Aventura At Assumption Village

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to ensure that required pre and post dialysis assessments were completed for one resident (Resident #14) of two residents reviewed for dialysis services. The facility census was 107. Findings include:Record review showed Resident #14 was admitted on [DATE] with diagnoses including pneumonia, Methicillin-resistant Staphylococcus aureus MRSA infection, end stage renal disease, hypertension, and dependency on hemodialysis. The resident's care plan, dated 02/25/26, identified a need for ongoing dialysis management, including monitoring of labs, infection prevention measures, monitoring of the arteriovenous (AV) shunt, and assessment for symptoms related to fluid balance, toxicity, or complications. Physician orders directed staff to monitor the hemodialysis shunt every shift, including assessment for bruit and thrill.Review of dialysis assessment records from 01/01/26 through 05/12/26 revealed significant gaps and inconsistencies in both pre and post…

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 medication administration policy review, the facility failed to provide physician prescribed medications to three residents (Residents #46, #52, and #110), resulting in missed doses of multiple medications across several dates. This affected three residents (#46, #52, and #110) of five residents reviewed for missed medications. The facility census was 107.Findings include:1. Review of the medical record revealed Resident #46 was admitted to the facility on [DATE] with diagnoses including myasthenia gravis with (acute) exacerbation, dementia with other behavioral disturbance, type II diabetes mellitus, chronic obstructive pulmonary disease, Alzheimer's disease, bipolar disorder, major depressive disorder, recurrent, anxiety disorder, and mixed obsessional thoughts and acts. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/02/26, revealed Resident #46 was cognitively intact and independent with activities of daily living (ADL); care planned 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, interview, and facility policy review, the facility failed to ensure that pharmacy medication regimen review (MRR) recommendations, including gradual dose reductions (GDRs), safety-related medication changes, and required clinical rationales, were addressed timely and completely for three (Residents #4, #31, and #57) of five residents reviewed for unnecessary medications. The facility census was 107.Findings include: 1. Record review showed Resident #57, admitted [DATE] with dementia and major depressive disorder, was receiving Buspirone (antianxiety) 10 milligrams (mg) twice daily. An MRR dated 01/14/26 recommended a GDR; however, the nurse practitioner (NP) marked disagree without providing the required clinical rationale and did not date the form. A psychiatric follow up note dated 01/26/26 indicated that a GDR would worsen the resident's symptoms; however, this information was not incorporated into the pharmacy MRR response. The care plan dated 03/03/26 included evaluating GDRs 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 observations, record reviews, interviews, manufacturer instructions, and facility policy review, the facility failed to ensure that insulin pens were dated when opened. This affected three of three insulin pens observed during the medication storage review (Residents #21, #42, and #99). This had the potential to affect an additional 11 residents (#3, #13, #28, #40, #50, #59, #63, #75, #94, #101, and #101) who were identified as receiving insulin. The facility census is 107.Findings include:1. Record review revealed Resident #21 was admitted on [DATE] with multiple diagnoses including Type II diabetes with neuropathy and angiopathy. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was cognitively intact and independent with activities of daily living (ADL). Physician orders included Lantus SoloStar (17 units twice daily) and Humalog KwikPen (4 units before meals).2. Record review revealed Resident #42 was admitted on [DATE] with diagnoses including metabolic…

