Avir At Gonzales

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure that all drugs and biologicals used in the facility, were labeled and stored in accordance with professional standards for 1 (Hall 300 Nurse's medication cart) of 3 medication carts reviewed for medication storage. The facility failed to ensure one controlled medication Morphine Sulfate 20mg/5ml oral suspension for Resident #8 was removed from the medication cart when it had expired on 12/28/2024. This failure could place residents at risk of not receiving the therapeutic benefit of medications.Findings included: Record review of Resident #8's admission Record dated 07/22/2025 revealed she was an [AGE] year-old woman admitted [DATE] with re-admission on [DATE] and with diagnoses which included: Chronic Obstructive Pulmonary Disease (lung disease that blocks air flow and makes it difficult to breathe). Record review of Resident #8's Quarterly MDS assessment dated [DATE] revealed she had a BIMS score of 2, indicating severe…

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 have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption, for 2 of 3 residents (Residents #4 and #15) reviewed for personal food policy, in that: 1.Resident # 4's personal refrigerator located in her room revealed food item of a glass jar of Picante Sauce which had been opened with a Best Use By Date of February 9,2025. There was no label or date of when the jar had been opened. 2.Resident # 15's personal refrigerator located in his room revealed food item of a Styrofoam cup covered with clear plastic wrap with white liquid inside it. There was no label or date identifying the name or date. These failures could place residents at risk of foodborne illness due to consuming foods which might be spoiled. The findings included:Record review of Resident #4's face sheet, dated 07/24/2025, reflected the resident was an [AGE] year old female…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed in accordance with accepted professional standards and practices, to maintain medical records on each resident that are complete and accurately documented, for 1 of 8 residents (Resident #1) reviewed for clinical records. The facility failed to ensure Resident #1's application of TED hose was accurately documented on his Medication Administration Record (MAR) for 23 of 23 daily entries in July 2025. This failure could place the residents at risk of not receiving the care and services needed due to inaccessible and inaccurate clinical records. Findings included: Record review of Resident #1's admission Record revealed he was a [AGE] year-old man admitted [DATE], and re-admitted on [DATE], with diagnoses which included: Legal Blindness (visual acuity of 20/200 meaning a person an see at 20 feet what a person with normal vision can see at 200 feet), Borderline Intellectual Functioning (cognitive abilities that are below average, but not enough to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 2 of 6 residents (Residents #4 and #24) reviewed for infection control: 1.The facility failed to maintain proper infection control procedures when LVN-A place Resident #4's open left heel wound directly onto the Resident's bedspread to during wound care treatment. 2.The facility failed to ensure MA-B sanitized the blood pressure cuff per facility protocol before and after checking Resident #24's blood pressure. These failures could place residents at-risk for infection due to improper care practices. The findings included: 1.Record review of Resident #4's admission Record dated 07/25/2025 revealed she was an [AGE] year-old woman admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses which included: Venous…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the comprehensive assessment accurately reflected the resident's status for 1 of 5 Residents (Resident #1) whose assessment records were reviewed. The facility failed when nursing staff did not code on Section GG of MDS Comprehensive assessment dated [DATE] that Resident #1 had functional limitation in range of motion to her upper extremity. This deficient practice could affect residents and contribute to residents not receiving care and services as needed. The findings included: Review of Resident #1's face sheet, printed 04/29/25, revealed the resident was admitted to the facility on [DATE]/24 with a primary diagnoses of myopathy (a disease of the muscle in which muscle fibers do not function properly), Rheumatoid Arthritis (an autoimmune disorder where the immune system attacks to joints, causing inflammation, pain and potential joint damage), Osteoarthritis (a degenerative joint disease characterized by the breakdown of joint…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 3 of 8 residents (Residents # 2, #3 and #7) reviewed for respiratory therapy. 1. The facility failed to ensure Resident #2 had a physician order, was care planned or had an oxygen safety sign on the resident's room door. 2. The facility failed to ensure Resident #3 had a physician order, was care plan or had an oxygen safety sign on the resident's room door. 3. The facility failed to ensure Resident #7 had a care plan or oxygen safety sign on the door. These deficient practices could place residents at risk of receiving incorrect or inadequate oxygen support which could result in a decline in health. Findings include: 1) Record review of Resident #2's, undated, face sheet revealed an [AGE] year-old male who 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 observation, interview, and record review the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 2 of 8 residents (Resident #2 and Resident #6) reviewed for reasonable accommodation of resident needs. 1. The facility failed to ensure Resident #2 had access to his call light which was draped over his nightstand outside of the resident's reach. 2. The facility failed to ensure Resident #6 had access to her call light which was wrapped around the call light plug on the wall, behind Resident #6 and outside of her reach. These deficient practices could place residents at risk of not maintaining and/or achieving independent functioning, dignity, and well-being. Findings include: 1) Record review of Resident #2's, undated, face sheet revealed an [AGE] year-old male who was admitted to the facility on [DATE].…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, 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 2 of 8 residents (Residents #1 and #4) reviewed for care plans. 1. The facility failed to ensure a care plan was developed to address Resident #1's enhanced barrier precautions which required staff to utilize gowns and gloves when direct care was provided. 2. The facility failed to ensure a care plan was developed to address Resident #4's enhanced barrier precautions which required staff to utilize gowns and gloves when providing direct care. These deficient practices could place residents at risk of an infection. The findings include: 1) Record review of Resident #1's, undated, face sheet revealed Resident #1 was an [AGE] year-old female who…

