Aviata At Saint Lucie

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure an accurate Minimum Data Set (MDS) assessment related to the discharge and transfer of Resident #139; Limited range of motion for Resident #5; Unnecessary medication for Resident #107 and Resident #64; and medication inaccuracy related to anticoagulant use for Resident #32. The findings included: 1. A review of the clinical records indicated that Resident #5 was first admitted to the facility on [DATE], and returned on [DATE], with a diagnosis of hemiplegia, which is characterized by unilateral weakness. The care plan, last revised on [DATE], noted that Resident #5 had impaired mobility due to weakness on the left side. A review of the quarterly comprehensive assessment dated [DATE], specifically within the section GG, pertaining to functional limitations in range of motion, indicated no impairment in the upper extremities, including the shoulder, elbow, wrist, and hand. Observations conducted on [DATE] at 9:54 AM; [DATE] at 7:44…

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 obtain a PASARR (Preadmission Screening for individuals with a mental disorder and individuals with intellectual disability) Level II in a timely manner for 1 of 2 Residents reviewed for PASARRs (Resident #86). The findings included: Resident #86 was admitted to the facility on [DATE]. A review of a PASARR Level 1 dated 01/28/25 indicated a Level 2 should have been completed. An interview was conducted with Regional Social Services Director (SSD) on 03/19/25 at 8:40 AM. The SSD stated a Level 2 was submitted for Resident #86 on 01/28/25. The SSD further stated the Level 2 was closed on 02/04/25 due to an incomplete signature for the resident. The SSD stated the Level 2 had not been resubmitted with the missing information.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure that baseline care plans are completed within 48 hours of admission for 3 of 38 residents reviewed (Resident #32, #117 and #103). The findings included: 1) Resident #32 was admitted to the facility on [DATE] with readmission from hospital on [DATE]. Review of a baseline care plan dated 11/05/24 (Monday) revealed this is 8 days after the resident was admitted . 2) Review of Resident # 103 medical records revealed Resident #103 was admitted on [DATE]. The surveyor or the facility was unable to locate a baseline care plan. 3) Review of Resident #117 medical records revealed Resident #117 was admitted on [DATE]. The Surveyor or the facility was unable to locate a baseline care plan. During an interview on 03/20/25 at 10:10 AM with the Social Service Director, she was asked where the baseline care plans are kept. She stated the Minimum Data Set (MDS) Coordinator has them or if not, they are in a binder at the nurse's station. During an interview on…

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

Based on observation, record review and interview the facility failed to offer and provide services of dental care and getting resident out of bed at his request for 1 of 1 resident reviewed for ADL's (Activities of Daily Living), Resident #32. The findings included: Observations were made on 03/17/25 at 12:26 PM with Resident #32 lying in bed. There is no wheelchair observed in his room or outside of his room. Observations were made on 03/18/25 at 11:15 AM Resident #32 lying in bed. Observations were made on 03/18/25 at 2:45 PM Resident #32 lying in bed. During an interview on 03/17/25 at 12:26 PM with Resident #32 he stated to the Surveyor that he has been asking to get out of bed when they get his roommate up. He stated they would state that they would get him up but then they do not. He says he has been in the facility since 10/24 and maybe has been up twice. The surveyor observed resident's teeth having food caked between his teeth and asked the resident if they ever brush his teeth for him. He stated no. He cannot brush his own teeth, and his thumbs are the only digits 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, record reviews and interviews, the facility failed to encourage and assist the residents to participate in Activities for 2 of 2 residents reviewed for Activities. (Resident #32 and Resident #243). The findings included: 1) Observations were made on 03/17/25 at 12:17 PM, Resident #32 is in his bed playing on his phone. Observations on 03/18/25 at 11:15 AM, Resident is in his bed doing nothing. Observations on 03/18/25 at 2:45 PM resident in bed. Resident #32 was admitted on [DATE] with a readmission date after a brief hospital stay on 03/12/25. A review of his care plan dated 12/06/24 for Activities revealed the resident has little or no Community Life involvement related to disease process Aortic Stenosis, Type 2 diabetes, pulmonary disease, Heart failure, Reflux disease, Hydronephrosis, Anemia, Restless leg syndrome, kidney disease. Resident #32 is alert and oriented able to make his needs and wants known he is self-regulated in daily activities of his choice he likes to watch television…

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, record reviews and interviews, the facility failed to follow physician's orders related to blood pressure medication, for Resident #103, thyroid medication for Resident #242, spasm medication for Resident #66 and lab orders for stool sample for C-Diff for Resident #83. The findings included: 1) Resident #103 was admitted to the facility on [DATE] with a diagnosis to include Essential Hypertension. Review of the current Physician's Orders revealed Metoprolol Tartrate Oral Tablet 25 MG to give 25 mg by mouth two times a day for hypertension, hold for systolic blood pressure less than 110 or pulse less than 60. Midodrine HCl Oral Tablet 5 MG to give 5 mg by mouth three times a day for hypotension hold for systolic blood pressure above 120. A review of the MAR (Medication Administration Record) for March 2025 revealed that the blood pressure (B/P) parameters were not followed. Metoprolol 25 MG for hypertension hold for SBP (systolic blood pressure) less than 110 or pulse less than 60, start…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a physician ordered urology appointment in a timely manner for 1 of 1 sampled resident, Resident #60, who had a suprapubic (located in the lower abdomen) urinary catheter. The findings included: Review of the record revealed Resident #60 was admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had an indwelling urinary catheter. Review of the current physician's orders revealed Resident #60 had a suprapubic urinary catheter. Further review of these orders documented a urinary consult appointment was ordered on 03/04/25. Review of the record lacked any evidence of an upcoming or completed appointment. Observations on 03/17/25 at 9:57 AM, 03/17/25 at 2:23 PM, and on 03/18/25 at 9:05 AM revealed very cloudy urine in the drainage tube of the urinary catheter for Resident #60. During an interview on 03/20/25 at 11:20 AM, when asked the process for obtaining consults, Staff…

