Aviata At Arbor Springs

Based on record review and interview, the facility failed to ensure residents received the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) within the required time frame for 1 of 3 residents reviewed for beneficiary notification (Resident #191).Findings include:Review of Resident #191's SNF Beneficiary Notification Review read, Medicare Part A Skilled Services Episode Start Date: 3/7//25, Last covered day of Part A Service: 6/12/25. The facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted.Review of Resident #191's Notice of Medicare Non-Coverage (NOMNC) notice showed the resident's Medicare coverage for current skilled services would end on 6/12/2025. The resident acknowledged the receipt of the notice and signed it on 6/11/2025.During an interview on 8/19/2025 at 11:20 AM, the Social Services Director stated, My assistant and I are responsible for the SNF ABN and NOMNC review with the residents and/or representatives, their signing the forms, and filing the signed forms appropriately in 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 record review and interview, the facility failed to ensure an accurate Level I Preadmission Screening and Resident Review (PASRR) screen was completed and failed to coordinate assessments for the residents with newly evident or possible serious mental disorder for 1 of 2 residents reviewed for behavioral diagnosis (Resident #22).Findings include: Review of Resident #22's admission record showed the resident was admitted on [DATE] with diagnosis including but not limited to generalized anxiety (onset date of 7/15/2025), major depressive disorder (onset date of 8/20/2025), and bipolar disorder (onset date of 8/20/2025). Review of Resident #22's PASRR dated 7/15/2025 showed no mental illness to include depression disorder, anxiety disorder, or bipolar disorder under Section I. PASRR Screen Decision Making.Review of Resident #22's physician order dated 7/15/2025 read, Clonazepam Oral Tablet 1 MG [milligram] (Clonazepam), Give 1 tablet by mouth every 12 hours for Anxiety.Review of Resident #22's physician…

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 Peripherally Inserted Central Catheter (PICC) dressings were changed as ordered for 2 of 10 residents reviewed for intravenous (IV) therapy (Residents #178 and #183) and failed to ensure residents received blood pressure medications as ordered for 1 of 7 residents reviewed for medication management (Resident #101). Findings include: 1) During an observation on 8/18/2025 at 10:39 AM, Resident #183 was lying in bed. There was a double lumen PICC line on the resident's left upper arm with a transparent dressing dated 8/8/2025, with dry black matter (Photographic evidence obtained). During an interview on 8/18/2025 at 10:39 AM, Resident #183 stated, My IV dressing was last changed on the 8th [8/8/2025] during my hospital stay. During an observation on 8/19/2025 at 8:30 AM, Resident #183 was lying in bed. There was a transparent dressing with gauze under the dressing dated 8/18/2025. During an observation on 8/21/2025 at 8:02 AM, Resident #183 was lying in bed. There was an IV transparent dressing 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.

Based on observation, interview, and record review, the facility failed to administer oxygen at the ordered flow rate for 2 of 3 residents reviewed for respiratory services (Residents #8 and #184).Findings include:1) During an observation on 8/18/2025 at 10:48 AM, Resident #184 was lying in bed, being administered oxygen at 2 liters per minute via nasal cannula.During an observation on 8/19/2025 at 10:39 AM, Resident #184 was lying in bed, with oxygen being administered at 2 liters per minute via nasal cannula.Review of Resident #184's physician order dated 8/12/2025 read, Oxygen at 3 liters/min [minute] via Nasal Cannula continuous every shift.During an observation on 8/20/2025 at 2:54 PM with Staff K, Licensed Practical Nurse (LPN), Resident #184 was being administered oxygen at 3 liters per minute.During an interview on 8/20/2025 at 2:54 PM, Staff K, LPN, stated, [Resident #184's name] has orders for oxygen to be administered at 3 liters per minute. I had to readjust his oxygen. Nurses are supposed to check every shift the residents' oxygen flow rate.During an interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure resident assessments accurately reflected each resident's status for 1 of 3 residents reviewed for nutrition, Resident #3. Findings include: Review of Resident #3's annual Minimum Data Set (MDS) dated [DATE] showed the resident was not on a therapeutic diet while a resident at the facility under Section K- Swallowing/Nutritional Status. Review of Resident #3's physician order dated 11/18/2024 read, Regular diet Regular texture, regular/thin consistency, CCD NAS (Controlled Carbohydrate Diet No Added Salt) diet. During an interview on 5/8/2025 at 10:13 AM, the MDS Coordinator stated, [Resident #3's name] MDS will have to be modified to reflect she was on a controlled carbohydrate diet back in November. During an interview on 5/8/2025 at 10:48 AM, the Director of Nursing stated, The MDS should be accurate, reflecting the correct information pertaining to the resident.

