Aviata At The Sea - Pompano Beach

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to follow the physician's orders for tube feeding and the facility's policy regarding weights, resulting in weight loss for 1 of 1 resident sampled for tube feeding (Resident #5). The findings included: The facility's policy titled, Weighing the Resident, dated 11/30/2014, revealed the following: Resident will be weighted unless ordered otherwise by the physician: Admission/readmission times 3 days. Weekly times 4 weeks. Monthly thereafter. As needed. A record review revealed that Resident #5 was readmitted to the facility on [DATE] with diagnoses of Type 2 Diabetes, Seizures, and Depressive Disorder. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #5 has a Brief Interview of Mental Status (BIMS) score of 03 which indicated Resident #5 was severely cognitively impaired. A review of the physician orders showed an order for Glucerna 1.5 (tube feeding formula) at 60 milliliters (ml) an hour for 20 hours to provide 1200ml,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide the correct fluid restrictions as per the Physician ' s order for 1 of 1 sampled Resident on Dialysis (Resident #27). The findings included: A record review revealed Resident #27 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Type 2 Diabetes, Severe Chronic Kidney Disease, and Anemia. The Annual Minimum Data Set (MDS) dated [DATE] revealed that Resident #27 had a Brief Interview of Mental Status (BIMS) score of 15, which is cognitively intact. The Physician ' s order dated 1/2/2025 showed the following: Fluid restriction: 1000 milliliters (ml) a day. Dietary 420ml a day, Breakfast coffee 180ml, Lunch apple juice 120ml, Dinner 120ml and Nursing 580ml. In an interview conducted on 3/31/25 at 12:00 PM, Resident #27 stated she goes to dialysis three times a week and is on fluid restriction. She said, I think I am allowed 32 ounces of fluids daily. The former Clinical Dietitian visited her but she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to provide sufficient nursing staffing to 4 of 22 sampled residents (Resident #2, #6, #36 and #52) as evidenced by failure to provide two nursing staff to provide assistance with repositioning/ turning a total dependent care resident (Resident #2); failure to provide personal care in a timely manner (Resident #6); failure to provide incontinent care in a timely manner (Resident #36) and failure to assist a resident during dining in a timely manner (Resident #52). This had the potential to affect 75 residents in the facility at the time of the survey. The findings included: 1) Review of Resident #2's clinical record documented an admission on [DATE] with a readmission on [DATE]. The resident's diagnoses included Cerebral Infarction, Diabetes Mellitus Type 2, Acute Hematogenous Osteomyelitis, Cerebral Vascular Disease, Peripheral Vascular Disease, Anxiety Disorder, Morbid Obesity and Apraxia (a disorder of the brain and nervous system 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to monitor the side effects and behavior of a resident on psychotropic medication (Resident #9), failed to have a written clinical rational note on the pharmacist recommendations for Resident #9 and Resident #2, and failed to monitor side effect for a resident on anticoagulant medication (Resident #2) for 2 of 5 residents sampled for Unnecessary Medications. The findings included: 1. A record review revealed Resident #9 was readmitted on [DATE] with diagnoses of Anxiety, Depression, and Psychosis. The annual Minimum Data Set (MDS) dated [DATE] revealed that Resident #9 had a Brief Interview of Mental Status (BIMS) score of 15, which is cognitively intact. A review of the Physician orders showed an order for Remeron (depressive medication) 15 milligrams 1 tablet at bedtime, which started on 11/21/24. The continued review did not show a Physician's orders to monitor the medication's side effects or the behavior of Resident #9. A review of…