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 promote the residents' right to receive mail, for 1 of 1 facility review for residents' right to receive mail, in that: Facility staff did not distribute mail received on Saturdays to the residents. This deficient practice could result in residents not receiving mail in a timely manner and a diminished quality of life. The findings were: During a confidential group meeting on 06/05/2024 at 11:00 AM, members of the resident group stated they did not receive mail on Saturdays, they did not understand why it was not distributed on Saturdays, and stated they felt this practice was disrespectful. During an interview on 06/07/2024 at 11:22 AM with the BOM she stated she was the only one who distributed mail to the residents and did so Monday through Friday. Mail that came in on Saturdays remained in the mailbox until Monday. This had been the practice at the facility since she was hired in 2018. Department heads rotated serving as the manager on duty every weekend, but did not distribute the mail even though they had access to…

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

Based on 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 nursing services. The facility failed to use the services of an RN as required, for 10 days, during the period between 3/1/2024 through 5/31/2024. This could result in resident's not receiving the needed care and services to meet their needs and could result in illness, a decline in health, and in quality of care. The findings were: Review of the facility's RN hours record revealed there were no RN coverage hours on 3/9/2024, 3/10/2024, 3/31/2024, 4/6/2024, 4/7/2024, 4/20/2024, 5/4/2024, 5/5/2024, 5/18/2024 and, 5/19/2024. All of these dates are on weekends. During an interview with the DON, on 6/6/2024 at 3:27 p.m., the DON stated the facility had two RN's, one full-time and one part-time, who worked different shifts, and confirmed there was no RN coverage on 3/9/2024, 3/10/2024, 3/31/2024, 4/6/2024, 4/7/2024, 4/20/2024, 5/4/2024, 5/5/2024, 5/18/2024 and, 5/19/2024. During an interview with 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 the medication error rate was not five percent or greater. The facility had a medication error rate of 10% based on 3 errors out of 30 opportunities, which involved 3 of 4 residents (Resident #3, Resident #22 and Resident #9) reviewed for medication errors. 1. Medication Aide D failed to administer medications as ordered to Resident #3 by administering hydrocodone (a treatment for Pain) )1 hour and 20 minutes after the scheduled time. 2. Medication Aide D failed to administer medications as ordered to Resident #22 by administering Duloxetine (a treatment for Depression and Nerve Pain) 1 hour and 42 minutes after the scheduled time. 3. Medication Aide D failed to administer medications as ordered to Resident #9 by administering Metoprolol (a treatment for High blood pressure and Heart failure) 1 hour and 55 minutes after the scheduled time. These failures could place residents at risk of not receiving the desired therapeutic effect 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 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: 1. There was a bag of shredded cheese past its use-by date in the reach-in cooler. 2. There were cleaning supplies in the dry storage room. 3. There was a bag of breadcrumbs that was opened, unsealed, without a label and use-by date in the dry storage room. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: 1. Observation on 06/04/2024 at 10:10 AM revealed there was a 5-lb. bag of shredded Cheddar cheese on a shelf in the reach-in cooler. The cheese was in its original package and placed in a clear, gallon-sized, zipper-sealed bag. There was approximately ¾ lb. of cheese remaining in the bag. A small white sticker on the bag read, 5-7. During an interview on on 06/04/2024 at 10:12 AM with the DM she stated the numbers on the sticker meant the bag of cheese had been opened on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 4 of 6 residents (Residents #5, #9, #10 and, #32) reviewed for infection control, in that: 1. Medication Aide D did not sanitize the Blood pressure cuff between Residents. 2. CNA B did not use the proper technique to sanitize her hands while providing incontinent care for Resident #10. 3. LVN E touched Resident #32's bed table and did not sanitize her hands prior to providing care. These deficient practices could place residents at-risk for infection due to improper care practices. The findings included: 1. Record review of Resident #5's face sheet, dated 06/06/2024, revealed an admission date of 06/18/2019 and, a readmission date of 02/07/2024 with diagnoses which included: Type 2 diabetes mellitus (high level of sugar in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the residents' right to request, refuse, and/or discontinue treatment and to formulate an advance directive for 1 (Resident #9) of 14 residents reviewed for advance directives, in that: Resident #9 was unable to make her wishes of being full code known and, her OOH-DNR was executed by her family member without her consent or knowledge. This deficient practice put residents at risk of not having their rights honored when they stop breathing and there is no pulse. The findings were: Record review of Resident #9's face sheet, dated 06/06/2024, revealed an admission date of 07/06/2019 and readmission on [DATE] with diagnoses including: Senile degeneration of brain (loss of intellectual ability associated with old age), chronic venous hypertension (abnormalities in the capillaries within the leg tissues allowing fluid, proteins and blood cells to leak into the tissues) and muscle wasting and atrophy (a decrease in muscle size and loss of muscle…

