Avir at Commerce

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 1 resident (Resident #14) reviewed for hospice services. The facility did not ensure Resident #14's hospice records were a part of their records in the facility. This deficient practice could place residents at risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. Findings included: Record review of Resident #14's face sheet, dated 02/12/26, reflected Resident #14 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnosis which included Alzheimer's (progressive disease that destroys memory and other important mental…

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

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 to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #6) reviewed for infection control. The facility failed to ensure CNA B and CNA H followed EBP and put on gown and gloves while providing incontinent care to Resident #6 on 02/11/26. This failure could place residents at risk for cross-contamination and the spread of infection. Findings Included:Record review of face sheet, dated 02/11/26, indicated Resident #6 was a [AGE] year-old male, admitted [DATE] and readmitted on [DATE], with diagnoses of Alzheimer's disease with late onset (progressive memory loss and cognitive decline), benign prostatic hyperplasia with lower urinary tract symptoms (enlargement of the prostate gland) and chronic kidney disease stage 3A (moderate kidney damage and moderate…

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, comfortable, and homelike environment for 1 of 12 resident rooms (Resident #16) reviewed for physical environment. The facility failed to ensure Resident #16's windowsill was in good repair without exposed and splintered wood. This failure could place residents at risk for further deterioration, uncomfortable temperatures, the inability to properly clean, and possible pest infestation.Findings included: During an observation and interview on 02/10/2026, at 5:30 p.m., Resident #16's room windowsill had a visible hole and separated wood along the lower interior portion beneath the window. The opening measured approximately 10-12 inches in length and approximately 1-2 inches in width. The area contained cracked, splintered, and deteriorated wood with exposed inner material. The damaged section of the windowsill was located at resident height and was accessible to the resident. The surface was not smooth, intact, or cleanable. The windowsill had no protective covering, or repair was in…

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 provide sufficient number of nursing staff on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans and the facility assessment for 1 of 1 facility reviewed for care and services. The facility failed to provide sufficient CNAs according to the facility assessment on 02/01/2025, 02/04/2025, 02/05/2025, 02/06/2025, 02/07/2025, 02/08/2025, 03/01/2025, 03/07/2025, 03/10/2025, 03/12/2025, 03/25/2025, 03/29/2025, 04/01/2025. This failure placed residents at risk of inadequate supervision, an unsafe environment, falls, serious harm and injury, exacerbations of disease processes, abuse, and death. Findings included: During an interview Anonymous Staff Member #1 said they had been working short staffed for a while, but it was getting better. Anonymous Staff Member #1 said there were multiple nights where there was one CNA for the whole building. Anonymous Staff Member #1 said they worked as a team to care for the residents. Anonymous Staff Member #1 said they provided care to the residents…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 5 residents (Resident #1) reviewed for resident rights. The facility failed to ensure Resident #1 was treated respectfully when CNA B spoke to Resident #1 in a loud manner and patted her hand on 04/14/2025. This failure could place residents at risk of embarrassment, feelings of worthlessness, decreased self-worth, loss of dignity, and a diminished quality of life. Findings included: 1. Record review of a face sheet dated 05/08/2025 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included Parkinsonism (condition that impacts movement and causes muscle stiffness, slow movement, speech impairment, tremors, slowed reaction time, frequent falls), anxiety disorder (mental illness defined by feelings of uneasiness, worry and fear), and major…

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 that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 1 of 2 medication carts (South Hall Nurse Medication Cart) reviewed for drugs and biologicals. The facility failed to ensure LVN C secured the South Hall Nurse Medication Cart, when it was not in use on 05/07/2025. This failure could place residents at risk of not receiving drugs and biologicals as needed, medication errors, medication misuse, and drug diversion. Findings included: During an observation on 05/07/2025 starting at 1:22 PM, there was an unlocked medication cart next to the nurse's station. The housekeeper was cleaning and moved the unlocked medication cart to the opposite side of the hallway. The nurse was not observed near the medication cart or in the hallway. The housekeeper said she thought the nurse, LVN C, was at break. During an interview on 05/07/2025 at 1:27 PM, LVN C said she was on break, and the medication cart was hers. LVN C said she guessed she got…