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

Based on observations, interviews, and record review, the facility failed to follow its own menu portions for a Regular diet. This has the potential to affect 39 out of 75 residents currently on a Regular diet. The findings included: A review of the facility ' s menu, week 1 lunch Day 4 showed the following: open-faced roast pork 1 sandwich 2 ounces portion with brown gravy, mashed potatoes, buttered noodles, and herb green beans. In an interview conducted on 4/2/25 at 11:30 AM with the Dietary Manager, he stated the portion for the pork today is 2 ounces on the regular diet. In an observation of the lunch tray line conducted on 4/2/25 at 11:35 AM, Staff I, the Account Manager, noted plating 3 plates with roast pork for the regular diet consistency. The weight of the first slice of pork was taken using a facility ' s scale, which showed that it was 1 ounce. The weight of the second slice of pork was taken using a facility ' s scale, which showed that it was 1.5 ounces. Both lunch plates contained less than the required 2 ounces of pork as per the facility ' s menu. In an 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 reviews, the facility failed to provide food that meets residents' preferences, for 2 out of 65 sampled residents observed during dining. (Resident #78, Resident #77) The findings included: 1. A record review showed that Resident #78 was admitted on [DATE] with diagnosis of malignant neoplasm of lower respiratory tract. The admission Minimum Data Set (MDS) dated [DATE] revealed that the Brief Interview of Mental Status (BIMS) score is 05, which indicates severe cognitive impairment. During an observation conducted on 03/31/2025 at 8:40 AM this surveyor observed that Resident #78 meal ticket consisted of: #8 Scoop of Pureed French Toast, 1 Margarine, 1 Syrup, #16 Scoop of Ground Sausage Patty, 2 ounces (oz) of [NAME] Gravy, #6 Scoop of Pureed Hot Cereal, 8oz of Honey Thickened Milk, 4oz of Honey Thickened Orange Juice and 6oz of Honey Thickened Coffee or Hot Tea. Resident #78's tray did not have the margarine, the syrup, and the 2 ounces of [NAME] Gravy. 2. A record…

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 Quality Assurance Performance Improvement (QAPI) meetings were conducted quarterly, and that the necessary staff members attended those meetings for 3 of 6 months reviewed during QAPI review. The findings included: A review of the facility ' s policy titled Quality Assurance Performance Improvement Program, dated 11/30/2014, showed that the Quality Assessment and Assurance Committee (QAA) meetings are at least quarterly but may be held more frequently as appropriate. The QAA committee members include, but are not limited to, the Executive Director, Medical Director, Director of Nursing, and Infection Preventionist. A review of records revealed the last QAPI meeting was held on December 18, 2024. Further review did not show that a QAPI meeting was conducted in March 2025 or the sign-in sheet with all the necessary staff members. In an interview conducted on 4/3/25 at 5:00 PM with the facility ' s Administrator, he started in this facility in March of this year and had one QAPI meeting with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review; the facility failed to follow infection control guidelines by failing to wear a disposable gown during personal care and wound care for Resident #36, failing to have PPE (Personal Protective Equipent) readily accessible for residents on Enhanced Barrier Precautions, failing to wear a disposable gown during medication administration to a resident on Enhanced Barrier Precaution for Resident #71, and failing to provide contact precautions per Physician order for Resident #31. This had the potential to affect 12 residents on Enhanced Barrier Precautions and 1 resident on Contact Precautions. The findings included: Review of the facility's policy titled Standard Precautions: revised on October 2018 documented .hand hygiene after .removing PPE (Personal Protective Equipment) .gloves .after gloves are removed, wash hands immediately to avoid transfer of microorganism to other resident or environment . Review of the facility's policy titled Enhanced Barrier Precautions…

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 meet infection control standards of practice related to a midline catheter used for intravenous (IV) antibiotics or fluids, for 2 of 2 observed residents (Residents #2 and #3). The findings included: 1. Record review revealed Resident #2 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident was cognitively intact and required substantial/maximum assist with activities of daily living (ADL). A review of Resident #2's orders revealed an order dated 02/07/25 for a midline catheter, and to flush the midline catheter with 10 milliliters (ml) of saline every shift and as needed. An observation of Resident #2 was conducted with Staff A, a Licensed Practical Nurse (LPN) on 02/11/25 at 11:45 AM. Resident #2's midline catheter IV line was observed without a cap, leaving the line open to the bloodstream. Staff A stated the midline catheter should have a cap on it. Resident #2 stated she was not aware…

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 develop and implement a discharge plan for 3 out of 3 residents sampled for discharge to the community (Residents #3, #7 and #8). The findings included: Review of the facility's policy titled Discharge Planning with an effective date of 11/30/14 included in part the following: To evaluate the resident's health status and formulate the best plan of discharge for each resident. Discharge planning begins the day of admission. The process involves the resident and family, Care Management/Social Services, and other members of the clinical team. An initial evaluation of a resident is completed upon admission. A discharge goal and length of stay will be established upon admission and reviewed/revised at plan of care conferences. The goal is based upon clinical findings, availability of community and family resources and resident/family goals. Discharge planning record will be completed within 7 days after admission. Discharge planning is adjusted as…

