Avir At Carthage

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure assessments accurately reflected the resident's status for 2 of 14 resident reviewed for assessments. (Resident #8 and Resident #15) The facility failed to ensure Resident #8's falls on 05/29/24 and 07/07/24 were coded on her MDS. The facility failed to ensure Resident #15's falls on 05/09/24, 06/26/24, and 07/06/24 were coded on her MDS. The facility failed to ensure Resident #15's diagnosis of dementia (is a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) was coded on her MDS. The facility failed to ensure Resident #15 was coded for receiving an anticoagulant (medicines that help prevent blood clots) not antiplatelet (medications that prevent platelets from sticking together and forming blood clots). These failures could place residents at risk of not having individual needs met. Findings included: 1. Record review of Resident #8's face sheet 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 develop, and implement a comprehensive care plan to meet the medical, nursing, mental and psychosocial needs for 3 of 14 residents (Resident #15, Resident #23, and Resident #35) reviewed for care plans. 1. The facility failed to care plan Resident #15's hearing problem and use of hearing aids. 2. The facility failed to care plan Resident #23's hearing problem, impaired vision, on antidepressant (is a type of medicine used to treat clinical depression) and oral antidiabetic (used in the treatment of diabetes mellitus to control glucose levels in the blood) medication, dental issue, and shortness of breath on exertion. 3. The facility failed to care plan Resident #35's impaired vision. These failures could place residents in the facility at an increased risk of a decline in physical or functional well-being, of not receiving necessary care or services, and having personalized plans developed to address their needs. Findings included: 1.…

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 to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation in that: 1. The facility failed to ensure ice machine was functioning properly and preventing ice from spilling out onto the floor. 2. The facility failed to ensure minimal black carbon buildup on iron gas stovetop and debris cleared from under burner. 3. The facility failed to ensure food was properly labeled, dated, and stored in a resident personal refrigerator. These failures could place residents who received meals from the kitchen at risk for chemical contamination and food-borne illness. The findings were: During an observation on 8/18/2024 at 9:00 AM, the ice machine in the dining hall had a beige/brown blanket absorbing melting ice cubes laying directly in front of ice machine where residents and staff navigate. During an observation on 8/18/2024 at 10:44 AM, Resident #16 had a green, moldy undated, unlabeled sandwich stored in her mini…

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 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 2 of 2 residents (Resident #19 and Resident #23) reviewed for incontinent care and 3 of 5 (Resident #5, Resident #18, and Resident #22) reviewed for Covid-19 infection control practices. 1.The facility failed to ensure MA A wore an N95 mask when entering Covid positive Resident #19 and #22's room. 2. The facility failed to ensure MA A changed her mask after leaving Covid positive Resident #19 and #22's room and entering another non-isolation room. 3. The facility failed to ensure CNA P and Housekeeper Q wore proper PPE in Resident #5's room on 08/18/24 and 08/19/24. Resident #5 was COVID-19 positive. 4. The facility failed to ensure CNA P changed her gloves and performed hand hygiene appropriately while…

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 residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 2 of 14 residents (Resident #8 and Resident #15) reviewed for reasonable accommodations. The facility failed to ensure Resident #8 and Resident #15's call light was placed within reach. This failure could place residents at risk for unmet needs. Findings included: 1. Record review of Resident #8's face sheet dated 08/18/24 indicated Resident #8 was a [AGE] year-old, female and admitted on [DATE] and readmitted on [DATE] with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (is one-sided muscle weakness) following cerebral infarction (stroke) affecting left non-dominant and flaccid hemiplegia affecting right dominant side. Record review of Resident #8's quarterly MDS assessment dated [DATE] indicated Resident #8 was usually understood and usually understood…

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 an encoded, accurate, and complete MDS discharge assessment was electronically completed and transmitted to the CMS System within 14 days after completion for 1 of 1 resident (Resident #44) reviewed for discharge MDS assessments. The facility did not ensure Resident #44's discharge MDS assessment was completed and transmitted within 14 days of completion. This failure could place residents at risk of not having records completed and submitted in a timely manner as required. Findings included: Record review of Resident #44's face sheet dated 08/19/24, indicated Resident #44 was an 85-years-old female, admitted on [DATE] with a diagnosis which included non-ST elevation myocardial infarction (is a type of involving partial blockage of one of the coronary arteries, causing reduced flow of oxygen-rich blood to the heart muscle). Resident #44 was discharged home with services on 04/19/24. Record review of Resident #44's discharge assessment-return not…

