Avir at El Paso

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan for 1 (Resident #1) of 4 residents reviewed for fall assessment after an unwitnessed fall. The facility failed to ensure LVN P appropriately assessed Resident #1 following an unwitnessed fall on 03/14/2026. This failure could affect others by placing them at risk for complications related to untreated injuries.Record review of Resident #1's face sheet dated 04/21/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE] and then readmitted on [DATE]. Resident #1's diagnoses included fracture of left pubis (crack or break in the hip bone area), subsequent encounter for fracture with routine healing, fracture of acetabulum (break in the hip socket), pain in left hip, muscle wasting (loss of muscle tissue), attention and concentration deficit (neurodevelopment issue where…

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 3 (Resident #2, Resident #3 and Resident #4) of 4 residents reviewed for pharmacy services and 3 of 4 medication carts (Halls 100, 200, and 300) reviewed for medications.- The facility failed to ensure timely acquisition of Resident #2's Lyricand was not administered per physician's orders.- The facility failed to ensure timely acquisition of Resident #3's Pregabalin and was not administered per physician's orders.- The facility failed to ensure timely acquisition of Resident #4's Tramadol and was not administered per physician's orders.-The facility failed to ensure licensed staff signed off on the Controlled Drugs-Count Records after verifying all controlled substances in the medication cart were accounted for with the on-coming nurse at 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 that incidents and investigations were complete and accurately documented for 2 of 6 (Resident #1 and #2) residents reviewed for accuracy and completeness of records. 1. The facility failed to have complete and accurate documentation and investigation for an allegation of misappropriation and exploitation for Resident # 1. 2. The facility failed to complete an incident report or accurately document progress notes, when Resident # 2 exited the facility. These deficient practices could put residents at risk of not receiving needed services such as monitoring or supervision, and incident investigations. Findings included: Resident # 1 Record Review of the admission record dated 6/30/25, revealed an [AGE] year-old male with an original admission date of 11/27/24 and a readmission date of 12/18/24.Record Review of the Initial Evaluation dated 11/27/24 revealed an [AGE] year-old male with a diagnosis of type two diabetes, coronary artery disease (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility failed to maintain a system to prevent Resident #1's personal money from being taken by a staff member.Findings included:Record Review of the admission record dated 6/30/25, revealed an [AGE] year-old male with an original admission date of 11/27/24 and a readmission date of 12/18/24. Record Review of Resident # 1's admission MDS record dated 11/27/24 revealed a BIMS score of 2 reflecting severe cognitive impairment. MDS revealed Resident #1 had short-term memory problems and was moderately impaired to make decisions regarding tasks of daily life. It described the resident as lethargic (a state of extreme tiredness, sluggishness, and lack of energy or enthusiasm. It implies a noticeable decrease in physical and mental activity). MDS indicated Resident #2 had anxiety disorder and depression.Record Review of Resident # 1's Care Plan initiated on 11/29/24 revealed Resident #1 had a diagnosis of depression and at risk of fluctuating moods with little interest or pleasure in doing things with decreased…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure each resident receives adequate supervision to prevent accidents for 1 (Resident #2) of 6 residents reviewed for accident prevention. The facility failed to provide supervision when Resident #2 exited the facility on 6/23/25 and propelled herself in her wheelchair down towards the sidewalk exiting the parking lot of the facility. This failure could place residents at risk of a fall, weather exposure, or being run over by a moving vehicle, which could result in injuries. Scope and Severity D Findings include:Record Review of Resident #2's admission record dated 6/26/25, revealed a [AGE] year-old female with an admission date of 4/22/25.Record Review of Resident #2's History and Physical dated 4/24/25 revealed diagnoses of atrial fibrillation (An irregular and often rapid heart rate that can lead to symptoms like palpitations, shortness of breath, and fatigue), hypothyroidism (A condition in which the thyroid gland doesn't produce enough crucial…

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 immediately inform the resident, consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status for one (Resident #1) of four residents reviewed for resident rights. The facility failed to ensure LVN A and LVN B communicate to the physician the need to administer medications while pending G-Tube placement result from KUB. This failure could place residents at risk of unmet medical needs and a decreased in quality of life. The findings included: Record review of Resident #1's hospital transfer form not dated revealed a [AGE] year-old female who was admitted to the facility on [DATE] and had diagnoses of: Attention and concentration deficit (Difficulty staying focused or paying attention, which can affect daily tasks and communication); Cognitive communication deficit (Problems with thinking and using language, such as trouble understanding, speaking, or remembering words); Unspecified…

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 labratory services were provided to meet the needs of the resident in accordance with professional standards of practice, and for 1 of 6 residents (Resident #1) reviewed for labratory service. The facility failed to ensure LVN A followed up with diagnostic lab for Resident #1's stat KUB order. This failure could place residents at risk of delayed treatment, unmet medical needs, and a decreased in quality of life. The findings included: Record review of Resident #1's hospital transfer form not dated revealed a [AGE] year-old female who was admitted to the facility on [DATE] and had diagnoses of: Attention and concentration deficit (Difficulty staying focused or paying attention, which can affect daily tasks and communication); Cognitive communication deficit (Problems with thinking and using language, such as trouble understanding, speaking, or remembering words); Unspecified dementia (general decline in memory and thinking skills, often due to…

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 develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident medical, nursing and mental and psychosocial needs for 2 (Residents #1 and 2) of 4 residents reviewed for care plans. -The facility failed to ensure Resident #1 and 2's diagnoses of dysphagia (difficulty swallowing) was addressed on their care plan. This failure could place resident at risk for not having their individual needs met in a timely manner injury, and a decline in physical well-being. Findings included. Review of Resident #1 face sheet, dated 04/10/2025, reflected a [AGE] year-old female with an original admission date of 01/07/2022 and a readmission date of 01/01/2025 to the facility with a diagnosis of dysphagia oropharyngeal phase(difficulty moving food and liquids from back of the mouth to esophagus). Review of Resident #1's Annual MDS, dated [DATE], reflected Resident #1 had moderate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 3 (Residents #5, #16 and #26 ) of 9 residents reviewed for dignity. Resident #16 did not have a privacy bag on his catheter bag. Resident# 5 and Resident# 26 had their names written on their clothes with black marker across their chest. This failure could place residents at risk of diminished quality of life. Findings included: Resident #5 Record Review of Resident # 5's admission Record dated 3/6/25 revealed he was an [AGE] year-old male with an initial admission of 8/1/23 and a readmission on [DATE]. His diagnoses included attention and concentration deficit, depression, unspecified dementia, anxiety, cognitive communication deficit and depressive episodes. Record Review of Resident # 5's quarterly MDS dated [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide reasonable accommodation of resident needs and preferences involving the call light for of 5 residents of 18 (Resident #76 #91, #278, #284, #286) in that: - Resident #76 had no access to his call light which was hanging behind his bed and in between the foot of his bed. - Resident #91 had no access to his call light which was lying on the floor at the foot of his bed. - Resident #278 did not have access to his call light which was lying on the floor next to his bed. - Resident #284 had no access to his call light which was lying on the floor. -Resident #286 did not have access to his call light which was hanging on the resident's bed frame. This deficient practice could affect the residents in maintaining and/or achieving independent functioning, dignity, and well-being. Findings included: Resident #76 Record Review of Resident #76's admission Record dated 3/3/25 revealed a [AGE] year-old male with an admission date of 9/25/23. His…

