Avoca Specialty Care

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, resident interview, staff interviews and policy review the facility failed to provide respiratory services in accordance with professional standards of practice for 1 of 2 residents reviewed (Resident #34) who required the use of a Continuous Positive Airway Pressure (CPAP) machine. The facility failed to have an order for the CPAP and failed to clean the CPAP. The facility reported a census of 33 residents.Findings include:The Minimum Data Set (MDS) dated [DATE] for Resident #34 documented a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. The MDS documented Resident #34 had a diagnosis of obstructive sleep apnea.On 3/2/26 at 3:38 PM Resident #34 stated he had not had his CPAP machine or mask cleaned by the staff since admission to the facility. Review of Resident #34's Electronic Health Record (EHR) documented no physician's order for use of a CPAP machine or any orders to clean Resident #34's CPAP machine / mask.On 3/4/26 at 4:21…

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, clinical record review, staff interview and policy review the facility failed to provide appropriate infection prevention practices when providing care to a resident with a catheter for 1 of 3 reviewed (Resident #10). The facility reported a census of 33 residents.Findings include:The Minimum Data Set (MDS) dated [DATE] for Resident #10 documented a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. The MDS also documented utilization of an indwelling catheter. Review of Resident #10's Treatment Administration Record (TAR) documented a physician's order to cleanse suprapubic catheter sites with soap, rinse/dry thoroughly. Apply 4x4 or drain sponge every shift. On 3/4/26 at 10:19 AM an observation of catheter cares and transfer of Resident #10 revealed Staff H, Certified Nurse Assistant (CNA) and Staff G, CNA / Certified Medication Assistant (CMA) completed hand hygiene. Staff G applied gloves, cleansed abdomen with peri wipe, cleansed catheter tubing down…

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, record reviews, and policy review the facility failed to provide services meeting professional standards for 1 of 3 residents (Resident #2). The facility failed to follow physician orders for completion of labs. The facility had a census of 31. Findings include:Resident #2's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10/15 indicating moderate cognitive impairment. The document provided the resident had diagnoses of diabetes mellitus, hypertension (HTN) and Type 2 Diabetes Mellitus with unspecified complications. The MDS disclosed the resident received 7 days of insulin injections with 2 days of orders for change of insulin orders during the reporting period. The Care Plan dated 6/20/25 contained a focus area for Diabetes Mellitus initiated 4/6/24. Interventions for staff included medications as ordered by physician, monitoring for and documenting side effects and effectiveness (4/6/24), monitor for side effects (4/6/24) and provide…

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 clinical record review, staff interview, and policy review the facility failed to provide bathing assistance for 2 of 4 residents reviewed for bathing (Residents #1 and #2). The facility reported a census of 35 residents. Findings include: 1. Resident #1's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS identified bathing activity for Resident #1 was not applicable/not attempted. Resident #1's MDS included diagnoses of cancer, anemia, atrial fibrillation (irregular heart beat), hypertension (high blood pressure), heart failure (heart does not pump blood well), and end stage renal disease (kidney). The Clinical Census documented Resident #1 was admitted to the facility on [DATE] and discharged from the facility on 6/4/25. The Care Plan with a target date of 6/12/25 identified Resident #1 required assistance of 1 staff member to provide bathing. Review of Point of Care (POC) Tasks in the electronic…

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, clinical record review, resident council notes, grievances, staff and resident interviews, and facility policy review, the facility failed to ensure residents received baths twice a week or per their requested amount a week for 6 of 6 residents reviewed (Resident #2, #4, #5, #6, #7, and #8). The facility also failed to offer toileting assistance for 2 of 4 resident reviewed (Resident #5 and #8). The facility reported a census of 31 residents. Findings include: 1. According to the quarterly Minimum Data Set (MDS) assessment tool with a reference date of 3/21/2025, documented Resident #2 had severely impaired cognitive skills for daily decision making. The MDS documented she required partial/moderate assistance for toileting hygiene, lower body dressing, personal hygiene and toilet transferring. In the bathing section not applicable was documented. The following diagnoses were documented for Resident #2: dementia, hyperlipidemia, dementia, malnutrition, and depression. The Care Plan Focus Area Activities of Daily Living (ADLs), with an initiation date of…

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

Based on observations, review of resident council notes, review of grievances and resident and staff interviews the facility failed to ensure they had adequate staff members to answer resident's call lights, provide baths, and assist with toileting needs. The facility reported a census of 31 residents. Findings Include: 1. According to the quarterly MDS assessment tool with a reference date of 4/11/2025, Resident #8 had a BIMS score of 15. A BIMS of 15 suggested no cognitive impairment. The MDS documented he had an impairment on one side of his lower extremity and utilized a wheelchair. Resident #8 required partial/moderate assistance with upper body dressing, was dependent of staff for lower body dressing and required substantial/maximal assistance with personal hygiene. The MDS documented a toilet transfer was not attempted due to his medical condition. Resident #8 was occasionally incontinent of urine and frequently incontinent of bowel. The MDS documented the following diagnoses for the resident: diabetes mellitus, anemia, depression, weakness, insomnia, and left below the knee…

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 clinical record review, resident and staff interviews and facility policy review the facility failed to maintain complete and accurate records for 7 of 7 residents reviewed (Resident #2, #3, #4, #5, #6, #7, #8). The facility reported a census of 31 residents. Findings include: 1. Review of Resident #2's shower/bath documentation from 2/1/2025 until 5/15/2025 revealed she was to receive a shower or bath on Mondays and Thursdays during the day shift. The documentation revealed the following: 2/3/2025-resident refused 2/10/2025-not applicable 2/13/2025-not applicable 2/24/2025-not applicable 3/13/2025-resident refused 3/24/2025-not applicable 3/27/2025-resident refused 3/31/2025-resident refused 4/7/2025-not applicable 4/14/2025-not applicable 4/17/2025-not applicable 4/28/2025-resident refused 5/1/2025-not applicable 5/8/2025-not applicable 5/15/2025-not applicable Record review revealed there were only two notes documented about her bathing refusals on 4/8/2025 and 4/29/2025. The progress notes lacked…

