Garnet Hill Rehabilitation And Skilled Care

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the resident representative had the right to exercise the resident's rights to the extent those rights are delegated to the representative for one of three residents (Resident #1) reviewed for resident rights. The facility failed to obtain consent from Resident #1's RR, prior to administering an antibiotic medication which resident was allergic to. This failure could place residents at risk of not having their preferred responsible party represent them in care decisions. Findings Include: Record review of Resident #1's face sheet revealed an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #1's face sheet identified her representative was a family member, RR. Resident #1's RR was listed as medical power of attorney. Resident #1 had diagnoses which included: Essential (primary) Hypertension (high blood pressure), Urinary Tract Infection (UTI), and AMS (Altered Mental Status). Resident #1's face sheet…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one of three residents (Resident #1) reviewed for pharmacy services. 1) The facility failed to update Resident #1's allergy list completely when they manually transcribed the information into their new operating system. 2) The facility failed to ensure Resident #1 was not administered Bactrim (Sulfa drug) on 3/13/25 when Resident #1 had an allergy to Sulfa. These failures could place residents at risk of receiving medications they have allergies to which could contribute to adverse reactions resulting in a decline in health and/or hospitalization. Findings Included: Record review of Resident #1's face sheet revealed an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #1's face sheet identified her…

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 interviews, the facility failed to maintain medical records on each resident that were accurately documented for one (Resident #1) of three residents reviewed for accuracy of records. The facility failed to add one of Resident #1's medication allergies, Sulfa, into the new operating system when they transferred the information. This failure could place residents at risk of not receiving medications as ordered which could cause a decline in the resident's overall health. Findings Included: Record review of Resident #1's face sheet revealed an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #1's face sheet identified her representative was a family member. Resident #1 had 37 allergies listed which included: Albuterol, Methocarbamol, Levodopa, Acetaminophen, Oxycodone, Hydrocodone, Lidocaine, Docusate, Senna, Calcium Carbonate, Carbidopa, Ferrous Sulfate, Potassium Chloride, Iodine, Penicillin G, Polyethylene Glycol, Pantoprazole,…

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 provide the right to personal privacy and confidentiality which includes privacy during medical treatment and confidentiality of medical records for four (Resident #31, Resident #42, Resident #79, and Resident #91) of eighteen residents reviewed for Privacy and Confidentiality. 1. The facility failed to ensure RN E and RN F closed the door while administering Resident #79's breathing treatment on 01/23/2025. 2. The facility failed to ensure RN E closed the door while administering Resident #91's medication through g-tube on 01/23/2025. 3. The facility failed to ensure MA I did not leave Resident #31's and Resident #42's health information on top of the medication cart unattended on 01/23/25. These failures could place the residents at risk of not having their personal privacy maintained during medical treatment and their medical information exposed to unauthorized individuals. Findings included: 1. Review of Resident #79's Face Sheet,…

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 observation, interview, and record review, the facility failed to ensure proper handling of the ice to prevent contamination and the potential for waterborne illness by one CNA (CNA D) out of four staff attending to the residents during lunch time. The facility failed to ensure CNA D did not put the ice scooper on the bowl of ice while preparing drinks for the residents during lunch time on 01/22/2025. This failure could place the residents at risk of cross-contamination and development of infections. Findings included: An observation on 01/22/2025 at 12:03 PM revealed CNA D was preparing some drinks for the residents. At the middle of the dining area was a table with some boxes of milk, a bowl of ice, a small plate, and some pitchers of iced tea. She placed four glasses on a tray, scooped some ice from a bowl of ice, and put them on the glasses. She used an ice scooper to put the ice. After she put the ice on the glasses, she placed the scooper on the bowl of ice, and poured iced tea on the glasses. She put the scooper on top of the bowl of ice with the handle of the scooper…

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 assessments accurately reflected the resident's status for two (Resident #20 and Resident #49) of eight residents reviewed for Accuracy of Assessments. 1. The facility failed to ensure Resident #20's Quarterly MDS assessment dated [DATE] accurately reflected that the resident had an external catheter (non-invasive device used to manage urinary incontinence) and was on oxygen therapy. 2. The facility failed to ensure Resident #49's Quarterly MDS assessment dated [DATE] accurately reflected that the resident was receiving Hospice Care (end of life care). This failure could place the resident at risk for not receiving care and services to meet their needs, diminished function of health, and regressions in their overall health. Findings included: 1. Review of Resident #20's Face Sheet, dated 01/24/2025, reflected a [AGE] year-old resident admitted to the facility on [DATE]. Resident #20 was diagnosed with overactive bladder (sudden…

