Estates At Shavano Park

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 1 of 20 residents (Residents #41) reviewed for food and nutrition services. The facility failed to ensure Resident #41's personal refrigerator, located in his room, did not have a small plastic cup that was not dated or labeled. This failure could place the residents at risk for food borne illness.The findings include: Record review of Resident #41's face sheet, dated 03/12/2026, revealed a 77-years-old male who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #41 had diagnoses which included lack of coordination (poor muscle control that causes clumsy movement), Chronic obstructive pulmonary disease (common lung disease causing restricted airflow and breathing problems), and allergy rhinitis (when a reaction occurs that causes nasal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to maintain clinical records in accordance with accepted professional standards and practices, on each resident that were complete and accurately documented for 1 of 20 residents (Resident #4) reviewed for accuracy and completeness of clinical records. The facility failed to ensure Resident #4 had physician orders that documented the could have liquid protein supplements by mouth instead of via gastrostomy tube. This failure could place residents at risk for incorrect medication administrations due to misinformation by incomplete and inaccurate medical record. Findings include: Record review of Resident #4's face sheet, dated 03/13/2026, revealed a 90-years-old female who was admitted to the facility on [DATE]. Resident #4 had diagnoses which included cerebral infarction (disrupted blood flow to the brain due to problem with the blood vessels that supply it), dysphagia (difficulty in swallowing), and gastrostomy status (surgical opening into stomach for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 5 residents (Resident #3) whose assessments were reviewed. The facility failed to indicate Resident #3 received oxygen on her Quarterly MDS dated [DATE]. This failure could place residents at risk for inadequate care due to inaccurate assessments. FindingsThe findings included: Record review of Resident #3's admission Record dated 09/28/2025, revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #3's Physician Progress Note, dated 09/24/25, revealed she was a [AGE] year-old female with a past medical history which included acute respiratory failure with hypoxia (difficulty breathing resulting in low levels of oxygen in the blood), high blood pressure, congestive heart failure (inability of the heart to adequately pump blood in the body resulting in fluid around the heart and lungs) and pneumonia (a type of lung…

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, is provided such care, consistent with professional standards of practice for 1 of 2 residents (Resident #3) reviewed for respiratory care. Resident #3 received oxygen at 2 liters per minute via nasal cannula without a physician order. This failure could affect residents with oxygen therapy and could lead them to a lack of care. The findings included: Record review of Resident #3's admission Record dated 09/28/2025, revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #3's Physician Progress Note, dated 09/24/25, revealed Resident #3 was a [AGE] year-old female with a past medical history which included acute respiratory failure with hypoxia (difficulty breathing resulting in low levels of oxygen in the blood), high blood pressure, congestive heart failure (inability of the heart to adequately pump blood in the body resulting in fluid…