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 clinical record review, facility investigative file review, staff interviews and policy review the facility failed to implement their abuse policies. The facility's staff member with concerns about the treatment of Resident #3 was not reported within two hours of the concerns. The facility also failed to complete a thorough investigation. The facility reported a census of 31 residents. Findings include: According to the quarterly Minimum Data Set (MDS) with a reference date of 2/6/2025, Resident #3 had a Brief Interview of Mental Status (BIMS) score of 12. A BIMS score of 12 indicated no cognitive impairment. The MDS documented she did not deny care during the 7-day review period. The MDS documented she did not have impairments to upper and lower extremities, but utilized a walker and wheelchair for mobility. The resident was dependent on staff for toileting hygiene and required substantial/maximal assistance for toilet transfer. The MDS documented she was frequently incontinent of urine and bowel. The following diagnoses were listed for Resident #1: atrial fibrillation,…

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, facility investigative file review, staff interviews and policy review the facility failed to report concerns about the treatment of Resident #3 within two hours of the alleged concerns observed. The facility reported a census of 31 residents. Findings include: According to the quarterly Minimum Data Set (MDS) with a reference date of 2/6/2025, Resident #3 had a Brief Interview of Mental Status (BIMS) score of 12. A BIMS score of 12 indicated no cognitive impairment. The MDS documented she did not deny care during the 7-day review period. The MDS documented she did not have impairments to upper and lower extremities, but utilized a walker and wheelchair for mobility. The resident was dependent on staff for toileting hygiene and required substantial/maximal assistance for toilet transfer. The MDS documented she was frequently incontinent of urine and bowel. The following diagnoses were listed for Resident #1: atrial fibrillation, heart failure, diabetes mellitus, Alzheimer's disease, and non-Alzheimer's dementia. The Clinical Census revealed Resident #3 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, facility investigative file review, staff interviews and policy review the facility failed to complete a thorough investigation. The facility reported a census of 31 residents. Findings include: According to the quarterly Minimum Data Set (MDS) with a reference date of 2/6/2025, Resident #3 had a Brief Interview of Mental Status (BIMS) score of 12. A BIMS score of 12 indicated no cognitive impairment. The MDS documented she did not deny care during the 7-day review period. The MDS documented she did not have impairments to upper and lower extremities, but utilized a walker and wheelchair for mobility. The resident was dependent on staff for toileting hygiene and required substantial/maximal assistance for toilet transfer. The MDS documented she was frequently incontinent of urine and bowel. The following diagnoses were listed for Resident #1: atrial fibrillation, heart failure, diabetes mellitus, Alzheimer's disease, and non-Alzheimer's dementia. Record review revealed Resident #3 was discharged from the facility on 4/11/2025. The facility's investigative…

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 clinical record review, staff interviews and policy review the facility failed to ensure 1 of 9 resident's care plans (Resident #3) was revised once her transfer assistance requirement was changed to the use of a mechanical lift. The facility reported a census of 31 residents. Findings include: According to the quarterly Minimum Data Set (MDS) with a reference date of 2/6/2025, Resident #3 had a Brief Interview of Mental Status (BIMS) score of 12. A BIMS score of 12 indicated no cognitive impairment. The MDS documented she did not deny care during the 7-day review period. The MDS documented she did not have impairments to upper and lower extremities, but utilized a walker and wheelchair for mobility. The resident was dependent on staff for toileting hygiene and required substantial/maximal assistance for toilet transfer. The MDS documented she was frequently incontinent of urine and bowel. The following diagnoses were listed for Resident #1: atrial fibrillation, heart failure, diabetes mellitus,…

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 clinical record review, staff interviews, and facility policy review the facility failed to implement additional individualized interventions for 1 of 3 residents (Resident #3) related to behaviors to assist residents with dementia in the completion of a task. Resident #3 refused staff to assist her to the bathroom and refused staff to check her for incontinence and change her when she was incontinent. The facility reported a census of 31 residents. Findings include: According to the quarterly Minimum Data Set (MDS) with a reference date of 2/6/2025, Resident #3 had a Brief Interview of Mental Status (BIMS) score of 12. A BIMS score of 12 indicated she had moderate cognitive impairment. The MDS documented she did not deny care during the 7-day review period. The MDS documented she did not have impairments to upper and lower extremities, but utilized a walker and wheelchair for mobility. The resident was dependent on staff for toileting hygiene and required substantial/maximal assistance for toilet transfer. The MDS documented she was frequently incontinent of urine and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and policy review the facility failed to ensure medications and supplies stored in the medication room and medication carts were stored and held within their expiration dates. The facility reported a census of 31 residents. Findings include: On [DATE] at 10:40 AM during a medication room check with Staff B Licensed Practical Nurse (LPN) present observed 12 unopened bottles of Aspirin 81 milligrams (mg), all with an expiration date of 4/2025. Staff B indicated she was under the impression the Director of Nursing (DON) overlooked the items in the medication room. The Regional Nurse Consultant was made aware of the expired Aspirin bottles. On [DATE] at 10:53 AM completed a check of the two medication carts with Staff C Certified Medication Aide (CMA) present. Noted one 3 milliliter (mL) empty syringe with an expiration date of [DATE] and one opened bottle of Aspirin 81 mg with an expiration date of 4/2025. The bottle was filled with tablets to the rim. Staff C was notified…

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 clinical record review, resident interviews, observations, and staff interviews the facility failed to provide nursing staff to assure residents safety by not responding to call lights in a timely manner for 4 of 16 resident reviewed (Resident #15, #20,#21 and #37). The facility reported a census of 38 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #15 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. The MDS indicated Resident #15 was frequently incontinent of urine and frequently incontinent of bowel. The MDS indicated Resident #15 was dependent on staff for eating, oral hygiene, toileting, personal hygiene, transfers and rolling left to right. The MDS documented Resident #15 had diagnoses of quadriplegia and resided in room [ROOM NUMBER]. On 1/27/25 at 1:16 PM Resident #15 stated through his communication device call lights frequently take longer than 20 minutes to answer. Resident #15 stated through his…