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 maintain a nutritional status for a resident receiving dialysis therapy related to ordered nutritional supplement for 1 of 1 resident reviewed for Dialysis (Resident #25). The findings included: Resident #25 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident was cognitively intact and was dependent for activities of daily living. The assessment further documented the resident received dialysis treatment. A review of Resident #25's care plan revealed a care plan dated 02/22/23 for a nutritional risk for disease management of End Stage Renal Disease on hemodialysis and history of significant weight change. Interventions included to provide and serve supplements as ordered (dated 01/26/25) and Registered Dietician (RD) to evaluate and make diet change recommendations as needed (dated 02/22/23). A review of Resident #25's orders revealed an order dated 01/16/25 for Nepro (nutritional supplement) 8 fluid…

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 care and service for oxygen therapy for 3 of 5 sampled residents, as evidenced by the failure to properly store the nebulizer mask for Resident #37, failure to ensure physician order for oxygen use for Resident #192, and failure to follow physician orders for the amount of oxygen used for Resident #117. The findings included: 1) Review of the record revealed Resident #37 was admitted to the facility 12/10/22 with an active diagnosis of respiratory disorder. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 9, on a 0 to 15 scale, indicating moderate cognitive impairment. This MDS also revealed the resident was dependent upon staff for mobility. Review of the current orders revealed the resident had received a medication four times daily via nebulizer (device to administer medication by spraying a fine mist) since 01/22/25. An…

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 pain medication was administered as ordered for one of three residents reviewed, Resident #109. The findings included: A clinical record review indicated Resident #109 was admitted to the facility on [DATE] with a diagnosis that included depression. The quarterly comprehensive assessment conducted on 12/17/24 included a brief interview with a mental status score of 11, suggesting that the resident was moderately cognitively impaired. Further review of the comprehensive care plan, revised on 01/05/25, revealed that Resident #109 was diagnosed with an arterial stasis ulcer on the left lower leg. The care plan included interventions such as administering prescribed medications for pain management. On 02/28/25, the physician ordered 50 mg tramadol to be administered as two tablets orally every eight hours as needed for moderate to severe pain, rated between 5 and 10. On 03/17/25, at 8:59 AM, Resident #109 expressed concerns regarding…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure dialysis communication forms were completed, and Hemodialysis Dietitian Recommendations were carried out in a timely manner for 1 of 1 resident reviewed for hemodialysis (Resident #25). The findings included: Resident #25 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident was cognitively intact and was dependent for activities of daily living. The assessment further documented the resident received dialysis treatment. A review of Resident #25's care plan revealed a care plan for the resident needs dialysis related to renal failure, with dialysis days Mondays, Wednesdays, and Fridays. A review of Resident #25's orders revealed an order dated 11/06/24 to complete dialysis communication form in (Narcotic book), hand it to the dialysis nurse. Collect it from the dialysis nurses, complete vital signs and put completed form in Narcotic binder for filing every Monday, Wednesday, and Friday. An order…

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 resident with PTSD (Post-Traumatic Stress Disorder) was assessed, and the care plan was individualized for 1 of 1 resident reviewed for PTSD (Resident #91). The findings included: Resident #91 was admitted to the facility on [DATE] with diagnoses that included PTSD. Record review revealed comprehensive assessment dated [DATE] that documented the resident was cognitively intact and was independent for activities of daily living. A review of Resident #91's care plan revealed a care plan dated 03/18/24 for behaviors related to Post Traumatic Stress Disorder and Obsessive Compulsive Disorder. Further review of the care plan did not reveal any specific trauma, behaviors, or triggers for behaviors. An interview was conducted with Resident #91 on 03/17/25 at 11:00 AM. The resident confirmed a diagnosis of PTSD, and stated it was the result of an abusive childhood and things that happened as an adult. Resident #91 stated crowds of people trigger him,…

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 there was sufficient staff to upload physician progress notes in a timely manner for 1 of 1 resident reviewed for diarrhea (Resident #83), and failed to ensure a urology consult was obtained in a timely manner for 1 of 1 sampled resident (Resident #60). The findings included: 1. Resident #83 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident was cognitively intact, and dependent for activities of daily living. Record review revealed no physician progress notes for 2025. An interview was conducted with medical records on 03/20/25 at 3:50 PM. Medical records stated physician notes were sent by the month for residents to be uploaded into resident's electronic medical records(EMR). Medical records stated it takes approximately 3 days to upload the physician notes into all the resident's EMR. Medical records acknowledged she had not uploaded any physician progress notes this year.…