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 records review and interviews, it was determined that the facility failed to have Level II Preadmission Screening and Resident Reviews (PASARR) completed for 2 of 19 sampled residents (Resident #15 & Resident #20). The findings included: Review of the PASARR level I, dated 8/4/2017 and updated on 12/1/2019, documented that Resident #20 was admitted to the facility with a non-provisional PASARR. The level I documented that Resident #20 had diagnoses or suspicion of Significant Mental Illness. Since the resident's admission, no Level II PASARR was completed. Resident #20's relevant diagnoses included: Cognitive communication deficit; Schizophrenia; Legal Blindness; and Convulsions. Review of the Psychiatric evaluation dated 06/15/23 revealed that Resident # 20 exhibited no delusions and no hallucinations. The psychiatric record recommended no changes in Resident #20's medications. The Psychiatrist noted that the benefits outweighed the risks for antipsychotic use. Resident #20 was still taking…

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

Based on observation, interview, and record review it was determined that the facility failed to employ sufficient dietary staff safely and effectively carry out the functions of the food and nutrition service that include; preparation of food to ensure nutritional value, appearance, and palatability, serve meals in a timely manner, ensure sanitation regulations are followed, and ensure physician ordered therapeutic and mechanically altered diets are followed. The findings include: During the initial food service sanitation tour conducted on 12/18/23 at 8:50 AM, it was noted that there were only 2 staff members working in the kitchen preparing and serving the breakfast meal. Further observation noted that the 2 members of staff included a newly hired cook and the Food Service Director (FSD). A review of the posted staffing schedule for 12/18/23 noted that 3 staff members (2 cooks and 2 diet aides) were scheduled. Interview with the FSD at the time of the observation noted that 2 diet aides failed to report to work without notification. Further observation noted that at 10 AM 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 and interview, it was determined that the facility failed to provide housekeeping and maintenance service necessary to maintain a sanitary, orderly, and comfortable interior for 14 of 21 resident rooms, 1 of 1 common areas on the first floor, 1 of 1 common areas on the second floor, and in the laundry area. The findings included: During the initial resident screening of resident rooms conducted by the surveyors on 12/18/23, and the Environment Tour conducted on 12/20/23 at 10:30 AM, accompanied with the facility's Director of Maintenance and Corporate Maintenance Director, the following were noted: 1) First Floor: room [ROOM NUMBER]: Bathroom lights not working (1 of 2) room [ROOM NUMBER]: Exterior of over-bed tables (2 of 2) were noted to have areas of peeling paint and rust. room [ROOM NUMBER]: Room window blinds broken and could not be closed. room [ROOM NUMBER]: Room floor tile cracked, stained black, and broken. room [ROOM NUMBER]: Offensive urine odor in main room and bathroom,…

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, observation, and interviews, the facility failed to initiate a grievance for 1 of 1 sampled resident (Resident #151) who reported the loss of his personal property (cell phone) at the facility. The findings included: Resident #151 was admitted to the facility on [DATE] with diagnoses of: Hemiplegia and Hemiparesis following Cerebral Infarction affecting left dominant side; Hypertension; Diabetes Mellitus due to underlying condition with other diabetic Kidney complications; Depression unspecified; Anxiety Disorder; Unspecified Psychosis not due to a substance or known physiological condition. Restlessness and Agitation. On 12/18/2023 at approximately 11:33 AM, Resident #151 was observed in bed. During this time, the resident's Power of Attorney (POA) stated, via an identified electronic device, that he had sent a cell phone to Resident #151 in order to facilitate communication with the resident when he is out of his room and around and about the facility. The POA stated, he was told by…

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 accuracy of the Minimum Data Set (MDS) assessment for 3 of 19 sampled residents (Residents #7, Resident #15 and Resident #45). The findings included: 1. Review of Resident #7's record revealed an admission date of 05/13/13, with the diagnoses of Atherosclerosis, Coronary Heart Disease, Anxiety Disorder and Schizoaffective Disorder. Review of the physician orders documented the following for Resident #7: Seroquel 25 mg at bedtime for Schizophrenia. Seroquel 50 mg at bedtime for Schizophrenia Risperdal 0.25 mg for Schizoaffective Disorders, 1 tab a day; Xanax tablet 2 mg for Anxiety, every 12 hours. Further record review showed that the pre-admission screening and resident review (PASARR) level II was completed on 05/11/21. Review of the quarterly (MDS) assessment section (I) dated 11/9/23 documented Resident # 7 was diagnosed with Anxiety and Schizophrenia which confirmed that the facility was aware of Resident #7's mental status. On 12/21/23 at 9:40 AM, the MDS Coordinator stated that she has been working at the…

