Avir at Gainesville

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain medical records that were accurate and complete in accordance with acceptable professional standards for 2 (Residents #23 and #24) of 4 residents reviewed for clinical records.1. Resident #23 had an OOH-DNR in their record that was missing information in Section B, Declaration by legal guardian, agent, or proxy on behalf of the adult person who is incompetent or otherwise incapable of communication.2. Resident #35 had an OOH-DNR in their record that the family member signed in sections they were not supposed to, the family member missed a required signature at the bottom, and the two witnesses to the family members signature did not sign until 14 days after the family member did.The facility's failure could place residents at risk for not receiving healthcare as per their or their legal representatives' wishes. Findings included:1.Record review of Resident #23's face sheet printed [DATE] revealed he was an [AGE] year-old male 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 interview and record review, the facility failed to designate a member of the facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident and to ensure facility obtained documentation from hospice for 1 of 2 residents (Resident #59) reviewed for hospice care. 1. The facility failed to ensure there was a designated member of the interdisciplinary team for hospice coordination of care. 2. The facility failed to ensure Resident #59's hospice election form and physician recertification of terminal illness for Resident #59 was available. These failures place residents at risk of lack of coordination of care and decrease in quality of care. Record Review of Resident #59's admission assessment dated [DATE] reflected Resident #59 was admitted to the facility on [DATE] with diagnoses of hip fracture, dementia (significant cognitive decline severe enough to disrupt daily life) and polyneuropathy (condition affecting multiple peripheral nerves 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 observation, interview and record review 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 one (Resident #11) of five residents reviewed for infection control. The facility failed to ensure CNA G performed hand hygiene and changed gloves during Resident #11's incontinent care on 12/10/2025.This failure could place residents at risk of cross-contamination and development of infections. Findings include:Review of Resident #11's Face Sheet, dated 12/11/2025, reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident had diagnoses which included dementia (decline in cognitive function that interferes with daily life) and diabetes mellitus (the body does not use insulin properly which leads to elevated blood glucose levels).Review of Resident #11'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure resident had a right to a dignified existence and self-determination that promotes enhancement of his or her quality of life, recognizing each resident's individuality for one of eight residents (Resident #1) reviewed for resident rights. The facility failed to ensure Resident #1's right to go to the hospital on [DATE] was followed by RN A. Police had to contact EMS for Resident #1 requesting to go to the hospital for a possible blood clot. The failure could place residents at risk of a loss of self-determination and dignity. Findings included: Review of Resident #1's face sheet undated reflected Resident #1 was a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] from the hospital. Resident #1 had diagnoses of acute embolism and thrombosis of right femoral vein (presence of a blood clot in the femoral vein of the right leg), atrial fibrillation (irregular heartbeat), acute embolism and thrombosis of right lower…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the resident's physician when there was a significant change in the physical status for one (Resident #1) of six residents reviewed for notification of changes. RN A failed to notify the physician of Resident #1 being sent to the hospital on [DATE]. This failure could place residents at risk for not notifying the physician for a change in condition and hospitalization. Findings included: Review of Resident #1's face sheet undated reflected Resident #1 was a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] from the hospital. Resident #1 had diagnoses of acute embolism and thrombosis of right femoral vein (presence of a blood clot in the femoral vein of the right leg), atrial fibrillation (irregular heartbeat), acute embolism and thrombosis of right lower extremity bilateral (presence of blood clots in the deep veins in both legs), chronic pulmonary edema (the buildup of fluid in your lungs), peripheral vascular disease (condition…

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

Based on observations, interviews and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for the facility's only kitchen for 2 of 2 Dietary Staff (Dietary Aide J and Dietary Aide K) reviewed for kitchen sanitation. Dietary Aide J and K failed to wear effective hair restraints and to perform hand hygiene during lunch meal service on 09/10/24. These failures could place residents at risk for food contamination and food-borne illness. Findings include: Observation on 09/10/24 from 12:03 pm to 12:06 PM with Dietary Aide J revealed she was taking puréed food temps on the steam table with her hair restraint not covering about 1.5 inches on the back of her hair and about 1 inch uncovered above both of her ears. Observations on 09/10/24 at 12:07 PM revealed Dietary Aide J started putting food on the plate for resident lunch. Observation revealed Dietary Aide J was wearing a hair restraint not covering about 1.5 inches on the back of her hair and about 1 inch uncovered above both of her ears.…

