Aventura At Prospect

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of facility documentation, review of clinical records, and interviews with staff and residents it was determined that the facility failed to provide assistance devices necessary to prevent an avoidable accident for one of 31 residents reviewed (Resident R24).Findings Include: Review of Resident R24's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated December 9, 2025, revealed the resident was admitted to the facility on [DATE], and had diagnoses of malnutrition (imbalance in a person's energy/nutrient intake), hemiplegia (paralysis that affects one side of the body) affecting left-side, contracture of right hand, and homonymous bilateral field defects (visual impairments affecting the same side of the visual field in both eyes). Continued review of Resident R24's MDS dated [DATE], revealed the resident was assessed as cognitively intact. Per Resident R24's physical therapy treatment notes dated January 24, 2026, indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of facility documentation, review of clinical records, and interviews with staff and residents it was determined that the facility failed to ensure adequate monitoring and timely reassessment to maintain acceptable parameters of nutrition status for 3 of 9 residents reviewed for nutrition (Resident R1, R87, and R11).Findings Include: Review of facility policy titled, Weight Policy with a revision date on July 2025 states, Policy- It is the policy of this facility to weigh each resident on admission, weekly for four weeks, then monthly thereafter, unless otherwise ordered by the physician/interdisciplinary team. The facility will utilize consistent procedures for monitoring weights to prevent unnecessary weight loss/gain in our residents. Any resident displaying a significant change in weight of greater than or equal to 5%, gain or loss in one month will be reported to the Registered Dietitian and reweighed. Review of undated facility documentation Clinical Dietitian Job…

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 clinical record and review of policy, as well as interview with staff, it was determined that facility did not ensure the accurate administration of psychotropic medication by administering a medication at a dose different from that prescribed for one of three residents observed (Resident R50)Findings include: Review of Resident R50's clinical record revealed medical history of bipolar disorder (condition in which a person has period of depression and periods of being extremely happy), schizoaffective disorder, drug induced parkinsonism (progressive disease of the central nervous system), generalized anxiety disorder, psychosis, drug induced subacute dyskinesis (involuntary, abnormal movements that develop days to weeks after starting or changing a medication; commonly caused by antipsychotics such as haloperidol/risperidone, antiemetics or antidepressants), recurrent depressive disorders, schizophrenia (mental disease characterized by loss of reality contact). Review of psychiatric progress note, completed on March 5, 2026, by Nurse practitioner…

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 interview and review of facility provided documentation, and review of clinical records, it was determined that facility failed to timely monitor and assess a resident's medical condition for one of eight residents reviewed. (Resident R1) Findings include: Review of Resident R1's clinical record revealed the resident was admitted to facility on [DATE], with diagnosis of history of hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, acute or chronic diastolic (congestive) heart failure, hypertensive heart disease with heart failure, chronic obstructive pulmonary disease, anemia and schizophrenia (mental disease characterized by loss of reality contact). Review of Resident R2's Minimum Data Set (MDS- assessment of resident needs), completed on [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident was cognitive intact. Review of Resident R1's clinical record revealed that on Friday, [DATE] at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Review of Resident R2 ' s quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated August 5, 2025, revealed the resident was rarely/never understood and had diagnoses of hemiplegia or hemiparesis, and functional quadriplegia. Continued review of Resident R2's quarterly MDS dated [DATE], revealed the resident had functional limitation in range of motion impairments on both sides of upper extremity.Review of Section GG0170. Mobility of Resident R2's quarterly MDS dated [DATE], revealed the resident was dependent (helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) on staff to roll left and right (the ability to roll from lying on back to left and right side, and return to lying on back on the bed). Review of Resident R2's comprehensive care plan dated August 13, 2021, revealed the resident was at risk for falls related to immobility. Review…

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 facility policy, observations, and interviews with staff and residents, it was determined that the facility did not ensure that food was stored, prepared, and served in accordance with professional standards for food service safety. Findings Include: Review of facility policy Dishwashing Machine Use revised March 2010 revealed dishwashing machine chemical sanitizer for use of chlorine solution, the minimum concentration should be 50-100 ppm (parts-per-million) for a contact time of 10 seconds. A tour of the main kitchen conducted on May 5, 2025, 9:30 a.m. with Food Service Director, Employee E29, revealed the following: Observations of the walk-in refrigerator revealed an open large sleeve of ground beef, poorly resealed, and not labeled with received or open date. The opened sleeve of ground beef was placed on top of a new, unopened box (delivered earlier in morning of 5/5/2025) of ground beef. The opened sleeve of ground beef was observed with raw meat drippings on the new box. Observations and interview revealed the main kitchen utilizes a low water…

