Avir at Killeen

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure that all alleged violations involving abuse and neglect are reported immediately, but not later than 24 hours if the events that cause the allegation involve abuse and do not result in serious bodily injury for 1 of 3 residents (Resident #1) reviewed for abuse and neglect.The facility failed to ensure that CNA A reported allegation of abuse immediately, but no later than 24 hours to the ADM when Resident #1 reported that her roommate slapped her on her thigh to CNA A.This failure could result in continued abuse or neglect of residents, injury, and/or psychosocial harm.Findings included:Record review of Resident #1's face sheet dated 02/26/26 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of type 2 diabetes, mild protein-calorie malnutrition, hypertension, cerebral infarction (stroke) , monoplegia of upper limb (paralysis of arm), muscle weakness, unsteadiness on feet and lack of coordination.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, observations, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that meet professional standards of quality care for 1 (Resident #2) of 4 residents reviewed for baseline care plans. The facility failed to update Resident #2 care plan on 12/28/2025 after they received orders from the nurse practitioner in regard to his rash.This failure could place residents at risk of getting insufficient care and having personal needs not met and could result in diminished physical and psychosocial well-being.Findings included:Review of Resident #2's face sheet dated 12/29/2025 reflected that he was a [AGE] year-old male admitted [DATE] with diagnoses of chronic obstructive pulmonary disease with (acute) exacerbation (a sudden, significant worsening of a person's COPD…

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, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one of four residents (Resident# 1) reviewed for ADL care.The facility failed to provide Resident #1 showers consistent on her shower days who were physically impaired.This failure could place ADL dependent residents at risk of experiencing embarrassment from odors, infection, and skin breakdown.Findings included:Record review of shower schedule from electronic records revealed the following:Resident #1- was scheduled for Tuesdays, Thursdays, and Saturdays on the 2pm-10pm shift for December 2025. The following dates revealed the resident received showers:12/2/2025 at 17:31 pm12/4/2025 at 23:22 pm12/6/2025 at 22:39 pm12:8/2025 at 4:08 am12/9/2025 at 23:46 am12/11/2025 at 22:43 pm12/13/2025 at 15:20 pm and 22:19 pm12/17/2025 at 00:01 am and 17:59 pm12/18/2025 at 4:07…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the right to be free from misappropriation of resident property for Resident #2 reviewed for misappropriation. The facility failed to ensure Resident #2 was protected from the AC accessing her bank account, leading to 4 unauthorized transactions totaling $10,250 from Resident #2's account between 10-18-2025 and 10-29-2025. This failure could place residents at risk of decreased quality of life, property misappropriation, and financial hardship.Findings included: Record review of Resident #2's admission record , dated 12-03-2025, indicated an [AGE] year-old female admitted to the facility on [DATE] with primary diagnoses of cerebral infarction, unspecified (blood flow to the brain disrupted due to issues with the arteries that supply it), and secondary diagnosis of Alzheimer's disease Resident #2 was her own responsible party, Record review of Resident #2's Quarterly MDS Assessment, dated 11-05-2025, revealed Resident #2 had a BIMS score of 12 ,…

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 follow their own established smoking policy for 2 (Residents #63 and #65) of 2 residents reviewed for smoking. The facility failed on 9/2/2025 to ensure that Residents #63 and #65 did not smoke without supervision and did not keep their personal cigarettes and lighters in their rooms, as per facility policy. This failure could place residents at risk of an unsafe smoking environment and injury. Findings include: Observation on 9/02/2025 at 11:19 AM revealed Resident #63 was observed in the designated smoking area for the facility, with a cigarette in her hand, smoking. There was no staff supervision in the smoking area at the time Resident #63 was smoking. There were no unsafe behaviors, and she did not have injuries from smoking. There is no evidence that she has been injured while smoking unsupervised. The resident did not say that they had been burned or injured while smoking cigarettes unsupervised. In an interview on 9/02/2025 at…

