Aviata At St Cloud

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to develop, implement, and revise the person-centered comprehensive care plan to ensure it met their preferences, goals, and addressed their medical, physical, mental and psychosocial needs, for 1 of 2 residents reviewed for changes in behavior, of a total sample of 3 residents, (#3). Findings: Resident #3 was admitted to the facility on [DATE] with diagnoses that included a wedge compression fracture of unspecified lumbar vertebra, Parkinson's Disease, adult failure to thrive, and cognitive communication deficit. He was discharged from the facility on 11/25/24 due to family request to take him to a different state. Resident #3's admission Minimum Data Set (MDS) assessment dated [DATE] revealed he had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which indicated severe cognitive impairment. The assessment revealed he did not exhibit any physical or verbal behaviors towards others and did not have any wandering behaviors. 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.

Based on interview, and record review, the facility failed to maintain medical records that were complete and accurately documented related to missing and incomplete documentation of a reportable incident for 2 of 3 sampled residents, (#2, and #3). Findings: Review of the facility's reportable/adverse incidents from September- November 2024, revealed a report of alleged resident to resident abuse involving resident #2 and #3. According to the report on 11/18/24 at approximately 1:00 AM, a nurse reported to the On-call Supervisor that resident #3 had entered resident #2's room and was observed by staff attempting to pull resident #2 out of bed by her wrist to take her to the shower. According to witness statements resident #3 was not wearing any clothing except for a blanket around him. The report indicated staff took resident #3 to his room and then completed an assessment on both residents. Resident #2 was found to have slight redness on her wrist with no other visible injuries and she expressed to the nurse that she was not afraid of resident #3 but was not intending to go with…

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

Based on observation, interview and record review, the facility failed to ensure a safe smoking environment for 10 of 10 residents reviewed for smoking, of a total sample of 17 residents, (#11, #15, #16, #17, #18, #19, #20, #21, #22, #23). Findings: On 9/18/24 at 10:45 AM, resident #11 was observed in his room sitting on the edge of his bed. He was noted with bilateral high above the knee leg amputations. On his night table next to the bed in clear view was a pack of cigarettes and lighter. He was alert and oriented to person, place, and time. He said that some of the residents were allowed to keep their cigarettes and lighters, but staff did hold some of the residents' lighters. On 9/18/24 at 11:20 AM, residents #11, #15, #16 and #17 were observed outside smoking on the patio, with no staff present outside on the patio. None of the residents had on smoking aprons and resident #11 lit resident #15's cigarettes with his own lighter. The four residents present smoking used an ashtray on the patio table that was overflowing with old cigarette butts as well as one butt that was still…

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 intravenous (IV) care and services according to standards of practice and plans of care for 2 of 2 residents reviewed for IV care, of a total sample of 17 residents, (# 2, and #18). Findings: 1. On 9/18/2024 at 12:14 PM, resident #2 was observed with a midline intravenous (IV) catheter in her right upper arm with a transparent dressing. There was no date on the dressing noted. Resident #2's medical record revealed that on 9/04/24 an Advanced Practice Registered Nurse ordered that due to the results of a Urine Analysis with a Culture and Sensitivity the resident was ordered Imipenem-Cilastatin (an antibiotic) Intravenous Solution Reconstituted 250 milligrams (mg) IV every 6 hours for 7 days. Resident #2's medical record contained a nursing note dated 9/09/24 that indicated the IV on the resident' s left forearm was not functioning for use for medication administration, and the company IV Access was contacted to place a new IV site.…

