental disorder can result in hallucinations, delusions, and extremely disordered thinking disorder), and generalized anxiety (a feeling of fear, dread, and uneasiness). 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 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 3 residents (Resident #26) reviewed for infection control practices. CNA D failed to wash or sanitize hands when changing gloves between dirty and clean while providing peri care for Resident #26. This failure could place residents and staff at risk for cross contamination and the spread of infection. Findings included: Record review of Resident #26's face sheet dated 04/10/24 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with the diagnoses diabetes mellitus type 2, epilepsy, high blood pressure, urine retention, and mood disorder. Record review of Resident #26's annual MDS dated [DATE] indicated he had a BIMS score of 11 which meant he had moderate…

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 implement their written policies and procedures to prohibit abuse and neglect for 1 of 15 residents reviewed for abuse. (Residents #1) The facility failed to report\per policy to the state agency within 2 hours of Resident #1's allegations of abuse. This failure could place residents at risk of unreported abuse, neglect, and exploitation. Findings included: Record review of facility's Policy for Abuse and Neglect with a revised date of 03/29/2018 indicated: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in the subpart e. Reporting Any person having reasonable cause to believe, and elderly or incapacitated adult is suffering from abuse, neglect or exploitation must report this to the DON, administrator, state and/or adult protective services . Record review of Resident #1's face sheet dated 04/01/2024 indicated he was a [AGE] year-old male who 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 interview and record review the facility failed to ensure that 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, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 15 (Resident #1) residents reviewed for abuse and neglect. The facility failed to report to the state agency within 2 hours of Resident #1's allegations of abuse. This failure could place the residents at risk for abuse. Findings included: Record review of Resident #1's face sheet dated 04/01/2024 indicated he was a [AGE] year-old male who admitted 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 interview and record review, the facility failed to notify the Office of the State Long-Term Care Ombudsman of the transfer or discharge and the reasons for the transfer or discharge in writing for 1 of 3 residents (Residents #1) reviewed for transfer and discharge. The facility initiated a discharge for Resident #1 due to a change of condition and did not notify the State Long-Term Care Ombudsman by phone or in writing. This failure could place residents at risk of improper discharge planning and diminished quality of life. Findings included: Record review of Resident #1's face sheet dated 04/01/2024 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses of Parkinson disease (a disorder of the central nervous system that affects movements, often including tremors), Type 2 Diabetes Mellitus (a long term condition in which the body has trouble controlling blood sugar and using it for energy), Cognitive communication, and Schizoaffective Disorder, Bipolar Type…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to establish and follow written policy on permitting residents to return to the facility after they were hospitalized for one (Resident #1) of 3 residents reviewed for transfer/discharge. 1. The facility failed to admit Resident #1 back to facility after he was sent to the psychiatric hospital on [DATE]. 2.The facility failed to give Resident #1 a 30-day discharge notice. This failure could place residents at risk of not receiving the care and services to meet their needs and could affect their mental and emotional well-being. Findings included: Record review of Resident #1's face sheet dated 04/01/2024 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses of Parkinson disease (a disorder of the central nervous system that affects movements, often including tremors), Type 2 Diabetes Mellitus (a long term condition in which the body has trouble controlling blood sugar and using it for energy), Cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure prompt efforts were made to resolve grievances for 3 of 17 residents (Residents #7, #47 and #45) reviewed for grievances. 1. The facility did not ensure a grievance was file for Resident #7 when three pair of shoes was not returned from the laundry. 2. The facility did not ensure a grievance was file for Resident #47 when a multicolored dress, a pair of socks, and a head band was not returned from the laundry. 3. The facility failed to file a grievance for Resident #45 when a jacket and green matching sweatshirt and pants was not returned from the laundry. 4. The facility failed to ensure the grievances for Residents #7, #47, and #45 were resolved until after surveyor interventions. These failures could place residents at risk for grievances not being addressed or resolved promptly. Findings include: 1.Record review of Resident #7's order summary report, dated 02/16/2023, indicated Resident #7 was a [AGE] year-old-female, originally admitted 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 interview and record review, the facility failed to have evidence that all alleged violations were thoroughly investigated for 2 of 17 resident incidents (Resident #58 and Resident #44) reviewed for abuse and neglect. The facility failed to have evidence that a thorough investigation was conducted. The Provider Investigation Report involving Resident #58 and Resident #44 failed to include witness statements from staff who witnessed the incident. These failures could place residents at risk for undetected abuse, neglect and/or decline in feelings of safety and well-being. Findings include: 1.Record Review of Resident #58's face sheet dated 02/16/23 indicated he was a [AGE] year-old male that was admitted to the facility on [DATE]. Resident #58 had a diagnosis of vascular dementia (impaired supply of blood to the brain), psychotic disorder with delusions (disconnection from reality) and major depression (persistently depressed mood or loss of interest in activities). Record review of Resident #58's MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure an accurate MDS was completed for 4 of 17 residents (Resident's #12, #22, #28, and #47) reviewed for MDS assessment accuracy. 1. The facility failed to accurately document oral status for Resident #47 on the MDS assessment. 2. The facility failed to accurately document hospice status for Resident #22 on the MDS assessment. 3. The facility failed to accurately document a diagnosis of pneumonia on Resident #28's MDS assessment. 4. The facility failed to accurately reflect Resident #12's dental status on the MDS assessment. These failures could place residents at risk for not receiving care and services to meet their needs. The findings included: 1. Record review of Resident #47's face sheet, dated 02/16/2023, revealed Resident #47 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar), chronic obstructive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 4 of 17 residents (Resident #17, Resident #26, Resident #40, and Resident #67) reviewed for care plans. The facility failed to develop and implement a care plan for Resident #17's need for assistance with ADLs. The facility failed to develop and implement a care plan for Resident #26's dental problems. The facility failed to develop and implement a care plan for Resident #40's contractures. The facility failed to develop and implement a care plan for Resident #67's wandering/risk for elopement. These failures could place residents at risk of not having individual needs met and a decreased quality of life. Findings included: 1. 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 observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 3 of 17 residents (Residents #15, #3 and #23) reviewed for palatable food. The facility failed to provide palatable food served at an appetizing temperature or taste to residents' who complained the food was served cold and did not taste good for Residents #15, #3, and #23. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. Findings include: 1. During an interview on 02/13/2023 at 10:54 a.m., Resident #15 stated the food was lousy and did not have enough flavor. Resident #15 stated she reported this to staff but could not recall their names. 2. During an interview on 02/13/2023 at 3:08 p.m., Resident #3 stated the meat was tough. Resident #3 stated sometimes the aides could not even cut the meat up for her. 3. During an interview on 02/13/2023 at 3:10 p.m., Resident #23 stated the food was nasty. Resident #23 stated, It looks like…

