Avir at Enchanted Rock

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, in accordance with accepted professional standards and practices, the facility failed to maintain medical records on each resident that were complete; accurately documented; readily accessible; and systematically organized, for 1 of 6 residents (Resident #55) reviewed for accurate records. LVN Z inaccurately documented care for Resident #55. This failure could place residents at risk for inaccurate records.Based on observations, interviews, and record reviews, in accordance with accepted professional standards and practices, the facility failed to maintain medical records on each resident that were complete, accurately documented, readily accessible, and systematically organized for 1 of 6 residents (Resident #55) reviewed for medical records. LVN Z inaccurately documented care for Resident #55. This failure could place residents at risk for their needs not being met accurately.Findings included: A record review of Resident #55's admission record, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for 2 of 6 residents (Residents #26 and #27) reviewed for infection prevention measures. RN BB assessed Residents #26's blood sugar with a glucometer (a portable device used to measure blood sugar levels; A drop of blood obtained via a lancing device is placed on the edge of the strip which was inserted into the meter) and did not disinfect the glucometer with an appropriate blood borne pathogen (germs or infectious agents and include viruses, bacteria, fungi, and parasites) disinfectant; and then proceeded to assess Resident #27's blood sugar with the same glucometer used for Resident #26. This failure could place residents at risk for blood borne pathogen infections.Based on observations, and record reviews, 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.

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 3 of 7 residents (Resident #1. #2 and #3) reviewed for infection control in that: The facility failed to ensure the Activity Director utilized hand hygiene during meal service between resident contact for Residents #1, #2 and #3. This deficient practice could affect all residents and place them at risk for infection. The findings were:Record review of Resident #1's face sheet dated 1/08/2026 revealed a [AGE] year-old female admitted on [DATE] with diagnoses which included: moderate dementia with mood disturbance (a person with dementia who also experiences depression, anxiety and aggression), type 2 diabetes mellitus with diabetic neurological complication (diabetes that also affects the nervous system) and generalized muscle…

