Sulphur Springs Health And Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source were reported immediately, but no later than 2 hours after the allegation was made, to the administrator of the facility and to other officials including to the State Survey Agency for 1 of 24 (Resident #11) residents reviewed for abuse and neglect. The Abuse Coordinator failed to identify and report an allegation of abuse to HHSC within 2 hours when LVN H informed him on 03/23/26 that Resident #11 stated the word rape and appeared scared while been provided a shower by CNA L. This failure to report could place the residents at risk for abuse and emotional distress. Findings included:Record review of Resident #11's face sheet, dated 03/25/26, reflected Resident #11 was an [AGE] year-old female, admitted to the facility on [DATE] with a diagnosis which included Alzheimer's disease (progressive disease that destroys memory and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure the services provided, as outlined by the comprehensive care plan, met professional standards of quality, for 1 of 2 residents (Resident #13) reviewed for services provided to meet professional standards. The facility did not ensure Resident #13's hospice POC reflected her medication regimen. This deficient practice could place residents at risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. Findings include: Record review of Resident #13's face sheet, dated 03/25/26, reflected Resident #13 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnosis which included CAD (occurred when plaque buildup in the arteries, restricting blood flow and oxygen to the heart muscle). Record review of Resident #13's quarterly MDS assessment, dated 03/05/26, reflected Resident #13 sometimes made herself understood and rarely/never understood…

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 grooming, and personal and oral hygiene were provided for 1 of 6 residents (Resident #10) reviewed for ADL care.The facility failed to ensure Resident #10's fingernails were free from a brown material substance.This failure could place residents at risk of not receiving care/services, and decreased quality of life impacting their loss of dignity. Findings included:Record review of a Resident #10's face sheet, dated 03/26/26, indicated a [AGE] year-old female who was re-admitted to the facility on [DATE] with diagnoses which included dementia (loss memory), muscle weakness, and depressive disorder (persistently depressed mood).Record review of Resident #10's quarterly MDS, dated [DATE], indicated Resident #10 sometimes made herself understood and rarely understood others. Resident #10 had difficulty with recall, and her BIMs…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 4 residents (Resident #43) reviewed for quality of care. The facility did not ensure that LVN A followed physician orders for wound care on Resident #43's right second toe on 03/21/26 and 03/22/26. This failure could place residents at risk for a decline in wounds, infection, pain and a decline in functional abilities. Findings include: Record review of Resident #43's face sheet, dated 0325/26, reflected Resident #43 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnosis which included hypotension (low blood pressure). Record review of Resident #43's quarterly MDS assessment, dated 02/06/26, reflected Resident #43 usually made himself understood and usually understood others. Resident #43 BIMS score of 8, which reflected his cognition…

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 environment was as free of accident hazards as is possible for 1 of 24 residents (Resident #51) reviewed for accidents and hazards. The facility failed to ensure CNA N locked the mechanical lift when transferring Resident #51 from his wheelchair to his bed. These failures could place residents at risk of accidents that could result in serious injury, harm, impairment, or death.Findings included: Record review of Resident #51's face sheet dated 03/25/26 indicated he was an [AGE] year-old male who re-admitted to the facility on [DATE] with diagnoses which included cerebrovascular disease (a group of conditions that affect blood vessels and blood flow in the brain), history of traumatic brain injury (disruption in normal brain function caused by a blow or bump to the head), cognitive communication deficit (when someone has trouble with one or more cognitive processes involved in communication), and glaucoma (a group of diseases…

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 provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 2 of 7 resident (Residents #5 and #15) reviewed for pharmacy services. 1.The facility did not ensure LVN A administered Resident #5's Sevelamer Carbonate (a medication used to manage high blood phosphorus levels in adults with chronic kidney disease) 800 mg on [DATE]. 2. The facility failed to ensure Resident #15's Novolog insulin vial (medication used to administer to residents with high blood sugars) on the west nurse medication cart was not expired prior to placing the open date of [DATE] on the bottle. These failures could place residents at risk for weak bones, joint pain, severe itching, and fractures.Findings include: 1.Record review of Resident #5's face sheet, dated [DATE], reflected Resident #5 was an [AGE] year-old male, admitted 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents' drug regimen was adequately monitored and free from unnecessary drugs for 2 of 6 residents (Resident #15 and Resident #4) reviewed for pharmacy services. 1. The facility failed to monitor Resident #15 for side effects/adverse reactions for the use of Eliquis (an anticoagulant medication- blood thinner). 2. The facility failed to monitor Resident #4 for side effects/adverse reactions for the use of Eliquis (an anticoagulant medication- blood thinner).These failures could place residents at risk of swelling, bruising, and bleeding. Findings include: 1.Record review of Resident #15's face sheet dated 03/25/26 indicated she was a [AGE] year-old female who re-admitted to the facility on [DATE] with the diagnoses which included chronic obstructive pulmonary disease (chronic disease of the lungs that causes difficulty breathing), ventricular tachycardia (life threatening heart arrhythmia defined by a fast heart rate more than 100 beats per…

