Avir at The Meadow

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 Residents (Resident#85) reviewed for infection control. The facility failed to ensure Resident #85's foley catheter was not on the floor. This failure could place residents at risk of urethral tears or dislodging catheter and urinary tract infections.Record review of Resident #85's quarterly MDS assessment, dated 01/30/26, reflected a [AGE] year-old female who was originally admitted to the facility on [DATE] and re-entry of 01/24/2026. Her BIMs score was 12, which indicated moderate cognitive impairment. Her diagnosis included neurogenic bladder (a condition that affects the bladder's ability to function properly due to damage or dysfunction in the nerves that control it). Section H-Bowel and Bladder…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide a safe environment for the secure unit residents, staff and the public in two (rooms [ROOM NUMBERS]) of four resident rooms on the secure unit observed for safety. The facility failed to ensure no portable heaters or space heaters were used in residents' rooms on the secure unit. This failure could place residents at risk for injury or accidents and hazards. Findings included: Observation and interview on 01/29/26 at approximately 10:00 AM with CNA A revealed resident room [ROOM NUMBER] with a portable space heater plugged into the wall on Resident #1's nightstand. The portable space heater was in the on position with a digital temperature on the display of 85 degrees Fahrenheit. Resident #1, nor the roommate, were in the room. Observation of the resident room [ROOM NUMBER] revealed a portable space heater plugged into the wall on Resident #2's nightstand. The portable space heater was not on. Resident #2 was in bed. Resident #2 did…

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 all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source were reported immediately, but no less than two hours after the allegation was made if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation did not involve abuse or did not result in bodily injury, to the facility administrator and to other officials in accordance with State law through established procedures for one (Resident #1) of four residents reviewed for abuse. The facility failed to report an allegation of abuse towards Resident #1 when reported by a staff member. This failure could place residents at risk for delayed investigation, intervention and abuse.Findings included: Record review of Resident #1's face sheet, dated 01/07/26, reflected he was an [AGE] year-old male, admitted on [DATE]. Resident #1'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 develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident's rights, that included measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that were identified in the comprehensive assessment for one (Resident #1) of four residents reviewed for care plans. The facility failed to develop and implement a care plan for Resident #1 that was individualized to his care needs, which included psychotropic medications, dementia and related behaviors, and acute use of PRN antipsychotic medication after a behavioral incident. This failure could place residents at risk for inappropriate responses to behavioral symptoms and inappropriate use of psychotropic medications.Findings included: Record review of Resident #1's face sheet, dated 01/07/26, reflected he was an [AGE] year-old male, admitted on [DATE]. Resident #1's diagnoses included metabolic…

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's drug regimen was free from unnecessary drugs for one (Resident #1) of four residents who were reviewed for psychotropic medications. The facility failed to ensure Resident #1, who had a diagnosis of dementia, was administered PRN Haldol (antipsychotic) with adequate indications for its use. The facility nurse administered PRN Haldol intramuscularly when Resident #1 refused ADL care and was combative. This failure could place residents at risk for being administered unnecessary antipsychotic medication to control behaviors and could have adverse side effects including over-sedation, confusion and decreased quality of life.Findings included: Record review of Resident #1's face sheet, dated 01/07/26, reflected he was an [AGE] year old male, admitted on [DATE]. Resident #1's diagnoses included metabolic encephalopathy (a brain dysfunction caused by systemic metabolic disturbances, leading to symptoms like confusion,…

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 were adequately equipped to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from-four of six residents (Resident #2, #3, #4, and #5) reviewed for Resident Call System. The facility failed to ensure the call light system in Resident #2, #3, #4, and #5's rooms were in a position that was accessible to the residents on 12/30/25. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.Findings include: Record review of Resident #2's Face Sheet, dated 12/30/25, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included reduced mobility and lack of coordination. Record review of Resident #2's Quarterly MDS assessment, dated 12/09/25, reflected a severe cognitive impairment. For ADL care, it reflected the resident…

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 that residents, who needed respiratory care, were provided care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of three residents (Resident #1) reviewed for respiratory care. The facility failed to ensure Resident #1's BPAP mask and nasal canula were properly stored in a bag when not in use on 12/30/25. This failure could place the resident at risk for respiratory infection and not having his respiratory needs met.Findings included: Record review of Resident #1's Face Sheet, dated 12/30/25, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnosis included COPD (shortness of breath). Record review of Resident #1's Quarterly MDS assessment, dated 12/16/25, reflected he had an intact cognitive response. The resident had an active diagnosis of COPD. Record Review of Resident #1's physician orders,…

