Avir at Kaufman

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, which includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs, for 2 of 4 (Resident #11 and Resident #27) residents reviewed. The facility failed to care plan Resident #11's oxygen (which is vital for the human body as it is used by cells to produce energy) therapy. The facility failed to care plan Resident #27's nebulizer treatments (which uses a machine to turn liquid medicine into a fine mist, inhaled through a mask or mouthpiece, to deliver medication deep into the lungs for respiratory conditions). This failure could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs.The findings included:1. Record review of Resident #11's face sheet, dated 01/08/26, indicated a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted 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 each resident received adequate supervision to prevent accidents for 1 of 7 residents (Resident #17) reviewed for smoking-related accidents and hazards of 1 of 1 smoking areas. 1.The facility failed to ensure Resident #17 did not smoke near a grill with propane gas attached.2. The facility failed to ensure that no trash was in the red cigarette butts' canisters.3. The facility failed to ensure that no cigarette butts were on the ground or near the oxygen storage area.This failure could place residents at risk for injury.Findings included:Record review of a face sheet dated 01/08/26 indicated Resident #17 was a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] with the diagnoses of Multiple sclerosis, also known as MS (a condition that affects nerves in your central nervous system), anxiety (a normal feeling of worry or fear in response to stress), and muscle weakness.Record review of a quarterly 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 observation, interview, and record review, the facility failed to ensure residents who were incontinent of bowel and bladder received appropriate treatment and services to prevent urinary infections for 1 of 2 residents (Resident #15) reviewed for incontinent care. The facility failed to ensure CNA G and CNA H properly cleaned the perineal/genital areas for Resident #15 during incontinent care. These failures could place residents at risk for urinary tract infections.During a record review of a face sheet dated 01/08/2026 indicated Resident #15 was a [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnosis of other cerebral infarction due to occlusion or stenosis of small artery (stoke because a small artery in the brain becomes blocked cutting off blood flow to a specific area of the brain). During a record review of Resident #15's quarterly MDS assessment dated [DATE] after a recent readmission to the facility revealed resident #15 toileting hygiene ability to maintain…

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 ensure the facility assessment was reviewed and updated as necessary, and at least annually for 1 of 1 facility. 1. The facility did not update the facility assessment to include Resident #15's gastrostomy (surgical procedure that creates an opening in the stomach, allowing for the insertion of a feeding tube (G-tube) for nutritional support). 2. The facility did not update the facility assessment to include Resident #36's oxygen and dialysis. These failures could affect residents by not having the necessary resources to ensure appropriate care is provided. Findings included: 1. Record review of Resident #15's face sheet, dated 01/08/26, reflected Resident #15 was a [AGE] year-old female, originally admitted to the facility on [DATE] with a diagnosis which included gastrostomy (surgical procedure that creates an opening in the stomach, allowing for the insertion of a feeding tube (G-tube) for nutritional support). Record review of Resident #15's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to establish policies in accordance with applicable Federal, State and local and regulations, regarding smoking, smoking areas, and smoking safety that also take into account nonsmoking residents for 2 of 4 residents (Resident #17 and Resident #36) reviewed for smoking.The facility failed to follow the policy on smoking by not completing a smoking screen assessment quarterly on Resident #17 and Resident #36. This failure could place residents at risk of unsafe smoking and injury.Findings included:1.Record review of a face sheet dated 01/08/26 indicated Resident #17 was a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] with the diagnoses of Multiple sclerosis, also known as MS (a condition that affects nerves in your central nervous system), anxiety (a normal feeling of worry or fear in response to stress), and muscle weakness.Record review of a quarterly MDS dated [DATE] indicated Resident #17 usually understood and 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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food and nutrition services. 1. The facility failed to ensure the can opener blade was free a black substance and a rusty-like material. 2. The facility failed to ensure 2 skillets, 5 large sheet pans, 3 small sheet pans, and 6 muffin pans were free from carbon build up on the cooking surface of the pan. 3.The facility failed to ensure the microwave was free from a thick, hard yellow substance, and a brownish substance resembling rust material on the inside top surface. These failures could place residents at risk of foodborne illness and food contamination. Findings included: During initial tour on 10/07/2024 at 11:02 a.m. - 11:55 a.m., the following was observed: 2 large skillets with black carbon build up on the inside cooking surfaces. 5 large sheet pans with black carbon build up on the outside pan surfaces, and on the sides of the inside pan surfaces. 3…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 14 residents (Resident #24 and Resident #36) and 1 laundry room reviewed for infection control practices and transmission-based precautions. 1) The facility failed to ensure LVN C provided proper hand hygiene during wound care to Resident #24's sacrum/coccyx area of the buttocks. 2) The facility failed to ensure the laundry staff were using a barrier when sorting contaminated linens. 3)The facility failed to ensure enhanced barrier precautions were initiated for Resident #36. These failures could place residents at increased risk for serious complications from a communicable disease that could diminish the resident's quality of life. Findings included: 1)Record review of Resident #24's face sheet dated 10/09/24…