Based on observation, interview, and record review, the facility failed to ensure residents received care and services according to professional standards of practice for 2 of 6 residents reviewed for IV (Intravenous) therapy, Residents #6 and #3. Findings include: 1) During an observation on 5/8/2025 at 5:40 AM, Resident #6 was sleeping. The resident had a single lumen midline catheter to her left upper arm, infusing IV fluids. The transparent dressing over the midline insertion site was lifting up at the edges. Under the transparent dressing, there was a gauze that had dried blood on it; occluding the view of the insertion site. The dressing was dated 4/29/2025. Review of Resident #6's physician order dated 4/29/2025 read, Insert midline: May use 1% Lidocaine for IV insertion one time only for IV hydration for one day. Review of Resident #6's physician order dated 5/1/2025, with discontinued date of 5/2/2025 read, Change Left arm midline catheter dressing every week with transparent dressing. Review of Resident #6's medication administration record (MAR) for May 2025 showed no…

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 residents' drug regimen were free from unnecessary antibiotic use based on adequate indications to reduce the risk of the development of antibiotic-resistant organisms for 1 of 3 residents reviewed for infection, Resident #7. Findings include: Review of Resident #7's physician order dated 5/4/2025 read, Ertapenem Sodium injection solution reconstituted 1 GM [gram], Inject 1 gram intramuscularly one time a day for UTI [Urinary Tract Infection] for 10 days. Review of Resident #7's physician order dated 5/4/2025 read, Urinalysis w [with]/reflex culture one time only related to quadriplegia, unspecified. Review of Resident #7's physician progress note dated 5/4/2025 read, Assessment/Plan: 1. Trach bleeding/Dark urine: Improved: No further episodes of bleeding from trach. Secretions are normal (pale yellow) in color, consistency. Eliquis was put on hold - but no improvement in color of urine. He has had history of UTI with brown-colored urine in March 2025. Ordered UA [urinalysis]/UC [urine culture] yesterday but do 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 and interview, the facility failed to implement the antibiotic stewardship program by failing to monitor the use of antibiotics to reduce the risk of the development of antibiotic-resistant organisms for 1 of 3 residents reviewed for infection, Resident #7. Findings include: Review of Resident #7's admission record showed diagnoses that included, but not limited to, acute and chronic respiratory failure with hypoxia, personal history of traumatic brain injury, traumatic subarachnoid hemorrhage without loss of consciousness, tracheostomy status, gastrostomy status, neuromuscular dysfunction of bladder, post traumatic seizures, and quadriplegia. Review of Resident #7's physician order dated 5/4/2025 read, Urinalysis w [with]/reflex culture one time only related to quadriplegia, unspecified. Review of Resident #7's physician order dated 5/4/2025 read, Ertapenem Sodium injection solution reconstituted 1 GM [gram], Inject 1 gram intramuscularly one time a day for UTI [Urinary Tract Infection] for 10 days. Review of Resident #7's physician progress note 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 observation, interview, and record review, the facility failed to ensure residents received the correct oxygen flow rate for 1 of 3 residents, Resident #6, reviewed for respiratory services. Findings include: During an observation on 3/6/2025 at 9:18 AM Resident #6 was lying in bed with oxygen being administered at 2 liters per minute via tracheotomy mask. During an observation on 3/6/2025 at 12:54 PM with the Director of Nursing (DON), Resident #6 was lying in bed. Oxygen was being administered at 2 liters via tracheostomy mask. Review of Resident #6 physician order dated 2/19/2025 read, Trach Ventilator Setting: FI027 [fraction of inspired oxygen], 5Lo2 (5 liters oxygen) humidified. Review of Resident #6 admission Record documented the resident was admitted on [DATE] with diagnosis that includes but not limited to chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, and sleep apnea. During an interview on 3/6/2025 at 12:56 PM the DON stated, Resident #6 has orders for 5…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents were transferred out of bed using mechanical lift for 1 of 3 residents reviewed, Resident #4. Findings include: Review of Resident #4's admission record showed the resident was admitted on [DATE] with diagnoses including type 2 diabetes mellitus with diabetic neuropathy, essential hypertension, hyperlipidemia, obesity, depression, sleep apnea, muscle weakness, neuralgia and neuritis, Transient Ischemic Attack (TIA) and cerebral infarction, and anemia. Review of Resident #4's care plan showed the resident was at risk for decreased ability to perform ADLs (Activities of Daily Living) in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion and toileting related to activity intolerance, CVA (Cerebrovascular Accident), recent hospitalization, and recent illness. During an interview on 8/21/2024 at 10:00 AM, Resident #4 stated, The Hoyer lift had dead batteries for 3 days, Friday [8/16/2024], Saturday…

