Avir at Mansfield

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, 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 for1 of 1 laundry room and 1 of 6 residents (Resident # 13) reviewed for infection control. The facility failed to handle, store, and process linens and residents clothing to prevent the spread of infection by not preventing cross contamination of staff belongings and resident personal clothing when staff placed their purses, in the same laundry cart with residents personal clothing. The facility failed to have in place a barrier between the clean and dirty areas of the laundry room to prevent the spread of infection. The facility failed to implement appropriate measures for sorting and folding resident laundry on a table that was free of staff personal keys and water cups to prevent cross contamination. The facility failed 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 care plans were developed in consultation with the resident and the resident's representative for 4 of 4 residents (Resident #20, Resident #24, Resident #42, Resident #167) reviewed for Comprehensive Care Plan. The facility failed to ensure Resident #20, Resident#24, Resident #42, and Resident 167, and/or the resident's representative were invited to participate in the comprehensive care plan meeting per resident rights guidelines that residents have the right to participate in their planning of care. This failure affected 4 residents and placed 62 residents at risk for a loss of independence, psychosocial well-being, and the opportunity for them to participate in their planning of care. Findings included: Record review of Resident #20's face sheet dated 04/25/2024, revealed a [AGE] year-old female readmitted to the facility on [DATE] with an initial admission to facility on 02/01/2013. Her diagnoses included Aphasia following unspecified…

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 and interviews the facility failed to provide a clean and functional environment for six (Residents #34, #54, #16, #59, #36, and #7) out of 24 residents reviewed for a sanitary, functional, and homelike environment, as evidenced by: 1. Resident #34's room had grimy, stained, dusty floors, a badly scraped chest with missing wood veneer and handle, and grimy, stained floor, and a bent privacy curtain runner. The bathroom, which was shared with Resident #54 in the room next-door had a non-working sink and toilet, and a damaged and badly repaired wall in the bathroom. The bathroom floor was also grimy, stained, and was repaired with noticeably mismatched tiles. Resident #34's door would not close completely, due to the placement of a bed next to the door. 2. Resident #16''s room had gnats, and the unmade bed was saturated with urine. 3. Resident #59's room had a cracked, flaking, translucent film over part of the window, and damaged windowsill and wall below the window. 4. Resident #36's room…

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 each resident received and the facility provided food that was palatable and attractive for two of two meals (lunch meals on 04/23/24 and 04/25/24) reviewed for food and nutrition services. The facility failed to deliver food with an appetizing taste for the lunch meals on 04/23/24 and 04/25/24. The deficient practice could place residents at risk of poor intake of nutrition, weight loss, and a decreased quality of life. Findings included: An interview on 04/23/24 at 10:53 AM with Resident #34 revealed she thought the food had gone downhill in quality since the new DM started, about a month and a half ago, and it was terrible. She also felt the current dietary manager was not very nice and was not accommodating. She told the state surveyor if there was any doubt about the food, to ask the other residents, because everyone hates it. She said they talked about food at every resident council meeting, and everyone she knew was unhappy with it. In an anonymous group interview on 04/24/24 at 1:00 PM six 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 observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in their only 1 of 1 kitchen. The grease in the deep fryer was dirty with blackened grease and food particles around edges. The stove surface under the metal grates had a build-up of blackened food debris. This failure could place 62 residents who consumed food prepared in the kitchen at risk of food-borne illness. Findings included: During an observation on 04/24/2024 at 9:10 am, the edge of the deep fryer had a thick build-up of brown and black grease with food particles around the inside edges. There was grease that had run off the edges and down the sides of the deep fryer. Deep fryer was stationed beside the stove in the kitchen. Stove had been used to cook breakfast and the staff were in the process of cleaning the stove. During an interview on 04/24/2024 at 9:10 am, the dietary manager acknowledged the deep fryer had old grease in it. The DM revealed the deep fryer was cleaned one time a month. The used grease was used to fry foods…

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 provide a safe, functional, sanitary, and comfortable environment for three hallways (front hall (Administrative offices and kitchen hallway), hall 16-39, and hall 40-54) of four halls reviewed for physical environment. 1. The facility failed to ensure the facility was free from pervasive urine odors and dirt and grime (most notably around doorways) on hallway floors. These failures could affect all residents, resulting infections, and low feelings of self-worth. Findings included: Observation on 04/23/24 at 8:35 AM revealed when the state surveyors initially entered the building, the smell of urine was very strong upon entering the facility through the front door. Observation beginning on 04/23/24 at 9:20 AM, at the start of the initial tour of the facility, and throughout the survey period (through 04/25/24 at approximately 4:30 PM), observations were made by all state surveyors noting urine odors in the halls, with the odor being strongest in the halls near rooms 40-58 and 12-24 but could be smelled…

