Avir At Jefferson

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an accurate MDS was completed for 1 of 18 residents reviewed for accuracy of assessments. (Resident #8) The facility failed to accurately document restraint usage for Resident #8. This failure could place residents at risk of not receiving needed care and services. Record review of an undated face sheet revealed Resident #8 was a 100- year-old- female, admitted on [DATE] with the diagnoses of Alzheimer's disease (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), anemia (a condition in which the body does not have enough healthy red blood cells), and malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function). Record review of a quarterly MDS, dated [DATE], for Resident #8 revealed a BIMS of 05, which indicated a severe cognitive impairment. The MDS also revealed Resident #8 required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to develop the baseline care plan within 48 hours of admission for 1 of 22 residents (Resident #55) reviewed for baseline care plans. The facility failed to ensure Resident #55's baseline care plan was completed within 48 hours of admission. This failure could affect residents by not addressing their physical, mental, and psychosocial needs for each resident to attain or maintain their highest practicable physical, mental, and psychosocial outcome. The findings included: Record review of the face sheet, dated 12/03/25, reflected Resident #55 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of extradural and subdural abscess (buildup of pus from an infection located in the brain), acute on chronic heart failure (chronic, progressive disease in which the heart muscle is unable to pump enough blood to oxygenate the body), and COPD (chronic lung condition in which the lungs are damaged). Record review of the admission MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who had a urinary catheter received appropriate treatment and services to prevent urinary tract infections to the extent possible for 1 of 2 residents reviewed for catheter care. (Resident #81).The facility failed to ensure Resident # 81's securement device was in place to reduce friction and movement at the insertion site on 12/1/2025.This failure could place residents at risk of not receiving care and services needed to address catheter care.Findings included: Record review of Resident #81's face sheet dated 12/2/2025 indicated Resident #81 was a [AGE] year-old, male and readmitted on [DATE] with diagnoses including cerebral infarction (a medical condition characterized by the interruption of blood supply to the brain), atherosclerotic heart disease of native coronary artery with other forms of angina pectoris (characterized by the buildup of plaque in the coronary arteries, leading to narrowed or blocked arteries which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure the PICC line site was maintained consistent with professional standards of practice for 1 of 1 residents (Resident #83) reviewed for central venous lines (a thin, flexible tube that's inserted into a large vein to provide access to the circulatory system). The facility failed to change a PICC line (a type of central venous line) dressing, consistent with physician's orders for Resident #83. This failure could place residents at risk of a systemic infection that could lead to serious illness and/or death. Record review of a face sheet dated 12/02/25 revealed Resident #83 was a [AGE] year-old male and was re-admitted on [DATE] with diagnoses including sepsis due to Escherichia Coli (a life-threatening condition caused by the body's extreme response to an E. coli (a type of bacteria) infection), muscle wasting, and lack of coordination. Record review of a progress note dated 11/21/25 at 10:11 p.m. indicated Resident #83 had returned 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, interview and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 1 of 22 residents reviewed for respiratory care. (Resident #10) The facility failed to properly store Resident #10's oxygen mask while not in use by the resident. This failure could place residents at risk of respiratory complications or respiratory infection. 1. Record review of a face sheet dated 12/04/25 indicated Resident #10 was [AGE] years old and admitted on [DATE] with diagnoses including acute respiratory failure (a life-threatening condition where the lungs cannot get enough oxygen into the blood or remove enough carbon dioxide from the blood), tracheostomy status (an opening in the neck to the windpipe, or trachea, through which a tube is inserted to provide an airway), and history of cardiac arrest (is when the heart suddenly stops beating effectively due to electrical problems, cutting off blood flow to the body ). Record review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and reviews, the facility failed to act upon the recommendations of the pharmacist report of irregularities for 1 of 6 residents (Resident #11) reviewed for (DRR) Drug Regimen Review. The facility failed to complete a psychotropic consent form for Resident #11 after the pharmacist recommended the form was needed on 11/10/2025 for Haldol (antipsychotic mediation) and Zyprexa (antipsychotic medication). This failure could place residents at risk residents of not having a drug regiment that is appropriate for their needs.Record review of an undated face sheet dated revealed Resident #11 was an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of schizophreniform disorder (a psychotic disorder characterized by symptoms similar to schizophrenia, such as delusions, hallucinations, and disorganized speech, but its duration is shorter, lasting from one to six months) psychotic disorder (a severe mental health condition characterized by a loss of contact with reality, resulting…