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 provide a clean and homelike environment (Photographic evidence obtained). Findings include: During an observation on 8/21/2024 at 10:22 AM, there was a dead brown small pest in a cobweb noted high on the left side of the bed directly below the ceiling tiles in Resident #5's room. During an interview on 8/21/2024 at 10:22 AM, Resident #5 stated, I don't want bugs in my room. During an observation on 8/21/2024 at 10:41 AM, the baseboard in Resident #1's room was peeling away from the wall and there were multiple dead brown small pests inside the baseboard. There were three dead brown small pests inside the cobwebs high on the walls. There were two dead brown small pests above the windows and one on the left side of the bed below the ceiling tiles, all three in cobwebs. During an interview on 8/21/2024 at 10:41 AM, Resident #1 stated, I see live bugs crawling all over especially in the bathroom. If they sprayed in here, I don't remember. I don't know if those bugs are alive or dead bugs on the walls, but they are gross. They…

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 that residents received treatment and care in accordance with professional standards of practice when a dietary supplement for wound healing was not provided as ordered for 1 of 3 residents, Resident #2. Findings include: Record review of Resident #2's clinical record revealed resident was admitted with diagnosis that included pressure ulcers, paraplegia, muscle wasting, and atrophy. Review of Resident #2's physician orders dated 8/14/2024 read Juven [a supplement that provides essential nutrients for wound healing] two times a day for supplement Juven 1 packet w/(with) 8 oz (ounces) water BID (twice a day). Review of Resident #2's Medication Administration Record (MAR) dated 8/1/2024 - 8/31/2024 revealed that Juven was not documented as administered on 8/16, 8/17, 8/18 (2 doses), 8/21 (2 doses), and 8/22. There was no documentation in the chart where the doctor or nutritionist was informed that Juven was not available and was not administered. During an interview on 8/21/2024 at 2:50 PM, Resident #2 stated, I'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.

Based on interview and record review, the facility failed to ensure resident environment was free of accident hazards by failing to ensure locks on the beds worked for 1 of 3 residents reviewed for accidents, Resident #2. Findings include: During an interview on 8/31/2024 at 2:50 PM, Resident #2 stated, I tried to transfer to the bed from the wheelchair, which I have done for years. The bed was not locked. The bed moved and I fell to the floor. The bed would not lock. It was broke. Review of Work Order #5582 for Resident #2's bed dated 8/1/2024 showed it read, Room/Area: [Resident #2's room number] . Comments: bed wheels replaced 8/2/24. Review of Work Order #5641 for Resident #2's bed dated 8/13/2024 showed it read, Notes: Resident stated that the bed is not going down. It is causing resident to be unable to on his feet. During an interview on 8/22/2024 at 12:51 PM, the Maintenance Director stated, The bed would not lock, and an order was placed in TELLS [communication tool for maintenance work orders]. I do not have a routine schedule to routinely check the beds to make sure the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene during medication administration, failed to ensure enhanced barrier precautions were followed and failed to ensure staff performed hand hygiene and followed infection control standards during wound care to prevent possible spread of infection and communicable diseases. Findings include: 1. During an observation on 5/21/2024 at 5:00 AM, Staff A, Registered Nurse (RN), unlocked the medication cart and obtained a blood glucose monitoring machine, blood glucose strips and alcohol wipe without performing hand hygiene. Staff A entered Resident #140's room, donned gloves without performing hand hygiene and obtained the blood glucose sample for testing. Staff A doffed gloves and exited the room without performing hand hygiene and returned to the medication cart. During an observation on 5/21/2024 at 5:05 AM, Staff A, RN, unlocked the medication cart and prepared Resident #460's medications without performing…

