Azria Health Longview

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and policy review the facility failed to use universal infection control measures and Enhanced Barrier Precautions (EBP) during cares for 4 of 5 residents reviewed for infection control (Residents #38, #57, #61, and #189). The Facility reported a census of 86 residents. Findings include: 1. Review of Resident #61's Minimum Data Set (MDS) dated [DATE] revealed diagnoses of renal insufficiency, Multidrug-Resistant Organism (MDR), and stroke. Review of Resident #61's Electronic Healthcare Record (EHR) page titled, Physician's Orders revealed treatments to a wound on Resident #61's coccyx as well as a treatment to Resident #61's right heel. Further review of the Physician Orders revealed an order for the implementation of EBP related to wounds and positive MRSA. Review of Resident #61's Care Plan with a revision date of 4/21/25 revealed Resident #12 required EBP related to a wound. The Care Plan further revealed interventions for staff to utilize proper personal protective…

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, Electronic Health Record (EHR) review, resident interviews, staff interviews and policy review, the facility failed to provide dignity and respect to 1 of 3 residents reviewed (Resident #54). The facility reported a census of 86 residents. Finding include: The Minimum Data Set (MDS) dated [DATE] for Resident #54 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. The MDS also documented diagnoses of hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting an unspecified side, anxiety disorder, unspecified, need for assistance with personal care and generalized muscle weakness. Review of EHR for Resident #54 revealed the resident resided in room [ROOM NUMBER]-B. A continuous observation on 6/9/25 at 1:49 PM revealed the call light on in room [ROOM NUMBER]. On 6/9/25 at 1:55 PM Staff M, Regional Director of Operations entered the room and shut off the call light. Staff M left the room and spoke to Staff G about…

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 document review, staff interview, and policy review the facility failed to provide a comprehensive care plan related to high risk medications for residents with an order for diuretics for 1 of 5 residents (Resident# 12) reviewed. The facility reported a census of 86 residents. Findings include: Review of Resident #12's Minimum Data Set (MDS) dated [DATE] revealed diagnoses of cancer, diabetes mellitus, and hyperlipidemia. The MDS further revealed that during the look back period Resident #12 received diuretic medication daily. Review of the Electronic Healthcare Record (EHR) page titled, Physician's Orders revealed an order for Furosemide 20 mg 1 tablet daily. Review of Resident #12's Care Plan with a revision date of 5/21/25 revealed no documentation of diuretic medications usage. Interview on 6/11/25 at 8:07 AM with the Director of Nursing (DON) revealed that diuretics should be in the Care Plan for Resident #12. Review of a facility provided policy titled, Care plans, Comprehensive…

