Aventura At West Park

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure medications were available to administer as ordered. This affected one (Resident #80) of five patients reviewed for medication administration. The facility census was 65. Findings include: Review of the medical record revealed Resident #80 was admitted to the facility on [DATE] and expired at the facility on [DATE]. Resident #80 had diagnoses including unspecified neoplasm of digestive organ, essential hypertension, gastroesophageal reflux disease, absence epileptic syndrome, oropharyngeal phase dysphagia, chronic ulcerative pancreatitis, unspecified lymphedema, sciatica, and unspecified anxiety disorder. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, had no behaviors, did not reject care, and did not wander. Review of the care plan dated [DATE] revealed Resident #80 received Hospice services related to a diagnosis 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 medical record review, staff interview, and review of facility policy, the facility failed to ensure residents were free from significant medication errors when they gave double the dose of Morphine to a resident. This affected one (Resident #80) of five residents sampled for medication administration. The facility census was 65. Findings include: Review of the medical record revealed Resident #80 was admitted to the facility on [DATE] and expired at the facility on [DATE]. Resident #80 had diagnoses including unspecified neoplasm of digestive organ, essential hypertension, gastroesophageal reflux disease, absence epileptic syndrome, oropharyngeal phase dysphagia, chronic ulcerative pancreatitis, unspecified lymphedema, sciatica, and unspecified anxiety disorder. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, had no behaviors, did not reject care, and did not wander. Review of care plan dated [DATE] revealed Resident #80…

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 staff interview, observation, record review, and review of the facility policy, the facility failed to ensure all food temperatures were checked prior to the start of meal service. This had the potential to affect all 78 residents in the facility. Findings include: Interview on 04/03/24 at 4:00 P.M. with Dietary [NAME] (DC) #430 confirmed he only gets the temperature of one food on the steam table at the beginning of each meal because if one was hot, the rest will be hot. DC #430 further confirmed he would be testing the temperature of the chicken for the meal because it was the only food on the steam table which did not have foil over it in addition to the metal lid. DC #430 then tested the temperature of the chicken and the thermometer read 140 degrees Fahrenheit (F). DC #430 confirmed the chicken needed to be at least 165 degrees F and then placed the chicken back in the steamer. Observation on 04/03/24 at 4:10 P.M. revealed DC #430 retrieved the pan of chicken from the steamer and placed it in the steam table. DC #430 obtained the temperature of the chicken at 179…

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

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure kitchen equipment was maintained in a sanitary manner. The facility also failed to ensure staff wore hair restraints which fully contained the hair while preparing food. This had the potential to affect all 78 residents in the facility. Findings include: 1. Observation on 04/01/24 at 8:37 A.M. revealed the hood in the kitchen, which covered the fryer, stove, grill, and steamers, was covered with a black and grey fuzzy substance. Further observation revealed a sticker on the hood, which indicated the last cleaning was completed on June 2023. Interview on 04/01/24 at 8:37 A.M. with Food Service Manager (FSM) #503 confirmed the slats of the hood in the kitchen were in need of cleaning. FSM #503 confirmed the cleaning was past due, and the hood should be cleaned every three months. Review of the facility policy titled Cleaning Instructions: Hoods and Filters undated revealed stove hoods and filters should be cleaned at least monthly and professionally cleaned at least yearly. 2.…

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

Based on record review, staff interview, and review of the facility policy, the facility failed to properly implement the Legionella plan. This had the potential to affect all of the residents residing in the facility. The facility census was 78. Findings include: Review of the facility's water management records revealed the facility failed to complete water temperatures for the year of 2023 which was one of the specific control measures the facility was using to monitor Legionella. Review of the facility temperature log revealed water temperatures had only been completed from January 2024 through March 2024. There were no water temperatures recorded for 2023. Interview on 04/10/24 at 1:03 P.M. with Maintenance Director (MD) #307 confirmed the facility had not completed water temperatures for the year 2023. Review of the facility policy titled Legionella Water Management Program dated July 2017 revealed the facility was committed to the prevention, detection, and control of water-borne contaminants, including Legionella. The purpose of the water management program was to identify…