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 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 infection and to restore continence to the extent possible for one of (Resident #20) two residents reviewed for Incontinent Care. The facility failed to ensure that Resident #20's external catheter was properly stored on 01/22/2025. This failure could place residents at risk of cross-contamination and development of urinary tract infections. Findings included: Review of Resident #20's Face Sheet, dated 01/24/2025, reflected a [AGE] year-old resident admitted to the facility on [DATE]. Resident #20 was diagnosed with overactive bladder. Review of Resident #20's Quarterly MDS Assessment, dated 12/24/2024, reflected the had a moderate impairment in cognition with a BIMS score of 11. Resident #20's Quarterly MDS Assessment did not indicate that the resident was using an external catheter. Review of Resident #20's Comprehensive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two (Resident #49 and Resident #64) of five residents reviewed for Respiratory Care. 1. The facility failed to ensure Resident #49's suction machine and the Yankauer suction tip (oral suctioning tool used to remove fluid and secretions from the airway) connected to it was properly stored on 01/22/2025. 2. The facility failed to ensure Resident #64's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) connected to the oxygen concentrator was properly stored on 01/22/2025. These failures could place the residents at risk for respiratory infection and not having their respiratory needs met. Findings included: 1. Record review of Resident #49's Face Sheet, dated 01/24/2025, reflected a [AGE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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 infection for one of one resident (Resident #1) reviewed for Incontinent Care. The facility failed to ensure CNA G did not use the same wipes used to clean Resident #5's lower abdomen to clean the resident's perineal area on 12/03/2024. This failure could place residents at risk of cross-contamination and development of urinary tract infections. Findings include: Record review of Resident #5's Face Sheet, dated 12/03/2024, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5 was diagnosed with chronic kidney disease (loss of kidney function) and overactive bladder (frequent feeling of needing to urinate). Record review of Resident #5's Comprehensive MDS Assessment, dated 10/08/2024, reflected the resident had a moderate impairment in cognition with a BIMS score of 11. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure the medications for two of two residents (Resident #2 and Resident #3) were stored in locked compartments and permit only authorized personnel to have access to the keys. 1. The facility failed to ensure Resident #6's bottle of Nature Made Fish Oil was not left on resident's recliner on 12/03/2024. 2. The facility failed to ensure Resident #7's Equate Lubricant eye drops was not left on top of the resident's overbed table on 12/03/2024. 3. The facility failed to ensure Resident #7's bottle of Allegra tablets was not left on top of the resident's overbed table on 12/03/2024. These failures could place the residents at risk of not receiving medications, accidental overdose, or misuse of medications. Findings include: 1. Record review of Resident #6's Face Sheet, dated 12/03/2024, reflected the resident was a [AGE] year-old male admitted on [DATE]. Resident #6 was diagnosed with dementia (term used to describe a group of symptoms…

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 observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of one resident (Resident #1) reviewed for Infection Control. 1. The facility failed to ensure CNA G changed her gloves and performed hand hygiene while providing incontinent care to Resident #5 on 12/03/2024. 2. The facility failed to ensure CNA G did not hang Resident #1's new brief on the wooden frame of the bed on 12/03/2024. These failures could place residents at risk of cross-contamination and development of infections. Findings include: Record review of Resident #5's Face Sheet, dated 12/03/2024, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5 was diagnosed with chronic kidney disease (loss of kidney function) and overactive bladder (frequent…

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 food was stored, prepared, distributed and served in accordance with professional standards for food service safety for the facility's only kitchen reviewed for kitchen sanitation. The facility failed to ensure foods in the facility's dry storage area, refrigerators, and freezer were labeled and dated according to guidelines and in a sanitary manner. The facility failed to ensure damaged food can was discarded according to guidelines. The facility failed to ensure the Dietary Manager wore a hair cover for his head. The facility failed to ensure the kitchen was clean and sanitized. These failures could place residents at risk for cross contamination and other foodborne illnesses. Findings included: Observations on 12/05/23 from 09:10 AM to 09:30 AM in the facility's only kitchen revealed: The ice machine had dark black dirt stains along the inside door of the machine and along the inside walls of the machine. The lid of the ice…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for four (Resident #91, Resident #92, Resident #93, and Resident #48) of eight residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #91, #92, #93 and #48's rooms were in a position that was accessible to the residents. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency. Findings included: Resident #91 Review of Resident #91's Face Sheet, dated 12/07/2023, reflected that resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included unspecified transient ischemic attack (mini strokes) and generalized muscle weakness. Review of Resident #91's Quarterly MDS Assessment, dated 10/11/2023, reflected Resident #91 had a moderately impaired cognition…

