Aventura At Oakwood Village

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, staff and resident interviews and policy review, facility failed to ensure a resident was afforded dignity during a meal when staff did not stand while providing feeding assistance. This affected one (#25) of three residents reviewed for dignity. Facility census was 104. Findings include: Review of the medical record of Resident #25 revealed an admission date of 04/20/22. Diagnoses included parkinsonism and moderate protein-calorie malnutrition. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident #25 had intact cognition. Resident #25 was dependent on staff for all activities of daily living. Observation on 05/14/25 at 12:38 P.M. revealed Certified Nursing Assistant (CNA) #252 delivered a lunch tray to Resident #25, who was resting in bed. CNA #252 set up Resident #25's tray and began to feed her, while standing over her. Observation on 05/14/25 at 12:39 P.M., Resident #25 asked CNA #252 if she was going to sit down. CNA #252 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, staff interview, and policy review, the facility failed to notify resident responsible party/power of attorney (POA) of significant weight loss. This affected one (#37) of three residents reviewed for weight loss. The facility census was 104. Findings include: Review of the medical record of Resident #37 revealed an admission date of 09/18/20. The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]. Diagnoses included aspiration pneumonia, chronic obstructive pulmonary disease, prostate cancer, type 2 diabetes mellitus, moderate protein-calorie malnutrition, and dementia with behavioral disturbance. Review of the 5-day Medicare Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognition. The resident required set-up/clean-up assistance for eating, substantial/maximal assistance with bed mobility, and was dependent on staff for toileting, bathing, dressing, and transfers. Review of weights revealed, 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, staff interview and policy review, the facility failed to ensure a resident was free from unnecessary medications by ensuring as needed psychotropic medications were limited to 14 days. This affected one (#61) of five reviewed for unnecessary medications. Facility census was 104. Findings include Review of the medical record for Resident #61 revealed an admission date of 11/01/23. Diagnoses included cerebrovascular disease, hemiplegia and hemiparesis, malnutrition, vascular dementia and unspecified psychosis. Review of the plan of care dated 03/19/24 revealed resident had a history of becoming aggressive and resisting care with interventions to administer medications as ordered and monitor behaviors. The care plan revealed resident used psychotropic medications related to anxiety and depression with interventions to give medications as ordered and monitor for side effects. The care plan also stated residents used antipsychotic's with interventions to consult with pharmacy, give…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews and record review, facility failed to ensure the activity careplan had appropriate and resident centered interventions. This affected one Resident (#49) of one reviewed for activities. Facility census was 104. Findings include Review of the medical record for Resident #49 revealed an admission date of 07/03/18. Diagnoses included senile degeneration of the brain, unspecified psychosis, anxiety, and spinal stenosis. Review of the activity assessment dated [DATE] revealed resident was alert and oriented with come confusion. Resident reported she was religious (Catholic) and enjoyed baking/cooking, country music, and television, movies and dogs. Review of the plan of care dated 03/03/23 revealed Resident #49 was at risk for alteration in activities with interventions for one on one activities. Review of the activity assessment dated [DATE] revealed resident had unchanged preferences and the preferences were for one to one activity participation. Review of the Minimum Data Set…

