Focused Care at Sherman

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person-centered care for the resident that met professional standards of care within 48 hours of the resident's admission for one of two (Resident #57) residents reviewed for baseline care plans. The facility failed to complete a baseline care plan for Resident #57. This failure could place newly admitted residents at risk of not receiving effective and person-centered care and services. Findings included: Review of Resident #57's 5-day MDS assessment dated [DATE], reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. She had a BIMS of 12 which indicated she was moderately cognitively impaired. She was always incontinent of bowel and bladder, required substantial to maximum assistance with ADL's and had diagnoses including chronic obstructive pulmonary disease (lung disease that blocks airflow…

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 with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for one (Resident #12) of six residents reviewed for range of motion. The facility failed to implement interventions to prevent further decline of Resident #12's contracture to her left hand upon discharge from therapy services. These failures could place residents at risk for decline in range of motion, decreased mobility, and worsening of contractures. Findings included: Review of Resident #12's admission MDS Assessment, dated 3/1/25, reflected she was a [AGE] year-old female with an admission date of 4/18/23. Resident #12 had minimal cognitive impairment, and her BIMS score was 15. She had upper and lower extremity impairment on one side and required use of a wheelchair. Resident #12 required assistance in putting shoes on, lower body dressing, bathing, toileting, 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 provide pharmaceutical services including procedures that assure the accurate acquiring and administering of all medications to meet the needs of each resident for two of six residents (Resident #8, and Resident #28) reviewed for pharmacy services. 1. The facility failed to ensure LVN B followed the manufacturer's instructions to prime the Insulin Apart (Novolog) Insulin (Hormone) Pen prior to dialing in required amount of Insulin to be administered to Resident #8. 2. The facility failed to ensure LVN D followed the manufacturer's instructions to prime the Lyumjev Insulin (Hormone) Pen prior to dialing in required amount of Insulin to be administered to Resident #28. These failures placed residents at risk of not receiving full dosage of medication. Findings included: 1. Record review of Resident #8's, Face sheet, dated 05/09/25 reflected an [AGE] year-old female with an admission date of 11/06/21. Resident #8 had a diagnosis which…

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 implement written policies and procedures that prohibit mistreatment, neglect, and abuse for two (Resident #2 and an unknown Resident) of four residents reviewed for abuse. The facility did not implement their policy on reporting abuse to state agency for a resident-to-resident altercation that occurred on 12/13/24 between Resident #2 and an unknown Resident. This deficient practice could place residents at risk for abuse, neglect, and not having their needs met. Findings included: Record review of the facility policy titled Abuse revised on 01/01/2023, reflected, Reporting/Investigation: The law requires the abuse coordinator/designee, or employee of the facility who believe that the physical or mental health or welfare of a resident has been or may be adversely affected by abuse, neglect, or exploitation caused by another person to report the abuse, neglect or exploitation .All events that involve an allegation of abuse or involved a suspicious…