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

Based on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for areas in the facility for 12 (Resident #'s 5, 6, 13, 19, 35, 42, 48, 49, 71, 81, 83, and 101's) of 24 resident rooms observed for a safe, clean, comfortable, and homelike environment. The facility failed to ensure that Resident #'s 5, 6, 13, 19, 35, 42, 48, 49, 71, 81, 83, and 101's rooms were cleaned, sanitized, and maintained. This deficient practice could place residents at risk of infections and living in an uncomfortable environment leading to a decreased quality of life. Findings included: Observation of Residents #13 and #19's room on 12/05/23 at 10:50 AM revealed the wall alongside Resident #13's bed had grayish stains and the two deep scrapes mixed among the stains. Both bed side tables in the room had dried-up reddish fluid stains on the bottom of the frames. The bathroom wall between the sink and toilet had brownish and grayish stains midway 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 observations, interviews, and record reviews the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 of 6 residents (Residents #49, #50, and #111) reviewed for ADLs care provided to dependent residents. The facility failed to ensure Residents #49, #50, and #111 received showers consistently based on records reviewed for November 2023. This failure could place residents at risk of not receiving necessary services to maintain good personal hygiene, skin integrity, or decreased self- esteem. Findings Included: Record review of Resident #49's Face Sheet, dated 12/08/23, revealed she was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses included Alzheimer's disease (severe memory loss), and difficulty in walking. Record review of Resident #49's MDS comprehensive assessment, dated 10/14/18, revealed she had a Brief Interview for Mental Status…

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 observation, interview, and record review the facility failed to ensure that three(Resident #4, Resident #91, and Resident #25) of six residents were provided pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of the residents. The facility failed to ensure CMA W re-ordered medications in a timely manner for Resident # 4 Resident #91, and Resident #25. This failure placed the residents at risk of not receiving medications as ordered by the physician. Findings included: Resident #4 Review of Resident #4's Face Sheet, dated 12/06/2023, reflected resident was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses included unspecified hyperlipidemia (a condition in which there are high levels of fat particles in the blood) and essential (primary) hypertension. Review of Resident #4's Quarterly MDS Assessment, dated 11/22/2023, reflected the resident had a moderate intact cognition…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure the medication error rate was less than 5% for four medication administration errors identified out of 42 opportunities for one (Resident #26) out of five residents reviewed for pharmacy services. There were three medication errors out of forty two opportunities yielding a medication error of 7.14% 1. The facility failed to ensure CMA W administered 3 capsules of Duloxetine to Resident #26 as ordered. 2. The facility failed to ensure CMA W read the alternate order for Omeprazole for Resident #26. 3. The facility failed to ensure CMA W did not crush medication with do not crush instruction for Resident #26. These failures could place residents at risk of wrong medication administration, mismanagement of care, adverse effects, and physical harm. Findings included: Resident #26 Review of Resident #26's Face Sheet dated 12/06/2023 revealed she was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses included major…

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 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 3 (Residents #26, Resident #63, and Resident #4) of ten residents observed for infection control. 1. The facility failed to ensure CNA Z performed hand hygiene between resident (Resident #26 and Resident #63) care in the dining room on 12/05/2023 between 12:19 PM and 12:40 PM. 2. The facility failed to ensure CMA W sanitized the blood pressure cuff between Resident #4 and Resident #26. 3. The facility failed to ensure CMA W washed her hands wore gloves before administering nasal spray to Resident #4. These failures could place the residents at risk of cross-contamination and development of infections. Findings included: 1. Review of Resident #26's Face Sheet dated 12/06/2023 revealed she was an [AGE] year-old female re-admitted…

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 treat residents with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 2 (Resident #26 and Resident #63) of 8 residents reviewed for resident rights. The facility failed to ensure CNA Z did not provide dining assistance to Resident #63 and Resident #26 at the same time during the dining observation on 12/05/2023. This failure could affect residents that require dining assistance during mealtimes, placing them at risk for not receiving care and services with dignity. Findings Included: Review of Resident #26's Face Sheet dated 12/06/2023 revealed she was an [AGE] year-old female re-admitted to the facility on [DATE]. Relevant diagnoses included metabolic encephalopathy (syndrome of a chemical imbalance in the blood that causes neurological deficits), right side contractures (abnormal thickening of the tissues…

