Avir at Grapevine

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 the facility's one and only kitchen reviewed for food and nutrition services. The facility failed to ensure the four steamtable compartments in the kitchen were clean and free of debris before food was placed in them.This failure could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination. Findings included:Observation on 07/09/25 at 9:10 AM of the facility's only kitchen revealed the four steamtable compartments had food and debris floating in them.Observation on 07/09/25 at 11:00 AM of the facility's only kitchen revealed the four steamtable compartments had food and debris floating in them. The steamtables had the following: the first one had a tray of sausage jambalaya; the second one had capri vegetables and fortified mashed potatoes; the third one had mechanical soft sausage jambalaya and brown gravy;…

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 menus were followed for 1 (the lunch meal on 07/09/25) of 1 meal reviewed for food and nutrition services.The facility did not serve the posted lunch menu of cornbread and seasoned okra. This failure could affect all residents in the facility, who eat from the kitchen, by placing them at risk of not knowing what was going to be served for that meal. Findings included:Observation on 07/09/25 at 10:15 AM of the menu posted in the dining room reflected for 07/09/25 the following: Sausage Jambalaya, Seasoned Okra, Cornbread, and a Brownie.Review of the facility's Week-At-A-Glance 2025 Week 3 for Wednesday reflected the following: Sausage Jambalaya, Seasoned Okra, Cornbread, Double Chocolate Brownie.Interview on 07/09/25 at 10:40 AM with Resident #1 revealed when he received his food, he was not sure what would be served because the menu did not match what was served to him often. Interview on 07/09/25 at 10:45 AM with Resident #2 revealed when she received her food, she was not sure what would 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 provide pharmaceutical services including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 of 1 resident (Resident #1) reviewed for pharmaceutical services. The facility failed to ensure MAs and nurses were following physician orders for administering Resident #1's Lidocaine Patch 4%, which was used for preventing pain, on 05/04/25. This failure could put residents at risk of not receiving their medications as ordered. Findings included: Record review of Resident #1's quarterly MDS assessment, dated 03/24/25, reflected the resident was an [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included age-related osteoporosis without current pathological fracture (a condition where bone density and mass decrease significantly due to the natural aging process, increasing the risk of fractures). The resident's cognition was…

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

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for 5 of 40 residents (Residents #3, #5, #8, #9, and #10) and one unit reviewed for a clean environment. 1. The facility failed to keep the Memory Care Unit was free of offensive odors. 2. The facility failed to ensure Residents #3, #5, #8, #9, and #10 rooms were kept in a sanitary and comfortable manner. This failure could place the residents at risk of exposure to infectious material and decreased feelings of self-worth. Findings included: Observation on 02/27/25 at 10:00 AM revealed upon entry to the Memory Care Unit there was a urine odor throughout the unit. Two housekeepers were cleaning rooms on the unit. Observation on 02/27/25 from 10:00 AM-10:30 AM Residents #3, #5, #8, #9, and #10 rooms had dead bugs, food particles, dirt, and debris at the head of the beds and between the bed and the wall. Observation on 02/27/25 at 10:30 AM a third housekeeper and the Housekeeping Supervisor joined the other two housekeepers 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 interview and record review, the facility failed to ensure the right to be free from misappropriation of property for 1 of 8 residents (Resident #12) reviewed for misappropriation of property. The facility failed to prevent the misappropriation of Resident #12's debit card when it was taken by CNA I. The noncompliance was identified as past noncompliance. The noncompliance began on 09/18/24 and ended on 09/18/24. The facility had corrected the noncompliance before the abbreviated survey began. This failure could place residents at risk of misappropriation of property. Findings included: Record review of Resident #12's MDS dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included diabetes, multiple sclerosis (a chronic autoimmune disease that affects the central nervous system), and anxiety disorder. The resident had a BIMS score of 14 which indicated her cognition was intact. Record review of the facility's Provider…