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 and record review, the facility failed to ensure narcotic removal was documented in the medication administration records (MARs) for 3 of 9 residents reviewed during the medication storage review process. This involved Residents #39, # 69 and #71. The findings included: On 03/20/25 at 12:27 PM the medication storage and labeling review process started. The medication binder on cart 1 was selected for review. During the review process, it was revealed that Resident # 39 had a physician order of Tramadol 50 mg 1 tablet by mouth every 12 hours as needed for pain. The medication control record was compared against the March 2025 MARs. There were discrepancies between the records. The medication control record revealed that the Tramadol was removed on 03/11/25 at 9:52 PM and 11 PM, however the MARs lack documentation for the removal at 9:52 PM. It was also documented the Tramadol was removed on 03/12/25 at 11 AM, 9:17 PM, and 11:28 PM. The MARs lacked documentation for the removal at 11 AM and 11:28 PM. Clinical record review evidenced Resident #69 had order 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 Record review and interview the facility failed to ensure adequate monitoring of side effects and behaviors for psychotropic medications for 1 of 5 residents reviewed for unnecessary medications, Resident #103. Resident #103 was admitted to the facility on [DATE] with diagnoses to include Generalized Anxiety, Major Depressive Disorder, Bipolar Disorder, Schizoaffective Disorder and Diabetes Mellitus. Review of the Physician Orders revealed that the resident is currently taking Venlafaxine HCl ER Oral Tablet Extended Release 24 Hour Give 150 mg by mouth one time a day for Depression and Give 37.5 mg by mouth one time a day for Depression, Quetiapine Fumarate Oral Tablet 200 MG Give 200 mg by mouth at bedtime for schizophrenia, Divalproex Sodium Oral Tablet Delayed Release 500 MG Give 500 mg by mouth two times a day for bipolar disorder and Divalproex Sodium Oral Tablet Delayed Release 250 MG Give 250 mg by mouth one time a day for bipolar disorder. During an interview on 03/20/25 at 12:07 PM with Staff…

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 medication error rate was 14.81 percent. Four medication errors were identified while observing a total of 27 opportunities, affecting 1 of 7 residents observed (Resident #193). The findings included: A medication pass observation was made for Resident #193 on 03/19/25 beginning at 8:39 AM with Staff J, Licensed Practical Nurse (LPN). The LPN obtained medications from the medication cart to include artificial tears eye drops, two docusate sodium (a stool softener) 100 mg (milligram) gel tablets, and one hydralazine (lowers blood pressure) 25 mg tablet. Upon entering the room, the LPN administered one eye drop in each of the resident's eyes. The LPN then gave Resident #193 the 6 pills, including the two docusate sodium and the one hydralazine. The LPN stated the resident's blood pressure was 156/93. Review of the corresponding Medication Administration Record (MAR) for March 2025, which included the current physician orders, revealed Resident #193 was to receive two eye drops in each eye, only one tablet of the docusate sodium,…

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 proper storage of medications for 1 of 5 residents during the medication pass observation (Resident #193,) and for 1 of 1 random sampled resident whose medications were observed at his bedside (Resident #242) The findings included: 1) A medication pass observation was made for Resident #193 on 03/19/25 beginning at 8:39 AM with Staff J, Licensed Practical Nurse (LPN). The LPN obtained a box of artificial tears and placed it on top of the medication cart. The LPN then decided to go into the resident's room to obtain his blood pressure. The LPN left the eye drops on top of the cart, unattended. A random resident was observed at that time, leaving her room, and self-propelling down the hallway in front of the medication cart. During an interview on 03/19/25 at 2:47 PM, the LPN agreed she had left the eye drops on top of the medication cart earlier that morning, and agreed with the concern related to unsecured medications. 2) 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 record review and interview, the facility failed to have a complete resident record for 5 of 28 sampled residents (Residents #83, #64, #37, #60, and #79). The findings included: 1. Resident #83 was admitted to the facility on [DATE]. Record review revealed the last documented physician progress note was in November 2024. An interview was conducted with medical records person in the presence of the Director of Nursing (DON) on 03/20/25 at 3:50 PM. Medical records stated physician notes were sent by the month for residents to be uploaded into resident's electronic medical records(EMR). Medical records stated it takes approximately 3 days to upload the physician notes into all the resident's EMR. Medical records acknowledged she had not uploaded any physician progress notes this year. Resident #83's medical records was incomplete. 2. Review of the records during the survey from 03/17/25 through 03/20/25 for Residents #37, #60, #64, and #79 all lacked any recent documented physician visits. The records for…

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 clinical record review and interview, the facility failed to provide evidence that the staff provided care and services that met professional standards of quality as evidenced by the staff failure to follow the physician orders for medication administration for 8 of 12 residents reviewed (Residents #7, #8, #9, #11, #12, #13, #14, #15). The findings included: 1) Review of the clinical record for Resident #8 revealed that the resident is one of 30 evacuated residents who remained in the facility after the storm. They arrived to this facility on 10/07/24. According to the Director of Nursing (DON) in an interview on 10/31/24 at 3:45 PM, she stated that when the other facility's staff left on 10/18/24, they took the Medication and Treatment Administration Records (MAR and TAR) with them but she gained access to their system and printed the MAR and TAR for the remaining residents to ensure her staff could provide the necessary care and services as of October 18, 2024. Review of the Medication Administration…