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

Based on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 2 of 6 resident (Residents #10 and #25) reviewed for privacy, in that: 1. CNA A and CNA B did not close completely Resident #10's privacy curtain while providing incontinent care. 2. LVN C left her computer screen open showing Resident #25's protected information while administering medications. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy. The findings include: 1. Record review of Resident #10's face sheet, dated 06/06/2024, revealed an admission date of 03/02/2015 and, a readmission date of 02/07/2019, with diagnoses which included: Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills), Hypothyroidism (under active thyroid), Type 2 diabetes mellitus (high level of sugar in the blood), Hemiplegia (Paralysis of one side of the body), Hyperlipidemia(Elevated level of any or all lipids(fat) in the blood), Hypertension (High blood pressure). Record review of Resident #10'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 develop and implement a comprehensive person-centered care plan for each resident for 1 of 14 residents (Resident #39) whose assessments were reviewed, in that: The facility failed to ensure that Resident #39's care plan correctly noted the resident's exit seeking behavior in his care plan. This deficient practice could lead to improper identification of residents with elopement tendencies resulting in potential harm. The findings were: Record review of Resident #39's face sheet, dated 04/21/2023, revealed the resident was admitted to the facility on [DATE] and again on 05/20/2023 with diagnoses including diabetes mellitus (a group of diseases that affect how the body uses blood sugar), cognitive communication deficit (a problem with one or more cognitive skills involved in communication, such as attention, memory, or reasoning), dementia with psychotic disturbance (a decline in cognitive functioning, which includes thinking, remembering,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received proper treatment and care to maintain mobility and good foot health for 1 of 1 resident (Resident #9) reviewed for foot care. The facility failed to provide Resident #9 with access to podiatry care. This deficient practice placed residents at risk of discomfort, poor foot hygiene, and a decline in residents' physical condition. The findings were: Record review of Resident #9's face sheet, dated 06/06/2024, revealed an admission date of 07/06/2019 and readmission on [DATE] with diagnoses including: Senile degeneration of brain (loss of intellectual ability associated with old age), chronic venous hypertension (abnormalities in the capillaries within the leg tissues allowing fluid, proteins and blood cells to leak into the tissues), coagulation deficit (problems with the ability to form clots) and muscle wasting and atrophy (a decrease in muscle size and loss of muscle tissue). Record review of Resident #9'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.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible for 1 of 3 halls (Hall 300) observed for accidents and hazards, in that: The facility failed to ensure potential hazards were locked up in Hall 300 This deficient practice could place residents at risk of a diminished quality of life due to an unsafe environment. The findings were: Observation on 06/06/2024 at 12:25 p.m. on Hall 300 revealed a container of Sani-Cloth, purple top (a germicidal wipe) on the 300 hall medication cart, on the left side of the cart. The container had physical and chemical hazard and precautionary statements., such as causes substantial but temporary eye damage. Call poison center or doctor for treatment advice. Further observation revealed several unnamed residents were seen in the hall. During an interview on 06/06/2024 at 12:30 p.m. with LVN E, she confirmed the container of Sani-Cloth was in the open and it contained wipes. She also confirmed there were multiple residents with dementia able to…