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 assure that medications were secure and inaccessible to unauthorized staff and residents for 2 (Medication Cart #1 and Medication Cart #2) of 2 medication carts observed for medication storage, in that: The facility failed to ensure controlled medications in unsecure bubble packaging cards were immediately removed from Medication Cart #1 and Medication Cart #2. These failures could place residents at risk of not having the medication available due to possible drug diversion and at risk of not receiving the intended therapeutic benefit of the medication. Findings Included: During an observation and record review of medication cart #1 on 02/15/25 at 2:09 PM revealed a pill bubble packaging card filled with Tramadol 50 mg tablets (controlled medication used to treat insomnia [trouble sleeping]). The seals that secured 3 pill bubbles (#6, #7, and #13) were not intact and covered with tape. A pink and blue capsule was noted inside each bubble. There were 14 pills remaining. The narcotic log count sheet 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 observations, interviews, and records review, the facility failed to ensure the right to be free from misappropriation of resident property for 1 of 5 residents (Resident #1) reviewed for misappropriation of resident property. RN A used Resident #1's prescribed Fentanyl (an opioid pain medicine that is used to treat moderate to severe chronic pain around the clock) 100 mcg 72-hour transdermal (skin) patch for personal recreational use on 02/12/25. This failure placed residents at risk of not receiving timely pain management care which could result in prolonged pain and diminished quality of life. Findings included: Record review of Resident #1's Quarterly MDS assessment, dated 12/06/24, revealed an [AGE] year-old female, who admitted to the facility on [DATE] - most recent re-admission on [DATE], with the following diagnoses: Ankylosing Spondylitis (an inflammatory disease that can fuse the vertebrae in the spine and cause back pain, stiffness and hunched posture), lumbar region; Erosive Osteoarthritis…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (Resident #1) of 5 residents reviewed for quality of care, in that: The facility failed to monitor, treat, and reassess a wound to Resident #1's lower back. LVN A documented that Resident #1 had a pressure, venous, arterial, diabetic, or surgical wound (no location, no description disclosed) in a weekly skin assessment on 05/27/24 and 06/03/24 but did not notify the WCN. On 06/06/24, RCP B informed the WCN about an open area on Resident #1's lower back (WCN identified area as the very bottom of spine area - tailbone). The WCN assessed, documented a Stage II wound to Resident #1's lower back, notified the PCP and started treatment to the wound. No treatment was provided to the wound site before 06/06/24. Resident #1 was discharged to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing for 12 (Residents #4, #23, #35, #36, #41, #52 and five residents in confidential group interview) of 12 residents reviewed for staffing concerns. 1. The facility failed to ensure there were sufficient staff to ensure Resident #35 and #23 received 8 AM medications on time on 03/10/24. 2. The facility failed to ensure there was sufficient staff available to provide timely incontinent care for Resident #4 on 03/10/24. 3. The facility failed to ensure residents received showers on their shower days due to staffing issues. 4. The facility failed to ensure sufficient staff to meet resident needs in February and March 2024. These failures placed residents at risk of not getting needed care and services, 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.

Based on observation, interview and record review, the facility failed to employ sufficient staff with appropriate competencies and skill sets to carry out the functions of the food and nutrition service for 1 of 1 facility kitchen reviewed for food and nutrition services. 1. The facility failed to have a qualified Dietary Manager who was full-time at facility. 2. The facility failed to ensure Dietary [NAME] met the required qualifications, the [NAME] did not have a food handling management certificate within 30 days of hire. This failure could place residents at risk for the spread of foodborne illness and negative impacts to their nutrition and health. The findings included: 1. Record review of the employee file for Dietary Manager revealed a certificate of completion for Food Safety Management Principles dated 11/12/2023 and no Dietary Manager license. Interview with the Dietary Manager on 03/10/2024 at 11:22 AM revealed she worked at the facility about 4 days per week and that she oversaw the kitchen. She said she reviewed menus for residents and ordered food and took inventory…

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

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation in that: On 3/10/2024, the facility failed to label and date 6 frozen tubes of raw ground beef, a box of frozen fried catfish, container of vegetable soup, container of ketchup, and container of refried beans, use appropriate hand hygiene practices, and failed to ensure proper food temperatures of ground beef puree and vegetable puree. These failures could place residents at risk for food contamination and food-borne illness and impact the health and nutrition of residents. Findings included: 1. Observation on 03/10/2024 at 9:19 AM of the walk-in fridge revealed undated container of a reddish liquid with corn and green beans, undated container of refried beans, and an undated container of red thick substance. Interview on 03/10/2024 at 9:21 AM with the [NAME] revealed the containers of vegetable soup, refried beans, and ketchup were undated and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review, the facility failed to ensure residents received services in the facility with reasonable accommodation of needs and preferences for two (Residents #45 and #69) of sixteen residents reviewed for call lights. 1. Facility failed to ensure Resident #45's call button was within reach of Resident #45 while he was lying in bed. 2.Facility failed to ensure Resident #69's call button was within reach of Resident #69 while he was lying in bed. These failures could place residents at risk for delay in assistance and decreased quality of life, self-worth, and dignity. Findings included: 1. Review of Resident #45's significant change MDS assessment dated [DATE] reflected Resident #45 was a [AGE] year-old male readmitted to the facility on [DATE] with diagnoses of injury at unspecified level of cervical spinal cord, cancer, cirrhosis, diabetes, Alzheimer's disease and chronic obstructive pulmonary disease and repeated falls. Resident #45 required partial/moderate assistance…