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 clinical record review and staff interview, the facility failed to provide evidence of providing the necessary care and services consistent with the prescribed treatment plan of care for 2 of 12 sampled residents (Resident # 8 and # 9). The staff failed to provide evidence they performed the prescribed treatments for tracheostomy care, wound care, catheter care, skin checks, oral care, and the PICC (Peripherally Inserted Central Catheter) dressing changes and monitoring. The findings included: 1) Resident #9 is one of 30 residents who remained in the facility after the storm. The resident had diagnoses which included seizures, persistent vegetative state, acute respiratory failure with hypoxia, pressure ulcer of sacral region Stage 4, and essential Hypertension. Resident #9 had a tracheostomy, is total care for all activities of daily living; received tube feeding via gastrostomy tube, Wound Vac for the sacral wound and had a Foley catheter. Resident # 9 is also the resident whom the staff failed to perform the necessary oral care, please refer to F 677 for specific details…

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, clinical record review and staff interview, the facility staff failed to provide the necessary care and services to maintain the oral hygiene of a resident who is unable to carry out activities of daily living, for 1 of 12 residents reviewed (Resident #9). The findings included: Resident #9 is one of 30 residents who remained in the facility after the storm. The resident had diagnoses which included seizures, persistent vegetative state, acute respiratory failure with hypoxia, pressure ulcer of sacral region Stage 4, and essential Hypertension. Resident #9 had a tracheostomy, is total care for all activities of daily living, received tube feeding via gastrostomy tube, Wound Vac for the sacral wound and had a Foley catheter. An observation of Resident #9 was conducted on 11/04/24 at 5:20 PM revealed that the resident was lying in bed. The resident's mouth was open and she was noted to have a copious amount of dry yellowish brown colored crusty substance inside her mouth and lips, due to lack of necessary mouth care. The surveyor requested Staff A, Registered…

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, clinical record review and policy review, the facility failed to ensure that 1 of 1 residents reviewed for intravenous medications (Resident #8) received the necessary care and services consistent with professional standards of practice. This is evidenced by the staff failing to complete the PICC (Peripherally Inserted Central Catheter) line dressing for multiple weeks. The findings included: Review of the facility's policy regarding Catheter Insertion and Care, Central Vascular Access Device (CVAD) Dressing Change, Revised 1/17/2019, documented the following: 1. Central vascular access devices (CVADs include: a. Peripherally Inserted Central Catheter (PICC). 2. The catheter insertion is a potential entry site for bacteria that may cause catheter-related infection. 3. A transparent dressing is the preferred dressing. If the patient is allergic to the transparent dressing, a sterile gauze and sterile tape dressing may be used. 4. Licensed nurses caring for patients receiving infusion therapies are expected to follow infection control and safety…

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 and interviews, the facility failed to honor the resident's right for food preference for portion sizes for 2 of 5 sampled residents (Resident #1 and #4). The findings include: 1) An interview was conducted with Resident # 1 on 06/25/24 at approximately 10:45 AM. He expressed that the facility no longer provides him with large portions after the new company took over. He further stated that he was a big guy, and this little protein portion of meat is not good. The resident then became emotional and stated, they don't listen to me, I've tried to tell them; this little bit of food is not enough. I will sometime order something from somewhere that will deliver. An observation of the resident's lunch tray on 06/25/24 revealed that the resident was served a small portion of chicken thigh on his plate. The resident's vegetables were in a separate container. The resident again expressed that the serving was insufficient. An interview with the Certified Dietary Manager (CDM) and the resident was conducted on 06/25/24 at approximately 12:30 PM. The resident expressed…

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, administrative record review and interviews, the facility failed to store, distribute and serve food in accordance with professional standards for food service safety. This is evidence by the facility serving and storing milk beyond the manufacturer's expiration date. This failure affected 1 of 4 sampled residents who have a preference for chocolate milk for three or more days (Resident #5). The findings included: The surveyor also conducted an observation of the kitchen refrigerator on 06/26/24 at approximately 9:00 AM accompanied by the Certified Dietary Manager. Observed in the refrigerator was a red crate full of approximately 30 plus individual chocolate milk cartons dated 6/23/24. Also noted were 2 cartons of chocolate milk dated June 23 on another tray which contained lunch items such as salad. An interview was conducted with the CDM at the time of the observation, who confirmed that the milk was out of date. She further stated that the milk was delivered on Monday, June 24. The surveyor then stated so, your staff accepted out of date milk when delivered…

