Avir at Luling

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to review and revise the person-centered, comprehensive care plan for 1 (Resident #43) of 6 residents reviewed for comprehensive care plan revisions. The facility failed to update Resident #43's care plan to reflect his current need for assistance with his indwelling catheter bag placement after self-transfers. This failure could put residents at risk of not receiving the appropriate care, services, or treatments they need. Findings included: Review of Resident #43's Face Sheet reflected he was admitted on [DATE] and readmitted on [DATE] with the following diagnoses cerebral infarction (the pathological process that results in an area of necrotic tissue in the brain) encephalopathy (A medical term used to describe a disease that affects brain structure or function. It causes altered mental state and confusion.) and retention of urine (inability to urinate). Review of Resident #43's Quarterly MDS dated [DATE] reflected Resident #43 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one of two residents reviewed for catheters (Resident #43). The facility failed to ensure Resident #43's received care to prevent Urinary Tract Infections when they stored his catheter bag on the floor. These failures could place residents with foley catheters at risk for urinary tract infections and change of condition. Findings Included: Review of Resident #43's Face Sheet reflected he was admitted on [DATE] and readmitted on [DATE] with the following diagnoses cerebral infarction (the pathological process that results in an area of necrotic tissue in the brain.) encephalopathy (A medical term used to describe a disease that affects brain structure or function. It causes altered mental state and confusion.) and retention of urine (inability to urinate). Review of Resident #43's Quarterly MDS dated [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on, interviews, and record review, the facility failed to ensure residents who were trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 4 residents (Resident # 38) reviewed for trauma-informed care. The facility did not ensure Resident #38 had a trauma screening that identified possible triggers when Resident #38 had a history of trauma. This failure could put residents at an increased risk for severe psychological distress due to re-traumatization. The findings included: Record review of Resident #38's Face sheet printed on 09/24/2025 reflected a [AGE] year-old male, originally admitted on [DATE]. Initial admission date is listed as 04/10/2025. The most recent admission date is listed as 09/17/2025. Diagnoses included atherosclerotic heart disease (thickening or hardening of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, 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 4 residents (Residents #13 and Resident #25) reviewed for infection control. The facility failed to ensure:1. TN used clean, sanitized scissors during wound care for Resident #25 on 09/24/2025.2. LVN D performed hand hygiene prior to preparing an injection for Resident #13 on 09/24/2025. 3. LVN D wore proper gloves (PPE) while administering an injection for Resident #13 on 09/24/2025. This failure could place residents at risk of exposure and/or possible transmission of communicable diseases and infections. Findings included: Record review of Resident #25's Face sheet printed on 09/24/2025 reflected a [AGE] year-old male, admitted to the facility on [DATE]. Diagnoses included Type 2 Diabetes (disorder…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified for two (Resident #2 and Resident #3) of five residents reviewed for care plans. 1. The facility failed to ensure Resident #2's elopement risk and interventions were included on his care plan. 2. The facility failed to ensure Resident #3's fall interventions were included on his care plan. These failures could place residents at risk of not receiving appropriate interventions to meet their needs. Findings include: 1. Review of Resident #2 face sheet reflected a [AGE] year-old man admitted on [DATE] with diagnoses of cerebral infarction (type a stroke where brain tissue dies due to lack of blood and oxygen), muscle weakness, other lack of coordination, unsteadiness on feet (difficulty 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 use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 8 of (03/15/2025, 03/16/2025, 03/22/2025, 03/23/2025, 03/29/2025, 03/30/2025, 04/11/2025, and 04/12/2025 ) 33 days reviewed for RN coverage. The facility failed to ensure they had an RN charge nurse on 03/15/2025, 03/16/2025, 03/22/2025, 03/23/2025, 03/29/2025, 03/30/2025, 04/11/2025, and 04/12/2025. This failure could place residents a risk of missed nursing assessments, interventions, care and treatment. Findings included: Review of daily sign-in schedule for March 15, 2025 through April 17, 2025, reflected zero hours work by an RN charge nurse on the following days: 03/15/2025, 03/16/2025, 03/22/2025, 03/23/2025, 03/29/2025, 03/30/2025, 04/11/2025, and 04/12/2025. During an interview on 04/17/2025 at 3:20 PM, the ADON reflected that between 03/15/2025 and 04/17/2025 there was not an RN that worked at the facility on the weekends. The ADON stated between that time, an agency RN worked on 04/05/2025 and the DON was at 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 develop a baseline care plan that included instructions needed to provide effective and person-centered care of the resident for one (Resident #1) of three residents reviewed for baseline care plans. 1. The facility failed to ensure Resident #1's elopement risk and interventions were included on his baseline care plan. This failures could place residents at risk of not receiving appropriate interventions to meet their needs. Findings include: Review of Resident #1 face sheet reflected at [AGE] year-old male admitted on [DATE] and discharged on 04/08/2025 with diagnoses of muscle wasting and atrophy (decrease in size and mass of skeletal muscle tissue leading to a loss of strength and function), difficulty in walking, unsteadiness on feet (difficulty with balance and coordination), other lack of coordination, and unspecified dementia (cognitive decline, impacting memory, thinking and problem-solving skills that are severe enough to impact…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure that all alleged violations involving exploitation or mistreatment were reported immediately, but not later than 24 hours after the allegation was made, if the events that caused the allegation did not involve abuse or result in serious bodily injury, to the State Survey Agency in accordance with state law through established procedures for 1 (Resident #1) of 3 residents reviewed for misappropriation of property. The facility failed to report to the state agency when the facility was notified that CNA A requested and accepted money from Resident #1 on the weekend of 11/09/24 and 11/10/24. This failure could place residents at risk for further misappropriation. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male initially admitted to the facility on [DATE], went out to another facility on 11/01/24, and was readmitted on [DATE]. His diagnoses included hypertension (high blood pressure), diabetes mellitus…

