Avante At Ocala, INC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure resident assessments were accurate and reflected the resident's current status for 3 of 12 residents, Residents #17, #50, and #152, reviewed for Minimum Data Set (MDS) accuracy.Findings include: 1) During an observation on March 23, 2026, at 11:53 AM of Resident #50, the resident had no teeth. Review of the Modification of Annual Minimum Data Set, dated [DATE], documented under Section L for Oral/Dental Status subsection B which asks does the resident have no natural teeth or tooth fragments, it was marked No. During an interview on March 25, 2026, at 10:23 AM, Staff C, LPN stated the entry of no for No natural teeth or tooth fragments was marked incorrectly. Review of the resident's denture appointment documentation from [name of local dental service] dated September 19, 2025, indicated Resident #50 had no teeth. 2) Record review of occupational therapy Discharge summary dated [DATE] for Resident #17 documented a past medical…

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 develop and/or implement a comprehensive, person-centered care plan for 3 of 12 residents, Residents #8, #17, and #28, reviewed for comprehensive, person-centered care plans. Findings Include: 1) During an observation on 3/23/2026 at 9:30 AM Resident #8 was sleeping and did respond to being addressed by name. Resident was dressed and lying in bed covered with a blanket. The head of the bed was elevated. During an interview on 3/23/2026 at 4:30 PM the Director of Nursing (DON) stated, She [Resident #8] is on hospice. A request was made to review Resident #8's care plan for hospice. The DON said the resident stated she did not want hospice and then wanted hospice. [Resident #8's name] should have an order for hospice and have a care plan for hospice. During an interview on 3/24/2026 at 8:20 AM Business Office Manager (BOM) provided a Change in [NAME] form for Resident #8 and stated, Here is the hospice information about the Resident. Review of the Long Term Care Facility-Change in [NAME] form for Resident #8…

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

Based on interview, observation, and record review, the facility failed to ensure assistance with activities of daily living (ADLs) for nail care for 1 of 6 residents, Resident #86, reviewed for ADL care. Findings includeDuring an interview on 03/23/2026 at 2:04 PM Resident Representative for Resident #86 stated, They don't cut her [Resident #86's] nails, and her nails were digging into her palm the last time I saw her. During an observation on 03/24/2026 at 9:18 AM Resident #86's right hand was contracted into a closed position. The Resident's fingernails extended beyond her fingertips, touching the palm of her right hand.During an observation on 03/25/2026 at 8:53 AM, Resident #86 had a brace on her right arm and a washcloth in her right hand. The Resident's fingernails were approximately 1-1.5 inches long on her right thumb, right second finger, right third finger and right fourth finger. During an interview on 03/25/2026 at 10:31 AM, Staff A, CNA (Certified Nursing Assistant) stated, I'm planning on giving her a bath in a little while. Her nails are too long right now. The CNA…

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 obtain the medication dosage prior to administration for 1 of 3 residents, Resident #84, and failed to ensure wound care treatment orders and wound care for 1 of 3 residents, Resident #157, observed for wounds. Findings include: Review of Resident #84's physician order dated 3/10/2026 read, Voltaren external gel 1% diclofenac sodium topical. Apply to knees topically before meals and at bedtime for pain. The required dosage for application is not documented. Review of Resident #84's Medication Administration Record for the period of 03/01/2026 to 03/25/2026 documented the Voltaren gel was administered. During an interview on 3/25/2026 at 1:46 PM, the Director of Nursing (DON) stated, The Voltaren order does not have a dosage. Review of my.clevelandclinic.org read, Voltaren Gel is a type of nonsteroidal anti-inflammatory drug (NSAID). This medication can cause serious bleeding, ulcers, or tears in the stomach. These problems can occur at any time and with no warning signs. They are more common with long-term…

