Avir at Longview

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 to meet each resident's medical, nursing, mental and psychosocial needs for 2 of 19 residents reviewed for care plans. (Resident #34 and Resident #55) 1. The facility failed to resolve and update a care plan for Resident #34's removed PICC line (a long, thin, flexible tube inserted into a vein in the arm and threaded up to a large vein above the heart for easy access for administering intravenous medications, fluids, and nutrition) and incision care to right femur on 5/5/2025. 2. The facility failed to update a care plan for Resident #55's dietary orders from pureed to mechanical soft on 1/3/2025. These failures could place residents at risk of not having individual needs met and cause residents not to receive needed services. Findings included: 1. Record review of a face sheet printed 5/5/2025 indicated Resident #34 was a [AGE] year-old, female and admitted on [DATE] 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure each resident's environment remained free of accident hazards for 1 of 22 residents (Resident #33) reviewed for accident hazards. The facility failed to keep prohibited items, hydrogen peroxide topical solution, out of Resident #33's room. This failure could place residents at risk for injury, harm, and impairment or death. Findings included: Record review of Resident #33's Face Sheet indicated she was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Heart Failure (a condition where the heart cannot pump enough blood to meet the body's needs), Urinary Tract Infection (an infection in any part of the urinary system, including the kidneys, bladder, urethra, or ureters), Pneumonia (a lung infection that inflames the air sacs and can fill them with fluid or pus). Record review of Resident #33's MDS dated [DATE] revealed that the resident's BIMS score was a 13 indicating no cognitive impairment. The MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that residents who need respiratory care are provided with such care, consistent with professional standards of practices for 1 of 22 residents (Resident #4) reviewed for respiratory care. 1. The facility failed to change the oxygen tubing for Resident #4. 2. The facility failed to ensure that Resident #4's oxygen concentrator reservoir was filled with water. These failures could place residents who receive respiratory care at risk of developing respiratory complications and a decreased quality of care. Findings included: Record review of Resident #4's face sheet, dated 3/16/24 revealed a [AGE] year-old female admitted on [DATE] with diagnoses that included Chronic Obtrusive Pulmonary Disease (a progressive lung disease that makes it hard to breathe), Pneumonia (a lung infection that inflames the air sacs and can fill them with fluid or pus), Hypokalemia (a condition where the amount of potassium in the blood is lower than normal).…

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 had the right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 1 of 8 (Resident #8) residents reviewed for environment. 1. The facility failed to ensure Resident #8's bathroom floor and toilet was free of brown substances from 2/28/2025-3/18/2025. 2. The facility failed to ensure soiled briefs were removed from Resident #8's trash can on 2/28/2025. 3. The facility failed to ensure the bathroom floor was free from debris of toilet paper scattered on the floor from 2/28/2025-3/18/2025. These failures could place residents at risk of an unsafe or uncomfortable environment and a decrease in quality of life and self-worth. Findings include: Record review of Resident #8's, face sheet dated 4/9/2025 reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #8 had diagnoses which included Alzheimer's disease…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that residents who need respiratory care are provided with such care, consistent with professional standards of practices for 1 of 10 residents (Resident #1) reviewed for respiratory care . The facility failed to ensure that Resident #1 had a supply of oxygen in her portable oxygen tank. These failures could place residents who receive respiratory care at risk of developing respiratory complications and a decreased quality of care. Findings included: Record review of Resident #1's face sheet, dated 10/27/24 revealed a [AGE] year-old female admitted on [DATE] with diagnoses that included Displaced fracture of base of neck of left femur (a break in a bone that can be partial or complete), Cognitive impairment (problems with thinking, learning, memory, or judgment), Urinary tract infection (an infection of the urinary tract, which includes the kidneys, ureters, bladder, and urethra). Record 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.