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 medical record review, staff interview, review of the facility policy, the facility failed to conduct care conferences as required. This affected four (Residents #16, #19, #23, and #41) of five residents reviewed for care planning. The facility census was 78. Findings include: 1. Review of the medical record for Resident #16 revealed an admission date of 10/25/23 with diagnoses including necrotizing fasciitis, generalized anxiety disorder, type two diabetes mellitus, peripheral vascular disease, anemia, lumbar spina bifida without hydrocephalus, atrial fibrillation, depression, and arthropathy. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #16 dated 02/26/24 revealed the resident had intact cognition, required setup assistance for eating, moderate assistance for oral hygiene, and maximal assistance for toileting, bathing, dressing, personal hygiene, bed mobility and transfer. Review of the social services progress note for Resident #16 dated 10/27/23 revealed the facility held a care conference with Resident #16. Further review of the social…

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

Based on observation, staff interview, and review of facility recipes, the facility failed to properly prepare pureed food. This had the potential to affect five (Residents #12, #22, #47, #49, #50) of five facility-identified residents who received a pureed diet. The facility census was 78. Findings include: Observation on 04/03/24 at 1:08 P.M. revealed Dietary [NAME] (DC) #430 began process of making pureed broccoli. DC #430 placed 6 scoops (3 cups) of broccoli into the blender pitcher and then placed the pitcher under the water spigot and filled the pitcher to the 6-cup line. Continued observation revealed DC #430 blended the broccoli mixture in the blender for approximately four minutes. DC #430 then poured the contents into a pan, covered the pan, and placed it in the steamer. The contents of the pitcher were liquified and runny. Interview on 04/03/24 at 1:10 P.M. with DC #430 confirmed he used equal parts of water and vegetables because he wanted to make sure the food was as watery as possible to ensure the residents could digest it without choking. DC #430 confirmed 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 medical record review, review of facility Self-Reported Incident (SRI), review of daily staffing sheet, review of time clock records, resident interview, staff interview, and review of the facility policy the facility failed to ensure residents were protected during abuse investigations. This affected one (Resident #14) of one reviewed for abuse. The facility census was 78. Findings include: Review of the medical record for Resident #14 revealed an admission date of 01/31/24 with diagnoses including acute and respiratory failure with hypercapnia, congestive heart failure (CHF), bipolar disorder, chronic kidney disease stage three, and type two diabetes mellitus. Review of the Minimum Data Set (MDS) assessment for Resident #14 dated 02/05/24 revealed the resident had intact cognition, required setup with eating, and was dependent on staff assistance with toileting, bathing, dressing, and transfers. Review of the Self-Reported Incident (SRI) #245840 for Resident #14 dated 04/01/24 timed at 2:11 P.M. revealed the resident alleged that on 03/11/24 State Tested Aide (STNA) #361…

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

Based on record review, observation, staff interview, and review of the facility policy, the facility failed to properly transfer the resident using an appropriate assistive lift device. This affected one (Resident #14) resident of two residents reviewed for falls. The facility census was 78. Findings include: Review of the medical record for Resident #14 revealed an admission date of 01/31/24 with diagnoses including acute and respiratory failure with hypercapnia, congestive heart failure (CHF), bipolar disorder, chronic kidney disease stage three, and type two diabetes mellitus (DM II). Review of the care plan for Resident #14 dated 02/01/24 revealed the resident was at risk for falls related to DM II and CHF. Interventions included the following: call light and personal items within reach while in room, staff to ensure a clutter-free environment and adequate lighting, staff to observe for safety, staff to provide rest periods, staff to use proper assistive devices. Review of the Minimum Data Set (MDS) assessment for Resident #14 dated 02/05/24 revealed the resident had intact…

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 medical record review, staff interview, and review of the facility policy, the facility failed to implement nutritional recommendations made per the licensed dietitian for residents with weight loss. This affected one (Resident #11) of three residents reviewed for nutrition. The facility census was 78. Findings include: Review of the medical record for Resident #11 an admission date of 03/31/20 with diagnoses including polyneuropathy, cellulitis of right lower limb, generalized anxiety disorder, major depressive disorder, dementia, other cervical disc degeneration, and peripheral vascular disease. Review of the plan of care dated for Resident #11 dated 01/03/24 revealed the resident was at risk for alteration in nutrition related to polyneuropathy, depression, hypertension, cervical disc degeneration, peripheral vascular disease, anemia, cognitive communication deficit, and anxiety. The plan of care also indicated the resident was at risk for malnutrition due to history of weight fluctuations and advanced age. Interventions included the following: administer medications 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.