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 or obtain laboratory services to meet the needs of its residents for 2 of 24 residents (Resident #6 and Resident #5) reviewed for laboratory services. 1. The facility failed to obtain Resident #6's CMP (lab test that provides an overall picture of your body's chemical balance and metabolism, and can help diagnose, screen for, or monitor health conditions or medication side effects), CBC (used to monitor and diagnose medical conditions, check the health of the immune system, and detect disorders including infections, anemia, and blood cancer), and HgA1c (lab test that provides a measurement of the average of the blood sugars in the last 2-3 months to manage diabetes) as ordered on 11/18/25 and every 3 months.2. The facility failed to obtain Resident #5's Magnesium lab (measures the amount of magnesium in the blood which can affect the heart, muscle, and nerve function) as ordered on 11/15/24 and every 12 months. These failures could place…

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 in (1 of 1) kitchen reviewed for dietary services. 1) The facility failed to dispose of expired food items in the refrigerator and freezer. 2) The facility failed to clean deep fryer weekly. 3) The Facility failed to label and date all food items in the refrigerator and freezer. These failures could place residents at risk for food contamination and foodborne illness. The findings included: Record Review of daily cleaning scheduled dated on the week of 3/31/25 did not indicated that the fryer had been cleaned by a cook on 3/31/25 (Monday), 4/1/25 (Tuesday). 4/2/25 (Wednesday), 4/3/25 (Thursday), 4/4/25 (Friday), 4/5/25 (Saturday) and on 4/6/25 (Sunday). Record Review of in-services on labeling and dating was last completed by staff on 2/10/25 and 4/7/25. Record Review of in-services on the cleaning schedule was last completed by staff on 12-11-24. Record Review of in-services on cleaning the deep…

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, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities both facility sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interation in the community for 3 of 3 residents (Residents #13, #42 and #48) reviewed for activities. The facility failed to provide their scheduled activities on December 9th, 10th and 11th for all residents which included Residents #12, #42 and #48. This failure could place residents at risk for not having activities to meet their interests or needs and a decline in their physical, mental, and psychosocial well-being. Findings include: 1. Record review of Resident #13's face sheet, dated 12/11/2024, indicated Resident #13 was an [AGE] year-old…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in (1 of 1) kitchen reviewed for dietary services. 1) The facility failed to date all food items. 2) The dietary staff failed to properly seal refrigerated food items. These failures could place residents at risk for food contamination and foodborne illness. The findings included: During observation in the kitchen Refrigerator 1 of 3 on 12/09/24 at 10:02 a.m., the following were observed: -(1) zip lock bag of flour tortilla was not sealed closed. -(1) boiled egg had a prep date of 12/7/24 and had no expiration date. During an interview and observation of the kitchen on 12/11/24 at 10:03 a.m., the Dietary Manager stated the flour tortilla should have been sealed closed. The Dietary Manager stated boiled egg found in a zip lock bag should have had a use by date. The Dietary Manager disposed of the hard-boiled egg found in 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 observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 2 of 4 residents (Residents #47 and Resident #3) reviewed for infection control practices. 1. The facility failed to ensure CNA Q used proper hand hygiene between glove changes while she provided incontinent care for Resident #47. 2. The facility failed to ensure CNA P and LVN R complied with Enhanced Barrier Precautions when providing incontinence care for Resident #3 These failures could place residents at risk of exposure to communicable diseases, cross-contamination, and infections. Findings included: 1.Record review of Resident #47's face sheet dated 12/11/24 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (disease 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 the promote resident had the right and the facility promoted and facilitated resident self-determination through support of resident choice for 1 of 6 residents (Resident #51) reviewed for resident rights . The facility failed to ensure Resident #51 was assisted out of bed per his preference on 12/09/2024 . This failure could place dependent residents at risk for feelings of depression, lack self-determination, and decreased quality of life. Findings include: Record review of Resident #51's face sheet, dated 12/11/2024, indicated an [AGE] year-old male who admitted to the facility on [DATE], readmitted on [DATE] and most recently readmitted on [DATE]. Resident #51 had diagnoses which included Parkinsonism (a syndrome characterized by tremor, bradykinesia, rigidity, and postural instability), Major Depressive Disorder (persistent feelings of sadness and loss of interest) and dementia (loss of memory). Record review of Resident #51's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide the resident access personal and medical records pertaining to him or herself, upon an oral or written request, in the form and format requested by the individual, if it is readily producible in such form and format (including in an electronic form or format when such records are maintained electronically, or, if not, in a readable hard copy from such other form and format as agreed to by the facility and the individual, within 24 hours (excluding weekends and holidays) and allow the resident to obtain a copy of the records or any portions thereof upon request and 2 working days advance notice to the facility for 1 of 2 residents (Resident #16) reviewed for access of records. The facility failed to provide Resident #16's legal representative copies of medical records after a request was submitted to the facility on [DATE]. This failure could place residents at risk of violation of their rights by not receiving copies of their medical records.…