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 clinical record review, resident interview, staff interviews and policy review the facility failed to represent an accurate assessment of the resident's status during the observation period of the Minimum Data Set (MDS) by not accurately assessing the use of an anticoagulant for 1 of 5 residents reviewed (Resident #6). The facility reported a census of 38 residents. Finding include: The MDS dated [DATE] for Resident #6 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. The MDS documented use of an anticoagulant. Review of Resident #6's Care Plan revealed focus, goal, and interventions for an anticoagulant. On 1/27/25 at 3:09 PM Resident #6 stated the only blood thinner (anticoagulant) she took was baby Aspirin. Review of Resident #6's Medication Administration Record (MAR) documented a physician's order for Aspirin 81 mg one tablet by mouth daily for pain. On 1/29/25 at 9:41 AM Staff A, MDS coordinator stated that Aspirin 81 mg was identified as an…

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 clinical record review, observation, staff interview and policy review the facility failed to provide appropriate infection prevention practices when administering medications for 1 of 4 residents reviewed (Resident #15). The facility reported a census of 38 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #15 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. The MDS documented Resident #15 had diagnoses of quadriplegia. On 1/28/25 at 9:21 AM an observation revealed Staff C, Registered Nurse (RN) completed hand hygiene, applied gloves and flushed Resident #15's enteral tube with 50 cc of water from pump prior to medication administration. Staff C administered medications to Resident #15 through the enteral tube. Gloves removed and hygiene completed. Gown was not donned by Staff C for medication administration for Resident #15. Review of Resident #15's Treatment Administration Record documented a physician's order 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.

Based on observations, clinical record review, resident, family, and staff interviews, and facility policy review the facility failed to provide baths for 3 of 4 residents (Resident #5, #8 and #9) reviewed. The facility also failed to provide personal hygiene for 2 of 4 residents (Resident #8 and #11) reviewed. The facility reported a census of 30 residents. Findings include: 1. According to the annual Minimum Data Set (MDS) assessment tool with a reference date of 5/22/24 Resident #5 had a Brief Interview of Mental Status (BIMS) score of 13. A BIMS score of 13 suggested no cognitive impairment. The Care Plan focus area with an initiation date of 10/9/23 documented Resident #5 required the assistance of 2 staff for bathing. Review of the past 30 days of bathing documentation for Resident #5 revealed her bath days were Mondays and Thursday. Staff documented Resident #5 received a bath on the following dates: a. 5/27/24 Monday b. 5/30/24 Thursday c. 6/3/24 Monday d. 6/10/24 Monday e. 6/13/24 Thursday f. 6/17/24 Monday g. 6/20/24 Thursday h. 6/24/24 Monday Staff failed to give Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident council meeting notes, grievance/concerns investigation forms, resident and staff interviews, and facility policy review the facility failed to ensure the facility had sufficient staffing to meet the needs of residents that included answering resident's call lights in a timely manner. The facility reported a census of 30 residents. Findings include: Observations on 6/23/24 from 5:10 PM until roughly 6:30 PM revealed numerous call lights going off on the 200 hall: a. room [ROOM NUMBER] call light on at 5:10 PM, off at 5:32 PM; call light was on for 22 minutes b. room [ROOM NUMBER] call light on at 5:40 PM and remained on when checked on at 6:07 PM; at that time call light was on for 27 minutes. c. room [ROOM NUMBER] call light on at 6:07 PM, off at 6:23 PM; call light was on for 16 minutes. d. room [ROOM NUMBER] call light on at 6:00 PM, off at 6:16 PM; call light was on for 16 minutes. e. room [ROOM NUMBER] call light on at 5:36 PM, off at 6:16 PM; call light was on for 40…

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 grievance/concern investigation forms, staff interviews, employee file review, and review of job descriptions the facility failed to ensure qualified staff assisted in the kitchen when they did not have adequate staff working. The facility reported a census of 30 residents. Findings include: Review of Grievance/Concern Investigation Forms revealed the following grievances: a. 4/23/24 a resident expressed frustration with staffing in the kitchen. Stated she's sick of not getting what she orders and the Administrator needed to figure it out. Action and follow-up: dietary manager was out unexpectedly. Administrator pulling staff from other departments to help cook and serve meals. b. 5/3/24 a resident asked for a peanut butter sandwich and they brought her the bread and the peanut butter packet, told her to make her own sandwich. She said for what she pays to stay here, her sandwich should be made for her. Action and follow-up: dietary manager spoke to all cooks about making the sandwich. This was done by a nursing staff that filled in as a cook. Education was provided. On…

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

Based on observations, staff interviews, and facility policy review the facility failed to store and serve food in a sanitary manner. The facility also failed to maintain infection control practices while in the dish area when going from the dirty area to the clean area. The facility reported a census of 30 residents. Findings include: On 6/18/24 at 10:23 AM observed three tubes of hamburger meat in a gray hard plastic bin with a tape label that indicated the hamburger was for Thursday 6/19/24 (Thursday was actually 6/20/24). Red, bloody looking, fluid gathered at the bottom of the gray hard plastic bin. This bin sat on the second to last shelf in the walk-in cooler with two cardboard boxes of stripped bacon on the shelf below. Also noted in the walk-in cooler, a box that contained 4 green peppers with what appeared mold on them (black and white fuzzy areas throughout). While speaking with the Dietary Manager, Staff A Dietary Aide, had gloved hands while in the dish area. With gloved hands he moved a trash can closer to the dish room, removed dishes (bowls, cups, small plates) 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.