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 proper treatment and care to maintain good foot health for 3 (Resident #28, Resident #57, and Resident #284) of 16 residents reviewed for foot care. -The facility's CNA's and licensed nurses failed to provide foot care for Resident #28, Resident #57, and Resident #284. This failure could affect residents by placing them at risk for poor foot health, decreased personal hygiene, and a decline in their quality of life. Findings included: Resident #28 Record review of Resident #28's admission Record dated 03/05/25 revealed a [AGE] year-old male with an original admission date of 09/25/2021 and a readmission date of 04/08/2024. His diagnoses included: cerebral infraction unspecified, aphasia, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, cognitive communication deficit, dementia in other disease classified elsewhere, unspecified severity with other behavioral disturbance,…

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 the observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food sanitation and storage, in that: -The facility failed to ensure gallon of liquid in the refrigerator was properly closed. -The facility failed to ensure tub of chocolate icing was free from dried drippings around lid. These failures could affect residents by placing them at risk of food borne illness. Findings include: Observation on 03/03/25 at 9:04 a.m. of the walk-in refrigerator revealed a tub of chocolate icing with dried dripping around lid and a gallon of red liquid not properly closed. During an interview on 03/06/25 at 3:30 p.m. with the kitchen cook, revealed she was trained to keep all containers clean after each use and properly sealed. She stated she was trained to clean the container with a damp cloth and sanitizer. She stated staff were supposed to make sure all containers and gallons were closed properly after each use. It was the responsibility…

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. - The facility failed to ensure Residents # 13, 16 and 82's indwelling catheter tubing was not on the floor. - The facility failed to keep linen cart covers in the laundry room free of tears. These failures could affect the residents at risk for spread of infection through cross-contamination of pathogens and illness. Findings included: Resident # 13 Record Review of Resident #13's admission Record dated 3/3/25 revealed an 82-year-female with an initial admission date of 5/18/23 and a readmission date of 1/13/24. Her diagnosis included chronic kidney disease stage four severe and neuromuscular dysfunction of the bladder (occurs when the nerves that control the bladder and its related muscles don't function properly). Record 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 reviews the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 of the facility's laundry department and 1 tankless water heater reviewed for patient care equipment in safe operating condition. -The facility failed to maintain dryer in operation condition. -The facility failed to ensure the residents for hallway 200 of the facility had hot water in their showers and bathrooms. These failures could place residents at risk for harm by the facility's inability to provide clean sanitary linens and could place residents at risk for poor hygiene and health. Findings include: 1.During an observation on 03/05/25 at 09:05 AM, the facility's laundry department revealed 1 commercial was not operational. During an interview on 03/05/2025 at 09:07AM, laundry Aide stated dryers and washer had been inoperable for about 3 weeks. Laundry Aide stated she was able to provide clean linens for the facility's residents…

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

Based on observation, interview and record review, the facility failed to ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable in that: -The facility failed to keep liquid medication bottle free from dried drippings in medication cart for 100 hall. This finding can lead to spills which obscure the label or cause the medication to be contaminated and affect the 26 residents that reside in 100 hall. Findings included Observation on 03/05/2025 at 11:30 AM of liquid medication bottle in medication cart for 100 Hall revealed red dried debris on opening of bottle. In an interview with ADON on 03/06/2025 at 01:56 PM revealed the medication aides and nurses are responsible for medication carts. She stated LVN F was also responsible for monitoring the facility's medication carts. ADON stated risks of oral medication bottles with debris around the opening include possible infection control issues as the debris…

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 the observations, interviews, and record reviews the facility failed to dispose of garbage and refuse properly for 1 of 1 dumpster reviewed for food safety requirements. -Dumpster had trash on the ground outside and around the dumpster. -Dumpster was left open and with food substance running down the side of it. This failure could result in providing harborage and breeding areas for insects, rodents and other pests which could infest the facility placing the residents at risk of illnesses, and living in an unsafe, unsanitary, and uncomfortable environment. Findings include: Observation on 03/06/2025 at 11:20 AM revealed dumpster to be open, with food left outside on the ground and an orange, brown food substance dripping down the side of it. Interview on 03/06/2025 at 12:34 p.m. with the ADON/ infection control nurse, revealed she was aware when throwing trash away staff tied up trash bags and disposes of them in dumpster. She stated the risk of leaving the dumpster open with food laying on ground outside of the dumpster would be breeding ground for bacteria, staff could…

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 ensure that the assessment accurately reflected the resident's status for 3 (Resident #5, Resident #9, and Resident #10) of 10 resident reviewed for accuracy of MDS assessment, in that: Resident #5's quarterly MDS did not accurately reflect the residents' oxygen therapy in the quarterly MDS assessment. Resident #9's quarterly MDS did not accurately reflect the residents' oxygen therapy in the in the quarterly MDS assessment. Resident #10's quarterly MDS did not accurately reflect the residents' oxygen therapy in the in the quarterly MDS assessment. This failure could affect residents at the facility who had been assessed for oxygen therapy use and could contribute to inadequate care. Findings included: Resident #5 Record review of Resident #5's face sheet dated 11/05/24, revealed, admission on [DATE] to the facility. Resident #5's profile picture had Resident #5 wearing his nasal cannula. Record review of Resident #5's facility history…

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 develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 2 of 10 residents (Resident #4 and Resident #7) reviewed for care plans. The facility failed to implement a comprehensive person-centered care plan for Resident #4's history of oxygen therapy. The facility failed to implement a comprehensive person-centered care plan for Resident #7's history of oxygen therapy. This failure could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed to address their needs. Findings include: Resident #4 Record review of Resident #4's face sheet dated 11/05/24, revealed, admission on [DATE] and re-admission on [DATE] to the facility. Record review of 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 reviews the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 5 (Resident #3, Resident #4, Resident #5, Resident #9, and Resident #10) of 10 residents observed for oxygen management and 6 (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) of 15 rooms observed for oxygen sign postings, and 1 (Resident#5) of 5 residents reviewed for oxygen orders. Resident #3's oxygen tank was empty behind his wheelchair. Resident #4's oxygen tank behind her wheelchair in her room was empty. Resident #5's oxygen tank was on empty behind his wheelchair while he was in the dining area. Resident #9's oxygen tank was empty behind her wheelchair she was in the dining area. Resident #10's oxygen tank was empty behind her wheelchair in her room. Residents on oxygen in Rooms 207, 211, 215, 302, 303, 315, 316, did not have…

