Avir at Mineola

Based on observation and interview the facility failed to ensure the resident environment remains as free of accident hazards as is possible for 1 of 1 secured unit living rooms observed. The facility failed to ensure CNA D and LVN B did not have a blanket covering the overhead light in the secured unit living room on 9/18/25. This failure places residents at risk for a fire hazard and decreased quality of life.Findings Include:During an observation on 9/18/25 at 4:35 a.m. LVN B and CNA D were in the secured unit living room with a blanket covering the overhead light. LVN B was observed removing the blanket when the surveyor and a CNA walked into the secured unit living room. During an interview on 9/18/25 at 4:41 a.m. LVN B said covering the overhead light in the living room of the secured unit was not safe. LVN B said CNA D usually covered the overhead light in the secured unit dining room with a blanket. LVN B said a blanket covering a light could get too hot and catch fire. During an interview on 9/18/25 at 4:45 a.m. CNA D said she usually hung a blanket over the overhead light…

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

Based on observation, interview, and record review, in accordance with State and Federal laws, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys on 3 of 7 (Medication Cart #1, Medication Cart #2, and Medication Cart #3) medication carts reviewed for labeling and storage of medication. The facility did not ensure the Medication Cart #1 (medication cart for the secured unit), Medication Cart #2 (nurse's medication cart for the west side of the building) and Medication Cart #3 ((nurse's medication cart for the east side of the building) were secured and unable to be accessed by unauthorized personnel on 9/18/25. This failure could place residents at risk for not receiving drugs and biologicals as needed or a drug diversion.Findings include: 1. During an observation on 9/18/25 at 4:30 a.m. Medication Cart #1 was in of the hallway unsupervised and unlocked. A CNA was walking by Medication cart #1 pushing a resident in their wheelchair down the hallway. 2.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure residents were free from any physical or chemical restraints imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms 1 of 13 (Resident #1) residents reviewed for restraints. The facility failed to ensure Resident #1 was administered her Xanax (medication used to treat anxiety) every 8 hours as needed per the physician's orders instead of Resident #1 having it administered in less than 8 hours on several dates in July 2025 by LVN A and LVN B to keep Resident #1 quiet. This failure could place residents who receive psychotropic medications at risk of not receiving the intended therapeutic benefit of the medications.Findings included: Record review of the face sheet dated 8/29/25 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including anxiety, dementia, muscle weakness, lack of coordination, and restlessness and agitation. Record review 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 interview and record reviews, the facility failed to ensure registry verification was received that the individual had met competency evaluation requirements before they were allowed to work as a nurse aide for 1 of 4 (CNA E) employees reviewed for registry verification. The facility failed to ensure CNA E had a current nurse aide certification while employed at the facility and actively providing care for residents from [DATE] through [DATE]. CNA E certificate expired on [DATE]. This failure placed residents at risk for decreased quality of care. Findings included:Record review of CNA E's employee file indicated her nurse aide certification was issued on [DATE] and would expire on [DATE]. The employee file indicated CNA E's initial nurse aide certification was issued on [DATE]. The employee file indicated she applied to the facility on [DATE] and was available for work on [DATE]. The employee application indicated her nurse aide certification would expire on [DATE]. Record review of CNA E's time sheets…

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 consult with the resident's physician when there was a significant change in the resident's physical and mental status that was, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) 1 of 13 (Resident #2) residents reviewed for notification of change. The facility did not notify the physician of Resident #2's weeping edema (a condition where fluid leaks from the skin), redness, and blister to her right leg. LVN B or D had not notified the physician or NP to obtain an order for an ace wrap or notify them of the swelling and weeping to Resident #2's right leg on 08/29/2025. The facility did not ensure physician orders were obtained for treatment of Resident #'2's swollen and weeping leg or application of dressings prior to applying dressings to Resident #2's leg. This failure could place residents at risk for not receiving care and services to meet resident needs.Findings…

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 receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 13 (Resident #2) residents reviewed for quality of care. The facility did not notify the physician of Resident #2's weeping edema (a condition where fluid leaks from the skin), redness, and blister to her right leg. The facility did not ensure physician orders were obtained for treatment of Resident #'2's swollen and weeping leg or application of dressings prior to applying dressings to Resident #2's leg. These failures could place residents at risk for not receiving care and services to meet resident needs and decreased quality of life. Findings included: Record review of the face sheet dated 8/29/25 indicated Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including edema (swelling that occurs when fluid builds up on the body's tissues),…