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, interviews, and record review the facility failed to ensure residents have the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives and to choose the option he or she prefers for 2 of 5 residents reviewed for the right to be informed. (Resident's #1 and #9) 1. The facility failed to ensure Resident #1's psychotropic consent for trazadone (antidepressant), Xanax (antianxiety), lorazepam (antianxiety), and sertraline (antidepressant) reflected the clinical indication for use, the benefits of the medication, and the statement of consent. 2. The facility failed to ensure Resident #9's psychotropic consent form for Zyprexa (antipsychotic) reflected the resident or resident representative's signature for consent. These failures could place residents at risk for treatment or services provided without their informed consent. The findings included: 1. Record review of the face…

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 promptly resolve grievances for 3 out of 24 residents (Resident's #42, #44, #47) reviewed for grievances. The facility did not ensure Resident's #42, #44, and #47 grievances concerning coffee temperature were addressed. This deficient practice could place the residents at risk for decreased quality of life and feelings of neglect. The findings included: 1. Record review of the face sheet, dated 11/07/24, reflected Resident #42 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of COPD (an ongoing lung condition caused by damage to the lungs resulting in limited air flow into and out of the lungs). Record review of the quarterly MDS assessment, dated 10/16/24, reflected Resident #42 had clear speech and usually understood others. The MDS reflected Resident #42 was usually able to understand others. The MDS reflected Resident #42 had a BIMS score of 12, which indicated moderately impaired cognition. The MDS…

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 residents who required dialysis (treatment that filters water and waste from the blood when the kidneys are no longer able to do so) received such services, consistent with professional standards of practice for 1 of 1 resident (Resident #49) reviewed for dialysis. The facility failed to ensure all pre and post-dialysis assessments were completed for Resident #49. This deficient practice could affect residents who received dialysis treatments and place them at risk for complications and not receiving adequate care and treatment to meet their needs. Findings included: Record review of Resident #49's face sheet, dated 11/06/24, revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including fluid overload (which happens when there is too much fluid in your body. It can raise blood pressure, cause swelling, and impact organ function), End-Stage Renal Disease also known as ESRD (a permanent condition 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to establish a system of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and determine that drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 1 of 1 storage area reviewed for expired and discontinued medications. The facility failed to keep a record of receipt of controlled medications awaiting disposition to allow accurate and periodic reconciliation. This failure could place residents at risk for loss of prescribed medications, resident's safety, and drug diversion. Findings included: During an observation and interview on [DATE] at 09:54 AM, the following medications were observed in a basket located inside the controlled medication closet located inside the DONs office, and were awaiting to be disposed: *Ativan/Benadryl 1mg/25mg/ml gel- 25 mls RX# 363926/001 *Hydrocodone-apap 5-325mg tablet (label 1 of 3)- 8 tablets…

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

Based on observations, interviews, and record review, the facility failed to ensure the meals served met the nutritional needs of residents for 1 of 1 meal (the lunch meal) reviewed for nutritional adequacy. The facility did not ensure an 8 oz scoop size was used to serve the chicken alfredo during the lunch meal on 11/05/24. This failure could affect all residents in the facility by placing them at risk of not receiving adequate nutritive food value needed to promote/maintain health. Findings included: Record review of the facility dietary spreadsheet dated 06/04/24, indicated an 8 oz scoop size should be used to serve chicken alfredo. During an observation on 11/05/24 at 11:52 AM, a 6 oz scoop was being used to serve chicken alfredo. Approximately 10 resident trays had already been served and delivered. During an observation and interview on 11/05/24 at 11:56 AM, the Dietary Manager said the size of the scoop that was needed was documented on the dietary spreadsheet. The Dietary Manager said she posted the colors of each scoop size on the window in front of the serving table. 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.

Based on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 4 of 19 residents (Resident's #22, #42, #44, and #47) reviewed for palatable food. The facility failed to provide palatable food served at an appetizing temperature or taste to Resident #22, #42, #44, and #47 who complained the food was served cold, was bland, and 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. The findings included: During an interview on 11/04/24 at 11:28 AM, Resident #42 stated the food was cold and did not have flavor. During an interview on 11/04/24 at 12:02 PM, Resident #22 said she wished the facility had better food. Resident #22 said the food was bland. During an interview on 11/04/24 at 12:06 PM, Resident #47 stated she did not like the food. Resident #47 stated the vegetables were musty and very bland. Resident #47 said the food was cold when she received it. During an interview 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 observation, interview, and record review the facility failed to effectively 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, including hand hygiene for 3 of 7 residents (Resident #48, Resident #44 and Resident#3) reviewed for infection control. 1. The facility failed to ensure LVN H changed gloves or performed hand hygiene while providing wound care for Resident #48's coccyx area. 2. The facility failed to ensure CNA F did not wear Personal protective equipment and gloves in the hallway after assisting Resident #44 with his breakfast tray who was in contact isolation. 3. The facility failed to ensure LVN B performed hand hygiene when she removed her gloves after she obtained Resident #3's blood sugar on 11/05/24 These deficient practices could place residents at risk for infection due to improper care practices. Findings included: 1.Record…

