Paradigm at The Pines

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to have evidence that all allegations of abuse, neglect, exploitation, or mistreatment, were thoroughly investigated for 4 of 6 residents (Resident #2, Resident #3, Resident #4 and Resident #5) reviewed for abuse and neglect. 1. The facility did not thoroughly investigate an incident in which Resident #2 was slapped on the neck by Resident #3 on 01/21/2025. 2. The facility did not investigate an incident in which Resident #2 was punched on the arm by Resident #3 on 05/18/2025. 3. The facility did not thoroughly investigate an incident in which Resident #4 pushed Resident #5 causing him to fall on 07/02/2025. This failure could place residents at risk for abuse/neglect and could lead to a diminished quality of life and psychosocial harm. The findings included: Resident #2Record review of Resident #2's admission Record dated 09/08/2025 indicated she was a [AGE] year-old female who was initially admitted to the facility on [DATE] with diagnoses 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 interviews, and record review, the facility failed to review and revise resident's comprehensive care plans by the interdisciplinary team after each assessment to reflect the current condition for 2 of 12 (Resident #2 and Resident #3) residents reviewed for comprehensive care plans. The facility failed to ensure Resident #2's care plan was updated to indicate Resident #2 had received aggression during a resident-to-resident incident on 01/21/2025 and 05/18/2025. The facility failed to ensure Resident #3's care plan was updated to indicate Resident #3 had an incident of resident-to-resident aggression on 01/21/2025 and 05/18/2025. This deficient practice could place residents at risk of not receiving appropriate interventions to meet their current needs. The findings included: Resident #2Record review of Resident #2's admission Record dated 09/08/2025 indicated she was a [AGE] year-old female who was initially admitted to the facility on [DATE] with diagnoses which included Huntington's disease (causes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse were reported, immediately but not later than 2 hours after the allegation was made, if the events that cause the allegation involves abuse or results in serious bodily injury, to the State Survey Agency for 1 of 5 residents (Residents #2) reviewed for reporting allegations of abuse. The facility failed to report an allegation of abuse to the state agency within 2 hours after Resident #3 punched Resident #2 in the arm on 05/18/2025. The failures could place residents at risk of not having allegations reported within the required timeframes. Findings included: Record review of Resident #2's admission Record dated 09/08/2025 indicated she was a [AGE] year-old female who was initially admitted to the facility on [DATE] with diagnoses which included Huntington's disease (causes nerve cells in the brain to decay over time and the disease affects a person's movements, thinking ability 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 establish a system of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and determine that drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 1 of 4 residents (Resident #6) reviewed for controlled medications. * LVN X and RN Y did not count the narcotic medications during the shift change to ensure the count was correct and all narcotics had an Inventory Sheet. * Resident #6's hydrocodone 5 mg /acetaminophen 325 mg (narcotic pain medication for moderate or severe pain) were not counted and did not have an Inventory Sheet on 10/04/24. This failure could place residents at risk for medication overdose, medication under-dose, ineffective therapeutic outcomes, and drug diversion. Findings included: Record review of the face sheet dated 09/10/25 indicated Resident #6 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included…

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 each resident received and the facility provided food prepared by methods that conserve nutritive value, flavor, and appearance and were palatable, attractive, and at a safe and appetizing temperature for 1 of 1 kitchen reviewed for food and nutrition services. The facility did not ensure the chicken wrap and potato salad served for lunch on 10/01/24 were palatable. These failures could place the residents at risk of a decline in their satisfaction and weight loss. Findings included: During confidential interviews on initial rounds on 9/30/24 from 9:38 a.m. to 11:00 a.m., the residents complained about the food tasting bad and not being edible at times. During an observation and interview on 10/01/24 at 1:14 p.m., the test tray contained a chicken ranch wrap, potato salad and pear crisp with topping. The chicken wrap was not wrapped and appeared to be a taco. The meat in the tortilla was breaded and appeared soggy, lettuce appeared fresh, tomatoes appeared canned, with ranch dressing. The meat 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.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions for 1 of 1 kitchen reviewed for dietary services. The facility failed to ensure food items were properly labeled with product and expiration date in the freezers. The facility failed to properly close items stored in the freezers. These failures could place residents, who ate meals prepared in the kitchen, at risk for food borne illness. Findings included: During an observation and interview with the Dietary Manager on 09/30/2024 at 8:52 a.m. the following were observed: -Freezer #1 contained: A large, opened bag of okra that was not labeled or dated. An opened sleeve of waffles that was not labeled or dated. A large, opened bag of corn that was not labeled or dated. An opened bag of squash that was not labeled or dated and had not been properly closed and was exposed to air. Pieces of frozen squash were scattered throughout the freezer. -Freezer #2 contained: An open bag of okra that was not labeled or dated and had not been properly closed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received an accurate assessment, reflective of the resident's status for 2 of 17 residents reviewed for accuracy of assessments. (Resident #s 5 and 54) The facility did not accurately complete the MDS assessment to indicate Resident #5 was receiving an anticoagulant medication. The facility did not accurately complete the MDS assessment to indicate Resident #54 was receiving an anticoagulant medication. This failure could place the residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being. Findings included: 1. Record review of a face sheet dated 10/02/24 indicated Resident #5 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included embolism (sudden blocking of an artery) and thrombosis (formation of a blood clot inside a blood vessel) of her left lower extremity on 02/20/24. Record review of the physician's orders dated 10/02/24 indicated Resident #5…