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 safety in the facility's only kitchen. The facility failed to ensure: 1. Food items were dated and labeled. 2. Expired food item was discarded. 3. The ice machine was clean and free from debris 4. K-Quat (sanitation) test strips were not expired 5. The juice machine spigot was clean 6. The toaster was clean and free of food debris. 7. The cooking grease in the deep fryer was kept clean. 8. The deep fryer was free of grease build up. These failures could place residents at risk for foodborne illness. Findings include: 1. During an observation in the refrigerators and freezers on 02/13/2023 starting at 11:20 a.m. revealed a plastic storage bag labeled ham with an opened date 02/02/2023 and used by date 02/09/2023; plastic storage bag that was identified by the Dietary Manager as sliced ham undated; 5 lb. container labeled tuna salad undated; plastic bag identified by the Dietary Manager as hamburger patties. 2. During…

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, and comfortable environment for 2 of 17 residents in rooms (#205-B and room#104-B) reviewed for environment. The facility did not repair the chipped paint on the walls in room [ROOM NUMBER]-B. The facility did not repair the torn away baseboards in room#205-B. The facility failed to ensure room#104-B was clean. These failures could place the residents at risk for an unsafe environment. Findings included: 1.During an observation and interview on 02/14/23 at 12:00 p.m., Resident in room [ROOM NUMBER]-B was sitting in her bed watching TV, observation made of baseboard trim tearing away from the walls in room. Resident in room [ROOM NUMBER]-B stated the shower next door leaked water in her closet and she thought that was why the trim was messed up. Observation made of paint chipped around the baseboards in room#205-B. Resident in room [ROOM NUMBER]-B stated she did not like the trim tearing away from the wall and would…

