Aviata At Oldsmar

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure care plans were developed to address identified needs for five (Residents #50, #67, #69, #71, #247) of 31 sampled residents. Findings included: 1. Resident #71 was admitted to the facility on [DATE] and re-admitted on [DATE] and had a Brief Interview for Mental Status (BIMS) score of 15 (Cognitively intact) dated 11/17/23. In an interview with Resident #71 on 02/05/24 at 12:30 p.m., she revealed she was having difficulty hearing and verbalized she needed hearing aids and had been waiting for them since before Christmas. A review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed under the heading of Hearing the following was documented: -Moderate difficulty -Hearing aid Yes A review of the resident's record revealed no documentation related to the resident having difficulty with hearing aids and no documentation that would indicate there had been communication with a vendor related to Resident #71's hearing aids. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure care plans were revised to reflect two (Residents #10 and #41) out of 19 sampled residents current needs, preferences and changing goals. Findings included: 1. A review of the facility's current smokers list showed Resident #41 was a current smoker in the facility. A review of the admission Record showed Resident #41 had an original admission date on 09/13/22 with diagnoses that included but was not limited to unspecified Dementia, other specified anxiety orders, Chronic Obstructive Pulmonary Disease (COPD), Atrial Fibrillation and anxiety disorder. A review of the Order Summary Report 02/07/24 showed no current physician order for smoking. A review of Resident #41's Quarterly Minimum Data Set (MDS) dated [DATE], Section C- Cognitive Patterns showed Resident #41 had a Brief Interview for Mental Status (BIMS) of 13 (cognitively intact). A review of a Smoking Evaluation dated 06/27/23 showed Resident #41 was not a current smoker in the facility.…

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 the appropriate treatment and assistive device to maintain residents hearing abilities for 1 of 31 (#71) total sampled residents. Findings included: Resident #71 was admitted to the facility on [DATE] and re-admitted on [DATE] and had a Brief Interview for Mental Status (BIMS) score of 15 (Cognitively intact) dated 11/17/23. Interview with Resident #71 on 02/05/24 at 12:30 PM the resident revealed that she was having difficulty hearing and verbalized that she needs hearing aids and has been waiting for them since before Christmas. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed that under the heading of Hearing the following was documented: -Moderate difficulty -Hearing aid Yes Review of the residents record revealed no documentation related to the resident having difficulty with hearing aids and no documentation that would indicate that there had been communication with a vendor related to Resident #71'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 review, and interviews, the facility failed to ensure appropriate services and equipment related to splint application for one (Resident #64) of two sampled residents. Findings included: Multiple observations were conducted of Resident #64, from 2/5/2024 at 9:58 a.m. to 2/8/2024 at 10:00 a.m. Resident #64 was observed in bed, with the head of the bed slightly raised without any splints or braces on the upper body or hands. Both of the hands of Resident #64 were closed, fingers bent touching the palms, wrists were curved under toward the forearms. A review of the medical record for Resident #64 was conducted. The admission Record revealed Resident #64 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included: Acute Respiratory Failure with Hypoxia, Tracheostomy status, Gastrostomy Status, Contracture of Right Hand, Contracture of Left Hand, Persistent Vegetative State and other co-morbidities. The Minimum Data Set (MDS) assessment dated [DATE] revealed in Section G…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure sufficient staffing in order to provide care and services for two (Residents #245 and #45) of five residents reviewed for timely medication administration. They also failed to ensure sufficient staffing to provide call light assistance for residents based on Resident Council Meeting Minutes for two of six months reviewed. Findings included: 1. An interview was conducted on 2/6/24 at 10:57 a.m. with Resident #245. The resident stated he had not yet received his 9:00 a.m. medication. An interview was conducted on 2/6/24 at 10:58 a.m. with Staff G, LPN. Staff G confirmed 9:00 a.m. medications had not been administered to all residents in room [ROOM NUMBER]-111, including Resident #245. Staff G said she was doing her best, but she was assigned 30 residents; two of which had a wound vacuum, 3 or 4 were on IV medications, some with fall risks, some new admissions, and some residents with aphasia. She said staffing is not done based 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 observations, interviews, and record review, the facility did not ensure the medication error rate was below 5% for three (Residents #79, #48, #45) out of five sampled residents who were administered medications. This resulted in seven errors from 27 medication administration opportunities for a medication error rate of 25.93%. Findings Included: An observation was conducted on 2/6/24 at 9:05 a.m. of Staff F, Licensed Practical Nurse (LPN) preparing and administering medication for Resident #79. The nurse administered the following medications: -Midodrine 2.5 mg x 1 tablet -Folic acid x 1 tablet -Glipizide XL Extended Release (ER) 5 mg x 2 tablets -Loratadine 10 mg x 1 tablet -Metoprolol 25 mg x 1 tablet Staff F, LPN did not take Resident #79's blood pressure before administering these medications. Review of Resident #79's physician orders showed an order for a multivitamin-minerals tablet to be administered at 9:00 a.m. Review of the Medication Administration Record (MAR) showed the medication was signed off but was not observed to be administered. There was a 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the proper diet, free of allergens, was served to one (Resident #42) of three reviewed for dietary restrictions. Findings included: An interview was conducted on 2/5/24 at 11:35 a.m. with a family member of Resident #42. The family member said Resident #42 was lactose intolerant and could not have dairy products and the facility continued to serve them to the resident. They said the resident had diarrhea when she consumed lactose products. The resident was observed to have a lunch tray with a grilled cheese sandwich. The family said they notified staff and asked them to send a different lunch for the resident. The family said they do not feel like dietary staff know what lactose is. (Photographic evidence obtained.) An observation was conducted on 2/5/24 at 11:50 a.m. of Resident #42's replacement lunch tray. The resident was sitting in a chair at her bedside eating her new lunch tray. The lunch consisted of chicken, broccoli,…

