Countryview Nursing & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 of 18 residents( Resident #192, Resident #30, Resident #34, Resident #12, and Resident #23) and 7 of 8 staff (LVN A, LVN C, CNA C, CNA L, LVN K, CNA B, and CNA O) reviewed for infection control practices and transmission-based precautions. 1. LVN A failed to ensure Resident #192 had the proper cap in place to prevent infection in PICC line. 2. LVN A failed to wash his hands while passing medications to Resident #30 and Resident #34. 3.The facility failed to ensure the EBP (enhanced barrier precautions) were in place for Resident #192 on 07/28/24. 4.LVN C failed to properly store urine obtained for urinalysis. 5.CNA L failed to perform hand hygiene during Resident #12's continent care. 6.CNA L failed to perform catheter care…

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 and/or the residents' representatives the right to participate in the development and implementation of his or her person-centered plan of care for 1 of 18 residents (Residents #19) reviewed for care plans. The facility failed to invite and include the input of the resident (Resident #19) and/or resident's representatives as members of the interdisciplinary team in the Care Plan Conference meetings on 4/19/24 and 7/19/24. These failures could place residents at risk of not having needs met by depriving them the opportunity to participate in the decision making regarding their care. Findings included: Record review of Resident #19's face sheet dated 07/30/24 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses of dementia (disease characterized by general decline in cognitive ability to perform everyday activities), cerebrovascular disease (disease that affects the blood vessels 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 reviews the facility failed protect and promote the rights of the residents for 1 of 11 residents (Resident #27) reviewed for resident rights. The facility failed ensure LVN N provided privacy when she provided wound care to Resident #27 on 07/28/2024. This deficient practice could place residents at risk for loss of dignity. Findings included: Record review of Resident #27's face sheet dated 07/30/24, indicated a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems), type 2 diabetes mellitus (long term condition in which the body has trouble controlling blood sugar and using for energy), malignant neoplasm of lung (lung cancer) and weakness. Record review of Resident #27's order summary report dated 07/20/2024, indicated Resident #27 had an order dated 01/24/2024 to cleanse wound to lower back with normal saline, pat dry, apply…

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 implement their written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident's property of 1 of 1 resident reviewed for abuse, neglect, and exploitation. (Resident #17) The facility did not implement their policy to report to HHSC when Resident #17 sustained a severe coffee burn on 8/16/23. This failure could place the residents at risk for further potential abuse, neglect, and injuries of unknown origin. Findings included: Record review of an Abuse/Neglect policy dated 2003 and revised on 5/09/2017 indicated the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents should not be…

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, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to the State Survey Agency for 1 of 8 residents (Resident #17) reviewed for abuse and neglect. The facility failed to report to the State Survey Agency on 8/16/2023 immediately but no later than 2 hours after becoming aware Resident #17 sustained a severe coffee burn to his right thigh. This failure could place residents at risk of further potential abuse or neglect. Findings included: Record review of a face sheet dated 7/30/2024 indicated Resident #17 was a [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses heart…

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 an ongoing program of activities based on the comprehensive assessment to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 7 of 12 residents (Resident #24, Resident #27, and 5 confidential residents) reviewed for activities. The facility failed to ensure quarterly activity assessments were completed for Resident #24, Resident #27, and 5 confidential residents to provide activities to meet their interests. 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 included: 1) Record review of a face sheet dated 7/30/2024 reflected Resident #24 was a 63 -year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses of chronic kidney disease, dependence on renal dialysis, and heart failure. Record review of the Quarterly MDS 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews the facility failed to ensure that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 18 (Resident #1) residents reviewed for accidents hazards and supervision. The facility failed to ensure Resident #1 did not keep cigarettes in her purse. The CNA D failed to ensure Resident #1 smoked only in the designated areas of the facility. These failures could place residents at risk for injury. The findings included: Record review of Resident #1's face sheet dated 07/30/24 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with the diagnoses multiple sclerosis(autoimmune disease in which the immune system eats away at the protective covering of the nerves and causes disruption of communication), major depressive disorder, and dementia. Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated she…

