Avir at Kerrville

Based on observations, 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 storage, preparation and sanitation. 1. The facility failed to discard hamburger burns, with a best used by date of 04/22/2026, from the kitchen cooking table on 04/23/2026. 2. The facility failed to label and date Jello stored in the refrigerator inside the facility kitchen. These failures could place residents who received meals and/or snacks from the kitchen at risk for food-borne illnesses. Findings included: 1. Observation of the kitchen on 04/23/2026 at 10:05 a.m., revealed there was one packet of hamburger burns (total 15 burns inside the packet) on the cooking table, the label on the packet said, Best used by 04/22/2026. 2. Observation on 04/23/2026 at 10:10 a.m., revealed a refrigerator labeled as C-1 Refrigerator had a tray with Jello inside, the Jello was not labeled and dated. Interview on 04/23/2026 at 10:13 a.m., the kitchen manager stated the hamburger…

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 employ a qualified social worker on a full-time basis for 1 of 1 facility reviewed for social work services.The facility failed to employ a full-time social worker for January- March 2026. This failure could result in residents' psychosocial needs not being met and diminished quality of life. Findings included:Record review of the SSA document Facility Summary Report undated/printed 3/13/2026, the facility had a total licensed capacity of 130 beds, and a license expiration date of 5/29/2028. Record review of the facility staff roster, untitled/undated and provided by the facility on 3/17/2026, did not reveal a staff member with the position title of social worker. In an interview with HR on 3/18/2025 at 10:45 AM, he said the facility did not have a full-time social worker. He said the last full-time social worker resigned in mid- December 2025, and the facility had no social worker on a full or part-time basis until Monday (3/16/2026). He said they were actively interviewing for a replacement. In an interview with RN A 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 ensure documented assessments accurately reflected the resident's status for 1 of 3 residents (Resident #1) reviewed for assessments. The facility failed to ensure the quarterly MDS submitted on 1/1/2026 for Resident #1 accurately reflected the resident's pain management in section J0100.This failure could result in improper care of residents. Findings included:Record review of Resident #1's admission Record dated 3/18/2026 reflected a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included pain, unspecified and drug-induced polyneuropathy (nerve damage of the extremities caused by medications, resulting in chronic pain, tingling, weakness, or numbness). Record review of Resident #1's quarterly MDS submitted 1/1/2026 reflected a BIMS score of 14, which indicated intact cognition. Section J0100 of the MDS revealed the following: At any time in the last 5 days, has the resident:A. Received scheduled pain medication regimen?…

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, in accordance with accepted professional standards and practices, maintain medical records on each resident that were complete, accurately documented, readily accessible, and systematically organized for four (4) of five (5) residents (Resident #1, Resident #2, Resident #3, and Resident #4) reviewed for clinical records. 1. The facility failed to ensure Resident #1's right thigh wound care treatments were documented in her medical record for 10 of 45 treatments (01/02/2026 during day shift, 01/03/2026 during day shift, 01/05/2026 during day shift, 01/15/2026 during day shift, 01/16/2026 at 08:00 a.m., 01/24/2026 at 08:00 a.m., 01/25/2026 at 08:00 a.m., 01/30/2026 at 08:00 a.m., 02/02/2026 at 08:00 p.m., and 02/03/2026 at 08:00 p.m.) scheduled between 01/01/2026 to 02/06/2026 (at 04:20 p.m.). 2. The facility failed to ensure Resident #1's diagnosis list was complete. 3. The facility failed to ensure Resident #2's tube feeds were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure the assessment accurately reflected the resident's status for one (1) of five (5) residents (Resident #1) reviewed for accuracy of assessments. The facility failed to ensure Resident #1 was coded on her Quarterly MDS assessment, signed as completed on 01/12/2026, for a wound that was acquired on 12/03/2025. This failure could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. The findings included: Record review of Resident #1's admission Record, dated 02/04/2026, reflected a [AGE] year-old female. She was admitted to the facility on [DATE]. Record review of Resident #1's Medical Diagnosis tab, dated 02/04/2026, reflected diagnoses which included cerebral infarction (a disruption in the blood flow to a part of the brain that can cause death of brain cells) due to unspecified occlusion (blockage) or stenosis (narrowing) of right middle cerebral…