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 follow established policy regarding smoking areas, and smoking safety for 1 of 1 smoking area. The facility failed to ensure flammable paper products (empty cigarette box, piece of a paper towel, blue sticky note, and a sonic cup) were not discarded in the red metal trash can designed for the disposing of cigarette butts. This failure could place residents who smoke at risk of physical harm and lead to an unsafe smoking environment. Findings Included: During an observation on 11/5/24 at 8:24 a.m., 4 residents were outside in the smoking area smoking with staff present. There was a red smoking can with cigarette butts, an empty cigarette box, piece of a paper towel, blue sticky note, and a sonic cup. During an interview on 11/7/24 at 10:34 a.m., the HR Coordinator stated whoever take the residents out to smoke should check the red smoking can for trash. The HR Coordinator stated the red can should not have any trash inside, only ashes and butts. The HR Coordinator stated it was important to ensure trash 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 the right to formulate an advanced directive was provided for 2 of 19 residents (Residents #40 and #44) reviewed for advanced directives. 1. The facility did not ensure Resident #40's OOH-DNR included the physician signature and licensed number. 2. The facility did not ensure Resident #44's full code status was discontinued after Resident #44 signed a DNR. These failures could place residents at risk of not receiving care and services to meet their needs. Findings included: 1. Record review of Resident #40's face sheet, dated [DATE], indicated Resident #40 was a [AGE] year-old male, originally to the facility on [DATE] with diagnoses which included dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life). Record review of Resident #40's physician order report, dated [DATE]-[DATE], indicated an active physician's order for code status: DNR with an order date [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 observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment for 1 of 19 residents (Resident #42) reviewed for reasonable accommodation of needs. The facility did not ensure Resident #42 was able to easily use the door to her room. This failure could place residents at risk for unmet needs and decreased quality of life. The findings included: Record review of the face sheet, dated 11/07/24, reflected Resident #42 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of chronic pain, difficult in walking, muscle weakness, unsteadiness of feet, and lack of coordination. Record review of the quarterly MDS assessment, dated 10/16/24, reflected Resident #42 had clear speech and usually understood others. The MDS reflected Resident #42 was usually able to understand others. The MDS reflected Resident #42 had a BIMS score of 12, which indicated moderately impaired cognition. The MDS reflected Resident #12 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 observation, interview, and record review the facility failed to provide appropriate treatment and service of care for 1 of 3 residents (Resident #30) reviewed for indwelling catheter. The facility failed to ensure Resident #30's indwelling catheter securement device was in place. The facility failed to ensure Resident #30's indwelling catheter drainage bag was kept from touching and resting on the floor. These failures could affect residents with an indwelling urinary catheter and place them at risk of at risk for urethral tears, discomfort, infection, and hospitalization. Findings included: Record review of a face sheet dated 11/07/24 indicated Resident #30 was a [AGE] year-old male, admitted on [DATE] and re-admitted on [DATE] with a diagnosis of Obstructive uropathy (a urinary tract disorder that occurs when urine flow is obstructed, either structurally or functionally),. Record review of a significant change in condition MDS dated [DATE] indicated Resident #30 rarely made himself 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 ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 2 of 5 residents (Resident's #15 and Resident #11) reviewed for respiratory care. 1. The facility failed to ensure Resident #11's oxygen was placed on 2 liters per nasal cannula as ordered by the physician. 2. The facility failed to change oxygen tubing weekly on Sunday nights for Resident #11 and Resident #15. These failures could place residents who receive respiratory care at risk of developing respiratory complications and a decreased quality of care. Finding included: 1.Record review of Resident #11's face sheet, dated 11/06/24 indicated she was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease also known as COPD, (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 interviews, and record review, the facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 3 residents (Resident # 49) reviewed for trauma-informed care. The facility did not ensure Resident #49 had a trauma screening upon admission that identified possible triggers when Resident 49 had a history of trauma. This failure could put residents at an increased risk for severe psychological distress due to re-traumatization. Findings included: Record review of a face sheet dated 11/07/24 indicated Resident #30 was a [AGE] year-old male, admitted on [DATE] and re-admitted on [DATE] with diagnoses including stroke, Obstructive uropathy (a urinary tract disorder that occurs when urine flow is obstructed, by either structurally, 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 that it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 24.24%, based on 8 errors out of 33 opportunities, which involved 2 of 6 residents (Resident #4 and Resident #25) reviewed for medication administration. The facility failed to ensure Resident #4 medications were administered during the scheduled time on 11/04/24. The facility failed to ensure LVN appropriately dosed Resident #25's MiraLAX on 11/05/24. These failures could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders. Findings included: 1. Record review of Resident #4's face sheet dated 11/06/24, indicated a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE]. Resident #4 had diagnoses which included dementia (memory loss), depression (persistent feeling of sadness and loss of interest),…

