Aventura At Carriage Inn

Based on medical record review, observation, staff interview and review of the facility policy, the facility failed to ensure staff donned appropriate personal protective equipment (PPE) for residents on enhanced barrier precautions. This affected three (Residents #61, #21, #14) of three residents observed for care. The facility also failed to ensure staff practiced proper hand hygiene. This affected one (Resident #21) of three residents observed for care and one (Resident #15) of two residents observed for medication administration. The facility census was 63 residents.Findings include:1.Review of the medical record for Resident #61 revealed an admission date of 09/23/25 with diagnoses including cerebral atherosclerosis, tracheostomy, and gastrostomy. Review of the physician's orders for Resident #61 revealed an order dated 09/24/25 for the resident to be on enhanced barrier precautions Observation on 10/21/25 at 8:27 A.M. revealed Licensed Practical Nurse (LPN) #30 was in Resident #61's room providing care without a gown. Interview on 10/21/25 at 8:29 P.M. with LPN #30 confirmed…

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 policy, the facility failed to ensure medications were not left unattended in resident rooms. This affected one (Resident #15) of two residents observed for medication administration. The facility census was 63 residents. Findings include: Review of the medical record for Resident #15 revealed an admission date of 04/08/25 with diagnoses including atrial fibrillation, malignant prostate cancer, and pneumonia. Review of the Minimum Data Set (MDS) assessment for Resident #15 dated 07/15/25 revealed the resident had intact cognition and required moderate staff assistance with activities of daily living (ADLs.) Review of the physician's orders for Resident #15 dated October 2025 revealed there was no order for the resident to self-administer medications. Observation on 10/20/25 at 10:01 A.M. with License Practical Nurse (LPN) #30 revealed the nurse entered Resident #15's room with an ampule of albuterol, an inhalant medication to assist with breathing. LPN #30 placed the contents of the ampule into the nebulizer…