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 staff interviews, the facility failed to ensure that Resident #12's tube feeding pump and pole were maintained in a clean and sanitary condition. This deficiency affected one resident (Resident #12) out of three reviewed for environmental concerns. The facility census was 107.Findings include:Record review for Resident #12 showed an admission date of 01/08/21. Her diagnoses included respiratory failure, asthma, malnutrition, heart disease, osteoporosis, sleep apnea, and epilepsy.Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 was cognitively intact. She required supervision for eating and toileting, set up assistance for oral and personal hygiene and partial to moderate assistance for showering. She had no significant weight loss or gain in the past six months.Review of physician orders for May 2026 revealed that Resident #12 had an active order for nocturnal tube feeding from 7:00 p.m. to 7:00 a.m. daily, initiated 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, interview, review of the facility self-reported incident (SRI) and facility policy review, the facility failed to accurately document controlled drug administration for Resident #12 to prevent a potential significant medication error and/or misappropriation. This affected one resident (#12) of two residents reviewed for controlled drug administration. The facility identified 27 residents (#1, #4, #6, #7, #8, #12, #16, #19, #23, #25, #26, #30, #31, #32, #33, #34, #35, #37, #40, #44, #,45 #48, #49, #51, #64, #66, and #78) who received controlled medications. The facility census was 98.Findings include:Review of the medical record for Resident #12 revealed an admission date of 04/19/25 with diagnoses of hereditary motor and sensory neuropathy, morbid (severe) obesity due to excess calories, type II diabetes mellitus with diabetic neuropathy, essential primary hypertension, hyperlipidemia, unspecified muscle weakness (generalized), low back pain, gastro-esophageal reflux disease without…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, facility policy review, review of the memorandum from the Department of Health & Human Services, and review of guidelines from the Centers for Disease Control and Prevention, the facility failed to ensure staff used appropriate infection control practices using required proper hand hygiene for Residents # 605 and Resident #629 using appropriate standards of practice with use of gloves during incontinence care for Residents #605 and #629 This affected two residents and had the potential to affect all 106 residents residing in the facility.Findings include:1. Review of the medical record revealed Resident #605 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction, diverticulosis, collapsed vertebra, unspecified dementia, hydronephrosis, Alzheimer's disease, essential hypertension, and acute kidney failure. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #605 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.

Based on review of the medical record, interview, and review of facility policy, the facility failed to ensure Resident #24 received pain management medication as ordered to ensure an effective pain management program was in place. This affected one resident (Resident #24) of three residents reviewed for pain management. The facility census was 106.Findings include:Review of the medical record for Resident #24 revealed an admission date of 01/10/25 with diagnoses including multiple sclerosis (MS), type two diabetes mellitus, essential hypertension, protein-calorie malnutrition, major depressive disorder, anxiety disorder, paraplegia, colostomy status, chronic kidney disease, long-term use of aspirin, and chronic pain.Review of the care plan last completed 04/25/25 revealed Resident #24 received pain medication therapy secondary to chronic pain, MS, and wounds. Interventions included administration of routine and as indicated pain medications as ordered. Review of the quarterly Minimum Data Set (MDS) assessment completed on 07/18/25 revealed Resident #24 had intact cognition and no…

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

Based on observation, interview, and record review, the facility failed to ensure Resident #60's insulin was administered properly. This affected one resident (Resident #60) of three residents observed for medication administration.Findings include:Review of the medical record for Resident #60 revealed an admission date of 04/18/25 with diagnoses including mixed hyperlipidemia, muscle weakness, primary hypertension, acquired absence of the left leg below the knee, primary open-angle glaucoma of the left eye, peripheral vascular disease, and type two diabetes mellitus.Review of the care plan dated 04/22/25 revealed Resident #60 had diabetes mellitus and used insulin to control blood sugar levels. Interventions included checking blood sugars and administering diabetes medications as ordered. Review of the admission Minimum Data Set (MDS) 3.0 assessment completed on 04/25/25 revealed Resident #60 had intact cognition and received insulin injections and hypoglycemic medications.Review of the orders revealed an order dated 04/21/25 for Humalog Injection Solution (Insulin Lispro) 100…

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 review of the medical record, interview and review of facility policy, the facility failed to ensure the medical record for Resident #60 contained complete and accurate documentation of specified assessment criteria to safely administer ordered medications. This affected one resident (Resident #60) of three residents observed for medication administration. The facility census was 106. Findings include:Review of the medical record for Resident #60 revealed an admission date of 04/18/25 with diagnoses including mixed hyperlipidemia, muscle weakness, primary hypertension, acquired absence of the left leg below the knee, primary open-angle glaucoma of the left eye, peripheral vascular disease (PVD), and type two diabetes mellitus.Review of the care plan dated 04/22/25 revealed Resident #60 had an altered cardiovascular status related to hyperlipidemia, hypertension, and PVD. Interventions included administering medications as ordered and monitoring, reporting, and documenting signs of coronary artery…

