Avir at Memorial

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 care plan to meet the highest practicable physical, mental, and psychosocial wellbeing for 1 (Resident #3) of 8 residents reviewed for comprehensive care plans. The facility failed to develop and implement a comprehensive care plan for Resident #3 to address the resident's left pelvic fracture and to address Resident #3's falls. This failure could place residents at risk for not receiving care required to meet their individualized needs and place them at risk for falls and injury. Findings included:Review of Resident #3's face sheet undated reflected Resident #3 was an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnose of dementia (group of conditions that cause a decline in cognitive abilities, memory and thinking skills that interfere with daily life), generalized muscle weakness, unsteadiness on feet, repeated falls and lack of coordination. Review of Resident #3'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 observation, interview 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 resident's goals and preferences for 1 of 5 (Resident #39) residents reviewed for respiratory care. 1. The facility failed to ensure Resident #39's oxygen was administered at the correct setting of 2 liters per minute on 9/9/25 and 9/10/25 as ordered by the physician. This failure could place residents who receive respiratory care at an increased risk of developing respiratory complications and a decreased quality of care. Record review of Resident #39's admission record dated 10/10/25 reflected an [AGE] year-old female with an admission date of 9/11/24. Resident #39 was diagnosed with chronic obstructive pulmonary disease (constriction of the airways with difficulty breathing).Record review of Resident #39's Annual MDS assessment dated [DATE] reflected 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 observation, interview, and record review the facility failed to ensure that the medication error rate was not 5% or greater. The facility had a medication error rate of 6.25 %, based on 2 errors of 32 opportunities, which involved one of six residents (Residents #14) and one of three staff (LVN A) reviewed for medication errors, in that: LVN A failed to administer Resident #19's Digoxin 250 mcg with Digoxin 125 mcg for a total dosage of 375 mcg daily and failed to administer Ergocalciferol 1.25 mg on 09/10/25 as ordered by the physician. This failure could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. The findings include: Record review of Resident #14's Quarterly MDS assessment, dated 08/29/25, reflected a [AGE] year-old female with an admission date of 06/15/18. Staff had assessed her mental status as severely cognitively impaired. Diagnoses included coronary artery disease (damage or disease in the heart's major blood vessels),…

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 all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 1 of 8 residents (Resident #7) reviewed for the storage of drugs and biologicals. The facility failed to ensure Resident # 7's Clobetasol Propionate external cream 0.05% was stored properly. This failure could place residents at risk of medication misuse, administration of incorrect dosage of medications which could result in non-therapeutic treatments or injuries. Findings included: Record review of Resident #7's quarterly MDS assessment dated [DATE] reflected a [AGE] year-old female with an admission date of 10/22/13. The resident had a BIMS score of 12 which indicated she was moderately cognitively impaired and had refused care 4-6 days out of the week. Resident #7 required supervision assistance with bathing and partial to moderate assistance with personal hygiene and dressing. Diagnoses included…

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

Based on observation, interview, and record review the facility failed to provide food that was served at an appetizing temperature, and prepared by methods which conserved the nutritive value, flavor, and appearance for one (Lunch 09/10/25) of one meals observed for food palatability. The facility failed to ensure egg salad was served at an appetizing temperature for lunch on 09/10/25. This failure could place residents at risk of food borne illness and a decline in their quality of life. Findings included: In a confidential group interview with five residents on 09/10/25 at 11:00 AM revealed residents' concerns with their food not being served at the right temperatures. Observation on 09/10/25 at 11:57 AM, revealed Dietary [NAME] L took the food temperature using a thermometer and food temperature of the pureed egg salad at 51.5 degrees Fahrenheit and 12:03 PM egg salad 42.3 degrees Fahrenheit. There was no ice under the egg salad containers. Dietary [NAME] L left the egg salad sandwiches and pureed egg salad on the serving line. Dietary [NAME] L did not take the food temperature…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 13 residents (Resident #1 and Resident #2) observed for infection control. 1. The facility failed to ensure RN A used the required PPE for Resident #1, who was on enhanced barrier precautions due to his wounds and foley catheter during a wound care observation on 05/20/25. 2. The facility failed to ensure Agency CNA C performed hand hygiene while providing incontinence care to Resident #2 on 05/20/25. These failures could place the residents at risk of cross-contamination and development of infection. Findings included: 1.Record review of Resident #1's undated face sheet reflected a [AGE] year-old male with an admission date of 01/15/25 and a readmission date of 05/07/25. Record review of Resident #1's 5-day MDS…