Based on clinical record review, resident interviews, staff interviews, and facility policy review the facility failed to speak in a dignified manner around residents and failed to speak to residents in a dignified manner to 3 of 4 (Resident #5, #6 and #8) residents reviewed. The facility reported a census of 30 residents. Findings include: 1. According to the annual Minimum Data Set (MDS) with a reference date of 5/22/24, Resident #5 had a Brief Interview of Mental Status (BIMS) score of 13. A BIMS score of 13 suggested no cognitive impairment. On 6/25/24 at 2:52 PM when Resident #5 was asked how Staff P Licensed Practical Nurse (LPN) was during medication pass and treatments she stated she is a b*tch. When asked to elaborate she stated last week she told her roommate to get up by herself but she only needed a little boost and would not help her. Staff P is just a bitter person. Resident #5 had asked Staff P to shut the over head light in her room, she told her no, she's passing pills, I am busy, I can't help you. Resident #5 stated she sees and hears how testy she gets with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, facility investigation review, staff interviews and facility policy review the facility failed to supervise 1 of 3 cognitively impaired residents (Resident #1). Staff were unaware Resident #1 had left the building on 5/26/24 at approximately 4:50 PM. Staff responded to an alarmed door, looked out the door window, disarmed the door alarm and went back to work. The staff member failed to go outside to visually check to see if a resident had left the building. The staff member assumed he saw another staff member in the vicinity. The staff member also failed to initiate a head count to ensure all residents were accounted for. The facility reported a census of 30 residents. Findings include: According to the annual Minimum Data Set (MDS) assessment tool with a reference date of 3/13/24 Resident #1 had a Brief Interview of Mental Status (BIMS) score of 7. A BIMS score of 7 suggested mild cognitive impairment. The MDS documented he did not exhibit wandering behavior during…

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, resident and staff interviews and facility policy review the facility failed to properly dispose of room trays with left-over food in a timely manner. The facility reported a census of 30 residents. Findings include: On 6/20/24 at 11:17 AM Staff S Dietary Aide stated when she comes in after having the weekend off she will find dishes still in resident's room from who knows what meal since she was gone all weekend. On 6/23/24 at 5:53 PM observed on Resident #12 entry table a white plate with a slice of wheat bread on it, bowl with milk in it, biscuit, egg, sausage sandwich on the plate as well. Also observed two drinking glasses, 1 of the glass was ½ full of milk. When asked how long those dishes has been there she stated breakfast and lunch. This happens all the time on the weekends, when staff not picking up her dishes. She indicated she went to the dining room this evening for dinner. On 6/27/24 at 3:39 PM observed on Resident #7's bedside table a white plate on top of a plate cover. A set of silverware lying on top of the plate, an empty sour cream packet…

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, clinical record review, resident and staff interviews, and facility policy review the facility failed to ensure 2 of 2 residents' (Resident #6 and #7) vape pens were properly stored. The facility also failed to ensure 1 of 2 residents (Resident #7) used her vape pen outside in the designated smoking areas. The facility reported a census of 30 residents. Findings include: 1. Review of Resident #6's clinical record revealed no documentation related to him being able to smoke with or without supervision. On 6/18/24 at 11:45 AM observed three vape pens in Resident #6's room on his dresser. On 6/23/24 at 5:32 PM observed Resident #6 outside with staff. Staff were assisting Resident #6 with his vape pen. 2. Review of Resident #7's clinical record revealed no documentation related to her being able to smoke with or without supervision. Clinical record revealed Resident #7 was admitted to the facility on [DATE]. On 6/18/24 at 11:24 AM Staff D Registered Nurse (RN) stated she has been around vape…

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 personnel document review, staff interviews and facility policy review the facility failed to employ a clinically qualified nutrition professional by not having a certified dietary manager. The facility reported a census of 40 residents. Findings include: On 1/30/24 a request for documentation from Staff O Dietary Manager, of qualifications for dietary manager revealed no certification or documentation. Interview on 1/30/24 at 9:02 AM, with Staff O revealed she was currently in charge of running the kitchen. Staff O stated she was not a certified dietary manager, a certified food service manager, does not have a certification for food service management and safety, does not have associate's or higher degree in food service, and does not have 2 or more years worth of experience in the position. Review of policy titled, Dietitian revealed that if a dietitian is not employed full time (35 or more hours per week) a director of food service management will be designated. This individual will be a certified dietary manager, be a certified food service manager, be nationally…

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 facility document review, policy review and staff interview the facility failed to have the minimum members of the quality assessment and assurance committee meet quarterly. The facility reported a census of 40 residents. Findings include: Review of documents titled, Quality Assurance Committee Meeting sign-in from 2/23 through 1/24 revealed 3/23 no DON or Infection Preventionist present, 4/23 no DON present, 5/23 no DON present, 7/23 no DON present, 8/23 no DON or Infection Preventionist present, 9/23 no DON or Infection Preventionist present, 10/23 no Infection Preventionist and only 5 members, and 1/24 only 5 members present for meetings. Review of the policy titled, QAPI Program Governance and Leadership revealed the following individuals serve on the committee: Administrator, or a designee who is in a leadership role, Director of Nursing Services, Medical Director, and Infection Preventionist. Also representatives of the following departments, as requested by the Administrator: Pharmacy, Social Services, Activity Services, Environmental Services, Human Resources, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, staff interviews, and policy review, the facility failed to fully review and revise the comprehensive care plan for 4 of 4 residents reviewed (#3, #15, #20, & #23) and failed to include family representatives of 1 of 1 resident reviewed (#15). The facility reported a census of 40 residents. Findings include: 1. On 1/30/24 at 2:56 PM, Resident #15's family member revealed the resident was treated for a Urinary Tract Infection (UTI) at the beginning of December 2023 and the resident declined in her functional abilities and was no longer receiving therapy. The family member also indicated the resident had no representative present for the initial care conference. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of 08 of 15, indicating moderate cognitive impairment. The MDS included diagnoses of unspecified injury of the head, disorders of the peripheral nervous system, inflammatory bowel…

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 facility document review, and staff interview the facility failed to provide sufficient nursing staff with appropriate competencies and skill sets by not having a staff on duty at the facility trained in cardiopulmonary resuscitation (CPR) for 5 days in the month of [DATE]. The facility reported a census of 40 residents. Findings include: Review of documents titled, Daily Staffing Sheets for the month of [DATE] revealed the facility had no staff trained in cardiopulmonary resuscitation on [DATE] from 6 PM till 6 AM, [DATE] from 6 PM till 6 AM, [DATE] from 6 PM till 10 PM, [DATE] from 10 PM till 6 AM, and [DATE] from 6 PM till 6 AM. On [DATE] at 9:00 AM the Administrator acknowledged on [DATE] 6 PM till 6 AM, [DATE] 6 PM till 6 AM, [DATE] 6 PM till 10 PM, [DATE] 10 PM till 6 AM, and [DATE] 6 PM till 6 AM there was not a CPR certified staff present at the facility. The Administrator stated the facility's expectation was that a staff member trained in providing CPR would be working at the facility 24 hours…

