Aviata At Seminole

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and facility record review, the facility failed to ensure sufficient staffing met the needs of the residents as evidenced by: 1. Resident interviews on untimely call light response for five residents (#5, #23, #24, #25 and #26) of six residents sampled, 2. Unresolved grievances related to call light response times for one resident (#5) of two residents reviewed for grievances. Findings Included: An interview was conducted on 04/02/2025 at 9:45 a.m. with Resident #23 and #24. Resident #24 stated that the staffing was often a problem. She stated staff often said they were Short-handed and didn't have time to assist her or she had to wait longer for assistance. Resident #24 stated she was often provided with incontinence care only one time during the first shift of the day. Resident #23 confirmed that she had brought up her concerns. He stated that he's an independent resident but had observed they took a long time to assist Resident #24. Record review revealed that Resident #23…

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 have a system in place to enable accurate reconciliation and accounting for all controlled medications for 4 out of 6 sampled medication carts. Findings included: An observation was conducted on 04/02/2025 at 10:20 a.m. with Staff L, Licensed Practical Nurse (LPN) for the 500 hallway medication cart. Staff L, LPN was observed placing one Medication Monitoring / Control Records log into the 500 hallway narcotic book. The Shift Change Controlled Substance Inventory Count Sheet showed there were 25 cards and 1 bottle of liquid in the narcotic drawer. Staff L counted the cards as well as the bottle of liquid controlled substance, and they matched the Shift Change Controlled Substance Inventory Count Sheet. The individual controlled drugs/cards were compared to the individual Medication Monitoring / Control Records log and they matched. The Shift Change Controlled Substance Inventory Count Sheet for the 500 hallway showed the following residents on 04/02/2025 had narcotics added to the medication cart, without 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.

Based on observations, interviews, and record review, the facility failed to establish and implement a Quality Assurance and Performance Improvement Program (QAPI) that enabled accurate reconciliation and accounting for all controlled medications for 4 out of 6 sampled medication carts. Findings included: Review of the facility's policy, QAPI Goals, 2025 QAPI Plan, not dated, showed the following: At Aspire at Seminole we are committed to focusing on clinical care, quality of life and resident choice. On behalf of those we serve, we are committed to using QAPI to improve our performance and practices and to assure wee meet and exceed regulatory requirements and standards. Scope: Aspire at Seminole's QAPI program encompasses all areas that impact quality of care, quality of life, resident choice and care transition with participation from all disciplines. Patient-Driven Care: all patient care is patient-driven to ensure that residents are properly cared for and are a part of their care planning and drive their outcomes. Performance Improvement Projects (PIPs): The QAPI team 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 the facility failed to abide by their smoking policy of ensuring residents are provided a safe, designated smoking area for nine (#10, #13, #8, #12, #14, #9, #11, #15 and #26) of 27 sampled residents. Findings included: Review of the facility's policy, Smoking-Supervised, revised 02/07/2020 showed the Center will provide a safe, designated smoking area for residents. For the safety of all residents the designated smoking area will be monitored by a staff member during authorized smoking times. Smoking is only allowed in designated areas and during designated times. The Center will have safety equipment available in designated smoking areas including: smoking aprons, a fire extinguisher and non-combustible self-closing ashtrays. Procedure: 1. Residents that wish to smoke will be evaluated on admission/re-admission, quarterly, and with a change in condition to determine if assistance or supervision is required for smoking. 2. If a resident is identified during 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 record review and interview, the facility failed to ensure a transfer notice was provided to the resident and the resident representative for one (Resident #3) of three residents sampled for emergency transfers. Findings included: Review of Resident #3's admission Record showed he was originally admitted to the facility on [DATE] and most recently readmitted on [DATE]. Review of paperwork dated 02/02/2025 at 2:38 PM showed the Psychiatric Advanced Registered Nurse Practitioner (ARNP) completed involuntary examination documents for Resident #3 for schizoaffective disorder, resident's inability to determine whether examination is necessary, and a substantial likelihood that without care or treatment the individual will cause serious bodily harm to self or others. The ARNP documented the patient presented with psychosis, significant agitation, aggression and threatening of staff. Resident threw his food tray at a staff member and smeared feces all over his room. Resident was refusing all care or any…

