Avir at Schertz

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that the resident has the right to be informed of, and participate in, his or her treatment, including the right to be informed in advance of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers for 1 (Resident #5) out of 24 residents reviewed for resident rights. The facility failed to obtain informed consent for the use of Risperdal (an antipsychotic medication) for Resident #5. These failures could place residents who receive psychotropic medications at risk of receiving medications without consent, knowledge of possible side effects of the medications, or other treatment options.Findings included: Record review of Resident #5's face sheet, dated 02/27/2026, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of epilepsy (a brain disorder that causes people to have recurring seizures),…

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 received services in the facility with reasonable accommodation of resident needs for 2 of 8 residents (Resident #15 and Resident #65) who were observed for call light placement. The facility failed to ensure the call light was within reach for Resident #15 and Resident #65. This deficient practice could place residents at risk of not being able to call for help as needed.The findings included: Record review of Resident #15's face sheet, dated 02/25/2026, revealed she was admitted to the facility on [DATE] with original admission date 10/21/2025 with diagnoses which included: mild intellectual disabilities, chronic pain syndrome, chest pain, cerebral palsy (group of conditions that affect movement and posture), and other lack of coordination. Record review of Resident #15's Quarterly MDS assessment, dated 01/13/2026, revealed the resident's BIMS score was 7, which indicated severe cognitive impairment. The 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 ensure PRN (as needed) orders for antipsychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication for 1 (Resident #5) of 24 residents reviewed for chemical restraint, in that: The facility failed to ensure Resident #5 was prescribed Risperidone for restlessness and agitation, no longer than 14 days PRN (as needed). This failure could place residents at risk of receiving unnecessary psychotropic medications. The findings were: Record review of Resident #5's face sheet, dated 02/27/2026, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of epilepsy (a brain disorder that causes people to have recurring seizures), restlessness and agitation (sudden, distressing state of intense restlessness), and schizoaffective (exhibiting symptoms of both schizophrenia and a mood disorder such as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure the assessment accurately reflected the resident's status for 2 of 10 Residents (Resident #3 and Resident 42 whose records were reviewed for assessments. Nursing staff failed to code Resident #3 had an anxiety disorder on her MDS assessment. Nursing staff failed to code Resident #42 had an anxiety disorder on his MDS assessment. This deficient practice could place residents at risk of not identifying care areas and result in residents not receiving needed care and services. The findings were:1. Review of Resident #3's face sheet, dated 2/27/26, revealed she was admitted to the facility on [DATE] with diagnoses including anxiety and schizoaffective disorder bipolar type (Schizoaffective disorder is a mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression, mania and a milder form of mania called hypomania. Bipolar type includes…

