Aventura At Creekside

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and staff interviews, it was determined the facility failed to ensure the attending physician acted upon and documented a clinical rationale regarding consultant pharmacist identified medication regimen irregularities for one of 19 residents reviewed (Resident 4). Findings include: A review of the clinical record revealed Resident 4 was admitted to the facility on [DATE], with diagnoses that included bipolar disorder (a mental health condition that causes significant changes in mood, energy, and ability to function, including episodes of depression and mania, which is a period of abnormally elevated mood or irritability). A review of the November 2025 consultant pharmacist Medication Regimen Review (MRR) (a monthly evaluation of a resident's medications conducted by a licensed pharmacist to identify potential medication concerns such as unnecessary medications, excessive doses, or risk of side effects) revealed the pharmacist identified the resident's order for Mirtazapine…

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 a review of clinical records, select facility policy, and staff interview, it was determined the facility failed to ensure a resident's drug regimen was free from the use of an unnecessary antibiotic for one of 19 residents reviewed (Resident 8).Findings Include:A review of Resident 8's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included dementia (a progressive condition involving decline in memory, thinking ability, and reasoning beyond normal aging) and muscle weakness. A review of the facility policy titled Antibiotic Stewardship, last reviewed by the facility on September 25, 2025, indicated antibiotics are prescribed only when there is sufficient clinical evidence of an active infection. The policy further indicated prescribers are expected to provide complete antibiotic orders including the medication name, dose, duration of treatment, and the clinical indication (medical reason) for use. The facility utilized the McGeer's Criteria Checklist…

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 a review of facility policy, observations of the food and nutrition services department, interviews with facility staff, and review of pest control records, it was determined that the facility failed to maintain an effective pest control program to ensure the facility was free of insects/pests, specifically cockroaches.Findings include: A review of the facility's Pest Control Policy last updated July 18, 2025, indicated the facility shall maintain an effective pest control program. The facility maintains an on-going pest control program to ensure the building is kept free of insects and rodents. Contracted outside pest control services are provided. Windows are always screened. Only approved FDA and EPA' insecticides and rodenticides are permitted in the facility and all such supplies are stored in areas away from food storage areas. Garbage and trash are not permitted to accumulate and are removed from the facility daily. Maintenance services assist, when appropriate and necessary, in providing pest control services. During observation of the kitchen on August 25, 2025, 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.

Based on observation, review of select facility policies, and staff interviews, it was determined that the facility failed to store, prepare, and serve food under sanitary conditions to prevent potential contamination and microbial growth in food, which increased the risk of food-borne illness in the dietary department.Findings included: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). A review of facility policies entitled Environment and Food Storage last reviewed by the facility on July 17, 2025, indicated all preparation areas, food service…

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 clinical record review, staff interviews, and review of the facility's abuse prohibition policy, it was determined that the facility failed to ensure allegations of abuse were reported to the State Survey Agency within 24 hours of the incident and failed to submit completed investigation findings within five (5) working days, for two of four abuse allegations reviewed (Residents 8 and 9).Findings include: A review of the facility policy entitled Abuse Policy, last reviewed July 17, 2025, revealed it is the policy of the facility that acts of physical, verbal, psychological, and financial abuse directed against residents are absolutely prohibited. Each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, mistreatment, neglect, exploitation, and misappropriation of property. Under the section titled Investigation and Reporting, the policy states the Administrator, Director of Nursing (DON), or designee shall notify the Department 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 a review of clinical records, the facility's abuse prohibition policy and information provided by the facility it was determined the facility failed to promptly conduct a thorough investigation to rule out abuse and implement corrective action and submit the results of the completed investigation to the State Survey Agency within five working days of the incident as evidenced by two of 4 residents reviewed (Resident 9 and 8).Findings include: A review of the facility's Abuse Policy that was last reviewed by the facility on July 17, 2025, indicated the Administrator/designee was responsible for operationalizing all policies and procedures that prohibit abuse and neglect and are required to report instances of suspected or actual abuse or neglect occurring within the facility. Abuse coordinators are the Administrator and the Director of Nursing (DON)/designee of the facility. They shall coordinate all investigations ensuring resident safety, and report the findings to the regulatory agencies, as required.…

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 a review of clinical records, select facility policy, observations, and resident and staff interviews, it was determined the facility failed to ensure oxygen therapy was administered in accordance with physician's orders for three of 20 residents reviewed (Residents 13, 79, and 85).Findings include: A review of the facility policy titled Oxygen Administration, last reviewed by the facility on July 17, 2025, revealed it is the facility's policy to provide oxygen therapy to residents upon order of the physician. The policy indicated it is the responsibility of the licensed nurse to initiate and monitor the administration of oxygen per physician's orders. Oxygen therapy is a medical treatment in which supplemental oxygen is administered to a resident to maintain adequate oxygen levels in the blood. Oxygen is typically delivered by a nasal cannula, which is a lightweight tube that splits into two prongs placed into the nostrils. The flow rate, measured in liters per minute (LPM), is determined by the…

