Avir at Tierra Este

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 # 51) of 6 reviewed for medication administration. The facility failed to ensure Licensed Staff signed the individual control drug record for Resident #51's after administering controlled medication on 09/02/2025 and 09/03/2025. This failure could place residents at risk for not receiving the intended therapeutic response of prescribed medications and drug diversion of controlled substances. The findings include: Resident # 51Review of Resident #51' s admission Record dated 09/04/2025 revealed [AGE] year-old male with an initial admission date of 02/14/2025 and readmission date of 07/05/2025. Review of Resident #51's Diagnoses dated 09/04/2025 revealed a diagnosis of insomnia (persistent problems falling asleep and staying asleep). Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident # 63) of fourteen residents observed for infection control in that: Resident #63's catheter drainage collection bag was left on the floor, and the wheel of her side table was on top of the bag. This deficient practice could result in cross contamination, spread of infection and could result in a urinary tract infection.The findings included:Record review of Resident #63's admission record dated 09/03/2025, revealed the resident was admitted on [DATE].Record review of Resident #63's history and physical revealed the resident was an [AGE] year-old female with a past medical history of significant dementia (a decline in memory and other thinking skills), chronic kidney disease (long-term loss of kidney function),…

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 designate a registered nurse to serve as the director of nursing on a full-time basis for 1 of 1 DON reviewed for DON coverage. The facility failed to have a full-time DON as of 03/23/25. This failure could place residents at risk of lack or nursing oversight and a higher level of care. Findings include: Record review of staff hours Employee Timecard Report, from 03/16/25 through 03/31/25, indicated there was no DON in the facility from 03/20/25 through 03/31/25. On 04/01/25 there was no DON. Record review of the DON's Letter of Resignation, dated 03/23/25, revealed the DON submitted his letter of resignation on 03/23/25 to immediate resignation on 03/24/25. In an interview on 03/31/25 at 2:23 PM with the ADON, he stated they did not have a DON anymore. The ADON stated they had one when the state agency entered the facility on 03/22/25 and was out on a personal matter but later resigned. The ADON stated the last day the DON worked at the facility was on 03/23/25. The ADON stated since then they had been without a DON. In 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 observation, interviews, and record review, the facility failed to ensure that a resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing and prevent infections for 1 of 2 (Resident #2) residents reviewed for quality of care. The facility failed to ensure Resident #2's wound vac setting was set at 115mmhg as ordered by the physician. This deficient practice could affect residents who receive wound care treatments by placing them at risk for receiving inadequate treatments resulting in the worsening of the wounds. The findings included: Record review of Resident #2's face sheet dated 12/21/24 revealed a [AGE] year-old male with diagnoses of sepsis (life-threatening emergency that happens when your body's response to an infection damages vital organs and, often, causes death), pressure ulcer to sacrum, and hemiplegia (paralysis on one side of the body). Record review of Resident #2's quarterly MDS assessment 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 ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 4 residents (Resident #4) reviewed for indwelling catheter. The facility failed to ensure Resident #4's indwelling catheter bag was kept from touching the floor. This deficient practice could place residents with indwelling catheters at risk of disease and infection. Findings include: Record review of Resident # 4's face sheet, dated 11/27/24, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #4 had diagnoses which included urinary tract infection (a bacterial infection that affects the urinary tract, which includes the bladder, ureters, and kidneys) and retention of urine (a condition that occurs when a person is unable to empty their bladder completely). Record review of Resident # 4'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 observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in four of four halls reviewed for environmental conditions. -The facility failed to clean facility over the weekend of 07/28/24 due to not having sufficient personal to clean the resident rooms and common areas. -The facility failed to maintain the environment free of accident hazards. This deficient practice could place residents at risk of not living in a safe, functional, sanitary, and comfortable environment. Findings included: Hall 100: In an observation on 07/29/24 at 6:30 AM, revealed tile floors by the entrance of the facility and resident halls were full of dust, dried black stains, and paper particles. There was a white tablet on the floor by the decentralized nurse's station in the 300 Hall. Observation on 07/29/24 at 7:26 AM, in room [ROOM NUMBER] revealed, floor was covered with food particles .There was toothette oral…

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 FACILITY Environment Observation on 07/29/24 at 6:30 AM, revealed tile floors by the entrance of the facility and resident halls were full of dust, dried black stains, and paper particles. There was a white tablet on the floor by the decentralized nurse's station in the 300 Hall. Observation on 07/29/24 at 7:34 AM, revealed there was a white sheet on the floor soaked with water and caution sign directly in front of Janitor's Closet. Observation on 07/29/24 at 8:05 AM, revealed water was leaking from the condensation pipe in the Mechanical Room, the drain was full of water and water was leaking into the hallway and Janitor Room next to the Mechanical Room. Observation on 07/29/24 at 8:05 AM, revealed water was leaking through the floor base into the Janitor room from the Mechanical Room. It was observed the the floor was full of dust and a piece of paper and plastic were on the floor. Observation and interview on 07/29/24 at 8:10 AM, revealed with Maintenance Supervisor, revealed the flapper rusted, and the edges…