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 medications were administered appropriately for 3 of 9 reviewed residents with enteral tube, Residents #91, #96, #151, and for 1 of 2 residents with central catheters, Resident #260. Findings include: 1. During an observation of medication administration on 5/22/2024 at 10:45 AM, Staff D, Registered Nurse (RN), prepared 5 medications for Resident #91. Staff D entered Resident #91's room and disconnected the enteral feeding from the pump and from the resident. Staff D did not verify gastrostomy tube placement and immediately administered 60 milliliters of water by pushing the piston of the feeding syringe and not letting water flow via gravity. Staff D administered all 5 medications one after the other without flushing the enteral feeding tube between medications. All 5 medications were administered by pushing down the piston of the syringe and not by gravity flow. Staff D flushed the enteral tube with 15 milliliters of water. During an interview on 5/22/2024 at 10:55 AM, Staff D, RN, stated, I 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 that residents received wound care treatment in accordance with professional standards of practice for 4 of 4 residents reviewed for wound care, Residents #91, #73, #133 and #155. Findings include: 1. Review of Resident #91's admission record showed the resident was most recently admitted on [DATE] with diagnoses including gastrostomy status, colostomy status, acute and chronic respiratory failure with hypoxia, tracheostomy status, and stage 4 pressure ulcer of sacral region. Review of Resident #91's nursing progress notes dated 5/18/2024 at 7:56 PM read, Family performed wound care on resident by themselves. Family was educated on the importance of infection control and safety precautions. During an interview on 5/21/2024 at 4:10 PM, Resident #91's Representative stated, I changed his dressing because they didn't. I told the nurse that. The dressing was in need of getting done. During an observation on 5/22/2024 at 6:40 AM, Staff…

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

Based on observation, interview, and record review, the facility failed to ensure residents received appropriate care and services for enteral nutrition for 2 of 4 residents reviewed for gastric feeding tubes, Residents #96 and #151. Findings include: 1. During an observation on 5/20/2024 at 9:30 AM, Resident #96's tube feeding formula bottle and water bag were empty. The feeding machine was beeping. There was an empty Jevity 1.5 formula bottle with no labeling. During an observation on 5/21/2024 at 12:25 PM, Resident #96 was receiving Jevity 1.5 via feeding tube at 50 milliliters per hour. During an observation on 5/22/2024 at 7:30 AM, Resident #96 was receiving Jevity 1.5 via feeding tube at 50 milliliters per hour. During an observation with Staff D, Registered Nurse (RN), on 5/22/2024 at 11:55 AM, Staff D confirmed Resident #96's feeding rate was 50 ml/hr [milliliter per hour] and the auto flush rate was running at 60 ml/hr. Review of Resident #96's physician order dated 5/17/2024 showed the order read, Enteral Feed Order one time a day Jevity 1.5 @ 55 ml/hr x 20 hrs on 2 pm off…