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, staff interviews and policy review, the facility failed to ensure facility offered a resident activities of interest. This affected one (#49) of one resident reviewed for activities. The facility census was 104. Findings include Review of the medical record for Resident #49 revealed an admission date of 07/03/18. Diagnoses included senile degeneration of the brain, unspecified psychosis, anxiety, and spinal stenosis. Review of the activity assessment dated [DATE] revealed resident was alert and oriented with come confusion. Resident reported she was religious (Catholic) and enjoyed baking/cooking, country music, and television, movies and dogs. Review of the plan of care dated 03/03/23 revealed Resident #49 was at risk for alteration in activities with interventions for one on one activities. Review of the activity assessment dated [DATE] revealed resident had unchanged preferences and the preferences were for one to one activity participation. Review of the Minimum Data Set…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Review of medical record for Resident # 58 revealed admission date of 02/19/2024 with end stage renal disease, diabetes mellitus type 2, dependence on renal dialysis, heart failure, and chronic obstructive pulmonary disease. Review of the quarterly MDS dated [DATE] revealed she had a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. Review of the care plan dated 03/27/25 revealed Resident #58 had renal insufficiency related to end stage chronic kidney disease stage 3 (CKD-3). Interventions included monitoring, documenting, and reporting to physician as needed the following signs and symptoms. Edema, weight gain of over two pounds a day, neck vein distension, difficulty breathing (dyspnea), increased heart rate (tachycardia), elevated blood pressure (hypertension), skin temperature, peripheral pulses, level of consciousness, monitor breath sounds for crackles. Review of the physician's orders revealed an order for daily weights one time a day for congestive heart failure (CHF)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Review of the medical record for Resident #91 revealed an admission date of 03/25/25 with diagnoses of unspecified sequelae of cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and anxiety disorder. Review of the Medicare-5 Day MDS dated [DATE] revealed resident had moderate cognitive impairment. Review of the Care Plan, dated 04/15/25 revealed resident is at risk for altered Cardiovascular, has Seizure Disorder/Narcolepsy, uses antidepressant medications related to anxiety depression, and mood disorder, and is at risk for negative mood / behavior related to diagnosis of major depressive disorder. Interventions include administer medications as ordered. Review of the Medication Administration Record (MAR) dated 05/01/25 through 05/31/25 revealed the following medications were not administered on 05/07/25 Metoprolol Tartrate Oral Tablet 25 MG 0.5 tablet with the Code #16, see nurse note. The following medications were not administered on 05/08/25…

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, review of arbitration agreements and staff resident interviews, the facility failed to ensure a resident was capable of understanding an arbitration agreement before signing. This affected one (#90) of three residents reviewed for arbitration agreements. The facility census was 104. Findings include: Review of Resident #90's medical record revealed an admission date of 04/16/25. Diagnoses listed included emphysema, hypertension, malnutrition, and peripheral vascular disease. Review of an admission Minimum Data Set (MDS) dated [DATE] revealed Resident #90 had moderately impaired cognition. Review of progress noted dated 04/16/25 at 7:35 P.M. revealed Resident #90 was alert to self with some confusion. Review of a daily skilled summary dated 04/17/25 at 3:45 A.M. revealed Resident #90 was alert with both long term and short term memory deficits. Resident #90 could probably make limited decision that require simple understanding. Review of a form titled, RESIDENT AND FACILITY…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and facility policy review, the facility failed to report an incident regarding an injury of unknown origin as required. This affected one (Resident #4) of three residents reviewed for injuries. The census was 108. Findings Include: Resident #4 was admitted to the facility on [DATE], diagnoses included fracture of unspecified part of neck of right femur, cerebrovascular disease, dementia, anxiety disorder, atrial fibrillation, polyneuropathy, atherosclerotic heart disease, brief psychotic disorder, hyperlipidemia, difficulty walking, degenerative disease of nervous system, hypertension, and cognitive communication deficit. Review of the 11/08/24 minimum data set (MDS) assessment revealed the resident had a severe cognitive impairment. Review of Resident #4's progress notes, dated 12/13/24, revealed an incident in which Resident #4 was being transferred via a mechanical lift. During the process, her arm got caught in the machine and sustained a small skin tear. In…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and facility policy review, the facility failed to complete a thorough investigation regarding an injury of unknown origin as required. This affected one (Resident #4) of three residents reviewed for injuries. The census was 108. Findings Include: Resident #4 was admitted to the facility on [DATE], diagnoses included fracture of unspecified part of neck of right femur dated 12/18/24, cerebrovascular disease, dementia, anxiety disorder, atrial fibrillation, polyneuropathy, atherosclerotic heart disease, brief psychotic disorder, hyperlipidemia, difficulty walking, degenerative disease of nervous system, hypertension, and cognitive communication deficit. Review of her minimum data set (MDS) assessment, dated 11/08/24, revealed she had a severe cognitive impairment. Review of Resident #4's progress notes, dated 12/13/24, revealed an incident in which Resident #4 was being transferred via mechanical lift. During the process, her arm got caught in the machine and she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of facility policy, the facility failed to obtain a laboratory value (labs) as ordered by physician. The affected one (#4) out of four residents reviewed for lab services. The census was 107. Findings include: Review of Resident #4's closed medical record revealed an admission date of 09/13/24. Diagnoses listed included heart failure, chronic kidney disease, hypertension, type two diabetes mellitus, and peripheral vascular disease. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 had intact cognition and was occasionally incontinent of urine. Review of physician orders revealed an order dated 09/23/24 to collect an urinalysis (UA) with reflex culture. Further review of Resident #4's closed medical record revealed no documentation of the UA with reflex culture being collected on 09/23/24. The review revealed there was no laboratory results were documented. Review of hospital documentation dated 10/04/24 through…

