Avante At Lake Worth, Inc.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3). Resident #56 was admitted on [DATE] with diagnoses that included Metabolic Encephalopathy, Alcohol Dependence with Alcohol-Induced persisting Dementia, Unspecified Psychosis, Major Depressive Disorder, and other Persistent Mood Disorders. A record review of Minimum Data Set (MDS) under Section C of the Brief Interview of Mental Status (BIMS) revealed a score of 7 indicating Resident #56 had impaired cognitive function. Section N revealed a yes response to antidepressant. A review of physician orders dated 03/05/25 revealed Trazodone Hydrochloride 50 milligram (mg), to give 0.5 tablet by mouth, two times a day for depression. An additional review of orders revealed the behavior code monitoring every shift as needed for behavior. An additional order revealed Memantine Hydrochloride 5 mg, to give 2 tablets by mouth, two times a day for Dementia. A review of psychiatry progress notes dated 05/08/25 revealed the following This resident struggled with alcohol use resulting in negative consequences on his life. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to ensure the medications were timely administered for 2 of 6 residents observed for medication passes (Resident #80 and Residetn#409). The facility also failed to follow the physician ordered and prescribed medications for 3 of 38 sampled residents (Resident # 41, Resident #8, and Resident #68). The Findings included: A review of facility's policy titled, General Dose Preparation and Medication Administration, with a recent revision date of 11/15/24, it was revealed the following: to administer the medication within timeframes specified by facility policy or manufacturer's information (proc. 5.4; pg. 97); prior to administration of medication, facility staff should take all measures required by facility policy and applicable law, including confirming that the Medication Administration Record (MAR) reflects the most recent medication order (proc. 3- 3.4; pg. 97). 1). Resident #80 was admitted on [DATE] with diagnoses that included…

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, interview, and record review the facility failed to follow their Safe Smoking policy to reassessa resident quarterlyand after a change in condition and failed to update the smoking care plan for 1 of 1 resident reviewed for smoking (Resident #72). The findings included: Review of the facility's policy titled, Safe Smoking with a revised date of 01/11/19 included in part the following: Screening - A safe smoking screen is performed on admission for a resident who wishes to smoke. Reassessment of the resident occurs annually and/or after a significant change in condition. Record review for Resident #72 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part Generalized Anxiety Disorder. The Minimum Data Set, dated [DATE] documented in Section C a Brief Interview of Mental Status score of 14 indicating a cognitive response. Review of the MDS for Resident #72 revealed Significant Change dated 08/22/24. The Care Plan for Resident #72 dated 09/19/23 with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, interviews, policy review, and review of professional standards of practice, the facility failed to maintain acceptable parameters of nutrition status for 1 of 4 residents investigated for nutrition (Resident #307). The findings included: A review of the facility's policy on Weight Management last revised on 03/02/19 stated that residents were to be weighed on a monthly basis unless otherwise ordered by the physician or deemed necessary by the dietitian and or the interdisciplinary team. Current professional standards of practice recommend weighing the resident on admission or readmission (to establish a baseline weight), weekly for the first 4 weeks after admission and at least monthly thereafter to help identify and document trends such as slow and progressive weight loss. A review of the policy on modified consistency diets provided by the Dietary Manager (DM) described the mechanical soft diet as a diet used for patients/residents with limited chewing ability. The foods…

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, interviews, policy review, and review of professional standards of practice, the facility failed to provide the appropriate treatment for enteral feeding to decrease the risk of complications including weight loss and dehydration, for 1 of 7 sampled residents on enteral feeding (Resident #92). The findings included: The facility's policies and procedure for Nutrition/Hydration Status Maintenance revised on 03/02/19 stated that a resident who is fed by enteral means must receive the appropriate treatment and services to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. A review of current professional standards of practice to promote the safe provision of enteral feeding recommends that the components of the feeding be included in the doctor's order. These include the following: the kind of feeding and its caloric value, the volume of the formula,…

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 tracheostomy care and services consistent with the professional standards of practice for 1 of 1 sampled for tracheostomy care (Resident #64); failed to obtain oxygen orders for 2 of 6 residents (Resident #408, and Resident #308); and failed to follow orders for oxygen therapies for 3 of 11 residents receiving oxygen (Resident #7, Resident #23, and Resident #66). The Findings included: A review of facility's policy titled, Policies and Procedures: Respiratory/Tracheostomy Care and Suctioning, with a revision date of 03/26/21, revealed the following: the facility will ensure that residents who need respiratory care including tracheostomy care, and tracheal suctioning , is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan and resident goals and preferences; the facility, in collaboration with the attending practitioner, must perform a comprehensive assessment 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 maintain completed dialysis communication records for 1 of 1 resident sampled for dialysis (Resident #90). The findings included: Review of the facility's policy titled, Dialysis with a revised date of 03/02/19 included in part the following: Nurses will educate the resident and/or family/resident representative on risks of non-compliance and document in the resident's clinical record as needed. The facility and the dialysis center should maintain regular communication and should a change in condition occur before or during dialysis treatment the sending facility should communicate the changes in needs to the receiving facility. Record review for Resident #90 revealed the resident was originally admitted to the facility on [DATE] with most recent readmission on [DATE] with diagnoses that included in part the following: End Stage Renal Disease, and Dependence on Renal Dialysis. The Minimum Data Set, dated [DATE] documented in Section C a Brief Interview…

