Aviata At Bryan Dairy

Based on record review, staff interviews, and review of the facility's policy titled Resident Assessment-Coordination with PASARR Program, the facility failed to complete the Level II Preadmission Screening and Resident Review (PASARR) documentation for one (#118) of six residents sampled for PASARRs. Findings included: Review of the admission record for Resident #118 revealed an admission date of 04/17/24 with diagnoses of Alzheimer's disease, primary, depression, and unspecified mood affective disorder. Review of the medical record showed a Level I PASARR was not conducted upon admission. Review showed it was initiated on 05/26/24. Review of Resident #118's Level I PASARR dated 05/26/24 showed diagnoses of Depressive Disorder, other Mood Disorder and Alzheimer's Disease were indicated. The Level I PASARR showed the resident had exhibited behaviors that made them a danger to themselves or others. Level II evaluation section showed Resident #118 had documented behavioral observations, has interpersonal functioning problems, concentration persistence and pace problems, and difficulty…

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 Activities of Daily Living (ADLs) were appropriately provided for two (Residents #32, and #68) of five residents sampled for ADLs. Findings included: 1. An observation and interview was conducted on 6/10/24 at 11:27 a.m. with Resident #32. She was observed in a hospital style gown with hospital arm bands on her wrist. The resident said she did not get showers, and no one got her out of bed. Review of the admission Record for Resident #32 showed she was re-admitted on [DATE] with diagnoses including anemia, dementia, morbid obesity, overactive bladder, and anxiety disorders. Review of Resident #32's Minimum Data Set (MDS) Section C, Cognitive Patterns, showed her Brief Interview for Mental Status (BIMS) score was not completed. Section C did note Resident #32 was severely cognitively impaired. Review of Resident #32's task documentation by the Certified Nursing Assistants (CNAs) showed the resident had two showers (6/3 and 6/10/24)…

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 did not ensure residents unable to carry out ADL (Activities of Daily Living) received assistance related to hair care for one (Resident #117) of five residents reviewed for ADLs. Findings included: An observation and interview was conducted on 06/09/24 at 2:14 p.m. with Resident #117. The resident was observed with matted, tangled clumps of hair. She stated she had asked staff for help. She said, I need help with my hair. The staff are not available to help. They are too busy. There is not enough time for me. It will take time to untangle. No one has the time. The resident stated she had been begging staff to help her with her hair since admission. She stated she did not like looking like a bird's nest. She said, it is embarrassing. I would like to brush my hair again. Review of the admission Record for Resident #117 showed an admission date of 04/15/24, with diagnoses to include partial traumatic metacarpophalangeal amputation of unspecified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident received proper treatment to maintain communication abilities for one (Resident #280) of three residents sampled. Findings included: Review of the admission Record for Resident #280 revealed an original admission date of 04/29/24 and a re-admission date of 06/03/24 with diagnoses to include Deaf non-speaking. During an observation on 06/09/24 at 9:30 a.m., Resident #280 was laying on his bed staring at the Television which was turned off. The resident did not respond to the interview. The resident looked at this surveyor and initiated hand movements, signaling he communicated via sign language. A look around the room revealed there were no personal effects and there were no communication assistive devices, or anything indicating the resident required assistance to communicate with others. Review of an admission Minimum Data Set (MDS) dated [DATE] showed in section B0200 - Hearing, Speech, and Vision, the resident 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 observation, interview, and record review, the facility failed to ensure proper care to prevent the worsening of pressure wounds for two (Residents #74 and #12) of four residents sampled for pressure wounds. Findings included: An observation was conducted on 6/11/24 at 11:48 a.m. of Resident #74 lying in bed with his legs exposed crying out for assistance. He said his feet hurt and he needed help moving his leg. The resident was observed to have bandages on both heels and his feet were propped up on a plastic pack of disposable briefs. (Photographic evidence obtained with resident permission.) An observation and interview was conducted on 6/11/24 at 11:50 a.m. of Staff V, Certified Nursing Assistant (CNA) entering Resident #74's room and assisting to reposition his leg. Staff V confirmed the resident's heels were being offloaded with a pack of briefs. She said his pressure relieving boots were in the laundry so someone must have put those there. Staff V said the resident had wound care that morning 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 record review and interview, the facility failed to monitor behaviors of side effects of psychotropic medications for two residents (Resident #36 and #77) out of the sampled five residents. Findings included: A review of the admission Record showed Resident #36 was initially admitted to the facility on [DATE] with a primary diagnosis of unspecified Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and other diagnoses to include schizoaffective disorder, bipolar type, major depressive disorder, and anxiety disorder. Section I- Active Diagnoses of the Minimum Data Set (MDS) dated [DATE] showed the resident had diagnoses of non-Alzheimer's Dementia, anxiety disorder, depression, and schizophrenia. The Order Review Report dated 06/01/24-06/30/24 revealed the following orders: 02/14/24 Cymbalta Oral Capsule Delayed Release Particles 60 MG- Give 1 capsule by mouth one time a day related to major depressive disorder; 03/06/24 Risperdal Oral Tablet…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide food to accommodate preferences for one (Resident #59) out of six residents sampled for food. Findings included: On 06/09/24 at 11:34 a.m., Resident #59 reported the facility was no longer serving chef salads. She stated she needed to eat the chef salads because she wanted to lose weight. On 06/09/24 at 1:48 p.m., the resident was observed in the room with the meal tray in front of her. The tray consisted of mashed potatoes, green beans, and chicken broth. The resident reported she wanted to eat chef salads because she needed to lose weight. She carried a lot of weight and had pain in her back, she had diabetes, and needed to lose 40 pounds. She needed protein on her tray and was not getting any protein. She sent messages to speak with the Kitchen Manager, but she never came On 06/12/24 at 1:00 p.m., Resident #59 reported every day they gave her chicken broth, and it was too salty. They never gave her crackers with the soup. She…

