Avir at Hillsboro

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for one (Resident #15) of eight residents reviewed for bathing/showering. 1. The facility failed to provide showers to Resident #15 in compliance with his shower schedule.2. The facility failed to have appropriate interventions in place when Resident #15 refused or was in too much pain to receive a bath. This deficient practice could place residents at risk of decline in skin integrity and overall healthFindings included: Review of Resident #15's quarterly MDS assessment dated [DATE] reflected a [AGE] year-old male who admitted to the facility on [DATE]. His diagnoses included: high blood pressure, kidney failure, high cholesterol, stroke, hemiplegia (complete paralysis on one side of the body), seizure disorder, depression, unspecified pain, generalized edema (swelling), constipation, and gout (sudden, 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 provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, 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, encouraging both independence and interaction in the community for 1 (Residents #4) of 8 residents reviewed for activities. The facility failed to ensure they provided in-room activities for Resident #4 who spent most of or all her time in her room. This failure placed residents at risk of boredom, depression, and diminished quality of life. Review of Resident #4's quarterly MDS assessment dated [DATE] reflected a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included: heart failure, high blood pressure, diabetes mellitus (body's impaired ability…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure a 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 1 of 6 Residents (Resident #17) reviewed for respiratory care. The facility failed to place Resident #17's oxygen tubing in a bag when not in use and failed to keep her concentrator filter clean. This failure could place residents at risk of not receiving appropriate air flow resulting in shortness of breath respiratory infections. The findings were: Record review of Resident #17's undated face sheet reflected a [AGE] year-old female admitted on [DATE] with diagnoses of Unspecified Dementia (a decline in memory, thinking, daily problem solving), Heart Failure, Hyperlipidemia (elevated cholesterol), and Hypertension (elevated blood pressure). Record review of Resident #17's care plan dated 03/31/2022 reflected Resident requires…

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 residents' drug regimen was adequately monitored and free from unnecessary drugs for 1 of 6 (Resident #10) residents reviewed for pharmacy services. The facility failed to obtain a stop date for Resident #10's Amoxicillin-Pot Clavulanate (an antibiotic used to treat an acute infection) started on 11/27/2025. This failure could place residents at risk of side effects (gastrointestinal upset, multiple drug-resistant infections) related to long term antibiotic use. Findings included: Record review of Resident #10's undated face sheet reflected an admission date of 08/01/2025 with diagnoses of diverticulosis of the small intestine (inflammation of pouches within the small intestine), diabetes type 2 (elevated blood sugar), chronic kidney disease, and cellulitis (an infection within the skin). Record review of Resident #10's care plan, dated 05/01/2025, reflected, (Resident #10) am at risk for frequent infections, pressure/venous/stasis ulcers,…

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 and prevention control program that included, at a minimum, a system for preventing and controlling infections for 3 of 6 residents reviewed for infection control (Resident #39, Resident #42, and Resident #57). 1) MA failed to clean the electronic blood pressure cuff after use on Resident #57 and prior to use on Resident #39 in an observation of medication pass at 8:45 a.m. on 12/4/25. 2) LVN A did not wear PPE for enhanced barrier precautions while performing wound care and wash/clean her hands when removing soiled gloves, prior to applying clean gloves on 12/04/2025 at 10:17 a.m. for Resident #42's wound care observation. This deficient practice could place residents at risk for cross contamination and the spread of infection. Findings included: 1. Record review of Resident #39's undated face sheet reflected an admission date of 10/01/2025 with diagnoses of Atrial Fibrillation (an irregular heartbeat),…