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, record review, interview and review of facility policy, the facility did not ensure residents were offered a substantial snack in the evening when the time between dinner and breakfast exceeded 14 hours. This had potential to affect all 92 residents receiving meals from the kitchen except for two residents (#70 and #86) the facility identified as receiving nothing by mouth (NPO). The facility census was 94. Findings include: Observation on 12/17/24 from 4:00 P.M. to 5:11 P.M. of dinner meal delivery and on 12/18/24 from 7:18 A.M. to 8:14 A.M. of breakfast meal delivery revealed the following delivery times: • Intermediate cart one dinner was delivered at 4:08 P.M. on 12/17/24 and breakfast on 12/18/24 was delivered at 7:18 A.M. (15 hours 10 minutes from dinner to breakfast) • Intermediate cart two dinner was delivered at 4:17 P.M. on 12/17/24 and breakfast on 12/18/24 was delivered at 7:20 A.M. (15 hours three minutes from dinner to breakfast) • Special Care cart one dinner was delivered at 4:30 P.M. on 12/17/24 and breakfast on 12/18/24 was delivered at 8:02…

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

Based on observation, interview, record review and review of facility policy, the facility failed to ensure food was stored, prepared and served under sanitary conditions. This had the potential to affect all 92 residents who received food from the kitchen. The facility identified two residents (#70 and #86) as receiving nothing by mouth (NPO). The facility census was 94. Findings include: 1. Observations on 12/16/24 from 8:05 A.M. to 8:35 A.M. with Dietitian #500 and Dietary Supervisor (DS) #351 revealed the following concerns: • In the dry storage area across from the walk-in coolers, there was one open and resealed half-full package of gluten-free dried macaroni not dated when opened, one open and resealed three fourth full package of gluten-free oats not dated when opened, and one package of gluten-free cookies half full open to air and not dated when opened. • In the walk-in cooler, which was connected to the walk in freezer, there was one extra-large roll of sandwich bologna which had been opened and resealed with plastic wrap but was not dated when opened, five four-ounce…

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

Based on observation, interview, record review and review of facility policy, the facility failed to ensure weekly and always available menus were followed. This affected seven residents (#2, #18, #40, #50, #58, #66, #76) of 92 residents receiving meals from the kitchen, and had the potential to affect all residents except for two residents (#70 and #86) the facility identified as receiving nothing by mouth (NPO). The facility census was 94. Findings include: Review of the facility always available menu, dated 12/17/24, revealed deli sandwich, chef salad, pasta, peanut butter and jelly sandwich, baked lemon pepper fish, cottage cheese and fresh fruit plate, hot dog on bun, grilled cheese sandwich, house garden salad, oven baked chicken, cottage cheese, chicken noodle soup, and mashed potatoes were always available. Review of the facility menu for week three Tuesday dinner (12/17/24) revealed roasted chicken, bread stuffing, peas and carrots, and fruit cobbler was to be served. Review of monthly Dietary Meeting minutes held with residents revealed on 10/02/24 the residents indicated…