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 discontinued controlled medications were removed from the medication carts, and initials and time matched on the MAR and control sheet, for 3 of 10 residents reviewed for controlled medication storage (Residents #91, #20, #97). The findings included 1). Resident #91 was admitted on [DATE] with diagnoses including Primary Hypertension, Unspecified Mood Affective Disorder, Anxiety Disorder, Unspecified Dementia, and Behavioral Disturbances. A review of Minimum Data Set (MDS) dated [DATE], under Section C, revealed a Brief Interview of Mental Status (BIMS) score of 3 indicating Resident #91 had severely impaired mental cognition. A review of Physician orders dated 11/06/24 revealed Lorazepam 0.5 mg, 1 tablet by mouth twice a day for 7 days. A review of Resident #91's Narcotic sheet revealed 12 counts of Lorazepam 0.5 mg tablets were received on 11/16/24. The medication is to be discontinued on 11/23/24 per physician order. A 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to ensure a medication cart was secured for 1 of 5 medication carts (Flamingo unit). The facility also failed to ensure medications are secured at bedside for 2 of 35 samplef residents (Resident #68 and Resident #8). The findings included: A review of facility's policy titled, General Dose Preparation and Medication Administration with revision date of 11/15/24, revealed the following: the facility staff should not leave medications or chemicals unattended ; and the facility should ensure that medication carts are always locked when out of sight or unattended. 1). Resident #97 was admitted on [DATE] with diagnoses that included Metabolic Encephalopathy, A review of Minimum Data Set under Section C revealed a Brief Interview of Mental Status (BIMS) score of 8 indicating impaired mental cognition. During a medication pass observation on 05/27/25 at 4:31 PM, Staff R, Registered Nurse, (RN), who stated he has been working in the facility 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 2). Resident #409 was admitted on [DATE] with diagnoses including Absence of Epileptic Syndrome Intractable without Status Epilepticus, Metabolic Encephalopathy, Hyperlipidemia and Obstructive and Reflux Uropathy. A review of the admission Minimum Data Set (MDS) under Section C revealed a Brief Interview of Mental Status (BIMS) score of 14 indicating Resident #409 had good mental cognition. During a medication pass observation on Flamingo Medication cart 1 with Staff E, a Registered Nurse (RN) on 05/28/25 10:45 AM, it was observed that her computer screen produced a pink color on the 9:00 AM medications for Resident #409. When Staff E , an RN was asked what the pink color meant, she responded, I am administering the medications later than the scheduled time. She added that medications must be administered one hour before and one hour after the scheduled time. She added, I think it is still ok. She administered the following medications: Cefuroxime 250 milligrams (mg), 1 tablet, 2 x a day. This medication was…

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 follow Enhanced Barrier Precaution (EBP) guidelines for a resident with sacral wounds and failed to initiate a care plan for a resident on EBP for 1 of 25 residents on EBP (Resident #408). The facility also failed to follow the manufacturer's recommendation for disinfection and storage of glucometer (Resident #73 and failed to follow the professional standards regarding glucose strip storage for 1 of 2 observation of glucose monitoring (Resident # 97). The findings included: A review of facility's policy titled, Enhanced Barrier Precautions issued on 04/01/24, revealed the following: all staff receive training on EBP upon hire and at least annually and are expected to comply with all designated precautions; Personal Protective Equipment (PPE) for EBP is only necessary when performing high-contact care activities. A review of Center for Disease Control and Prevention (CDC)'s EBP poster revealed the following: everyone must clean their…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide a clean and comfortable environment for 3 of 3 sampled Residents (Resident #2, Resident #3 and Resident #4). The findings included: 1. Review of the record revealed Resident #2 was last admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #2 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 observation and interview on 03/28/25 at 10:25 AM, when asked if there were any cleanliness concerns regarding the room, Resident #2 stated there were roaches seen all the time. When asked what the facility did about it, Resident #2 stated pest control comes out but believed whatever they are using was not working because she still saw them around. She voiced that they got in her way and went up the walls. It's not acceptable she stated. An observation was made of Resident #2 room, heavy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care is provided such care, for 3 out of 5 sampled residents with tracheostomy (Resident #3, #2, and #4) and failed to ensure trach tube at bedside for 2 out of 5 sampled residents for tracheostomy (Residents #4 and #5). The findings included: Review of the facility's policy titled, Tracheostomy Care and Suctioning with an issued date of 03/26/21 included in part the following: The facility will ensure that residents who need respiratory care, including tracheostomy care and tracheal suctioning, is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan and resident goals and preferences. Procedures: 2 The facility will provide necessary respiratory care and services such as oxygen therapy, treatments, mechanical ventilation, tracheostomy care and/or suctioning. 3 Tracheostomy care will be provided according…

