Avante At Boca Raton, Inc.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to attempt to use appropriate alternatives and obtain informed consent prior to installing bedside rails, and failed to provide regular inspection and maintenance to identify areas of possible entrapment for 1 of 1 sampled resident, reviewed for bedrails, Resident #90. The findings included:Review of the facility's policy titled, Bed Rails with an issued and revised date of 03/02/19, included in part, the following: The facility shall provide adequate management of bedrails to ensure that residents attain or maintain the highest practical physical, mental and psychosocial well-being. Procedure: 2. If a bed or side rail is used, the facility will ensure correct installation, use, and maintenance of bedrails, including but not limited to the following elements: a) Assess the resident for risk of entrapment from bed rails prior to installation. b) Review the risks and benefits of bed rails with the resident or resident representative and…

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

Based on review of policy and procedure, observation and interview, the facility failed to ensure that it maintained a currently dated posting for the Nurse Staffing Information, which had documented dates of two (2) incorrect days, for 1 of 4 days observed, at the start of this survey, for day of 09/02/25. The findings included:Record review of the facility policy and procedure, titled, Staffing, provided by the Administrator effective and revised 04/16/25 documented in the Policy Statement: It is the policy of this facility to make nurse staffing information readily available in a readable format to residents, staff, and visitors at any given time. Policy Explanation and Compliance Guidelines: 1. The Nurse Staffing document will be posted on a daily basis and will contain the following information:.b. The current date.2. The facility will post the Nurse Staffing Sheet at the beginning of each shift. 3. The information posted will be:.b. In a prominent place readily accessible to residents, staff, and visitors.An observation on entrance tour to the facility, located at front desk,…

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 attending physician documented in the residents' medical records that the identified irregularity by the consulting pharmacist had been reviewed and what, if any, action has been taken to address it, as evidenced by lack of documentation by the attending physician, if no change in the medication, of his or her rationale in the residents' medical records for 2 of 5 sampled residents reviewed for unnecessary medications, Residents #14 and #142. The findings included: Review of the facility's policy titled, Medication Regimen Review with a revised date of 06/01/24, included in part the following: The consultant pharmacist will provide the resident's MRRs (Medical Record Review) to the facility identified personnel who will ensure that the attending physician, medical director, director of nursing and other necessary facility staff receive the recommendations. The attending physician/prescriber should address the consultant's pharmacist'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, interview and review of policy and procedure, the facility failed to ensure that only authorized staff had access to the first-floor medication cart #1's keys as evidenced by the Registered Nurse (RN) handed the medication cart keys to a Certified Nursing Aide (CNA) to open the smoking room; failed to ensure that residents medications were properly supervised / stored as evidenced by medications being left unattended on the resident's bedside table during a Medication Administration Observation for 1 of 9 sampled residents (Resident #79); failed to ensure that expired wound care dressings were removed from 2 of 2 treatment carts located in the medical preparation room in the first floor and the second floor units; failed to ensure that 2 of 2 Medical Preparation / medication storage room reviewed had readily accessible soap and/or alcohol-based hand rub (ABHR) to perform hand hygiene; and failed to ensure the medication storage room was free of resident's personal belongings as evidenced by…

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 provide food in correct form (mechanical soft), as ordered by the physician for Resident #56. The census at the time of survey was 135. The findings included: Record review revealed Resident #56 was admitted to the facility on [DATE]. Review of the most recent complete assessment, an admission MDS, with a reference date of 07/23/25, revealed Resident #56 had a Brief Interview for Mental Status (BIMS) score of 13, indicating that the resident was cognitively intact. Resident #56's diagnoses at the time of the assessment included: Cancer, Hypertension, Hyperlipidemia, Thyroid disorder, Malnutrition, and Chronic Lung Disease. Review of Resident #56's physician diet orders included: Regular Diet, Mechanical Soft texture, dated 08/27/25. During an observation of the lunch meal served to the residents in the Dining room on the 200 unit, on 09/02/25 at 12:20 PM, Resident #56 was observed with a piece of bone-in chicken with skin on it. 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 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 of 38 residents on Enhanced Barrier Precautions (Residents #20, #77, #14); failed to disinfect reusable equipment between residents' use (Resident #128 and #79); and failed to perform hand hygiene during medication administration observation for 2 of 9 residents (Resident #95 and #127). The findings included: Review of the facility's policy titled, Enhanced Barrier Precautions with an issued date of 04/01/24 included in part the following: Policy: It is the policy of this facility to implement enhanced barrier precautions (EBP) for the prevention of transmission of multidrug-resistant organisms (MDRO). Definitions: EBP refer to an infection control intervention designed to reduce transmission of multidrug-resistant…

