Avir at Coronado

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to maintain medical records on each resident that are complete, accurately documented, readily accessible and systematically organized for 1 of 19 (Resident #54) residents reviewed for nursing assessments. The facility failed to ensure readmission Assessment was included in the medical record for Resident #54 after hospitalization on 4/18/2026 per facility policy.This failure could put residents at risk of records not being completed and staff not having all information needed to provide quality care to its residents.Findings included:Record review of Resident #54'a electronic face sheet, dated 04/22/2026, reflected she was a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses including diastolic congestive heart failure (left lower chamber in the heart cannot fill with blood properly reducing blood flow to the body), atrial fibrillation (irregular heartbeat that can prevent the heart from pumping 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 observation, record review, and interview, the facility failed to store drugs and biologicals in locked compartments during medication storage inspection for 1 (medication Cart #1) of 1 medication cart reviewed for storage. The facility failed to store drugs and biologicals in locked and secured while unattended. This failure could place residents at risk of drug diversion.Findings included:During an observation on 10/14/2025 at 1:00 PM, medication cart #1 was observed unlocked outside of the nurse's station, prior to entering the hallway. Residents and staff were observed approximately within 10 feet of the cart out of eyesight from staff, with unlocked drawers facing outward. On top of the unsupervised cart were observed a butter knife, nail clippers, mouth wash and an unopened package of petrolatum dressing. The top drawers were observed as having glucometers, lancets, lab draw kits with included needles, hand sanitizer, zinc oxide skin protectant creams, and moisture barrier creams. The second drawer contained OTC medications such as Milk of Magnesia, cough suppressant,…

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 and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and describes the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 6 of 6 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6) reviewed for comprehensive person-centered care plans. 1. The facility failed to develop a care plan based on assessed needs with measurable objectives in the areas of Hospice, Encephalopathy, Seborrheic dermatitis, Anxiety Disorder, Trisomy 21, Hepatitis B, Hyperlipidemia, Gastro-esophageal reflux disease, without esophagitis, Fatty Live, and Unspecified Convulsions, Dementia for Resident #1. 2. 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 interview and record review, the facility failed to ensure the comprehensive care plan was prepared by an interdisciplinary team, that included but not limited to a nurse aide with the responsibility for the resident for 6 of 6 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6) reviewed for care plans. The facility failed to ensure the nurse aides with responsibility for the residents were invited and attended the resident care plan conferences. This failure could place residents at risk for not receiving the care and services to meet their needs.The findings include: 1. Record review of Resident #1's Facesheet, dated 07/09/2025, revealed a [AGE] year-old male, with an admission date into the facility of 05/08/2025. Resident #1 had a diagnosis which included Encephalopathy (a broad range of conditions that cause brain dysfunction, leading to altered consciousness, cognitive impairment, and neurological symptoms), unspecified. Record review of Resident #1's admission…

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, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitization. 1. The facility failed to ensure ground meat was thawed properly. 2. The facility failed to ensure the cook performed hand hygiene appropriately when preparing food. 3. The facility failed to ensure foods were sealed and/or labeled properly. 4. The facility failed to ensure the foods were not stored past expiration date. Thess failures could place residents that eat out of the kitchen at risk for contamination and foodborne illnesses. Findings included: During an observation of the kitchen on 01/19/2025 between 2:15 p.m. - 2:50 p.m. revealed the following: Sink: 1 plastic dish sitting in a sink with 4 tubes of ground meat sitting vertically in the dish that was filled with water and water running into the container. The ground meat was not submerged in the water 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 interview and record review, the facility failed to ensure residents/resident's representative had the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he/ she preferred for 2 of 23 residents (Resident #29 and Resident #44) reviewed for antipsychotic consents. 1. The facility failed to ensure Resident #29 or their representative signed consent for antipsychotic medication Seroquel (quetiapine) (an antipsychotic medication used to treat mental health disorders, such as schizophrenia) prior to administering medication and after dosage increased and prior to administering new dosage ordered by physician. 2. The facility failed to ensure Resident #44's or their representative signed consent for antipsychotic medication Seroquel (quetiapine) prior to administering medication. These failures could affect residents by placing…