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 and interviews, the facility failed to ensure the resident was free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for 1 of 6 (Resident #49) residents reviewed for restraints. The facility failed to ensure Resident #49 was not left sitting in a Geriatric (elderly) Chair (with the feeding tray still fully attached, while the resident was sitting in the media room. This failure could unnecessarily inhibit the resident's freedom of movement or activity. Findings included: Record review of Resident #49's Face Sheet, dated 12/08/23, revealed she was an 81 -year-old female admitted on [DATE]. Relevant diagnoses included Alzheimer's disease (severe memory loss), and difficulty in walking. Record review of Resident #49's MDS comprehensive assessment, dated 10/14/18, revealed she had a Brief Interview for Mental Status (BIMS) score of 05 (severe cognitive impairment) and for Activities for Daily…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record reviews, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately for 1 of 1 Resident (Residents #12) reviewed for neglect, and exploitation or misappropriation. The facility failed to report Resident #12's fall to the Texas Department of Health and Human Services Commission (HHSC) on 11/23/23. This failure could place residents at risk of sustaining an injury and not receiving all services . Findings included: A record review of Resident #12's face sheet dated 12/08/23 reflected an [AGE] year-old female admitted on [DATE] with Diagnoses which included: Parkinson's disease (nervous system disorder), muscle weakness, and lack of coordination. Review of Resident #12's quarterly MDS assessment, dated 10/31/23, reflected resident had a BIMS of 13 (cognitively intact), and the Resident required assistance to perform ADL 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 each resident received an accurate assessment, reflective of the resident's status for 1 of 8 residents (Resident #26) reviewed for Accuracy of Assessments. The facility failed to ensure Resident #26's Quarterly MDS assessment dated [DATE] and 10/29/2023 accurately reflected that Resident #26 had impairments to the upper extremity and lower extremity on one side of the body. This failure could place residents at risk for not receiving care and services to meet their needs, diminished function of health, and regressions in their overall health. Findings included: Resident #26 Review of Resident #26's Face Sheet, dated 12/06/2023, revealed she was an [AGE] year-old female re-admitted to the facility on [DATE]. One of the relevant diagnosis was unspecified joint contracture (tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen). Review of Resident #26's Quarterly MDS Assessment, 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 observation, interview and record review , the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for one (Resident #26) of 20 residents reviewed for care plans. The facility failed to ensure the comprehensive care plan for Residents #26 was developed and identified and implemented goals and interventions to accurately address the resident's need for dining assistance. This failure could place residents that require dining assistance at risk for not receiving care and services to meet their needs. Findings Included: Review of Resident #26's Face Sheet dated 12/06/2023 revealed she was an [AGE] year-old female re-admitted to the facility on [DATE]. Relevant diagnoses included metabolic encephalopathy (syndrome of a chemical imbalance in the blood that causes neurological deficits,) right side…

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 the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team for 1 (Resident #26) of 6 residents reviewed for Revised Care Plan. The facility failed to ensure Resident #26's care plan was revised to reflect the specific devices used for Resident #26's impairment. This failure could place the resident at risk of needs not being met. Findings included: Review of Resident #26's Face Sheet dated 12/06/2023 revealed she was an [AGE] year-old female re-admitted to the facility on [DATE]. One of the relevant diagnosis was unspecified joint contracture. Review of Resident #26's Quarterly MDS Assessment, dated 10/29/2023, revealed the resident had a severe impairment in cognition with a BIMS score of 02. Resident #26 was totally dependent upon two or more staff for bed mobility and transfers. She required limited assistance of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received services and assistance to prevent urinary tract infections for one (Resident #4) of two residents reviewed for urinary incontinence. The facility failed to place Resident #4's indwelling urinary foley catheter device below the bladder. This failure placed the resident at risk for the development of new or worsening urinary tract infections. Findings included: Review of Resident #4's Face Sheet, dated 12/06/2023, reflected resident was an [AGE] year-old female admitted on [DATE]. One of the relevant diagnosis was neuromuscular dysfunction of bladder (The muscles and nerves that control the bladder do not work properly due to illness). Review of Resident #4's Quarterly MDS Assessment, dated 11/22/2023, reflected the resident had a moderate intact cognition with a BIMS score of 10. Resident #4 required extensive assistance for bed mobility, transfer, walk in, dressing, toilet use, 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 observations, interviews, and record review, the facility failed the medication was labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions for one (Resident #4) of two residents reviewed for labelling of drugs and biologicals. The facility failed to ensure CMA W placed a change of instruction label for Resident #4's Phenytoin after a change to the order. This failure could place residents at risk of wrong medication administration, mismanagement of care, adverse effects, and physical harm. Findings included: Review of Resident #4's Face Sheet dated 12/06/2023 reflected the resident was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses include allergic rhinitis (an allergic reaction to tiny particles in the air called allergens) and seizures. Review of Resident #4's Quarterly MDS assessment dated [DATE] reflected resident had a moderately impaired cognition with a BIMS score of 10. Resident #4 required…

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.