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 implement written policies and procedures that prohibit and prevent abuse and misappropriation for 1 of 2 incidents (Resident #6) reviewed for reporting. 1. The facility failed to implement its policy by ensuring LVN Z and CNA V reported an incident of resident-to-resident abuse immediately to the Administrator, who was the Abuse Coordinator, on 01/21/25 when Resident #7 pushed Resident #6, causing her to fall and sustain a pelvic fracture. 2. The Administrator failed to investigate an incident of abuse when Resident #6 was pushed by Resident #7 on 01/21/25 and sustained a pelvic fracture. 3. The Administrator failed to report to HHSC when Resident #7 pushed Resident #6 causing Resident #6 to sustain a pelvic fracture. This failure could place the residents in the facility at risk of continued abuse. Findings included: Record review of the facility's Identifying Types of Abuse policy, revised September 2022, reflected: 1. Abuse of any…

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 all alleged violations involving abuse were immediately report, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the Administrator of the facility and to other officials including the State Survey Agency (HHSC) in a timely manner for 1 of 3 residents (Resident #6) reviewed for abuse. 1. LVN Z and CNA V failed to report an incident of resident-to-resident abuse immediately to the Administrator, who was the Abuse Coordinator, on 01/21/25 when Resident #7 pushed Resident #6, causing her to fall and sustain a pelvic fracture. 2. The Administrator failed to report to HHSC within 2 hours of Resident #6 being pushed by Resident #6 causing her to sustain a pelvic fracture. The failure could place residents at risk of serious harm or neglect. Findings included: Record review of Resident #6's face sheet, dated 02/27/25, reflected the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to investigate and report an allegation of abuse for 1 of 3 residents (Resident #6) reviewed for abuse allegations. The Administrator failed to investigate an incident of abuse when Resident #6 was pushed by Resident #7 on 01/21/25 and sustained a pelvic fracture. This failure could place residents at risk of harm and injuries related to abuse and a delay in investigating. Findings included: Record review of Resident #6's face sheet, dated 02/27/25, reflected the resident was an [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #6's significant change in status MDS Assessment, dated 01/29/25, reflected she had a BIMS score of 06, indicating severe cognitive impairment. Her MDS indicated she had delusions but no other behaviors. Her diagnoses included unspecified fracture of sacrum and depression. Record review of Resident #6's care plan, revised 01/22/25, 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.

Based on observation, interview, and record review, the facility failed to equip rooms to assure full visual privacy for each resident for 4 of 20 residents (Residents #1, #2, #3, and #4) reviewed for privacy curtains. The facility failed to ensure Residents #1, #2, #3, and #4 had full visual privacy. This failure could place residents at risk of exposure while care was being provided. Findings included: Observation on 02/27/25 from 10:00 AM-10:30 AM of the Memory Care Unit revealed Resident #1's room had a privacy curtain that would not extend around the bed due to damage of the track. Residents #2, #3, and #4 had no privacy curtain at all. Residents were not in their rooms, staff kept residents in the dining area for observation. Residents were unable to give interviews. Interview on 02/27/25 at 12:27 AM with the Housekeeping Supervisor revealed her Floor Tech was responsible for changing out privacy curtains when they were soiled or damaged. If the track was damaged, then maintenance would have to fix the track. She stated the reason the curtains were needed was to provide each…

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 effective pest control program so that the facility was free of pests and rodents for 5 of 40 residents (Residents #3, #5, #8, #9, and #10) reviewed for effective pest control. The facility failed to ensure Residents #3, #5, #8, #9, and #10 rooms were free of pests. These failures could place residents at risk of exposure to bugs and bug bites. Findings included: Observation on 02/27/25 from 10:00 AM-10:30 AM revealed Resident #5's bathroom had two live cockroaches. Residents # 3, #8, #9, and #10 had dead cockroaches and other bugs at the head of their beds between the bed and the wall. Record review of the facility's Pest Control log revealed cockroaches had been reported every month since May 2024. Pest control had treated for cockroaches every month. The last visit was on 02/20/25. Interview on 02/27/25 at 5:04 PM with the Director of Plant Operations revealed bugs in the facility was an on-going problem. He stated it was an older building with multiple means of entry for bugs. He stated their…