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 provide residents with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for one (Resident #44) of 24 residents reviewed for call lights. The facility failed to ensure Resident #44's call light was within reach of the resident. This failure could place the residents at risk of falling, injury, and feelings of low self-worth due to not being able to call for help. Findings included: Review of Resident #44's face sheet, dated 04/25/24, reflected the resident was a [AGE] year-old male, admitted on [DATE]. His diagnoses included cerebral palsy (a condition affecting motor control), other lack of coordination, and severe intellectual disabilities. Review of Resident #44's quarterly MDS assessment, dated 01/27/24, revealed he had unclear speech, was sometimes understood by others, and sometimes understood others. He had a BIMS score of seven,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and mental and psychosocial needs in order attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one resident (Resident #34) of 24 residents reviewed for care plans. The facility failed to create a care plan addressing Resident #34's PTSD and colostomy. This failure could affect residents by placing them at risk for not receiving care and services to meet their needs. Findings included: Review of Resident #34's face sheet, dated 04/25/25, reflected she was a [AGE] year-old female, admitted on [DATE], with diagnoses of paraplegia (lower body paralysis), colostomy, pressure ulcers, mood disorder, bi-polar disorder, post-traumatic stress disorder, anti-social personality disorder, and seizures. Review of Resident #34's Quarterly MDS, dated [DATE], revealed she could understand others, and 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 observations, interviews, and record review, the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relayed the call directly to a centralized staff work area, for two of two nursing stations reviewed for call lights. The facility failed to ensure the call system was working properly for the nursing stations in zone 1 and zone 2. On two hallways, causing the call system to sound when no call light was on, and no light for call buttons appearing on the panel. In addition, the call light of one resident (Resident #34, near station #2) would not turn off properly when used. This failure could cause residents who relied on the call light system to have a delayed response or no way to contact staff to meet their needs. Findings included: An observation on 04/23/24 at 11:08 AM revealed Resident #34's call light would shut off. Multiple staff were observed to go in and out of the room, heard to be trying to figure out how to turn off…

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, interviews, and record reviews, the facility failed to provide a safe, clean, comfortable and homelike environment for residents, staff, and the public on 2 of 4 halls (Zones 4 and 6), Four bedrooms (Rooms#11, #13, #18, and #35) and the 1 of 1 dining room reviewed for environmental conditions. 1. The facility failed to ensure ceiling tiles in its Zone 4, 6, and dining room were free of brown dried substances. 2. The facility failed to ensure the air condition vent covers in Rooms #11, #13, #18, and #35 were free of damage and debris. These failures could place residents at risk of living in an unsafe, unsanitary, and uncomfortable environment. The findings included: Observation on 03/05/24 from 2:05 p.m. to 2:20 p.m., revealed the following: - Occupied Rooms #11, #13, #18, and #35's air conditioner vent covers were observed to be damaged and covered in black, green and white substances. - three ceiling tiles in the facility's Zone 6 had dried brown rings on them - two ceiling tiles near the station 2 nurses' station had dried brown rings on them - three ceiling…

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 foods stored in the walk-in cooler were properly labeled and dated. 2. The facility failed to ensure leftover food was discarded prior to the use by date. 3. The facility failed to ensure cooler temperatures were monitored and recorded since 02/12/24. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: Observations on 03/05/24 at 11:05 a.m., accompanied by the Dietary Manager, of the facility's walk in cooler revealed the following: - The temperature log near the door of the facility's cooler had the last recorded temperature dated 02/12/24. - a Ziploc bag of prepared meat, labeled taco meat and dated 02/24/24. - a covered bowl of fruit that was not labeled or dated In an interview on 03/05/24 at 11:11 a.m., [NAME] A stated he did not realize 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 review the risks and benefits of bed rails and enabler bars with the resident or resident representative and obtain informed consent prior to installation for three (Residents #1, #3, #4) of 3 resident rooms observed and reviewed for bed rails/enabler bars. The facility failed to have consents signed for the quarter bed rails/enabler bars for Residents #1, #3, and #4. This failure could affect residents who used bed rails/enabler bars at risk of the resident/responsible party not being aware of the risk. Findings included: 1. Record review of Resident #1's face sheet, dated 01/11/2024 revealed resident was originally admitted on [DATE] and current admit on 01/09/2024 with diagnoses of chronic respiratory failure with hypercapnia (high levels of carbon dioxide in the blood), Unspecified sequelae of cerebral infarction (unknown complication or condition that results from a pre-existing ischemic stroke; a result of disrupted blood flow to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident resided and received services in the facility with reasonable accommodation of resident needs and preferences for 2 (Resident #1 and Resident #2) of 10 residents reviewed for call lights. Staff failed to ensure Resident #1 and Resident #2's, call buttons were within reach. This failure could affect 2 residents who resided on Station 1 at risk for decreased quality of life, self-worth, and dignity. Findings included: Review of Resident #1's face sheet dated 01/11/2024 reflected a [AGE] year-old female admitted to the facility on 01/09/2024 with diagnoses of Chronic Respiratory Failure with Hypercapnia (May occur either acutely, insidiously, or acutely upon chronic carbon dioxide retention); Unspecified sequelae of cerebral infarction (Residual effects or conditions produced after the acute phase of an illness or injury has ended); Dementia in other diseases classified elsewhere, unspecified severity, without behavioral…