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 provide maintenance services necessary to maintain an orderly and comfortable homelike environment for 3 (Resident #9, #19, and #45) of 6 residents reviewed for resident rights. The facility failed to ensure the shared bathroom sink for Resident #9, Resident #19, and Resident #45 was in working order. This failure could place residents at risk for infection and living in an unsanitary and uncomfortable environment. Findings included: Record review of Resident #19's Quarterly MDS assessment, dated 08/19/2024, reflected she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. She had a BIMS score of 15 which indicated cognition was intact. Diagnoses included chronic obstructive pulmonary disease (a lung disease that limits airflow), dementia (loss of cognition) Parkinson's disease (brain disorder that causes uncontrollable movements), and stroke. Record review of Resident #19's care plan initiated 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, interview and record review, the facility failed to develop and implement comprehensive person-centered care plans for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 6 of 24 (Residents #7, #28, #39, #43, #46, #50) of 24 residents reviewed for comprehensive care plans. 1. The facility failed to develop a comprehensive person-centered care plan for Resident #50. The comprehensive care plans failed to adress the specific psychotropic medications ordered by the physician, specific required ADL assistance and comfort measures and discharge goals. 2. The facility failed to develop a care plan for Resident #43 and #46's significant weight loss. The facility failed to develop ADL assistance comprehensive person-centered care plans for Resident #43 and #46. 3. The facility failed to include in the care plan last revised on 08/28/24 Resident #39's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide, based on the comprehensive assessment and care plan, both facility-sponsored group and individual activities and independent activities designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident for three (Resident #13, #26 and #36) of 7 residents reviewed for activities. 1. The facility failed to provide individualized and group activities for Resident #13 on the secure unit who did not consistently attend group activities off the secure unit. The facility failed to ensure Resident #13 had an individualized activity care plan. 2. The facility failed to provide individualized and group activities for Resident #26 on the secure unit who did not attend the group activities off the secure unit. The facility failed to follow Resident #26's individualized activity care plan. 3. The facility failed to provide individualized activities for Resident #36 on the secure unit who did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 4 (Resident #25, Resident #28, Resident #37, and Resident #253) of 6 residents reviewed for respiratory care. 1. The facility failed to obtain a Physician's order for Resident #37's continuous supplemental oxygen. 2. The facility failed to ensure Resident #25's nasal cannula, oxygen tubing and humidifier were changed out on 09/08/24 per physician orders. 3. The facility failed to ensure Resident # 28's humidifier was changed out when empty on 09/10/2024 per physician orders. 4. The facility failed to ensure Resident # 253 humidifier was changed out when empty on 09/10/2024 per physician orders. These failures could place residents who received oxygen therapy at risk of oxygen toxicity, respiratory infections, nose bleeds, 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 use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility reviewed for RN coverage. The facility failed to provide RN coverage for 8 consecutive hours daily on Saturdays and Sundays in June, July, and August 2024. This deficient practice had the potential to affect residents in the facility by leaving staff without supervisory coverage for RN-specific nursing activities. Findings include: Record Review of RN timesheets for June to September 2024 for facility and Agency staff revealed no RN coverage for the following weekends: 06/01/24 - 06/02/24, 06/08/24 - 06/09/24, 06/15/24 - 06/16/24, 06/22/24 - 06/23/24, 06/29/24 - 06/30/24, 07/13/24 - 07/14/24, 07/20/24 - 07/21/24, 08/03/24 - 08/04/24, 08/10/24 - 08/11/24 and 08/24/24 - 08/25/24. Interview on 09/12/24 at 2:08 PM with ADON revealed she was contacted on the weekends when facility did not have RN coverage on the weekends. She stated she would notify the DON if she needed further assistance. Interview on 09/12/24 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation , interview and record review, the facility failed to promote and facilitate resident self- determination through support of resident choice for 1 of 7 residents (Resident #50) reviewed for resident rights. The facility failed to promote Resident #50's self-determination by not offering her an opportunity to smoke when smoke breaks occurred at the facility. This failure could place residents at risk of a decreased self-worth due to their preferences not being met. Findings include: Review of Resident #50's face sheet undated reflected Resident #50 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of stroke, cognitive communication deficit, diabetes, anxiety disorder, Alzheimer's disease and seizures. Review of Resident #50's admission MDS assessment date 08/27/24 reflected Resident #50 had a BIMS of 14 indicating she was cognitively intact. Review of Resident #50's comprehensive care plan last revised on 08/23/24 reflected Resident #50 had the Potential for safety…