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

Based on observation, review of select facility policy, and staff interviews, it was determined the facility failed to adhere to acceptable storage and labeling for multi-dose medications in one of two medication carts observed (Lilac Hall).Findings include: Review of the facility policy titled Medication Labeling and Storage last reviewed by the facility July 17,2025, indicated that multi-use medication vials/bottles that have been opened or accessed (e.g. seal broken) are to be labeled with the date they were opened to ensure proper tracking for expiration purposes. An observation of the medication cart located on Lilac hall unit on July 30, 2025, at 8:22 AM, in the presence of Employee 8 (Licensed Practical Nurse) of the medication stored in the medication cart, revealed one (1) multi-dose insulin pen of Insulin Degludec (a long acting insulin medication used to lower blood sugar) and one (1) multi-dose pens of Insulin Glargine (a long acting insulin medication used to lower blood sugar) that had been opened and available for resident use, but not dated when initially opened.…

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 a review of clinical records, select investigative reports, and employee job descriptions and staff interview it was determined the facility's administration failed to effectively use its resources to promote resident safety and maintain the highest practicable physical and mental functioning of residents in the facility by failing to prevent the physical abuse of one resident (Resident 49) out of 5 sampled residents. Findings include: A review of the clinical record for Resident 49 revealed that the facility failed to immediately remove Employee 3,Nurse Aide (NA), an employee alleged to have physically abused a resident, from resident contact. Despite the allegation, Employee 3 (NA) remained in the facility with access to residents while the allegation was unresolved. This failure to implement immediate protective measures placed Resident 49 and all residents in danger and resulted in the Immediate Jeopardy cited at F600. Further review revealed the facility failed to fulfill mandatory reporting obligations for additional abuse allegations:The facility did not report an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and interviews with staff, it was determined the facility the facility did not identify and respond to significant unplanned weight loss for one of 20 sampled residents . (Resident 9).Findings include: A clinical record review revealed Resident 9 was admitted to the facility on [DATE], with diagnoses that included Parkinson's Disease (a progressive neurodegenerative disorder that primarily affects movement often causing tremors, muscle stiffness and balance problems) A clinical record review revealed Resident 9 weighed 133.5lbs on March 12, 2025. The clinical record revealed the resident weighed 111lbs on April 18, 2025, indicating a significant weight loss of 16.9% over 37 days. Meal intake records documented the resident's consumption was variable, ranging from 25% to 100% of meals offered. Review of a dietary note dated April 20, 2025, at 09:18AM (two days after the weight loss was documented), indicated the resident had an unplanned significant weight loss confirmed by…

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

Based on a review of facility policies, medication count records, and staff interviews, it was determined that the facility failed to ensure nursing staff consistently follow established procedures for verifying and documenting the count of controlled substances at shift change on two of two medication carts observed.Findings include: A review of the facility policy entitled Controlled Substances last reviewed July 17, 2025, revealed it is the expectation of nursing staff to count controlled medication inventory at the end of each shift. The policy further revealed the nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services. A review of the facility Narcotic Card Count from the green nursing unit medication cart revealed the following: July 22, 2025, the night shift on coming nurse failed to sign that the narcotic count was completed and correct. July 25, 2025, the day shift on coming nurse failed to sign that the narcotic count was completed and correct. July 26, 2025, the day shift 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 review of clinical records, facility policy, observation, and resident and staff interviews, it was determined that the facility failed to implement its established smoking policy to ensure resident safety and regulatory compliance. Specifically, the facility failed to post smoking policies in a conspicuous and legible manner, ensure required smoking safety equipment was available in the designated smoking area for 12 residents who smoke, and assess one cognitively intact resident (Resident 1) who requested to smoke for safe smoking practices out of 6 residents sampled. These failures created a potential for fire hazards and compromised resident safety. Findings include: Review of the facility policy titled Resident smoking policy and procedure, no review date available revealed, to ensure compliance with regulatory guidelines and safety protocols, the facility prohibits smoking except for in specifically designed areas. Review of the facility's undated policy titled Resident Smoking Policy 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined the facility failed to ensure that the discharge process honored the resident's preferences and goals and failed to demonstrate that the discharge was appropriate and necessary, for one of six sampled residents (Resident 1). Findings include: Clinical record review revealed the resident was admitted to the facility on [DATE] with diagnosis to include, Wernicke's Encephalopathy (an acute inflammatory hemorrhagic encephalopathy caused by thiamine deficiency, often associated with chronic alcoholism or malnutrition, characterized by loss of muscle coordination, visual disturbances such as diplopia, and confusion), alcohol-induced psychotic disorder, alcoholic cirrhosis of the liver without ascites, and nicotine dependence. Documentation indicated the resident was cognitively intact. While it was noted that the resident had a legal guardian, the facility was unable to produce documentation confirming guardianship status during the survey. 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.

