Avir At Childress

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations and record review, the facility failed to provide the right to personal privacy which includes accommodations during wound care for 1 of 12 (Resident #7) residents reviewed for Privacy. LVN B failed to close the door or the curtain during wound care for Resident #7. This failure could place the residents at risk of not having their personal privacy maintained during medical treatment. Finding included: Record review of Resident #7's face sheet dated 05/14/25 revealed a [AGE] year-old male with an admission date of 05/01/25 with the following diagnoses: pneumonia (lung infection), right knee contracture, hypertension (high blood pressure), weakness and pain. Record review of Resident #7's Comprehensive MDS dated [DATE] revealed a BIMS score of 6 which indicated resident cognition was severely impaired. During an observation of wound care on 05/13/25 at 01:23 PM LVN B failed to close the door or the curtains during wound care. Resident #7 was lying in bed with his feet exposed to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure each resident the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 1 (Resident #33) of 12 residents reviewed for homelike environment. The facility failed to ensure Resident #33's personal refrigerator was free of rotten and expired food and that his personal food was stored properly. This failure could place residents at risk of contracting food borne illness. Findings Included: Record review of Resident #33's face sheet dated 05/13/25 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Parkinsonism (conditions that affect the ability to move and live independently), need for assistance with personal care, and unspecified dementia (breakdown of thought process). Record review of Resident #33's quarterly MDS completed on 02/25/25 revealed the following: Section C…

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 1 (Resident #44) of 12 residents reviewed for continence. The facility failed to ensure Resident #44's catheter was changed timely. This failure could place residents at risk of harm due to infection. Findings Included: Record review of Resident #44's face sheet dated 05/12/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified sequelae of cerebral infarction (long-term effects and complications occurring after a stroke) and neuromuscular dysfunction of bladder (the nerves and muscles of the bladder do not work well resulting in the bladder not filling or emptying well). Record review of Resident #44's quarterly MDS completed on 05/05/25 revealed the following: Section C Cognitive…

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 provide a safe, clean, and comfortable homelike environment for 1 of 2 shower rooms (100 hall) reviewed for homelike environment. A. The facility failed to ensure the shower room on the 100 Hall did not have black grime buildup on the walls and floor of the shower room. B. The facility failed to ensure the shower room on the 100 Hall did not have a foul smell coming from the drain. These failures could place the residents at risk for a decreased quality of life, an uncomfortable, unhomelike environment due to unsanitary conditions. Findings included: During the confidential Resident Council meeting one resident stated there was black mold in the shower room and a putrid smell. She stated she felt the mold and the smell in the shower played a part in her not being able to breathe. She stated it was not good for her to breathe in the mold or the smell in the shower. She stated the mold had been in the shower for at least a month. During an observation and interview on 5/13/25 at 1:10 pm, with the DOR revealed…

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 respect the residents' right to confidentiality in his or her personal and medical records for one (Resident #1) of 6 residents reviewed for privacy. Resident #1's medical information was shared with a surgeon via a nurse's personal email account. This failure could affect the residents residing in the facility by placing them at risk of losing their right to privacy and confidentiality. Finding included: Record review of Resident #1's Face Sheet dated 02/19/2025 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included but not limited to cellulites of left lower limb, type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene(blockage of blood vessels affecting toes and feet), acquired absence of left left leg below the knee, contracture, right hip acquired absence of right leg below knee. Record review of Resident #1's admission MDS assessment dated [DATE] revealed…

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 treatment and care in accordance with the comprehensive person-centered care plan and in accordance with professional standards of practice for 1 of 6 residents reviewed for quality of care (Resident #1). LVN A did not inform facility Administration of a surgeon's recommendation for Resident #1 in a timely manner. The failure could place residents at risk for a delay of treatment. Findings included: Record review of Resident #1's Face Sheet dated 02/19/2025 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included but not limited to cellulitis of left lower limb, type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene(blockage of blood vessels affecting toes and feet), acquired absence of left leg below the knee, contracture, right hip acquired absence of right leg below knee. Record review of Resident #1's admission MDS assessment dated [DATE] revealed…

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.

FACILITY Kitchen Based on observation, interview and record review the facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service for 1 of 1 kitchen staff (Dietary Manager) reviewed for qualifications. The facility failed to appoint a dietary manager with the appropriate license, certification, or qualifications. This failure could place the residents who consume food prepared from the kitchen at risk of not receiving services to meet their nutritional needs, contributing to food dissatisfaction, and placing residents at risk of food-borne illness. Findings included: The initial tour of the kitchen on 4/7/24 at 9:52AM revealed two workers (Cook D and DA I) in the kitchen preparing food for the luncheon service. The Investigator asked DA I if they (the Investigator) could speak with the Dietary Manager and was told that currently, the facility did not have a Dietary Manager, and that facility staff had been preparing meals, since his dismissal on 4/1/24. Cook D and DA I stated they did 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.