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, resident interview, staff interviews, Electronic Health Record (EHR) review and policy review the facility failed to provide timely and adequate treatment and interventions to prevent the worsening of pressure ulcers for 1 of 4 residents reviewed (Resident #61.) The facility failed to request or apply any treatment or dressing to Resident #61's right heel for 8 days until seen by the visiting wound care nurse, to prevent the worsening of the wound. The facility reported a census of 86 residents. Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, staff interview, and policy review the facility failed to assess a resident for safety while smoking for 1 of 2 residents reviewed (Resident #16). The facility reported a census of 86 residents. Findings include: Review of Resident #16's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS further revealed that Resident #16 uses tobacco products. The MDS then revealed an admission date of 3/6/25 from a skilled nursing facility. The MDS revealed diagnoses of hypertension, peripheral vascular disease, renal failure, respiratory failure, and acquired absence of left leg above the knee. Review of Resident #16's Electronic Healthcare Record (EHR) page titled, Progress Notes revealed an entry 5/9/25 at 1:45 PM documenting Resident #16 requested to have his cigarettes and a lighter to take with him to his appointment. The Administrator advised Resident #16 these items would be given to 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 Electronic Health Records (EHR) review, resident interview, policy review and staff interviews the facility failed to provide dialysis services consistent with professional standards by not completing a post dialysis assessment to 1 of 1 residents reviewed (Resident #39). The facility reported a census of 86 residents. Finding include: The Minimum Data Set (MDS) dated [DATE] for Resident #39 documented a Brief Interview for Mental Status (BIMS) score of 13 indicating no cognitive impairment. The MDS documented diagnoses of type 2 diabetes mellitus with diabetic chronic kidney disease, dependence on renal dialysis, and end stage renal disease. On 6/9/25 at 1:00 PM Resident #36 stated she goes to dialysis appointments every Monday, Wednesday and Friday. Review of Resident #39's EHR titled, Orders documented an order for a complete pre/post vital signs, weight and evaluation. The EHR titled, Orders also revealed an order for dialysis schedule 3 times a week on Monday, Wednesday and Friday. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to serve residents their therapeutic menu as ordered, for 3 of 22 residents (Residents #31, #69 and #6) with mechanically altered diets. The dietary staff ran out of the scheduled vegetable of the day and served corn to residents that required a mechanical soft diet. The facility reported a census of 86 residents. Findings include: According to the Diet Spreadsheet for week 4, the mechanical soft menu on 6/10/25 included; ground sweet and sour chicken with sauce, soft steamed rice w/gravy, soft and chopped steamed broccoli and chopped fruit fluff. 1) According to the Minimum Data Set (MDS) dated [DATE], Resident #31 had a Brief Interview for Mental Status (BIMS) score of 2 (severe cognitive deficits) and he required partial assistance with eating. The Care Plan for Resident #31, updated on 1/25/24, showed that he was at risk for nutritional deficits related to dysphagia, and had diet texture modifications; with a mechanical soft diet. An order…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. According to the Minimum Data Set (MDS) dated [DATE], Resident #136 was independent with self-care and mobile with the use of a wheel chair. His diagnoses included heart failure, renal insufficiency, diabetes mellitus, anxiety disorder and respiratory failure. The following was found in the nursing progress notes for Resident #136: a. On 1/30/25 at 3:35 PM, mental status upon admission oriented x 3 communicated verbally, speech clear, is able to understand and be understood when speaking. Mood was pleasant no unwanted behaviors witnessed. Arrived by private transportation, reported shortness of breath, b. On 1/30/25 at 4:20 PM, he was admitted to the facility from the hospital at 3:00 PM. He had difficulty ambulating and shortness of breath. The resident required 3-4 liters of supplemental oxygen, stated that he wanted physical therapy to evaluate him in the morning. c. On 1/31/25 at 10:00 AM, Resident #136 wanted to leave Against Medical Advice (AMA) and he signed the required paperwork. He said he 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 observations, review of resident council notes and grievance/complaint logs, resident and staff interviews and facility policy review the facility failed to answer call lights in a timely manner. The facility reported a census of 72 residents. Findings include: On 1/15/25 at 7:58 AM noted room [ROOM NUMBER] had their call light on. At the nurse's station is a computer with a program displayed called Visonlink that displayed room [ROOM NUMBER] activated their call light at 7:40 AM and response was waiting. Staff walked in to the room at 8:03 AM, call light was turned off. The call light was activated for 23 minutes. On 1/15/25 at 2:02 PM noted room [ROOM NUMBER] had their call light on. Observed staff had assisted the resident and turned the call light off at 2:24 PM. The call light was activated for 22 minutes. Review of the resident council notes included the following resident council concern: - On 9/3/24 residents expressed concerns in regards to Certified Nursing Assistants (CNAs) turning off 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 clinical record review, staff interviews, physician interview, and policy review the facility failed to complete physician's orders for 2 of 3 residents (Resident #3 and #4) reviewed. The facility reported a census of 72 residents. Findings include: 1. According to the Quarterly Minimum Data Set (MDS) with a reference date of 10/23/24 documented a Brief Interview of Mental Status (BIMS) score of 15. A BIMS score of 15 suggested Resident #3 had no cognitive impairment. No rejection of care was noted during the review period. The MDS listed the following diagnoses for Resident #3: Parkinson's Disease, coronary artery disease, diabetes mellitus, anxiety, depression, post traumatic stress disorder (PTSD) and insomnia. The following Progress Notes were documented for Resident #3: -On 11/20/22 at 11:33 AM the nurse practitioner (ARNP) saw Resident #3 today. Resident indicated his knee is a lot better since surgery. Resident indicated he had a sore throat, PCP ordered strep test, flu test and COVID-19 test.…