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 thoroughly investigate a neglect allegation related to wound care for 1 of 3 residents reviewed for wound care (Resident #3).The findings included:Review of the facility's policy titled, Abuse, Neglect, Exploitation, Mistreatment, Misappropriate of Property and Injury of Unknown Source Prevention (ANEMMI), dated 03/02/19, included the following: The facility will develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property; to include the use of physical and or chemical restraints. The purpose is to ensure that the facility is doing all that is within its control to prevent occurrences.Investigation:Investigate different types of incidents; and identify the staff member responsible for the initial reporting, investigation of alleged violations 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 treatment measures were implemented for pressure ulcers for 1 of 3 sample residents, Resident #3, reviewed for Pressure Ulcer/Injury, as evidenced by physician orders for wound care and intravenous (IV) antibiotic therapy were not followed, increasing the risk of pressure ulcer worsening for Resident #3.The findings included: Review of the facility's policy titled, Clean Dressing Change, dated 03/02/19, included the following: It is the policy of the facility to ensure change dressings in accordance with State and federal Regulations, and national guidelines.Procedure:1.Verify and review physician's order for procedure. Record review for Resident #3 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Wedge Compression Fracture of Third Lumbar Vertebra, Type 2 Diabetes Mellitus without Complications, Bacteremia, Overactive Bladder and History of Falling. On 07/05/25, Resident #3 was discharged…

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 enter orders for indwelling catheter care for a resident admitted with an indwelling catheter for 1 of 1 resident sampled for an indwelling catheter (Resident #3). The findings included: Review of the facility's policy titled, Infection Control-Indwelling Catheter Care, dated 03/02/19, included the following: It is the policy of the facility to ensure that the residents receive care and services to prevent urinary tract infections in those residents with an indwelling catheter, in accordance with standards of practice. Record review for Resident #3 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Wedge Compression Fracture of Third Lumbar Vertebra, Type 2 Diabetes Mellitus without Complications, Bacteremia and Overactive Bladder. On 07/05/25, Resident #3 was discharged to the hospital from the facility. Review of Section C of the 5-day Minimum Data Set (MDS) dated [DATE] revealed that Resident #3 had a Brief…

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 a physician-ordered ultrasound was scheduled and performed for 1 of 3 sampled residents (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included Hypertension, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant Side, and Dysphagia. A review of the most current Minimum Data Set (MDS) assessment, dated 03/06/25, under Section C, revealed a Brief Interview of Mental Status Score of 6 indicating Resident #1 had impaired cognition. Section GG under functional limitations in range of motions revealed Resident #1 had impairment on one side. Toileting and hygiene which included the ability to maintain perineal hygiene, revealed that Resident #1 need substantial and maximal assistance. A review of the wound care progress notes in December 2024 indicated the resident had fungal rashes to the vaginal folds, they were treated with Nystation cream, and which had…

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, record review, and observation, the facility failed to provide a clean, homelike environment for the residents in the facility. The findings included: 1) The shower room on the second floor had brown colored matter on the floor of the shower stall on the left side of the room from the entrance. The wall above the grab bar on the left facing into the stall had a rust colored stain. There were rust colored stains on the surfaces of the grab bars. The walls of the shower were noticeably marked with black stains. The paint on the floor had peeled in several locations. 2) The shower room on the first floor had gaps between the floor and walls on both shower stalls. The floors and walls had black markings. 3) The floor tiles on the south wing of the second floor had noticeable cracks in several tiles. 4) room [ROOM NUMBER], the bed rail had peeling paint with rust colored staining. 5) Privacy Curtains in room [ROOM NUMBER] and 222 had black stains. 6) room [ROOM NUMBER] blanket had holes.…

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 and interview, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. The findings included: 1) During the initial kitchen/food service sanitation tour conducted on 04/29/24 at 9 AM and accompanied with the facility's Certified Dietary Manager (CDM), the following were noted: (a) The exterior of the exhaust hood system that is located directly over the major cooking equipment was noted to be soiled and covered with rust. It was discussed with the CDM at the time that the rust could fall into foods being prepared and result in food contamination. The CDM stated that she has put in numerous request to maintenance over the past 3 months for the issue to be resolved, however no one has assessed the hood issue. (b) Observation of the ceiling mounted commercial light fixtures (7) noted that exteriors were heavily soiled. Two of the light fixtures were noted to be potentially falling from the ceiling over food preparation and serving areas. The CDM stated that she has…