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 treat each resident with respect, dignity, and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 2 (Residents #22 and #47) of 3 residents reviewed for dignity. RN D failed to maintain Resident #22 and #47's dignity and respect by standing between the residents while feeding both of them during lunch time on 08/27/24 at 12:17 PM . The failure could negatively affect the mental and psychological well-being of all residents who required the assistance of staff with eating. Findings included: Record review of Resident #22's face sheet dated 08/29/2024 reflected the resident was an [AGE] year-old male admitted to the facility on [DATE] with diagnosis of Alzheimer's disease (most common type of dementia), lack of coordination, dysphasia (language disorder marked by deficiency in the generation of speech), and cognitive communication deficit (difficulty thinking…

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 service of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for 5 of 30 days (05/25/2024, 05/26/2024, 06/01/2024, 06/08/2024, and 06/15/2024) reviewed during a look back period from 05/25/2024 to 08/25/2024 for weekend coverage. The facility failed to have RN coverage in the facility for eight consecutive hours on 05/25/2024, 05/26/2024, 06/01/2024, 06/08/2024, and 06/15/2024. This failure could place residents at risk for not having their nursing and medical needs met and improper care. Findings included: Review of the facility's Time Detail Reports from 05/25/2024 to 08/25/2024 reflected the following: - RN C worked from 6:00 PM to 10:00 PM (4 total hours), clocked out for lunch, then resumed work from 10:30 PM to 12:00 AM (1.5 total hours) on 05/25/2024. RN E worked from 6:00 PM to 11:00 PM, clocked out for lunch, then resumed work from 11:30 PM to 12:00 AM (.5 total hours) on 05/25/2024. RN D worked from 6:00 PM to 11:00 PM, clocked out for lunch, then resumed work 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 observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety for 1 of 1 kitchen and 1 of 1 steamtable reviewed for kitchen sanitation, in that: Cook A placed food containers, of the lunch meal in a steamtable that contained contaminated tinted water and burnt food particles floating in it on 08/28/2024. This failure could place residents at risk for food contamination and foodborne illness. Findings included: Observation on 08/28/2024 at 10:58 AM of the kitchen's steamtable revealed six compartments total, but the first and sixth from the left were not being used and had no water in them. [NAME] A placed hamburger steaks and gravy in the second compartment from the left side that had a few inches of dark brown tinted water in it as well as burnt food particles floating in it. [NAME] A placed pinto beans, pureed pinto beans, and pureed cabbage in the third compartment from the left side that also 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 interview and record review, the facility failed to ensure the residents' rights to formulate an advance directive for 1 of 18 residents (Resident #239) reviewed for advanced directives. The facility failed to ensure Resident #239's code status (advance directives) was accurate and consistent with all records at the facility and did not provide information to the resident related to her right to formulate an advance directive. This failure placed residents at risk of not having their end of life wishes honored. Findings included: Record review of Resident #239's face sheet dated [DATE] reflected the resident was a [AGE] year-old female admitted on [DATE]. Record review of Resident #239's admission MDS assessment dated [DATE] reflected the resident was cognitively intact with a BIMS score of 15. The resident's diagnoses included multiple sclerosis (chronic disease of the central nervous system), anxiety disorder (mental health disorder) and hyperkalemia (high potassium). Record review of Resident #239'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 interview and record review, the facility failed to assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every three months for 1 of 5 (Resident #80) residents reviewed for MDS assessments. The facility failed to complete Resident #80's Quarterly MDS Assessment within three months of their most recent comprehensive assessment. This failure could lead to residents not receiving care required for their individualized needs. Findings included: Record review of Resident #80's admission Record dated 08/29/2024 reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE]. Review of Resident #80's Significant Change in Status MDS assessment dated [DATE] reflected the resident had moderate cognitive impairment with a BIMS score of 11. Her diagnoses included diabetes (a chronic disease that affects how the body uses insulin and glucose), hypothyroidism (the thyroid gland does not make enough thyroid…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights as set forth at 483.10(c) and 483.10(c)3, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for one of eight residents (Resident #239) for care plan revisions, in that: The facility failed to develop a care plan addressing Resident #239's elected code status or advance directive. These failures could place residents at risk of receiving inappropriate care. Findings included: Record review of Resident #239's face sheet dated [DATE] reflected the resident was a [AGE] year-old female admitted on [DATE]. Record review of Resident #239's admission MDS assessment dated [DATE] reflected the resident's cognition was intact with a BIMS score of 15. The resident's diagnoses included multiple sclerosis (chronic disease of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a final summary of the resident's status at the time of the discharge was available for release to authorized persons and agencies, with consent of the resident or resident's representative for 1 of 3 residents (Resident #87) reviewed for discharge summary. The facility failed to complete a discharge summary after Resident #87 left the facility and did not return. This failure could place residents at risk for a lack of continued care and services. Findings included: Record review of Resident #87's face sheet dated 08/29/2024 reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. He discharged from the facility on 08/08/2024 to his home. Record review of Resident #87's most recent MDS assessment dated [DATE] reflected he had diagnoses of bipolar disorder (a mental health condition that causes extreme mood swings between emotional highs and lows) and alzheimer's disease (a brain disorder that causes memory…