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 an injury of unknown origin that resulted in a transfer to a higher level of care for one (#1) of one resident out of ten residents reviewed. Findings Included: A review of Resident #1's admission Record showed an original admit date of [DATE] with a readmission date of [DATE] with the following diagnoses: Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting right dominant side Other abnormal of gait and mobility Need for assistance with personal care Difficulty in walking, not elsewhere classified. Muscle weakness (generalized) Muscle wasting and atrophy, not elsewhere classified, unspecified site A review of Resident #1's care plan dated [DATE] showed a Focus area: ADL (Activity of Daily Living)/ self-care performance deficit related to hemiparesis, weakness, dementia, schizoaffective disorder- depressive type, major depressive disorder, insomnia, incontinence, muscle wasting and atrophy, lumbar spondylosis…

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 1. provide treatment and services in accordance with physician orders for one (#9) out of three residents reviewed; and 2. failed to ensure call lights were answered within a timely manner for four (#5, #6, #7, and #8) of ten sampled residents. Findings Included: 1. Review of the admission Record showed Resident #9 was admitted to the facility on [DATE] with diagnoses to include acute osteomyelitis, chronic ulcer of the right heel and midfoot, peripheral vascular disease, and type 2 diabetes mellitus with foot ulcer. Review of Resident #9's Medication Administration Record for November 2024 showed the following: -Cleanse left Achilles with [antimicrobial wound cleanser] 0.125% solution, apply nickel thick [topical enzyme medication] and cover with dry dressing every day shift for arterial wound, completion of wound care was not documented on 11/3, 11/4, 11/5, 11/6, and 11/9/2024. -Cleanse left anterior lower leg with [antimicrobial…

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

Based on observation, record review, and interviews, the facility failed to ensure adequate nail care and consistent shower services for one (Resident #1) of three residents sampled for Activity of Daily Living services. Findings included: A review of Resident #1's clinical chart, documented an initial admission of 05/2022; readmission of 03/2024. Medical Diagnoses included: Metabolic Encephalopathy; Hyperosmolality and Hyponatremia; Aphasia; chronic kidney disease; contracture of muscle right hand, diabetes insipidus . On 09/16/2024 at 1:08 p.m., a phone interview was conducted with Resident #1's family member. She stated she communicated with (Resident #1) daily by way of video chat. She stated his appearance was unclean at times and his fingernails are long and unclean. On 09/16/2024 at approximately 1:30 p.m., Resident #1 was observed in his room, sitting in his wheelchair at bedside. He agreed to answer questions. He showed the surveyor his hands. Resident #1 was observed to have a closed right hand, which he pulled open to show his nails. The skin on the right hand 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, record review, and interview, the facility failed to ensure a dignified existence was provided to one resident (#16) out of eight residents sampled. Findings included: During an observation made on 05/20/2024 at 2:51 p.m. Resident #16 was observed scooting around on the floor in her room with staff surrounding her. The resident scooted from her room into the middle of the hallway in front of other residents and staff. During an observation made on 05/22/2024 at 10:30 a.m., in the activities room, Resident #16 was observed in a corner separated from other residents in the activities room while an activities program was being conducted with other residents. She was observed sleeping with a blanket over her whole body, reclined back in the chair's lowest position and her feet positioned upward. Review of an admission Record, dated 05/23/2024, showed Resident #16 was admitted originally on 05/18/2022 and readmitted on [DATE] with diagnoses to include senile degeneration of brain, not elsewhere…