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, clinical record review, policy review, and staff interviews, the facility failed to secure medications in a locked compartment for to 1 of 3 residents reviewed (Residents #33). The facility also failed to label open medication with the date the medication was opened for 27 of 30 medications reviewed. The facility reported a census of 40 residents. Findings include: The Minimum Data Set, dated [DATE] documented Resident #33 had a Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive impairment. Review of physician orders for Resident #33's revealed a discontinued order for Lorazepam Intensol 2 mg/mL. Orders to give 0.25 mL by mouth as needed for restlessness. On 2/1/24 at 10:45 AM an observation of both medication carts and treatment cart revealed Vitamin D-3 2000 IU, Bisacodyl 5 mg, Vitamin E 180 mg, Vit D 1000 IU, Magnesium Oxide 400 mg, Multi-Vitamin, Cranberry 450 mg, B-12 500 mg, Folic Acid 400 mcg, Calcium 500 mg, Aleve 220 mg, Loratadine 10 mg, Vitamin B-12…

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, facility document review and staff interview the facility failed to follow the menu and prepare food to meet the nutritional needs of the resident for 1 of 19 residents reviewed (Resident #9). The facility reported a census of 19 residents. Findings include: On 1/30/24 at 12:56 PM a continuous observation of lunch service revealed a #10 white handled scoop used for the service of Spanish rice to all residents that requested the regular lunch except to residents with a pureed diet. Review of scoop sizes revealed a #10 scoop was 3 ¼ oz. Review of document titled, Therapeutic Spread report - Fall and Winter regular menu revealed #8 scoop, 4 oz. or ½ cup of Spanish rice to be served to all diets. An observation on 1/30/24 at 1:41 PM revealed Staff P [NAME] using a spatula to empty pureed Doritos chicken from the food processor into 2 bowls. 1/4 cup pureed mix left in the food processor. On 1/30/24 at 1:41 PM Staff P stated she eyeballed the size and made the bowls level with each other when splitting the portions of the pureed meal. Staff P stated she usually just…

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, clinical record review, resident interview, staff interviews, and policy review, the facility failed to serve the appropriate diet type to 4 of 4 resident reviewed (#1, #8, #10, & #11). The facility reported a census of 40 residents. Findings include: 1. During an observation on 1/29/24 at 1:14 PM observed Resident #8 eating amd she spit out chunks of food in a napkin on her bedside table. She stated she had difficulty swallowing the food and indicated her diet was supposed to be pureed. She confirmed the chunks of food were carrots and potatoes. Her tray included a cookie and a slice of bread. The quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 of 15, indicating completely intact cognition. It included diagnoses of retromolar cancer (area directly behind the last teeth), hyponatremia (low salt levels in the blood), malnutrition, sialoadenitis (inflamed salivary glands), and Chronic Obstructive Pulmonary Disease (COPD). It also…

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, staff interview, and policy review the facility failed to prepare food in accordance with professional standards by not completing appropriate hand hygiene during meal preparation and service of a meal. The facility reported a census of 40 residents. Findings include: An observation on 1/30/24 at 11:45 AM revealed Staff O, Dietary manager scooping ice from the ice machine and supporting the bottom front lip of the ice scoop with a bare hand and pouring it into tubs to keep liquids cold. Observed this repeated 6 times. An observation on 1/30/24 at 11:47 AM revealed Staff P [NAME] removed an entire loaf of bread from the sack with gloves on. Staff P placed the bread on the cooking sheet, used her right hand to butter the bread and left hand to hold the bread. Staff P obtained a bag of cheese from across the kitchen in a refrigerator, opened the bag and removed a stack of cheese from the bag of cheese. Staff P placed the cheese on the bread, placed the leftover cheese back into the bag and zipped the bag shut. Staff P obtained foil to cover the cooking sheet, put…

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, clinical record review, staff interviews, and policy review the facility failed to implement appropriate infection control practices to prevent infection and/or cross contamination. The facility reported a census of 40 residents. Findings include: 1. On 1/29/24 at 12:51 PM, Resident #20 observed receiving nasal cannula oxygen while she slept in bed. The tubing labeled with an orange sticker and dated 1/28/24. The Minimum Data Set, dated [DATE] indicated the resident had a BIMS score of 8 out of 15, indicating a moderate cognitive impairment. It included diagnoses of pneumonia, Coronary Artery Disease, Non-Alzheimer's dementia, and hypoxemia (low blood oxygen level). The Electronic Health Record (EHR) included a physician's order dated 1/14/24 directing staff to titrate oxygen to keep the resident's oxygen saturation (O2 sat) above 90%. The Care Plan lacked documentation of the use of oxygen therapy. On 1/29/24 at 1:41 PM, observed the resident lying in the same position with her blanket…

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, staff interview, visitor interview, and facility policy review, the facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff and the public. The facility reported a census of 40 residents. Findings include: Observation on 1/29/24 at 12:45 PM of the facility resident halls revealed a pungent odor of urine noted primarily in front of room [ROOM NUMBER] and extended past room [ROOM NUMBER]. The same odor noted upon entry of the 200 hallway and noted primarily around rooms [ROOM NUMBERS]. On 2/01/24 at 10:45 AM, Staff T, Housekeeping Aide (HA) stated the facility is cleaned on a routine schedule and housekeeping relied on nursing staff for notification of subsequent cleaning needs. She stated the toilet in room [ROOM NUMBER] leaked within the last year and staff have not been able to rid the facility of the urine odor. Subsequent observations on 1/30/24, 1/31/24, and 2/01/24 revealed the odor not as pungent but could still be noted in both…