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 review, the facility failed to ensure a registered nurse signed and certified that the MDS assessment was completed for 1 of 1 resident (Resident # 44) reviewed for MDS completion. The facility failed to ensure the RN signed Resident #44's discharge MDS assessment as completed. This failure could place residents at risk for incomplete or inaccurate documentation that does not completely reflect the resident's status. Findings included: Record review of Resident #44's face sheet dated 08/19/24, indicated Resident #44 was an [AGE] year-old female, admitted on [DATE] with a diagnosis which included non-ST elevation myocardial infarction (is a type of involving partial blockage of one of the coronary arteries, causing reduced flow of oxygen-rich blood to the heart muscle). Resident #44 was discharged home with services on 04/19/24. Record review of Resident #44's discharge assessment-return not anticipated MDS assessment dated [DATE] indicated Resident #44's discharge date was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 5 (Resident #23) residents reviewed for quality of care. The facility failed to ensure Resident #23 had daily blood sugar glucose checks due to being on an antidiabetic (help manage blood sugar (glucose) levels in people who have Type 2 diabetes) medication. This failure could place residents of risk for not receiving appropriate care and treatment for hyperglycemia (when there's too much sugar (glucose) in your blood) or hypoglycemia (when your blood sugar (glucose) level falls too low for bodily functions to continue). Findings included: 1. Record review of Resident #23's face sheet dated 08/18/24 indicated Resident #23 was a [AGE] year-old male and admitted on [DATE] with diagnoses including Type 2 diabetes (is a condition that happens because of a problem in the way the body regulates and uses…

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 who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 2 residents reviewed for urinary and bowel incontinence (Resident #18 and #32). 1. The facility failed to ensure Resident #18 was not found excessively wet on 08/19/24. 2. The facility failed to ensure CNA C performed proper incontinent care by ensuring Resident #32 was completely clean after bowel movement and before placing a new brief on 8/19/2024. These failures placed residents who required assistance with incontinent care at risk for urinary tract infections, skin breakdown, and hospitalization. Findings included: 1. Record review of Resident #18's face sheet dated 08/18/24 indicated Resident #18 was a [AGE] year-old, female and admitted on [DATE] with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (is one-sided…

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 nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs for 1 (CNA B) of 2 staff reviewed for demonstration of skills and techniques necessary for residents' needs. The facility failed to ensure CNA B identified and addressed a change in condition and failed to report to LVN L, when Resident #18's pink tinged urine visualized during incontinent care on 08/19/24 which delayed physician notification and treatment. This failure could place residents at risk for not receiving the appropriate care and services to maintain their health and safety. Finding included: Record review of Resident #18's face sheet dated 08/18/24 indicated Resident #18 was a [AGE] year-old female and admitted on [DATE] with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (is one-sided muscle weakness) following cerebral infarction (stroke) affecting left non-dominant and urinary…

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 pharmaceutical services, including the accurate acquiring, administering, and receipt of all drugs and biologicals, to meet the needs of 1 of 14 residents (Resident #9) reviewed for pharmacy services. The facility failed to ensure MA A signed off on the Narcotic Drug Record for Resident #9's lacosamide (a medication used to reduce the number and severity of seizures) medication when the last dose on the medication card was administered. This failure could place residents who received medications at risk of missing medications or missing doses of medications and staff being unable to reconcile controlled substance counts. Findings included: Record review of Resident #9's face sheet, dated 08/20/24, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included pseudobulbar affect (a neurological disorder that causes people to have sudden, uncontrollable, and inappropriate episodes of crying or laughing),…

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 each resident's drug regimen was free from unnecessary medications (a medication used in excessive doses and including duplicate therapy or for excessive duration; or without adequate monitoring, or without adequate indications for its use; or in the presence of adverse consequences which indicated the dose should be reduced or discontinued) for 1 of 5 residents reviewed for unnecessary medications. (Resident #35) The facility failed to ensure Resident #35 did not receive Minocycline, an antibiotic, without an indication of use and an excessive duration. The facility failed to ensure Resident #35 did not receive Acidophilus, a type of probiotic (good bacteria) found in the human gut, mouth, and vagina, and also in certain foods, for an excessive duration. This failure could place residents receiving antibiotics at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased antibiotic-resistant infections (happens when germs…