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 staff administered blood pressure medications according to physician-ordered parameters. This affected one (Resident #15) of two residents observed for medication administration. The facility census was 63 residents. Findings include: Review of the medical record for Resident #15 revealed an admission date of 04/08/25 with diagnoses including atrial fibrillation, malignant prostate cancer, and pneumonia.Review a physician's order for Resident #15 revealed an order dated 04/09/25 for Diltiazem 120 milligram (mg) once daily with parameters to hold the medication if the resident's systolic blood pressure was less than 110.Review of the Minimum Data Set (MDS) assessment for Resident #15 dated 07/15/25 revealed the resident had intact cognition and required moderate staff assistance with activities of daily living (ADLs.)Observation on 10/20/25 at 10:05 A.M. with Licensed Practical Nurse (LPN) #30 revealed the nurse withheld Resident #15's dose of Diltiazem…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, medical record review, and policy review, the facility failed to ensure staff followed the policy to check placement of the resident's gastrostomy tube (G-tube) before medication was administered. This affected one (#62) of four residents observed for medication administration. The facility census was 60. Findings included: Review of an admission medical record for Resident #62 revealed an admission on [DATE]. Diagnoses for Resident #62 included: moderate protein-calorie malnutrition and dysphagia (difficulty swallowing foods or liquids) in the oral phase. Review of the admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 12/11/24, revealed Resident #62 had severe cognitive impairment. The MDS indicated Resident #62 was dependent on staff for completion of all activities of daily living (ADLs). The MDS also revealed Resident #62 received 51% or more of their total calories and fluid intake through their feeding tube. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, medical record review, and policy review, the facility failed to maintain a medication error rate of less than five percent (%). There were 3 medication errors of 38 medication opportunities, which resulted in a medication error rate of 7.89%. This affected two (#62 and #111) of four residents observed for medication administration. The facility census was 60. Findings included: 1. Review of an admission medical record for Resident #111 revealed an admission date of 12/04/24. Diagnoses for Resident #111 included: hypertensive urgency, hypertensive chronic kidney disease, atherosclerotic heard disease, and essential hypertension. Observation on 12/10/24 beginning at 8:14 A.M., during medication administration, Licensed Practical Nurse (LPN) #1 prepared one vitamin B12, 500 micrograms (mcg) and one enteric coated aspirin, 81 milligrams (mg). The medications were administered to Resident #111. Review of Resident #111's physician Order Summary Report for active orders as 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, resident interview, staff interview, medical record review, and policy review, the facility failed to ensure medications were not left unattended at the bedside. This affected one (#45) of three sampled residents reviewed for potential accidents. The facility census was 60. Findings included: Review of the admission medical record for Resident #45 revealed an admission date of 08/18/22. Diagnoses for Resident #45 included: neurocognitive disorder with Lewy bodies (a neurological brain disorder with symptoms of Alzheimer's disease) and aphasia (the inability to verbally express ideas and thoughts). Review of the quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 09/20/24, revealed Resident #45 had severe cognitive impairment. Review of Resident #45's care plan, revised 03/20/23, included a focus area indicating the resident had impaired decision-making ability and impaired memory. The care plan indicated Resident #45 would be assisted in decision making and care. Observation on 12/09/24 at 10:28 A.M., revealed on the top 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, staff interview, and policy review, the facility failed to maintain infection control procedures when administering medications. This affected one (#111) of four residents observed for medication administration. The facility census was 60. Findings included: Observations on 12/10/24 at 8:14 A.M., during the medication administration, in the presence of Registered Nurse (RN) #2, Licensed Practical Nurse (LPN) #1 removed the following medications from the medication package and place the medications in her bare hands: amlodipine (a high blood pressure medication), Plavix (a medication to help prevent blood clots), Lexapro (an antidepressant medication), Microzide (a blood pressure medication), and Lopressor (a blood pressure medication). Interview on 12/10/24 at 8:23 A.M., with LPN #1 stated she had not been taught anything about touching medication, but stated touching the medication with her hands could contaminate the medication. Interview on 12/10/24 at 8:24 A.M., with RN #2 stated she planned to speak with LPN #1 about touching medications with her hands 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 medical record review, staff interview, and policy review, the facility failed to ensure a resident's representative was notified of development of new pressure ulcer and treatment plan. This affected one (#75) out of three residents reviewed for pressure ulcers. The facility census was 61. Findings include: Review of the medical record for Resident #75 revealed an admission date of 04/03/24 with medical diagnoses of cerebral atherosclerosis, protein calorie-malnutrition, chronic obstructive pulmonary disease, and obstructive and reflux uropathy. Review of the medical record for Resident #75 revealed a quarterly Minimum Data Set (MDS) assessment, dated 06/17/24, which indicated Resident #75 had severe cognitive impairment and required partial/moderate staff assistance with toilet hygiene, bed mobility, and transfers. The MDS indicated Resident #75 required substantial/maximum staff assistance with bathing and no pressure ulcer/injuries were noted. Review of the medical record for Resident #75 revealed a wound observation evaluation, dated 07/25/24, which stated Resident #75…

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, medical record review, staff and resident interviews, and policy review, the facility failed to follow infection control procedures. This affected one (#22) out of three residents reviewed for wound care. The facility census was 61. Findings include: Review of the medical record for Resident #22 revealed an admission date of 02/21/22 with medical diagnoses of heart failure, diabetes mellitus, severe protein calorie malnutrition, peripheral vascular disease, and hypertension. Review of the medical record for Resident #22 revealed a quarterly Minimum Data Set (MDS) assessment, dated 06/30/24, which indicated Resident #22 was cognitively intact and was independent with eating, bed mobility, and transfers, required supervision with bathing, and set-up assistance with toileting. The MDS did not indicate Resident #22 had any skin areas. Review of the medical record for Resident #22 revealed a wound observation evaluation, dated 08/28/24, which stated Resident #22 had a Stage III pressure ulcer to her sacrum and treatment was in place. Review of the medical record for…