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 facility documentation, interview with staff and residents, it was determined that the facility failed to make financial record available to the resident through quarterly statements and upon request for one out one resident reviewed. (Resident R63). Findings include: On May 6, 2025, at approximately 12:00 p.m., an interview was conducted with Resident R63. The resident stated that they do not have access to their $3,000.00 and expressed a desire to gain access to these funds. On May 7, 2025, at 1:22 p.m., an interview was held with the Business Office Manager (Employee E22) and the Regional Business Office Manager, Employee E23. They reported that the previous Business Office Manager-who is no longer employed at the facility-did not maintain records indicating when or how residents and their representatives received quarterly financial statements. Employee E23 further confirmed that efforts are currently underway to develop and implement policies and procedures to ensure that residents and their representatives receive financial statements on a quarterly basis…

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 reviews, review of facility policies and documentation and interviews with staff, it was determined that the facility failed to ensure that pharmacist recommendations were reviewed by the physician in a timely manner for four of five residents reviewed related to medication regime reviews (Residents R48, R86, R85 and R125). Findings include: Review of facility policy, Pharmacy Services Policy and Procedure dated 2025, revealed, The drug regimen of each resident shall be reviewed at least once a month by a licensed pharmacist . The pharmacist shall report any irregularities to the attending physician and the Facility's medical director and director of nursing, who shall act upon these reports . The attending physician shall document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician shall document his or her rationale in the resident's medical record. Review of Resident R85's Medication Regimen Review…

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 facility policy, observations, and staff and resident interviews, it was determined that the facility failed to maintain an effective pest control program for two of three nursing units and the main kitchen (2nd floor South nursing unit, 1-North Nursing Unit, and main kitchen ). Findings include: Review of facility policy Pest control dated April 1, 2022, revealed Aventura at Prospect shall maintain an effective pest control program. 1. The facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.2. Pest control services are provided a contracted vendor. 3. 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. 4. Garbage and trash are not permitted to accumulate and are removed from the facility daily. 5. Maintenance services assist, when appropriate and necessary, in providing pest control services. Interview during an initial tour…

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, facility policy and interviews with resident and staff, it was determined that the facility failed to protect personal property of Resident's (R68) by removing items from her/his room without prior notice. This failure resulted in the facility not providing an environment that maintains and enhances the dignity of one of 30 residents reviewed. (Resident R68) Findings include: A review of the facility policy titled Safeguarding Resident Property Policy and Procedure undated, revealed To ensure that residents' personal possessions are property safeguarded, while not limiting residents from using their personal possessions. On May 6, 2025, at 10:46 a.m., Resident R68 attended a resident council meeting. Following the meeting, Resident R68 entered the conference room in tears and reported that the facility had removed her personal boxes from her room with no prior notice. She also stated that the Social Worker handed her a letter, which was neither dated nor signed. At 12:02 p.m., an observation was conducted, and it was noted that several boxes previously placed…

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 facility policies, and interviews with residents and staff, it was determined that the facility failed to provide a safe, clean, comfortable and homelike environment for three of three nursing units observed (2 South Nursing Unit, 2 North Nursing Unit and 1 North Nursing Unit). Findings include: Review of facility policy, Quality of Life - Homelike Environment revised May 2017, revealed, Staff shall provide person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. Continued review revealed, Comfortable and adequate lighting is provided in all areas of the facility to promote a safe, comfortable and homelike environment. On May 5, 2025, at 12:27 p.m., an observation was conducted on the 2 North Nursing Unit in room [ROOM NUMBER]-D, where it was noted that Resident R68 had approximately six different boxes on the floor next to her bed and window. Underneath the bed, the entire floor was covered with various boxes containing open…

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 interviews with residents and staff, review grievance, and review of facility policy, it was determined that the facility did not ensure prompt efforts were made to resolve residents' grievances and/or concerns for 7 of 7 residents interviewed (Residents R79, R52, R63, R61, R46, R68, R98) and related to missing items for one of 30 resident records reviewed (Resident R54). Findings include: Review of facility policy titled, Resident and Family Concerns and Grievances Policy and Procedure not dated, states, To provide for the prompt resolution of medical and non-medical grievances while maintaining confidentiality, in accordance with applicable federal and state statutes and regulations. On May 6, 2025, at 9:52 a.m. an interview was held with Resident R54 who reported that this is the second time when facility has lost her clothing when she gave the housekeeping staff to wash her items. Reported her missing items to the Social Worker a month ago and she has not heard back. On May 6, 2025, at 10:46 a.m. an resident council meeting was held with seven alert and oriented…