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

Based on observation, interview, and record review, the facility failed to ensure all drugs and biological were stored in locked compartments for 1 of 3 medication carts (Hall 300 Medication Cart) reviewed for storage, in that: During medications administration, LVN C left Hall 300 Medication cart unlocked on 1 occasion. This deficient practice could place residents at risk of misappropriation of medications or harm due to accidental ingestion of unprescribed mediations. The findings were: Observation on 06/06/2024 at 11:16 a.m revealed LVN C was administering medications to residents. LVN C was checking Resident #5's blood sugar and going in his rooms. On one occasion the medication cart was left unlocked and out of sight of LVN C. Inside the unlocked cart were blister packs, bottles, and vials of medications for the residents. During an interview with LVN C on 06/06/2024 at 11:18 a.m., LVN C confirmed the medication cart was left unlocked while she was doing a blood sugar check in the resident's room. LVN C confirmed she knew she had to keep the cart locked and had forgotten.…

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 collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 2 residents (Resident #42) reviewed for hospice services, in that: The facility did not have Resident #42's most recent Physician Certification of Terminal Illness. This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. The findings were: Record review of Resident #42's face sheet, undated, revealed the resident was admitted to the facility on [DATE] and again on 10/11/2023 with diagnoses including: unspecified injury of right vertebral artery (can lead 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 observation, 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 personal and oral hygiene for 3 of 16 residents (Residents #15, #35, and #43) reviewed for ADL's. 1. Resident #15 did not receive his scheduled showers. 2. Resident #35 did not receive her scheduled showers. 3. Resident #43 did not receive his scheduled showers. This failure could place residents at risk of not receiving the care they require to maintain their highest practical well-being, and could result in low self-esteem, anxiety, embarrassment, and a decline in their quality of life. The findings were: 1. Record review of Resident #15's face sheet, dated 04/21/2023, revealed the resident was admitted to the facility on [DATE] with diagnoses including: age-related cognitive decline, rhabdomyolysis, and muscle wasting and atrophy. Record review of Resident #15's comprehensive MDS, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care to include but not limited to assessing, evaluating, planning, and implementing resident care plans and responding to resident's needs for 1 of 5 facility nurses (GVN) evaluated for licensed nurses. The facility failed to ensure the GVN (Graduate Vocational Nurse) did not continue to work as a GVN after her permit to practice was expired from [DATE] to [DATE]. This failure could place residents at risk of not receiving appropriate care and services to meet their needs by qualified, competent nurses. The findings were: Review of staff qualifications and training revealed the GVN was hired on [DATE]. Review of an email report from the Texas BON on [DATE] at 9:58 pm indicated the GVN was issued a graduate permit (pre-exam) for a LVN permit to practice on…

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

Based on 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 and failed to designate a registered nurse to serve as the director of nursing on a full-time basis for 1 of 1 facility reviewed for nursing services. 1. The facility failed to designate a full time DON from 4/4/23 to 4/21/23. 2. The facility failed to use the services of an RN as required for 9 days. This could result in resident's not receiving the needed care and services to meet their needs and could result in illness, a decline in health, and in quality of care. The findings were: 1. Review of the facility's staff list revealed no DON was listed for the facility. Review of staffing records revealed the DON's last day at the facility was 4/4/23. In an interview on 4/18/23 at 2:30pm, the ADON stated the facility had two RN's that worked different shifts and the facility was utilizing them when an RN was needed. In an interview on 4/21/23 at 1:27pm the Administrator stated the DON's last day was 4/4/23 and a new DON had been…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect and promote the residents' right to a dignified existence for 1 of 16 residents (Resident #15) reviewed for dignity, in that: Resident #15's wheelchair was soiled and in disrepair. This deficient practice could lead to diminished self-esteem and quality of life. The findings were: Record review of Resident #15's face sheet, dated 04/21/2023, revealed the resident was admitted to the facility on [DATE] with diagnoses including: age-related cognitive decline, rhabdomyolysis, and muscle wasting and atrophy. Record review of Resident #15's comprehensive MDS assessment, dated 04/04/2023, revealed a BIMS score of 04 which indicated severe cognitive impairment. Record review of Resident #15's care plan, revised 04/20/2023, revealed a problem, Category: Pain. Resident is at risk for alteration in comfort and or pain R/T [related to]: chronic pain and an approach, Encourage mobility, physical activity as tolerated. Invite to activities…