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 that assessments accurately reflected the resident's status for 2 (Resident #1 and Resident #8) of 3 residents reviewed for accuracy of assessments. The MDS did not address Resident #1 and Resident #8's oxygen use. This failure could place residents at risk of missed services, treatments, and overall decline in health. Resident #1Record review of Resident #1's face sheet, dated 11/04/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with other specified cough and obstructive pulmonary disease (a chronic inflammatory disease that causes obstructed airflow from the lungs). Record review of Resident #1's Comprehensive MDS Assessment, dated 10/29/2025, reflected the resident was cognitively intact with a BIMS score of 12, indicating the resident had moderately impaired cognition Section O Special treatments, procedures, and programs did not address resident oxygen…

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 that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #1) of 3 residents reviewed for respiratory care. Resident #1's NC was not replaced when dirty.Resident #8's 02 concentrator humidification bottle was not dated. These failures could place residents at risk for respiratory infection and not having their respiratory needs met. Findings:Resident #1Record review of Resident #1's face sheet, dated 11/04/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with other specified cough and obstructive pulmonary disease (a chronic inflammatory disease that causes obstructed airflow from the lungs). Record review of Resident #1's Comprehensive MDS Assessment, dated 10/29/2025, reflected the resident was cognitively…

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 with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for two (Residents #3 and #12) of seven residents reviewed for range of motion. The facility failed to implement interventions to prevent further decline of Resident #3's and Resident #12's contracture to her left hand upon discharge from therapy services. These failures could place residents at risk for decline in range of motion, decreased mobility, and worsening of contractures. Findings included: Resident #3 Review of Resident #3's Face sheet dated 1/15/25 reflected a [AGE] year-old female with an admission date of 5/3/17. Review of Resident #3's quarterly MDS assessment, dated 10/12/24, reflected she was severely cognitively impaired with a BIMs of 00. The resident had upper and lower extremity impairment on one side. Resident #3 was started on OT on 9/25/24. Active…

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 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 2 (Med Aid cart 2 west front and Nurses cart 2 Central ) of 3 carts reviewed for pharmacy services. The facility failed to ensure: 1. LVN P, responsible for Med Aid cart 2 west front, counted controlled drugs every shift change. 2. The Nurses cart 2 Central had 1 insulin pen for Resident #24 with an expired opened date. This failure could place residents at risk of not having the medication available due to possible drug diversion. Findings Included: 1. Record review and observation on [DATE] at 12:06 PM of Med Aid cart 2 west front, with MA M revealed missing signatures for Off duty and On duty for [DATE], [DATE] of the narcotic count sheet. Interview on [DATE] at 12:08 PM, MA M stated nurses and medication aides should have signed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure residents obtained needed dental services, including routine dental services for 2 of 2 residents (Resident #8 and Resident #23) reviewed for dental services. The facility did not obtain routine dental services for Resident #8 and #23. This failure could place the residents at risk by contributing to mouth pain, difficulty eating and weight loss. Findings included: 1.Review of Resident #8 Face sheet dated 1/15/25 reflected a [AGE] year-old female with an admission date of 3/11/23. Review of Resident #8's quarterly MDS assessment, dated 12/11/24, reflected she was moderately cognitively impaired with a BIMs of 12. The resident had no impairment to upper or lower extremities. Resident #8's active diagnoses included Anemia (a condition in which the blood does not have enough healthy red blood cells and hemoglobin), and Essential Hypertension (high blood pressure with no identifiable cause). Resident #8 was on a regular diet. Her funding source 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.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen. 1. The facility failed to ensure food items in the facility kitchen were covered. 2. The facility failed to ensure hot holding temperature were above 135 F for three menu items on the lunch service. This failure could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination. Findings included: Observation on 1/13/2025 at 9:09 AM of the walk-in freezer revealed food items such as cut zucchini, cut carrots, cinnamon rolls, cooked sausages were left open in a plastic bag inside their individual cardboard boxes. Observation on 01/13/25 at 11:56 AM of the tray line temperatures for the lunch service revealed [NAME] A was measuring Holding Temperatures before serving the residents. [NAME] A used cleaned thermometer and sanitized the thermometer between each use. [NAME] A took the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to 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 (Resident #53) of 8 residents observed for infection control and for 2 of 2 clean linen closets observed for sanitary environment. The facility failed to ensure: 1. Clean linen closets were kept sanitary. 2. CNA N failed to performed hand hygiene and changed gloves during incontinent care for Resident #53. These failures could place residents at risk of cross-contamination resulting in infections. Findings included: 1- An observation of the Clean Linen Closet in the Secured Unit, on 1/13/25 at 10:58 AM revealed an additional cart with a broken bottom most shelf apart from the clean linen cart. The cart had the following items on it: The top shelf contained 2 sets of bagged clothes without…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 (Resident #30 and Resident #48) of 8 residents reviewed for ADLs. The facility failed to ensure: - Resident #30 had his fingernails cleaned and trimmed. - Resident #48 had his fingernails cleaned and trimmed. These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Findings include: Resident #48 Record review of Resident #48's Quarterly MDS assessment dated [DATE] reflected Resident #48 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses included cerebral infarction (a condition that occurs when blood flow to the brain is blocked. The blockage can lead to brain tissue death), muscle weakness, and need for assistance with personal care. Resident #48's BIMS score of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, and record review, the facility failed to maintain an environment as free of accident hazards as is possible for one of two shower rooms (shower room [ROOM NUMBER]) in the facility's secured unit, reviewed for accidents and hazards. The facility failed to ensure shower room [ROOM NUMBER] was locked. These failures could place residents at risk of accidents, injury, or consuming hazardous personal care products. Findings included: An observation of the secured unit on 01/13/25 10:55 AM revealed Shower room [ROOM NUMBER] was unlocked when not in use. An observation of the secured unit on 01/13/25 03:07 PM revealed Shower room [ROOM NUMBER] was unlocked. A cabinet in the shower room was unlocked with the unpadlocked hanging on the door. The cabinet contained multiple bottles of Shampoo, body cleanser, body lotion, and an opened twin [NAME] razor box. The shower area of the shower room had a cleanser that was kept by itself on a table. In an interview on 1/13/25 at 3:20 PM, CNA F…