Based on resident billing record review, clinical record review, facility document review, and staff interview, it was determined the facility failed to provide advance written notice of a per diem (daily) room rate increase for 1 of 2 residents reviewed for billing notification of charges (Resident 1). Findings include: Clinical record review revealed that Resident was admitted to the facility June 15, 2022, with diagnosis including, but not limited to, diabetes. An admission Minimum Data Set assessment (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated January 5, 2025 revealed the resident was cognitively intact with a BIMS score of 13 (brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information, a score of 13-15 indicates intact cognition). Documentation indicated the resident was his own responsible party, with his sister listed as an emergency and HIPAA contact (Health Insurance Portability and Accountability Act federal…

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 of the main kitchen and staff interview, it was determined the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness for 78 of 78 residents residing in the facility. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). A tour of the kitchen was conducted with Employee 2 Dietary Manager, on October 1, 2024, at approximately 8:15 AM, that revealed the following…

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, review of clinical records and staff interview it was determined that the facility failed to ensure therapeutic devices to provide support and maintain proper positioning were applied for one two of 19 residents reviewed (Resident 48). Findings include: A review of Resident 48's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included contracture (a permanent stiffening of the muscles, tendons, ligaments, skin, and other tissues surrounding a joint that limits its range of motion) to the right and left ankle and contracture to the right and left elbow. Further review of the resident's clinical record revealed the resident was receiving restorative nursing and was to have right and left ankle plantar flexion contracture boots (a type of boot that can help with contractures, a condition that limits the ability to bend the foot and ankle downward) on in the morning and off at night. Also, the resident was to have [NAME] elbow splints (soft…

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 a review of select facility policy, clinical records, and staff interview, it was determined that the facility failed to thoroughly assess and evaluate bowel and bladder function and implement individualized approaches to restore normal bowel and bladder function to the extent possible for four out of 19 sampled residents (Resident 20, 48, 3 and 22). Findings include: A review of facility policy entitled Urinary Incontinence last reviewed July 8, 2024, revealed it is the policy of the facility to identify, assess, and provide the appropriate treatment and services to achieve or maintain as much normal urinary function as possible. A three day bladder diary will be completed for every resident upon admission, readmission, and as needed to determine if the resident requires a toileting plan or a every two hour check and change program. A review of the clinical record revealed that Resident 20 was admitted to the facility on [DATE], with diagnoses which included cerebral palsy (a group of neurological…

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 a review of clinical records and staff interview it was determined that the facility failed to ensure that the pharmacist conducted medication regimen reviews at least monthly for two residents out of five sampled (Resident 42 and 54 ). Findings include: A review of Resident 42's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses to include dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A review of Resident 42's clinical record conducted at the time of the survey ending October 4, 2024, revealed no evidence that the pharmacist had conducted drug regimen reviews at least once a month between December 2023 and March 2024. A review Resident 54's clinical record revealed the resident was admitted to the facility on [DATE], and had diagnoses that included Picks Disease (A specific type of dementia that affects a person's ability to speak and be understood), and Alzheimer's disease (a brain…

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 a review of the facility's planned cycle menus, observations, and staff interview it was determined that the facility failed to follow planned menus for 4 of 4residents requiring a pureed diet. Findings included: A review of the planned menu for October 1, 2024, revealed the lunch meal consisted of a barbecue cheeseburger, lettuce, tomato, a pickle spear, confetti coleslaw, french fries, and an oatmeal raisin cookie. Further review of an extension menu for October 1, 2024, for pureed (a method for turning solid foods into a smooth, creamy, or paste-like consistency) diets revealed residents on a pureed diet would receive a pureed barbecue cheeseburger, pureed mixed vegetable salad, mashed potatoes, and a pureed sugar cookie. Observation of the lunch meal service on October 1, 2024, at approximately 11:55 AM revealed there were no pickles, pureed marinated mixed vegetables, or pureed sugar cookies on the tray line as indicated on the menu. Further observations of the lunch meal service on October 1, 2024, revealed Resident 15, 33, 34, and 53 meal tickets revealed they were…

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

Based on observations, review of test tray results and staff interview, it was determined that the facility failed to serve foods at safe and palatable temperatures for 1 out of 5 residents. Findings include: According to the federal regulation 483.60(i)-(2) Food safety requirements - the definition of Danger Zone, found under the Definitions section, is food temperatures above 41 degrees Fahrenheit and below 135 degrees Fahrenheit that allow rapid growth of pathogenic microorganisms that can cause foodborne illness. Review of the facility meal service time schedule revealed that the scheduled lunch time for dining room cart one was 12:20 PM and dining room cart two was 12:25 PM. Observation of the lunch meal tray line on October 1, 2024, at 11:55 AM, revealed dining room cart one left the kitchen at 12:35 PM and dining room cart two left the kitchen at 12:48 PM. Observations on the nursing unit at approximately 1:15 PM revealed the staff were pushing a cart of meal trays out of the dining room and on to the nursing unit. The trays on that cart started to be delivered to residents…

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

Based on observations and resident and staff interviews, it was determined the facility failed to provide food that accommodated residents' preferences for four residents of 9 residents reviewed (Resident 8, 60, 58, and 49). Findings include: An observation of lunch meal tray line on October 1, 2024, at 11:55 AM revealed the following concerns were identified: Resident 8's meal ticket indicated the resident wanted pasta salad on his tray for lunch. The kitchen staff did not have pasta salad available for the resident and he did not receive pasta salad as requested. Resident 60's meal ticket indicated the resident wanted pasta salad on his tray for lunch. The kitchen staff did not have pasta salad available for the resident and he did not receive pasta salad as requested. Resident 58's meal ticket indicated the resident wanted fruit cocktail on his tray for lunch. The kitchen staff did not have fruit cocktail available for the resident and he did not receive fruit cocktail as requested. Resident 49's meal ticket indicated the resident wanted a barbecue cheeseburger on his tray for…