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, record review, facility policy review, and plan of correction review, the facility failed to ensure it had a functioning Quality Assurance and Performance Improvement (QAPI) committee. The facility was actively involved in the effective creation, implementation and monitoring of the plan of correction for deficient practice during a recertification and complaint survey conducted on 2/5/24 through 2/21/2024 and was cited F761. On 4/2/2024 the facility was recited F761. The facility had developed a Plan of Correction with a completion date 3/21/2024. Findings included: Review of the facility's plan of correction revealed: On 3-12-24 the Director of Nursing and/or Designee in-serviced licensed nursing staff on storage of medications and biologicals in medication carts, treatment carts, & medication rooms Any newly hired licensed nursing staff and/or any agency licensed nursing staff will be in-serviced on storage of medications and biologicals in medication carts, treatment carts, &medication rooms. The Director of nursing and/ or designee will…

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 facility failed to ensure two residents (#79 and #65) out of three residents reviewed for blood pressure medication were free from significant medication errors related to blood pressure medication. Findings included: An observation was conducted on 2/6/24 at 9:05 a.m. of Staff F, Licensed Practical Nurse (LPN) preparing and administering medication for Resident #79. The nurse administered the following medications: -Midodrine 2.5 mg x 1 tablet -Folic acid x 1 tablet -Glipizide XL Extended Release (ER) 5 mg x 2 tablets -Loratadine 10 mg x 1 tablet -Metoprolol 25 mg x 1 tablet Staff F, LPN did not take Resident #79's blood pressure before administering these medications. Review of Resident #79's physician orders showed an order for a multivitamin-minerals tablet to be administered at 9:00 a.m. Review of the Medication Administration Record (MAR) showed the medication was signed off but was not observed to be administered. There was a physician order, 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, record review and interview, the facility failed to ensure one resident (Resident #5) out of three residents reviewed for reporting allegations of abuse, neglect, exploitation, or mistreatment, had an immediate report submitted no later than 2 hours after an allegation that resulted in serious bodily injury. Findings included: A review of Resident #5's admission record showed Resident #5 was originally admitted to the facility on [DATE] and a re-admission date on 10/11/23. Resident #5's diagnoses included Malignant neoplasm of head, face and neck, Malignant neoplasm of unspecified kidney, except renal pelvis and Secondary malignant neoplasm of left lung. Review of Resident #5's comprehensive care plan showed, Focus-Risk for Harm: Self Directed or Other-Directed Behavior Potentially Causing Harm (Episodic). [Resident #5] has a history of suicide attempt. He will be monitored on a 1:1. dated 10/11/23 The interventions included: 1:1 Supervision, administer medications as prescribed, monitor of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to implement provider orders for one diabetic ulcer and document the presence of a developed wound whose etiology was to be determined for one (#1) out of one resident sampled for diabetic foot ulcers resulting in a delay of treatment. Findings included: The admission Record for Resident #1 identified the resident was admitted on [DATE] with diagnoses not limited to Type 2 Diabetes Mellitus with hyperglycemia, dependence of renal dialysis, and unspecified protein-calorie malnutrition. Review of the admission Minimum Data Set (MDS), dated [DATE], for Resident #1 identified a Brief Interview of Mental Status score of 9, indicating a moderate impaired cognition. The MDS revealed the resident did not have a pressure ulcer, diabetic foot ulcer(s), infection of the foot, or other open lesion(s) on the foot. The review of Resident #1's Admit/Readmit Screener, dated 7/14/23, identified the resident had no areas of skin breakdown and the 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 observations, record reviews, and interviews, the facility failed to ensure that the medication error rate was less than 5.00%. Twenty-one medication administration opportunities were observed and seventeen (17) errors were identified for three (#6, #7, and #8) of three residents observed. These errors constituted a 77.27% medication error rate. Findings included: 1. On 10/24/23 at 9:31 am, an observation of medication administration with Staff A, Licensed Practical Nurse (LPN), was conducted with Resident #6. Staff A was observed dispensing the following medications: - Amlodipine 5 milligram (mg) tablet - Iron 325 mg over-the counter (otc) tablet The staff member placed a blood pressure wrist cuff on Resident #6's left wrist while it lie in the residents lap and obtained a blood pressure of 138/80 and pulse of 62. - Zyprexa 2.5 mg tablet - Briviact 50 mg tablet - Clonazepam 0.5 mg tablet Staff A confirmed 5 tablets had been dispensed for Resident #6 and administered the medications