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 coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid incorporating the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's care planning for 1 of 2 Residents (Resident #42) reviewed for PASARR services. The MDS Coordinator failed to include Resident #42 had chosen to continue with habilitative services on his Care Plan. This deficient practice could place residents at risk of not receiving services identified by the local authority. The findings were: Review of Resident #42's face sheet, dated 2/26/26, revealed he was admitted to the facility on [DATE] with diagnoses including anxiety, depression, schizoaffective disorder, bipolar type (mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression, mania and a milder form of mania called…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care within 48 hours of a resident's admission, including initial goals based on admission orders, physician orders, dietary orders, and social services for 2 of 2 residents (Resident #4 and Resident #70) reviewed for baseline care plans. The facility failed to ensure a baseline care plan was completed within 48 hours from admission for Resident #4 and Resident #70. This deficient practice could place newly admitted residents at risk for not receiving care and services as needed. The findings were:Review of Resident #70's face sheet, dated [DATE], revealed she was admitted to the facility on [DATE] with diagnoses including unspecified atrial fibrillation (irregular heartbeat, or arrhythmia. Can lead to blood clots, stroke, heart 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 observation, interview and record review the facility failed to ensure that the resident environment remained as free of accident hazards as was possible for 1 of 2 residents (Resident #52) reviewed for mechanical lift transfers and for 1 of 2 Residents (Resident 19) reviewed for smoking assessments. 1. Nursing staff failed to lock the wheelchair, the base of the mechanical lift and failed to widened the base of the mechanical lift when transferring Resident #52 from the wheelchair to the bed.2. The facility failed to ensure conducting Resident #19's smoking assessment quarterly. This deficient practice could place residents at risk of having avoidable falls and or accidents.2. Record review of Resident #19's face sheet, dated 02/27/2026, revealed the resident was a 65-years-old female, originally admitted on [DATE], and readmitted to the facility on [DATE] with diagnosis of anxiety disorder (symptoms of intense anxiety or panic that are directly caused by a physical health problem), cystitis…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder and bowel received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 (Resident #5 and #56) of 3 residents reviewed for incontinence care. 1. When CNA-O was providing incontinent care to Resident #5 on 02/26/2026, the CNA-O did not open the resident's labia area. 2. When CNA-J was providing incontinent care to Resident #56 on 02/26/2026 and the resident was uncircumcised, CNA-J did not pull back the foreskin of the resident's penis, cleaned the perineal area with multiple pass of one wipe. These failures could place residents who required incontinence care at risk for cross contamination and the development of new or worsening urinary tract infections. The findings included: 1. Record review of Resident #5's face sheet, dated 02/27/2026, reflected the resident was a [AGE] year-old female admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure the facility acted upon the pharmacist drug regimen report of any irregularities reported to the attending physician for 1 of 2 Residents (Resident #42) reviewed for gradual dose reductions. The DON failed to follow the pharmacist recommendation to change Resident #42's order for Fluoxetine from 50 mg to 40 mg administered QD per pharmacist recommendation. This deficient practice could place residents at risk for not receiving gradual dose reductions per pharmacist recommendations. The findings were: Review of Resident #42's face sheet, dated 2/26/26, revealed he was admitted to the facility on [DATE] with diagnoses including depression and schizoaffective disorder bipolar type (Schizoaffective disorder is a mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression, mania and a milder form of mania called hypomania. 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 ensure each resident's drug regimen was free from unnecessary drugs without adequate indications for its use for 1 of 2 residents (Resident #5) reviewed for psychotropic use. Nursing staff failed to indicate an appropriate indication for Resident #5's use of Trazadone, an anti-depressant. This deficient practice could place residents at risk for the use of unnecessary medications. The findings were:Review of Resident #5's annual MDS assessment, dated 2/21/26, revealed she was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease and her BIMS score was 0 of 15 reflecting severe cognitive impairment. Review of Resident #5's consent, dated 7/31/25, for the use of Trazadone 150 mg QHS for depression. Review of Resident #5's physician orders for February 2026 revealed an order for traZODone HCl Oral Tablet 150 MG (Trazodone HCl)[NAME] with the start date, 02/18/2026. Further review revealed the order indicated to give 1 tablet by…

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 all drugs and biologicals were labeled in accordance with currently accepted professional principles and stored in locked compartments for 2 (Resident #58 and #53) of 24 residents reviewed for medication storage. 1. Resident #58's insulin Glargine-yfgn Solos Flex Pen for diabetes had no open date, found inside A-hall nursing cart on 02/25/2026. 2. Resident #53's antifungal ointment cream was left unattended on the resident's nightstand in his room on 02/24/2026. These failures could place residents at risk of not using medications correctly and not having therapeutic effects by using old insulins. The findings were: 1. Record review of Resident #58's face sheet, dated 02/27/2026, revealed Resident #58 was a [AGE] year-old female and admitted to the facility 06/09/2020 and re-admitted to the facility 12/20/2025 with diagnoses of schizoaffective (exhibiting symptoms of both schizophrenia and a mood disorder such as bipolar…

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 or obtain from an outside resource routine dental services for 1 of 1 Resident (Resident #2) reviewed for dental services. The facility failed to follow up and ensure the dental provider filled the prescription for a full set of dentures for Resident #42. This deficient practice could place residents at risk for not being able to chew food properly affecting their quality of life. The findings were: Review of Resident #42's face sheet, dated 2/26/26, revealed he was admitted to the facility on [DATE] with diagnoses including anxiety disorder and type 2 diabetes mellitus without complications (condition where a person has elevated blood sugar levels but has not yet developed any serious health issues related to diabetes.) Review of Resident #42's quarterly MDS, dated [DATE], reflected that Resident #42 had a diagnosis of Diabetes and depression. Further review revealed Resident #42's BIMS score was 15 of 15 reflecting he did not have…

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 follow the menus for 1 of 4 days (2/25/26) observed for meal observation. The DM failed to serve spinach for the lunch meal on 2/26/26 per menu. The DM substituted it with mixed vegetables. This deficient practice could place residents at risk for not being satisfied with the food item substitutions. The findings were: Review of the facility week at a glance monthly menu for the Fall/Winter 2025-26 revealed the following menu would be prepared and served for lunch on 2/26/26: Thursday 2/26/26, Lunch: Sliced Pork with GravyWhipped Sweet PotatoSeasoned Spinach Honey Kissed RollMargarineFruit Cobbler Served Observation on 02/26/2026 at 12:00 PM revealed a posted sign in the dining room included the lunch meal per the menu written in the week at a glance for 2/26/26. Further observation revealed a smaller sign which read there may be substitutions. Observation on 2/26/26 at 12:15 PM of the lunch meal service revealed residents received sliced pork with gravy, whipped sweet potato and mixed vegetables, honey kissed…