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 were free of significant medication errors for 1 of 6 residents (Resident #4) reviewed for pharmacy services. The facility failed to ensure Resident #4 medications were administered during the scheduled time of 6:00 AM and 10:00 AM on 11/04/24 which resulted in medications being administered 1 hour and 36 minutes late after the 1-hour grace period. The facility failed to ensure Resident # 4's medications were administered during the scheduled time of 6:00 AM and 10:00 AM on 11/05/24 which resulted in medications being administered 4 hour and 55 minutes late after the 1-hour grace period. These failures could place residents at risk of medical complications and not receiving the therapeutic effects of their medications. Findings included: 1. Record review of Resident #4's face sheet dated 11/06/24, indicated a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE]. Resident #4 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel, and labeled and dated correctly for 1 of 4 medication carts (south nurse's treatment cart) and 2 of 7 residents (Resident #3) observed for medication storage. 1. The facility did not ensure the south side nurse's treatment cart was secured and unable to be accessed by unauthorized personnel on 11/05/24. 2. The facility failed to ensure Resident #3's insulin lispro pen was properly secured when LVN B left it on top of the nurse's treatment cart on 11/05/24. 3. The facility failed to ensure Resident #38 wound care supplies was properly safe and secured. These failures could place residents at risk for not receiving drugs and biologicals as needed and a drug diversion. Findings included: Record review of Resident #3's face sheet dated 11/06/24, indicated a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses which…

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 2 residents (Resident #1) reviewed for hospice services. The facility did not ensure Resident #1's updated plan of care and most recent medication list from the hospice were a part of their current medical records in the facility. This deficient practice could place residents who receive 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 included: Record review of the face sheet, dated 11/07/24, reflected Resident #1 was a [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis 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 provide a safe, functional, sanitary, and comfortable environment for 1 of 3 doors reviewed for a safe environment. The facility failed to ensure the wander guard system operated correctly on the north side door when the Maintenance Supervisor tested the door on 11/07/24. This failure could place residents at risk of elopement, injury, or harm. Findings included: During an observation on 11/07/24 at 9:54 a.m., the Maintenance Supervisor checked the wander guard door on the north side hall and the alarm did not activate. He then checked the other 2 wander guard doors, and they were functioning properly. During an observation on 11/07/24 at 10:08 a.m., LVN D checked 2 different residents' wander guards using their handheld system and they both worked properly. During an interview on 11/07/24 at 10:13 a.m., the Maintenance Supervisor said he checked the door for functionality last week (unknown day). He said the doors were functioning properly during the inspection. He said he checked the doors weekly as part 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 observations, interviews, and record review, the facility failed to provide residents with a nourishing, palatable, well-balanced diet that meets their daily nutritional and special dietary needs, taking into consideration the preferences of each resident for 1 of 1 meal (the lunch meal) reviewed for nutritional adequacy. The facility failed to prepare an adequate amount of food for the lunch meal on 10/29/24. This failure could affect all residents in the facility by placing them at risk of not receiving adequate nutritive food value needed to promote/maintain health. Findings included: 1. Record review of Resident #1's face sheet dated 10/29/24, indicated a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included liver cancer, cerebral vascular disease (a group of conditions that affect blood flow and the blood vessels in the brain, congestive heart failure (a serious condition that occurs when the heart cannot pump enough blood to meet the body's needs), and anemia (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 and record review the facility failed to consult with the resident's physician when there was a significant change in the resident's physical and mental status that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications for 1 of 6 (Resident #2) residents reviewed for notification of change. The facility failed to notify Resident #2's physician of a weight loss of 9.8 lbs. in 8 days. These failures could result in residents with weight loss not receiving treatments, supplements, or nutrition needed to maintain acceptable and desired weight and nutritional needs for healing. Findings Include: 1. Record review of a face sheet dated [DATE] indicated Resident #2 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses pressure ulcer (injury to the skin and underlying tissue resulting from prolonged pressure on the skin) of the sacral region (area located below the lumbar spine and above the tailbone),…