to the resident while in the hallway. A review of Resident #6's Medication Administration…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure a written Notice of Transfer and/or Discharge was issued in a timely manner for 5 residents (#7, #8, #12, #13, #14) out of 6 residents who were reviewed for transfer/discharge notification. Findings included: 1. A review of Resident #7's clinical record revealed an Administration progress note on 7/31/2023: sent to ED [Emergency Department] for trt [treatment] and evaluation. A Nursing Home Transfer and Discharge Notice was not able to be found nor was documentation found stating this notice was provided to the resident/resident representative within the medical record. Continued review of the medical record revealed Resident #7 was readmitted to the facility on [DATE]. 2. A review of the facility's admission/transfer log revealed Resident #8 was sent to the hospital on 8/23/2023 and had not returned to the facility as of 8/31/2023. The Nursing Home Transfer and Discharge Notice was not able to be found nor was documentation found stating…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, medical record and policy review the facility failed to ensure a written bed hold notice was issued in a timely manner for 5 residents (#7, #8, #12, #13, and #14,) out of 6 residents reviewed for transfer/discharge process. Findings included: 1. A review of the progress notes for Resident #7 revealed an administration note on 7/31/2023: sent to Emergency Department for treatment and evaluation. The Bed Hold Policy was not able to be found nor was documentation found to show the Bed Hold Notice was provided to the resident/resident representative within the medical record. Resident #7 was readmitted on [DATE] with the same diagnosis and transferred to the hospital on 8/20/2023. The record contained a Bed Hold Policy form with the date 8/18/2023 on the bottom (two days prior to the hospital transfer). The form documented: information was provided to: Resident #7, no resident or resident representative signatures were observed on the form. The form was signed by a staff member, with Copy sent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure two residents/resident representatives (#1 and #2) had grievances resolved in a timely manner out of seventeen residents sampled for grievances. Findings included: 1) On 8/28/2023 at 9:40 a.m., during a tour of the facility and review of the list of current admissions, it was determined Resident #1 was no longer residing at the facility and had since been discharged home. Multiple phone communication attempts were made to contact Resident #1, but contact was unsuccessful. A review of the medical record revealed Resident #1 was admitted to the facility on [DATE] and discharged from the facility on 7/31/2023. Resident #1 was her own responsible party and made her own medical and financial decisions during her admission. Resident #1 had diagnoses to include but not limited to: anxiety, and a need for assistance with Activities of Daily Living (ADL). A review of the Minimum Data Set (MDS) admission assessment, dated 7/19/2023, revealed 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 interview with a resident, facility staff, and hospital staff, and record review, to include the admission/discharge log, medical record review, and policy review, the facility failed to permit readmission for one resident (Resident #8) of two residents reviewed for transfer and discharge to the hospital. Findings included: A review of the facility's admission/discharge log revealed Resident #8 was discharged to an acute care hospital on [DATE] and had not returned to the facility as of 8/31/2023. A review of Resident #8's admission Record revealed he was originally admitted to the facility in March of 2022, with diagnosis to include but not limited to, paraplegia and history of assault by other bodily force (gunshot to the spine). A review of the complete medical record revealed no documentation of a transfer or discharge notice on or after the 8/23/2023 hospitalization, and no facility documentation to include a rationale for not readmitting Resident #8. On 8/31/2023 at 11:30 AM a telephone interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to implement fall care planning interventions related to the placement of floor fall mats for one resident (#2) of seventeen sampled residents. Findings included: On 8/28/2023 at 9:32 a.m. Resident #2's room door was observed closed all the way and had a sign posted that read in marker handwriting DO NOT COME IN THIS ROOM. The sheet listed the specific times of not coming in the room. The sheet of paper was listed in both English and Spanish. The room was very dark, and the window blinds were closed making the room pitch dark. A visitor was observed in the room, who was identified as Resident #2's in house sitter, Staff G. Staff G stated she was hired by Resident #2's family to work thirteen-hour days at the facility, three days a week and on call as per the need for services. Resident #2 was observed lying in bed, under the covers, with the call light placed within his reach. He was observed resting with his eyes closed. A fall floor mat…