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 have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption, for 2 (Residents #18 and #61) of 24 residents reviewed, in that: 1. Resident #18's personal refrigerator located in his room was observed on 02/24/2026. There was a small plastic cup inside the refrigerator with no date and no label on the plastic cup. 2. Resident #61's personal refrigerator had unlabeled, undated food and no temperature logs. The failure could place the residents at risk for food borne illness. The findings included: 2. Record review of Resident #61's face sheet, dated 02/27/2026, revealed he was admitted to the facility on [DATE], original admission date 08/20/2021 with diagnoses which included: multiple sclerosis, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, and 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.

Based on interview and record review the facility failed to include as part of its QAPI program mandatory training that outlines and informs staff of the elements and goals of the facility's QAPI program for 1 of 8 staff unlicensed staff (MA G) and 1 of 4 licensed staff (LVN H) whose records were reviewed for training The facility failed to ensure all unlicensed and licensed staff completed QAPI training. This deficient practice could place residents at risk of receiving care from nursing staff who did not understand the purpose of the QAPI program. The findings were: Review of personnel files for MA G's and LVN H they had not completed QAPI training. Interview on 2/27/26 at 4:15 PM with the HR staff revealed she had been in her position for a few months. She stated she was responsible for ensuring all employees completed the required training. She stated MA G and LVN H had not completed QAPI training. The HR staff was asked for the facility policy on completing QAPI training and it was not provided by the end of the survey on 2/27/26 at 8:30 PM.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to assess residents for risk of entrapment from bed rails prior to installation, failed to review the risks and benefits of bed rails, and failed to check bed rails regularly to make sure they are still installed correctly with 1 (Resident #1) of 4 residents reviewed for the use of bed rails. Resident #1 used one-quarter bed rails bilaterally for increasing bed mobility. However, the facility did not conduct safety assessments for bed rails quarterly per the facility care plan, and the bed rails were installed incorrectly as evidence by not lowering the bed rails because the bed rails were jammed. This failure could place residents at risk of injury, hinder residents from getting out of bed, and/or cause a decline in resident's ability to engage in activities of daily living.Findings included: Record review of Resident #1's face sheet, dated 02/03/2026, revealed she was an [AGE] year-old female, originally admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 1 of 2 nurse medication cart (B hall nursing medication cart) reviewed for storage of drugs. 1. The facility failed to ensure the B hall nursing medication cart was locked. 2. The facility failed to ensure B hall nursing medication cart did not contain a narcotic blister pack with a broken seal for one of the pills and all narcotics were logged on the narcotic count sheets. This deficient practice could place residents at risk of medication misuse and diversion.The findings were: 1. Observation and interview on 1/7/26 at 4:22 p.m. revealed the B hall nurse medication cart was on the on the side of the nursing station facing the hallway and unlocked. LVN E was sitting at the nurses station and not in view of the nurse medication cart. LVN E stated the cart was unlocked and should not be left unlocked. 2. Record review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 4 residents (Resident #6) reviewed for care plans: The facility failed to ensure Resident #6's Care Plan reflected a code status of DNR. This deficient practice could cause confusion for staff members responsible for providing direct care to the residents and place residents at risk of receiving improper care and services. Record review of Resident #6's admission Record dated [DATE] revealed a [AGE] year old female who was admitted to the facility on [DATE]. Her diagnoses included unspecified dementia (progressive or persistent loss of intellectual functioning) depression (mental health disease of high and low mood swings), epilepsy (chronic brain…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 4 residents (Resident #6) reviewed for administration, in that:Resident #6's OOH-DNR was signed and listed under Miscellaneous documents in the electronic medical record while her face sheet and care plan were listed as Full Code.This deficient practice could place the resident at risk of receiving care inconsistent with their wishes.Record review of Resident #6's admission Record dated [DATE] revealed a [AGE] year old female who was admitted to the facility on [DATE]. Her diagnoses included unspecified dementia (progressive or persistent loss of intellectual functioning) depression (mental health disease of high and low mood swings), epilepsy (chronic brain disorder characterized by recurrent seizures), paranoid schizophrenia (form of psychosis characterized by intense distrust, suspiciousness, and delusions…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to ensure the residents had the right to voice grievances to the facility without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which had been furnished as well as those which were not furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay, for 1 of 4 residents reviewed (Resident #3) for making grievances. On the morning of 8/14/2025 LVN A failed to generate a grievance report on behalf of Resident #3's complaint Resident #4 had harassed him for his personal property and both Residents had engaged in a verbal shouting match with an exchange of cursing insults between Resident #3 and Resident #4. This failure could place residents at risk for harm by not having their grievances heard and resolved. The findings included: A record review of Resident #3's admission record dated 10/28/2025 revealed an 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 interviews and record reviews 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, were 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 and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. In response to allegations of abuse, neglect, exploitation, or mistreatment for 2 of 4 residents (Residents #3 and #4) reviewed for reporting allegations of ANE.On the morning of 8/14/2025 LVN A failed to report an allegation…