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 all alleged violations involving abuse or neglect were reported immediately or no later than 24 hours for one (Resident #1) of three residents reviewed for abuse and neglect. The facility failed to report to the State Agency an incident where Resident #1 eloped from the facility without staff knowledge and was found approximately an hour later after he had fallen on railroad tracks approximately one mile from the facility on 10/07/24. This failure could place residents at risk of abuse or and neglect. 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, history of falling, Parkinson's disease (a movement disorder that affects the nervous system and worsens over time, cerebral infarction (stroke), unsteadiness on feet, and muscle wasting and atrophy (wasting away). Review of Resident #1's quarterly MDS assessment, dated…

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 for 1 of 1 kitchen reviewed for kitchen sanitation, in that: 1. The facility failed to store clean plastic cups in a manner that allowed for air circulation. 2. The facility failed to ensure the tabletop can opener blade and base were free of buildup of grime and debris. 3. The facility failed to ensure an opened 5-lb. bag of pancake mix was stored in a sealed bag or container in the dry storage room. 4. The facility failed to ensure the interior racks, walls and floor of the reach-in refrigerator were free of dirt and debris. 5. The facility failed to ensure the low-temperature dishwasher reached 120 degrees Fahrenheit during the wash cycle. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: 1. Observation on 09/03/2024 at 11:35 AM revealed two plastic trays of clear plastic drinking cups on the clean side of…

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

Based on 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 and employ a full time DON for 74 of 184 days reviewed in that: The facility failed to have an RN scheduled on 74 dates that were reviewed and has not had a fulltime DON since 7/31/24. This deficient practice could place residents at risk of not the nursing services received by the residents properly supervised. Record review of the facility's RN staffing hours from the time period of 3/1/24 through 8/31/24 revealed that an RN was not working in the building for an 8 hour shift on the following dates: 3/2/24, 3/3/24, 3/10/24, 3/16/24, 3/17/24, 3/21/24, 3/22/24, 3/24/24, 4/14/24, 4/21/24, 4/28/24, 4/29/24,4/30/24, 5/1/24, 5/4/24, 5/6/24, 5/7/24, 5/8/24, 5/13/24, 5/14/24, 5/15/24, 5/18/24, 5/19/24, 5/20/24, 5/21/24, 5/22/24, 5/26/24, 5/27/24, 5/28/24, 5/29/24, 6/1/24, 6/2/24, 6/3/24, 6/4/24, 6/5/24, 6/9/24, 6/14/24, 6/15/24, 6/16/24, 6/18/24, 6/19/24, 6/22/24, 6/23/24, 6/29/24, 7/6/24, 7/7/24, 7/13/24, 7/14/24, 7/19/24, 7/20/24,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to assist residents in obtaining routine dental care for 1 of 8 residents (Residents #33) reviewed for dental services in that: The facility failed to assist Resident #33 in obtaining needed dental services following referral to an oral surgeon for tooth extraction after being diagnosed with abscessed tooth. These failures could lead to pain and infection of teeth and gums. The findings included: Record review of Resident #33's face sheet dated, 09/06/2024, reflected a [AGE] year-old resident initially admitted on [DATE] with diagnosis including cerebral infarction (the pathologic process that results in an area of necrotic tissue in the brain); Type 2 diabetes mellitus with other diabetic kidney complication; and periapical abscess without sinus (a pocket of pus at the root of a tooth caused by an infection that doesn't involve the sinuses). Record review of Resident #33's annual MDS Assessment, dated 08/14/2024, reflected Resident #33 had…