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 to ensure a new resident was not admitted with a mental disorder, unless the state mental health authority determined, based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority prior to admission, that the individual requires the level of services provided by a nursing facility and if the resident requires such level of services, whether the resident requires specialized services for one (Resident #9) of six residents reviewed for PASARR screening. The facility failed to ensure Resident #9 received a PASARR level 2 evaluation. This failure could affect residents with mental illness and place them at risk of not being assessed to receive needed services. Findings included: Record review of Resident #9's Comprehensive MDS assessment, dated 08/02/2024, reflected she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. She had a BIMS score of 15 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 the comprehensive care plans were prepared by an IDT that included the attending physician, a registered nurse and a nurse aide with responsibility for the resident, a member of food and nutrition services staff and the participation of the resident for one of 8 residents (Resident #50) reviewed for care plan conference. The facility failed to ensure Resident #50 had a care plan conference to discuss her treatment and discharge goals. This failure could place residents at risk for not receiving adequate or individualized care. Findings include: Review of Resident #50's face sheet undated reflected Resident #50 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of stroke, cognitive communication deficit, diabetes, anxiety disorder, Alzheimer's disease and seizures. Review of Resident #50's admission MDS assessment dated [DATE] reflected Resident #50 had a BIMS of 14 indicating she was cognitively intact. Resident #50 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for one of thirteen residents (Resident # 18) reviewed for ADLs. The facility failed to ensure Resident #18 had her facial hair removed and her nails cut. These failures could place residents who were dependent on staff for ADL care at a loss of dignity and a decreased quality of life. Findings include: Record review of Resident #18's annual MDS assessment, dated 06/20/24, reflected a [AGE] year-old female with an admission date of 07/01/22 and a re-admission date of 03/13/24. Resident #18 had BIMS score of 3 which indicated she was severely cognitively impaired. She required moderate assistance for bathing and personal hygiene. Diagnoses included Alzheimer's and osteoarthritis (chronic condition that breaks down the cartilage in the joints, causing pain and stiffness). Record review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 (Resident #7) of 6 residents reviewed for quality of care. The facility failed to follow physician orders and perform wound treatments as ordered for Resident #7. 1. The ADON failed to discontinue the previous physician order from a xeroform dressing for Resident #7's surgical incision to the updated order for a wet to dry dressing on 07/01/2024. 2. Agency LVN D failed to notify the ADON, DON, or Physician of the conflicting orders and provided a xeroform and wet to dry dressing of Resident #7's incision site on 09/10/2024. These failures could place residents at risk for complications including skin break down, infection, or decreased physical and mental functioning. Findings included: Record review of Resident #7's comprehensive 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 observation, interview and record review, the facility failed to provide treatment and services to prevent complications of enteral feeding for one of one resident (Resident #4) reviewed for feeding tubes. 1. The facility failed to ensure LVN A flushed Resident #4's G-Tube with 30 cc of water prior to the medication administration per physician's orders. 2. The facility failed to ensure LVN A dissolved all the medications prior to administration through Resident #4's G-Tube. 3. The facility failed to ensure LVN A administered medications through Resident #4's G-Tube by gravity, and instead she pushed one of the medications with the plunger and syringe. 4. The facility failed to ensure LVN A clamped the tubing before it drained completely between each medication administration. These failures could affect residents by placing them at risk of abdominal discomfort, obstruction of the G-tube and incomplete medication administrations. Findings included: Record review of Resident #4's Significant change 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 observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three of thirteen residents (Resident #32, Resident #7, and Resident #4) reviewed for infection control. 