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 develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 17 residents. (Resident #5) The facility failed to develop a care plan for Resident #5's anticoagulant (blood thinner) medication, Eliquis. This failure could place the residents at risk of not receiving care and services to maintain their highest level of well-being. Findings included: Record review of a face sheet dated 10/02/24 indicated Resident #5 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included embolism (sudden blocking of an artery) and thrombosis (formation of a blood clot inside a blood vessel) of her left lower extremity on 02/20/24. Record review of physician's orders dated 10/02/24 indicated Resident #5 was prescribed Eliquis 2.5 mg two times…

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, receiving, dispensing, and administering of all drugs and biologicals) in 1 of 3 medication carts reviewed (Hall B and right side of Hall C Nurse medication cart) in that: An insulin pen of Insulin Glargine yfgn (used to lower blood sugar) with an open date of 08/03/24, had been expired for 60 days and not removed from use. This failure could place residents at risk for accidents, hazards, and not receiving therapeutic effects of medication. The findings included: Record review of Resident #26's face sheet dated 10/02/24 indicated an [AGE] year-old male admitted [DATE] with diagnoses included: end stage renal disease (disease in which the kidneys lose the ability to remove waste and balance fluids) and type 2 diabetes mellitus (trouble controlling blood sugar). Record review of Resident #26's quarterly MDS assessment with an ARD of 07/16/24 indicated…

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 the menu was followed for 1 of 3 meals reviewed for menus and nutritional adequacy. (Lunch meal 10/01/24) The facility did not ensure the recipes were followed for the chicken wrap and potato salad served for lunch on 10/01/24. This failure could place residents at risk of not having their nutritional needs met. Findings included: During an observation and interview on 10/01/24 at 1:14 p.m., the test tray contained a chicken ranch wrap, potato salad and pear crisp with topping. The chicken wrap was not wrapped and appeared to be a taco. The meat in the tortilla was breaded and appeared soggy, lettuce appeared fresh, tomatoes appeared canned, with ranch dressing. The meat did not taste like chicken, and it was wet, soggy, and jelly like. The inside of the patties tasted burnt and appeared grey in color. The potato salad had a strong unsavory flavor of garlic. The DM said he did not taste the food when preparing it and he did not follow the recipes. He refused to taste the food because he said he 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 protect a resident's right to be free from abuse for 2 of 11 residents reviewed for abuse. (Resident #1 and #2) The facility failed to protect Resident #1 from inappropriate sexual touching by Resident #2. This failure could place residents at risk of for psychosocial harm and a diminished quality of life. Findings included: 1. Record review of a face sheet dated 09/17/2024, indicated Resident #1 was a [AGE] year-old female, with an admission date of 09/30/2015 with diagnoses including Dementia (loss of cognitive functioning), Bipolar Disorder (mental disorder associated with episodes of mood swings ranging from depressive lows to manic highs), Cirrhosis of the liver (a condition in which healthy tissue is replaced with scar tissue), anxiety disorder (persistent and excessive worry that interferes with daily activities) and depressive disorder (mental illness that negatively affects how you feel, the way you think and how you act). 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.