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 #6, #296 and Resident #80) of 6 reviewed for pharmacy services. -The facility failed ensure physician order dated 02/24/24 for Resident #6 had a dosage for the Voltaren Gel ordered for shoulder pain. -The facility failed to ensure Med Aide I notified the nurse when Resident #296 refused to take Lactulose on 07/29/24 according to physician's orders. -The facility failed to administer Resident #80 Zinc Sulfate 220 mg on 07/29/24 according to physician's orders. -The facility failed to ensure Licensed Staff (LVN J, and LVN D) did not sign off on the Controlled Drugs-Audit Record form prior to counting and verifying that all controlled substances in the medication cart had been accounted for with the on-coming nurse at the change 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 Resident #18 Unnecessary Meds, Psychotropic Meds, and Med Regimen Review 07/31/24 02:49 PM Antipsychotic: Order Summary: Aripiprazole Oral Tablet 10 MG (Aripiprazole) Give 1 tablet by mouth at bedtime related to DEPRESSION, UNSPECIFIED (F32.A) Opioid: tramadol HCl Oral Tablet 50 MG (Tramadol HCl) *Controlled Drug* Give 1 tablet by mouth every 4 hours as needed for Pain - Moderate. Antidepressant: trazodone HCl Oral Tablet 50 MG (Trazodone HCl). Give 1 tablet by mouth at bedtime related to INSOMNIA, UNSPECIFIED (G47.00). Wellbutrin XL Oral Tablet Extended Release 24 Hour 150 MG (Bupropion HCl). Give 1 tablet by mouth one time a day for SMOKING CESSATION AID. Diuretics: acetazolamide Oral Tablet 250 MG (Acetazolamide). Give 1 tablet by mouth two times a day related to EDEMA, UNSPECIFIED (R60.9) Resident #44 Unnecessary Meds, Psychotropic Meds, and Med Regimen Review 07/31/24 02:23 PM Hydroxyzine was supervised to the resident with a starting date of 6/18/24 and was supervised Based on interviews and 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 observation, interview, and record review, the facility failed to ensure the medication error rate was not five percent or greater. The facility had a medication error rate of 22% based on 12 errors out of 53 opportunities, for two residents (Resident #21, Resident #295) of six residents observed for medication administration, by one (Med Aide E) of four staff reviewed for medication errors. -The facility failed to ensure Med Aide E administered eight morning medications to Resident #21 on 07/29/24. - The facility Med Aide E failed to administer Resident #295 Famotidine 20 mg, Amiodarone HCL 200 mg, Budesonide Inhalation Solution, and Cholestyramine Oral Pkt on 07/29/24 according to physician's orders for the scheduled morning medication pass. These failures had the potential to affect facility residents by placing them at risk of not achieving the therapeutic effects of ordered medications to manage their medical conditions and decline in health. Findings include: Resident #21 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.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, safe and secure storage of medications for 4 of 4 nurse carts checked for controlled substances; 2 of 2 Med Aide carts checked for storage of medications. -The facility failed to ensure liquid medication stored in medication carts on three halls (200, 300 and 400) did not have dried drippings on the sides of the bottles. -The facility failed to ensure medications were stored according to routes of administration. -The facility failed to ensure 1 of 7 medication carts was locked when not in use. The facility failed to ensure bottle of Betadine stored in the treatment cart was free of dried drippings. -The facility failed to ensure opened bottles of Acidophilus Probiotic Dietary Supplement were refrigerated after opening in 7 of 7 medication carts. This failure could result in drug diversion of controlled substances. These failures could affect residents that received medications at the facility by placing them at risk…

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

Based on observations, interviews, and record reviews the facility failed to prepare food by methods that conserve nutritive value in 1 of 1 kitchen reviewed for food preparation. The facility [NAME] N failed to prepare instant mashed potatoes according to manufacturer's serving chart. These failures could could impact the nutritional value of the meal. Findings included: In an observation and interview on 07/29/24 with [NAME] N revealed they had 16 residents on Pureed Food and was going to prepare 20 servings for the lunch meal. He said he was going to prepare Mashed Potatoes and was going to 2 lbs. of potato flakes to 4 quarts of water. He said I just eyeball the amount of water and potato flakes to get the correct consistency and amount of potato flakes to get 20 servings. I don't go by the serving chart on the container. In an interview and record review on 08/01/24 at 1:58 PM, with Dietary Manager revealed, Recipe for Mashed Potatoes documented Instructions: Follow manufacturer directions for exact amounts. The Dietary Supervisor stated, I don't understand why you are concerned…