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 disease and infection for 3 (Resident #3, Resident #4, Resident #5) of 10 residents and 1 (room [ROOM NUMBER]) of 6 rooms reviewed for infection control. 1. Resident #3's nasal cannula was not stored in a zip lock bag and or baggy. 2. Resident #4's nasal cannula was not stored in a zip lock bag and or baggy. 3. Resident #5's nasal cannula was not stored in a zip lock bag and or baggy. room [ROOM NUMBER] in the restroom was a nasal cannula that was hanging in the shower area and not in zip lock bag and or baggy. These failures could place residents at risk for infection due to improper care practices. Resident #3 Record review of Resident #3's face sheet dated 11/05/24, revealed, admission on [DATE] and re-admission on [DATE] to the facility. Record 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 interview and record review the facility failed to immediately notify and consult with the resident's physician and resident's representative when a significant change in a resident physical, mental, or psychosocial status (that was a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 (Resident #2) of 4 residents reviewed for change in condition. The facility failed to immediately inform the NP/MD and the family (RP/POA) on 09/24/24 of Resident #2's change in condition addressing her fall on 09/24/24. This failure could place residents at risk of serious decrease in health related to delayed treatment. Findings included: Record review of Resident #2's face sheet dated 11/05/24, revealed, admission on [DATE] and re-admission on [DATE] to the facility. Record review of Resident #2's facility history and physical dated 11/03/24, revealed, an [AGE] year-old female diagnosed with Dementia and falls. Record review of Resident #2'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 coordinate assessments with the pre-admission screening and resident review program for one (Resident #10) of 3 residents reviewed for compliance with PASRR regulations. -The facility failed to submit and coordinate Resident #10's PASRR assessment and screening in the LTC Online Portal -The facility failed to refer Resident #10 for a PASRR evaluation based on mental disorder diagnoses including [NAME]-[NAME] Syndrome (genetic disorder that causes obesity, intellectual disability, and shortness in height). This failure could place residents at risk of not receiving necessary care and services in accordance with individually assessed needs. The findings were: Record review of Resident #10's admission Record dated 08/14/2024, revealed Resident #10 was admitted to the facility on [DATE] and originally admitted on [DATE] with diagnoses to include cerebral palsy (congenital disorder of movement, muscle tone or posture due to abnormal brain development, often…

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 that includes measurable objectives and time frames to meet a resident's medical, nursing, mental, and psychosocial needs and describes the services to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 1 (Resident #10) of 6 residents reviewed for comprehensive care plans in that: -The facility failed to develop a comprehensive care plan for Resident #10's diagnosis of [NAME]-[NAME] syndrome. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and not having personalized plans developed to address their needs. Findings include: Record review of Resident #10's admission Record dated 08/14/2024, revealed Resident #10 was admitted to the facility on [DATE] and originally admitted on [DATE] with diagnoses to include cerebral palsy (congenital disorder 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, interviews and record review the facility failed to ensure residents the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 2 (Residents #1, and #2) of 4 residents reviewed for call light placement. The facility failed to ensure that Residents #1, and #2 's call lights were within their reach. This failure placed residents at risk of not being able to call for assistance when needed. Findings included: Resident #1 Review of the admission Record dated 07/08/24 at 5:31 PM revealed, Resident #1 was initially admitted on [DATE] and re-admitted [DATE]. Review of the Hospital History & Physical dated 06/23/24 for Resident #1 revealed, Chief Complaint: Right Hip Fracture. [AGE] year-old-female with PMH (past medical history) of DM II (insulin dependent), recurrent UTI, dementia, hypertension was brought to our hospital due to fall. Patient had an accidental mechanical fall 2 days ago from her bed, when she rolled from her bed.…

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 allow the resident to obtain a copy of the records upon request and upon two working days advance notice to the facility for 2 of 6 residents (Resident #2 and Resident #5) whose records were reviewed in that: -The facility failed to provide Resident #5's legal representative copies of medical records after a request was submitted to the facility. - The facility failed to provide Resident #2's family member a copy of the EKG report. This failure could place residents at risk of violation of their rights by not receiving copies of their medical records. The findings were: Resident #5 Closed Record Review of admission Record dated 07/10/24 at 9:44 AM, for Resident #5 revealed an original admission date of 03/09/23. Responsible Party was listed as family member. Resident was transferred to the hospital via EMS on 04/28/24. Review of the Medical Visit dated 03/18/23 for Resident #5 revealed Reason for visit: Initial Visit. [AGE] year-old-female, transferred…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to consult with the resident's physician when there was a significant change in the resident's physical status for two (Resident #2 and Resident #3) of six residents reviewed for physician notification. -The facility failed to immediately consult with physician and/or Nurse Practitioner when the facility did not have 7 doses of the prescribed IV antibiotics on hand to administer to Resident #2 according to physician's orders. -The facility failed to immediately consult with physician and/or Nurse Practitioner when the facility did not have 8 doses of the prescribed IV antibiotics on hand to administer to Resident #3 according to physician's orders. This failure could place residents at risk of delayed medical treatment. Findings include: Resident #2 Review of the admission Record dated 07/08/24 at 5:30 PM revealed, Resident #2 was initially admitted on [DATE] and re-admitted [DATE]. Review of the Annual History & Physical dated 08/01/23 for Resident #2…

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 the assessment accurately reflected the resident's status for 2 (Resident #1, and Resident #3) of 6 residents reviewed for accuracy of MDS assessments. - The facility failed to ensure that Resident #1's MDS accurately reflected resident had an Enteral Feeding. -The facility failed to ensure that Resident's #3's MDS accurately reflected resident had an infection to right knee. These failures could put residents at risk of not receiving the necessary care and services to prevent falls and injuries related to inaccurate MDS assessment. Findings included: Resident #1 Record review of the admission Record dated 07/08/24 at 5:31 PM revealed, Resident #1 was initially admitted on [DATE] and re-admitted [DATE]. Record review of the Hospital History & Physical dated 06/23/24 for Resident #1 revealed, Chief Complaint: Right Hip Fracture. [AGE] year-old-female with PMH (past medical history) of DM II (insulin dependent), recurrent UTI, dementia,…

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 coordinate with the appropriate, State-designated authority, to ensure that individuals with a mental disorder, intellectual disability, or related conditions received care and services to meet the needs of the residents for 2 (Resident #4 and Resident #6) 2 residents reviewed for PASRR services. -The facility failed to provide Specialized Services to Resident #4 as agreed to during the interdisciplinary meeting. -The facility failed to ensure that all PSCR benefits were being provided to Resident #6. The failures could affect residents who are PASRR positive by placing them at risk of not receiving needed PASRR services which could lead to a decline in health and well-being. Findings included: Resident #4 Review of the admission Record dated 07/09/24 for Resident #4 revealed original admission date 12/28/23; re-admission date 01/23/24. Review of a Medical Visit dated 01/02/24 for Resident #4 revealed, [AGE] year-old-female status post fracture right…

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 comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #1) reviewed for comprehensive care plans in that: The facility failed to develop a comprehensive care plan for Resident #1 after she sustained a fall on 06/22/24 that addressed the resident's skin tear and fracture to her left wrist. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and not having personalized plans developed to address their needs. Findings include: Resident #1 Review of the admission Record dated 07/08/24 at 5:31 PM revealed, Resident #2 was initially admitted on [DATE] and re-admitted [DATE]. Review of the Hospital History & Physical dated 06/23/24 for 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 a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 1 (Resident #1) of 1 resident observed for oxygen management. Resident #1 was on oxygen without a physician's order. This failure could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health; and place them at risk of an unsafe environment which could lead to accidents and injuries. Findings included: Resident #1 Record review of the admission Record dated 07/08/24 at 5:31 PM revealed, Resident #1 was initially admitted on [DATE] and re-admitted [DATE]. Record review of the Hospital History & Physical dated 06/23/24 for Resident #1 revealed, Chief Complaint: Right Hip Fracture. [AGE] year-old-female with PMH (past medical history) of DM II (insulin dependent), recurrent UTI, dementia, hypertension. Record review of the Quarterly MDS dated [DATE] 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.