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 a reasonable accommodation of resident needs for one resident (#44) out of eight sampled residents related to having an appropriate bed to sleep in. Finding included: During an observation made on 5/20/2024 at 12:00 pm. Resident #44 was observed lying down in bed with his feet hanging off the edge of the bed mattress. He was observed dressed in his night gown. He said his legs were too long for his bed and the staff at the facility had known about it for a long time, but had not done anything about it. During an observation on 5/22/2024 at 8:00 a.m. Resident #44 was observed lying down in bed with his head slightly elevated and his feet hanging off the edge of his bed. He said he would like to have another bed because he was not able to fit on his bed. Review of an admission Record, dated 5/22/2024, showed Resident #44 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses to include but not limited to difficulty…

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, interview, and review of the facility's policy Preadmission Screening and Resident Review (PASRR), the facility failed to ensure residents received an accurate Level I Preadmission Screening and Resident Review (PASRR) for four residents (#6, #68, #36 and #43) of twenty-three sampled residents who were reviewed for PASRR screens. Findings included: 1. Review of the admission Record showed Resident #43 was admitted to the facility on [DATE] with diagnoses that included but not limited to undifferentiated schizophrenia, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, and major depressive disorder, recurrent. Review of the Aging Solution Form, dated 04/15/24, showed under the Diagnosis and Active Diagnoses section Resident #43 had a Primary Diagnosis Dementia; Secondary Diagnosis Traumatic Brain Injury. Review of the admission Minimum Data Set (MDS), dated [DATE], showed in Section C - Cognitive Patterns a Brief…

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, observation, and record review, the facility failed to develop and implement a person-centered care plan to meet the resident's communication needs for one (Resident #491) of one sampled resident and for one (Resident #87) of one resident sampled for Cardiopulmonary Resuscitation (CPR) status. Findings included: 1. On [DATE] at 1:17 p.m. Resident #491 was observed in her room laying down in bed. Resident #491's [family member], the resident's responsible party, was speaking in Spanish with her roommate, Resident #491's [family member] stated the resident did not speak English and asked for the interview to be conducted in Spanish. Both Resident #491's [family member] and her roommate stated the roommate would help communicate with staff, in Spanish, in the [family member's] absence. Resident #491's [family member] stated the nurse on shift during the day spoke Spanish. At 1:24 p.m. Staff F, Registered Nurse (RN) entered the room and asked the resident, in Spanish, if she was having any…

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 interviews, the facility failed to review and revise the care plan for one resident (#87) out of the sampled thirty-nine residents. Findings included: On 05/20/24 at 11:28 a.m. Resident #87's room door was observed with signage that showed enhanced barrier precautions. A review of the admission Record revealed Resident #87 was initially admitted to the facility on [DATE] with diagnoses to include candidiasis and pneumonia. Section I - Active Diagnoses of the Minimum Data Set (MDS), dated [DATE], showed Resident #87 had an active diagnosis of pneumonia. The care plan with a focus area that showed Resident #87 had candida auris was initiated on 04/02/24. Interventions included but were not limited to contact isolation. The care plan with a focus area that showed Resident #87 was on antibiotic therapy related to sepsis and pneumonia was initiated on 04/23/24. Interventions included but were not limited to administer antibiotic medications as ordered by physician. A review of the Order…

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, observation, and record review, the facility failed to ensure the proper and timely interventions to prevent pressure ulcers for one (Resident #290) out of three sampled residents. Findings include: On 5/20/24 at 9:30 a.m., an interview was conducted with the family of Resident #290. Resident #290's family member stated the resident had a pressure sore on her bottom and left ankle, stating, we aren't too surprised because she has been in a regular bed since she has been here. Resident #290 was sitting in bed slightly less than ninety degrees upright while her family member attempted to assist with a high protein yogurt brought from the family member's home. The family member stated, I know a diet high in protein will help heal her wounds. Resident #290 had both her legs drawn in close to her buttocks and incapable of naturally straightening her legs. A review of Resident #290's admission Record showed an admission date of 5/03/2024 with a primary diagnosis of urinary tract infection.…