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 the resident and/or resident representative of the facility policy for bed-hold for three (#177, #280, and #427) of four residents reviewed for hospitalization. Findings included: 1. A review of the admission Record showed Resident #177 was admitted to the facility on [DATE]. She was discharged to the hospital on [DATE]. Additional review of the Electronic Medical Record and the Resident's 'Hard Chart' revealed no 'Bed Hold Policy'. On 06/11/24 at 5:48 p.m., the Administrator reported they could not find a bed hold policy for Resident #177. A review of the admission Record showed Resident #177 was admitted to the facility on [DATE]. A review of a change in condition form revealed she was transferred to the hospital on [DATE] for altered mental status and did not return to the facility. Review of the medical record revealed no evidence of a bed-hold notice at the time of transfer. On 06/11/24 at 5:48 p.m., the Administrator confirmed they could…

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 interviews, the facility failed to ensure resident council meeting concerns were documented and responded to for three of three months of Resident Council meetings and Food Committee meetings for five (Residents #2, #3, #5, #6 and anonymous resident) who reported concerns pertaining to food and inadequate staffing concerns of eleven sampled residents. Findings included: A review of the facility's Resident Council Meeting Minutes for 12/22/2023, 01/18/2024, and 02/22/2024 revealed the following: On 12/22/2023, for Nursing, No concerns at this time but turnover is a problem. No further issues with staffing and the Dietary subject was blank. On 01/18/2024, for the Nursing subject, it was blank. For Dietary: N/A (not applicable). On 02/22/2024, for the Nursing subject, it was blank. For Dietary: N/A. On 02/28/2024, the facility provided Food Committee notes, dated 11/03/2023, 12/08/2023, and 01/05/2023. The notes documented no concerns with food. On 02/28/2024 at 9:27 a.m., an interview was conducted with Resident #2, she stated for food, there is just not…