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 food was prepared in a form designed to meet individual needs for four of four residents (Residents #17, #20, #32 and #37) reviewed for food meeting residents' needs, in that: The DM did not puree the peach cobbler to a pudding or mashed potato consistency as required for Residents #17, #20, #32 and #37 who were ordered a pureed diet. This deficient practice could affect residents who received pureed meals from the kitchen by contributing to choking, poor intake, and/or weight loss. The findings included: Record review on 09/05/2024 of the resident menu for 09/05/2024 for residents whose diet order was a pureed diet was: Pureed spaghetti with meat sauce, pureed sauteed peas with onions, pureed dinner roll, pureed peach cobbler, and a beverage. Record review on 09/05/2024 of the electronic health records of Residents #17, #20, #32 and #37 revealed four residents had the diet order: Regular diet, Pureed texture, and Thin liquids.…

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 2 of 8 residents (Residents #39 and #47) and 1 of 2 halls (South Hall) reviewed for infection control, in that: 1. During a wound dressing change for Resident #39, LVN-F did not sanitize hands or change gloves in between removal of old dressing and cleansing and application of new dressing. 2. While providing incontinent care for Resident #47, CNA-E did not sanitize her hands in between glove changes when moving between soiled and clean incontinent pads, touched wipes dispenser with dirty gloves, and stored clean gloves in the front pocket of her scrubs where her cell phone was also stored. 3. The facility failed to ensure a shared shower and toilet area was clean and free from sources of infection. These deficient practices…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 1 facility reviewed for environmental concerns. 1. The facility failed to repair the overhead light in room#4 that had mold inside the cover, remove rust from an overhead pipe above a bed in room [ROOM NUMBER], clean a dirty chair cushion in room [ROOM NUMBER], repair a window sill in room [ROOM NUMBER] that was stripped of paint, remove the mold on the hallway ceiling outside of room [ROOM NUMBER], remove the dust/dirt from two hallway air conditioning vent, across from room [ROOM NUMBER], re-attach the covers for the 2 overhead lights in room [ROOM NUMBER], secure the overhead light to the ceiling in room [ROOM NUMBER], replace the 3 ceiling panels in room [ROOM NUMBER], remove the mold from a side wall vent in room [ROOM NUMBER], remove the mold from a wall area above the door entrance in room [ROOM NUMBER], replace a broken…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a resident environment that was free of pests and rodents for 1 of 1 facility reviewed for effective pest control in that: The facility failed to provide a resident environment that was free of pests and rodents as live roaches were observed in resident rooms and in the kitchen. This deficient practice could place residents at risk of remaining in an environment that was not free of pests and rodents. The findings included: 1. During an observation on 9/3/24 at 10:45 AM in Resident room [ROOM NUMBER] a live roach was observed on the right wall after entrance to the room. During an interview with CNA A on 9/3/24 at 10:46 AM she revealed that she had also observed the live roach in resident room [ROOM NUMBER]. During an interview with Resident #22 and Resident # 29 on 9/3/24 at 11:20 AM the residents stated that they had observed live roaches on their bedroom floor approximately 2 weeks ago. 2. During an observation on 09/05/2024 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 interviews and record review, the facility failed to ensure the resident had the right to be informed of the risks, and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives, or treatment options and to choose the alternative or options he or she preferred, for 1 (Resident #6) of 6 residents reviewed for resident rights. The facility failed to obtain a signed consent for antipsychotic medication Ziprasidone and antidepressant medications Zoloft and Trazodone prior to their administration to Resident #6. This failure could place residents at risk of receiving medications without their, or that of their responsible party's prior knowledge or consent, placing residents at risk of inability to make decisions regarding their plan of care and an increased risk for adverse reactions to the medications. Findings included: 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 interview and record review the facility failed to develop and implement a comprehensive person-centered care plan that describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 8 residents (Residents #3 and #33) reviewed for care plans. The facility failed to ensure that: 1. Resident #3's order for Xarelto (a medication used to treat/prevent blood clots) was reflected in the resident's current comprehensive care plan. 2. Resident #33's use of Sertraline (a medication used to treat depression, also known as Zoloft) was reflected in the resident's current comprehensive care plan. This deficient practice could affect residents by contributing to missed or inaccurate care. The findings included: 1. Record review of Resident #3's face sheet, dated 09/06/2024, revealed a [AGE] year-old resident initially admitted on [DATE] with diagnoses including Epilepsy (a disorder that causes seizures), Hemiplegia (…