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 accommodate the needs and preferences for one of seven residents (Residents #1) reviewed for accommodation of needs, in that:The facility failed to ensure that Resident #1 had his call light in reach on 8/8/2025. This deficient practice could place residents at risk of injury, for not receiving timely care and nursing interventions.Findings included: Review of Resident #1's Face sheet dated 8/8/2025 reflected a [AGE] year-old male admitted on [DATE] with diagnoses that included: Hemiplegia (paralysis of one side of the body, Chronic Kidney Disease, Heart Failure, Obstructive Uropathy (disrupted urine flow) and, Atrial Fibrillation (irregular heart rhythm). Review of admission MDS dated [DATE] for Resident #1 reflected a BIMs of 14 suggesting no cognitive impairment. Review of Resident #1's Care plan dated 8/8/2025 for Resident #1 reflected the focus I am at risk for falls [related to] impaired mobility, with the Intervention: Evaluate,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 7 residents (Resident #1) reviewed for Infection control. The facility failed to ensure Resident #1's catheter bag was not laying on the floor on 8/8/2025. This failure could result in the spread of diseases to residents which could result in decreased quality of life, illness, and hospitalization.Findings included: Review of Face sheet dated 8/8/2025 reflected a [AGE] year-old male admitted on [DATE] with diagnoses that included: Hemiplegia (paralysis of one side of the body), Chronic Kidney Disease, Heart Failure, Obstructive Uropathy (disrupted urine flow) and Atrial Fibrillation (irregular heart rhythm). Review of admission MDS assessment dated [DATE] for Resident #1 reflected a BIMS score of 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 notify the resident and resident's representative(s) of the discharge, reasons for the move, and right to appeal in writing and in a language and manner they understand and send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 2 (Resident #1 and Resident #2) of 10 residents reviewed for discharge planning. A) 1. The facility failed to notify Resident #1 and Resident #1's RP of Resident #1's discharge, reasons for the move, and right to appeal in writing, in a language and manner they understand, and at least 30 days before Resident #1 was discharged from the facility on 05/25/25 in a facility-initiated discharge to another skilled nursing facility.2. The facility failed to send a copy of the notice to the facility's Ombudsman before Resident #1 was discharged from the facility on 05/25/25. B) 1. The facility failed to notify Resident #2 of a reason for his discharge from the facility, an effective…

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 that a resident who needs respiratory care is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for three (Resident's #13, 14, 17) of five residents reviewed for oxygen use and storage. The facility failed to ensure Resident's #13, 14, 17 nebulizer masks were documented when they were changed. This deficient practice could place residents receiving oxygen therapy at risk for infection. Findings include: Review of Resident #13's admission Record, dated 04/16/25, reflected a [AGE] year old female who was admitted into the facility on [DATE] with diagnosis including Diabetes Mellitus due to underlying condition with Diabetic Neuropathy (a condition that occurs when the body develops insulin resistance and no longer responds effectively to insulin), Rheumatoid Arthritis (an ongoing, called chronic, condition that causes 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility for 1 (Resident #63) of 5 residents reviewed for resident rights. The facility failed to offer language assistance services or interventions to communicate with Resident #63 who had limited English proficiency. These failures affected the residents at risk of a lack of a dignified existence, self-determination, and quality of life Review of Resident #63's face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of diabetes mellitus (a condition where the body either doesn't produce enough insulin or can't effectively use the insulin it makes) with other diabetic arthropathy (a progressive joint disorder that can occur in individuals with diabetes and peripheral neuropathy), cognitive communication deficit (difficulties…

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, and interviews, the facility failed to keep residents' information secure. This constitutes a failure to protect residents' personal and medical records and violated HIPAA regulations for 1 of 1 laptop. Because of this the facility was in a deficient practice. facility laptop was left open and unattended on a medication cart in the hallway with residents' personal medical information visible to anyone who passed by on 05/17/2025 while the medication aid was in a resident's room. These failures could place residents at risk of having their private information changed or viewed and not kept secure. Findings included: Observation on 05/17/2025, reflected that a staff member left the medication cart laptop open and unsupervised in a resident care area. The laptop screen displayed confidential resident information, accessible to unauthorized individuals. - Interview on 4/17/2025 at 2:37 PM, MA B stated that if the laptop was left open, residents or others could access information on the resident and possibly change the information. MA B said that this would be a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not provide pharmaceutical services to meet the needs of each resident for one (Resident #63) of four residents reviewed for pharmaceutical services, in that: The facility failed to ensure Resident #63 received his Acidophilus (bacterium found in the mouth) on 04/11/25, 04/12/25, and two times on 04/15/25. This deficient practice could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements, could result in worsening or exacerbation of medical conditions. Findings included: Review of Resident #63's face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of diabetes mellitus (a condition where the body either doesn't produce enough insulin or can't effectively use the insulin it makes) with other diabetic arthropathy (a progressive joint disorder that can occur in individuals with diabetes and peripheral neuropathy),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received necessary services to maintain good nutrition, grooming, and personal and oral hygiene for three of five residents (Resident #3, Resident #4, and Resident #5) reviewed for ADLs. The facility failed to provide showers to Residents #3, #4, and #5 in compliance with their shower schedules. This deficient practice could place residents at risk of a decline in hygiene, at risk of skin breakdown, level of satisfaction with life, and feelings of self-worth. Findings included: Review of Resident #3's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction (stroke) affecting right dominant side, muscle weakness, and muscle wasting and atrophy (wasting away). Review of Resident #3'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 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 1 of 3 residents (Resident #2) reviewed for infection prevention and control. CNA B failed to don PPE while performing incontinent care for Resident #2 who was on enhanced barrier precautions. CNA B and LVN C failed to perform hand hygiene while performing incontinent care and wound care for Resident #2. LVN C failed to have a clean field for supplies while performing wound care for Resident #2. The facility failed to have a liner in the trash can in Resident #2's room. These failures could place residents at risk for infection. Findings include: Review of Resident #2's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including dermatitis (skin conditions), type II…

