Avantara Pierre

Based on observation, interview, record review, and policy review, the provider failed to ensure an in-room call light (a device activated by a resident to alert staff for assistance) was accessible for one of one sampled resident (2) to use. Findings include:1. Observation and interview on 6/29/26 at 5:00 p.m. with resident 2 in his room revealed that he sat in his wheelchair near the television. The resident's hands had a tremor. The television was on the west wall of his room. There was a red mat on the floor on the exit side of the resident's bed. The head of the resident's bed was on the east wall of the room. The resident stated that the non-skid red mat was used to steady his feet and reduce his risk of falling when he stood up from his bed. He was not supposed to stand up without having staff with him. He had Parkinson's disease (a progressive neurological disorder that primarily affects movement). The resident's call light was wrapped around and secured with medical tape to the top of a positioning pole near the head of his bed. The call light was attached to the call light…

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 South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interviews, and policy review the provider failed to ensure the on-call physician was notified of complaints of acute pain by one of one sampled resident (1) for determination of treatment. This citation is considered past non-compliance based on review of the corrective actions the provider implemented immediately following the incident. Findings include: 1. Review of provider's 4/2/25 SD DOH FRI revealed: *Resident 1 was admitted on [DATE]. *On 4/2/25 resident 1 reported to senior regional nurse consultant (SRNC) A that he was having trouble with two-night nurses and he expressed: -They were mean to him. -They would not get him water. -They would not give him pain medication. *Resident 1's pertinent diagnoses are: -Cirrhosis of liver (liver damage and scaring). -Diabetes Mellitus type II. -Cardiomyopathy (a disease that makes it harder to pump blood through the heart) -Unspecified convulsions. -Difficulty 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 observation, interview, record review, Voluntary Agreement for Arbitration review, and policy review, the provider failed to ensure 50 of 55 residents (1, 2, 3, 4, 5, 7, 10, 12, 13, 15, 16, 19, 20, 21, 22, 24, 25, 26, 27, 28, 29, 30, 31, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 46, 47, 48, 50, 104, 105, 106, 115, 154, 156, 204, 205, 206, 304, 305) who had entered into an Arbitration Agreement upon admission to the facility were explicitly granted the right to rescind the agreement within 30 calendar days of signing it. Findings include: 1. Observation and interview on 3/31/25 at 1:25 p.m. with resident 34 in her room regarding the Voluntary Agreement for Arbitration addendum she had signed upon admission revealed she: *Knew she signed several papers when she was admitted . *Was not sure what a Voluntary Agreement for Arbitration was for. *Did not recall signing a Voluntary Agreement for Arbitration specifically. Review of resident 34's electronic medical record (EMR) revealed: *She was admitted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, testing, and policy review, the provider failed to ensure adequate temperatures for three of three sampled residents (24, 27, and 304) who expressed their rooms were cold and uncomfortable. Findings include: 1. Observation and interview on 3/30/25 at 4:40 p.m. in resident 27's room revealed: *The temperature of the room felt cold in comparison to other areas within the facility. *The resident was in bed and covered with blankets. *The window shade was down with a blanket along the bottom edge of the window. *The resident stated: -She would get into her bed under the blankets to stay warm. -The room was cold and she had no control over the temperature in her room. -The maintenance man would check the boiler when she reported her room was cold, but her room temperature would remain cold and uncomfortable for her. 2. Review of resident 27's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *She had a Brief Interview for Mental Status (BIMS)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to ensure resident care plans reflected the residents' current needs and/or to provide interventions as directed on the care plans for four of twenty sampled residents (3, 34, 205, and 206) as follows: *Interventions were not provided as directed on the care plan for resident 3 who required a fall mat and a call light within her reach. *The care plan did not include interventions to prevent the development of a pressure ulcer for resident 205. *Interventions were not provided as directed on the care plan for resident 206 who required the use of a positioning alarm. *The care plan did not include interventions for lymphedema (condition causing swelling in the arms or legs) wraps for resident 34. Findings include: 1. Observations on 3/30/25 at 3:05 p.m., 4:44 p.m., 5:06 p.m. and 5:13 p.m. of resident 3 revealed: *She was in her bed which was in a low position and against the wall. *The privacy curtain