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

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, in that, 1. The facility failed to ensure chest freezer was free of ice accumulation. 2. The facility failed to ensure freezer items were labeled, dated and sealed. 3. The facility failed to ensure the kitchen was free of gnats and flies. 4. The facility failed to ensure steam table was not dripping. These failures could place residents at risk for food contamination. Findings include: 1. Observation on 08/06/24 at 9:26 AM revealed inside the chest freezer, which had turkeys and frozen popsicles in it, in the kitchen had ice accumulation of at least inch on the sides and back. Interview on 08/06/24 at 9:27 AM with Dietary Manager revealed he did not open the chest freezer very often and was unaware of ice accumulation in the chest freezer. 2. Observation on 08/06/24 at 9:28 AM of 1 of 3 freezers revealed three pizza crusts in a plastic bag not labeled, dated or sealed…

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 record review and interview the facility failed to implement their written policies and procedures to prohibit and prevent abuse, neglect and exploitation for 7 of the 10 employees (Activity Director, LVN AA, CNA BB, LVN DD, CNA EE, CNA FF, CNA GG) reviewed for background screenings. The facility failed to screen, through the Employee Misconduct Registry (EMR)/Nurse Aide Registry (NAR), 7 employees, which included: the Activity Director, LVN AA, CNA BB, LVN DD, CNA EE, CNA FF, CNA GG. This failure could place residents at risk of care by staff who have been reported for misconduct such as abuse, neglect, or exploitation. Findings Included: Record review of facility's Abuse, Neglect, Exploitation, or Mistreatment prohibition policy titled Leadership Policies and Procedures Section III Organizational Ethics, dated 2019, reflected: Component I: Screening 1. Pre-employment background screening is mandated for all facility employees: A. Facility state-specific Background Investigation Policy is available through the facility's regional HR consultant. B. The facility may not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for two of 17 (Residents #41 and Resident #39) reviewed for comprehensive care plans. 1. The facility failed to include in the care plan with an onset date of 05/29/24, Resident #41's ADLs functional limitations, Bowel incontinence and foley catheter and interventions necessary for care. 2. The facility failed to include in the care plan last revised on 07/16/24 Resident #39's contractures to bilateral hands with interventions required to prevent further decline. These failures could affect residents by not addressing their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, and psychosocial outcome. Findings include: Record review of Resident #41's quarterly MDS assessment, dated 06/12/24,…

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 unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for three of sixteen residents (Residents #41, Resident #44, and Resident #47) reviewed for ADL care. The facility failed to ensure staff provided consistent showers/baths and grooming for Resident #41, Resident #44, and Resident #47. This failure could place residents at risk of not receiving needed hygiene care which could cause skin breakdown, a loss of dignity and self-worth. Findings include: 1. Record review of Resident #41's quarterly MDS assessment, dated 06/12/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. She had a BIMSscore of 11, which indicated her cognition was moderately impaired. Resident #41 required substantial/maximum assist with toileting and shower/bathe dependent. Resident #41 had diagnoses which included…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure all residents were provided, based on the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility sponsored activities and individual activities, designed to meet the interests and support the physical, mental, and psychosocial well-being of each resident for 3 of 4 residents (Residents #10, #12, and #43) reviewed for activities. The facility failed to provide regular, individualized activities for Resident #10, Resident #12, and Resident #43. This failure placed residents at risk of decreased physical, mental, and psychosocial well-being. Findings included: Record review of Resident #10's face sheet, undated, revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had the diagnoses of dementia (loss of cognition), heart failure, major depressive disorder (persistent feels of sadness and loss of interest) and hypertension (high blood pressure). Review…

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 all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 3 of 9 residents (Resident #44, Resident #47, and Resident #30) and one of one medication room reviewed for drugs and biologicals. 1. The facility failed to ensure Resident #44's Dakins Solution (a bleach based wound cleanser) was stored properly. 2. The facility failed to ensure Resident # 47's anti-fungal powder was stored properly. 3. The facility failed to ensure Resident #30's Sevelamer carbonate blister pack (used to lower phosphate in the blood for chronic kidney disease) was labeled with the correct dosage. 4. The facility failed to remove expired medication from the medication room refrigerator. These failures could place residents at risk of medication misuse, administration of incorrect dosage of medications which could result in non-therapeutic treatments or injuries and ineffective treatment with…