1. The facility failed to ensure LVN A disinfected the blood pressure cuff in between blood pressure checks for Residents #32, Resident #7, and Resident #4) on 09/11/24. 2. The facility failed to ensure LVN A performed hand hygiene during medication administration and did not cross contaminate the medication for Resident #32 and Resident #7 on 09/11/24. 3. The facility failed to ensure LVN A did not cross contaminate Resident #32's eye drops, allergy nasal spray and antifungal powder during medication pass on 09/11/24. These failures could place residents at risk of cross contamination which could result 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 prompt efforts were made to resolve grievances for 4 of 6 residents (Resident #1, Resident #2, Resident #3, Resident #4) reviewed for grievances. The facility did not ensure grievances from 06/01/2024 to 08/27/2024 were completed for Resident #1, Resident #2, Resident #3, Resident #4, who were not comfortable in their rooms due to lack of proper air conditioning (room temperatures). This deficient practice could place residents at risk of living in an uncomfortable environment leading to a decreased quality of life. Findings included: Record review of Grievance log from 06/01/2024 to 08/27/2024 reflected no grievances related to air condition/room temperatures were recorded. Record review of Resident #1's quarterly MDS assessment, dated 08/21/2024 reflected she was a [AGE] year-old female who was admitted on [DATE]. Resident #1's diagnoses included: Acute upper respiratory infection (infection that can affect the nose, throat, 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, interview and record review, the failed to implement their written abuse prevention policy and investigate allegations for two residents (Residents #1 and #8) of eight residents reviewed for resident abuse and one (LVN B) of three staff files reviewed for employee files. 1. The Administrator failed to follow facility policy when Resident #1 had an injury of unknown origin resulting in serious injury by not reporting the injury within the required timeframe. 2. CNA H failed to immediately report an allegation of abuse to the Administrator or DON related to Resident #8. 3. Facility failed to ensure LVN B's Criminal Background Check and EMR/NAR check were completed upon hire and in her employee file. These failures places residents at risk of abuse along with allegations of abuse identified and investigated thoroughly. Findings included: Record Review of facility's policy for staff reporting abuse allegations dated 2001 and revised January 2011 titled Policy for Reporting Abuse to 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 observations, interview and record review, the failed to report allegations of abuse within 2 hours to HHSC for abuse allegations for two residents (Residents #1, #8 and) of 8 residents reviewed for reporting resident abuse. 1. The Administrator failed to report Resident #1's fall with serious injury within 2 hours to HHSC. 2. The facility failed to report an allegation of abuse involving Resident #8 to the appropriate State Agency immediately on 09/25/2023. These failures could place resident at risk of not having abuse, neglect, exploitation allegations reported. Findings include: 1. Review of Resident #1's face sheet dated 07/16/2024 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of traumatic brain injury, type-2 diabetes, hypertension (high blood pressure), muscle weakness, cognitive communication deficit, anxiety disorder and depression disorder with a BIMS score of 00 (severely impaired cognition). Review of Resident #1's care plan 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide a safe, clean, comfortable and homelike environment for one of three halls (Hall 300) observed for daily living safely. The facility failed to ensure a shared bathroom on hall 300 was clean and sanitary for rooms [ROOM NUMBERS]. The facility failed to ensure a clean and sanitary mattress for Bed B in room [ROOM NUMBER]. This failure could place residents at risk for diminished quality of life due to the lack of unsanitary and unclean environment. Findings include: Observation on 07/16/2024 at 10:00 a.m., revealed a strong smell of urine from room [ROOM NUMBER]. Observation of Bed B revealed a sheetless mattress with a strong smell of urine which contained a wet circle. Observation of the shared bathroom with rooms [ROOM NUMBERS], revealed dried feces spread around the toilet seat and no toilet paper. Loose paper was observed on the floor in front of sink. Observation on 07/16/2024 at 11:30am revealed a strong smell of urine from…