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 have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable, physical, mental, and psychosocial well-being for 1 of 4 (CNA A) certified nurse assistant reviewed for competent nursing care. The facility failed to ensure CNA A followed the facility policy while providing incontinent care to Resident #1 when she did not perform proper perineal care (the process of washing the genital and anal areas of the body) during a disposable underwear change. The non-compliance was identified as Past Noncompliance. The past noncompliance began on 5/31/2024 and ended on 6/02/2024. The facility had corrected the non-compliance before the survey began through training, reviews of clinical information, revision of processes, and the QAPI process. The deficient practice placed residents who depend on nursing care at risk for infection, 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 residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 11 residents (Resident #1) reviewed for activities of daily living. The facility failed to ensure Resident #1 received her showers as scheduled, received nail care, and received assistance with oral hygiene. The failure placed residents at risk of embarrassment, injury, skin breakdown, and infection. Findings included: Review of the undated face sheet for Resident #1 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included cerebral infarction (stroke that resulted in a necrotic area of the brain), depression, stiffness of joints, muscle wasting and atrophy, and spastic hemiplegia (muscles on one side of the body in a constant state of contraction). Review of the admission MDS assessment for Resident #1 dated 03/22/24…

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.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's only kitchen reviewed for sanitation. The facility failed to discard of food products that were past the use by date in the dry storage area. The facility failed to discard of a food product that was past the use by date in their double door refrigerator. The facility failed to store boxes off the floor in the walk-in-freezer. These failures could place residents at risk of cross contamination and foodborne illness. Findings included: Observation on 02/20/2024 at 6:53 AM revealed that the dry food storage area contained the following expired food products on the shelf: 19 twelve-ounce cans of evaporated milk with a displayed use by date of 1/13/24, 5 forty-eight-ounce containers of prune juice dated 5/26/23 with a displayed use by date of 12/15/23, and 1 forty-six-ounce container of prune juice dated 8/20/21 with a displayed use by date of 4/9/22. Observation on 02/20/2024 at 7:04 AM of the facility's walk-in freezer…