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 resident has a right to a safe, clean, comfortable and homelike environment for 9 (Residents #1, #5, #20, #21, #39, #41, #59, #67, #69) of 24 residents reviewed for safe and sanitary environment. 1. The facility failed to ensure Resident #20, #21, #41 and #59 had bed sheets in good condition without holes in them. 2. The facility failed to ensure Resident #39's curtain was without food stains. 3. The facility failed to ensure sheet rock behind toilet was in good condition not exposing pipes in Resident #69's bathroom. 4. The facility failed to ensure Resident #67's room had a curtain over the window. The facility failed to ensure Resident #67's bathroom had a toilet paper holder, a mirror, and sheet rock in bathroom wall did not expose pipes. 5. The facility failed to ensure residents in secure unit (500 hall) were comfortable with room temperature. These failures could place residents at risk of living in an unsafe, unsanitary, 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 provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 9 (Resident #4, Resident #26, Resident #16, Resident #2, Resident #36, Resident #41, Resident #52, Resident #5, Resident #47) of 24 residents reviewed for ADLs. The facility failed to ensure: 1- Resident #4, who required extensive assistance, was provided with timely incontinence care on 03/10/24 from 6:30 a.m. to 3:15 p.m. 2- Resident #26 had her fingernails cleaned and trimmed. 3- Resident #16 was shaved and not having facial hair. 4- Resident #2 was shaved and not having facial hair. 5- Residents #36, #41 and #52 received showers on shower days. 6- Resident #5 her fingernails cleaned and teeth brushed. 7- Resident #47 had her fingernails cleaned These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased…

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 residents with an ongoing program of activities for 5 out of 5 residents (Resident #67, #46, #48, #70 and #5) reviewed for activities. The facility did not provide routine activities for Residents #67, #46, #48, #70 and #5. The failure could affect residents by placing them at risk for depression, boredom, and decreased quality of life. Findings included: 1. Record Review of Resident #67's Quarterly MDS dated [DATE] revealed resident was an [AGE] year-old female admitted to the facility on [DATE]. Resident #67 diagnoses included: Metabolic Encephalopathy (brain dysfunction due to disease or toxins in body), Dementia (loss of cognition), Hypotension (low blood pressure), and a BIMS score of 11 (moderately impaired cognition). Record review of Resident #67's Care Plan dated 11/28/2023 revealed resident would maintain involvement in cognition stimulation and social activities. Interview on 03/10/2024 at 11:00 a.m. with Resident #67…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring and administering of all medications to meet the needs of each resident for two of four residents (Residents #14 and Resident # 5) reviewed for pharmacy services in that- 1. RN G failed to follow the manufacturer's instructions to prime the Lispro Insulin (Hormone) Pen prior to dialing in required amount of Insulin to be administered to Resident #14. 2. RN D failed to follow the manufacturer's instructions to prime the Novolog Insulin (Hormone) Pen prior to dialing in required amount of Insulin to be administered to Resident #5. These failures placed residents at risk of not receiving full dosage of medication. Findings included: 1. Review of Resident #14's Face sheet dated 03/14/24 reflected an [AGE] year-old female admitted to the facility on [DATE]. Active diagnoses included diabetes mellitus. Record review of Resident #14's Physicians order summary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 6 residents (Resident #35, Resident #23, Resident #5, Resident #51, Resident #15, and Resident #45) of 8 observed for infection control. The facility failed to ensure: 1. MA F sanitized the blood pressure cuff between uses on Resident #35 and Resident # 23 and performed hand hygiene after performing blood pressure checks. 2. RN D prevented cross contamination of Resident #5's insulin and the medication cart when she dropped the insulin pen cap onto the floor, removed her gloves after administering Resident #5's insulin and leaving Resident #5's room and opening the medication cart, retuning Resident #5's box containing the resident's glucometer and insulin pen. 3. RN G prevented cross contamination of Resident #51's wound care supplies when she failed to set up a clean field in the residents' room and failed to perform hand hygiene…