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 facility policy, review of facility documentation, review of clinical records, and staff interviews, it was determined that the facility failed to complete a thorough investigation and maintain documentation that an allegation of neglect was thoroughly investigated for one of two residents reviewed (Resident R51). Findings Include: Review of undated facility policy Residents Right to Freedom from Abuse, Neglect, and Exploitation Policy and Procedure revealed in response to allegations of abuse, neglect, or mistreatment the facility should have evidence that alleged violations are thoroughly investigated and prevent further abuse, neglect, or mistreatment while the investigation is in progress. Further review of facility policy revealed that the results of investigations should be reported to the administrator and State Survey Agency within 5 working days of the incident. Review of Resident R51's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated February 5, 2025, revealed the resident had diagnoses of muscle…

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 reviews, review of facility policies and staff interviews, it was determined that the PASRR (Preadmission Screening and Resident Review) was not appropriately completed according to the resident assessment for three of three residents reviewed related to PASRR assessments (Residents R24, R63 and R125). Findings include: The PASRR (Preadmission Screening Resident Review) was created in 1987 through language in the Omnibus Budget Reconciliation Act (OBRA) and it has three goals: to identify individuals with mental illness and/or intellectual disability, to ensure they are placed appropriately, whether in the community or in a nursing facility, and to ensure they receive the services they require for their mental illness or intellectual disability. The PASRR Level 1 must be completed on all persons who are considering admission to a Medicaid certified nursing facility. A Level II PASRR evaluation must be completed if the Level 1 PASRR determined that the person is a targeted person with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, review of clinical record, and staff interviews, it was determined that the facility failed to notify the state mental health authority of a significant change in a mental health condition for one of three residents reviewed for Preadmission Screening and Resident Review (PASARR) screening (Resident R24). Findings Include: The PASRR (Preadmission Screening Resident Review) was created in 1987 through language in the Omnibus Budget Reconciliation Act (OBRA) and it has three goals: to identify individuals with mental illness and/or intellectual disability, to ensure they are placed appropriately, whether in the community or in a nursing facility, and to ensure they receive the services they require for their mental illness or intellectual disability. Review of Resident Assessment Policy and Procedure dated 2025 revealed The Facility shall notify the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in 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 review of facility policy and review of clinical records, it was determined that the facility failed to develop and implement a baseline careplan for one of two new admissions reviewed (Resident R449). Findings Include: Review of facility policy, Comprehensive Person-Centered Care Planning Policy and Procedure dated 2025, revealed, the facility will develop and implement a baseline care plan, within 48 hours of a resident's admission, that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Review of Resident 449's clinical record revealed the resident was admitted to the facility on [DATE], and had a diagnosis of opioid dependence with other opioid-induced disorder, and cannabis abuse with other cannabis-induced disorder. Continued review of Resident R449's clinical record revealed a History and Physical dated May 3, 2025, by Physician, Employee E28, that indicated Resident R449 was a new admit to the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to develop comprehensive person-centered care plans related to behavioral health needs for one of 34 residents reviewed (Resident R85). Findings include: Review of facility policy, Comprehensive Person-Centered Care Planning Policy and Procedure dated 2025, revealed, The Facility will develop and implement a comprehensive person-centered care plan for each resident . that includes measurable objectives and timeframes to meet each resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Review of Resident R85's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated April 1, 2025, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), Parkinson's Disease…

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 facility documentation, review of clinical records, and staff interview, it was determined that the facility failed to promptly assess a resident status post a fall for one of two residents reviewed for falls (Resident R51). Findings Include: Review of Resident R51's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated February 5, 2025, revealed the resident had diagnoses of muscle weakness, lack of coordination, Aphasia (communication disorder), Cerebrovascular Accident (CVA - stoke; loss of blood flow to part of the brain), Hemiplegia (paralysis on one side of the body) and Hemiparesis (weakness on one side of the body). Continued review of Resident R51's MDS assessment revealed the resident's BIMS (Brief Interview of Mental status) score of 14, which indicated that the resident was cognitively intact. Further review of the MDS assessment indicated Resident R51 used a wheelchair for mobility. Review of Resident R51's comprehensive care plan dated January 18, 2018, revealed the resident had a potential for falls…

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 facility policy, review of clinical records, and staff interviews, it was determined that the facility failed to ensure that residents with limited range of motion received treatment and services to maintain or improve range of motion/mobility for two of 34 residents reviewed for limited range of motion (Resident R1 and Resident R36). Findings include: Review of facility policy on Restorative Nursing Services with a most recent revision date of October 31, 2024 revealed that under section POLICY STATEMENT: Residents will receive restorative nursing care and services as needed to help promote optimal safety and independence. PROCEDURE #1. Residents may be started on a restorative nursing program upon admission, during their course of stay or upon discharge from rehabilitative care. #2. A registered nurse will complete an assessment before establishing a restorative nursing program for program additions on admission or during the course of stay. Therapy will provide program…

