Paradigm at the Oak

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure all alleged violations involving abuse, 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 was made, if the events caused the allegation involved abuse or result 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 State Survey Agency in accordance with State law through established procedures for 1 of 6 residents (Resident #1) reviewed for reporting allegations of abuse. The facility failed to report physical and verbal abuse to the State Agency within 2 hours when, on 02/07/2026, it was reported to Administrator by MT A that LVN A made a threat to Resident #1 and tapped Resident #1 in the back of the head. The noncompliance was identified as Past Noncompliance. The Immediate Jeopardy (IJ)…

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 residents received adequate supervision, to the extent possible for 1 of 8 residents (Resident #2) reviewed for safety. The facility failed to ensure Resident #2 followed the facility safe smoking policy when on 12/14/2026 and additional unknown dates staff smelled cigarette smoke in Resident #2's room.on 01/31/2026 staff members observed two packages of cigarettes in Resident #2's roomon unknown dates CNAs observed Resident #2 with lighters. These failures could place residents at risk for avoidable accidents and injuries.Findings included: Record review of Resident #2's face sheet, dated 02/19/2026, revealed a thirty-seven-year-old male who was admitted to the facility on [DATE]. His admitting diagnoses included paraplegia (impairment or loss of motor and sensory function in the lower extremities), anxiety disorder, and major depressive disorder. Record review of Resident #2's MDS (clinical assessment to determine resident's strength and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection 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 9 residents (Resident #1) observed for infection control practices. The facility failed to ensure LVN A followed standard precautions during wound care on 12/11/2025 for Resident #1's wounds when she failed to perform hand hygiene between glove changes. This failure could place residents at risk for healthcare-associated cross-contamination and infections. Findings included: Review of Resident #1's face sheet dated 12/11/2025 revealed Resident #1 is a [AGE] year-old male who was admitted into the facility on [DATE] with the following diagnoses: Multiple Myeloma (a rare blood cancer of plasma cells in the bone marrow), Paraplegia (paralysis affecting the lower half of the body), Generalized muscle weakness, Anxiety…

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 an effective pest control program was implemented so the facility was free of pests and rodents for 1 of 1 facility reviewed for pest control observed and four (Resident #1, Resident #3, Resident #6, and Resident #7) of seven residents reviewed.The facility failed to keep roaches and rodents out of resident rooms, the facility kitchen, facility common areas, and rest rooms.These failures placed residents at risk of infection, feelings of fear, anxiety, disgust, helplessness, shame, and a diminished quality of life.Findings included:Review of Resident #1's face sheet dated 09/22/25 reflected a 62-year-male who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including human immunodeficiency virus [HIV] disease (a virus that attacks the body's immune system), type 2 diabetes mellitus with unspecified complications (a chronic condition in which the body does not use insulin effectively and has not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs for one (Resident #3) of six residents reviewed for pharmacy services.The facility failed to administer Resident #3's Lidocaine Pain Relief External 21 times between 08/08/25 and 09/06/25. This failure could place residents at risk of worsening of their condition, increased risk of falls, pain, and injury.Findings included:Review of Resident #3's face sheet, dated 09/11/25, reflected a 36-year-male who was admitted to the facility on [DATE] with diagnoses including paraplegia (a condition characterized by the loss of voluntary movement and sensation in both lower limbs, typically resulting from an injury to the spinal cord in the thoracic or lumbar regions), displaced fracture of acromial process, right shoulder, initial encounter for closed fracture (a broken bone (acromion)…

