Texoma Healthcare Center

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 4 (Residents #1, #2, #3, and #9) of 9 residents reviewed for comprehensive care plans. 1. The facility failed to create a care plan that reflected Resident #1's preference for bed baths and shower refusals. 2. The facility failed to create a care plan that reflected Resident #2's shower refusals. 3. The facility failed to create a care plan that reflected Resident #3's shower refusals. 4. The facility failed to create a care plan that reflected Resident #9's vision needs. This failure puts residents at risk of not being provided personalized care and negatively impact their quality of life. Findings included: 1. Review of Resident #1's Quarterly MDS, dated [DATE], reflected she was an [AGE] year-old female admitted to the facility on [DATE] 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 an effective pest control program was implemented so the facility is free of pests and rodents for 1 of 9 residents (Resident #7), 1 out of 5 halls (hall A) and 1 out of 5 exterior perimeters of resident halls (hall A) reviewed for pest control. 1. The facility failed to effectively treat Resident #7's room for ants. 2. The facility failed to keep an effective pest control program, so the facility was free of ants on the exterior perimeter of resident hall A. 3. The facility failed to keep an effective pest control program, so the facility was free of ants in 2 rooms in the A hall. These failures placed residents at risk for the spread of infection and disease, and a reduced quality of life. Findings included: 1. Record review of Resident #7's MDS, dated [DATE], reflected she was an [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of Hypertension (high blood pressure), Diabetes (a condition resulting 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 that each resident who experiences a significant change in status is comprehensively assessed within 14 days for 1 of 9 residents (Residents #4) reviewed for significant change. The facility failed to ensure Resident # 4 had a Significant Change Assessment completed after she had a change in vision needs. This failure could place residents at risk of not having assessments completed when there has been a significant change in their condition and could lead to failure to not provide necessary care. Findings included: Record review of Resident #4's face sheet, dated [DATE], reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: Type 2 Diabetes Mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), Hypertension (a condition in which the force of the blood against the artery walls it's too high), and Cognitive Communication Deficit (refers…

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 label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 (D hall Nurses Cart) of 2 medication nurses carts reviewed for pharmacy services in that: The facility failed to ensure RN U responsible for the D hall Nurses Cart removed medications in unsecure containers from the Nurses Cart. This failure could place residents at risk of not having the medication available due to possible drug diversion. The findings included: Record review and observation on 06/17/25 at 11:58 AM of D hall Nurses Cart, with RN U revealed the blister pack for Resident #8's APAP/codeine 300-30 mg tablet (controlled medication used for pain) had 1 blister seal broken and the pill still inside the broken blister and tapped over. Interview on 06/17/25 at 12:04 PM, RN U stated the count was done at shift change and the count was correct. She stated she did not check the…

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

Based on observation, interviews, 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 reviewed. The facility failed to ensure the dining room's ice machine's drip tray was cleaned and sanitized, and free from build-up of slime, mold, and an old, used and soaked paper napkin. This failure placed residents at risk of food contamination and foodborne illness. Findings included: Observation of the dining room ice machine on 06/17/25 at 09:45 AM, revealed the presence of buildup of a grayish slime/mold, and an old, used and soaked paper napkin within the drip tray of the ice machine. In an interview on 06/17/25 at 9:46 AM, the DFN looked at the ice machine drip tray and stated it looked dirty with a used paper napkin there. He stated the ice machine supposed to be cleaned daily after each meal. He was unable to recall the last time the machine had been cleaned and sanitized. He stated he had to check the daily cleaning schedule log. He stated it was his responsibility 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 observation, interviews, and record review the facility failed to provide, based on the preferences of each resident, activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for nine of nine confidential residents reviewed for activities. The facility failed to provide activities to meet the residents' interests on Saturdays and Sundays for 9 confidential residents. These failures placed residents at risk for decline in quality of life, social and mental psychosocial wellbeing. Findings Include: During a confidential group interview on 11/19/24 at 10:02 a.m., with 9 residents, all residents stated that there are no weekend activities. They stated that they can attend church on Sundays, but no other activities are provided. They stated that they would love to have weekend activities, as it gets boring. They stated that the only time they have weekend activities is during holidays. During an interview with the Activities Director on 11/19/24 at 11:41 a.m., revealed that aides, nursing staff and the Activities…

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, observation, and record review, the facility failed to ensure that residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing for three of five residents (Resident #82, Resident # 85, and Resident #21) reviewed for quality of care. The facility failed to ensure LVN H provided Resident #82, Resident #85 and Resident #21 their physician ordered wound care on 11/16/24 and 11/17/24. This failure could place residents at risk of developing infections or worsening of their wounds. Findings included: 1. Record review of Resident #82's 5-day MDS assessment, dated 10/12/24, reflected an [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE]. He had a BIMS score of 10, which indicated he was moderately cognitively impaired. He had not rejected care and required substantial to maximum assistance with ADL care and was occasional…