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, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 2 of 14 residents (Resident # 23 and Resident #33) reviewed for pharmacy services. The facility failed to safely store wound cleanser in a locked compartment in a clean, safe, and sanitary manner for Resident #23 and Resident #33. This failure could place residents at risk for misuse of medication and overdose, adverse reactions of medications, and not receiving the therapeutic benefit of medications. Findings included: 1. Record review of Resident #23's face sheet dated 08/18/24 indicated Resident #23 was a [AGE] year-old male and admitted on [DATE] with diagnoses including pressure ulcer (an injury that breaks down the skin and underlying tissue) of sacral region, stage 4, pressure ulcer and pressure ulcer of other site, stage 3.…

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, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did 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 of 10 residents (Resident #2) reviewed for abuse and neglect. The facility failed to report Resident #2's abuse allegation within 24 hours to the state agency. This failure could place residents at risk for continued abuse and neglect due to inappropriate interventions and failure to report the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 2 of 6 residents (Resident #1 and Resident #2) reviewed for storage of medications. The facility failed to ensure Resident #1's Tussin DM (cough suppressant) bottle was properly safe and secured. The facility failed to ensure Resident #2's [NAME] decongestant nasal spray (relieves sinus pressure and nasal congestion) was properly safe and secured. These failures could place residents at risk of medication misuse and diversion. Findings include: 1. Record review of Resident #1's face sheet indicated an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included essential hypertension (high blood pressure), mild protein calorie malnutrition (type of malnutrition that results from not getting enough…

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, record reviews, and interviews, the facility failed to protect and promote the rights of the resident in an environment that promoted maintenance or enhancement of his or her quality of life for Anonymous Residents #1-6 and 2 of 18 residents (Resident #33 and Resident #46) reviewed for resident rights. The facility failed to protect and value Anonymous Residents #1-6, Resident #33, and Resident #46's private spaces from Residents #39 and Resident #52, who frequently wandered into residents' rooms and went through their belongings. This failure could place residents at risk for decreased quality of life, increased anxiety, and increased stress. Findings included: During a group meeting on 6/27/23 at 2:30 PM, Anonymous Residents #1-6 said Resident #39 and Resident #52 bothered them. Anonymous Residents #1-6 said Resident #39 and Resident #52 wandered the facility the entire day. Anonymous Residents #1-6 said Resident #39 and Resident #52 caused trouble everywhere they went. Anonymous…

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, functional, sanitary, and comfortable environment for 4 of 7 (Resident #36, Resident #37, Resident #42, Resident #160) residents and 1 of 6 Halls (Hall 1) reviewed for environment. 1. The facility failed to ensure resident #37 could close her bedroom door. 2. The facility failed to ensure Resident #36 did not have brown and orange stains on the wall. 3. The facility failed to ensure Resident #36 did not have a torn vent cover behind the headboard. 4. The facility failed to ensure Resident #42, and Resident #160 did not have torn walls of sheetrock. 5. The facility failed to ensure Resident #160 did not have brown and yellow stain on the wall. 6. The facility failed to ensure Resident #160 door was not obstructed by a footboard causing it not to completely close. 7. The facility failed to endure 4 foam ceiling tiles on Hall 1 were not bowing and brown stained. These failures could place residents at risk of an unsafe or…

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 received adequate supervision to prevent accidents or hazards for 2 of 7 residents that wandered reviewed for supervision. (Resident #39 and Resident #52) 1.The facility failed to provide adequate supervision to continue to prevent Resident #39 from entering Resident #15's room following a previous incident on 5/31/23 where Resident #39 had put his hands around Resident #15's neck. 2.The facility failed to provide adequate supervision to prevent Resident #52 from exiting the building twice on 6/18/23. 3.The facility failed to provide adequate supervision to prevent Resident #39 and Resident #52 from entering Resident #46's room and going through her things, resulting in Resident #46 being pushed by Resident #52. These failures could place residents at an increased risk of injury. Findings included: 1.Record review of Resident #39's face sheet dated 6/28/23 indicated he was [AGE] years old and admitted to the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide services by sufficient numbers of other nursing personnel, which included but not limited to nurse aides, on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans for 5 of 17 residents (Residents #30, Resident #39, Resident #43, Resident #45, Resident #52) and Anonymous Resident Council members (AR 1-AR7) reviewed for care and services. The facility failed to provide sufficient staff on the 6a-2pm, 2pm-10pm, 10pm-6am (04/01/23-06/25/23) shifts to meet the needs of the residents who required assistance with activities of daily living. This failure could place residents at risk of infection, skin breakdown, low self-esteem, depression, embarrassment, and psychological harm. Findings included: Record review of the PBJ staffing Data Report dated 01/01/23-03/31/23 indicated the facility triggered for one star staff rating. Record review of the Facility Assessment Tool updated 04/24/23, 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.