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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation in that: 1. Dietary Manager not properly securing facial hair. 2. Particles on top of dishwasher. 3. Grease buildup on the left side of gas stove and grease [NAME]. These deficient practices could place residents who received meals from the kitchen at risk for food borne illness. The findings were: 1. During an observation on 9/16/2024 at 8:55 AM, the dietary manager was not wearing proper facial covering upon entry into the kitchen. During an observation on 9/17/2024 at 8:19 AM, the dietary manager was not wearing facial covering. During an observation and interview on 9/18/2024 at 9:50 AM, Dietary Aide A said everyone should be wearing hair covering while entering the kitchen. She said males should have their facial hair covered and no hair should be sticking out of the hair net.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that residents who need respiratory care are provided with such care, consistent with professional standards of practices for 3 of 22 residents (Resident #8, Resident #48, and Resident #190) reviewed for respiratory care. 1. The facility failed to change the oxygen tubing for Resident #8. 2. The facility failed to ensure Resident #48's nasal cannula humidification bottle (aids in preventing a patient's airways from becoming dry) had water in it. 3. The facility failed to ensure LVN Q performed Resident #190's tracheostomy care using aseptic technique per the facility's policy. 4. The facility failed to ensure LVN Q performed Resident #190's tracheostomy care and cleaning per the facility's policy. 5. The facility failed to ensure LVN Q used the prescribed solution to clean Resident #190's tracheostomy site. These failures could place residents at risk for of respiratory infections. Findings included: 1. Record review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure each resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 3 of 24 residents (Resident #7, Resident #17, and Resident #50) reviewed for reasonable accommodations. The facility failed to ensure Resident #7, Resident #17, and Resident #50's call button was within reach while in bed. These failures could place residents at risk for a delay in assistance and decreased quality of life, self-worth, and dignity. Findings include: 1. Record review of Resident #7's face sheet, dated 4/19/24 revealed a [AGE] year old female admitted on [DATE] with diagnoses that included Pneumonia (a lung infection that causes the air sacs in the lungs to fill with fluid or pus, which can make breathing difficult and painful), Dementia (a group of conditions that cause a gradual decline in cognitive abilities, such as thinking, remembering, and reasoning), and Hypertension (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that that all alleged violations involving a drug diversion were reported after the allegation was made to other officials (including to the State Survey Agency) in accordance with State law through established procedures for 1 resident (Resident #25) of 4 resident reviewed for drug diversion in that: The facility was made aware of a possible drug diversion on 07/12/2024. LVN M reported to the ADM receiving a bottle of hydromorphone from Hospice Nurse N that was tampered with upon receipt of the medication. This failure could result in allegations or instances of resident drug diversion not being reported or investigated by the state survey agency. Findings include: Record review of an undated face sheet indicated Resident #25 was a [AGE] year-old male admitted to the facility on [DATE] with the diagnoses of Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), COPD (A group of lung…

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 baseline care plan that included the instructions for resident care needed to provide effective and person-centered care was completed and provided to the resident and/or their representative for 3 of 9 residents reviewed for new admissions (Resident #2, Resident #36, and Resident #190). The facility failed to complete a baseline care plan for Resident #36 within 48 hours of admission. The facility failed to provide Resident #2 and Resident #190's RP, a copy of the summary of the baseline care plan. These failures could place residents at risk of not receiving care and services to meet their needs. Findings included: 1. Record review of Resident #36's face sheet dated 09/16/24 indicated Resident #36 was an 85-years-old, male admitted to the facility on [DATE] and 09/04/24 with diagnoses including fracture of upper end of left femur (is a break in the uppermost part of thighbone, next to the hip joint), Extended Spectrum Beta Lactamase (ESBL)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 2 of 26 residents reviewed for care plans.(Resident #30 and Resident #43). 1. The care plan for Resident #30 failed to address his Stage IV sacral pressure ulcer. 2. The care plan for Resident #43 failed to address new interventions and updates for fall prevention. Theses failures could place residents at risk for not receiving the necessary care or having important care needs identified. Findings include: 1. Record review of an undated face sheet indicated Resident #30 was a [AGE] year-old-male admitted to the facility on [DATE] with the diagnoses of spinal stenosis (condition in which the spinal canal narrows and puts pressure on the nerve root) and dementia (a group of conditions that can cause gradual decline in cognitive abilities), and diabetes mellitus. Record review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents received care, consistent with professional standards of practice, to prevent pressure ulcers based on the comprehensive assessment for 2 of 4 residents (Resident #36 and Resident #187) whose record were reviewed for skin integrity. The facility failed to ensure Resident #36 and Resident #187's pressure-relieving mattress (is designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) was on the correct settings. This failure could place residents at risk for developing and/or worsening of pressure ulcers Findings included: 1. Record review of Resident #36's face sheet dated 09/16/24 indicated Resident #36 was an [AGE] year-old, male admitted to the facility on [DATE] and 09/04/24 with diagnoses including fracture of upper end of left femur (is a break in the uppermost part of thighbone, next to the hip joint), Extended Spectrum Beta Lactamase (ESBL) resistance (is an enzyme…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 5 residents (Resident #2) reviewed for appropriate treatment and services to prevent urinary tract infections (an infection in any part of the urinary system, the kidneys, bladder, or urethra (is a hollow tube that lets urine leave your body)). The facility failed to ensure LVN Q documented Resident #2 had red-tinged urine (a urinary tract infection (UTI) is one of the most common causes of blood in your urine) in his indwelling catheter (drains urine from your bladder into a bag outside your body). The facility failed to ensure LVN Q reported to LVN M that Resident #2 had red-tinged urine in his indwelling catheter. The facility failed to ensure LVN Q reported to MD T Resident #2's red-tinged urine after Resident #2 had reported increased confusion and elevated white blood cell count. These failures…