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 #87) out of the sampled seven residents, who was fed by enteral means, received appropriate treatment and services per physician orders. Findings included: On 05/22/24 at 10:23 a.m., Resident #87 was observed in bed sleeping. The enteral feeding pump was observed at 65 ml per hour and the total fed was 12,217 milliliters (ml). A review of the admission Record revealed Resident #87 was initially admitted to the facility on [DATE] with diagnoses to include dysphagia and pneumonia. Section C- Cognitive Patterns of the Minimum Data Set (MDS) showed Resident #87 was rarely/never understood. Section I- Active Diagnoses of the MDS showed Resident #87 had a diagnosis of dysphagia, oropharyngeal phase. Section K- Swallowing/ Nutritional Status showed the resident had a nutritional approach of feeding tube. A review of the Order Listing Report with a date range of 03/01/24-05/31/24 revealed the following active orders: Enteral…

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, interview, and review of the facility's policy Medication Management-Psychotropic Medications, the facility failed to ensure side effects monitoring was in place for one (Resident #8) out of five residents reviewed for unnecessary and psychotropic medication regimen review. Findings included: Review of the admission Record revealed Resident #8 was initially admitted to the facility 05/15/23 with diagnoses that included but not limited to Schizoaffective Disorder, Bipolar type, Parkinson's Disease without dyskinesia, Major depressive disorder, recurrent and anxiety disorder, unspecified. A review of the Order Summary Report showed the following psychotropic medication ordered: - A physician order dated 05/11/24 showed, Xtapaza ER Oral Capsule ER 12-hour abuse- deterrent 9 MG- Give 1 capsule by mouth two times a day for chronic pain. - A physician order dated 05/07/24 showed, Duloxetine HCI Oral capsule Delayed Release Particles 60 MG- Give 1 capsule by mouth for Major Depressive Disorder…

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 reviews, the facility failed to ensure the medication error rate was less than 5.00%. Twenty-six medication administration opportunities were observed and three errors were identified for three residents (Residents #79, #22 and #6) of six residents observed. These errors constituted a 11.54% medication error rate. Findings Include: On 5/22/24 at 9:29 a.m., an observation was conducted during medication administration with Staff C, Licensed Practical Nurse (LPN) for Resident #79. Staff C dispensed the following medication: -Aspirin 81 milligrams (mg) chewable one tablet -Carvedilol 3.125 mg one tablet -Plavix 75 mg one tablet -Ezetimibe 10 mg one tablet one tablet -Sertraline 50 mg one tablet -Senna Plus one tablet A review of the physician orders dated 9/12/2023 for Resident #79 showed Telmisartan 20 mg one tablet by mouth once daily related to hypertension On 5/22/24 at 3:30 p.m., an observation was conducted during medication administration with Staff D, LPN for Resident #22. Staff D cleared the feeding pump total infused to zero and…

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

Based on observation, interview, and record review, the facility failed to provide proper infection control practices for two (Residents #51 and #22) out of six residents observed during medication administration. Findings include: On 5/22/24 at 8:40 a.m., an observation was made of Staff A, Licensed Practical Nurse (LPN) administering eye drops to Resident #51. During administration, the tip of the dropper was observed touching the resident's eyelids from one eye to the next eye. Resident # 51 was sitting at an angle of ninety degrees with head tilted down. Resident #51 struggled to open eyes wide unassisted and closed when the eye dropper touched his lids. Staff A continued to administer the eye drops under the same circumstances for the next eye. The eye dropper medication was covered with its cap and returned to the box labeled with the resident's name and then returned to the medication cart. On 5/22/24 at 3:30 p.m., an observation was made of Staff D, LPN during medication administration of physician orders for Resident #22 's enteral feedings. Staff D demonstrated the process…

