Avantara Palos Heights

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow policy procedures and failed to review/revise a comprehensive care plan for one of 53 residents (R64) in the sample reviewed for restorative care. Findings include:R64 was admitted to the facility on [DATE] (almost 2 years ago). The (undated) facility splints/brace/prosthetic log includes R64's name. However R64's comprehensive care plan (received 9/16/25) excludes splints, brace and/or prosthetics. On 9/15/25 at 12:02pm, R64's hands were noted to be severely contracted however splints were not in use. Surveyor inquired if R64 uses hand splints R64 affirmed that she does. On 9/17/25 at 12:27pm, surveyor inquired if R64 uses a restorative device V4 (Restorative Nurse) stated, She (R64) has a left palm protector. Surveyor inquired why R64's restorative device was excluded from the comprehensive care plan (received 9/16/25). V4 responded, It's in there. V4 accessed R64's care plan (via EMR/Electronic Medical Records) which states, I 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that staff were aware of resident required restorative devices, failed to include restorative devices in the care plan, failed to ensure that required devices were included in facility tasks, and failed to ensure that restorative devices were applied as directed for one of 53 residents (R64) in the sample reviewed for restorative care. Findings include:The (undated) facility splints/brace/prosthetic log (received 9/16/25) includes R64's name however which required restorative device - was excluded.R64's comprehensive care plan (received 9/16/25) excludes splints, brace and/or prosthetics. On 9/15/25 at 12:02pm, R64's hands were noted to be severely contracted however splints were not in use. Surveyor inquired if R64 can move her left fingers (which were in a fixed position - almost touching the palm of her hand), however R64 was unable to do so. Surveyor inquired if R64 can move her right fingers…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement fall prevention measures as indicated on the care plan, failed to ensure bed alarms were in use, and failed to ensure residents received adequate supervision to prevent falls and prevent repeated falls. This failure affected 3 residents (R2, R4, R10) reviewed for falls in a sample of 53 residents. This failure resulted in R2 sustaining radial, ulnar, and femoral fractures due to an unwitnessed fall.1. R4's records show the following: R4 had unwitnessed falls on 9/2/25 and on 9/4/25 and was sent to the hospital for each fall. Face sheet shows diagnoses which include but are not limited to Dementia, History of Falling, Anxiety Disorder, Obesity, Encephalopathy, Gout, Polyosteoarthritis, and Leg Pain. MDS section GG dated 8/13/25 states R4 needs assistance for mobility/functional ability. Care plan dated 9/1/25 states R4 is at risk for falls. Intervention states in part to use bed/chair alarm to alert staff when residents attempt to get out of…

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

Based on observation, interview, and record review the facility failed to ensure that the enteral feeding pump was functioning properly, failed to follow physician orders, failed to provide enteral nutrition as directed, and failed to prevent weight loss for one of 53 residents (R10) in the sample reviewed for tube feeding management. Findings include:R10's diagnoses include severe protein-calorie malnutrition and gastrostomy status.R10's (5/5/25) care plan includes risk for alteration in nutritional status related to dysphagia, intervention g (gastrostomy) tube feeding as ordered.R10's physician orders include (7/30/25) NPO (nothing by mouth) diet. (8/5/25) Enteral feed order: Jevity 1.2 rate: 75ml (milliliters)/hr (hour) start at 2pm and infuse until 1,500ml formula total volume is reached per day. On 9/15/25 at 11:18am, R10 appeared frail and notably thin. R10's Jevity 1.2cal hung on 9/15 at 9:30am (per container) was set to be infused at 75cc/hr (cubic centimeters/per hour) via pump however the pump was noted to be alarming and 1,000ml (milliliters) remained in the (1,000ml)…

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 upon observation, interview, and record review the facility failed to follow policy procedures and failed to ensure that prescribed medications were available for one of 5 residents (R119) reviewed for medication administration. Findings include:R119's Physician Order Sheets include (9/16/25) Benzonatate 100mg three times daily for 5 days and Guaifenesin -DM (Dextromethorphan) 100mg/10ml (milliliters) give 10 ml every 6 hours for 2 days.On 9/15/25 at 8:49am, V15 (Registered Nurse) dispensed R119's medications (scheduled for 7:30am administration - per EMAR/Electronic Medical Administration Record) however the prescribed Benzonatate was unavailable. V15 stated, The Benzonatate, that's a new order so I have to call the pharmacy for that. V15 then affirmed that she was prepared to administer the medications however Guaifenesin (house stock) was dispensed. Surveyor inquired if Guaifenesin - DM (prescribed medication) was available V15 searched the medication cart to no avail and replied, No.On 9/17/25 at 9:16am, surveyor inquired who places the order for facility house stock…