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 review of Self-Reported Incidents (SRIs), the facility failed to thoroughly investigate an allegation of resident-to-resident abuse. This affected two (Residents #4 and #21) of three residents reviewed for abuse. The facility census was 102. Findings include: Medical record review revealed Resident #4 admitted to the facility on [DATE] with diagnoses of dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #4 was cognitively impaired. Resident required set-up assistance with eating, required supervision assistance with wheelchair mobility, required partial assistance with oral hygiene and bed mobility, and required substantial assistance with toileting hygiene, bathing, dressing, personal hygiene, and transfers. Review of the care plan dated 07/22/24 revealed Resident #4 was at risk for alteration in mood state due to dementia,…

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 staff interview, the facility failed to communicate with the physician about family concerns related to the discontinuation of a medication. This affected one (Resident #4) out of four residents reviewed for medication changes. The facility census was 102. Findings include: Medical record review revealed Resident #4 admitted to the facility on [DATE] with diagnoses of dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #4 was cognitively impaired. Resident required set-up assistance with eating, required supervision assistance with wheelchair mobility, required partial assistance with oral hygiene and bed mobility, and required substantial assistance with toileting hygiene, bathing, dressing, personal hygiene, and transfers. Review of the medical record revealed Brexpiprazole (Rexulti) Oral Tablet 0.5 milligrams (mg) was ordered on 07/23/24…

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 medical record review, observation, staff interview and review of the facility policy the facility failed to ensure fall prevention interventions were in place to prevent resident injury from falls. This affected two (Residents #20 and #41) of three residents reviewed for falls. The facility census was 111 residents. Findings include: 1.Review of the medical record for Resident #20 revealed an admission date of 05/24/11 with diagnoses including diabetes, malnutrition, heart disease, anxiety, chronic pain, and dementia. Review of the Minimum Data Set (MDS) assessment for Resident #20 dated 12/26/23 revealed the resident was cognitively impaired and required partial to moderate assistance for ambulation, moving in bed, and moving from a sitting to a standing position. Review of the plan of care for Resident #20 updated 02/07/24 revealed the resident was at risk for falls due to decreased endurance, impaired judgment and cognitive impairment. Interventions included the following: assist with toileting as needed, bilateral bedrails to enable mobility in bed, keep call light and…

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

Based on observation, staff interview and policy review, the facility failed to ensure safe and sanitary storage of food and to ensure trash cans were covered when in the kitchen. This had the potential to affect all residents, excluding Resident #24 who does not eat food from the kitchen. Facility census was 105. Findings include: Observation on 07/24/23 from 9:37 A.M. to 10:18 A.M. revealed the following findings in the kitchen area. In the refrigerated areas there were the following items uncovered or not dated: over 10 pudding cups undated; two premade salads uncovered; two premade salads undated; over 10 cups of potato salad; six fruit parfait uncovered; over 20 cups of Jello uncovered; over 15 cups of mixed fruit uncovered; a block of cheese slices was uncovered and undated; a opened package of lunch meat was undated; broccoli salad undated; pack of hotdogs undated; green beans with bacon undated; two containers of unidentified red liquid substance (looked similar to vegetable soup) was unlabeled and undated; macaroni and cheese was undated; unknown soup was undated; sausage…

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 record review, the facility failed to follow the facility menu and spreadsheets for residents with altered textured diets. This affected 24 (#1, #2, #3, #7, #11, #16, #26, #30, #35, #40, #50, #52, #59, #62, #64, #67, #70, #71, #73, #76, #87, #89, #210 and #204) of 24 residents with orders for pureed and mechanical soft diets. Facility census was 105. Findings include: Review of the facility menu for dated 07/26/23 revealed facility was serving turkey club sandwiches, a balsamic tomato cucumber salad, chips, and pineapple tidbits. Review of the menu spreadsheets for mechanical soft diets dated 07/26/23 revealed the lunch meal included ground turkey sandwich with shredded lettuce and diced tomatoes, diced tomatoes in place of the salad, ranch pasta salad in place of the chips and crushed pineapple. Review of the menu spreadsheets for pureed diets dated 07/26/23 revealed the lunch meal included a turkey sandwich with lettuce, tomatoes, and cheese that was made into a pureed texture with 2 scoops, pureed tomatoes in place of the salad, pureed…