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 2 of 5 residents (Resident #2 and Resident #3) reviewed for infection control practices. 1. The facility failed to ensure the ADON applied enhanced barrier precautions when she assisted the nurse with positioning and holding Resident #2 during wound care treatment on 2/20/2025 at 1:24 PM. 2. The facility failed to ensure CNA B applied enhanced barrier precautions when she assisted the nurse with positioning and holding Resident #3 during wound care treatment on 2/26/2025 at 11:55 AM. 3. The facility failed to ensure Resident #3 was clean and dry after wound care was performed by CNA B and Treatment nurse on 2/26/2025 at 11:55 AM. These failures could place residents at risk of cross-contamination and infections…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide pharmaceutical services, including the accurate acquiring, administering and receipt of all drugs and biologicals, to meet the needs of 1 of 4 residents reviewed for pharmacy services. (Resident #1) The facility failed to ensure Resident #1 was administered her diltiazem (medication used to treat high blood pressure) and lisinopril (medication used to treat high blood pressure) 7 days in the month of March 2024. This failure could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications. Findings Include: 1. Record review of an undated face sheet indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including hypertension (high blood pressure), aphasia (language disorder that affects a person's ability to understand and express language, reading, and writing), cognitive communication deficit, heart disease, and atrial fibrillation…

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

Based on interview, and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility reviewed for RN coverage. The facility failed to provide RN coverage for 8 consecutive hours daily on 10/07/2023, 10/08/2023, 10/21/2023, and 10/22/2023. The deficient practice had the potential to affect residents in the facility by leaving staff without supervisory coverage for RN specific nursing activities and for coordination of events such as emergency care and disasters. Findings include: Record review of nursing staff information sheets dated 10/07/2023, 10/08/2023, 10/21/2023, and 10/22/2023 indicated that the facility did not have an RN in the facility that worked 8 consecutive hours. During an interview on 03/26/2024 at 10:50 a.m., the DON said the facility had a hard time getting RN coverage at that time but she had been working the weekends since she began in March 2024 to ensure they had coverage. The DON said not having RN coverage left the facility with no supervisory nurse on those days. During…

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

Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety requirements and kitchen sanitation. 1. The facility failed to ensure food was properly sealed and not exposed to air in the storeroom and refrigerator. 2. The facility failed to ensure food and drink items were labeled and dated in the refrigerator, freezer, and drink dispenser. 3. The facility failed to ensure raw chicken was thawing in the appropriate sink under constant flow of cool, running water. 4. The facility failed to ensure items were not stored on the floor in the storeroom and back area near refrigerators. 5. The facility failed to ensure the kitchen did not have a splattered brown substance on the walls near industrial mixer. 6. The facility failed to ensure food preparation equipment and drink dispensers were cleaned after use. 7. The facility failed to ensure a black metal shelve holding cookware was 6 inches from the ground. 8. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure, based on the comprehensive assessment of a resident, residents who had not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record and residents who use psychotropic drugs received gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in and effort to discontinue these drugs for 3 of 17 residents, (Residents #56, #28, and #50) reviewed for unnecessary medications. 1.The facility failed to ensure Resident #50 received a gradual dose reduction for her Ziprasidone (antipsychotic). 2.The facility failed to ensure Resident #28 received a gradual dose reduction for his Risperdal (antipsychotic). 3.The facility failed to have an appropriate diagnosis or indication of use for Resident #56's Seroquel (antipsychotic). These failures could place residents at risk of receiving unnecessary psychotropic…