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 incorporate the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care for 1 of 3 (Resident #3) PASSAR services in that: The facility failed to submit a complete and accurate request for nursing facilityspecialized services in the LTC Online Portal within 20 business days after the date of IDT meeting.This failure could affect residents on PASARR services and could result in Resident not proving PASARR services.The findings: Record review of Resident #3's admission Record dated 07/09/2025 documented he was admitted on [DATE], re-admitted on -2/04/2024 with diagnoses of Parkinson's disease, and Intellectual Disabilities. Record review of Resident #3's Quarterly MDS dated [DATE] documented his BIMs score was 5/15 (severely impaired), mobilized with wheelchair and had a diagnosis of Parkinson's disease, and Intellectual Disabilities.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 observations, interviews, and record reviews the facility failed to ensure a process which provided 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 of 6 residents (resident #1 and Resident #2) reviewed for procedures for accurate acquiring, receiving, dispensing, and administering of all drugs, in that: 1. The facility had Resident #1's controlled medications unsecured, 3 loose, 0.25mg pills of clonazepam stored in the ADON's desk drawer separated from the narcotic count sheet. 2. The facility had Resident #2's controlled medications unsecured, a bottle of liquid Dilauded, loose in a narcotic drawer separated from the narcotic count sheet. These failures could place residents at risk for safety from medication errors. The findings included: 1 a record review of Resident #1's admission record dated 7/8/2025, revealed an admission date of 8/17/2024 with 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 interviews and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care within 48 hours of a resident's admission, including initial goals based on admission orders, physician orders, dietary orders, and social services for 3 of 8 (Resident #21, Resident #51 and Resident #207) reviewed for baseline care plans. The facility failed to ensure a baseline care plan was completed within 48 hours from admission for Resident #21, Resident #51 and Resident #207. These failures could place residents at risk of not receiving care and services to meet their needs. The findings were: Record review of Resident #21's face sheet, dated 02/10/2025, revealed Resident #21 was admitted on [DATE], with diagnoses which included: chronic obstructive pulmonary disease, type 2 diabetes mellitus without complications, unspecified cirrhosis 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 residents received services in the facility with reasonable accommodation of resident needs for 1 of 8 residents (Resident #207) who were observed for call light placement. The facility failed to ensure the call light was within reach for Resident #207. This deficient practice could place residents at risk of keeping them from calling for help as needed. The findings were: Record review of Resident #207's face sheet, dated 02/12/2025, revealed she was admitted to the facility on [DATE] with diagnoses which included: fracture of other parts of pelvis, subsequent encounter for fracture with routine healing, wedge compression fracture of unspecified thoracic vertebra, subsequent encounter for fracture with routine healing, muscle weakness (generalized), unspecified abnormalities of gait and mobility, and age-related osteoporosis without current pathological fracture. Record review of Resident #207's admission MDS assessment, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents have the right to formulate an advance directive and determine the choice to receive or not receive CPR (cardiopulmonary resuscitation) for 1 of 8 residents (Resident #46) whose records were reviewed for code status. The facility failed to obtain a DNR order and complete a care plan for Resident #46 after the completion of the Texas OOHDNR dated [DATE]. This deficient practice could affect any resident who requested a DNR code status and could result in staff providing CPR for a resident who did not wish to be resuscitated. The findings were: Record review of Resident #46's face sheet, dated [DATE], revealed she was admitted on [DATE] wit diagnoses which included: hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right non-dominant side, nontraumatic acute subdural hemorrhage, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure that all allegations involving abuse, neglect, and misappropriation were reported immediately, but no later than 2 hours after the allegation was made to the State Survey Agency for 1 of 8 residents (Resident #2) reviewed for abuse and neglect. The facility did not report to the State Survey Agency (HHSC) an incident in which Resident #2 alleged that CNA J told her that her butt was too big. This failure could place residents at risk for abuse/neglect and could lead to a diminished quality of life and psychosocial harm. The findings included: Record review of Resident #2's Face Sheet, dated 2/12/2025, reflected a [AGE] year-old female resident with an initial admission date of 01/29/2018, with diagnoses including Multiple Sclerosis (A disease in which the immune system eats away at the protective covering of nerves), and major depressive disorder. Record review of Resident #2's Quarterly MDS Assessment, dated 11/27/2024, reflected the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure that all allegations involving abuse, neglect, and misappropriation were investigated for 1 of 8 residents (Resident #2) reviewed for abuse and neglect. The facility did not report to the State Survey Agency (HHSC) an incident in which Resident #2 alleged that CNA J told her that her behind was too large. This failure could place residents at risk for abuse/neglect and could lead to a diminished quality of life and psychosocial harm. The findings included: Record review of Resident #2's Face Sheet, dated 2/12/2025, reflected a [AGE] year-old female resident with an initial admission date of 01/29/2018, with diagnoses including Multiple Sclerosis (A disease in which the immune system eats away at the protective covering of nerves), and major depressive disorder. Record review of Resident #2's Quarterly MDS Assessment, dated 11/27/2024, reflected the resident had a BIMS of 14, reflecting the resident had intact cognition. 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 interview and record review, the facility failed to conduct an accurate comprehensive assessment of each resident's functional capacity including the resident's needs, strengths, goals, life history and preferences for 1 of 8 Residents (Resident #44) reviewed for assessments. Resident #44's Quarterly MDS Assessment did not reflect his diagnosis of depression. This failure could place residents at risk for not receiving the care and services as needed. The findings included: Record review of Resident #44's face sheet, dated 02/12/2025, reflected a [AGE] year-old male resident admitted on [DATE] with diagnosis of type 2 diabetes mellitus, and anxiety disorder. Depression was not listed as a diagnosis on Resident #44's face sheet. Record review of Resident #44's Quarterly MDS assessment dated [DATE], reflected under Section I - Active Diagnosis, subsection Psychiatric/Mood Disorder reflected that Resident #44 only had anxiety disorder and did not include depression. Record review of Resident #44's Care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs that are identified in the comprehensive assessment, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 8 residents (Resident #8 and #46) reviewed for care plans. 1. The facility failed to ensure Resident #46's care plan reflected that the resident was a DNR. 2. Resident #8 was prescribed a thoracic-lumbar-sacral orthoses (TLSO) back brace, to be worn daily and it was not reflected in the care plan. This deficient practice places residents at risk for not receiving proper care and services due to inaccurate care plans. The findings were: 1 Record review of Resident #46's face sheet, dated [DATE], revealed she was admitted on [DATE] with diagnoses which included: hemiplegia and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure residents were free from significant medication errors for 2 of 8 residents (Residents #2, and #6) reviewed for significant medication errors. 1. On 2/10/2025 at 1:37 PM, LVN O administered Resident #2's Baclofen late by 32 minutes. 2. On 2/10/2025 LVN O administered Resident #6's: a. Hydrocodone at 12:10 PM; late by 3 hours and 10 minutes. b. Cipro at 12:10 PM; late by 2 hours and 10 minutes. c. Hydrocodone at 2:10 PM; late by 1 hour and 25 minutes These deficient practices placed residents at risk for not receiving the therapeutic effects of their prescribed medications. The findings included: A record review of Resident #2's admission record revealed 9/22/2023 with diagnoses which included multiple sclerosis (a disease that causes breakdown of the protective covering of nerves. Multiple sclerosis can cause numbness, weakness, trouble walking, vision changes and other symptoms. It's also known as MS), stiffness of right, left…