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 staff interview, the facility failed to notify residents that the amount of funds in their accounts was 200 dollars less than the social security income resource limit and that the resident's may lose eligibility for Medicaid or social security income. This affected two (#16 and #40) of five residents reviewed for personal funds. The facility census was 105. Findings include: 1. Review of the Resident #16's medical record revealed an admission date of 06/15/16, with diagnoses including: chronic obstructive pulmonary disease, gastrointestinal hemorrhage, major depressive disorder, hypertension, major depressive disorder, and hyperlipidemia. Review of Resident #16's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be severely cognitively impaired and Resident #16 required extensive assistance with bed mobility, dressing, eating, toileting, and personal hygiene. Resident #16 only transferred once or twice during the review period. Review of Resident #16's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and staff interview, the facility failed to have accurate advance directives in the electronic and medical record. This affected two (#70 and #71) of four residents reviewed for advanced directives. The facility census was 105. Findings include: 1. Review of Resident #70's medical record revealed an admission date of 06/15/23, with diagnoses of fracture of humerus right arm, chronic obstructive pulmonary disease, hypotension, atherosclerotic heart disease of native coronary artery, heart failure, and atrial fibrillation. Review of the five-day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance with personal hygiene, toilet use, dressing, transfer, and bed mobility. The Resident uses a walker to aid in mobility and is frequently incontinent. Review of Resident #70's paper medical record on 07/25/23 at 11:04 A.M., revealed the resident had a do not resuscitate comfort care (DNR-CC) form in the paper…

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, fall alarm list review, incident report review, and staff interview, the facility failed to ensure a resident was assessed to utilize a position change alarm (pull-tab alarm). This affected one (#86) of seven residents reviewed for falls. The facility identified three residents with pull-tab fall alarms in the facility. The facility census was 105. Findings include: Review of the Resident #86's medical record revealed admitted to than admission date of 05/25/23, with diagnoses including: hypertensive heart disease with heart failure, atrial fibrillation, chronic kidney disease stage three, osteoarthritis, muscle weakness, and hyperlipidemia. Review of Resident #86's admission assessment dated [DATE] revealed the resident was severely cognitively impaired and required extensive assistance with bed mobility, dressing, toileting, transfers, and personal hygiene. Resident #86 required supervision with eating and had fallen in the last month prior to admission. 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, record review, policy review and staff interview, the facility failed to develop resident care plans for anticoagulant medication use, oxygen use, and psychotropic medication use. This affected three (#51, #60, and #73) resident of 22 residents reviewed for care plans. The facility census was 105. Findings include: 1. Review of the Resident 51's medical record revealed an admission date of 09/03/20, with diagnoses including: transient cerebral ischemic attack, type two diabetes mellitus with hyperglycemia, diarrhea, schizoaffective disorder, and major depressive disorder. Review of Resident #51's quarterly minimum data set (MDS) assessment dated [DATE], revealed Resident #51 was severely cognitively impaired and required extensive assistance with bed mobility, dressing, toileting, transfers, and personal hygiene. Resident #51 required supervision with eating and received anticoagulant medication during the review period. Review of Resident #51's physician orders dated 09/24/23 revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, policy review, and staff interview, the facility failed to ensure a resident's fall care plan was updated to include new fall interventions. This affected two (#86 and #66) of 22 residents reviewed for care plans. The facility census was 105. Findings include: Review of the Resident #86's medical record revealed admitted to than admission date of 05/25/23, with diagnoses including: hypertensive heart disease with heart failure, atrial fibrillation, chronic kidney disease stage three, osteoarthritis, muscle weakness, and hyperlipidemia. Review of Resident #86's admission assessment dated [DATE] revealed the resident was severely cognitively impaired and required extensive assistance with bed mobility, dressing, toileting, transfers, and personal hygiene. Resident #86 required supervision with eating and had fallen in the last month prior to admission. Review of Resident #86's fall assessment dated [DATE] revealed Resident #86 was at moderate risk for falls. 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 record review and staff interview, the facility failed to ensure a physician's response to a pharmacy recommendation was followed. This affected one (#52) of five residents reviewed for unnecessary medications. The facility census was 105. Findings include: Review of the Resident #52's medical record revealed an admission date of 03/18/17, with diagnoses including: fracture of unspecified part of neck of right femur subsequent encounter for closed fracture with routine healing, depression, dysphagia, aphasia following cerebral infarction, cerebral infarction, anemia, anxiety disorder, unspecified convulsions, and mixed hyperlipidemia. Review of Resident #52's quarterly minimum data set assessment dated [DATE] revealed Resident #52 was severely cognitively impaired and was prescribed insulin, antianxiety medication, antidepressant medication, and opioids. Review of Resident #52's medication regimen review dated 10/17/22 revealed medications for seizures. Resident #52 was being monitored routinely 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, staff interviews, and record review, facility failed to ensure facility made pureed food in a way to keep nutritive values. This affected three (#1, #40 and #67) of three residents with orders for pureed diets. Facility census was 105. Findings include: Review of the facility menu for dated 07/26/23 revealed facility was serving turkey club sandwiches, a balsamic tomato cucumber salad, chips, and pineapple tidbits. Review of the menu spreadsheets for mechanical soft diets dated 07/26/23 revealed the lunch meal included ground turkey sandwich with shredded lettuce and diced tomatoes, diced tomatoes in place of the salad, ranch pasta salad in place of the chips and crushed pineapple. Review of the menu spreadsheets for pureed diets dated 07/26/23 revealed the lunch meal included a turkey sandwich with lettuce, tomatoes, and cheese that was made into a pureed texture with 2 scoops, pureed tomatoes in place of the salad, pureed ranch pasta salad in place of the chips and pureed peaches in place…