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 serve foods that were palatable and prepare food by methods that conserve nutritive value, flavor, and appearance for 1 of 1 kitchen observed and five (Resident #1, Resident #3, Resident #4, Resident #5, and Resident #6) of ten residents reviewed.The facility failed to serve warm food to residents.These failures could place residents at risk of decreased food intake, hunger, unwanted weight loss, and diminished quality of life. Findings included:Review of Resident #1's face sheet, dated 09/22/25, reflected a 62-year-male, admitted on [DATE] and readmitted on [DATE] with diagnoses including human immunodeficiency virus [HIV] disease (a virus that attacks the body's immune system), type 2 diabetes mellitus with unspecified complications (a chronic condition in which the body does not use insulin effectively and has not developed any specific complications that can be identified), and bipolar disorder, current episode manic without…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility for one (Resident #2) of five residents reviewed for transfer and discharge rights, in that:The facility failed to:1. provide documentation that Resident #2's guardian received sufficient preparation and orientation when Resident #2 was discharged to a facility not within Resident #2's guardian's jurisdiction2. Provide documentation from Resident #2's psychiatric NP that Resident #2 was a danger to himself or other residents3. Provide documentation that the ombudsman was informed of the discharge4. Provide documentation that Resident #2 received a discharge notice.This failure could place residents at risk of not receiving care and services to meet their needs upon discharge.Findings included: Review of Resident #2's face sheet dated 09/11/25 reflected a 49-year-male who was admitted to the facility on [DATE] 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 record reviews and interviews, the facility failed to develop and implement a baseline care plan that included the instructions needed to provide effective and person-centered care of the residents that meet professional standards of quality care for one (Resident #3) of five residents reviewed for baseline care plans. The facility failed to create a baseline care plan for how to transfer Resident #3, a paraplegic, within 48hours of his admission. This failure could place residents at risk of not receiving goals and interventions for their individual needs for person centered care and safe transfers. Findings included:Review of Resident #3's face sheet, dated 09/11/25, reflected a 36-year-male who was admitted to the facility on [DATE] with diagnoses including paraplegia (a condition characterized by the loss of voluntary movement and sensation in both lower limbs, typically resulting from an injury to the spinal cord in the thoracic or lumbar regions), displaced fracture of acromial process, 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 observations, interviews, and record reviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for 3 of 8 (Resident #1, Resident #2 and Resident #3) residents reviewed for a homelike environment. The facility failed to ensure Resident #1 and Resident #2's wheelchairs were clean and free of debris. The facility failed to maintain the cleanliness of the upstairs and downstairs dining rooms.The facility failed to clean the floors, leaving a sticky residue.The facility failed to provide toilet paper and paper towels in Resident #1, #2 and #3's bathrooms.These failures could place residents at risk of living in an uncomfortable and unsafe environment, decreased feelings of self-worth, and a diminished quality of life.During an observation on 7/7/25 at 4:49 p.m. of the downstairs dining room in the secured unit revealed the floor had a sticky/tacky residue, and a squeaking sound was heard from the floor as residents and staff walked around the dining room. The State surveyor's shoes stuck to the floor. The floors looked brown from old food…

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, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public.The facility failed to ensure the halls outside of the rooms of Residents #1, #2, #3, #4, #5, #6, and #7 were thoroughly cleaned and sanitized.The walls had bare pieces of unpainted drywall.This deficient practice could place residents at risk of living in an unclean and unsanitary environment, which could lead to a decreased quality of life.Findings included:Record Review of Resident #2's Facesheet demonstrates they are a resident at Paradigm at the Oak and reside on the secure unit. Resident #2 has a BIMS of 9.An observation on 07/07/25 at 3:25 PM upon entering the facility, the floor was covered in a thin film of grime, causing the investigators' shoes to stick to the floor. The floor was so sticky, detritus stuck to it, giving the floor a textured appearance. Flecks of dirt and pieces of paper were visible and could not be moved when prodded 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 were free from abuse for 4 of 8 residents reviewed for abuse. Resident #1 and Resident # 2 had an altercation on 5/2/25 due to Resident # 1 was moving too slowly per Resident # 5. Resident #3 and Resident #4 had an altercation on 5/1/25 regarding possession of sunglasses. These failures could place residents at risk of physical harm, mental anguish, and/or emotional distress. Findings included: Resident #1 and Resident #2: Record review of Resident #1's chart revealed Resident #1 was admitted to the facility on [DATE] and was a [AGE] year-old male with diagnoses which include: Atherosclerotic Heart Disease (Atherosclerosis is the buildup of plaque in the arteries, which can reduce blood flow and cause heart disease, stroke, or other conditions), Type 2 Diabetes Mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates 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 interview and record review, the facility did not provide pharmaceutical services to meet the needs of each resident for one (Resident #1) of six residents reviewed for pharmaceutical services. The facility repeatedly failed to administer scheduled time-sensitive medications to Residents #1 from 02/05/25 through 02/24/25. This deficient practice could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements or could result in worsening or exacerbation of chronic medical conditions. Findings included: Review of Resident #1's 03/27/25 face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including schizoaffective disorder (a mental health condition that combines symptoms of schizophrenia and a mood disorder, such as depression or bipolar), dementia, cognitive communication, presence of cerebrospinal fluid drainage device (a hollow tube surgically placed in the brain to help drain…