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 that accommodates resident preferences for 2 of 32 residents (Resident #76 and Resident # 31) reviewed for resident food and drink preferences. The facility failed to follow the breakfast menu and obtain resident input on changes made to the menu. This failure could affect residents by contributing to dissatisfaction, poor intake, and weight loss. Findings include: Review of the quarterly MDS, dated [DATE], revealed Resident # 76 was a [AGE] year old male admitted to the facility on [DATE]. He had a BIMS score of 11, which indicated he was moderately cognitively impaired. His active diagnosis included: Diabetes and Malnutrition (unintentional weight loss). Review revealed Resident #76 required setup assistance with meals and no chewing or swallowing issues. Review of the physician orders dated 7/10/24 revealed Resident #76 was on a regular texture diet. Review of Resident #76's care plans dated 7/11/24 revealed .Determine 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.

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 the facility's only kitchen. 1. The facility failed to ensure food items in the facility walk-in refrigerator were covered, labeled, and dated. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination. Findings included: Observation on 11/18/24 at 7:50 AM of the walk-in refrigerator revealed: - 8 to 10 hamburger patties in a quart size Ziplock bag was not labeled or dated, - Sliced raw onions in plastic bag not labeled or dated, petite cut carrots were not covered or dated, - Cheese slices in Ziplock bag with some white mold-like growth that were not labeled or dated, and - Tortillas were not covered or dated. In an interview on 11/19/24 at 10:23 AM, the Dietary Manager stated the cooks and himself are responsible for dating and labeling all food items in the kitchen. He stated that his…

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 unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for one of eight residents (Resident #82) reviewed for ADL care. The facility failed to ensure staff provided consistent showers/baths for Resident #82. This failure could place residents at risk of not receiving needed hygiene care which could cause skin breakdown, a loss of dignity and self-worth. Findings include: Record review of Resident #82's 5-day MDS assessment, dated 10/12/24, reflected an [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE]. He had a BIMS score of 10, which indicated he was moderately cognitively impaired. He had not rejected care and required substantial to maximum assistance with showers and baths. His active diagnoses included diabetes and aftercare following hip replacement surgery. Record review of Resident #82's care plan, initiated on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications for 1 (Resident #75) of 2 residents reviewed for enteral nutrition. The facility failed to ensure Resident #75's water flush administered via tube feeding pump was not being administered as ordered by the physician. This deficient practice could affect residents who receive tube feedings by not receiving the appropriate nutrition/ hydration. The findings were: Review of Resident #75's Annual MDS assessment dated [DATE] revealed that Resident #75 was a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included Hypertension (high blood pressure), Cerebrovascular Accident ( stroke or blood flow to the brain is suddenly cut off), Gastrostomy status (surgical opening into the stomach for administering feeding , hydration, and medication), Malnutrition (inadequate amount of nutrients in the body to function…

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 and administering of all medications to meet the needs of each resident for two of seven residents (Resident #15 and Resident #97) reviewed for pharmacy services. 1. LVN J failed to follow the manufacturer's instructions to prime the Lantus Insulin (Hormone) Pen prior to dialing in required amount of Insulin to be administered to Resident #15. 2. LVN J failed to follow the Physician orders and facility procedures for administering one medication at a time with water flush between each medication when she crushed Resident #97's Sertraline (antidepressant) 25 mg 1 tablet and Levothyroxine (hormone) 50 mcg 1 tab and combined them in one medication cup for administration on 11/18/24. These failures placed residents at risk of not receiving full dosage of medication and potential for drug interactions. Findings included: 1. Review of Resident #15's quarterly MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to immediately notify the resident's representative, consistent with his or her authority, when there was a significant change in the resident's physical, mental, or psychosocial status for 1 (Resident #1) of 3 residents reviewed for notification of changes in condition. The facility failed to ensure Resident #1's resident representative was immediately notified when the resident had a change in condition that required Resident #1 to be transported via ambulance to the hospital due to him being unresponsive. This failure could result in resident representatives not being able to make important medical decisions regarding their family member. Findings included: Record Review of Resident #1's face sheet, dated 11/1/24, revealed the resident was a [AGE] year-old male and was admitted to the facility on [DATE] from an acute care hospital. Diagnoses included: Cerebral Infarction due to Embolism of Cerebral Artery (refers to a stroke where a blood clot…