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 designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two of 16 residents (Resident #41 and Resident # 6 ) reviewed for infection control. 1 The facility failed to ensure LVN B completed hand hygiene during wound care for Resident #41. 2. The facility failed to ensure LVN B used proper infection control prevention by taking the multi-use absorbent dressing (Alginate calcium with silver 4x4 dressing) packet inside Resident #41's room, cut a piece of it to use on the resident and returned the packet to the wound care cart for further use. 3. The facility failed to ensure LVN B used proper infection control prevention by returning the pair of scissors used to cut the Alginate calcium with silver dressing back in her cart without any form of sanitization. 4. 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 ensure proper treatment and assistive devices to maintain hearing abilities for one of one resident (Resident #13) reviewed for hearing devices. The facility failed to have Resident #13 assessed for his hearing loss and failed to provide any amplification device to assist with his hearing impairment. This failure could place residents at risk for limited social interactions. The findings included: Record review of Resident # 13's undated Face sheet reflected an [AGE] year-old male admitted to the facility on [DATE] with a readmission date of 06/24/24. Diagnoses included visual loss, chronic obstructive pulmonary disease (disease that blocks air flow and makes it difficult to breath), adult failure to thrive, and conductive hearing loss (when sounds cannot get through the outer and middle ear). Record Review of Resident #13's quarterly MDS assessment, dated 06/28/24, reflected he was moderately cognitively impaired with a BIM score of 9. He…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents receive adequate supervision and assistance devices to prevent accidents for one of two residents (Resident #13) reviewed for assisted transfers The Facility failed to ensure NA J used a gait belt when transferring Resident #30 from his wheelchair to the bed. These failures could affect the residents by placing the residents at risk for discomfort, pain, falls, injuries, and skin tears. Findings included: Record review of Resident # 13's undated Face sheet reflected an [AGE] year-old male admitted to the facility on [DATE] with a readmission date of 06/24/24. Diagnoses included visual loss, chronic obstructive pulmonary disease (disease that blocks air flow and makes it difficult to breath), adult failure to thrive, and conductive hearing loss (when sounds cannot get through the outer and middle ear). Record Review of Resident #13's quarterly MDS assessment, dated 06/28/24, reflected he was moderately cognitively impaired…

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 received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one of three residents (Resident #41) reviewed for catheter and incontinence care. The facility failed to ensure CNA I did not place the urine catheter drainage bag on the bed during Resident #41's incontinent care, and wound dressing change. The facility failed to ensure CNA I did not perform hand hygiene during Resident #41's incontinent care. These failures could place residents at risk for not receiving care appropriate to address their incontinence and could increase the risk of urinary tract infections. Findings included: Record review of Resident #41's quarterly MDS assessment, dated 06/12/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. She had a BIMS score of 11, which indicted her cognition was moderately impaired.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide treatment and services to prevent complications of enteral feeding for one of three residents (Residents #39) reviewed for feeding tubes. The facility failed to ensure staff followed physician ordered water flushes before and after medication administration given via the G-Tube for Resident #39. These failures could place residents at risk of tube obstruction and a decrease in hydration. Findings include: Record review of Resident #39's undated face sheet reflected a [AGE] year-old female with and admission date 03/01/23 and a re-admission date of 12/13/23. Diagnoses included dehydration, dysphagia(difficulty swallowing), cerebral vascular accident (stroke), contractures (a permanent tightening or shortening of the muscles, tendons and skin that causes a physical deformity) and unspecified severe protein-calorie malnutrition. Record review of Resident #39's quarterly MDS assessment, dated 04/26/24, reflected Resident #39 had BIMS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice for one of 2 residents (Resident #30) reviewed for dialysis. The facility failed to ensure post dialysis communication sheets were reviewed and completed for Residents #30. This failure could place residents at risk of inadequate post dialysis care. Findings included: Record review of Resident #30's undated face sheet reflected a [AGE] year-old male with the latest return to the facility on [DATE]. Diagnoses included type 2 diabetes mellitus ( a long-term condition in which the body has trouble controlling blood sugar) with diabetic chronic kidney disease and dependence on renal dialysis. Record review of Resident #30s Annual MDS assessment dated [DATE], reflected an initial admission of 12/26/23. Resident #30 was able to make himself understood and understood others and had a BIMs score of 15, which indicated he 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 provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 4 (Resident #23, Resident #44, Resident #49, and Resident#24) of 16 residents reviewed for ADLs. The facility failed to ensure: 1- Resident#23 had her fingernails cleaned and trimmed. 2- Resident#43 had her fingernails cleaned and trimmed. 3- Resident#49 had his fingernails cleaned and trimmed. 4- Resident#24 had her facial hair under her chin 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: 1- A record review of Resident #23's Quarterly MDS assessment dated [DATE] reflected Resident #23 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included dementia (a progressive loss of intellectual functioning, especially with 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 based on the comprehensive assessment of a resident, the residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan for one (Resident #56) of fifteen residents reviewed for quality of care. 1. The facility staff failed to obtain physician orders for the use of compression socks for Resident #56. 2. The facility staff failed to perform weekly skin assessments for the month of June 2023 for Resident #56. These failures could place residents at risk of not receiving the care and treatment needed to meet their needs and could result in undetected skin issues and delay in treatments. Findings included: Record review of Resident #56's undated face sheet reflected a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of cellulitis (bacterial skin infection) of right and left lower limbs, diabetes, and chronic congestive heart failure…