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 and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 6 of 23 residents (Residents #23, #26, #36, #39, #53, and #62) reviewed for care plans in that: 1. The facility failed to define measurable objectives on Resident #23's care plan regarding the problems of resisting care, visual function, oral hygiene, pain, mobility, cognitive loss, and daily tasks. 2. The facility failed to define measurable objectives on Resident #26's care plan regarding the problems of psychotropic drugs, psychosocial well-being, pain, mood, behaviors, activities of daily living and daily tasks. 3. The facility failed to define measurable objectives on Resident #36's care plan regarding the problems of mobility and daily tasks and failed to address on Resident #36's comprehensive…

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

Based on observation, interview, and record review, the facility failed to implement its policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption for 5 (Resident #5, Resident #17, Resident #22, Resident #43, and Resident #49) of 23 residents reviewed for food and nutrition services. The facility failed to ensure that Resident #17's personal refrigerator did not have expired goods stored and failed to log refrigerator's temperatures. The facility failed to ensure that Resident #43's personal refrigerator had a thermometer inside to check temperature and failed to log refrigerator ' s temperatures. The facility failed to ensure that Resident #22's personal refrigerator had temperature log during the month of February 2025 (last checked on 1/14/2025). The facility failed to ensure that Resident #5 ' s personal refrigerator had temperature log during the month of February 2025 (last checked on 1/22/2025). The facility failed to ensure that Resident #49 ' s personal refrigerator 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 observation, interview, and record review, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for (Resident #169) 1 of 23 resident's rooms observed for environmental conditions. The facility failed to ensure that Resident #169 ' s toilet was free from cracks at the base and was sturdily attached to the floor. The facility's failure placed the residents at risk for diminished quality of life, discomfort, and safety. The findings included: Record review of Resident #169's electronic face sheet dated 02/19/2025 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and most recently on 02/01/2025 with diagnoses to include: right foot drop (difficulty lifting the front part of the right foot and foot might drag on the floor when walking), muscle wasting and atrophy (breakdown of muscle fibers), muscle weakness, and unspecified abnormalities of gait and mobility. Record review of Resident #169's admission…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys for 1 (Resident #17) of 23 residents reviewed for medication storage. The facility failed to ensure medications were not left in Resident #17 ' s personal refrigerator. This failure could result in unauthorized persons having access to medication that was not intended for them or drug diversion. Findings included: During an observation and interview on 02/17/2025 at 11:42 a.m., Resident #17 ' s personal refrigerator had a bottle of prescription hydrocortisone (a steroid topical solution used for skin irritation) cream inside of the refrigerator with expiration date of 02/08/2025. Resident #17 stated just throw it away, I do not want anyone to get into trouble. Record review of Resident #17 ' s quarterly MDS dated [DATE] Section M – Skin Conditions revealed Resident #17 had intact skin with no pressure ulcers or other…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain 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 diseases and infections for 1 of 3 residents (Resident #18) observed for infection control. 1. The facility failed to ensure CNA B used the required PPE for Resident #18, (gown) who was on enhanced barrier precautions due to her Foley Catheter while performing Foley Catheter Care on 02/19/25. These failures could place the residents at risk of cross-contamination and development of infection. Findings included: Record review of Resident #18's face sheet, dated 2/18/25, reflected a [AGE] year-old female with an admission date of 2/15/19. Resident #1 had a diagnosis which included dementia, disorder of urinary system, and type 2 diabetes mellites. Record review of Resident #18's MDS dated [DATE] with a quarterly assessment dated [DATE] indicated BIMS of 8,…

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, interviews, and record reviews, the facility failed to provide the residents a safe, clean, comfortable, and homelike environment for 2 of 4 residents (Resident #3 and Resident #8) reviewed for the right of a homelike physical environment. The facility failed to ensure Resident #3 and Resident #8's bathrooms were free live cockroaches, and the air conditioner window unit filters were free of being clogged with lint. The failures placed residents at risk of an unsanitary and uncomfortable environment and a decrease in quality of life. Findings include: Record review of Resident #3's Facesheet, dated 12/18/2024, revealed Resident #3 was an [AGE] year-old female, with an admission date into the facility on [DATE] and diagnoses included Cerebral infraction, unspecified (a condition where blood flow to the brain is interrupted, leading to damage to the brain tissue without a specific cause), Generalized anxiety disorder (a chronic mental health condition characterized by excessive, persistent,…