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

Based on observations, interviews, and record reviews the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation and food storage. -The facility failed to ensure the shelf in the food preparation area used to store spices was free of food particles. -The facility failed to keep food preparation tables and equipment free of white stains, and food particles. -The facility failed to keep the tiles floors free of black grease build-up. - The facility failed to keep food coloring bottle free of dried drippings. The facility failed to keep trash can covered in the food preparation area. -The facility failed to store foods in the refrigerators and freezers in sealed containers. - The facility failed to keep food containers free of grease build up, and dried stains in the dry storage room. -The facility failed to store foods stored on metal racks in the dry storage room in sealed containers. -The facility failed to store foods in the refrigerators and freezers in sealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY FACILITY Kitchen Observation on 07/29/24 at 6:38 AM during the initial tour in the kitchen revealed: Food Preparation Area: -The shelf directly above the food preparation table by the stove where spice bottles are stored was full of particles food particles. -Stainless steel tables had dried white stains under the steamer and sides of the table -Steamer had white dried stains on the sides -Deep Fryer was full of crumbs and pieces of chicken strips were in the oil -Tile floor between the deep fryer and steamer had dried black stains and there was a piece of chicken on the floor. The sides of the stove had dried stains and grease build-up -broken toaster was full of dust and food particles -storage shelve under stainless steel table had dried white stains and food particles -tile floor throughout the kitchen had black grease build-up and food particles -Multiple Spice bottles were opened, bottles had grease build-up on lids and sides of bottles -small bottle of food color had dried drippings on cap and sides of…

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

Based on interviews and record review, the facility failed to maintain a quality assessment and assurance committee consisting at a minimum the required committee members for 5 of 9 meetings reviewed for QAPI. The facility did not ensure the MD, or a representative attended QAPI meetings. This failure could place residents at risk for quality deficiencies being unidentified, no appropriate plans of action developed and implemented, and no appropriate guidance developed. Findings included: Interview on 08/02/24 at 12:27 AM, with the Administrator revealed the facility held monthly QAPI meetings. The DON stated all department heads, and the Medical Director attended the QAPI meetings. The DON stated the Medical Director had only attended one QAPI meeting in 2023 and none in 2024. Record review on 08/02/24 12:50 AM with the Administrator of QAPI Signature Sheets for 2023 and 2024 revealed the following: 07/13/23 Medical Director and/or designee did not attend QAPI meeting. 08/23/23 Medical Director and/or designee did not attend QAPI meeting. 04/24/24 Medical Director and/or designee…

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

Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections, for 1 of 1 treatment car; and 3 of 4 resident halls reviewed for infection control practices. -The facility failed to ensure dirty linen hampers were covered. -The facility failed to ensure opened packages of gauze non-sterile sponges were stored in sealed plastic bags. -The facility failed to store mattress off the floor in storage. -The facility failed ensure facility staff did not store personal belongings in clean linen closet. This failure could place residents at risk for cross contamination and the spread of infection. Findings included: Hall 300: In an observation on 07/29/24 at 7:16 AM, in the 300 Hall revealed dirty linen hamper was full and cover was not sealed. Treatment Cart: In an observation and interview on 07/29/24 at 8:46 AM, with Treatment Nurse revealed there was an opened bag…

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 the resident had the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility for 1 of 12 residents (Resident # 298) reviewed for resident rights, in that: Resident #298's indwelling urinary catheter bag was not covered. The deficient practice could affect residents by contributing to poor self-esteem, and dignity issues. The findings included: Record review of Resident #298 ' s face sheet dated 08/01/2024 documented he was [AGE] years old and was admitted to the facility on [DATE]. Record review of Resident #298 ' s MDS dated [DATE] revealed he had a BIMS score of 11 (Moderate Cognitive impairment). He had a diagnosis of neuromuscular dysfunction of bladder (the nerves and muscles do not work together well and as a result the bladder may not fill or empty correctly), urinary tract infection and benign prostatic hyperplasia without lower…