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 Acronyms: HTN COPD MDS DON ADM LVN BIMS Based on interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan within 7 days after comprehensive assessment and within 21 days from admission for 1 of 1 resident (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1 had a Comprehensive Care Plan that was due within 21 days of admission to reflect the person-centered needs of Resident #1. Resident #1 received only a Baseline Care plan at the time of admission. This failure could place residents at risk of getting insufficient care and having personal needs not met. This could result in diminishing physical and psychosocial well-being. Findings include: Review of Resident #1's undated face sheet reflected that she was a [AGE] year-old female admitted [DATE] with diagnoses of COPD (lung disease), Dementia, Diabetes Type 2, HTN, and Hypothyroidism. Review of Resident #1's 4/17/25 Quarterly MDS reflected her BIMS score was 05, 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 Acronyms: HTN COPD MDS DON ADM LVN BIMS Based on observations, interviews, and record review the facility failed to ensure that the resident's record reflected an ongoing assessment of the resident's respiratory status, a practitioner's order, and indications for use of oxygen for 1 of 1 resident (Resident #1) reviewed for oxygen therapy. The facility failed to ensure Resident #1's chart reflected a practitioner's order for oxygen indicating the amount and flow type for Resident #1's use of oxygen. There was no oxygen assessments in the chart for Resident #1's diagnosis of COPD. This failure placed residents at risk of developing respiratory distress by receiving too much or too little oxygen . Findings included: Review of Resident #1's undated face sheet reflected that she was a [AGE] year-old female admitted [DATE] with diagnoses of COPD (lung disease), Dementia, Diabetes Type 2, HTN, and Hypothyroidism. Review of Resident #1's Quarterly MDS dated [DATE] reflected her BIMS score was 05, which indicated 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 ensure that the resident environment remained as free of accident hazards as possible for one (Resident #1) of four residents reviewed for accidents hazards, in that: The facility failed to ensure Resident #1 was transferred by mechanical device from her shower chair to her bed without receiving a cut and a bruise on her right toe. This failure could place residents at risk of pain, bruising, or skin tears. The findings included: Review of Resident #1's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including dementia (a decline in mental ability severe enough to interfere with daily life, diastolic (congestive heart failure - a condition where the heart muscle is unable to relax properly between heartbeats, leading to reduced filling of the heart chambers and decreased cardiac output),). Review of Resident #1's care plan reflected no goal, problem, or approach related 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #1) of 6 residents reviewed for incidents. The facility failed to identify a purple bruise observed on Resident #1's forearm on 11/19/24. This deficient practice could place residents at risk of abuse, neglect, and untreated and unassessed injuries. Findings included: Review of Resident #1's face sheet, dated 11/19/24, reflected she was a [AGE] year-old female who was admitted to the facility on [DATE] and had diagnoses including type 2 diabetes mellitus, unsteadiness on feet, muscle wasting and atrophy, generalized muscle weakness, other lack of coordination, unspecified protein-calorie malnutrition, mild cognitive impairment, and weakness. Review of Resident #1's quarterly MDS assessment, dated 10/10/24, reflected she had a BIMS score of 8, 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.

Based on observations, interviews, and record review the facility failed to ensure the resident environment remained free of accident hazards as was possible for 1 of 1 doorway in the 100-hallway reviewed for accidents and hazards. The facility failed to ensure the storage room on the 100-hallway remained closed and locked while a staff member was not actively retrieving or stocking hazardous items in the storage room when the door to the storage room was observed open on 9/24/2024. This failure could place residents who accessed the 100- hallway at risk of injury or illness from access and exposure to hazardous items. Findings included: Observation on 9/24/2024 at 8:40 AM of the 100-hallway revealed the door with punch number keypad open approximately 6 inches. No staff member was visible on the hallway for more than five minutes while the door was open. Items observed in the storage room were Medline mouthwash rinse, Medline fluoride toothpaste, Medline premium adult toothbrushes, denture cleanser tablets, Medline twin blade disposable razors, aerosol can of shave cream, Remedy…

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, 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 18 (Resident #1, #4, #5, #12, #14, #19, #20, #26, #33, #34, #40, #42, #53, #57 #58, #65, #72, and #122) of 24 residents reviewed for late medications. Facility failed to ensure Resident #1, #4, #5, #12, #14, #19, #20, #26, #33, #34, #40, #42, #53, #57 #58, #65, #72, and #122 were given medications at 9:00 AM in the morning and not administered after 11:00 AM on 09/25/24. These failures could place residents at risk for medication errors and jeopardize the resident health and safety. Finding included: Review of Resident #1's face sheet dated 09/25/2024 reflected a [AGE] year-old female who was admitted to the facility on [DATE]. She had allergy to Lisinopril. Her diagnoses included cerebral palsy (a congenital disorder of movement, muscle tone 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 observation, interview, and record review, facility failed to ensure the medication error rate was not 5 percent (5%) or greater for total number of errors, 27 of 177 opportunities for errors, resulting in an 15% medication error rate for 16 of 24 residents observed for medication pass (Resident #1, #4, #5, #14, #19, #20, #22, #26, #34, #40, #42, #53, #57 #58, #65, and #122) per observation on 09/25/2024. Facility failed to ensure Resident #1, #4, #5, #14, #19, #20, #22, #26, #34, #40, #42, #53, #57 #58, #65, and #122 were given medications at 9:00 AM in the morning and not administered after 11:00 AM on 09/25/24, which resulted in medication errors. These failures could place residents at risk for significant medication errors and jeopardize the resident health and safety. Finding included: Review of Resident #1's face sheet dated 09/25/2024 reflected a [AGE] year-old female who was admitted to the facility on [DATE]. She had allergy to Lisinopril. Her diagnoses included cerebral palsy (a congenital…