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, based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (1) of five (5) residents (Resident #1) reviewed for quality of care. 1. LPN D failed to complete Resident #1's wound care on 01/26/2026 per physician order and documented an exception code for resident sleeping. 2. LPN E failed to complete Resident #1's wound care on the evening shift of 02/04/2026 and 02/05/2026 per physician order. These failures could place residents at risk of not receiving necessary medical care, harm, and hospitalization. The findings included: Record review of Resident #1's admission Record, dated 02/04/2026, reflected a [AGE] year-old female. She was admitted to the facility on [DATE]. Record review of Resident #1's Medical Diagnosis tab, dated 02/04/2026, reflected diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident and failed to determine that drug records were in order and that an account of all controlled drugs was maintained for 2 of 4 residents (Resident #1 and Resident #2) reviewed for narcotic reconciliation. Resident #1 was missing narcotic medication (Tramadol) on 12/23/25. Resident #2 was missing a narcotic medication (Hydrocodone) on 12/23/25. This failure could place residents at risk for not receiving therapeutic effects of treatment. The findings include: Resident #1 Record review of Resident #1's face sheet dated 1/13/26, reflected a female age [AGE] who was admitted on [DATE] with diagnoses that included: fracture of third lumbar vertebra (break in the lower back), cellulitis (bacterial infection of the skin), difficulty walking and cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments and controlled drugs must be stored in separately locked, permanently affixed compartments for 1 of 1 container reviewed (Resident #3) for proper storage for destruction of narcotics. Resident #3's, a DEA controlled substance (valium), was not stored appropriately in a double locked container. This failure could place residents at risk of not receiving prescribed medications as ordered and drug diversions. The findings include: Record review of Resident #3's face sheet dated 1/13/26 reflected the resident was a [AGE] year-old male admitted on [DATE]. The resident's diagnoses included: surgical aftercare on the digestive system, vertigo (dizziness) and intestinal obstruction. The RP was listed as a family member. Record review of Resident #3's quarterly MDS dated [DATE] reflected the resident's BIMS score was 13 indicative of no impairment in cognition. The resident's ADLs…

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, in accordance with accepted professional standards and practices, maintain medical records on each resident that were complete and accurately documented for 6 of 8 residents (Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7). The facility failed to ensure Resident #2's treatment administration record noted wound care treatments on 12/6/2025, 12/8/2025 and 12/9/2025 as required by the orders noted on the electronic medical record. The facility failed to ensure Resident #3's treatment administration record noted wound care treatments on 12/4/2025, 12/6/2025, 12/7/25, and 12/8/2025 as required by the orders noted on the electronic medical record. The facility failed to ensure Resident #4's treatment administration record noted wound care treatments on 12/4/2025, 12/6/2025, 12/7/2025, and 12/8/2025 as required by the orders noted on the electronic medical record. The facility failed to ensure Resident #5's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement written policies and procedures to prohibit and prevent neglect. The facility failed to ensure that all alleged violations involving neglect were reported immediately, but not later than 2 hours after the significant medication error was discovered for 1 of 3 residents (Resident #1). The facility failed to report an injury from a medication error to HHSC when Resident #1 was noted as receiving twice the ordered daily dose of medication causing confusion and was sent to the hospital on [DATE]. This failure could place residents at risk for further neglect.The findings included: Review of Resident #1's face sheet, dated 10/24/25, revealed she was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including metabolic encephalopathy (brain dysfunction caused by systemic metabolic disturbances) and muscle weakness. Review of Resident #1's quarterly MDS assessment, dated 10/24/25, revealed her BIMS score was 12 out…

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 ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activities professional who was licensed or registered by the State to for 72 of 72 residents reviewed for qualifications of activity professionals.The facility failed to have a qualified Activities Professional to direct their activities program.This deficient practice could place residents at risk of not receiving approaches that were individualized to match the skills, abilities, and interests/preferences of each resident for activities.The findings include: During an interview on 10/01/2025 at 3:40 p.m., the HR [TF1] Director stated the personnel file for the Activity Director did not have any proof of education. He stated it was his understanding, the Activity Director had a year to complete training. The HR Director stated the Administrator had intentions on enrolling the Activity Director in training but as of this interview she had not yet been enrolled. During an interview on 10/01/2025…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 residents (Resident #1) reviewed for care plans.The facility failed to ensure Resident #1's comprehensive care plan included information on required ADL care and assistance, interventions for cardiac diet, or interventions for nutritional status with a weight management plan. This failure could place residents at risk for not having their needs and preferences met.The findings include:Record review of Resident #1's face sheet dated 9/30/2025 revealed a [AGE] year-old male admitted on [DATE] with diagnoses which included: morbid (severe) obesity due to excess calories, Body mass index (BMI) [TF1] 50.0-59.9 (normal BMI for adult male 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 ensure medical records were maintained in accordance with accepted professional standards and practices for each resident, that were complete and accurately documented for 1 of 6 residents (Residents #2[TF1] ) reviewed for accuracy of medical records. The facility failed to ensure Resident #2's progress notes were documented accurately and according to professional standards of practice when RN B documented under LVN A's profile. This deficient practice could place residents at risk for errors in care and treatment and inaccuracies in documentation. The findings include: Record review of Resident #2's face sheet dated 9/30/2025 revealed an [AGE] year-old female admitted on [DATE] with diagnoses which included: retention of urine, type 2 diabetes mellitus and hypertension. [TF1] Record review of Resident #2's EMR revealed a progress note, dated 9/24/2025 at 18:10 (6:10 p.m.), of an assessment note, with RN B's typed name at the end of the note. 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 observations, interviews, and records review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive care plan for the 1 resident (Resident #22) reviewed for skin conditions. The facility failed to ensure Resident #22 received wound care treatment for over 30 days for his chronic skin impairment as ordered by the physician. This failure could lead to exacerbation of a resident's chronic condition, skin breakdown and injury, or infection. Findings included: Record review of Resident #22's face sheet, dated 6/25/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included venous insufficiency (lack of circulation due to impaired veins) and peripheral vascular disease (impaired veins in the arms and/or legs).Record review of the annual MDS submitted on 5/26/2025 revealed a BIMS score of 13, indicating moderately impaired cognition. Review of Resident #22's active physician…