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 one (Resident #15) of 15 residents reviewed for accommodation of needs. The facility failed to ensure that Resident #15's electronic monitoring camera was not obstructed when care was being provided as requested by the family. This failure could put residents at increased risk of not having their rights/preferences honored. Findings included: Record review of Resident #15's face sheet dated 08/02/2024 revealed she was [AGE] years old and was admitted to the facility on [DATE]. The face sheet identified Family Member Z as the resident's responsible party and Power of Attorney. Record review of Resident #15's quarterly MDS dated [DATE] revealed she had a BIMS score of 5 (severe cognitive impairment). She required substantial to moderate assistance to use the toilet, shower or bathe, dress her upper or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to consult with the resident's physician when there was a significant change in the resident's physical status for 2 (Resident #295 and Resident #6) of 6 residents reviewed for physician notification. -The facility failed to consult with physician and/or Nurse Practitioner when the facility did not have Famotidine 20 mg, Amiodarone HCL 200 mg, Budesonide Inhalation Solution, and Cholestyramine Oral Pkt to administer as ordered on 07/29/24 during the morning medication pass. -The facility failed to consult with physician and/or Nurse Practitioner when the facility did not have a dosage for the Voltaren Gel for Resident #6 ordered 02/24/24. This failure could place residents at risk of delayed medical treatment. Findings include: Resident #295 Record review of Resident #295's admission Record dated 08/01/24 revealed she was [AGE] years old and was admitted to the facility on [DATE]. Record review of Resident #295's Hospital History & Physical…

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 Resident #15 Privacy 07/29/24 03:19 PM camera [NAME], [NAME], Santa - putting the pillow over the camera - they says it for her privacy- went on administrator . Aracelli DON is telling [NAME] to cover block the cameras. Leave TV and light on during the night - does not know if this is her or the other resident's TV or liResident ght. 7/30/24 - 1:40 PM - COnsurla [NAME] DTEs [NAME] - Moved camera from head of bed to sid [NAME] now cover it Cant give instructions. over the camera. 08/01/24 03:07 PM DON - policies related to cameras - has had concerns about this Homes - reason that they cover if for dignity - want to see Mom - Says to keep an eye on her - Daughters says she is is not sure of the care. Says dignity and privacy concern. question of balance between resident and family rights. [NAME] moves the camera around - hatdit by the lght fixutre but a fire dcncern. Mr [NAME] has not said anything . He does have a camera - no concerns expessed. will ask for set up help. Plocy - provied regulation - regulation is…

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 #50) of 2 residents reviewed for compliance with PASARR regulations. The facility failed to screen Resident #50 for PASARR when she received a new diagnosis of Schizophrenia. This failure could put residents eligible for PASSR services at risk of not receiving PASSR-recommended specialized services. Findings included: Record review of Resident #50's face sheet dated revealed she was [AGE] years old and was admitted to the facility on [DATE]. Her principal diagnosis was Encounter for attention to gastrostomy (attention to a feeding tube). Record review of Resident #50's physician's progress note dated 07/28/2013 revealed she had diagnoses including dementia, delusional disorders and recurrent major depressive disorder. She had attention seeking behaviors and was prescribed Sertraline (a medication for depression, panic disorder, obsessive-compulsive…