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 develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights for 1 of 4 residents (Resident #1) reviewed for care plans. On 8/21/2025 Resident #1 returned to the facility after hospitalization for a left arm fracture. Resident #1 was prescribed to wear a stabilization arm sling. The sling was not added to the care plan. This failure could place residents at risk for not having a care plan for care needed. The findings included: A record review of Resident #1's admission record dated 10/28/2025 revealed an admission date of 7/9/2024 with diagnoses which included hemiplegia (a medical condition characterized by paralysis or severe weakness on one side of the body). A record review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 was a [AGE] year-old male admitted for LTC with supports for ADLs and his needs for care with semi-paralysis. Resident #1 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for three of eight residents (Residents #3, #6, #8), in the facility reviewed for infection control, in that: 1.Resident #6's oxygen tubing (oxygen machine side) was observed uncovered and on the floor. Resident #6's portable oxygen tubing was stored uncovered. 2. CNA B did not sanitize their hands between providing Resident #3 with a meal tray and then proceeding to pick up the next meal tray. 3. CNA C did not sanitize their hands between providing Resident #8 with a meal tray and then proceeding to pick up the next meal tray. These failures placed residents at risks of tubing contamination with/ transmission of infectious diseases, damaged tubing, respiratory infections, and risks of bacterial infections/diseases.…

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 the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section, for two of eight residents (Residents #3, #8), in the facility reviewed for residents' rights, in that:1. CNA B did not knock nor announce themselves before entering Resident #3's room.2. CNA C did not knock nor announce themselves before entering Resident #8's room. This failure could place residents at risk for diminished quality of life, loss of dignity and self-worth.The findings included:Record review of Resident #3's admission Record, dated 09/15/2025, revealed the resident being a [AGE] year-old female, originally admitted to the facility on [DATE], with a current admission date of 8/31/2024. Record review of Resident #3's admission Record, dated 09/15/2025, reflected an admission diagnosis of other idiopathic peripheral autonomic…