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

Based on observation, interview, and record review, the facility failed to follow policy procedures, failed to ensure that prescribed medications were available, failed to ensure that the correct medication was dispensed, and failed to ensure that unauthorized medications were not administered. There were three medication errors out of 25 opportunities, resulting in a 12% medication error rate. Two of five residents (R25, R119) in the medication administration sample were affected. Findings include:R25's (9/8/25) POS (Physician Order Sheets) include Hydrocodone 7.5/325mg (milligrams) tablet every 6 hours as needed for severe pain 7-10.On 9/16/25 at approximately 8:35am, R25 requested pain medication. V15 (RN/Registered Nurse) dispensed Hydrocodone 7.5/325mg then requested R25's pain level. R25 rated current pain level a 4. V15 responded the Hydrocodone is prescribed for pain above 7 (which affirmed V15 was aware), however administered Hydrocodone to R25 (unauthorized). R119's POS includes (9/16/25) Benzonatate 100mg three times daily for cough for 5 days and Guaifenesin -DM…

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

Based on observation, interview, and record review the facility failed to follow policy procedures and failed to ensure that one of five residents (R25) reviewed for medication administration remained free from significant medication errors. Findings include: R25's (9/8/25) Physician Order Sheet includes Hydrocodone 7.5/325mg tablet every 6 hours as needed (for severe pain 7-10). On 9/16/25 at approximately 8:35am, R25 requested pain medication. V15 (RN/Registered Nurse) dispensed Hydrocodone 7.5/325mg then requested R25's pain level. R25 rated current pain level a 4. V15 responded the Hydrocodone is prescribed for pain above 7 (which affirmed V15 was aware) however administered Hydrocodone to R25 (unauthorized). R25's (September 2025) Medication Administration Record affirms Hydrocodone 7.5/325mg was also administered on 9/9 for pain level 4, on 9/13 for pain level 6, on 9/14 for pain level 5 and on 9/15 for pain level 5 therefore administered 4 additional times - unauthorized. The medication pass policy (revised 7/2/25) states it is the policy of the facility to adhere to all…

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 reviews, the facility failed to follow their policy related to incontinence and perineal care for one (R1) of three residents reviewed for incontinence care. This failure resulted in R1 developing incontinence associated dermatitis (IAD) on the scrotal area. Findings include: R1 is a [AGE] year-old male, admitted in the facility on 09/26/24, with diagnoses of: Unspecified Dementia, Anemia, Acute Kidney Failure, Benign Prostatic Hyperplasia, and History of Cerebral Infarction. According to R1's MDS (Minimum Data Set) dated 06/17/25, R1's BIMS was not conducted due to R1's severe cognitive impairment. According to Section GG, R1 is dependent on staff for eating, toileting and hygiene, toilet transfer, mobility. Section H indicated that R1 is always incontinent of urine, and frequently incontinent of bowel. On 06/30/25 at 11:41am, R1 was sitting in the reclining chair in front of the dining table. Alert, not interviewable. Activity on-going, however R1 doesn't appear to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure resident safety by failure to provide 2 persons assist when providing incontinence care. This failure resulted in resident (R61) to fall from bed required visit to emergency hospital for evaluation due to bruising, swelling and pain on forehead. The facility also failed to ensure fall preventive measures were being implemented for residents who are at high risk for falls. This deficiency affects five (R13, R33, R61, R105, R392) residents in the sample of 27 reviewed for Fall prevention program. Findings include: R61 On 10/29/24 at 10:35AM, Observed R61 lying in bed with dark blue purple discoloration /bruising and swelling on face which is more prominent on forehead, bilateral eyes, cheeks, and right side of neck. R13 can barely open her eyes because of the swelling. R61 said she was pushed out of the bed by CNA during providing care. She has bilateral floor mats on the sides of her bed, but her bed in not in low position. V9 LPN…