FACILITY Kitchen Based on observation, interview and record review the facility failed to store and distribute food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure stored foods were properly labeled and dated. 2. The facility failed to ensure expired foods were discarded. 3. The facility failed to store foods in accordance with professional standards. This failure could place residents at risk of acquiring a food-borne illness and a diminished quality of life. Findings included: The initial tour of the kitchen on 4/7/24 at 9:52AM revealed no free-standing thermometers in the refrigerator, freezer, or dry panty. The temperatures being checked and logged were taken from the manufacture's thermometers on the outside of each appliance. There was no thermometer or logbook for the dry panty. Inspection of the refrigerator revealed: 2-4oz. boxes of thickened cranberry juice with no date, 4-4oz. glasses of tomato juice: open to air, with no date, 1-1-gallon pitcher of fruit juice: no label…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 6 (Resident #5, Resident #9, Resident #18, Resident #35, Resident #36, and Resident #42) of 13 residents and for 1 (hall 600) of 6 halls reviewed for residents' rights. 1. The facility failed to keep the floor of Resident #5's room clean. 2. The facility failed to keep the floor and walls of Resident #35's room clean. 3. The facility failed to keep the floor of Resident #36's room clean. 4. The facility failed to keep the floor of Resident #42's room clean. 5. The facility failed to keep the bathroom of Resident #9 and Resident #18 clean. 6. The facility failed to keep the floor of hall 600 clean. These failures could lead to residents being harmed due to falls, feeling uncomfortable in their surroundings, or becoming sick due to spread of germs. Findings Included:…

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 hours. The facility failed to have RN coverage for one day in October 2023, for two days in November 2023, and for four days in December 2023. This failure could negatively affect residents in the facility by leaving residents and staff without supervisory coverage for coordination of events such as emergency care and disasters. Findings Included: Record review of the facility's Payroll Based Journal Staffing Data Report for fiscal year quarter 1 2024 (October 1-December 31) revealed the facility triggered for no RN hours on 10/01/23, 11/18/23, 11/19/23, 12/02/23, 12/03/23, 12/16/23, and 12/17/23. During an interview on 04/08/24 at 08:41 AM DON stated there were no RN hours on 10/01/23, 11/18/23, 11/19/23, 12/02/23, 12/03/23, 12/16/23, and 12/17/23. She stated she had been employed by the facility for 2 months in October of 2023 and the other RN who worked for the facility went on maternity leave…

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 ensure residents received, and the facility provided three meals daily, at regular times comparable to normal mealtimes in the community, as well as suitable, nourishing alternative meals and snacks for residents who want to eat at non-traditional times or outside of scheduled meal service times, consistent with the resident's plan of care. The facility failed to ensure all residents in the facility, received food trays at times comparable with normal mealtimes in the community. The facility failed to provide all residents who wanted snacks, at regular intervals between the three daily meals. These failures could place residents at risk of diminished nutritional status, food dissatisfaction and diminished physical well-being. Findings included: On 4/7/24 at 11:32PM 6 residents were observed sitting in the dining room, waiting for lunch service. On 4/7/24 at 12:00PM an observation of the dining room revealed the posted luncheon mealtime was 12:00PM and there were 27 residents sitting in the dining room, waiting…

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 develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident's property for two (Cook C and DA E) of 14 employees reviewed for criminal history background checks prior to or at hire. The facility failed to implement their policy and complete a criminal history background check on [NAME] C and DA E prior to hire. This failure could place residents at risk of abuse, neglect, exploitation, or misappropriation of their property by staff members. Findings Included: Record review of facility policy titled, Abuse, Neglect, and Exploitation and dated 10/2023 revealed the following: . The facility will provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, and exploitation and misappropriation of resident property. Screening A. Potential employees will be screened for a history of abuse, neglect, exploitation, 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 observations, interviews, and record reviews the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 (Resident #97) of 13 residents reviewed for baseline care plans. The facility failed to address Resident #97's oxygen therapy in her baseline care plan. This failure could place residents at risk of not receiving correct and/or necessary care/treatment. Findings included: Record review of Resident #97's undated face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, disease of biliary tract (disease of the network of organs and vessels that make, store and transfer bile through the body), peritonitis (inflammation of the membrane that lines the inner abdominal wall and encloses organs within the abdomen), and wheezing (shrill whistle or coarse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #97) of 13 residents reviewed for respiratory care. The facility failed to ensure Resident #97 had physician's orders for oxygen before administering oxygen. This failure could place residents at risk for receiving oxygen at the wrong rate which could lead to hypercapnia (too much carbon dioxide in the blood), pulmonary oxygen toxicity (damage to the lung lining tissues and air sacs), hypoxemia (low levels of oxygen in the blood, decreasing the oxygen supply to vital organs), and shortness of breath. Findings included: Record review of Resident #97's undated face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that…