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 allow the resident to obtain a copy of the medical records upon request and within 2 working days advance notice to the facility for 1 Resident (#227) of 24 sampled residents. The facility failed to provide a copy of Resident #227's medical records upon request by the resident's representative. The deficient practice could place residents at risk of contributing to a delay in the due legal process for residents and not having continuity of care. Findings included: Record Review of Resident #227's face sheet revealed resident was a [AGE] year-old male admitted to the facility on [DATE]. The resident's MDS dated [DATE] revealed a BIMS score of 6 (severely cognitively impaired). Interview on 3/12/24 at 9:34 a.m. with Resident #227's POA, revealed the POA was unable to get any medical records and had requested them through email and in person on 1/31/24. Interview on 3/13/24 at 12:48 p.m. was attempted with Corporate Medical Records. A voicemail was left…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest, practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for one of four (Resident #51) residents reviewed for wound care. RN D failed to provide Resident #51 her prescribed wound care on 03/09/24. This failure could place residents at risk for a decline in the resident's condition, increased risk of infection and decline in wound healing. Findings Included: Review of Resident #51's Quarterly MDS assessment dated 12/2924 reflected a [AGE] year-old female admitted to the facility on [DATE]. Resident was cognitively intact with a BIMS of 14. She was always incontinent of bladder and frequently incontinent of bowel, required substantial to extensive assistance with ADL care and was high risk for pressure ulcer/injury. She had no skin issues at the time of assessment. Resident #51 had active diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one (Resident #45) of two residents reviewed for incontinence care. The facility failed to ensure RN D provided appropriate perineal care for Resident # 45 after an incontinent episode when she failed to clean the resident's scrotum, and penis. This failure could place residents at risk for the development and/or worsening of urinary tract infections and skin breakdown. Findings included: Record review of resident #45's Comprehensive MDS assessment, dated 01/02/24, reflected a [AGE] year-old male with an admission date of 08/29/22 with diagnoses included injury of cervical spinal cord (permanent complete or partial loss of sensory function), muscle weakness, lack of coordination, and need for assistance with personal care. Resident #45 had a BIMS score of 15 which indicated Resident #45's cognition was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the medication error rate was not 5% or greater. The facility had a medication error rate of 6.45%, based on 2 errors of 31 opportunities, which involved two of four residents (Residents #35 and #23) and one of three staff observed during medication administration for medication errors in that-. 1. MA F failed to administer Resident #35's Pantoprazole 40 mg on 03/10/24 as ordered by the physician. 2. MA F failed to administer Resident #23's Omeprazole 20 mg on 03/10/24 as ordered by the physician. This failure could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. The findings include: 1. Record review of Resident #35's Face sheet, dated 03/14/24, reflected a [AGE] year-old male with an admission date of 11/29/23. Resident #33 had a diagnoses which included diverticulitis (inflammation of the digestive tract), gastro-esophageal reflux (condition where stomach content…

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 assist residents in obtaining routine and 24-hour emergency dental care for 1 of 8 residents (Residents #18) reviewed for dental services. The facility failed to provide timely dental services for Resident #18 and follow up on dental referral. This failure could place residents at risk of oral complications, dental pain, and diminished quality of life. Findings included: Record review of Resident #18's Quarterly MDS dated [DATE] revealed she was a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses of bi-polar type schizoaffective disorder (episodes of extreme mood swings including delusions), encephalopathy, dementia (loss of cognitive function), hypertension (high blood pressure) and a BIMS score of 99 indicating resident was unable to complete interview. Record review of Resident #18's nurse's progress note dated 02/16/2024 by SSD revealed Resident #18 requested a dental referral because it was difficult 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 observations, interview and record review the facility failed to store, prepare, distribute and serve 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 refrigerator item in walk -in refrigerator was labeled, dated and sealed. 2. The facility failed to ensure black refrigerator unit with freezer on top and drink cooler freezer had thermometers. The facility failed to document temperatures. The facility failed to ensure cleanliness of drink cooler freezer. 3. The facility failed to ensure the Dietary Manager and Food Service Manager E washed their hands when touching PPE and changing gloves during lunch preparation on 02/08/23. 4. The facility failed to ensure hamburger patties' food temperature was taken after cooked and before served to residents for lunch on 02/08/23. 5. The facility failed to ensure the low temperature dish machine was meeting the temperature of 120 degrees Fahrenheit for wash and rinse cycle. 6. The facility failed to ensure trays and bowls were…