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 wear Personal Protective Equipment (PPE) mask appropriately when providing trach suctioning for residents on Enhanced Barrier Precautions (EBP) for 1of 1 resident observed for tracheostomy suctioning (Resident #5) and failed to ensure PPE (including disposable gowns) was readily available for 9 out of 9 residents with tracheostomy and failed to have EBP signage on door for resident with trach and PEG tube (Resident #3). 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: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Policy Explanation and Compliance Guidelines: 3. Implementation of Enhanced Barrier Precautions: a. Make gowns and gloves available immediately near or outside of the resident's room. Note: face protection may also be needed…

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 sufficient fluid intake and tube feeding to maintain proper hydration for 1 of 4 residents sampled for tube feeding (Resident #2). The findings included: Record review for Resident #2 revealed the resident was originally admitted to the facility on [DATE] with most recent readmission on [DATE] with diagnoses that included in part the following: Nontraumatic Subarachnoid Hemorrhage from Intracranial Artery, Osteomyelitis of Vertebra, Sacral and Sacrococcygeal Region. Review of the MDS for Resident #2 dated 11/02/24 documented in Section C a BIMS could not be conducted due to resident is rarely/never understood. Review of the Physician's Orders for Resident #2 revealed an order dated 07/02/24 for two times a day Auto water flush at 60 ml/hour x 20 hours (1200 ml total water). Review of the Physician's Orders for Resident #2 reveled an order dated 09/19/24 for Enteral feed order two times a day Jevity 1.5 at 75 ml/hour x 20 hours via…

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 maintain a complete and organized medical record for 1 of 3 residents reviewed for respiratory care (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] for diagnoses that included Acute and Chronic Respiratory Failure, Dependence on respiratory ventilator and Muscular Dystrophy. Physician orders included full code, tracheostomy (trach) care and to be on the ventilator at night. Resident #1 was able to breathe without the ventilator during the day with oxygen at 3 liters per minute. Review of the medical record revealed from [DATE]-[DATE] the resident was using oxygen 3 liters per minute during the day and on the ventilator at night. On [DATE] at 8:42 AM, a nursing progress note was written as a late entry. The note stated Resident was found to be unresponsive by RT (Respiratory Therapist) approximately 5:50 AM. Code blue called, CPR initiated, HR (heart rate) diminished at 42, 911 called at 6 AM. 911…

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 that ponteitiall effected 75 of the facility's residents. The findings included: 1) During the initial kitchen/food service observation tour conducted on 02/11/24 at 8:45 AM, there was no dietary supervisor present. The following were noted during the tour: a) Numerous small black flying insects noted to be in the food preparation and serving area. (b) Upon entering the kitchen it was noted a 1/3 steam table pan of pureed vegetables (10 portions) and 1/3 steam table pan of pureed beef sitting out at room temperature. The breakfast [NAME] (Staff A) stated that the pans included pureed mixed vegetables and pureed ground beef which were prepared earlier in the morning. At the request of the surveyor the temperature of the foods were tested using the facility's calibrated digital food thermometer. The temperatures were recorded as follows: pureed beef 110 degrees F and pureed vegetables 108 degrees…

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 maintenance and housekeeping services to maintain a clean, sanitary and home like environment for 17 of 29 rooms on the Hibiscus unit (Rooms #100 to 128), 6 of 17 rooms on the Dolphin Unit (Rooms #200 to 222), 3 of 3 unit corridors and the common areas that included the Activities/Dining area, lobby/reception area, the laundry, and corridors leading to the units from the lobby/reception area. The findings included: 1). During the Environment Tour conducted on the Hibiscus Unit (rooms 100 to 128), on 02/13/24 at 2:15 PM, accompanied with the Director of Maintenance, the following were noted: room [ROOM NUMBER]: The floor area surrounding the room entry door and throughout the room were noted to be black stained and heavily soiled with dust, dirt, and debris. Small hole (2 diameter) in wall above Bed-A. room [ROOM NUMBER]: The exterior of the room entry door was in disrepair. Room floor and base boards were soiled and stained…