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 licensed nurses have the specific competencies, and skill sets necessary to care for two (2) residents' (Resident #1 and Resident #2) needs for one (1) of five (5) licensed nurses (the ADON) reviewed for staff competency. 1. While providing wound care for Resident #1 on 11/24/2025, the ADON did not fully cover the resident's wound bed with the calcium alginate dressing per physician order.2. While providing wound care for Resident #1 on 11/25/2025, the ADON did not date or initial the wound dressing.3. While providing wound care for Resident #2 on 11/25/2025, the ADON did not date or initial the wound dressing. These failures could place residents at risk for improper care and complications of residents' medical care.The findings included: 1. Record review of Resident #1's admission Record, dated 11/24/2025, reflected a [AGE] year-old female. She was admitted on [DATE] and re-admitted on [DATE]. Record review of Resident #1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to 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 disease and infection for two (2) of two (2) residents (Resident #1 and Resident #2) reviewed for infection control. 1. The facility failed to post signage on 11/24/2025 to indicate Resident #1 was ordered to be on contact isolation precautions prior to or immediately upon notification of the order. While providing wound care for Resident #1 on 11/24/2025 and 11/25/2025, the ADON did not wash her hands prior to or after providing wound care to a resident who was on contact precautions. The ADON did not sanitize her hands between glove changes. While providing wound care for Resident #1 on 11/25/2025, the ADON placed open wound care supplies directly on the resident's bed. 2. While providing wound care for Resident #2 on 11/25/2025, the ADON did 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 observation, interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 5 residents (Resident #3) whose assessments were reviewed. The facility failed to indicate Resident #3 received oxygen on her Quarterly MDS dated [DATE]. This failure could place residents at risk for inadequate care due to inaccurate assessments.The findings included: Record review of Resident #3's admission Record dated 09/28/2025, revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #3's Physician Progress Note, dated 09/24/25, revealed she was a [AGE] year-old female with a past medical history which included acute respiratory failure with hypoxia (difficulty breathing resulting in low levels of oxygen in the blood), high blood pressure, congestive heart failure (inability of the heart to adequately pump blood in the body resulting in fluid around the heart and lungs) and pneumonia (a type of lung infection) 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, interviews, and record review, the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice for 1 of 2 residents (Resident #3) reviewed for respiratory care. Resident #3 received oxygen at 2 liters per minute via nasal cannula without a physician order. This failure could affect residents with oxygen therapy and could lead them to a lack of care.The findings included: Record review of Resident #3's admission Record dated 09/28/2025, revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #3's Physician Progress Note, dated 09/24/25, revealed Resident #3 was a [AGE] year-old female with a past medical history which included acute respiratory failure with hypoxia (difficulty breathing resulting in low levels of oxygen in the blood), high blood pressure, congestive heart failure (inability of the heart to adequately pump blood in the body resulting in fluid…

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 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 5 (Residents #27, #38, #9, #2, and #49) of 8 residents observed for infection control. 1. The facility failed to ensure Resident #27's Foley catheter bag was not touching the floor twice on 12/03/2024. 2. The facility failed to ensure Resident #38's Foley catheter bag was not touching the floor on 12/03/2024. 3. The facility failed to ensure Resident #9's Foley catheter bag was not touching the floor on 12/03/2024 and on 12/05/2024. 4. The facility failed to ensure Resident #2's Foley catheter bag was not touching the floor on 12/03/2024 and on 12/05/2024. 5. The facility failed to ensure Resident #49's Foley catheter bag was not touching the floor on 12/06/2024. These failures could place residents at risk 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 §483.20(g) Accuracy of Assessments. The assessment must accurately reflect the resident's status. Based on observation, interview, and record review, the facility failed to ensure Quarterly comprehensive assessment accurately reflected the resident's status for 1 of 6 [Resident #33] residents reviewed for accuracy of assessments in that Residen #33's diagnosis was not coded. 1. The facility failed to accurately code Resident #33 diagnosis status on the quarterly comprehensive assessment dated [DATE] and quarterly comprehensive assessment dated [DATE]. These failures could place resident at risk for improper or incorrect care and services necessary for their physical, mental and psychosocial well-being. The findings include: 1. Record review of Resident #33 admission Record dated 12/06/24 revealed resident was initially admitted [DATE], re-admitted [DATE] and was [AGE] years old. 2. Record review of Resident #33 Medication Review Report dated 12/05/24 revealed diagnoses to include Adjustment Disorder with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure its medication error rate was not 5% or greater. The facility had a medication error rate of 11.54%, based on 3 errors out of 26 opportunities which involved 2 of 2 residents (Resident #52 and #18) and 1 MA, reviewed for medication administration and medication errors. 1.) The facility failed to ensure medications were administered timely for Resident #52 on 12/5/2024. 2.) The facility failed to ensure medications were administered timely for Resident #18 on 12/5/2024. These failures could place residents at risk of incomplete therapeutic outcomes, increased negative side effects, and decline in health. The findings included: 1.) Record review of the Face Sheet printed 12/6/2024, reflected Resident #52 was a [AGE] year-old male originally admitted on [DATE]. Record review of the Diagnosis Report printed on 12/6/2024, reflected Resident #52 had the following diagnoses: chronic kidney disease [long term condition that affects 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 residents were free of any significant medication errors for 1 of 8 residents (Resident #31) reviewed for medication administration. Resident #31 was provided medications, Amlodipine Besylate and Carvedilol, outside of physician parameters. This failure could place residents at risk for not receiving the therapeutic effects of their prescribed medications. The findings included: Record review of Resident #31's face sheet, dated 12/5/2024, reflected an [AGE] year-old resident with an initial admission date of 4/8/2023 and diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (condition that affects one side of the body usually caused by a stroke that can cause paralysis), unspecified atrial fibrillation (a heart condition that causes an irregular and often rapid heartbeat), and hypertension (high blood pressure). Record review of Resident #31's quarterly MDS assessment, dated 11/12/2024,…