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

Based on observation, interview, record review and review of facility policy, the facility failed to ensure palatable food was served to all residents. This affected eight residents (#2, #4, #18, #40, #50, #58, #66 and #76) of 92 residents receiving meals from the kitchen, and had the potential to affect all 92 residents excluding two residents (# 70 and #86) who the facility identified as receiving nothing by mouth (NPO). The facility census was 94. Findings include: Review of the monthly Residents' Dietary Meeting minutes, dated 10/02/24, revealed the residents voiced they would like the food to be seasoned more and hotter. Interview on 12/16/24 at 11:05 A.M. with Resident #4 revealed the food was terrible, all of it' and stated she had people bring her food from the outside. Interview on 12/17/24 at 8:52 A.M. with Ombudsman #507 revealed he had seven open cases and systemically he felt there was a concern with food quality, food choices, and food temperatures. Observation on 12/17/24 at 5:05 P.M. to 5:25 P.M. of the dinner tray line and a test tray revealed at 5:08 P.M. the test…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interviews and review of the facility policy, the facility failed to notify the physician/nurse practitioner and resident representative of a significant weight change. This affected one resident (Resident #70) out of three residents reviewed for nutrition. The facility census was 94. Findings include: Review of the medical record for Resident #70 revealed an admission date of 06/07/24. Pertinent diagnoses included hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left non-dominant side, dysphagia following cerebral infarction, vascular dementia, lymphedema, and obesity. Review of Resident #70's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 12/12/24, revealed the resident was severely impaired cognitively, had no behaviors or rejection of care, had a significant unplanned weight loss, was on a therapeutic diet, and was receiving 51 percent (%) or more of proportion of calories from a feeding tube, and 501 cubic centimeters (cc) or more…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, review of the medical record and review of the facility policy, the facility failed to ensure residents received the required level of assistance for meals. This affected one resident (Resident #36) of two residents reviewed for activities of daily living (ADL). The facility census was 94. Findings include: Review of the medical record revealed Resident #36 was admitted to the facility on [DATE] with diagnoses including cerebral ischemia, dementia, hemiplegia or hemiparesis following cerebral infarction affecting the left non-dominant side, difficulty in walking, major depressive disorder, osteoporosis, anxiety, glaucoma, hearing loss, dysphagia, psychophysical visual disturbances, atrial fibrillation, and muscle weakness. Review of the care plan dated 08/23/24 revealed Resident #36 had an ADL self-care deficit related to decreased mobility, difficulty walking, generalized muscle weakness, left-sided weakness, and glaucoma. Interventions included staff setup and cleanup 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 observation, interview, medical record review and facility policy review, the facility failed to ensure Resident #70's weekly weights were obtained as ordered and failed to monitor and follow Resident #57's fluid restriction. This affected two residents (#57 and #70) out of three residents reviewed for nutrition. The facility census was 94. Findings include: 1. Review of the medical record for Resident #70 revealed an admission date of 06/07/24. Pertinent diagnoses included hemiplegia (total or nearly complete paralysis on one side of the body) and hemiparesis (weakness of one entire side of the body) following nontraumatic intracerebral hemorrhage (bleeding in the brain) affecting left non-dominant side, dysphagia (difficulty swallowing) following cerebral infarction (stroke), vascular dementia, lymphedema (swelling in various areas of the body), and obesity. Review of the care plan dated 06/15/24 revealed Resident #70 had a nutritional problem related to advanced age, receiving nothing by mouth 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.

Based on medical record review, staff interviews and review of communication forms from dialysis center, the facility failed to ensure ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for Resident #57. This affected one resident (#57) of one resident reviewed for dialysis but had the potential to affect two additional residents (#15 and #77) identified by the facility as receiving dialysis. The facility census was 94. Findings include: Review of the medical record for Resident #57 revealed an admission date of 03/8/24. Pertinent diagnoses included end stage renal disease, hypertensive chronic kidney disease with stage one through four chronic kidney disease or unspecified chronic kidney disease, anemia in chronic kidney disease, and dependence on renal dialysis. Review of Resident #57's physician's orders revealed an order dated 09/09/24 for dialysis every Tuesday, Thursday, and Saturday with a chair time of 11:15 A.M. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/16/24, revealed Resident #57 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interviews, medical record review and review of the facility policy, the facility failed to ensure medications were not left unattended. This affected two of four residents (#4 and Resident #27) who were observed with medications at the bedside and had the potential to affect 20 additional residents (#2, #6, #8, #9, #16, #19, #31, #32, #33, #38, #39, #40, #41, #43, #50, #54, #78, #80, #81 and #88) who received medications in the 1400 and 1600B hall. The facility census was 94. Findings include: 1. Review of the medical record for Resident #27 revealed an admission date of 01/13/24 with diagnoses including non-traumatic intracerebral intraventricular hemorrhage, congestive heart failure (CHF), repeated falls, altered mental status, unspecified dementia, hypertension, hyperlipidemia, muscle weakness, major depressive disorder, muscle weakness, and the need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed on 12 04/24…