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

Based on review of clinical records and staff interview, it was determined that the facility failed to demonstrate systematically organized, readily accessible and secured resident medical records. Findings include: Observations on October 1, 2024, at 10:00 AM and again at 2:00 PM revealed a copier room in the front lobby with the door unlocked and open. The room contained multiple resident medical records. The records were not secure and being stored in a location where non-medical staff can enter and access these confidential medical records. Observations on October 2, 2024, at 11:00 AM revealed a copier room in the front lobby with the door unlocked and open. The room contained multiple resident medical records. The records were not secure and being stored in a location where non-medical staff can enter and access these confidential medical records. Observations on October 3, 2024, at approximately 9:15 AM revealed an unlocked shed outside of the facility. The shed had a box of papers that contained resident medical records sitting on the floor. The records were not secure 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of select facility policies and the facility's infection control tracking log, and staff interview, it was determined that the facility failed to maintain and implement a comprehensive program to monitor and prevent infections in the facility, including protocols and provisions for Enhanced barrier precautions and their implementation for 5 of five residents observed (Residents 42, 22, 48, 15, and 24). Findings include: A review of the facility's current enhanced barrier precautions policy dated as reviewed by the facility March 2024, revealed that it is the policy of this facility for PPE should be stored near residents' room and accessible to staff. Near the exit or outside the room is acceptable. For residents for whom EBP are indicated EBP is employed when performing high contact resident care activities A review of MEMO FROM THE Center for Clinical Standards and Quality/Quality, Safety & Oversight Group, Ref: QSO-24-08-NH, CDC, Centers for disease control, dated March 20, 2024 regarding,…

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 and staff interview, it was determined the facility failed to ensure that essential equipment was in safe operating condition in the facility's storage area. Findings include: A tour of the facility's storage area on October 3, 2024, at approximately 9:15 AM revealed two sheds that stored resident equipment. Dirt and debris were observed on the floor of the sheds. Mattresses were noted to be sitting directly on the shed floor. Dirt and dust were noted on the resident mattresses. There were pails for bed side commodes sitting on the floor of the shed. One pail was noted to have a dried white and brown substance inside it. Bed bolsters were uncovered and lying on the floor of the shed. There were boxes of air mattresses sitting directly on the dirty floor. Wheelchairs were noted to have dirty wheel and dust on them. An interview with the Nursing Home Administrator (NHA) on October 3, 2024, at 9:20 AM revealed NHA was unable to provide any information as to why the residents' items were stored in poor condition and confirmed the facility failed to ensure that…

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 select facility policy, observations of the food and nutrition services department, and staff interview, it was determined that the facility failed to maintain an effective pest control program. Findings include: A review of facility policy entitled Pest Control last reviewed July 8, 2024, indicated the facility shall maintain an effective pest control program to ensure the building is kept free of insects and rodents. Observation of the food and nutrition services department on October 1, 2024, at approximately 8:15 AM revealed small flies (which resembled a fruit fly) flying around the juice machine. A review of a pest control contract initiated on June 17, 2024, indicated the pest company will treat for roaches, ants, mice and rats, and common spiders. Further it was indicated the company would provide monthly services to the facility. It was not indicated in the contract that the company would provide services for flies. A review of pest control invoices dated June 18, 2024, July 25, 2024, August 28, 2024, September 12, 2024, and September 20, 2024, revealed the company…

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 resident and staff interviews, it was determined that the facility failed to provide care in a manner and environment that promotes each resident's quality of life and assures that each resident is treated with dignity by failing to respond timely to residents' requests for assistance, as evidenced by experiences reported by five of five residents sampled (Residents 4, 16, 14, 2, and 70). Findings include: During a resident group interview with alert and oriented residents on October 2, 2024, at 10:00 AM, the residents in attendance expressed concerns regarding the long wait times for staff to provide assistance with their care when requested/needed. All five residents (Residents 4, 16, 14, 2, and 70) in attendance stated that it often takes longer than 30 minutes for staff to answer their call lights. The residents stated that often when they have to wait longer than 30 minutes they end up soiling themselves and having to sit in a soiled brief waiting for staff to come take care of them. The residents in attendance stated that they have brought this concern up to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation staff interviews, it was determined that the facility failed to provide housekeeping and maintenance services to maintain a clean and safe resident environment. Findings include: An observation on October 1, 2024, at approximately 10:52 AM of the main dinning room revealed debris and food particles on the floor. The floor was noted to be sticky. Dirty place setting were still on the table from the breakfast meal service. A resident breakfast tray was still sitting on a table in the dining room. An observation on October 1, 2024, at 2:02 PM in room [ROOM NUMBER], revealed a hole in the wall in the residents' bathroom covered with plaster. The floor in the resident's bathroom was also noted to have debris and dirt near the hole. Observations on October 3, 2024, at approximately 8:40 AM revealed the main dining room had debris and food particles on the floor. Further dried sticky spills were noted on the floor. Interview with the Nursing Home Administrator on October 4, 2024, at approximately…