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 was possible 1 of 14 resident (Resident #36) reviewed for quality of care. The facility failed to maintain resident use hot water at safe and comfortable temperature between 100 to 110 on Hall/Room where the hot water temperatures was 122 F on 10/09/2024. This failure could place residents at risk for sustaining scalding injuries when using resident accessible hot water. The findings include: Record review of the face sheet, dated 10/09/2024, revealed Resident # 36 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses metabolic encephalopathy (a brain dysfunction caused by a chemical imbalance in the blood that affects the brain), cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), venous insufficiency (a condition that occurs when the veins in the legs…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 1 of 14 residents (Resident #30) reviewed for pharmacy services. The facility failed to ensure MA A secured Resident #30's medications when she left Resident #30's medications on the top of the medication cart unattended. This failure could place residents at risk of not receiving drugs and biologicals as needed, medication errors, medication misuse, and drug diversion. Findings included: Record review of a face sheet dated 10/08/2024 indicated Resident #30 was a [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnoses of chest pain, eye pain, and lower abdominal pain. Record review of a Quarterly MDS assessment dated [DATE] indicated Resident #30 was understood and understood others. The MDS indicated Resident #30 was cognitively intact with a BIMS score of 13. Section J-Health…

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 respiratory care was provided with professional standards of practice for 3 of 3 residents (Residents #7, #31, and #8) reviewed for respiratory care and services. 1. The facility failed to administer oxygen at 1L via nasal cannula as prescribed by the physician for Resident #7. 2. The facility failed to ensure Resident #31 and Resident #8's oxygen concentrator filters were cleaned. These failures could place residents who require respiratory care at risk for respiratory infections and exacerbation of respiratory distress. Findings included: 1. Record review of Resident #7's face sheet, dated 09/12/2023, indicated Resident #7 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included acute respiratory failure (difficulty breathing), and essential hypertension (high blood pressure) and COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of the…

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

Based on interview, and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility reviewed for RN coverage. The facility failed to provide RN coverage for 8 consecutive hours daily on 1/19/2023, 1/20/2023, 1/29/2023, 2/18/2023, 2/19/2023, 2/25/2023, 2/26/2023, 3/11/2023, 3/15/2023, 3/16/2023, 3/17/2023, 3/20/2023, 3/24/2023, 3/25/2023, 3/29/2023, 3/30/2023, and 3/31/2023. This failure had the potential to affect residents in the facility by leaving staff without supervisory coverage for RN specific nursing activities and for coordination of events such as an emergency care and disasters. Findings included: During an interview on 09/12/2023 at 4:52 p.m., the DON stated she was hired for this position effective 8/10/2023. During an interview on 09/12/2023 at 5:42 p.m., the Administrator stated she had no documentation that a RN was in the facility on 1/19/2023, 1/20/2023, 1/29/2023, 2/18/2023, 2/19/2023, 2/25/2023, 2/26/2023, 3/11/2023, 3/15/2023, 3/16/2023, 3/17/2023, 3/20/2023, 3/24/2023,…