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

Based on observation, interview, record review and review of facility policy the facility failed to ensure residents on mechanical soft diets received appropriate meal consistency. This affected one resident (Resident #6) of eight residents reviewed for food and nutrition. The facility identified 13 residents (#4, #6, #8, #11, #14, #30, #40, #46, #69, #73, #76 #86, and #146) who received a mechanical soft diet. The facility census was 94. Findings include: Review of the medical record for Resident #6 revealed an admission date of 01/21/20. Diagnoses included quadriplegia, dysphagia,, unspecified dementia, and macular degeneration. Review of Resident #6's annual Minimum Data Set (MDS) 3.0 assessment, dated 11/29/24, revealed the resident was cognitively intact, required setup and clean up assistance from staff for eating, and was on a mechanically altered diet. Review of Resident #6's physician orders revealed an order dated 11/13/24 for regular diet, mechanical soft texture, thin consistency. Review of Resident #6's care plan, dated 08/30/24, revealed the resident may be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain proper infection control procedures to prevent the spread of infection. This affected three residents (#68, #148 and #151) of three observed for isolation precautions. This had the potential to affect nineteen residents (#10, #15, #47, #51, #56, #60, #68, #71, #82, #83, #87, #89, #144, #145,#146 #147, #148, #150 and #151) residents residing on the 1100, 1200 and 1300 halls. The facility census was 94. Findings include: 1. Review of Resident #68's medical records revealed an admission date of 07/13/23. Diagnoses included stroke with right sided weakness and dementia. Review of the care plan dated 09/02/24 revealed Resident #68 required staff assistance for activities of daily living (ADL) care. Interventions included maintain isolation precautions during care. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #68 had impaired cognition. Resident #68 was dependent for toileting, bathing and personal…

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 interview the facility failed to develop and implement a comprehensive, person-centered care plan to meet the needs of Resident #65 for his highest practicable well-being regarding leave of absence (LOA) from the facility. This affected one resident (#65) of three residents reviewed for care plans. The facility census was 104. Findings include: Record review for Resident #65 revealed an admission date of 03/17/23 with diagnoses including multiple sclerosis, paraplegia, type two diabetes, severe protein calorie malnutrition, pressure ulcer sacral region stage four, neuromuscular dysfunction on bladder, anemia, hypertension, acute kidney failure, major depressive disorder, absence of left toes, absence of right toes, absence of fingers, colostomy, chronic ulcer of foot. Record review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #65 was cognitively intact, used a wheelchair for mobility, did not attempt to walk and was dependent on staff 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, interview, and admission contract review, the facility failed to convey a final accounting of overpayment to Resident #102's spouse within thirty days of discharge. This affected one resident (#102) of three residents who were discharged as private pay residents. The facility census was 101. Findings include: Review of the closed medical record for Resident #102 revealed a date of admission as [DATE] with diagnoses including dislocation of an unspecified cervical vertebrae and respiratory failure. The resident had severe cognitive impairment and expired in the facility on [DATE]. A review of the document titled; Resident admission Agreement, dated [DATE], revealed Resident #102 was admitted on [DATE]. The document was signed by Resident #102's spouse. Also included in the admission pack was an addendum page signed by Resident #102's spouse verifying Resident #102 was in the facility as private pay. The addendum was dated [DATE]. A review of the document titled; Assumption Village AR…

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 interview, the facility failed to ensure Resident #9 received proper assistance with activities of daily living to prevent a fall. This affected one resident (Resident #9) out of three residents reviewed for falls. Findings include: Review of Resident #9's medical records revealed an admission date of 09/06/17. Diagnoses included vascular dementia, neoplasm of endometrium, atrial fibrillation, cerebrovascular disease, obesity, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, depressive disorder, anxiety disorder, and diastolic congestive heart failure. Review of Minimum Data Set (MDS) dated [DATE] revealed resident required extensive two plus assistance for bed mobility, transfers, toileting and extensive one person assistance with dressing and personal hygiene. Review of care plan dated 09/21/23 revealed resident was at risk for falls related to dependence on staff for transfers using lift equipment, balance deficits, obesity, use 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 and staff interview, the facility failed to provide adequate supervision and assistance by staff when rolling Resident #75 in bed to provide incontinence care which resulted in Resident #75 falling out of the bed sustaining injuries to his face and upper extremities. This affected one resident (#75) of three residents reviewed for falls. The facility census was 70. Findings include: 1. Record review was conducted for Resident #75 who was admitted to the facility on [DATE] with diagnoses including monoplegia of upper limb following a stroke affecting right dominant side, aphasia, dysphagia, dysarthria, unspecified dementia, malignant neoplasm of bronchus and lung, secondary malignant neoplasm of bladder, obesity, need for assistance of personal care and gastrostomy. Review of Resident #75's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/14/23, revealed the resident had unclear speech and never made himself understood by others. Resident #75 had short-term 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, review of facility policy and interview, the facility failed to ensure antipsychotic medications were only used to treat appropriate diagnoses with clinical rationale. This affected four residents (#24, #32, #78, and #341) of five residents reviewed for unnecessary medications. The census was 96. Findings include: 1. Review of the medical record for Resident #24 revealed an admission date of 05/23/21. Diagnoses included dementia with behavioral disturbance, cerebrovascular disease, recurrent depressive disorders, neonatal cerebral leukomalacia, anxiety disorder, and altered mental status. Review of the care plan, dated 05/24/21, revealed Resident #24 received psychoactive medications including antipsychotics and antidepressants to manage mood and behaviors related to anxiety disorder, depression, cerebral leukomalacia, and vascular dementia with behaviors. Interventions included administer medications per orders, monitor for adverse effects of medications, monitor for changes in levels of behavior and mood, monthly medication review completed monthly…