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 distribute and serve food in accordance with professional standards for food service safety for the facility's only kitchen reviewed for one (06/21/23 lunch) of one meal observed for food temperatures. The facility failed to ensure pureed ham was served at minimum of 145 degrees F and cabbage was served at least 135 degrees F for 06/21/23 lunch for residents with pureed diet. This failure could place residents at risk for food contamination and food-borne illness. Findings included: Observation on 06/21/23 at 11:30 AM revealed Dietary [NAME] I took food temperature of pureed cabbage which revealed it was 122 degrees F. At 11:32 AM Dietary [NAME] I took food temperature of pureed ham of 120 degrees F. Interview on 06/21/23 at 11:35 AM with Dietary [NAME] I revealed ham food temperature needed to be at least 120 degrees F to 145 degrees F before serving. She stated vegetables, like cabbage, should have been 115 to 120 degrees F before serving. Observation on 06/21/23 at 11:48 AM revealed Dietary [NAME] I…

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

Based on observation, interview, and record review, the facility failed to ensure an effective pest control program was implemented so the facility was free of pests and rodents for the dining room and one of four halls (Hall 3) reviewed for pest control. The facility failed to keep an effective pest control program to ensure the dining room, kitchen, and residents' rooms on Hall 3 were free of flies and gnats. This failure could place residents at risk for a reduced quality of life. Findings included: Observation on 06/20/23 at 10:09 AM revealed three flies on Resident #11's bed and 1 fly landed on her pillow. Interview with Resident # 11 revealed the flies bothered her and she used to have a fly swatter in her room, but someone took it. She stated she would swat at them all the time. Resident #11 stated the flies were constantly in her room on a daily basis and at least the last month the flies had gotten worse. Observation and interview on 06/20/23 at 10:12 AM revealed Resident # 16 stated he had flies in his room. Observed 2 flies in the resident room. Observation on 06/20/23 at…

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 comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Residents #56) of fifteen residents reviewed for comprehensive care plans. The facility failed to document Resident #56's use of compression stockings in his comprehensive care plan. This failure could place residents at risk for possible adverse side effects, adverse consequences, and decreased quality of life. Findings include: Record review of Resident #56's undated face sheet reflected a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of cellulitis (bacterial skin infection) of right and left lower limbs, diabetes, and chronic congestive heart failure (chronic condition in which the heart does not pump blood as it should). Record review of Resident #56's quarterly MDS assessment dated [DATE] reflected a BIMSs of 12,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring and administering of all medications to meet the needs of each resident for two (Residents #15 and #58) of four residents reviewed for pharmacy services. 1. Agency LVN A failed to follow the manufacturer's instructions to [NAME] the Humalog Insulin (Hormone) Pen prior to dialing in required amount of Insulin to be administered to Resident #15. 2. Agency LVN A failed to flush Resident #58's G-Tube (a tube inserted through the abdomen that delivers nutrition directly to the stomach) with 60 cc water prior to and after medication administration per physician orders and failed to flush the G-tube by gravity, and instead pushed 50 cc of water prior to and after medication administration. These failures placed residents at risk of not receiving full dosage of medication, and abdominal discomfort or dislodgement of the G-tube. Findings included: 1. Review of Resident #15'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 observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #15) of five residents observed for infection control in that: 1. The facility failed to ensure Agency LVN A performed hand hygiene after completion of FSBS 2. The facility failed to ensure Agency LVN A failed to sanitize the glucometer prior to and after obtaining FSBS on Resident #15. Theses failure could place residents at risk for infection and cross contamination. Findings included: Review of Resident #15's undated Face Sheet reflected a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included type 2 diabetes mellitus. Review of Resident #15's Physician Orders Report dated 06/01/23 to 06/30/23 reflected, . FSBS AC &HS with Humalog SQ sliding scale as follows .151 to 200 = 3 Units . An…

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.