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 staff failed to ensure that nebulizer mask stored after use consistent with professional standards of practice for 2 residents( Resident # 84 and Resident #121) of 6 Residents reviewed for respiratory care. Findings include:Findings include: 1) Review of Resident #84's clinical record documented the resident was admitted on [DATE] with diagnosis to include osteomyelitis (infection in the bone), acute respiratory failure, and pneumonia. During an observation on 3/23/2026 at 10:50 AM of Resident #84's room, the resident's nebulizer mask was lying across the nebulizer machine on the bedside table open to air and not in a bag. During an interview on 3/23/2026 at 10:50 AM Resident 84 stated, I take breathing treatments two times a day. I had the treatment this morning around 8 AM. During an observation on 3/23/2026 at 3:30 PM of Resident #84's room, the resident's nebulizer mask was lying across the nebulizer machine on the bedside table, open to air 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, interview, and record review, the facility failed to ensure the medication error rate was not five percent or greater for 2 out of 37 observations. The facility had a medication error rate of 5.41%.Findings include:During an observation on 3/25/2026 at 8:29 AM Staff BB, Licensed Practical Nurse (LPN) was preparing medications for Resident #100. Staff BB placed an 81 milligram (mg) chewable aspirin into the medication cup along with other prescribed medications. Prior to Staff BB entering Resident #100's room, the surveyor requested verification of the order for the 81 mg aspirin. During an interview on 3/25/2026 at 8:34 AM with Staff BB, LPN stated, [Resident #100's name] has an order for Aspirin 81 milligrams delayed release. I cannot interchange the two different Aspirins. I will have to go look for the medication in the medication room.Review of Resident #100's physician order dated 10/7/2025 read, Aspirin 81 Tablet Delayed Release 81 mg [milligram] (Aspirin) give 1 tablet by mouth one time a day for heart health.During an observation on 3/25/2026 at 8:50 AM…

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 drugs were secured and/or not expired in accordance with professional standards for 2 of 3 units, for Residents #28, #155, #156, residents observed with unsecured and/or expired medications, not securing medications when unattended for 1 of 5 medication carts, and expired medications for 2 of 5 medication carts.Findings include: 1) During an observation on 3/23/2026 at 10:20 AM of Resident #155's room one bottle of Xlear Nasal decongestant and one bottle of extra strength Tums Antacid were on Resident #155's bedside table unsecured. (Photograph evidence obtained). During an observation on 3/23/2026 at 2:54 PM of Resident #155's room there was one bottle of Xlear Nasal decongestant and one bottle of extra strength Tums Antacid on Resident #155's bedside table unsecured. During an observation on 3/24/2026 at 2:58 PM with the Clinical Staff one bottle of Xlear Nasal decongestant and one bottle of extra strength Tums Antacid were on Resident #155's bedside table unsecured. 2) During an observation on…

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

Based on record review and interview, the facility failed to ensure resident records were complete and accurate for 5 of 8 residents, Residents #11, #12, #14, #49, and #77, reviewed for medical records.Findings include: 1) Review of Resident #11's physician order dated 12/3/2025 read, Atorvastatin Calcium Oral Tablet 40 mg [milligrams], Give 1 tablet by mouth one time a day for HPLD [hyperlipidemia]. Review of Resident #11's Medication Administration Record (MAR) for March 2026 revealed no documentation for administration of Atorvastatin Calcium Tablet 40 mg on 3/10/2026 and 3/15/2026. Review of Resident #11's physician order dated 12/3/2025 read, Potassium Chloride ER [Extended Release] 10 meq [milliequivalent], Give 1 tablet by mouth one time a day for hypokalemia. Review of Resident #11's MAR for March 2026 revealed no documentation for administration of Potassium Chloride ER 10 meq on 3/10/2026, and 3/15/2026. Review of Resident #11's physician order dated 10/3/2025 read, Apixaban Oral Tablet 2.5 mg, Give 1 tablet by mouth two times a day for DVT [Deep Vein Thrombosis]…

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 staff performed hand hygiene during medication administration, failed to ensure staff sanitized enteral medication flush syringe, failed to ensure an infection control barrier was provided in the laundry room, and failed to ensure staff used appropriate PPE (Personal Protective Equipment) for the residents on transmission based precautions to prevent the possible spread of infection and communicable diseases.Findings include: 1) During an observation on 3/25/2026 at 8:50 AM, Staff AA, Licensed Practical Nurse (LPN), exited a resident's room and walked to the medication cart, and poured medications for Resident #142 without performing hand hygiene. Staff AA entered Resident #142's room, did not perform hand hygiene, handed the resident his medication and handed the resident a Styrofoam cup to drink water, touching the straw. Staff AA exited Resident #142's room without performing hand hygiene. Staff AA began to pour Resident #76'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 interview and record review, the facility failed to implement care plan interventions related to management of a metabolic condition/concern related to hypokalemia for 1 (Resident #4) of 3 residents reviewed for nutritional services and failed develop a care plan to address 1 (Resident #1) of 3 with a diagnosis of post traumatic stress disorder reviewed for behavioral health.Findings include: 1.) Review of Resident #4's care plan, initiated 8/16/2023, documented Resident #4 had a metabolic condition/concern related to hypokalemia [low potassium]. Resident #4's care plan documented nutritional interventions that included, RD [Registered Dietician] to evaluate quarterly and PRN [as needed]. Monitor caloric intake, observe/review/estimate needs and make recommendations as indicated. Review of Resident #4's clinical record failed to reveal documentation the Registered Dietician had completed quarterly evaluations of Resident #4 to monitor Resident #4's caloric intake and to observe/review/estimate Resident…