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, clinical record review, resident interview, staff interviews, and facility policy review the facility failed to ensure that residents have the right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility is changed for 1 of 5 residents reviewed (Resident #37). The facility reported a census of 40 residents. Findings Include: The Minimum Data Set (MDS) dated [DATE], documented Resident #37 had a Brief Interview for Mental Status (BIMS) score of 15 (no cognitive impairment). The MDS documented the resident required substantial assistance for toileting hygiene, personal hygiene, footwear, and functional transfers. Resident #37 completed transfers with the use of dependent weight bearing lift. The MDS documented Resident #37 had diagnoses including: chronic diastolic (congestive) heart failure, anxiety disorder, gastro-esophageal reflux disease without esophagitis, chronic kidney disease stage 3, hypertensive chronic kidney…

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 clinical record review, family interviews, staff interviews, and policy review, the facility failed to provide timely notification to the physician or family when changes occurred in the resident's physical or mental condition for 2 of 2 residents reviewed (Resident #15 & #17). The facility reported a census of 40 residents. Findings include: 1. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of 08 of 15, indicating moderate cognitive impairment. The MDS included diagnoses of inflammatory bowel disease, retinal vascular occlusion (an eye condition that causes blurred vision), and right eye glaucoma. It also revealed she had not had a poor appetite during the previous seven (7) day look-back period but required only setup assistance with eating. The Care Plan dated 10/13/23 indicated the resident was at risk for altered nutrition and weight loss and directed staff to monitor her diet tolerance. The Progress Note dated 11/13/23…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, staff interviews, and facility policy review the facility failed to ensure that residents' equipment was kept clean and in good repair for 1 of 5 residents reviewed (Resident #4). The facility census was 40 residents. Findings Include: Resident #4's Minimum Data Set (MDS) dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Resident #4 required the use of a wheelchair (w/c), and required partial/moderate assistance for transfers. The MDS documented the Resident #4 had diagnoses of syncope and collapse, gastrointestinal hemorrhage, other secondary Parkinsons, chronic atrial fibrillation, essential (primary) hypertension, moderate protein-calorie malnutrition, metabolic disorder, hypothyroidism, allergy, depression, and melena. The Care Plan revised on 1/4/24 revealed that Resident #4 utilized a w/c for long distance mobility. Observations revealed the following: On 01/29/24 at 12:00 PM Resident #4's w/c…

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 clinical record review, family and staff interviews, and policy review, the facility failed to ensure each resident received an accurate Minimum Data Set (MDS) assessment, reflective of the resident's status at the time of the assessment for 1 of 12 residents (Resident #15) reviewed. The facility reported a census of 40 residents. Findings include: The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of 08 of 15, indicating moderate cognitive impairment. The MDS included diagnoses of unspecified injury of the head and disorders of the peripheral nervous system. It revealed the resident was dependent with toileting and personal hygiene but indicated the resident had not had a UTI in the last 30 days. On 1/30/24 at 2:56 PM, Resident #15's family member revealed the resident was treated for a Urinary Tract Infection (UTI) at the beginning of December 2023. The Electronic Health Record (EHR) physician orders indicated the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, staff interviews, and policy review, the facility failed to implement a comprehensive, person-centered care plan for 3 of 3 residents reviewed (#15, #17, & #20). The facility reported a census of 40 residents. Findings include: 1. The quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident had a Brief Interview for Mental Status (BIMS) score of 06 of 15, indicating severe cognitive impairment. It included diagnoses of fractures other than her hip, disorders of the peripheral nervous system, and sprain of the ligaments of the lumbar spine (lower back). It also revealed the resident dependent for putting on and removing footwear and required a wheelchair for mobility. The Care Plan dated 12/22/23 directed staff to ensure the resident had moon boot heel protectors on the left lower extremity at all times. On 1/29/24 at 2:56 PM, Resident #15's family member indicated the resident should have moon boots (a device used to stabilize sprains, fractures, 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 observations, clinical record review, staff interviews, and reviews of policy the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice regarding respiratory treatments, oxygen administration and insulin administration per orders for 2 of 3 residents reviewed. The facility census was 40. Findings Include: 1. The Minimum Data Set (MDS) dated [DATE], documented that Resident #37 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. The resident required substantial assistance for toileting hygiene, personal hygiene, footwear, and functional transfers. Resident #37 completed transfers with the use of dependent weight bearing lift. Resident #37 had diagnoses to include: chronic diastolic (congestive) heart failure, anxiety disorder, venous insufficiency (chronic peripheral), morbid (severe) obesity, and personal history of pulmonary embolism. Resident #37 was on supplemental oxygen therapy via nasal…

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 clinical record review, staff interview, and policy review, the facility failed to provide restorative activities for 2 of 2 residents reviewed (#15 & #23). The facility reported a census of 40 residents. Findings include: 1. On 1/29/24 at 2:56 PM, Resident #15's family member stated the resident had declined in her functional abilities and was no longer receiving therapy. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of 08 of 15, indicating moderate cognitive impairment. The MDS included diagnoses of inflammatory bowel disease, retinal vascular occlusion (an eye condition that causes blurred vision), and right eye glaucoma. The MDS indicated the resident was independent with mobility, required moderate assistance with toilet and shower transfers, and substantial assistance with ambulating 10 feet. She also required setup or supervision assistance for Activities of Daily Living (ADLs) and moderate assistance with putting on…

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

Based on clinical record review, resident interview, staff interview, and policy review the facility failed to provide an opportunity for bath or shower to 1 of 5 residents (Residents #3) reviewed. The facility reported a census of 40 residents. Findings include: Review of the Minimum Data Set (MDS) for Resident #3 dated 11/22/23 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS further revealed diagnosis of diabetes mellitus, hyperlipidemia, and hemiplegia. Review of the Electronic Healthcare Record (EHR) document labeled Plan of Care (POC) Response History for 1/1/24 through 1/29/24 revealed Resident #3 had been given a bath/shower on 1/6/24 and 1/8/24. This document further revealed that Resident #3 refused bath/shower on the 4th, 18th, and 22nd of January. During an observation 1/29/24 at 12:55 PM of Resident #3 revealed her hair uncombed and disheveled. During an interview 1/30/24 at 1:42 PM with Staff J Certified Nurse Assistant (CNA) revealed baths and showers will be documented in the EHR if a resident refused and she would…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, staff interview, and policy review, the facility failed to prevent a resident from developing a preventable pressure ulcer for 1 of 1 resident reviewed (Resident #15). The facility reported a census of 40 residents. Findings include: On 1/29/24 at 2:56 PM, Resident #15's family member indicated the resident had multiple pressure ulcers that were not present upon admission. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of 8 of 15, indicating moderate cognitive impairment. The MDS included diagnoses of inflammatory bowel disease, retinal vascular occlusion (an eye condition that causes blurred vision), and right eye glaucoma. It also indicated the resident did not have any pressure ulcers but was at risk of developing them. The Care Plan dated 10/13/23 indicated the resident was at risk for altered nutrition and weight loss and directed staff to monitor her diet tolerance. The Braden Scale…