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 residents were free of any significant medication errors for 1 resident (Resident #1) of six residents reviewed for pharmacy services. The facility repeatedly failed to administer scheduled time-sensitive medications to Residents #1 from 02/05/25 through 02/24/25. This deficient practice could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements, worsening or exacerbation of chronic medical conditions, and hospitalization. Findings included: Review of Resident #1's 03/27/25 face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including schizoaffective disorder (a mental health condition that combines symptoms of schizophrenia and a mood disorder, such as depression or bipolar), dementia, cognitive communication, presence of cerebrospinal fluid drainage device (a hollow tube surgically placed in the brain to help…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 4 of 27 residents (Resident #26, Resident #54, Resident #58, and Resident #365) and 1 of 1 facility reviewed for a clean and homelike environment. A) The facility failed to ensure Resident #54, Resident #58, and Resident #365 had hot water to use for comfortable bathing/showers and ADL care. B) The facility failed to ensure Resident #26's wheelchair was maintained. C) The facility failed to: a. ensure the baseboard in the downstairs dining room next to the soda machine was attached to the wall and the damage to the sheetrock along the wall was repaired. b. ensure the flooring tiles around the soda machine and the ice machine in the dining room were securely attached to the floor and the missing floor tiles were replaced. c. ensure the floor in the downstairs dining room was cleaned and free of dirt, debris, sticky residue, and water. These failures could place residents at…

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 a comprehensive care plan within seven days after completion of the comprehensive assessment for three ( Resident #4, Resident #21, and Resident #31) of six residents reviewed for care plans. The facility failed to ensure Resident #4, Resident #21, and Resident #31 comprehensive care plans were completed within seven after of their comprehensive assessments. This failure placed residents at risk of not receiving appropriate care and services to maintain the highest practical well-being. Findings included: Review of Resident # 4's face sheet, dated 01/22/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident # 4 had diagnoses which included seizures ( a sudden burst of abnormal activity in the brain that causes temporary changes in behavior, movement, and awareness), neuroleptic induced parkinsonism (medication caused parkinsonism antipsychotic -included one of the three criteria:…

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 provide an ongoing activities program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interest of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction on the secure unit. The facility failed to provide activities on the secure unit as scheduled for the month of January 2025. This failure placed residents at risk for boredom, depression, increased behaviors, and diminished quality of life. Findings include: Review of the January 2025 Activity Calendar for the secure unit reflected it was the same calendar for residents not residing on the secure unit. Review on 01/26/2025 of the large print activity calendar located on the wall in the secure unit reflected on 01/26/2025 Church was to be provided at 9:00 AM. Observation on 01/26/2025 at 9:05 AM there was not church services on the secure unit. Review of the in-room activity participation binder…