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 facility policies and procedures, observations of care and services, and interviews with staff, it was determined that the facility failed to consistently provide respiratory care and supplemental oxygen as ordered by the physician for one of 30 residents reviewed. (Resident R95). Findings included: A review of the facility policy titled Oxygen Administration dated April 1, 2022, stated The purpose of this procedure is to provide guidelines for safe oxygen administration. Bulletin # 1 under Preparation paragraph further stated verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. A review of the clinical record for Resident R95 revealed an admission date of September 15, 2021, with diagnoses including chronic pulmonary edema, heart failure, and both acute and chronic respiratory failure with hypoxia (low levels of oxygen). Review of Resident R95's physician orders dated January 12, 2024, for supplemental oxygen via nasal cannula every shift for shortness 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 observations, review of facility documentation, review of personnel files and interviews with staff, it was determined that the facility failed to ensure that agency nursing staff demonstrated competencies and skill sets necessary to care for residents' needs for three of three agency personnel files reviewed (Employees E3, E15 and E16). Findings include: Review of facility staffing schedules revealed that Employee E3, licensed nurse; Employee E15, licensed nurse; and Employee E16, nurse aide; worked at the facility on May 5, 2025, as agency nursing staff. Observation of morning medication pass on May 5, 2025, at 9:45 a.m. revealed that Employee E3, agency licensed nurse, made a medication error as well as failed to maintain appropriate infection control practices during medication administration. Continued observation of morning medication pass on May 5, 2025, revealed that Employee E15, agency licensed nurse, left the medication cart unlocked and unattended, next to the resident dining area, from 10:36 a.m. through 10:42 a.m. Review of personnel files for Employee E3,…

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 facility policies and interviews with staff, it was determined that the facility failed to ensure that drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for four of four medication carts reviewed (2 North upper medication, 2 North low medication cart, 2 South back medication cart ) and maintain a system that allows for timely identification of narcotic diversion. Findings include: Review of facility policy, Pharmacy Services Policy and Procedure dated 2025, revealed, The Facility shall have a system to account for controlled medications' receipt and disposition in sufficient detail to enable an accurate reconciliation. Observation on May 5, 2025, at 10:03 a.m. of the 2 North upper medication cart, with Employee E3, agency licensed nurse, revealed that the number of blister pack medication cards was not documented during the shift-to-shift narcotic medication reconciliation process. Interview, at the time of the observation, Employee E3, agency licensed nurse, confirmed the above finding.…

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 facility policies, clinical record review and interviews with staff, it was determined that the facility failed to ensure that the medication error rate was less than five percent for two of four residents observed during medication administration (Residents R83 and R88). Findings include: The facility's medication error rate was 5.88% based on observation of 34 medication administration opportunities with two errors observed. Review of facility policy, Medication Administration Policy dated December 4, 2023, revealed, Medications must be administered in accordance with orders, including any required time frame. Review of Medication Administration Records (MARs) for Resident R83 revealed a physician's order, dated March 14, 2025, for aspart (rapid acting) insulin (medication used to lower blood sugar levels), inject 24 units subcutaneously (under the skin) before meals. Continued review revealed another order, dated April 4, 2025, for aspart insulin sliding scale (variable dosage…

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 facility policies and interviews with staff, it was determined that the facility failed to ensure that medications were stored and labeled in accordance with professional practice standards and failed to ensure that compartments for storage of controlled medications were permanently affixed within storage areas, for thee of five medication storage areas reviewed (2 North upper medication, 2 North low medication cart, 1 North low medication cart, first floor medication room.). Findings include: Review of facility policy, Medication Administration Policy dated December 4, 2023, revealed, The individual administering the medication must check the label to verify the right medication, right dosage, right time and right method of administration before giving the medication. Check the expiration date on the medication label. When opening a multi-dose container, place the date on the container. Continued review revealed, During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse. It may be…