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 to include procedures that assured the accurate dispensing and administering of all drugs to meet the needs of 1 of 7 residents reviewed for pharmaceutical services. (Resident #17) Facility staff left Resident #17's medications at the bedside. These deficient practices could affect residents and place them at risk of not receiving the therapeutic dosage and drug diversion. The findings were: Record review of Resident #17's face sheet, dated 1/4/24 revealed a [AGE] year old female admitted on [DATE] with diagnoses that included Systolic Heart Failure (occurs when the left ventricle of the heart is too weak to pump enough blood to the body), Hypertensive Herat Disease (a constellation of changes in the left ventricle, left atrium, and coronary arteries as a result of chronic blood pressure elevation), Old Myocardial Infarction (a previous heart attack that's detected by an electrocardiogram (ECG) as pathologic…

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, based on the comprehensive assessment of a resident, residents who had not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 26 residents (Resident #287) reviewed for psychotropic medications. The facility failed to have an appropriate diagnosis or indication of use for Resident #287's Quetiapine (antipsychotic). These failures could put residents at risk of receiving unnecessary psychotropic medications. Findings included: Record review of a face sheet dated 9/17/2024 indicated Resident # 287 was an [AGE] year-old female who was admitted on [DATE] with diagnosis including dementia (a group of thinking and social symptoms that interferes with daily functioning), heart failure (a chronic condition in which the heart does not pump blood as well as it should) , atrial fibrillation (an irregular, often rapid heart rate that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that residents were free of significant medication errors for 1 of 5 residents (Residents #36) reviewed for pharmacy services. The facility failed to ensure Resident #36 Levothyroxine (is used to treat hypothyroidism, a condition where the thyroid gland does not produce enough thyroid hormone) and Pantoprazole (is used to treat heartburn and certain other conditions caused by too much acid in the stomach) were scheduled and administered for optimal therapeutic effect (is a consequence of the medical treatment of any kind, the results of which are judged to be desirable and beneficial). This failure could place residents at risk of medical complications and not receiving the therapeutic effects of their medications. Findings included: Record review of Resident #36's face sheet dated 09/16/24 indicated Resident #36 was an 85-years-old, male admitted to the facility on [DATE] and 09/04/24 with diagnoses including hypothyroidism (a condition where…

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 and provide supervision to prevent avoidable accidents for 1 of 6 residents reviewed for accidents. (Resident #1) The facility failed to ensure Resident #1 was properly transferred in bed by facility staff. This failure could place residents at risk of injury from accident and hazards. Findings included: Record review of the face sheet dated 07/30/24 revealed Resident #1 was [AGE] years old and admitted on [DATE] with diagnoses including Alzheimer's Disease (A progressive disease that destroys memory and other important mental functions), dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities), and age-related osteoporosis (a condition that causes bone to become weak and brittle). Record review of the quarterly MDS dated [DATE] revealed Resident #1 was sometimes understood and sometimes understood others.…

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 program designed to provide a safe sanitary and comfortable environment and to prevent the development of infections for 4 of 5 residents reviewed for infections. (Residents #1, #3, #4, and #5) The Treatment Nurse did not wash her hands while providing wound treatments for Residents #1, #3, #4, and #5. The treatment nurse did not change her gloves between dirty and clean wounds for Resident #1. The Treatment Nurse did not change gloves from one wound to the next wound during Resident #5's wound treatments. This negative finding had the potential to cause infections. Finding included: Record review of Resident #1's face sheet dated 4/23/24 indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included diabetes, muscle wasting and difficulty walking. Record review of Resident #1's computerized physician order dated 4/23/24 indicated an order dated 4/19/24 to cleanse…