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, it was determined that the facility failed to be administered in a manner to ensure an adequate food supply necessary to provide the nutritional needs of 111 of the 120 residents in the facility. The findings included: During the initial kitchen/food service tour conducted on 04/29/24 at 9 AM, with the facility's Certified Dietary Manger (CDM), it was noted there was limited food supplies on hand to ensure that the nutritional needs of the facility's 111 residents who eat by mouth. It was noted that the facility currently had 9 residents who receive their nutrition by a gastrostomy tube feedings. During the initial tour, it was noted a shortage of on-hand food supplies that included: frozen foods (meats, entrees, vegetables, etc.), dairy products (milk, cottage cheese, sliced cheeses, yogurt, etc.), canned foods (fruits, vegetables, puddings, etc.), fresh fruits and vegetables, juices ( individual portion control orange juice, apple juice, cranberry juice, etc.), and daily pantry food supplies (crackers, peanut butter, pastas,…

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 and interview, it was determined that the facility failed to provide housekeeping and maintenance services necessary maintain a sanitary, orderly, and comfortable interior for 12 of 27 resident rooms located on the facility's first floor, 11 of 31 rooms located on the facility's second floor, and the second floor dining room. The findings included; During the surveyors screening of the residents and resident rooms on 04/29-30/24 and the environment tour conducted on 05/02/24 accompanied with the facility's Corporate Maintenance Director, the following were noted; First Floor: room [ROOM NUMBER]: A/C filter dust laden, bathroom toilet requires recaulking to the floor, and room call light cord too short. room [ROOM NUMBER]: Bathroom toilet base was loose, and room electrical cover missing. room [ROOM NUMBER]: A/C filter dust lade, and loose wall cable cover. room [ROOM NUMBER]: Room window sill in disrepair. room [ROOM NUMBER]: A/C filter dust laden, Room walls (4) damaged and numerous large…

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, it was determined that the the facility failed to provide 2 (Resident's #60 and #23) of 2 sampled residents with a nourishing, palatable, well balanced bagged meal or snack to take to dialysis appointments. The findings included: 1) During an interview conducted with the alert and interviewable Resident #60 on 04/29/24 and 04/30/24, he stated he has resided in the facility for the past 3 years and leaves the facility for dialysis appointments three times per week (Tuesday/Thursday/Saturday) at 5-5:30 AM. Resident #60 went on to state that a breakfast meal or snack is not provided to him prior to leaving for the dialysis appointments. The resident further stated that a bagged snack or lunch is not being provided on a regular basis to take with him to the dialysis appointments. Stated that when a bagged snack is sent it contains only a package of crackers and a 4 ounce House Shake. The resident also stated he is hungry prior to leaving for dialysis and is also hungry during…

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, it was determined that the facility's approved menu was not followed that potentially effected 111 of the facility residents. The findings included 1) Review of the facility's approved menu the week of 04/28/24 noted that 2% Milk is documented to be served to Regular Diet, No Added Salt Diet, Pureed Diet, Mechanical Soft Diet, Renal Diet, and Skim Milk to be served to Low Fat/Cholesterol Diet. Orange Juice to Regular Diet, Mechanical Soft Diet, Pureed diet, Therapeutic Diet. Observation of the facility's food supply on hand conducted on 04/29/24 at 9 AM noted that only Whole Milk was available for residents and no supply of 2% milk and skim milk. Interview with the Certified Dietary Manager at the time of the observation noted that the facility's residents were without milk for the last 2 days and an emergency whole milk order was obtained and delivered on 04/28/24. It was also noted that there was no supply of Orange Juice on hand. She also stated that there has been no supply of Orange Juice for the last 7 days. 2) Review of the…

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

Based on observation, interview, and record review, it was determined that the facility failed to prepare food by methods that conserve nutritive value, flavor , and appearance that potentially affected 111 of the facility residents. The findings included: During the initial kitchen/food service observation tour conducted on 04/29/24 at 9 AM, it was noted that there were approximately 11 pans of foods covered with aluminum foil located on the stove top. Further observation noted that there was no heat being applied to the covered food pans. An interview with the breakfast/lunch [NAME] (Staff A) at the time of the observation noted that all of the pans located on the stove top were for the lunch meal of 04/29/29. Also stated that all foods in the pans were totally cooked and would be put in to the steam table. Further interview noted that the food pans contained lunch foods which were identified as the following: * Maple Glazed Fish (3 pans) * Ground Maple Glazed Fish (1 pan) * Pureed Maple Glazed Fish (1 pan) * Parsley Noodles (2 pans) * Pureed Parsley Noodles (1pan) * Carrots (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.