Based on record review, staff interview, and review of the facility policy, the facility failed to implement physician orders following pharmacy recommendations. This affected three (Residents #5, #16, and #23) of five residents reviewed for unnecessary medications. The facility census was 78. Findings include: 1. Review of the medical record for Resident #5 revealed an admission date of 09/12/22 with diagnoses including cerebral infarction, schizophrenia, anxiety, expressive language disorder, depression, and dementia. Review of the Minimum Data Set (MDS) assessment for Resident #5 dated 01/15/24 revealed the resident had severe cognitive deficits and required extensive to total dependence with activities of daily living (ADLs.) Review of pharmacy recommendation for Resident #5 dated 06/21/23 revealed a recommendation to discontinue Seroquel 25 milligrams (mg) by mouth at bedtime signed by the medical director on 07/17/23 indicating agreement with the recommendation. Review of the physician orders for Resident #5 revealed an order dated 11/03/23 to discontinue Seroquel 25 mg.…

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 medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure a medication error of below five percent for medication administration observation. The medication error rate was eight percent (%.) This affected one (Resident #55) of four residents observed for medication administration. The facility census was 78. Findings include: Review of the medical record for Resident #55 revealed an admission date of 02/16/23 with diagnoses including diabetes, atrial fibrillation, insomnia, hypertension, and Asperger's syndrome. Review of the Minimum Data Set (MDS) for Resident #55 dated 02/19/24 revealed the resident was cognitively impaired and required staff assistance with activities of daily living (ADLs). Review of physician orders for Resident #55 revealed the resident had an orders for pantoprazole 40 milligrams in the morning and Flonase nasal spray two sprays in each nostril each morning. Observation on 04/03/24 at 9:03 A.M. of medication administration for Resident #55 per Licensed Practical Nurse (LPN #505) revealed 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 medical record review, observation, staff interviews, and review of the facility policy, the facility failed to ensure insulin pens were properly labeled and stored. This affected two (Residents #23 and #55) of 39 residents with medications stored in the 700 hall cart. The facility census was 78. Findings include: Review of the medical record for Resident #23 revealed an admission date of 09/29/21 with diagnoses including congestive heart failure (CHF), type two diabetes mellitus (DM II), and acute kidney failure. Review of the physician orders for Resident #23 revealed an order dated 01/17/24 for Lantus insulin inject ten units at bedtime. Review of the medical record for Resident #55 revealed an admission date of 02/16/23 with diagnoses including type one diabetes mellitus, atrial fibrillation, and Asperger's syndrome. Review of the physician orders for Resident #55 revealed an order dated 01/17/24 for Lantus insulin inject 25 units and an order dated 03/29/24 for Humalog insulin inject four units. Observation on 04/03/24 at 4:02 P.M. of medication cart on 700 hall…

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

Based on record review, staff interview, and review of the facility policy, the facility failed to provide the pneumococcal vaccine in a timely manner. This affected three (Residents #10, #11, and #21) of five resident reviewed for vaccinations. The facility census was 78. Findings include: Review of the medical record for Resident #10 revealed an admission date of 10/22/19 with diagnoses including type two diabetes mellitus, generalized anxiety, depression, and chronic kidney disease stage three. Review of the medical record for Resident #10 revealed Pneumococcal vaccine 23 (PPSV23) was given on 02/01/13. Resident #10 should have received PCV15 or PCV20 at least one year after PPSV23. Review of the medical record for Resident #11 revealed an admission date 03/31/20 with diagnoses including generalized anxiety disorder, major depressive disorder, and dementia. Review of the medical record for Resident #11 revealed the PPSV23 was given on 07/01/18. Resident #11 should have received PCV15 or PCV20 at least one year after PPSV23. Review of the medical record for Resident #21 revealed…