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 policy review, the facility failed to treat four (Residents #30, #31, #37, and #57) of thirty sampled residents with dignity and respect. Findings included: 1. During a facility tour on 10/26/21 at 10:06 a.m., Staff I, RN (Registered Nurse) was observed entering Resident #31's room without knocking on the door. Staff I walked into the room, interacted with Resident #31, and walked out a couple minutes later. On 10/26/21 12:14 p.m., Staff L, CNA (Certified Nurse's Aide) dropped off a lunch tray into Resident #31's room and left it without initiating meal prep or assistance. On 10/26/21 at 12:39 p.m., Resident #31 was observed in her room in bed, her lunch tray noted by bedside. Resident #31 was not being assisted with her meal. An immediate interview was conducted with Staff I, RN. Staff I stated that Resident #31 received tube feeding from 6:00 p.m. to 8:00 a.m. but ate regular meals during the day. Staff I looked inside Resident #31's room, saw the tray, and walked away.…

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 urinary catheter care and maintenance was conducted for one (Resident #46) of two sampled residents. Findings Included: An observation of Resident #46 on 10/26/21 at 9:53 a.m., revealed that the resident's catheter was draining dark amber urine with sediment. An observation of Resident #46's catheter on 10/27/21 at 12:10 p.m., revealed the urine that was draining was thick, cloudy, and pink in color. During an observation on 10/27/21 at 12:12 p.m., of the indwelling catheter with Staff G, RN, she said, He does not have an order to flush the catheter but I will check and left the room. Observation of Resident #46's catheter on 10/27/21 at 2:27 p.m., revealed cloudy, pink in color urine with thick white chunks in the catheter tubing. (photographic evidence obtained) Observation and interview was conducted on 10/27/21 at 2:29 p.m. with the Nurse Practitioner. She confirmed that the resident did get sediment in his urine and needed to increase his fluids. She looked at the catheter and stated she would…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, the facility failed to ensure that treatment with a continuous positive airway pressure (CPAP) machine was delivered properly and hygienically for one (Resident #59) out of two residents in the facility receiving treatment from a CPAP machine. Findings included: An observation of Resident #59's room was conducted on 10/26/21 at 10:50 a.m. The resident was not present. A CPAP machine was observed on top of the bedside table next to the resident's bed and the CPAP mask was observed hanging by its straps from the mobilizer bar of the bed, the mask was not contained in a bag. (Photographic evidence obtained) On 10/27/21 at 8:20 a.m. Resident #59 was observed in his room. The CPAP machine was observed on top of the bedside table next to the resident's bed and the CPAP mask was observed hanging by its straps from the mobilizer bar of the bed. The resident was interviewed and confirmed that he used the CPAP machine at night, and it was his practice to hang the mask on the…