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, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law procedures for 1 of 5 residents (Resident #3) reviewed for reporting allegations of abuse, neglect, and exploitation. The facility failed to report an allegation of abuse to the state agency when a family member of Resident #3 alleged Resident #3 had been abused…

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, and record review the facility failed to have evidence that all alleged violations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated and prevent further potential abuse or mistreatment while the investigation was in progress for 1 of 5 residents (Resident #3) reviewed for abuse. 1. The Administrator failed to investigate an alleged allegation of abuse when a family member of Resident #3 alleged Resident #3 had been abused by CNA B. 2. The facility failed to prevent further potential abuse or mistreatment by allowing CNA B to remain on duty after the facility became of aware of the alleged allegation of abuse. These failures could place residents at risk for abuse and neglect by not investigating and implementing preventive measures. Findings include: Record review of Resident #3's Facesheet, dated 12/18/2024, revealed Resident #3 was an [AGE] year-old female, with an admission date into the facility on [DATE] and diagnoses included Cerebral infraction, unspecified…

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 observation, interview, and record review, the facility failed to maintain an effect pest control program to keep the facility free of roaches for two (2) common areas, and for 2 of 4 residents (Resident #3 and Resident #8) reviewed for pest control program. The facility failed to ensure the facility was free of roaches The facility failed to ensure Resident #3 and Resident #8's bathrooms were free live cockroaches This failure could affect residents by placing them at risk for potential spread of infection, cross-contamination, and decreased quality of life. Finding include: Record review of Resident #3's Facesheet, dated 12/18/2024, revealed Resident #3 was an [AGE] year-old female, with an admission date into the facility on [DATE] and diagnoses included Cerebral infraction, unspecified (a condition where blood flow to the brain is interrupted, leading to damage to the brain tissue without a specific cause), Generalized anxiety disorder (a chronic mental health condition characterized by excessive,…

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 and record review, the facility failed to ensure that all allegations involving abuse, neglect, exploitation or mistreatment were reported immediately but not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 (Resident #1) of 16 resident reviewed for abuse or neglect. The facility failed to report to the State Survey Agency allegations of Abuse and Neglect when learning of an elopement of Resident #1. This failure could affect residents by placing them at risk of not having incidents of abuse and neglect being reviewed and investigated in a timely manner by the facility and State Survey Agency. The findings included: Record review of Resident #1's face sheet…

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 and record review, the facility failed to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the discharge was necessary for 1 (Resident #2) of 3 residents reviewed for discharge requirements. 1. The facility failed to ensure Resident #2 was provided a discharge in writing 2. The facility failed to document a discharge summary. This failure placed residents at risk of not receiving necessary care and services. Findings included: Record review of Resident #2 electronic face sheet revealed a [AGE] year-old male admitted on [DATE] with diagnosis Anxiety, Type II Diabetes Mellitus, Dysuria , Hypertension, Altered Mental Status, acquired absence of right leg below knee, Acquired absence of left leg below knee. Record review of Resident's #2 Discharge MDS assessment dated [DATE] revealed: Section C Cognitive Patterns #2's BIMS Score was 12 indicating moderate cognitive impairment. Section E Wandering behavior was not exhibited. Section…