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 food that was palatable for one of one regular diet test trays reviewed for food and nutrition services. The facility failed to properly cook rice, serving rice which had hard, uncooked bits. This failure could affect the residents who are provided daily meals by the facility, by placing them at risk for not enjoying meals, and weight loss. Findings included: In an anonymous group interview on 09/25/24 at 10:30 AM, residents complained that the food at the facility was not good. They said there had been some improvement under the new dietary manager and the facility had to buy the food in bulk from a company. The acknowledged it was not ever going to be the same as home cooking, but they felt the food was not cooked properly. They said they really wished there was something that could be done about the quality of the food. One resident said that the vegetables were so overcooked they were just mush and they were sick of being served that repeatedly. Another resident said the food often just isn't…

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 infections for all residents in the memory care unit and for 4 residents on the 300 hallways (Residents #5, #12, #20, #34 and #38) reviewed for infection control. 1. The facility failed to ensure LVN H, CNA I, and CNA J performed hand hygiene while passing trays and setting up meals for all residents in the memory care unit on 09/24/2024. 2. The facility failed to ensure LVN H and CNA I performed hand hygiene before and after helping Resident #38 eat her lunch in the dining room on 09/24/2024. 3.The facility failed to ensure CNA F performed hand hygiene and sanitized the blood pressure cuff in between resident use on Residents #5, #12, #20, and #34 on 09/25/2024. These failures could place residents at risk of infectious diseases and cross…

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 to keep the facility free of pests for two of four halls and the food preparation area in the facility's only kitchen reviewed for physical environment. 1) The facility failed to effectively treat for the flies on hall 200 and hall 300. 2) The facility failed to implement preventative measures in the kitchen to prevent flies. These failures could place residents at risk for the potential spread of infection, cross-contamination, food-borne illness, and decreased quality of life. Findings included: Observation and interview with Resident #10 on 09/24/2024 at 09:25 AM, revealed upon entry to Resident #10's room, flies are observed flying around in her room. Resident #10 stated she was sick and tired of the flies in her room. Resident #10 stated she had a family member to buy a fly swatter. She stated the flies were just a pest and all over her drink. 4 large flies are observed in her room with one on her pink hydration cup. She stated they drive me nuts as she moved…

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 care for residents in a manner and in an environment that maintained or enhanced dignity and respect for 1 (Resident #38) of 21 residents in memory care dining rooms in that: 1. The facility failed when on 09/24/2024 LVN H was standing while feeding (Resident #38) in the memory care unit dining room at lunch meal. 2. The facility failed when on 09/24/2024 CNA I was standing while feeding (Resident #38) in the memory care unit dining room at lunch meal. This deficient practice could affect residents who were dependent on eating and could contribute to feelings of poor self-esteem and decreased self-worth. The findings included: Record review of Resident #38's face sheet dated 09/26/2024 reflected she was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of Unspecified dementia, mild, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a person with memory loss, difficulty…

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 review the risks and benefits of bed rails and enabler/grab bars (smaller bars used by the person in bed to reposition themselves), with the resident or resident representative, have physician orders, conduct a safety assessment, and obtain informed consent prior to installation for one (Resident #224) of three residents beds observed and reviewed for quarter bed rails/enabler bars. The facility failed to have evidence on 09/25/2024 of informed consent, assessment of the resident for risk of entrapment, care planning or a physician's order for the quarter bed rails/enabler bars for Resident #224. This failure could affect residents who used quarter bed rails/enabler bars at risk of the resident/responsible party not being aware of the risks, informed consent not being obtained from the resident or responsible party, physician not being aware of use of the enabler/grab bars, and care plan not being properly documented. Findings included:…

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 food that accommodated resident's preferences for one (Resident #40) of five residents reviewed for food and nutrition services. The facility failed to provide Resident #40 with his preferred food when they failed to provide toast for his breakfast, and provided pancakes instead. This failure could affect the residents who are provided daily meals by the facility, by placing them at risk for not enjoying meals, and weight loss. Findings included: Resident #40: Review of Resident #40's admission record, dated 09/25/24, reflected a [AGE] year-old male with an initial admission to the facility on [DATE], and readmitted on [DATE]. Resident #40 had diagnoses of Quadriplegia (paralysis that affects all four limbs due to spinal cord injury), kidney injury due to long term drug therapy, abdominal distention, urinary catheter, cramps and muscle spasm, Myocardial infraction (heart attack), high blood pressure, congestive heart failure,…