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

Based on observation, interview and record review, the facility failed to ensure, each resident's dignity was maintained by not placing the urinary catheter inside of his pants leg and securing it for 1 of 3 residents (R128) in a sample of 27 reviewed for dignity. Findings include: On 10/29/2024 at 11:50am R128 was observed with the unit manager, at the dining room table with his urinary catheter exposed and coming out the top of his pants and not secured. On 10/29/2024 at 11:55am V13 (Unit Manager) said R128's urinary catheter should be inside of his pants and secured down his leg into the privacy bag. On 10/30/2024 at 1:00pm V2 (Director of Nursing-DON) said she expects all residents with a urinary catheter to have it properly secured and not exposed. An order summary report indicates R128 has a diagnosis of urinary tract infection, a urinary catheter of 22 French for obstructive uropathy. A care plan dated 10/7/2024 indicated R128 has a potential for infection related to the indwelling catheter, and an intervention of ensure proper placement of the indwelling catheter secure lock…

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 the facility failed to follow their policy and procedures in providing safety during incontinence care by not providing 2 persons assist. The facility also failed to ensure reporting and documentation of the incident immediately in resident medical record. This deficient affects one (R61) of three residents reviewed for Quality of Care. Findings include: On 10/29/24 at 10:35AM, Observed R61 lying in bed with dark blue purple discoloration /bruising and swelling on facial more prominent on forehead, bilateral eyes, cheeks, and right side of neck. R13 can barely open her eyes because of the swelling. R61 said she was pushed out of the bed by CNA during providing care. She has bilateral floor mats on the sides of her bed, but her bed is not in low position. V9 LPN (Licensed Practical Nurse) said R61 is at high risk for falls due to her recent fall. V9 said R61's bed should be in the lowest position. V9 adjusted the bed to the lowest position using the bed control at the…

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

Based on observation, interview and record review the facility failed to ensure pain was thoroughly assessed and treated before, during and after surgical wound care for 1 of 4 resident's (R127) reviewed for pain management in a sample of 27. Findings include: On 10/30/2024 at 10:40 am R127 was observed flinching during sacral wound care treatment. R127 said she had pain medication about 15 minutes ago and it was okay V14 (Wound Care Nurse) could continue. On 10/30/2024 at 11:15am V14 was asked did he apply R127 lidocaine gel to the sacral wound before starting the wound care treatment? V14 said He does not apply the lidocaine gel and he was not aware if the nurse had applied the gel. On 10/30/2024 at 12:00 noon V15 (Unit Nurse) said she did not apply the lidocaine gel to R127 surgical wound because it is for the treatment nurse and the lidocaine gel was given to V14 when it arrived from the pharmacy. On 10/30/2024 at 12:00 noon V2 (Director of Nursing) said, I expect the wound care nurses and the staff nurses to assure all residents are medicated before, during and after treatment…

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

Based on observation, interview, and record review the facility failed to ensure appropriate infection control practices were followed when handling soiled linens/gown. This deficiency affects one (R60) of three residents in the sample of 27 reviewed for Infection control during ADL (Activity of Daily Living) care. Findings include: On 10/29/24 at 10:50AM, Observed V10 Hospice CNA (Certified Nurse Assistant) providing morning care/personal hygiene to R60. Observed all soiled linen and gown were on the floor. Surveyor asked V10, why the soiled linens are on the floor. V10 said that it is okay for her to placed it on the floor because the linens are soiled. V7 Restorative Nurse corrected V10 Hospice CNA and informed her that it is not right to place the soiled linens on the floor. It should be placed in plastic bag for infection control. On 10/29/24 at 12:53PM, Informed V5 Infection Preventionist Nurse of above observation. She said V10 Hospice CNA should not place the soiled linens/gown on the floor. She should use soiled hamper linen or placed the soiled linens in plastic bag.…

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 reviews, the facility failed to follow their policy and procedures for proper nursing care by not ensuring a resident who requires assistance with transfers was immediately assessed for injury after being found in an abnormal position and not ensuring the incident was immediately documented in the residents medical record and the physician and family were notified. This failure applies to one of three residents (R1) reviewed for quality of care. Findings include: R1 is an [AGE] year-old male with a diagnoses history of Parkinson's Disease, Dementia, Major Depressive Disorder, Muscle Wasting and Atrophy, Psychotic Disorder with Delusions, Diverticulitis, Cardiomegaly, Atherosclerotic Heart Disease, Encephalopathy, Malignant Neoplasm of Spinal Cord, and chronic kidney disease who was admitted to the facility 01/27/2020. On 10/02/2024 at 11:21 AM Observed R1 sitting in a wheelchair in the dining room. Observed R1 wearing a sling on his right arm, observed R1's right arm…