was tucked between the bed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and manufacturer's manual review, the provider failed to ensure appropriate infection control practices were followed for: *Enhanced barrier precautions (EBP) (gloves and gown use when providing direct contact care) by two of two certified nursing assistants (CNAs) ( J and S) for one of one sampled resident (205) with a catheter, multidrug-resistant organism (MDRO), and a pressure injury. *Appropriate whirlpool (WP) tub cleaning by two of two CNAs (F and I) in one of two WP tub rooms used for bathing residents. *Maintaining the cleanliness of the laundry room. Findings include: 1. Observation on 3/30/25 at 5:26 p.m. with resident 205 revealed: *There was a sign on his door that indicated Stop Enhanced Barrier Precautions Everyone must: Clean their hands, including before entering and leaving the room. Providers and staff must also: Wear gloves and a gown for the following high-contact resident care activities dressing bathing/showering, transferring, changing linen…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (24) who self-administered medications was able to safely self-administer those medications and had a physician's order for self-administration of medications per the provider's policy. Findings include: 1. Observation and interview on 3/30/25 at 5:10 p.m. in resident 24's room revealed: *The resident was sitting in his recliner chair, administering a nebulizer (a liquid medication that turns into mist and is inhaled through a mask or mouthpiece via a small machine) treatment. *There was a medication cup that contained one medication tablet on the resident's bedside table. -The resident indicated the medication was Tums (an antacid medication). *A bottle of nasal spray (Fluticasone Propionate) was on the resident's bedside table. *He stated that he was able to administer medications and the nebulizer treatment independently in his room, just as he would at home. 2. Review of resident 24's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the provider failed to ensure one of five sampled residents (28) had received a bed hold notice upon her transfer out of the facility to the emergency room (ER). Findings include: 1. Review of resident 28's electronic medical record (EMR) revealed: *She was transferred to the emergency room for evaluation on 11/18/24. *Her emergency contact had been notified 11/18/24 of the need for an emergency room evaluation. *No documentation indicated she had received the bed hold policy information. *She was readmitted on [DATE]. *A written notification of the bed hold was signed by the resident and her representative on 11/27/24. 2. Interview on 4/2/25 at 10:15 a.m. with administrator A regarding the bed hold for residents that required to be transferred to the ER or hospital revealed: *He confirmed resident 28 was transferred to the ER on [DATE]. *The social services director was to follow up with the resident or resident representative for the bed hold as needed. *It…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the provider failed to ensure the implementation of their smoking policy for one of one sampled resident (11) who smoked and was not assessed for smoking risks and safety. Findings include: 1. Review of resident 11's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *She had a history of being burned while smoking, preferring to smoke down to the filter of the cigarette. *Her current care plan had a focus area that indicated she preferred to smoke and had the potential for injury. That focus area was initiated on 9/28/21 and revised on 5/10/22. *Interventions for the focus area included: -Ascertain her wishes about smoking and respect her decision. -Assess her ability to smoke independently/safely. Staff were to supervise her while she was smoking. -If the weather was below zero, she was not allowed to smoke. -She was to use a cigarette extender and a protective smoking apron to prevent her from further burns when she smoked. -She could…

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

Based on observation, interview, record review, and policy review, the provider failed to: *Maintain the dishwasher, scoop storage drawer, ceiling ventilation fans, ceiling pipes, and floor drains in a clean and sanitary manner to prevent the buildup of crumbs, rust, grime, limescale, and dust. *Ensure one of three reach-in refrigerators was maintained at a temperature below 41 degrees Fahrenheit to prevent the potential growth of foodborne illness-causing bacteria. *Ensure the high-temperature dishwasher reached a minimum temperature of 180 degrees Fahrenheit during the rinse cycle to adequately sanitize dishware. *Properly store two food items that had manufacturer's labels that read refrigerate after opening. Findings include: 1. Observation and interview on 1/7/24 from 2:11 p.m. through 2:38 p.m. in the kitchen revealed: *The reach-in refrigerator that was located to the left of the steam table had a Refrigerator Temperature Log taped to the door. There were nine recorded instances of temperatures above 41 degrees Fahrenheit for the month of January. *Interview with dietary…