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 and staff interview, the facility failed to maintain resident furniture/equipment in safe working order. This affected one (#72) of one resident reviewed for environment. Facility census was 105. Findings include: Review of the medical record for the Resident #72 revealed an admission date of 10/26/22,with diagnoses including femur fracture, chronic obstructive pulmonary disease, hemiparesis and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 was cognitively impaired and required extensive assistance of two staff members for bed mobility and transfers. Observation on 07/24/23 at 10:41 A.M., revealed Resident #72's bed side table had two gold ball size chunks broken off with rough edges. Interview on 07/24/23 at 10:42 A.M. with State Tested Nursing Aide (STNA) #201 confirmed residents over the bed table was broken with jagged edges on one side. STNA #201 revealed it had been that way. Interview and observation on 07/26/23 at 3:30…

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 facility record review, staff interview, review of the facility's policy, review of the online resources from the Centers for Disease Control and Prevention (CDC), and memorandums from the centers for Medicare and Medicaid services (CMS), the facility failed to implement a water treatment program that followed the American Society of Heating, Refrigerating and Air Conditioning Engineers (ASHRA) industry standards and the CDC toolkit for prevention of Legionella. This had the potential to affect all 80 resident who resided in the facility. Findings included: During the facilities infection control log books and programs on 07/15/21 at 2:00 P.M. revealed the facility failed to implement an appropriate water treatment program to monitor and prevent the spread of Legionnaires Disease. The facility did not have any records of routine maintenance, cleaning and water treatment services. Review of the facility's policy titled Monitoring Waterborne Organisms, dated 05/19/17, revealed the facility would provide guidance for monitoring the domestic and open water systems suspected 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 and staff interview, and review of the facility's policy, the facility failed to provide a safe and comfortable environment for the residents. This affected one (#38) of 24 residents reviewed for physical environment and had the potential to affect all 80 residents who resided in the facility. Findings included: 1. During an observation of the laundry area on 07/15/21 at 9:25 A.M. revealed the facility had three natural gas dryers in operation. Further observation revealed dryer #1 (far left) was on and the burner assembly compartment had excessive amount of dryer lint in the compartment. Further observation of dryers #2 and #3 revealed an excessive amount of dryer lint in the burner assembly compartments. Interview with Director of Nursing (DON) on 07/15/21 at 9:27 A.M. verified the excessive lint build up in the burner assembly compartments in all three dryers. Interview with Director of Support Services (DSS) #30 on 07/15/21 at 1:30 P.M. indicated the facility maintenance staff were supposed to clean out the burner assembly compartments. DSS #30…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and policy review, the facility failed to ensure residents personal funds were managed appropriately. This affected two (#4 and #49) of five resident reviewed for personal funds. The facility identified six residents with a personal funds account managed by the facility. The facility census was 80. Findings include: 1. Review of the medical record for Resident #4 revealed the resident admitted to the facility on [DATE]. Diagnoses include dementia and chronic pain syndrome. Review of the Minimum Data Set (MDS) assessment, dated 06/23/21, revealed Resident #4 was rarely to never understood and had short and long term memory problems. Review of a document titled Trust Statement, dated 06/30/21, revealed a deposit was made into Resident #4's personal funds account on 05/17/21 for 1,400.00 dollars. The deposit was identified as stimulus. Continued review of the trust statement revealed the 1,400.00 dollars stimulus deposited on 05/17/21 was withdrawn from the account for a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident record review and staff interview, the facility failed to notify the resident/resident representative of the bed hold and reserve bed payment policy upon the resident's transfer to the hospital. This affected one (#79) of two residents reviewed for hospitalization. The facility census was 80. Findings include: Review of the medical record for Resident #79 revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, chronic bronchitis, and irritable bowel syndrome. Review of the five-day Minimum Data Set (MDS) assessment, dated 05/02/21, revealed Resident #79 had intact cognition. Review of a progress note, dated 05/02/21 at 8:50 A.M., revealed Resident #79's oxygen saturation was 60. The resident had diminished lung sounds with wheezing and was using accessory muscles to breath. The resident complained of nausea. Four liters of oxygen was administered to the resident and the resident's oxygen saturation increased to 86. The physician…