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

Based on medical record review and staff interview, the facility failed to develop a baseline care plan for a resident. This affected one (#76) of three residents reviewed who were new admissions. The census was 74. Findings include: Review of Resident #76's closed medical record revealed an admission date of 05/16/24. Diagnoses listed included osteoarthritis, restless leg syndrome, type two diabetes mellitus, and morbid obesity. Resident #76 was discharged from the facility on 05/19/24. Further review of Resident #76's closed medical record revealed no documentation of baseline careplan being developed. During an interview on 06/05/24 at 10:50 A.M. The Director of Nursing (DON) confirmed a baseline careplan had not been completed for Resident #76. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to update a resident's comprehensive care plan for suicide risk/suicidal ideation. This affected one (#59) of three residents reviewed for comprehensive care plans. The census was 74. Findings include: Review of Resident #59's medical record revealed an admission dated of 01/31/23. Diagnoses listed include hypertensive kidney disease, major depressive disorder, bradycardia, impulsiveness, dementia, and congestive heart failure. Review of quarterly Minimum Data Set (MDS) assessment revealed Resident #59 was severely cognitively impaired with a brief interview for mental status (BIMS) score of four out of a possible 15. Review of progress notes revealed on 05/09/24 expressed thoughts of harming himself and having plan to do so by telling a state tested nursing assistant (STNA). Resident #59 was placed on one on one (1:1) supervision until a psychiatric evaluation on 05/10/24. On 05/20/24 Resident #59 was found with a call light wrapped around…

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 provide urinary catheter care to a resident. This affected one (#76) of three residents reviewed for urinary catheters. The census was 74. Findings include: Review of Resident #76's closed medical record revealed an admission date of 05/16/24. Diagnoses listed included osteoarthritis, restless leg syndrome, type two diabetes mellitus, and morbid obesity. Resident #76 was discharged from the facility on 05/19/24. Review of a Nursing Administration Evaluation dated 05/16/24 revealed Resident #76 had an indwelling urinary catheter. Further review of Resident #76's closed medical record revealed no documentation of urinary catheter care being provided to Resident #76 from admission [DATE] to discharge 05/19/24. During an interview on 06/05/24 at 9:55 A.M. The Director of Nursing (DON) and Regional Nurse #100 confirmed urinary catheter care was not documented as being provided Resident #76. Urinary catheter 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, review of facility policy, and review of medication information from Medscape, the facility failed to monitor a resident's blood glucose level before administering insulin. This affected one (#76) of three residents reviewed for insulin administration. The census was 74. Findings include: Review of Resident #76's closed medical record revealed an admission date of 05/16/24. Diagnoses listed included osteoarthritis, restless leg syndrome, type two diabetes mellitus, and morbid obesity. Resident #76 was discharged from the facility on 05/19/24. Review of physician orders revealed an order dated 05/16/24 to inject 60 units of insulin glargine subcutaneous solution 100 units per milliliter (unit/ml) subcutaneously (SQ) at bedtime for diabetes mellitus. Review of medication administration records (MAR) revealed 60 units of insulin glargine subcutaneous solution was administered to Resident #76 on 05/17/24 and 05/18/24. No documentation of blood glucose levels checks…

