Focused Care of Waxahachie

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident's right to a safe, clean, comfortable, and homelike environment for 1 (Resident #1) of 5 residents reviewed for environment. The facility failed to ensure Resident #1 was provided clean bed linens that were in good condition. This failure placed residents at risk of living in an uncomfortable environment leading to a diminished quality of life. Findings included: Record review of Resident #1's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Diabetes Mellitus with Diabetic Nephropathy (elevated blood sugar that has caused kidney damage) and constipation. Record review of Resident #1's Baseline Care Plan, dated 06/17/2025, reflected Resident #1 was dependent for transferring from chair to bed and bed to chair, toileting hygiene, showering and bathing, and lower and upper body dressing. The care plan reflected Resident #1 was always…

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 unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 1 of 5 residents (Resident #1) reviewed for ADLs. The facility failed to ensure Resident #1 received showers on 06/18/2025, 06/23/2025, 06/27/2025, and 06/30/2025. This failure could place residents at risk of not being provided care and assistance when needed. Findings Included: Record review of Resident #1's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Diabetes Mellitus with Diabetic Nephropathy (elevated blood sugar that has caused kidney damage) and constipation. Record review of Resident #1's Baseline Care Plan, dated 06/17/2025, reflected Resident #1 was dependent for transferring from chair to bed and bed to chair, toileting hygiene, showering, bathing, lower and upper body dressing. The 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 observation, interview and record review, the facility failed to provide residents with an ongoing resident centered activity program, designed to meet the interests of and support the physical, mental, and psychosocial well-being of 3 (Residents #25, #31, and #42) of 8 residents reviewed for activities. The facility failed to provide activities as scheduled from January 23, 2025, through February 12, 2025. This failure placed residents at risk of boredom, depression, isolation, and a diminished quality of life. Findings include: Record review of Resident #25's face undated sheet reflected a [AGE] year-old male initially admitted to the facility on [DATE], and readmitted on [DATE], with the following diagnoses: Type 2 Diabetes Mellitus (a chronic disease that causes a person's blood glucose levels to rise too high) Chronic Pulmonary Edema (a condition where fluid accumulates in lung tissues, making it difficult to breathe), Acute Respiratory Failure with Hypoxia (acute impairment in gas exchange between…

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 resident assessment accurately reflected the resident's status for 1 (Resident #12) of 8 residents who were reviewed for accuracy of assessments. The facility failed to ensure Resident #12's MDS assessment accurately reflected his hearing ability and use of hearing aids. This failure could place residents at risk of their needs going unmet. Findings included: Record review of Resident #12's quarterly MDS, dated [DATE], indicated Resident #12 was a [AGE] year-old male, who was admitted to the facility on [DATE]. He had diagnoses of dementia, major depressive disorder, depression, hereditary and idiopathic neuropathy (nervous system disorders that interfere with normal nerve function). His MDS reflected he had minimal difficulty with his ability to hear, (difficulty in some environments (e.g., when person speaks softly or setting is noisy), as well as that he did not have hearing aids or other hearing appliances. His BIMS score…

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 accurate PASRR screenings for individuals with a mental disorder for 2 (Resident #16 and Resident #52) of 14 residents reviewed for PASSAR assessments. Resident #16 did not have a new PASSAR level I screening completed or a PASSAR level II screening completed although a diagnosis of mental illness was diagnosed after the admission date. Resident #52 did not have an accurate PASSAR Level 1 screening after Resident #52 was admitted with a negative PASSAR Level 1 screening but had a mental illness. These failures could place all residents who had a mental illness or intellectual or developmental disability at risk for not receiving needed assessment, care, and services to meet their needs. Findings Included: Record review of Resident #165's Face Sheet indicated the resident was a [AGE] year-old male who admitted to the facility with an original admission date of 02/06/2015., an initial admission date of 06/10/2022, and an admission date 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, interviews, and record review the facility failed to ensure the resident care plan accurately reflected the resident's status for 1 of 4 residents (Resident #12) who were reviewed for care plans. The facility failed to care plan Resident #12's use of hearing aids. This failure could place residents at risk of their needs going unmet. Findings included: Record review of Resident #12's quarterly MDS, dated [DATE], indicated Resident #12 was a [AGE] year-old male, who was admitted to the facility on [DATE]. He had diagnoses of dementia, major depressive disorder, depression, hereditary and idiopathic neuropathy (nervous system disorders that interfere with normal nerve function). His MDS also reflected in Section B Hearing, Speech, and Vision that Resident #12's ability to hear, had minimal difficulty, as well as that he did not have hearing aids or other hearing appliances. His BIMS score was 12, which indicated moderately impaired cognition. Record review of Resident #12's care plan 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.