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 ensure food was stored, prepared, and or distributed in accordance with professional standards for food service safety, for 1 of 4 kitchen refrigerators reviewed for professional standards for food service safety, in that: The facility failed on 06/25/2025 when the produce refrigerator presented with 3 boxes, all containing 20lbs. of produce past the best by: date. This failure could place residents at risk for food borne illness. The findings included: During an observation on 6/25/2025 at 11:14 AM revealed the facility's kitchen produce refrigerator contained the following foods which were stored and available for serving: 1. 1 box containing 4, 5lb. bags of salad lettuce. The distributor labeled the box, best if used by: June/20/25 sic[6/20/2025]. 2. 1 box containing 4, 5lb. bags of shred lettuce. The distributor labeled the box, best if used by: June/9/25 sic[6/9/2025]. 3. 1 box containing 4, 5lb. bags of diced green cabbage. The distributor labeled the box, best if used by: June/16/25 sic[6/16/2025].…

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 reviews the facility failed to maintain medical records on each resident that were complete, accurately documented, readily accessible, and were systematically organized, for 2 of 8 residents (Resident #6 and Resident ##42) reviewed for accurate medical records, in that:A) Resident #6's June 2025 medication and treatment administration report (MAR and TAR) had no documentation for her prescribed:1. olodaterol and tiotropium (a combination medicine used to prevent airflow obstruction and reduce flare-ups in adults with COPD [chronic obstructive pulmonary disease] on 6/8/2025.2. Apply nystatin paste to bilateral buttocks related to rash and skin prep to the left heel (a liquid that when applied to the skin forms a protective film or barrier) on 6/17/2025.3. Change oxygen tubing and administration devices weekly on 6/15/2025.4. Insulin glargine injection on 6/8/2025. 5. Insulin glulisine injection on 6/8/2025 and on 6/17/2025. B) The facility failed to obtain written consent for…

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 ensure maintenance of all mechanical, electrical, and patient care equipment was in safe operating condition, for 1 of 1 facility reviewed for safe and functioning mechanical, electrical, and patient care equipment. The facility failed when the following occurred: 1. The facility's commercial electric dishwasher had a malfunctioning temperature gauge on 06/24/2025. 2. The facility did not equip 1 of 2 beds in an occupied resident room with a mattress on 06/26/2025. These failures could place residents at risk for unsafe patient care equipment. The findings included: 1. A record review of the facility's dishwasher temperature logs dated June 2025, revealed from 6/1/2025 to 6/24/2025 the temperature ranged from 100°F to 120°F. During an observation and interview on 6/24/2025 at 9:46 AM revealed the facility's kitchen dirty dish area presented with dirty breakfast dishes and an operating commercial dishwashing machine. The commercial dishwashing machine had a manufactures metal label affixed to the front 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 be adequately equipped to allow residents to call for staff through a communication system which relays the call directly to a staff member or a centralized staff work area from toilet and bathing facilities for 11 of 15 resident rooms (rooms #101, #103, #105, #107, #111, #117, #202, #210, #308, #315, and #405) reviewed for call lights. The facility failed to ensure emergency call lights in resident room bathrooms were able to be accessed and used from the floor on 06/24/2025. This failure could place residents at risk of injury, pain, hospitalization, and a diminished quality of life.Findings included:Observation on 06/24/2025 at 10:27 AM, room [ROOM NUMBER] was observed to have the call light wrapped around the metal assistance bar next to the toilet. The call light cable was not reachable from the floor and was approximately 2 feet above the floor. If pulled, the call light did not activate, and only put tension from the call light…