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

Based on observation, interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 (medication cabinet in the central supplies unit) and one refrigerator in the medication room for 100 and 200 halls reviewed for pharmacy services. The facility failed to ensure expired influenza vaccine, with an expiration date of 05/10/2024, in the Hall 100/200 Medication Room refrigerator and expired medications in the Central Supply medication cabinet were removed and destroyed on 08/28/2024 at 10:45 AM. The failure placed residents at risk of receiving medications that were ineffective due to having expired. Findings included: Observation on 08/29/2024 at 10:45 AM of the 100 and 200 Medication Room refrigerators with LVN K revealed 4 vials of the influenza vaccine lot 370677 with expiration date of 05/10/2024. Interview on 08/29/2024 at 10:55 AM, LVN K stated the night shift nurses were the ones who were…

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 designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Residents #2) of 2 residents reviewed for infection control. LVN L failed to put on a gown before entering Resident #2's room to administer a bolus feeding and medications to Resident #2, who was on enhanced barrier precautions. This failure placed residents at risk of cross contamination and the spread of infection. Findings included: Record review of Resident #2's face sheet dated 08/29/2024 reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #2's Quarterly MDS assessment dated [DATE] reflected his diagnoses included hypertension (high blood pressure), dysphagia (difficulty swallowing) and gastrostomy status (presence…

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 treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices based on the comprehensive assessment of residents for three of six residents (Residents #1, #2, and #3) reviewed for wound care. The facility failed to follow physician orders for wound care for Residents #1, #2, and #3. The failure placed residents at risk of wound deterioration and infection. Findings included: 1. Review of Resident #1's closed clinical record reflected a face sheet, dated 08/22/24, indicating the resident was an [AGE] year-old female admitted to the facility on [DATE]. Resident #1's diagnoses included unspecified fracture of upper end of left humerus (the bone of the upper arm forming joints at the shoulder and the elbow), metabolic encephalopathy (a brain dysfunction that occurs when a chemical imbalance in the blood affects the brain), and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, administering for one (Resident #1) of five residents reviewed for pharmacy services in that: LVN A failed to follow physician's orders for the administration of the medication lorazepam (an anti-anxiety medication) and hydrocodone (a pain medication) to Resident #1 on 09/04/23. This failure could affect residents and place them at risk of not receiving medications as ordered by their physician. Findings included: Review of Resident #1's face sheet, dated 10/02/23, reflected the resident was admitted to the facility on [DATE]. Her diagnoses included anxiety disorder (a group of mental illnesses that cause constant fear and worry) and primary osteoarthritis (a condition that causes several different symptoms that can impact your function and affect your ability to perform your daily activities). Review of Resident #1's Significant Change in Status MDS, dated [DATE],…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the clinical record were maintained in accordance with accepted professional standards and practices and were complete and accurately documented for one (Resident #1) of five residents records reviewed for resident records, in that: LVN A failed to accurately document the administration of Resident #1's hydrocodone and lorazepam on 09/04/23 on the resident's MAR. This failure could affect the residents medical record not being an accurate representation of the resident's medical condition or medical needs. Findings included: Review of Resident #1's face sheet, dated 10/02/23, reflected the resident was admitted to the facility on [DATE]. Her diagnoses included anxiety disorder (a group of mental illnesses that cause constant fear and worry) and primary osteoarthritis (a condition that causes several different symptoms that can impact your function and affect your ability to perform your daily activities). Review of Resident #1's Significant…

