Aviata At Fletcher

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow standard and enhanced barrier precautions when performing urinary catheter care and services for one (#3) of three sampled residents Findings included During an observation on 10/24/2024 at 1:45 p.m., Resident #3 was lying in bed. His urinary catheter bag was lying on the floor. Yellow urine was observed in the bag. No ants noted. During observation and interview with Staff A, Licensed Practical Nurse (LPN) she entered the room and moved the urinary catheter bag from the floor. She attached it to the bed. She entered the bathroom and washed her hands. During an interview, Staff A stated the resident went to the bathroom by himself and must have left the bag on the floor. She stated the catheter bag needed to be off the floor. She reviewed the Enhanced Barrier sign on the door and stated he was on enhanced precautions due to his catheter. Staff A stated she did not put on gloves nor a gown to move his catheter bag. She 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.

Based on observations, staff interviews and review of records, the facility failed to ensure one (dining room) of two ice makers used for residents was free from bio-growth. Findings included: On 7/8/2024 at 12:30 p.m. and at 3:20 p.m. the main dining room was observed during the lunch meal dining service. The back wall area near the door leading to the kitchen was observed with a walled space containing a counter space, equipment storage area and a large ice maker. Observations revealed staff taking ice from the machine with an ice scoop. Further observations of the machine revealed heavy oxidation, calcification on the outside metal cover. When the ice machine door was opened, it was observed full with ice. Observations on the inner plastic ice chute revealed heavy black discoloration to include bio-growth spotting. It was determined this ice machine was used to serve ice to residents for consumption. On 7/9/2024 at 11:00 a.m., 2:00 p.m., 7/10/2024 at 7:30 a.m., 11:30 a.m., and 1:07 p.m., the dining room ice machine was again observed with black bio-growth in and surrounding 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 establish a policy to ensure a safe smoking area where protection from excessive heat and access to hydration was provided to nine of nine ( #13, #108, #30, #106, #165, #98, #19, #317, #166) residents identified as smokers. Findings included: On 7/8/2024 the facility provided a Resident Smoking List which included Resident #13, #108, #30, #106, #165, #98, #19, and #166. Observations of the smoking patio from 7/8/2024 through 7/11/2024 revealed Resident #166 was also a smoker but was not included on the original list provided. Observations on 07/08/24 at 2:28 PM revealed approximately eight residents on the smoking patio. The smoking patio was noted to have no covered area to provide shade for the residents, who were observed to be lined up against the right side of the patio to get relief from the sun from the approximate 12 inches of shade created by the height of the building. Additional observations revealed there was no fluids 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 interview and record review, the facility failed to identify and report an allegation of physical abuse by a staff member for one (#314) of three residents reviewed for abuse. Findings Included: A review of the admission Record showed Resident #314 was most recently admitted to the facility on [DATE] with diagnoses to include cerebrovascular Accident (CVA), aphasia, hemiplegia, depression, and legal blindness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #314 had a Brief Interview Status (BIMS) score of 14 out of 15, indicating intact cognition. Resident #314 needed maximum assistance with one-person physical assistance with bed mobility, dressing, toilet use, and personal hygiene, and extensive assistance with two plus persons physical assistance with transfers. During an interview on 7/8/2024 at 9:17 AM, Resident #314 reported a concern regarding not being able to get up into a wheelchair. Review of the grievance log, from April 2024 to current, revealed 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 observations, record review, and interview the facility failed to complete an accurate Minimum Data Set (MDS) assessment that accurately reflected the dental status for one (#21) of 48 sampled residents. Findings Included: Interview with Resident #21 on 07/08/24 at 3:38 PM revealed he has had some toothache pain recently and that the facility puts cream on it. He reported that the cream does not always work and that he has not seen a dentist. On 07/10/24 at 12:40 PM, the resident reported that he has a few teeth left and that one on the bottom has a hole and that one on top was cracked. The resident reported that other than his usual body pain he constantly has mouth pain. The resident reported that he has trouble eating and has to cut everything up small. The resident reported that his dental pain is at a level of 7 to 8 and that all staff give him a cream to rub on his teeth that does not work. The resident reported that the medication he takes for his general pain does not work for his mouth pain.…