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 needs respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, for one of one resident (Resident #6), in the facility reviewed for respiratory care, in that: The facility failed to ensure Resident #6's oxygen tubing was connected to the oxygen machine (on and running). This failure placed residents at risks of decreased oxygen levels, respiratory distress, falls, a decrease in the ability to perform daily tasks, and hospitalization.The findings included: Record review of Resident #6's admission Record dated 09/15/2025 reflected a [AGE] year-old male originally admitted to the facility on [DATE] with a current admission date of 04/21/2025. Record review of Resident #6's admission Record dated 09/15/5025 under the Diagnosis Information section revealed an admission diagnosis of 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 observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for one (Resident #3) of six residents reviewed for care plans. The facility failed to develop and implement a comprehensive person-centered care plan to meet Resident #3's fall risk needs. The care plan listed interventions that were not in use and interventions that were in use but not listed on the care plan/Kardex. This failure could place the residents at risk of not receiving necessary care and services.Findings include: Record review of Resident #3's Face Sheet, dated 07.1.2025, reflected an [AGE] year-old female who was readmitted to the facility on 08.25.2025 with diagnoses of unspecified dementia, 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 review, the facility failed to provide a working call light for one (Resident #3) of ten residents reviewed for working call lights consistent with the residents needs as outlined in the care plan and facility policy for the Call System. The facility failed to ensure that Resident #3 had a functional call light to call for assistance as a fall risk intervention. This failure could place the residents at risk of not receiving necessary care and services.Findings include: Record review of Resident #3's Face Sheet, dated 07.1.2025, reflected an [AGE] year-old female who was readmitted to the facility on 08.25.2025 with diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Muscle wasting and atrophy, muscle weakness (generalized), and difficulty in walking. Record review of Resident #3's MDS completed on 6.9.2025 revealed a BIMS score of 0 which indicated severely impaired cognition.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure a resident maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrated this was not possible or the resident preferences indicated otherwise for 9 of 9 Residents (Residents #1, #2, #3, #4, #5, #6, #7, #8, and #9) whose records were reviewed for nutrition staus maintenence. 1. Record review of the facility's Weights and Vitals Summary from 12/15/24-05/31/25, dated 05/06/25, reflected Residents #3, #4, #5, #8 and #9 did not have any heights documented. 2. Record review of the inspection of scale for facility weights, assessed 05/06/25 at 04:41PM, reflected the last inspection was January 20, 2023, and the next inspection was January 20, 2024, which was not done. 3. Meal percentage intakes were input inaccurately and in advanced in the residents' electronic medical record for Resident # 1, #6 and # 7. 4. The facility failed to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and timeframes to meet residents' medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and described the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 7 residents (Resident #1) reviewed for care plans. The facility failed to complete the Mini Nutritional Evaluation per Resident #1's care plan. This failure could affect residents and place them at risk for not having their needs and preferences met. The findings included: Record review of Resident #1's admission Record reflected a [AGE] year-old female initially admitted [DATE] and re-admitted [DATE]. It further reflected she had diagnoses to include muscle weakness and atrophy, lack of coordination, and 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 interviews and record review the facility failed in accordance with accepted professional standards and practices, to maintain medical records on each resident that are complete; accurately documented, readily accessible for 2 of 8 residents reviewed for care plans (Resident #2 and Resident #6). Resident #2 and Resident #6 did not have care plans accessible in their current active record. These failures could place the residents at risk of not having accurate car plans leading to Residents not recieving person centered individualized care as needed. Findings included: Record review of Resident #2's admission Record reflected a [AGE] year-old female initially admitted [DATE] and re-admitted [DATE]. It further reflected she had diagnoses to include muscle weakness and atrophy, lack of coordination, and cognitive communication deficit. Record review of Resident #2's annual MDS assessment, dated 03/25/25, reflected he had a BIMS score of 10 out of 15, indicating moderate cognitive impairment. Record review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to inform residents in advance of the risks and benefits of proposed care and treatment for 3 of 4 residents (Resident #9, Resident #25, and Resident #30) reviewed for psychotropic medications (medications that affect behavior, mood, thoughts, and perception). 1. The facility failed to obtain signed consents for psychotropic medications for Resident #9 who was administered paliperidone palmitate extended release injectable suspension (is an atypical antipsychotic indicated for the treatment of schizophrenia) and paliperidone orally daily and required a written signature on the Nursing Facility Consent for Antipsychotic or Neuroleptic Medication Treatment form. 2. The facility failed to obtain signed consent for Resident #25's psychiatric medications and explain the possible side effects to a responsible party who could make an informed decision for trazadone (medication is used to treat depression), paroxetine (antidepressant that belongs to group 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 ensure residents received services in the facility with reasonable accommodation of resident needs for 1 of 16 residents (Resident #162) who were observed for call light placement. The facility failed to ensure the call light was within reach for Resident #162 on 11/20/24. This failure could affect any resident and keep them from calling for help as needed. The findings were: Record review of Resident #162's admission MDS assessment, dated 5/10/24, revealed an [AGE] year-old female was admitted on [DATE] with diagnosis of fractures and other multiple trauma, atrial fibrillation (a heart condition that causes the upper chambers of the heart to beat irregularly), heart failure, and renal insufficiency (when the kidneys are not functioning properly). Section O of the MDS showed she received hemodialysis dialysis (treatment that filters waste and extra water from the blood when the kidneys are not functioning properly). The resident's BIMS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused result in serious bodily injury for 4 of 16 residents (Resident #9, Resident #36, Resident #21, and Resident #40) whose records were reviewed for abuse and neglect: The facility failed to report to the state reporting agency (HHSC) when Resident #9, #21, #36, and #40 tested positive for amphetamines during a facility investigation of possible drug use at the facility. These deficient practices could affect residents by contributing to further abuse and neglect. The findings were: Resident #9 Record review of Resident #9's admission record revealed a [AGE] year-old male admitted [DATE] and readmitted [DATE] with diagnoses of chronic obstructive pulmonary disease (a common lung disease that makes it difficult to breathe. It's caused by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice for 2 of 2 (Resident #29 and Resident #163) reviewed for respiratory care. 1. The facility failed to ensure Resident #29 had a oxygen sign posted on his door to alert he had an oxygen tank and concentrator in his room. 2. The facility failed to post a sign to show Resident #163 had oxygen in use. The facility failed to ensure Resident #163 had an active order for oxygen. The facility failed to ensure Resident #163 oxygen tubing was not on the floor. This deficient practice could place residents at risk for an increase in respiratory complications and make other unaware oxygen is in use. The findings included: 1. Record review of Resident #29's admission record dated 11/22/24, revealed a [AGE] year old male resident was admitted on [DATE] and readmitted on [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician and others participating in the provision of care for 1 of 2 residents (Residents #30) reviewed for hospice services in that: The facility failed to maintain required hospice forms and documentation in the current hospice binders in the facility to ensure residents received adequate end-of-life care. This failure could place the residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. The findings included: Record review of Resident #30's Resident Face Sheet documented a [AGE] year old female admitted to the facility on [DATE] with diagnoses that included opioid…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs that are identified in the comprehensive assessment, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 7 of 10 residents (Resident #1, 2, 3, 4, 5, 6, and 7) reviewed for comprehensive care plans, in that: 1. The facility failed to ensure Resident #1, who needed to have one staff assist for transfer, had a care plan regarding how to transfer the resident from bed-to-chair. 2. The facility failed to ensure Resident #2, who needed to have one staff assist for transfer, had a care plan regarding now to transfer the resident from bed-to-chair. 3. The facility failed to ensure Resident #3, who was assessed as dependent for transfers, described as needing assistance of 2 or more helpers,…