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

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service in the facilities only kitchen. The facility failed to ensure proper storage and labeling of food in airtight container after opening. The facility failed to ensure that trash was properly disposed of. The facility failed to ensure that kitchen staff appropriately restrained hair with the hairnet. The facility failed to ensure cans were free from damage. These failures could place residents at risk of cross contamination and foodborne illness. Findings included: During an observation on 9/10/12 starting at 10:00 AM.: ? one tray with one cup of cranberry juice and twelve cups of orange juice with a use by date of 9/7/23. There was no open date,. ? a ½ full one gallon pitcher of orange juice had no use by date, ? a pitcher of cranberry juice was ¾ full dated 09/04/23, a pitcher of apple juice was ¼ full and dated 09/03 and a full pitcher of water dated 09/05., ? a ½ gallon of lemonade had a used by date 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 collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 1 resident (Resident #31) reviewed for hospice services. The facility did not ensure Resident #31's hospice records were a part of their records in the facility. This failure could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. Findings included: Record review of Resident #31's face sheet, dated 09/12/2023, indicated Resident #31 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included atherosclerosis heart disease (buildup of fats and other substances…

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 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 2 of 15 residents reviewed for resident rights. (Residents #18 and #7) 1. The facility failed to treat Resident #18 with respect and dignity when she received her lunch tray 25 minutes after the other resident at her table had already been served their meal and was eating in front of her. 2. The facility failed to ensure Resident #7's wanderguard was discontinued, after the elopement assessment indicated she was at no risk for elopement. These failures could place residents at risk for decreased quality of life, decreased self-esteem and increased anxiety. Findings included: 1. Record review of the consolidated physicians' orders date 09/12/2023, indicated Resident #18 was a [AGE] year-old female, re-admitted to the facility on [DATE] with diagnoseis including cerebral infarction…

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 each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of changes for those services, which included changes for services not covered under Medicare/Medicaid or by the facility's per diem rate for 2 of 3 residents (Residents #18 and #150) reviewed for Medicare/Medicaid coverage. The facility failed to ensure Resident #18 and #150 was given a SNF ABN when discharged from skilled services at the facility prior to covered days being exhausted. This failure could place residents at risk for not being aware of changes to provided services. Findings include: 1. Record review of Resident #18's face sheet, dated 09/13/2023, indicated Resident #18 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included cerebral infarction (stroke), and essential hypertension (high blood pressure). Record review of the quarterly 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 provide a safe, clean, and comfortable homelike environment for 1 of 15 resident rooms (room [ROOM NUMBER]), 1 of 15 residents (Resident #46), 3 male shower rooms #1, #2 and #3 and 1 of 1 female bathrooms reviewed for physical environment. The facility failed to repair the trim in room [ROOM NUMBER]. The facility failed to replace the missing shower tile in male bathroom [ROOM NUMBER]. The facility failed to unclog the shower drain in the male bathroom [ROOM NUMBER]. The facility failed to ensure that the toothbrush in Resident #46 bathroom was labeled with Resident # 46 name and room number. The facility failed to ensure that the used single-use razors in the facility's male shower room [ROOM NUMBER] were discarded after use. The facility failed to ensure unused single-use razors in the facility male shower room # 3 cabinet were labeled with residents' names and room numbers. The facility failed to ensure that the hairbrush in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure residents were free from abuse for 2 of 15 residents (Resident #20 and Resident #14) reviewed for resident abuse. The facility did not ensure Resident #20 was free from abuse, as a result Resident #20 was physically assaulted by Resident #14 with no injuries. This failure could place residents at risk of physical harm, mental anguish, or emotional distress. The findings included: 1.Record review of Resident #20's face sheet, 09/11/23, indicated Resident #20 was a [AGE] year-old male, originally admitted to the facility on [DATE] with a diagnosis which included bipolar (episodes of mood swings), dementia (memory loss and poor judgment), and HTN (force of blood against the artery walls is too high). Record review of Resident #20's quarterly MDS dated [DATE] indicated he made himself understood and was able to understand others. There was no BIMS score indicated. Section E of the MDS did not indicate any behavior issues. 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 implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, for 2 of 15 residents (Resident's #44 and #33) reviewed for abuse. 1. The facility failed to implement the abuse and neglect policy and procedure regarding reporting fall incident. 2.The facility did not implement policy on reporting neglect for bruise of unknown origin for Resident #33 to the abuse coordinator (Administrator). These failures could place the residents at increased risk for abuse and neglect. Findings included: Record review of the facility policy for Abuse Prevention Program dated 01/09/23, indicated, Policy Statement:1. The Administrator is responsible for the overall coordination and implementation of our Center's abuse prevention program policies and procedures in accordance with the Elder Justice Act. 2. Our residents have the right to be free from abuse, neglect, misappropriation of resident property 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 the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source were reported immediately, but no later than 2 hours after the allegation was made, for 2 of 15 residents (Residents #44 and 33) reviewed for abuse and neglect. 1. The facility failed to report to the state agency within 2 hours of being notified of fall incident for Resident #44. 2. The facility failed to report Resident #33's bruised left arm, an injury of unknown origin, timely to HHS. These failures to report could place the residents at risk for abuse. Findings included: 1. Record review of the Provider Investigation Report dated on 8/12/23 indicated an allegation of fall with left hip fracture incident on Resident #44 occurred on 8/11/23 at 3:45 p.m. The report indicated no staff witnessed the fall incident. The report indicated LVN B completed a neuro assessment on Resident #44 on 8/11/23. The report…