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 ensure reasonable efforts to accommodate individual food preferences, dietary needs, and food quality related complaints for 9 sampled residents that include: Resident's #22, #32, #39, #46, #49, #51, #56, #57, #66, and one resident who requested to stay anonymous. The findings included: 1) During the screening of Resident #39 on 02/11/24 at 10:15 AM, the alert and oriented resident was noted to state that the facility menu is either not posted to view or the posted menu is not followed on a regular basis. The resident further stated he was given the phone number of the kitchen to call food food requests or food issues, however he always gets the answering machine and leaves messages that are never returned. Further stated that he never is served food preferences and is sent food that the quality is terrible and does not eat the meals. On 02/13/24 at 9 AM Resident #39 interviewed again concerning his meal issues and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to honor a residents choices for being out of bed for 2 of 4 residents sampled for choices (Residents #37 and Resident #56); failed to honor resident's choice for eating in the Dining room for 3 of 4 residents reviewed for choices (Resident #56, Resident #22, and a resident that wished to remain anonymous); and failed to honor residents choices for showers for 1 of 4 residents sampled for choices (Resident #38). The findings included: 1a). Resident #56 was initially admitted to the facility on [DATE], According to a quarterly MDS, dated [DATE], Resident #56 had a BIMS score of 15, indicating the resident was 'cognitively intact'. The MDS documented that the resident was dependent upon staff for ADLs except for eating. Resident 356's diagnoses at the time of the assessment included: Hemiplegia, Seizure disorder, Anxiety disorder, Depression, Epilepsy. Resident #56's care plan, initiated on 02/11/24, documented, Resident has indicated 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 and interview, the facility failed to notify representative for change of condition for 1 of 4 residents sampled for hospitalizations (Resident #9) and 1 of 3 residents reviewed for falls (Resident #12). The findings included: 1. Resident #9 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident was moderately cognitively intact. A progress note dated 01/17/24 at 1:13 PM documented the resident was confused and not oriented. The physician/nurse practitioner was called and was in the facility to assess the resident. An order was received to transfer Resident #9 to the hospital for altered mental status for evaluation. Resident #9 was transferred from the facility at 2:50 PM. Further record review did not reveal the resident's representative was notified of the resident's change in condition. 2. Resident #12 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident was mildly cognitively intact.…

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 close privacy curtain during wound care for 1 of 2 residents sampled for wound care (Resident #20); and failed to provide privacy during medication administration for 1 of 4 residents observed for medication administration (Resident #4). The findings included: Review of the facility policy titled Resident Rights- Exercise of Rights with a revised date of 03/02/19 included the following: The facility will treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Each resident will be treated with dignity and respect. 1) Record review for Resident #4 revealed the resident was admitted to the facility on [DATE] with a diagnoses that included: Anoxic Brain Damage, Tracheostomy Status, Other Involuntary Movements, and Unspecified Voice and Resonance. Review of the Minimum Data Set…

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 1 (Resident #79) of 10 sampled residents for nutrition review failed to be given the appropriate treatment of supervision and adaptive eating equipment with meals to maintain or improve ability to eat independently. The findings included: During the observation of the lunch meal conducted on 02/11/24 at 12:15 PM, it was noted that the lunch tray was placed in front of resident and staff left room. It was noted that the tray foods were served in bowls and only 1 built-up spoon and regular spoon, fork, and knife were provided on the tray. The resident was noted to have visual impairment and some cognitive impairment. The resident was noted to attempt to eat the foods with the regular spoon but ate with the spoon upside down. The resident was noted to utilize the built -up spoon only for a few attempts with the foods in bowls. Staff were noted not to assist or supervise Resident #79 during the meal, and the resident consumed less than 20 %…