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 inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident's representative when there was a significant change in the resident's physical, mental, or psychosocial status, that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications for 1 of 2 residents (Resident #16) reviewed for notification of changes. The facility failed to notify Resident #16's physician when Resident #16 had a change in condition on 11/22/24. This failure could place residents' at risk of a delay in treatment and decline in the residents' health and well-being. Findings include: Record review of Resident #16's face sheet, dated 12/11/24, indicated an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included parkinsonism (a chronic and progressive movement disorder that initially causes tremor in one hand,…

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 had a right to personal privacy and confidentiality of his or her personal and medical records for 1 of 4 residents (Resident #17) reviewed for privacy and confidentiality. The facility failed to ensure LVN BB logged out of her computer and protected Resident#17's Medication Administration Record. This failure could place residents at risk for low self-esteem, loss of dignity, and decreased quality of life due to medication administration records being accessible to others. Findings include: Record review of Resident #17's face sheet, dated 12/11/24, indicated a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #17 had diagnoses which included diabetes ( a disease that occurs when your blood glucose, also called blood sugar, is too high), anxiety (a feeling of fear, dread, and uneasiness), depression (sadness), and high blood pressure. Record review of Resident #17's 5-day…

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 develop and implement a baseline care plan each residnet that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality of care for 1 of 2 resident's (Resident #108) reviewed for baseline care plans. The facility failed to ensure Resident #108's weight bearing status to her fractured right arm was addressed on the baseline care plan. This failure could place residents at risk of increased pain, and worsening of fractures. Findings include: Record review of Resident #108's face sheet, dated 12/11/2024, indicated a [AGE] year-old female who admitted to the facility on [DATE]. Resident #108 had diagnoses which included fracture of the right humerus (right upper arm), muscle weakness, unsteadiness on feet and the lack of coordination. Record review of Resident #108's Baseline Care Plan, dated 11/26/2024, indicated Resident #108 desired to discharge back home, advance directive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to develop 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 for1 of 2 residents (Resident #37) reviewed for Care Plans. The facility failed to update Resident #37's Care Plan to reflect a history of Staph dermatitis (an infection caused by staphylococcus bacteria) with interventions for the antibiotic use and the staff to monitor the resident for possible Staph symptoms. This deficient practice could place residents at risk of not receiving the care and services they needed. Findings include: Record review of Resident #37's face sheet, dated 10/10/24, indicated a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #37 had diagnoses which included cerebral infarction (a stroke resulting from disrupted blood flow in the brain),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure that residents requiring respiratory care were provided such care, consistent with professional standards of practices for 2 of 57 residents (Resident #14 and Resident #31) reviewed for respiratory care. 1. The facility failed to ensure Resident #14's oxygen was administered at 3 liters per minute via nasal cannula as prescribed by the physician. 2. The facility failed to ensure Resident #31's oxygen was administered at 4 liters per minute via nasal cannula as prescribed by the physician. This failure could place residents who receive respiratory care at risk for developing respiratory complications. The findings included: 1. Record review of the face sheet, dated on 12/10/24, indicated that Resident #14 was an [AGE] year-old female who admitted to the facility on initial admission dated 11/20/16, with diagnoses of COPD (chronic obstructive pulmonary disease with (acute) exacerbation (chronic inflammatory lung disease that 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 observations, interviews, and record review the facility failed to ensure all drugs were only accessible by authorized personnel, for 1 of 6 medication carts (400 hall medication cart) observed for medication storage. The facility did not ensure the 400-hall medication cart was secured and unable to be accessed by unauthorized personnel. This deficient practice could place residents at risk for harm due to improper storage and drug diversion. Findings included: Record review of Resident #17's face sheet, dated 12/11/24, indicated a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included diabetes, anxiety (a feeling of fear, dread, and uneasiness), depression (sadness), and high blood pressure. Record review of Resident #17's 5-day MDS assessment, dated 11/01/24, indicated Resident #17 sometimes understood and was sometimes understood by others. Resident #17's BIMS score was 07, which meant she was moderately cognitively impaired. The 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 interviews and record review, the facility failed to ensure laboratory services were obtained to meet the needs of 2 of 7 residents (Resident #48 and Resident #12) reviewed for laboratory services. 1. The facility failed to ensure Resident #48's lipid level (a blood test that measures the levels of different fats in your blood. The test can help identify abnormalities in your blood lipids and determine your risk for certain diseases, including heart disease and stroke) was drawn on 08/14/24. 2. The facility failed to obtain Resident #12's ordered Hgb A1C (hemoglobin A1C measures blood glucose level). These failures could place residents at risk of not receiving lab services as ordered, not receiving timely diagnosis and treatment, and not receiving appropriate monitoring for certain diseases. Findings included: 1)Record review of Resident #48's face sheet dated 12/11/24, indicated a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which 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 interviews, and record review, the facility failed to ensure professional staff were certified in accordance with applicable State laws for 1 (NA EE) of 15 personnel reviewed for licensed nursing. The facility failed to ensure NA EE had become a Certified Nurse Aide by passing her certification test. This failure could place residents at risk of being provided care by staff who were not qualified per state law. Findings included: Record review of NA EE's employee file indicated she was hired on 4/1/24 as a full-time nursing staff trainee and had no evidence of CNA certification. The employee file indicated NA EE had completed the CNA training course on 04/26/24 but no evidence of the certification. During an interview on 12/12/24 at 11:00 AM NA EE said she had been working at the facility from 4/1/24 up until last week on 12/07/24 providing care for residents to include bathing, transfers, incontinent care, and repositioning. She said the facility notified her on 12/07/24 that she could no longer work as a CNA until she passed her clinical portion of the CNA course 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 arrange an appointment with an outside resource for 1 of 1 resident (Resident #108) reviewed for the use of outside resources. The facility failed to ensure Resident #108's appointment for the orthopedic specialist (specialty for prevention, diagnosis, and treatment of disorders, conditions, and injuries of the skeleton and its associated structures, including muscles, ligaments, joints, and tendons) was made for her right arm fracture. This failure could place residents at risk of not receiving needed medical care. Findings included: Record review of a face sheet dated 12/11/2024 indicated Resident #108 was a [AGE] year-old female who admitted on [DATE] with the diagnoses of a fracture of the right humerus (right upper arm), muscle weakness, unsteadiness on feet, and the lack of coordination. Record review of the AHS-Baseline Care Plan dated 11/26/2024 indicated Resident #108 desired to discharge back home, advance directive status was a full code…