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 family interview, clinical record review, staff interview and policy review, the facility failed to maintain acceptable parameters of nutritional and hydration status by failing to prevent excessive weight loss and dehydration for 1 of 1 resident (#15). The facility reported a census of 40 residents. Findings include: On 1/30/24 at 2:56 PM, Resident #15's family member indicated the resident had not received assistance with meals and she was transported to the Emergency Department and received intravenous (IV) fluids. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of 8 of 15, indicating moderate cognitive impairment. The MDS included diagnoses of inflammatory bowel disease, retinal vascular occlusion (an eye condition that causes blurred vision), and right eye glaucoma. It also revealed she had not had a poor appetite during the previous seven (7) day look-back period but required only setup assistance with eating. The Care…

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 clinical record review, observation, staff interviews, and policy review the facility failed to implement policies and procedures regarding the technical aspect of feeding tubes by not verifying gastrostomy tube (G-tube) is functioning properly before administering medications for 1 of 1 residents (Resident #18) reviewed. The facility reported a census of 40 residents. Findings include: Record review of the Minimum Data Set (MDS) for Resident #18 dated 12/6/23 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. Further review of the MDS revealed diagnosis of quadriplegia, anoxic brain damage, seizure disorder, dysphagia, and need for assistance with personal care. Review of the Electronic Healthcare Record (EHR) tab labeled orders revealed physician orders for 18 french g-tube, three times a day verify tube placement every shift for AM, Midday, and bedtime, three times a day check residual every shift if less than 30mL (milliliters) note in progress note, and every 4 hours Jevity 1.5 formula with a flow rate of 50 ml per hour x 4…

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 clinical record review, staff interviews, and policy review the facility failed to provide dialysis services consistent with professional standards by not completing a pre and post dialysis assessments for 1 of 1 residents (Resident #30) reviewed. The facility reported a census of 40 residents. Findings include: Review of the Minimum Data Set (MDS) for Resident #30 dated 11/1/23 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. Further review of the MDS revealed diagnosis of end-stage renal disease, and dependence on renal dialysis. Review of the Electronic Healthcare Record (EHR) document titled Clinical Physician Orders revealed orders for pre-dialysis and post-dialysis evaluations on Monday, Wednesday, and Fridays related to dependence on renal dialysis. Further review revealed an order for non-dialysis day evaluation every day shift on Tuesdays, Thursdays, Saturdays, and Sundays related to end stage renal disease. Review of the EHR document titled Clinical-Assessment from 1/1/24 through 1/29/24 revealed pre-dialysis assessments…

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, clinical record review, staff interviews and facility policy review the facility failed to ensure medication error rates are not 5 percent or greater by having a medication error rate of 7.41%. The facility reported a census of 40 residents. Finding include: The Minimum Data Set, dated [DATE] documented Resident #37 had a Brief Interview for Mental Status (BIMS) score of 6 indicating severe cognitive impairment. Observation completed of 26 medications administered and 1 medication ordered but not administered. A total of 27 medication administration opportunities for error. Observation of 2 medication administration errors when Staff A had intention on giving 6 units of Insulin Glargine (long acting insulin) when 6 units of Aspart Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Aspart) was ordered. This revealed a medication error rate of 7.41%. Review of Resident #37's physician orders revealed an order for Insulin Glargine Solostar Subcutaneous Solution Pen-injector 100 UNIT/ML…

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, staff interviews and policy review the facility failed to ensure the residents were free of significant medication errors to 1 of 4 residents reviewed (Resident #37). The facility reported a census of 40 residents. Finding include: The Minimum Data Set, dated [DATE] documented Resident #37 had a Brief Interview for Mental Status (BIMS) of 6 indicating severe cognitive impairment. Review of Resident #37's physician orders revealed an order for Insulin Glargine Solostar Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) inject 25 unit subcutaneously at bedtime for diabetes and an order for Insulin Aspart Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Aspart) inject 6 units under the skin three times daily before meals. During an observation on 1/31/24 at 8:30 AM of insulin administration observed Staff A, Licensed Practical Nurse (LPN), draw up 6 units of Insulin Glargine (long acting insulin) and enter Resident #37's room with the insulin. On 1/31/24 at 8:39 AM Staff…