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

Based on interviews and observations, the facility failed to ensure sufficient clean linen, washcloths, towels, and protective bed pads, to meet the care needs of residents Findings include:During an interview on 8/13/2025 at 4:30 PM, Resident #5 stated, At the end of a shift, we have to wait for the laundry to deliver or someone has to go get some from the laundry. The laundry is not open during the night shift.During an interview on 8/13/2025 at 4:45 PM Resident #1 stated, I do not have anything to wash my face and hands.During an interview on 8/13/2025 at 6:15 PM, Resident #6 stated, The aids scramble at the end of shift to find bed pads that help keep the sheets dry. They do not have enough.During an interview on 8/13/2025 at 8:40 PM Resident #2 stated, I have reported it [not enough linens, washcloths or towels]. They do not have enough to last the night. I have had to wait to get clean washcloths and towels.During an interview on 8/13/2025 at 4:58 PM Staff L, Laundry Staff stated, Generally the CNAs will let me know if they need any linen. I work until 12 midnight. They do run…

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 interviews, observations, and policy and procedure review the facility failed to ensure snacks were offered and/or served to 5 of 5 residents, Residents #1, #2, #3, #4, and #5, sampled for evening snacks.Findings include:During an interview on 8/13/2025 at 4:30 PM Resident #3 stated, I am a diabetic. They never come to you or your room and ask if you want a snack. You can get a snack if you go to the nurses' station and ask for one. Residents #4 and #5 were present during the interview. Resident #4 stated, That is if there is someone at the desk to ask. Resident #5 added, Not all the residents can come to the nursing station. My roommate can't come to the nurses' station. The CNAs (Certified Nursing Assistants) should check with all the residents and ask them if they want a snack.During an interview on 8/13/2025 at 4:45 PM with Resident #1 when asked when snacks are provided Resident #1 stated, They don't come around and give you snacks.During an interview on 8/13/2025 at 8:40 PM, Resident #2 stated, I don't like to leave my room because I have seizures, and I am…

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

Based on interview and record review the facility failed to ensure residents medical records were complete and accurate for 1 of 3 residents, Resident #1, reviewed for mood and behaviors. Findings include: Review of the Active Orders for Resident #1, physician's order dated 12/25/2024, provided for a documentation system to track Resident #1 for behavior monitoring and staff interventions that read as follows, Behavior code-0-no behavior, 1-Fear/panic, 2-anger, 3-Scream/yell, 4-Danger/self/others, 5-Delusions, 6-Hallucinations, 7-Sad/tearful, 8-Emotion/Acts withdrawal, 9-other. Interventions - 1-music/aromatherapy, 2-Reminiscence/reality orient, 3-Exercise/activity, 4-1:4 5-Reduce stim [stimuli] 6-PRN [as needed] med outcome I-improved S-Same, W-Worse, Side Effects - 0-none, 1-EPS [extrapyramidal symptoms] 2-Tardive Dys [Dyskinesia] 3-Hypotension, 4-Inc behavior, 5-Sedation/drowsy, 6-Inc Falls/dizzy as needed for behavior. Review of Resident #1 physician order dated 3/16/2025 read, Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 MG (milligram)give 250 mg by mouth two…

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 and interview, the facility failed to ensure an accurate Level I Preadmission Screening and Resident Review (PASRR) screen was completed for 1 of 2 residents who were diagnosed with serious mental disorder, Resident #58. Findings include: Review of Resident #58's admission record with an initial admission date of 10/20/2022 and the most recent admission date of 7/25/2024 revealed Resident #58 had diagnosis of bipolar disorder, with an onset date of 1/6/2020. Review of Resident #58's Level I PASRR screening dated 10/6/2023 showed depressive disorder documented under PASRR Screen Decision-Making section for mental illness. Review of Resident #58's clinical records failed to show documentation Resident #58's diagnosis of bipolar disorder had been included on his Level I PASRR screening dated 10/6/2023. During an interview on 10/16/2024 at 10:04 AM, the Director of Nursing confirmed Resident #58's diagnosis of bipolar disorder had not been included on his Level I PASRR screening dated 10/6/2023.