Based on observation, interview, and record review, it was determined the facility failed to provide food preferences and food options of similar nutritive value to potentially 111 residents who may choose not to eat food that is initially served or who request a different meal choice. Findings included: 1) During the observation of the lunch meal in the main kitchen on 04/29/24 at 11:30 AM, it was noted that approved menu items of maple Glazed Fish, Parsley Noodles, and Carrots were being served to regular, mechanically altered diet and therapeutic diets. Further observation of the meal service noted that there was not an alternate hot entree, hot starch food, or hot vegetable prepared and available as an alternate for the facility residents. Interview with breakfast/lunch [NAME] (Staff A) at the time of observation noted to state a baked chicken breast or leg is supposed to be always available for the lunch and dinner meals but the facility has not had chicken available for meals for over 7 days. Staff A stated she was not informed why chicken was not available for meal…

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 interview, observation, and record review, it was determined that the facility failed to provide suitable, nourishing snacks to potentially 111 facility residents who want to eat at non-scheduled times or outside of scheduled meal service times. The findings included: 1) During the initial food service tour conducted on 04/29/24 at 9 AM with the facility's Certified Dietary Manager, it was noted low levels of food supplies of frozen, canned, dairy, and daily pantry foods. The surveyor requested a copy of the Snack Menu and list of residents who received scheduled between meal snacks. A review of the facility's Resident Snack Menu noted the following foods to be always available: Puddings Gelatins Cookies Crackers Sandwiches for diabetics Turkey (alternate days) Cheese (alternate days) Peanut Butter & Jelly A review of scheduled Nourishment/Snacks to be prepared daily as part of the residents nutritional care plan (diabetes, underweight, dialysis) noted only 8 listed residents which included Sampled Residents #23, #37, #45, #64, #75, and #98. Further review of the list noted…

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 provide fingernails grooming for 2 of 3 sampled residents, Residents #26 and #43, observed for nail grooming/care. The findings included: Review of the facility's policy titled, Activities of Daily Living (ADLS) Maintain Abilities revised on 03/02/19 documented .a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good .grooming and personal hygiene . Review of the facility's Job Description for Certified Nursing Assistants (CNAs) documented under essential job functions: personal care functions- assist residents with bathing, dressing, grooming . 1) Review of Resident #26's clinical record documented an admission on [DATE] and a readmission on [DATE]. The resident diagnoses included: Seizures, Muscle Weakness, Unspecified Protein-Calorie Malnutrition, Cognitive Communication Deficit, Expressive Language Disorder, Psychosis, Generalized Anxiety Disorder, Major Depressive…

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 address a significant weight loss in a timely manner for 1 of 10 residents sampled for nutrition (Resident #48). The findings included: Resident #48 was admitted to the facility on [DATE] with diagnoses including malnutrition. A comprehensive assessment dated [DATE] documented the resident had mild cognitive impairment and had weight loss. Resident #48 was care planned for nutritional problem or potential nutritional problem related to anorexia on 04/12/24. An intervention included to administer medications as ordered. Record review revealed Resident #48 was sent to the hospital for lethargy on 03/23/24, and returned to the facility on [DATE] with a diagnosis of Urinary Tract Infection. Resident #48's last recorded weight at the facility prior to hospitalization was 182.8 pounds (lbs). Resident #48's weight was 162.6 lbs on readmission to the facility on [DATE]. A review of Resident #48's Nutrition Comprehensive Evaluation/Risk Screen…

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 , it was determined the facility failed ensure that dialysis communication forms completely and accurately document the condition and monitoring for complications before and after dialysis treatments for 1 (Resident #23) of 1 resident sampled for dialysis. The findings included: During the review of the clinical record of Resident #23 on 04/30/24 and 05/01/24, the following were noted: Date of admission: [DATE] (original, 12/26/23 (re-admission) Diagnoses: End Stage Renal Disease Current Physician's Orders: Resident to receive Dialysis on T-Th-Sat at Dialysis Center-1 PM Pick-up time for End Stage Renal Disease. During the review of the facility's Dialysis Communication Forms from 02/06/24 through 04/30/24 noted that 24 of the 25 communication documents failed to be properly documented. A review of the facility's form noted that the form has 3 sections which included the following: (1) Facility to Complete Prior to Dialysis: medications administered prior to dialysis, vital…

