Paradigm At Stevens

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents received proper treatment to maintain vision; the facility must, if necessary, assist the resident in making appointments, and by arranging for transportation to and from the office of a practitioner specializing in the treatment of vision for 1 of 1 Resident (Resident #35) whose records were reviewed for optometry care. Nursing staff failed to ensure Resident #35 received transportation in order to obtain optometry care as needed for more than 2 months. This deficient practice could affect any resident and contribute to the decline of the resident's vision. The findings were: Review of Resident #35's face sheet, dated 3/5/25, revealed she was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus without complications and Anxiety Disorder. Review of Resident #35's quarterly MDS assessment, dated 12/24/24, revealed her BIMS score was 15 of 15 which was reflective of no cognitive impairment and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that licensed staff were able to demonstrate the specific competencies and skill sets necessary to care for resident's needs for 3 of 6 nursing staff(CNA C, CNA-E and CNA K) reviewed for competencies. 1. a. CNA C and CNA K failed to use safe technique when transferring Resident #19 from the bed to the wheelchair using a mechanical lift. 2. When CNA D and E mechanically transferred Resident #28 from the bed to the wheelchair on 03/05/2025, CNA E did not hold the spreader bar to prevent the spread bar from hitting the resident's head that was swinging while CNA D was lowering the spread bar to connect it to the sling. These failures could place the residents at risk for avoidable falls and injuries as a result of a fall. The findings included: 1. Review of Resident #19's face sheet, dated 3/6/25, revealed she was admitted to the facility on [DATE] with diagnosis including Hemiplegia, unspecified affecting left non-dominant 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.

Based on observations, interviews, 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 1 of 2 medication rooms (3-side medication room) reviewed for pharmacy services. There were total eighteen (18) syringes of 0.9 % sodium chloride injection for flush 10 milliliters expired on 02/28/2025 found inside 3-side medication room on 03/05/2025. This failure could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects. The findings included: Observation on 03/05/2025 at 11:28 a.m. revealed a total of eighteen (18) syringes of 0.9 % sodium chloride injection for flush 10 milliliters expired on 02/28/2025 found inside the 3-side medication room. Interview on 03/05/2025 at 11:46 a.m. with DON acknowledged there were total of eighteen (18) syringes of 0.9 % sodium chloride injection for flush 10 milliliters expired on 02/28/2025 found inside the 3-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 residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 14 residents (Residents #6) reviewed for accommodation of needs. The facility failed to ensure Resident #6's call light was within reach while she was positioned on her bed in her room. This failure could place residents at risk for delay in care and services, and increased risk of falls and injuries. The findings included: Record review of Resident #6's face sheet, dated 03/07/2025, revealed the resident was a [AGE] year old female and an original admission date of 10/16/2023 with diagnoses that included: traumatic subdural hemorrhage with loss of consciousness of unspecified duration (a pool of blood between the brain and it outermost covering), dysphagia (difficulty swallowing), hypertension…

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 clean, comfortable, and homelike environment including a clean bed in good condition for 1 of 1 Resident (Resident #14) whose bed was observed for sanitation. The facility failed to replace Resident #14's mattress which was heavily soiled with urine and the urine stains covered at least 50% of the mattress. This deficient practice could affect any resident and result in dissatisfaction and poor self-esteem. The findings were: Review of Resident #14's face sheet, dated 3/7/25, revealed she was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus, Schizoaffective Disorder (according to Mayo clinic: mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression, mania and a milder form of mania called hypomania), Major Depressive Disorder, recurrent severe without psychotic, Anxiety Disorder, unspecified…