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 and resident interviews, and policy review the facility failed to assist 3 of 3 residents (Resident #5, #7 and #8) that were dependent on staff for Activities of Daily Living (ADLs) care when they were incontinent of urine and/or bowel. The facility reported a census of 72 residents. Findings include: 1. The quarterly Minimum Data Set (MDS) with a reference date of 10/22/24 documented Resident #5 had a Brief Interview of Mental Status (BIMS) score of 15. A BIMS score of 15 suggested no cognitive impairment. Resident #5 did not experience rejection of care during the review period. The MDS documented she was frequently incontinent of bowel. The MDS documented the following diagnoses for Resident #5: metabolic encephalopathy, diabetes mellitus, malnutrition, depression, schizophrenia, palliative care, stage 4 pressure ulcer to sacral region, and obesity. The Care Plan with a revision date of 11/7/23 documented Resident #5 had activities of daily living (ADLs) self care performance deficit and impaired mobility related to activity intolerance,…

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 interviews, staff interviews, resident council notes, and policy review the facility failed to provide food at an appetizing temperature to 4 of 20 residents reviewed (Resident #25, #52, #59, and #61). The facility reported a census of 65 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #52 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. On 7/15/24 at 1:13 PM Resident #52 stated the food is cold half the time when it should be warm. 2. The Minimum Data Set (MDS) dated [DATE] revealed Resident #59 had a Brief Interview for Mental Status (BIMS) score of 13 indicating no cognitive impairment. On 7/15/24 at 10:56 AM Resident #59 stated the corn dogs were served cold a couple nights ago. Resident #59 stated the manager in the kitchen will not listen to the residents about the food. Resident #59 stated when she first came to the facility she told the kitchen manager the food was slop and…

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

Based on observations, staff interviews, and policy review the facility failed to follow proper sanitation, food safety and food handling practices in accordance with professional standards. The facility reported a census of 65 residents. Findings include: Observation on 7/15/24 at 9:30 AM noted Staff H, cook, to have facial hair but not a facial covering. Continuous observation on 7/15/24 at 10:38 AM noted Staff H, cook, to have facial hair and no covering, Staff I, Dietary Aide, observed to have facial hair and no facial covering, and Staff U, Dietary Aide, to have facial hair and no facial covering. Continued continuous observations revealed the following: Staff H, served food items from the steam table using gloves and scoops and placed the plates on the trays with insulated covers. Staff S, cook, took the tray with hot food, added uncovered cold beverages and uncovered desserts to the trays, and placed the trays in the transportation carts for delivery to Memory Care, assisted living which resides on the bottom floor of the building and room tray delivery. Staff S wore gloves…

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 clincal record review, resident interview, staff interview, and policy review the facility failed to make prompt efforts to resolve grievances the resident may have for 1 of 1 residents reviewed (Resident #52). The facility reported a census of 65 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #52 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. On 7/15/24 at 1:17 PM Resident #52 stated she reported to Staff O, Social Service Designee and Staff P, Business Office Manager that she was missing $5.00 worth of change, $100.00 in $20 bills, $50.00 in $1 bills, and a couple [NAME] tickets that were no good. Resident #52 stated nothing was done about it. Resident #52 stated she was told by Staff P that she shouldn't have had that much money laying around. Resident #52 stated the facility did not replace the money. Resident #52 stated this happened a couple months ago. On 7/16/24 at 11:42 AM Staff O, Social Service…