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, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 (Resident #2 and Resident #3) of 6 reviewed for medication administration in that: -The facility failed to immediately consult with physician and/or Nurse Practitioner when the facility did not have 7 doses of the prescribed IV antibiotics on hand to administer to Resident #2 according to physician's orders. -The facility failed to immediately consult with physician and/or Nurse Practitioner when the facility did not have 8 doses of the prescribed IV antibiotics on hand to administer to Resident #3 according to physician's orders. This failure put residents at risk of delayed medical treatment. Findings include: Resident #2 Review of the admission Record dated 07/08/24 revealed, Resident #2 was initially admitted on [DATE] and re-admitted [DATE]. 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 interviews, and record review, the facility failed to provide laboratory services to meet the needs of its residents, for 1 of 6 (Resident #3) residents reviewed for laboratory orders. -The facility failed to ensure that labs were done on a timely basis and lab results were promptly received to prevent delay in medical treatment for and for 8 doses of the prescribed IV antibiotics on hand to administer to Resident #3 according to physician's orders. This failure could place residents at risk for untreated medical conditions and diminished quality of care. Findings included: Resident #3 Closed Record review of the admission Record dated 07/09/24 for Resident #3 revealed, original admission date: 06/06/24. Resident discharged home on [DATE] with Home Health Services. Review of the Initial Medical Visit dated 06/10/24 for Resident #3 revealed, [AGE] year-old-female discharge from the hospital where she was treated for right knee septic arthritis (is a painful infection in a joint that can come from germs…

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 medical records were maintained on each resident that were complete and accurately documented for 2 of 6 (Resident #1, and Resident #2) reviewed for accuracy and completeness of medical records. -The facility failed to document notification of change of condition for Resident #2 on 07/03/24. -The facility failed to ensure SBAR INTERACT Communication Form for Resident #1 did not have blanks in the documentation. -The facility failed to document in Event Report for Resident #1 injuries and mental status at time of incident on 06/22/24. -The facility failed to document an order for use of grab bars for Resident #1. -The facility failed to document for Resident #1 the type of pain and pain medication that was administered. -The facility failed to ensure Pain Evaluation dated 06/26/24 for Resident #1, was signed and dated. -The facility failed to ensure the Pain Evaluation dated 07/12/24 for Resident #1 did not have blanks in the documentation. -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 the prompt resolution of all grievances to include all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns, a statement as to whether the grievance was confirmed, any corrective action or to be taken by the facility as a result of the grievance, and the date when the decision was issued for 1 of 6 (Resident #3 ) reviewed for resident rights. -The facility failed to ensure prompt resolution when Resident #3 was not administered 8 doses of the prescribed IV antibiotics according to physician's orders. These failures could place residents at risk for grievances not being addressed or resolved promptly. Findings included: Resident #3 Closed Record review of the admission Record dated 07/09/24 for Resident #3 revealed, original admission date: 06/06/24.…

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 protect the residents' right to be treated with dignity and respect, to include the right to be free from physical restraints for 1 of 6 residents (Resident #1) reviewed for physical restraints. The facility failed to have medical symptoms for Resident #1 that warranted use of physical restraint; failed to have an order for use of Grab Bars on the bed; and failed to conduct on-going evaluation for use of restraint. Resident #1 sustained a fall on 06/22/24, left arm was caught between the mattress and the grab bar resulting in a left wrist fracture and contusion to right hip. This failure could place residents with restraints at risk of restricted movement, entrapment, decline in ADLs function, and psychological distress. The findings included: Review of the admission Record dated 07/08/24 at 5:31 PM revealed, Resident #1 was initially admitted on [DATE] and re-admitted [DATE]. Review of the Hospital History & Physical dated 06/23/24 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 implement written policies that prohibit and prevent abuse for 1 of 12 employees (the Administrator) reviewed for criminal background checks. The facility failed to run the Administrator's criminal background check prior to him starting his duties on 05/13/24. This failure could place residents at risk of potential abuse. Findings included: Interview and record review on 07/12/24 at 5:08 PM with the Administrator revealed his start date was 05/13/24. The Administrator informed surveyor facility did not have any documentation in his personal file that Criminal Check, Employee Misconduct Check and Nurse Aide Registry Check had been completed prior employment or on this first day of work. The Administrator reported that he had terminated the HR manager on 07/11/24 and would send him a text message to see if he would respond back to check if he had completed his criminal check prior to and/or on first day of employment. The Administrator stated, I have checked my personnel file several times and the HR Manager's office and 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 assess the resident for risk of entrapment from an enabler (bed rail) prior to installation or review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for 1 (Resident #1) of 5 residents reviewed for enablers (bed rails/grab bars). On 06/22/24, Resident #1 fell out of bed at 12:31:04 AM - Resident #1 was noted to have an enabler (bed rail/grab bar) connected to the upper area of her bed. Resident #1's Enabler assessment dated [DATE], revealed, that it was incomplete. The digital form was not signed nor was there any input in the questions such as, Was there a risk to the resident if enablers are used? (all left blank). This failure could place residents who have grab bars (enablers) at risk of having inappropriate or unnecessary enablers in place, increasing their risk of injury. Findings included: Record review of Resident #1's admission Record dated 07/08/24…

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 that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan for 5 (Resident # 1, 2, 3, 4, 5 and 6) of 7 residents reviewed for wound treatment of wounds, 1. Resident #1 did not receive physician-ordered wound treatment on 6 occasions: for physician's order 04/09/2024 provision of care was not documented on 04/21/2024; for physician's order 04/09/2024 through 04/24/2024 provision of care was not documented on 04/14/2024, 04/20/2024, 04/21/2024, 04/24/2024; for physician's order dated 04/09/2024 through 04/19/2024 for provision of care was not documented on 04/19/2024. 2. Resident #2 did not receive physician-ordered wound treatment on 16 occasions: for physician's order dated 3/4/24 to 3/11/24 provision of care was not documented on 03/10/2024 or 03/11/1024: for physician's order dated 03/12/2024 to 4/8/2024 provision of care was not documented 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.

