Avir at Fredericksburg

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 1 of 16 residents (Residents #29) reviewed for care plans. The facility failed to develop care plan interventions to include Resident #29 needing a therapeutic hold for medication administration. This failure could place residents at risk of not receiving care and services related to their identified needs to maintain or reach their highest practicable physical, mental and psychosocial well-being. The findings include: Record review of Resident #29's admission record revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #29's had diagnoses which included schizophrenia (mental health condition that affects how people think, feel,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible, for 1 of 8 residents (Resident #18) reviewed for urinary catheters. 1. The facility failed to ensure Resident #5 received appropriate care and treatment for the indwelling catheter device placed after admission. 2. The facility failed to ensure Resident #5's foley catheter was secured appropriately. This failure could lead to infection or injury. Record review of Resident #5's facesheet, printed 6/17/2025, revealed a [AGE] year-old male, originally admitted to the facility on [DATE]. Resident #5 diagnoses included benign prostatic hyperplasic without lower urinary tract symptoms (enlargement of the prostate gland that can cause difficulty or the inability to urinate). Record review of the quarterly MDS, submitted 5/21/2025, revealed a BIMS score of 9, which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that licensed nurses had the specific competencies and skill sets necessary to care for resident's needs, as identified through resident assessments, and described in the plan of care for all nursing staff in 1 of 1 facilities where therapeutic holds were used. The facility failed to ensure nursing staff were trained to therapeutically hold Resident #29 for medication administration. This failure could place residents at risk for harm due to staff who lack the appropriate skills and competencies to provide and minimize infections. The findings include: Record review of Resident #29's admission record reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #29 had diagnoses which included schizophrenia (mental health condition that affects how people think, feel, and behave), anxiety disorder, psychosis (state of impaired reality), and restlessness and agitation. Record review of Resident #29's admission MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to have drugs and biologicals used in the facility labeled in accordance with currently accepted professional principles and the expiration date when applicable for 1 of 2 medication carts (200-300 halls cart) reviewed for medication storage. The facility failed to label the expiration dates of opened/unrefrigerated insulin stored in the medication cart for Resident #2. This failure could lead to ineffective insulin therapy, hyperglycemia, and illness. Findings included: Record review of Resident #2's facesheet, printed [DATE], revealed a [AGE] year-old female, originally admitted to the facility on [DATE] with a relevant diagnosis of type 2 diabetes mellitus with hyperglycemia (the body's inability to self-regulate blood sugar leading to elevated levels). Review of the quarterly MDS, submitted [DATE], revealed a BIMS score of 8, indicating moderately impaired cognition. Record review of Resident #2's EMR contained the following…

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 residents had the right to be informed of, and participate in, their treatments, for 1 of 8 residents (Resident #29) reviewed for antipsychotic medication administration. Resident #29's June MAR did not reflect that RisperDAL Consta Intramuscular Suspension Reconstituted ER 50 MG was given on 06/04/25 and 06/17/25. The deficient practices could place residents at risk for side effects for which they did not consent. The findings included: Record review of Resident #29's admission record revealed Resident #29 was a [AGE] year-old female admitted on [DATE] with diagnoses to include schizophrenia (mental health condition that affects how people think, feel, and behave), anxiety disorder, psychosis (state of impaired reality), and restlessness and agitation. Record review of Resident #29's admission MDS assessment, dated 05/20/25, reflected Resident #29 had a BIMS score of 0 out of 15, indicating severe cognitive impairment. It further reflected…