Based on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were stored properly for 1of 2 medication storage rooms (room located by Hall 300). The facility failed to ensure expired medication administration supplies were removed from the medication room located by hall 300. These failures could place residents at risk for ineffective treatments, intravenous catheter dislodgements and infections. Findings include: Observation on 2/11/25 at 10:30 AM of the Hall 300 Medication Storage Room revealed the following: 8 Zyno IV Administration sets expired 3/19/2023. 7 Zyno IV Administration sets expired 6/20/2022 1 Stat lock PICC PLUS Catheter stabilizer expired 4/28/2023. 1 Central Line Dressing Kit expired 2/28/2021. In an interview on 2/12/25 at 12:48 PM LVN-A stated, the policy on expired medical supplies was to take them back to medical records department where they get rid of them. She stated the nurses, and the medication aides were responsible for checking the rooms. She said this was important because 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 to ensure residents received services in the facility with reasonable accommodations of each resident's needs for 4 of 13 residents (Residents #2, #3, #4, & #5) reviewed for resident rights in that: The facility failed to ensure Residents #2, #3, #4, & #5's call light was within reach on 12/20/24. This failure could affect residents who needed assistance with activities of daily living and could result in needs not being met. Findings included: 1.Record review of Resident #2's admission record dated 12/20/24 documented a [AGE] year-old female admitted on [DATE]. Resident #2 had diagnoses which included: acute cystitis with hematuria (a bladder infection that results with blood in the urine), major depressive disorder severe with psychotic symptoms (a mental illness that involves depression and a loss of touch with reality, or psychosis), anxiety disorder (a mental health condition that causes a person to experience excessive and intense…

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 develop and implement a comprehensive person-centered care plan for each resident, which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 2 of 13 residents (Residents #1, and #5) reviewed for care plans. The facility failed to revise Resident #1's care plan to reflect an unwitnessed fall out of bed on 12/11/24 and 12/14/24. The facility failed to revise Resident #5's care plan to reflect interventions for nutritional impairment, behavior problem, and resistive to care that was initiated on 11/20/24. This failure could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. Findings Included: 1. Record review of Resident #1's admission record dated 12/20/24 documented a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: unspecified fall (sudden movement…

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 were informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he prefers for one (Resident #1) of four residents reviewed for consents. The facility failed to obtain a written consent from Resident #1 before administering the following psychoactive medications: Risperdal (anti-psychotic), Paroxetine (anti-depressant) , Depakote (mood stabilizer , Nudexta (anti-depressant), Quetiapine (antipsychotic), Lorazepam (anti-anxiety). This failure placed residents who received psychoactive medications at risk for not understanding the risks and dangerous side effects of psychoactive medications without their opportunity for informed consent and opportunity to refuse the drug. Findings included: Review of Resident #1's face sheet dated 9/23/2024 reflected a [AGE] year-old male who…

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 did not provide pharmaceutical services to meet the needs of each resident for one (Resident #1) of four residents reviewed for pharmaceutical services, in that: The facility failed to ensure they had enough Depakote medication (mood stabilizer medication) on hand from 3/20/2024 to 4/10/2024 for Resident #1. This deficient practice could place residents at risk of not receiving the intended therapeutic benefit of the medications and could result in worsening or exacerbation of chronic medical conditions, and hospitalization. Findings included: Review of Resident #1's face sheet dated 9/23/2024 reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder (mood disorder), Traumatic Brain Injury (injury to the brain), malignant neoplasm of prostate (prostate cancer), ataxia (impaired coordination), and gout (form of arthritis which causes joint swelling and pain). Resident #1 was his own responsible…

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 ensure residents received services in the facility with reasonable accommodations of each resident's needs for 2 of 7 residents (Residents #1 & #2) reviewed for resident rights in that: The facility failed to ensure Residents #1 and #2 call lights was within reach on 10/29/24. This failure could affect residents who needed assistance with activities of daily living and could result in needs not being met. Findings included: Record review of Resident #1's admission record dated 10/29/24 documented a [AGE] year-old male admitted on [DATE]. Resident #1 had diagnoses which included: sepsis (serious condition in which the body responds improperly to an infection), major depressive disorder (persistent low mood and loss of interest in activities that people enjoy), muscle weakness (lack of muscle strength), and gastro esophageal reflux disease without esophagitis (a digestive disorder that occurs when stomach acid flows back into the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 of 7 residents (Resident #3) reviewed for a clean and homelike environment. The facility failed to ensure Resident #3's urinal was emptied appropriately on 10/29/24. This failure placed residents at risk of decreased feelings of self-worth and a diminished quality of life. Findings included: A record review of Resident #3's face sheet dated 10/29/24 reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #3's diagnoses included osteomyelitis (serious bone infection that causes inflammation and swelling in the bone), Unspecified dementia (loss of cognitive functioning to the extent that it interferes with a person's daily life and activities), major depressive disorder (persistent low mood and loss of interest in activities that people enjoy), Type 2 diabetes mellitus with foot ulcer (open sore that can develop on the foot of someone with…