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 obtain a physician order for Oxygen (O2) therapy and failed to administer O2 therapy as ordered by the physician for 2 of 2 residents reviewed for O2 therapy, of a total sample of 17 residents, (#2, #13). Findings: 1. On 9/18/24 at 12:14 PM, resident #2 was observed seated in her wheelchair with a nasal cannula in her nose. The O2 tubing connected to an oxygen tank on the back of her wheelchair. The O2 flow rate indicated on tank was 3 liters per minute (L/min). Review of resident #2's medical record revealed she was readmitted to the facility on [DATE] from the hospital. Her diagnoses included: Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, Cardiomegaly, and unspecified sequelae of unspecified cerebrovascular disease. There was no physician's order for oxygen. On 9/18/24 at 2:07 PM, Licensed Practical Nurse (LPN) E, resident #2's assigned nurse, verified she had seen resident #2 with her O2 nasal cannula in her nose…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review; the facility failed to investigate after a resident was found with suspected illicit drugs for 1 of 1 resident reviewed, (#11), of 17 sampled residents. Findings: Resident #11 a [AGE] year-old male was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included absence of bilateral legs above the knees, diabetes type 2, peripheral vascular disease, chronic obstructive pulmonary disease, depression, phantom limb pain syndrome, heart failure, repeated falls and nicotine dependence. On 8/11/24 at 1:40 AM, the weekend supervisor nurse documented a behavior note that read, Resident found by this nurse at [1:30 AM] to be sitting in wheelchair on patio area between timeclock and South wing dayroom passed out, slow to arouse. Resident leaning forward towards concrete, eyeglasses on ground in front of him, pack of cigarettes on ground. This nurse assisted CNA [Certified Nursing Assistant] to return resident to room. When pack of cigarettes picked up from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to update an individualized care plan for potential for adverse drug interactions for 1 of 1 reviewed for opioid and antianxiety medications, of a total sample of 17 residents, (#11). Findings: Resident #11, a [AGE] year-old male was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included absence of bilateral legs above the knees, diabetes mellitus type 2, peripheral vascular disease, chronic obstructive pulmonary disease, depression, phantom limb pain syndrome, heart failure, repeated falls and nicotine dependence. On 8/11/24 at 1:40 AM, the Weekend Supervisor documented a behavior note that read, Resident found by this nurse at [1:30 AM] to be sitting in wheelchair on patio area between timeclock and South wing dayroom passed out, slow to arouse. Resident leaning forward towards concrete, eyeglasses on ground in front of him, pack of cigarettes on ground. This nurse assisted CNA [Certified Nursing Assistant] to return…

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 treat residents who required assistance with meals in a dignified and respectful manner for 4 of 4 residents reviewed for dining, of a total sample of 17 residents, (#4, #15, #16, and #17). Findings: 1. Review of resident #4's medical record revealed she was admitted to the facility on [DATE] with diagnoses including multiple sclerosis and aphasia. Review of resident #4's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 6/13/24 revealed a Brief Interview for Mental Status (BIMS) score of 7 out of 15, indicating severely impaired cognition. She was totally dependent on staff for bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. On 6/19/24 at 8:25 AM, resident #4 sat in bed while Certified Nursing Assistant (CNA) H assisted her with breakfast. CNA H fed resident #4 while standing next to her bed. CNA H then sat down and stated someone else was coming to feed resident #4's roommate.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain a medical record that accurately documented activities of daily living (ADLs) for 3 of 3 residents reviewed for ADLs, of a total sample of 17 residents, (#4, #14, and #17). Findings: 1. Review of resident #4's medical record revealed she was admitted to the facility on [DATE] with diagnoses including multiple sclerosis and aphasia. Review of resident #4's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 6/13/24 revealed a Brief Interview for Mental Status (BIMS) score of 7 out of 15, indicating severely impaired cognition. She was totally dependent on staff for ADLs. Review of resident #4's CNA (Certified Nursing Assistant)-ADL Tracking Form for May 2024 revealed eating was documented 11 out of 31 days on the 3 PM to 11 PM shift, and 0 out of 31 days on the 7 AM to 3 PM shift. Meal consumption percentage was documented on 27 days from the 3 PM to 11 PM shift, 0 out of 31 days for the 7 AM to 3 PM shift…

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 review or revise the individualized pressure ulcer plan of care for 1 out of 4 residents reviewed for pressure ulcers, (#3) and failed to develop and implement an individualized comprehensive care plan for a resident reviewed for care planning, (#4), of a total sample of 17 residents. Findings: 1. Resident #3 was an [AGE] year-old male, admitted to the facility on [DATE] with diagnoses to include abscess of lung with pneumonia, Alzheimer's disease, anxiety, type 2 diabetes, prostate cancer, difficulty walking, cognitive communication deficit, and urinary retention. The medical record indicated resident #3's skin was intact when he was admitted to the facility. The record indicated resident #3 was discharged to an acute care hospital on 5/08/24. Review of the Minimum Data Set (MDS) Discharge Return Anticipated assessment with assessment reference date of 5/08/24 revealed resident #3 had severely impaired cognitive skills for daily…