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 for two of four residents (Resident #1 and #2) reviewed for ADLs. 1. The facility failed to provide timely incontinent care to Resident #1 who was observed on 08/31/23 wearing a saturated incontinent brief and laying on a bedsheet stained with a large dried brown ring. 2. The facility failed to provide timely incontinent care to Resident #2 who was observed on 08/31/23 wearing a saturated incontinent brief and laying on a draw sheet that covered a bedsheet stained with a large dried brown ring. These failures could place residents at risk of not receiving necessary services to maintain good personal hygiene, decreased self-esteem, lack of dignity and risk for skin breakdown. Findings include: 1. Record review of Resident #1's physician orders, dated 08/2023, revealed 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, record reviews, and interviews the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior and failed to provide clean bed linens that were in good conditions for 7 (Residents #1, #2, #3, #4, #5, #6 and #7) of 7 residents reviewed for safe environment. The facility failed to maintain a clean environment for Residents #1, #2, #3, #4, #5, #6 and #7. This failure placed residents at risk of decreased feelings of self-worth, and possible infections. Findings included: Observation on 08/16/23 at 9:40 AM of Resident #2's room revealed her floor had the paper wrapped for silverware lying in the middle of the room, her bathroom had a dead cricket on the floor and the toilet contained urine that had not been flushed. Interview on 08/16/23 at 9:40 AM with Resident #2 revealed the wrapper had been on the floor since the previous afternoon. She stated she had her urinary catheter removed this morning; she can now use a bedside commode. Resident stated she never used her bathroom because it 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 a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 1 (Resident #1) of 7 residents reviewed for hygiene. The facility failed to maintain Resident #1's fingernails and prevent them from digging into the palm of her hand. This failure placed the resident at risk of decreased feelings of self-worth, and potential infections. Findings included: Review of Resident #1's face sheet revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included morbid obesity, emphysema (lung disease), high blood pressure, stroke, and heart failure. Review of Resident #1's MDS, dated [DATE], revealed her BIMS score was calculated at 15, indicating intact cognition. Her Functional Status revealed she required extensive assistance with all of her ADLs. Review of Resident #1's care plan, dated 07/14/23, revealed she was 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.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 1 of 6 sharps boxes reviewed for accident hazards. The facility failed to maintain a sharps container in the shower room of 2nd Hall and prevent it from being over filled. This failure placed residents at risk of being exposed to used sharps and potential bloodborne pathogens. Findings included: Observation on 08/16/23 at 9:15 AM of the shower room for 2nd Hall revealed the sharps container, used to dispose of sharp medical instruments, was past the fill line and had one razor protruding out of the opening. Interview on 08/16/23 at 11:47 AM with LVN B revealed the nurses were responsible for monitoring the sharps boxes and changing them out when needed. He stated the nurses rarely went into the shower rooms so they relied on the CNAs to tell them when a sharps box in the shower rooms needed to be changed. Review of the facility's Infection Prevention and Control Committee policy revealed it did not address sharps boxes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for three shared restrooms and 1 of 3 shower rooms checked for hot water temperature in the [NAME] side of the facility. The facility failed to provide hot water for the [NAME] side of the facility restrooms and shower room. This failure could affect residents who take showers on the [NAME] side of the facility by placing them at risk for uncomfortable environment, low self-esteem, and a diminished quality of life. Findings included: Observation during facility initial tour on 02/21/23 between the times of 10:45 AM - 11:50 AM of shared restrooms for room [ROOM NUMBER], room [ROOM NUMBER] and #11, Rooms #13 and #15 revealed the restroom sink water upon touch did not get warm or hot. Interview during a confidential group meeting on 02/22/23 at 2:30 PM, five out of ten residents revealed the facility had been without hot water in Station 2 (West side) shower room. Residents stated…