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 1 (Resident #19) of 10 sampled residents who are unable to carry out activities receives the necessary services to maintain good nutrition. The findings included: During resident screenings conducted on 02/11/24 at 10 AM it was noted that Resident #19 appeared underweight/malnourished and was cognitively impaired. Observation conducted on 02/13/24 at 8:30 AM noted regular meal tray served to the room of Resident #19. Staff was noted to only set up the tray in front of the resident and then staff left room. Resident noted to be cognitively impaired and could not eat independently and required supervision and assistance with eating. During the 30 minute observation no staff were noted to enter the room and provide assistance with Resident #19. Resident was noted to consume 0% of the breakfast meal. At 8:45 AM the resident was noted to be sleeping in front of the meal tray and staff were noted to remove 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 ongoing activities program for 4 of 4 residents, Residents #56, 22, 37, and a resident that wishes to remain anonymous. The findings included: The Admissions packet documented, the Activity Department at Avante offers a variety in both group and individual programs designed to meet the needs and interests of our residents. Participation is encouraged but not mandatory. We encourage our residents to continue to do things they have enjoyed in the past, as well as trying new opportunities. Suggestions for programs are welcome and your involvement is encouraged. Programs such as arts and crafts, physical activities, religious programs, bingo, discussion groups, and current events are offered on a daily, weekly, or monthly basis. The facility's policy, 'Activities Meet Interest/Needs of Each Resident', with an issue date of 03/02/19 documented, The facility will provide, based on the comprehensive assessment and care plan and 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, it was determined that the facility failed to provide treatment and care in accordance with professional standards of practice to ensure that 1 (Resident #31) of 2 sampled residents for dialysis review with meals prior to leaving for dialysis appointments and bagged lunches to take to dialysis treatment appointments; failed to provide 1 (Resident #98) of 2 sampled residents with physician ordered pain medication; and failed to provide a consult for 1 (Resident #48) of 2 residents reviewed for physician ordered dermatology consults. The findings included: 1) During the screening and interview conducted with Resident #31 on 02/12/24 at 8:15 AM, it was noted that she was located in the hallway and stated to the surveyor that the dialysis transport will be at the facility soon to take her to dialysis. Resident #31 further stated that she would be leaving for dialysis transport at 8:30 AM and had not eaten the breakfast meal and she would like to eat her breakfast…

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 respiratory equipment was stored in a manner to prevent infection for 2 out of 3 sampled residents for respiratory care (Residents #155 and #60). The findings included: Review of the facility's policy titled, Nebulizer Equipment Storage with a revised date of 02/2019 included: It will be the standard of this facility that nebulizer equipment will be stored according to current best practice guidelines. Between uses store nebulizer parts in a dry, clean plastic storage bag. 1) Record review for Resident #155 revealed the resident was admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). Review of the Minimum Data Set for Resident #155 dated12/19/23 revealed in Section C a Brief Interview of Mental Status score of 15 indicating a cognitive response. Review of the Physician's Orders for Resident #155 revealed an order dated 12/20/23 for Ipratropium-Albuterol Solution 0.5-2.5 (3) mg/3ml…

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 ensure that 1 (Resident #31) of 2 residents reviewed for dialysis did not receive services consistent with professional standards of practice that included ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. The findings included: During the Dialysis review for Resident #31 on 02/13/24, it was noted that there was no evidence, written or computer, of communication with the dialysis center after each session. A request was made by the surveyor to the Director of Nursing (DON) on 02/13/24 for documentation of communication for all dialysis sessions concerning Resident #31. On 02/13/24 the DON informed the surveyor that the written documentation that was normally kept in a binder at the facility at the 100 Wing Nursing Station was missing. A review of the clinical record of Resident #31 noted that the resident had a current MDS BIMS score of 14. Further review noted diagnoses of Adjustment Disorder with Mixed Anxiety and Depressed Mood.…

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 sufficient staffing to accommodate resident's choices for being out of bed, to accommodate residents' participation in activities, and choices for having meals in the dining room. The insufficient staffing has the potential to affect all residents in the facility, including Residents #22, 56, 37 and a resident who wished to remain anonymous. The census at the time of the survey was 108 residents. 1). The Facility Assessment, most recently updated on 01/30/24, did not address the staffing needs to provide activities based on the facility census and the acuity of the residents being provided care. A review of the Activities Calendar for the month of February 2024 revealed the following: Each Sunday, the only activity is Bible Study at 2:45 PM. Each Thursday, the only activities are 'Biggest Loser' at 1:15 PM and Bingo at 2:30 PM. Each Saturday the only activities are Morning News and word search puzzles that are kept at 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 identify medications that were not supposed to be crushed for a resident with a PEG tube for 1 of 5 sampled residents reviewed for unnecessary medications (Resident #18). The findings included: Record review for Resident #18 revealed the resident was admitted to the facility on [DATE] with the most recent readmission date of 05/11/23 with diagnosis of Gastrostomy Status. Review of the Minimum Data Set for Resident #18 dated 12/23/23 revealed in Section C a Brief Interview of Mental Status was not conducted due to the resident is rarely/never understood. Review of the Physician's Orders for Resident #18 revealed an order dated 04/05/23 for Flomax oral capsule 0.4mg (Tamsulosin HCL) give 0.4 mg via PEG tube at bedtime. Review of the Physician's Orders for Resident #18 revealed an order dated 05/30/23 for Linzess oral capsule 290mcg give 290 mcg via PEG tube one time daily. Review of the Pharmacy Consultation Report for Resident #18 was as follows:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure the medication error rate was not 5% or greater. The medication error rate was 10%, 3 medication errors were identified while observing a total of 30 opportunities, affecting Residents #4 and #60. The findings included: 1) Record review for Resident #4 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Anoxic Brain Damage, Chronic Obstructive Pulmonary Disease, Essential (Primary) Hypertension, and Tracheostomy Status. On 02/11/24 at 9:48 AM an observation was made of Staff C, Registered Nurse (RN), performing medication administration for Resident #4. The nurse obtained a blood pressure reading for the resident of 99/63. The nurse stated she was holding the following medications due to the low blood pressure: Amlodipine Besylate 10mg and Lasix (Furosemide) 20mg. Review of the Physician's Orders for Resident #4 revealed an order dated 01/12/24 for Amlodipine Besylate oral tablet 10mg give 1…