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 implement fall interventions for 1 of 1 residents reviewed for falls, of a total sample of 17 residents, (#2). Findings: Resident #2 was admitted to the facility from an acute care hospital on 3/07/24 with a diagnosis of drug induced subacute dyskinesia (uncontrolled, involuntary movements). Other diagnoses included Alzheimer's disease, spinal stenosis, muscle weakness, difficulty walking, unspecified abnormalities of gait and mobility, and Parkinson's disease with dyskinesia. Review of hospital discharge papers dated 3/05/24, revealed a handwritten note that stated, Ok to accept. No clinical reason not to accept except safety concerns with falls due to [diagnoses] of dyskinesia and involuntary movement. Review of the admission assessment dated [DATE] revealed the resident's cognition as alert to person with memory problems. The assessment indicated resident #2 was noted to have fallen within the last 30 days. A progress note attached to…

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

Based on observation, and interview, the facility failed to serve food at proper safe food temperature during the dinner meal. Findings: On 5/15/24 at 5:04 pm, the cook began serving dinner from the serving line. The cook did not take the temperature of the food before serving the line. The first dinner cart was pushed out the kitchen door at 5:30 pm. The temperatures of the food on the serving line were taken by the cook on 5/15/24 at 6:02 pm, after the meal service. On 5/15/24 at 6:05 pm, the temperature of the parmesan baked zucchini liquid was 109 degrees Fahrenheit (F). The cook continued taking temperatures of the rest of the serving line and did not explain why the temperature of the zucchini liquid was not at the appropriate temperature. On 5/16/24 at 3:32 pm, during an interview, the Interim Certified Dietary Manager (CDM) explained the temperature of the parmesan baked zucchini liquid at 109 degrees F was too low and stated the temperature of any food item on the steam table, even after meal service, should be above 135 degrees F to prevent food borne illnesses. On 5/16/24…

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

Based on observation, and interview, the facility failed to promote dignity for one of four residents sampled for activities for daily living, (#3). Findings: On 5/15/2024 at 12:25 pm, resident #3 was seated at a square table in the day room on the 100 hall. Resident #3 wore a yellow hospital gown that tied around the neck. The resident's left hip was exposed and visible to staff and visitors as they walked by the day room. On 5/15/2024 at 12:29 pm, the resident stated, I don't like wearing a hospital gown. I have very few clothes in my room. I am more of a short-sleeved shirt and pants person. On 5/15/2024 at 12:40 pm, the Director of Nursing (DON) walked by and commented that she could see the resident's side and bottom exposed from the hallway. The DON said the resident should not be wearing only a hospital gown in the day room but might not have clothes in her room. The DON explained if the resident did not have any clothes in their room, they could get clothes from the laundry department. On 5/15/2024 at 12:43 pm, observation of resident #3's closet revealed one drawer 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 interview and record review, the facility failed to complete a pre-admission screening and resident review (PASARR) for 3 of 5 residents reviewed for PASARR who were later identified with Intellectual Disability (ID) or Serious Mental Illness (SMI) out of a total sample of 45 residents. (#87, #15 and #39) Findings: 1. Resident #87 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis, anemia, hypertension, dementia and hypothyroidism. Review of the Minimum Data Set (MDS) quarterly assessment with assessment reference date (ARD) of 7/17/23 revealed resident #87 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated she had moderate cognitive impairment. The document indicated her active diagnoses included anxiety disorder, depression other than bipolar and bipolar disorder. Review of resident #87's care plan revealed a behavior care plan related to increased anxiety initiated 12/10/21; a mood care plan related to depression, bipolar and anxiety…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to complete and submit a Preadmission Screening and Resident Review (PASARR) in accordance with the state process for 1 of 5 residents reviewed for PASARR from a total sample of 40 residents. (#23) Finding: Review of the medical record revealed resident #23 was admitted to the facility on [DATE] and re-admitted on [DATE] from an acute care hospital. The resident had diagnoses that included schizoaffective disorder, bipolar type, bipolar disorder, major depressive disorder, anxiety disorder, cognitive communication deficit, and other symbolic dysfunctions (communication disorder). The Minimum Data Set quarterly assessment with Assessment Reference Date 7/12/23 showed the resident scored 15 out of 15 on the Brief Interview for Mental Status that indicated she was cognitively intact, and had not rejected evaluation or care. Functional Status noted the resident required staff supervision and support to complete Activities of Daily Living (ADL).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure 1 of 4 residents reviewed for care planning participated in their care conference of a total sample of 45 residents. (#97) Findings: Resident #97, a [AGE] year-old male was admitted to the facility on [DATE] from an acute care hospital. His diagnoses including cerebral infarction, hypertension, diabetes type II, hemiplegia/hemiparesis following cerebrovascular disease affecting left non-dominant side, atrial fibrillation, and aphasia. Review of the resident's admission Minimum Data Set (MDS) assessment, with Assessment Reference Date (ARD) of 7/22/23, indicated the resident's cognition was moderately impaired with a Brief Interview For Mental Status (BIMS) score of 12/15. The assessment indicated the resident required extensive assistance of one person for bed mobility, dressing, toilet use, and personal hygiene. He had impairment in functional limitation in range of motion (ROM) to one side of his upper and lower extremities. On 8/15/23 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, interviews and record review, the facility failed to ensure clinical staff administered medication according to standards of practice, facility policy and procedure for administration of medication through enteral route via gastrostomy tube for 1 of 2 residents out of a total sample of 12 residents observed for medication administration. (#72) Findings: Florida Board of Nursing, Nurse Practice Act, 464.003 (19) (20) (a) (b) reads, Practice of practical nursing means the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirm; the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician . A practical nurse is responsible and accountable for making decisions that are based upon the individual's educational preparation and experience in nursing. 20) Practice of professional nursing means the performance of those acts requiring…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a Restorative Nursing Program (RNP) to maintain function as recommended by Physical Therapy for 1 of 1 resident reviewed for rehabilitative/restorative services of a total sample of 45 residents. (#97) Findings: Resident #97, a [AGE] year-old male was admitted to the facility on [DATE] from an acute care hospital. His diagnoses including cerebral infarction, hypertension, diabetes type II, hemiplegia/hemiparesis following cerebrovascular disease affecting left non-dominant side, atrial fibrillation, and aphasia. Review of the resident's admission Minimum Data Set (MDS) assessment, with Assessment Reference Date (ARD) of 7/22/23, indicated the resident's cognition was moderately impaired with a Brief Interview For Mental Status (BIMS) score of 12/15. The assessment indicated the resident required extensive assistance of one person for bed mobility, dressing, toilet use, and personal hygiene. He had impairment in functional…