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 all patient care equipment was in safe operating condition for 1 of 2 resident (Resident#1) reviewed safe, functional equipment. The facility failed to ensure Resident #1's wheelchair brakes were functioning correctly. This failure could place residents at risk of injuries and falls. Findings included: Record review of Resident #1's face sheet, dated 09/19/23, indicated a [AGE] year-old female who was admitted to the facility on [DATE], with a readmission on [DATE]. Resident #1 had diagnoses which included generalized muscle weakness, history of falling, age-related cognitive decline (experience of worsening or more frequent confusion or memory loss), age related osteoporosis (is a bone disease that develops when bone mineral density and bone mass decreases, or when the quality or structure of bone changes) without current pathological fracture (a complete or partial break in a bone), muscle wasting and atrophy (shortening), and…

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

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety in the facility's only kitchen, reviewed for kitchen sanitation. The facility failed to ensure refrigerated foods were properly labeled and dated. This failure could place residents at risk for food-borne illness. Findings included: During an observation of the kitchen refrigerators on 08/14/23 at 09:05AM these items were found: *1 container of black-eyed peas marked with a date of 8-9 *1 container of brown gravy marked with a date of 8-9 *1 container of sausage marked with a date of 8-6 *1 container of bacon, not labelled with a name or date *1 container of celery marked with a date of 8-9 *1 container of mandarin oranges marked with a date of 8-9 During an interview on 08/14/23 at 9:10AM, the Dietary Manager said the dates on the food items in the fridge were the date they were prepared and placed in the refrigerator. She said most items were good for 3 days and then they throw them out. During an interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care and provide the resident and their representative with a summary of the baseline care plan that included goals of the resident, summary of medications and dietary instructions, and services and treatments for 5 of 10 residents reviewed for baseline care plans. (Resident #238, Resident #240, Resident #339, Resident #388, and Resident #389) 1.The facility failed to develop a baseline care plan with initial goals and the minimum healthcare information necessary to provide person-centered care for Resident #238, Resident #240, Resident #339, Resident #388, and Resident #389. 2.The facility failed to provide a copy of the summary of the baseline care plan to the resident and his representative. These failures could place residents at risk of not receiving care and services to meet their needs. 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 observations, interviews, and record reviews the facility failed to treat residents with respect and dignity and care for them in a manner and in an environment that promoted maintenance or enhancement of their quality of life for 1 of 24 residents reviewed for resident rights in the memory care unit. (Resident #60) The facility failed to treat Residents #60 with respect and dignity when she had to wait 15 minutes to receive her lunch tray after the other resident at her table had already been served their meal and been eating in front of her. This failure could place residents at risk for decreased quality of life, decreased self-esteem and increase anxiety. Findings included: Record review of Resident #60's face sheet dated 8/15/23 revealed she was an [AGE] year-old female, who admitted to the facility on [DATE]. Resident #60 had diagnoses of dementia (forgetfulness), diabetes (elevated blood sugar), and heart failure. Record review of Resident #60's quarterly MDS dated [DATE] revealed she had a BIMS…

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 for 1 of 4 residents (Resident #11) reviewed for reasonable accommodations. The facility failed to ensure Resident #11 call light was within reach. The facility failed to ensure Resident #11 had an alternative means to get assistance due to her visual impairment. The facility failed to collaborate with Resident #11 and Resident #11's responsible party to ensure her environment accommodated her visual impairment. These failures could place residents at risk for unmet needs. Findings included: Record review of a face sheet dated 08/14/23 indicated Resident #11 was a [AGE] year-old female and admitted on [DATE] with diagnoses including dementia with other behavioral disturbance (is a group of thinking and social symptoms that interferes with daily functioning), Parkinson's disease (is a brain disorder…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment 1 of 17 residents reviewed for environment. (Resident #48) The facility failed to repair the wall mounted bathroom toilet paper dispenser of Resident #48. This failure could place residents at risk of an unsafe or uncomfortable environment and a decrease in quality of life and self-worth. Findings included: Record review of the face sheet 08/14/23 indicated Resident #48 was an [AGE] year old female and was admitted on [DATE] with diagnoses including psychotic disturbance (severe mental disorders that cause abnormal thinking and perceptions), anxiety (a feeling of fear, dread, and uneasiness), major depressive disorder (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), hyperlipidemia (an elevated level of lipids - like cholesterol and triglycerides - in your blood), 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 develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 3 of 17 residents reviewed for care plans. (Resident #239, Resident #11, Resident #43) 1. The facility failed to implement the comprehensive person-centered care plan for Resident #239 by not having a fall mat at the bedside. 2. The facility failed to implement Resident #11's care plan to document behavioral monitoring for antidepressant (treats clinical depression), antipsychotic (manage psychosis (disconnect from reality)), and anti-anxiety (treats chronic anxiety) medications. 3. The facility failed to develop a care plan problem for Resident #43 to address behavioral monitoring for Aripiprazole (antipsychotic). These failures could place residents at risk of not having individual needs met, a decreased quality of life, and cause residents not to receive needed services Findings include: 1. Record review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 3 of 34 residents (Resident #239, Resident #25, Resident #11) reviewed for adequate supervision. 1.The facility failed to place Resident #239's fall mat next to her bed. 2. The facility failed to ensure Resident #11, and Resident #25 did not have fall hazards in their room. These failures could place residents at risk for injury, harm, and impairment or death. Findings included: 1. Record review of Resident #239's admission Record indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain), fracture of pelvis, protein calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), type 2 diabetes (a condition that happens…