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 assessments accurately reflected the resident status for 1 of 5 residents (Resident #7) reviewed for MDS assessment accuracy. The facility did not ensure Resident #7's MDS assessment was accurately coded to reflect her level II PASRR status for mental illness. This failure could place residents at risk for not receiving care and services to meet their needs. Findings included: Record review of Resident #7's face sheet, dated 09/12/2023, indicated Resident #7 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included schizoaffective disorder (a condition that can make you feel detached from reality and can affect our mood), bipolar (serious mental illness characterized by extreme mood swings) and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of the significant change in status MDS assessment, dated 05/02/2023, indicated Resident #7 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review program (PASRR) to the maximum extent practicable to avoid duplicative testing and effort for 1 of 5 (Resident #15) residents reviewed for PASRR. The facility failed to refer Resident #15 for PASRR Level ll assessment when a diagnosis of Major Depressive Disorder was diagnosed after admission on [DATE]. This failure could affect residents with mental illnesses and place them at risk of not being assessed to receive needed services. Findings include: Record review of a face sheet dated 09/12/23 indicated Resident #15 was [AGE] years old female admitted on [DATE] with diagnoses including vascular dementia (deterioration of memory, language, and other thinking abilities with behaviors), Epileptic seizures (disorders of the brain characterized by repeated seizures) related to external causes, not intractable, without status epilepticus, major depressive disorder, recurrent,…

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 that included measurable objectives and timeframes to meet a resident's needs for 1 of 15 residents (Resident #7) reviewed for care plans. The facility failed to ensure Resident #7 care plan indicated she was PASRR positive. This failure could place residents at risk for unmet care needs and decreased quality of care. Findings included: Record review of Resident #7's face sheet, dated 09/12/2023, indicated Resident #7 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included schizoaffective disorder (a condition that can make you feel detached from reality and can affect our mood), bipolar (serious mental illness characterized by extreme mood swings) and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of the significant change in status MDS assessment, dated 05/02/2023, indicated…

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 implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 1 of 15 residents (Resident #20) reviewed for care plans. The facility failed to ensure Resident #20's care plan was updated to not indicate a stage 3 pressure ulcer to his coccyx. This failure could place the resident at increased risk of not having their individual needs met and a decreased quality of life. Findings included: Record review of Resident #20's face sheet, 09/11/23, indicated Resident #20 was a [AGE] year-old male, originally admitted to the facility on [DATE] with a diagnosis which included bipolar (episodes of mood swings), dementia (memory loss and poor judgment), and HTN (force of blood against the artery walls is too high). Record review of Resident #20's order summary report, no date, did not indicate any treatments to his coccyx. Record review of Resident #20'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 interviews, and record review, the facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 2 of 15 residents' (Resident #'s 7 and 31) reviewed for trauma-informed care. 1. The facility did not ensure Resident #7 had a trauma screening that identified possible triggers when Resident #7 had a history of trauma. 2. The facility did not ensure trauma screenings were completed upon admission to the facility. These failures could put residents at an increased risk for severe psychological distress due to re-traumatization. The findings included: 1. Record review of Resident #7's face sheet, dated 09/12/2023, indicated Resident #7 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included schizoaffective…