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 interviews and record review, the facility failed to ensure each resident was free from misappropriation of resident property for 2 of 3 residents (Resident #2 and Resident #3), reviewed for drug diversion. The facility failed to prevent the misappropriation of Resident #2 and Resident #3's hydrocodone-acetaminophen 5-325 mg (formerly known under the brand name Norco, this combination medication containing 5 mg of hydrocodone [an opioid analgesic] and 325 mg of acetaminophen [also known as Tylenol] is used to treat pain). This failure could place residents at risk for not receiving their prescribed medications, unrelieved pain, and decreased quality of life. Findings include: 1.Record review of Resident #2's face sheet dated 5/8/25 indicated he was [AGE] years old, admitted to the facility on [DATE] with diagnoses including, Herpes viral vesicular dermatitis (a painful skin infection caused by the Herpes Simplex Virus); myelopathy (neurological deficits and pain stemming from damage or injury to the spinal…

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, in accordance with accepted professional standards and practices, medical record maintained for each resident were complete and accurately documented for 1 of 4 residents (Resident #1) reviewed for resident records. The facility failed to ensure accurate documentation was documented for Resident #1's wound care on 3/21/25 when the DON (who did not perform the wound care) edited LVN B's (the nurse that performed the wound care) progress note for Resident #1 five days after the wound care (3/26/25). This failure could place residents at risk for delayed interventions, appropriate interventions, health complications and decreased quality of life. Findings include: Record review of Resident #1's face sheet dated 5/8/25 indicated Resident #1 was [AGE] years old, admitted to the facility on [DATE] with diagnoses including non-pressure chronic ulcer of buttock with fat layer exposed, unspecified skin changes, and history of cellulitis (a common…

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 a safe, clean, and comfortable homelike environment for 1 of 2 shower rooms (B hall) reviewed for homelike environment. The facility failed to ensure the shower room on B hall did not have black grime buildup on the walls and missing tiles on the floor. This failure could place the residents at risk for a decreased quality of life, an uncomfortable, unhomelike environment due to unsanitary conditions. Findings included: During an observation and interview on 04/09/2025 at 4:04 PM, an observation of the shower room on B hall revealed the shower was missing tiles on the floor, the walls of the shower room had thick black gunk on them. LVN A said it looked like the shower room had not been cleaned. LVN A said housekeeping should be cleaning the shower, but she had not seen them clean it recently. LVN A said it was important for the shower to be clean for hygiene purposes and cleanliness, and the tile missing could result in mildew. During an observation on 04/10/2025 at 8:38 AM, the shower on B hall 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 8. Record review of a face sheet dated 04/09/2025 indicated Resident #6 was a [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included diffuse traumatic brain injury with loss of consciousness (injury to the brain which results in loss of consciousness), bipolar disorder (a disorder associated with episodes of mood swings ranging from depression lows to manic highs), and schizophrenia (mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech and behavior). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #6 was understood and understood others. The MDS assessment indicated Resident #6 had a BIMS of 15, which indicated his cognition was intact. The MDS assessment indicated Resident #6 required substantial/maximal assistance with personal hygiene, supervision with bathing/showering, and he was independent with eating, toileting and dressing. The MDS assessment indicated Resident #6 did…

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 an effective pest control program to keep the facility free from pests for 4 of 18 (Resident #3 Resident #4, Resident #9 and Resident #14) residents reviewed for pest control. The facility did not maintain an effective pest control program to ensure the facility was free of roaches and water bugs. This failure could place residents at risk for an unsanitary environment and a decreased quality of life. Findings included: 1. Record review of a face sheet dated 04/09/2025 indicated Resident #3 was a [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on 04/08//2024 with diagnoses which included dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life without behaviors), and anxiety and chronic obstructive pulmonary disease (chronic inflammatory lung…

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 residents had 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 of 13 residents (Resident #13) reviewed for resident rights. The facility failed to get written consent from Resident #13 on the HHSC form 3713 for having Seroquel (antipsychotic medication) prescribed. This failure could place residents at risk for receiving unnecessary antipsychotic medications without informed consent. Findings included: Record review of Resident #13's face sheet dated 04/08/25, indicated a [AGE] year-old female who admitted to initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #13 had diagnoses of personality disorder (mental health condition that involves long-lasting, disruptive patterns of thinking, behavior, mood…

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 prompt efforts were made to resolve grievances for 2 of 18 residents (Resident #3 and Resident #13) reviewed for grievances. 1. The facility did not ensure a grievance was filed for Resident #3's underwear that was part of the facility fire. 2. The facility did not ensure a grievance was filed for Resident #13's missing pants. These failures could place residents at risk for grievances not being addressed or resolved promptly. Findings included: 1. Record review of a face sheet dated 04/09/2025 indicated Resident #3 was a [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on 04/08//2024 with diagnoses which included dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life without behaviors), and anxiety and chronic obstructive pulmonary 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 a resident who is unable to carry out activities of daily living receives the necessary services to maintain grooming and personal hygiene for 1 of 10 residents reviewed for ADLs. (Resident #35) The facility failed to ensure Resident #12 received his shower as scheduled. This failure could place residents at risk of not receiving services/care, decreased quality of life, and decreased self-esteem. Findings included: Record review of Resident #12's face sheet dated 04/10/25, indicated an [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #12 had diagnoses of myocardial infarction (heart attack), essential hypertension (high blood pressure), muscle weakness, and chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). Record review of Resident #12's quarterly MDS assessment dated [DATE], indicated he was able to make…