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 accurately assess a resident for wandering for 1 of 3 sampled residents reviewed for elopement (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE]. An interview was conducted with the Nursing Home Administrator (NHA) on 04/10/24 at 10:00 AM. The NHA confirmed Resident #1 had a room change done on 03/18/24 due to exit seeking/wandering behaviors. The resident was care planned for at risk for elopement on 03/19/24, with an intervention of an electronic monitoring device (wanderguard) in place on the right ankle. A comprehensive assessment dated [DATE] documented the resident had severe cognitive impairment and did not exhibit any wandering behaviors.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to provide food service in a manner consistent with professional standards for food safety. The findings included: A). During the initial kitchen tour, on 11/13/23 at 7:54 AM, accompanied by the Dietary Director, the following were noted: 1. Staff were observed using a damp towel that was kept on the counter of the hot holding unit, to wipe debris from the area. 2. The handle of a spatula that Staff was using to plate the French toast bake was melted and damaged to the point that it was not easily cleanable. 3. There was a leak in the ceiling from the air conditioning unit near the end of the food prep/assembly line/area. The Dietary Director stated that it was from the air conditioning unit and that the facility was waiting for parts to come in to complete the repairs. While the air conditioning unit was not in operation, the facility was using portable air conditioning units. 4. The concentration of quaternary ammonia used for sanitizing food 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 treat 3 of 29 sampled residents and additional Resident Council members, in a dignified manner, related to staff attitudes and manner in which personal care is provided, speaking in foreign languages in front of residents, response to call bells, not addressing residents by their proper name and use of hospital armbands (Resident #31, #43, #85, and voiced concerns during Resident Council, including Resident #6, #41 and #7). The findings included: 1) Review of the record revealed Resident #31 was admitted to the facility on [DATE] to her current room, and had not been sent out to the hospital since her admission. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #31 had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. This same MDS documented the resident was incontinent of bowel movements and that it was very important for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to provide a clean, comfortable, and home like environment for the residents. The findings included: 1). During the Initial Pool process, the following concerns were noted: On 11/13/23 at 9:40 AM, in room [ROOM NUMBER], it was noted that the floor next to Bed A was dirty and the bathroom floor was very dirty and over the toilet chair was rusted. On 11/13/23 at 9:56 AM, in room [ROOM NUMBER], it was noted that the room floors were dirty with food crumbs on the floor. On 11/13/23 at 10:03 AM, in room [ROOM NUMBER], the resident in Bed -A, voiced that his call light has been out for over 2 months, due to an electrical problem, and that the Administrator was in the process of taking care of it. When asked how he has to reach out to the staff when he needs them, Resident #22 stated he has to call front desk during the day and has called the staff on his phone at night. On 11/13/23 at 2:22 PM, in room [ROOM NUMBER], Resident #43 voiced that he and his roommate…

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 of a resident's ability to to use an overhead light for 1 of 1 sampled residents observed (Resident #31). The findings included: Review of the record revealed Resident #31 was admitted to the facility on [DATE] to her current room. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #31 had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. During an interview and observation on 11/14/23 at 10:03 AM, the string that was used to turn the over the bed light on and off by the resident and staff was missing. Resident #31 stated she asked for it to be fixed, and it was supposed to be fixed yesterday. (Photographic Evidence Obtained). When asked if she uses the over the bed light, Resident #31 stated she did and would like it fixed. An additional observation on 11/15/23 at 9:46 AM revealed the pull string was still missing. 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, record review, and policy review, the facility failed to ensure 2 of 4 sampled residents were free from abuse and neglect, as evidenced by a resident-to-resident altercation between Resident #87 and #45, resulting in physical harm to Resident #87. The findings included: Review of the policy Abuse, Neglect, Exploitation & Misappropriation revised 11/16/22 documented, Definitions: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful, as used in this definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical abuse includes but is not limited to: hitting, slapping, punching, . Review of the record revealed Resident #87 was initially admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis that included Hemiparesis (one sided weakness). Resident #87 resided 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 record review, interview, and policy review, the facility failed to report to the State Survey Agency 2 of 3 allegations of abuse, within two hours. Resident #43 voiced an allegation of abuse by a staff member. Residents #45 and #87 were involved in a resident-to-resident altercation. The findings included: Review of the policy Abuse, Neglect, Exploitation & Misappropriation revised 11/16/22 documented, Definitions: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful, as used in this definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical abuse includes but is not limited to: hitting, slapping, punching, . Mental and Verbal Abuse include, but are not limited to . Threatening residents, depriving a resident of care or withholding a resident from contact with family and friends. Protection: Any suspect, who…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to protect 1 of 4 sampled residents from further abuse, after a voiced allegation by Resident #43, of alleged abuse by Staff E, Licensed Practical Nurse (LPN). The facility also failed to ensure a thorough investigation for 2 of 4 sampled residents involved in a resident-to-resident altercation (Residents #45 and #87). The findings included: Review of the policy Abuse, Neglect, Exploitation & Misappropriation revised 11/16/22 documented, Definitions: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful, as used in this definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical abuse includes but is not limited to: hitting, slapping, punching, . Procedure: . 5. The Abuse Coordinator or his/her designee shall investigate all reports…

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 staff interview, the facility failed to accurately complete the quarterly Minimum Data Set (MDS) assessment for 2 of 5 sampled residents reviewed for Unnecessary Medications (Resident #83, as it relates to missing diagnosis of Depression; and Resident #71, as it relates to missing diagnosis of Anxiety). The findings included: Resident #83 was admitted to the facility on [DATE] with documented diagnoses which included Huntington's Disease, Acute Follicular Conjunctivitis, Disorders of white blood cells, Adult Failure to Thrive, Muscle Weakness, Unsteadiness on Feet, Dysphasia, Benign Prostatic Hyperplasia, Insomnia, and Anemia. According to Resident #83's MDS Quarterly assessment dated [DATE] (completion date 05/26/23), Resident #83 reported feeling down, depressed and/or hopeless for 2-6 days during the 14 day look-back period. There was no diagnosis of Depression or Anxiety documented, but there were 3 days of antidepressants provided during this time. A Psychiatry Note dated 05/22/23…

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, policy, and staff interview, the Facility failed to complete a Level II PASARR for 1 of 1 sampled resident reviewed with diagnosis of severe mental illness (Resident #77). The findings included: The facility's policy and procedure titled, Preadmission Screening and Resident Review (PASRR), document SS-402, dated 11/08/21, notes: Policy The center will assure that all Serious Mentally Ill (SMI) and Intellectually Disabled (ED) residents receive appropriate pre-admission screenings according to Federal/State Guidelines. The purpose is to ensure that the residents with SMI or are ID receive the care and services they need in the most appropriate setting. Procedure 1. It is the responsibility of the center to assess and assure that the appropriate preadmission screenings, either Level I or Level II, are conducted and results obtained prior to admission and placed in the appropriate section of the resident's medical record. Resident #77 was admitted to the facility on [DATE] with diagnoses…

