Avir at Comfort

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 4 residents (Resident #10) reviewed for infection control. The facility failed to post a sign on Resident #10's door to indicate she was on Contact Isolation (any of the techniques used in addition to standard precautions that decrease the likelihood of infection by microorganisms transmitted through direct or indirect contact with the patient or patient care items, e.g., methicillin-resistant Staphylococcus aureus). This deficient practice could affect staff, residents, and visitors who may enter Resident #10's room without the appropriate PPE and expose them to infection. The findings included: Record review of Resident #10's electronic face sheet (undated) reflected she was originally admitted to the facility on [DATE] and readmitted on [DATE]. Her…

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 1 kitchen, in that: 1. The facility failed to ensure the facility fryer was clean and old oil discarded. 2. The facility failed to ensure homemade Jell-O was discarded after 3 days. These deficient practices could place residents who ate food from the kitchen at risk for foodborne illness. The findings were: 1. In an observation on 6/4/2023 at 9:45 a.m. of the facility fryer located in the facility kitchen revealed there were two separate wells with oil. Further inside the oil wells revealed the well on the right was dark and was unable to see the bottom of the pan. Further review of the kitchen fryer revealed there was a thick splatter of oil on the outside of the fryer and on the table the fryer was sitting on. In an interview on 6/4/2023 at 9:52 a.m. with the FSS revealed they used only the fryer on the left and used the right side for run off from the fried food item. The FSS reported he…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to complete a performance review of every nurse aide at least once every 12 months, and provide regular in-service education based on the outcome of these reviews for 4 (Lead CNA K, CNA E, CNA F, and CNA G) of 6 staff, in that; The facility failed to provide an annual performance review and subsequent trainings based on the outcome of the review for 4 (Lead CNA K, CNA E, CNA F, and CNA G) of 6 nurse aides reviewed for competencies. This failure could place residents at risk of being cared for by untrained staff. Findings included: Review of the excel spread sheet, entitled CEUs, received 6/06/2023 at 6:41 PM from the ADM, revealed inclusion of the following staff: Lead CNA K, CNA F, CNA G. The total number of CEUs did not total 12 hours per year on the required annual training topics for any staff. Spread sheet did not include the follow staff: CNA E. Review of CNA Lead K's personnel record had a hire date of 10/03/2013, with annual training in-services…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop, implement, and maintain an effective training program for all new and existing staff for 19 of 31 facility staff reviewed for trainings consistent with their expected roles, in that; The facility failed to provide the ADM, the DON, the SW, the PT, OT L, OT M, CNA H, RN P, LVN B, Lead CNA K, CNA E, DA Q, CNA F, CNA G, the ACT DIR, LVN D, RN N, LVN C, and LVN O with trainings consistent with their expected roles. Findings included: Review of the undated excel spread sheet, entitled CEUs, received 6/06/2023 at 6:41 PM from the ADM, revealed inclusion of the following staff: ADM, PT, OT L, OT M, Lead CNA K, DA Q, CNA F, CNA G, ACT DIR, LVN D, RN N, LVN C, and LVN O. The total number of CEUs did not total 12 hours per year on the required annual training topics for any staff. Spread sheet did not include the follow staff: DON, SW, CNA H, RN P, LVN B or CNA E. Review of ADM's personnel record had a hire date of 9/10/2021, with annual 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 include effective communications as mandatory training for 17(DON, the SW, the PT, OT L, OT M, CNA H, RN P, LVN B, Lead CNA K, CNA E, CNA F, CNA G, the ACT DIR, LVN D, RN N, LVN C, and LVN O) of 31 direct care staff reviewed for trainings, in that; The facility failed to provide the DON, the SW, the PT, OT L, OT M, CNA H, RN P, LVN B, Lead CNA K, CNA E, CNA F, CNA G, the ACT DIR, LVN D, RN N, LVN C, and LVN O with effective communications as mandatory training. This failure could place residents at risk of being cared for by untrained staff. Findings included: Review of the excel spread sheet, entitled CEUs, received 6/06/2023 at 6:41 PM from the ADM, revealed inclusion of the following staff: PT, OT L, OT M, Lead CNA K, DA Q, CNA F, CNA G, ACT DIR, LVN D, RN N, LVN C, and LVN O. The total number of CEUs did not total 12 hours per year on the required annual training topics for any staff. Spread sheet did not include the follow staff: DON, SW, CNA H, RN…