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 medication error rate was not five percent or greater. The facility had a medication error rate of 9.68% based on 3 out of 31 opportunities, which involved 2 of 4 residents (Resident #17 and Resident #29) and 2 of 2 MA's (MA F and MA G) observed during medication administration reviewed for medication error. 1. The facility failed to ensure Resident #17's blood pressure medication Lisinopril and Losartan had blood pressure parameters for administration. On 01/27/2025 at 8:18 AM, MA F held the medications without physician orders. 2. The facility failed to ensure Resident #29's physician orders were followed for vitamin D tablet 50 mcg. On 01/27/2025 at 9:23 AM, MA G administered Resident #29 Vitamin D 25 mcg. These deficient practices could place residents at risk of not receiving therapeutic dosage of medications and symptomatic changes in vital signs. Findings include: 1. Record review of Resident #17 face sheet, dated…

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

Based on observation, interview, and record review, the facility failed to store, prepare, distribute food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure Dietary Aide M wore a beard guard and Dietary Aide O wore a hair net when standing over the food prep table, clean dishes, and plates of food. 2. The facility failed to ensure Dietary Aide M used proper hand sanitation during food preparation for the lunch meal. These failures could place residents at risk for foodborne illness. Findings include: 1. Observation on 01/26/2025 at 9:15 AM revealed Dietary Aide O stood over the food prep table and clean dishes and did not wear a hair net . Observation on 01/26/2025 at 12:15 PM revealed Dietary Aide M was not wearing a beard guard and was standing over the plates of food being placed on the meal trays. He had approximately 8 inches of hair growth on the area of his chin and partial both jaws Interview on 01/26/2025 at 9:20 AM, Dietary Aide O stated she was expected to wear a hair…

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 16 residents reviewed for infection control practices. 1. The facility failed to ensure RN A used aseptic technique during tracheotomy suctioning and tracheotomy care for Resident #54 on 01/27/2025. 2. The facility failed to ensure RN A performed hand hygiene between glove changes during wound care for Resident #54. 3. The facility failed to ensure RN A performed wound care for Resident #54 using a sterile technique. 4. MA G failed to sanitize the blood pressure cuff during medication pass after using it on Resident #29. These failures could place residents at risk for developing wounds, upper respiratory infections and risk for healthcare associated cross-contamination and infections. Findings include:…

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 care plan that describes the services that are to be furnished to maintain the resident's highest practicable physical, mental, and psychosocial well-being for one resident (Resident #18) of 18 reviewed, in that: The facility failed to ensure Resident #18's Comprehensive Care Plan reflected a plan of care for her right-hand contracture (A permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen and a decrease in ROM). This failure could place residents with contractures at risk for decrease in mobility, range of motion, and contribute to worsening of contractures. Findings included: Review of Resident #18's face sheet dated 01/28/2025 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: Alzheimer's disease (A type of brain disorder that causes problems with memory, thinking and behavior.),…

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 unable to carry out activities of daily living receives the necessary services to maintain grooming and personal hygiene for 1 of 13 residents (Resident #58) reviewed for ADLs. The facility failed to ensure Resident #58's fingernails were cleaned 01/26/2025 through 01/28/2025. This failure could place residents at risk of not receiving services or care, decreased quality of life, and decreased self-esteem. The findings included: Review of Resident #58's Face Sheet dated 01/28/2025 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (metabolic disorder in which the body has high sugar levels for prolonged periods of time) with diabetic chronic kidney disease, methicillin resistant staphylococcus aureus (infections caused by specific bacteria that are resistant to commonly used antibiotics) infection as the cause of diseases classified elsewhere,…

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 received care, consistent with professional standards of care to prevent development or worsening of pressure ulcers for one of five residents (Resident #54) reviewed for pressure ulcers. The facility failed to ensure RN A followed standard precautions during wound care on 01/27/2025 for Resident #54's right and left heels, right and left ischial and coccyx Stage IV pressure ulcers, when she failed to perform hand hygiene between glove changes, use a cleaning technique on the pressure ulcer that did not cross contaminate the pressure ulcer or prevent the pressure ulcer once cleaned from becoming re-contaminated. This failure could place residents at risk for worsening pressure ulcers leading to discomfort, pain, and potential infections. Findings included: Review of Resident #54's face sheet dated 01/28/2025 reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses paraplegia (is…