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

Based on observations, review of facility policies and interviews with staff, it was determined that the facility failed to ensure that personal foods were stored and labeled in accordance with food safety standards for one of two nursing units reviewed (2 North medication room). Findings include: Review of facility policy, Medication Storage Policy dated December 4, 2023, revealed, Employee or resident food should not be stored in the medication refrigerator. Review of facility policy, Outside Food undated, revealed, Resident and or person bringing in the food will be notified that perishable food will only be kept for 72 hours. Continued review revealed, Staff will monitor resident's room, unit pantry, and refrigeration units for food and beverage disposal. Observation on May 5, 2025, at 9:58 a.m. of the 2 North medication room, with Employee E3, agency licensed nurse, revealed that the refrigerator contained both resident medications as well as foods brought into the facility. Continued observation revealed several opened containers of foods; none of the containers had dates 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 observations, review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related to insulin administration and hand hygiene during medication administration for two of three licensed nurses observed (Employee E3 and E20). Findings include: Review of facility policy, Medication Administration Policy dated December 4, 2023, revealed, The individual administering medications must verify the resident's identity before giving the resident his/her medications . The individual administering the medication must check the label to verify the right medication, right dosage, right time and right method of administration before giving the medication. Check the expiration date on the medication label. When opening a multi-dose container, place the date on the container. Continued review revealed, Staff shall follow established facility infection control procedures (e.g., hand washing, antiseptic technique, gloves, isolation precautions, etc.) when these apply 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.

Based on observations and staff interviews, it was determined that the facility failed to ensure equipment was maintained in safe and operating conditions related to the main kitchen and fire doors. Findings Include: An initial tour of the main kitchen was conducted on May 5, 2025, at 9:30 a.m. with Food Service Director, Employee E29. Observations and interview with Food Service Director, Employee E29, revealed the main kitchen is equipped with two steamers, four ovens, and one tilt skillet. Further interview and observation revealed one steamer, three ovens, and the tilt skillet are broken. Further observations during the initial tour of the main kitchen on May 5, 2025, at 9:30 a.m. revealed the stainless steel, industiral preparation table was noted to be on a slant. The table was observed to be holding other kitchen prep equipment such as cutting boards, food processor, and toaster oven. Food Service Director, Employee E29, confirmed the table was broken and needed to be replaced or fixed. Follow-up observations on May 8, 2025, at 12:00 p.m. in the main kitchen with 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.

Based on observations of the physical environment of the dietary department, reviews of the pest control operators reports and interviews with residents and staff, it was determined that the facility failed to ensure an effective pest control program so that the facility was pest free. Findings include: A group meeting held at 10:30 a.m., on July 25, 2024 revealed that residents were dissatisfied with the pest control program at the facility. The residents said that they have repeatedly reported to administration that they have a rodent problem in the building. The Residents R11, R126, R101, R77, R107, R93 and R61 indicated that the mice are entering the building through the air conditioning/heating units inside their bedrooms. Observations of the food and nutrition department on July 23 and 24, 2024 confirmed entry ways and easy access to the building for common household pests (mice, roaches, flies). The wood surrounding the air conditioning unitcontained voids/holes from water damage. Observations revealed obvious chewing and burrowing by rodents. Mice droppings throughout 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 observations, review of clinical records, review of facility policy and interview with staff, it was determined that the facility did not ensure residents receive adequate supervision to prevent accidents for three of 29 residents reviewed (Residents R51, R126, R446). Facility did not ensure to provide environment free of potential hazards related to unlocked housekeeping storage rooms on two units. (Unit One North and Two North ) Findings include: Review of facility policy Hazardous Areas , Devices and Equipment, revised July 2017, indicates A hazard is defined as anything in the environment that has the potential to cause injury or illness such as: Equipment and devices that are left unattended or are malfunctioning, Sharp objects that are accessible to vulnerable residents, Open areas or items that should be locked when not in use, Access to toxic chemicals, Disabled locks, latches or alarms. Review of facility policy Shaving the resident, revised February 2018, indicates to review the resident's care plan to assess for any special needs of the resident, and if using 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 observations of care and services, clinical record review, interviews with residents and staff and reviews of policies and procedures, it was determined that the facility failed to ensure that two of 29 residents reviewed maintained acceptable parameters of nutritional status for usual body weight, desirable body weight and electrolyte values. (Residents R113, R118) Findings include: Review of the policy titled Nutritional assessment dated [DATE] revealed that it was the dietitian's responsibility to comprehensively assess each resident and their individual nutrition needs. As part of the nutritional assessment the multidisciplinary team was responsible for identifying the following components: usual body weight, usual meal and snack intake, food preferences and dislikes and preferred portion sizes. Clinical record review revealed a comprehensive assessment MDS (an assessment of care needs) for Resident R113 dated February 24, 2024. This assessment indicated that this resident was cognitively intact.…

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

Based on clinical record reviews, interviews with staff and reviews of policies and procedures, it was determined that the facility failed to ensure that one of 29 residents received medications consistent with professional standards of practice through an on going communication and collaboration of care with the dialysis care center. (Resident R113) Findings include: Review of the policy titled administering medications dated August 2022 revealed that it was the responsibility of the licensed nurse to administer medications safely and timely to each resident. the policy also indicated that medications are to be administered in accordance with the physician's orders, including any required time frames. Clinical record review revealed a admission MDS (an assessment of care needs) dated February 24, 2024 for Resident R113. The assessment indicated that this resident had diagnoses of heart failure, end stage renal disease (kidney failure requiring a course of dialysis to filter waste products from the blood) and diabetes mellitus (a metabolic disorder in which the body has high blood…

