Avir at Converse

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 5 of 8 residents (Residents ##28, #25, #37, #31. and #38) reviewed for pharmacy services. 1. Resident #28's insulin flex pen (Humalog) for diabetes had an open date of [DATE] found inside the 100/200-hall nursing cart on [DATE]. It should have been discarded 28 days after opening. 2. Resident #25's insulin (Lispro) for diabetes had an open date of [DATE] found inside the 100/200-hall nursing cart on [DATE]. It should have been discarded 28 days after opening. 3. Resident #37's insulin (Novolog) for diabetes had an open date of [DATE] found inside the 100/200-hall nursing cart on [DATE]. It should have been discarded 28 days after opening. 4. Resident #31's insulin (Novolog) for diabetes had an open date of [DATE] found inside the 100/200-hall…

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 ensure all drugs and biologicals were stored in locked compartments for 4 of 8 residents (Residents #37, #49, #31, and #54) reviewed for storage. 1. Resident #37's insulin Glargine (Lantus) for diabetes had no open date, found inside 100/200-hall nursing cart on [DATE]. Per the label of the insulin said, Discard 28 days after date opened. 2. Resident #49's insulin Glargine (Lantus) for diabetes had no open date, found inside 100/200-hall nursing cart on [DATE]. Per the label of the insulin said, Discard 28 days after date opened. 3. Resident #31's insulin Glargine (Lantus) for diabetes had no open date, found inside 100/200-hall nursing cart on [DATE]. Per the label of the insulin said, Discard 28 days after date opened. 4. Resident #54's insulin (Novolog) for diabetes had no open date, found inside 100/200-hall nursing cart on [DATE]. Per the label of the insulin said, Discard 28 days after date opened. These failures could place…

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, implement, and maintain an effective training program for all new and existing staff for 11 of 23 (Housekeeper N, CMA F, CNA G, LVN H, Dietary Aide I, RN J, CNA K, CNA L, LVN M, LVN/MDS, Dietary Manager) employees reviewed for training requirements. The facility failed to implement and maintain a training program that ensured Housekeeper N, CMA F, CNA G, LVN H, Dietary Aide I, RN J, CNA K, CNA L, LVN M, LVN/MDS, Dietary Manager received required trainings annually. The facility failed to implement and maintain a training program that ensured Dietary Manager received required trainings upon hire. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. Findings include: Record review of the personnel records for Housekeeper N revealed a hire date of 10/04/2016. Review of a training in-services for Housekeeper N from the previous 12 months, provided by the HR Coordinator revealed no evidence of communication training, QAPI training, ethics training, or falls…

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 communications training for 4 of 23 employees (Housekeeper N, CMA F, CNA G, LVN H) reviewed for training, in that: The facility failed to ensure effective communication training was provided to Housekeeper N, CMA F, CNA G and LVN H annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. Findings include: Record review of the personnel records for Housekeeper N revealed a hire date of 10/04/2016. Review of a training in-services for Housekeeper N from the previous 12 months, provided by the HR Coordinator revealed no evidence of communication training being provided annually. Record review of the personnel records for CMA F revealed a hire date of 01/27/2020. Review of a training in-services for CMA F from the previous 12 months, provided by the HR Coordinator revealed no evidence of communication training being provided annually. Record review of the personnel records for CNA G revealed a hire date of 07/31/2023. Review of a training in-services for…

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 include as part of its QAPI program mandatory training that outlines and informs staff of the elements and goals of it's QAPI program for 5 of 23 employees (Housekeeper N, CNA G, Dietary Aide I, CMA F, RN J) employees reviewed for training requirements. The facility failed to ensure required QAPI trainings was provided to Housekeeper N, CNA G, Dietary Aide I, CMA F, and RN J annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. Findings include: Record review of the personnel records for Housekeeper N revealed a hire date of 10/04/2016. Review of a training in-services for Housekeeper N from the previous 12 months, provided by the HR Coordinator revealed no evidence of QAPI training being provided annually. Record review of the personnel records for CMA F revealed a hire date of 01/27/2020. Review of a training in-services for CMA F from the previous 12 months, provided by the HR Coordinator revealed no evidence of QAPI training being provided annually.…