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, staff and resident interviews, and record review, the facility failed to implement care plan interventions for one (#96) of 48 sampled residents, during four of four days (7/8/2024, 7/9/2024, 7/10/2024, and 7/11/2024). Findings included: Review of Resident #96's care plan revealed: The resident has an activity of daily living (ADL) self-care performance deficit related to disease process, impaired balance and limited mobility (date initiated: 10/8/23, date revised: 3/2/24). An intervention for this area included a heel protective boot to bilateral feet while in bed. May remove for ADL care (date initiated: 5/2/2024). The resident has potential for pressure injury development related to immobility (date initiated: 1/25/2024, date revised: 3/2/24). An intervention for this area included follow facility policies/protocols for the prevention/treatment of skin breakdown (date initiated 1/25/2024). The resident has peripheral vascular disease (PVD) related to diabetes and heart disease (date…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to provide care according to standards of practice related to an intravenous (IV) line, related to labeling of an IV line and accurate identification of the type of IV line for one resident (#264) out of one resident sampled for IV antibiotics. Findings included: Review of Resident #264's admission Record revealed he was admitted to the facility on [DATE] from an acute care hospital with diagnoses to include urinary tract infection (UTI), artificial openings of urinary tract status, and sepsis due to Escherichia Coli (E. Coli). An interview and observation were conducted on 07/08/24 at 12:45 PM with Resident #264. Resident #264 was observed to be sitting on the side of the bed, clean, dressed in day clothes, without odors. Resident #264 was observed to have an intravenous (IV) pump in his room next to his bed. He said he has an IV in his right upper arm. He held his arm out and there was no date on the IV dressing and blood in the IV line.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interview the facility failed to provide dental services in a timely manner for 1 of 48 (#21) sampled residents. Findings Included: Review of Resident #21's record revealed this resident was re-admitted to the facility on [DATE] with diagnoses to include Ataxia, Chronic Obstructive Pulmonary Disease and Hyperlipidemia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating cognitively intact. Interview with Resident #21 on 07/08/24 at 03:38 PM revealed that he has had some toothache pain recently and that the facility puts cream on it. He reported that the cream does not always work and that he has not seen a dentist. During an interview with Resident #21 on 07/10/24 at 12:40 PM the resident reported that he has a few teeth left and one on the bottom has a hole and one on top was cracked. The resident reported that other than his usual body pain he constantly has mouth pain. 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 administer medications in a clean and sanitary manner to prevent the spread of infection related to touching resident medications with bare hands for one resident (#36) out of six residents observed during the medication administration task. Findings included: Review of Resident #36's physician orders revealed an order with a start date of 12/19/2018 and no end date for carbidopa-levodopa 25-100 milligram (mg), give one tablet by mouth five times a day for Parkinson's. A start date of 12/19/2018 and no end date for carbidopa-levodopa 50-200-200 mg give one tablet by mouth at bedtime for Parkinsons. A start date of 12/19/2018 and no end date for amlodipine besylate 5 mg, give 1 tablet by mouth one time a day for hypertension. A start date of 3/7/2019 and no end date for furosemide 20 mg, give one tablet by mouth one time a day every other day for fluid retention. A start date of 6/29/24 and no end date for multivitamin, give one tablet by mouth daily for supplement. A start date of 5/16/24 and no end date 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to provide and honor the resident rights for choice related to health insurance for 3 of 3 (#21, #26, #50) residents reviewed for payer source changes. Findings included: 1. Review of the facility policy titled Resident Rights with an effective date of 11/30/24 revealed it is the policy of the company to provide on-going training on residents rights to staff members as required by state and/or federal regulations. Interview with the Business Office Manager (BOM) on 07/10/24 at 9:23 AM revealed that if a resident was admitted with straight Medicare their stay would be covered 100% for the first 20 days and at Day 21 the resident will have a deductible unless they have a secondary insurance. She reported that straight Medicare and a Medicare HMO (Health Maintenance Organization) are similar but with the HMO, the facility would have to report to a case manager every week. The BOM reported that when approaching the 20-day mark, the resident was encouraged 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 record review and interview, the facility failed to ensure one of three immediate reports reviewed for allegations of neglect was reported within the required 24 hour timeframe. Findings included: A review of a facility's Immediate Report with [report number] showed an incident of neglect. The Immediate Report showed the facility allowed Staff A, Certified Nursing Assistant (CNA) to work as a Licensed Practical Nurse (LPN) on the dates of 07/27/23, 07/28/23, 07/29/23 and 08/01/23 without prior nursing licensure verification. The facility discovered the incident of neglect on 08/09/23. A review of the Nursing Home Reporting- Federal 5 Day Report Manager showed the immediate report [number] was initially submitted by the Administrator on 08/11/23 at 8:29 p.m. During an interview on 10/30/23 at 3:50 p.m., the Nursing Home Administrator (NHA) stated report [number] was not reported in the 24-hour timeframe because it was a huge one. The NHA stated normally the required timeframe for reporting an allegation of abuse was within a two hour timeframe and reporting an allegation of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review, the facility failed to accommodate the needs of three (Residents #3, #23, and #244) of four residents sampled for the provision of appropriate incontinent briefs. Findings included: 1. Review of Resident #23's record revealed that this resident was admitted to the facility on [DATE], with diagnoses that included Morbid Obesity and had a Brief Interview for Mental Status (BIMS) dated 2/11/22 with a score of 09 (Moderate Cognitive Impairment). A review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident required extensive assist of two people for bed mobility, dressing, and toilet use, required extensive assist of one person for personal hygiene and was totally dependent on two staff for bathing. An observations of Resident #23 on 04/19/22 at 10:00 a.m. revealed the resident lying in her bed. During an interview with the resident, she reported the facility never had her size adult disposable briefs, the staff always put small briefs on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to provide colostomy care consistent with profession standards of practice for one (Resident #449) of two sampled residents with a colostomy. Findings included: An observation was made for Resident #449 on 4/18/22 at 11:29 a.m. The resident was resting in his bed with his head elevated. The resident was a quadriplegic. An indwelling catheter and colostomy bag were observed. A review of the admission record indicated Resident #449 was admitted on [DATE] with diagnoses that included unspecified displaced fracture of fifth cervical vertebra, quadriplegia, polyneuropathy, neuromuscular dysfunction of the bladder, colostomy status and neurogenic bowel. A review was conducted of Resident #449's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form, dated 4/11/22. The from noted the resident had an ostomy upon transfer. An interview was conducted with Resident #449 on 4/20/22 at 10:04 a.m. The resident stated the…