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 clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that it was free of medication error rate of five percent or greater, for 11 out of 31 medications reviewed. Findings include: Review of physician order for Resident R545, dated July 22, 2024, revealed an order to administer Gabapentin Oral Capsule 300 mg one time a day. On July 24, 2024, 9:19 a.m., Employee E20, a Licensed Nurse was observed administering to Resident R545, Gabapentin Oral Capsule 600 milligrams (mg) one tablet, by mouth. Interview with licensed nurse, Employee E20 at the time of the observation confirmed that the administration of 600 mg and not 300 mg as ordered by the physician. On July 25, 2024, at 12:19 p.m.,Employee E21, a Licensed Nurse, was observed administering to Resident R39, the following medications by mouth: 1 Vitamin D3 Tablet (Cholecalciferol), give 2000 mg by mouth one time a day for immune support. Employee E21 gave 1000mg two tablets) 2 amLODIPine Besylate Tablet 10 MG, Give 10 mg by mouth one time a day…

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 reviews of policies and procedures, interviews with staff, observations of the meals served throughout the facility, interviews with residents, reviews of resident council meeting minutes and planned menus, it was determined that the facility failed to take in consideration food preferences of seven of seven resident reviewed. (Residents R113, R54, R106, R132, R110, R77 and R11) Finding include: Review of the policy titled nutritional assessment dated [DATE], revealed that it was the responsibility of the dietitian and the multidisciplinary team to complete a comprehensive assessment of each resident to identify the resident's usual routines, meal and snack patterns, along with food preferences and dislikes. Observations of the noon meal service on July 25 and 26, 2024 revealed several Residents R113, R54, R106, R132, R110, R77 and R11 that were asking for substitiute food items instead of the planned menu entre being served. A group meeting held at 10:30 a.m., on July 25, 2024 revealed that 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of policies and procedures, observations of the operations within the food and nutrition department and interviews with staff, it was determined that the facility failed to ensure that food was stored, prepared, distributed and served in accordance with professional stadards for food service safety. Findings include: Review of the policy titled food prepartion and service dated October 2017 revealed that food preparation staff were responsible for adhearing to proper hygiene and sanitation practices to prevent the spread of foodborne illness. Review of the undated policy titled food safety requirements revealed that it was the policy of the facility to provide safe and sanitary storage, handling and consumption of foods and fluids. The policy indicated that the facility was responsible for ensuring the food service equipment and dish ware was not contaminated by poor personal hygiene and improper sanitation. Review of the dietary policy titled food receiving and storage dated October 2017…

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 facility policy as well as review of facility provided documentation, interview with staff, it was determined that facility did not maintain and implement a comprehensive program to monitor and prevent infections in the facility. Findings include: Review of facility policy 'Legionella Water Management Program,' revised July 2017, indicates that water management program includes identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria, including: 1) Storage tanks; 2) Water heaters; 3) Filters; 4) Aerators; 5) Showerheads and hoses; 6) Misters, atomizers, air washers and humidifiers; 7) Hot tubs; 8) Fountains; and Medical devices such as CPAP machines And specific measures used to control the introduction and/or spread of legionella (e.g., temperature, disinfectants); The control limits or parameters that are acceptable and that are monitored; A diagram of where control measures are applied; A system to monitor control limits and the effectiveness of control measures; A plan 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 facility provided documentation, review of policy, and interview of staff, it was determined facility did not ensure to designate one or more individual as the infection preventionist and therefore did not meet the requirement for professional and specialized training. Findings include: Review of facility policy surveillance for infections, revised September 2017, indicates that The Infection Preventionist will conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions. A request for a copy of the approved Infection Preventionist specialized training in infection prevention and control certification was made to the nursing home director of nursing, employee E1 on July 26, 2024 at 1:00 p.m. Director of Nursing did not provide the documentation that the facility employed an Infection Preventionist who completed specialized training in infection prevention…

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 facility policy, clinical record review, and interviews with staff, it was determined that the facility failed to ensure a resident was free from misappropriation of personal property for one of three residents reviewed. (Resident R143). Findings Include: Review of facility policy titled, Personal Property with a revision date on August 2022 states, Resident are permitted to retain and use personal possessions, including furniture and clothing, as space permits, unless doing so would infringe on the rights or health and safety of other residents. 2. Resident belongings are treated with respect by facility staff, regardless of perceived value. 6. The resident's personal belongings and clothing are inventoried and documented upon admission and updated as necessary. Review of Resident R143's closed record revealed the resident had an inventory sheet completed April 15, 2024 upon admission to the facility. The inventory had items listed on the bottom portion of the form labeled admission Inventory. The following items were listed on the record: one jacket, one shaving…