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 clinical record review and staff interviews, it was determined the facility failed to develop person-centered care plans that included individual behavioral management for one resident and smoking for two residents out of 18 sampled (Residents 56, 58 and 60). Findings include: A review of the clinical record revealed Resident 56 was admitted to the facility on [DATE], with diagnoses to include depression. A review of nursing progress notes beginning in September 2024 revealed Resident 56 was exhibiting an increase in behaviors, particularly after his wife, who is also a resident in the facility, would be early in the evening pushing resident back to his room and asking staff to put Resident 56 to bed. Resident 56 does not like to go to bed early and becomes frustrated and agitated. These incidents and Resident 56's personal preferences for bedtimes were not addressed on the resident's care plan reviewed during the survey ending October 5, 2024. A review of the clinical record revealed Resident 58 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.

Based on clinical record review and resident and staff interview it was determined the facility failed to develop and implement an individualized discharge plan for one of 18 residents sampled (Resident 47). Findings Include: A review of facility policy titled Discharge Summary and Plan last reviewed July 2024 revealed that every resident will be evaluated for his or her discharge needs, the discharge plan will be reevaluated based on changes in the residents needs or condition, and residents will be asked about their interest in returning to the community. A review of the clinical record of Resident 47 revealed admission to the facility on July 14, 2020, with diagnoses including bipolar disorder. An annual Minimum Data Set Assessment (MDS- standardized assessment process conducted at periodic intervals to plan resident care) dated July 3, 2024, revealed the resident had a BIMS (brief interview to aid in detecting cognitive impairment) score of 15, indicating that his cognition was intact. Review of Resident 47's comprehensive care plan revealed a focus area dated December 26, 2023,…

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 select facility policy and clinical records, and staff interviews it was determined that the facility failed to provide nursing services consistent with professional standards of quality by failing to demonstrate that licensed nurses fully evaluated a resident's status after an unwitnessed fall for one resident (Resident 8) out of 19 residents reviewed. Findings included: According to the Title 49, Professional and Vocational Standards, Department of State, Chapter 21 State Board of Nursing Subsection 21.11 (a) The register nurse assesses human responses and plans, implements and evaluates nursing care for individuals or families for whom the nurse is responsible. In carrying out this responsibility, the nurse performs all of following functions: (4) Carries out nursing care actions which promote, maintain, and restore the well-being of individuals (6)(b) The registered nurse is fully responsible for all actions as a licensed nurse and is accountable to clients for the quality of care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical and select facility policy, information submitted by the facility, it was determined that the facility failed to provide a resident who sustained repeated falls effective fall interventions to prevent the resident from falling for one of the 19 sampled residents (Resident 10). Findings include: A review of facility policy titled Falls and Fall Risks, managing last reviewed by the facility on July8, 2024, indicated that the facility will identify interventions related to the residents' specific risks and causes to prevent the resident from falling and to try to minimize complications from falling. Review of clinical records for Resident 10 was admitted to the facility on [DATE], with diagnoses that included Schizophrenia (a mental illness that affects how a person thinks, feels and behaves) Anxiety (a mental condition that causes a felling of worry, nervousness or unease) and hypertension (High blood pressure). Resident 10 has a documented history of falls, as noted in 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 a review of select facility policy, observation, and staff interview, it was determined that the facility failed to maintain respiratory equipment in a manner to promote optimal functioning for one resident out of 19 sampled residents (Resident 48). Findings include: A review of facility policy entitled Nebulizer Therapy last reviewed on July 8, 2024, revealed to care for the nebulizer equipment the staff will clean the equipment after each use, disassemble parts after each treatment, rinse the nebulizer cup and mouthpiece with water, shake off excessive water, and air dry on an absorbent towel. A review of Resident 48's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors). Further review of the resident's clinical record revealed a physician's order dated January 29, 2024 and discontinued on August 19, 2024, a nebulizer (a small machine…

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 clinical record review and staff interview, it was determined that the facility failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of a narcotic pain medication prescribed on an as needed basis for one resident (Resident 24) of 19 residents reviewed. Findings include: A review of the clinical record revealed that Resident 24 was admitted to the facility on [DATE], with diagnoses to include neuropathy ( a nerve condition that can cause a range of symptoms, including pain, numbness, tingling, swelling, or muscle weakness) and hypertension (high blood pressure). The resident had a current physician order initially dated September 10, 2024, for oxycodone ( a narcotic pain medication) 15 mg (milligram) tablet give one tablet by mouth, every eight hours as needed for moderate to severe pain. A review of the resident's September 2024 Medication Administration Record (MAR) revealed that staff administered the pain medication 29 times for the month of September. 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 facility documentation review, policy review, clinical record review, and staff interview, it was determined that the facility failed to provide pharmaceutical services to ensure a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable accurate accounting of controlled drugs when acquiring, receiving, dispensing, and or administering to identify possible diversion for one of three residents reviewed (Resident 76). Findings include: Review of facility policy, titled Discharge Medications, last reviewed July 2024, revealed The nursing staff shall forward completed drug disposition records to medical records. The complete list of the resident's medications shall also be provided to the resident upon discharge. Review of Resident 76's clinical record revealed the resident was admitted on [DATE] with diagnoses that included diabetes. Review of Resident 76's clinical record revealed they were discharged home from the facility on July 25, 2024. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to show adequate monitoring of behaviors and potential adverse consequences of psychoactive drug use and failed to consistently attempt non-pharmacological interventions prior to the administration of psychoactive drugs for one resident out of 19 residents reviewed (Resident 24). Findings include: A review of the clinical record revealed that Resident 24 was admitted to the facility on [DATE], with diagnoses to include neuropathy ( a nerve condition that can cause a range of symptoms, including pain, numbness, tingling, swelling, or muscle weakness) and hypertension (high blood pressure). A review of physician orders revealed an order initially dated September 9, 2024, the resident had an order for Ativan 1mg (psychotropic medication) give one tablet by mouth every eight hours as needed for anxiety. The physician failed to include a stop date for the as needed psychotropic drug. A review of a medication administration…