Based on observation, interview and record review the facility failed to store all drugs and biologicals in locked compartments for one of four medication carts (Medication Cart 100 Hall) and four Treatment Carts (Treatment Carts in 300 hall, facility rotunda, 200 hall, 100 hall) of five Treatment carts observed for being locked when staff were absent from the area. On 05/04/2024 the 300 hall Treatment cart was unlocked and unattended. On 05/04/2024 Rotunda Treatment Cart was unlocked and unattended. On 05/04/2024 The 200 Hall Treatment Cart was unlocked and unattended. On 05/04/2024 The 100 Hall Medication Cart was unlocked and unattended. On 05/04/2024 The 100 Hall Treatment Cart was unlocked and unattended. This failure put residents at risk of unauthorized and unsupervised access to medications and medical equipment. Findings included: Observation on 05/04/2024 at 12:03 PM in the 300 hall revealed a cart labeled Treatment. A lock for a key was observed to be protruding from the front of the cart. No staff were observed at or near the cart. Opening the top drawer of the cart…

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, in accordance with accepted professional standards and practices, the facility maintained medical records on each resident that were complete and accurately documented for four (Residents #1, #3, #4 and #6) of seven residents reviewed for documentation of provision of assistance with bathing. The CNAs software for documentation of bathing assistance was incorrectly set up at admission/readmission for Residents #1, #3, #4 and #6 so there was no documentation showing bathing assistance had been provided. This failure put residents at risk of diminished self-image, poor self-hygiene, and impaired skin integrity as a result of undetected lapses in the provision of assistance with bathing. Findings included: Record review of Resident #1's face sheet dated 05/06/2024 revealed he was [AGE] years old and was admitted to the facility on [DATE]. Record review of Resident #1's physician's admission note dated 04/08/2024 revealed 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 interview and record review the facility failed to ensure that it employed a qualified social worker on a full-time basis for one of one social worker positions reviewed. The facility, which was licensed for 124 beds, failed to employ qualified social worker on a full-time basis since on 02/29/2024 This failure put facility residents at risk of not having their psychosocial or discharge planning needs met. Findings included: Record review of the facility census dated 05/07/2024 revealed that the facility had 124 beds. In an interview on 05/06/2024 at 1:44 PM the ADON revealed that the facility did not have a full-time social worker and that the person who currently occupied the social work office [Social Work Trainee] was not licensed. In an interview on 05/06/2024 at 2:38 PM the Social Work Trainee revealed that she had worked at the facility for about two months. She said she was working on completing her Bachelor of Social Work degree and was not yet licensed as a social worker. She said she was responsible for assessments of residents at admission and was helping…

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 a baseline care plan for each resident within 48 hours of a resident's admission for one (Resident #1) of seven residents reviewed for baseline care plan. The facility failed to complete Resident #1's baseline care plan until 04/09/2024 although he was admitted on [DATE]. This failure could put residents at risk of not having their care needs met. Finding included: Record review of Resident #1's face sheet dated 05/06/2024 revealed he was [AGE] years old and was admitted to the facility on [DATE]. Record review of Resident #1's physician's admission note dated 04/08/2024 revealed that resident had a history of diabetes, hypertension (high blood pressure) and paraplegia (lower body paralysis). He had been in the hospital for surgeries for his right knee and for an infected pressure wound (injury to the skin from extended pressure) on the sacral area (tail bone). Record review of Resident #1's baseline care plan dated 04/09/2024 revealed he had a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to implement an effective discharge planning process that focused on the resident's discharge goals and ensured that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident for one (Resident #1) of seven residents reviewed for development of a discharge plan. The facility failed to develop a discharge plan for Resident #1 who was admitted on [DATE] until the day before he was discharged on 05/07/2024. This failure increased resident's risks for not having their care needs addressed after discharge. Findings included: Record review of Resident #1's face sheet dated 05/06/2024 revealed he was [AGE] years old and was admitted to the facility on [DATE]. Record review of Resident #1's physician's admission note dated 04/08/2024 revealed that resident had a history of diabetes, hypertension (high blood pressure) and paraplegia (lower body paralysis). He had been in the hospital for surgeries for his…

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 two (Resident #4 and #7) of seven reviewed for infection prevention and control. The facility failed to ensure that Resident #4's catheter tubing and catheter drainage bag was not touching the floor on 5/4/2024. The facility failed to ensure that Resident #7's catheter tubing and catheter drainage bag was not touching the floor on 5/6/2024. This failure put residents at increased risk of infection. Findings included: Record review of Resident #4's face sheet dated 05/07/2024 revealed he was [AGE] years old and was admitted to the facility on [DATE]. Record review of Resident #4's Medical Visit doctor's note dated 04/25/2024 revealed he had a medical history that included a urinary tract infection, encephalopathy (disturbance 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, interview, and record review, the facility failed to develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 3 of 4 residents (Resident #1, Resident #2, and Resident #4) reviewed for comprehensive care plans in that: - The facility failed to develop a comprehensive care plan for Resident #1 that addressed antiplatelet platelet medication, feeding tube, restlessness when in bed, anti-anxiety medication, hematoma to right side of head, UTI, and pneumonia. - The facility failed to develop a comprehensive care plan for Resident #2 that addressed restlessness while in bed and orders for anti-anxiety, hematoma to the right side of forehead, behaviors and risk for bruising r/t use of ASA 81 mg. -The facility failed to develop a comprehensive care plan for Resident #4 that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan for 3 (Resident #1, Resident #2, and Resident #4) of 4 residents reviewed for neurological checks. -The facility failed to ensure Resident #1 had neurological checks done after she was found with a hematoma (a pool of mostly clotted blood that forms in an organ, tissue, or body space) to right side of forehead on 04/17/23 on the morning shift. -The facility failed to ensure Resident #2 had neurological checks done after she was found with a hematoma on the forehead on 04/05/23 on the morning shift. -The facility failed to ensure Resident #4 had had neurological checks done after he was found on the floor on 02/03/24 and could not say what had happened and if he had hit his head. This failure could affect residents by placing them at risk of changes in condition due to not conducting…

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 consult with the resident's physician when there was a significant change in the resident's physical status for one (Resident #1) of four residents reviewed for physician notification. The physician/FNP were not notified that Resident #1 was restless on 04/16/24 on the night shift and was found with her face on the air mattress pump on the foot of the bed. This failure put residents at risk of delayed medical treatment. Findings include: Resident #1 Review of Resident #1's admission Record dated 04/18/24 revealed Initial admit date : [DATE]. admission Date: 02/11/2024. admitted from the hospital. Review of Resident #1's History & Physical dated 01/23/2024, revealed a [AGE] year-old with a history of diabetes mellitus type 2, hypertension, and atrial fibrillation (an irregular heartbeat) and anemia. The resident was cognitively impaired; alert and oriented x 0 (resident was not oriented to person, place, or time). Review of 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 implement written policies that prohibit and abuse, neglect, and exploitation of residents and to investigate any such allegations for two (Resident #1 and Resident #2) of 4 residents reviewed for implementation of written abuse, neglect, and exploitation policies: The facility failed to follow the facility policy on reporting allegations of all alleged violations to the Administrator, State agency and other officials in accordance with state law on and to investigate any such allegations on; -04/17/24 when Resident # 1 was found with a hematoma to right side of forehead of unknown origin. -04/05/24 when Resident # 2 was found with a hematoma to ghe forehead of unknown origin. This failure could place all residents at the facility at risk for abuse. Findings included: Review of facility's undated policy & procedure on Abuse, Neglect, and Exploitation provided by Administrator on 04/18/24 revealed, Policy: It is the policy of this facility to provide…

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 observation, interviews and record reviews the facility failed to ensure all alleged violations which involved abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately 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 2 of 4 Residents (Residents #1, and #2) reviewed for injuries of unknown origin. 1. The facility failed to ensure staff reported to the Administrator and or the state agency on 04/17/24 when Resident #1 was found with a hematoma (a pool of mostly clotted blood that forms in an organ, tissue, or body space) to the right side of her forehead and the cause of injury was unknown. 2. The facility failed to ensure staff reported to the Administrator and or the state agency on 04/05/24 when Resident #2 was found with a hematoma to her forehead and the cause of injury was unknown. These…