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 ensure medical records were accurate for 4 of 4 residents reviewed for wound care, Residents #91, #73, #133 and #155, for 1 of 2 residents with central catheter, Resident #260, and for 1 of 4 residents with feeding tube, Resident #151. Findings include: 1. Review of Resident #91's admission record showed the resident was most recently admitted on [DATE] with diagnoses including gastrostomy status, colostomy status, acute and chronic respiratory failure with hypoxia, tracheostomy status, and stage 4 pressure ulcer of sacral region. Review of Resident #91's Treatment Administration Record (TAR) for May 2024 showed no entries documented on 5/1/2024, 5/2/2024, 5/3/2024, 5/7/2024, 5/8/2024, and 5/16/2024 for Cleanse coccyx with n/s [normal saline] saline, pat dry, apply medi-honey and collagen particles, cover with Calium alginate, top with bordered foam dressing every day shift related to pressure ulcer of sacral region, stage 4. Start Date:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for language and communication for 1 of 3 residents reviewed, Resident #155. Findings include: During an interview on 5/20/2024 at 10:31 AM, Resident #155 stated in Spanish, I only speak Spanish and at times I have a hard time communicating with staff. Review of Resident #155's Medicare 5-Day Minimum Data Set (MDS) dated [DATE] showed the assessment read, Section A: Identification information. A110. Language: Spanish. Review of Resident #155's care plan did not include language or communication as a focus. During an interview on 5/22/2024 at 12:22 PM, the MDS Coordinator stated, I don't see where he is care planned for communication. I will translate for him. Nurses who take care of him and communicate with him in Spanish. The social services also speaks Spanish. We spoke to therapy to get him a picture board. Review of the facility policy and procedures titled Plans of Care with the last approval date of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received appropriate respiratory care services for 2 of 5 residents reviewed for respiratory care, Residents #91 and Resident #96. Findings include: 1. Review of Resident #91's admission record showed the resident was admitted on [DATE] with diagnoses including acute and chronic respiratory failure with hypoxia and tracheostomy status. Review of Resident #91's physician orders showed an order dated 3/28/2024 for administration of oxygen at 4 liters/minute via tracheostomy collar, with humidification every shift and as needed. Review of Resident #91's physician order dated 5/6/2024 read, Suction tracheostomy tube as needed to clear airway. Document results in PN [progress notes] as need for trach [tracheostomy] care. During an observation on 5/20/2024 at 10:30 AM, Resident #91 was in bed with a tracheostomy collar, receiving oxygen at 5 liters per minute. During an observation on 5/22/2024 at 6:02 AM, Resident #91 was in…

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

Based on record review and interview, the facility failed to ensure 2 of 2 residents (Resident #21 and Resident #80) received a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN Form 10055) as required. Findings include: 1. Review of the Notice of Medicare Non-Coverage form for Resident #21 revealed the skilled nursing services would end on 10/10/2022. Review of the Beneficiary Protection Notification Review form completed by the Social Services Director revealed the facility/provider initiated Resident #21's discharge from Medicare Part A Services when his benefit days were not exhausted. Review of Resident #21's medical records did not reveal any documentation that Resident #21 had been provided the SNF ABN Form 10055 to inform her or her representative of potential liability for payment and related standard claim appeal rights. 2. Review of the Notice of Medicare Non-Coverage form for Resident #80 revealed the skilled nursing services would end on 9/7/2022. Review of the Beneficiary Protection Notification Review form completed by the Social Services…