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 mandatory ethics training for 7 of 23 employees (Housekeeper N, CNA G, RN J, CNA K, CNA L, LVN M, LVN/MDS) employees reviewed for training, in that: The facility failed to ensure ethics training was provided to Housekeeper N, CNA G, RN J, CNA K, CNA L, LVN M, and LVN/MDS annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. The findings include: Record review of the personnel records for Housekeeper N revealed a hire date of 10/04/2016. Review of a training in-services for Housekeeper N from the previous 12 months, provided by the HR Coordinator revealed no evidence of ethics training being provided annually. Record review of the personnel records for CNA G revealed a hire date of 07/31/2023. Review of a training in-services for CNA G from the previous 12 months, provided by the HR Coordinator revealed no evidence of ethics training being provided annually. Record review of the personnel records for RN J revealed a hire date of 02/17/2023. Review 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 interview and record review, the facility failed to ensure CNA received the required minimum 12 hours annual in-service for 3 of 6 CNAs (CNA G, CNA K, CNA L) reviewed for training. The facility failed to provide the required 12 hours of annual training to CNA G, CNA K, CNA L. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. The findings include: Record review of the personnel records for CNA G revealed a hire date of 07/31/2023. Review of a training in-services for CNA G from the previous 12 months, provided by the HR Coordinator revealed no evidence that the facility provided the required 12 hours of in-service trainings including communication training, QAPI training or ethics training being provided annually. Record review of the personnel records for CNA K revealed a hire date of 01/29/2024. Review of a training in-services for CNA K from the previous 12 months, provided by the HR Coordinator revealed no evidence that the facility provided the required 12 hours of in-service trainings including ethics…

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 behavioral health training consistent with the requirements at §483.40 and as determined by the facility assessment at §483.71 for 2 of 28 (Dietary Aide I and Dietary Manager) employees reviewed for training, in that: The facility failed to ensure behavioral health training was provided to Dietary Aide I annually. The facility failed to ensure behavioral health training was provided to Dietary Manager upon hire. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. The findings include: Record review of the personnel records for Dietary Aide I revealed a hire date of 12/08/2022. Review of a training in-services for Dietary Aide I from the previous 12 months, provided by the HR Coordinator revealed no evidence of behavioral health training being provided annually. Record review of the personnel records for Dietary Manager revealed a hire date of 10/23/2024. Review of a training in-services for Dietary Manager from the previous 12 months, provided by the HR…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs for 1 of 8 residents (Resident #18) who were observed for call light placement. The facility failed to ensure the call light was within reach for Resident #18. This failure could affect any resident and keep them from calling for help as needed. The findings were: Record review of Resident #18's face sheet, dated 04/02/2025, revealed he was admitted to the facility on [DATE] with diagnoses which included: epilepsy (disorder in which nerve cell activity in the brain is disturbed, causing seizures), unspecified, not intractable, with status epilepticus (a seizure that lasts longer than 5 minutes or when seizures occur in rapid succession without the person regaining consciousness between them), essential hypertension (high blood pressure), muscle weakness generalized, and unspecified dementia (a group of symptoms affecting memory, thinking and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to transmit encoded, accurate, and complete MDS data to the CMS System for 1 of 16 residents (Resident #6) reviewed for MDS transmission. Resident #6's discharge MDS assessment was not completed and transmitted within 14 days of completion. This failure could place residents at risk of not having assessments completed and submitted in a timely manner as required. The findings were: Review of Resident #6's face sheet, dated 04/04/2025, revealed an admission date of 07/13/2021 with diagnoses that included: chronic systolic (congestive) heart failure, respiratory failure, unspecified, unspecified whether with hypoxia (state of insufficient oxygen supply to the body's tissues, leading to a deficiency in oxygen delivery) or hypercapnia (occurs when the body's ability to eliminate carbon dioxide through breathing is impaired, leading to a buildup of carbon monoxide in the blood), essential hypertension (high blood pressure), atherosclerotic heart disease 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 ensure the assessment accurately reflected the resident's status for 1 of 20 residents (Resident #1) reviewed for assessments: Resident #1's quarterly MDS, dated [DATE], identified the resident had anticoagulant (blood thinner). However, Resident #1 did not have anticoagulant. This failure could place residents at risk for inadequate care due to inaccurate assessments. The findings included: Record review of Resident #1's face sheet, dated 04/04/2025, revealed the resident was [AGE] years old female, originally admitted on [DATE], and re-admitted to the facility on [DATE] with diagnoses of urinary tract infection (bladder infection), cerebral palsy (congenital disorder of movement, muscle tone, or posture), heart failure (the heart did not pump enough blood to the body), peripheral vascular disease (narrowed blood vessels reduced blood flow to the limbs), hypothyroidism (low level of thyroid hormone in the body), and cognitive communication deficit.…