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 staff interview, the facility failed to review and revise comprehensive, personalized care plan related to the diagnosis of Depression and use of antidepressant medication therapy for 1 of 5 sampled residents reviewed for Unnecessary Medications (Resident #83). The findings included: Resident #83 was admitted to the facility on [DATE] with documented diagnoses which included Huntington's Disease, Acute Follicular Conjunctivitis, Disorders of white blood cells, Adult Failure to Thrive, Muscle Weakness, Unsteadiness on Feet, Dysphasia, Benign Prostatic Hyperplasia, Insomnia, and Anemia. According to Resident #83's MDS Quarterly assessment dated [DATE] (completion date 05/26/23), Resident #83 reported feeling down, depressed and/or hopeless for 2-6 days during the 14 day look-back period. There was no diagnosis of Depression or Anxiety documented, but there were 3 days of antidepressants provided during this time. A Psychiatry Note dated 05/22/23 documents: Chief Complaint: Depression,…

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 enteral feeding as ordered by the physician for 1 of 1 sampled residents reviewed for Tube feeding (Resident #58). The findings included: Resident #58 was admitted to the facility on [DATE]. According to a Quarterly Minimum Date Set (MDS) assessment, dated 09/08/23, Resident #58 was not assessed for cognition due to 'the resident is rarely/never understood'. Resident #58's diagnoses at the time of the MDS included: Hyperlipidemia, Alzheimer's disease, Non-Alzheimer's dementia, Malnutrition, Anxiety disorder, Depression, Psychotic disorder, Dysphagia following cerebrovascular disease, Metabolic encephalopathy Syncope and collapse, Disorders of electrolyte and fluid balance, Adut failure to thrive, and Bradycardia. Review of the care plan initiated on 12/13/21 with a revision date of 11/09/23, documented, The resident is at a nutritional risk or potential nutritional risk related to need for enteral nutrition, 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 policy review, the medication error rate was 11.11 percent. Three medication errors were identified while observing a total of 27 opportunities, affecting 3 of 8 sampled residents observed during medication administration observations (Residents #65, #31, and #14). The findings included: Review of the policy titled, Oral Administration of Medication revised 08/15/19 documented, Procedure: . Review physician's order. Review the MAR (Medication Administration Record) or eMAR (electronic MAR) should there be any uncertainties verify the MAR or eMAR with the Physician's Order Sheet (POS) and seek clarification as indicated. 1) A medication administration observation for Resident #65 was made on 11/15/23 beginning at 3:42 PM with Staff F, Licensed Practical Nurse (LPN). The LPN pulled two medications, one of which was 100 mg (milligrams) of Caramazepine (Tegretol, a medication to prevent seizures). The LPN popped from the bubble pack (card of pills) one tablet of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, the facility failed to ensure proper storage of medications in the treatment cart for 1 of 1 sampled resident observed for wound care (Resident #21). This observation was made on the [NAME] Unit were 7 of 22 residents were identified and/or observed to independently ambulate or self-propel throughout the unit, to include sampled Resident #65, #45, #28, #84 and #69. The facility also failed to ensure expired medications were removed from 2 of 6 medication carts (Emerald cart #3 and [NAME] A/front cart). The finding included: Review of the policy Medication Storage (not dated) documented, Procedure: A. With the exception of Emergency Drug Kits, all medications will be stored in a locked cabinet, cart, or medication room that is accessible only to authorized personnel, as defined by facility policy. C. Medications will be stored in an orderly, organized manner in a clean area.F. Expired, discontinued and/or contaminated medications will be removed from 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, record review, and review of the respiratory services contract, the facility failed to maintain accurate and complete records for 3 of 33 sampled residents, related to respiratory services for Resident #1, a fall for Resident #43, and a newly identified skin impairment for Resident #28. The facility also failed to ensure all progress notes completed by the Nurse Practitioner (NP) for the Medical Director were maintained in the medical records. The findings included: 1) Review of the Respiratory Care Services agreement, effective 08/15/23, and signed by both entities, documented, the respiratory services provider was to 1.2 . assist in Facility's evaluation of residents, and to plan and direct care for the Facility's residents in accordance with established plans of treatment and physician's written orders. 2.1 Facility shall (i) have primary responsibility for maintaining all resident records, . 2.2 Facility shall be responsible for obtaining all required written orders for…

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, interview, and policy review, the facility failed to ensure collection of urinalysis for 1 of 1 sampled resident, prior to initiation of an antibiotic (Resident #31). The findings included: Review of the policy titled, Antibiotic Stewardship - Orders for Antibiotics revised December 2016 documented, 3. appropriate indications for use of antibiotics include: a. Criteria met for clinical definition of active infection or suspected sepsis; and b. Pathogen susceptibility, based on culture and sensitivity, to antimicrobial (or therapy begun while culture is pending). 7. When a culture and sensitivity (C&S) is ordered, it will be completed, and: a. Lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued. During an interview on 11/13/23 at 9:10 AM, Resident #31 stated she now has a UTI (Urinary Tract Infection). The resident stated they (staff) don't clean…