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 1of 2 residents reviewed with limited range of motion (Resident #18), received appropriate treatment and services to prevent a decrease in range of motion. The facility failed to ensure Resident #18 had interventions in place for her right- hand contracture (A permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen and a decrease in ROM) to prevent further decline of the range of motion in her right hand. This deficient practice placed residents with contractures at risk for decrease in mobility, range of motion, and could contribute to worsening of contractures. Findings Include: Review of Resident #18's face sheet dated 01/28/2025 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: Alzheimer's disease (A type of brain disorder that causes problems with memory, thinking and behavior.), Parkinsonism (A progressive…

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 who are incontinent of bladder receive appropriate treatment and services to prevent urinary tract infections for one of one residents reviewed for catheters (Resident #54). The facility failed to ensure Resident #54 received care to prevent urinary tract infections when RN A placed his catheter bag on the bed with him during wound care. These failures could place residents with external catheters at risk for urinary tract infections and change of condition. Findings included: Review of Resident #54's face sheet dated 01/28/2025 reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: paraplegia (is an impairment in motor or sensory function of the lower extremities.), respiratory failure (happens when something keeps your body from getting oxygen into your blood or getting carbon dioxide out of your blood.), and anoxic brain damage (is damage to the brain due to a lack of oxygen…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents goals and preferences for 1 of 1 resident (Resident #54) reviewed for tracheostomy care. The facility failed to ensure RN A used aseptic technique (a procedure that healthcare providers use to prevent the spread of germs that cause infection.) during tracheostomy care and tracheal suctioning for Resident #54 by not performing hand hygiene, placing barriers, or using sterile equipment. This failure could place residents at risk for respiratory infections and respiratory distress. Findings include: Record review of Resident #54's face sheet, dated 01/28/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #54 had diagnoses which included paraplegia (is an impairment in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for 1 of 7 residents (Resident #6) reviewed for unnecessary drugs. The facility failed to monitor Resident #6 for adverse effects of prophylactic antibiotic use. This failure could place residents at risk of nausea, diarrhea, and secondary infection. Findings include: Record review of Resident #6's admission record, dated 01/26/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included, but not limited to, cerebral infarction (a stroke occurs when blood vessels in the brain are blocked or reduced), paranoid schizophrenia (a mental health condition that affects thinking, memories, and senses, and often involves paranoia and delusions), encephalopathy (a group of disorders that affect the brain and cause altered mental state), and retention of urine. Record review of Resident #6's admission MDS, dated [DATE], reflected…

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 an infection prevention and control program (IPCP) that included, at a minimum, an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for 1 of 5 residents (Resident #6) reviewed for antibiotic stewardship program. The facility failed to follow antibiotic stewardship policy for Resident #6 by not ensuring a duration for medication. This deficient practice could place residents at risk for unnecessary antibiotic use, inappropriate antibiotic use and increased multi drug resistant organisms. Findings include: Record review of Resident #6's admission record, dated 01/26/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included, but not limited to, cerebral infarction (a stroke occurs when blood vessels in the brain are blocked or reduced), paranoid schizophrenia (a mental health condition that affects thinking,…