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 residents have a right to personal privacy for 1 of 8 residents (Resident #8) reviewed for privacy, in that: CNA B and CNA C failed to provide privacy while providing peri-care to Resident #8 by not closing Resident #8's privacy curtain. This failure could place residents at-risk of loss of dignity due to lack of privacy. The findings include: Record review of Resident #8's face sheet, dated 11/08/2024, reflected an admission date of 08/12/2024 with diagnoses which included: Rheumatoid lung disease (lung condition associated with rheumatoid arthritis which can cause scarring, inflammation and nodules in the lung); Noninfective gastroenteritis (stomach virus) and colitis (inflammation in colon); Rheumatoid arthritis of right knee (type of arthritis where immune system attacks the tissue lining the joints); Type 2 diabetes mellitus (chronic condition of high level of sugar in blood), Major depressive Disorder (mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, 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 ensure that a resident who was incontinent of bladder and bowel received appropriate treatment and services for 1 of 10 residents (Residents #10) reviewed for incontinent care, in that: When LVN-D and CNA-E was providing bowel and bladder incontinent care to Resident #10 on 11/06/2024 at 4:24 p.m., LVN-D wiped Resident #10's buttock by only one pass with a cleaning cloth wipe as the resident had bowel movement, and LVN-D put the new brief under the resident's buttock after changing gloves, but the resident's buttock had still residual of stool. These failures could place residents at-risk for infection due to improper care practices. The findings included: Record review of Resident #10's face sheet, dated 11/08/2024, reflected the resident was [AGE] years old, male, and admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of cerebral infarction (disrupted blood flow to the brain due to problems with the blood…

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

Based on observation, interview, and record review, the facility failed to ensure all drugs and biological were stored in locked compartments of one out of two nursing carts (200-hall nursing cart) reviewed for storage, in that: The facility failed to ensure the 200-hall Nursing Cart was locked when left unattended. This failure could place residents at risk of misappropriation of medications or harm due to accidental ingestion of unprescribed mediations. The findings were: During an observation on 11/07/2024 at 1:08 PM, the 200-hall nursing cart was found unlocked and unattended. This surveyor was able to open all drawers revealing multiple blister packs and bottles of medication. Interview on 11/07/2024 at 1:10 PM with LVN-F stated she was helping a resident due to call-light on. LVN-F stated she did not realize she left the nursing cart unlocked. LVN-F stated it was important the nursing cart was locked at all times due to resident, visitor, and staff safety. LVN-F stated by the nursing cart being unlocked, anyone could get into the cart and take medications from the cart.…