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 Resident #39 General 07/29/24 09:53 AM [NAME], LVN - - wound draining - sent out culture - dressing is not dated - states for hygiene and should be changed - this would be PRN change. - no date. Care Plan - Resident has and LVAD. At risk for complications. Date Initiated: 07/28/2023 Revision on: 08/21/2023 08/01/24 02:20 PM DON - wound care is [NAME] and if she is not avavile and needs to be changes will be done by nursing. Whena wound dressing in schanged it should be dated. shoud be dated so nikno w wound change date and prevent infections. LVAC [NAME] infoemed her - it was soiled. Nurses monitor it as they do their rounds. 3xQ24 hours - condition of dressing should have been caught during rounds. Trigger woudl be how soiled it is - dressing not intact. Risk for infection from the draininge. Tested postive - Was tested in APril, June, negative, last one Monday colledted cam positve. started on amoxicilliin and infections disease and drew labs this AM to see changes. Based on observation, interview and record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with the comprehensive person-centered care plan, the resident's goals and preferences for one (Resident #192) of seven residents reviewed for respiratory care and 1 of 1 oxygen storage room observed for oxygen management. -The facility failed to ensure Resident #192 had her nasal cannula on per physicians' orders and that the nasal cannula was covered when not in use. -The facility failed to ensure 4 oxygen metal cylinders were stored in the oxygen storage room. -The facility failed to ensure an oxygen sign was posted outside of the scale room where oxygen was stored. This failure could put the resident at increased risk of receiving insufficient oxygen and of infection. These failures could place residents on oxygen therapy at risk of not receiving oxygen support due to improper storage. The findings included: Record review of Resident #192's face sheet…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure drug regimen irregularities reported by the Pharmacist Consultant were acted upon by the physician for 1 (Resident #21 ) of 6 residents reviewed for physician response to medication regimen review. The facility failed to ensure that the physician responded timely to Pharmacist Consultant recommendations for Resident #21 to evaluate the continued need for iron sulfate beyond 8 weeks of therapy as per CMS Guidelines. These failures could place residents at risk for unnecessary medications. Findings included: Record review of Resident #21's admission Record dated 07/30/24 revealed she [AGE] years old and was initially admitted on [DATE] and re-admitted on [DATE]. Record review of Resident #21's Hospital History & Physical dated 02/01/24 for revealed had a diagnosis of anxiety, depression, hyperlipidemia (in condition where there are high levels of fats, or lipids in the blood), hypertension (a condition where the pressure in your blood vessels is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice for 1 of 3 (Resident #5) residents reviewed for quality of care, in that: The facility failed to maintain communication, coordination, and collaboration with the dialysis facility for Resident #5. This failure could place residents who received dialysis treatments at risk for complications and not receiving proper care and treatment to meet their needs. Findings included: Record review of Resident #5's face sheet dated 06/26/24 revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Record review of Resident #5's history and physical dated 11/10/23 revealed a diagnosis of end stage renal failure on hemodialysis [Monday, Wednesday, and Friday]. Record review of Resident #5's quarterly MDS assessment dated [DATE] revealed a BIMS score of 12, indicating his cognitive was moderately impaired. 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 interview and record review, the facility failed to ensure medical records were maintained on each resident that were complete and accurately documented for 3 of 5 (Resident #1, #4 and Resident #2) reviewed for accuracy and completeness of medical records. 1. The facility failed to document the event of Resident #2's allegation of being called stupid and handled rough when ADLs were being performed in the facility progress notes and conduct an incident report. 2. The facility failed to have complete and accurate documentation for a resident to resident altercation between Residents #1 and #4 on 06/23/24. These failures could place residents at risk of not receiving needed service. Findings included: Record review of Resident #2's face sheet dated 06/25/24, revealed, admission on [DATE] and re-admission on [DATE] to the facility. Record review of Resident #2's facility history and physical dated 09/28/23, revealed, a [AGE] year-old female diagnosed with Diabetes Mellitus, kidney disease stage 2, COPD (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public for 1 of 5 resident rooms reviewed for environment. The facility failed to ensure the broken window in room [ROOM NUMBER] was fixed. This failure could place residents at risk of living in an unsafe environment which may create a potential for a cut, insect bites, or respiratory problems. Findings included: Record review of Resident #7's vitals for oxygen dated 06/02/24-06/25/24, revealed, oxygen saturation to be between 92 percent to 97 percent saturation. Record review of Maintenance Director text message that was provided dated 01/26/24, stated the following: Maintenance Director - Good afternoon, President we need a window replacement asap please. Text message dated 01/30/24 - Maintenance Director - Good morning, President any news for window replacement yet? Text message dated 01/31/24 - President - Ok they are working on getting the…

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

Based on interview and record review, the facility failed to implement written policies that prohibit and prevent abuse for 1 of 9 employees (the Administrator) reviewed for criminal back ground checks. The facility failed to run the Administrator's criminal background check prior to her starting her duties on 12/04/23. This failure could place residents at risk of potential abuse. The facility completed the following corrective actions to address the non-compliance after the incident occurred but prior to the surveyor entering: Findings included: Record review of the Administrators undated New User Access Approval revealed a start date of 12/04/23. During an observation and record review of the employee background checks on 06/27/24 at 9:44 am, HR stated the Administrator had started working for the company on 12/04/23 and the criminal background check was completed on 12/14/23 . HR stated all administrative positions' criminal background checks were completed by corporate. HR stated she had just received a call notifying her about the Administrator start date on 12/04/23. HR…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse were reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to other officials (including State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with state law for 2 of 7 residents (Resident #1 and Resident #4 ) reviewed for abuse. The facility failed to report resident to resident altercation to HHSC involving Resident 31 and Resident #4. This failure could place residents at risk of continued abuse. Findings included: 1. Record review of Resident #1's face sheet dated 06/25/24 revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Record 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 observations, interviews, and record reviews, the facility failed to provide the necessary treatment and services based on the comprehensive assessment and consistent with professional standards of practice for 1 (Resident #3) of 7 resident reviewed for quality of care. The facility failed to date/initial Resident #3's dressings after treatment was done. This deficient practice could place residents at risk for worsening venous injuries, pain, and a decline in health. The findings include: Record review of Resident #3's face sheet dated 06/27/24, revealed, admission on [DATE] and re-admission on [DATE] to the facility. Record review of Resident #3's facility history and physical dated 02/07/24, revealed, a [AGE] year-old male diagnosed with lymphedema, chronic venous hypertension, leg wound, and elephantiasis (It is caused by infection with parasites classified as nematodes (roundworms) that are transmitted through the bites of infected mosquitos). Record review of Resident #3's quarterly MDS dated…