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 a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 1 of 8 residents (Resident #34) reviewed for hygiene, in that. Nursing staff failed to ensure Resident #34 received a shower and changed his stained shirt when his shower was scheduled on 09/04/2024. This deficient practice could place residents who were dependent on staff for ADL care at risk for loss of dignity, and/or a diminished quality of life. The findings were: Record review of Resident #34's face sheet, dated 09/06/2024, revealed a [AGE] year-old male with an admission date of 03/16/2023, and diagnoses which included: cerebral infarction (serious condition that occurs when b rain tissue dies due to a lack of blood flow); Hemiplegia and hemiparesis (a condition that causes partial or complete paralysis on one side of the body)affecting left dominant side; Type 2 Diabetes mellitus (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 the environment remained as free of accident hazards as is possible for 1 of 23 Residents (Resident #22) reviewed for accident hazards in that: The facility failed to ensure Resident #22 was safe from hazards when there a small refrigerator (19x32 inches) placed on top of clothes drawer that was positioned near the head of the resident's bed. This deficient practice could place residents at risk of remaining in an environment that was not free of accident hazards and being injured as a result of the hazard. The finding included: During an observation on 9/3/24 at 11:20am in Resident # 22's room revealed a personal resident refrigerator which measured approximately 19x32 inches which was placed on top of a 4 drawer clothes dresser which measured approximately 30x30 inches. The refrigerator was noted to be directly beside the head of the Resident # 22's bed. Record review of the face sheet dated 9/4/24 for Resident #22 revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents' pharmacist medication regimen review recommendations were reviewed by the resident's attending physician and documentation of what, if any, action has been taken to address them, for 2 of 8 residents (Residents #3 and #33) whose records were reviewed for pharmacy services. The facility failed to ensure the Physician provided a clinical response to the consulting pharmacist's recommended changes which consisted of: 1. To ensure monitoring for side effects for Resident #3's Xarelto (a medication used to treat and prevent blood clots, commonly referred to as an anti-coagulant.); and 2. To clarify diagnosis for use of an anti-depressant, and for dose reduction consideration for that anti-depressant for Resident #33. This failure could place residents at risk for significant health status declines. The findings included: Record review of Resident #3's face sheet, dated 09/06/2024, revealed a [AGE] year-old resident initially admitted on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the resident was not given a psychotropic drug unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 (Resident #33) of 8 residents reviewed for unnecessary medications, in that: Resident #33 was prescribed a psychotropic drug for depression without a documented diagnosis of depression in the clinical record. This deficient practice could place residents at risk of receiving unnecessary psychotropic medications. The findings included: Record review of Resident #33's face sheet dated, 09/06/2024, reflected a [AGE] year-old resident initially admitted on [DATE] with diagnoses including cerebral infarction (the pathologic process that results in an area of necrotic tissue in the brain); Type 2 diabetes mellitus (long-term condition in which body has trouble controlling blood sugar) with other diabetic kidney complication; and Irritability and Anger. Record review of Resident #33'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.