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 all alleged violations were reported to HHSC for 1 (Resident # 1) of 6, residents reviewed for accidents and supervision. The facility failed to report to HHSC a serious injury that occurred. The facility failed to investigate a serious injury that occurred when Resident # 1 sustained a wrist fracture and other injuries CNA A left her unsupervised and she fell out the bed on 4/14/2024. The failure could place residents at risk of accidents and harm. Findings included: Record review of Resident #1's face sheet dated 1/9/2024 reflected, Resident #1 is a [AGE] year-old female who was admitted to the facility on [DATE]. The face sheet reflected Resident #1 had the following diagnoses Other acute osteomyelitis ( bone inflammation that can result in pelvis trauma), left femur, Muscle wasting and atrophy (wasting, thinning or loss of muscle tissue), not elsewhere classified, right upper arm, Muscle wasting and atrophy (muscle that lose their nerve…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure residents received services in the facility with reasonable accommodations of each resident's needs for 4 of 5 residents (Residents #1, #2, #3 & #4) reviewed for call lights in that: Residents #1, #2, #3, & #4's call lights were not within reach. This failure could affect all residents who needed assistance with activities of daily living and could result in needs not being met. Findings included: Resident #1 Record review of Resident #1's admission record dated 10/17/23 documented a [AGE] year-old female admitted on [DATE]. Resident #1's documented diagnoses included: Unspecified Dementia (loss of thinking abilities), Disorder of bone density (thin fragile bones), Weakness, Essential hypertension (elevated blood pressure), Fracture of the third cervical vertebra (broken vertebra in the neck region) Record review of Resident #1's Significant change MDS assessment dated [DATE] revealed the resident had a BIMS score of 99…

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 immediately notify the resident's representative(s) when there was a significant change in the resident's physical status for one (Resident #1) of four residents reviewed for changes in condition. The facility failed to ensure Resident #1's POA was notified that he had a fall and was sent out to the local hospital for further evaluation. This failure placed residents at risk of a decreased quality of life and increased psychosocial harm by depriving residents of the right to have representative(s) notified of significant changes in resident condition. Findings included: Record review of Resident #1's undated face sheet printed 09/16/23 reflected a 90 -year-old male who was admitted to the facility on [DATE] with diagnoses including dementia(loss of memory), hypothyroidism(thyroid gland doesn't produce enough thyroid hormone), lymphedema(blockage in the lymphatic system), congestive heart failure(heart does not pump blood as well )((hypertension(high…

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 residents' right to a safe, clean, comfortable, and homelike environment for one of four (secured unit) halls reviewed for environment. The secure unit of the facility possessed a strong foul odor. This failure placed residents at risk of discomfort and diminished quality of life. Findings included: Observation on 08/14/23 at 10:56 AM revealed a strong foul odor immediately upon entering the secure unit of the facility. During observation and an interview on 08/14/23 at 12:48 PM the strong foul odor was still present in the secure unit of the facility, and CNA E stated she noticed the odor and that it was urine. She stated she worked in the unit regularly and had noticed the odor for weeks. When asked what she thought caused the odor, she stated she thought it might be the mattresses. A walk through the hall and into the resident rooms revealed no clear source of the odor. No resident in the secure unit had an obvious foul odor emanating from their person. Observation on 08/14/23 at 04:05 PM…

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 sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for one of four halls (hall 300/secure unit) reviewed for sufficient staff. The facility regularly had only one staff person working with the 20 residents in the 300 hall/secure unit. This failure placed residents at risk of falls, escalating aggressive behaviors, and diminished quality of life. Findings included: Review of the resident roster for 08/14/23 reflected 20 residents lived on the 300 hall/secure unit of the facility. Review of nurse staffing schedules for 08/14/23 to 08/16/14 reflected one CNA and one were nurse assigned to the 300 hall/secure unit. Review of the undated face sheet for Resident #41 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of severe dementia, Alzheimer's disease,…

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 residents' rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental, and psychosocial needs for 1 of 15 residents (Residents #20) reviewed for care plans. The facility failed to ensure Resident #20's care plan included his use of an O2 concentrator and a C-PAP machine. This failure could place residents at risk of receiving inadequate interventions that were not individualized to their care needs. Findings included: Record review of an undated Face Sheet for Resident #20 reflected he was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Unspecified Dementia (loss of thinking, remembering and reasoning skills) that are severe enough to interfere with daily life, Congestive Heart Failure (a chronic condition in which the heart doesn't pump…

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 respiratory care consistent with professional standards of practice for 2 of 2 residents (Resident #20 and Resident #42) reviewed for oxygen therapy. A) The facility failed to ensure Resident #20's C-PAP mask and tubing, O2 tubing, and oxygen concentrator filter were kept clean for his use. The humidifier bottle was empty. B) The facility failed to ensure Resident #42's O2 tubing was bagged and kept clean for her use. These failures could place all residents who use respiratory equipment at risk for respiratory infections. Findings included: A) Record review of an undated Face Sheet for Resident #20 reflected he was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Unspecified Dementia (loss of thinking, remembering and reasoning skills) that are severe enough to interfere with daily life, Congestive Heart Failure (a chronic condition in which the heart doesn't pump blood as well…

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.