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, select facility policy review and staff interview, it was determined the facility failed to implement and adhere to procedures to ensure acceptable storage and use by dates for multi-dose medications in the medication storage room. Findings include: A review of facility policy titled Expiration Dating of Multidose Vials last reviewed by the facility July 8, 2024, revealed the expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-use container, the nurse's initials, and the date opened shall be recorded on the container. Observation of the medication room on October 3, 2024, at 9:35 AM, in the presence of Employee 1 (registered nurse), of medication stored in the medication refrigerator, revealed a multi-dose vial of Lidocaine Hydrochloride Injection USP (a local anesthetic agent) as well as a vial of Tuberculin Purified Protein Derivative (a solution used for Tuberculosis skin test) that had been opened, and available for use, but was not dated. Interview with Employee 1 at the time of the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of the facility's plan of correction from the survey ending October 4, 2024, the outcome of the activities of the facility's quality assurance committee, a review of clinical records, and staff interview it was determined the facility failed to effectively identify ongoing deficient practices related to unnecessary psychotropic medication. Findings include: As a result of the deficiencies cited under the requirements related to the unnecessary administration of psychotropic anti-anxiety drugs during the survey of October 4, 2024, the facility developed a plan of correction to serve as their allegation of compliance, which included a quality assurance monitoring component to ensure that solutions were sustained. This corrective plan was to be completed and functional by November 11, 2024. However, during the survey ending November 26, 2024, continuing deficient facility practice was identified with these same requirements. According to the facility's plan of correction for the deficiency cited…

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 clinical record review and staff interview it was determined that the facility failed to provide care consistent with a resident's advanced directive and honor the resident's requests for future treatment for one resident out of four sampled (Resident 1). Findings include: A review of the clinical record revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses to include dementia and hypertension. An admission minimum data set assessment (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated April 7, 2024 revealed the resident to be severly cognitively impaired with a BIMS (Brief Interview for Mental Status) is a tool to screen and identify the cognitive condition of residents in long-term care facilities) score of 00( 0 to 7 indicates sever cognitive impairment) and required maximum assistance of staff for activities of daily living. An nursing admission assessment dated [DATE] at 6:20 PM did not indicate the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and grievances lodged with the facility and staff interview it was determined that the facility failed to ensure that residents receive services to maintain hearing ability for one of four residents sampled (Resident 1). Findings include: Clinical record review revealed that Resident 1 was admitted to the facility on [DATE] with diagnoses to include dementia and hypertension. An admission minimum data set assessment (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated April 7, 2024, revealed that the resident was severely cognitively impaired with a BIMS (Brief Interview for Mental Status) is a tool to screen and identify the cognitive condition of residents in long-term care facilities) score of 00 (0 to 7 indicates severe cognitive impairment) and required maximum assistance of staff for activities of daily living. An admission nursing assessment dated [DATE], revealed that Resident 1 was admitted 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 observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness, in the dietary department and the resident unit food storage area. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). During a tour of the unit resident pantry area in the presence of the food service manager on May 16, 2024, at 11:30 a.m., observation of the…

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

Based on staff interviews and a review of documentation provided by the facility, it was determined that the facility failed to conduct a facility wide assessment that accurately reflected the personnel and specific resources presently available and to identify those that are necessary to care for its current resident population. Findings include: There was no facility assessment available for review at the time of the survey ending July 22, 2024. Following conclusion of the survey, the Nursing Home Administrator provided a facility assessment electronically dated as created and reviewed July 23, 2024, which indicated that the assessment would be next reviewed August 16, 2024, at the next QAPI meeting to determine the specific and unique needs of its resident population and the available and accessible resources to meet these needs on a daily basis and during emergent situations. The facility provided a facility assessment tool to the survey team electronically after the survey ended on July 23, 2024. There was no documentation on the form that identified and addressed the ongoing…