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 maintain acceptable parameters of nutritional status related to weight loss for 1 of 5 residents reviewed for nutrition out of a total sample of 45. (#70) Findings: Resident #70 was admitted to the facility on [DATE] with diagnoses including encephalopathy, altered mental status, Alzheimer's disease, anxiety disorder, gastro-esophageal reflux disease, major depressive disorder and malignant neoplasm of larynx. Review of the Minimum Data Set 5-Day Medicare assessment with assessment reference date of 7/05/23 revealed resident #70 had a Brief Interview for Mental Status score of 10 which indicated she had moderate cognitive impairment. The document indicated resident #70 had an unplanned weight-loss of 5% or more in 30 days. Review of resident #70's Electronic Medical Record (EMR) revealed resident weighed 113.8 pounds on 5/30/2023 and weighed 108.0 pounds on 6/27/2023 which was a weight loss of 5.10 percent. Review of resident #70'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 observation, interview, and record review, the facility failed to provide routine dental services to 1 of 3 Medicaid-funded residents reviewed for dental from a total sample of 40 residents. (#91) Findings: Review of the medical record revealed resident #91 was admitted to the facility on [DATE] from an acute care hospital and had diagnoses that included gastric ulcer, intestinal infection, difficulty swallowing, gastroesophageal reflux disease (GERD), diabetes, vitamin deficiency, anemia, and muscle weakness. The Minimum Data Set (MDS) quarterly assessment with Assessment Reference Date 7/01/23 noted the resident scored 15 out of 15 on the Brief Interview for Mental Status that indicated the resident was cognitively intact. The assessment showed the resident did not have any episodes of behavior or rejection of care or services, and she required staff supervision and support to complete activities of daily living. On 8/14/23 at 10:53 AM, resident #91 was observed sitting in a wheelchair in her room.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report the results of an abuse allegation investigation within 5 working days involving 2 of 3 residents reviewed for abuse out of a total sample of 45. (#21 and #87) Findings: 1. Resident #21 was admitted to the facility on [DATE] with admitting diagnoses of heart failure, hypertension, dementia and major depressive disorder. Review of the Minimum Data Set (MDS) quarterly assessment with assessment reference date (ARD) of 6/21/23 revealed resident #21 had a Brief Interview for Mental Status (BIMS) score of 04 which indicated she was severely cognitively impaired. Resident #21 did not exhibit any physically aggressive behaviors during the review period. Review of resident #21's electronic medical record (EMR) revealed a Change in Condition assessment dated [DATE] which indicated resident was victim of other aggressive resident who initiated an altercation. A Weekly Skin Integrity Review dated 6/11/23 noted resident #21 sustained a small discoloration…