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

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. -On 02/09/2024 at 11:51 a.m., [NAME] L and [NAME] M had beards and were not wearing beard nets while preparing food in the kitchen. This failure could affect residents by placing them at risk of food borne illness. Findings included: Observation on 02/09/2024 at 11:50 a.m., revealed a sign posted on the kitchen entrance door that reads Hairnets must be worn upon entering. Observation and interview on 02/09/2024 at 11:51 a.m., revealed Cooks L and M with beards. [NAME] L was preparing plates for lunch. [NAME] M was preparing dessert for lunch trays. [NAME] L said the DM recently stopped working at the facility and they did not have a DM at the time of the visit. [NAME] L said that no one had said anything about needing to wear a beard net. [NAME] M said no one had told him anything about needing to wear a beard net. During 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 observation, interview, and record review the facility failed to assure that one (Resident #10) of five residents reviewed for enteral feeding, received appropriate treatment and services to prevent complications of enteral feeding. -The facility failed to ensure that Resident #10's feeding tube bags were labeled with name of resident, date, and time the administration began to ensure residents maintain nutritional status within optimal parameters. This failure could place residents receiving enteral feedings at risk of not being provided the correct enteral feeding and not receiving feeding care in a timely manner to prevent complications. Findings included: Record review of Resident #10's face sheet dated 02/09/2024, revealed an [AGE] year-old male who was admitted on [DATE]. Diagnosis included Ileus (intolerance of oral intake due to inhibition of the gastrointestinal propulsion without signs of mechanical obstruction), gastrostomy status (presence of artificial opening to stomach), and dysphagia…

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 (Residents #12) of 10 residents reviewed for infection control. - The facility failed to ensure staff followed infection control practices of washing hands after glove use during patient care. These deficient practices could place residents at risk for infection due to improper care practices. Findings included: Record review of Resident #12's face sheet dated 02/09/2024, revealed a [AGE] year-old female, with an admission date of 01/02/2024. Resident 12's diagnoses included: quadriplegia (paralysis of all four limbs), and history of urinary tract infections. Record review of Resident #12's quarterly MDS assessment dated [DATE] revealed a BIMS score of 11 indicating moderate cognitive impairment. Review of Resident #12's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 2 (Resident #3 and Resident #4) of 6 residents reviewed for repositioning. The facility failed to ensure Resident #3 and Resident #4 were repositioned every 2 hours. This failure could affect others by placing them at risk of potential medical complications related to changes in condition. Findings included: Resident #3 Record review of Resident #3's face sheet dated 1/23/24 revealed a [AGE] year-old female who was admitted on [DATE] with diagnoses of obesity, memory deficit following cerebral infraction, muscle weakness, difficulty in walking, pain, adult failure to thrive. Record review of Resident #3's significant change MDS assessment dated [DATE] revealed a BIMS score of 12, she was cognitive intact. She required partial/ moderate assistance was able to do more than half the effort.…

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 needs for 2 (Residents #9 and #16) of 12 residents reviewed for reviewed for call light button placement.: -The facility failed to ensure that Residents #9's and #16's call lights were within their reach. This failure could place residents at risk of not being able to have their needs met. Findings included: Resident #9: Record review of Resident #9's face sheet dated 01/19/2024, revealed an [AGE] year-old female, with an initial admission date of 07/03/2023 and readmission date of 01/14/2024. Resident #9's diagnoses included: anxiety disorder (persistent and excessive worry that interferes with daily activities), seizures (sudden uncontrolled burst of electrical activity in the brain), osteoporosis (bone disease that develops when bone mineral density and bone mass decreases or when the quality or structure of bone changes), acute kidney failure (condition in which the kidneys suddenly can't filter…

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 (Residents #14) of 12 residents reviewed for infection control. - The facility failed to ensure staff followed infection control practices of washing hands after glove use after assisting a resident with toileting. These deficient practices could place residents at risk for infection due to improper care practices. Findings included: Resident #8: Record review of Resident #8's face sheet dated 01/19/2024, revealed a [AGE] year-old male, with an initial admission date of 07/21/2023 and readmission date of 11/25/2023. Resident #8's diagnoses included: convulsions (sudden, violent, irregular movement of a limb or of the body), Parkinsonism (disorder of the central nervous system that affects movement, often including…

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 of 4 residents (Resident #4) reviewed for infection control in that: There was no sign posted outside of Resident #4's room indicating the resident was in isolation. There was no physician orders for Resident #4 being in isolation. These deficient practices could place residents at risk for infection due to improper care practices. The findings include: Record review of Resident #4's face sheet dated 11/07/23 revealed admission on [DATE] and readmission on [DATE] to the facility. Record review of Resident #4's history and physical dated 11/01/23 revealed a [AGE] year-old female diagnosed with stroke and end stage heart failure. Record review of Resident #4's significant MDS dated [DATE] revealed a minimum BIMS (a quick snapshot…