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 staff members are educated on the rights of the resident and the responsibilities of a facility to properly care for its residents 19 (ADM, the DON, the SW, the PT, OT L, OT M, CNA H, RN P, LVN B, Lead CNA K, CNA E, DA Q, CNA F, CNA G, the ACT DIR, LVN D, RN N, LVN C, and LVN O) of 31 facility staff reviewed for education records, in that;:: The facility failed to provide the ADM, the DON, the SW, the PT, OT L, OT M, CNA H, RN P, LVN B, Lead CNA K, CNA E, DA Q, CNA F, CNA G, the ACT DIR, LVN D, RN N, LVN C, and LVN O with education on the rights of the resident and the responsibilities of a facility to properly care for its residents. This failure could place residents at risk of being cared for by untrained staff. Findings included: Review of the undated excel spread sheet, entitled CEUs, received 6/06/2023 at 6:41 PM from the ADM, revealed inclusion of the following staff: ADM, PT, OT L, OT M, Lead CNA K, DA Q, CNA F, CNA G, ACT DIR, LVN…

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 staff members are educated on abuse, neglect, and exploitation and activities that constitute such actions, procedures for reporting incidents, and dementia management and resident abuse prevention, for 19 (ADM, the DON, the SW, the PT, OT L, OT M, CNA H, RN P, LVN B, Lead CNA K, CNA E, DA Q, CNA F, CNA G, the ACT DIR, LVN D, RN N, LVN C, and LVN O) of 31 facility staff reviewed for education, in that; The facility failed to provide the ADM, the DON, the SW, the PT, OT L, OT M, CNA H, RN P, LVN B, Lead CNA K, CNA E, DA Q, CNA F, CNA G, the ACT DIR, LVN D, RN N, LVN C, and LVN O with training that education on abuse, neglect, and exploitation and activities that constitute such actions, procedures for reporting allegations, and dementia management and resident abuse prevention. This failure could place residents at risk of being cared for by untrained staff. Findings included: Review of the excel spread sheet, entitled CEUs, received…

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 include as part of its infection prevention and control program mandatory training that includes the written standards, policies, and procedures for the program for 19 of 31 facility staff reviewed for trainings on infection control, in that; The facility failed to provide the ADM, the DON, the SW, the PT, OT L, OT M, CNA H, RN P, LVN B, Lead CNA K, CNA E, DA Q, CNA F, CNA G, the ACT DIR, LVN D, RN N, LVN C, and LVN O with trainings on infection control. This failure could place residents at risk of being cared for by untrained staff. Findings included: Review of the undated excel spread sheet, entitled CEUs, received 6/06/2023 at 6:41 PM from the ADM, revealed inclusion of the following staff: ADM, PT, OT L, OT M, Lead CNA K, DA Q, CNA F, CNA G, ACT DIR, LVN D, RN N, LVN C, and LVN O. The total number of CEUs did not total 12 hours per year on the required annual training topics for any staff. Spread sheet did not include the follow staff: DON, SW, CNA…