Based on record review and interview, the facility failed to ensure residents received treatment and care according to professional standard of practice by administering narcotic pain medication out of parameters for 2 of 3 residents reviewed, Residents #73 and #318. Findings include: 1) Review of Resident #73's physician order dated 10/2/2024 read, Tramadol HCl Oral Tablet 50 mg [milligrams] (Tramadol HCl) Controlled Drug Give 1 tablet via G-Tube [gastrostomy tube] every 8 hours for pain scale 5-10. Review of Resident #73's care plan dated 3/8/2022 read, Focus: [Resident #73's name] has the potential for alteration in comfort related to: limited mobility, general body aches, diabetes . Interventions . Medicate for pain as ordered. Review of Resident #73's Medication Administration Record (MAR) for October 2024 showed the resident received 6:00 AM dose of Tramadol 50 mg on 10/4/2024, 10/5/2024, 10/6/2024, 10/7/2024, 10/8/2024, 10/9/2024, 10/10/2024, 10/11/2024, 10/12/2024 and 10/15/2024 with the pain level documented as zero, and on 10/8/2024 with the pain level documented as NA…

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.

2) During an observation on 10/14/2024 at 10:17 AM, Resident #8 was lying in bed watching television. There was one tube of Diclofenac Sodium gel in a plastic bin on the resident's overbed table. During an observation on 10/15/2024 at 8:15 AM, Resident #8 was lying in bed sleeping. There was one tube of Diclofenac Sodium gel in a plastic bin on her overbed table. During an interview on 10/15/2024 at 11:19 AM, Resident #8 stated, I keep the gel there all the time because I use it a lot. Review of Resident #8's physician order dated 10/8/2024 read, [Brand Name of Product] (Diclofenac Sodium) Topical, Apply to affected area topically every day and evening shift for pain. During an interview on 10/16/2024 at 11:28 AM, the Director of Nursing stated, It is my expectation that all residents are assessed to be able to self-administer their medications, and if they are able to, then those medications should be kept in a lockbox. Review of the facility policy and procedure titled Storage and Expiration Dating of Medications, Biologicals dated 1/11/2024 read, Procedure . 3. General Storage…

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 food was safely stored, covered, labeled, or discarded in the areas of the kitchen and reach-in coolers (Photographic evidence obtained). Findings include: During an observation on 10/14/2024 at 9:00 AM, while conducting the initial walk-through tour of the kitchen with the Certified Dietary Manager (CDM), there were assorted cut melon and other fruit that were not in the original container without an identifying or date label in the reach-in cooler, two 10-pound rolls of raw ground beef laying on the counter not prepped in a pan or under running water, and uncovered and undated pans containing cake. During an interview on 10/14/2024 at 9:05 AM, the Morning Charge [NAME] stated she should not have placed the dirty rolls of raw ground beef on the counter and the beef should have been in the prep sink with running water. During an interview on 10/14/2024 at 9:07 AM, the CDM verified the unmarked fruit container was in the reach-in cooler without an identifying label or date and confirmed that the raw…