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 facility documentation, facility policy, clinical records, and interview with staff and residents, it was determined that the facility failed to conduct a thorough investigation related to misappropriation of resident property and did not have evidence that all alleged violations were thoroughly investigated for one of 29 residents reviewed. (Resident R70) Findings include: Review of facility policy 'Internal Investigation of Violations Checklist,' indicates that it is important to investigate internal allegations of misconduct in a thorough and consistent manner. Policy further indicates to consider providing training to the offender and to all employees, and consult outside counsel if necessary. Review of facility provided investigation report, dated April 30, 2024, revealed that Resident R70 with brief interview of mental status score (BIMS) of 14, informed facility of missing funds from personal bank account. Resident R70 was able to identify two employees, housekeeper, Employee E12, and activities aide, Employee E11, as alleged perpetrators. According 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 review of facility documents of Quality Assurance meeting attendance and staff interviews, it was determined that the facility failed to ensure that the Infection Preventionist and Medical Director or their designee attended a quarterly Quality Assurance Process Improvement (QAPI) committee meetings for one of four quarters (February 2024 through June 2024). Findings Include: A review of QAPI committee meeting sign in-sheets revealed no sign in sheets for the month of February 2024, March 2024, April 2024, or June 2024. Further review of the QAPI binder revealed a sign in sheet for month of May 2024 that lacked an Infection Preventionist and Medical Director. Interview with the Director of Nursing, Employee E1 and the interim Nursing Home, Administrator Employee E2 on July 29, 2024 at 12:20 p.m. revealed there has not been an Infection Preventionist employed at the facility since February 2024. Further interview with Employee E1 and E2 revealed the Medical Director has been invited to the QAPI meetings but has not attended or picked a designee to attend since their time 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 interviews with facility staff and review of facility documentation, it was determined that the facility did not initiate the grievance process for one of three residents reviewed (Resident R2). Findings include: Review of facility documents revealed that resident R2 reported an incident of alleged verbal abuse to administration. The incident occurred on May 9, 2024. The nature of the allegation was that the resident asked to change the TV channel and a nursing aide yelled at the resident. An interview was conducted with Nursing Home Administrator, Employee E1 on June 6, 2024, at 1:00 p.m. Employee E1 confirmed that he and the director of nursing met with the resident regarding her concern. The allegation of verbal abuse was reported to the State Survey Agency and that an investigation was initiated. Employee E1 acknowledged that the resident's complaint was not processed as a grievance. 28 Pa. Code 201.29(a)(d)(k) Resident rights

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, review of facility documentation, clinical record review and interviews with residents and staff, it was determined that the facility failed to ensure that an elopement incident and a transfer to the hospital as a result of a possible drug overdose were reported the the State Survey Agency for two of six residents reviewed (Resident R1 and Resident R2). Findings include: Review of facility, Abuse Policy revised April 20, 2023, revealed that Administrator or designee is responsible for operationalizing all policies and procedures that prohibit abuse and neglect. They are also required to report instances of suspected or actual abuse or neglect occurring within the facility. Review of the clinical record for Resident R1 revealed that she was admitted to the facility on [DATE], for care after pelvic fracture from being struck by a motor vehicle. Further review of Resident R1's clinical record revealed a history of substance abuse. Review of nursing note by Licensed nurse,…

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 a review of facility documentation, it was determined that the facility was not maintaining an effective pest control program. Findings include: Interview with Resident R8 in room [ROOM NUMBER], on April 1, 2024, at 11:40 a.m. revealed that the resident had often seen mice in the facility. Interview with Resident R9 in room [ROOM NUMBER], on April 1, 2024, at 11:43 a.m. revealed that the resident had often seen mice in the facility, and the exterminator too. Interview with Resident R10 in room [ROOM NUMBER], on April 1, 2024, at 11:45 a.m. revealed that the resident saw mice in the facility in the past. Interview with Resident R11 in room [ROOM NUMBER], on April 1, 2024, at 11:50 a.m. revealed that the resident often had seen mice and roaches in the facility, the mice run from room to room. I stomped my foot and they don't even run away, just look at you. Interview with Resident R12 in room [ROOM NUMBER], on April 1, 2024, at 11:00 a.m. revealed that the resident had…