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 communicate the compliance and ethics program's standards, policies and procedures through a training program or other practical manner which explains the requirements for 19 of 31 facility staff reviewed for education, in that; The facility failed to communicate the compliance and ethics program's standards to the ADM, the DON, the SW, the PT, OT L, OT M, CNA H, RN P, LVN B, Lead CNA K, CNA E, DA Q, CNA F, CNA G, the ACT DIR, LVN D, RN N, LVN C, and LVN O. This failure could place residents at risk of being cared for by untrained staff. Findings included: Review of the excel spread sheet, entitled CEUs, received 6/06/2023 at 6:41 PM from the ADM, revealed inclusion of the following staff: ADM, PT, OT L, OT M, Lead CNA K, DA Q, CNA F, CNA G, ACT DIR, LVN D, RN N, LVN C, and LVN O. The total number of CEUs did not total 12 hours per year on the required annual training topics for any staff. Spread sheet did not include the follow staff: DON, SW, CNA H, RN P, LVN B or CNA E. Review of ADM's personnel record had a hire date 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 interview and record review, the facility failed to provide in-service training that was sufficient to ensure the continuing competence of nurse aides but must be no less than 12 hours per year and included dementia management training, resident abuse prevention training, and care of the cognitively impaired for 5 (CNA H, Lead CNA K, CNA E, CNA F, and CNA G) of 5 CNAs reviewed for annual training, in that; The facility failed to provide CNA H, Lead CNA K, CNA E, CNA F, and CNA G with 12 hours per year of annual training that included dementia management training, resident abuse prevention training, and care of the cognitively impaired. This failure could place residents at risk of being cared for by untrained staff. Findings included: Review of the undated excel spread sheet, entitled CEUs [Continuing Education Units], received 6/06/2023 at 6:41 PM from the ADM, revealed inclusion of the following staff: Lead CNA K, CNA F, CNA G. Spread sheet did not include the follow staff: CNA H, or CNA E. The total…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to have a system in place to assure assessments are conducted in accordance with the specified timeframes for each resident for 3 of 22 residents (#11, #25, #26) reviewed for MDS timeliness, in that; 1. Resident #11 discharged from the facility on 1/13/2023 however the resident's discharge MDS Assessment was not completed until 5/31/2023. 2. Resident #25 was discharged from the facility on 2/18/2023 however the resident's discharge MDS Assessment was not completed until 6/8/2028. 3. Resident #26 was discharged from the facility on 2/18/2023 however there was not a discharge MDS completed. These failures could result in incorrect billing to the residents' insurance and could prevent additional services the residents could receive in the community. The findings included: 1. Record review of Resident #11's face sheet dated 6/7/2023 revealed the resident was a [AGE] year-old male who was admitted to the facility on [DATE] and discharged from the facility 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that an assessment was completed for residents within 14 days after a significant change in the resident's status for 1 of 22 residents (Resident #7) reviewed for MDS assessments, in that: The facility failed to complete a Significant Change MDS for Resident #7 within 14 days after the resident was discharged from hospice services. This deficient practice could place residents discharged from hospice services at-risk of not having their individual needs met. The findings were: Record review of Resident #7's face sheet dated 6/6/2023 revealed the resident was a [AGE] year-old male who was initially admitted to the facility on [DATE], most recent admission date of 2/6/2015 and had diagnoses that included alcohol dependence with alcohol-induced persisting dementia, Wernicke's encephalopathy (a degenerative brain disorder caused by lack of vitamin B1), schizoaffective disorder bipolar type (a chronic mental health disorder characterized by abnormal…

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 Minimum Data Set (MDS) was electronically completed and transmitted to the CMS System within 14 days after completion for 1 of 22 (Resident #25) residents reviewed for MDS transmittal in that: Resident #25's discharge MDS assessment dated [DATE] was not submitted as of 6/7/2023. This deficient practice could place residents at risk of not having their assessments transmitted timely. The findings were: Record review of Resident #25's face sheet dated 6/7/2023 revealed the resident was a [AGE] year-old female who was admitted to the facility on [DATE] and discharged from the facility on 2/18/2023. The resident's diagnoses listed on the face sheet included hypertensive heart disease (a long-term condition that develops over many years in people who have high blood pressure), spinal stenosis (when spaces in the spine narrow and create pressure on the spinal cord and nerve roots), generalized muscle weakness, and age-related physical disability.…