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 ensure that all alleged violations involving abuse, and neglect, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with state law through established procedures for 1 of 17 residents (Resident #7) reviewed for abuse. The facility failed to acknowledge, investigate, and report neglect to the state agency on behalf of Resident #7. This failure could place residents at risk for neglect due to unreported and uninvestigated allegations of neglect. Findings include: 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 review, the facility failed to complete a comprehensive resident-centered assessment of each resident's cognitive, medical, and functional capacity in a timely manner for 1 of 17 residents (Resident #47) reviewed for accuracy of assessments. The facility failed to complete Resident #47's MDS assessment within 14 days of admission to the facility. This failure could place residents at risk of not having their needs met. The findings included: Record review of Resident #47's face sheet, dated 02/16/2023, revealed Resident #47 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar), chronic obstructive pulmonary disease, COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and acquired absence of left leg below knee (left leg amputation below the knee). Record review of Resident #47's comprehensive MDS assessment with an ARD…

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 assess each resident quarterly (every 3 months) using the Minimum Date Set (MDS) specified by the state and approved by CMS for 1 of 17 residents (Resident #45) reviewed for quarterly assessments. The facility failed to ensure Resident #45's MDS assessments were done quarterly. This failure could place residents at risk for not having their assessments completed timely and not having their individually assessed needs met. Findings include: Record review of Resident #45's face sheet, dated 02/16/2023, revealed Resident #45 was a [AGE] year-old female initially admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease with (acute) exacerbation (lung disease that causes obstructed airflow from the lungs), type 2 diabetes mellitus with unspecified complications (high blood sugars), and schizoaffective disorder, bipolar type (mental disorder that causes abnormal thought processes and unstable mood). Record review of Resident #45'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, interviews, and record reviews, the facility failed to ensure residents received proper treatment and assistive devices to maintain or enhance vision abilities for 1 out of 1 resident (Resident #12) reviewed for vision services. The facility failed to assist resident #12 in locating and utilizing any available resources for the provision of the services the resident needs. The facility did not make an appointment for Resident #12 to have a vision evaluation. This failure could affect residents in need of referrals for vision evaluations and place them at risk of not receiving necessary treatment and services. Findings included: Record review of the consolidated physician orders dated 02/16/23 indicated Resident #12 was a [AGE] year-old female that was admitted to the facility on [DATE] and had a diagnosis of Schizophrenia (disorder that affects a person's ability to think, feel and behave clearly), Asthma (inflamed airways that make it difficult to breath) and HTN (force of blood against…

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 the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 17 (Resident #64) residents reviewed for monitoring and supervision. The facility failed to provide supervision and interventions as evidenced by Resident #64's wandering behaviors. This failure could place residents at an increased risk for injury and for future resident-resident altercation. The findings included: Record review of a face sheet dated 02/16/2023 revealed, Resident #64 was a [AGE] year-old female initially admitted on [DATE] with diagnoses of Alzheimer's disease (progressive disease that destroys memory and other important mental functions), schizoaffective disorder, unspecified (mood disorder characterized by abnormal thought processes and unstable mood), and anxiety disorder, unspecified (severe, ongoing anxiety that interferes 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 ensure respiratory care was provided with professional standards of practice for 1 of 17 residents (Resident #17) reviewed for respiratory care and services. The facility failed to administer oxygen at 3-4 liters per minute via nasal cannula as prescribed by the physician for Resident #17. This failure could place residents who receive respiratory care at risk for developing respiratory complications. The findings included: Record review of Resident #17's face sheet, dated 02/16/2023, revealed she was a [AGE] year-old female initially admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease, unspecified (lung disease that causes obstructed air flow in the lungs), unspecified combined systolic (congestive) and diastolic (congestive) heart failure (heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), and dependence on supplemental oxygen. Record review of the MDS comprehensive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure that it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 8%, based on 2 errors out of 25 opportunities, which involved 1 of 8 residents (Resident #61) reviewed for medication administration. The facility failed to ensure Resident #61 received docusate sodium tablet 100 mg and naproxen tablet 250 mg between 6:00 a.m. and 8:00 a.m. This failure could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders. Findings included: Record review of Resident #61's order summary report, dated 02/16/2023, indicated Resident #61 was a [AGE] year-old-female, admitted to the facility on [DATE] with a diagnosis which included congestive heart failure (chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), constipation, and pain in right…