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

Based on record review, observation, interviews and photographic evidence, the facility failed to ensure the provision of a therapeutic diet for one (Resident #2) of eleven sampled residents. Findings included: On 02/28/2024 at 9:27 a.m., Resident #2 was observed in her bed, eyes open, clean, groomed, and comfortable. She agreed to an interview. She stated she had resided in the facility for more than one year. She stated she ate her meals in her room. She confirmed she received three meals a day. She said the food taste was ok, there was just not enough. She stated, Yes, I have had weight loss. I eat independently. Sometimes not enough, sometimes I go hungry. A review of Resident #2's clinical record, the admission Record, documented an admission of 05/03/2023 with readmission of 02/19/2024. Her diagnosis information included: Chronic obstructive pulmonary disease, unspecified severe protein-calorie malnutrition, and ulcerative colitis. A review of Resident #2's Minimum Data Set, a 12/18/2023 PPS (Prospective Payment System) Part A Discharge assessment, Section C, documented a…

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

Based on observations, record review, and interview, the facility failed to ensure each resident received a diet that met their dietary needs for four (#2, #7, #9, #10) of eleven sampled residents. Findings included: A review of the food committee meeting minutes for the past 6 months revealed that each meeting minutes recorded the date and time but did not record the names of the residents in attendance and did not record any concerns. An interview on 2/28/24 at 10:44 a.m. with the Certified Dietary Manager (CDM) revealed there was a food committee meeting the 1st Friday of each month. He said there were a variety of concerns, with ongoing concerns from some of the residents wanting double and triple portions. When asked why residents were asking for double and triple portions, the CDM reported Because people like to eat. He said they (the dietary department) try to accommodate resident's requests. Observations on 2/28/24 at 11:31 a.m., of the midday meal tray-line, revealed Staff A, [NAME] cutting the meat loaf into small squares using a flat spatula and then started plating each…

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, record review, and interview, the facility failed to employ dietary staff that displayed appropriate competencies to meet the resident's nutritional needs related to one (Staff A) of three cooks and the Certified Dietary Manager. Findings included: Review of the Dining Services Director/Account Manager job description revealed the following: -Provides leadership, support and guidance to ensure that food quality standards, inventory levels, food safety guidelines and customer service expectations are met. -Training, quality control and in-servicing staff to HCSG standards is an essential part of the Manager's responsibility and includes touring kitchen several times per day to assess work quality using QCIs for documentation purposes. Review of the [NAME] job description revealed the following: -Plates appropriate foods to resident meal trays. -Inspect special diet trays to ensure that the correct diet is served to the resident. -Adhere to menus and portion control standards, including those for special diets when preparing and serving meals. -Review tray card…

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

Based on observations, interviews and record review, the facility did not ensure the kitchen was maintained in a clean and sanitary manner, related to sanitation, food storage, and equipment cleaning and maintenance. Findings included: An initial kitchen tour was conducted on 03/29/22 from 9:30 a.m. to 9:57 a.m. with the Certified Dietary Manager (CDM). The CDM stated there were two staff working today, The Dietary Manager in Training (MIT) and Staff R, Dietary Aide. During the tour observations were made of: Ceiling vents noted with dirt, debris in the cooking areas and the dish room. Walls were observed with dust, dirt, and stains. The kitchen floors were observed with food residue, dirt, dust, and debris. Tiles were noted missing by the dish machine with water collected in the hole. The kitchen equipment (stove) was noted with food spills and oil splatters. A vent was noted on the floor with caked-in food remains, dust, dirt, and debris. Kitchen equipment - dish machine, microwave, blender, and dough mixer were noted with brown matter on the surfaces. The CDM stated the kitchen…