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 policy review the facility failed to ensure the kitchen equipment and area were maintained in a sanitary manner, and food was prepared, distributed and served in accordance with professional standards for food service safety, to include not ensuring the milk cooler maintained appropriate temperatures as evidenced by a temperature of 49 degrees Fahrenheit, and the facility failed to ensure the two nourishment rooms located on the 200 and 500 hall for residents were maintained and clean as well as have foods that were labeled properly, and foods were disposed of properly for three days (01/11/22, 01/12/22 and 01/13/22) of four days of survey. Findings included: On 01/11/22 between 9:28 a.m. and 10:40 a.m., an initial kitchen tour was initiated with the Dietary Manager (DM) and the observations included: *A ceiling vent above the food service area was noted with dirt and debris. The DM stated the maintenance department should be maintaining vents. *A water bottle was observed on top of the cart near the dish machine and noted with a pink solution.…

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 did not ensure dignity was maintained for four residents (#71, #23, #25 and #11) of four residents related to 1. three staff members (O, J, H) assisting two residents (#71, #23) with meals while standing, 2. not ensuring catheter bags for two residents (#71 and #11) were covered with privacy bags, and 3. not ensuring privacy during wound care for one resident (#25), for a total of three days (01/11/22, 01/12/22 and 01/13/22) of four days. Findings included: 1. During multiple facility tours on 01/11/22 at 12:45 p.m., 01/12/22 at 9:03 a.m., 01/12/22 at 12:19 p.m., and 01/13/22 at 12:41 p.m., observations were made of Staff O, Certified Nursing Assistant (CNA) standing while assisting Resident #71 with a meal. An admission Record printed on 01/13/22 showed Resident #71 was admitted to the facility on [DATE] with diagnoses to include: other lack of coordination, Type 2 diabetes, Dysphagia, facial weakness, sequelae of Guillain-Barre syndrome,…

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 review, interviews, and the plan of correction review, the facility failed to ensure it had a functioning Quality Assurance system. The facility was actively involved in the creation, implementation, and monitoring of an effective plan of correction for deficient practice identified during a recertification survey, conducted on 01/11/2022 to 01/14/2022, and cited at F812. The facility developed a plan of correction with a compliance date of 02/14/2022. During a revisit survey, conducted on 02/24/2022, deficient practice was again identified at F812 related to kitchen equipment and food storage. Findings included: The facility developed a plan of correction that included: -All soiled equipment was cleaned on 01/12/22. -Undated/unlabeled food items were disposed of by dietary manager. -Daily sanitation observations of the kitchen, walk in refrigerator/freezer and nourishment rooms will be conducted by the dietary manager and/or designee. -Dietary staff were reeducated on the cleaning and maintenance of kitchen equipment and labeling/dating of foods. -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 observations, interviews and record review the facility failed to provide services with reasonable accommodation of a resident's need and preference related to smoking during the assigned smoking times for one resident (#59) of a total sample of 15 residents who smoked for four days (01/11/22, 01/12/22, 01/13/22 and 01/14/22) out of four days. Findings included: During a facility tour on 01/11/22 at 10:32 a.m., Resident #59 was observed in his room waiting to be assisted out of bed and to be dressed. Resident #59 stated, I want to get out and have my cigarette. I missed my 9:00 a.m. cigarette. On 01/12/22 at 9:10 a.m., Resident #59 was observed in his room, lying in bed. Resident #59 said, They won't let me go to smoke. I have to get dressed, and no one is assisting me. Resident #59 stated if he missed the smoke time at 9:00 a.m., he has to wait until 1:00 p.m. On 01/12/22 at 12:51 p.m., Resident #59 complained that he still had not had a cigarette. Resident #59 said, They said I missed it, because I…