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 written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, and misappropriation of resident property and establish policies and procedures to report and investigate such allegations, for 2 of 17 residents (Resident #38, Resident #50), reviewed for abuse/neglect. The facility failed to ensure the ADM/Abuse Preventionist, followed the facility's policy to report an allegation of neglect for Resident #50 within 2 hours when she was found on the floor on 2/28/24 resulting in an elbow and pelvic fracture. The allegation of neglect was not reported to HHSC until 3/25/24. The facility failed to ensure the ADM/Abuse Preventionist, followed the facility's policy to report an allegation of abuse on 03/09/24, toward Resident #38 by CNA S within 2 hours of the allegations. The allegation of abuse was not reported to HHSC until 03/11/24. The facility failed to immediately remove the alleged perpetrator, CNA 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, interviews and record reviews the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials, including to the State Survey Agency for 2 of 17 residents (Resident #50 and Resident #38) reviewed for allegations of abuse, neglect, exploitation, and mistreatment. The facility failed to ensure the ADM/Abuse Preventionist reported the neglect allegation on 2/28/24 for Resident #50 within 2 hours when she was found in the floor resulting in an elbow and pelvic fracture. The allegation of neglect was not reported 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 interviews and record review the facility failed to ensure assessments accurately reflected the resident's status for 1 of 17 residents (Resident #56) reviewed for MDS assessment accuracy. The facility failed to code Resident #56's diagnosis of Schizophrenia on her MDS. These failures could place residents at risk for not receiving care and services to meet their needs. Findings included: Record review of Resident #56's face sheet dated 3/27/2024 revealed she was a [AGE] year-old female, who admitted to the facility on [DATE]. Resident #56 had diagnoses of Charcot's joint, right ankle, and foot (a disease that attacks the bones, joints, and soft tissue of feet), Acute osteomyelitis, right ankle, and foot (an infection in a bone), Diabetes Mellitus (group of diseases that affect how the body uses blood sugar) and anxiety disorder due to known physiological condition (frequent intense, excessive, and persistent worry or fear about everyday situations). Record review of Resident #56's Comprehensive MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 17 (Resident #52) residents reviewed for quality of care. The facility failed to ensure Resident #52 received daily wound care per her care plan. A complaint was filed by a local hospital that Resident #52 arrived in the ER on [DATE] with dressings dated 02/29/24. This failure could place residents of risk for not receiving appropriate care and treatment, a decreased quality of life, and pressure ulcers. Findings included: Record review of Resident #52's face sheet printed 03/25/24 indicated Resident #52 was a [AGE] year-old, female and admitted on [DATE] and 03/15/24 with diagnoses including congestive heart failure (is a serious condition in which the heart doesn't pump blood as efficiently as it should), cellulitis (is a deep infection of the skin caused by bacteria.), Type 1 diabetes (is 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 failed to ensure residents who had urinary incontinence, received appropriate treatment and services to prevent urinary tract infections to the extent possible for 1 of 8 residents reviewed for urinary incontinence. (Resident #22) 1. The facility failed to provide routine incontinent care for Resident #22, resulting in a urinary tract infection. This failure could place residents at risk for urinary tract infections, pain, confusion, and sepsis (infections that spread to the blood). Findings included: Record review of an undated face sheet revealed Resident #22 was a [AGE] year-old, admitted on [DATE] with the diagnoses of Alzheimer's disease (progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), depression, and anemia (a condition in which the body does not produce enough red blood cells). Record review of an admission MDS assessment dated [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to 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 2 of 13 residents (Residents #46 and Resident #23) reviewed for pharmacy services. The facility failed to ensure medications were administered timely for Resident #46 and Resident #23. This failure could place residents at risk for inaccurate drug administration and overdosing of medications. Findings include: 1. Record review of Resident #46's face sheet, dated [DATE], reflected a [AGE] year-old female who was originally admitted to the facility on [DATE]. Resident #46 had diagnoses which included COPD (is a group of long-term lung conditions, including emphysema and chronic bronchitis), pneumonia (infection of the air sacs in one or both the lungs) and neoplasm of the lung (tumors that form either from lung tissue, also known as a primary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that the medication error rate was not 5 percent or greater. The facility had a medication error rate of 6.06%, based on 2 errors out of 33 opportunities, which involved 2 of 7 residents (Residents #2 and #53) reviewed for medication errors . 1. The facility failed to ensure MA Z administered Resident #2's Artificial saliva (mimics natural saliva and helps provide relief for dry mouth) and failed to ensure the medication was in the facility and available for the resident. 2. The facility failed to ensure LVN P did not crush Guaifenesin 600mg tab (help clear mucus or phlegm from the chest when you have congestion from cold or flu) for Resident #53. These failures could place residents at risk of not receiving the intended therapeutic benefit of their medication or receiving them as prescribed, per physician orders. The findings include: 1. Record review of Resident #2's face sheet, printed 3/28/24, reflected a [AGE] year-old female…