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 medical record review, observation, staff interview, and facility policy review, the facility failed to administer ordered medications with an error rate of less than 5 percent (%). There were six errors observed of 26 opportunities, resulting in an error rate of 23.08%. This affected two Residents (#17 and #24) of four observed for medication administration. The facility census was 71. Findings include: 1. Medical record review revealed Resident #24 was admitted to the facility on [DATE] with diagnoses including Alzheimer's, hypertension, depression, and pulmonary embolism. Review of Resident #24's physician's orders dated 05/24/19 revealed an order for Xarelto (blood thinner) tablet, 20 milligrams (mg) daily, Citracal (supplement) slow release tablet 600-40-500 mg, twice a day, Midodrine (for orthostatic low blood pressure) HCI tablet 2.5 mg before meals, and Citalopram (anti-depressant) hydrobromide 10 mg daily. There was no evidence in the medical record of any orders to crush 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 observation, staff interview, and facility policy review, the facility failed to label open vials of insulin and failed to dispose of expired medications in a timely manner. This affected two medication carts of three observed, and one out of one medication room observed for medication storage. The facility census was 71. Findings include: 1. Observation on 04/14/21 at 3:30 P.M. with Licensed Practical Nurse (LPN) #8 of the east medication cart revealed one vial of Lantus (insulin) prescribed to Resident #16, a vial of Levemire (insulin) and Novolog (insulin) prescribed to Resident #14 were opened with no open date on the label. Interview at the time of the observation with Licensed Practical Nurse (LPN) #8 verified the vials of insulin were opened and not dated. 2. Observation on 04/14/21 at 3:39 P.M. with LPN #5 of the south medication cart revealed a vial of Novolog with an opened date 02/16/21 prescribed to Resident #17, and a Basaglar insulin pen which had an expiration date of 03/21 prescribed to Resident #44. 3. Observation on 04/14/21 at 3:54 P.M. with the Director…

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 medical record review, resident and staff and interviews, review of self reported incidents (SRI's), personnel file review and policy review, the facility failed implement their policy to ensure allegations of sexual abuse and/or misappropriation were reported to authorities and thoroughly investigated. This affected four (#46, #58, #94, and #424) residents out of four SRI's reviewed during the annual survey. Facility census was 115. Finding included: 1. Review of Resident #424's medical record revealed an admit date of 08/01/18 and a discharge date of 08/14/18. The diagnosis included congestive heart failure, hypertension, gastroesophageal reflux disease, right artificial hip, unsteadiness on feet, and weakness. Review of admission Minimum Data set assessment dated [DATE] indicated Resident #424 was cognitively intact and required limited assist of one for activities of daily living. Review of a SRI dated 10/29/18 revealed Resident #424 complained of sexual abuse in a voice message left for 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 medical record review, resident and staff interviews, review of self reported incidents (SRI's), personnel file review and policy review, the facility failed to report allegations of sexual abuse and/or misappropriation to local authorities. This affected four (#46, #58, #94, and #424) residents out of four SRI's reviewed during the annual survey. Facility census was 115. Finding included: 1. Review of Resident #424's medical record revealed an admit date of 08/01/18 and a discharge date of 08/14/18. The diagnosis included congestive heart failure, hypertension, gastroesophageal reflux disease, right artificial hip, unsteadiness on feet, and weakness. Review of admission Minimum Data set assessment dated [DATE] indicated Resident #424 was cognitively intact and required limited assist of one for activities of daily living. Review of SRI form dated 10/29/18 revealed Resident #424 complained of sexual abuse in a voice message left for the Licensed Nursing Home Administrator and then a letter hand…