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 parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician ordersto help prevent the development and transmission of communicable diseases and infections were maintained for the facility for 1 of 2 (Resident #1) residents reviewed for parenteral fluids. The facility did not ensure Resident #1's central line (a tube that is inserted into a large vein in the neck, chest, groin, or arm to give fluids, blood, medications, or to do medical tests quickly) dressing was changed every seven days per the physician's order. This failure could place residents at risk for central line associated bloodstream infections. Findings Included: 1. Record review of the face sheet dated 1/18/24 indicated Resident #1 was a [AGE] year-old female re-admitted to the facility on [DATE] with diagnoses including pressure ulcer (injury to the skin and underlying tissue resulting from prolonged…

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. Expired food was not disposed of. 2. Food was not labeled or dated. 3. Kitchen equipment was not kept free of carbon buildup. These deficient practices could place residents who received meals from the kitchen at risk for food borne illness. The findings were: During an observation on 10/09/23 at 9:00 a.m., a cast iron skillet was on the stove that was used to cook breakfast. The cast iron skillet was observed with a thick layer of carbon buildup. The cast iron stove top had a thick layer of carbon buildup. Inside the refrigerator it was observed that a tub of cottage cheese was out of date, 10/04/2023. It was observed 8 bags of hotdog buns without dates or labels and no expiration date was printed on bag. It was observed that a loaf of bread was opened and laying on a serving table with no date or label and no expiration date printed 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 interviews and record review the facility failed to ensure assessments accurately reflected the resident status for 1 of 14 residents (Resident #33) reviewed for MDS assessment accuracy. The facility did not ensure Resident #33's quarterly MDS identified a medication as an anti-platelet instead of an anticoagulant. These failures could place residents at risk for not receiving care and services to meet their needs. Findings included: Record review of Resident #33's face sheet, dated 10/11/23, indicated he was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included cerebral infarction (the pathologic process that results in an area of necrotic tissue in the brain). Record review of Resident #33's quarterly MDS assessment, dated 07/20/23, indicated in Section N0410 Medications Received item E. Anticoagulant was marked as having been given for the last 7 days. The instructions for this section read, Indicate the number of DAYS the resident received the following medications by…

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 respiratory care was provided with professional standards of practice for 1 of 2 resident reviewed for respiratory care and services. (Resident #142) The facility failed to administer oxygen at 3 liters via nasal cannula as prescribed by the physician for Resident #142. This failure could place residents who receive respiratory care at risk for developing respiratory complications. Findings included: Record review of Resident #142's face sheet dated 10/10/23, indicated a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #142's diagnoses included pneumonia (infection of the air sacs in one or both lungs), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), chronic respiratory failure with hypoxia (not enough oxygen in the blood), and malignant neoplasm of mandible (jaw cancer). Record review of Resident #142's…

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

Based on observations, interviews, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the appropriate accessory and cautionary instructions, and the expiration date when applicable for one of one medication room reviewed for medications storage (North Side Medication Room). The facility failed to remove an expired medication from the North Side Medication Room. These failures could place residents at risk for not receiving the therapeutic benefit of medications or adverse reactions to medications. Findings included: During an observation on 10/11/23 at 09:47 AM, this surveyor reviewed the North Side Medication Room with RN A. A 2mL vial of Lidocaine HCL injection 1% (a medication used to alleviate pain and discomfort by numbing the targeted area of the body) was found with an expiration date of September 2013. During an interview on 01/11/23 at 09:55 AM, RN A said the expired lidocaine vial should not have been in the medication room. She said it was missed…

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 use of psychotropic medications was documented in the clinical record for 1 of 5 residents reviewed for unnecessary psychotropic drugs (Resident #30). The facility failed to adequately monitor Resident #30's side effects regarding her antidepressant medication. This failure could place residents at risk of receiving unnecessary psychotropic medications with possible medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications. Findings included: Record review of Resident #30's face sheet dated 10/10/23, indicated a [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #30's diagnoses included depression, anxiety, congestive heart failure (condition in which the heart does not pump blood as well as it should), and essential hypertension (high blood pressure). Record review of Resident #30's quarterly MDS assessment dated [DATE], 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.