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 all allegations involving abuse, neglect, and misappropriation were reported immediately, but no later than 2 hours after the allegation was made to the State Survey Agency for 1 of 8 residents (Resident #27) reviewed for abuse and neglect.The facility did not report to the State Survey Agency (HHSC) an incident in which Resident #27 was slapped in the face by Resident #119 on 05/17/2025. This failure could place residents at risk for abuse/neglect and could lead to a diminished quality of life and psychosocial harm. The findings included: Record review of Resident #27's Face Sheet, dated 06/27/2025, reflected an [AGE] year-old resident with an initial admission date of 02/05/2025, with diagnoses including aphasia (a language disorder that affects a person's ability to communicate), severe intellectual disabilities, and cognitive communication deficit. Record review of Resident #27's Quarterly MDS Assessment, dated 06/15/2025, reflected 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 observations, interviews, and records review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 9 residents (Resident #22) reviewed for MDS accuracy. The annual MDS for Resident #22 failed to accurately document the continuous compression dressings worn by the resident. This failure could lead to residents not receiving the required care and decreased quality of life. Findings included: Record review of Resident #22's face sheet, dated 6/25/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included venous insufficiency (lack of circulation due to impaired veins) and peripheral vascular disease (impaired veins in the arms and/or legs). Review of annual MDS submitted on 5/26/2025 revealed a BIMS score of 13, indicating moderately impaired cognition. Question M1200 of the MDS (application of non-surgical dressings other than to feet) indicated no. Record review of the skin assessment dated [DATE] revealed a check mark…

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, record review, and interview, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care for 1 of 2 residents (Resident #61) reviewed for new admissions. The facility failed to develop a baseline care plan within 48 hours of admission for Resident #61. This failure could lead to residents not receiving necessary care and decreased quality of life. Findings included: Record review of Resident #61's face sheet, dated 6/26/2025, revealed a [AGE] year-old female admitted to the facility on [DATE] and discharged to an acute care hospital on 4/14/2025 (10 days total). Relevant diagnoses included traumatic subdural hemorrhage without loss of consciousness (internal head injury with bleeding of the brain) and cognitive communication deficit. Record review of Resident #61's basline care plan report, printed 6/26/2025,…

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, record review and interview, the facility failed to ensure residents are offered a therapeutic diet when there is a nutritional problem, and the healthcare provider orders a therapeutic diet for 1 of 4 residents (Resident #20) reviewed for food and nutrition. The facility to ensure Resident #20 received nutritional supplement beverages as ordered by the physician. This failure could lead to nutritional deficits and unintended weight loss. Findings included: Record review of Resident #20's face sheet, dated 6/25/2025, revealed an [AGE] year-old female, originally admitted to the facility on [DATE]. Relevant diagnoses included nondisplaced comminuted fracture of shaft of humerus, right arm, sequela (right, upper arm bone fracture). The quarterly MDS submitted 3/12/2025 revealed a BIMS score of 09, indicating moderately impaired cognition. Review of Resident #20's documented weights did not reveal significant loss. Record review of scanned consultation reports for Resident #20 revealed…

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 of any significant medication errors for 1 of 8 residents (Resident #10) reviewed for medication administration.The facility provided Resident #10 with amlodipine without assessing for blood pressure as ordered by the physician.This failure could place residents at risk for not receiving the therapeutic effects of their prescribed medications. The findings included: Record review of Resident #10's Face Sheet, dated 06/27/2025, reflected a [AGE] year-old resident with an initial admission date of 04/10/2024 and diagnoses including epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), aphasia (language disorder that affects a person's ability to communicate), and nontraumatic intracerebral hemorrhage (a type of stroke where bleeding occurs within the brain tissue). Record review of Resident #10's MDS assessment, dated 03/15/2025, reflected Resident #10 was assessed with a BIMS score of…

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

Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 1 of 2 medication carts (Medication Cart for 200 hall) reviewed for storage of drugs and biologicals.The facility failed on 06/24/2025 when LVN I did not ensure the medication cart for 200 hall was locked and secured.These deficient practices could place residents at risk of medication misuse or drug diversion.The findings included:Observation on 06/24/2025 at 10:35 AM revealed a medication cart was left unlocked and unattended next to the entrance to the 200 hall closest to the resident activities room. Interview and observation on 06/24/2025 at 10:40 AM, LSW stated the cart was assigned to LVN I and 200 hall. LSW proceeded to then lock the medication cart.Interview and observation on 06/24/2025 at 10:40 AM, LVN I stated she was preparing her medications and had walked away from the cart but thought she had locked it. During an interview on 6/18/25 at 4:13 p.m., the DON who stated it was her…