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 complete an accurate assessment of each resident's functional capacity for 1 of 16 residents (Resident #35) whose assessments were reviewed, in that: The facility failed to ensure that Resident #35's MDS assessment correctly noted the resident's lack of natural teeth, tooth fragments, and/or dentures. This deficient practice could lead to diminished quality of life or an inability to eat regular texture foods. The findings were: Record review of Resident #35's face sheet, dated 04/21/2023, revealed the resident was admitted to the facility on [DATE] with diagnoses including vascular dementia, muscle wasting and atrophy, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Record review of Resident #35's comprehensive MDS assessment, dated 02/13/2023, revealed a BIMS score of 14 which indicated intact cognition. Further review revealed Section L: Oral Dental, Box B: No natural teeth or tooth…

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 complete an accurate assessment of each resident's functional capacity for 1 of 16 residents (Resident #35) whose assessments were reviewed, in that: The facility failed to ensure that Resident #35's MDS assessment correctly noted the resident's lack of natural teeth, tooth fragments, and/or dentures. This deficient practice could lead to diminished quality of life due to an inability to eat regular texture foods. The findings were: Record review of Resident #35's face sheet, dated 04/21/2023, revealed the resident was admitted to the facility on [DATE] with diagnoses including vascular dementia, muscle wasting and atrophy, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Record review of Resident #35's comprehensive MDS assessment, dated 02/13/2023, revealed a BIMS score of 14 which indicated intact cognition. Further review revealed Section L: Oral Dental, Box B: No natural teeth or tooth…

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 complete an accurate assessment of each resident's functional capacity for 1 of 16 residents (Resident #35) whose assessments were reviewed, in that: The facility failed to ensure that Resident #35's care plan correctly noted the resident's lack of natural teeth, tooth fragments, and/or dentures. This deficient practice could lead to diminished quality of life due to an inability to eat regular texture foods. The findings were: Record review of Resident #35's face sheet, dated 04/21/2023, revealed the resident was admitted to the facility on [DATE] with diagnoses including vascular dementia, muscle wasting and atrophy, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Record review of Resident #35's comprehensive MDS assessment, dated 02/13/2023, revealed a BIMS score of 14 which indicated intact cognition. Further review revealed Section L: Oral Dental, Box B: No natural teeth or tooth…

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 assure drugs and biologicals were secured properly in 1 of 2 nurses' stations (Station 1) observed, in that: Three unsecured medications were found inside Resident #35's clinical record binder at nursing station #1. This deficient practice could place residents at-risk for harm due to ingesting medications not prescribed to them, and possible drug diversion. The findings were: Record review of Resident #35's face sheet, dated 04/21/2023, revealed the resident was admitted to the facility on [DATE] with diagnoses including vascular dementia, muscle wasting and atrophy, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Record review of Resident #35's comprehensive MDS, dated [DATE], revealed a BIMS score of 14 which indicated intact cognition. Further review revealed the resident was dependent upon staff for assistance with activities of daily living. Record review of Resident #35's physician orders as 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 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 facility kitchen, in that: 1. Individual packets of whipped spread were not refrigerated and not placed in an ice bath during preparation for the breakfast meal. 2. The top and sides of the dish sanitizing unit were soiled with a substance resembling sand. These deficient practices could lead to diminished quality of life due to foodborne illness. The findings were: Observation on 04/20/2023 at 7:24 a.m. revealed individual packets of whipped spread had been removed from the refrigerator and placed on a serving cart in preparation for the morning meal service. Further observation revealed the packets of whipped spread had not been placed in an ice bath. During an interview with Dietary Aide A on 04/20/2023 at 7:25 a.m., Dietary Aide A confirmed that this was the usual procedure, and that packets of whipped spread or butter were not placed in an ice bath routinely. During an interview with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 3 resident (Resident #33) reviewed for hospice services, in that: The facility did not have Resident #33's most recent hospice Plan of Care, Hospice Consent and Election Form, and Physician Certification of Terminal Illness. This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. The findings were: Record review of Resident #33's facesheet, dated 04/21/2023, revealed the resident was admitted to the facility on [DATE] with diagnoses including: unspecified…

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

Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 1 public restroom on the 300 Hall, in that: The public restroom utilized by residents, staff, and visitors on the facility's 300 Hall had a sink which was loosely affixed to the wall, a toilet with stained and missing caulking and loosely affixed to the floor, dark gray and black stains in the toilet, and a stained washcloth on the floor. This deficient practice could lead to residents living in, staff working in, and residents visiting in an environment that is not safe, functional, sanitary, and comfortable. The findings were: Observation on 04/18/2023 at 12:19 p.m., revealed the public restroom utilized by residents, staff, and visitors on the facility's 300 Hall had a sink which was loosely affixed to the wall, a toilet with stained and missing caulking and loosely affixed to the floor, dark gray and black stains in the toilet, and a stained washcloth on the floor. During an interview with 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.