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 their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 2 of 4 (Resident #1 and Resident #2) reviewed for abuse and injuries of unknown origin. The facility failed to ensure Resident #1's and Resident #2's injuries of unknow origin were thoroughly investigated. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings include: Resident #1 Review of Resident #1's admission Record dated 04/18/24 revealed Initial admit date : [DATE]. admission Date: 02/11/2024. admitted from the hospital. Review of Resident #1's History & Physical dated 01/23/2024, revealed a [AGE] year-old with a history of diabetes mellitus type 2, hypertension, and atrial fibrillation (an irregular heartbeat) and anemia. The resident was cognitively impaired; alert and oriented x 0 (resident was not oriented…

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 reviews, the facility failed to ensure the assessment accurately reflected the resident's status for 2 (Residents #1, and Resident #4) of 4 residents reviewed for accuracy of MDS assessments. - The facility failed to ensure that Resident #1's MDS accurately reflected resident's behaviors that put her at risk for falls. -The facility failed to ensure that Resident's #3's MDS accurately reflected resident had a history fo falls and use of anti-anxiety medication. These failures could put residents at risk of not receiving the necessary care and services to prevent falls and injuries related to inaccurate MDS assessment. Findings included: Resident #1 Review of Resident #1's admission Record dated 04/18/24 revealed Initial admit date : [DATE]. admission Date: 02/11/2024. admitted from the hospital. Review of Resident #1's History & Physical dated 01/23/2024, revealed a [AGE] year-old with a history of diabetes mellitus type 2, hypertension, and atrial fibrillation (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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that resident assessments accurately reflected the resident's status for one (Resident #6) of nine residents reviewed for accuracy of resident assessments. The facility failed to ensure that Resident #6's MDS admission assessment accurately reflected the resident's history of falls. This failure put residents at increased risk of falling as a result of staff not being aware of their history of falling. Findings included: Closed record review of Resident #6's face sheet dated 3/26/2024 revealed he was [AGE] years old and was admitted to the facility on [DATE]. He had admitting principal diagnoses of syncope and collapse (passing out and falling). Other diagnoses included muscle weakness (generalized), unsteadiness on feet, and difficulty in walking, Closed record review of Resident #6's hospital History and Physical dated 01/31/2024 revealed he had falling while in the hospital and had a history of his legs giving out. The hospital assessment…

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 receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #9) of nine residents reviewed for quality of care. The facility failed to ensure that an unlicensed staff member did not put a bandage on Resident #9's left forearm without prior assessment by a nurse or a physician's order. This failure could put residents at risk of unassessed wounds, undocumented treatment and undiagnosed infections. Findings include: Record review of Resident #9's face sheet dated 03/26/2024 revealed he was [AGE] years old, was initially admitted on [DATE] and readmitted on [DATE]. Record review of Resident #9's history and physical effective date 12/27/2023 for readmission of 02/03/2024 revealed he had diagnoses including diabetes, hypertension (high blood pressure), and hyperlipidemia (high cholesterol). No problems with his…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review the facility failed to ensure residents the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 (Residents #3) of 4 residents reviewed for call light placement. The facility failed to ensure that Residents #3's call light was within reach. This failure placed residents at risk of not being able to call for assistance when needed. Findings included: Record review of Resident #3's face sheet dated 02/07/24, revealed, admission on [DATE] to the facility. Record review of Resident #3 's most recent facility history and physical in the facility system dated 10/29/23, revealed, an [AGE] year-old diagnosed with End Stage Renal Disease (condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), Dementia (loss of memory), Renal Cancer (a disease in which malignant (cancer) cells…

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 immediately notify and consult with the resident's physician when a significant change in a resident physical, mental, or psychosocial status (that was a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 (Resident #7) of 3 residents reviewed for change in condition. The facility failed to immediately inform NP/MD on 02/12/24 of Resident #7's change in condition addressing her antibiotics that the facility did not have on hand and had to wait two days before the facility could administer her antibiotics. This failure could place residents at risk of serious decrease in health related to delayed treatment. Findings include: Record review of Resident #7's face sheet dated 02/20/24, revealed, admission on [DATE] to the facility. Record review of Resident #7 's local hospital history and physical dated 02/05/24, revealed, an [AGE] year-old female diagnosed with Dementia (loss 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 that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan for 1 (Resident #3) of 4 residents reviewed for folowing physician orders. Resident #3 was not given wound care as prescribed by physician orders. This failure could affect others by placing them at risk of potential medical complications related to changes in condition. Findings included: Record review of Resident #3's face sheet dated 02/07/24, revealed, admission on [DATE] to the facility. Record review of Resident #3's most recent facility history and physical in the facility system dated 10/29/23, revealed, an [AGE] year-old diagnosed with End Stage Renal Disease (condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), Dementia (loss of memory), Renal Cancer (a disease in which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide the necessary treatment and services based on the comprehensive assessment and consistent with professional standards of practice to promote healing and prevent worsening of pressure injuries for 1 (Resident #3) of 3 residents reviewed for pressure ulcers. The facility failed to provide and assess care for Resident #3's facility acquired pressure ulcers to the left elbow in which the same Q-tip was used for two wounds in cross contaimation and to the right outer heel with pulling off the dressing without soaking to the dressing to prevent injury to Resident #3. This deficient practice could place residents at risk for worsening pressure injuries, pain, and a decline in health. Findings include: Record review of Resident #3's face sheet dated 02/07/24, revealed, admission on [DATE] to the facility. Record review of Resident #3's most recent facility history and physical in the facility system dated 10/29/23, revealed, an [AGE]…

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, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #7) of 4 reviewed for medication administration in that: Resident #7 was not given her antibiotics according to physician's orders four times a day every day for 02/13/24, 02/14/24, and on 02/18/24, two doses at 9:00 AM and 1:00 PM . This deficient practice could result in a decline in health due to incorrect medication administration and inaccurate count of controlled medications. Findings included: Record review of Resident #7's face sheet dated 02/20/24, revealed, admission on [DATE] to the facility. Record review of Resident #7 's local hospital history and physical dated 02/05/24, revealed, an [AGE] year-old female diagnosed with Dementia (loss of memory) and Rheumatoid arthritis was a chronic (long-lasting) autoimmune disease that mostly…

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 medical records, in accordance with accepted professional standards and practices, were maintained on each resident that were accurately documented for 1 (Resident #3) of 5 residents reviewed for medical records. The Assistant Wound Care Nurse failed to ensure Resident #3's treatment administration record accurately documented treatment for the Resident #3's wound care according to physician's orders. This failure could place residents at risk of not receiving needed services. Findings include: Record review of Resident #3's face sheet dated 02/07/24, revealed, admission on [DATE] to the facility. Record review of Resident #3's care plan dated 10/27/23 , revealed, was on hemo-dialysis due to renal failure. Check and change dressing daily at access site. Monitor/document for peripheral edema, bleeding. At risk for pressure ulcers. Monitor skin for changes of redness, circulatory problem, breakdown and report to medical doctor and representative…