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 develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs that were identified in the comprehensive assessment, and described services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 20 residents (Resident #58) reviewed for care plans. The facility failed to ensure Resident #58's care plan reflected his smoking status and included a care plan regarding how to take care of the resident's smoking. This failure could place residents at risk for not receiving proper care and services due to inaccurate care plans. The findings included: Record review of Resident #58's face sheet, dated 04/04/2025, revealed the resident was a [AGE] year-old male, originally admitted to the facility on [DATE], and re-admitted to 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 observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bowel and bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #4) reviewed for incontinence care. When CNA-A was providing incontinent care to Resident #4 on 04/03/2025, CNA-A did not separate the resident's labia and did not clean the base of her labia. This failure could place residents who required incontinence care at risk for cross contamination and the development of new or worsening urinary tract infections. The findings included: Record review of Resident #4's face sheet, dated 04/04/2025, revealed a [AGE] year-old female, admitted to the facility originally on 03/24/2015, and re-admitted to the facility on [DATE] with diagnoses of vascular disorder of intestine (blood flow to the intestines slows), pervasive developmental disorder (developmental delays that affect social…

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 that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice for 1 of 2 (Resident #20) reviewed for respiratory care. Resident #20's oxygen nasal cannula was not covered in a plastic bag when it was not used on 04/01/2025. This failure could affect residents with oxygen therapy and could lead them to lack of care including possible infection by not following infection control. The findings included: Record review of Resident #20's face sheet, dated 04/04/2025, revealed the resident was a [AGE] year-old female, originally admitted to the facility on [DATE], and re-admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis (weakness on one side of the body), heart failure (not pumping blood enough), type 2 diabetes mellitus (not control blood sugar), chronic respiratory failure (lung cannot get enough oxygen), and cerebral vascular disease (stroke). 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to enact a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption, for 1 (Resident #3) of 3 residents reviewed, in that: Resident #'3s personal refrigerator located in her room was observed on 04/01/2025. There was a small plastic cup inside the refrigerator, with no date and no label on the plastic cup. This failure could place residents at risk of foodborne illness due to consuming foods which might be spoiled. The findings included: Record review of Resident #3's face sheet, dated 04/04/2025, reflected the resident was [AGE] years old female and was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses included: type 2 diabetes mellitus (not control blood sugar in the body), cholelithiasis (stone in the gallbladder), rheumatoid arthritis (chronic inflammatory affecting small joints in the hands and feet),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 1 resident (Residents #24) of 7 residents reviewed for infection control practices. MA C did not clean the blood pressure cuff between use and prior to taking Resident #24's blood pressure. These deficient practice could place residents at risk for cross contamination and infections. The findings included: Record review of Resident #24's face sheet, dated 04/042025, revealed the resident an [AGE] year-old male and admitted to the facility on [DATE] with the diagnoses of chronic kidney disease (the kidneys cannot filter waste and excess fluid from the body), heart failure (the heart cannot pump blood), type 2 diabetes mellitus (not control blood sugars in the body), and hypertension (high blood pressure). Record review of Resident #24'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 8 residents (Resident #7) reviewed for accuracy of medical records in that: 1. a. The facility failed to have an accurate fall risk assessment for Resident #7 when the resident had 4 falls between February and August 2024 and the assessment on 08/19/2024 indicated Resident#7 was at low risk. b. The facility failed to accurately document neuro checks for Resident #7 for every 30 min Neurological checks times 3 after the fall on 09/17/2024. This deficient practice could place residents at risk for errors in care and treatment. The findings included: 1. Record review of Resident #7's face sheet, dated 03/28/25, revealed Resident #7 was admitted to the facility on [DATE] and, readmitted on [DATE], with diagnoses that included: Type 2 diabetes mellitus (high level of sugar in the blood), Vascular dementia (decline…