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, it was determined that the facility failed to provide liquids in a Nectar Thick form for 1 (Resident #60) of 2 resident's with physician ordered thickened liquids. The findings included: During the review of the clinical record of Resident #60, the following were noted: Date Of admission: [DATE] re-admission: [DATE] Diagnoses: Chronic Kidney Disease Stage 4, Acute Kidney Failure, Type 2 Diabetes, Protein-Calorie Malnutrition, Dyspahgia, Dependence on Dialysis Current Physician Orders: 2/27/24 - Renal Diet, Mechanical Soft Meat, Nectar Consistency, 9/26/23- ProHeal Critical Care 3/1/23 - 1500 ml Fluid Restriction - 900 ml Dietary/600 ml Nursing (7-3 = 240/3-11=300 ml/11-7 = 60 ml 11/2/22 - Dialysis - Tuesday/Thursday/Saturday - pick-up time 05:15 -0545. MDS: 2/7/24 - Quarterly Section C: BIMS =12 (Mild Cognitive Impairment Section D: No Mood issues Section GG: Set-up/Clean Up Assist Section K: NO Swallow Dis - 68 152#, Mechanical Altered Diet, Therapeutic Diet…

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, it was determined that the facility failed to provide physician ordered therapeutic diet (Fluid Restriction) of 1 (Resident #60) of 2 residents sampled for Dialysis. The findings included: During the review of the clinical record of Resident #60, the following were noted: Date Of admission: [DATE] re-admission: [DATE] Diagnoses: Chronic Kidney Disease Stage 4, Acute Kidney Failure, Type 2 Diabetes, Protein-Calorie Malnutrition, Dyspahgia, Dependence on Dialysis Current Physician Orders: 2/27/24 - Renal Diet, Mechanical Soft Meat, Nectar Consistency, 9/26/23- ProHeal Critical Care 3/1/23 - 1500 ml Fluid Restriction - 900 ml Dietary/600 ml Nursing (7-3 = 240/3-11=300 ml/11-7 = 60 ml. 11/2/22 - Dialysis - Tuesday/Thursday/Saturday - pick-up time 05:15 -0545. MDS: 2/7/24 - Quarterly Section C: BIMS =12 (Mild Cognitive Impairment Section D: No Mood issues Section GG: Set-up/Clean Up Assist Section K: NO Swallow Dis - 68 152#, Mechanical Altered Diet, Therapeutic…

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, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a safe, clean, comfortable, and homelike environment, including the maintenance of equipment in the laundry department. The findings included: 1. A tour of the laundry room conducted on 01/09/2024 at 8:40 AM accompanied by Staff A, the Housekeeping Manager, showed that three large dryers were noted with heavy layers of lint debris on the top and bottom of the filters. Continued observation of the clean linen folding table showed an open round garbage bin with dirty napkins and leftover food debris that had no lids. A record review of the Laundry Dryer Log revealed that the staff documented no data since November 2023. Further review did not show that any documentation was done regarding the laundry dryer lint for today. An interview with Staff A on 01/09/24 at 8:44 AM stated that he was on vacation for the last ten days and that the lint 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to provide nutritional interventions in a timely manner to prevent significant weight loss for 3 of 3 residents reviewed for nutrition (Resident #5, Resident #7, and Resident #6). The findings included: A review of the facility's policy titled Weight Management revised on 03/02/2019 showed the following: Residents will be weighted monthly unless otherwise ordered by the physician or deemed necessary by the dietician and or the interdisciplinary team. Monthly weights will be completed each month. Dietary will evaluate all weights each month. A re-weight will be obtained for any weight change of +/- 5 pounds. from the previous weight unless other parameters have been ordered by the physician. The physician and the resident or resident representative will be notified by the resident's nurse of any significant unexpected and or unplanned weight changes. 1) On 12/01/23, Resident #5 was admitted to the facility with a medical history 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, record review and review of policy and procedure, it was determined that the facility failed to ensure that it practiced appropriate hand hygiene 1) after performing a blood sugar check for a resident during an Accucheck Observation for 1 of 1 sampled residents (Resident #16); and 2) Before and after medication administration; and 3) failed to disinfect reusable blood pressure equipment before and after each use with an approved EPA as per the facility's policy. The findings included: Review of the facility's policy titled Infection Prevention and Control and Surveillance Program revised on 03/02/19 documented .hand hygiene should be performed .before and after performing any invasive procedure (e.g., finger stick blood sampling) .upon and after coming in contact with a resident's intact skin (e.g. when taking a pulse or blood pressure) .after removing gloves .all shared medical equipment will be cleaned using an EPA-approved disinfectant wipe against TB (tuberculosis) 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, record review and interview, the facility failed to provide service to ensure negative factors that may impact skin integrity and wound healing treatment were prevented for 1 of 1 sampled resident, Resident #80, reviewed for wound care. The findings included: Review of Resident #80's clinical record documented an admission on [DATE] and no readmissions. The resident diagnoses included Parkinson's Disease, Myocardial, Benign Prostatic Hyperplasia, and Muscle Weakness. Review of Resident #80's Minimum Data Set (MDS) admission assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 15 indicating that the resident has no cognition impairment. The assessment documented under Functional Status that the resident needed extensive assistance with his activities of daily living including toileting and transfers. Further review of the assessment documented that the resident did not have a pressure reducing device for bed and was coded for Risk of Pressure…