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 special eating equipment for residents who needed them and appropriate assistance to ensure that the resident could use the assistive devices when consuming meals for 1 of 8 residents (Resident #2) reviewed for special eating equipment and assistance when consuming meals. The facility failed to ensure Resident #2 was provided with a divided plate to meet Resident #2's need for assistance while eating. This failure could place residents at risk for harm by weight loss, diminished independence, and self-esteem. The findings included: Record review of Resident #2's face sheet, dated 12/6/2024, reflected a [AGE] year-old resident admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (condition that affects one side of the body usually caused by a stroke that can cause paralysis), a traumatic brain injury, and a cerebral infarction (stroke).…

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 implement their written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents for 15 of 26 staff (ADMN, ADON, DM, AD, RN J, RN K, LVN D, LVN L, CNA M, CNA N, CNA O, RA P, Hskg Q, Recept R, MR S) reviewed for abuse and neglect, in that: The facility failed to implement their abuse policy when the ADMN, ADON, DM, AD, RN J, RN K, LVN D, LVN L, CNA M, CNA N, CNA O, RA P, Hskg Q, Recept R, MR S's annual EMR was not completed in the past year. This failure could place residents at risk for abuse and neglect. The findings were: Record review of facility policy titled Abuse, Neglect, Exploitation, Mistreatment of Resident, or Misappropriation of Resident Property, reviewed 08/2017 which read 5. [ .] Screening: Potential employees will be screened, per federal &/or state regulation, [ .] Screening will consist of: [a] Inquiries into the State licensing authorities [b] Inquires into State nurse aide registry [ .]. 1. Record review of the Staff Roster, undated, revealed the ADMN was hired…

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

Based on interview and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 3 of 25 residents (Resident #28, #29, and #37) for care plan revisions, in that: 1. The facility failed to ensure Resident #28's care plan was revised to indicate the residents change in code status. 2. The facility failed to ensure Resident #29's and Resident #37's care plan was revised to include tube feedings. These failures could place residents at risk of receiving inappropriate care. The findings include: 1. Record review of Resident #28's face sheet dated 10/24/2023 revealed an initial admission date of 09/11/2023 with a most recent admission of 10/03/2023 and diagnoses which included: acute posthemorrhagic anemia (acute blood loss anemia), gastrointestinal hemorrhage (bleeding from the gastrointestinal tract) and adult failure to thrive (insufficient weight gain, loss of appetite). Further review of Resident #28's face sheet, revealed under the section DNR. Record review of Resident #28's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, failed to provide a therapeutic diet which was prescribed by the attending physician for two residents (Resident #4 and Resident #7) out of 8 residents reviewed for therapeutic diets, in that: 1. The facility did not serve Resident #4 a minced & moist diet and a magic cup for lunch as prescribed by the attending physician. 2. The facility did not serve Resident #7 soft & bite sized potatoes & onions as was reflected in his 10/24/2023 lunch meal tray ticket and the recipe. The facility did not change Resident #7's diet on for 10/24/2023 lunch from a soft & bite sized diet to a minced & moist diet as was revealed as a doctor's order on 10/23/2023. These failures could place residents who received food from the kitchen at risk for decreased meal satisfaction, potential weight loss due to poor meal intake, not having their nutritional needs met, and a decline in health status. The findings were: 1. A record review of Resident #4's face sheet on 10/25/2023…