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 collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure the quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 7 residents (Resident #38) reviewed for hospice services. The facility failed to maintain Resident #38's hospice binder containing information related to hospice services provided for the resident such as the most recent plan of care, hospice election form, and physician recertification. These deficient practices could place residents who receive hospice services at risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs. The findings included: Record review of Resident #38's face sheet, dated 12/11/24 indicated Resident #38 was a [AGE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 2 of 6 residents (Resident #1 and Resident #2) reviewed for resident rights. CNA B did not treat Resident #1 and Resident #2 with dignity or respect when she spoke to them in a rude tone. This failure could place residents at an increased risk of embarrassment, anger, feelings of worthlessness, sadness, and diminished quality of life. The findings included: 1.Record review of Resident #1' s face sheet dated 8/8/24 indicated she was [AGE] years old, re-admitted to the facility on [DATE] with diagnoses including dementia, COPD (chronic obstructive pulmonary disease is group of lung diseases that block airflow and make it difficult to breathe), age related macular degeneration (macular degeneration causes loss in the center of the field of vision), and poly osteoarthritis ( having arthritis…

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 that was palatable and served at an appetizing temperature for 3 of 22 residents (Resident's #4, #36, and #42) reviewed for palatable food. The facility failed to provide palatable food served at an appetizing temperature or taste to Resident #4, Resident #36, and Resident #42, who complained the food was served cold, was bland, and did not taste good. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. The findings included: During an interview on 11/13/2023 beginning at 10:03 AM, Resident #36 stated the food was terrible. Resident #36 stated sometimes the food was cold. During an interview on 11/13/23 beginning at 11:24 AM, Resident #42 stated the food was tasteless and cold at times. During an interview on 11/13/23 beginning at 1:18 PM, Resident #4 was sitting up in his bed with the head of the bed elevated to an upright position. Resident #4 had his meal tray in front of him on his bedside table.…

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 at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care for 2 of 2 meals (Lunch meal on 11/13/23 and 11/14/23) observed for frequency of meals. The facility did not serve the 11/13/23 and the 11/14/23 lunch meal at the scheduled time. This failure could place residents at risk for decreased meal satisfaction, decreased intake, loss of appetite, side effects from medication given without food, and diminished quality of life. The findings included: Record review of the facility's mealtimes indicated lunch was served at 12:00 PM. During an interview on 11/13/23 beginning at 11:20 AM, Resident #3's daily visitor stated she was concerned Resident #3 was served lunch at around 1:00 PM most of the time. Resident #3's visitor stated Resident #3 was supposed to be served her lunch around 12 PM, not 1 PM. During an observation on 11/13/23 beginning at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility did not ensure: 1. DA E wore a hair net while in the kitchen. 2. Paper towels were readily available at the handwashing sink. 3. Meat was thawing in the appropriate container and sink. 4. Food preparation areas were kept clean and free of crumbs and dirty dishes. 5. The refrigerator was kept at the appropriate temperature. 6. The refrigerator was not leaking condensation. 7. The refrigerator was free of foul-smelling rotting odors. 8. The containers in the refrigerator were labeled, dated, and not expired. 9. Eggs were not cracked. 10. The frozen packages in the freezer were labeled and dated. 11. The can opener tip, microwave, and fryer were kept clean. 12. The grease in the fryer was clean and see-through. 13. The bread was not molding. 14. Items in the dry storage area were labeled. 15.…