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 clinical record review, observations, resident interviews, staff interview, and policy review the facility failed to provide food at an appetizing temperature to 3 of 5 residents ( Residents #6, #8, and #9) reviewed. The facility reported a census of 40 residents. Findings include: 1. Review of the Minimum Data Set (MDS) for Resident #6 dated 12/27/23 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. During an interview on 1/29/24 at 2:45 PM Resident #6 revealed that sometimes food is cold when it should be hot. 2. Review of the MDS for Resident #9 dated 12/23/23 revealed a BIMS score of 15 indicating intact cognition. During an interview on 1/29/24 at 3:13 PM Resident #9 revealed that the food is sometimes cold when it should be hot. 3. On 1/30/24 at 1:36 PM a sample tray taken to the residents rooms. On 1/30/24 01:38 PM the sample tray returned to the kitchen and the temperature of the food obtained. The temperature of the rice registered 101.9 degrees, the Dorito chicken 122.4 degrees, and the corn 103.7 degrees. On 1/30/24 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 observations, interviews with family and staff, and record review the facility failed to maintain a clean, homelike environment and failed to alleviate offense odors throughout the facility. The facility reported a census of 36 residents. Findings include: 1. According to the Minimum Data Set (MDS) dated [DATE], Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability). He required extensive assistance with the help of 2 for bed mobility, transfers, dressing and toileting. The care plan for Resident #3 indicated that he had a suprapubic catheter and required a mechanical lift for transfers. Diagnosis included; acquired absence of the right great toe, anxiety disorder, cellulitis and obesity. Observation on 7/31/23 at 7:30 AM it was noted that there was a heavy urine smell around the nurse's station. The smell became increasingly stronger down the 200 hallway and in the room of Resident #3. Certified Nurse Aide (CNA), Staff M, was emptying the catheter bag the 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, interview and record review the facility failed to treat 2 of 13 residents with dignity and respect. Resident #6 was found to be soaked with urine in the morning and she told the staff that she had been instructed to urinate in her brief. Resident #6 was told to decrease his fluid intake so he didn't have to be taken to the restroom so often. The facility reported a census of 36 residents. Findings include: 1) According to theadmission Minimum Data Set (MDS) dated [DATE], Resident #6 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognitive skills. The resident required extensive assistance with the help of 2 staff for bed mobility, transfers and toileting. The resident was occasionally incontinent of urine and always continent of bowel. The Care Plan initially dated on 3/29/23 showed that the resident had acute pain related to cervical vertebrae fracture and she was on an antibiotic for a urinary tract infection. On 8/1/23 at 9:42 AM, Family Member (FM)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview with family, record and policy review the facility failed to notify family of an emergency transfer for 1 of 3 resident reviewed. When Resident #6 was sent to the hospital, staff failed to contact the family. The facility reported a census of 36 residents. Findings include: According to the admission Minimum Data Set (MDS) dated [DATE], Resident #6 had a Brief Interview for Mental Status (BIMS) score of 15. She required extensive assistance with the help of 2 staff for bed mobility, transfers and toileting. She was occasionally incontinent of urine and always continent of bowel. The Care Plan initially dated on 3/29/23 showed that the resident had acute pain related to cervical vertebrae fracture and she was on an antibiotic for a urinary tract infection. A Nurses Note dated 6/3/23 at 4:24 PM, showed that Resident #6 was sent to the hospital that afternoon and the primary care physician and the Director of Nursing (DON) were notified. The nurse was later told that the resident had passed away…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review the facility failed to provide comprehensive care plans for 3 of 13 residents reviewed. Resident #9 was admitted with a chronic heel ulcer the care plan lacked goals and interventions to prevent worsening of pressures. Resident #11 had a suprapubic urinary catheter, the care plan lacked details on specific catheter cares. Resident #7 was admitted to the facility with a diagnosis of Human Immunodeficiency Virus (HIV) the care plan lacked notice of the virus and any special precautions for staff to take. The facility reported a census of 36 residents. Findings include: 1. Observation on [DATE] at 7:55 AM, revealed Resident #9 in his bed on his back, wearing gripper socks and his heels rested on the bed. The resident reported a sore on his left heel. According to the admission Minimum Data Set (MDS) dated [DATE], Resident #9 had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability). He required extensive assistance with the help of 2…

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 follow up with physician orders for 3 of 13 residents reviewed. Resident #9 had an order for wound care on a chronic heel ulcer. The order did not get entered into the electronic chart. Upon admission, Resident #7 had an order for daily weights and orthostatic blood pressures, the facility failed to follow through with this order. Resident #6 developed a pressure sore and the dietician recommended some supplements. Staff failed to make sure the doctor received the recommendations and wrote an order. The facility reported a census of 36 residents. Findings include: 1. In an observation on 8/1/23 at 7:55 AM, Resident #9 was in his bed on his back, wearing gripper socks and his heels were resting on the bed. The resident said he had a sore on his left heel. According to the admission Minimum Data Set (MDS) dated [DATE], Resident #9 had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability). He required extensive…

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 use safe transfer techniques for 2 of 3 residents, and failed to implement an intervention to prevent falls for 1 of 3 residents. (Resident#3, #2, #13). The facility reported a census of 36 residents. Findings include: 1. According to the Quarterly Minimum Data Set (MDS) dated [DATE], Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability). He required extensive assistance with the help of 2 for bed mobility, transfers, dressing and toileting. The Care Plan for Resident #3 indicated that he had a suprapubic catheter (date initiated 8/6/19) and required a mechanical lift for transfers (date initiated 9/16/22). Diagnosis included; acquired absence of the right great toe, anxiety disorder, cellulitis and obesity. On 7/31/23 at 7:57 AM Resident #3 sat on the edge of the bed as Certified Nurse Aide (CNA), Staff F, and CNA, Staff A, pushed the EZ Stand mechanical lift in front of him and applied 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 provide adequate urinary catheter care for 1 of 3 residents reviewed. After surgery for a suprapubic catheter, Resident #11 continued to have leakage and staff failed to notify the urologist. The resident was found to have the catheter bag on the bed next to him and not hung lower than the bladder. The facility reported a census of 36 residents. Findings include: According to the Quarterly MDS dated [DATE], Resident #11 required extensive assistance with the help of two staff for bed mobility, transfers, dressing and toileting. A BIMS assessment dated [DATE] showed a score of 14 (intact cognitive ability). The resident had an indwelling catheter and diagnosis included; renal insufficiency, benign prostate hyperplasia, The Care Plan updated on 11/27/22 showed that the resident was frequently incontinent of urine with history of catheter use. The care plan lacked information regarding the suprapubic catheter. A review of the clinical record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review the facility failed to implement infection control practices for 1 of 13 residents reviewed. Resident #3 had a urinary catheter and staff hooked the bag on the trash can while he was in his recliner during the day. The facility reported a census of 36 residents. Findings include: 1) According to the Minimum Data Set (MDS) dated [DATE], Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability). He required extensive assistance with the help of 2 for bed mobility, transfers, dressing and toileting. The care plan for Resident #3 indicated that he had a suprapubic catheter and required a mechanical lift for transfers. Diagnosis included; acquired absence of the right great toe, anxiety disorder, cellulitis and obesity. On 7/31/23 at 2:16, Resident #3 was sitting in his recliner chair with the catheter bag hooked on the trashcan next to the chair. He said that he stayed in his recliner chair all day and he would let the staff…

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.