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 and procedures that prohibit and prevent abuse, neglect and misappropriation for 1 of 5 staff (housekeeper-F) reviewed for criminal backround checks. The facility administrator and human resources completed checking housekeeper-F's criminal background on 03/06/2025, but the housekeeper was hired to the facility on [DATE]. This failure could place all residents at risk of abuse from facility staff. Findings included: Record review of housekeeper-F's employee's profile revealed the housekeeper was hired and started working to the facility on [DATE], but the housekeeper's criminal background was checked on 03/06/2025. Interview on 03/07/2025 at 3:12 p.m. with the administrator stated housekeeper-F was hired and started working at the facility on 02/05/2025, but the housekeeper's criminal background was checked on 03/06/2025. The facility did not have staff for human resources, so the staff from the ssociated facility came to 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 ensure the assessment accurately reflected the resident's status for 2 of 7 Residents (Resident #16 and Resident #35) whose records were reviewed. 1. Resident #16's quarterly MDS did not reflect he used one 1/4 bed rail for mobility and transfers. 2. Resident #35's quarterly MDS did not reflect she had impaired vision. This deficient practice could affect any resident and could result in the inaccuracy of assessments and contribute to residents not receiving care for identified care needs. The findings were: 1. Review of Resident #16's face sheet, dated 3/4/25, revealed he was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction affecting non-dominant side and Dementia in other Diseases classified elsewhere, severe, with psychotic disturbance. Review of Resident #16's quarterly MDS assessment, dated 1/22/25, revealed his BIMS score was 14 of 15 reflective of minimal cognitive…

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 develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs that were identified in the comprehensive assessment, and described services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 14 residents (Resident #143) reviewed for care plans. The facility failed to ensure Resident #143's care plan reflected her bowel incontinence and included a care plan regarding how to take care of the resident's bowel incontinence. These deficient practices could place residents at risk for not receiving proper care and services due to inaccurate care plans. The findings included: Record review of Resident #143's face sheet, dated 03/07/2025, revealed Resident #143 was [AGE] years old, female, and originally admitted to the facility 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the observations, interviews, and record review, the facility failed to ensure that the resident's environment remained free of accidents and hazards as was possible and each resident received adequate supervision to prevent accidents for 2 of 2 (Resident #19 and Resident #28) reviewed for mechanical transfers. 1. a. CNA K and CNA C failed to use safe technique when transferring Resident #19 from the bed to the wheelchair using a mechanical lift. b. Nursing staff failed to ensure a floor mat was at Resident #19's bedside while she was in bed. 2. When CNA-D and CNA E mechanically transferred Resident #28 from the bed to the wheelchair on 03/05/2025, CNA-E did not hold the spreader bar to prevent the spread bar from hitting the resident's head that was swinging while CNA-D was lowering the spread bar to connect it to the sling. These failures could place the residents at risk for avoidable falls and injuries as a result of a fall. The findings included: 1. a. Review of Resident #19's 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 observations, interviews, 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 2 of 2 residents (Resident #11 and #143) reviewed for incontinence care. 1. When CNA-C was providing incontinent care to Resident #11 on 03/05/2025, CNA-F did not clean the resident's suprapubic area (the area of the abdomen located below the umbilical region). 2. When CNA-B was providing incontinent care to Resident #143 on 03/06/2025, CNA-G did not separate and clean the resident's labia area. These failures could place residents who required incontinence care at risk for cross contamination and the development of new or worsening urinary tract infections. The findings included: 1. Record review of Resident #11's face sheet, dated 03/07/2025, revealed the resident was a [AGE] year old male and admitted to the facility on [DATE] with diagnoses of type 2…

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 a resident who needs respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan for 2 of 2 Resident (Resident #16, Resident # 13) whose records were reviewed for oxygen therapy. 1. Nursing staff failed to ensure Resident #16's oxygen concentrator filter was clean while he was receiving oxygen via nasal cannula. 2. Resident #13's nebulizer mask was observed on the resident's dresser on 03/04/2025, and it was not covered in a plastic bag when it was not used. This deficient practice could affect any resident receiving oxygen therapy and could cause the resident to develop an upper respiratory infection. The findings were: 1. Review of Resident #16's face sheet, dated 3/4/25, revealed he was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction (paralysis after having a stroke) affecting…