Based on interview and record review the facility failed to ensure they had a full time DON and failed to ensure the had an RN for 8 consecutive hours 7 days a week for 6 of 6 months reviewed for RN coverage. * The facility did not have a full-time DON between 9/02/23 and 9/18/23. * The facility did not have RN coverage for 8 consecutive hours on Saturday and Sunday. These failures could place residents at risk of lack of nursing oversight and a higher level of care. 1. During an interview upon entrance on 09/18/23 at 08:46 a.m. the ADM said she had no full time DON and will call to try and get interim back. During an interview on 09/19/23 at 10:35 a.m. the ADM said the previous DON's last day was 07/21/23. She said the Interim DON originally began on 07/24/23. She said the Interim DON was off on 07/25/25 but they did have RN coverage for the day. She said the interim DON contract ended on 09/01/23. She said she thought the Interim DON was going to stay until October 2nd. She said she renewed the contract for the Interim DON on Monday 09/18/23. During an interview on 09/20/23 at…

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

Based on 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. The facility failed to designate a person to serve as the Dietary Manager who met the required qualifications. The facility designated Dietary Manager did not have a Dietary Managers certification or any other qualifying credentials. This failure could place residents at risk for the spread of foodborne illness and residents not having their nutritional needs met. The findings include: Record review of the personnel file for the DM indicated documentation that she had completed the certified Dietary Manager course on 07/27/23 and she had not completed the final certification test or other qualifying credentials. She had a date of hire of 07/06/23. During an interview on 9/19/23 at 10:07 a.m., the DM said since she started the position of DM, she had completed the certified Dietary Manager course and had not taken the final certification test. She said she had a 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 observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the kitchen reviewed for dietary services. The facility failed to prevent the following: Two of 4 freezers had 3-to-4-inch layer of buildup of ice. The juice dispenser nozzle (gun) had thick buildup of black and red substance on the inside of the nozzle. The deep fryer contained very dark grease with particles of food debris and had an odor. Food items were not properly labeled with product and expiration date in the refrigerator. The grates on the stove had buildup of black substance. These failures could place residents, who ate meals prepared in the kitchen, at risk for food borne illness. Findings included: During an observation and interview with the DM on 9/18/23 from 8:30 a.m. through 9:45 a.m. revealed: Two of the 4 freezers in the kitchen had a thick buildup (approximately 3-4 inches) of ice and frost along the inside walls of the freezers. The DM said the freezers needed to be defrosted and she was responsible for dethawing 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 interview and record review the facility failed to follow guidelines for mandatory submission of staffing information based on payroll data in a uniform format. The facility failed to submit direct care staffing information on the schedule specified by CMS (Centers for Medicare and Medicaid Services), but no less frequently than quarterly for 1 of 3 quarters reviewed for payroll data information. *The facility failed to submit staffing information to CMS for the 3rd quarter of the fiscal year 2023. This failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment. Findings included: Record Review of the facility's Civil Rights form (3761) dated 09/18/23 indicated the following: 5 RN's 14 LVNs 19 Direct Care Staff 8 Dietary 6 Housekeeping & Laundry 20 All Others Record review of the CMS PBJ Staffing Data Report (payroll-based staffing), CASPER Report (Certification and Survey Provider Enhanced Report)1705 D FY Quarter 3 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.

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 status for 5 of 5 residents (Residents #9, #18, #31, #40, and #58) reviewed for MDS assessment accuracy. The facility did not ensure Residents #9, #18, #31, #40, and #58 assessment was accurately coded to reflect falls since the previous assessment. This failure could place residents at risk for not receiving care and services to meet their needs. Findings included: 1. Record review of a face sheet dated 09/20/23 indicated Resident #9 was a [AGE] year-old female admitted on [DATE]. Record review of Incident Reports Log for 04/23 through 09/23 indicated Resident #9 had a fall on 04/13/23. Record review of an MDS dated [DATE] for Resident #9 indicated it was incorrectly marked as she had 2+ falls since the last assessment. Record review of Resident #9's MDSs indicated her last assessment prior to 06/20/23 was 04/06/23. Record review of the care plan dated 11/17/22 for Resident #9 indicated it 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 that the resident environment remained as free of accident hazards 2 of 2 residents reviewed for smoking safety assessments and 7 of 7 residents reviewed for fall risk assessments. The facility did not have Smoking-Safety Screens completed for Residents #9, and #13. The facility did not have Fall Risk Assessments completed for Residents #9, #18, #29, #31, #40, #54, and #58 after they had a fall. These failures could place residents at risk of harm or injury and contribute to avoidable accidents. Findings included: 1. Record review of a face sheet dated 09/20/23 indicated Resident #9 was a [AGE] year-old female admitted on [DATE] . Record review of an annual MDS assessment dated [DATE] indicated Resident #9 was a smoker. Record review care plan dated 07/08/22 Indicated Resident #9 was at risk for injury related to smoking, also uses smokeless dipping tobacco. The unsafe smoker interventions included to: Inform the resident of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that residents receiving enteral feeding received appropriate care and services to prevent complication of enteral feeding for 3 of 3 residents (Residents #14, #44, and #57) reviewed for enteral feeding. The facility failed to initiate dietician recommendations for Resident #14. LVN F force flushed water through Resident #44's G-tube that was clogged. LVN G failed to check Resident #57's G-tube placement by aspirating for residual feeding before enteral administration of medications. These failures could place residents receiving enteral nutrition and medications at increased risk of not receiving the proper nutrition, infection, and aspiration. Findings include: 1. Record review of Resident #14's face sheet indicated she was [AGE] years old and admitted on [DATE] with diagnosis of tracheostomy (surgical opening in the windpipe). Record review of Resident 14's physician orders dated September 2023 indicated NPO (Nothing by Mouth)…