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

Based on observations, interviews, and record review, the facility failed to ensure that the medication error rate was less than 5.00%. Twenty-six medication administration opportunities were observed, and four errors were identified for one (Resident #1) of five residents observed. These errors constituted a 15.38% medication error rate. Findings included: 1. On 10/26/21 at 5:09 p.m. an observation of medication administration with Staff F, Registered Nurse (RN), was conducted with Resident #1. Staff member F was observed administering the following medications: Admelog Solostar sliding scale 4 units for blood sugar of 263. Sliding scale from 251-300 = 4 units. Staff F gave the insulin in the right arm. Staff F did not prime the insulin pen. Semglee (Lantus) 15 units. Staff F gave the insulin in the left arm. Staff F did not prime the insulin pen. Brimonidine eye drops 2, one drop in the right eye and one drop in the left eye. After confirming the drops were for right eye. Staff F gave one more drop in the right eye. During an interview with Staff F on 10/26/21 at 5:15 p.m. he…

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 and interview, the facility failed to ensure four staff members knocked, announced themselves, and requested permission to enter resident occupied rooms during two of four days (02/09/20 and 2/11/20) of the survey. Findings included: On 02/09/20 at 11:09 a.m. Staff K, Certified Nursing Aide (CNA), was observed walking into resident room [ROOM NUMBER] and room [ROOM NUMBER]. Staff K did not knock or announce himself before walking in the room. On 02/11/20 at 7:57 a.m. Staff I, CNA, was observed walking into resident room [ROOM NUMBER] without knocking or announcing name. On 02/11/20 at 3:03 p.m., Staff L, CNA, and the Director of Nursing were observed walking into a resident room [ROOM NUMBER] without knocking or introduction. Review of Resident Council minutes, dated 10/17/2019, labeled Discussion of old business, revealed Council concerned staff don't wait for their permission when knocked upon entering resident's room-Resolved and council agreed. During the Resident Council on 2/11/2020 at…

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 complete an accurate assessment of the resident's capacity for one (#30) of 37 sampled residents. Findings included: On 02/10/20 at 11:50 a.m., Resident #30 was alert and oriented in a wheelchair in the hallway area next to the nurse's station. Upon greeting Resident #30, she stated, I am having a hard time hearing you. Resident asked staff to step to left side, stating I can hear better on this side. On 02/11/20 at 8:04 a.m., Resident #30 was observed in bed and awake. She stated she was waiting on the hairdresser. Resident #30 stated she was unable to hear and asked if the surveyor could come to the left side of bed. The resident was not observed to have hearing aids in at that time. On 02/11/20 at 3:11 p.m., Resident #30's husband was observed in the room visiting with the resident. He said he bought the first pair of hearing aids when she was at another facility, and they were stolen. He stated, She needs severe hearing aids and I can't afford them right now. They use the standard ones here and sometimes…

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 interventions were implemented for one (#38) out of 39 sampled residents after a fall with a major injury. Findings included: Resident #38 was admitted on [DATE] and re-admitted on [DATE]. The admission Record included diagnoses not limited to: subsequent encounter for closed fracture with routine healing unspecified fracture of right femur; onset 11/28/19, and subsequent encounter for closed fracture with routine healing unspecified fracture of left femur; onset 12/6/19. The significant change in status Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview of Mental Status (BIMS) of 11, indicating a moderate cognitive impairment. An observation on 2/10/20 at 9:41 a.m., revealed Resident #38 lying in bed with a trapeze overhead. The call light was observed tied around the raised bed rail, hanging down the side of the bed. The resident attempted and was unable to reach the call light. Staff Member I, Certified Nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to ensure one (#113) out of seven residents with a nothing by mouth diet did not receive oral intake. Findings included: Resident #113 was admitted on [DATE] and re-admitted on [DATE]. The admission Record included diagnoses not limited to unspecified cerebral infarction and dysphagia following cerebral infarction. The quarterly Minimum Data Set (MDS), dated [DATE], identified the Brief Interview of Mental Score (BIMS) of 9, indicating a moderate cognitive impairment. The Swallowing/Nutritional status portion of the MDS indicated the resident had a feeding tube, received more than 51% of intake and 501 cc (cubic centimeters) per day or more from an artificial route. An interview was attempted and an observation of Resident #113 was made at 9:52 a.m. on 2/10/20. The observation revealed there was no enteral nutrition infusing into the resident. The resident stated he did not know if he got nutrition through a feeding tube. On 2/11/20 at…