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 who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 3 residents reviewed (Resident #12) for incontinent care, or catheter care. CNA L failed to perform hand hygiene during Resident #12's continent care. CNA L failed to perform catheter care when Resident #12 received incontinent care. This failure placed residents who required assistance with incontinent care at risk for urinary tract infections, skin breakdown, and hospitalization. Findings included: Record review of a face sheet dated 7/30/2024 indicated Resident #12 was a [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnoses of rheumatoid arthritis end-stage (a chronic inflammatory disorder that can affect more than just your joints), fractured right femur (upper leg bone), and multiple pressure ulcers. Record review of the consolidated physician's orders dated July…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were offered sufficient fluid intake to maintain proper hydration and health for 1 of 1 resident (Resident #24) reviewed for fluid restriction. The facility failed to ensure Resident #24's 1 liter fluid restriction was monitored. This failure could place residents at risk for dehydration. Findings included: Record review of a face sheet dated 7/30/2024 reflected Resident #24 was a 63 -year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses of chronic kidney disease, dependence on renal dialysis, and heart failure. Record review of a Dehydration Risk Screener dated 7/14/2021 indicated Resident #24 was a dehydration risk. The screen indicated Resident #24 was on diuretic therapy, received medications, had a terminal illness, was incontinent and required assistance with ADLs. Record review of the comprehensive care plan dated 7/27/2021 and revised on 1/05/2023 indicated Resident #24 had a potential…

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 respiratory care was provided such care consistent with professional standards of practice for 1 of 4 residents (Resident #8) reviewed for respiratory care and services. The facility failed to properly store Resident #8's nebulizer (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) mask while not in use. This failure could place residents who require respiratory care at risk for respiratory infections and exacerbation of respiratory distress. Findings include: 1. Record review of Resident #8's order summary report, dated 07/30/2024, indicated Resident #8 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (a group of lung diseases that blocks air flow and causes difficulty breathing), diabetes mellitus (a group of diseases that result in too much sugar in the blood), essential hypertension (high blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that licensed nurses were able to demonstrate the specific competencies and skill sets necessary to care for resident's needs for 1 resident's needs (Resident #192). Three Licensed Vocational Nurses (LVN A, LVN C, and LVN H) provided Intravenous (IV) therapy to Resident #192 during the month July 2024, without certification of training for Intravenous therapy. This deficient practice could place residents requiring Intravenous therapy at risk from adverse effect from improper Intravenous (IV) therapy techniques. Findings included: Record review of Resident #192's face sheet dated 07/30/24 indicated she was an [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses of acute and chronic respiratory failure, diabetes mellitus type 2, Hypertension (high blood pressure), peripheral vascular disease (circulation condition in which causes decreased blood flow to the limbs), and bacteremia(blood stream infection). Record review…

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, and dispensing of routine drugs and biologicals to meet the needs of each resident for 1 of 1 resident reviewed for pharmacy services. (Resident #17) The facility failed to ensure Resident #17's methocarbamol (treatment of muscle spasms/pain) 500 milligrams one tablet 3 times daily was available for administration for 2 of the 3 doses due on 7/29/2024. This failure could place residents at risk for unrelieved or increased pain from muscle spasms. Findings included Record review of a face sheet dated 7/30/2024 indicated Resident #17 was [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnosis diagnoses of heart failure, quadriplegia (paralysis of all four limbs), and other muscle spasms. Record review of the Quarterly MDS dated [DATE] indicated Resident #17 understood and was understood by others. 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.

Based on observation, interview and record review, the facility failed to ensure the meals served met the nutritional needs of residents for 1 of 3 meal (the lunch meal) reviewed for nutritional adequacy, as evidenced by: The facility failed to follow the menu for the noon time (lunch) meal served on 7/28/24. This failure could affect all residents in the facility by placing them at risk of not receiving adequate nutritive food value needed to promote/maintain health. Findings included: Record Review of the facility week 1 menu received on 7/28/24, indicated the lunch meal items included chicken fried chicken with cream gravy, mash potatoes, Mexicali corn, honey kissed roll, banana pudding with wafers and iced tea. During an observation on 7/28/24 at 12:31 p.m., revealed the residents were served chicken fried steak instead of chicken fried chicken, cream corn instead of Mexicali corn and cantaloupe instead of banana pudding with wafers for the lunch meal on 7/29/24. During an interview on 7/29/24 at 8:47 a.m., the Dietician stated she had been the full time Dietician for the past 4…