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 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, which must include, at a minimum, standard and transmission-based precautions to be followed to prevent spread of infections, for 1 of 2 residents reviewed (Residents #23) for infection control and prevention. On 2/12/2025, CNA L provided catheter care for Resident #23 without donning Enhanced Barrier Precautions Personal Protection Equipment (EBP PPE). This failure could place residents at risk for harm by cross-contamination. The findings included: A record review of Resident #23's admission record dated 2/12/2025 revealed an admission date of 2/4/2024 with diagnoses which included benign prostatic hyperplasia with lower urinary tract symptoms (non-cancer tumors of the urinary tract), retention of urine, and obstructive and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that include measurable objectives and time frames to meet residents' mental, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and to ensure that the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including the right to refuse treatment for 16 of 26 residents (Residents #11-#26) reviewed for care plans, in that. Resident #11 through Resident #26 were at high risk for elopement after completing their respective Elopement Risk Assessment and their care plans were not updated to reflect this finding per facility policy and interviews. This failure could affect residents who have care areas not addressed by the care plans by not having their needs met and putting them at risk of not receiving…

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 that all alleged violations involving abuse, neglect, exploitation, or mistreatment, were reported immediately, but not later than 2 hours after the allegation was made for 2 (Resident #1 and #2) of 26 residents reviewed for reporting of alleged violations, in that: The facility failed to report to the state agency: 1. an elopement incident regarding Resident #1, after he had taken a car that did not belong to him from the nursing home parking lot and drove to a town over 60 miles away . 2. an incident involving a missing resident (Resident #2). This failure could place facility residents at risk of harm due to delays in reporting allegations of abuse and neglect. Findings included: 1. Record review of Resident #1's admission record, dated 01/15/25, reflected a [AGE] year-old male with admission date 08/31/24 and discharge date [DATE]. It reflected Resident #1 had diagnoses to include alcohol abuse with intoxication delirium (a mental state in…

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 resident environment remained as free of accident hazards as is possible; and each resident received assistance devices to prevent accidents for 1 of 3 Residents (Resident #1) whose records were reviewed for falls. Nursing staff failed to ensure both brakes on Resident #1's wheelchair were locked while not in use and that Resident #1's call light was in place per Resident #1's Care Plan. These deficient practices could affect any resident at risk for falls and could contribute to a decline in resident's physical health. The findings were: Review of Resident #1's face sheet, undated, revealed she was admitted to the facility on [DATE] with diagnoses including unspecified Dementia, unspecified abnormalities of gait and mobility, unspecified lack of coordination and cognitive communication deficit. Review of Resident #1's MDS assessment, dated 6/12/24, revealed her BIMS was 5 of 15 reflecting severe cognitive impairment; she…

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 resident could receive care and services safely and that the physical layout of the facility maximizes resident independence and did not pose a safety risk and received housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 3 of 48 residents (Resident #29, #58, and #36) and 1 of 1 facility's reviewed for a safe, clean, homelike environment, in that: 1.The facility failed to maintain Resident #36's room, a Resident with legal blindness, in a safe, clean, well - lit and, homelike environment. 2.The facility failed to ensure the 100 / 200-hall shower room had a functioning heater. 3. The facility failed to appropriately store an oxygen cylinder which was covered with towels in Resident 58's room. 4. The facility failed to ensure Resident #58's room fan was free from dust for Resident #58, who had chronic obstructive pulmonary disease [a group of diseases that cause airflow…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 24 residents (Resident #21) reviewed for comprehensive care plans, in that: Resident #21's care plan did not address that the resident was at the high risk for falls. This deficient practice could result in a loss of quality of life due to residents receiving improper care. The findings were: Record review of Resident #21's admission record, dated 1/12/24, revealed an admission date of 11/11/23 with diagnoses which included fracture of .part of neck of left femur (thigh bone), lack of coordination, cognitive communication deficit, dementia (the loss of cognitive functioning that interferes with daily life and activities), muscle weakness, osteoporosis (bone strength weakens and is susceptible to fracture), arthritis (swelling and tenderness of one or more joints), and abnormalities with gait and mobility. Record review of Resident #21's MDS admission assessment, dated 11/14/23,…