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 assess the resident for risk of entrapment from bed rails prior to installation; to review the risks and benefits of bed rails with the resident and obtain informed consent prior to installation for 1 of 3 Residents (Resident #16) who were reviewed for bed rail use. Nursing staff failed to take the necessary steps prior to allowing Resident #16 to use a bed rail; complete an assessment; attempt the use of alternatives; review risks vs benefits; and to obtain a consent. These deficient practices could affect the residents who used a bed rail and could contribute to avoidable accidents. The findings were: Review of Resident #16's face sheet, dated 3/4/25, revealed he was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis (paralysis) following Cerebral Infarction (stroke) affecting non-dominant side and Dementia in other Diseases classified elsewhere, severe, with psychotic disturbance. Review of 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 observations, interviews, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments for 1 of 2 medication rooms (the 4-side medication room) and 1 of 3 medication carts (the medication aide cart) review for storage and medication carts. 1. The narcotic box located inside a refrigerator in the 4-side medication room was not affixed permanently to the refrigerator, and there were total 12 capsules of Resident #144's Dronabinol 5 mg inside the narcotic box. 2. There were brand new and unopened two eye drop bottles of Latanoprost 0.005% ophthalmic solution stored inside medication aide cart at the room temperature, but the label of the two eye drop bottles said Keep refrigerator unopened. Store opened at room temperature. This failure could place residents at risk of misappropriation of medications or harm due to not having appropriate therapeutic effects. The findings were: 1. Record review of Resident #144's face sheet, dated 03/07/2025, revealed 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 maintain medical records that were complete and accurately documented for 1 (Resident #7) of 14 residents reviewed for clinical records, in that: Resident #7's psychiatric provider indicated the resident had Depakote one tablet 125 mg two times a day for mood disorder, but the facility made an entry in the order incorrectly by Depakote one tablet 125 mg two times a day for dementia. These deficient practices could result in in errors in care and treatment. The findings were: Record review of Resident #7's face sheet, dated 03/06/2025, revealed the resident was [AGE] years old male, originally admitted to the facility on [DATE], and re-admitted to the facility on [DATE] with diagnosis of heart failure (hear not pumping enough), muscle weakness, mood disorder (disturbance in the person's mood), dementia (loss of cognitive functioning), type 2 diabetes mellitus (not control blood sugar), and hypoxemia (low level of oxygen in the blood). Record review 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 observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public on 1 of 14 residents (Resident #31) reviewed for environmental concerns. There was a hole sized width 20 cm and length 3 cm on Resident #31's bathroom door in the resident's room. These failures could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe. The findings included: Record review of Resident #31's face sheet, dated 03/07/2025, revealed the resident was [AGE] years old female, originally admitted to the facility on [DATE], and re-admitted on [DATE] with diagnosis of adjustment disorder with anxiety (feeling worked, anxious, and overwhelmed), schizophrenia (mental illness that affects how a person think), muscle weakness, traumatic subarachnoid hemorrhage (bleeding in the space between the brain and the membrane that covers it), and Parkinsonism…

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 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 and handle, store, process, and transport linens to prevent the spread of infection for 2 of 47 residents (Resident #1 and Resident #2) reviewed for infection control. The facility failed to report to the State Survey Agency (HHSC) an outbreak of scabies infection. These failures could place residents at risk of a delay of identification infectious outbreaks and lack of timely follow-up on recommended interventions to prevent harm, or impairment. The findings included: 1. Record review of Resident #1's face sheet, dated 1/17/25 revealed a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included diabetes (a long-term condition in which the body has trouble controlling blood sugar…