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 each resident received and the facility provided drinks, including water and other liquids consistent with resident needs and preferences for one of thirteen residents reviewed for hydration. (Resident #17). The facility failed to ensure Resident #17 was served cranberry juice with all meals and not tea. This failure could lead to dehydration and urinary tract infections. Findings included: Record review of a face sheet dated 7/30/2024 indicated Resident #17 was a [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnosis heart failure, quadriplegia (paralysis of all four limbs), and other muscle spasms, contractures of the left and right hands (a condition where the one or more fingers bend toward the palm of the hand), lack of coordination, muscle weakness, muscle wasting and atrophy. Record review of the Quarterly MDS dated [DATE] indicated Resident #17 understood and was understood by others. 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 observation, interview, and record review, the facility failed to ensure that residents received and consumed foods with the appropriate nutritive content as prescribed by the physician for 2 of 2 resident (Resident #'s 31 and 16) reviewed for large protein portions for 2 of 2 meals observed. The facility failed to ensure Resident #31 received a large meat portion, per physician's orders, on his lunch tray on 7/28/2024. The facility failed to ensure Resident #16 received a large meat portion, per physician's orders, on his breakfast tray on 7/30/2024. This failure could place residents who require large servings of meat at risk of not receiving their daily protein requirements and weight loss. Findings included : 1)Record review of a face sheet dated 7/30/2024 indicated Resident #31 was an [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses of dementia (memory loss), heart failure, and high blood pressure. Record review of the Annual MDS dated [DATE] indicated Resident…

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 arrange an appointment with an outside resource for 1 of 6 residents (Resident #27) reviewed for the use of outside resources. The facility failed to ensure Resident #27's appointments with a dermatologist (specialty for skin disease, function) was scheduled after the order dated 11/25/2023 was received by the facility. This failure could place residents at risk of not receiving needed medical care. Findings included: Record review of Resident 27's face sheet dated 07/30/24, indicated a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems), type 2 diabetes mellitus (long term condition in which the body has trouble controlling blood sugar and using for energy), malignant neoplasm of lung (lung cancer) and weakness. Record review of Resident #27's quarterly MDS assessment dated [DATE], indicated Resident #27 was able…

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 collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure 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 2 of 2 residents (Residents #8 and #12) reviewed for hospice services. The facility failed to obtain Resident #8 and #12's most recent hospice plan of care. The facility failed to ensure Resident #8 and #12's hospice plans of care accurately reflected their medication regimen. This deficient practice 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. Findings included: 1. Record review of Resident #8's face sheet, dated 07/30/2024, indicated Resident #8 was a [AGE] year-old female, 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.

Based on observation, interview and record review, the facility failed to ensure medications were secured on 3 of 4 medication carts reviewed for pharmacy services. (500 Hall, 600 Hall and 800/900 Halls Medication Carts) - LVN B failed to ensure the Medication carts for 500 Hall and 600 Hall was not left unlocked, unsecured, and unattended. -DON failed to ensure the Medication cart for 800/900 Halls was not left unlocked, unsecured, and unattended. These failures could affect the residents, who received medications from those carts, by placing them at risk of drug diversions or misuse of medications. Findings included: During an observation on 11/3/23 at 4:46 p.m., revealed the 500 Hall medication cart and the 600 Hall medication cart was unlocked and unattended in front on the nurse station. All the drawers of the medication could be opened, and the medication was easily accessible. The cart was unattended for unknown amount of time. Residents were observed passing by the medication cart. During an interview on 11/3/23 at 4:49 p.m., LVN B was sitting behind the nurse station…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, are reported immediately, but no 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 1 of 2 facility self-reported incidents reviewed for reporting to the State Survey Agency. (Incident #461859) The facility failed to report to Health and Human Services Commission within 2 hours when CNA C spilled hot coffee on Resident #2 abdomen, resulting in burn/blisters. This failure could place the residents at risk for increased risk for abuse and neglect. Findings included: Record review of Resident #2's face sheet, printed on 11/3/23, indicated she was a [AGE] year-old female who admitted to facility on 11/03/22 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side (paralysis 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 interview and record review, the facility failed to implement written policies to prevent abuse, neglect, and exploitation for 1 of 7 (Resident #1) residents reviewed for abuse. The facility staff did not implement their abuse policy when they did not report to the state agency or investigate Resident #1's scalp hematoma (a bad bruise that occurs when an injury causes blood to collect and pool under the skin; the pooling blood gives the skin a spongy, rubbery, lumpy feel) that was discovered on 09/21/23. This failure could place residents at risk for abuse and neglect due to staff not reporting or investigating incidents to rule out abuse and neglect. Findings include: Record review of the facility's Abuse/Neglect policy revised 3/29/18 indicated, The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation .The facility will identify and investigate events that may constitute abuse/neglect. The facility will determine the direction 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 ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury for 1 of 7 (Resident #1) residents reviewed for abuse and neglect. The facility staff did not report Resident #1's Resident #1's scalp hematoma (a bad bruise that occurs when an injury causes blood to collect and pool under the skin; the pooling blood gives the skin a spongy, rubbery, lumpy feel) that was discovered on 09/21/23 to the state agency. This failure could place residents at risk of injuries, abuse, and/or neglect due to staff not reporting incidents as required. Findings include: Record review of the face sheet dated…