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 all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, but no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury to the administrator of the facility and to other officials, including to the State Survey Agency, in accordance with State law through established procedures for one of one resident (Resident #1) reviewed for abuse. The facility failed to report when the Activities Assistant spoke rudely to Resident #1 and called her names on Thanksgiving Day, 11/28/24. This failure could place residents at risk of continued abuse or mistreatment. Findings included: Record review of Resident #1's face sheet, dated 12/06/24, reflected a [AGE] year-old female, who admitted to the facility on [DATE]. Resident #1 had a diagnosis of Mood Disorder (mental illness that affects a person's emotional state), Insomnia…

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 comfortable, homelike environment, with safe temperature levels within a range of 71 to 81 degrees Fahrenheit for 5 of 11 rooms (room [ROOM NUMBER], #204 #208, #210, and #213) reviewed for environmental concerns. On 01/25/24, the facility failed to ensure the temperatures in room [ROOM NUMBER], #204 #208, #210, and #213 were maintained at a safe and comfortable range, even after the facility's boiler had been adjusted. This failure could place residents at risk of an uncomfortable environment and diminish their quality of life. Findings included: An observation on 01/25/24 at 9:10 AM revealed, when entering the facility, the entrance lobby area, the hallways near the entrance, and the conference room all felt cold. The conference room's HVAC unit was blowing cool air. An observation of the thermostat on the wall in the front hallway was observed to be set at 73 degrees Fahrenheit but reflected an inside temperature of 64 degrees…

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 and interview, the facility failed to provide a private space for residents' monthly council meetings for 08 of 08 residents (Residents #14, #17, #18, #24, #25, #41, #42 and #50) reviewed for resident council. The facility did not provide a private space for resident council meetings for Residents #14, #17, #18, #24, #25, #41, #42 and #50 This failure could place residents, who attended resident council meetings, at risk of not being able to voice concerns due to a lack of privacy. Findings included: In an interview and observation on11/29/23 at 11:00 AM, the Activity Director stated resident council was held in the downstairs dining area monthly. The Activity Director said there was not a private area in the facility for the Resident Council to meet. The Activity Director placed three wet floor signs in the entrance way to dining hall. The Activity Director stated the signs were placed to prevent staff and visitors from walking into the meeting. In an observation on 11/29/23 at 11:03 AM, a Resident Council Meeting was conducted with Residents #14, #17, #18,…