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 complete a Pre-admission Screening and Resident Review (PASRR) for 1 of 1 residents (Resident #25), who was diagnosed with new mental disorder diagnoses since admission to the facility. The facility reported a census of 65 residents. Findings include: Review of Resident #25's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive deficit. The MDS further revealed diagnoses of anxiety disorder, depression, and post traumatic stress disorder (PTSD). Review of a facility provided document titled, PASRR Notice of Nursing Facility Approval, dated 10/11/22 revealed a summary of findings indicating that Resident #25 that did not show evidence of a serious mental illness or an intellectual or developmental disability (IDD) that appears to require PASRR intervention. The document further revealed the screen remained valid for the stay at the nursing…

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 resident interview, staff interview, electronic health records (EHR) review, and policy review the facility failed to maintain medical records on each resident that were complete and accurate by not signing medication administration records when the enteral feeding was given for 1 of 2 residents reviewed (Resident #52). The facility reported a census of 65 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of 13 indicating no cognitive impairment. The MDS also revealed Resident #15 required use of an enteral feeding tube for nutritional intake. On 7/15/24 at 3:09 PM Resident #15 stated the evening nurse forgets to turn the pump on sometimes and the am nurse finds it in the morning. Resident #15 stated she did not miss any feedings. On 7/17/24 at 9:00 AM Resident #15 stated when the enteral feedings were not started on time she would notify the nurse and the feeding would be started or sometimes she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, clinical record review and facility policy review the facility failed to provide adequate hand hygiene and Enhanced Barrier Precautions (EBP) for 3 of 9 residents reviewed for precaution. Staff failed to change gloves during incontinence cares for Resident #17, and failed to use proper Personal Protective Equipment (PPE) during catheter cares for Residents #25 and #21. The facility reported a census of 65 resident. Findings include: 1. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #17 had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability). He was totally dependent on staff for dressing, and toileting hygiene. He was frequently incontinent of urine and always incontinent of bowel. His diagnosis included; anemia, benign prostatic hyperplasia, neurogenic bladder, wound infection, paraplegia, anxiety disorder, and unspecified intellectual disability. The Care Plan revised on 5/29/24 showed that he had urinary…

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, facility policy review, and staff interviews, the facility failed to complete comprehensive, weekly wound assessments of the resident's skin for 2 of 3 residents sampled (Residents #1 and #2). The facility reported a census of 71 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #1 revealed that she had modified independence with cognitive skills for daily decision making. The MDS revealed the resident had Parkinson's disease and bipolar disease. The MDS also revealed she required extensive assistance of 2 with bed mobility, toileting, transfers and personal hygiene. The Incident Report dated 10/30/23 revealed, the resident inadvertently received a burn to her forehead while a HHA (hospice health assistant) was curling her hair. The Skin Assessment on 10/31/23 lacked assessment of the resident's burn to her forehead. Review of the clinical record revealed the record lacked a skin assessment of the burn until 11/10/23. In an interview on 2/27/24…

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

Based on observations, clinical record review, and staff interviews, the facility failed to assure residents on pureed diets received appropriate portions for 5 of 5 residents reviewed (Resident #24, #26, #27, #36, and #63). The facility reported a census of 69 residents. Findings include: 1) Resident #24's Clinical Physician's Orders dated 4/28/23 included a regular diet, pureed texture. 2) Resident #26's Clinical Physician's Orders dated 10/26/22 included a regular diet, pureed texture. 3) Resident #27's Clinical Physician's Orders dated 11/2/22 included a general diet, pureed texture. 4) Resident #36's Clinical Physician's Orders dated 1/4/22 included a general diet, pureed texture. 5) Resident #63's Clinical Physician's Orders dated 2/16/23 included a general diet, pureed texture. The Diet Spreadsheet Week 3 indicated the noon pureed menu on 5/3/23, consisted of: -A pureed taco burger on a bun, (a #10 dipper of taco meat and a bun), -A #8 dipper of pureed Mexican rice, and -A 4 ounce serving of pureed creamed corn. On 5/3/23 at 10:40 a.m. the Dietary Manager (DM) pureed 5…

