Avir at Beaumont

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 1 staff smoking area reviewed for environmental concerns. The designated staff smoking area was unkempt and had trash buried in the tall grass and weeds, This failure placed the staff and visitors at risk of uncomfortable environment. Findings included: During an observation on 06/16/25 at 1:00 p.m., the grass in courtyard between hall 200 and 300 was approximately 20 inches high and the weeds were over 4 feet tall. There were plastic wrappers trash and, paper towels, and cigarette butts were buried in the vegetation. During an interview on 06/16/25 at 2:00 p.m., Maintenance A said the maintenance department was responsible for ensuring the trash was picked up. He said this smoking area between hall 200 and 300 was for the staff and visitors smoking area. He said the areas should be maintained and be homelike for the 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 observation, interview, and record review, the facility failed to ensure that residents receiving enteral feeding received appropriate care and services to prevent complication of enteral feeding for 1 of 1 resident (Resident #2) reviewed for enteral feeding. The facility failed to ensure LVN Q mixed each crushed medications with water and administered one medication at a time when giving medications to Resident #2 through his G-tube (a tube inserted through the wall of the abdomen directly into the stomach which allows the delivery of nutrition, fluids, and medications directly into the stomach). The facility failed to ensure LVN Q administered Resident #2's G-tube medications by gravity, and instead she pushed the medications using the plunger of the syringe. These failures could place residents receiving enteral nutrition and medications at increased risk of not receiving proper nutrition, infection, and aspiration. Findings include: Record review of a face sheet dated 06/18/25 indicated Resident #2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles and provide separately locked, permanently affixed compartments for storage of controlled drugs for 1 of 21 residents (Resident #64) and 1 of 3 medication rooms reviewed for storage of medications and biologicals. 1. The facility failed to ensure the lockbox for controlled medications was permanently affixed to the refrigerator in the Hall 300 medication room. 2. The facility failed to ensure Resident #64's medication was secured inside the locked medication cart in the women's unit on Hall 300. These failures could place residents at risk of not receiving prescribed drugs or contaminated medication. Findings included: 1. During an observation and interview on 06/18/25 at 1:17 p.m. of the Hall 300 medication room the lockbox for controlled medications was locked but not permanently affixed to the refrigerator. LVN N said she had never…

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 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 diseases and infections for 1 of 2 residents reviewed for infection control. (Resident #49) The facility failed to ensure CNA S performed proper hand hygiene while assisting to feed Resident #49. This failure could place residents at risk for cross contamination and the spread of infection. Findings include: Record review of a face sheet dated 06/16/25 indicated Resident #49 was a [AGE] year-old-female readmitted on [DATE] with a diagnosis of dementia (a group of thinking and social symptoms that interfere with daily function). Record review of the quarterly MDS assessment dated [DATE] indicated Resident #49 was severely impaired of cognition with a diagnosis of dementia and needed maximum assistance with eating. Record review of a care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment for 2 of 2 resident rooms (Room #s 230 and 231) and 1 of 2 shower rooms (Unit 100 Hall D shower) reviewed for physical environment. 1. The facility did not ensure the shower room on 100 D Hall was in good repair and in good working condition. 2. The facility failed to ensure two of two resident nightstands and rooms on Unit 2 were treated for cockroaches. These failures could place the residents at risk for decreased quality of life and infection due to unsafe and unsanitary conditions. Findings included: 1. During an observation on 10/22/24 at 12:40 p.m., the shower room on Unit 100 Hall D had peeling and rusted door frames around the 2 of 2 shower stalls and toilet room, the sink had no drain (the drain pipe section was in a drawer on a stand adjacent to the hand sink), there were missing tiles and grout on the floor and in 2 of 2 shower stalls, there was unknown substance…