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 has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility for 3 (Residents #11, #15, and #18) of 20 residents reviewed for dignity. 1. Resident #11's wheelchair on 05/14/2024 at 10:00 a.m. had the left armrest vinyl torn and sharp and appeared worn and damaged. 2. Resident #15's wheelchair on 05/14/2024 at 10:12 a.m., had both armrests vinyl torn and worn on the edges. 3. Resident #18's wheelchair on 05/14/2024 at 10:15 a.m. had both armrests vinyl torn and worn. The left side armrest was missing vinyl and foam and the baseboard was exposed. These deficient practices affect residents who rely on facility equipment for mobilization and could result in loss of self-esteem, dignity, and increased lack of self-worth. The findings included: 1. Record review of Resident #11's electronic face sheet dated 05/14/2024 reflected he was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment, for 7 of 20 residents (Residents #11, #15, #16, #19, #21, #22, and #29) reviewed for care plans. 1. The facility failed to ensure Resident #11's incontinence was reflected in his care plan. 2. The facility failed to ensure Resident #15's pacemaker information was in his care plan. 3. The facility failed to ensure Resident #16's bowel incontinence was reflected in her care plan. 4. The facility failed to ensure Resident #19's did not have a care plan for handrails in bed. 5. The facility failed to ensure Resident #21's diagnoses, compression stockings, and diuretic were reflected in her care plan. 6. The facility failed to ensure Resident #22'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 interviews and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 2 (residents #21, and #22) of 20 residents reviewed for care plans. 1. Resident #21's comprehensive person-centered care plan was not revised after her quarterly MDS assessment with an ARD of 03/17/24 to reflect she had taken antianxiety medication. 2. Resident #22's comprehensive person-centered care plan was not revised or updated based on the facility policy to not use chair and bed alarms for prevention of fall, but the care plan reflected continually using chair and bed alarms. These deficient practices affect residents who receive assessments and could result in an inaccurate comprehensive person-centered care plan and missed care. The findings included: 1. Record review of Resident #21's electronic face sheet dated 05/14/2024 reflected she was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable, physical, mental, and psychosocial well-being for 4 (Residents #6, #16, #26, and #134) of 20 residents reviewed for competent nursing care. 1. CNA G failed to spread and cleaned within Resident #6's labial folds after an incontinent episode. 2. CNA A applied barrier cream to Resident #16's open wounds. CNA A reapplied Resident #16's wound dressing that had fallen off into the soiled brief. 3. LVN D failed to follow facility procedure when she instilled eye drops for Residents #26. 4. LVN C crushed medications for Resident #134, that were noted to be Do Not Crush. These deficient practices affect residents who depend on nursing care and could place residents at risk for injury, infection, and harm. The findings included: 1. 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 observations, interviews and record review the facility failed to ensure Menus and nutritional adequacy. Menus must Meet the nutritional needs of residents in accordance with established national guidelines.; Be prepared in advance; Be followed for 1 of 1 kitchen, in that: 1. Food items were not in the kitchen, pasteurized eggs or shelled eggs, bananas, bread and onions. Resident #29 and #17 preferred fried eggs. Resident group stated they would prefer fried eggs (#17, #24, #13) and Resident #18 preferred hard-boiled eggs for chef salad . 2. Kitchen cook J served residents for breakfast 1 slice of bacon, instead to two slices. Resident #2, #4, #13, #24, #29 had 1 slice of bacon for breakfast. 3. The facility failed to post of the weekly at a glance menu. This could affect all residents that eat in the dining area and could result in residents not aware of what will be on menu for the week. This could affect all residents that eat from the kitchen and place them at risk of improper food handling. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review the facility failed to ensure each resident receives and the facility provides-Food that accommodates resident preferences for 5 of 16 (#13, #17, #18, #24 and #29) reviewed for preferences, in that: Residents #13, #17, #18, #24 and #29 were not served their preferences. No documentation of dietary assessment with preferences. This could affect all residents with food preferences and could result in a decrease in resident choices and diminished interest in meals. The Findings were: Interview on 5/14/2024 at 1:35 PM in a group meeting, Resident #13, #17, #24 and #29 stated they preferred fried eggs and Resident #18 preferred hard-boiled eggs for his chef salad. 1. Record review of Resident #13's face sheet dated 5/16/2024 reflected she was admitted on [DATE], re-admitted on [DATE] she was [AGE] years old. Resident #13 Quarterly MDS dated [DATE] reflected she had a BIMS score of 9/15 (moderate cognitive impairment). Record review of Resident #13's food preference assessment…