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 ensure dignity for one (Resident #73) of twelve residents that had indwelling urinary catheters. Findings included: On 3/29/22 at 12:29 p.m., an interview was conducted with Resident #73. The resident was lying in bed with the urinary drainage bag hanging from the bed frame facing the hallway. The drainage bag was not covered and held approximately 600 milliliter (mL) of concentrated yellow urine. An observation from the hallway was conducted on 3/30/22 at 4:57 p.m., of the resident sitting up in bed, eating dinner. The urinary drainage bag was observed hanging from the bed frame with yellow-colored urine in the bag. On 3/31/22 at 2:50 p.m., an observation was conducted from the hallway with Staff CC, Licensed Practical Nurse (LPN), escorting Resident #73's roommate from the room. Resident #73's urinary drainage bag held yellow-concentrated urine, while hanging from the bed frame. The staff member confirmed, from the hallway, 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 ensure two (Residents #73 and #97) of forty-three sampled residents were assessed for self-administration of medications. Findings included: 1. During an observation and interview, on 3/29/22 at 12:33 p.m., with Resident #73, Staff A, agency Licensed Practical Nurse (LPN) sat a medication cup which contained a tablet of medication down on the over-bed table in reach of the resident then left the room. On 3/29/22 at 12:36 p.m., Resident #73 ingested the tablet identifying it as Lisinopril. On 3/29/22 at 12:46 p.m., Staff A reported that he had left Lisinopril with Resident #73. He said the resident was getting it after other hypertensive's due to the resident having low kidney function. A review was conducted on 3/29/22 at 12:55 p.m., of Resident #73's assessments. The review indicated that an assessment to evaluate the resident's ability to self administer medications was not completed. The review of Resident #73's Order Summary…

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 did not ensure physician orders were in place for one (Resident #90) of one sampled resident with an orthopedic device. Findings included: During a facility tour on 03/29/22 at 10:00 a.m., Resident #90 was observed lying on her bed with an abductor pillow in place. Both legs were noted secured with the pillow. Resident #90 stated she wore the pillow all day. Resident #90 stated she was wearing it because she fell and broke her left hip. Resident #90 stated she would like to walk again. Resident #90 stated she did not like wearing the device but was looking forward to her ortho (orthopedic) appointment to evaluate the healing process. Review of an admission record for Resident #90 showed Resident #90 was re-admitted to the facility on [DATE] with a diagnosis of an encounter for orthopedic aftercare, displaced intertrochanteric fracture of unspecified femur and subsequent encounter for closed fracture with routine healing. Review of Resident #90's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to ensure one (Resident #97) out 43 sampled residents received care in accordance with professional standards of practices related to the staff not initiating written physician orders. Findings included: Resident #97 was admitted on [DATE] and readmitted on [DATE]. The admission Record included diagnoses not limited to Type 2 Diabetes Mellitus, Acquired absence of left leg below knee, and End Stage Renal Disease (ESRD). An observation was made of a telephone order flagged in the hard copy of Resident #97's clinical record. The telephone order included the following: - Start patient (pt) on a Vitamin A containing Multivitamin. - Restart Tramadol 50 milligram (mg) by mouth (po) every 6 hours as needed (q6 prn), mod-severe pain. - Wound care consult - Left (L) knee, - Start a triple antibiotic three times a day (TID) to pustular skin lesions x 4 weeks. The telephone order was written and signed by the physician on 3/25/22. The order did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure one (Resident #51) of three residents sampled for positioning received services and equipment to prevent further decrease in range of motion. Findings included: On 03/29/2022 at 12:05 p.m., Resident #51 was observed in his room lying in bed. He was interviewable and his left hand appeared contracted. He was not wearing a splint/brace on his left hand. However, a blue and gray [hook and loop] splint/brace was observed placed on the left side of the bed, on the dresser, and out of his reach. He stated he did not receive therapy services. Photographic evidence obtained. On 03/30/2022 at 12:05 p.m., Resident #51 was observed sitting in his wheelchair. He was noted not wearing his left-hand brace and it was again observed positioned on the left side of the bed on the dresser. It was observed in the same exact position as from the observations the day before (03/29/2022). Photographic evidence obtained. On 03/31/2022 at 10:02 a.m.,…