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, the residents' goals, and preferences for 3 of 3 residents (Resident #388, #82, and #63) reviewed for respiratory care and services. The facility failed to properly store Resident #388's respiratory equipment when not in use. The facility failed to date Resident #388's oxygen tubing and humidifier water bottle. The facility failed to change oxygen tubing every Friday, as ordered by the physician for Resident #82. The facility failed to label/date and properly store Resident #63's nasal cannula/humidifier and nebulizer mask. These failures could place residents at risk for developing respiratory complications. Findings included: 1. Record review of Resident #388's face sheet dated 8/14/23 revealed she was an [AGE] year-old female, who 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 interview and record review, the facility failed to ensure dialysis service were provided consistently with professional standards of practice for 1 of 1 resident reviewed for dialysis services. (Resident #240) The facility failed to develop a process to communicate, with the dialysis facility, Resident #240 received care and services. This failure could place residents who received dialysis at risk for complications and not receiving proper care and treatment to meet their needs. Findings included: Record review of a face sheet dated 07/27/23 indicated Resident #240 was [AGE] year-old male and admitted on [DATE] with diagnoses including hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease (is high blood pressure caused by damage to the kidneys), or end stage renal disease (a condition in which the kidneys lose the ability to remove waste and balance fluids). Record review of the MDS revealed Resident #240 was admitted to the facility less than 21 days…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate administering of all drugs and biologicals, to meet the needs of 2 of 4 residents reviewed for pharmacy services. (Residents #43 and Resident #240) The facility failed to keep in stock medications for Resident #43 and Resident #240. This failure could place residents at risk for inaccurate drug administration. Findings included: 1. Record review of a face sheet dated 08/16/23 indicated Resident #43 was a [AGE] year-old female and admitted on [DATE] with diagnoses including paranoid schizophrenia (is characterized by predominantly positive symptoms of schizophrenia, including delusions and hallucinations), major depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), recurrent, severe with psychotic symptoms (refers to symptoms that happen when a person is disconnected from reality), generalized…

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 accommodate residents' food preferences for 1 of 2 residents (Resident #52) reviewed for preference. The facility failed to honor Resident #52's food dislikes. This failure could result in a decrease in resident choices, diminished interest in meals, and weight loss. Findings included: Record review of a face sheet dated 08/17/23 indicated Resident #52 was [AGE] year-old male and admitted on [DATE] with diagnosis including protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function). Record review of a quarterly MDS dated [DATE] indicated Resident #52 was usually understood and usually understood others. The MDS indicated Resident #52 had minimal difficulty hearing, clear speech, and adequate vision with corrective lenses. The MDS indicated Resident #52 had a BIMS of 13 which indicated intact cognition and required supervision for eating. Record review…

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 diseases and infections for 2 of 22 residents reviewed for infection control. (Resident #45, Resident #68) The facility failed ensure blood was cleaned from the wall near the bed of Resident #45. The facility failed to ensure that personal protective equipment used in Resident #68's room was thrown away properly and that bloody soiled toilet paper was thrown away. Findings include: 1. Record review of the face sheet dated 08/14/23 indicated Resident #45 was [AGE] years old and admitted on [DATE] with diagnoses including Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), anxiety, and high blood pressure. Record review of the MDS dated [DATE] indicated Resident #45 was usually understood and usually…

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.