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

Based on observation, interview, and record review, the facility failed to provide care and services for necessary adaptive eating equipment for 1 of 7 sampled residents reviewed for Nutrition (Resident #28). The findings included: During the observation of the Breakfast meal on 12/19/23 at 8:30 AM, it was noted that the meal tray was served to the room of Resident #28. A review of the tray ticket noted documentation of a Renal Diet with a 1500 ml Fluid Restriction and Weighted Fork. Observation of the meal tray noted only a weighted fork and spoon. Interview with the alert and oriented resident at the time of the observation noted to state that she would like to receive a weighted Knife with all meals and had requested weighted silverware on previous occasions. She further stated that numerous meals she is not receiving weighted silverware and also stated she needs weighted utensils due to poor grasping ability for both hands. During the observation of the Lunch meal on 12/19/23 at 12:30 PM, it was noted on only a weighted fork was included on the meal tray. The tray did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure that a resident receives wound care consistent with professional standards of practice for 1 of 2 sampled residents reviewed for wound care (Resident #200) . The findings included: Review of the facility's policy provided by the facility's Regional Nurse, titled Clinical Guideline Skin and Wound effective 04/01/17 with no revision date documented .on admission/readmission the resident's skin will be evaluated for baseline skin condition and documented in the medical record . Review of Resident #200's clinical record documented an admission on [DATE] with no readmissions. The resident diagnoses included Local Infection of the Skin and Subcutaneous Tissue, Osteomyelitis of Ankle and Foot, Non-Pressure Chronic Ulcer of Foot, Diabetes Mellitus, and Morbid Obesity. Review of Resident #200's Admission/readmission Data Collection (nursing form) and the skilled nurse note dated 12/09/23 lacked written description of Resident#200's foot…

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 physician orders to provide care to a Central/Midline venous access catheter for 1 of 1 sampled resident reviewed for Catheter Care (Resident #200). The findings included: Review of the facility's policy titled Catheter Insertion and Care- Midline Dressing Changes revised on 01/17/19 documented .change midline catheter dressing .every 5-7 days or if it is wet, dirty, no intact or compromised in any way .the following information should be recorded in the residents' medical record: date and time dressing was changed, condition of sutures, any education given to the resident, resident's statement regarding IV therapy . Review of the facility's policy titled Catheter Insertion and Care-Flushing Central Venous and Midline Catheters revised on 01/17/19 documented .midline and central line access devices will be flushed to maintain patency .flush catheter at regular intervals . the following information should be recorded in the resident'' medical record: date and time the medication was administered, type…