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

Based on observation, interview, and record review, the facility failed to ensure there were no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack was served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal spa: the failure to ensure residents were made aware of how to obtain a snack when desired for 4 of 9 residents (confidential residents in group) reviewed for frequency of meals. The facility failed to ensure residents were offered snacks at bedtimes as required due to mealtimes being more than 14 hours apart. This failure could affect all residents who received meals served from the facility's only kitchen by placing residents at risk for, unplanned weight loss, and side effects from medication given without food, and diminished quality of life. Findings included: Record review of the resident snack list, no date was provided by the DM. There were 27 residents that received morning and afternoon snacks. There was no…

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

Based on observation, interview, and the facility failed to ensure garbage was disposed of properly for 1 of 1 facility, in that: The area near the facility's two dumpsters was on dirt and not concrete slab . This deficient practice could lead to an unsanitary environment and encourage the presence of pests. The findings were: Observation on 5/13/2024 at 10:02 AM., of the area near the facility's 2 dumpsters reflected there were on dirt and not concrete slab. Observation of a concrete slab big enough for 1 dumpster near the 2 dumpsters. Interview on 5/14/2024 at 10:03 AM with the DM stated the 2 dumpsters had been moved to a dirt ground due to only had room for 1 dumpster on a concrete slab. DM was not sure how long the 2 dumpsters were moved to the dirt. Interview on 5/16/2024 at 5:33 PM with ADM stated she was not aware of the 2 dumpsters in dirt, instead of a concrete slab. ADM stated no policy on dumpsters that required to be on concrete slab. Record review of FDZ Food code, 5-5 Refuse, Recyles, and Returnables section- 5-501.11 Outdoor Storage Surface. An outdoor storage…

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 control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 3 (#16, #29 and #134) of 20 residents reviewed for infection control, in that:. 1. CNA A, and CNA E failed to follow EBP signage instructions for Resident #16 by not sanitizing hands prior to entering or reentering Resident #16's room, and CNA #16 put the dirty dressing back onto Resident #16's buttock wound after the dressing fell onto the dirty brief during incontinent care. RN F performed a dressing change for Resident #16 without wearing a gown. 2. The facility failed to have signage on Resident #29's room door to indicate he was on EBP. 3. Resident #134's nebulizer mask and oxygen tubing with nasal cannula was left unbagged when not in use. These deficient practices could affect residents and place them at risk for cross contamination…