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

Based on observation, interview, record review, policy and procedure and job description the provider failed to ensure the facility was operated and administered by administrator A, in a manner that ensured the safety and overall well-being of all 52 residents in the facility. Findings include: 1. Refer to F812, finding 1 2. Observation on 1/7/24 at 1:52 p.m. revealed the posted nursing staffing information was not consistently posted. 3. Interview on 1/9/24 at 3:52 p.m. with administrator A revealed: *He stated if he knew Minimum Data Set (MDS) coordinator D was gone, he would have assigned another staff member to have completed the posted nurse's staffing information. *He had been attending quality assurance and performance improvement (QAPI) monthly. *When staff called in to say they could not work, the nurses attempted to find a replacement. If they had not been able to, then the nurse management worked the floor. *He was not aware the kitchen refrigerator temperature had been getting too high and the dishwasher temperature had not been getting high enough. -He stated he…

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

Based on record review, interview, and review of the Hospice and Nursing Facility Services Agreement, the provider failed to ensure there was current collaborative communication documented and accessible between the provider and hospice agency for three of three sampled residents (24, 33, and 50) receiving hospice services. Findings include: 1. Review of resident 24's electronic medical record (EMR) revealed: *Hospice services had been initiated on 11/14/23. *There was no Hospice tab or any hospice agency documentation found in the resident's paper chart. 2. Review of resident 33's EMR revealed: *Hospice services were initiated on 10/14/22. *Behind the Hospice tab in that resident's paper chart was the hospice agency's Hospice Plan of Care/Care Plan Summary dated 7/27/23 through 9/24/23. 3. Review of resident 50's EMR revealed: *Hospice services were initiated on 8/23/23. *Behind the Hospice tab in that resident's paper chart was the hospice agency's Care Plan Summary dated 8/23/23 through 11/23/23. Interview on 1/8/24 at 9:15 a.m. with an unidentified hospice agency masseuse…

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 interview, policy review, and quality assurance and performance improvement (QAPI) plan, the provider failed to ensure performance improvement projects (PIP) had been thoroughly implemented, monitored, and resolved with an effective QAPI process. Findings include: 1. Interview on 1/9/24 at 3:52 p.m. with administrator A revealed: *The provider held QAPI meetings monthly. *They used information from each department audits, grievances (from family or staff), and resident council minutes. *They ranked identified issues and then prioritized the issues from that listing. -They had falls and bathing for their PIPs. *When staff were calling in, the nurses would attempt to find a replacement. If they were not able to find a replacement, then the nurse management would work the floor. *He was unaware the kitchen refrigerator temperature had been getting too high and the dishwasher temperature had not been getting high enough. -He stated he completed audits in the kitchen from January 2023 through September 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.

Based on observation, interview, and policy review, the provider failed to ensure daily staffing information was consistently posted. Findings include: 1. Observation on 1/7/24 revealed: *At 2:00 p.m. the staffing information that was posted was for 1/5/24. *At 5:30 p.m. the posted staffing information referred to above was replaced with updated staffing information for 1/7/24. Interview on 1/7/24 at 5:30 p.m. with Minimum Data Set (MDS) coordinator/registered nurse (RN) D regarding the posted staffing information referred to above revealed she: *Had removed the 1/5/24 posted nurse staffing information at about 2:30 p.m. and replaced it with nurse staffing information for 1/7/24. *Was responsible for posting daily staffing information. -Nursing staff were responsible for updating her posted staffing information each shift with any staffing changes such as a staff member calling out for their scheduled shift. Continued interview and review of the daily staffing information posted between 12/15/23 and 1/7/24 revealed: *No staffing information was posted from 12/29/23 through 12/31/23,…