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, record review, and observation, the facility failed to ensure residents have a right to personal privacy for 1 of 2 resident (Resident #6) reviewed for privacy, in that: CNA A and CNA B did not close Resident #6's privacy curtain while providing incontinent care on 3/27/25. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy. The findings included: Record review of Resident #6's face sheet, dated 03/27/2025, revealed an admission date of 03/14/2014 and, a readmission date of 05/18/2021 and, a readmission date of 11/09/2024, with diagnoses which included: Type 2 diabetes mellitus (high level of sugar in the blood), Vascular dementia (decline in cognitive abilities), Anxiety (A group of mental illnesses that cause constant fear and worry), Depression (mood disorder that causes a persistent feeling of sadness and loss of interest) and, Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood). Record review of Resident #6's Annual MDS assessment, dated 02/07/2025, revealed the resident had a BIMS score of 3,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment, and describes services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 4 residents (Resident #1) reviewed for care plans. The facility failed to ensure a care plan was developed to address Resident #1's high risk for falls which was identified in his admission fall risk assessment, and failed to include a care plan regarding how to prevent falls. This deficient practice could place residents at risk for not receiving proper care and services due to incomplete care plans. The findings included: Record review of Resident #1's face sheet, dated 03/23/2025, revealed a 74-…

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 was incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 1 resident (Resident #1) reviewed for incontinence care, in that: Resident #1 was provided with inadequate incontinence care by CNA A and CNA B. This failure could place residents who required incontinence care at risk for the development of new or worsening urinary tract infections. The findings included: Record review of Resident #1's face sheet, dated 9/5/24 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included type 2 diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), dementia without behavioral disturbance (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), heart disease, hyperlipidemia (high fat…

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 maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 6 residents (Resident #1) reviewed for accuracy of medical records. The facility failed to ensure Resident #1 had physician orders for crushed medications on the electronic medication administration record (EMAR ). This deficient practice could affect residents whose records were maintained by the facility and could place them at risk for errors in care and treatment. The findings included: Record review of Resident #1's face sheet, and Health Record information revealed an admission date of 5/17/24 with diagnosis to include Alzheimer's disease. Record review of Resident #1's initial MDS dated [DATE] revealed a BIMS score of 00/15 which indicated unable to perform due to cognitive status. Record review of Resident #1's care plan dated 5/17/24 revealed needs anticipated by the staff. Required total assistance…

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 protect the confidentiality of personal health care information for 1 of 4 residents (Resident #1) reviewed for confidentiality of records during the survey in that: The facility failed to ensure LVN A locked and closed the laptop during the medication pass exposing Resident #1's personal information. This failure could affect residents by placing them at risk for loss of privacy and dignity. The findings included: Review of Resident #1's face sheet dated 3/10/2024 revealed a resident was admitted to the facility on [DATE] with diagnoses which included Cerebral Infarction (a pathological process that results in an area of necrotic, or dead, tissue of the brain), dysphagia (difficulty swallowing foods and/or liquids), depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Observation on 03/09/2024 at 12:13 PM of LVN A's medication…