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, record review and policy review, the facility failed to provide restorative services for 1 of 1 residents sampled for position and mobility (Resident #117). The findings included: The facility's policy issued and revised on 03/02/19 titled Specialized Rehabilitative and Restorative Services revealed the facility will provide restorative services such as but not limited to walking, transfer training, bowel and or bladder training, bed mobility, Range of Motion (ROM), splint and brace .when necessary as indicated by the assessment of the interdisciplinary team. An interview was conducted with Resident #117 on 02/13/23 at 2:15 PM. He stated his left shoulder was hurting him. He had a fall a couple of weeks ago and it hurt when his left shoulder was moved. He continued to say that he had Physical Therapy a couple of weeks ago but now no one was working with him to move his left shoulder. Resident #117 was admitted to the facility on [DATE] from an acute care hospital. The Minimum…

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 follow Physician orders for tube feeding for 1 of 1 resident reviewed for tube feeding (Resident #113). The findings included: Resident #113 was readmitted on [DATE], transferred to the hospital on [DATE], and was readmitted again on 01/23/23. Diagnoses included dysphagia, acute respiratory failure and anemia. An order was noted for enteral feeding with Isosource 1.5 at 55 ml an hour, on at 4:00 PM and off at 12:00 PM dated 01/23/23. In an observation conducted on 02/13/23 at 10:00 AM, Resident #113 was in the room with the tube feeding off. The tube feeding bag was noted with Isosource 1.5 (tube feeding formulary), which started on 02/12/23 at 4:00 PM the day before. At the time of the observation, the tube feeding was at the 300 milliliters (ml) mark out of a 1000 ml capacity bottle. In this observation, Staff V, Certified Nursing Assistant (CNA), stated that she just stopped the tube feeding for daily care and that she will restart…

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, record and policy review, the facility failed to provide pain management in a timely manner for 2 of 5 residents sampled for pain management (Resident #117 and #377). The findings included: 1) The facility's policy titled Pain Management Program issued and revised on 03/02/19 reveals the facility shall provide adequate management of pain to ensure that residents attain or maintain the highest practicable physical, mental, and psychosocial well-being. Resident #117 was admitted to the facility on [DATE] from an acute care hospital. The Minimum Data Set (MDS) admission assessment with an assessment reference date of 12/16/22 revealed his Brief Interview for Mental Status (BIMS) score was 15 indicating he was cognitively intact. His medical diagnoses included Cerebral Infarction with left-sided Hemiplegia, Malignant Neoplasm of the Larynx and Anxiety Disorder. An interview was conducted with Resident #117 on 02/13/23 at 2:15 PM. He stated his left shoulder was hurting him. He 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.