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 1 of 6 residents (Resident #14) reviewed for infection control. The facility failed to ensure staff performed proper hand hygiene and PPE utilization while performing indwelling catheter care for Resident #14. This failure could lead to infection, illness, and decreased quality of life. Findings included: Record review of Resident #14's face sheet, dated 6/26/2025 revealed a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included benign prostatic hyperplasic without lower urinary tract symptoms (swelling of the prostate gland causing difficulty or inability to urinate). Review of the admission MDS submitted 4/8/2025 revealed a BIMS score of 14, indicating intact cognition. 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 maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 5 of 7 residents (Residents #1, #2, #3, #4, and #5) reviewed for infection control: 1. The facility failed to ensure MA-A sanitized the wrist blood pressure cuff in-between use with Residents #1 and #2 on 06/05/2025. 2. The facility failed to ensure LVN-B sanitized her hands in between feeding and assisting Residents #3, #4 and #5 with their breakfast meal on 06/05/2025. These failures could place residents at risk for infection due to improper care practices. The findings included: 1. Record review of Resident #1's admission record revealed he was an [AGE] year-old man admitted on [DATE] with diagnoses which included: Essential (Primary) Hypertension. Record review of Resident #1's Order Summary dated 06/05/2025 revealed an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #1) of 4 residents reviewed for accuracy of assessments. The facility failed to ensure Resident #1 was coded on her Quarterly MDS assessment, signed as completed on [DATE], for a psychiatric/mood disorder, an anxiety disorder diagnosed [DATE]. This failure could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. The findings included: Record review of Resident #1's admission Record, dated [DATE], reflected a [AGE] year-old female. She was initially admitted on [DATE] and re-admitted on [DATE]. She discharged on [DATE]. Record review of Resident #1's Diagnosis Report, dated [DATE], reflected a principle diagnosis of Alzheimer's Disease (a progressive disease that affects memory and other important mental functions) with onset dated [DATE], a diagnosis of anxiety disorder (a condition in 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 interviews and record reviews, the facility failed to ensure resident medical records were kept in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete and accurately documented for 2 of 4 residents (Resident #1 and Resident #2) reviewed for clinical records. 1. The facility failed to ensure Resident #1's pain status was accurately documented on [DATE] and [DATE]. 2. The facility failed to ensure Resident #1's Medication Administration Record (MAR) reflected the administration of Tylenol (medication to treat pain) was accurately documented on [DATE] and [DATE]. 3. The facility failed to ensure Resident #1's weekly skin assessments were documented in her medical record for 2 (the weeks of: [DATE] and [DATE]) of 14 weeks. 4. The facility failed to ensure Resident #2's weekly skin assessments were documented in her medical record for 3 (the weeks of: [DATE], [DATE], and [DATE]) of 13 weeks. These failures could place…

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

Based on observations interviews, and record review the facility failed to ensure residents had the right to personal privacy and confidentiality of his or her personal and medical records, for 11 of 73 residents (Residents #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14) reviewed for the right to personal privacy and confidentiality of his or her personal and medical records. Medication Aide AI left a lap top computer she was assigned unattended, unsupervised, and unlocked displaying Residents #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14 protected health information (PHI). This failure could place residents at risk of a breach of their PHI. The findings included: During an observation and interview on 4/2/2024 at 8:27 AM revealed the medication cart parked on the facility's 300-hall. Further observation revealed the medication cart had a laptop computer atop of the cart. The lap top computer was unattended, unsupervised, and unsecured. The laptop computer was actively displaying PHI for 11 residents, Residents #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14.…

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 reviews the facility failed to ensure the residents had the right to voice grievances to the facility. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay, for 1 of 8 residents (Resident #2) reviewed for grievances. 1. On February 13, 2025, the previous Administrator and the DON heard a grievance on Resident #2's behalf and failed to initiate the grievance process. 2. On February 27, 2025, the DON heard a complaint on Resident #2's behalf and failed to initiate the grievance process. 3. On February 24,2025 the DON received a complaint via an email on behalf of Resident #2 and failed to initiate the grievance process. 4. On March 3, 2025, the SW received a complaint via an email on behalf of Resident #2 and failed to initiate the grievance process. These failures could place residents at risk of not…