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

Based on observation, interview and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary 1 of 24 residents (Resident #16), reviewed for care plan revisions, in that: Resident #16 had healed pressure areas that were not being marked as resolved in her care plans. These failures could place residents at risk for lack of coordination of services. These findings were: Record review of Resident #16's admission Record, dated 01/13/24, revealed an admission date of 12/06/23 with diagnoses which included fracture of right lower leg and unspecified fall. Record review of Resident #16's MDS comprehensive assessment, dated 12/11/23, revealed Resident #16 had a BIMS score of 15/15, which indicated intact cognition. It also revealed that Resident #16 was at risk for developing pressure ulcers/injuries. Resident #16 had no unhealed pressure ulcers/injuries. Record review of Resident #16's care plan revealed Resident #16 had the following, initiated and revised 01/08/24: Problem: The resident has pressure injuries: DTI 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 observation, interview and record review the facility failed to ensure its medication error rates were not 5% or greater. The facility had a medication error rate of 12%, based on three errors out of 25 opportunities which involved 3 of 6 residents (Resident #53, #63, and #70) observed during medication administration reviewed for medication errors . 1. LVN J failed to administer Resident #53's 8:00 AM scheduled dose of intravenous (in the vein) cefazolin (an antibiotic - works by killing bacteria or preventing their growth). 2. Medication Aide CC failed to administer Resident #70's 7:00 AM metformin (a diabetes control medication) timely, according to physician orders and instead administered the medication at 9:10 AM. 3. Medication Aide CC failed to administer Resident #63's 7:00 AM omeprazole (a medication which decreases the amount of acid produced by the stomach) timely, according to physician orders and instead administered the medication at 9:00 AM. These deficient practices could place 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure Residents are free of any significant medication errors, for 5 of 24 residents (Residents #7, #27, #43, #52 and #225) reviewed for significant medication errors, in that: 1. Medication Aide DD administered late medications to: a. Resident #7 was ordered Acetaminophen 325mg [pain reliever] and duloxetine 60mg [an antidepressant] to be administered twice a day with the first dose administered at 09:00 AM and was administered at 10:35 AM. b. Resident #27 was ordered pilocarpine ophthalmic solution [eye drops] and dorzolamide - timolol ophthalmic solution [eye drops] for glaucoma [a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of your eye called the optic nerve] twice a day, anytime from 06:00 AM to 10:00 AM with the first dose administered at 11:05 AM. c. Resident #43 was ordered sacubitril - valsartan 24mg-26mg [used to treat patients whose heart cannot pump a normal amount of blood…

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 store and label Drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date, for 1 of 4 medication carts, reviewed for insulin injection pens. The facility failed to label Resident #15's insulin injection pen with the dates to identify when the insulin injection pen was taken out of refrigeration storage and the date to indicate when the insulin injection pen should be discarded. This failure could place residents at risk for harm by receiving ineffective insulin therapy. The findings included: A record review of Resident #15's admission record dated 01/12/2024 revealed an admission date of 02/24/2022 with diagnoses which included type 1 diabetes [a chronic condition in which the pancreas produces little or no insulin]. A record review of Resident #15's quarterly MDS assessment dated [DATE] revealed…

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 for 1 of 1 kitchen, reviewed for kitchen sanitation, in that: The facility failed to ensure that sanitizing buckets were not near containers of food. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: During an observation, during the initial kitchen tour, on 01/09/24 starting at 09:38 AM, revealed there was 1 sanitizing bucket next to a tray of several plastic wrapped, clear plastic bowls of dry cereal, prepared 12/03/23. The exact number of bowls of dry cereal was unknown. The FNS director instructed FNS Dietary Aide Z to throw the dry cereal away because they were near the sanitizing bucket. During an interview on 01/11/24 at 09:03 AM, the FNS Director revealed that FNS Dietary Aide Z was sanitizing a cart after food service. The sanitizing bucket was being used by FNS Dietary Aide Z and she placed it on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside, for 3 of 70 Residents (Resident #1 #41 and Resident #226) reviewed for the ability to call for staff, in that: The facility failed to provide Residents #1, #41 and #226 functioning nurse call light systems. This failure could place residents at risk for injury and diminished self-esteem, due to the inability to call for assistance. The findings included: 1. Record review of Resident #1's face sheet, dated 1/13/24, revealed the [AGE] year old resident was admitted to the facility on [DATE] with diagnoses including: Alzheimer's disease late onset (a common form of dementia that begins after age [AGE] with progressive memory loss), type 2 diabetes (a chronic condition that affects the way the body processes blood sugar), and…