Based on observation, interviews and record review, the facility failed to ensure controlled substance medication reconciliation was accurate for 4 of 6 sampled residents reviewed during the controlled substance record review at the facility's Seaside, 1st floor East and 2nd floor East Units, for Residents #51, #60, #377 and #381. The finding included: Review of the facility's policy titled General Dose Preparation and Medication Administration revised on 01/01/22 documented .document the administration of controlled substance in accordance with applicable law .after medication administration, facility staff should .document necessary medication administration/treatment information . 1) On 02/16/23 at 8:04 AM, a side by side review of the facility's 1st floor East Medication cart's controlled substance records was conducted with Staff G, Licensed Practical Nurse (LPN). The review revealed Resident #51's Controlled Medication Utilization Record (CMUR) for Oxycodone 10 mg (milligrams) every 8 hours as needed for pain. During the review, Staff G, LPN stated once she administer 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 observation, interview, and record review, it was determined the medication error rate was 10.81 percent. Four (4) medication errors were identified while observing a total of 37 opportunities, affecting Residents #82, #380, and #91. The findings included: Review of the facility's policy titled General Dose Preparation and Medication Administration revised on 01/01/22 documented .prior to preparing or administering medications .staff should follow facility's infection control policy (e.g., handwashing) .prior to administration of medications, facility staff should take all measures required by the facility .verify each time a medication is administered that it is the correct medication, at the correct dose .as set forth in facility's medication administration schedule .after medication administration, facility staff should .document necessary medication administration/treatment information . 1) On 02/13/23 at 4:40 PM, medication administration observation for Resident #82 performed by Staff T, Licensed…

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 review of policy and procedure, observation, interview and record review, it was determined that the facility failed to: 1) ensure that it secured the over-the-counter (OTC) medications in an empty resident room; 2) ensure that it secured an OTC medication observed during tour for Resident #46; 3) ensure that it secured an un-ordered OTC and expired prescription medication observed during tour for Resident #4; 4) ensure that it properly secured a second floor Wound Care Treatment Cart; 5) ensure that it properly secured an E-kit which was left unlocked in the Medication Room on the 300 unit; and 6) ensure that it properly secured loose pills in 2 out of 3 carts reviewed, in the Seaside North Medication cart and Second Floor East Medication Cart. The findings included: Review of the facility policy and procedure on [DATE] at 9:48 AM titled Storage and Expiration Dating of Medications, Biologicals provided by the Director of Nursing (DON) revised [DATE] documented in the Policy Statement: . This policy…

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 dental services in a timely manner for 1 of 1 resident reviewed for dental (Resident #75). The findings included: A review of the facility's policy titled Dental Service, revised on 03/02/19, showed the following: It is the policy of the facility to ensure that residents obtain needed dental services, including routine dental services; to ensure the facility provides the assistance needed or requested to receive these services; to ensure the resident is not inappropriately charged for these services; and if a referral does not occur within three business days, documentation of the facility's to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay. Resident #75 was readmitted to the facility on [DATE] with diagnoses of adult failure to thrive, unspecific dementia, and anemia. A review of the Order Summary Report showed an order for a Dental…

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 recorded review, the facility failed to ensure the correct fluid restrictions as per Physicians orders for 1 of 1 resident reviewed for Dialysis (Resident #110). The findings included: A chart review showed that Resident #110 was readmitted on [DATE] with diagnoses of chronic kidney failure, type 2 diabetes, and dependency on dialysis. The Treatment Administration Records revealed an order for 1500 milliliters (ml) of fluid restriction, with 900 ml for meals and 600 ml provided for nursing, which was dated 01/28/23. In an interview conducted on 02/13/23 at 9:40 AM with Resident #110, he stated that he goes to dialysis on Mondays, Wednesdays, and Fridays. He further said that he was aware that he was on a fluid restriction. Closer observation showed 16 ounce Styrofoam cup with water at the bedside. In an observation conducted on 02/13/23 at 5:10 PM, the dinner trays arrived on the unit. At 5:30 PM, Resident #110's tray was placed at the bedside. Closer observation 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 interviews and record review, the Facility failed to notify and ensure that the arbitration agreement grants the Resident or their representative the right to rescind the Agreement within 30 calendar days of signing it for 2 of 3 residents reviewed during the Arbitration review (Resident #83 and Resident #102). The findings included: A review of the Facility's Arbitration Agreement titled Voluntary Binding Arbitration Agreement provided by facility staff, under section F showed the following. This Agreement may be canceled by written notice sent by certified mail, return receipt requested, to the Facility's Administrator within fifteen (15) calendar days of the Resident's admission date. If alleged acts underlying the dispute are committed before the cancellation date, this Agreement shall be binding with respect to said alleged acts. If not canceled in writing, this Agreement shall be binding on this admission and all `the Resident's other admissions to the Facility without any need for further…

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.