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 respond and resolve grievances in a timely manner. The findings included: Review of the resident council minutes for January to July 2022 revealed the following: 04/08/22- resident's concerns included that the facility needs more help; there is a bug problem; and call lights not being answered in a timely manner. 05/13/22- call lights not being answered (ongoing issue); and bugs in the facility. 06/16/22- under old business residents voiced concerns about call lights not being answered in a timely manner; and bugs getting out of control. Documented under new business, CNA's (Certified Nursing Assistant) not responding to call lights and turning the call lights off; and staff shortage on weekends. 07/08/22- residents spoke about bugs. Review of the grievance log from March 2022 to June 2022 documented there were 9 complaints on call light response. Further review documented the following: On 03/04/22, Resident #68 stated that a CNA (Certified Nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide a safe, clean, comfortable, and home like environment, for multiple residents in the facility. The census at the time of the survey was 94 residents. The findings included: During a room by room tour of the facility, on 07/21/22 at 3:00 PM, accompanied by the Director of Maintenance, the Housekeeping Manager and the Regional Maintenance Director, the following concerns were brought to their attention: In room [ROOM NUMBER], the interior of the residents' closets was in disrepair, one of the three closets was not structurally sound, the floor appeared to be dirty and stained, the baseboard was not secured/sealed to the wall to prevent pest harborage and there was an accumulation of debris on the floor around bed C. In room [ROOM NUMBER], there was an accumulation of dust on the air conditioning vent; the privacy curtain between A and B bed had numerous stains from unknown sources; and throughout the room, the baseboards were damaged…

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 point of care staff were part of an interdisciplinary team (IDT) that participated in the care planning review and revision for 22 of 32 sampled residents reviewed for care plans (Resident #34, 57, 82, 94, 23, 7, 89, 54, 33, 9, 66, 1, 44, 58, 63, 74, 81, 87, 24, 37, 84 and 3). The findings included: 1). A Care Conference Record for Resident #34, documented that the staff in attendance for an admission Care Conference meeting, dated 12/15/21 included Social Services and the MDS (Minimum Data Set) Coordinator. The record documented that the staff in attendance for a Quarterly Care Conference meeting, dated 05/05/22, included the MDS Coordinator, Social Services, Dietary, Unit Manager and Activities. Further review of the record revealed that there was no point of care staff documented as having participated in the meeting or care planning process. 2). Review of Care Conference Records for Resident #57, documented that the staff in attendance for 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 observations, interviews and record reviews, the facility failed to provide an environment free of accident hazards with the potential to affect residents that use the shower room on the Emerald Unit who are independently ambulatory; failed to secure the soiled utility room and storage room; failed to maintain the door to room [ROOM NUMBER] in order for residents to exit the room in case of an emergency; and the facility failed to accurately assess a resident post-fall for 1 of 1 sampled resident reviewed for falls, Resident #58. The findings included: 1). During an observation of the Emerald Unit Shower Room, on 07/18/22 at approximately 12:30 PM, it was noted that the door to the shower room was not secured. The surveyor was able to enter the room through the door by turning the handle and applying minimal force to open the door. Once inside of the Shower Room, the surveyor observed a sharps container that was installed to the wall just inside of the door that was overflowing with shaving razors 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 facilitiy failed to ensure appropriate staffing levels to provide appropriate care and services, as evidenced by unresolved grievances related to staffing identified by Resident Council, numerous complaints by residents during the survey and resident falls. This has the potential to affect the entire resident population. The census at the time of the survey was 94 residents. The findings included: During an interview on 07/18/22 11:18 AM, with Resident #57, with a BIMS score of 15, according to a Quarterly MDS (Minimum Data Set) assessment, dated 06/01/22, when asked about staffing, Resident #57 replied I used to be up in my power chair and now there is not enough staff to get me out of bed and into my chair. The last time I was in it was 8 months ago for therapy. I only get out for showers and back to bed. During an interview, on 07/19/22 09:38 AM with Resident #94, with a Brief Interview for Mental Status (BIMS) score of 15, according to a Quarterly…

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 faciity failed to provide prepared foods, stored and served in accordance with professional standards for food service safety. The findings included: During the initial kitchen tour, on 07/18/22 at 8:44 AM, accompanied by the Dietary Manager, the following observations were made: 1). There was an accumulation of ice on ceiling and fan guards in walk in freezer. 2). There was an accumulation of debris under and behind the microwave oven. 3). Staff A, Dietary Aide, was observed sorting and placing soiled and dirty wares in racks to be sent through the mechanical ware washing machine, using gloved hands to sort and rinse the wares. Staff A proceeded to the clean side of the mechanical ware washing machine to collect cleaned and sanitized equipment and utensils with the same gloved hands, without changing/removing gloves and performing hand hygiene. 4). There was an accumulation of residue and debris on the wall under and behind the food preparation table. 5). There was an accumulation of black mold-like substance inside of the ice…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement appropriate plans of actions to correct identified quality concerns especially related to pest control. The findings included: Review of Resident Council meeting minutes from a meeting held on 04/18/22 revealed that residents in attendance voiced concerns that included, Bug Problem. Review of Resident Council meeting minutes from a meeting held on 05/13/22 revealed that residents in attendance voiced concerns that included, bugs in facility. Review of Resident Council meeting minutes from a meeting held on 06/16/22 revealed that residents in attendance voiced concerns that included, bugs are getting out of control. Review of Resident Council meeting minutes from a meeting held on 07/08/22 revealed that residents in attendance voiced concerns that included, Residents spoke about bugs in their rooms. Documentation in the form of 'Pest Sightings Log' documented that roaches were observed: *On 07/19/22 in room [ROOM…