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 effective pest control program to keep the facility free from pests in 2 of 2 resident rooms. The facility failed to ensure two of two resident nightstands and rooms on Unit 2 were treated for cockroaches. This failure could place residents at risk for an unsanitary environment and a decreased quality of life. Findings included: During an observation on 10/24/24 at 1:50 p.m., there were cockroaches in the nightstand drawers of Resident #1 and Resident #2. During an interview on 10/24/24 at 1:50 p.m., Resident #1, who resided in room [ROOM NUMBER], said he reported the cockroaches a few weeks ago to the lady at the front of the facility. He said the cockroaches had infested his room for weeks. He said the cockroaches crawled on his face and woke him up at night. He said he should not have to deal with roaches crawling on him in his bed. He said the facility should have addressed the issue after he reported to staff. During an…

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

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 3 dining rooms and 1 of 1 kitchen reviewed for sanitation. (Main dining room) The facility failed to ensure an air conditioner return air vent in the dining room was free of dust particles. The facility did not ensure kitchen equipment was sanitary and in good repair. This failure could place the residents at risk of food borne illnesses. Findings included: 1. During observations of the noon meal in the main dining room on 4/29/24 at 12:00 p.m., an AC return air vent, approximately 8 ft high by 4 foot wide, had dust approximately 1/4 thick on each slat of the vent. Air was blowing through the vent slats. Approximately 20 residents were sitting in the dining room eating lunch. During an interview on 4/29/24 at 12:02 p.m., the DM said the air conditioner return air vent had thick dust and needed to be cleaned. She said maintenance was supposed to clean it. She stated the dust is thick and nasty.…

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 ensure assessments accurately reflected the status for 2 of 28 residents reviewed for assessments. (Residents #13 and #109)). The facility failed to complete an accurate resident assessment for Resident #13. Resident #13's resident assessment did not reflect she was a tobacco user. The facility failed to complete an accurate resident assessment for Resident #109. Resident #109's resident assessment did not reflect her active diagnosis of anxiety disorder. This failure could place residents at risk of not having individual needs met and a decreased quality of life. Findings included: 1. Record review of a face sheet dated 04/30/24 indicated Resident #13 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (a lung disease that blocks airflow making it difficult to breathe) and respiratory failure (a serious condition that makes it difficult to breathe on your own). Record review of 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 observation, interview, and record review, the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 24 resident reviewed for range of motion. (Resident #7) The facility did not ensure Resident #7's splint was placed in her contracted right hand. This failure could place the residents at risk of not receiving the care and services to maintain their highest level of well-being. Findings included: Record review of physician orders dated April 2024 and May 2024 indicated Resident #7, admitted [DATE], was [AGE] years old with diagnoses of right sided hemiplegia (paralysis) and cerebrovascular disease (stroke). The order did not indicate the resident had a splint. Record review of the most recent quarterly MDS dated [DATE] indicated Resident #7 was a BIMs score of 8 (moderate cognitive impairment) and did not have onset of acute mental status changes 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, and record review, the facility failed to ensure a medication error rate of less than 5 percent. There were 2 errors out of 25 opportunities which resulted in an 8 percent error rate involving Residents' #58 and #92. LVN O administered Resident #58's midodrine HCL 5 mg (a medication used to treat low blood pressure) when the blood pressure was outside the prescribed parameters. LVN P administered Resident #92's clopidogrel 75 mg (a medication used to thin blood and prevent clotting) over 3 hours past the administration time frame listed on the medication administration record, according to the facility's policy that medications are scheduled according to the routine schedule of 7am. This failure could place residents at risk of not receiving the therapeutic benefits of their medications as ordered. Findings included: ERROR #1 Physician orders dated April 2024 indicated Resident #58, admitted [DATE] was [AGE] years old with a diagnosis of high blood pressure. Physician orders…