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 reviews the facility failed to ensure all suspected violations involving abuse, neglect, exploitation, or mistreatment are reported to the state agency not later than 2 hours after the allegation is made, if the allegation does not concern abuse, for 2 of 8 residents (Residents #1, and #2) reviewed for reporting allegations of ANE. 1. On [DATE] LVN A, the ADON, the previous DON, and the Administrator at that time, failed to report an allegation of neglect on behalf of Resident #1 when LVN A performed CPR on Resident #1 while Resident #1 wished to not have CPR and had wished to be DNR status. 2. On [DATE] the previous Administrator and the DON heard an allegation of neglect on Resident #2's behalf and failed to report the allegation to the state agency. 3. On [DATE] the DON received an allegation of neglect via an email on behalf of Resident #2 and failed to report the allegation to the state agency. 4. On [DATE], the DON heard an allegation of neglect on Resident #2's behalf 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 interviews and record reviews the facility, in response to allegations of abuse, neglect, exploitation, or mistreatment, failed to ensure all alleged violations were thoroughly investigated and reported the results of all investigations to the State Survey Agency, within 5 working days of the incident, for 2 of 8 residents (Residents #1, and #2) reviewed for investigating and reporting results to the state survey agency. 1. On [DATE] LVN A, the ADON, the previous DON, and the Administrator at that time, failed to investigate an allegation of neglect on behalf of Resident #1 when LVN A performed CPR on Resident #1 while Resident #1 wished to not have CPR and had wished to be DNR status. 2. On [DATE] the previous Administrator and the DON heard an allegation of neglect on Resident #2's behalf and failed to investigate the allegation and report the results to the state agency. 3. On [DATE] the DON received an allegation of neglect via an email on behalf of Resident #2 and failed to investigate 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 observations and interviews, the facility failed to ensure all drugs and biologicals were in locked compartments and permitted only authorized personnel to have access, for 2 of the facility's 7 medication carts (a treatment cart and a medication cart), reviewed for security and supervision. 1. Medication Aide AI left the medication cart unattended, unsupervised, and unlocked. 2. LVN AM left the treatment cart unattended, unsupervised, and unlocked. These failures could place residents at risk for harm by unsecured medications. The findings included: During an observation and interview on 4/2/2024 at 8:27 AM revealed the medication cart and the treatment cart were parked on the facility's 300-hall. Further observation revealed the medication cart, and the treatment cart were unlocked and unattended. Continued observations revealed housekeeper AL, Driver AK and CNA AJ had alternately ambulated past the unlocked carts over 5 minutes elapsed time. At 8:37 AM the surveyor alerted LVN AM the treatment cart, and the medication carts were unattended, unsupervised, and unsecured.…

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 revealed the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, for 1 of 1 Resident's food / snack pantry reviewed for food safety. The facility's Resident food snack pantry located on the residents hall had a refrigerator with 15 containers of food. The containers had various food safety concerns to include old, expired food available for residents' consumption. These failures could place residents at risk for harm by food borne illnesses. The findings included: During an observation and interview on 4/1/2025 at 2:56 PM revealed the facility's Resident food and snack pantry room with CNA AN revealed the refrigerator had a temperature of 45 degrees Fahrenheit and held the following items: 1. A 32-ounce tub of yogurt with manufactures use by date of 1/13/2025 and a handwritten date of 3/25/2025 and written upon the lid was the word residents. 2. An individual sealed serving cup of a name brand yogurt with the manufactures use by date of 2/21/2025. 3. 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.

Based on observations, interviews, and record reviews the facility failed to ensure personnel handled, stored, processed, and transported linens so as to prevent the spread of infection, for 1 of 1 laundry departments reviewed for infection prevention and control. 1. The laundry department presented with resident's clean blankets stored with soiled infectious laundry. 2. Laundry Aide AO and Laundry Aide AP donned only gloves and did not don full PPE while handling soiled infectious laundry. These failures could place residents and staff for cross-contamination of infectious diseases. The findings included: During an interview on 4/1/2025 at 9:10 AM the Administrator and the DON stated their census was 73 with some residents were on isolation for potential communicable diseases with some residents on droplet precautions due to influenza, some residents were on EBP, and others were on contact precautions. During an observation of the laundry department on 4/2/2025 at 3:22 PM revealed residents' clean blankets were stored in the soiled laundry room alongside 4 boxes of soiled…

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, based on the comprehensive assessment of a resident, the resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 5 residents (Resident #1) reviewed for quality of care. The facility failed to ensure Resident #1 received wound care on 2/22/25 as ordered by the physician for cellulitis. The noncompliance was identified as PNC. The noncompliance began on 2/22/25 and ended on 2/23/25. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk of a decline in health, worsening wounds, and psychosocial harm. The findings include: Record review of Resident #1's face sheet, dated 2/28/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: leukemia and cellulitis (swollen skin). The RP was listed…

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 conduct an initial comprehensive assessment of each resident's functional capacity including the resident's needs, strengths, goals, life history, and preferences for 4 (Resident #1, Resident #2, Resident #3, and Resident #6) of 6 reviewed for assessments. 1. The MDS Coordinator failed to complete Resident #1's admission comprehensive assessment within 14 days after admission, 11/15/2024. 2. The MDS Coordinator failed to complete Resident #2's admission comprehensive assessment within 14 days after admission, 11/21/2024. 3. The MDS Coordinator failed to complete Resident #3's admission comprehensive assessment within 14 days after admission, 11/21/2024. 4. The MDS Coordinator failed to complete Resident #6's admission comprehensive assessment within 14 days after admission, 11/14/2024. This failure could affect newly admitted residents and result in residents not receiving the care and services as needed. The findings included: 1. Record…