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 interviews and record reviews, the facility failed to develop a comprehensive person-centered care plan based on assessed needs with the ability to be evaluated or quantified to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #1) of 13 residents reviewed for comprehensive person-centered care plans. The facility failed to ensure Resident #1's comprehensive care plan contained interventions that addressed his need for supervision for wandering. This failure could affect the residents by placing them at risk for not receiving care and services to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being. Findings included: Resident #1 Record review of Resident #1's face sheet dated 04/24/2024 revealed [AGE] year-old male admitted on [DATE] with diagnoses of Alzheimer's disease, type 2 diabetes mellitus (body does not make enough insulin or does not use insulin well), hypertension (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 observation, interviews, and record review the facility failed the have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident and determined by considering the number, acuity, and diagnoses of the facility's resident population with accordance with 1 of 1 facility reviewed for sufficient staffing The facility failed to ensure the facility had sufficient staffing based off of facility assessment. This failure could place the residents at risk of resident's needs, safety and psychosocial well-being not being met. The findings include: During an observation on 04/09/2024 at 9:45 a.m. staffing posting for 4/9/2024 revealed: census was 78 and there were 3 LVNs (36 hours) and 4 CNAs (48 hours) scheduled 12 hours on both day and night shift. Unit 1 had 2 LVNs and 3 CNAs working at this time with 61 residents. Unit 2, a secured unit, had 1 LVN and 1 CNA working at this time with 16 residents. Total of hours scheduled to be worked during…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the nessary care and services to attain the highest practicable, physicial, mental, and psychosocial well-being consisted for 2 (Resident #10 and Resident #12) of 12 residents reviewed for quality of life The facility failed to ensure Resident #10 received showers per resident's request. The facility failed to ensure Resident #12 transferred from bed to chair per resident's request. This failure could place residents at risk of a diminished quality of life and lead to a loss of self-esteem and isolation. Findings included: Resident #10 Record review of Resident #10's face sheet dated 04/09/2024 revealed [AGE] year-old female originally admitted on [DATE] with most recent readmission on [DATE] and the following diagnoses: candida stomatitis (yeast causing inflammation inside the mouth), cough, acute upper respiratory infection, pneumonia, osteoarthritis (degenerative joint disease) right ankle and foot, nicotine dependence (smokes…

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 and record reviews, the facility failed to accurately assess the residents' status for 4 (Resident #4, Resident #30, Resident #54, and Resident #324) of 6 residents reviewed for assessment accuracy. The facility did not accurately indicate on Resident #4, Resident #30, or Resident #54's MDS (Minimum Data Set) the results of a Brief Interview for Mental Status evaluation. The facility did not accurately indicate on Resident #324's MDS a urinary tract infection. These failures could place residents at risk for receiving inadequate or inappropriate care and services . Findings included: Review of Resident #4's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE] with medical diagnoses of major depression, bipolar disorder (a serious mental illness that causes extreme shifts in mood), schizoaffective disorder (a mental illness similar to schizophrenia but with added features that affect mood), and a history of traumatic brain injury. Review of the Brief Interview…

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 interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan based on assessed needs with measurable objectives that have the ability to be evaluated or quantified to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 (Resident #5, Resident #30, Resident #54, and Resident #65) of 7 residents reviewed for comprehensive person-centered care plans. 1. The facility failed to develop care plans based on assessed needs with measurable objectives and timeframes in areas such as bathing, impaired decision making related to insulin dosage, skin breakdown, adverse consequences related to antipsychotic medications, adverse consequences related to antianxiety medication, disruptive behaviors, keeping food and dirty dishes in her room, cognitive loss, compliance with medications and self-care, medication administration time preference, non-participation in activities, communication, elopement risk, PASRR…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to attempt to use alternatives prior to installing a side or bed rail and assess the resident for risk of entrapment from bed rails prior to installation for 3 of 3 residents (Resident #7, Resident #10, and Resident #13) reviewed for bed rails. The facility failed to assess residents for entrapment risks and attempt less restrictive measures prior to installing bed rails. These failures could place residents at risk for injury. The findings include: Resident #7 Record review of Resident #7's undated electronic face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease (a brain disorder that causes unintended and uncontrollable body movements), left shoulder pain, lack of coordination, and weakness. Record review of Resident #7's quarterly MDS assessment dated [DATE] revealed: Section C (Cognitive Patterns) BIMS assessment revealed a score of 14 meaning cognitively…