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

Based on observation, interview and record review, the facility failed to provide incontinence care with 2 hours for residents who were identified as dependent for staff assist for toileting/incontinence care. This affected four of four (R2, R5, R6 and R7) residents reviewed for incontinence care. This failure resulted in R2 being left soiled in urine for over fifteen hours and feeling drenched and disgusted. R5 being left soiled in urine for over eight hours feeling wet and cold with chills. R6 being left soiled in urine for sixteen hours and R7 being left soiled and saturated in urine with a strong ammonia smell for over eighteen hours. Findings Include: 1.) R2 was diagnosis with need assistance with personal care. Minimal data set section C (cognitive pattern) brief interview for mental status dated 7/25/24 documents a score of fifteen which indicates cognitively intact. Section H (bladder and bowel) dated 8/3/24 documents: urinary/bowel- always incontinent. Care plan dated 8/18/24 documents: R2 displays bowel and bladder incontinence. Intervention document: R2 would like the…

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

Based on observation, interview and record review, the facility failed to follow their skin care regimen and treatment formulary by not documenting and obtaining a physician order for a resident who was identified as high risk for skin breakdown. This affected one of three residents (R2) reviewed for non-pressure wound care. This failure resulted in R2 have two small pink opened circular areas on the inner right upper thigh and right posterior thigh. Findings Include: R2's Braden scale dated 9/5/24 documents: a score of sixteen which indicates at high risk for skin breakdown. Moisture: very moist skin is often, but not always moist. Linen must be changed at least once a shift. Friction and shear: Potential Problem: Moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair, restraints or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down. Scoring: 20 and Below = High Risk On 9/12/24 at 10:15am, during incontinence care with V6 (treatment nurse) and V5 (CNA), R2 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 follow one resident plan of care, who was identified as high risk for skin breakdown with a stage four and stage three pressure wounds by not following the wound practitioner's treatment orders and ensuring an air loss mattress was in place. This affected one of three residents (R3) reviewed for pressure sore prevention interventions. Findings include: R3 was admitted to the facility on [DATE] with a diagnosis of pressure ulcer stage four, anemia, peripheral vascular disease, depression, psychotic disorder with delusions, unspecified dementia, and surgical amputation. R3's Braden score dated 9/5/24 documents a score of 13 which indicates high risk for skin breakdown. On 9/12/24 at 9:30AM, R3 wound care observations with V6 (wound care nurse) was conducted. R3 right buttocks (facility refers to right ischium) wound dressing removed. Area cleaned with normal saline. Silver alginate packed into the area and covered with bordered gauze. R3's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review; the facility failed to provide a safe environment by not adequately monitoring residents at risk for falls for 5 of 5 residents (R1, R2, R3, R4, R5) reviewed for falls; failed to follow facility policy of ensuring all staff were educated on residents at risk for falls and/or fall prevention program. This failure resulted in all five reviewed residents falling unsupervised. Findings include: Reviewed undated incident list with date range from 05/01/2024 through 08/04/2024 provided by facility that showed incident dates as follows: R1 and R5 both on 06/05/2024; R2 on 06/08/2024, 06/12/2024, and 06/12/2024; R3 on 06/21/2024; R4 on 06/23/2024. 1: R1's electronic medical record indicated resident last admitted to the facility on [DATE] and has a past medical history not limited to: dislocation of left humerus and right shoulder joint, vascular dementia, repeated falls, symbolic dysfunctions, depression, anxiety, encephalopathy, traumatic subarachnoid hemorrhage,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents were treated in a dignified manner for 5 of 7 residents (R4, R5, R6, R7, R9) reviewed for abuse/neglect in the sample 9. The findings include: 1. On 6/23/24 at 10:33AM, R5 was standing in her room. R5 had a walker at her bedside. R5 said, Ya, the staff treat her pretty good. The people during the day are beautiful. During the evening, some are good, and some can go home where they belong. Others are like, what do you want? (R5 raised her hands like claws while saying this). R5 said they are sometimes rough with her roommate (R4). R5's facility assessment dated [DATE] shows she has moderate cognitive impairment, has no behaviors, and requires supervision with showers. 2. On 6/23/24 at 10:45AM, R4 (R5's roommate) was sitting in a wheelchair in her room. R4 was propelling herself around in her room in her wheelchair. R4 was asked if she had concerns with how staff treat her. R4 said, not really, I open my mouth if I have too.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident was free from abuse for 1 of 7 residents (R2) reviewed for abuse in the sample of 9. The findings include: R2's facility assessment dated [DATE] shows she is cognitively intact, does not have behaviors, and is dependent on staff for toileting hygiene. This assessment shows R2 needs partial/moderate assistance from staff rolling side to side in bed (helper does less than half the effort) and is dependent on staff for transfers in and out of the bed. R2's admission record printed 6/23/24 shows diagnoses to include: major depressive disorder, malignant neoplasm of the colon, generalized anxiety disorder, morbid obesity, sciatica, history of TIA (cerebral infarct), disc degeneration, rheumatoid arthritis, and bilateral hearing loss. R2's Physician Order Set printed 6/23/24 shows an order for alprazolam 0.5mg every 8 hours as needed for anxiety. Hydrocodone-acetaminophen 7.5/325mg (narcotic pain medication), give one tablet by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain dignity by having the catheter collection visible for one resident (R142) of 31 residents reviewed for dignity in the sample of 31. Findings include: On 12/26/23 at 11:55 AM R142 was in the bed closest to the door. The catheter collection bag for R142 was visible from the hall. There was no dignity bag covering the collection. On 12/26/23 at 12:00 PM V5 (LPN-Licensed Practical Nurse) was asked if R142 should have a dignity over the catheter collection bag should have a dignity bag covering it. V5 said, Absolutely he should have one (dignity bag). He came from the hospital like that. I'll have to check to see what's in supplies. The census in R142's electronic record indicates that R142 was admitted on [DATE]. The care plan for R142 indicates; interventions, please position catheter bag and tubing below the level of the bladder and away from entrance room door. Policy: Privacy and Dignity reviewed 7/28/23 4. Urine bags will be…