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 record review and interview, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility for one (Resident #1) of three residents reviewed for transfer and discharge rights, in that: The facility failed to provide documentation that Resident #1 received sufficient preparation and orientation when he was discharged to a group home to ensure a safe discharge. Resident #1 was discharged from the facility on 10/11/24. This failure could place residents at risk of not receiving care and services to meet their needs upon discharge. Findings Included: Review of Resident #1's face sheet, dated 10/11/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included diffuse traumatic brain injury (occurs when the brain is injured by blunt force, causing the brain's nerve fibers to shear of tear), depression and heart failure. Resident #1 is listed as his own responsible…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to develop 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 three (Residents #3, #4 and #5) out of eleven residents reviewed for care plans. The facility failed to develop a comprehensive care plan for Resident #3, #4 and #5 in order to provide care in that: Resident #3's care plan was blank, Resident #4's care plan was incomplete and had only one intervention for vaccine status, Resident #5's care plan was incomplete and had only two interventions for code status and alertness. This failure placed residents at risk of not having their individualized needs met in a timely manner and communicated to providers which could result in injury or a decline in physical well-being. Findings included: Review of Resident #3's face sheet dated 3/26/2024 reflected a [AGE] year-old male who was admitted to the facility on [DATE] with…

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 record review and interview, the facility failed to ensure that all drugs and biologicals were properly stored and inaccessible to unauthorized staff and residents for one resident (Resident #2) of four residents reviewed for medication storage. The facility failed to ensure narcotics were received and then stored in a manner to prevent diversion on 03/04/2024 when a refill of Hydrocodone, 10-325 milligrams, quantity of 75, for Resident #2 was received from the pharmacy by LVN A, given to LVN B on 3/4/2024 and discovered missing on 03/06/2024. This failure could place residents at risk for drug diversion and access to medications that could cause harm, sickness, or hospitalization. Findings included: Review of Resident #2's face sheet dated 3/26/2024 reflected an eighty-three-year-old male admitted on [DATE] with diagnoses that included: Senile Degeneration of Brain (gradual loss of thinking ability), Hypertension (high blood pressure), Dementia (progressive loss of intellectual functioning), Shoulder…

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 store foods properly and maintain a sanitized food preparation area for the facility's only kitchen, which was reviewed for dietary services. The facility failed: 1. The facility failed to properly seal, label, and date food containers in the facility's freezer. 2. The facility failed to properly defrost food at the appropriate temperature. 3. The facility failed to utilize plates that were free from chips. 4. The facility failed to monitor and maintain the appropriate sanitizer concentration the facility's only dishwashing system. 5. The facility failed to maintain clean kitchen equipment and appliances. These failures placed residents at risk of exposure to food borne pathogens. Findings include: Observations on 12-19-2023 at 9:00 AM reflected one clear plastic bag of frozen onion rings that was closed with a knot WLD and one clear plastic bag of frozen dinner rolls onion rings that was closed with a knot WLD. There was a sign on the…

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

Based on interviews, and record reviews, the facility failed to ensure a person designated as the infection preventionist worked at least part-time at the facility for 1 of 1 Infection Preventionist reviewed. The facility did not have an infection preventionist in place who worked at least part-time at the facility. The DON was the infection preventionist and did not work at least part-time in the position at the facility. This deficient practice could place residents at risk of cross contamination and infection. Findings included: During an interview on 12/19/23 at 9:35 AM with the ADM, he stated the DON was the infection preventionist for the facility. During an interview on 12/21/23 at 11:22 AM with the ADON, she stated she had completed the IP training but only helped with IP duties if needed. During an interview on 12/20/23 at 11:52 AM with the DON, she stated she was the infection preventionist. She stated the previous ADON had been the IP, but she no longer worked at the facility and had been gone about three or four weeks. She stated she works as the DON usually about nine…