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 requiring respiratory care were provided such care, consistent with professional standards of practices for 3 of 9 residents (Residents #10, #21 and #115) reviewed for respiratory care. 1. The facility did not ensure Resident #10 and Resident #21's oxygen concentrator filters were cleaned. 2. The facility did not ensure Resident #21's oxygen was set at 3 LPM as ordered by the physician. 3. The facility did not ensure Resident #115's oxygen was set at 2 LPM as ordered by the physician. These failures could place residents who receive respiratory care at risk for developing respiratory complications and a decreased quality of care. Findings included: 1. Record review of Resident #10's face sheet, dated 11/15/2023, indicated Resident #10 was a [AGE] year-old male, readmitted to the facility on [DATE] with diagnoses which included COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs) 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 interviews and record review, the facility failed to act upon the recommendations of the pharmacist report of irregularities for 1 of 5 residents (Resident #4) reviewed for (DRR) Drug Regimen Review. 1. The facility failed to timely implement Resident #4's signed Note to Attending Physician/Prescriber on 10/12/23, which agreed with the pharmacy recommendation to schedule Resident #4's antianxiety medication. 2. The facility failed to timely implement Resident #4's signed Note to Attending Physician/Prescriber on 10/12/23, which agreed with the pharmacy recommendation for a gradual dose reduction on an antidepressant medication. This failure could place residents at risk for receiving unnecessary medications at the most effective dosage. The findings included: Record review of the face sheet, dated 11/14/23, revealed Resident #4 was a [AGE] year-old male who re-admitted to the facility on [DATE] with diagnoses of major depressive disorder (disorder that causes a persistent feeling of sadness and loss 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 interviews and record review the facility failed to ensure residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs and the facility failed to have target behavioral monitoring in place for behaviors associated with the use of psychotropic medications documented in the clinical record for 3 of 5 (Resident's #4, #10, and #36) reviewed for unnecessary medications. 1. The facility failed to ensure Resident #4 received a gradual dose reduction of his anti-depressant medication. 2. The facility did not ensure a clinical rationale for declination of a GDR was documented by the physician for Resident #10. 3. The facility did not ensure Resident #36's behaviors were adequately monitored regarding her antianxiety, and antidepressant medications. 4. The facility did not ensure Resident #36's adverse drug event was adequately monitored regarding her antianxiety, and antidepressant medications.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 residents (Resident #56) reviewed for infection control practices related to transmission-based precautions and 1 of 3 facility staff members (MA B) reviewed for infection control practices related to medication pass. 1. The facility did not ensure Resident #56 had an order for isolation precautions and appropriate signage outside the door to alert staff and visitors of isolation status and appropriate PPE to wear inside Resident #4's room. 2. The facility did not ensure MA B disinfected the manual blood pressure monitor and stethoscope between Resident #52, #41 and #20. These failures could place residents at increased risk for infection or cross-contamination of communicable disease that could diminish the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to consult with the resident's physician when there was a significant change in the resident's physical and mental status that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications for 1 of 22 (Residents #61) residents reviewed change of condition. The facility did not ensure Physician D was notified when Resident #61 was exhibiting suicidal ideation on 11/12/23. This failure could place residents at risk of a delay in treatment or interventions, worsening of their physical and psychological condition, and a decreased quality of life. The findings included: Record review of the face sheet, dated 11/15/23, revealed Resident #61 was an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of retention of urine, acute kidney failure (condition when an abrupt reduction in kidneys' ability to filter waste products occurs within a few hours or a few days), gross hematuria…