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

Based on observation, interview and record review the facility failed to assess a resident for self-administration of nasal and oral medication that was kept at the bedside for 1 of 4 residents (R361) reviewed for self-administration of medications in a sample of (31). Findings include: On 12/26/2023 at 11:30am R361 was observed in bed alert and oriented times three with unopened Insulin (Humalog) at bed side in a local hospital bag a bottle of over-the-counter nasal spray opened at the bedside, a bottle of nasal spray Fluticasone Propionate Suspension 50 micrograms open at the bedside, and Albuterol Sulfate HFA solution inhaler at the bedside open. On 12/26/2023 at 11:35am R361 said, I don't know why the insulin is at my bedside I don't have any syringes and I wouldn't give myself an injection. I always have the nasal spray and the inhaler at my bedside since I've been here, I came from the hospital last night and no-one came and picked up the insulin. On 12/26/2023 at 11:40am V17(Registered Nurse-RN) observed with the writer medication at the bedside and removed all three…

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 check the Low Air Loss mattress plugged in and functioning, failed follow manufacturer's recommendation in limiting the amount of layers on top of the mattress. This deficiency affects one (R40) of three residents in the sample of 31 reviewed for Pressure ulcer Prevention and Management. Findings include: R40 was admitted on [DATE] with diagnosis listed in part but not limited to Cirrhosis of liver, Liver cell carcinoma. Active physician order indicates pressure relieving mattress. Sacrum: Clean with NSS, apply A&D ointment and leave open to air every shift. Skin: Apply house stock incontinence barrier cream to buttock and perineal area after each incontinence episode. CNA may apply. May keep at bedside every shift and as needed daily. Skin: Apply house stock topical moisturizer. CNA may apply. May keep at bedside. Care plan indicates: She has an actual impairment to skin integrity: Incontinence associated dermatitis to sacrum. And…