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's status for 1 of 1 (Resident #3) residents reviewed for assessments. Resident #3 was discharged and did not have a discharge MDS in the electronic record. This could affect all resident discharged and could result in residents missing services. The findings included: Record review of Resident #3's admission record, dated 03/09/2024, reflected an [AGE] year-old resident with an admission date of 05/26/2020, and diagnoses of Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors) and dementia (group of thinking and social symptoms that interferes with daily functioning). The discharge date was 3/14/2024. Record review of Resident #3's telephone order for discharge was signed by the physician on 3/14/2024. Record review of Resident #3's Annual MDS assessment, dated 1/19/2024, reflected Resident #3 had not exhibited behaviors of wandering, and 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 observations, interviews, and record reviews the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys, for 1 of 2 medication cart s (Medication Cart 4), reviewed for security, in that, A medication cart was unattended and unlocked. This failure placed residents at risk for harm by misappropriation of property and not receiving the therapeutic effects of their medications. The findings included: During an observation on 03/09/2024 at 12:13 PM, it was revealed that the medication cart assigned to LVN A was unattended and unlocked. The medication cart was observed to have the lock button unengaged and unlocked. During an interview on 03/09/2024 at 12:18 PM, LVN A stated she was assigned to the medication cart. LVN A stated she had only been gone for a few minutes and was getting something for a resident's family member. LVN A stated that the medication cart should have been locked. During an interview on 03/09/2024 at 01:06 PM, RN B stated that she was the 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 observation, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objective and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 4 (Residents #35, #36, #44 and #56) of 16 residents reviewed for care plans. 1. Resident #35's comprehensive care plan did not address she was contracted in her hands. 2. Resident #36's comprehensive care plan did not address all areas affected by the resident's hemiplegia. 3. Resident #44's compression stockings were not reflected in the resident's care plan. 4. Resident #56's Renal Diet was not reflected in his care plan. These failures placed residents at risk of not receiving needed care and services in accordance with their individually assessed needs which could result in not having their needs met and a decreased quality of life 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.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for 1 of 1 kitchen observed for food service. 1. [NAME] P and DA S did not properly wear hair restraints in a way that covered all their hair. 2. DA Q and DA R were wearing jewelry while preparing food in the kitchen. 3. The walk-in freezer contained: a. A clear, plastic bag of food that was knotted at the top, contents unknown, without a label or date. b. There was a single serve ice cream cup on the floor of the walk-in freezer. 4. Excessive amount of debris and food scraps on the floor between meal serves. 5. Wall behind the clean dish storage was dirty. These failures could affect the residents who received meals from the kitchen and place them at risk for foodborne illness. Findings include: Observation of the facility's kitchen at 9:08 AM on 02/20/2024 revealed the wall behind and above the clean dish's storage appeared to be dirty with what looked like dust. Observation of the facility's walk-in freezer, at 9:10 AM 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.

Observation, interview and record review revealed the facility failed to ensure the residents had a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 1 of 4 hallways (100) and in 2 of 2 shower rooms (men and women's) observed for environmental conditions. 1. The facility failed to ensure the floor on 100 hall was a flat and even surface. 2. The facility failed to ensure the men and women's shower stall had an even floor surface and the water drained while residents were showered. These deficient practices could affect any resident and could contribute to trips, falls and unsatisfactory shower room condition for residents. The findings were: 1. Review of an invoice revealed from a local contractor revealed on 2/29/16 the wing 100 and 200 were lifted and stabilized. Observation on 02/20/24 at 1 PM revealed an area at the end of 100 hall which was cracked, buckled and uneven. Observation and interview on 02/23/24 at 03:05 PM revealed an area at the end of 100 hall which was cracked,…

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 ensure alleged violations involving abuse, neglect, exploitationexploitation, or mistreatment, including injuries, of unknown source and misappropriation of resident property are reported immediately, but not later than 2 hours after the allegation was reported for 1 (Resident #69) of 4 residents reviewed for reporting of alleged violations. The facility failed to report that Resident #69's wishes to die a dignified death was not honored and that nursing staff failed to honor a signed OOH DNR order on [DATE] at 09:30 AM when Resident #69 was found unresponsive without a pulse and had a full code initiated to include CPR for approximately 25 minutes. This facility failure affects residents involved in incidents and could result in alleged violations not being investigated in a timely and proper manner. The findings included: Record review of Resident #69's electronic face sheet dated [DATE] reflected he was originally admitted to 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 observation, interview, and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 resident (Resident #35) of 24 residents reviewed for MDS assessments. Resident #35's MDS assessment did not accurately reflect she had limitations on her upper extremities and she was on continuous oxygen therapy. This deficient practice could result in missed or inaccurate care. The findings included: Record review of Resident #35's electronic face sheet dated 02/21/2024 reflected she was originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: Alzheimer's Disease (a type of dementia that affects memory, thinking and behavior. Symptoms eventually grow severe enough to interfere with daily tasks), bacteremia (viable bacteria in the blood), pressure ulcer of right hip, stage IV (may look like a reddish crater in the skin. Muscles, bones, and/or tendons may also be visible at the bottom of the stage IV), dementia (impaired ability…

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 refer all residents with possible serious mental disorder or a related condition for level II resident review upon a significant change in status assessment for 2 of 6 Residents (Resident #9 and Resident #43) whose records were reviewed for mental disorders. The facility failed to refer Resident #9 for a PASARR evaluation based on mental disorder diagnoses including Major Depressive Disorder and Psychosis. The facility failed to refer Resident #43 for a PASARR evaluation based on mental disorder diagnoses including Major Depressive Disorder and Psychosis. This deficient practice could affect residents with a mental illness and contribute to a delay in services needed. The findings were: 1. Review of Resident #9's face sheet, dated 2/24/24, revealed she was admitted to the facility on [DATE] with diagnoses including Major Depressive Disorder (MDD) recurrent, dated 9/28/21 and Unspecified Psychosis not due to a substance or known physiological condition,…