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 disease and infection for 1 (Resident #3) of 5 residents reviewed for infection control in that: Wound Care Nurse used the same Q-tip dipped in Med-honey to apply to two different pressure ulcers on Resident #3. These deficient practices could place residents at risk for infection due to improper care practices. Findings Resident #3 Findings include: Record review of Resident #3's face sheet dated 02/07/24, revealed, admission on [DATE] to the facility. Record review of Resident #3 's most recent facility history and physical in the facility system dated 10/29/23, revealed, an [AGE] year-old diagnosed with End Stage Renal Disease (condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course 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, interview, and record review the facility failed to develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 3 (Resident #15, Resident #23, and Resident #54) of 28 residents reviewed for care plans in that: The facility failed to implement a comprehensive person-centered care plan for Resident #15 that reflected the physician ' s order for continuous tube feeding. The facility failed to implement a comprehensive person-centered care plan for Resident #23 that reflected the resident ' s diagnosis of dysphagia. The facility failed to implement a comprehensive person-centered care plan for Resident #54 that addressed the resident ' s renal dialysis, or his behaviors related to bowel movements. This deficient practice could place residents in the facility at risk of 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, interviews, and record review the facility failed to ensure residents received parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders for 2 (Resident #27 and Resident #20) of 2 residents reviewed for Midline/PICC (Peripherally Inserted Central Catheter) care. The facility failed to ensure that Resident #27's and Resident #20's midline dressing was changed according to doctor's order. This failure placed residents at risk of developing an infection. Findings included: Resdient #27 Record review of Consolidated Physician Orders dated 01/10/2024 indicated Resident #27, admitted [DATE], was [AGE] years old with diagnoses which included essential (primary) hypertension, chronic kidney disease, morbid obesity, non-pressure chronic ulcer of other part of right foot, type 2 diabetes mellitus with unspecified complications. Record review of the MDS with a completed date of 09/07/2023 indicated Resident #27's cognition was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of one (Resident #105) of five residents reviewed for accurate administering of drugs. The facility failed to obtain physician-ordered medication for sleep apnea (Modafinil) for Resident #105 from admission until 01/11/2024. This failure placed residents at risk of inadequate therapeutic outcomes and a decline in health due to not receiving medication for sleep apnea as ordered. Findings included: Record review of Resident #105 ' s face sheet dated 01/10/2024 revealed he was [AGE] years old and was admitted to the facility on [DATE]. Record review of Resident #105 ' s History and Physical dated 11/07/2023 revealed he had diagnoses including quadriplegia (paralysis of all four limbs), chronic hypoxic respiratory failure (not enough oxygen in the blood) and morbid obesity. 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 interview and record review the facility failed to ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 (Resident #24) of 6 residents reviewed for psychotropic medication. The facility failed to ensure that Resident #24 did not receive antipsychotics (Seroquel/quetiapine and Risperdal/risperidone) that were not necessary to treat a specific condition. These failures could put residents at risk of side effects from unnecessary psychotropic medications. Findings included: Record review of Resident #24 ' s face sheet dated 01/10/2024 revealed she was [AGE] years old and was admitted to the facility on [DATE]. Record review of Resident #24 ' s hospital Physician ' s Report dated 12/08/2023 revealed that the resident had medical history including dementia and was taking 25 MG of Quetiapine at bedtime. While at the hospital she was diagnosed with delirium…

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 food was prepared in a form designed to meet individual needs for two (lunch) of two meals reviewed. The facility failed to ensure the mechanical soft lunch meals were prepared to the desired consistency. This placed residents who received mechanical soft meals from the kitchen at risk of weight loss, poor intake, choking, and aspiration. The findings included: Review of Resident #23's admission Record, dated 01/11/24, revealed a [AGE] year-old female admitted to the facility 02/17/21 with diagnoses which included cerebral infarction (stroke caused by disrupted blood supply and restricted oxygen supply in the brain), facial weakness following cerebral infarction, and dysphagia - oropharyngeal phase (difficulty initiating swallowing). Review of Resident #23's Speech Therapy Plan of Care, dated 02/18/21, revealed a current level of function of patient presents with marked left sided labial weakness, evident in retraction (meaning a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide snacks at times outside of the scheduled meal service times and consistent with the plan of care for 1 of 39 residents reviewed for bedtime snacks. (Resident #27) The facility did not provide Resident #27 with a bedtime snack. The facility failure could place residents who received ordered bedtime snacks at risk of low blood sugar, experiencing hunger in the evening hours, weight loss, and a diminished quality of life. Findings included: Review of Consolidated Physician Orders dated 01/10/2024 indicated Resident #27, admitted [DATE], was [AGE] years old with diagnoses which included essential (primary) hypertension, chronic kidney disease, morbid obesity, non-pressure chronic ulcer of other part of right foot, type 2 diabetes mellitus with unspecified complications. Review of the most recent MDS signed date of 09/07/2023 indicated Resident #27' ' s cognition was intact. The resident had clear speech, was understood, and could usually…

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 disease and infection for 5 of 6 unidentified residents observed during glucose checks , 1 (yellow bin) of 2 yellow bins, and 1 (laundry cart cover) of 1 laundry cart reviewed for infection control in that: 1. Failed to disinfect the glucometer between residents. 2. 1 yellow bin had its lid off exposing the linen. 3. 1 laundry cover had holes and was coming apart. These deficient practices could place residents at risk for infection due to improper care practices. Findings include: An observation on 01/09/24 at 11:30 PM, LVN K checked five resident's blood glucose without cleaning or disinfecting the glucometer between each resident. Observed LVN K after each glucose check to gather the testing used strip, used alcohol wipe, used lancet in her palm,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review the facility failed to ensure residents the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 3 (Residents #98, #101, and #431) of 10 residents reviewed for call light button placement. The facility failed to ensure that Residents #98, #101, and #431 ' s call lights were within their reach. This failure put residents at risk of not being able to call for assistance when needed. Findings included: Resident #98 Record review of Resident #98 ' s admission MDS dated [DATE] revealed he had a BIMS score of 15 (cognitively intact). He had no symptomatic behaviors. He had impaired range of motion in both arms. He required substantial assistance from one person to use the toilet and to bathe. He had an indwelling catheter and was always incontinent of bowel. He had no history of falls. In an observation and interview on 01/09/2024 at 11:26 AM, Resident #98 revealed staff were slow to respond to call…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to have evidence that all alleged abuse violations are throroughly investigated for 1 (Resident #18) of 23 residents reviewed for employee treatment of residents. The facility failed to interview CNA P who had provided services to Resident #18 at the time abuse was alleged. This failure could put residents at increased risk of abuse or neglect. Findings included: Record review of Resident #18 ' s face sheet dated 01/02/2024 revealed he was [AGE] years old and was admitted to the facility on [DATE]. Record review of Resident #18 ' s annual MDS assessment dated [DATE] revealed he had a BIMS score of 10 (Moderate cognitive impairment. He had no symptoms of delirium or psychosis. He rejected evaluation or care 4 to 6 of the days during the 7-say look-back period. He used a wheelchair and was dependent on staff members to feed him, provide oral care, for toileting and bathing, to dress and for personal hygiene. He was dependent on staff to move around in bed,…