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

Based on observation, interview, and record review, it was determined the medication error rate was 12 percent. Three medication errors were identified while observing a total of 25 opportunities, affecting Resident #200, #37 and #12. The findings included: 1) Review of Resident #200's physician order dated 12/17/23 documented Vancomycin Intravenous solution use 1.5 gram intravenously three time a day for Osteomyelitis until 01/03/24, in sodium chloride 0.9%, 500-millimeter (ml) bag, rate: 250 ml/hour every 8 hours. Review of the facility's pharmacy Vancomycin delivery receipt documented that the antibiotic was delivered on 12/18/23 at 1:49 AM. Review of Resident #200's December 2023 Medication Administration Record (MAR) documented Vancomycin Intravenous use 1.5-gram three time a day for Osteomyelitis until 01/03/24, in sodium chloride 0.9%, 500-millimeter (ml) bag, rate: 250 ml/hour every 8 hours. The Vancomycin administration times were scheduled as 9:00 AM, 1:00 PM and 5:00 PM. The review revealed that the Vancomycin antibiotic solution first dose was administered on 12/18/23 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 review of policy and procedure, the facility failed to: 1) ensure that residents medications and biologicals were properly stored as evidenced by medications and biologicals being left on the resident's night stand for 2 of 2 sampled residents (Resident #5 and #12); and 2) to ensure that it secured the Medication cart #1 (second floor unit) and Treatment Cart (second floor unit). The findings included: Review of a document provided by the Acting Director of Nursing titled Medication Storage Information-Best Practice Guidelines undated documented that medication carts and storage rooms must be locked at all times . The document did not address medication at the resident's bedside and did not address treatment carts. The sister facility's Director of Nursing and the Regional Nurse were asked multiple times for the facility policy related to medication Storage and was not provided. 1) Review of Resident #5's clinical record revealed an admission to the facility on [DATE] with 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 observation, interview, and record review, the facility failed to provide 66 of 69 residents with foods that were prepared by methods that conserve nutritive value, flavor, appearance, and is palatable, attractive, and appetizing. The findings included: Review of the facility's Policies & Procedures noted the following: Food Quality and Palatability: Policy Statement (Revised 2/2023): < Food will be prepared by methods that conserve nutritive value, nutritive flavor, and appearance. < Food will be palatable, attractive, and served at a safe and appetizing temperature. < Food and liquids are prepared and served in manner, and texture to meet resident's needs. Procedures Include: < Cooks are responsible for food preparation. Menus are prepared according to the menu, production guidelines, and standardized recipes. < Cooks prepare food in accordance with recipes and use proper cooking techniques to ensure color and flavor retention. 1) During the initial kitchen sanitation tour conducted on 12/18/23 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 ensure pureed foods were prepared in a form to meet the needs of 4 of 4 sampled residents (Resident #6, #16, #20, and #31) with physician ordered pureed diets. The findings include: 1) During the observation of the lunch meal in the main kitchen on 12/18/23 at 11:45 AM, a half pan of Pureed Tilapia was observed and located on the steam table. Further observation of the pureed fish, it was noted to have small pieces of fish within the pureed mixture. At the request of the surveyor, the pureed fish was test tasted by the surveyor and the Contacted District Manager to ensure that the pureed mixture was the correct pureed smooth consistency. The surveyor and District Manager both agreed that the fish was not pureed to the proper smooth consistency and could potentially be an issue for residents with swallowing or Dysphagia issues. The District Manager requested from the cook (Staff C), that the pureed fish not be served until the proper consistency was obtained. A further interview with Staff C, revealed that 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, interview, and record review it was determined that the facility failed to ensure that physician ordered therapeutic diets (Fluid Restriction) were not followed for 1 of 7 sampled residents reviewed for nutrition (Resident #28). The findings included: During the review of the clinical record of Resident #28, the following were noted: Date Of re-admission: [DATE] Diagnoses: Chronic Kidney Disease of which noted the resident requires Dialysis (3 times per week (Monday/Wednesday/Friday). The resident leaves the facility on these days at 9:30 AM and returns at 4 PM. Review of current physician orders noted: 4/26/22: Renal Diet 7/25/23: 1500 ml Fluid Restriction (800 ml from dietary and 700 ml from nursing) Review of current Quarterly MDS (Minimum Data Set) assessment dated 10/18 /23 noted: Section C: BIMS (Brief Interview for Mental Status score=15 (No Cognitive Impairment) Section G: Eat = Independent Section K: No weight loss Section l: No dental issues During the review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety that potentially affected 66 of the facility's 69 residents. The findings included: 1) Review of the facility's Dietary Department Policy & Procedures noted the following: 1. Environment (No Implementation Date): * All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition. Procedures Included: < The Food Service Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, ceilings, lighting, and ventilation. < The Food Service Director will ensure that all employees are knowledgeable in their proper procedures for cleaning and sanitizing all food service equipment and surfaces. < The Food Service Director will ensure that a routine cleaning schedule is in place for all cooking equipment, food storage areas, and surfaces. 2: Food…

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 the residents were offered eligible immunizations annually as evidenced by the lack of written consents for declination or acceptance of immunizations for 3 of 5 sampled residents reviewed for immunization review (Resident #5, #21 and #200). The findings included: 1) Review of Resident #5's clinical record revealed an admission to the facility on [DATE] with a readmission on [DATE]. The resident's diagnoses included Dementia, Major Depressive Disorder, Diabetes Mellitus Type 2 and Panic Disorders. Review of Resident #5's Minimum Data Set annual assessment dated [DATE] revealed a Brief Interview for Mental Status score of 0, indicating severe cognitive impairment. On 12/21/23 at 1:38 PM, an interview was conducted with the facility's Director of Nursing (DON). The DON stated that the admission nurse should be offering the Influenza and Pneumococcal vaccine to the residents on admission. A side by side review of Resident #5's immunization record…