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, observations, resident and staff interviews and policy review, the facility failed to provide a resident with timely incontinence care and timely assistance with the use of a bed pan. This affected one (#44) of three residents reviewed for incontinent care. The facility census was 75. Findings include: Review of medical record for Resident #44 revealed admission date of 02/18/24. Diagnoses include diabetes mellitus type two, morbid obesity and hypertension. The resident was scheduled to be discharged [DATE] to another facility. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #44's Brief Interview Mental Status (BIMS) score was 15 indicating intact cognition. Resident #44 required maximum assistance for bed mobility, dependent for transfers and maximum assistance for eating. Review of Resident #44's admission skin assessment dated [DATE] revealed bruising to the right forearm and healed pressure area to the sacrum. Review of Resident #44's Body assessment dated [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff and physician interviews, and review of facility policy, the facility failed to notify a resident's physician of abnormal laboratory results. This affected one (#77) of three residents reviewed for notification of change. The census was 74. Findings include: Review of Resident #77's closed medical record revealed an admission dated of 07/29/23. Diagnoses listed included obstructive sleep apnea, muscle weakness, type two diabetes mellitus, urine retention, and chronic kidney disease. Resident #77 was transferred to a local hospital on [DATE]. Resident #77 passed away while at the hospital on [DATE]. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #77 was moderately cognitively impaired with a brief interview for mental status (BIMS) score of eight. Resident #77 had an indwelling catheter. Review of progress notes revealed Resident #77 was noted with penile discharge with a foul odor on 12/19/23. Resident #77 was assessed by physician on 12/19/23…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff and physician interviews, and review of Centers for Disease Control and Prevention (CDC) information, the facility failed to timely treat a resident's urinary tract infection (UTI). This affected one (#77) of three residents reviewed for UTI's. The census was 74. Findings include: Review of Resident #77's closed medical record revealed an admission dated of 07/29/23. Diagnoses listed included obstructive sleep apnea, muscle weakness, type two diabetes mellitus, urine retention, and chronic kidney disease. Resident #77 was transferred to a local hospital on [DATE]. Resident #77 passed away while at the hospital on [DATE]. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #77 was moderately cognitively impaired with a brief interview for mental status (BIMS) score of eight. Resident #77 had an indwelling catheter. Review of progress notes revealed Resident #77 was noted with penile discharge with a foul odor on 12/19/23. Resident #77 was assessed 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, staff interviews, record review, and policy review, the facility failed to ensure pressure ulcer treatments were completed as prescribed and failed to ensure pressure ulcer assessment were completed. This affected two (Residents #10 and #12) of three residents reviewed for pressure ulcers. The facility census was 73. Findings include: 1. Review of the medical record for Resident #10 revealed an admission date of 02/20/23. Diagnoses included peripheral vascular disease and cognitive communications deficit. The resident was cognitively impaired. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 required assistance with eating, toileting, bed mobility, and transfers. Review of the 12/13/23 wound evaluation revealed a Suspected Deep Tissue Injury (SDTI) (purple or maroon localized area of discolored intact skin due damage of underlying soft tissue from pressure) on the left proximal foot measuring 1.5 centimeters (cm) by (x) 1.5 cm and left proximal…

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 review of the facility's policy, record review, observations, review of online resources for the Centers for Disease Control and Prevention (CDC) and the Center for Medicare and Medicaid Services (CMS), and staff interview, the facility failed to ensure staff wore Personal Protective Equipment (PPE) while caring for residents to the prevent the potential spread of COVID-19. In addition, the facility failed to have a Legionella management plan in place. This had the potential to affect all 72 residents residing in the facility. Findings include: 1. Observation on 08/02/22 at 1:26 P.M. revealed there were two staff members supervising five residents smoking. Residents were spaced approximately six feet apart. Activity Aide #168 was sitting at a table with two residents, within six feet with his mask pulled down to his chin. This was verified by Licensed Practical Nurse (LPN) #125. Observation on 08/03/22 at 8:29 A.M. revealed State Tested Nursing Assistant (STNA) #163 went into Resident #63's room while he was present, with her mask pulled down to her chin and her goggle on…

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

Based on observations, staff interviews, and recipe review, the facility failed to ensure therapeutic texture diets were made according to a recipe and maintained palatability. This had the potential to affect 13 residents who received a puréed diet. The facility census was 72. Findings include: Observation and interview on 08/02/22 at 11:08 A.M. with Dietary Staff (DS) #185 revealed DS #185 was preparing mixed vegetables of 14 servings. DS #185 stated the vegetables already had liquid in the can and she added chicken broth. DS #185 put in several unmeasured scoops of vegetables in the roboku and blended for several seconds. DS #185 then dumped an unmeasured amount of liquid from the container in the roboku (estimated around half to three-fourths cup). The vegetables and liquid were blended to a tomato soup consistency. DS #185 stated she needed to add thickener to the mixture. DS #185 added four unmeasured spoonfuls (about one tablespoon each) of thickener then blended the mixture. DS #185 stated the mixture was still too thin and Kitchen Manager (KM) #180 added a large scoop…