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 daily living for two residents (Resident #24 and Resident #5) of eighteen residents reviewed for environmental concerns. 1. Resident #24's and Resident #5's room had a foul odor, the floor was sticky with debris, and the toilet was covered in feces. The two residents shared a room. 2. There was a pervasive foul odor on the Memory Care Unit (300 Hall). These failures could place residents at risk of living with unclean, uncomfortable, un-homelike rooms and a diminished quality of life. Findings included: Record review of Resident #24's face sheet revealed the resident was an [AGE] year-old male, initially admitted on [DATE], and readmitted on [DATE] with diagnoses that included: dementia behavioral disturbance (loss of memory and thinking abilities), Type II diabetes, Parkinson's disease (nervous system disorder), anorexia (eating disorder), and atrial fibrillation (irregular…

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 total privacy for residents in 6 (Rooms 303 A bed, 304 B bed, 306 A bed, 307 A bed, 308 B bed and 309 A bed) of 19 rooms reviewed for privacy. The facility failed to provide curtains to ensure resident's privacy in Rooms 303 A bed, 304 B bed, 306 A bed, 307 A bed, 308 B bed and 309 A bed. This failure could place residents at risk of decreased self-worth by being exposed during resident care. Findings included: Observation and interview on 06/20/23 at 11:09 AM of room [ROOM NUMBER] (A bed) revealed the resident, who resided in this room, was sitting in her chair watching television. Further observation revealed there was not a privacy curtain available to surround the A bed, which was nearest the door. The resident stated she wished she had a privacy curtain in her room so she could have privacy when she wanted it. She stated she had been at the facility for a while and had never had a privacy curtain for her bed. Observation 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 observation, interview, and record review, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (Resident #32) of two residents reviewed for pressure ulcers. The facility failed to ensure the Stage 4 pressure ulcer on Resident #32's sacrum was covered with a dressing as ordered by the physician. This failure could affect the residents, who received pressure ulcer care, by placing them at risk for contamination of their wounds and causing unnecessary infections and worsening of pressure ulcers. Findings included: Record review of Resident #32's face sheet revealed the resident was a [AGE] year-old male who was admitted into the facility on [DATE] with diagnoses, unstageable pressure ulcer on right hip (refers to an ulcer that has full thickness tissue loss but is either covered by extensive necrotic tissue or by an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure it was free of a medication error rate of five percent (5%) or greater on 3 errors of 33 opportunities for errors leading to 9.09% medication error rates for one (LVN B) of two staff observed for medication pass. The facility failed to ensure LVN B administered all the crushed medication in the medication cups without leaving residue for Resident #2. These failures resulted in a 9.09% medication error rate and could put residents at risk who received medications via g-tube for not receiving the correct dose of medication and getting intended therapy. Findings included: Review of Resident #2's Quarterly MDS assessment dated [DATE], revealed the resident was a [AGE] year-old male, admitted to the facility on [DATE]. Resident #2 had diagnoses which included difficulty in swallowing, oropharyngeal phase (middle part of the throat), and gastrostomy status (an opening into the stomach from the abdominal wall made surgically). Resident #2…

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.