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 or implement a person-centered comprehensive care plan for one (Resident #2) of five residents reviewed for care plans. The facility failed to provide a comprehensive and person-centered care plan for Resident #2 about resident's behaviors and preferences. This failure puts residents at risk of not being provided personalized care and negatively impact their quality of life. Findings included: Record review of Resident #2's face sheet was a [AGE] year-old male admitted to the facility on [DATE] with the diagnoses of unspecified dementia, bi-polar disorder (intense shifts in mood and energy levels), chronic obstructive pulmonary disease (lung disease causing difficulty breathing), emphysema (lung condition that causes shortness of breath), and alcohol abuse. Review of Resident #2's Quarterly MDS dated [DATE] revealed a BIMS score of 03 (severe cognitive impairment). Record review of Resident #2's care plan revealed problem start…

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 control program designed to prevent the development and transmission of infection for 1 resident of 8 residents (Resident #5) observed for infection control. The facility failed to ensure CNA G performed hand hygiene and changed gloves during incontinent care for Resident #5. This failure could place residents at risk for infection and cross contamination of pathogens and illness. Findings include: Record review of Resident #5's Quarterly MDS assessment dated [DATE] reflected Resident #5 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses included hemiplegia (paralysis that affects only one side of the body), muscle wasting, and cerebral infarction (a condition that occurs when blood flow to the brain is disrupted, causing tissue death in the brain). Resident #5's BIMS score of 10, which indicated Resident #5's cognition was moderately impaired. The MDS assessment indicated Resident #5 required…

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 and interview, the facility failed to ensure the resident's environment remained as free of accident hazards as possible for one (Resident #8) of fourteen residents on the secure unit, 300 wing reviewed for quality of care. The facility failed to ensure several doors in the secure unit were not found to be open and able to be secured, allowing residents possible access to hazardous chemicals stored in the janitors closet of the secure wing, and an activity supplies closet. This failure could expose residents to undue harm, chemical exposure or poisoning. Findings included: Record review of Resident #8's face sheet, dated 12/16/23, revealed that the resident was a [AGE] year-old male who was initially admitted to the facility on [DATE] with diagnosis of Alzheimer's disease, Unspecified Dementia, Diabetes mellitus, and Insomnia. Record review of Resident #8's Minimal Data Sheet (MDS) assessment dated [DATE] revealed the resident had a Brief interview for Mental Status (BIMS) Score of 0…

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 a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming and oral hygiene for one resident (Resident #1) of six residents reviewed for quality of life. The facility failed to ensure Resident #1 received showers per her shower schedule. This failure could place residents at risk of low self-esteem, anxiety, embarrassment, and a decline in their quality of life. Findings included: Record review of Resident #1's face sheet dated 12/16/23, revealed that the resident was an [AGE] year-old female, initially admitted to the facility on [DATE] with diagnosis that include hemiplegia and Hemiparesis following non-traumatic hemorrhage affecting right dominant side, Primary, admission (Paralysis of half of the body), Lack of coordination, Acute embolism, and thrombosis (obstruction of an artery or blood vessels), and need for assistance with personal care. 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.

Based on 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 for one (Dietary [NAME] J) of two dietary staff reviewed for qualifications. 1. The facility failed to employ a qualified Dietary Manager. 2. The facility failed to ensure Dietary [NAME] J had a current food handlers license. This failure could place the residents at risk of not being provided a nutritional well-balanced diet and not have their dietary needs identified and addressed. Findings included: Interview on 07/18/23 at 09:45 AM with Dietary [NAME] J revealed she was by herself after 2pm, no dietary aide or dishwasher during the week. Dietary [NAME] J stated the facility had been without a Dietary Manager for 3 weeks. Interview on 07/20/23 at 1:15 PM with Administrator revealed the Dietary Manager quit last month. The Administrator stated they were currently looking for a Dietary Manager. Record Review of Dietary [NAME] J's employee file reflected her date of hire was 01/20/22.…