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 unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for two of seven residents (Residents #2 and Resident #3) reviewed for ADL care. The facility failed to ensure staff provided consistent showers/baths for Resident #2 and Resident #3. This failure could place residents at risk of not receiving needed hygiene care which could cause skin breakdown, a loss of dignity and self-worth. Findings include: 1. Record review of Resident #2's Quarterly MDS assessment, dated 07/29/24, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. She had a BIMS score of 12, which indicated she was moderately cognitively impaired. She had not rejected care and required substantial to maximum assistance with showers and baths. Her active diagnoses included a cerebral vascular accident (stroke) and aftercare following joint replacement surgery. Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 of three (Resident #1) residents reviewed for pharmacy services. The Facility failed to ensure Facility staff ordered medications in a timely manner for Resident #1 upon his admission on [DATE] which resulted in missed doses of Anastrozole 1 mg, Liothyronine Sodium 5 mg, Bupriopion HCL ER 150 mg, Cefadroxil 500 mg and Propranolol HCL 20 mg on 07/24/24. This failure placed the residents at risk of not receiving medications as ordered by the physician and a delay in treatment and worsening of their condition. Findings included: Review of Resident #1's Face Sheet dated 07/31/2024 reflected a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included hypertension (high blood pressure) hypothyroidism (deficiency of the thyroid gland), methicillin…

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 protect the confidentiality of personal health care information for two (Charge Nurse and Med Tech A ) of two staff observed for confidentiality of records. The facility failed to ensure the Charge Nurse and Med Tech A locked and closed the laptop during the medication pass exposing all resident on the hall's personal information. This failure could affect residents by placing them at risk for loss of privacy and dignity. The Findings included: Observation and interview on 12/06/2023 at 11:40AM the Charge Nurse left the computer screen open and unlocked while she went into a resident room to pass medication. The computer screened displayed all resident names on the hall and if they were due to receive medication. During an interview with the Charge Nurse, she stated she had worked PRN in the facility for 3 years and was aware that the computer should have been locked. The Charge Nurse stated the risk of leaving the computer unlocked would be that resident personal information would be visible to others.…

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 assessments accurately reflected the resident's status for one of three (Resident #1) residents whose MDS records were reviewed for accuracy in that: Resident #1's care plan did not reflect that the resident had pneumonia. This failure could place residents at risk for inadequate care due to inaccurate assessments. The findings included: Record review of Resident #1's face sheet dated 12/06/2023 revealed a 72- year- old female admitted to the facility on [DATE] with a re admit date of 11/26/2023 with diagnoses that included heart failure, chronic obstructive pulmonary (diseases that cause airflow blockage and breathing-related problems), and type 2 diabetes. Review of Resident #1's care plan dated revised 12/01/2023 did not indicate that Resident #1 had pneumonia. Review of Resident #1 quarterly MDS completed 11/30/2023 indicated a BIMS score of 15 which indicated the resident was cognitively intact. Review of the nursing notes dated 12/02/2023…

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 ensure all drugs and biological were stored in locked compartments of two medication carts (Med cart #1 and Med cart #2 ) reviewed for storage, in that: The facility failed to ensure Med cart #1 and Med cart#2 was locked when left unattended. This deficient practice could place residents at risk of misappropriation of medications or harm due to accidental ingestion of unprescribed mediations. Findings include: Observation and interview on 12/06/2023 at 11:40AM the Charge Nurse left Med Cart #1 unlocked while she entered to resident room to pass medication. Med Cart #1 was visible unlocked and all routine medications for the hall were accessible. Interview with the Charge Nurse revealed the medication cart should have been locked while she was away from the cart. The Charge Nurse stated the risk of leaving the medication cart unlocked would be that staff or residents would have access to the medication. Observation and Interview on 12/06/2023 at 12:00PM Med Tech A left the Med cart #2 unlocked and unattended…

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 the facility's only kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure refrigerator and freezer items were dated, labeled, and sealed. 2. The facility failed to ensure Dietary Cooks H and I performed hand hygiene during lunch meal preparation on 10/11/23. 3. The facility failed to ensure Dietary [NAME] I sanitized food thermometer when checking food temperatures on 10/11/23. at lunch. These failures could place residents at risk for food contamination and food-borne illness. Findings included: 1. Observations on 10/10/23 at 9:42 AM revealed the following in the refrigerator: - a plastic bag open to air about 2 inches with cheese not dated or sealed. - a plastic bag with turkey meat not sealed. Interview with the Dietary Manager on 10/10/23 at 9:44 AM revealed the items in the refrigerator should be dated and sealed. Observation on 10/10/23 at 9:47 AM in the walk-in freezer…