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 prepared in advance and not followed and not reviewed by the facility's dietitian or other qualified nutrition professional, for potentially 75 facility residents. The findings included: 1) During the review of the approved menu for the lunch meal of 02/11/24 it was noted that the menu for Regular, Therapeutic, and Mechanically Altered Diets included: Apple Pork Chops Onion Roasted Potatoes Dill Carrots Roll Pineapple Chunks During the observation of the lunch meal in the main kitchen on 02/11/24 at 9 AM, it was noted that the Cook, Staff E, was preparing canned Beef Ravioli , Carrots, and Pears Halves. The surveyor requested Staff E to provide a copy of the approved lunch menu and replied that she did not have a copy of the approved lunch menu. Staff E provided the surveyor a menu that she stated was left for her by the Food Service Director to prepare for the lunch meal that only included; Ravioli, Vegetable Blend , Garlic Bread, and Pears. The menu did not document…

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 facility foods were not palatable and not prepared by methods that conserve nutritive value, flavor, and appearance for potentially 75 of 75 of the facility's residents. The findings included: 1) During the observation of the lunch meal of 02/11/24 at 10 AM in the main kitchen, it was noted that the approved lunch menu of Pork Chops, Dilled Carrots, Onion Roasted Potatoes, and Pineapple Chunks would be substituted with Beef Ravioli, Cooked Carrots, Tomato Soup, and Pears. During the meal service conducted in the main kitchen on 02/11/24 at 11:45 AM, it was noted that the meal was not appetizing/appealing due to orange color from the Ravioli (tomato sauce) , Carrots, and Tomato Soup. Interview conducted with the lunch [NAME] (Staff E) at the time of the meal observation, and she stated that she was not given a menu to follow for the lunch meal and was unaware of how unappetizing the meal appearance was. A review of the facility's Standardized Recipe for the preparation of Cheese Ravioli noted that the ingredients…