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 consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life and failed to demonstrate their response and rationale for such response for one of one resident council meeting. There was no documentation of the facility's effort to resolve grievances collected at Resident Council meetings on 11/07/2023, 12/12/2023, and 01/09/2024. This failure placed residents at risk of indignity and diminished quality of life. Findings included: Review of Resident Council Minutes reflected the following with no resolutions or follow-up documented: -11/07/2023: Variety of Brief sizes, Nurses should help CNAs, missing clothing and clean under the beds. -12/12/2023: Call Lights not being answered, Not getting their briefs changed, Staff gossiping in front of residents, Medications are late, not getting showers, eggs and toast not good and second time they have complained about not cleaning under the beds -01/09/2024: CNAs does not return to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to maintain a clean, sanitary, comfortable, and homelike environment in 1 of 1 resident rooms (Resident #69) and 1 of 2 medication storage rooms (Pod 1 medication storage room) as evidenced by, 1) Resident #69 had feces on his commode, feces-soaked towels on his floor, and brown stains on his bedspread and wheelchair. 2) The Pod 1 medication storage room had loose trash, a box of ostomy bags, and debris and dirt on the floor. The interior of the specimen refrigerator had brown and yellow stains and chunks of brown debris. The freezer section had a large amount of unidentified brown debris. These failures could place all residents in the facility at risk for a diminished quality of life and a diminished clean, homelike environment. Findings included: 1. Record review of Resident #69's undated Face Sheet reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Abscess of bursa (localized collection of pus in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to ensure residents had the right to be free from abuse and neglect for one resident (Resident #68) out of 18 reviewed for abuse. The facility to failed to ensure a social worker at the facility did not verbally abuse a resident when they yelled at Resident #68 and called him stupid; the incident was witnessed by the ADON, who reported it immediately. The failure could place residents at risk of physical or emotional distress, and injury. Findings include: Review of the Face sheet for Resident #68 reflected he was admitted on [DATE] with diagnosis of: Vascular Dementia, Anxiety, Acute Congestive heart Failure, Major Depressive disorder, Irritable Bowel syndrome, Acute Kidney Failure and Chronic Atrial fibrillation. Review of the annual MDS assessment for Resident #68 dated 10/29/23 reflected a BIMS score of 15 indicating normal cognitive abilities. His physical assessment reflected he was independent in performing all his ADLs. He was assessed as…

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 the facility failed to provide the necessary services to maintain grooming and personal care for 6 of 10 residents (#4, #69, #81, #74, #12, and # 240) reviewed for ADL care. The facility failed to ensure Residents #4, #69, #81, #74, #12, and # 240 were provided assistance with personal hygiene. These failures could place residents at risk of skin breakdown, infection, and loss of self-esteem. Findings included: Record review of Resident #4's undated Face Sheet reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease with acute exacerbation (group of disease that cause airflow blockage and breathing related problems), Cerebral Infarction (disrupted blood flow to the brain due to problems with blood vessels that supply and can cause death of brain cells), Dementia (a group of thinking and social functions that interferes with daily functioning), and difficulty in walking. 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 provide, based on comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choices of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interest of and support the physical, mental, and psychosocial well-being of each resident, encouraging interaction in the community for 3 of 6 residents (Resident #6, Resident #36 and Resident #37) reviewed for activities. The facility failed to ensure one-on- one activities for Residents #6, Resident #36 and Resident #37 was provided according to the one-one activity schedule. This failure could place residents at risk for a decline in social, mental, psychosocial well-being and a diminished quality of life. Findings included: 1. Record review of Resident #6's face sheet, dated 02/22/2024, revealed Resident #6 was an [AGE] year-old female who was admitted to the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents who need respiratory care were provided such care, consistent with professional standards of practice for 2 (Resident #18 and #19) of 4 Residents reviewed for respiratory care. The facility failed to ensure that Resident #18's Nebulizer tubing and mouthpiece, which includes the nebulizing chamber (unit into which liquid medicine is converted into aerosol or mist by the pressurized air pumped through the tubing), were dated, bagged, and replaced every seven (7) days. The facility failed to ensure that Resident #19's Nebulizer tubing and mask were bagged and replaced every seven (7) days. The facility failed to ensure that the oxygen tubing for Resident #19 was dated and replaced every seven (7) days. The facility failed to ensure that the air filter for Resident #19's air concentrator was cleaned and free of debris. These failures could place residents at risk for respiratory discomfort, compromise, and infection.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents received services in the facility with reasonable accommodation of each resident's needs for 5 of 15 residents (Residents #54, #24, #52, #81 and #69) reviewed for call lights. Residents #54, #24, #52, #81 and #69 were observed in their rooms with their call lights not in reach. This failure could affect residents who needed assistance with activities of daily living and could result in needs not being met. Findings included: Record review of Resident #54's undated Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE] for respite care with diagnoses of Unspecified atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), and Unspecified combined systolic and diastolic congestive heart failure (left and right ventricles of heart are not functioning properly. Blood may back up into the lungs and or the body tissues leading to shortness of breath, fatigue,…