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 During an observation, interview, and record review, the facility failed to provide food prepared by methods that conserve nutritive value, flavor, and appearance as well as failed to provide food and drink that was palatable, attractive, and at a safe and appetizing temperature for 1 of 1 meal observed. The facility failed to provide a lunch meal that was flavorful and palatable. These failures can place residents at risk for weight loss. Findings Include: During an observation on 12/20/2023 at 11:41 AM, test meal arrived at 11:55 am. The meal consisted of Salisbury steak, cauliflower and broccoli vegetable mix, potato wedges, and a roll. The Salisbury steak and the cauliflower and broccoli vegetable mix was not flavorful and palatable. During an interview on 12/20/2023 at 3:30pm, DON stated that the meal was not flavorful and palatable. DON stated that if the food was more palatable, the residents would possibly eat more. DON stated that with the food not being flavorful and palatable, the residents could lose…

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, interviews, and record reviews, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for 1 of 1 kitchen observed. The facility failed to ensure that opened food was labeled and dated with date open. These failures place residents at risk for food borne illness Findings include: During observation on 12/18/2023 at 10:10 AM the facility kitchen revealed: Pantry: 1. One clear gallon bag that contained an opened bag of chips not labeled and no open date. 2. One clear gallon bag that contained an opened bag of what was labeled Tostitos with date received of 11/08 , and no open date. 3. One opened box labeled corn starch had an date received of 10/25, and no open date. Freezer #1: 1. One opened box labeled Homestyle Dinner Rolls had an in date 12/06, and no open date. 2, One opened box labeled Bread sticks had an in date 12/13, and no open date. 3. One opened box labeled Omelets had an in date 12/13, and no open date. Refrigerator #1: 1. One opened 5 lb bag labeled parmesan…

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, interviews, and record reviews, the facility failed to maintain infection control protocols to prevent infections for 1 of 2 resident (Resident #27) observed for catheter care needs. The facility failed to ensure CNA A used a peri-care cleaning wipe and cleaned catheter tubing toward the resident and not away toward catheter bag to clean catheter tubing. These failures place residents at risk for unnecessary infections while in the facility. Findings include: Record Review of Resident #27's undated electronic face sheet revealed she was a [AGE] year-old female, admitted to the facility originally on 02/15/2019 and most recently on 03/06/2023, with a diagnoses of urinary tract infection. Record Review of Resident #27's quarterly MDS assessment dated [DATE] revealed: Section C (Cognitive Patterns) revealed no BIMS score (test to determine cognitive status) and Section H (Bladder and Bowel) revealed resident had an indwelling catheter. Record Review of Resident #27's comprehensive care plan…

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 interview and record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation, and maintain an account of all controlled drugs for 1 of 24 controlled medications reviewed for security. The facility failed to ensure hydrocodone-acetaminophen 10-325mg, a prescribed narcotic medication, was secured. This failure could place residents at risk of not receiving prescribed narcotic medications and pain. Findings were: Record Review of the Provider Investigation Form 3613-A dated 10/13/2023 revealed on 10/06/2023 at 8:30 p.m., there were 180 tablets of hydrocodone-acetaminophen 10-325mg missing from the medication cart. Further review of Form 3613-A revealed the facility reviewed all medication counts for the resident since admission, and all medication carts were assessed to ensure medications were not placed in a different cart. The resident was discharged on the same day as the discovery of the missing medication and the resident was contacted to see if the 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 interview and record review, the facility failed to ensure that drugs and biologicals used in the facility were secured in accordance with currently accepted professional principals for 1 of 24 controlled medications reviewed for security. The facility failed to ensure hydrocodone-acetaminophen 10-325mg, a prescribed narcotic medication, was secured. This failure could place residents at risk of not receiving prescribed narcotic medications and pain. Findings were: Record Review of the Provider Investigation Form 3613-A dated 10/13/2023 revealed on 10/06/2023 at 8:30 p.m., there were 180 tablets of hydrocodone-acetaminophen 10-325mg missing from the medication cart. Further review of Form 3613-A revealed the facility reviewed all medication counts for the resident since admission, and all medication carts were assessed to ensure medications were not placed in a different cart. The resident was discharged on the same day as the discovery of the missing medication and the resident was contacted to see if the resident was discharged with the medication and advertently 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.