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 complete an accurate assessment of each resident's functional capacity for 1 of 22 residents (Resident #8) whose assessments were reviewed, in that: The facility identified Resident #8 had two stage 3 pressure ulcers on the resident's MDS Assessment however the resident did not have any stage 3 pressure wounds. This failure could place residents at risk of inadequate care due to inaccurate assessments. The findings were: Record review of Resident #8's face sheet dated 6/6/2023 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included dementia, hypothyroidism (underactive thyroid diagnose through blood tests), heart disease with heart failure, pressure wounds of right buttock stage 1 (affects the upper layer of the skin which appears reddened with no open wound), and two stage 3 pressure wounds (open wounds that have burrowed past the skins second layer and reached the fat layers…

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 22 residents (Resident # 25) reviewed for MDS completion, in that; The facility failed to ensure the RN signed Resident #25'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 current status. The findings included: Record review of Resident #25's face sheet dated 6/7/2023 revealed the resident was a [AGE] year-old female who was admitted to the facility on [DATE] and discharged from the facility on 2/18/2023. The resident's diagnoses listed on the face sheet included hypertensive heart disease (a long-term condition that develops over many years in people who have high blood pressure), spinal stenosis (when spaces in the spine narrow and create pressure on the spinal cord and nerve roots), generalized muscle weakness, and age-related…

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 baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care within 48 hours of a resident's admission for 1 of 22 residents (Resident #8) reviewed for care plans, in that; The facility failed to develop a baseline care plan within 48 hours for Resident #8 after the resident was admitted to the facility. This deficient practice could result in residents not receiving care and services as needed. The findings were: Record review of Resident #8's face sheet dated 6/6/2023 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included dementia, hypothyroidism (underactive thyroid diagnose through blood tests), heart disease with heart failure, and chronic kidney disease stage 3 (mild to moderate damage to the kidneys which are less able to filter waste 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 develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's mental, nursing, and psychosocial needs that were identified in the comprehensive assessment, for 1 of 22 Residents (Resident #8) reviewed for care plans, in that: 1. The facility failed to develop a comprehensive person-centered care plan that was specific for Resident #8 to address hospice information, details of hospice care provided and coordination of services. This failure could place residents at risk for not getting their medical, physical, and psychosocial needs met and not being provided with the necessary care or services and having personalized plans developed to address their specific needs. The findings were: 1. Record review of Resident #8's face sheet dated 6/6/2023 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] 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 ensure that a resident who was incontinent of bladder received appropriate treatment and services for 1 of 3 residents (Resident #23) reviewed for urinary catheters, in that: Resident #23 had an indwelling urinary catheter for 5 days without a physician's order or related care orders to be provided. This deficient practice could affect residents who had urinary catheters at risk of not receiving care needed. The findings were: Record review of Resident #23's face sheet dated 6/7/2023 revealed the resident was a [AGE] year-old female with an initial admit date of 4/24/2023, a readmit date of 5/29/2023, and had diagnoses that included heart disease, type 2 diabetes mellitus (the body either does not produce enough insulin or it resists insulin) with diabetic polyneuropathy (progressive death of nerve fibers), chronic pain, and osteoarthritis. The face sheet also noted the resident was on hospice services. Review of Resident #23'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 ensure a registered nurse was present in the facility for at least eight consecutive hours per day and seven days per week, for 1 of 1 facility reviewed for registered nursing coverage, in that; A registered nurse [RN] was not present in the facility for at least eight consecutive hours per day and seven days per week on 4 occasions (4/01/2023, 4/08/2023, 4/15/2023, and 5/14/2023) in the 3 months (3/01/2023 - 6/04/2023) prior to the survey period. This deficient practice had the potential to affect all residents in the facility by leaving staff without supervisory coverage for coordination of events such as assessments, interventions, care and treatment requiring the advanced education, skills and judgement of an RN. The findings were: Review of PBJ [Payroll Based Journal] Staffing Data Report, with a run date of 5/30/2023 revealed inadequate RN coverage, less than 8 consecutive hours, 7 days a week, for over approximately 2 months, between 10/03/2022 through 12/10/2022. Review of sign in sheets for the previous 3 months…