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, functional, sanitary, and comfortable environment for dining room and three of five resident halls (B hall, C hall and D hall) reviewed for physical environment. 1. The facility failed to ensure D hall hallway area was maintained with floorboards in place and intact walls to preclude the entry of insects or rodents. 2. The facility failed to ensure resident rooms on B hall, C and D hall had door protection coverings that were secure to the room entry door and not impeding resident entry and egress. 3. The facility failed to ensure a resident room on C Hall RM [ROOM NUMBER], had a shower in working order. These failures could place residents at risk for an unsanitary and unsafe environment. Findings included: 1. Observations of D Hall on 10/11/23 at 12:47 PM revealed that two areas of floorboard at the end of D hall, approximates 6 inches each had peeled away from the wall exposing the drywall beneath. It was also noted…

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 treated with respect and dignity, for 1 (Resident#85) of 24 residents reviewed for dignity issues. The facility failed to ensure Resident #85 was treated with dignity. This failure could place residents at risk of feeling uncomfortable, disrespected and decline in self-worth. Findings included: Review of Resident #85's face sheet dated 10/11/23 reflected Resident #85 was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] to the facility with diagnoses of metabolic encephalopathy (altercation in consciousness due to brain dysfunction), diabetes, chronic obstructive pulmonary disease (diseases that cause airflow blockage and breathing-related problems) and alzheimers disease. Resident #85 was her own responsible party. Review of Resident #85's quarterly MDS assessment dated [DATE] reflected Resident #85 had a BIMS score of 3 indicating she was severely cognitively impaired. Resident #85…

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 with or without an indwelling catheter, receives the appropriate care and services to prevent urinary tract infection to the extent possible for one (Resident#7) of three residents reviewed for indwelling catheter care. The facility failed to ensure Resident #7's indwelling catheter bag was maintained off the floor. This failure could place residents at risk of infection. Findings included: Record review of Resident #7's Quarterly MDS assessment, dated 09/08/23, reflected a [AGE] year-old-female admitted to the facility on [DATE]. Resident #7's diagnoses included anxiety disorder, high blood pressure, and depression. Her BIMS score was 09 revealing that resident has moderately impaired cognition. Her functional status reflected extensive assistance for bed mobility and hygiene. Bladder and bowel section of the MDS revealed that the resident has an indwelling catheter in place. Record review of Resident #7's comprehensive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care, was provided such care, consistent with professional standards of practice for one (Resident #52) of four residents reviewed for respiratory care. The facility failed to replace/change the humidifer weekly or when the humidifer was empty. These failures could place residents at risk for hyperoxygenation, skin issues, and infection. Findings include: Review of Resident #52's quarterly MDS assessment, dated 09/08/2023, reflected that the resident was a [AGE] year-old female admitted on [DATE]. Resident #52's BIMS score was an 11 which revealed a moderately impaired cognition. Her active diagnoses included anemia, high blood pressure, and diabetes mellitus. The MDS did not have oxygen therapy checked under her specialty treatment section. Review of Resident #52's Physician orders summary dated 10/10/23 , reflected, .may use oxygen at 2-4l/m via nasal canula as…

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

Based on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration dates for 1 (Medical Specialty medication room) of 2 medication rooms reviewed for medication storage. The facility failed to ensure one medication room on Medical Specialty Unit was free of expired medications. This failure could place residents at risk for increased or decreased potency of vaccination. Findings included: Observation on 10/11/23 at 01:16 PM of the Medical Specialty Unit medication room revealed, four vials of Shingrix with an expiration date of 10/6/23 in their refrigerator. Interview on 10/11/23 at 1:16 PM, LVN D stated she checks all medication rooms and carts weekly and as needed. LVN D missed that they were expired. LVN D thought they were labeled 10/30/23. LVN D stated they do dispose of expired medications due to changing the efficacy of the medication. The medication can…

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 right to personal privacy for 1 of 14 sampled residents (Resident #1). The facility failed to ensure Resident #1's dignity by closing personal curtain and/or door while using her bedside commode. The deficient practice had the potential to allow residents to be treated in undignified manner. Findings include: Review of Resident #1's face sheet, dated 08/01/23, reflected she was a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Her diagnoses included Anxiety Disorder, Hypertension, and Acute Kidney Failure. An observation on 08/01/2023 at 09:34 AM revealed Resident #1's door open with a clear view of Resident #1 with her brief at her ankles and sitting on the bedside commode. The curtain was not closed. During this observation, several people were walking in the hall near the resident room. An interview on 08/01/23 at 09:35 AM with Resident #1 in her room 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.