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 maintenance of mechanical, electrical, and patient care equipment in safe operating condition for 3 (Residents #11, #15 and #18) of 20 residents reviewed for safe environment, in that:. 1. Resident #11's wheelchair on 05/14/2024 at 10:00 a.m. had the left armrest vinyl torn and sharp and appeared worn and damaged. 2. Resident #15's wheelchair on 05/14/2024 at 10:12 a.m., had both armrests vinyl torn and worn on the edges. 3. Resident #18's wheelchair on 05/14/2024 at 10:15 a.m. had both armrests vinyl torn and worn. The left side armrest was missing vinyl and foam and the baseboard was exposed. These deficient practices could affect residents who rely on facility equipment for mobilization and could result in skin tears or injuries. The findings included: 1. Record review of Resident #11's electronic face sheet dated (05/14/2024) reflected he was admitted to the facility on [DATE]. His diagnoses included: abnormalities 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 interviews and record review, the facility assessments failed to accurately reflect the resident's status for 2 (Resident #14 and #21) of 20 residents reviewed for assessments. 1. Resident #14's significant change MDS assessment with an ARD of 02/08/2024 inaccurately reflected the resident had significant weight loss, but she did not have significant weight loss. 2. Resident #21's quarterly MDS assessment with an ARD of 03/17/24 did not reflect she had a fall, and inaccurately reflected she was taking an antidepressant and diuretic. These deficient practices affect residents at the facility who require assistance with services and ADL's and could result in missed or inaccurate care. The findings were: 1. Record review of Resident # 14's electronic face sheet dated 05/17/2024 reflected she was admitted to the facility on [DATE]. The resident's diagnoses included: hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting left dominant side (paralysis of partial body function 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 interviews and record review the facility failed to ensure that when the facility anticipated discharge, a resident must have a discharge summary that included, but was not limited to, the following: A recapitulation of the resident's stay that included, but was not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results for 1 of 3 (#31) closed records. Resident #31's discharge summary was not signed by a physician. This could affect all discharge residents and could result in record errors. The Findings were: Record review of Resident #31's face sheet dated 5/17/2024 revealed she was admitted on [DATE] and discharged on 2/27/2024. Record review of Resident #31's discharge MDS dated [DATE] reflected this was a planned discharge, to home/community and she was cognitively intact. Record review of Resident #31's Discharge summary dated [DATE] revealed Resident #31 went home with home health and no physician signature or date. 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 observations, interviews, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident choices for 1 (Resident #16) of 20 residents observed for quality of care. The facility failed to obtain an order for barrier cream to be applied to Resident #16's buttocks and peri area after incontinent care. The findings included: Record review of Resident #16's electronic face sheet dated 05/15/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: Alzheimer's disease (progressive mental deterioration that can occur in middle or old age, due to general deterioration of brain), age related osteoporosis (deterioration in bone mass, increasing risk for fracture), contracture (condition of shortening and hardening of muscles, tendons, or other tissues, often leading to deformity and rigidity of joints) of right and left shoulder, and psychosis…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 3 resident (Resident #6) reviewed for incontinent care. CNA G failed to spread and clean within Resident #6's labial folds after an incontinent episode. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices. The findings were: Record review of Resident # 6's electronic face sheet dated 05/17/2024 reflected she was admitted to the facility on [DATE]. The resident's diagnoses included: cerebral infarction (damage to tissues on the brain due to a loss of oxygen to the area), dementia (loss of memory, language, problem-solving, and other thinking abilities that were severe), hypothyroidism (thyroid gland does not make enough thyroid hormone), neuropathy (weakness, numbness, and pain form nerve damage), and glaucomatous flecks (disease 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 ensure its medication error rates were not 5% or greater. The facility had a medication error rate of 11.54%, based on 3 errors out of 26 opportunities which involved 1 of 6 residents (Resident #134) reviewed for medication administration and medication errors. LVN C crushed 3 medications, 2 capsules and 1 tablet that were on the Do Not Crush list during medication pass for Resident #134. This deficient practice places residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. The findings included: Record review of Resident #134's electronic face sheet dated 05/15/2024 reflected he was admitted to the facility on [DATE]. His diagnoses included: encephalopathy (a group of conditions that cause brain dysfunction), chronic obstructive pulmonary disease (a common lung disease causing restricted airflow and breathing problems), poisoning by cardiac-stimulant glycosides and drugs of similar…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure 1 out of 6 residents (Resident #134) were free of any significant medication errors whenobserved for medication pass. LVN C crushed 3 medications for Resident #134 that had Do Not Crush labeled on them during medication administration pass. This deficient practice affects residents with medications that are not recommended to be crushed and could result in physical harm or distress. The findings included: Record review of Resident #134's electronic face sheet dated 05/15/2024 reflected he was admitted to the facility on [DATE]. His diagnoses included: encephalopathy, chronic obstructive pulmonary disease, poisoning by cardiac-stimulant glycosides and drugs of similar action, congestive heart failure and cognitive communication deficit. Resident #134 was not at the facility long enough for an MDS assessment. Record review of Resident #134's baseline care plan dated 05/13/2024 reflected Resident admitted for skilled 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.

Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care, and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required for 1 of 1 facility, in that: The Dietary Manager (DM) did not have the appropriate certification, education, or qualifications to serve as the Director of Food and Nutrition Services. This deficient practice could place the residents who consume food prepared from the kitchen at risk of food borne illness and not receiving adequate nutrition. The findings included: Observation on 5/14/2024 at 9:50 AM in the kitchen with the DM revealed no pasteurized eggs or shelled eggs in refrigerator. Interview on 5/14/2024 at 3:55 PM the Dietary Manager (DM) stated he was not certified, and he was not trained as a kitchen manger. The DM stated he used to be a dietary aide and was promoted. (not sure of 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 ensure Food prepared in a form designed to meet individual needs for 1 of 8 (#2) residents, in that: Resident #2 was served a puree meat, instead of mechanical soft. This could affect all resident with diet orders that were prescribed by a physician and could result in residents not served the correct diet texture. The Findings were: Record review of Resident #2's face sheet dated 5/16/2024 reflected she was admitted on [DATE], age was 71. Her diagnoses included polyneuropathy (the simultaneous malfunction of many peripheral nerves throughout the body) in disease, muscle weakness, dysphagia (difficulty or discomfort in swallowing, as a symptom of disease.), feeding difficulties, cognitive communications deficit. Record review of Resident #2's consolidated physician orders for May 2024 reflected her diet, regular mechanical soft, ground meat and pureed fruits and vegetables, diagnoses Dysphagia. Record review of Resident #2's quarterly…

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 maintain an infection prevention and control program designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 (Resident #1) whose records were reviewed for infections. The facility failed to follow protocols when Resident #1 was diagnosed with Salmonella: a. There was not a physician's order or a sign on Resident #1's room to inform nursing staff and others he was on contact precautions for an infection. b. The ADM and DON did not contact the local state authority or HHSC to report Resident #1 was diagnosed with Salmonella. These deficient practices could affect any resident and contribute to the spread of infections. The findings were: Review of Resident #1's face sheet, dated 3/7/24, revealed he was admitted to the facility on [DATE] with diagnoses including Atrial Fibrillation (an irregular and often very rapid heart rhythm.) and Hyperlipidemia (elevated lipid…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs for 4 of 8 residents (Resident #2, #32, #28, and #7) reviewed for care plans in that: Residents #32 and #7 did not have a comprehensive person-centered care plan in their resident file. Residents #2 and #28 did not have a comprehensive care plan that met a resident's medical needs. These failures could place residents at risk of receiving inadequate interventions not individualized to their care needs. The findings were: - Record review of Resident #32's face sheet dated 3/23/23, revealed an [AGE] year-old female admitted on [DATE] with diagnosis that include malignant neoplasm of brain (a fast-growing tumor in the brain), gastro-esophageal reflux disease (a condition where acidic gastric fluid flows backward into the esophagus), and depression. -…

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 (RN) to serve as DON on a full-time basis in that: - The facility had no full time Director of Nurses (DON) from October of 2022 through present [3/22/23]. This failure could place all residents at risk for not receiving necessary care and services. The findings included: Record review of facility policy on Director of Nursing Services revealed that the Director is employed full-time at 40-hours per week. In an interview on 3/21/23 at 11:28 AM, the ADON stated there was no DON at the facility, and she believed the regional DON was the acting DON. In an interview on 3/21/23 at 3:20 PM, the Administrator stated the facility had no full time DON and the corporate regional RN's assisted with nursing services. In an interview on 3/24/23 at 1:10 PM the Regional DON stated the facility had no full-time designated DON. The regional DON stated she was not in the facility for 40 hours a week and occasionally was in the facility.

Based on interviews and record review, the facility failed to employ or contract with a qualified social worker for a facility of 120 beds or less for 1 of 1 facility in that: The facility failed to ensure an employed or contracted social worker visited the facility as needed. This failure could place all residents at risk for not receiving necessary social services. The findings included: In an interview on 3/21/23 at 11:28 AM, the ADON stated that the facility did not have a social worker employed, and she was not aware of a contracted social worker. In an interview on 3/21/23 at 3:20 PM, the Administrator stated the facility did not have a social worker employed or contracted to come to the facility. The administrator stated they do not have a specific policy on social workers or social services, and the facility follows federal and state regulations as policy. In an interview on 3/24/23 at 1:10 PM, the regional DON stated that the facility did not employ or contract a social worker on a full-time or part-time basis. The regional DON stated the facility follows the federal 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 observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: The facility failed to ensure proper food storage of dry goods and fresh produce. This failure could place all residents who consume food prepared from the kitchen at increased risk of food borne illness. The findings included: Observation on 3/21/23 at 11:09 AM revealed a 10-pound box labeled imitation bacon bits open, undated, in a dry storage area in the kitchen. Upon further investigation, box appeared open with bag full of red flakes approximately 3 cm in diameter, and the bag is open. Observation on 3/22/23 at 9:11 AM revealed a box labeled Idaho potatoes unlabeled and on the floor of a dry storage area in the kitchen. Fresh produce resembling potatoes observed through holes in box. In an interview on 3/25/23 at 10:20 AM, the FSM stated that boxes should be dated with either markers or stickers. She stated that the items in the box labeled imitation bacon bits should…