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 a review of grievances filed with the facility and the minutes from Residents' Council meetings and resident and staff interviews, it was determined that the facility failed to provide care in a manner and environment that promotes each resident's quality of life by failing to respond timely to residents' requests for assistance, including experiences reported by three out of the 10 residents sampled (Residents 11, 17, and 50). Findings include: A review of resident council meeting minutes dated February 22, 2024, revealed that residents voiced concerns of waiting 35 - 40 minutes for staff to answer their call bells. The meeting minutes indicated that residents in attendance also indicated that there are not enough nurse aides on the floor to provide timely care to residents. A grievance form filed on behalf of a resident dated March 22, 2024, revealed that the resident had been waiting for nursing staff to assist him to the restroom, but staff did not respond timely. After waiting for a response, the resident's family member went to find staff assistance and observed…

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, review of clinical records and staff interviews, it was determined that the facility failed to conduct meal service in a manner respectful of each resident's personal dignity for two residents observed during meals (Residents 61 and 68), failed to maintain a respectful environment as evidenced by observation of staff conduct and behaviors and as reported by two residents (Resident 50 and 17) and failed to ensure that resident maintained a dignified personal appearance for two of the 10 residents sampled (Residents 29 and 66). Findings include: A clinical record review revealed that Resident 29 was admitted to the facility on [DATE]. A review of an initial Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated April 18, 2024 revealed that Resident 29 is moderately cognitively impaired with a BIMS score of 12 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and resident and staff interviews it was determined that the facility failed to provide housekeeping services to maintain a clean and orderly environment in three of the three nursing halls. Findings include: During a facility tour on May 16, 2024, an observation of the resident activity room at 11:11 AM revealed crumbs, food, and paper debris on the floor. An observation in the hallway outside the activity room at 11:12 AM revealed two three-inch clumps of hair on the floor. During another observation at 5:06 PM, the clumps of hair were still in the hallway outside the activity room. An observation of the nursing station at 11:14 AM revealed a brown substance splattered on the handrail and on the wall above the handrail. A buildup of dirt and debris was observed on the surface of the handrail extending along the nursing station. Multiple dried tan liquid stains were observed on the wall across from the nursing station. An observation of resident room [ROOM NUMBER] at 11:18 AM revealed used…

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 a review clinical record, the facility's plan of correction from the survey ending May 16, 2024, observations and the outcome of the activities of the facility's quality assurance committee it was determined that the facility failed to develop and implement a quality assurance plan, which was able to identify, and correct ongoing quality deficiencies related to providing a safe, clean and homelike environment. Findings included: The facility developed a plan of correction that included that all areas identified were cleaned or repaired as needed and a walk thru was performed on the remaining areas to identify any similar concerns. Any area identified were cleaned/repaired as appropriate. A new system would be placed into effect with the Department Heads. Each Department Head would be assigned areas to monitor on a weekly basis. The days and times of these Ambassador Rounds would be random, assuring the chances for compliance. Any issues identified during these rounds, would be discussed during stand-up or stand-down meetings. Housekeeping and Maintenance staff were educated…

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 a review of clinical records and select incident reports, and staff interviews, it was determined that the facility failed to provide nursing services consistent with professional standards of practice by failing to demonstrate that a registered nurse promptly assessed a resident displaying possible signs and symptoms of a potential change in condition for one resident (Resident 38) out of 15 sampled residents sampled. Findings include: According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient's EHR (electronic health record) to support the ability of the health care team to ensure informed decisions and high-quality care in the continuity of patient care: • Assessments • Clinical problems • Communications with other health care professionals regarding the patient • Communication with and education of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and select facility policy and staff interviews it was determined that the facility failed to consistently and accurately monitor resident weights to timely identify changes in nutritional parameters for two residents out of 15 sampled (Residents 51 and 47). Findings included: Review of facility policy entitled Weight Policy and Procedure Facility Guidelines, provided by the facility on May 16, 2024, indicated that monthly weights would be documented in the resident's electronic medical record and that nursing needs to ensure completion of weekly weights. Discontinuation of weekly weights should occur once stabilization has been determined by the Dietitian and Interdisciplinary Team. A progress note by the Dietitian needs to reflect the stabilization and return to monthly weights. Weekly weights should not go on for months at a time unless truly clinically indicated. Weight accuracy issues require problem solving. Dietitians need to drive the re-weight process and re-weights…

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 clinical records and staff interview, it was determined that the facility failed to maintain accurate and complete clinical records, according to professional standards of practice, by failing to ensure that a resident's clinical record included details related to injuries sustained post incidents with changes in medical status for one out of 15 sampled residents (Resident 38). Findings include: According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient record to support the ability of the health care team to ensure informed decisions and high-quality care in the continuity of patient care: Assessments, Clinical problems, Communications with other health care professionals regarding the patient, Communication with and education of the patient, family, and the patient's designated support person 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 interviews and a review of employee credentials and current staffing of the facility's food and nutrition services department it was determined that the facility failed to consistently provide qualified staff to provide oversight of the food and nutrition services department. Findings include: During a tour of the food and nutrition services department on March 13, 2024, at approximately 10:00 a.m., the facility's designated Dietary Manager stated that she started working at the facility three days prior to this survey and her responsibilities included oversight of food preparation, service and storage of food. The Dietary Manager, stated that presently she did not possess the regulatory required qualifications for this position, which was confirmed during review of the employee's personnel file. During an interview on March 13, 2024 at 1 PM, the Nursing Home Administrator (NHA) confirmed that there was no qualified dietary manager in the facility from January 30, 2024 through March 4, 2024, when the current Dietary Manager came to the facility from 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.