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 policy review the facility failed to serve food in accordance with professional standards for food service safety. The facility reported a census of 69 residents. Findings include: During an observation on 5/3/23 at 12:31 p.m. Staff B Cook, served the meal on East Court. He served the meal wearing gloves, touching the steam table, serving utensils, plates, and menus. Staff B intermittently touched buns with his gloved hands that he had touched multiple surfaces and items with. Staff E Dietary Aide also touched a bun with gloved hands. Menus that laid on the front of the steam table fell in on the soft shell tortillas. Staff F [NAME] pulled them off the tortillas and Staff B used the tortilla the menus had contact with. Staff B picked up the last 7 tortillas he served from the steam table with his gloved hand. On 5/3/23 at 1:40 p.m. the Dietary Manager, stated food should be served with utensils to avoid contamination. The facility policy Food Preparation and Service revised April 2019 documented bare hand contact with food 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 and staff interview, the facility failed to ensure resident privacy for 1 of 24 residents reviewed (Resident #34). The facility reported a census of 69 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #34 identified a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. The MDS indicated that Resident #34 required extensive assistance of two persons with bed mobility and toilet use, extensive assistance of one person for dressing, and was totally dependent for transfers with a Hoyer and two persons. The MDS included diagnoses of diabetes mellitus, end stage renal disease, hypertension, asthma, atrial fibrillation, and [NAME]-Danlos syndrome (a connective tissue disorder). During an observation of a Hoyer transfer on 5/4/23 at 10:45 AM, Resident #34 was being prepared to be transferred from bed to her motorized wheelchair with a Hoyer lift to go for her shower. The Director of Nursing (DON) was also observing.…

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 and staff interview, the facility failed to notify the physician of family reported concerns for 1 of 5 residents reviewed (Resident #70). The facility reported a census of 69 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #70 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The MDS documented the resident required extensive assistance with transfer, dressing, and toilet use, and depended on staff for personal hygiene. The MDS documented the resident's diagnoses to include chronic respiratory failure with hypoxia (low level of oxygen in tissues). The Care Plan dated 8/20/20 identified a focus of respiratory issues related to chronic obstructive pulmonary disease (COPD), hypoxia, and oxygen dependant. Goals included the resident would not need a hospital stay related to hypoxia, with a target date of 8/6/22. The Progress Notes for the resident documented the following: 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, staff interview and facility policy review the facility failed to provide residents or their representatives the appropriate written notices in a timely manner when they no longer qualified for services covered by Medicare for 2 of 3 residents reviewed (Resident #40 and #59). The facility reported a census of 69 residents. Findings include: 1) Resident #40's Census page showed she was on Medicare A (skilled care) from 1/10/23 to 3/28/23. A Notice of Medicare Non Coverage (NOMNC) documented Resident #40's Skilled Nursing Services would end 3/28/23. The notice showed the resident signed on 3/27/23. The notice documented if the resident/representative wanted an appeal they should do so as soon as possible, but no later than noon the day before the effective date indicated above (3/28/23). 2) Resident #59's Census page showed she was on Medicare A (skilled care) from 3/22/23 to 4/19/23. A Notice of Medicare Non Coverage (NOMNC) documented Resident #59's Skilled Nursing Services would end 4/19/23. The notice revealed the facility notified 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.