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 reviews and interviews the facility failed to develop, implement, and maintain an effective training program for all new and existing staff; individuals providing services under a contractual arrangement; and volunteers, consistent with their expected roles, for 1 of 1 Activities Director Care Plan Coordinator, reviewed for training as the care plan coordinator, in that: The facility failed to train the Activities Director in the assigned job as the care plan coordinator. This failure could place residents at risk for harm by not having a complete and accurate care plan to support the residents needs and preferences. The finding included: A record review of Resident #2's Face Sheet, dated 03/22/2023, revealed an admission date of 02/27/2023, with diagnoses which included pneumonia due to inhalation of food and vomit [an infection of the lungs can be life-threatening to anyone, but particularly to infants, children, and people over 65], reduced mobility and the need for assistance with personal…

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, including injuries of unknown source are reported immediately, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures, for 1 of 24 Residents (Resident #13) reviewed for injuries of unknown origin, in that: The facility failed to report an injury of unknown origin to the state agency when Resident #13 was discovered with a large bruise over her chest and around her back . Resident #13 could not state how she developed the bruise, and no one witnessed the development of the bruise. This failure could place residents at risk for harm by not reporting, not investigating and providing for oversight of the investigation to reveal the possible source of the injury.…

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's assessment accurately reflected the resident's status, for 1 of 24 residents (Resident #2) reviewed for lack of assessment for dentures, in that: 1. Resident #2 was admitted and assessed without documenting her need for dentures after a hospitalization where Resident #2 was treated for having swallowed her dentures. This failure could have placed residents at risk for harm by unidentified dentures and lack of care and support for the dentures. The findings included: A record review of Resident #2's Face Sheet, dated 03/22/2023, revealed an admission date of 11/22/2022 and 02/27/2023, with diagnoses which included pneumonia due to inhalation of food and vomit [an infection of the lungs can be life-threatening to anyone, but particularly to infants, children, and people over 65], reduced mobility and the need for assistance with personal care. A record review of Resident #2's hospital discharge records, 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 employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnosis of the facility's resident population in accordance with the facility assessment requirement, for 1 of 1 kitchen staff (Food Service Manager) reviewed for qualifications, in that: - The Dietary Manager did not have the appropriate license, certification, or qualifications to function as the food service supervisor. This failure could place all residents who consume food prepared from the kitchen at increased risk of food borne illness and not receiving adequate nutrition. The findings included: Record review of the certifications obtained by facility kitchen staff revealed that the FSM did not have the certification required for her current position. In an interview on 3/25/23 at 10:20 AM, the FSM revealed she does not have the certification required for her current…

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 medical records on each resident that are complete; accurately documented; readily accessible; and systematically organized, for 1 of 24 residents (Resident #30) reviewed for accurate medical records, in that: LVN A failed to document an order for a urinalysis laboratory test ordered for Resident #30. This failure could place residents at risk for harm by inaccurate records. The findings included: A record review of Resident #30's Face Sheet, dated 03/22/2023, revealed an admission date of 01/06/2022, with diagnosis which included obstructive and reflux uropathy [a condition when the passage of urine from the kidneys to the exterior is blocked by an obstruction anywhere along the urinary tract]. A record review of Resident #30's quarterly MDS, dated [DATE], revealed Resident #30 was an [AGE] year-old female assessed with severe mental cognition impairment, as evidenced by a Brief Interview for Mental status score of 05 out 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.