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, review of manufacturer's guide, policy review, and record review, the facility failed to ensure food was safely and properly stored in the kitchen. The facility also failed to ensure the dishwasher was in safe working order. This had the potential to a affect all residents except three (Residents #5, #39 and #54) who do not eat food from the kitchen. The facility census was 72. Findings include: Observations and interview on 08/01/22 from 9:05 A.M. to 9:20 A.M. with Kitchen Manager #180 revealed pancakes and bratwurst were left undated in the freezer. In addition, a box of green beans, chicken breast, and cut up sausage were left open to air and undated in the freezer. Many items in the freezer appeared to have freezer burn and were covered in frost. The refrigerator had an employee lunch that was left undated and four gallons of milk dated 07/27/22 and 07/28/22. The dry storage area included three bags of pasta, two bags of brownie mix, and three bags of yellow cake mix that was unsealed and undated. The dry storage also contained a pack 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 staff interview and record review, the facility failed to ensure an updated and accurate pre-admission screening and resident review (PASARR) assessment was completed for the residents. This affected three (Residents (#39, #45, and #53) of six resident reviewed for the PASARR program. The facility census was 72. Findings include: 1. Review of the medical record for Resident #39 revealed an admission date of 09/28/16. Diagnoses included respiratory failure with hypoxia, encephalopathy, psychosis, and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 was cognitively intact. Review of the PASARR assessment dated [DATE] revealed Resident #39 has no mental health diagnoses. Interview on 08/03/22 at 1:33 P.M. with Social Services (SS) #173 confirmed the PASARR assessment was not accurate for Resident #39 to reflect Resident #39 had a mental health diagnosis. SS #173 stated she would complete a new PASARR assessment for Resident #39. 2. Review of the medical…

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 and staff interviews, review of the facility's policy, and record review, the facility failed to ensure Resident #39 who required assistance with activity of daily living (ADL) care received adequate and timely nail care. This affected one (Resident #39) of two residents reviewed for ADL care. The facility identified 71 residents who required assistance with bathing. The facility census was 72. Findings include Review of the medical record for the Resident #39 revealed an admission date of 09/28/16. Diagnoses included respiratory failure with hypoxia, cerebrovascular disease, hemiplegia and hemiparesis, diabetes mellitus, psychosis, tremor, and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 was cognitively impaired and required extensive assistance of one staff for hygiene care and required extensive assistance of two staff for bathing. Review of the plan of care dated 06/22/22 revealed Resident #39 had impaired activity 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, medical record reviews, review of the facility's policy, and staff interviews, the facility failed to ensure the resident's skin assessments were completed as physician ordered, failed to monitor a resident's wounds routinely, and failed to timely identify new wounds. This affected two (Residents #39 and #56) of two residents reviewed for skin. The facility census was 72. Findings include: 1. Review of the medical record for Resident #39 revealed an admission date of 09/28/16. Diagnoses included respiratory failure with hypoxia, cerebrovascular disease, hemiplegia and hemiparesis, malnutrition, diabetes mellitus, tremor, and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 was cognitively intact and required extensive assistance of two staff members for transfers and bed mobility. Resident #39 had no wounds or skin conditions. Review of the plan of care dated 06/22/22 revealed Resident #39 was at risk for impaired skin integrity with…

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 review of the National Pressure Injury Advisory Panel (NPIAP) resources, the facility failed to have documented timely treatment and interventions for a resident who was admitted to the facility with deep tissue injuries (DTIs). This affected one (Resident #23) of two residents reviewed for pressure ulcers. The facility identified four residents with pressure ulcers. The facility census was 72. Finding include: Review of Resident #23's medical record revealed an admission date of 05/22/22. Diagnoses included anxiety disorder, hypertension, rhabdomyolysis, stage III pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed) of left ankle, and unstageable pressure ulcer (slough and/or eschar: known but not stageable due to coverage of wound bed by slough and/or eschar) of left hip. Review of Resident #23's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 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 medical record review, resident and staff interview and review of Medscape guidance, the facility failed to ensure the residents were free from unnecessary medication use. This affected one (Resident #58) of five residents reviewed for unnecessary medication use. The facility census was 72. Findings include: Medical record review for Resident #58 revealed an admission date of 12/27/19. Diagnoses included chronic obstructive pulmonary disease and stroke. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #58 had impaired cognition and was dependent on staff for toileting. Review of the physician's orders dated 07/08/22 revealed Resident #58 had an order for Miralax (laxative) 17 grams by mouth daily. Review of the bowel record for Resident #58 revealed loose/diarrhea was noted on 07/07/22, 07/09/22, 07/10/22, 07/11/22, 07/12/22, 07/13/22, 07/14/22, 07/15/22, 07/16/22, 07/19/22, 07/20/22, 07/21/22/ 07/23/22, 07/24/22, 07/25/22, 07/27/22, 07/29/22, 07/30/22, 07/31/22,…