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

Based on observations, staff interview, and facility record review, the facility failed to ensure one of one kitchen dish washing machine was running at the required specifications during two of four days observed, (4/18/2022 and 4/19/2022). Findings included: On 4/18/2021 at 9:18 a.m., an initial tour of the kitchen was conducted with the facility's Kitchen Manager. The Kitchen Manager revealed they had a dish washing machine and it was a High temp (temperature) machine. However, observations of the front metal cover revealed a bright yellow sticker that revealed, Notice: This machine is currently in chemical sanitizing mode. There was a clear plastic container placed on top of the machine with approximately five to six tubes of chemical sanitizer test strips, and approximately five to six slide out chemical sanitizer test strips. Also, the wall behind the dish machine was observed with a container with a hose leading from it down to the machine. The container was full with a blue/green liquid and the label indicated, [Company name] Rinse Max II, Electronic solid rinse additive…

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 develop a care plan for one (Resident #450) of one resident in the facility on Transmission Based Precautions (TBP). Findings included: Review of the clinical record for Resident #450 revealed an admission date of 04/05/2022, with diagnoses that included Malignant neoplasm and Antineoplastic Chemotherapy Induced Pancytopenia. Review of the Physician's Orders showed an order for Reverse Isolation related to malignant Neoplasm of unspecified site of left female breast, dated 04/08/2022. The care plan for Resident #450 was reviewed and did not include a focus, goals, or interventions related to Transmission Based Precautions. On 04/19/2022 at 10:01 a.m., an interview was conducted with Staff A, Licensed Practical Nurse (LPN). The LPN confirmed the resident was on TBP, stating, it is 'reverse isolation' as she is neutropenic. An interview was conducted with the Director of Nursing (DON) on 04/21/2022 at 9:11 a.m The DON confirmed it was his expectation the TBP, along with goals and interventions, would be on the resident'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 The facility failed to reassess care plan problem areas and interventions for one (Resident #10) of forty sampled residents related to accuracy of care plans. Findings included: On 4/18/2022 at 10:00 a.m., and 1:23 p.m. Resident #10 was observed in his room and lying in bed at its lowest position and with the call light placed within his reach. Resident #10 was not able to communicate or be interviewed with relation to his care and services. Further observations revealed he had arm and leg contractures. Both elbows and both knees were observed without any type of splints or braces. On 4/19/2022 at 7:45 a.m., 10:00 a.m., 12:45 p.m., 1:25 p.m., and 2:20 p.m., Resident #10 was observed lying in bed with the call light placed within his reach. He was noted with his eyes closed and not presenting with any behaviors, pain or discomfort. Resident #10 was observed with both of his elbows and both of his knees without any type of braces or splints. On 4/20/2022 at 7:50 a.m., 8:40 a.m., and 12:45 p.m., Resident #10 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.

Based on record review and interview, the facility failed to ensure wound care was completed and documented according to Physician's Orders and professional standards on three (04/14/2022, 04/15/2022 and 04/16/2022) of thirteen days reviewed, and for one (Resident #494) of thirteen residents with pressure wounds. Findings included: Review of the clinical record for Resident #494 showed an admission date of 04/08/2022, with diagnoses that included Necrotizing Fasciitis, Osteomyelitis and Pressure Ulcers. Continued review of the record revealed the following pressure wounds: -Unstageable Deep Tissue Injury (DTI) to Left Heel - 3 centimeters (cm) x 3.5cm x unable to determine depth (utd) -Unstageable DTI to Right posterior heel - 4.2cm x 1.8cm x utd -Unstageable DTI to Right posterior Calf - 5.1cm x 1.6cm x utd -Stage 4 to Sacrum - 15cm x 13.8cm x 0.5cm -Unstageable Pressure Ulcer due to necrosis on Right buttock - 6cm x 4.6cm x utd Review of the Physician's Orders revealed: -Apply betadine to left heel wound daily and leave open to air, dated 04/11/2022 -Apply betadine to right…