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 routine drugs and biologicals to its residents, or obtain them for 1 of 12 residents (Resident #31) observed for pharmacy services, in that; The facility failed to obtain gabapentin medication as required for Resident #31. This deficient practice placed residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health. The findings included: Record review of the admission face sheet, dated 6/08/2023, revealed Resident #31 was a [AGE] year-old female admitted [DATE]. Record review of the quarterly MDS assessment, dated 4/29/2023, revealed Resident #31 was admitted for non-traumatic brain dysfunction as the primary reason for admission. Other active diagnoses included alcoholic cirrhosis [degenerative disease resulting in scarring and functional failure] of the liver with ascites [abnormal buildup of fluid in the belly, prognosis is poor]. Resident #31 had a summary BIMS score of 15,…

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 are free of any significant medication errors for 1 of 12 residents (Resident #31) observed during medication administration, in that; The facility failed to administer medications (gabapentin, a medication to relieve nerve pain) as prescribed for Resident #31. This deficient practice placed residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health. The findings included: Record review of the admission face sheet, dated 6/08/2023, revealed Resident #31 was a [AGE] year-old female admitted [DATE]. Record review of the quarterly MDS assessment, dated 4/29/2023, revealed Resident #31 was admitted for non-traumatic brain dysfunction as the primary reason for admission. Other active diagnoses included alcoholic cirrhosis [degenerative disease resulting in scarring and functional failure] of the liver with ascites [abnormal buildup of fluid in the belly, prognosis is…

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, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys in 1 of 3 medication carts (Treatment Cart) reviewed for medication storage, in that; The facility failed to ensure the Treatment Cart was locked when it was left unattended at the Nurses' Station in a common area. This deficient practice could place residents at risk of medication misuse or drug diversion. The findings were: In an observation on 6/07/2023 at 12:50 PM, the Treatment Cart was observed to be unlocked and unattended at the Nurses Station. This was a common pass-through area to common areas of the smoking patio, break room, television room and exit. There were ambulatory and self-mobilizing residents, visitors, and staff in the immediate vicinity. In an observation and interview on 6/07/2023 at 12:53 PM, the RVP stated the cart should be locked when not attended. The Treatment Cart contained prescription and over-the-counter…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record reviews the facility failed to maintain medical records on each resident that are complete; accurately documented; readily accessible; and systematically organized, for 1 of 22 residents (Resident #23) reviewed for accurate medical records, in that: Resident #23's electronic medical record did not have a diagnosis for her indwelling catheter. This failure could place residents at risk for harm due to inaccurate records. The findings included: Record review of Resident #23's face sheet dated 6/7/2023 revealed the resident was a [AGE] year-old female with an initial admit date of 4/24/2023, a readmit date of 5/29/2023, and had diagnoses that included heart disease, type 2 diabetes mellitus (the body either does not produce enough insulin or it resists insulin) with diabetic polyneuropathy (progressive death of nerve fibers), chronic pain, and osteoarthritis. The face sheet also noted the resident was on hospice services. Review of Resident #23's admission MDS assessment dated [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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 7 residents (Resident #2) reviewed for hospice services, in that: The facility failed to obtain Resident #2's copy of the hospice Plan of Care and a signed copy of the Hospice Election Form. This failure could place the residents who received hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. The findings were: Record review of Resident #2's face sheet dated 6/7/2023 revealed a [AGE] year-old female who initially admitted on [DATE], readmitted on [DATE] and had diagnoses that included vascular dementia (a term describing…

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.