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 review of the facilities legionella risk assessment and control plan and facility staff interview the facility failed to implement control measures to ensure the facility water source was free from legionella bacteria. This had the potential to affect all 63 residents who reside in the facility. Findings include: Review of the facilities legionella risk assessment and control plan revealed the facility would test the water for the presence of legionella bacteria when there was a risk presented to the facility's water source, to ensure the water was free of legionella bacterium. The facility had the water tested after recent tornado activity as the water was shut off for a week. The facility was under a boil advisory for the water after the water was turned back on by the municipal water supplier. The test the facility had conducted was for Escherichia coli (E.Coli) and for Coliform, both were negative. During an interview with the Administrator on 08/01/19 at 2:45 P.M. it was verified the facility called the local county health department and received guidance to test 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 record review and interviews, the facility failed to provide a copy of the notification of bed hold status, or transfer and discharge notice to the resident, their representative or the Ombudsman for residents that discharged to the hospital. This affected seven (#20, #21, #26, #44, #58, #106 and #256) of seven residents reviewed for hospitalization. The facility identified 24 residents who had an unplanned discharge to the hospital in the past six months who additionally did not receive these notifications. The facility census was 63. Findings include: 1. Review of the record for Resident #20 revealed she was admitted to the facility on [DATE] with diagnoses to include type 2 diabetes, hypertension, chronic obstructive pulmonary disease, chronic kidney disease, hypokalemia, major depressive disorder, angina pectoris, Parkinson's disease, encephalopathy, disorder of calcium metabolism, hypercholesterolemia, constipation, gastro-esophageal reflux disease, retention of urine and schizoaffective disorder,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to provide a copy of the notification of bed hold status, or transfer and discharge notice to the resident, their representative or the Ombudsman for residents that discharged to the hospital. This affected seven (#20, #21, #26, #44, #58, #106 and #256) of seven residents reviewed for hospitalization. The facility identified 24 residents who had an unplanned discharge to the hospital in the past six months who additionally did not receive these notifications. The facility census was 63. Findings include: 1. Review of the record for Resident #20 revealed she was admitted to the facility on [DATE] with diagnoses to include type 2 diabetes, hypertension, chronic obstructive pulmonary disease, chronic kidney disease, hypokalemia, major depressive disorder, angina pectoris, Parkinson's disease, encephalopathy, disorder of calcium metabolism, hypercholesterolemia, constipation, gastro-esophageal reflux disease, retention of urine and schizoaffective disorder,…