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, interview and record review, the facility failed to ensure residents received services in the facility with reasonable accommodation of needs and preferences for three (Residents #26, #4 and #5) of nine residents reviewed for call lights. 1. Facility failed to ensure Resident #26's call button was within reach of Resident #26 while she was lying in bed. 2. Facility failed to ensure Resident #4's call button was within reach of Resident #4 while she was lying in bed. 3. Facility failed to ensure Resident #5's call button was within reach of Resident #5 while she was lying in bed. These failures could place residents at risk for delay in assistance and decreased quality of life, self-worth, and dignity. Findings included: 1. Review of Resident #26's Annual MDS assessment dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Parkinsons disease, stroke, diabetes, seizures and chronic obstructive pulmonary disease. Resident #26 had a BIMS of…

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

Based on observations, interview, 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 and the residents' goals and preferences for three (Residents #47, #48 and #230) of five residents reviewed for oxygen therapy. 1. The facility failed to ensure there was a process in place to ensure there was an adequate amount of portable oxygen in the facility to meet the needs and preferences of residents who were on oxygen therapy. The administration did not maintain a reserve of portable oxygen tanks for residents to use as needed. 2. The Administration did not contact the Oxygen Vendor timely to ensure a delivery of portable oxygen tanks would be received before running out of portable oxygen tanks. 3. The facility did not have a designated staff assigned to monitor the supply of portable oxygen tanks and therefore was not aware that the facility was running low on supply of portable oxygen tanks. These failures placed residents on continuous oxygen therapy 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.

Based on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for one (Dietary Manager) of three dietary staff reviewed for qualifications. The facility failed to employ a qualified Dietary Manager. This failure could place the residents at risk of not being provided a nutritional well-balanced diet and not have their dietary needs identified and addressed. Findings included: Review of the Dietary Manager's employee file revealed a hire date of 12/30/21 and she had food handlers' training certificate dated 08/04/22 with expiration date of 08/04/24. She did not have certified dietary manager certificate or ServeSafe Manager certification in her file. The Dietary Manager did not have an associate degree or higher in food service management or in hospitality. The Dietary Manager's job description was not in the employee's file. Interview on 02/07/23 at 10:13 AM revealed the Dietary Manager stated she started working at the facility as the Dietary Manager…

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 comprehensive care plan described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for two (Residents #71 and Resident #62) of eighteen residents reviewed for comprehensive care plans. 1. Resident #71's care plan failed to address interventions to prevent complications related to his indwelling urinary catheter and his G-tube. 2. Resident # 62's care plan failed to address his hospice election and failed to identify services that were provided by the hospice. These failures placed residents at risk of not receiving individualized care and services to meet their needs and interventions to prevent complications related to each individuals identified concerns. Findings included: 1. Record review of Resident #71's quarterly MDS assessment, dated 12/21/22, reflected he was a [AGE] year-old male admitted to the facility on [DATE] and readmitted…

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 treatment and services to prevent complications of enteral feeding for one (Residents #71) of one resident reviewed for feeding tubes. The ADON failed to check placement of Resident #71's G-Tube by checking for gastric residual prior to administering the resident's medications. This failure could affect residents by placing them at risk of obstruction of the G-tube, nausea, vomiting and potential for aspiration and discomfort. Findings included: Record review of Resident #71's quarterly MDS assessment, dated 12/21/22, reflected he was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. The resident was unable to complete the brief interview for mental status and was coded as severely cognitively impaired by staff assessment. Diagnoses included dysphagia (swallowing difficulties), cerebrovascular accident (stroke) neurogenic bladder (lack of bladder control due to brain or nerve problem), 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.

Based on observations, interviews and record review, the facility failed to ensure resident rooms were adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for two (Residents #4 and #5) of 10 residents reviewed for resident call system in that: The facility failed to ensure Resident # 4 and Resident # 5 call light outside the resident door was working properly. Resident # 4 and Resident # 5 resided in the same room. This failure could place residents at risk for delay in assistance and decreased quality of life, self-worth, and dignity. Findings included: Observation and interview on 02/07/23 at 11:34 AM with Resident # 4 revealed she was lying in her bed. She stated her call light had not been working for the last 2 days and was not within reach for her to use. Observation at 11:35 AM revealed the call light outside resident room did not light up when the call button was pushed by Resident #4. Observation and interview on 02/07/23 at 11:38 AM revealed…

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.