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 pureed foods in a consistency designed to meet the needs of 6 (includes Resident #12) physician ordered pureed diets. The findings included: During the observation of the lunch meal in the main kitchen on 02/13/24 at 11:30 AM, it was noted that the approved menu documented pureed Turkey Goulash and pureed Cauliflower (sub Capri Vegetables). Observation of the tray assembly line noted visible pieces of Turkey were in the Turkey Goulash and visible pieces of vegetables were in the pureed Capri Vegetables. A taste test of the entrée and vegetables conducted by the surveyor and the Lunch [NAME] (Staff F) confirmed pieces of turkey and vegetables in the pureed mixtures. Interview conducted with Staff F at the time of the observation noted that he does not taste test pureed foods to ensure that the pureed mixture is smooth in consistency. Also noted that Staff F was not aware that dysphagia pureed foods must be smooth in consistency when there is a diagnoses of Dysphagia. 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 interviews and record review, the facility failed to maintain accurate and complete medical records for 2 of 34 residents in the final sample (Residents #29 and #92). The findings included: Review of the Frequently Asked Questions About a Do Not Resuscitate Order (DNRO) located at https://www.floridahealth.gov/licensing-and-regulation/trauma-system/_documents/dnro-faq.pdf included: Does it have to be notarized or witnessed? No, the form is simply signed by the patient, health care surrogate or health care proxy as defined in section 765.202, Florida Statutes, and the patient's physician. This is a physician's order. 1.) Record review for Resident #29 revealed the resident was admitted to the facility on [DATE] with most recent readmission on [DATE] with diagnoses that included: Multiple Sclerosis, Tracheostomy Status, Gastrostomy Status, Paraplegia, and Neuromuscular Dysfunction of Bladder. Review of the Minimum Data Set (MDS) for Resident #29 dated 01/25/24 revealed in Section C a Brief Interview of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to administer medications in a safe and sanitary environment for 1 of 4 residents observed for medication pass (Resident #4); failed to ensure medications are stored in a sanitary manner for 1 of 4 medication carts; failed to provide wound care in a sanitary manner for 1 of 2 residents sampled for wound care (Resident #20); and failed to provide care for laceration in a sanitary manner for 1 of 34 sampled residents (Resident #31). The findings included: Review of the facility's policy titled, Infection Control-Hand Hygiene with a revised date of 03/02/19 included: It is the policy of the facility to perform hand hygiene in accordance with national standards from the Centers for Disease Control and Prevention and the World Health Organization. Soap and water are required for hand hygiene when hands are visibly soiled, after caring for resident with diarrheal infection such as C difficile, after potential exposure to body fluid, before 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 observation and interview, the facility failed to ensure a low air loss mattress was functioning for 1 of 2 residents reviewed for wound care (Resident #20). The findings included: On 02/11/24 at 12:03 PM, during a tour of the facility, the air mattress on the bed for Resident #20 was observed off. The pump was not lit and the mattress was not firm (photographic evidence obtained). The resident was asked if the mattress felt different and he stated that it felt a little lower on one side. The sheets were not fitted on the bed and the resident was lying on the actual mattress in some areas. Resident #20 currently has a Stage 3 wound to his left hip. Discussed this observation with the wound care nurse, Staff K, on 02/13/24 at 11:30 AM. Staff K stated she checks all of the air mattresses Monday thru Friday when she is at the facility and was unsure who checks them on the weekends.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide appropriate wound care for 2 of 3 residents reviewed, who were admitted with wounds (Resident #1 and Resident #2). The findings included: 1. Resident #1 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident was cognitively intact and was admitted with two stage 3 pressure ulcers. A review of Resident #1's orders revealed an order dated 12/22/23 for wound care consult for wounds to head, left knee, right anterior leg, elbow, and abdomen. Further review of Resident #1's orders revealed orders for wound care dated 12/26/23. A progress note dated 12/26/23 at 2:07 PM documented: Second skin assessment completed by wound care nurse. Findings are head/scalp open surgical wound, red in color; right knee open pressure injury red in color; left knee open pressure injury, right thigh/hip area open area pressure injury, this is deep, red in color; right abdomen open wound red color; and right elbow outer…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain acceptable parameters of nutritional status for 1 of 3 residents reviewed for nutrition (Resident #2). The findings included: Resident #2 was admitted to the facility on [DATE] with a gastrostomy tube (feeding tube). A comprehensive assessment dated [DATE] documented the resident had severe cognitive impairment and required tube feedings for nutritional support. Resident #2 was care planned for nutritional problem or potential nutritional problem related to dependent on tube feedings for all nutritional needs and with increased nutritional needs. Interventions included Registered Dietictian (RD) to evaluate and make diet change recommendations as needed. A review of Resident #2's orders revealed an order dated 10/12/23 for TF diabetasource 55 milliliters an hour (ml/hr), goal rate 100 ml/hr times 20 hours. Titrate up to 20 ml/hr every eight hours to go rate. H2O (water) flushes 40 ml/hr. A nutritional evaluation progress note dated 10/12/23…

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 interview and record review, the facility failed to medicate a resident for pain as ordered for 1 of 4 resident reviewed for pain (Resident #1). The findings included: A telephone interview was conducted with Resident #1's representative on 01/09/24. The representative stated the resident was admitted to the facility with a wound on the right side of head and right hip. The resident had asked for pain medication and was told by the nurse they could not give any pain medication because it was not on hand. Record review revealed Resident #1 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident was cognitively intact and required partial assist with activities of daily living. Resident #1 was care planned for alteration in comfort related to low back pain. Interventions included follow up with resident after medicating for pain to evaluate effectiveness of pain control, medicate as ordered, and notify physician if pain control is ineffective. A 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 Facility Policy, observation, record review and interview the facility failed to initiate isolation precautions for 4 of 4 residents reviewed for Transmission Based Precautions (Resident #293, #298 , #68 and #82), failed to maintain oxygen equipment in a sanitary manner for 4 of 7 residents reviewed for Respiratory Care (Resident#26, #28, #71 and #296), and failed to maintain suction equipment in a sanitary manner for 1 of 1 residents reviewed for suctioning (Resident #50). The findings included: Facility Policy titled Infection Control- Standard and Transmission-Based Precautions dated 03/02/19 documented, It is the policy of the facility to ensure that appropriate infection prevention and control measures are taken to prevent the spread of communicable disease and infection in accordance with State and Federal Regulations, and national guidelines; Transmission-based precautions are applied presumptively or upon first suspicion that a resident may have and infection that requires transmission-based…