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

Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles in locked compartments and permit only authorized personnel to have access to the keys for 2 of 4 medication carts (Nurse E Hall and Med Aide E Hall) reviewed for storage of drugs. The facility failed to ensure E Hall nurse and Med Aide medication carts were locked when unattended. This deficient practice could place residents at risk of medication misuse and diversion. Findings include: 1. During an observation on 02/13/2023 at 3:54 p.m., LVN A left the E Hall medication cart unlocked and unattended in Resident #28's door while administering Resident #28's medication. During an interview on 02/16/2023 at 10:33 a.m., LVN A stated she should have locked the medication cart prior to going in Resident #28's room. LVN A stated she was nervous and forgot to lock the cart. LVN A stated she noticed the medication cart not locked after administering the medication. LVN A stated this failure could potentially put…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure medical records were maintained in accordance with accepted professional standards and practices on each resident and accurately documented for 1 of 17 residents (Resident #271) reviewed for accuracy of medical records. The facility failed to ensure Resident #271's medication administration record was accurate and complete. This failure could place residents at risk of not receiving care and services to meet their needs. The findings included: Record review of Resident #271's face sheet, dated 02/16/2023, revealed Resident #271 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of unspecified dementia without behavioral disturbance (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar), and cerebrovascular disease (a group of conditions that affect…

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 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 staff (LVN T) reviewed for infection control. The facility failed to ensure LVN T performed hand hygiene while checking blood sugars for Resident #2 and Resident #7 and when administering insulin to Resident #7. This failure could place residents and staff at risk for cross-contamination and the spread of infection. Findings included: During an observation on 02/13/2023 at 3:56 PM, LVN T put on a pair of gloves and went into Resident #2's room to check her blood sugar. LVN T came out of Resident #2's room with the gloves still on and removed them at the medication cart and started charting on her tablet (used for documentation of medications). LVN T did not perform hand hygiene after glove removal. After this, LVN T put on gloves and went into Resident #7's and checked her blood sugar. LVN…

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

Based on observation, interview, and record review the facility failed to ensure all patient care equipment was in safe operating condition for 1 (Resident # 35) of 17 residents reviewed for safe operating patient care equipment. The facility failed to ensure Resident #35's headboard was not broken. This failure could place resident at risk of injury. Findings included: During an observation and interview made on 02/14/23 at 11:50 a.m., Resident #35' s headboard was missing the rubber trim on the top left side and the rubber was sticking straight up on the right top side. Resident #35 was not interviewable. During an observation and interview on 02/15/23 at 12:05p.m., CNA E stated she had never noticed the headboard, or she would have written it in the maintenance logbook. During an interview on 02/15/23 at 12:15 p.m., CNA D stated she did not know Resident #35's headboard was broken. CNA D stated items that needed to be fixed should be put in the maintenance logbook at the nursing station. CNA D stated she might not always write needed repairs in the maintenance logbook because 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain at least 80 square feet per residents in multiple resident bedrooms, and at least 100 square feet in single resident rooms for 1 of 31 multiple-residents bedroom, reviewed for bedroom measurement. room [ROOM NUMBER] measured 147.4 square feet. This failure could place residents at risk of having inadequate space for personal belongings and guest. Findings included: During an observation of room [ROOM NUMBER] from 02/13/2023 through 02/16/2023 measure 147.4 square feet which was less than the 160 square feet required for a two-bedroom. There was no resident residing in room [ROOM NUMBER]. During an interview on 02/16/2023 at 6:06 p.m., the VP of Clinical Operations stated a waiver was requested from CMS in August 2021 and October 2021. The VP of Clinical Operations stated the waiver was approved from Texas HHSC. The VP of Clinical Operations stated the facility must state on the 2567/3724 that they had submitted the request, the…

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

Based on observations, interviews, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 1 smoking area. The facility failed to ensure cigarette butts were disposed of appropriately. The facility failed to provide ashtrays of a safe design and a self-closing metal container to open empty ashes. These failures could place residents at risk for injury, burns and an unsafe smoking environment. Findings include: During an observation on 02/13/2023 at 3:37 PM, the designated smoking area had 1 chimney-type ashtray and no self-closing metal container. During an observation on 02/16/2023 at 12:00 PM, the designated smoking area had 1 chimney-type ashtray and no self-closing metal container. There were 3 cigarette butts on the ground close by the chimney-type ashtray. During an interview on 02/26/2023 at 7:54 PM, the DON stated she was not responsible for the smoking area, and she did not know who was. The DON stated the self-closing metal container was replaced by the cigarette butt holder that was outside and to her knowledge…

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.