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, facility staff interview and resident interview and review of facility policy the facility failed to complete a comprehensive care plan that addressed resident individual needs. This affected two (#5 and #47) of 19 residents care plans reviewed. The total facility census was 63. Findings include: 1. Review of Resident #47's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included respiratory failure with hypoxia, cerebrovascular accident, hemiplegia, hyperkalemia, atrial fibrillation, hypertension, hyperlipdiemia, dysarthria, diabetes type two, anxiety, depression, alcohol abuse, obesity and deconditioning. Review of the most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had cognitive impairment, had no hallucinations or delusions; however, did have rejection of care one to three days of the review period. The resident was coded as requiring extensive assist for bed mobility, dressing, eating, toileting and, dependent on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and facility staff interview the facility failed to update care plans timely. This affected one (#47) of 19 residents' care plans reviewed. The total facility census was 63. Findings include: Review of Resident #47's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included respiratory failure with hypoxia, cerebrovascular accident, hemiplegia, hyperkalemia, atrial fibrillation, hypertension, hyperlipdiemia, dysarthria, diabetes type two, anxiety, depression, alcohol abuse, obesity and deconditioning. Review of the most recent quarterly Minimum Data Set (MDS) dated [DATE] the resident had cognitive impairment, had no hallucinations or delusions; however, did have rejection of care one to three days of the review period. The resident was coded as requiring extensive assist for bed mobility, dressing, eating, toileting and, dependent on staff for transfer. The resident is coded as having hypertension, hemiplegia, anxiety, and depression included 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 record review, observation, staff and resident interview and policy review, the facility failed to timely refer a resident for restorative nursing care. This affected one Resident (#5) of 24 reviewed. The facility census was 63. Findings include: Record review revealed Resident #5 was admitted to the facility on [DATE]. Diagnoses included fracture of the left humerus, repeated falls, hearing loss and major depression. Review of the assessment dated [DATE] revealed the resident required extensive assistance of staff for bed mobility, transfer, and all activities of daily living. Review of the notification of discharge from therapy dated 05/28/19 revealed she would be discharged from physical therapy (PT) and occupational therapy (OT), and referred to restorative. Review of the plan of care (POC) dated 05/28/19 revealed the restorative plan was not in place. Review of the quarterly assessment dated [DATE] revealed she had improved in only one area (eating), which was documented as supervision. 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 record review, observation, staff and resident interview and policy review, the facility failed to provide timely weights, reweighs and acknowledge a significant weight loss. This affected one Resident (#5) of 24 reviewed. The facility census was 63. Findings include: Record review revealed Resident #5 was admitted to the facility on [DATE]. Diagnoses included fracture of the left humerus, repeated falls, hearing loss and major depression. Review of the Treatment Administration Record (TAR) dated April 2019 revealed weekly weights were ordered times four weeks. There were no weekly weights documented for Resident #5. Review of the admission dietary assessment dated [DATE] documented her current body weight (CBW) on 04/02/19 was 139.7 pounds, her usual body weight (UBW) was 136 pounds per resident. Resident #5 was alert and oriented and stated she had no recent weight changes, she had been on ensure at the former facility and was explained she would be placed on a similar product three times daily for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and facility staff interview the facility failed to the monitor the dialysis access site. This affected one Resident (#21) of one reviewed. The facility identified three residents who were receiving dialysis services. The total facility census was 63. Findings include: Review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic ischemic heart disease, end stage renal disease, paroxysmal atrial fibrillation, and diabetes mellitus. Review of the most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had cognitive impairment, had no delusions or hallucinations, but did have rejection of care one to three days. The resident was coded as receiving dialysis services. Review of Resident #21's care plans revealed the resident had a care plan in place that identified the dialysis center where dialysis occurred, the address and contact information. The care plan also indicated the staff were to check 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 record review, observation and facility staff interview the facility failed to have required medications available. This affected one (#20) of four observed during medication administration. The total facility census was 63. Findings include: Review of Resident #20's medical record revealed the resident was admitted on [DATE]. Diagnoses included type two diabetes, hypertension, chronic obstructive pulmonary disease, chronic kidney disease, hypokalemia, major depressive disorder, angina pectoris, Parkinson's disease, encephalopathy, disorder of calcium metabolism, hypercholesterolemia, constipation, gastro-esophageal reflux disease, retention of urine and schizoaffective disorder Bi Polar type. Review of the progress notes dated 07/30/19 revealed the notes were silent to the resident being administered the medication, the medication being signed as given in error, or the physician or family being notified of the missing dose of medication. During observation on 07/30/19 at 8:35 A.M., Licensed Practical…

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, facility staff interview and review of package insert the facility failed to store ophthalmic solution correctly in one of two medication carts observed. The facility had a total of four medication carts. This directly affected two (#26 and #41) residents who medications were stored in the 400 hall medication cart. The total facility census was 63. Findings include: Observation on 07/31/19 at 9:35 A.M. of the 400 hall medication cart with Licensed Practical Nurse (LPN) # 482 revealed there was Latanopros ophthalmic solution 0.005% for Resident #26 with an opened date of 05/25/19 and the attached sticker indicated to discard 42 days after opening. The 42nd day would have been 7/06/19. At the time of the observation LPN #482 confirmed the resident was still receiving the eye drops and that was the only bottle available. Additionally there was Olopathadine 0.1% ophthalmologist solution for Resident #41 without an open date on the medication. The bag the medication was stored in had a deliver date from the pharmacy of 04/25/19. LPN #482 confirmed the resident had…

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.