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, record review, facility policy and procedure review and interview the facility failed to ensure Resident #20 received timely treatment for a urinary tract infection. This affected one resident (#20) of three residents viewed for medications. The facility census was 96. Findings include: Review of Resident #20's medical record revealed an admission date of 04/04/23 and diagnoses included monoplegia (paralysis restricted to one limb) of upper limb following cerebral infarction affecting right dominant side, aphasia following unspecified cerebrovascular disease, and dementia. Review of Resident #20's progress notes dated 04/08/23 at 6:08 P.M. included Resident #20 had dark, blood tinged urine draining from his catheter. CNP (certified nurse practitioner) was notified and labs were sent. At 6:18 P.M. Resident #20 had a urinalysis and a culture and sensitivity ordered. Review of Resident #20's progress notes dated 04/09/23 at 3:45 A.M. included the CNP was updated regarding increasing hematuria…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure Resident #20's behavior, including frequent episodes of loud and continuous yelling out was monitored and addressed timely. This affected one resident (#20) of three residents reviewed for behavioral health treatment. Findings include: Review of Resident #20's medical record revealed an admission date of 04/04/23 and diagnoses included monoplegia (paralysis restricted to one limb) of upper limb following cerebral infarction affecting right dominant side, aphasia following unspecified cerebrovascular disease, and dementia. Review of Resident #20's physician orders dated 05/23/23 revealed orders to monitor behaviors: 1 equaled no behavior, 2 equaled aggressive; 3 equaled verbally abusive, 4 equaled physically aggressive, 5 equaled withdrawn, 6 equaled tearful, 7 equaled accusatory, 8 equaled wandering, 9 equaled resisted care. Interventions included 1 equaled one to one supervision, 2 equaled redirection, 3 equaled engage in…

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

Based on record review, observation and interview the facility failed to prepare pureed foods using a standardized recipe to maintain the nutritional adequacy of the pureed foods. This affected four residents (#41, #46, #60 and #75) who had been ordered pureed diets. The facility census was 106. Findings include: Record review was conducted of the facility document titled Wednesday Lunch Week 2 Therapeutic Spread Report. The report indicated a serving of stuffed, pureed cabbage was a #10 ivory scoop. The report was signed by Registered Dietitian (RD) #504 on 09/10/2021. Observation was conducted with the Dietary Services Manager (DSM) #600 on 11/03/21 at 9:46 A.M. of [NAME] #700 who identified herself as a cook in the kitchen for three years and would be preparing five servings of pureed stuffed cabbage. [NAME] #700 began the demonstration by placing five whole stuffed cabbage into the food blender saying she had four pureed diets and would make one extra serving just in case it was needed for someone. She then added 32 ounces of beef broth to the blender, five ounces of red sauce,…

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 interview the facility did not maintain a clean reclining chair for Resident #40. This affected one of two residents reviewed for physical environment. The facility census was 106. Findings include: Record review was conducted for Resident #40 who was admitted to the facility on [DATE] with diagnoses including vascular dementia without behavioral disturbance. A physician order dated 09/20/19 indicated he could sit in his recliner for comfort and when fatigued. The Minimum Data Set assessment dated [DATE] revealed he had severely impaired cognition and required extensive assistance by one staff person for bed mobility, transfers, dressing, toileting and hygiene. The Plan of Care with a date initiated of 12/08/20 indicated he preferred to sleep in his recliner. Observation was conducted on 11/01/21 at 3:30 P.M. of Resident #40 in his room with his wife. He presented as alert with confusion and unable to carry on a reciprocal conversation. He was sitting in his reclining…