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

Based on observation, interview and record review, the facility failed to provide restorative nursing program to paraplegic resident for one (R1) of two residents reviewed for range of motion in a sample of 31. Findings include: R1's Order Summary Report dated 12/29/2023 indicated admission date of 10/25/2021 and diagnoses of not limited to unspecified osteoarthritis and paraplegia, unspecified. R1's Multidisciplinary Therapy Screen quarterly dated 7/21/2023 indicated R1 to be screened quarterly or as needed to address changes in functional mobility, ADLs (Activities of Daily Living), diet, etc. Facility was unable to provide comprehensive nursing and restorative and functional assessment for R1. On 12/27/2023 at 10:34AM R1 was observed lying on bed with limited range of motion on both lower extremities. On 12/27/2023 at 2:00PM, V2 (Director of Nursing) said R1 is not on any restorative nursing program because he is a long-term care resident. On 12/28/2023 at 12:30PM, V1 (Administrator) said restorative nursing assessment should be done quarterly. On 12/28/2023 at 1:05PM, V13…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure fall preventive interventions were being implemented to resident who is at high risk for falls. This deficiency affects one (R74) of three residents reviewed for Fall Prevention Program in the sample of 31. Findings include: R74 is admitted on [DATE] with diagnosis listed in part but not limited to History of falling, Chronic pain, Congestive heart failure. Care plan indicates: He is at risk for falls related to decreased strength, endurance, balance, cardiac issues, chronic pain syndrome, incontinence, and history of falls. Interventions: Keep the bed in the low position for safety. Keep patient in the middle of the bed with each round and as needed when patient is on the edge of the bed. Please provide a wide bed. Propped pillows on left side to his knees for positioning to prevent from sliding out of bed. R74's fall history for 2023 indicates: 3/23/23 Unwitnessed fall. R74 found lying on the floor in his room. 3/25/23 Witnessed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure coordination of care and communication between hospice provider was in place for two (R49 and R74) of five residents reviewed for Hospice care in the sample of 31. Finding includes: On 12/26/23 at 10:30AM, V10 LPN (Licensed Practical Nurse) said R49 and R74 are both hospice residents. V10 said hospice residents have each own hospice binder where all hospice documentation is kept for communication. When hospice staff comes to visit hospice resident, they document in the hospice binder care provided to the resident. On 12/26/23 at 10:35AM, Observed R49 lying in bed with oxygen via nasal cannula. R49 is alert and oriented, able to verbalize needs to staff. On 12/26/23 at 10:40AM, Observed R74 lying in bed leaning to his left side, with his head and pillow hanging from bed. R74's is on high position. He has bilateral floor mats. He is confused. On 12/26/23 at 10:43AM, Review R49's hospice binder in the unit. No IDT (Interdisciplinary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a resident received the necessary care and services by not arranging transportation to important follow-up appointments following hospitalization. This applies to 1 of 15 resident (R5) reviewed for care and services in the sample of 15. The findings include: R5's EMR (Electronic Medical Record) reviewed on 9/1/23 shows R1 was admitted to the facility on [DATE] and discharged on 7/5/23. R5 was admitted with diagnoses including Non-traumatic Subarachnoid Hemorrhage, Obstructive Hydrocephalus, Non-traumatic Intracerebral Hemorrhage and Localization-related (focal)(partial)Symptomatic Epilepsy and Epileptic Syndromes with Simple Partial Seizures. R5's Hospital After Visit Summary dated 5/26/23-6/13/23 (provided to the facility upon R5's admission) shows R5 had a scheduled appointment on 6/27/23 at 8:00 AM for a Vascular Ultrasound Ankle Brachial Indices Lower Extremity Limited, an appointment on 6/27/23 at 9:45 AM with the Vascular Surgeon and 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 interview, and record review the facility failed to monitor and assess R4's pressure injuries for 1 of 3 residents (R4) reviewed for pressure in the sample of 15. The findings include: R4's Weekly Wound Report shows R4 was admitted to the facility on [DATE]. R4's Initial Wound assessment dated [DATE] shows R4 was admitted with pressure injuries: groin- Stage 2, right trochanter (hip)- stage 4, left trochanter- suspected deep tissue injury, right buttock-stage 4, left buttock-stage 4, left lower leg- stage 3, right heel-suspected deep tissue injury, and right heel-suspected deep tissue injury. This same assessment does not include measurements for the wounds. R4's Skin and Wound Note dated 7/6/23 (6 days after admission) shows R4 has deep tissue injuries to his left hip and right heel, a venous wound to the left lateral malleolus, a medical device associated wound to the penis, and stage 4 pressure injuries to the right hip, sacral, and left ischium, and includes measurements done by the Wound Nurse…

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.