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 of the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure stored canned goods, had an uncompromised seal, free from dents. 2. The facility failed to ensure items in the kitchen and dry storage were labeled and stored in accordance with the professional standards for food service. 3. The facility failed to ensure that two of three refrigerators and two freezers' outsides were free from dirt, dust and dead bugs/pests. 4. The facility failed to discard items stored in reach-in refrigerator, kitchen area or dry storage that were not properly labeled or past the 'best buy', consume by or expiration dates. 5. The facility failed to ensure the handwashing sink was free from leaking/running water (hot side). 6. The facility failed to ensure the kitchen remained free of bugs and insects (pests). 7.…

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, interview and record review the facility failed to maintain mechanical and electrical equipment in safe operating condition for residents in one of one dining room and 300 hall reviewed for physical environment. 1. The facility failed to ensure dining room air conditioning was working properly to maintain safe and comfortable air temperatures for residents in the dining room. 2. The facility failed to ensure Residents #99 and #41 had working air conditioner in their room. 3. The facility failed to ensure resident room [ROOM NUMBER] and hall 300 had working air conditioner. The failure could place residents at risk of living in an unsafe, unsanitary, and uncomfortable environment. Findings included: Observation and Interview on 07/18/23 at 10:06 AM with Resident #41 revealed it was hot in her room for the last 2 days. She stated facility was aware of it and gave 2 fans to try to keep the room cooler. Observation of Resident #41's room revealed it was warm and stuffy with 2 fans blowing.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide comfortable and safe temperature levels for 17 residents including five residents (#8, #41, #23, #38, #99) and 12 residents in confidential group interview) reviewed for resident rights. 1. The facility failed to ensure dining room air conditioning was working properly to maintain safe and comfortable air temperatures for residents in the dining room. 2. The facility failed to ensure Residents #99 and #41 had working air conditioner in their room. The failure could place residents at risk of living in an unsafe, unsanitary, and uncomfortable environment. Findings included: Observation and Interview on 07/18/23 at 10:06 AM with Resident #41 revealed it was hot in her room for the last 2 days. She stated facility was aware of it and gave 2 fans to try to keep the room cooler. Observation of Resident #41's room revealed it was warm and stuffy with 2 fans blowing. Observation and Interview on 07/18/23 at 11:50 AM revealed the dining…

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 use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility reviewed for RN coverage. The facility failed to provide RN coverage for 8 consecutive hours daily on Saturdays and Sundays in May to July 2023. This deficient practice had the potential to affect residents in the facility by leaving staff without supervisory coverage for RN-specific nursing activities. Findings included: Record Review of facility's timesheets and sign in sheets for staff for May 2023 to June 2023 reflected the following: -05/06/23 reflected LVNs E, L, T and ZC worked at facility -05/07/23 reflected LVNs L, T and ZC worked at facility -05/13/23 reflected LVNs T, R Agency LVN S, and Agency LVN T worked at facility -05/14/23 reflected LVN P, LVN R, Agency LVN S and Agency LVN ZB worked at facility. -05/20/23 reflected LVN E, LVN T, LVN ZC and Agency LVN U -05/21/23 reflected LVN E, LVN T, LVN ZC and Agency LVN U -05/27/23 reflected LVN L, LVN R, Agency LVN S and Agency LVN V -05/28/23 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 interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring and administering of all medications to meet the needs of each resident for two (Residents #28 and #7) of six residents reviewed for pharmacy services. 1. Agency LVN A failed to follow the manufacturer's instructions to [NAME] the Novolin R Insulin (Hormone) Pen prior to dialing in required amount of Insulin to be administered to Resident #28. 2. LVN B failed to follow the procedure for accurate administration of Resident #7's Flonase (corticosteroids to treat allergy's) Nasal Spray. LVN B did not ensure Resident #7 cleared his nasal passages before use. These failures placed residents at risk of not receiving therapeutic dosage of medication. Findings included: 1. Review of Resident #28's Quarterly MDS dated [DATE] reflected a [AGE] year-old male admitted to the facility on [DATE]. Resident had a BIMs of 15 which indicated he was cognitively intact. Diagnoses…