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 the observation, interview and record review the facility failed to ensure the resident environment remained free of accidents hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (Resident #2) and 1 of 5 hallways (hall #1) reviewed for accidents and supervision. 1. The facility failed to ensure CNA C used a gait belt when transferring Resident #2, which resulted in a resident fall. 2. Housekeeper E failed to place a wet floor sign after mopping a hallway in the front entrance. These failures could place residents at risk of falls. Findings include: 1. Record review of Resident #2's face sheet, dated 09/27/23, revealed admission on [DATE] and readmission on [DATE] to the facility. Record review of Resident #2's history and physical, dated 08/06/23, revealed an [AGE] year-old female with a diagnosis which included osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time). 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, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 2 of 6 residents (Resident #1 and Resident #5) reviewed for accuracy and completeness of medical records. 1. The facility failed to completely and accurately document neurological checks for Resident #1 after an unwitnessed fall. 2. The facility failed to ensure Resident #5's peer to peer incident was documented. These failures could place residents at risk of not receiving needed services. Findings include: 1. Record review of Resident #1's face sheet, dated 09/27/23, revealed admission on [DATE] and readmission on [DATE] to the facility. Record review of Resident #1's history and physical, dated 09/12/23, revealed an [AGE] year-old female with a diagnosis which included dementia. Record review of Resident #1's admissions MDS, dated [DATE], revealed an [AGE] year-old female diagnosed…

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 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 infections for 2 of 6 closets (Clean Linen Closet and Soiled Linen Closet) reviewed for infection control. The facility failed to ensure one clean linen closet and one soiled closest door remained closed to prevent facility residents from going inside. This deficient practice could place residents at risk for infection due to improper care practices. Findings include: Observation on 09/26/23 at 3:57 PM revealed in hallway one hundred to have had a soiled linen closet that had the door open. Inside the closet was a yellow container with a gown sticking out. Next to the yellow container was a gray container with the lid cracked open. On the floor was a used clear glove. Across from the soiled clothes was a linen closet that was open. Serval shelves had towels, gowns, and Hoyer slings. Observation and interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents choices for 1 of 2 residents (Resident #1) reviewed for neurological checks. The facility failed to ensure Resident #1 who had a fall received neuro-checks (a physical examination to identify signs of disorders affecting your brain, spinal cord and nerves [nervous system]). This failure could place residents at risk of potential medical complications related to changes in condition. Findings include: Record review of Resident #1's progress notes, dated 09/09/23, indicated LVN A was notified of resident being on the floor at approximately 7PM. This nurse (LVN A) had resident in close proximity to staff at the nursing station. Resident #1 had poor safety awareness, poor cognition, and fall history. Neuro-checks began. Record review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 2 residents (Resident #4) observed for respiratory therapy. The facility failed to ensure Resident #4 did not have an empty oxygen tank. This failure could place residents at risk of receiving incorrect or inadequate oxygen support and decline in health. Findings include: Record review of Resident #4's face sheet, dated 09/29/23, revealed admission on [DATE] to the facility. Record review of Resident #4's order recap, dated 08/25/23, revealed oxygen continuously via nasal cannula. May titrate between 2-5 liters per minute for shortness of breath or pulse oximetry greater than 90 percent, every shift for shortness of breath and to maintain pulse oxygen greater than 90 percent. Observation and interview on 09/28/23 at 1:25 PM with…

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

Based on interview and record review the facility failed to ensure the facility assessments were documented and facility-wide assessments determined what resources were necessary to care for residents competently during both day-to-day operations and emergencies for 1 of 1 facility (Facility) reviewed for facility assessment. The facility failed to ensure the facility assessment contained information regarding the level of staff needed to meet the needs of each resident. This failure could place residents at risk of inadequate care of treatment. Findings include: Record review of the facility assessment, dated 08/23/23, did not include information regarding the level of staff needed to meet the needs of each resident. Interview on 09/29/23 at 11:34 AM, the Interim Administrator stated he was not aware there was a facility assessment and did not know what that was. Interview on 09/29/23 at 1:20 PM, the Regional Nurse stated the Administrator and other department heads were responsible for creating the facility assessment before the facility was opened. Record review of the facility…

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

Based on observation, interview and record review the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public for __1__ of __5___ halls reviewed for environment. The facility failed to ensure wet floor signs were posted when the facility floor was mopped. This failure could place residents at risk of living in an unsafe environment which may create a potential for a fall. Findings include: Observation on 09/27/23 at 3:21 PM revealed 3 unknown residents and family members walking through and sitting on the couches in the hallway near the front entrance. The floor did not appear wet. Observation and interview on 09/28/23 at 8:32 AM with the DON, in the hallway near the front entrance, revealed the long hallway was wet. There was no wet floor sign posted up on the floor. The DON stated there needed to be a wet sign posted. The DON stated anytime they mopped the floor, a wet floor sign needed to be placed. The DON stated there was a risk of falls to the residents, visitors, and staff. Observation on 09/29/23 at 8:46 AM…