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

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #68) observed for infection control. 1. The facility failed to ensure clean linen closets were kept sanitary. 2. ADON D failed to complete hand hygiene while providing wound care to Resident #68 These failures could place residents at risk of cross-contamination resulting in infections. Findings included: 1. An observation of the Clean Linen Closet in the Secured Unit, on 11/28/23 at 11:48 AM revealed a pair of white running shoes on the bottom shelf, resting on top of clean linen. In an interview on 11/28/23 at 12:23 PM, CNA B said the clean linen closet should only contain clean linen. She stated she did not know why running shoes were in the closet. She said the laundry staff stocked the closet and all staff were responsible to ensure the closet was kept…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents had the right to be free misappropriation of resident property for 1 of 8 residents (Resident #57) reviewed for drug diversion. The facility failed to prevent an employee with access to controlled medications from diverting an unknown number of Tylenol #3 tablets (a Schedule III narcotic drug used to treat pain) tablets belonging to Resident #57 from a medication cart. This failure could place residents at risk for unrelieved pain due to his medication not being readily available. Findings included: Record review of Resident #57's Face Sheet dated 11/29/23 revealed the resident was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including vascular dementia, unspecified open wound of the right lessor toe, non-pressure chronic wound of the right foot, pressure ulcer of other site Stage 2, pain in unspecified joint, and pain unspecified. Record review of Resident #57's Physician's orders dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the Office of the State Long-Term Care Ombudsman of the transfer or discharge and the reasons for the transfer or discharge in writing for one (Resident #228) of one resident reviewed for transfer and discharge. The facility failed to send a transfer or discharge notice in writing to the facility's Ombudsman as soon as practicable when Resident #228 was discharged on 04/10/23. This failure could affect residents at the facility by placing them at risk of being discharged and not having access to available advocacy services, discharge/transfer options, and the appeal processes. Findings included: Record review of Resident #228's electronic face sheet, dated 11/30/23 revealed the resident was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses to include dermatitis, contact with COVID, muscle wasting and atrophy. Review of Resident #228's progress notes dated 04/10/23 11:59 PM, indicated Resident #228 discharged via stretcher/…

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 who were unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for one (Residents #15) of two residents reviewed for personal care. The facility failed to provide personal care and skin care for Resident #15 by not trimming his fingernails. This failure could place residents who require staff assistance at risk of dermatitis, infections, and low self-esteem. Findings included: Record review of Resident #15's face sheet, dated 05/18/21, reflected Resident #15 was a [AGE] year-old male admitted to the facility on [DATE]. Resident #15 had diagnoses of Other cerebrovascular disease ( group of conditions that affect blood flow and the blood vessels in the brain), hemiplegia (severe or complete loss of strength leading to paralysis on one side of the body ), unspecified affecting unspecified side, muscle wasting and atrophy( body tissue or an organ waste away),…

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 implement measures to prevent further decrease in ROM for 2 of 10 residents (Residents #15 and #21) reviewed for contractures. The facility did not apply a splint on Resident #15's and Resident#21's hands to prevent a decline in ROM. This failure could place residents at risk for further decline in ROM and development of contractures. Findings included: 1. Record review of Resident #15's quarterly MDS assessment dated , 10/20/23, reflected Resident #15 was a [AGE] year-old male admitted to the facility on [DATE]. Resident #15 had diagnoses of Other cerebrovascular disease ( group of conditions that affect blood flow and the blood vessels in the brain), hemiplegia (severe or complete loss of strength leading to paralysis on one side of the body ), unspecified affecting unspecified side, muscle wasting and atrophy( body tissue or an organ) waste away,), neuromuscular dysfunction(a wide-range of diseases affecting the peripheral nervous…

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 and interview, and record review, the facility failed to maintain an environment as free of accident hazards as is possible for two of two rooms (storage room and shower room) in the facility's secured unit, reviewed for accidents and hazards. The facility failed to ensure the storage room and shower room doors, in the secured unit were locked. These failures could place residents at risk of accidents, injury, or consuming hazardous personal care products. Findings included: Observation on 11/28/23 at 11:34 AM in the secured unit revealed the storage room door in the secured unit was unlocked. The door had two locks, a dead bold and a regular lock on the doorknob. Both were unlocked. The storage room contained oxygen condensers and bottles,, deodorants and wound care supplies including wound spray labeled, Keep out of reach of children. Shampoo and conditioner, shoes, a fan, fall mats, hand sanitizer, and alcohol pads were also in the room. The room was observed to be clustered with these items which made it difficult to move in the room. Observation on 11/28/23…

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, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 1 resident (Resident #1) reviewed for respiratory care. The facility failed to perform routine bi-pap (bilevel positive airway pressure is a machine that helps you breathe) maintenance. This failure has the potential to affect residents who use bi-pap machines in the facility. Findings included: Resident #40 Face Sheet Record Review revealed the resident was a [AGE] year-old male admitted [DATE]. Resident#40 face sheet revealed a BIMS score of 14 indicating the resident was cognitively intact. Resident #40's MDS revealed a diagnosis of Arthritis and Alzheimer's disease. Observation of resident in resident's room on 11/28/23 at 12:04 PM revealed a yellow sediment in the bottom of the water reserve of the ci-pap/bi-pap…

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.