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 the menu met the nutritional needs of residents in accordance with established national guidelines, be prepared in advance and was followed for two of three meals (lunch on 09/18/23 and breakfast on 09/19/23) reviewed for food and nutrition services. The facility failed to ensure the menu was followed for the lunch on 09/18/23 The facility failed to ensure the menu was followed for the breakfast meal on 09/19/23 These deficient practice could place residents at risk of dissatisfaction, poor intake, and/or weight loss. Findings include: During an observation on 09/18/23 at 12:30 p.m., a posted menu in the dining room indicated the lunch meal was Lunch: Slow-Cooked Beef Tips in Gravy, Steamed Rice, Seasoned Mixed Vegetables and Chocolate Chip Cookies. During observations on 09/18/23 at 12:35 p.m. in the dining room revealed the residents were served chocolate chip cookies with no chocolate chips. Some of the cookies were very brown and the residents were unable to eat them. During a confidential interview,…

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 provide food in a form designed to meet individual needs for reviewed for food form. The facility failed to ensure the residents who required a pureed textured diet, received the appropriate food form to meet their needs on 9/19/23 for the noon meal. The pureed broccoli had small pieces and strings of the broccoli was not fully pureed and smooth consistency. This failure could place the residents at risk of aspiration and choking. Findings included: During an interview and observation on 09/19/23 at 11:30 a.m. [NAME] H said she was the person responsible for pureeing the food and had been trained on pureeing food on hire. She said the roasted broccoli takes longer to puree thoroughly as she placed the broccoli in the food processor. She placed a piece of bread into the processor and said this helps make broccoli smooth. During an observation of a test tray on 09/19/23 at 12:55 p.m., the pureed broccoli had small pieces and had stringy texture. The regional nurse tasted the pureed broccoli and said the food did…

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 notify the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in the mental or physical condition of a resident who had mental illness or intellectual disability for 1 of 18 residents (Residents #54) reviewed for PASARR. The facility failed to notify the local mental health authority after Resident #54's significant change in mental illness diagnosis following a new diagnosis of psychosis. This failure could place residents requiring PASARR services at risk of not having their special needs assessed and met by the facility. Findings include: Record review of face sheet dated 09/20/23 indicated Resident #54 was a [AGE] year-old female who admitted on [DATE] with diagnoses including Huntington's disease (inherited disorder that cause nerve cells in the brain to breakdown and die) and an adjustment disorder with anxiety. The diagnosis related to unspecified psychosis not due to a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to implement their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 4 of 16 residents (Resident #s 1, 2, 3, and 5) reviewed for abuse and neglect. The facility failed to ensure all allegations of abuse or neglect were reported to the administrator immediately and failed to ensure the abuse coordinator and/or designee reported immediately to HHSC after: Facility staff noted suspicious bruises to Resident #1's perianal area on 03/27/23. The administrator was not notified until 04/01/23. Resident #2 alleged Resident #5 slapped her face, and Resident #5 grabbed Resident #3's inner thigh. These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: Record review of a face sheet dated 08/30/23 indicated Resident #1 was an [AGE] year-old female, admitted on [DATE], and her diagnoses included…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury for 4 of 16 residents (Resident #s 1, 2, 3, and 5) reviewed for abuse and neglect. The facility failed to ensure the abuse coordinator and/or designee reported immediately to HHSC after: they were made aware of suspicious bruises to Resident #1's perianal area, Resident #2 alleged Resident #5 slapped her face, and Resident #5 grabbed Resident #3's inner thigh. These failures could place residents at risk of emotional, physical, and mental abuse. Findings included: Record review of a face sheet dated 08/30/23 indicated Resident #1 was an [AGE] year-old female, admitted on [DATE], and her diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness or the inability to…

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