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

Based on observation, interview, and record review the facility failed to provide food prepared by methods, which conserved nutritive value, flavor, and appearance for one (lunch meal) of one meal services reviewed. The facility failed to ensure the Dietary Manager prepared the pureed lunch meal in a manner to conserve nutrition, flavor, and palatability on 02/22/23. Tap water was used to obtain an appropriate consistency. The failure could place residents, who were on a pureed diet, at risk for a decrease in nutritive status, loss of appetite, decreased intake and unwanted weight loss. Findings included: Observation of the Dietary Manager preparing pureed lunches on 02/22/23 at 11:16 AM revealed he used tap water to thin and smooth out green vegetables, pork tips, and white rice. All food items appeared to be slightly too thin and did not have a pudding-like consistency. Interview on 02/22/23 at 11:25 AM with the Dietary Manager revealed that all kitchen staff, including himself, knew to follow a recipe when preparing pureed foods; however, he had not gotten a chance to update 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 observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. -The Facility failed to ensure food items were properly labeled, dated, and thawed in accordance with professional standards. These failures could place all residents, who receive food from the kitchen, at risk for food contamination and food-borne illness. Findings included: An observation on 02/21/23 at 9:45 AM revealed the following: In refrigerator: -Raw ground beef thawing on a top shelf, above cooked/prepared foods. -Large metal pan of Jell-O uncovered. -Uncooked French fries, outside of original package, in plastic bag, unlabeled and undated. -Gravy in a metal pan, undated and unlabeled. -Meat patties in a metal pan, undated and unlabeled. -Cooked rice in a metal pan, undated and unlabeled. -Cooked beans in a metal pan, undated and unlabeled. Interview on 02/21/23 at 9:58 AM with [NAME] I revealed he had worked at the facility since July 2022. He stated he had been trained…

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 fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings for 1 of 6 residents (Resident #24) reviewed for tube feeding. LVN A failed to flush Resident #24's g-tube prior to initiating a bolus feeding (feeding method using a syringe to deliver formula through feeding tube). LVN A failed to follow physician orders regarding Resident #24's bolus feeding by adding water to the formula. This deficient practice could place residents who require enteral feedings at risk for weight loss, dehydration, metabolic abnormalities, and hospitalizations. Findings included: Record review of Resident #24's Face Sheet, dated 02/23/23, revealed Resident #24 was a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE] with a diagnoses of gastrostomy status (surgical opening into the stomach), gastro-esophageal reflux disease without esophagitis…

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 respiratory care was provided consistent with professional standards of practice for one (Resident #44) of two residents reviewed for respiratory therapy. The facility failed to ensure Resident #44 had an order prescribed by a physician to receive oxygen. Resident #44 was receiving oxygen without any physician orders from 02/02/23 - 02/23/23. This failure placed residents who received oxygen therapy at risk for inadequate or inappropriate amounts of oxygen delivery and ineffective treatment. Findings included: Record review of Resident #44's face sheet, dated 02/23/23, revealed the resident was a [AGE] year-old female with an initial admission date of 08/04/22 and re-admission date of 12/26/22. The resident's diagnoses included: acute respiratory failure with hypercapnia (build-up of carbon dioxide in bloodstream), obesity, hypertension, and congestive heart failure. Record review of Resident #44's 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.

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 dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 (Resident #41) of 4 residents reviewed for pharmaceutical services. LVN C failed to follow the facility policy for flushing Resident #41's gastrostomy tube with 15 mL (or prescribed amount) of water before, between, and after medications, when she administered Aspirin 81 mg, Vitamin D 25 mg, Omega 3 capsule, Thiamin Vitamin B-1, FeSo4 (ferrous sulphate) 10 ml, and Keppra 2.5 ml to the resident. These failures could put residents who received medications via gastrostomy tube at risk for overload and aspiration. Findings included: Review of Resident #41's MDS (a standardized tool that measures health status in nursing home residents), dated 01/17/23, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] and re-admission on [DATE]. 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 observation, interview, and record review, the facility failed to ensure all drugs and biologicals were labeled in accordance with currently accepted professional principles for two (Station 1 front medication cart and Station 1 back medication cart) of four medication carts reviewed for labeling and storage. 1. The facility failed to ensure insulin vials were dated after they were opened. 2. The facility failed to ensure expired insulins were removed from the cart. The failure could place residents at risk of receiving medications that were ineffective due to not labeling with opening dates and removing the expired medications. Findings included: Observation on 02/22/23 at 12:15 PM of the Station 1 front Medication Cart with LVN B revealed two insulin pens, Insulin Aspart and 1 lispro were opened, partially used, with the open date of 01/13/23 and 01/20/23. Interview on 02/22/23 at 12:25 PM with LVN B, who was the Station 1 front Charge Nurse, revealed she knew insulin pens and vials for short acting were good for only 28 days. She stated she knew it was her and all…

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.