Based on observations, review of the facility's planned written menus, menu extensions, and select facility policy, and staff interviews, it was determined that the facility failed to follow planned menus, failed to ensure that the facility's dietitian periodically updated the planned menus to reflect variety, the preferences of the current resident population and nutritional adequacy and failed to assure consistent availability of food to serve the emergency menu in the event of an emergency. Findings included: A review of the current facility census at the time of the survey on March 13, 2024, revealed 71 residents were currently residing in the facility. Review of the facility's Week 3 lunch menu for Wednesday March 13, 2024, revealed that the planned menu included barbecued chicken (4 oz), mashed sweet potatoes (1/2 cup), cauliflower (1/2 cup), dinner roll, chilled peaches (1/2 cup), apple juice (4 oz), 2% milk (4 oz) and coffee (8 oz). The Week 3 lunch meal, Renal diet extension, revealed baked chicken (3 oz) no BBQ sauce, Mashed sweet potatoes (1/2 cup), cauliflower (1/2/cup),…

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 clinical record review, observation, and staff interview, it was determined that the facility failed to provide adaptive dining equipment as required by one of seven residents reviewed (Resident 1). Findings include: A review of the clinical record revealed that Resident 1 was admitted to the facility on [DATE], and had a current physician's order dated February 13, 2024, for the use an adaptive lip plate (dishes with built up rims and ridges to allow the elderly, seniors or disabled to catch the food on your fork or spoon) and lidded cup for all meals. Observation of the lunch meal on March 13, 2024, at approximately 12 p.m. revealed that the above resident, with physician orders for the adaptive lip plates, was served his lunch meal on a regular plate and cup and did not receive the lip plates as ordered. Interview on March 13, 2024, at approximately 1 PM with the Nursing Home Administrator confirmed that the adaptive lip plate and lidded cup were not being utilized at the time of the meal observation…

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 a review clinical records, the facility's plan of correction from the survey ending March 13, 2024, and the outcome of the activities of the facility's quality assurance committee it was determined that the facility failed to develop and implement a quality assurance plan, which was able to identify and correct ongoing quality deficiencies related to adherence to written menus and menu planning to meet the needs and preferences of residents Findings include: During the survey the March 13, 2024, deficient facility practice was identified related to the facility's failure to serve meals as planned by the facility. The facility developed a plan of correction that included a new facility process Administrator will educate Dining Room Manager on substitutions or menu changes requiring approval by Registered Dietitian (RD) before being implemented. The Dining Room Manager would educate Dietary Cooks on substitution logs and the process of making substitutions and the Dining Room Manger would educate Dietary Cooks on the requirement of following planned facility menus as written.…

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 and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department and the resident pantry. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). A tour of the facility's kitchen conducted on January 24, 2024, at approximately 10 AM, in the presence of the Director of Nursing, 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 and staff interview it was determined that the facility failed to provide housekeeping services to maintain a clean and orderly environment and resident care equipment in one resident room out of 34 (room [ROOM NUMBER]) and as observed for one resident on the one resident unit in the facility. Findings include: Observations of resident room [ROOM NUMBER] revealed that just inside the door there blankets were observed laying on the floor. The overbed table was soiled with food debris. Dirty resident laundry, and tissues were observed on the floor and a plastic medicine cup containing a moist substance on the floor under the center resident bed in the room. Observation of room [ROOM NUMBER]'s resident bathroom revealed moist towels hanging on the assist bars of the toilet. A soiled brief was observed on the floor next to the garbage can. The trash can in the bathroom was overflowing with garbage. A bedpan was placed on the top of the toilet assist/grab bar. Observation in the hallway of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff and resident interview it was determined that the facility failed to maintain an environment free of potential accident hazards on one of one nursing unit Findings include: Observations conducted during a tour of resident rooms on January 24, 2024, at 11:25 AM revealed in occupied resident room [ROOM NUMBER] two bottles of Nystatin powder (antifungal powder), one container of calmoseptine ointment, and one bottle of antifungal cream were observed on Resident 1's nightstand. Additional observations of the resident rooms on January 24, 2024, at 12:35 PM revealed that the above noted creams and powders remained on the nightstand in Resident 1's room. Resident 1 was present in the room at the time of the observation and the resident care supplies and personal care products were within the resident's reach. An observation of occupied room [ROOM NUMBER] revealed two containers of hydrogel wound ointment and one bottle of nystatin powder on Resident 2's nightstand within reach of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interview it was determined that the facility failed to provide each resident with a clean mattress on one bed out of 81 available in the facility (Resident room [ROOM NUMBER]). Findings revealed: Observations of resident room [ROOM NUMBER] on January 24, 2024, at 11:25 AM revealed that the resident bed located by the door was stripped of its bottom fitted sheet. Further observation of the exposed mattress on the bed revealed that there were distinct dirty shoe footprints visible on top of the mattress. Interview with the Nursing Home Administrator on January 24, 2024, at approximately 2:30 PM confirmed the facility is to provide a clean and sanitary mattress for each resident. 28 Pa. Code (e)(2.1) Management