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 follow the Registered Dietician's recommendations and maintain acceptable parameters of nutritional status for one (Resident #45) of forty sampled residents. Findings Included: An observation and interview were conducted for Resident #45 on 4/18/22 at 12:00 p.m. Resident #45 was lying in bed with her roommate sitting at her bedside. The resident appeared small and frail. She stated her biggest concern was the food, she did not like it. A review of the admission records indicated Resident #45 was admitted on [DATE] with diagnoses including cerebral infarction, diabetes mellitus type II, major depressive disorder, peripheral vascular disease, gastroesophageal reflux disease (GERD,) and dysphagia. A review of Resident #45's care plans indicated care plans in place for activities of daily living (ADL) self-care performance deficit, peripheral vascular disease (PVD,) and risk for a potential nutrition problem or malnutrition. The care plan 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure behavior monitoring was in place for one (Resident #444) of five sampled residents on psychotropic medications. Findings included: A review of admission records indicated Resident #444 was admitted on [DATE] with diagnoses including acute pain due to trauma, major depressive disorder, and schizophrenia. A review of orders revealed the following: Donepezil HCL Tablet 10 milligrams (mg). Give 10mg by mouth at bedtime for Alzheimer related Alzheimer's disease. Start date: 4/9/22 Quetiapine Fumarate Tablet 25mg. Give 25mg by mouth one times a day related to schizophrenia. Start date: 4/12/22 Escitalopram Oxalate tablet 5mg. Give 5mg by mouth one time a day for depression. Start date: 4/9/22 Quetiapine Fumarate Tablet 50mg. Give 50mg by mouth at bedtime related to schizophrenia. Start date: 4/9/22 Trazodone HCL Tablet 50mg. Give 50mg by mouth one time a day for depression/insomnia. Start date: 4/9/22 Sertraline HCL tablet 50mg. Give 50mg by mouth…

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, staff interview, and maintenance record review, the facility failed to maintain a safe, clean, comfortable and homelike environment on two (East and West) of two units, as evidenced by damage and holes in the walls of resident rooms, common area handrails with missing end bumpers exposing internal components and frayed plastic wall bumpers with sharp edges exposed, an unsanitary shower room with floor and wall tiles missing, and a broken bed footboard exposing unsanitary and unsafe composite rough edges. The findings included: On 02/24/21 at 9:57 a.m., an observation of room [ROOM NUMBER] revealed a hole in the wall behind the headboard of the bed. The occupying resident stated the hole had been there for as long as she had been its occupant for the last several weeks. On 2/24/21 at 11:04 a.m., an observation in room [ROOM NUMBER] revealed damage to the walls behind the beds and nightstands. The bathroom wall was observed to have a large area of damage. Photographic evidence was obtained.…

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 implement care plan interventions for one (Resident #49) of two residents sampled for accidents related to ensuring floor mats were in place for a high fall risk resident. Findings included: A review of Resident #49's admission Record revealed an admission date of 01/06/21 with medical diagnoses of dysphagia, severe protein-calorie malnutrition, major depressive disorder, and malignant neoplasm of the bladder and nasopharynx. His Minimum Data Set (MDS), dated 1/13/21, Section C: Cognitive Patterns revealed the Resident had a Brief Interview for Mental Status score of 02, indicating impaired cognition. Under Section G: Functional Status it was revealed Resident #49 required extensive assistance with two people for bed mobility and personal hygiene and was total dependence for transfers. A review of Resident #49's Fall Risk Eval [Evaluation] ., dated 01/06/21, revealed a score of 95, indicating the Resident was at high risk for falling due to overestimating/forgetting limitations, having an impaired gait, and 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 observation, interview, and record review the facility failed to provide indwelling catheter care related to creating physician orders, creating an individualized care plan with interventions, and monitoring and reporting signs and symptoms of infection for one (Resident #67) of five residents with an indwelling catheter. Findings included: A review of Resident #67's admission Record revealed an admission date of 01/26/2021 with medical diagnoses of unstageable pressure ulcers to the left and right heel, acute kidney failure, adult failure to thrive, and stiff-man syndrome. A review of Resident #67's Medical Certification for Medicaid Long-Term Care Service and Patient Transfer Form (3008) form, dated 1/26/21, revealed in Section P: Patient Health Status that the Resident has urinary retention related to a neurogenic bladder and requires a catheter. Under Section S: Physical Function it is indicated that the Resident is not ambulatory with no weight bearing abilities on either the left or right side. A review of the Minimum Data Set (MDS), Section C: Cognition Patterns,…

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.