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 establish and maintain an infection 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 CNAs (CNA B and CNA C) reviewed for infection control. CNA B and CNA C failed to don appropriate PPE when delivering meals to Covid positive residents. This failure could place well residents who took meals in their rooms, at risk of sickness due to the transmission of Covid-19 which could lead to a reduction in resident's quality of life and psychosocial well-being. Findings included: An interview with LVN A on 11/13/23 at 12:02PM revealed the Dietary Manager was at home with Covid-19. She stated there were currently 10 residents who had Covid-19. They were sequestered to their rooms with droplet precaution signs on the doors and bins with full PPE (Personal Protective Equipment) outside of the rooms for nursing staff use. She stated all staff should don full PPE before entering 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 interview, observation and record review the facility failed to inform the resident's physician and resident's representative when there was an accident or incident which resulted in injury or had the potential for physician intervention for 2 of 6 residents (Resident #1 and Resident #2) reviewed for Change in Status. The facility failed to inform Resident #1 physician after Resident #1 was involved in an altercation. The facility failed to inform Resident #2's physician and responsible party after Resident #2 was involved in an altercation and three additional falls, one of which resulted in injury. This failure could place residents at risk of not receiving essential physician care and resident representatives not being notified of change in status, which could affect the resident's physical and psychosocial well-being. Findings included: Resident #1 Record review of Resident #1's admission records revealed a [AGE] year-old female who was admitted to the facility on [DATE] with the following…

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, at the time of admission, have physician orders for the resident's immediate care for 1 of 6 (Resident #3) residents reviewed for admission orders. Resident #3's clinical record did not contain physician orders for care of Resident #3's surgical incision. This failure could place residents at risk of not receiving essential care consistent with the resident's physical and psychosocial well-being upon admission to the facility. Findings included: An interview and observation with Resident #3 on 11/13/23 at 3:14PM revealed that she had been admitted to the facility on [DATE] with a surgical site to the bottom of her left foot, resulting from surgical debridement of a diabetic foot ulcer. She stated the dressing to the bottom of her foot had only been changed once since her admission. The date observed on the dressing was noted as 11/11/23. Resident #3 thought the dressing was to be changed daily. Record Review of Resident #3's admission…

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

Based on interview and record review, the facility failed to, except when waived, use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. The facility failed to have an RN working at the facility for 8 consecutive hours, 7 days a week, during the months of December 2022, January 2023 and half of February 2023. This deficient practice could place residents at risk of staff being without supervisory support for the coordination of events such as emergency care, disasters, and resident emergencies. LVN and CNA staff are required to have RN supervision at all times. Findings include: Record review of the facility provided time sheets for registered nurses for the last 90 days revealed the following: The facility did not have an RN working in the facility on December 26 and 27, 2022; January 2023 on 1, 6, 9, 10, 13, 14, 15, 18, 19, 23, 24 and 27, and February 2023 on1, 2, 3, 6, 7, 10, 11, 12, and 15. During an Interview on 02/15/2023, at 2:43 PM, the ADM indicated he was aware the facility had not had RN coverage for several days during the months of…

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

Based on observation, interview, and record review, the facility failed to provide food that was palatable, attractive, and appetizing for residents who consumed foods orally from 1 of 1 lunch meals from 1 of 1 kitchen. The facility failed to provide food that was palatable for 1 of 1 lunch meal observed on 2/16/2023. This failure could place residents at risk of decreased food intake, hunger, and unwanted weight loss. Findings include: During an interview on 02/15/2023 at 11:20 AM Resident # 15 stated the food was bad. During an interview on 02/15/2023 at 11:25 AM Resident # 42 stated the food was bad. During an interview on 02/15/2023 at 02:48 PM Resident # 35 stated the food here is awful. Resident stated even the alternative food is bad most of the time. During an interview on 02/15/2023 at 03:00 PM Resident # 22 stated the food was so, so. During confidential interviews on 02/16/2023 at 10:05 AM, four residents, stated food sometimes is good at other times is not good. Observation of the test tray on 02/16/2023 at 12:40 PM revealed the food tray consisted of a bowl of beans…

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 of food safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to make sure expired foods were disposed and open food items labeled. This deficient practice could place residents at risk of causing food-born illness, weight loss, and a diminished meal experience. Findings include: In an observation on 02/15/2023 at 10:05 AM on initial kitchen rounds revealed the following: 1. The Walk-in cooler had a plastic container, which contained sweet potatoes with an open date of 2/8/2023 use by date of 2/11/2023. 2. The Walk-in cooler had a plastic container, which contained spiced apples with prep date of 12/2/2022 and use by date of 12/10/2022. 3. The dry storage area had a plastic bag which contained four open bags of bread with no open date or use by date listed on any of the bags of bread. Each of the bags of bread contained approximately four to five pieces of bread. On 02/16/2023 at 08:25 AM, a follow-up…

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 four out of twelve staff members (ADON, LVN A, CNA B and OTA) reviewed for infection control. 1. The facility failed to ensure LVN A doffed gloves and performed hand hygiene appropriately during wound care. 2. The facility failed to ensure OTA, ADON and CNA B performed hand hygiene appropriately during lunch with residents requiring feeding assistance. These failures could place residents at risk for transmissible diseases or slow wound healing due to cross contamination. Findings include: 1. During dining observation on 02/15/23 at 12:30 PM, OTA (Occupational Therapy Assistant) was observed walking around the dining room when Resident #41 dropped his fork. OTA retrieved a new fork for Resident #41, touching him on…

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