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 a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice for 1 of 7 (Resident #1) reviewed for respiratory care. Resident #1's oxygen tubing, humidifier and nasal canula were not replaced within the facility's time frame for replacement (every Wednesday during the night shift (10:00 pm to 6:00 am). This failure could affect residents administered oxygen and could lead to infections if the tubing, humidifier and canula are not cleaned/ or replaced as common practice in the facility and per facility policy. The findings were: Record review of Resident #1's face sheet, dated 5/30/24 revealed, the resident was admitted on [DATE] with diagnoses that included: depression, dementia, COPD (respiratory disease) and anemia. The Resident was a Male; age [AGE]. The RP was listed as: the resident. Record review of Resident #1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to provide the services of a Registered Nurse to serve as the director of nursing on a full-time basis for 1 of 1 facility reviewed for nursing services, in that: The facility failed designate a registered nurse to serve as the Director of Nursing on a full time basis on [DATE]th and 13th 2024. This failure affected residents who resided in the facility by putting them at risk of poor nursing care. The findings were: Record review of employee time sheet revealed during the month of [DATE] the facility employed two registered nurses: RN A and RN B. RN A and RN B did not clocked hours on [DATE]th and 13th, 2024. At the time of exit on [DATE], the Administrator had not provided a policy or procedure for the Director of Nurses. During an observation and interview on [DATE] at 5:40 pm, RN A was physically present and stated that she usually provided RN coverage on weekends. RN A stated that an RN was required 8 hours per day so as to provide…

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 maintain medical records, in accordance with accepted professional standards and practices, which are complete; and accurately documented for 1 of 7 residents (Resident #1) reviewed for completeness and accuracy: Resident #1 was prescribed PRN (as needed) O2 and the April and May 2024 MARs did not capture or document the resident's nebulizer, humidifier, and 02 tubing needed to be changed every seven days per facility's procedure. This failure could result in the facility not documenting in the medical record residents on oxygen therapy not having their O2 nebulizer, humidifier and tubing changed which could cause infections and a diminished quality of life. The findings were: Record review of Resident #1's face sheet, dated 5/30/24 revealed, the resident was admitted on [DATE] with diagnoses that included: depression, dementia, COPD (respiratory disease) and anemia. The Resident was a Male; age [AGE]. The RP was listed as: the resident. 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 interview and record review, the facility failed to provide and document sufficient preparation and orientation to ensure safe and orderly transfer or discharge from the facility for 1 of 6 (Resident #1) residents reviewed for transfer or discharge. The facility failed to ensure sufficient resident education was provided to Resident #1, who had a recent AKA, osteomyelitis (serious infection of the bone), midline (venous access device inserted in a deep vein of the arm) and an order for IV antibiotics/wound care, and his RP when discharged home from the facility on 5/13/24. 1. Facility did not arrange home health services for Resident #1's wound care, ordered 5/10/24, and IV medication administration, ordered 5/11/24, when the resident was discharged on 5/13/24. 2. Facility staff did not provide Resident #1's RP with proper education related to IV antibiotic administration. 3. Facility staff did not provide Resident #1's RP with proper education related to midline catheter care. 4. Facility staff did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect and exploitation for 1 of 4 residents (Resident #1) reviewed for abuse, in that; The facility failed to develop and implement a written abuse policy for reporting abuse within 2 hours to the State Survey Agency (HHSC) which resulted in a failure to report an allegation of abuse made by Resident #1 until surveyor intervention. This failure could place all residents at risk for potential abuse due to unreported allegations of abuse. The findings included: Record review of the facility policy titled Abuse, Neglect, and Exploitation Prevention Policy and Procedure last revised 9/10/2020 revealed: The facility Administrator, or his/her designee, will be designated as the facility's ANE Coordinator and will be responsible for overseeing the ANE Prevention program and directing any such investigation. Investigation of ANE: 13. Administrator, or his/her designee,…

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 allegations involving abuse, neglect, and misappropriation were reported immediately, but no later than 2 hours after the allegation of abuse to the State Survey Agency for 1 of 4 residents (Resident #1) reviewed for abuse, in that: The facility failed to report to the State Survey Agency (HHSC) allegations of abuse made by Resident #1 immediately or within 2 hours. This failure could place all residents at increased risk for potential abuse due to unreported allegations of abuse. The findings included: Record review of Resident #1's face sheet dated 3/26/2024 revealed an admission date of 1/05/2024 with diagnoses which included: cerebral infarction, hemiplegia, and hemiparesis following cerebral infarction (stroke with resulting paralysis and weakness on one side of the body), major depressive disorder, recurrent mild and generalized anxiety disorder. Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 15…