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 maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 kitchen reviewed for essential equipment. The facility did not ensure the gas stove and the convection ovens were in safe operating condition. This failure could place the residents at risk of a fire and not receiving their meals timely. Findings included: During observation and interview on 4/29/24 at 9:00 a.m., the double oven had a thick black substance on the interior walls, on the metal racks and on the base/floor of the oven. The DM said the oven was not used and had not worked since she started working at the facility about a year ago. The DM said the oven needed to be repaired. She said there was not an open work order for repair of the oven. During observation and interview on 4/30/24 at 10:45 a.m., the left and right sides of oven were not hot and there was no food in the oven. The DM said the oven did not work, the single gas convection oven did not work and the bottom half of the double…

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 employees received the required training effective communications mandatory training was completed for 6 of 21 employees (LVN F, ST, PT, CNA K, CNA M, and the HS) reviewed for training. The facility did not ensure effective communication training was completed by LVN F, ST, PT, CNA K, and CNA M during orientation. The facility did not ensure effective communication training was completed by the HS annually. These failures could place residents at risk of miscommunication and social isolation due to lack of staff training. Findings included: Record review of the employee files and trainings indicated: * LVN F, hire date 02/29/24, had not completed a communication training during orientation; * ST, hire date 04/18/24, had not completed a communication training during orientation; * PT, hire date 05/23/23, had not completed a communication training during orientation; * CNA K, hire date 04/23/24, had not completed a communication training during orientation; * CNA M, hire date 04/23/24, had not completed a…

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

Based on interview and record review, the facility failed to ensure the rights of the resident and responsibilities of the facility were completed for 3 of 21 employees (OT, CNA M, and HS) reviewed for training. The facility failed to ensure the rights of the resident and responsibilities of the facility training was completed by OT and CNA M during orientation. The facility failed to ensure the rights of the resident and responsibilities of the facility training was completed by HS annually. These failures could affect residents and place them at risk of being uninformed due to lack of staff training. Findings include: Record review of the employee files and trainings indicated: * OT, hire date 09/28/23, had not completed rights of the resident and responsibilities of the facility training during orientation; * CNA M, hire date 04/23/24, had not completed rights of the resident and responsibilities of the facility training during orientation; and * HS, hire date 05/16/18, last completed rights of the resident and responsibilities of the facility training on 03/23/23. During an…

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

Based on interview and record review, the facility failed to ensure employees received the required training on Abuse, Neglect, and Exploitation (ANE) for 2 of 15 (OT and HS) and dementia management for 2 of 15 employees (OT and LVN C) reviewed for training. The facility did not ensure dementia management training was completed by the OT and LVN C during orientation. The facility did not ensure ANE training was completed by the OT during orientation. The facility did not ensure ANE training was completed by the HS annually. This failure could place residents with dementia at risk of abuse, neglect, and exploitation and a poor quality of care by staff with inadequate training when caring for dementia residents. Findings included: Record review of the employee files indicated: * LVN C, hire date 07/12/23, had not completed dementia management training during orientation; * OT, hire date 09/28/23, had not completed ANE and dementia management training during orientation ; and * HS, hire date 05/16/18, last completed ANE training on 03/23/23. During an interview on 05/01/24 at 11:16…

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 Quality Assurance and Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program was completed for 15 of 21 employees (Administrator, BOM, DON, ST, PT, SW, AD, LVN C, LVN D, LVN F, CNA G, CNA H, CNA J, CNA K, CNA L and CNA M) reviewed for training. The facility did not ensure QAPI training was completed by the Administrator, BOM, DON, ST, PT, SW, AD, LVN C, LVN D, LVN F, CNA G, CNA H, CNA J, CNA K, CNA L and CNA M. This failure could place staff and residents at risk for not being aware of facility programs, implementation, and monitoring. Findings included: Record review of employee files indicated QAPI training was not done for the following staff: * Administrator, hire date 01/17/23, * BOM, hire date 03/18/24, * DON, hire date 08/02/22, * PT, hire date 05/25/23, * ST, hire date 04/18/24, * SW, hire date 02/29/24, * AD, hire date 12/21/20, * LVN C, hire date 07/12/23, * LVN D, hire date 10/26/23, * LVN F, hire date 02/29/24, * CNA G, hire date…