Based on clinical record review and staff interviews, the facility failed to refer a resident to the appropriate state-designated authority for a Level II Preadmission Screening and Resident Review (PASARR) evaluation and determination who was identified with a newly evident mental disorder for one of three residents reviewed (Resident #36). The facility reported a census of 69 residents. Findings include: The Minimum Data Set assessment for Resident #36, dated 2/15/23, included diagnoses of anxiety disorder, depression, and psychotic disorder. Review of PASARR Level I Screen form dated 1/3/22 for Resident #36, documented no major mental illnesses and no mental disorders. Review of Medication Administration Records dated 5/1/23 - 5/31/23, documented the resident received Risperdal (antipsychotic medication) 0.5 milligrams (mg) 1 tablet daily related to depression and Sertraline (antidepressant medication) 50 mg 1 tablet daily for Major Depressive Disorder. Review of Behavioral Health visit progress note dated 11/23/22, documented presenting problems of delusions with paranoid…

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 revise the Care Plan with resident specific data after a urinary catheter related hospitalization for 1 of 1 resident reviewed (Resident #40). The facility reported a census of 69 residents. Findings include: The discharge Minimum Data Set (MDS) dated [DATE] for Resident #40 documented the type of assessment as unplanned. The MDS documented her memory as ok with modified independence for cognitive skills. The MDS documented the resident had a urinary catheter and required extensive assistance with toileting which included catheter maintenance and supervision for personal hygiene. The MDS documented diagnoses to include hemiplegia and overactive bladder. The quarterly MDS dated [DATE] for Resident #40 documented an entry date of 01/10/23. The MDS documented the resident entered from an acute hospital. The MDS documented the resident scored 15 out of 15 possible points indicating she is cognitively…

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 and staff interview, the facility failed to follow a physician's order for weekly weights, due to weight loss, for 1 of 17 residents reviewed (Resident #57); and failed to apply compression stockings per physician's orders for 1 of 1 residents reviewed (Resident #80). The facility reported a census of 69 residents. Findings include: 1. The Minimum Data Set (MDS) for Resident #57, dated 4/6/23, included diagnoses of schizophrenia and hemiplegia (paralysis of one side of the body). The MDS identified the resident required setup and supervision with eating and extensive assistance of two staff for bed mobility, transfers, dressing, and personal hygiene. The MDS also documented a weight loss of 5% or more in the last month or 10% or more in the last 6 months and not on a physician-prescribed weight-loss regimen. The MDS documented the resident had a Brief Interview for Mental Status score of 13 out of 15 possible points, indicating mild cognitive impairment. The Care Plan 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, family and staff interviews and facility policy review, the facility failed to provide nail care that resulted in a palm and nose wounds, and failed to provide showers per resident preference for 2 of 24 residents reviewed (Resident #23 and #72). The facility reported a census of 69 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #23 identified the presence of short and long-term memory impairment. The MDS indicated that Resident #23 was totally dependent and needed assistance of two persons with bed mobility, transfers, dressing, eating, personal hygiene, and toilet use. The MDS included diagnoses of stroke, cancer, aphasia (inability to verbally communicate), seizure disorder, dysphagia (difficulty swallowing), and mood disorder. The MDS also revealed the resident had functional limitations in range of motion to an upper extremity and both lower extremities. The Care Plan revised 4/25/23 identified Resident #23 as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, family and staff interviews the facility failed to provide adequate assessment and timely intervention for 1 of 5 residents reviewed (Resident #70). The facility reported a census of 69 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #70 scored 15 out of 15 possible points on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The MDS documented the resident required extensive assistance with transfer, dressing, and toilet use, and depended on staff for personal hygiene. The resident's diagnoses included chronic respiratory failure with hypoxia (low level of oxygen in tissues). The Care Plan for Resident #70 identified a focus of respiratory related to chronic obstructive pulmonary disease (COPD), hypoxia, and oxygen dependant initiated 8/20/20. Goals included the resident would not need a hospital stay related to hypoxia with a target date of 8/6/22. The Progress Notes for the resident documented…