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 1. failed to ensure oxygen therapy equipment was stored in a sanitary manner for two (Residents #97 and #106) of three sampled residents and 2. failed to ensure physician orders were in place for the administration of oxygen therapy one (Resident #97) of three sampled residents Findings included: On 3/30/22 at 10:38 a.m., an observation was conducted of Resident #97's room, between Resident #97's bed and the privacy curtain was an oxygen concentrator with tubing and nasal cannula attached. The nasal cannula was observed lying on floor in front of the concentrator. The resident stated the cannula had probably been there for 2 weeks. The observation identified a Continuous positive airway pressure (CPAP) machine with mask was sitting on top of the bedside dresser beside the resident's bed. The CPAP mask was lying on top of machine, uncovered and undated. On 3/31/22 at 12:51 p.m., an observation was conducted of Resident #97's room with 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, interviews, and record review, the facility, 1. failed to ensure two (Residents #64 and #97) of six residents on dialysis, received a meal and/or snack during Dialysis and 2. failed to ensure one (Resident #97) received pre-dialysis, and post dialysis assessments, which is a standard of care consistent with professional practices. The findings included: 1. On 03/29/22 at 10:30 a.m., an observation and interview were conducted with Resident #64, who indicated the facility did not prepare snacks and/or meals to take to the dialysis center, and said, he was diabetic. Resident #64 revealed he would prefer the facility pack a snack and/or meal to keep his blood sugar stabilized during Hemodialysis. A record review for Resident #64 indicated he was initially admitted on [DATE] with multiple diagnoses that included End Stage Renal Disease and Type 1 Diabetes Mellitus. A review of the Order Summary Report for Resident #64 revealed an active order dated 12/28/2021 for Dialysis every Monday,…

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 did not ensure medications were stored appropriately in four of seven medication carts and in one of three medication rooms. 2. On [DATE] at 10:18 a.m., the 100-low medication cart was observed unlocked and unattended while Staff BB, Licensed Practical Nurse (LPN) was in a resident room. The staff member returned to the medication cart and confirmed the cart was unlocked and unattended. A review of the medication cart located on the 300-hall was conducted with Staff AA, Registered Nurse (RN). An unopened and undated bottle of Latanoprost 0.005% eye drops were observed in the cart. One of the labels on the bottle instructed that the medication Refrigerate Until Opened. The other label instructed staff to discard 42 days after opening. On [DATE] at 12:55 p.m., an observation was conducted with Staff M, LPN, of the 200-high medication cart. The bottom drawer was disorganized and cluttered, the drawer contained an aerosol can of Sanitizing Spray…

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 did not ensure garbage and refuse receptacles were covered, the garbage area was maintained in a sanitary manner and the garbage was disposed of in a timely manner. Findings included: During a facility tour on [DATE] at 9:59 a.m., an observation was made of the facility's trash area with a large size dumpster, noted overflowing with trash and refuse. The garbage was not in a covered receptacle. Piles of bags of garbage were observed on the ground next to the dumpster. (Photographic evidence was obtained) An interview was conducted on [DATE] at 9:59 a.m. with the Director of Maintenance (DOM). He stated their contract with the compactor had expired and that was why they rented a dumpster. He stated he had been calling the vendor and the vendor was not responding. Their agreement was that they would pick up every 7 days. The last time trash was picked up was on [DATE]. He expressed frustration with the process and said, Of course this is not…