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 to help prevent the development and transmission of communicable diseases and infections for 1 of 8 residents (Resident #8) reviewed for infection control in that: CNA B and CNA C failed to follow Enhanced Barrier Precautions (EBP) by not wearing gowns while performing peri-care for Resident #8. This failure could place residents at risk for cross contamination and the spread of infection. Finding include: Record review of Resident #8's face sheet, dated 11/08/2024, reflected an admission date of 08/12/2024 with diagnoses which included: Rheumatoid lung disease (lung condition associated with rheumatoid arthritis which causes scarring, inflammation and nodules in lungs); Noninfective gastroenteritis (stomach virus) and colitis (inflammation in colon); Rheumatoid arthritis of right knee (type of arthritis where immune system attacks the tissue lining the joints); Type 2 diabetes mellitus…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to treat residents with respect and dignity for 1 of 6 (Resident #21) residents reviewed for dignity in that: Facility staff stood over Resident #21 while assisting the resident with her meal in the dining area. This failure could affect residents who require assistance with activities of daily living and place them at risk for psychosocial harm due to a diminished quality of life. The findings were: Review of Resident #21's Face Sheet dated 10/15/2023 reflected a [AGE] year-old-female initially admitted on [DATE] with diagnoses including but not limited to the following: heat failure, moderate protein calorie malnutrition, and pneumonitis due to inhalation of other solid and liquids. Review of Resident #21's Quarterly MDS, dated [DATE] reflected sever cognitive impairment, never/rarely making decisions. Review of Resident #21's Care Plan dated 10/16/2023 reflected the following problems: Resident is receiving a pureed textured diet 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.

Based on interview and record review the facility failed to provided a private meeting space for residents' monthly council meetings for for 6 out of 8 residents reviewed for resident council in that: Six residents in a confidential resident group interview said they were not able to meet without interruptions from staff. This failure could place residents that participate in a resident council at risk of not having the right to voice their concerns without staff being present or overhearing their concerns and to conduct resident council meetings without interference. Findings include: In an interview with the Activity Director on 10/16/2023 at approximately 2:45 p.m., after the confidential Resident Meeting conducted during survey, the Activity Director said they do have the monthly Resident Council Meetings in the dining area and staff do sometimes walk through the meetings but they should not so the residents can have privacy. In an interview with the Administrator on 10/18/2023 at 4:18 p.m., the Administrator said the residents should be able to have as much privacy as possible…

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 The facility failed to have the physician's signature on the Out of Hospital Do Not Resuscitate (OOHDNR) order, for Resident # 25 which made the advanced directive invalid. This failure could affect any resident in the facility who had an OOHDNR in their chart and place them at risk of having cardiopulmonary resuscitation (CPR) performed against their wishes. Findings: Record review of Resident #25's face sheet dated [DATE] revealed a (current) admission date of [DATE] with diagnoses that included: cerebral infarction (sometimes called a stroke or a brain attack), hypertension (high blood pressure), dementia (impaired thinking), dysphagia (difficulty swallowing), cognitive communication deficit (difficulty with thinking and how someone uses language to communicate). Record review of Resident #25's Quarterly MDS review assessment revealed a BIMS of 10, which suggested moderate cognitive impairment. Record review of Resident #25's most recent care plan dated [DATE] revealed code status of DNR (no CPR), with a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 1 of 5 residents (Residents #38) reviewed for privacy. The facility failed to ensure Resident #38 was provided privacy during a treatment. This failure could place residents at-risk of loss of dignity due to lack of privacy. The findings included: Record review of Resident #38's face sheet dated 10/16/23 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included chronic pain syndrome, pain in joints of left hand, lack of coordination and repeated falls. Record review of Resident #38's most recent quarterly MDS, dated [DATE] revealed the resident was moderately cognitively impaired for daily decision-making skills. Record review of Resident #38's comprehensive care plan, edit date 9/19/23 revealed the resident had experienced falls with approach to monitor for pain. Record review of Resident #38's physician's orders, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide housekeeping and maintenance services necessary to maintain a safe, sanitary, orderly, and comfortable interior for 1 of 10 Resident's (Resident #41) reviewed for environment. The facility failed to ensure the broken and missing tiles in the restroom and the peeling drywall in Resident #41's bedroom was repaired. These failures could affect any resident and place them at risk for not having a safe and sanitary homelike environment. The findings included: Record review of Resident #41's face sheet, dated 10/17/23 revealed a [AGE] year old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included lack of coordination, morbid obesity due to excess calories, pain, muscle wasting and atrophy (muscle wasting) and multiple sclerosis (chronic, progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord causing numbness, blurred vision and severe fatigue). Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident received care consistent with professional standards of practice to prevent pressure ulcers and does not develop pressure ulcers unless the resident's clinical condition demonstrated they were unavoidable for 1 of 1 resident (Resident #20) reviewed for pressure ulcers in that: The facility failed to ensure Resident #20's offloading boots, which were used to prevent skin breakdown, were placed on the resident. This failure could place residents at risk for the development of pressure injuries. The findings included: Record review of Resident #20's face sheet, dated 10/17/23 revealed an [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included pain due to internal orthopedic prosthetic devices, lack of coordination, muscle wasting and atrophy (wasting away of body tissue) and open wound left hip. Record review of Resident #20's most recent quarterly MDS assessment, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that a resident who need respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences, for 1 of 2 residents (Resident #20) reviewed for respiratory care. The facility to ensure Resident #20's oxygen concentrator nasal canula tubing and water reservoir was labeled with a date and the oxygen concentrator filter was missing. These failures could affect residents who were dependent on respiratory care and could contribute to upper respiratory infections and worsening of their physical condition. The findings included: Record review of Resident #20's face sheet, dated 10/17/23 revealed an [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included [NAME] cardia (slow heartbeat), seizures, heart disease, muscle wasting, and encounter for prophylactic measures. Record review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an irregularity noted by the pharmacist was acted upon for 1 (Resident #31) of 2 residents reviewed for pharmacy review in that: The licensed pharmacist made recommendations for an evaluation and a consideration of a dose reduction of Citalopram (a psychotropic medication used for depression) but there were no actions taken and no documented rationale for why actions were not taken. This failure could place resident as risk of not having their pharmacy consultations reviewed. The finding were: Record review of Resident # 31's face sheet, dated 10/18/2023, revealed the resident was admitted to the facility on [DATE] with diagnoses that included but not limited to: major depressive disorder, recurrent (feelings of sadness for a prolonged period of time that cycle and repeat more often than not), dysphagia (causes difficulty swallowing), moderate protein calorie malnutrition (person is not able to get enough nutrition from intake to sustain…