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 medical record review, the facility failed to ensure that psychoactive medications for four (#113,# 74, #80, and # 83) out of five residents were being monitored for target behaviors and side effects. Findings Included: 1. Resident #113 was admitted on [DATE] and re-admitted on [DATE]. The admission Record included diagnoses not limited to unspecified schizophrenia and other recurrent depressive disorders. The residents' physician orders included an order for Fluoxetine 20 milligram - give 2 capsules via Percutaneous endoscopic gastrostomy (PEG) tube at bedtime related to other recurrent depressive disorders, start date 10/29/19. The February 2010 Medication Administration Record (MAR) indicated the resident had received Fluoxetine daily at bedtime. According to medlineplus.gov, Fluoxetine was used to treat depression, obsessive-compulsive disorder, some eating disorders, and panic attacks. The side effects may cause nervousness, anxiety, difficulty falling asleep or staying…

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, policy and record review, the facility failed to ensure that the medication error rate was less than 5.00%. Twenty-five medication administration opportunities were observed, and two errors were identified for two (#94 and #58) of four residents observed. These errors constituted an 8.00% medication error rate. Findings included: 1. On 2/11/20 at 10:08 a.m., an observation of medication administration with Staff Member D, Registered Nurse (RN), was conducted with Resident #94. Staff Member D was observed administering the following medications: - Losartan Potassium 100 milligrams (mg) orally - Duloxetine 60 mg orally - Furosemide 40 mg orally - Metformin 500 mg orally - Hydralazine 50 mg orally - Cetirizine Hydrochloride (HCl) 10 mg orally - Senna Plus 8.6-50 mg orally - Guaifenesin Extended Release (ER) 600 mg orally - Polyethylene Glycol 17 gram (gm) orally - Fluticasone Propionate 50 microgram (mcg) nasal spray - Gabapentin 100 mg - 6 capsules (600 mg) orally - Oxycodone Immediate Release (IR) 10 mg orally A review of the physician orders and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, policy review, and interviews, the facility failed to store medications safely, per manufacturer recommendations, and inaccessible to unauthorized persons in two (North 400 back & North 400 front) out of three observed medication carts and one out of one observed treatment carts (400 hall). Findings included: On [DATE] at 9:39 a.m., a treatment cart was observed on the 400-hall, unlocked and unattended by licensed personnel. The treatment cart contained multiple containers of medicated topical creams/ointments. Photographic evidence was obtained. At the time of the observation, Staff Member O, Registered Nurse (RN), was overheard exclaiming, Oh snap, then began yelling for Staff Member B, Licensed Practical Nurse (LPN). At 9:41 a.m., Staff Member B arrived to the treatment cart and confirmed the cart had been left unlocked. On [DATE] at 5:07 p.m., an observation was conducted with Staff Member M, Registered Nurse (RN), of the North 400-back medication cart. The observation revealed 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 did not ensure food was served at an appetizing temperature and menu items were changed according to season. On 2/11/20 at 11:00 a.m., a Comprehensive Tour was done of the kitchen with Staff E, Dietary Manager. Six staff members were observed present and assisting with meal preparation. Staff E stated she would be checking the temperature of each food item, and that the temperature for the items had not been taken prior. Staff E stated, All of the puree food items were served hot because that's the way the residents like it. Staff E stated, It's been that way since I've been here. Findings included: Milk at 41 degrees Fahrenheit Regular Buttermilk Coleslaw at 40 degrees Fahrenheit Buttermilk Coleslaw Puree at 200 degrees Fahrenheit Deluxe Mac and Cheese Regular at 200 degrees Fahrenheit Mac and Cheese Puree at 190 degrees Fahrenheit Stewed Tomatoes Regular at 170 degrees Fahrenheit Alternative veggie at 180 degrees Fahrenheit Cheese sauce at 180…

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 medical record & policy review, the facility failed to ensure that applied infection control practices for four (# 58, 94, 166, and 84) of thirty-nine sampled residents were consistent with facility policy and/or current standards of practice including: 1. An invasive device was cleaned and sanitized in between use for one (#58) resident; 2. That a non-invasive device was cleaned and sanitized after use for one (#94) resident; 3. That appropriate hand hygiene was utilized for one (#166) resident with Clostridioides Difficile; 4. And that personal care equipment was not removed from the room after being used for one (#84) resident with Methicillin-resistant Staphylococcus aureus to a wound. Findings Included: 1. During the observation of medication administration, which began at 10:08 a.m. on 2/11/20, Staff Member D, Registered Nurse (RN), was observed obtaining a blood pressure of Resident #94. The staff member removed a purple blood pressure cuff and stethoscope from the bottom of drawer of the medication cart. Staff Member D placed the blood…

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.