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 each resident received adequate supervision to prevent accidents for 1 (Resident #43) of 3 residents reviewed for accidents, hazards, and supervision. The facility failed to ensure safe smoking for Resident #43 when he had a lighter and cigarettes in his possession, outside of scheduled smoking hours unsupervised. This failure could place residents who smoke at risk of harm. Findings included: Record review of Resident #43's face sheet dated 09/02/22, reflected he was admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes Mellitus (refers to a group of diseases that affect how the body uses blood sugar) with Diabetic Autonomic (Poly-multiple) Neuropathy (nerve damage), Gastro-Esophageal Reflux Disease (occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach) without Esophagitis (inflammation of the tube connecting your mouth and stomach), Other Dental Procedure Status, and Dry…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 8.57%, based on 3 errors out of 35 opportunities, which involved 1 (Residents #46) of 3 residents reviewed for medication errors. LVN E failed to administer medication by mouth as ordered and gave medications via gastrostomy (stomach) tube. These failures could place residents at risk of inadequate therapeutic outcomes. Findings included: Record review of Resident #46's undated Face Sheet reflected she was a [AGE] year-old female admitted on [DATE] with a diagnosis of Parkinson's (a disorder of the central nervous system that affects movement), unspecified protein malnutrition, generalized anxiety disorder, dysphagia (difficulty swallowing), and adult failure to thrive. Record review of Resident #46's Significant change in status MDS assessment dated [DATE] reflected the resident had a BIMS score of 15 indicating the 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 observation, record review and interview the facility failed to ensure that residents are free of significant medications error for 1 of (Resident #46) of 3 residents reviewed for medications errors. The facility failed to ensure that Resident #46's medications were given as ordered by the physician. This failure placed all resident who received medications at risk of not getting their medications as ordered which could result in resident not receiving the therapeutic benefits of the medication and decreased quality of life. Findings included: Record review of Resident #46's undated Face Sheet reflected she was a [AGE] year-old female admitted on [DATE] with a diagnosis of Parkinson's (a disorder of the central nervous system that affects movement), unspecified protein malnutrition, generalized anxiety disorder, dysphagia (difficulty swallowing), and adult failure to thrive. Record review of Resident #46's Significant change in status MDS assessment dated [DATE] reflected the resident had a BIMS score…

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 the resident's medical record included documentation that indicated the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal for 2 of 5 residents (Residents #23 and Resident #63) reviewed for influenza and pneumococcal immunizations. The facility failed to document pneumococcal immunizationstatus for Resident #23 and Resident #63. These failures could place residents at risk for contracting a viral disease and cause respiratory complications and potential adverse health outcomes. Findings included: Review of Resident #23's undated face sheet reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included hemiplegia (paralysis on one side of the body), congestive heart failure (progressive heart disease that affects pumping action of the heart muscles), hypertension (high blood pressure), cerebral infarction (stroke), aphasia…

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 be adequately equipped to allow residents to call for staff assistance through a communication system, which relays the call directly to a staff member or to a centralized staff work area, for 1 of 6 residents (RES #59) who were observed for access to facility services. The facility failed to ensure RES #59 had access to a functioning call light button. This failure could place residents at risk for unmet needs. Findings include: Record review of RES #59's AR reflected she was an [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with Moderate Vascular Dementia (which resulted in problematic reasoning, planning, judgement, memory, and other thought processes) and Cognitive Communication deficit (which resulted with difficulty in thought and how she used language.) Record review of RES #59's Quarterly MDS assessment, dated 11/29/2023, reflected Section C0500, Cognitive Patterns, indicated RES #59 had a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the resident and the resident's representative(s)were notified of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood, and the facility failed to ensure the a copy of the notice was sent to a representative of the Office of the State Long-Term Care Ombudsman for one of six residents (Resident #1) reviewed for discharges. The facility failed to provide a 30-day discharge notice as soon as practicable to Resident #1's RP and the ombudsman. This failure could place residents at risk for not receiving care and services to meet their needs upon discharge, a disruption of care, and being discharged without alternate placement. Findings include: Record review of Resident #1's, undated, face sheet reflected a [AGE] year-old male was admitted to the facility on [DATE] with diagnoses which included ataxia (poor muscle control), cognitive communication deficit (difficulty paying attention to a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility for one (Resident #1) of three residents reviewed for transfer and discharge rights, in that: The facility failed to make arrangements for safe and orderly discharge through care planning and involving the RP (Representative) for Resident #1. This failure placed residents at risk of not receiving care and services to meet their needs upon discharge. Findings Included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male was admitted to the facility on [DATE] with a diagnosis of ataxia (poor muscle control), cognitive communication deficit (difficulty paying attention to a conversation, staying on topic, remembering information, or responding accurately), type 2 diabetes mellitus (blood sugar is too high), hyperlipidemia (excess of lipids or fats in your blood), bipolar disorder (Mental illness…

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.