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

Based on interview and record review, the facility failed to ensure that the facility's medical director or his/her designee attended the QAPI meetings for one of one facility, reviewed for QAPI, in that: The facility failed to ensure the Medical Director attended QAPI meetings since 09/23/22. This failure placed residents at risk for quality deficiencies being unidentified and no appropriate plans of actions developed or implemented. Findings include: Review of the facility's QAPI meeting sign in sheets for July 2022 to June 2023 reflected QAPI meetings were held monthly. The QAPI meeting sign in sheet dated 09/23/22 reflected Medical Director met with facility QAPI. The Medical Director did not meet when facility had QAPI meetings in October 2022, 12/13/22, 1/19/23, 2/16/23, 3/16/23, 4/20/23, 5/16/23 and 6/29/23 with QAPI. Interview on 07/19/23 at 5:10 PM the Administrator stated there had only been one QAPI meeting since he started as the Administrator at the facility. He stated the Medical Director did not attend the June QAPI meeting. He stated the DON went over information…

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

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for three (Resident #28, Resident #35, and Resident#7) of six residents and four of six staff members reviewed for infection control. 1. Agency LVN A failed to perform hand hygiene during wound care for Resident # 28. 2. CNA C and CNA D failed to perform hand hygiene after performing ADL care and mechanical lift transfer on Resident # 28 and before leaving the resident's room. 3. LVN B failed to disinfect the blood pressure cuff in between blood pressure checks for Residents #35 and Resident #7. These failures could place residents at-risk of cross contamination which could result in infections or illness. Findings included: 1. Observation on 07/18/23 at 10:05 a.m. revealed CNA C and CNA D completing ADL care on Resident #28 and placing him on mechanical lift sling in preparation to transfer from bed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review. the facility failed to provide a safe, functional, sanitary, and comfortable environment for dining room and three of four resident halls (200, 300 hall and 400 hall) reviewed for physical environment. 1. The facility failed to ensure the secure unit (300 hall) common area was maintained with floorboards in place and the wall not exposed. One of two doors in common area did not have a door sealant in place. 2. The facility failed to ensure resident room [ROOM NUMBER]'s closet ceiling was not leaking and had blackish stains on ceiling. 3. The facility failed to ensure resident rooms' 404 and 406 had a shower in working order. 4. The facility failed to ensure resident room [ROOM NUMBER] had a working air conditioner which did not leak. 5. The facility failed to ensure hall 200 overhead lights were free of dead bugs. 6.The facility failed to ensure resident common area at end of 400 hall was kept clean and window seals were cleaned. These failures placed 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 observation, interview, and record review, the facility failed to ensure an effective pest control program was implemented so the facility was free of pests and rodents for the facility's dining room and three of four halls (Halls 200, 300 and 400) reviewed for pest control. 1. The facility failed to keep an effective pest control program to ensure dining room was free of flies, gnats and spiders. The facility failed to ensure bug zapper in dining room was serviced and not full of flies and gnat. The facility failed to ensure ice machine was free of dead gnat. 2. The facility failed to ensure hall 300 and dining area for hall 300 was free of bugs. 3. The facility failed to ensure halls 200 and 400 were free of bug activity. These failures could place residents at risk for spread of infection, cross-contamination, and decreased quality of life. Findings included: 1. Observations during residents' lunch on 07/18/23 at 12:18 PM in dining room revealed in front of the 2nd set of sliding doors from the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one (Resident #28) of two resident reviewed for catheter care. CNA C and CNA D failed to keep Resident #28's urine catheter bag below the level of the bladder during a mechanical lift transfer. This failure could place residents at risk for urinary tract infections. Findings included: Review of Resident #28's Quarterly MDS dated [DATE] reflected a [AGE] year-old male admitted to the facility on [DATE]. Resident had a BIMs of 15 which indicated he was cognitively intact. Resident had a foley catheter and was always incontinent of bowel. He required extensive two-person assistance for transfers and had infection of the foot. Diagnoses included neurogenic bladder (lack of bladder control due to a brain, spinal cord, or nerve problem), paraplegia (paralysis of lower body), multiple sclerosis (nervous system…

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.