Based on interview and record review, the facility failed to ensure a registered nurse was present in the facility for at least eight consecutive hours per day and seven days per week, for 22 of 93 day reviewed for registered nursing coverage, in that: The facility failed to ensure a registered nurse [RN] was present in the facility for at least eight consecutive hours per day and seven days per week on 22 separate occasions in the months of May 2023 - July 2023. This failure could place residents at risk of assessments, interventions, care and treatment requiring the advanced education, skills and judgement of an RN and leaving staff without supervisory coverage for coordination of events. The findings were: Review of PBJ [Payroll Based Journal] Staffing Data Report, with a run date of 08/04/2023 revealed No RN Hours and Failed to have Licensed Nursing Coverage 24 Hours/Day were triggered for the fiscal year Quarter 2 2023 (January 1 - March 31). Record review of RN time sheets, for the 3 months prior to survey (May to July 2023) revealed 22 days without a total of 8 hours RN…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure that all alleged violations involving abuse, neglect, including injuries of unknown source were 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 and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 18 residents (Resident #2) reviewed for abuse, neglect, and misappropriation of property, in that: The facility failed to report on 3 separate occasions Resident #2 smoking or bringing marijuana into the facility. This failure could affect residents residing in the facility by placing them…

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 for 1 of 1 kitchen, in that: 1. The facility failed to ensure there was a foot operated, covered trash receptacle at the hand washing sink. 2. The facility failed to prevent an opened box of bacon in the main refrigerator past the use by date. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings were: Observation on 08/08/2023 at 11:15 a.m., revealed there was not a foot operated, covered trash receptacle at the hand washing sink. A small, uncovered trash can was beside the sink and was full of paper towels. An observation and interview with the DS on 08/10/2023 at 10:45 a.m. revealed a trash receptacle at the hand washing sink with a swing-top lid. When asked about a foot-operated, covered trash receptacle for the hand washing sink, the DS stated there should be one at that sink so clean hands didn't touch the swing top 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 provide reasonable accommodation of resident needs for 2 of 15 residents (Residents #6 and #9) reviewed for preferences, in that: 1. Resident #9's call light was unplugged. 2. Resident #6's call light was not within reach This failure could place residents who used call lights for assistance at risk in maintaining and/or achieving independent functioning, dignity, and well-being. The findings were: 1. Record review of Resident #9's face sheet dated 8/10/23 revealed a [AGE] year-old male was admitted on [DATE] with the diagnosis that included: [Type 2 diabetes] is a long-term medical condition in which your body doesn't use insulin properly. [Morbid Obesity] A serious health condition resulting from an abnormally high body mass diagnosed with a body mass index greater than 40 kg/m². [Schizophrenia] is a serious mental disorder in which people interpret reality abnormally. Review of Resident #9's quarterly MDS, dated [DATE], revealed a BIMS…

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

Based on observation, interview, and record review, the facility failed to ensure that the menus were followed for 2 of 2 meals observed in that: 1. mashed potatoes were served instead of scalloped potatoes for the lunch meal on 08/09/2023 2. green beans were served instead of breaded okra for the dinner meal on 08/10/2023 This failure could place residents at risk for dissatisfaction, poor intake, and diminished quality of life. The findings were: 1. Record review of the facility's, Summer 2023 menu, Day 10, revealed meatloaf with tomato sauce, scalloped potatoes, green peas with sauteed onions and chocolate pudding were to be served with the lunch meal on 08/08/2023. The daily menu posted in the dining room revealed no indication for a substitute. An observation on 08/08/2023 at 12:03 p.m. revealed meatloaf with tomato sauce, mashed potatoes, green peas with sauteed onions and chocolate pudding had been served to the residents for the lunch meal. 2. Record review of the facility's, Summer 2023 menu, Day 12, revealed hamburger stew, breaded okra, cornbread and ice cream were to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to establish policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that also take into account nonsmoking residents for 2 of 2 residents (Residents #16 and #27) reviewed for smoking, in that: The facility failed to ensure Residents #16 and #27 did not have lighters in their possession. This failure could place residents at risk for smoking-related injuries and fires in the facility. The findings were: 1. Record review of Resident #16's face sheet, dated 08/11/2023, revealed the resident was admitted to the facility on [DATE], with diagnoses that included: schizoaffective disorder (mental disorder characterized by abnormal thought processes and an unstable mood), transient cerebral ischemic attack (mini-stroke, symptoms usually end in less than an hour), difficulty walking and other lack of coordination, dementia (group of symptoms affecting memory,…

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.