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 initial comprehensive assessment accurately reflected the resident's status for 2 (Resident #4 and Resident #5) of 4 residents reviewed for accuracy of assessments. 1. The facility failed to accurately code Resident #4's bladder and bowel appliance status on her admission comprehensive assessment. 2. The facility failed to accurately code Resident #5's fall history with fracture on her admission comprehensive assessment. These failures could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. The findings included: 1. Record review of Resident #4's admission Record, dated 11/25/2024, reflected Resident #4 was admitted on [DATE]. Resident #4 was noted to be [AGE] years old. Record review of Resident #4's Diagnosis Report, dated 11/25/2024, reflected Resident #4 was diagnosed with cerebral infarction (a disruption in the brain's blood flow),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs that are identified in the comprehensive assessment, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 (Resident #1, Resident #4, Resident #5, Resident #6) of 4 residents reviewed for comprehensive care plans. 1. The facility failed to ensure Resident #1, who was documented for full code status, assessed as requiring supervision or touching assistance for transfers, and had a history of falls; had a care plan regarding code status, specified how many staff members were required to transfer the resident from bed to chair, and specified her fall risk and to include interventions to prevent and/or mitigate injury from falls. 2. The facility failed to ensure Resident #4, who…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice for 1 of 3 (Resident #1) reviewed for respiratory care. The facility failed on 09/18/2024 when Resident #1's oxygen tubing and humidifier bottle were outdated for 2 weeks; and the humidifier bottle was empty of water dated, 9/2/24. This failure could affect residents administered oxygen and could lead to infections if the tubing and humidifier bottle are not cleaned/ or replaced as ordered by the physician. The findings included: Record review of Resident #1's face sheet, dated 9/18/24, revealed, resident was a male age [AGE] with a re-admission date of 7/9/24 with diagnoses that included: cerebrovascular disease (primary), depression, heart disease, and COPD (chronic obstructive pulmonary disease). The RP was listed as a family member. 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 record review, the facility failed to maintain medical records, in accordance with accepted professional standards and practices, which are complete; and accurately documented for 1 of 5 residents (Resident #1) reviewed for completeness and accuracy: Resident #1's POC (point of care) for September 2024 did not reflect documentation of incontinent care and transfer being completed on the day shift for the dates 9/16/24 and 9/17/2024. This failure could result in the facility not documenting in the medical record residents ADL activities, experiencing accidents, injuries and/or a diminished quality of life. The findings included: Record review of Resident #1's face sheet, dated 9/18/24, reflected, resident was a male age [AGE] with a re-admission date of 7/9/24 with diagnoses that included: cerebrovascular disease (primary), depression, heart disease, and COPD (chronic obstructive pulmonary disease). The RP was listed as a family member. Record review of Resident#1's quarterly MDS (minimum…

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 a registered nurse signed and certified that the MDS assessment was completed for 2 of 4 residents (Resident #1 and #3) reviewed for MDS completion, in that; 1. The facility failed to ensure Resident #1's admission MDS assessment was completed. 2. The facility failed to ensure Resident #3's entry admission MDS assessment was completed. These failures could place residents at risk for incomplete or inaccurate documentation that does not completely reflect the resident's current status. The findings included: 1. Record review of Resident #1's face sheet, dated 6/25/2024 revealed an admission date of 6/05/2024 with diagnoses which included: unspecified fracture of fifth lumbar vertebra sequela (6/04/2024 - a fracture that occured after initial encounter), parkinsonism (movement disorder from deterioration of the brain which typically involves slowed movements, rigidity or stiffness and tremors), progressive supranuclear ophthalmoplegia…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 4 residents (Resident #2) reviewed for pharmacy services. The facility failed to acquire and administer Resident #2's scheduled dose of oxycodone prior to rehabilitation services on 6/25/2024. This failure could place residents at risk of increased pain and poor quality of life. The Findings were: Record review of Resident #2's face sheet, dated 6/25/2024 revealed an admission date of 6/12/2024 with diagnoses which included hypertension and type 2 diabetes mellitus. Record review of Resident #2's baseline care plan, dated 6/12/2024 revealed the resident was cognitively intact and did not have the presence of pain and would be receiving physical and occupational therapy to improve functional status. Record review of Resident #2's Pain…

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 employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care, and the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment required for 1 of 1 kitchen in that: The facility failed to have a certified Dietary Manager or Registered Dietician to serve as the Director of Food and Nutrition Services. This deficient practice could place the residents who consume food prepared from the kitchen at risk of food borne illness and not receiving adequate nutrition. The findings included: Record review of a staff roster (undated) obtained on date of entrance (6/25/2024) revealed the facility had three dietary staff members and no Dietary Manager or Registered Dietician was listed on the staff roster. During an interview on 6/26/2024 at 7:44 a.m., the DON stated the facility did not have Dietary Manager. During an interview on 6/26/2024 at 9:05…