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 standards, policies, and procedures for an infection prevention and control program was completed for 4 of 21 staff (LVN C, OT, HS, and CNA M) reviewed for training. The facility did not ensure infection prevention and control training was completed by the OT, CNA M, and LVN C during orientation. The facility did not ensure infection prevention and control training was completed by the HS annually. These failures could place residents at risk of illness due to lack of staff training. Findings included: Record review of employee files indicated: * OT, hire date 09/28/23, had not completed infection prevention and control training during orientation; * LVN C, hire date 07/12/23, had not completed infection prevention and control training during orientation; * CNA M, hire date 04/23/24, had not completed infection prevention and control training during orientation; and * HS, hire date 05/16/18, last completed infection prevention and control training on 03/31/23. During an interview on 05/01/24 at 11:16 a.m., the DON…

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 compliance and ethics training was completed for 21 of 21 employees (Administrator, BOM, DON, ADON, ST, OT, PT, SW LVN D, LVN E, LVN F, CNA G, CNA H, CNA J, CNA K, CNA L, and CNA M) reviewed for training. The facility did not ensure compliance and ethics training was completed for the BOM, ADON, LVN C, LVN D, LVN F, ST, OT, PT, SW, MD, CNA K, CNA L, and CNA M during orientation. The facility did not ensure compliance and ethics training was completed by the Administrator, DON, LVN E, AD, HS, CNA G, CNA H, and CNA J annually since the company had a total of 6 facilities. This failure could affect residents and place them at risk of poor care or victimization due to lack of staff training. Findings included: Record review of employee files indicated the following staff had not completed compliance and ethics training during orientation: * BOM, hire date 03/18/24, * ADON, hire date 10/02/23, * LVN C, hire date 07/12/23, * LVN D, hire date 10/26/23, * LVN F, hire date 02/29/24, * ST, hire date 04/18/24, * OT, hire date…

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 training on behavioral health was completed for 4 of 21 employees (Administrator, OT, LVN C, and CNA M) reviewed for training. The facility did not ensure behavioral health training was completed by the OT, LVN C, and CNA M during orientation. The facility did not ensure behavioral health training was completed by the Administrator annually. This failure could place residents with behaviors at risk of not receiving care to attain or maintain their highest practicable physical, mental, and psychosocial well-being due to lack of staff training. Findings included: Record review of employee files indicated: * OT, hire date 09/28/23, had not completed behavioral health training during orientation,; * LVN C, hire date 07/12/23, had not completed behavioral health training during orientation,; * CNA M, hire date 12/07/23, had not completed behavioral health training during orientation,; and * Administrator, hire date 01/17/23, last completed behavioral health training on 01/24/23. Record review of a Training Programs…

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 review, the facility failed to consult with the resident's physician when there was a need to alter treatment for 1 of 24 residents (Resident #92) reviewed for notification of changes. The facility failed to ensure the physician was notified of a missed dose of Oxacillin (used to treat bacterial infections) 1gm IV Q6H x 5 days was to start at 6:00 a.m. on 04/30/24 and unable to start the prescribed Oxacillin for Resident #92. The facility failed to ensure the physician was consulted when the pharmacy indicated the Oxacillin was outside of the recommended dose or frequency. This failure could place residents at risk of not receiving appropriate medical treatments, which could result in severe illness or hospitalization. Findings included: Record review of a face sheet dated 04/30/24 indicated Resident #92 was admitted on [DATE] with diagnoses of urinary tract infection (UTI), altered mental status, and heart disease. Record review of the quarterly MDS assessment dated…