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 have evidence that all alleged violations are thoroughly investigated for 1 of 7 residents (Resident #1) reviewed for abuse and neglect. The facility did not provide evidence of a thorough investigation for Resident #1's scalp hematoma (a bad bruise that occurs when an injury causes blood to collect and pool under the skin; the pooling blood gives the skin a spongy, rubbery, lumpy feel.) which was first discovered on 9/21/23. This failure could place residents at risk of abuse and neglect due to the facility not performing a thorough investigation to rule out abuse and neglect. Findings include: Record review of the facility's Abuse/Neglect policy revised 3/29/18 indicated, The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation .The facility will identify and investigate events that may constitute abuse/neglect. The facility will determine the direction of the investigation based on a thorough…

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 coordinate assessments with the pre-admission screening and resident review program (PASRR) to the maximum extent practicable to avoid duplicative testing and effort for 3 of 5 (Resident #9, Resident #12, and Resident #25) residents reviewed for PASRR. The facility failed to ensure Resident #9 had quarterly PASRR IDT meetings. The facility failed to ensure Resident #12 had quarterly PASRR IDT meetings. The facility failed to convene Resident #25's initial PASRR IDT meeting. These failures could affect residents with mental illnesses and place them at risk of not being assessed to receive needed services. Findings include: 1.Record review of Resident #9's face sheet dated 05/17/23 indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #9 had a diagnoses which included progressive dementia (progressive disease that destroys memory), major depressive disorder (depressed mood that causes impairment in daily life) 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 implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 3 of 13 residents (Resident #25, Resident #28, and Resident #30) reviewed for care plans. The facility failed to care plan that Resident #25 and Resident #28 were PASRR positive. The facility failed to ensure Resident #30's care plan reflected he had a condom catheter. These failures could place the residents at increased risk of not having their individual needs met and a decreased quality of life. Findings included: 1. Record review of a face sheet dated 05/17/2023, indicated Resident #25 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included bipolar disorder (a disorder associated with episodes of mood swings ranging from depression lows to manic highs), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed…

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 necessary services to maintain grooming and personal hygiene were provided for 3 of 13 residents reviewed for ADLs (Resident #16, Resident #17, and Resident #23). The facility failed to provide assistance with facial hair removal for Resident #16. The facility failed to ensure Resident #17, and Resident #23 received showers or bed baths as scheduled. These failures could place residents at risk of not receiving services and care, and a decreased quality of life. Findings included: 1. Record review of a face sheet dated 05/17/2023, indicated Resident #16 was a [AGE] year old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included type 2 diabetes mellitus without complications (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), essential hypertension (high blood pressure), and hemiplegia and hemiparesis following cerebral infarction…

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 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 4 of 4 staff (CNA B, CNA C, LVN D, and the Housekeeping Supervisor) reviewed for infection control. The facility failed to ensure the Housekeeping Supervisor covered the clean linen cart while passing out resident's personal laundry. The facility failed to ensure CNA B and CNA C changed gloves and performed hand hygiene while providing incontinent care to Resident #28. The facility failed to ensure LVN D changed gloves while providing wound care to Resident #20. These failures could place residents and staff at risk for cross-contamination and the spread of infection. Findings included: 1. During an observation on 05/15/2023 starting at 3:26 PM, the Housekeeping Supervisor was passing out clean linen on hall 500. The clean linen cart was not covered. The clothes hanging from the cart were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to assure residents who have authorized the facility in writing to manage any personal funds have ready and reasonable access to those funds for 2 of 2 residents (Resident #12 and Resident #23) reviewed for personal funds. The facility failed to ensure Resident #12, and Resident #23 had access to their personal funds when they requested it. This failure could place residents whose funds are managed by the facility at risk of not receiving their personal funds deposited with the facility and not having their rights and preferences honored. Findings included: 1. Record review of a face sheet dated 05/17/2023 indicated Resident #12 was a [AGE] year old female initially admitted to the facility 06/12/2018 and readmitted on [DATE] with diagnoses which included type 2 diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel resulting in high blood sugars), hypertensive heart disease with heart…