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

Based on observation, interview, and record review the facility failed to ensure that one (Resident #62) of 40 residents sampled was assessed to self-administer a respiratory (nebulizer) treatment. Findings included: On 01/28/21 at 08:01 a.m., Resident #62 was observed to be sitting in bed watching television, coloring a book, and wearing a nebulizer facemask. The resident's nebulizer machine was running and no staff were present in or around Resident #62's room. An interview was conducted with Staff G, Licensed Practical Nurse (LPN), immediately following the observation. Staff G indicated she performed everything she was told to do by someone who came to her earlier and did not recall the staff member's name. Staff G stated, No one told me I had to stay in the room. I never knew that. A record review of Physician Order dated 12/04/2020 for Resident #62 revealed the following order: Ipratropium Albuterol Solution 0.5-2.5 (3) MG/ML 3 ml inhale orally every 4 hours as needed for (Diagnosis) Acute Respiratory Distress Syndrome (ARDS) Continued review of the record revealed there 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 observation, interview, medical record review, and policy review the facility failed to provide respiratory care in accordance with standards of practice and the comprehensive plan of care for four (#30, #51, #62, #66) sampled residents out of 45 facility residents receiving respiratory treatment as evidenced by: 1) the improper storage of respiratory equipment for Resident #51, #62, and #66, and 2) Resident #30 not receiving administration and oversight of a C-PAP (Continuous positive airway pressure ) device. Findings included: 1. On 01/26/21 at 12:19 p.m., observation of Resident #62's room revealed a nebulizer facemask was located in the nightstand's first drawer. Resident #62 was interviewed about the placement of the equipment. Resident #62 indicated she placed the facemask in the top drawer and indicated that the staff don't have time to stay while the treatment is administered. She stated, They [referring to the nursing staff] have no time to do that, they are busy. Clinical record review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility did not ensure that one (#314) of 40 sampled residents had medically necessary appointments for the Cardiologist and the Ophthalmologist scheduled in a timely manner and followed through. Findings included: An interview with Resident #314 on 1/27/2021 at 9:30 a.m. revealed that he has been requesting the facility Social Worker to set up an appointment for him to see a Cardiologist as recommended by the dentist to have two of his teeth removed. Resident #314 stated that the facility has not made the appointment for him to see a Cardiologist. The resident stated that his eyesight has been getting progressively worse to the point where he was now legally blind, and he had been requesting a follow up appointment to see the eye doctor for quite a while, but no one was assisting him with the appointment. Medical record review for Resident #314 revealed an original admission date in 2019 and a re-admission date in November of 2020 with multiple diagnosis including…

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

Based on observation, interviews, and policy review, the facility did not appropriately secure medications in six (200 Low, 200 High,100 High, Cart #1, Cart #2, 100 Low) of seven medication carts and failed to ensure controlled substances were stored in a permanently attached container in one (300 hall medication storage room) of two refrigerators sampled. Findings included: Review of facility provided policy titled, Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles, with a revision date of 07/23/19 revealed under General Storage: 10. Facility should ensure that the medications and biologicals for each resident are stored in the containers in which they were originally received. On 01/29/21 at 10:21 a.m., an observation of the 200 Low Hall medication cart included a ½ and ¼ loose pieces of a tablet in second drawer from the top, and a white ¼ piece of white tablet in the drawer. Staff B Registered Nurse (RN), confirmed the presence of the unsecured tablets and pieces in both drawers. On 01/29/21 at 10:31 a.m., an observation of the 200 Hall High…

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 policy review the facility failed to ensure that food items were labeled and dated in three (100, 200, and 300) of three nourishment refrigerators on the units. Findings included: On 1/26/21 at 10:08 a.m., a tour of the kitchen and nourishment areas was conducted with the Certified Dietary Manager (CDM). The nourishment refrigerator on the 200 unit was observed with a brown substance in the bottom of the refrigerator. There was a jar of open cheese that was not dated. There were also containers of unknown food in bags unlabeled and undated. The nourishment refrigerator on the 300 unit was observed with unknown food in bags unlabeled and undated. The nourishment refrigerator on the 100 unit was observed with one bag of food with room [ROOM NUMBER]B written on the bag with a black marker, but the food items were undated. The Certified Dietary Manager (CDM) reported that the unlabeled/undated food in bags probably belonged to staff and confirmed that the items were not labeled…

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.