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 treatment and care in accordance with professional standards of practice for 3 of 7 residents reviewed for central venous access devices (Residents #131, #107, and #239) and for 1 of 4 residents reviewed for gastrostomy tube (Resident #113). Findings include: 1. During an observation on 1/17/2023 at 9:25 AM, Resident #131 was sitting up at bed side with a single lumen midline. The dressing was dated 1/10/2023 and was covered with a transparent dressing, with gauze under the dressing. During an interview on 1/17/2023 at 9:25 AM, Resident #131 stated, Staff have not changed my IV [intravenous] dressing in a long time. The staff do not take care of it. Review of the admission record for Resident #131 revealed he was admitted to the facility on [DATE] with the diagnoses including but not limited to a history of osteomyelitis (bone infection), type 1 diabetes mellitus with foot ulcer, cardiac arrest, hereditary and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received respiratory care services in accordance with professional standards of practice for 5 of 8 residents reviewed for respiratory care (Residents #30, #81, #113, #390, #392). Findings include: 1. During an observation on 1/17/2023 at 9:13 AM, Resident #390 was lying in bed wearing a nasal cannula with oxygen running at 2 liters per minute. No time and date were noted on tubing. During an interview on 1/17/2023 at 9:13 AM, Resident #390 stated that she has used oxygen since she was admitted to the facility. During an observation on 1/18/2023 at 10:25 AM, Resident #390 was sitting in his wheelchair with oxygen running at 2 liters per minute via nasal cannula. Review of the admission record for Resident #390 revealed the resident was admitted to the facility on [DATE] with the diagnoses including but not limited to other orthopedic aftercare, fracture of orbital floor, left side, subsequent encounter for fracture 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 observation, interview, and record review, the facility failed to ensure that all drugs and biologicals used in the facility were stored and labeled in accordance with professional standards in 4 of 6 medication carts (300 hall cart, 400 hall cart, south front cart and 5 acute cart) and failed to ensure medications were secured (photographic evidence obtained). Findings include: 1. On [DATE] at 8:45 AM, during an observation of the 5 acute cart with Staff A, Licensed Practical Nurse (LPN), there were one unopened Levemir flex touch pen and three Aplisol injectables that required refrigeration and expired on [DATE], [DATE] and [DATE], respectively. During an interview on [DATE] at 8:45 AM, Staff A, LPN, stated that the Levemir flex touch pen was unopened, and three Aplosol injectables should have been in the refrigerator and not in cart. 2. On [DATE] at 9:00 AM, during an observation of the 400 hall cart, there were two Timolol eye drops, one opened Ciprodex ear drops, and one opened Polymyxin eye drops,…

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 foods and beverages were stored in a safe and sanitary manner. Findings include: During the tour of the facility main kitchen with the Certified Dietary Manager (CDM) on 1/17/2023 beginning at 9:15 AM, there were an opened bag of raw chicken breast, an opened bag of raw beef patties, and an opened box of omelets stored in the walk-in freezer exposing the food items to drying out and freezer burn. In the main food preparation/production area, there were three serving scoops, two serving ladles, and two serving spoons observed in a utensil storage drawer that had a buildup of food residue on them. The utensil storage drawer had numerous food particles and crumbs in two of three storage drawers used for clean utensil storage. During an interview on 1/17/2023 at 9:30 AM, the CDM acknowledged the open bags of food items stored in the walk-in freezer and stated they should have been closed after the needed items were removed from the bags of raw foods. The CDM verified the dirty utensils stored in the…

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

Based on record review and interview, the facility failed to ensure a minimum data set (MDS) assessment was completed in a timely manner for 1 of 4 residents reviewed for timely submission of the MDS, Resident #116. Findings include: Review of Resident #116's MDS records showed the facility had completed an admission MDS on 9/7/2022. Further review of the records did not reveal a completed Quarter 1 MDS on 12/8/2022 when Resident #116's Quarter 1 MDS was due. Resident #116's Quarter 1 MDS was 27 days overdue on 1/18/2023. During an interview on 1/18/2023 at 12:57 PM, the MDS Coordinator verified Resident #116's Quarter 1 MDS had not been completed in a timely manner.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medical records were accurate and complete for 4 of 7 reviewed residents (Residents #76, #107, #131, and #239). Findings include: 1. During an observation on 1/17/2023 at 9:25 AM, Resident #131 was sitting up at bed side with a single lumen midline. The dressing was dated 1/10/2023 and was covered with a transparent dressing, with gauze under the dressing. During an interview on 1/17/2023 at 9:25 AM, Resident #131 stated, Staff have not changed my IV [intravenous] dressing in a long time. The staff do not take care of it. Review of the admission record for Resident #131 revealed he was admitted to the facility on [DATE] with the diagnoses including but not limited to a history of osteomyelitis (bone infection), type 1 diabetes mellitus with foot ulcer, cardiac arrest, hereditary and idiopathic neuropathy, and sepsis, resistance to multiple antibiotics, and enterocolitis due to clostridium difficile. Review of the Treatment…

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.