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 prevent pressure ulcer development for 1 of 3 resident reviewed for pressure ulcers (Resident #21). The facility reported a census of 69 residents. Findings include: The admission Minimum Data Set (MDS) dated [DATE] documented the resident required extensive, one-person assistance with personal hygiene, dressing, and bed mobility and extensive, two-person assistance with toileting, ambulating, and transfers. The MDS documented the resident had diagnoses to include heart failure, renal insufficiency, arthritis, edema, muscle weakness and need for assistance with personal care. The MDS documented the resident was did not have any pressure ulcers on admission but was at risk for developing pressure ulcers. The quarterly MDS dated [DATE] for Resident #21 documented she scored 15 out of 15 possible points on the Brief Interview of Mental Status (BIMS), indicating intact cognitively. The MDS documented 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, and staff interviews, the facility failed to ensure safe transfer techniques used for 2 of 3 residents reviewed (Resident # 21, #24). The facility reported a census of 69 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #24, dated 3/11/23, included diagnoses of hip fracture and Non-Alzheimer's Dementia. The MDS identified the resident required extensive assist of two staff for bed mobility, transfers, dressing, and toilet use. The MDS identified the resident was always incontinent of bladder and bowel and a Brief Interview for Mental Status score of 5 out of 15 possible points, indicated severe cognitive impairment for decision-making. During an observation on 5/08/23 at 10:45 AM, Staff G, Certified Nurse Aide (CNA) and Staff H, CNA transferred Resident #24 from a Broda chair (adjustable padded wheelchair) to the bed with a gait belt and assist of both staff. Staff G and Staff H provided incontinence care to the resident. Staff G…

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 interview, and facility policy review the facility failed to provide appropriate incontinence care for one of three residents reviewed (Resident #24) . The facility reported a census of 69 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #24, dated 3/11/23, included diagnoses of hip fracture and Non-Alzheimer's Dementia. The MDS identified the resident required extensive assist of two staff for bed mobility, transfers, dressing, and toilet use. The MDS identified the resident was always incontinent of urine and bowel and a Brief Interview for Mental Status score of 5 out of 15 possible points, indicated severe cognitive impairment for decision-making. The Care Plan with the revised date 4/3/23 documented Resident #24's skin problems related bowel and bladder incontinence. The Care Plan directed staff to keep her skin clean and dry. During an observation on 5/08/23 at 10:45 AM, Staff G, Certified Nurse Aide (CNA) and Staff H, CNA transferred Resident #24 from a Broda chair (adjustable padded…

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 facility policy review the facility failed to consistently assess and obtain vitals before and after dialysis for 1 of 1 resident reviewed (Resident #34). The facility reported a census of 69 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #34 identified a Brief Interview for Mental Status (BIMS) score of 15 out of 15 possible points indicating intact cognition. The MDS indicated the resident required extensive assistance of two persons with bed mobility and toilet use, extensive assistance of one person for dressing, and was totally dependent for transfers with two persons. The MDS included diagnoses of diabetes mellitus, end stage renal disease, hypertension, asthma, atrial fibrillation, and [NAME]-Danlos syndrome (a connective tissue disorder). The MDS documented the resident received dialysis. The Care Plan dated 11/13/22 identified Resident #34 went to dialysis three times a week on Monday, Wednesday, 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 clinical record review, observation and staff interview the facility failed to ensure staff performed proper hand hygiene during patient care for 1 of 24 residents reviewed (Resident #34). The facility reported a census of 69 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #34 identified a Brief Interview for Mental Status (BIMS) score of 15 out of 15 possible points, indicating intact cognition. The MDS documented the resident required extensive assistance of two persons with bed mobility and toilet use, extensive assistance of one person for dressing, and was totally dependent for transfers with a Hoyer and two persons. The MDS documented the resident had an indwelling catheter and was frequently incontinent of bowel. The MDS included diagnoses of diabetes mellitus, end stage renal disease, hypertension, asthma, atrial fibrillation, and [NAME]-Danlos syndrome (a connective tissue disorder). During an observation of a Hoyer transfer on 5/4/23 at 10:45 AM,…

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.