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 follow their established smoking policy regarding smoking safety for 1 of 1 resident reviewed for safe smoking. (Resident #56) The facility failed to implement Resident #56's care plan intervention to keep her electronic vape secured at the nurse's station per the facilities policy. The facility failed to implement Resident #56's care plan intervention to be supervised while smoking. The facility failed to implement Resident #56's care plan intervention to charge her electronic device with a designated staff member in non-resident areas for safety during charging per the facility's policy. These failures could place residents at risk for not receiving necessary care and services or having important care needs identified. Findings included: 1. Record review of Resident #56's face sheet dated 3/27/2024 revealed she was a [AGE] year-old female, who admitted to the facility on [DATE]. Resident #56 had diagnoses of Charcot's joint, right ankle,…

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 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 wellbeing of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment for one of one facility reviewed for sufficient staff. The facility failed to have sufficient staff available to provide resident care on 2/12/2024. The facility failed to have sufficient staff available to provide resident care from 10:00pm to 6:00am according to the facility assessment tool on 2/13/24, 2/14/24, 2/15/24, 2/16/24, 2/17/24, 2/18/24, 2/19/24, 2/20/24, 2/21/24, 2/22/24, 2/23/24, 2/25/24, 2/26/24, and 2/27/24. This failure could put residents at risk of not receiving necessary…

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 3 of 7 residents (Resident#1, # 3 and #4) reviewed for ADL care. 1. The facility failed to ensure Residents #1, #3 and #4 were checked prior to breakfast to determine if they needed care. 2. The facility failed to ensure residents were provided care for at least 3 hours and resident briefs were saturated with urine. These deficient practices could place residents at risk of being uncomfortable and could cause skin breakdown. Findings include: 1. Record review of Resident #1's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility 6/2/23. Resident #1 had diagnoses which included neuro muscular dysfunction of the bladder, high blood pressure, fracture of the lumbar vertebra and difficulty walking. Record review of Resident #1'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 ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 2 of 5 residents (Resident #1, and Resident #3) reviewed for appropriate treatment and services to prevent urinary tract infections. The facility failed to ensure Resident #1's catheter bag was placed below the level of the bladder and remained free of dependent loops (a configuration of catheter tubing where the drainage tubing dips below the entry point into the catheter bag). The facility failed to ensure Resident #3's catheter tubing remained free of dependent loops. These failures could place residents at risk for urinary tract infections. Findings include: 1.Record review of the face sheet dated 10/24/23 for Resident #1 indicated she was re-admitted to the facility on [DATE] with diagnoses including high blood pressure, COPD (chronic obstructive pulmonary disease is a group of lung diseases that block…

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 2 residents (Residents #2) reviewed for infection control practices. CNA B did not dispose of the dirty brief, remove her dirty gloves, perform hand hygiene (wash her hands or use hand sanitizer) and place clean gloves on before she placed a clean brief on Resident #2 and pulled up her pants. These failures could place residents at risk for cross contamination and infections. Findings included: 1. Record review of the face sheet dated 10/24/23 indicated Resident #2 was [AGE] years old, readmitted to the facility on [DATE] with diagnoses including, Dementia, fibromyalgia (chronic disorder characterized by widespread pain and other symptoms such as fatigue, muscle stiffness) history of urinary tract infection, and heart…

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 the necessary services to maintain good nutrition, grooming, and personal and oral hygiene were provided for 2 of 3 residents (Residents #44 and #48) reviewed for ADLs care. 1. The facility failed to ensure Resident #48 was routinely showered/bathed . 2. The facility failed to ensure Resident #48's fingernails were free from a brown materialsubstance. 3. The facility failed to ensure Resident #44 was showered on 02/06/2023, 02/07/2023, 02/08/2023, 02/09/2023, 02/10/2023 and 02/13/2023. These failures could place residents at risk of not receiving care/services, decreased quality life impacting their loss of dignity. Findings included: 1.) Record review of a Resident #48's face sheet, dated 02/14/2023, indicated an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included Parkinson's (disease causing tremors), vascular…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 5 of 7 residents (Resident #118, #19, #119, #6, #26) reviewed for respiratory care and services. The facility failed to administer oxygen at 2 liters per minute via nasal cannula as prescribed by the physician for Residents #118, #19, #119, #6, and #26. This failure could place residents at risk for developing respiratory complications. Findings included: 1. Record review of Resident #118's, undated, face sheet indicated Resident #118 was an [AGE] year-old female who was admitted to the facility on [DATE]. She had diagnoses which included pulmonary hypertension (a type of high blood pressure that affects arteries in the lungs and in the heart), weakness, and heart failure (a chronic condition in which the heart does not pump blood 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.

Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 62 days reviewed for RN coverage. The facility failed to provide RN coverage for 8 consecutive hours daily on 12/04/2022, 12/31/2022, 01/14/2023, 01/15/2023, 01/28/2023 and 01/29/2023. The deficient practice had the potential to place residents at risk by leaving staff without supervisory coverage for RN specific nursing activities and for coordination of events such as an emergency care and disasters. Findings included: Record review of the facility's last 2 months (December 2022 and January 2023) of time sheets for RN coverage revealed that the facility did not have an RN in the facility for at least 8 hours on 12/04/2022, 12/31/2022, 01/14/2023, 01/15/2023, 01/28/2023 and 01/29/2023. During an interview on 02/15/2023 at 1:47 p.m., the ADON said there had been times when there was no registered nurse scheduled on the weekends. The ADON said she had made the DON aware when a registered nurse would not be in the facility. 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, interviews, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 3 of the 3 medication carts reviewed for medications storage (rooms 101-112 medication cart, rooms 417-428 medication cart, and rooms 114-121 medication cart). 1. The facility failed to remove expired over the counter medications from rooms 101-112 medication cart. 2. The facility failed to remove expired over the counter medications from rooms 417-428 medication cart. 3. The facility failed to remove expired over the counter medications from rooms 114-121 medication cart. These failures could place residents at risk for not receiving the therapeutic benefit of medications or adverse reactions to medications. Findings included: During an observation on 02/13/23 at 2:38PM rooms 101-112 medication cart revealed an over-the-counter calcium with vitamin D3 that expired April 2022,…

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 state and federal laws, all drugs and biologicals were stored in locked compartments for 1 of 22 residents (Resident #118) reviewed for storage of medication. The facility failed to securely store Resident #118's [NAME] 2 Cyclo 2 Diclo 5 Lido 5 (Pain relief) cream and Afrin nose spray. These failures could place residents at risk for adverse reactions to medications or overdose. Findings included: Record review of Resident #118's undated face sheet indicated Resident #118 was an [AGE] year old female, admitted to the facility on [DATE]. She had diagnoses that included pulmonary hypertension (a type of high blood pressure that affects arteries in the lungs and in the heart), weakness, and heart failure (a chronic condition in which the heart does not pump blood as well as it should). Record review of Resident #118's admission MDS assessment dated [DATE] indicated resident #118 had a BIMS score of 12 which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to 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 3 of 3 reviewed (Resident #'s 14, 35, and 268) for wound care infection control practices. 1. LVN Q failed to change gloves and sanitize hands after cleaning wound and touching the clean dressing during wound care for Resident #14 and Resident #268. 2. CNA S failed to wash her hands or use hand sanitizer before and after providing care to Resident #35. 3. CNA S failed to remove the soiled gloves prior to touching the clean brief, bed linen, Resident #35's gown, and the sit to stand machine. This failure could place any resident at the facility requiring incontinent care and wound care at risk for infections including but not limited to urinary tract infections and any residents at the facility requiring wound…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents had the right to a dignified existence, self-determination, and communication with access to persons and services inside and outside the facility for 2 of 2 residents (Resident #44 and Resident #170) reviewed for resident rights. The facility failed to ensure Resident #44's and Resident #170's catheter bags had privacy covers. This deficient practice could place residents at risk of loss of dignity. Findings include: 1. Record review of Resident #44's face sheet, dated 02/14/23, indicated an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included flaccid hemiplegia affecting left nondominant side (left sided paralysis), cerebrovascular disease (condition that affect blood flow to the brain), depression (persistent feeling of sadness), and rheumatoid arthritis (inflammatory disorder affecting joints). Record review of the annual MDS, dated [DATE], indicated 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 interview and record review the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of changes for those services, which included changes for services not covered under Medicare/Medicaid or by the facility's per diem rate for 1 of 3 residents (Resident #66) reviewed for Medicare/Medicaid coverage. The facility failed to ensure Resident #66 was given a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) when discharged from skilled services at the facility prior to covered days being exhausted. This failure could place residents at risk for not being aware of changes to provided services. The findings were: Record review of Resident #66's face sheet, dated 02/15/2023, revealed the resident was admitted to the facility on [DATE], and readmitted on [DATE] and discharged on 11/23/2022. Record review of the physician's orders, dated October 2022, indicated Resident #66 had 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 observation, interview and record review the facility failed to ensure, at the time each resident was admitted , there were physician orders for the resident's immediate care for 1 of 12 residents (Resident #268) reviewed for admission physician orders. The facility failed to ensure Resident #268 had a physician order for dressing change to his left lower leg/foot, PICC line care, and IV antibiotics, Cefazolin 2GM IV every 8 hours. This failure could place residents at risk for not receiving appropriate care, treatment services, and at risk for infection. Findings include: Record review of Resident #268's face sheet, dated 02/14/23, indicated a [AGE] year-old male, who was admitted to the facility on [DATE] with a diagnosis which included cellulitis of the foot (infection). Record review of Resident #268's medical record revealed the resident did not have an MDSs in his medical record. Record review of Resident #268's physician order report dated, 01/14/23-02/14/23, indicated the resident had an order…