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 3. Resident #94 was admitted to the facility in February of 2015 with diagnoses including Parkinson's disease, dementia with lewy bodies, acute and chronic respiratory failure, congestive heart failure, atrial fibrillation, diabetes mellitus and anxiety disorder. The facility complete an annual Minimum Data Set (MDS) assessment of Resident #94's cognitive status and physical functional abilities dated 01/04/19. The 01/04/19 assessment identified the resident with good memory and recall and requiring the physical assistance of at least one staff person for completion of all activities of daily living with the exception of eating for which she was independent. On 01/29/19 at 10:05 A.M. an interview was conducted with Resident #94 to discern if she had any concerns related to personal property being missing. She stated that about four months ago, a housekeeper, took $60.00 out of her room, and she reported it to staff. Resident #94 stated the facility came and asked her questions about the missing money, 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, staff interview and policy review, the facility failed to secure hazardous materials. This had the potential to affect 19 (#4, #5, #7, #12, #14, #15, #21, #28, #31, #36, #37, #40, #55, #74, #86, #89, #91, #93, and #418) residents who the facility identified as cognitively impaired and independently mobile and that could potentially access the hazardous materials. Facility census was 115. Findings include: A random observation on 01/29/19 at 10:01 A.M. revealed the central shower room wall cabinet open with a large spray bottle of Virex (powerful cleaner, sanitizer and disinfectant) and a tub of Sani wipes (germicidal disposable wipes) visible. Labeling of both items indicated the product is hazardous to humans. Interview on 01/29/19 at 10:15 A.M. with the Director of Nursing (DON) reported the Virex and Sani wipes should be locked up when not in use by staff. She verified the unit had confused residents who wander. DON verified both items had labeling of keep out of reach of children and stated the cabinet door child proof device was broken. The facility…

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 and staff interviews, medical record review and policy review, the facility failed to gather resident preferences for care and failed to honor a resident's expressed care preferences. This affected two (#64 and #419) of three residents assessed for choices and had the potential to affect all residents. The facility census was 115. Findings include: 1. Review of the medical record for Resident #419 revealed an admit date of 01/14/19 with diagnosis including but not limited to chronic obstructive pulmonary disease, hypertension, chronic kidney disease, degenerative joint disease, and diabetes. A five-day Minimum Data Set (MDS) assessment dated [DATE] indicated resident was cognitively intact and required limited assist of one for toileting, ambulation, and bed mobility. The MDS also indicated resident required extensive assist of one for dressing and locomotion with supervision for eating, and physical assistance for bathing. The MDS section F did not address showering frequency. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of facility policy, the facility failed to inform the Office of the State Long-Term Care Ombudsman when a resident was transferred to an acute care facility. This affected one (#46) of two residents reviewed for hospitalizations. The facility census was 115. Findings include: Resident #46 was admitted [DATE] with diagnoses including dementia, paroxysmal atrial fibrillation, major depressive disorder, cerebral infarction, and osteoarthritis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status of 12 out of 15, indicating moderately impaired cognition and required one-person extensive assistance for activities of daily living (ADL's). Review of the medical record progress note dated 07/30/18 revealed the resident was transferred to an acute care hospital 07/30/18 via 911 emergency, and returned to the facility 08/01/18. The medical record contained no evidence that 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 medical record review, staff interview, and review of facility policy, the facility failed to ensure written bed hold information was provided to residents when hospitalized . This affected one (#110) of two residents reviewed for hospitalizations. The facility census was 115. Findings include: Resident #110 was admitted [DATE] with diagnoses including atrial fibrillation and Parkinson's Disease. Review if the quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status of 15 out of 15, indicating intact cognition. Review of the medical record revealed the resident was emergently transferred to an acute care hospital on [DATE]. The medical record contained no evidence that a written bed-hold notice provided to the resident or his/her representative when the resident was hospitalized . Interview on 01/29/19 at 2:37 P.M., Business Office Manager (BOM) #15 stated the facility provided written bed hold information to residents upon admission but…

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 medical record review, staff interview, and review of the Minimum Data Set (MDS) 3.0 User's Manual, the facility failed to ensure resident assessments accurately reflected a resident's fall with major injury. This affected one (#46) of 26 residents sampled during the survey. Facility census was 115. Findings include: Resident #46 was admitted [DATE] with diagnoses including dementia, paroxysmal atrial fibrillation, major depressive disorder, cerebral infarction, and osteoarthritis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status of 12 out of 15, indicating moderately impaired cognition and required one-person extensive assistance for activities of daily living (ADL's). The assessment indicated the resident had no falls since the prior assessment. Review of the quarterly Minimum Data Set (MDS) assessment dated five days earlier on 11/10/18 documented the resident had two falls without major injury. Review of the care…