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, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 4 medication carts (Front Hall Cart) reviewed for storage of medications. The facility failed to ensure the Front Hall medication cart was locked when unattended. This deficient practice could place residents at risk of medication misuse and diversion. Findings include: During an observation on 9/11/23 at 8:18 AM, the medication cart on the front hall was unlocked while CMA F was giving resident medications. During an observation and interview on 09/11/23 at 8:58 AM, CMA F did not lock the med cart prior to going into room [ROOM NUMBER] and administers medications. CMA F stated she pushed the lock in, but it sometimes does not go in all the way. CMA F stated the importance of locking the medication cart was to prevent…

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 and served at an appetizing temperature for 4 of 19 residents (Resident's #28, Resident #5, Resident # 46, and Resident #22) reviewed for palatable food. The facility failed to provide palatable food served at an appetizing temperature or taste to Resident's #28, Resident #5, Resident # 46, and Resident #22 who complained the food was served cold and did not taste good. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. The findings included: During an interview on 09/10/2023 at 11:05 AM, Resident # 28 said the food does not taste good and it was cold when he received the tray on the hall. During an interview on 09/10/2023 at 11:09 AM, Resident #5 said the food is always cold when he received his tray in his room. During an interview on 09/10/2023 at 02:12 PM, Resident #46 said he ate his own food and eats very little kitchen food as the food is too salty. 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 observation, interview, and record review, the facility failed to ensure the medical record was complete and accurately documented for 1 of 15 residents (Resident #35) reviewed for resident records. The facility failed to ensure LVN G accurately completed the elopement evaluation on Resident #35. Findings included: Record review of a face sheet dated 09/11/2023 indicated Resident #35 was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses which included Schizoaffective disorder (combination of mood disorder and depression), COPD (chronic obstructive pulmonary disease is a lung disease that block the airflow and cause it difficult to breathe) and psychosis (mental disorder). Record review of the Quarterly MDS assessment, dated 09/07/2023, indicated Resident #35 was usually understood and usually understood others. The MDS assessment indicated Resident #35's BIMS score was 6, which indicated his cognition was severely impaired. The MDS assessment indicated Resident #35 did not exhibit…

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 the facility was free from pests and rodents for 1 of 1 kitchen reviewed for pest control. The facility failed to maintain an effective pest control program to ensure the facility kitchen was free from gnats. This failure could place residents at risk of unsanitary environment and decreased quality of life. Findings included: During an observation on 09/10/2023 at 10:29 AM, gnats swarmed over a bowl of dingy brown water with the juicer spout lying in it. During an observation on 09/10/2023 at 11:45 AM, gnats swarmed over a bowl of dingy brown water with the juicer spout lying in it. During an observation on 09/11/2023 at 12:15 AM, gnats flew over the area where the juice boxes were stored. Record review of a statement dated 08/30/2023 indicated the facility was treated for pest management and insect light trap monitoring. Record review of a document dated 9/5/2023 titled Service Inspection Report indicated rooms 1-5, 8, 10, 12,13, 14 and the kitchen were treated to…

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

Based on observations, interviews and record reviews, the facility failed to follow their own established smoking policy for one visitor (Resident #31's family member) reviewed for smoking. The facility failed to ensure Resident #31's family member was smoking in the designated smoking area. The facility failed to ensure smoked cigarettes were extinguished in a fire-retardant receptacle. Findings included: During an observation on 9/11/23 at 12:00 PM, Resident #31's family member was smoking in the front of the building under a gazebo with a no smoking sign posted. During an observation and interview on 09/12/23 at 9:00 AM, CNA H was sitting outside in the smoking area with residents. Observation made of cigarette butts on the ground outside of the laundry room and next to the oxygen tank storage. CNA H stated she did not think that anyone in the laundry department smoked, and residents only smoked in the designated areas. During an interview on 9/12/23 at 11:00 AM, Resident #31's family member stated he never thought to look at the no smoking signs posted under the gazebo because…

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.