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 facility policy, record review and interview the facility failed to follow physician's orders for diagnostic tests in a timely manner for 2 of 3 residents reviewed (Resident #71 and Resident #298). The findings included: Facility Policy titled Diagnostic Services documented, It is the policy of this facility to ensure that laboratory, radiology, and other diagnostic services meet the needs of residents, that results are reported promptly to the ordering provider to address potential concerns and for disease prevention, provide for resident assessment, diagnosis, and treatment, and that the facility has established policies and procedures, and is responsible for the quality and timeliness of services whether services are provided by the facility or an outside resource. Facility Policy titled Tuberculosis Screening dated August 2013 documented, The facility will administer and interpret tuberculin skin tests (TST) in accordance with recognized guidelines and pertinent regulations. A qualified nurse 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, policy, and record review the facility failed to provide care and services to ensure resident safety (Resident #20 and #89) and failed to provide supervision to prevent accidents and adequate evaluations post fall (Resident #71) for three of four residents reviewed. Findings included: 1) Resident #20 was admitted to the facility on [DATE] after a stroke which required removal of the right side of his skull due to swelling. He has left sided paralysis, a seizure disorder, heart failure, a tracheostomy and is unable to speak. Due to the lack of skull bone to protect his brain, a protective helmet should be worn as was physician ordered. The most recent MDS assessment from 07/12/22 revealed a BIMS (Brief Interview for Mental Status) score of 15 out of 15 (no cognitive decline). The resident is bed bound and is totally dependent on staff for all activities of daily living. He communicates with his hands, head movement and a simple electronic device that he can write on. In November…

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, records review, and interviews, the facility failed to follow Physicians' orders to ensure 1 of 30 sampled residents (Resident #143) received a dietary supplement. The findings included: On 10/05/22 at 09:48 AM, Resident #143 was observed in bed; he looked very frail. Resident # 143 spoke Spanish and was incoherent in his speech. The clinical record showed that Resident #143 was admitted to the facility on [DATE]. His admitting diagnoses are: Essential (Primary) Hypertension, Difficulty In Walking, Not Elsewhere Classified Other Pancytopenia; Pneumonia, Unspecified Organism; Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance; Psychotic Disturbance; Mood Disturbance, And Anxiety; Dysphagia, Oropharyngeal Phase; Other Toxic Encephalopathy, Acute Neurologic Post Covid-19 Condition, Other Asthma; Benign Prostatic Hyperplasia Without Lower Urinary Tract Symptoms; Personal History Of Covid-19;Unspecified Protein-Calorie Malnutrition. Review of the Dietary assessment dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide pain medication as physician ordered for one of three residents reviewed (Resident #18). The resident missed seven doeses, and there were discrepancies in the documentation. The findings included On 10/04/22 at 10:09 AM, Resident #18 was interviewed. The resident stated, I haven't had my pain medication in three days, if it's charted as given it's a lie. Resident #18 was initially admitted to this facility on 03/14/2020. The most recent comprehensive assessment showed a BIMS (Brief Interview for Mental Status) score of 15/15 which indicated no cognitive decline or memory loss. The resident's care plan notes and intervention to Administer medications as per MD orders. Review of the current physician orders revealed an order for Percocet 10-325 mg, one tablet, every eight hours for pain which started on 06/01/22. Review of the September MAR (Medication Administration Record) recorded only one of the 90 doses for the month was held. For 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 Facility Policy, observation, record review and interview the facility failed to have a physician's order for oxygen administration for 2 of 7 Residents reviewed for oxygen administration (Resident #71 and Resident #296) The findings included: Facility Policy titled Oxygen Administration dated 03/02/19 documented, Oxygen is administered under orders of a physician, except in the case of an emergency. 1. On 10/04/22 at 12:51 PM Resident #296 was observed wearing oxygen via nasal cannula at a rate of 3 liters per minute. On 10/05/22 at 08:22 AM Resident #296 was observed wearing oxygen via nasal cannula at a rate of 3 liters per minute. Resident #296 stated he has the oxygen on all the time. Photographic evidence taken. Record review of Resident #296 documented an admission date of 09/26/22 with diagnoses that included Heart Disease, Malignant Cancer, and Diabetes. A Minimum Data Set (MDS) resident assessment dated [DATE] documented Resident #296 as cognitively intact requiring extensive assistance 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.

Based on observation and interview, the facility failed to prepare and serve food in a sanitary manner, with the potential to affect all residents. Finding included: On 10/04/22 at 9:35AM conducted an initial tour in the main kitchen accompanied by the Certified Dietary Manager (CDM). The following was observed: (1) The oven was stained with grease and food. (2) The pot on the stove had black burnt on food. (3) The stove was very greasy. (4) The tray under the burner of the stove was built up with dried burnt food. (5) The walk in Freezer door has black stains. (6) The Floor in front of the walk in freezer was black. (7) The toaster was rusted and dirty. On 10/06/22 at 11:50 AM, conducted a follow up tour of the main kitchen for the lunch meal. The temperatures of two 8oz container of regular milk in a ice bath on the tray line, were 46 .6 and 46.8 degrees. On 10/7/22 at 1:20PM, conducted an interview with the Certified Dietary Manager and the Regional Dietary Manager, and and they were informed of the findings.