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

Based on observation, interview, record review, and policy review, the provider failed to accommodate one of one sampled resident's (33) clothing, activity, and mealtime preferences. Findings include: 1. Observation and interview on 1/7/24 at 6:05 p.m. with resident 33 in her room revealed she: *Was in bed dressed in a hospital gown. *Waited for staff to help feed her the evening meal. -There was no reason why she had eaten meals in her room and stated she would have liked to have been asked by staff to go out to the main dining room and eat her meal. *Liked to play bingo and got a nickel when she won. Interview on 1/7/24 at 6:15 p.m. with certified nurse aide (CNA) T in resident 33's room revealed: *She was not aware why the resident was not eating in the dining room and had not known the resident wanted to be asked where she preferred to eat her meals. -We'll have to start taking you to the dining room [for meals] but she had not offered to take the resident to the dining room that evening. Random observations and interviews on 1/8/24 from 9:13 a.m. through 2:40 p.m. with resident…

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

Based on record review, interview, and policy review, the provider failed to ensure a Bed Hold Notice form was given to one of one sampled resident (38) prior to transfer to the hospital. Findings include: 1. Review of resident 38's electronic medical record (EMR) revealed: *On 6/17/23, she was transferred to the hospital when she had multiple episodes of vomiting with pain in her right lower abdomen. The bed hold forms were requested from DON B on 1/9/24 at 9:00 a.m. for the above hospital transfer for resident 38 and the facility was not able to produce that documentation. Interview on 1/9/24 at 1:40 p.m. with licensed practical nurse (LPN) I revealed: *She usually worked the night shift. *If a resident was to have been transferred, they would have the resident sign a Bed Hold Notice form located at the nurse's station. *The form would then be placed at the nurse's station for the day shift to file in the resident's electronic medical record (EMR). *If the resident was not able to sign the form, the resident's name would have been written on the form and the day shift would take…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the provider failed to ensure two of two recently admitted sampled residents (6 and 157) had a baseline care plan that was established within 48 hours of admission and reviewed with the resident, their representative, or their responsible family member. Findings include: 1. Review of resident 6's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *There was a Nursing-Admission/Readmission assessment that was completed on 8/30/23. *Within the first 48 hours after she was admitted to the facility, the following was the only information included in her baseline care plan: -I am at risk for alteration in nutritional status related to: Dementia. Date Initiated: 8/30/23. --There were no goals or interventions associated with that focus area until 9/6/23. -The rest of her care plan was not developed until 9/6/23, a week after she was admitted . *There was no indication in her EMR that a baseline care plan was developed or shared with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, review of a facility-reported incident (FRI), and policy review, the provider failed to ensure one of one closed record sampled resident (258) with a do not resuscitate (DNR) code status who had no pulse or respirations when found by staff had not received cardiopulmonary resuscitation (CPR). Findings include: 1. Review of resident 258's closed electronic medical record (EMR) revealed his: *admission date was [DATE] and he was [AGE] years old. *Medical history included an acute bilateral subdural hematoma (bleeding on the brain). *Resuscitation Designation Order form signed on [DATE] by business office manager O, the resident's representative, and the resident's physician indicated his resuscitation code status was a DNR. Review of the FRI submitted by administrator A to the South Dakota Department of Health on [DATE] revealed: *On [DATE] at 12:25 a.m. certified nurse aide R (CNA) answered resident 258's call light and straightened his urinary catheter bag from under his leg.…

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

Based on observation, interview, record review, and policy review, the provider failed to: *Monitor and implement bowel management interventions for one of one sampled resident (50) who received hospice services. *Provide appropriate duration and meaningful activities to maintain the well-being for one of one sampled resident (8) with unique psychosocial needs. Findings include: 1. Random observations of resident 50 in her room throughout the survey revealed: *On 1/7/24 at 2:45 p.m. she was in bed with her eyes closed. *On 1/8/24 at 9:15 a.m. she was in bed with her eyes closed. -At 12:25 p.m. she fed her noon meal by staff in bed. -At 2:40 p.m. she was in bed with her eyes closed. *On 1/9/24 at 8:15 a.m. she was in bed with her eyes closed. *The resident was non-verbal during the above observations and displayed no indications that she was in pain. Review of resident 50's electronic medical record (EMR) revealed: *Her diagnoses included Alzheimer's disease, stroke, dysphagia, and severe protein-calorie malnutrition. *An 8/23/23 physician's order for admission to hospice services.…