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 comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments for 1 of 24 (Resident #35) residents reviewed for care plan revisions. The facility failed to ensure Resident #35's care plan was updated to reflect the resident was on oxygen therapy. This deficient practice could place residents at risk of not receiving appropriate interventions to meet their current needs. The findings included: Record review of Resident #35's electronic face sheet dated 02/21/2024 reflected she was originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: Alzheimer's Disease (a type of dementia that affects memory, thinking and behavior. Symptoms eventually grow severe enough to interfere with daily tasks), bacteremia (viable bacteria in the blood), pressure ulcer of right hip, stage IV (may look like a reddish crater…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure each resident received assistance devices to prevent accidents for 1 of 3 Residents (Resident #14) reviewed for accidents and hazards. CNA X did not widen the base of the mechanical lift while transferring Resident #14 from bed to his wheelchair on 2/23/24. This deficient practice could placed residents transferred via mechanical lift at risk of falls which could result in injury and hospitalization. The findings were: Review of Resident #14's face sheet, dated 2/24/24, revealed he was admitted to the facility on [DATE] with diagnoses including Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves) without Dyskinesia (a condition that causes involuntary, erratic movements of different body parts), and Cerebral Infarction (Stroke). Review of Resident #14's quarterly MDS assessment, dated 1/2/24, revealed his BIMS was 11 reflective of moderate cognitive impairment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan for 1 of 1 Resident (Resident #38) whose records were reviewed for oxygen care. The facility failed to ensure Resident #38's oxygen concentrator was cleaned and the filter was not covered in lint. This deficient practice could affect residents residents on oxygen at risk of decreased efficiency of the concentrator and infection. The findings were: Review of Resident #38's face sheet, dated 2/21/24, revealed she was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (lungs are susceptible to infections) and Chronic Systolic (Congestive) Heart Failure. Review of Resident #38's quarterly MDS assessment, dated 1/28/23, revealed her BIMS was a 15 reflective of no cognitive impairment and she was receiving Hospice care and 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 reviews, the facility failed to maintain medical records on each resident that are-accurately documented for 1 (Resident #44) of 24 residents reviewed for accurate medical records in that: LVN F initialed off on Resident #44's MAR that the resident's compression stockings were applied on 02/22/2024, when they were not. This deficient practice could affect residents who have medical records and could result in misinformation about professional care provided. The findings included: Record review of Resident #44's electronic face sheet, dated 02/20/2024, revealed the resident was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included: diabetes mellitus (a disease of inadequate control of blood levels of glucose), atherosclerotic heart disease (a common condition that develops when plaque builds up inside the arteries), obstructive sleep apnea (when the throat muscles relax and block the airway), Alzheimer's disease (a progressive disease…

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 reviews, 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 (Resident #44) of 5 residents reviewed for infection control in that: Resident #44's ventilator mask and oxygen nasal cannula tubing were left unbagged for 2 days when not in use. This facility failure affects residents on oxygen therapy and could result in upper respiratory infections. The findings included: Record review of Resident #44's electronic face sheet, dated 02/20/2024, revealed the resident was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included: diabetes mellitus (a disease of inadequate control of blood levels of glucose), atherosclerotic heart disease (a common condition that develops when plaque builds up inside the arteries), obstructive sleep…

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 conduct an initial Comprehensive Assessment within 14 days calendar days after admission 1 of 18 residents (Resident #1) reviewed for Comprehensive Assessments and timing. The facility failed to ensure an MDS Assessment for Resident #1 was completed within 14 days after admission. This failure could place residents at risk for improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. The Findings include: Record review of Resident #18's face sheet dated 08/18/2023, revealed an original admission date of 01/16/2020 while the resident was on Respite Care (short period of rest or relief) and each time he would be Discharge Return Anticipated. The resident never returned until 07/21/2023 when he was officially admitted to the facility on Hospice. Resident #1 had diagnoses which included cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), Type 2 diabetes (a chronic (long-lasting) health 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.