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 to ensure residents the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 resident (Residents #2) out of 5 residents reviewed for accommodation of needs. The facility failed to ensure Residents #2 call light was placed within reach. This failure could put residents at risk of not being able to have their needs met. Findings Include: Record review of Resident #2's face sheet dated 08/17/23, documented she was a [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #2's History and Physical dated 08/10/23 documented a [AGE] year-old female history of Alzheimer's dementia, with history of multiple falls and unsteady gait. Record review of Resident #2' s admission MDS signed by MDS Nurse B 08/28/23 revealed MDS in progress. Section C - Cognitive Pattern a BIMS score of a 5 indicating cognitive status severely impaired. Record review of…

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

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 of a resident's admission for 1(Resident #1) of 5 residents reviewed for baseline care plan. Resident #1 did not have a baseline care plan that addressed her Respiratory infection. This failure could have placed newly admitted residents at risk of not receiving the care and services and continuity of care. Findings included Record review of Resident #1's face sheet dated 08/31/23 documented an [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #1's History and Physical dated 08/25/23 documented she had diagnoses of asthma, COPD (a group of lung diseases that block airflow and make it difficult to breathe), pulmonary nodule (abnormal growth that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #1) of 5 residents reviewed for infection prevention and control. The facility failed to ensure direct care staff used proper PPE when providing care for Residents #1 who had COVID-19. This failure could place other residents at risk of exposure to cross contamination of Covid-19. Findings included: Record review of Resident #1's face sheet dated 08/31/23 documented an [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #1's History and Physical dated 08/25/23 documented she had diagnoses of asthma, COPD (a group of lung diseases that block airflow and make it difficult to breathe), pulmonary nodule (abnormal growth that forms in a lung) and was and active smoker. Record review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 3 (Resident #51, Resident #52, Resident #53) of 3 residents reviewed for activities. The facility failed to provide morning activities for Resident #54, #55, and #56. This failure placed the residents at risk of boredom, loneliness, social isolation, and decline in quality of life. Findings included: Resident #5 2 Record review of Resident #52's face sheet dated 5/19/23 revealed a [AGE] year-old female was admitted on [DATE]. Record review of Resident #52's1 history and physical dated 5/11/23 revealed diagnoses of cervical and thoracic laminectomy Resident #52 Record review of Resident #52's face sheet…

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 is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for 1 (Resident #53) of 2 residents reviewed for indwelling catheter. The facility failed to ensure Resident #53 indwelling catheter strap was properly secured on her leg and failed to ensure indwelling catheter was hanging below the bladder preventing urine backflow. These deficient practices could affect residents with indwelling catheters at risk of disease and infections. Findings include: Record review of Resident #53's face sheet dated 5/19/23 revealed [AGE] year-old female admitted on [DATE]. Record review of Resident #53's history and physical dated 5/11/23 revealed diagnoses of dementia and was started on Macrobid (an antibiotic that can treat urinary tract infections) for urinary tract infection. Record review of Resident #53's MDS admission assessment dated [DATE] revealed a BIMS score of 3,…

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

Based on observation and interview the facility failed to ensure that the daily nurse staffing was posted as required. The facility failed to update the daily staffing information posting. This failure could affect residents, their families, and facility visitors by placing them at risk of not having access to information regarding staffing data and facility census. Findings include: Observation on 5/19/23 at 8:28 AM revealed Direct Care Posting dated 5/17/23 was posted on postings wall. Interview on 5/19/23 at 9:15 AM LVN A stated DON had been the person responsible of updating and posting nursing staffing sheet. LVN A stated the purpose of the posting was to give visitors information on census and staffing ratio. Interview on 5/19/23 at 9:17 AM DON stated she was responsible of posting the daily direct care posting. DON stated she had the records in her binder and got ahead of herself due to yesterdays opening party overlooked it. DON stated she tends to update the direct care posting shortly after arriving and today she was granted permission to work little later 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.

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for residents. 1. Food temperature was not recorded for dinner on 5/18/23. This failure could affect residents by placing them at risk of food borne illness. Findings include: Record review of Temperature Record of Food on Standard Menu dated May 2023 revealed food temperatures for dinner meal on 5/18/23 were not recorded. Interview on 5/19/23 at 8:08 AM Dietary Manager stated food temperatures were required to be taken before serving and documented on food temperature log. Dietary Manager stated the facility had a grand opening party yesterday evening and forgot to record the dinner temperatures on log. Dietary Manager stated by not recording food temperatures could reflect that task was not completed. Dietary Manager stated he received training on taking food temperatures and documenting upon hire. Dietary Manager stated by not recording meal temperatures taken prior 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.