Based on interview, and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility reviewed for RN coverage. The facility failed to provide RN coverage for 8 consecutive hours daily on 04/10/23, 06/04/23, 06/10/23, 06/24/23, 06/25/23. The deficient practice had the potential to affect residents in the facility by leaving staff without supervisory coverage for RN specific nursing activities and for coordination of events such as an emergency care and disasters. Findings include: Record review of a nursing staff information sheet dated 04/10/23, 06/04/23, 06/10/23, 06/24/23, 06/25/23 indicated that the facility did not have an RN in the facility or did not work 8 consecutive hours. During an interview on 06/29/23 at 10:50 a.m., the ADON C said she was currently the only RN scheduled due to the DON being on vacation. She said until the DON returned, she was solely responsible for RN coverage. She said the facility had two other RNs, but they no longer worked for the facility. The ADON C said she…

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 food that was palatable and served at an appetizing temperature for 6 of 18 residents and 7 anonymous residents reviewed for palatable food. (Anonymous Resident #1 - #7, Resident #22, Resident #25, Resident #35, Resident #38, Resident #50, and Resident #110) The facility failed to provide palatable food served to Resident #22, Resident #25, Resident #35, Resident #38, Resident #50, and Resident #110 who complained the food did not taste good. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. Findings included: Record review of Resident Council Minutes dated 01/30/23 indicated .Res. (residents) would like more toss salad. Still too many of the same vegetables .Res. would like to have a meeting with the dietician . The response from the Dietary Manager indicated, We go by the menu. We a will tired get different veg. Next time dietician…

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 promote resident self-determination through support of resident choice for 1 of 1 resident reviewed for self-determination. (Resident #45) The facility did not assist Resident #45 out of bed when he requested. This failure could place dependent residents at risk for feelings of lack of self-determination and decreased quality of life. Findings included: Record review of the face sheet dated 06/26/23 indicated Resident #45 was a [AGE] year-old male and admitted on [DATE] with diagnoses including generalized muscle weakness, congestive heart failure (the heart muscle doesn't pump blood as well as it should.), cerebral infarction (stroke), nicotine dependence (is an addiction to tobacco products caused by the drug nicotine), and flaccid (loose or floppy) hemiplegia (weakness or paralysis of one side of the body) affecting right dominant side. Record review of the quarterly MDS assessment dated [DATE] indicated Resident #45 was understood and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were free from abuse for 1 of 24 residents (Resident #18) reviewed for resident abuse. The facility did not ensure Resident #18 was free from abuse, as a result Resident #18 was verbally abused by DA J. This failure could place residents at risk of physical harm, mental anguish, and/or emotional distress. The findings included: Record review of Resident #18's face sheet, dated 6/28/23, revealed he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of schizoaffective disorder, bipolar type (mental illness that affects thoughts, mood, and behavior with mania-extremely elevated & excitable mood, psychosis-thoughts and emotions that resident losses contact with reality, and depression-persistent sadness) and cognitive communication deficit (difficulty with thinking and how someone uses language). Record review of Resident #18's quarterly MDS assessment, dated 6/12/23, revealed he had clear speech and was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure assessments accurately reflected the status for 2 of 2 residents reviewed for assessments. (Resident #6 and Resident #34) The facility failed ensure Resident #6's MDS assessment was properly coded for PASRR and medication classification. The facility failed to ensure Resident #34's MDS assessment was properly coded for having an indwelling catheter. These failures could place residents at risk of not having individual needs met. Findings included: 1. Record review of a face sheet dated 06/26/23 indicated Resident #6 was a [AGE] year-old male admitted on [DATE] with diagnoses including Type 2 diabetes mellitus (is a common condition that causes the level of sugar (glucose) in the blood to become too high), psychotic disorder (is a mental health problem that causes people to perceive or interpret things differently to those around them) with hallucinations (is a false perception of objects or events involving your senses: sight, sound, smell,…