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 staff used proper personal protective equipment while providing high contact care to the residents on Enhanced Barrier Precautions to prevent the possible spread of infection and communicable diseases. Findings include: During an observation on 10/16/2024 at 1:55 PM, Resident #1's room was had a signage on the door that read, Stop. Enhanced Barrier Precautions. Everyone must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must Also: Wear gloves and a gown for the following High-Contact Resident Care Activities: Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy, Wound Care: any skin opening requiring a dressing. The Infection Prevention Officer was applying a wound dressing on Resident #1's lower left leg. The Infection Prevention Officer did not wear a gown during the dressing change for Resident #1. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the assessment accurately reflects the resident's status for 2 of 3 residents, Residents #38 and #121. Findings include: 1) Review of Resident #38 physician's order dated 2/23/2023 documented, oxygen at 2 liters/min [2 liters per minute] via nasal cannula for sob [shortness of breath] as needed. Review of Resident #38's Oxygen Sats [saturation] Summary documented, Oxygen via nasal cannula on 5/26/2023, 5/23/2023, 5/22/2023, 5/19/2023, 5/18/2023, and 5/15/2023. Review of Resident #38's MDS (Minimum Data Set) Annual dated 5/27/2023 documented, Section O Special Treatment procedures, and programs. 2. While a Resident. Oxygen. No. 2) Review of Resident #121's medical record documented the resident was admitted on [DATE] with diagnoses to include aftercare following joint replacement. Review of the physician's order dated 5/23/23 read, Pt. [patient] to discharge home on 5/26/23 patient declined home health but therapy wants to discharge…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a resident who was diagnosed with a serious mental illness received re-admission screening and resident review (PASARR) to ensure the resident receives care and services in the most appropriate setting for 1 of 3 residents, Resident #23 for PASARR. Findings include: Review of Resident #23's admission record documented Resident #23 was admitted on [DATE] with a diagnosis of paranoid schizophrenia on 1/26/2023. Review of Resident #23's Quarterly MDS (Minimum Data Set) dated 3/28/2023 documented, Section I, subcategory 1600, of the MDS indicates an active diagnosis of Paranoid Schizophrenia. Review of Resident #23's medical record revealed no level II preadmission screening and resident reviewed (PASARR) was in the medical record. Review of Resident #23's (Name of the Psychiatry Provider Group) Psychiatry Subsequent Note dated 12/15/2023 documented, Chief Complaint: Patient reported hallucinations and delusions. Reason for today's encounter: Today,…

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 care and services for central venous access devices in accordance with professional standards of practice for 1 of 3 residents, Resident #174, and for treatment and care of contractures for 1 of 3 residents, Residents #92. Findings include: 1) During an observation on 6/12/2023 at 11:30 AM Resident #174 was lying in bed with a single lumen midline covered with a transparent dressing dated 6/4/2023. During an observation on 6/13/2023 at 8:45 AM Resident #174 was lying in bed with a single lumen midline covered with a transparent dressing dated 6/4/2023. During an observation on 6/14/2023 at 8:10 AM Resident #174 was lying in bed with a single lumen Midline covered with a transparent dressing dated 6/4/2023. During an interview on 6/14/2023 at 8:14AM with Staff C, Licensed Practical Nurse (LPN) stated, I just flushed the line. The dressing is dated 6/4/2023, midline dressing should be changed every seven days, the dressing should…

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 residents received respiratory care services consistent with professional standards of practice for 2 of 4 residents, Residents #84 and #95. Findings include: 1) During an observation on 6/13/2023 at 8:19 AM Resident #84 was lying in bed and had a nasal cannula and tubing lying on the floor by the resident's shoe. The tubing was dated 6/5/2023. (Photographic evidence obtained). During an observation on 6/13/2023 at 9:30 AM Resident #84 was lying in bed with oxygen being administer via nasal cannula at 3.5 liters per minute. The oxygen tubing was dated 6/5/2023. During an interview on 6/13/2023 at 4:10 PM Staff D, License Practical Nurse stated, Oxygen is being administer close to 4 liters I will adjust it a little. The oxygen tubing is dated 6/5/2023 it should have been changed. During an interview on 6/13/2023 at 4:25 PM Director of Nursing stated, The nasal cannula and tubing should have been replaced once the staff found it on…

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

Based on observation, record review, and interview the facility failed to ensure all drugs and biologicals were stored in locked compartments to permit only authorized personnel to have access for 1 of 3 hallways, the South Unit. Findings include: 1) During an observation on 6/12/23 at 10:30 AM in Resident #8's room there was a tube of Mupirocin Ointment (a medicated ointment used to treat certain skin infections) on the bedside table. (Photographic evidence obtained). During an observation on 6/13/23 at 11:30 AM in Resident #8's room there was a tube of Mupirocin Ointment on the bedside table. During an observation on 6/14/23 at 10:20 AM in Resident #8's room there was a tube of Mupirocin Ointment on the bedside table. Review of the physicians' orders did not have an order for Resident #8 for Mupirocin Ointment or an order for Resident #8 to have medications at bedside. During an interview on 6/12/23 at 10:28 AM Resident #8 stated, That is my cream for my skin sore. I use it anytime my sore opens up. During an Interview on 6/14/23 at 10:28 AM the Director of Nursing stated,…

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.