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

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 ensure that one of XXX residents reviewed received psychiatric consultations as ordered by the physcian.(Resident Cl1) Findings include: Review of Resident Cl1's clinical record revealed that the resident was admitted admitted on [DATE], with a history of delirium and confusion due to a diagnosis of hepatic encephalopathy (a loss of brain function as a result of failure in the removal of toxins from the blood due to liver damage). Review of Resident Cl1's admission Minimum Data Set (MDS- an assessment of care needs) dated February 15, 2024, indicated that the resident had moderately impaired cognition. The assessment also indicated that Resident Cl1 was exhibiting behaviors of inattention and disorganized thinking. Review of Resident Cl1's Cl1's physician notes dated February 28, 2024 indicated that Resident Cl1 had increased anxiety and pacing behaviors. The resident had several elopment attempts from 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, facility documentation and interviews with staff, it was determined that the Nursing Home Administrator and the Director of Nursing failed to effectively manage the facility related to to the proper discharge on one of three residents reviewed (Resident Cl1) and resulted in an Immediate Jeopardy situation. Findings include: Review of the job description for the Nursing Home Administrator revealed, The Administrator is responsible for directing the day-to-day functions of the facility in accordance with current federal, state and local standards governing long-term care facilities to ensure that the highest degree of quality resident care and services are delivered and maintained. He/she will ensure all personnel are treated fairly and consistent with company policy and applicable laws .Ensures that each resident received the necessary nursing, medical, and psychological services to attain and maintain the highest possible mental and physical functional status .Interprets…

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 facility policy, observation, review of clinical records, interview with staff and residents, it was determined the facility failed to ensure that medications were administered in accordance with professional standards for two of five residents reviewed (Resident R1 and Resident R2). Findings include: Review of facility policy on administering medication with last revision date of August 2022 revealed that under policy statement: medications are administered in a safe and timely manner and as prescribed. Under policy interpretation and implementation: The Director of Nursing Services, supervises, and directs all personnel who administer medications and or have related functions. #4. Medications are administered in accordance with prescriber orders. Including any required time frame. #5. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: A. enhancing optimal therapeutic effect of the medication. B. preventing…

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 facility policy, interview with staff, and review of clinical records, it was determined that the facility failed to maintain proper infection control practices during care for one of two residents reviewed (Resident R1) Findings include: Review of facility policy on Infection Prevention and Control Program with revision date of July 2022, under section Policy revealed that it is the policy of the facility to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections. Under section Policy Explanation and Compliance Guidelines #2. The RN's (Registered Nurse) and LPN's (Licensed Practical Nurse) supervise direct care staff in daily activities to assure appropriate precautions and techniques are observed, assess the resident's isolation needs, initiate appropriate precautions in accordance with our established policies and 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 observations and interviews with residents and staff, it was determined that the facility failed to maintain a safe and homelike environment on one of three nursing units observed (1 North unit). Findings include: Interview on October 10, 2023, at 1:39 p.m. Resident R1 stated that the facility does not keep any foods in the pantry on the 1 North unit and that he would like to have access to snacks due to his diabetes (ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of blood sugar levels). Observation on October 10, 2023, at 1:54 p.m. Employee E7, nurse aide, was in the 1 North pantry room preparing cups of ice for residents. Continued observation revealed that there were no foods, snacks or beverages readily available for residents. Further observation revealed that multiple cabinets and shelves were broken and unusable in the pantry room. Employee E7, nurse aide, confirmed that the cabinets and shelves were broken and unusable and that no foods were stored in the room. Observation on…

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

Based on clinical record reviews and interviews with residents and staff, it was determined that the facility failed to follow physician orders related to blood sugar monitoring for one of six residents reviewed (Resident R1). Findings include: Interview on October 10, 2023, at 8:50 a.m. Resident R1 stated that the facility does not effectively assist him with managing his diabetes (ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of blood sugar). Review of Resident R1's care plan, dated initiated July 30, 2020, revealed that the resident is at risk for hyperglycemia (high blood sugar) and hypoglycemic (low blood sugar) episodes related to diabetes. Interventions include to administer medications as ordered by the physician, monitor blood sugar as ordered by the physician and report to the physician any signs of hyperglycemia. Review of physician orders for Resident R1 revealed an order, dated September 1, 2023, for Novolin R insulin (regular insulin - medication used to lower blood sugar levels)…

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 reviews and interviews with staff, it was determined that the facility failed to ensure complete and accurate documentation of medications and assessments for two of six residents reviewed (Residents R5 and R6). Findings include: Review of Resident R5's admission MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated September 7, 2023, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including diabetes (ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of blood sugar), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe) and surgical amputation of left leg below the knee. Review of Medication Administration Records (MARs) for Resident R5 revealed that on October 9, 2023, during the evening shift, the following medications and assessments were not documented: Assess for pain every…

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.