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 each resident bedside and toilet and bathing facilities were adequately equipped to allow all residents to call for staff assistance through a communication system that would relay the call directly to a staff member or a centralized staff work area for 1 of 13 residents (Resident #58) reviewed for resident call system . The facility failed to provide a working communication system, that was easily at reach, that would allow Resident #58 the ability to safely call for staff for assistance. This failure could place residents at risk of not having a means of directly contacting caregivers in an emergency or when they needed support for daily living. The findings include: Record review of Resident #58's Face Sheet, dated 01/28/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #58 had diagnoses which included type 2 diabetes mellitus (metabolic disorder in which the body has high sugar levels for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality and failed to protect and promote the rights of the residents for three (Resident #4, Resident #5, and Resident #6) of eight residents reviewed for resident rights. The facility failed to purchase cigarettes for approximately five days for Residents #4, #5, and #6. This failure placed residents at risk for a decreased quality of life, loss of enjoyment, and loss of freedom. Findings included: Resident #4 Review of Resident #4's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including legal blindness, history of stroke, and type II diabetes. Review of Resident #4's quarterly MDS assessment, dated 08/10/24, reflected a BIMS score of 6, indicating he had a severe…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide food prepared by methods that conserve nutritive value, flavor, and appearance for three (Resident #5, Resident #7, and CR #8) of eight residents reviewed for meal palatability. The facility failed to serve food that was palatable and aesthetically appetizing for Resident #5, Resident #7, and CR #8 . This failure could place residents at risk for altered nutritional status, weight loss, and a decline in quality of life. Findings included: Resident #5 Review of Resident #5's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including depression, generalized anxiety disorder, bipolar disorder, and history of stroke. Review of Resident #5's quarterly MDS assessment, dated 09/14/24, reflected a BIMS score of 10, indicating he had a moderate cognitive impairment. Review of Resident #5's quarterly care plan, dated 09/10/24, reflected he had a nutritional problem or potential…

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 if the alleged violation involved abuse or neglect resulted in bodily injury, to other officials (including the State Agency) for one (Resident #1) of five residents reviewed for abuse. The facility failed report an incident of sexual abuse to HHSC after Resident #2 was observed sexually assaulting Resident #1. This deficient practice could place residents at risk of abuse and neglect. Findings included: Review of Resident #1's undated care plan reflected a [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses including dementia, cognitive communication deficit, depressive episodes, anxiety disorder, and muscle weakness and atrophy (wasting away). Review of Resident #1's quarterly care plan assessment,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #1) of four residents reviewed for medications. The facility failed to ensure LVN A did not administer Resident #1 an injection of diphenhydramine HCl solution (an antihistamine) used for agitation without a physician's order. This deficient practice could place residents at risk of consuming unprescribed medications, harm, and hospitalization. Findings include: Record review of Resident #1's, undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included epilepsy (seizures), bipolar disorder, major depressive disorder, and anxiety disorder. Record review of Resident #1's quarterly MDS assessment, dated 02/08/24, reflected he had a BIMS of 15, which indicated he had no…

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 store, prepare, distribute, and serve food under sanitary conditions in the facility's only kitchen. The facility failed to date food and beverages found within the facility's freezers and refrigerator. The facility failed to date and properly seal food products in facility freezers. The facility failed to remove dented cans from the dry storage area to prevent service to residents. The facility failed to clean the juice machine nozzle and industrial can opener. These failures could place the residents who ate food from the kitchen at risk of cross contamination, loss of nutritional value, weight loss, and foodborne illness. Findings included: In an observation on 11/07/2023 at 9:39 AM, the facility's three door refrigerator (no name or number) was found to contain two plastic bins that held plastic glasses with juice in them. Both bins had aluminum foil across the top of the glasses with one stacked on top of the other, with no 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 observation, interview, and record review the facility failed to ensure maintenance services necessary to maintain a sanitary, orderly, and comfortable interior environment for residents in the secured unit for ten (room [ROOM NUMBER], 5, 6, 7, 9, 11, 12, 13, 15, and 16) of sixteen occupied rooms. The facility failed to ensure that resident rooms had adequate pressure and hot water. The facility failed to ensure that the faucets in resident rooms had both hot and cold-water knobs. The facility failed to ensure that resident rooms faucets were free of leaks and operational. The facility failed to make repairs to a damaged metal door frame placing residents at risk for injury. These failures could place the residents at risk of not receiving a safe, clean, comfortable, and homelike environment to attain and maintain their highest practicable physical, mental, and psychosocial well-being. Findings included: In an observation on 11/07/2023 at 11:03 AM, the faucet in room [ROOM NUMBER] had no cold-water…