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 be administered in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable well-being of each resident for 1 of 1 facility reviewed for Administration. The facility failed to hire an onsite MDS Coordinator to ensure resident MDS assessments were completed accurately and timely and transmitted and comprehensive care plans were developed. This deficient practice could affect all residents and place them at risk for inaccurate, incomplete and unverified MDS assessments and incomplete care plans which could result in incomplete and inaccurate care and services. The findings included: Record review of a staff roster (undated) obtained on date of entrance (6/25/2024) revealed the facility did not have an MDS Coordinator listed as a member of staff. During an interview on 6/25/2024 at 3:29 p.m., the Administrator stated the DON was not in the facility because she had been working night shift for a staff…

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 reviews the facility failed to, within 14 days after a facility completes a resident's assessment, electronically transmit encoded, accurate, and complete MDS data to the CMS System, including the admission assessment for 3 of 3 residents (Residents #101, #102, and #103) reviewed for MDS assessments. The facility failed to transmit the MDS withing 14 days of assessment for Resident's #101, #102, and #103. These failures placed residents at risk by not providing resident specific information for payment and quality measure purposes. The findings included: 1. A record review of Resident #101's admission record dated 05/07/2024 revealed an admission date of 04/10/2024 which included diagnoses of hemiplegia (partial body paralysis), epilepsy (seizures), and chronic kidney disease . A record review of Resident #101's admission MDS assessment, dated 04/16/2024, revealed Resident #101 was a [AGE] year-old male admitted for long term care and assessed with medically complex conditions 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 record reviews and interviews the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies for 1 of 1 facility reviewed for facility assessment. The facility failed to complete a facility-wide assessment to determine what resources was necessary to care for its residents competently during both day-to-day operations and emergencies. This failure could place residents at risk for not receiving necessary care and services required. The findings included: 1. A record review of Resident #101's admission record dated 05/07/2024 revealed an admission date of 04/10/2024 which included diagnoses of hemiplegia, epilepsy, and chronic kidney disease. A record review of Resident #101's admission MDS assessment, dated 04/16/2024, revealed Resident #101 was a [AGE] year-old male admitted for long term care and assessed with medically complex conditions and extensive assistance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure the activities program was directed by a qualified professional who is a qualified therapeutic recreation specialist or an activity professiona l for 3 of 3 residents (Residents #101, #102, and #103) reviewed for a qualified Activities Director. The facility admitted Residents #101, #102, and #103, without the services of a qualified Activities Director. This failure placed residents at risk for not receiving the serviced of a qualified Activities Director. The findings included: 1. A record review of Resident #101's admission record dated 05/07/2024 revealed an admission date of 04/10/2024 which included diagnoses of hemiplegia, epilepsy, and chronic kidney disease. A record review of Resident #101's admission MDS assessment, dated 04/16/2024, revealed Resident #101 was a [AGE] year-old male admitted for long term care and assessed with medically complex conditions and extensive assistance with activities of everyday life. 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.

Based on observation, interview, and record review, the facility failed to ensure the menu was followed for pureed foods (1 of 2 diets served at the facility), in that: The facility failed to ensure the kitchen had recipes for pureed diets. These failures could place residents at risk for dissatisfaction, poor intake, and diminished quality of life. The findings were: During an interview on 05/07/24 at 06:13 PM, the FSD revealed it was important for residents who have a pureed diet to not consume regular diets to prevent choking. During an observation and interview on 05/07/24 at 04:55 PM, there were no recipes for pureed diets present. The FSD and Dietary [NAME] A revealed they did not have a recipe to follow for pureed diets but they knew what consistency to look for pureed foods. During an interview on 05/07/24 at 05:30 PM, Corporate Administrator B revealed he would want access to pureed recipes if he needed to help in the kitchen if there was an emergency. He further revealed it was important to make diets like the pureed diet appropriately for their resident. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record reviews the facility with more than 120 beds must employ a qualified social worker on a full-time basis for 1 of 1 facility reviewed for a Social Worker. The facility did not have a full time Social Worker. This failure could place residents at risk for not receiving needed social services and place them at risk of psycho-social decline. The findings included : A record review of the facility's census, dated 05/07/2024, revealed 3 residents, Resident #101, #102, and #103. 1. A record review of Resident #101's admission record dated 05/07/2024 revealed an admission date of 04/10/2024 which included diagnoses of hemiplegia, epilepsy, and chronic kidney disease. A record review of Resident #101's admission MDS assessment, dated 04/16/2024, revealed Resident #101 was a [AGE] year-old male admitted for long term care and assessed with medically complex conditions and extensive assistance with activities of everyday life. A record review of Resident #101's care plan dated 05/07/2024…

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.