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 develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must be developed within 48 hours (about 2 days) of a resident's admission for 2 of 5 residents (Resident #57 and Resident #428) reviewed for baseline care plan. Resident #57 did not have a baseline care plan that addressed her focus areas of needed care. Resident #428 baseline care plan address her focused area of diabetes care. This failure could have placed newly admitted residents at risk of not receiving the care and services and continuity of care. Findings include: Record review of Resident #57's face sheet dated 01/10/24 revealed admission on [DATE] and re-admission on [DATE] to the facility. Record review of Resident #57's facility physical and history dated 12/14/23 revealed a [AGE] year-old female…

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 pnecessary services to maintain good grooming for 1 of 6 residents (Resident #20) reviewed for foot care. The facility failed to provide nail care for Resident #20 . This deficient practice placed residents at risk of poor foot hygiene and decline in residents' physical condition. Findings include: Record review of Resident #20's face sheet dated 01/10/24 revealed admission on [DATE] and re-admission on [DATE] to the facility. Resident #20 was a [AGE] year-old male diagnosed with type 2 Diabetes Mellitus and Alzheimer's Disease. Record review of Resident #20's admission MDS dated [DATE] revealed an independent cognition to be able to make daily decisions BIMS (an assessment used to monitor cognition) score of 15. Resident #20 was diagnosed with diabetes mellitus, Alzheimer disease. Record review of Resident #20's care plan dated 01/09/24 revealed risk of infections due to history of diabetes mellitus. Podiatrists consult as needed…

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 proper treatment and care to maintain mobility and good foot health in accordance with professional standards of practice, including to prevent complications from the resident's medical conditions and if necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments for 1 of 6 residents (Resident #431) reviewed for foot care. The facility failed to provide access to a podiatrist for Resident #431. This deficient practice placed residents at risk of poor foot hygiene and decline in residents' physical condition. Findings include: Record review of Resident #431's face sheet dated 01/1/24 revealed admission on [DATE] to the facility. Record review of Resident #431's facility history and physical dated 12/28/23 revealed a [AGE] year-old male diagnosed with Type 2 Diabetes Mellitus, Peripheral vascular disease (the reduced circulation of blood to a body part…

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 all drugs and biologicals in locked compartments for 1 of 7 medication carts reviewed for medication storage and security. Medication Cart #1. Facility failed to ensure Medication Cart #1 was secured when it was left unattended. These failures could place clients at risk for drug diversion or accidental ingestion. Findings included: Observation on 01/09/24 at 12:50 PM of Medication Cart #1 unlocked and unattended with no staff present from 12:50 -12:52. LVN K locked cart after receiving medication from cart for a resident. There were no residents present near the medication cart during this time. Observation on 01/10/24 at 03:30 PM, Medication Cart #1 at end of hall 100 to be unlocked with no staff present. Medication cart #1 remained unlocked from 3:30 pm until 3:58 pm, 1 resident rolled past cart to her room. LVN L placed gloves into top of cart then locked cart. Interview on 01/10/24 at 04:02 PM, LVN L stated there is one set of keys per hall with three of the four halls having two medication carts.…

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 safeguard medical records against loss, destruction, or unauthorized use for 1 (medical records black box) of 1 reviewed for medical records. The facility medical records black box had resident information coming out of its slit opening exposing resident information to the public. This failure could place residents at risk of having their personal information exposed to everyone. Findings include: Observation and interview on 01/09/24 at 12:50 PM with the ADON C. The medical records black was hanging off the wall next to the door of the medical records office. Residents paper works were sticking out of the slit of the medical records black box underneath the slit was a posting sign stating in big red bold letters, - If full do not continue to shove papers inside!! The ADON C stated having resident papers sticking out of the medical records black box was inappropriate. ADON C stated the medical records black box contained 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, interviews and record review the facility failed an adequately equipped system allowed residents to call for staff assistance through a communication system for 1 (Resident #227) of 10 residents reviewed for call light button placement. The facility failed to ensure that Resident #227 ' s call light was functioning properly. This failure put residents at risk of not being able to call for assistance when needed. Findings included: Record review of Resident #227 ' s face sheet dated 01/12/2024 revealed she was [AGE] years old and was admitted to the facility on [DATE]. Record review of Resident #227 ' s admission Note dated 01/02/2023 revealed she had diagnoses including dementia, left hip surgery, urinary tract infection. She had memory deficits and was on fall precautions, Record review of Resident #227 ' s baseline care plan dated 01/10/2024 revealed she needed extensive assistance from one person to bathe, for toileting and for walking. She required limited assistance from one person to…

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

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for professional standards for food service safety. -1 bag of fish fillets found in freezer opened to air and outside of its original package without a label of its contents. -1 bag of garlic bread found in freezer removed from the original package that was without a label of its contents. These failures could place residents at risk of food-borne illness. Findings include: Observation and interview on 11/29/2023 at 11:10 a.m., of the walk-in freezer revealed a bag of 14 fillets opened to air and without a label of its contents. The Dietary Manager (DM) identified the fillets to be fish fillets. The DM said the bag should have been labeled with contents and sealed. Observation and interview on 11/29/2023 at 11:10 a.m., of walk-in freezer revealed a clear bag of garlic bread out of its original package and not labeled. The DM said the garlic bread should have been labeled when…

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 provide an MDS assessment that accurately reflected the resident's status for 1 of 4 residents (Resident #1) reviewed for accurate assessments in that: -The facility failed to accurately reflect Resident #1's active diagnosis of chronic obstructive pulmonary disease (COPD), and oxygen therapy on the Quarterly MDS assessment. This deficient practice could affect residents who receive MDS assessments and could cause residents not to receive correct care and services. The findings were: Record review of Resident #1's face sheet, dated 09/01/2023, revealed Resident #1 was an [AGE] year-old female, with admission date of 03/22/2022. The resident had diagnoses of cognitive communication deficit, hypertension, muscle wasting, anemia, type 2 diabetes, hyperlipidemia, hypertension, retention of urine, and adult failure to thrive. Record review of Resident #1's History and Physical dated 04/04/2023, reflected the History of Present Illness indicated in part…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care was provided with such care, consistent with professional standards of practice for 1 of 4 residents (Residents #8) reviewed for respiratory care in that: -The facility failed to ensure that Resident #8's humidifier for her oxygen concentrator had water. This deficient practice could affect residents who received oxygen therapy and could result in residents receiving incorrect or inadequate oxygen support and could result in a decline in health. Findings included: Record review of Resident #8's face sheet dated 09/06/2023, revealed an [AGE] year-old female, admitted to the facility on [DATE]. No diagnosis noted on the face sheet. Record review of Resident #8's initial MDS (in progress) dated 09/06/2023, Section C. revealed Resident #8 BIMS score of 0 indicating the resident was severely impaired cognitively. Section G. revealed Resident #8 required extensive assistance with bed mobility,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 8 residents (Resident #8) reviewed for infection control, in that, -The facility failed to ensure that staff sanitized a nasal cannula that was observed on the floor before placing the nasal cannula back on the resident. -The facility failed to ensure that staff performed hand hygiene and don gloves when in contact with Resident #8's oxygen equipment. This deficient practice had the potential to affect residents in the facility by placing them at risk of contracting, spreading and/or exposing them to pathogens that could lead to the spread of communicable diseases. The findings included: Record review of Resident #8's face sheet dated 09/06/2023, revealed an [AGE] year-old female, admitted to the facility on [DATE]. No…

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.