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

Based on observation, resident and staff interviews, medical record review and policy review, the facility failed to develop a baseline care plan to address a residents fluid restrictions. This affected one (#410) of two residents reviewed for hydration. The facility identified three residents with fluid restriction orders. Facility census was 115. Findings include: Review of Resident #410's medical record revealed an admit date of 01/26/19 with diagnosis including but not limited to rheumatoid arthritis, atrial fibrillation, osteoporosis, vertebral fractures, hypertension, esophageal strictures, and hyponatremia. A Minimum Data Set was not available for review since resident was such a recent admit. Review of a therapy progress note dated 01/28/19 and a nursing progress note dated 01/31/19 revealed Resident #410 was cognitively intact and required extensive assist of one for all activities of daily living except supervision only for eating. The notes also indicated resident was incontinent of bowel and bladder. Review of Resident of Resident #410's physician orders dated 01/26/19…

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, resident and staff interviews, medical record review and policy review, the facility failed to implement a resident's physician ordered fluid restrictions. This affected one (#410) of two residents reviewed for hydration. The facility identified three residents with fluid restriction orders. Facility census was 115. Findings include: Review of Resident #410's medical record revealed an admit date of 01/26/19 with diagnosis including but not limited to rheumatoid arthritis, atrial fibrillation, osteoporosis, vertebral fractures, hypertension, esophageal strictures, and hyponatremia. A Minimum Data Set was not available for review since resident was such a recent admit. Review of a therapy progress note dated 01/28/19 and a nursing progress note dated 01/31/19 revealed Resident #410 was cognitively intact and required extensive assist of one for all activities of daily living except supervision only for eating. The notes also indicated resident was incontinent of bowel and bladder. Review of Resident of Resident #410's physician orders dated 01/26/19 revealed 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 resident, resident representative and staff interview, medical record review and policy review, the facility failed to assess and implement interventions to prevent significant weight loss. This affect one (#68) of four residents reviewed for nutrition. The facility census was 115. Findings include: Review of Resident #68's medical record revealed an admit date of 12/19/18 with a readmit date of 01/06/19. Her diagnosis included but were not limited to wedge compression fracture of thoracic vertebra 11 and 12, fracture of pelvis, fracture of right lower leg, dysphagia, heart failure, hypertension, anxiety disorder, major depressive disorder, and chronic obstructive pulmonary disease. A five-day Minimum Data Set assessment dated [DATE] indicated resident was cognitively intact and required extensive assist of two for bed mobility, transfers, toileting, and locomotion. Resident #68 required extensive assist of one for dressing and hygiene but was supervision only for eating. A PHQ-9 depression screening…

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 and staff interview, and medical record review the facility failed to provide behavioral health care services when requested. This affected one (#68) resident of four residents assessed for mood and behavior. The facility census was 115. Findings include: Review of Resident #68's medical record revealed an admit date of 12/19/18 with a readmit date of 01/06/19. Her diagnosis included but were not limited to wedge compression fracture of thoracic vertebra 11 and 12, fracture of pelvis, fracture of right lower leg, dysphagia, heart failure, hypertension, anxiety disorder, major depressive disorder, and chronic obstructive pulmonary disease. A five-day Minimum Data Set assessment dated [DATE] indicated resident was cognitively intact and required extensive assist of two for bed mobility, transfers, toileting, and locomotion. Resident #68 required extensive assist of one for dressing and hygiene but was supervision only for eating. A PHQ-9 depression screening tool included in the MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and policy review, the facility failed to ensure any irregularities noted by the pharmacist during residents' monthly drug regimen reviews were reviewed and responded to in writing by residents' attending physician regarding any action to be taken, if any. This affected two residents (#16 and #21) of five residents reviewed for Unnecessary Medications. The facility census was 115. Findings include: 1. Resident #16 was admitted to the facility from an acute care hospital in July of 2018 with diagnoses including status post left hip fracture, wedge compression fracture, pain in thoracic spine, repeated falls, dementia without behavioral disturbance, unilateral primary osteoarthritis, anxiety disorder, insomnia, hypertension, and gastro-esophageal reflux disease. The facility completed a quarterly Minimum Data Set (MDS) assessment of Resident #16's cognitive and physical functional status dated 01/18/19. The 01/18/19 MDS identified the resident as having mild to moderate…

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.