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

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. The facility failed to ensure dietary staff with facilal hair, were wearing beard restraints. These failures could place resident who received meals and/or snacks from the kitchen at risk for food borne illness. The findings were: Observations on 01/25/24 11:28 a.m. revealed DA not wearing beard restraint/beard guard with approximately 1/2 inch to inch beard to his chin. DA was further observed taking dishware from the dish room area throughout the kitchen and hanging cooking utensils above the food prep table near the steam table. Observations on 01/25/24 at 11:39 a.m. revealed DA washing cooking utensils and pans in the 3 compartment sink without a beard restraint/beard guard. During an interview on 01/25/24 at 11:41 a.m. the DM stated DA should have been wearing a beard guard and that hair restraints should be worn anytime someone was in the kitchen. DM further stated by not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health and safety of the resident and or other residents for 2 (Resident #16 and #44) of 8 residents observed for accommodation of needs. 1. Resident #16's call light was not placed within reach. 2. Resident #44's call light was not placed within reach. This deficient practice could affect residents who require assistance with care and could result in an emergent need not being addressed. The findings included: 1. Record review of Resident #16's electronic face sheet dated 01/23/2023 reflected he was initially admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included: hemiplegia (symptom that involves one sided paralysis) and hemiparesis (one sided muscle weakness) following cerebral infarction (disrupted blood flow to brain causes parts 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 assessments accurately reflected the resident's status for 1 of 8 Residents (Resident #12) whose MDS records were reviewed for accuracy. Resident #12's Quarterly MDS assessment dated [DATE] incorrectly documented the resident had received tube feedings while a resident at the facility. This failure could place residents at risk for inadequate care due to inaccurate assessments. The findings included: Record review of Resident #12's face sheet dated 01/25/2024 revealed Resident #12 was admitted to the facility on [DATE] with diagnoses that included: cerebral infarction, chronic obstructive pulmonary disease with (acute) lower respiratory infection, acute respiratory failure with hypoxia, aphasia, cerebellar stroke syndrome, schizophrenia, hyperlipidemia, cerebral aneurysm, and dysphagia, oropharyngeal phase. Record review of Resident #12's Quarterly MDS assessment, dated 12/18/2023, documented the resident while a resident had received tube…

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 develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #18) of 8 residents reviewed for care plans. Resident #18's care plan did not reflect that she required supervision when she smoked. This deficient practice could affect residents who required supervision and could result in an accident or harm. The findings included: Record review of Resident #18's electronic face sheet dated 01/26/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: altered mental status (change in mental function), depression (a common and serious medical illness that negatively affects how one feels, thinks and acts), hemiplegia (paralysis of one side of the body), affecting right…

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 is incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 4 residents (Residents #1 and #20) reviewed for incontinent care. While providing incontinent care for Resident #98, CNA E did not return Resident #1's foreskin to the normal position. This deficient practice could place residents at-risk for infection, paraphimosis (urologic emergency in uncircumcised males) and skin break down due to improper care practices. The findings were: Record review of Resident #98's electronic face sheet dated 01/24/2024 reflected he was admitted to the facility on [DATE]. His diagnoses included: cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), hemiplegia (paralysis of one side of body) and hemiparesis (one sided muscle weakness) following…

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 a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents goals and preferences for 1 (Resident #16) of 2 residents reviewed for oxygen therapy. LVN B turned off Resident #16's oxygen concentrator and did not return to turn it back on. This deficient practice could affect residents on oxygen therapy and could result in low or high oxygen levels in the blood and cause respiratory distress. The findings included: 1. Record review of Resident #16's electronic face sheet dated 01/23/2023 reflected he was initially admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included: hemiplegia (symptom that involves one sided paralysis) and hemiparesis (one sided muscle weakness) following cerebral infarction (disrupted blood flow to brain…

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