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 an encoded, accurate, and complete Quarterly MDS assessment was transmitted to the CMS System within 14 days after completion for 1 of 22 residents (Resident #54) reviewed for MDS assessments. The facility did not ensure Resident #54's Quarterly MDS assessment, dated 09/27/2023, and completed on 09/28/2023, was transmitted within 14 days of completion. This deficient practice could place residents at risk of not having records completed and submitted in a timely manner as required. Findings included: Record review of a face sheet dated 11/15/2023, indicated Resident #54 was a [AGE] year-old male, admitted to the facility on [DATE], with a primary diagnosis of Parkinsonism (a clinical syndrome characterized by tremors, slowed movements, postural instability, and stiffness). Record review of Resident #54's Quarterly MDS assessment dated [DATE] indicated it was completed on 09/28/2023 (Section Z0500B). Record review of Resident #54's electronic…

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 a comprehensive person-centered care plan to meet resident's medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment for 2 of 22 residents (Residents #20 and #59) reviewed for care plans. 1. The facility did not develop Resident #20's care plan related to him being PASRR positive effective 04/01/2023. 2. The facility did not develop Resident #59's care plan related to Hepatitis C (infection caused by a virus that attacks the liver and leads to inflammation) effective 10/06/2023. These failures could place residents at risk for unmet care needs and decreased quality of care. Findings included: 1. Record review of Resident #20's face sheet, dated 11/15/2023, indicated Resident #20 was a [AGE] year-old male, readmitted to the facility on [DATE] with diagnoses which included bipolar disorder (serious mental illness characterized by extreme mood swings, major depressive disorder, and generalized anxiety…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living, received services to maintain personal hygiene for 2 of 64 (Residents #10 and #21) residents reviewed for ADLs. 1. The facility failed to ensure Resident #10's fingernails were trimmed routinely. 2. The facility did not ensure Resident #21's fingernails were trimmed and free from a brown colored substance routinely. These failures could place residents at risk of not receiving services or care, decreased quality of life, and decreased self-esteem. Findings included: 1. Record review of Resident #10's face sheet, dated 11/15/2023, indicated Resident #10 was a [AGE] year-old male, readmitted to the facility on [DATE] with diagnoses which included COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs) and obstructive sleep apnea (intermittent airflow blockage during sleep). Record review of the quarterly MDS assessment dated [DATE],…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide mentally related social services to attain or maintain the highest practicable mental and psychosocial well-being for 1 of 1 (Resident #61) residents reviewed for social services. 1. The facility failed to ensure the Social Worker was notified and social services were provided after Resident #61 exhibited suicidal ideations on 11/12/23. 2. The facility failed to ensure Resident #61 received a psychiatric referral after he exhibited suicidal ideations on 11/12/23. These failures could place residents at risk for their mental and psychosocial needs not being met and a decreased quality of life. The findings included: Record review of the face sheet, dated 11/15/23, revealed Resident #61 was an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of retention of urine (holding urine in the bladder and inability to empty bladder fully), acute kidney failure (condition when an abrupt reduction in kidneys' ability to filter waste…