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

Based on interview and record review the facility failed to immediately consult with the resident's physician and notify, consistent with his or her authority, the resident representative when there was an accident, and it had the potential for requiring physician intervention for 1 of 24 Residents (Resident #21) whose records were reviewed for accidents, in that: LVN D failed to notify Resident #21's physician when the resident had a fall on 11/21/23. This failure could contribute to residents not receiving the medical care and treatment needed and a decline in physical condition. The findings were: Record review of Resident #21's Face Sheet, dated 1/12/24, revealed an admission date of 11/11/23 with diagnoses which included fracture of .part of neck of left femur (thigh bone), lack of coordination, cognitive communication deficit, dementia (the loss of cognitive functioning that interferes with daily life and activities), muscle weakness, osteoporosis (bone strength weakens and is susceptible to fracture), arthritis (swelling and tenderness of one or more joints), and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure residents' rights to voice grievances to the facility or other agencies or entities that heard grievances without discrimination or reprisal and without fear of discrimination or reprisal for 1 of 24 residents (Resident #22) reviewed for grievances, in that; 1. The facility failed to ensure CNA X, LVN J, and ADON E initiated a grievance report on behalf of Resident #22 when the Resident reported a grievance to CNA X. This failure could place residents at risk by denying their right to make and have grievances heard and contributed to feelings of not being heard and unresolved issues. The findings included: A record review of Resident #22's admission record dated 01/12/2024 revealed an admission date of 09/21/2023 with diagnoses which included a non-ruptured cerebral aneurysm [a ballooning arising from a weakened area in the wall of a blood vessel in the brain]. A record review of Resident #22's quarterly MDS assessment, 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 interviews and record reviews the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not 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 not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials, including to the State Survey Agency, for 1 of 24 residents (Resident #21) reviewed for abuse and neglect, in that: LVN D did not report Resident #21's fall immediately to the DON and the Administrator. The Administrator, DON, and LVN D did not report Resident #21's fall with a fracture to the state agency. This deficiency could have placed resident at risk for harm by abuse, neglect, and or mistreatment. The findings included: Record review of Resident #21's Face Sheet, dated 1/12/24, revealed 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 observations, interviews, and record reviews the facility failed to ensure residents received care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers for 1 of 24 residents (Resident #8) reviewed for prevention of pressure ulcers, in that: The facility failed to follow physicians' orders for Resident #8's ordered pressure ulcer preventions. This failure could place residents at risk for pressure ulcer development. The findings included: A record review of Resident #8's admission record dated 01/11/2024 revealed an admission date of 09/06/2021 with diagnoses which included Alzheimer's disease [a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment]. A record review of Resident #8's quarterly MDS assessment dated [DATE] revealed Resident #8 was an 86-yr-old female admitted for long term care and assessed with a BIMS score of 0 out of 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 ensure that a resident who needed respiratory care was provided with such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 24 residents (Resident #58) reviewed for respiratory care, in that: The facility failed to ensure Resident #58's oxygen tank was stored and handled properly. This deficient practice could place residents at risk for danger, including decline in health. The findings included: A record review of Resident #58's admission record dated 01/10/2024, revealed an admission date of 12/13/2023 with diagnoses which included acute respiratory failure with hypoxia [serious condition that causes fluid to build up in your lungs with low level of oxygen in your blood], asthma [condition in which your airways narrow and swell and may produce extra mucus, which can make breathing difficulty and trigger coughing], obstructive sleep apnea…

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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure standard and transmission-based precautions were followed to prevent the spread of infections to include hand hygiene procedures were followed by staff involved in direct resident contact, for 2 of 24 residents (Residents #53 and #38) reviewed for infection control, in that: 1. LVN J did not perform hand hygiene in between, dirty to clean and in between glove changes while preparing and administering Resident #53's intravenous antibiotic medication. 2. CNA GG did not perform hand hygiene in between glove changes while performing suprapubic catheter care for Resident #38. These failures could place residents at risk for contracting and spreading infectious diseases. The findings…

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.