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 appropriate treatment and services of an indwelling catheter for two residents (#11, and #71) of seven residents with indwelling catheters. Findings included: 1. On 01/11/22 at 12:10 p.m., Resident #11 was observed in his room during lunch. His catheter bag was observed on the floor and not covered by a privacy bag. Resident #11 was non-verbal. On 01/11/22 at 12:50 p.m., Resident #11 was wandering the halls dressed in a hospital gown, open in his back, exposing his brief. Resident #11 was carrying his catheter bag in his hand. The catheter bag was not covered with a privacy bag. Resident #11 was pointing to a full catheter bag asking if it could be emptied. On 01/12/22 at 9:05 a.m., Resident #11 was observed ambulating himself to the bathroom, holding his catheter bag in one hand, the tubing was dragging on floor. Resident #11 mumbled, Help me. At this time Staff J, CNA said to Resident #11, I will be right with you, and as 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 observation, interview and record review, the facility failed to ensure the medication error rate was below 5.00%. A total of twenty-five medications were observed administered, and two errors were identified for two (Resident #21 and #49) of three residents observed. These errors constituted a medication error rate of 8.00 percent. Findings included: On 1/13/22 at 08:30 a.m., an observation of medication administration with Staff A, Registered Nurse (RN), was conducted with Resident #21. Staff A, (RN) was observed administering Advair HFA Aerosol 115-21 MCG (microgram) ACT one (1) application inhale orally two times a day for diagnosis of Shortness of Breath. (SOB). After the medication was administered Resident #21 did not rinse her mouth and spit out with water after inhalation of the medication. An immediate interview with Staff A, (RN) was conducted and Staff A, (RN) stated I forgot, when she was asked why she did not follow pharmacy package directions on the medication. An interview was obtained at the same time with the resident who revealed that she often forgets…

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 interviews, the facility failed to ensure ordered medication was available to dispense on an as needed (PRN) basis for one resident (#61) of four residents reviewed for the provision of ordered medications. Findings included: Review of the face sheet in the admission record for Resident #61 revealed a diagnosis of pressure ulcer of right buttock, stage 3. A review of the Minimum Data Set (MDS) assessment, Section C, Cognitive Patterns, dated 12/11/21 reflected a Brief Interview for Mental Status (BIMS) score of 15, indicating her cognition was intact. Review of physician's orders in the medical record revealed an order dated 12/23/21 for cyclobenzaprine hcl 5 mg (milligram) every 8 hours as needed for muscle relaxer related to muscle weakness, generalized. On 1/11/22 at 11:35 AM an interview was conducted with Resident #35. She said a nurse told her the prescription for the muscle relaxer disappeared after it was delivered from the pharmacy, and said it took a week and a half to get them reordered and delivered. A review of the Proof of Delivery Shipment…

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 did not ensure nutritional parameters were addressed and maintained for one resident (#79), related to weight loss, for three residents reviewed for nutritional care. Findings included: A review of the 10/8/20 Minimum Data Set (MDS) assessment revealed Resident #79 had a Brief Interview for Mental Status (BIMS) score of 10 (moderate cognitive impairment) and required supervision for eating with one person physical assistance. A review of the physician's orders in the medical record revealed a 9/22/20 order of regular diet dysphagia mechanical soft texture, regular/thin liquids consistency, regular, mechanical soft, thin liquids. A review of the care plan dated 10/20/20 revealed Resident #79 has a nutritional problem r/t (related to) suboptimal meal intake r/t receiving a mechanically altered diet. Diagnoses: dysphasia, diabetes, anemia, aphasia. He has a history of significant weight loss, and major depression. Eats meals with hands at times. Interventions included provide and serve supplements as ordered, RD (registered…

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, and policy review the facility did not practice infection control procedures to avoid potential infection as evidenced by 1) failure to practice hand hygiene during medication administration by one (Staff A) of four nurses observed, and 2) failure to disinfect a glucometer for one (#73) of three residents observed for blood glucose monitoring during the medication administration task by one (Staff A) of four nurses observed. Findings included: 1. On 10/27/20 at 4:27 p.m., Staff A, Licensed Practical Nurse (LPN) was observed preparing to administer medication to Resident #63. Staff A knocked on the bedroom door. Staff A put on a pair of gloves, verified the resident's identification and checked her temperature. The resident refused the medication. Staff A exited the room still wearing a glove on her left hand. She removed the glove and disposed of it in a trash can on the medication cart. She removed keys from her pocket and opened the medication cart. Staff A, LPN, removed a bottle for wasting/disposing of medications. She poured 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.