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 safeguard residents' protected health information for 5 of 5 residents' names with Protected Health Information (PHI) posted in public area, Residents #7, #20, #25, #37 and #107. The census at the time of the survey was 55. The findings included: Review of the facility's policy, titled, Confidentiality and Privacy, effective date 11/30/14, provided by the Director of Nursing (DON) documented, in part, the policy is implemented for the purpose of complying with the privacy/security regulations promulgated under the Health Insurance Portability and Accountability Act (HIPAA) .It is the policy of The Company, LLC to protect the confidentiality of Protected Health Information of its residents . On 08/15/22 at 7:40 AM, an entrance to the facility was made through a locked double door into the main hallway. Observation revealed an open large dining room to the left and the kitchen door to the right. Further observations revealed an 8 x 11 inch…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to provide appropriate assessment and treatment related to mental health concerns; failed to ensure a physician signature on the order for a [NAME] Act; and failed to ensure correct documentation on a [NAME] Act Form for one of one resident, Resident #25. The findings included: Resident #25 was originally admitted to the facility on [DATE]. Resident #25 was sent to the hospital as an involuntary admission to an acute care hospital, as a State [NAME] Act, on 08/08/22. The resident was returned to the facility a few hours later on 08/08/22, as the [NAME] Act had been removed. Resident #25 had a medical history of a stroke, leaving it difficult for him to speak and swallow, muscle weakness, depression and anxiety, seizures, and chronic obstructive pulmonary disease. A Quarterly Minimum Data Set (MDS) was completed by the facility on 06/08/22 which showed Resident #25 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated…

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 medication error rate was 12 percent (%). Three (3) medication errors were identified while observing a total of (25) opportunities, affecting 2 of 8 residents observed, Residents #54 and #29. The findings included: Review of the facility's policy, titled, General Dose Preparation and Medication Administration with a revision date 01/01/22, documented, in part, .during medication administration .administer medications within the timeframe specified by facility .after medication administration .document necessary medication administration/treatment information . 1. Review of Resident #54's clinical record documented an admission on [DATE] and a readmission on [DATE]. The resident's diagnoses included Right Femur Fracture, Pleural Effusion, Cholecystitis, Urinary Tract Infection, Gastrointestinal Hemorrhage and Deficiency of other Vitamins. Review of Resident #54's Minimum Data Set (MDS) admission assessment, dated 07/24/22, documented, a Brief Interview of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that residents' medications were properly supervised / stored as evidenced by over the counter medications being left unattended on the resident's bedside table for Resident #22 and #24 and as evidenced by residents' insulin (pens) medications being left on top of the medication cart unattended and unsecured for Resident #106 and #108. The findings included: Review of the facility's policy titled, General Dose Preparation and Medication Administration, with a revision date of 01/01/22, provided by the Director of Nursing, documented .facility staff should not leave medications or chemicals unattended . Review of the facility's policy, titled, Self-Administration of Medications at Bedside, revised on 08/22/17, provided by the administrator, documented .verify physicians order in the resident's chart for self-administration of specific medications under consideration. Complete Self-Administration of Medications Evaluation .complete…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, policy review and record review, the facility failed to provide physical therapy as ordered by the physicians for 2 of 3 sampled residents (Residents #14 and #36). The findings included: The facility's policy titled Rehab Services Policies and Procedures effective 05/01/02 and revised 11/05/21 reveals Genesis Rehab Services .provide skilled rehabilitation services to patients as ordered by physician or appropriately credentialed/licensed non-physician practitioner (NPP). 1. Resident #14 was admitted to the facility on [DATE] from a long term care facility post spinal fusion. He had additional diagnoses of Dorsalgia, Muscle Weakness, and unsteadiness on feet. His brief interview of mental status (BIMS) was 15, per the Minimum Data Set (MDS) admission assessment with an assessment reference date (ARD) of 05/22/22, which indicated he was cognitively intact. On 05/16/22, the physician wrote an order for physical therapy evaluate and treat. On 08/15/22 at 9:38 AM, Resident #14 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to ensure that the residents medications were documented as administered for prescribed medications for 2 of 8 sampled residents, Resident # 24, and Resident #54 during medication administration observation. The findings included: Review of the facility's policy, titled, Physician Orders, revised, on 03/03/21, documented The center will ensure that Physician orders are appropriately and timely documented in the medical record. Information received from the referring facility or agency to be reviewed, verified with the physician and transcribed to the electronic medical record. The attending physician will review and confirm orders 1. Review of Resident #54, clinical record documented an admission on [DATE] and a readmission on [DATE]. The resident diagnoses included Right Femur Fracture, Pleural Effusion, Cholecystitis, Urinary Tract Infection, Gastrointestinal Hemorrhage and Deficiency of other Vitamins. Review of Resident #54's Minimum…

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.