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 to determine that drug records are in order and that an account of all controlled drugs was maintained and periodically reconciled for 2 of 4 medication carts (North and [NAME] Hall) and 1 of 5 residents (Resident #20) reviewed for pharmacy services. 1. The facility did not ensure Resident #20's lactobacillus 0.2 mg (medication that is used to prevent or treat infections in children and adult) as ordered by the physician was administered instead of the lactobacillus 10 mg. 2. The facility did not ensure LVN M counted controlled drugs every shift change on 11/02/2023 and 11/05/2023. These failures could result in an inaccurate controlled medication count, drug diversion, and decreased therapeutic effects from medications. Findings included: 1. Record review of Resident #20's face sheet, dated 11/15/2023, indicated Resident #20 was a [AGE] year-old male, readmitted to the facility on [DATE] with 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 interview and record review, the facility failed to ensure laboratory services were obtained to meet the needs of 1 of 22 residents (Resident #10) reviewed for laboratory services. The facility did not obtain a physician's ordered Hgb A1c (a blood test that measures the average blood sugar levels over the past three months) for Resident #10. This failure could place residents at risk of not receiving lab services as ordered and not managing medications at a therapeutic level. Findings included: Record review of Resident #10's face sheet, dated 11/15/2023, indicated Resident #10 was a [AGE] year-old male, readmitted to the facility on [DATE] with diagnoses which included bipolar type 2 diabetes with diabetic neuropathy (chronic condition that affects the way the body processes blood sugar and a type of nerve damage that can occur with diabetes) Record review of the order summary report, dated 11/15/2023, indicated an order for Hgb A1c every 3 months with a start date 03/02/2023. Record review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy and providing written rationale, by the provider, when an antibiotic was used despite criteria, to determine the appropriate use of an antibiotic for 1 of 2 residents (Residents #3) reviewed for antibiotic use. The facility failed to assess and incorporate monitoring of antibiotic use for Resident #3. This failure could place residents receiving antibiotics at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased antibiotic-resistant infections. Findings included: Record review of Resident #3's face sheet, dated 11/15/2023, revealed an [AGE] year-old female initially admitted to the facility on [DATE] with a diagnosis which included unspecified fracture of shaft of right fibula (broken leg), type 2 diabetes (blood sugar disorder) and heart failure (heart does not pump blood as good as it should). Record review of the MDS Resident Assessment…

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

Based on observation, interview and record review, the facility failed to follow their established smoking policy for 1 of 1 smoking area reviewed for smoking. The facility did not ensure smoked cigarettes were extinguished in a fire-retardant receptacle. This failure could place residents at risk for smoking-related injuries and fires in the facility. Findings included: During an observation on 11/13/2023 at 12:25 p.m., the designated smoking area had numerous cigarette butts laying on the ground. During an observation on 11/14/2023 at 3:27 p.m., the designated smoking area had numerous cigarette butts laying on the ground. During an interview on 11/15/2023 at 4:28 p.m., the Maintenance Manager stated the maintenance supervisor was responsible for monitoring the smoking area. The Maintenance Manager stated he was filling in for the maintenance supervisor since he was on vacation. The Maintenance Manager stated he had not been outside to the smoking area. The Maintenance Manager stated the cigarette butts should be disposed in the metal container. The Maintenance Manager stated it…

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.