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 6 of 33 rooms were clean, and in good repair on the North Wing, (rooms #102, #107, #108, #110, #112, #116). Findings: In room [ROOM NUMBER] on 11/15/21 at 10:52 AM, the privacy curtain was noted with tan colored stains. The wall between the beds had tan colored stains extending down the wall to the baseboard. There was dark buildup at the base of the faucet on the basin in the bathroom. The floor tiles behind the toilet bowl had brownish discoloration. On 11/15/21 at 11:43 AM, room [ROOM NUMBER] was noted to have black discolored areas on the bathroom floor, and the toilet bowl was splattered with a dark substance. Observations on 11/16/21 at 9:42 AM and 12:32 PM, and on 11/17/21 at 9:12 AM showed the toilet bowl was still splattered with the dark substance and had rust and brownish discoloration. On 11/15/21 at 11:53 AM, the toilet bowl in room [ROOM NUMBER] had rust, yellowish streaks, and a yellowish ring around the water level. On 11/15/21 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 interview and record review, the facility failed to ensure the Long Term Care Ombudsman's office was notified in writing of the reason for transfer/discharge to the hospital for 3 of 4 residents reviewed for hospitalizations, (#2, #63, #101) of a total sample of 45 residents. Findings: Review of the clinical record revealed resident #2 was transferred to the hospital on 9/09/21 for altered mental status. The resident was again transferred to the hospital on [DATE] for escalating behavior, and was readmitted to the facility on [DATE]. Resident #63 was transferred to the hospital on 6/09/21 and was readmitted to the facility on [DATE] with a diagnosis of gastrostomy infection. Resident #101 was transferred to the hospital on 8/07/21 and readmitted to the facility on [DATE]. The clinical records of residents #2, #63 and #101 did not include notification to the Ombudsman's office of the residents' transfers to the hospital. On 11/18/21 at 11:14 AM, the Director of Nursing (DON) stated the notification to…

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 care plans were updated to include current interventions for falls/elopement for 1 of 5 residents reviewed for falls of a total sample of 45 residents, (#2). Findings: Resident #2 was initially admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses of dementia, anxiety disorder, generalized muscle weakness, difficulty in walking, and mood disorder. The resident's admission Minimum Data Set (MDS)assessment with assessment reference date of 7/27/21 revealed the resident's cognition was severely impaired with a Brief Interview For Mental Status score of 5/15. The assessment noted the resident exhibited physical and verbal behavior symptoms directed toward others, rejected care, and required extensive assistance of one-person with bed mobility, transfers, locomotion on/off unit, dressing, eating, toilet use and personal hygiene. The resident was assessed to be frequently incontinent of bladder and bowel and had 2 or…

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 nail care for 1 of 3 residents reviewed for Activities of Daily Living (ADL), of a total sample of 45 residents, (#73). Findings: Resident #73 was admitted to the facility on [DATE] with diagnoses of dementia, psychosis, aphasia and cirrhosis of the liver. Review of the resident's annual Minimum Data Set assessment dated [DATE] noted the resident had a Brief Interview for Mental Status score of 4 indicating severe cognitive impairment. He was dependent on 1-2 staff for all Activities of ADLs including personal hygiene. On 11/16/21 at 2:04 PM, the resident was sitting in his wheelchair across from the nurse's station. His finger nails were noted to be long, very thick, and discolored. The resident's care plan for ADLs dated 11/17/21 noted an intervention added on 3/26/21, Resident has very thick, elongated fingernails-Podiatry to trim down. On 11/17/21 at 2:32 PM, the resident's direct care Certified Nursing Assistant (CNA) F stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure oxygen (O2) therapy was administered per physician orders for 1 of 2 residents reviewed for O2 therapy of a total sample of 45 residents, (#101). Findings: Resident #101 was admitted to the facility on [DATE] with diagnoses including pneumonitis due to inhalation of food and vomit, generalized anxiety disorder, chronic obstructive pulmonary disease, heart failure, dementia, and pleural effusion. The resident's quarterly Minimum Data Set (MDS) assessment, with assessment reference date of 10/20/21, revealed the resident's cognition was severely impaired, with a Brief Interview For Mental Status score of 4/15. Resident #101 required extensive assistance with her activities of daily living. Observations on 11/15/21 at 2:30 PM, and on 11/16/21 at 12:55 PM, showed resident #101 received O2 therapy via nasal cannula (NC), infusing at 4 Liters per minute (LPM). Review of the resident's physician orders, revealed an order dated 11/12/21 for…

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.