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 conduct an accurate comprehensive assessment of each resident's functional capacity for one (Resident #240) of eight residents reviewed for comprehensive assessments. The facility failed to ensure Resident #240's admission assessment was completed by the 14th day of admission. These failures placed residents at risk of not receiving the proper care required to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Findings included: Record review of Resident #240's Face Sheet, dated 02/22/2024, reflected a [AGE] year-old female admitted on [DATE] with diagnoses included muscle wasting and atrophy, not elsewhere classified, unspecified site (the decrease in size and wasting of muscle tissue), lack of coordination ( muscle control problem that causes an inability to coordinate movement) difficulty in walking (inability to walk properly), chronic kidney disease (damage or loss of function in the kidneys), Pneumonia (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 failed to develop a comprehensive care plan within seven days after the comprehensive assessment was required to be completed for one (Resident # 240) of seven resident reviewed for comprehensive care plans. The facility failed to complete comprehensive person-centered care plan to address Resident #240's needs within seven days after the comprehensive MDS assessments was expected to be completed. This failure could place residents at risk of not having their individual care needs met in a timely manner or diminished quality of life. Findings included: Record review of Resident #240's Face Sheet, dated 02/22/2024, reflected a [AGE] year-old female admitted on [DATE] with diagnoses included muscle wasting and atrophy, not elsewhere classified, unspecified site (the decrease in size and wasting of muscle tissue), lack of coordination ( muscle control problem that causes an inability to coordinate movement) difficulty in walking (inability to walk properly),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that residents received treatment and care accordance with professional standards of practice for one (Resident #29) of four residents reviewed for quality of care. The facility failed to assess Resident #29 prior to moving resident after a fall from her bed to the floor. This failure placed residents at risk for potential delay in medical intervention, decline in health and a decreased quality of life. Finding included: Record review of Resident #29's face sheet, dated 02/22/2024, revealed Resident #29 was an [AGE] year-old female who was admitted to the facility on [DATE] with the following diagnoses which included repeated falls (older adults which falls more than once a year), dizziness and giddiness (dizziness- a general feeling of being off-balance. Giddiness- feeling that you are your surroundings are moving or spinning), muscle weakness ( when full effort does not produce a normal muscle contraction or movement), wedge…

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 labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions and the expiration date when applicable for 1 (Pod 2 medication storage room) of 2 medication storage rooms, 1 (Pod 2 medication cart) of 1 medication carts and 1 (Pod 2 treatment cart) of 1 nurse treatment carts. The facility failed to ensure three medications (total of 5 bottles) were not past their expiration dates in the Pod 2 medication storage room. The facility failed to ensure two medications were not expired in the Medication Aide cart on Pod 2. The facility failed to ensure one bottle of aspirin was not expired in the nurse treatment cart on Pod 2. These failures could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications. Findings included: Observation on 02/21/2024 at 9:00 AM in the Pod 2 medication storage room revealed 2 bottles of Naproxen (pain reliever) with…

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 establish policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that take into account nonsmoking residents for one of one facility reviewed for smoking. The facility failed to develop a policy to address residents within the facility that were smokers. The facility failed to develop a policy to address smoking materials possessed by residents who are known smokers within the facility. The facility failed to notify residents in writing during admission that it is a no smoking facility and address options for smokers. These failures could place residents at risk for injury, burns, and an unsafe smoking environment. Findings Include: Interview on 02/21/2024 at 8:00 AM, the RN Consultant was requested to provide their policy in reference to smoking. The RN Consultant advised that she did not believe they had one because they are a no smoking facility. Interview on 02/21/2024 at 8:08 AM, the ADMINISTRATOR stated that they do not have a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not provide pharmaceutical services to meet the needs of each resident for one (Resident #1) of four residents reviewed for pharmaceutical services, in that: The facility failed to check Resident #1's blood pressure and administer one scheduled blood pressure medication (Hydralazine) as ordered on the morning of 01/17/24. This deficient practice could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements, worsening or exacerbation of chronic medical conditions, and hospitalization. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including type II diabetes, shortness of breath, epilepsy (seizures), and hypertension (high blood pressure). Review of Resident #1's quarterly MDS assessment, dated 11/23/23, reflected a BIMS of 10, indicating a moderate cognitive impairment . Review of Resident #1's quarterly…

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 medical records were accurately documented for 1 (Resident #1) of 5 residents reviewed for accurate medical records, in that: The facility failed to ensure Resident #1's medical chart reflected nursing documentation of his wounds, and that his wounds were accurately reflected on the weekly facility report for the wound care physician; wounds that were present since 06/20/23 appear one week and then are absent another week, then reappear the next week and continued that patter until the time of investigation. This deficient practice could impact all residents with wounds and result in errors in care and treatment due to improper documentation. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including chronic ulcer of the lower leg, depression, brain bleed, and partial paralysis. Review of Resident #1's 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.