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, in that: 1. There were 3 storage containers of prepared food in two separate refrigerators that were not properly sealed. 2. DA K wore jewelry with dangling charms on her wrist while engaged in food preparation in the kitchen. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: 1. Observation on 10/23/2023 at 9:52 AM in one of the refrigerators revealed an opened clear bag (the manufacturer's bag that would be inside of the product's box) of French fries. In the next refrigerator there was an opened clear, plastic bag of sausage patties. This exposed the contents of the bags to the ambient air in the cooler and potential contamination by pathogens and bacteria. The DM then went to get a Ziploc bag to put the French fries in, to seal it. Observation on 10/25/2023 at 11:31 AM, revealed an opened…

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 treat each resident with respect and dignity and care in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality and protect and promote the rights of the Resident, for 3 of 25 (Resident #215, Resident #42, Resident #214) residents reviewed for dignity, in that; 1. The facility failed to ask Resident #215 and Resident #42 if they wanted to wear a clothing protector around their neck to protect their clothes from getting dirty, while they had their meal. Resident #215 did not want to wear the clothing protector on 10/23/2023 and 10/25/2023 lunch. Resident #42 did not want to wear a clothing protector around her neck for 10/25/2023 lunch. 2. The facility failed to give Resident #214 an egg roll that she ordered and was looking forward to, for 10/25/2023 lunch. This failure placed residents at risk for diminished quality of life, loss of dignity, 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 failed to ensure that the assessments accurately reflected the resident's status for 1 of 29 residents (Resident #57) reviewed for resident assessments, in that: The facility failed to ensure Resident #57's discharge MDS, dated [DATE], was coded as a hospital discharge instead of a community discharge. This deficient practice could place residents at risk of not having their individually assessed needs met. The findings were: Record review of Resident #57's face sheet, dated 10/26/2023, revealed the resident was admitted to the facility on [DATE] with the diagnoses that included: end stage renal disease, vascular dementia without behavioral disturbance, and major depressive disorder. Record review of Resident #57's Quarterly MDS, 09/12/2023, revealed on A2100. Discharge status entered as 01. Community instead of 03. Acute Hospital. Record review of Resident #57's Progress Notes, dated 10/26/2023, note entered 09/12/2023 at 2:18 p.m., revealed As per family…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews, the facility failed to 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 (Residents #43) out of 5 residents reviewed for medication administration, in that: The facility failed to ensure Resident #43 received Acetylcysteine [a medication to help thin and loosen mucus in the airways due to certain lung diseases], and Baclofen [a medication for the treatment of muscle spasms] on 10/25/2023 as ordered. This failure could place residents at risk for not receiving the intended therapeutic effects of their medications and result in a diminished quality of life. The findings include: Record review of the admission Record revealed Resident #43 was a [AGE] year-old male originally admitted on [DATE]. Record review of the quarterly MDS assessment dated [DATE] revealed Resident #43's primary reason 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.

Based on observation, interview, and record review the facility failed to ensure all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys in 1 medication carts of 6 medication carts (Treatment Cart 300-hallway) reviewed for medication storage, in that; The facility failed to ensure the Treatment Cart 300-hallway was locked when left unattended in the hallway. This deficient practice could place residents at risk of medication misuse or drug diversion. The findings were: In an observation on 10/25/2023 at 8:50 AM, the Treatment Cart on the 300-hallway was unlocked and unattended. The Treatment Cart contained prescription and over the counter medications related to skin and wound care. There were ambulatory residents and visitors in the immediate vicinity. Staff were seated at the 300-hallway nurses' station but could not see the Treatment Cart from their position. In an interview on 10/25/2023 at 8:54 AM, LVN D stated the Treatment Cart was her responsibility. LVN D stated she had…

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