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 treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his quality of life for one (Resident #4) of one resident reviewed for rights. The facility failed to provide Resident #4 with dignity during breakfast and lunch service when they served his meals to him on a rolling tray table that faced a wall, while all other residents sat at dining tables in view of each other. The facility failed to ensure that Resident #4 was provided assistance when needed during meal times, which resulted in him eating food with his hands, off the tray table, off his wheelchair seat, and the floor. This failure placed the resident at risk of a decline of their sense of dignity, level of satisfaction with life, and feelings of self-worth. Findings included: Review of Resident #4's Face Sheet ([DATE]) revealed that he was a [AGE] years of age male, who was admitted to the facility on [DATE]. 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 observation, interview and record review, the facility filed to ensure assessments accurately reflected the status of 1 of 15 residents reviewed for assessments (Resident #40) Resident #40's quarterly MDS assessment dated [DATE] incorrectly documented active diagnoses of pneumonia and septicemia. This failure could place residents at risk of not having individual needs met. Findings included: Review of Resident #40's face sheet printed 11/09/2023 reflected Resident #40 was admitted on [DATE] with diagnoses including Essential Hypertension (high blood pressure), Cerebral Infarction (a blockage that cuts off the blood supply to part of the brain killing brain cells), Acute Respiratory Failure with Hypoxia (a condition where the lungs cannot supply oxygen to the blood and organs), Sepsis Unspecified Organism (an infection in the blood stream), Pneumonia (an infection of the air sacks in the lungs often with cough, fever, and difficulty breathing), Hemiplegia (decreased or no movement on one side of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure all Pre-admission Screening and Resident Review (PASARR) Level I residents with a mental illness was completed correctly and were provided with a PASARR Level II assessment for two (Resident #44 and Resident #52) of seven residents reviewed for PASARR assessments. Resident #44's PASARR Level l did not indicate a diagnosis of mental illness, although diagnosis was present upon admission. Resident #52's PASARR Level l did not indicate a diagnosis of mental illness, although diagnosis was present upon admission. These failures could place all residents who had a mental illness at risk for not receiving needed assessment, care, and services to meet their needs. Findings included: Review of Resident #44's face sheet printed on 11/09/2023 reflected Resident #44 was admitted [DATE] and readmitted on [DATE] with diagnoses including schizoaffective disorder (a mental disorder in which people interpret reality abnormally combined with a impaired mood) 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 ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 (Resident #36) of 1 resident reviewed for trauma-informed care. The facility failed to accurately identify possible triggers for Resident #36 who had a diagnosis of Post-Traumatic Stress Disorder. This failure could place residents at increased risk for psychological distress due to re-traumatization. Findings included: Review of Resident #36's face sheet printed on 11/09/2023 reflected Resident #36 was admitted [DATE] and readmitted on [DATE] with diagnoses including Post-Traumatic Stress Disorder Chronic (mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent…

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 special eating equipment and utensils for residents who need them for one (Resident #4) of one resident reviewed for feeding assistance. The facility failed to provide Resident #4 with a divided plate to assist him with eating independently. This failure could place residents at risk for loss of self-worth and empowerment for independent eating, which could lead to unplanned weight loss. Findings included: Review of Resident #4's Face Sheet ([DATE]) revealed that he was a [AGE] years of age male, who was admitted to the facility on [DATE]. Resident #4 is diagnosed Neuroleptic Induced Parkinsonism (antipsychotic medication induced motor syndrome that manifests as rigidity, tremors, and slowness of movement), Schizoaffective Disorder (mental illness that can affect thoughts, mood, and behavior), Severe Dementia with Psychotic Disturbance (decline in thinking and problem-solving skills as well as delusions or hallucinations 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.