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 1 of 4 Medication Carts (A Wing Medication Cart) reviewed for storage of drugs, in that: The A Wing Medication Cart was left unlocked, unattended and had 6 bottles of medications on top of the medication cart counter. This failure could place residents at risk of medication misuse and diversion. The findings included: Observation on 10/15/23 at 9:07 a.m. revealed the A Wing Medication Cart was facing the entry to the facility in the main hallway with the medication cart unlocked and unattended. Upon closer inspection, the A Wing Medication Cart had 6 stock bottles of medications on top of the medication cart. During an interview on 10/15/23 at 9:08 a.m., RN C stated the A Wing Medication Cart she was using had only been unlocked for a short time. RN C stated the medication cart was not supposed to be left unlocked…

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

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. The facility failed to label and date food items in the kitchen walk-in refrigerator and walk-in freezer. The facility failed to ensure staff used beard net during food preparation. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. Findings included: Observations on 10/15/2023 at 9:10 am and on 10/16/2023 at 7:08 am revealed KS was not wearing a beard net while he prepared food. Interview on 10/16/2023 at 7:08 am with KS and DM, both verified that KS should have worn a beard net to prevent the potential for food contamination. Observation on 10/17/2023 at 10:55 am revealed an opened box of bacon not dated, opened bag of pancakes in the freezer not dated, a package of frozen hamburger buns opened, not dated, with one bun missing with a date of July 2023. Interview on 10/18/2023 at 10:45 AM the DM stated people could…

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 clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 5 residents (Resident #20) reviewed for accuracy of medical records. The facility failed to accurately document Resident #20's physician's orders to apply bilateral heel boots (offloading boots) while the resident was in the bed. This failure could affect residents whose records are maintained by the facility and could place them at risk for errors in care and treatment. The findings included: Record review of Resident #20's face sheet, dated 10/17/23 revealed an [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included pain due to internal orthopedic prosthetic devices, lack of coordination, muscle wasting and atrophy (wasting away of body tissue) and open wound left hip. Record review of Resident #20's most recent quarterly MDS assessment, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 3 residents (Resident #38 and #116) reviewed for infection control practices, in that: 1. LVN A failed to utilize appropriate hand hygiene during the medication pass with Resident #38. 2. CNA D and LVN E failed to utilize appropriate infection control practices when entering Resident #116's room who was on transmission-based precautions. These failures could place residents at risk for infection and or a decline in health. The findings included: 1. Record review of Resident #38's face sheet dated 10/16/23 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included chronic pain syndrome, pain in joints of left hand, lack of coordination 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.