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 a safe, clean and homelike environment for 1 of 24 residents (Resident #92) reviewed for environment. The facility failed to provide Resident #92 with a thoroughly clean room without other resident's personal belongings in his room. This failure could place residents at risk of unclean, unhomelike environment and a decline in health. The findings included: Record review of face sheet dated 04/30/24 indicated Resident #92 was admitted on [DATE] with diagnoses of urinary tract infection, altered mental status and heart disease. Record review of the quarterly MDS assessment dated [DATE] indicated Resident #92 with a BIMS score of 10 (moderate cognition impairment) and moderate assistance with toileting hygiene and showering. Record review of the care plan dated 04/30/2024 for Resident #92 has UTI / with Staphylococcus aureus was prescribed: Oxacillin Sodium. Interventions included to check at least every 2 hours for incontinence,…

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 refer residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change of condition to the State-designated authority for 1 of 12 residents (Resident #109) reviewed for PASRR. The facility did not refer Resident #109 to the LMHA when the NP provided a new mental illness diagnosis of anxiety. This failure could place residents at risk of not receiving the needed PASSAR services to meet their individual needs and could result in a decreased quality of life. Findings included: Record review of a face sheet dated 04/30/24 indicated Resident #109 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included depression (mental illness that negatively affects how you feel, the way you think and how you act) and diabetes mellitus type 2 (chronic condition that affects the way the body processes blood sugar). Record review of a 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 ensure preadmission screening for individuals identified with MI, DD, or ID were evaluated for services for 1 of 24 residents reviewed for resident assessments (Resident #415). The facility did not have an accurate PASRR level 1 screening (PL1) for Resident #415 upon admission. This failure could place residents at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs. Findings included: Record review of a face sheet dated 04/29/24 indicated Resident #415 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included psychosis (a mental disorder characterized by a disconnection from reality), dementia (a group of thinking and social symptoms that interfere with daily functioning), and anxiety disorder (persistent and excessive worry that interferes with daily activities) on 04/11/24. Record review of a PASRR level 1 screening completed by the transferring…

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 pharmaceutical services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required for 1 of 24 residents reviewed for physician orders. (Resident #92) The facility failed to follow physician orders related to ferrous gluconate (used to treat or prevent low blood levels of iron) for Resident #92. This failure could place the residents at risk of not receiving care and services as ordered by the physician. Findings included: Record review of face sheet dated 4/30/24 indicated Resident #92 was admitted on [DATE] with diagnoses of urinary tract infection, altered mental status and heart disease. Record review of the physician's orders for Resident #92 dated 04/30/24 indicated ferrous gluconate tablet 324 mg, Give 1 tablet by mouth one time a day with start date of 04/18/2024. Record review of the MAR for Resident #92 indicated from 4/18/24 to 4/29/24 the ferrous…

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 ensure each resident's drug regimen was free from unnecessary drugs when used without adequate monitoring for 2 of 24 residents reviewed for unnecessary medication. (Residents #58 and #415) The facility failed to hold Resident #58's midodrine hcl (used to treat low blood pressure) when the resident's blood pressure was outside parameters set by the physician from 04/01/24 to 04/29/24. The facility failed to monitor Resident #415 for side effects from 04/12/24 to 04/29/24 of the anticoagulant medication Eliquis (a blood thinning medication). This failure could place residents at risk of complications and not receiving the intended therapeutic effects of their medications. Findings included: 1. Record review of a face sheet dated 04/30/24 indicated Resident #58 was an [AGE] year-old male admitted on [DATE]. His diagnoses included hypertension (high blood pressure), hypotension (low blood pressure), atherosclerotic heart disease (a buildup of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure based on the comprehensive assessment of a resident, residents who use psychotropic drugs received gradual dose reduction and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for 1 of 24 residents (Resident #415) reviewed for unnecessary medications. The facility failed to monitor Resident #415 for side effects of the antipsychotic medication quetiapine fumarate and Abilify and the antianxiety medication buspirone hcl. This failure could place residents at risk for adverse consequences such as dizziness, drowsiness, oversedation, agitation, restlessness, and suicidal thoughts related to the use of psychotropic medications. Findings include: Record review of a face sheet dated 04/29/24 indicated Resident #415 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included psychosis (a mental disorder characterized by a disconnection from reality) and anxiety (a mental…