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 effective pest control program in order to maintain an environment free from pests The findings included: During an observation in room [ROOM NUMBER], on 07/18/22 at 10:29 AM, live and dead roaches, in all stages of life and too numerous to count, were observed in the closets as well as under and around the furniture in the rooms. During an observation in room [ROOM NUMBER], on 07/18/22 at 10:59 AM, live and dead roaches, in all stages of life and too numerous to count, were observed under and around the room furniture. During an interview, on 07/18/22 at 10:41 AM with Staff P, RN, when asked about pest observations, Staff P replied, I started here about 7 months ago, it has been a problem at least since then. Pest control comes here. We have a book that we document where we see them. During an observation in room [ROOM NUMBER], on 07/18/22 at 11:06 AM, live fruit flies, too numerous to count were noted to be in the area 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 observation, interview and record review, the facility failed to provide opportunities for a resident to be out of bed for 1 of 3 samples residents reviewed (Resident #57). The findings included: Resident #57 was admitted to the facility on [DATE]. According to a Quarterly Minimum Data Set (MDS), dated [DATE], Resident #57 had a Brief Interview for Mental Status (BIMS) score of 15, indicating 'cognitively intact'. The MDS documented that Resident #57 was dependent upon staff for activities of daily living (ADLs) with the exception of eating. Resident #57's diagnoses at the time of the assessment included: Cerebral Palsy; Quadriplegia; GERD (Gastroesphageal Reflux Disease); Polyneuropathy; Psoriasis; Chronic pain syndrome; Benign Prostatic Hyperplasia; posterior subcapsular polar age-related cataract, bilateral and age related nuclear cataract bilateral. Resident #57's care plan, initiated on 12/07/18 and most recently revised on 06/16/21, documented, The resident is dependent on staff for meeting…

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 implement and develop care plan for Diabetes for 1 out of 5 sampled residents reviewed for unnecessary medications Resident #58; and failure to implement an ADL (Activities of Daily Living) care plan for Resident #74 for 1 of 4 sampled residents reviewed for ADL's. The findings included: 1) During record review for Resident#58 revealed the resident was admitted to the facility on [DATE] with a diagnosis to include Type II Diabetes. A review of the MDS (Minimum Data Set) dated 06/22/22 documented the resident's BIMS (Brief Interview Mental Status) score was a 15, which means her cognition is intact. Further review revealed resident had insulin injection for 7 days. A review of the physician orders documented an active order for Insulin of Lantus Solostar Solution Pen-injector and to Inject 20 unit subcutaneously daily for diabetes. A review of Resident #58's baseline care plan has Diabetes was checked off, however there was no evidence of a care plan…

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 follow physician orders for wound care treatment for 1 of 3 sampled residents reviewed for wound care (Resident #66); the facility failed to follow physician orders for blood pressure medications for 1 of 5 sampled residents reviewed for unneccessary medications (Resident#33); and failure to follow physician orders for skin care treatment 1 of 4 sampled residents reviewed for ADL's. (Resident #74). The findings included: 1) During the unnecessary medication review process for Resident #33, it was revealed a physician order dated 06/11/22 for Hydralazine (a blood pressure medication) 50 mg give 1 tablet by mouth twice daily every Monday, Wednesday, and Friday for Hypertension. Upon reviewing the July 2022 Medication Administration Record (MAR), discrepancy was found. The July 2022 MAR evidenced this order was scheduled in the morning, not as ordered by the physician. This MAR documented the medication was scheduled in the morning one time per day from…

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 proper positioning of indwelling catheter bag and failed to ensure appropriate hand hygiene technique during catheter care for 1 of 2 sampled residents reviewed with a history of urinary tract infection (UTI) (Resident #88). The findings included: On 07/18/22 at 9:52 AM Resident #88 was observed lying in bed, the foley catheter bag was observed touching the floor. On 07/19/22 at 12:27 PM another observation was conducted of Resident #88, the foley catheter bag was observed positioned immediately next to the trash can, and the foley catheter bag was touching the trash can. On 07/21/22 at 1:45 PM, an observation was made of Resident #66's catheter tube, there was sediment in the catheter tube and cloudy urine. On 07/18/22 at 1:50 PM, catheter care observation was conducted; the care was rendered by Staff C, a Certified Nursing Assistant (CNA). During the care, Staff C changed her gloves 2 times without conducting hand hygiene in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure accurate reconciliation of controlled medications for 2 of 4 sampled residents reviewed(Resident #68 and #200). The findings included: An observation of the medication cart on the [NAME] Unit was conducted on 07/20/22 at 2:00 PM with Staff I, an RN (Registered Nurse). The Medication Administration Record (MAR) and the Controlled Medication Utilization Record were reviewed for Resident #68. The resident had an order for Percocet 5-325 mg, 1 tablet to be given every four hours for pain. Review of the Controlled Medication Utilization Record reveals the Percocet was signed out on 07/05/22 at 6 PM and not documented on the MAR as given to the resident. On 05/23/22, 05/24/22 and 05/25/22 the Percocet was signed out on the Controlled Medication Utilization Record with no removal times documented. The MAR and the Controlled Medication Utilization Record was reviewed for Resident #200. Resident #200 had an order for Clonazepam 0.5 mg to be given every…

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.