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 review, and interview the facility failed to provide nail care to one (Resident #3) of two residents reviewed for activities of daily living. Thirty two residents were observed and/or interviewed regarding assistance with activities of daily living. The facility census was 106. Findings include: Review of Resident #3's medical record revealed diagnoses including Parkinson's disease, psychotic disorder with hallucinations, congestive heart failure, dementia, osteoarthritis, and age-related nuclear cataracts. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #3 was moderately cognitively impaired and required extensive assistance with personal hygiene. Observations on 11/01/21 at 2:06 P.M. revealed Resident #3's fingernails were approximately 1/8 inch long and had a dark brownish discoloration under them. Additional observations on 11/02/21 at 12:34 P.M. and on 11/03/21 at 12:02 P.M. revealed Resident #3's fingernails remained dirty. On 11/03/21 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview the facility failed to transcribe and implement orders to treat skin impairment. This affected one (Resident #26) of two residents reviewed for non-pressure skin conditions. Thirty two residents were observed for non-pressure skin conditions. The facility census was 106. Findings include: Review of Resident #26's medical record revealed diagnoses including spinal stenosis, fusion of the spine, type 2 diabetes mellitus, and peripheral vascular disease. A skin grid revealed Resident #26 had an arterial ulcer (ulcer due to the inadequate blood supply to the affected area) to the right great toe which was present on admission. According to skin grids another arterial ulcer was discovered to the second toe of the right foot on 10/04/21. A nutritional risk assessment dated [DATE] indicated Resident #26 had lost 2% of his body weight in one month. Meal intakes were recorded as 76-100%. The assessment indicated Resident #26 had venous stasis wounds. The dietitian indicated…

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 and staff interview, the facility failed to ensure fall interventions were implemented for one (Resident #3) of seven residents reviewed for falls. The facility census was 106. Findings include: Review of Resident #3's medical record revealed diagnoses including Parkinson's disease, psychotic disorder with hallucinations, overactive bladder, dementia, atrial fibrillation, osteoarthritis of the right knee, repeated falls, and age related nuclear cataracts. A physician's order dated 08/06/21 indicated knee pads were to be applied every morning and removed at bedtime. A care plan (initiated 08/27/21) addressing fall risk indicated Resident #3 attempted self transfers at times which had resulted in numerous falls. One of the interventions listed was to encourage Resident #3 to wear knee pads while out of bed. Observations of Resident #3 on 11/02/21 at 12:34 P.M., 12:38 P.M., 12:45 P.M., 12:50 P.M., and 1:19 P.M. and on 11/03/21 at 11:34 A.M. through 11:45 A.M. revealed Resident #3 was sitting in a Broda chair with no knee pads observed. 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 observation, interview and record review the facility failed to ensure Resident #44's urine collection bag was maintained in a manner consistent with appropriate infection control measures. This affected one (Resident #44) of three residents reviewed for indwelling urinary catheter use. The facility identified five residents with urinary catheters in the facility. The facility census was 106. Findings include: Medical record review for Resident #44 revealed an admission date of 08/31/21. The diagnoses listed included hemiplegia and hemiparesis following a cerebral infarction affecting the left dominate side, acute kidney failure, type two diabetes mellitus, obesity, hypertension, dementia, depression, and anxiety. Review of the comprehensive assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 13 which indicated an intact cognition. The section titled bladder and bowel revealed Resident #44 was admitted to the facility with an indwelling urinary catheter. Observation 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 medical record review and staff interview the facility failed to ensure psychotropic medication (a chemical substance that changes nervous system function and results in alterations in perception, mood, consciousness, cognition, or behavior) ordered on an as necessary basis was ordered for a limited time frame prior to re-evaluation of it's use and failed to ensure residents using a psychotropic medication on an as necessary basis were provided non-pharmacological interventions prior to administration of the medication. This affected one (Resident #3) of five residents reviewed for medication use. The facility identified 67 residents receiving psychoactive medication. The facility census was 106. Findings include: Review of Resident #3's medical record revealed diagnoses including Parkinson's disease, psychotic disorder with hallucinations, and depression. Physician orders included Vistaril (anti-anxiety medication) 25 milligrams (mg) every eight hours as needed for agitation (08/18/21), Vistaril 25 mg every eight hours as needed for anxiety (10/19/21) and Vistaril 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.