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

Based on record review, interview, and policy review, the provider failed to ensure the resident, their representative, physician, and a registered dietitian (RD) had been notified of a significant weight loss for one of one sampled resident (21). Findings include: 1. Review of resident 21's weight history revealed: *On 9/12/23, she weighed 316.6 pounds (lbs.). *On 10/9/23, she weighed 320.6 lbs. *There were no weights recorded in November 2023. *On 12/6/23, she weighed 321.4 lbs. *On 12/30/23, she weighed 321.3 lbs. *On 1/2/24, she weighed 301.8 lbs., which was a 19.5 lbs. and 6.32% (percent) weight loss in 3 days. *On 1/4/24, she weighed 301.7 lbs. Review of resident 21's electronic medical record revealed: *There was no indication that the resident, her representative, her primary care physician, or an RD was notified about the significant weight loss. 2. Interview on 1/9/24 at 9:10 a.m. with director of nursing (DON) B about resident 21's significant weight loss revealed: *When a resident's weight was entered into their electronic medical record, the program calculated 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, interview and policy review, the provider failed to clean one of one sampled resident's (210) nebulizer mask after providing and aerosol treatment. Findings include: 1. Observation on 1/8/24 at 10:50 a.m. of licensed practical nurse (LPN) E while performing resident 210's nebulizer treatment revealed she: *Removed the nebulizer mask from the resident's face after the treatment was completed. *Placed the mask on the resident's nebulizer machine. *Did not rinse and disinfect the mask after the treatment was completed. Interview on 1/9/24 at 11:36 a.m. with infection prevention/licensed practical nurse (LPN) F regarding the above observation revealed she would have expected that the staff would have rinsed the nebulizer mask after the treatment was completed. Interview on 1/9/24 at 3:18 with director of nursing (DON) B revealed: *She would have expected the staff to follow the nebulizer policy which includes rinsing and disinfecting the nebulizer mask after nebulizer treatments were completed. Review of the provider's undated ORAL INHALATION ADMINISTRATION policy…

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

Based on observation, interview, and policy review, the provider failed to ensure: *Resident medications were secured in one of two medication (med) carts that was left unattended and unlocked by the staff member administering meds. *Resident's personal information was secured on the computer that was sitting on the med cart. Findings include: 1. Observation and interview on 1/8/24 at 10:45 a.m. with licensed practical nurse (LPN) E revealed: *The med cart was located in the hallway outside of a resident's room. *The med cart computer screen was opened to a resident's electronic medical record (EMR). *She was administering a nebulizer treatment for two residents who were roommates in their room. *The med cart was unlocked. *The med cart contained meds for all the residents that resided in that hallway. *The director of nursing (DON) B observed the surveyor opening the drawers of the medication cart and requested that LPN E come out to the medication cart and speak with her. *LPN E agreed that she should have locked the med cart and the computer screen when she walked away 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, interview, and menu review, the provider failed to follow the written menus for seven of seven sampled residents (5, 10, 13, 19, 25, 28, and 50) who received a pureed diet, and one of one sampled resident (9) who received a mechanical soft diet with pureed meats. Findings include: 1. Observation and interview on 1/9/24 from 11:10 a.m. to 11:56 a.m. with cook J in the kitchen revealed: *He was placing pans of food into the steam table. *He placed a green-handled scoop into the pureed broccoli, a gray-handled scoop into the mashed potatoes, and a blue-handled scoop into the pureed pork chops. *He was not sure what the scoop sizes were because the scoop size number on the scoops had either worn away or was not visible, and there was no guide to associate the color of the scoop handle with the serving size of the scoop. *The resident tray tickets indicated their diet order and specified the food item serving sizes. -Those residents who received a pureed diet were to have been served 4 ounces (oz.) (equates to 1/2 cup) of pureed pork, 4 oz. of mashed potatoes, 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.