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 CNAcans completed Abuse, Neglect, and Exploitation (ANE) and dementia management trainings for 1 of 6 CNAs (CNA M) revicanewedreviewed for training. The facility did not ensure ANE and dementia management trainings were completed by CNA M during orientation. This failure could place residents with dementia at risk of abuse, neglect, and exploitation and a poor quality of care by staff with inadequate trainincang when caring for dementia residents. Findings included: Record review of employee files indicated: * CNA M, hire date 12/07/23, had not completed ANE and dementia management trainings during orientation. Record review of a Training Programs policy dated October 2021 indicated Purpose: To ensure employees are provided the necessary training to perform their job at a high level while meeting state and federal regulations regarding annual training and in-servicing. Policy: Upon hire, and on an ongoing basis, employees will be provided the appropriate training to include state and federally mandated training…

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 provide a 30-day notice to the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand before the resident was discharged for 1 of 1 (Resident #101) reviewed for Discharge Rights. The facility did not provide a written discharge notice to Resident #101 (who admitted on [DATE] and discharged on 08/30/23) or their representative prior to discharging the resident, not allowing the 30-day advance notice. The facility discharged Resident #101 to a behavioral hospital. This failure could place residents who are transferred or discharged from the facility, at risk for not receiving care and services to meet their needs upon discharge and the right to appeal. Findings included: Record review of Resident #101's face sheet dated 01/09/24 indicated Resident #101 was a [AGE] year-old male who admitted on [DATE], readmitted on [DATE] with diagnoses including…

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 reviewed for a written plan of care received care and services as ordered by the physician for 3 of 23 residents. (Resident #22, #64 and #109) The facility failed to follow physician orders related to a blood pressure medication for Resident #22. The facility failed to follow physician orders related to blood pressure medication for Resident #64. The facility failed to initiate physician orders related to new order for anticoagulant for Resident #109. This failure could place the residents at risk of not receiving care and services as ordered by the physician. Findings included: 1.Physician orders dated February 2023 indicated Resident #22, admitted [DATE], was [AGE] years old with diagnosis of hypertension (high blood pressure). An order was received 01/06/23 for clonidine HCl 0.1 mg. Instructions included give 1 tablet by mouth every 8 hours as needed for B/P (blood pressure) at 160/90 and above. The MAR dated February 2023 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 observation, interview and record review, the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 of 23 residents reviewed for respiratory care and services. (Resident #100) The facility failed to administer the correct dose of oxygen to Resident #100. This failure could place the residents at risk for not receiving the appropriate care and services to maintain their highest level of well-being. Findings included: Record review of physician orders dated March 2023 indicated Resident #100, admitted [DATE], was [AGE] years old with diagnoses of chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), dependence on supplemental oxygen and shortness of breath. The resident was to receive oxygen at 3 liters per nasal cannula (a device used to deliver supplemental oxygen)…

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 were free of significant medication errors for 2 of 23 residents reviewed for medications. (Resident #22 and #64) Resident #22 missed several doses of a PRN blood pressure medication when her blood pressure was extremely elevated. Resident #64 received the antihypotension medication when it should have not been given and it was held when it should have been given on multiple occasions This failure could place resident at risk of not receiving medications as prescribed and/or significant medication errors. Findings included: 1. Physician orders dated February 2023 indicated Resident #22, admitted [DATE], was [AGE] years old with diagnosis of hypertension (high blood pressure). An order was received 01/06/23 for clonidine HCl 0.1 mg. Instructions included give 1 tablet by mouth every 8 hours as needed for B/P (blood pressure) at 160/90 and above. The MAR dated February 2023 indicated on the following dates at 8:00 a.m., Resident #22'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.