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 each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of changes for those services, which included changes for services not covered under Medicare/Medicaid or by the facility's per diem rate for 1 of 1 resident (Resident #20) reviewed for Medicare/Medicaid coverage. The facility failed to ensure Resident #20 was given a SNF ABN when discharged from skilled services at the facility prior to covered days being exhausted. Resident #20 did not incur any out-of-pocket cost. This failure could place residents at risk for not being aware of changes to provided services. Findings include: Record review of Resident #20's face sheet, dated 05/17/2023, indicated Resident #20 was a [AGE] year-old female, originally admitted to the facility on [DATE] with a diagnosis which included type 2 diabetes (blood sugar disorder), chronic kidney disease (loss of kidney…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to have physician orders for the resident's immediate care for 1 of 13 residents (Resident #30) reviewed for admission physician orders. The facility failed to ensure Resident #30 had a physician order for a condom catheter. This failure could place resident at risk for not receiving appropriate care, treatment services, and at risk for infection. Findings included: Record review of Resident # 30's face sheet dated 05/16/23 revealed Resident #30 was a [AGE] year-old male that was admitted to the facility on [DATE] with a diagnoses of Alzheimer's disease (disease of the brain), type 2 diabetes (blood sugar disorder) and hypertension (high blood pressure). Record review of Resident #30's comprehensive MDS dated [DATE] indicated Resident #30 made himself understood and was able to understand others clearly. Resident #30 had a BIMS score of 15 indicating he was cognitively intact. Section H of the MDS indicated Resident #30 had an indwelling…

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 1 of 13 residents (Resident #9) reviewed for MDS assessment accuracy. The facility failed to accurately reflect Resident #9's medications on the MDS assessment on 04/15/2023 when the MDS reflected Resident #9 was on the antidepressant and Resident #9 had no order for an antidepressant. This failure could place residents at risk for not receiving care and services to meet their needs. Findings included: Record review of Resident #9's face sheet dated 05/17/23 indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #9 had a diagnoses which included progressive dementia (progressive disease that destroys memory), major depressive disorder (depressed mood that causes impairment in daily life) and hemiplegia (weakness on one side of the body). Record review of Resident #9's Comprehensive MDS dated [DATE] indicated Resident #9 had a BIMS score of 12 which 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to develop the baseline care plan within 48 hours of admission for 1 of 2 residents (Resident #25) reviewed for baseline care plans. The facility failed to ensure Resident #25 had a baseline care plan completed within 48 hours of admission. This failure could affect residents by not addressing their physical, mental, and psychosocial needs for each resident to attain or maintain their highest practicable physical, mental, and psychosocial outcome. Findings included: Record review of a face sheet dated 05/17/2023, indicated Resident #25 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included bipolar disorder (a disorder associated with episodes of mood swings ranging from depression lows to manic highs), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and essential hypertension (high blood pressure). Record review of Resident #25's Baseline Care…

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, review, and revise a comprehensive care plan of each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 13 residents (Resident #9) reviewed for care plans. The facility failed to ensure Resident #9's care plan was updated and revised to reflect she was not taking any antidepressant medications. These failures could cause the resident to not receive the correct care impacting the patient's health and/or serious illness. Findings include: Record review of Resident #9's face sheet dated 05/17/23 indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #9 had a diagnoses which included progressive dementia (progressive disease that destroys memory), major depressive disorder (depressed mood that causes impairment in daily life) and hemiplegia (weakness on one side of the body). Record review of Resident #9's Comprehensive 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 observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 1 resident (Resident #28) reviewed for incontinence. The facility failed to ensure Resident #28 was provided prompt incontinent care. This failure could place residents at risk for urinary tract infections, skin breakdown, and decreased quality of life. Findings included: Record review of Resident #28's Order Summary Report dated 5/15/2023 indicated he was a [AGE] year-old male readmitted to the facility on [DATE], initially admitted [DATE], with diagnoses which included major depressive disorder, recurrent, severe with psychotic symptoms (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks), hemiplegia and hemiparesis following cerebral infarction…

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 it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 10.34%, based on 3 errors out of 29 opportunities, which involved 1 of 6 residents (Resident #10) reviewed for medication administration. The facility failed to ensure Resident #10 received Methocarbamol (treat muscle spasms/pain, and Tylenol (treat aches and pain). This failure could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders. Findings included: Record review of Resident #10's order summary report, dated 05/16/2023, indicated Resident #10 was a [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis included dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), essential hypertension (high blood pressure), and…

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

Based on observation, interview, and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 3 medication carts (Hall 6/8/9) reviewed for storage of medications. The facility failed to ensure Hall 6/8/9 medication cart was locked when unattended. This deficient practice could place residents at risk of medication misuse and diversion. Findings included: During an observation on 05/16/2023 at 10:25 a.m., the DON left Hall 6/8/9 medication cart unlocked and out of sight, facing Resident #82's room, while administering Resident #82's medication. During an interview on 05/16/2023 at 11:15 a.m. the DON stated she should have locked the medication cart prior to going in Resident #82's room. When asked why she did not lock the cart, she stated, I forgot. The DON stated this failure allowed residents, staff, and visitors access to other residents' medication. During an interview on…

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