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 baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care for 2 of 2 residents (Residents #119 and #268) reviewed for baseline care plans. 1. The facility failed to address Resident #268's PICC line, IV antibiotics and Wound care on his baseline care plan. 2. The facility failed to ensure Resident #119 had a baseline care plan for respiratory care. These deficient practices could place residents at risk of missed care. The findings were: 1. Record review of Resident #268's face sheet, dated 02/14/23, indicated Resident #268 was a [AGE] year-old male who was admitted to the facility on [DATE] with a diagnosis which included cellulitis of the foot (infection). Record review of Resident 268's medical record revealed the resident did not have an MDS in his medical record. Record review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to review and revise the person-centered care plan to reflect the current condition for 1 (Resident #170) of 6 resident reviewed for care plan revisions. The facility failed to update Resident 170's care plan to reflect interventions of suicidal ideations on mood state. This deficient practice could place residents at risk of not receiving appropriate interventions to meet their current needs. Findings include: Record review of Resident #170's electronic face sheet, dated 02/14/23, revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included depression (sadness), PVD [ Peripheral vascular disease] (a systemic disorder that involves the narrowing of peripheral blood vessels), anxiety (what we feel when we are worried, tense, or afraid), and high blood pressure. Record review of Resident #170's admission MDS assessment, with an ARD of 02/02/23, revealed under Section B, Hearing, Speech, and Vision,…

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 drug regimen was free from unnecessary drugs for 1 of 22 residents reviewed for medications. (Resident #4) The facility did not provide Resident #4 a drug regime free from unnecessary medication. The residents did not have a diagnosis or adequate indication for Seroquel (An antipsychotic medication used to treat certain mental/mood disorders such as schizophrenia, and bipolar disorder). This failure could place residents who received antipsychotic medications at risk of receiving unnecessary medication. Findings include: Record review of Resident #4's electronic face sheet, dated 02/14/23, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included dementia, depression (feeling sad), anxiety (what we feel when we are worried, tense, or afraid), and high blood pressure. Record review of Resident #4's admission MDS assessment, with an ARD of 11/30/22, revealed under Section B, Hearing, Speech, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to maintain medical records on each resident that were complete and accurately documented, in accordance with accepted professional standards and practices, for 1 (Resident #170) of 1 resident whose records were reviewed for accuracy and completeness. The facility failed to have the Nurses document every 4 hours the assessment of the resident in the medical records per policy for Resident #170. This deficient practice could place residents at risk of having incomplete or inaccurate records and inadequate care. Findings: Record review of Resident #170's electronic face sheet, dated 02/14/23, revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included depression, PVD (a systemic disorder that involves the narrowing of peripheral blood vessels), anxiety (Feelings of being worried, tense, or afraid that are triggered by certain traumatic situations), and high blood pressure. Record review of Resident #170'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.