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 baseline care plan that included the instructions for resident care needed to provide effective and person-centered care was completed and provided to the resident and/or their representative for 1 of 2 residents reviewed for new admissions (Resident #160). The facility failed to complete Resident #160's baseline care plan within 48 hours of admission. This failure could place residents at risk of not receiving care and services to meet their needs. Findings included: Record review of a face sheet dated 06/26/23 indicated Resident #160 was a [AGE] year-old male admitted on [DATE] with diagnosis including pressure ulcer of sacral region, stage 4 (The wound penetrates all three layers of skin, exposing muscles, tendons, and bones in your musculoskeletal system), pain, Type 2 diabetes mellitus (is a disease in which your blood glucose, or blood sugar, levels are too high), nicotine dependence (is an addiction to tobacco products caused by the…

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

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 to meet each resident's medical, nursing, mental and psychosocial needs for 1 of 17 residents reviewed for care plans. (Resident #13) The facility failed to implement the comprehensive person-centered care plan for Resident #13 by not weighing the resident weekly. This failure could place residents at risk of not having individual needs met, a decreased quality of life, and cause residents not to receive needed services Findings include: Record review of a face sheet dated 06/27/23 revealed Resident #13 was [AGE] years old and was admitted on [DATE] with diagnoses including dementia, abnormal weight loss, and heart failure. Record review of physician's orders for Resident #13 dated 06/27/23 indicated an order for weekly weights for 30 days with a start date of 06/05/23 and an end date of 07/05/23. Record review of the most recent MDS dated [DATE] indicated Resident #13 was understood and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 2 of 12 residents reviewed for ADLs (Residents #43 and Resident #30). 1. The facility did not clean or trim Resident #43's fingernails. 2. The facility did not shave Resident # 30's facial hair. These failures could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health. The findings were: 1. Record review of an electronic face sheet dated 06/27/23 revealed Resident #43 was an [AGE] year-old male admitted on [DATE] with diagnoses including quadriplegia (paralysis of all four limbs), urinary tract infections (an infection in any part of the urinary system), Constipation (not passing stools regularly or you're unable to completely empty your bowel), Neuromuscular dysfunction of bladder (the bladder…

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 dialysis service were provided consistently with professional standards of practice for 1 of 3 residents reviewed for dialysis services. (Resident #159) The facility failed to consistently document on Resident #159's dialysis communication form. This failure could place residents who received dialysis at risk for complications and not receiving proper care and treatment to meet their needs. Findings included: Record review of a face sheet date 06/26/23 indicated Resident #159 was [AGE] year-old male and admitted on [DATE] with diagnoses including dependence on renal dialysis (is a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) and end stage renal disease (occurs when the kidneys are no longer able to work at a level needed for day-to-day life). Record review of the MDS revealed Resident #159 was admitted to the facility less than 21 days ago. No MDS for Resident #159 was completed prior…

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 4 errors out of 26 opportunities, resulting in an 15.38% percent medication error involving 1 of 6 residents reviewed for medication pass. (Resident #45) The facility failed to administer scheduled medications in a timely manner for Resident #45. This failure could place residents at risk for inaccurate drug administration. The findings were: Record review of a face sheet dated 06/27/23 revealed Resident #45 was [AGE] years old and was admitted on [DATE] with diagnoses including heart failure, high blood pressure, chronic atrial fibrillation (an irregular, often rapid, heart rate that commonly causes poor blood flow), and cerebral infarction (stroke). Record review of consolidated physician orders for Resident #45 dated 06/27/23 indicated an order with a start date of 02/28/22 for Eliquis (a blood thinner used in people with an irregular heartbeat to lower the risk 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 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 2 of 5 residents (Residents #43, Resident #160) reviewed for infection control practices. The facility failed to ensure CNA A kept Resident #160's indwelling catheter off the floor. The facility failed to ensure Resident #43 was provided water in a sanitary manner. These failures placed residents at risk for cross contamination and infection. Findings included: 1. Record review of a face sheet dated 06/27/23 revealed Resident #43 was a [AGE] year-old male admitted on [DATE] with diagnoses including quadriplegia (paralysis of all four limbs), urinary tract infections (an infection in any part of the urinary system), Constipation (not passing stools regularly or you're unable to completely empty your bowel), Neuromuscular…

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.