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, resident and family interview, staff interview, and policy review, the facility failed to have quarterly care conferences and include the resident and the resident's representatives to participate in care planning. This affected one (#5) of one resident reviewed for care planning. This had the potential to affect all 80 residents residing in the facility. Findings include: Review of the medical record of Resident #5 revealed an admission date of 03/23/19. Diagnoses included unspecified cord compression, chronic obstructive pulmonary disease, muscle weakness, unspecified edema, pharyngeal phase dysphagia, hypotension, hyperlipidemia, hypothyroidism, gastro-esophageal reflux disease, anxiety disorder, major depressive disorder, and osteoarthritis. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/18/21, revealed the resident had intact cognition. Review of the progress notes, dated 01/01/20 through 07/14/21, revealed care conferences were held on 01/23/20, 07/02/20, and 10/19/20. There was no evidence of any further communication…

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 the physician documented rationale for disagreeing with the pharmacy recommendations. This affected two (#12 and #47) of five residents reviewed for unnecessary medications. The facility census was 80. Findings include: 1. Review of the medical record for Resident #12 revealed an admission date of 05/20/20. Diagnoses included gastroesophageal reflux disease (GERD) and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/01/21, revealed the resident had intact cognition. Review of the physician orders, dated 06/21/21, revealed an order for Reglan (anti-vomiting agent) 10 milligrams (mg.) by mouth four times per day. The orders were not changed as of 07/14/21. Review of the Consultant Pharmacist admission Review, dated 06/22/21, revealed a pharmacologic concern regarding the resident receiving Metocloprimide (Reglan) 10 mg. four times daily for GERD. Further instructions were documented Metocloprimide can cause extrapyramidal effects. May wish to…

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

Based on medical record review and staff interview, the facility failed to obtain lab work as ordered by the physician and the facility failed to ensure laboratory results were promptly reported to the advanced provider. This affected two (#19 and #47) of eight residents reviewed for laboratory orders. The facility census was 80. Findings include: 1. Review of the medical record for Resident #47 revealed an admission date of 04/05/21. Diagnoses included heart failure and atrial fibrillation. Review of the Medicare five-day Minimum Data Set (MDS) assessment, dated 05/21/21, revealed the resident had impaired cognition. Review of the physician's orders, dated 05/14/21, revealed an order for a Digoxin level (to monitor for toxicity and/or low levels of Digoxin) to be drawn on 05/18/21. Review of Resident #47's labs revealed no evidence of a Digoxin level being completed as ordered. Interview on 07/14/21 at 11:44 A.M. with the Administrator verified no Digoxin level was completed on 05/18/21 as ordered, nor had a Digoxin level been checked since the lab work was ordered on 05/14/21. 2.…

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