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 review, the facility failed to ensure residents had the right to a clean, comfortable, and homelike environment, which included but not limited to receiving treatment and supports for daily living safety, clean bed and bath linens for 1 of 1 facility reviewed for resident rights. The facility failed to ensure clean towels and wash rags were available for use on 09/11/24. This failure could place residents at risk for an uncomfortable, unhomelike environment, and a diminished quality of life. Findings included: During an observation on 09/11/24 at 10:42 AM revealed the clean linen closet on hall B had only gowns and pillowcases. There were no fitted sheets, flat sheets, towels or wash rags available for use. During an observation on 09/11/24 at 10:43 AM revealed the hall B clean linen cart only had 3 pillowcases available for use. There were no bed linens, towels or wash rags available for use. During an interview on 09/11/24 at 10:44 AM, CNA H said depending on the time they had to wait for clean linen to get back to them. CNA H said…

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 prompt efforts were made to resolve grievances for 4 of 4 residents (Resident #'s 10, 46, 73, and 182 ) reviewed for grievances. The facility failed to appropriately resolve Resident #46, Resident #182, Resident #73 and Resident #10's grievances when issues with missing clothing from continued from May 2024 to September 2024. This failure could place residents at risk for grievances not being addressed or resolved promptly. Findings included: Record review of Resident #46's face sheet dated 09/11/24, indicated an [AGE] year-old male who admitted to the facility on [DATE] and readmitted [DATE]. Resident #46 had diagnoses of anxiety, unspecified psychosis (mental disorder characterized by disconnection from reality), depression (persistent depressed mood), and Alzheimer's disease (progressive disease that destroys memory and other mental functions). Record review of Resident #46's quarterly MDS assessment dated [DATE], indicated he 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 store, prepare, distribute and serve food in accordance with professional standards for food service safety in (1 of 1) kitchen reviewed for dietary services, in that: 1) The facility failed to label and date all food items. 2) Dietary staff failed to dispose of expired foods items. 3) Dietary Staff failed to effectively reseal, label and date frozen food items. These failures could place residents at risk for food contamination and foodborne illness. The findings included: During observations with [NAME] E on 09/10/24 beginning at 9:39 am, the following observations were made in the kitchen Refrigerator (1 of 1): -(1) 128 fluid ounce bottle of white vinegar had an open date of 10/26/23 and expiration date of 3/3/24. (expired) -(1) gallon of tartar sauce had an open date of 5/24/24 and no expiration date. -(1) gallon of tartar sauce had an open date of 6/20/24 and no expiration date. -(1) sandwich bag of shredded carrots was not labeled,…

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 collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure the quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 3 of 4 residents (Resident #27, Resident #35, and Resident # 15) reviewed for hospice services. The facility failed to maintain Resident #27's, Resident #35's, and Resident #15's hospice binder containing information related to hospice services provided for the resident such as the most recent plan of care, hospice election form, physician recertification, and hospice medication profile. These deficient practices could place residents who receive hospice services at risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs. The findings included: 1.…

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 4 (Resident #35, Resident #60 and Resident #77) and 1 of 1 laundry room reviewed for infection control practices. 1. The facility failed to ensure the ADON and CNA D wore proper PPE when providing incontinent care and wound care to Resident #35 who was on enhanced barrier precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and gloves use during high contact resident care activities. 2. The facility failed to ensure CNA C properly cleaned the genital area, changed gloves, and used hand hygiene before going from dirty to clean while providing incontinent care for Resident #60. 3.The facility failed to properly…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the residents or responsible party had the right to be informed of and participate in his or her treatment which included, the right to be informed in advance, by the physician or other practitioner or other professional, of the risks and benefits of proposed care, treatment, and treatment alternatives or treatment options to choose the alternative or option he or she preferred for 1 of 4 residents (Resident #74) reviewed for psychoactive medications. The facility failed to ensure LVN B obtained informed consent based on the information of the benefits and risks for Resident #74 before administering Klonopin (Clonazepam), a medication used to treat anxiety on 08/28/24. This failure could place residents at risk of receiving medications they had not consented to, experiencing potential adverse reactions, and a potential decline in physical and mental health status. Findings included: Record review of Resident #74's face sheet, dated 09/11/24…

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, interview, and record review, the facility failed to ensure each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 of 21 residents (Residents # 46), reviewed for care plans. The facility failed to revise Resident #46's care plan after he fell on [DATE], 07/12/2024, and 08/25/2024. This failure could affect residents of the facility by not addressing their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, and psychosocial outcome. Findings included: Record review of Resident #46's face sheet dated 09/11/24, indicated an [AGE] year-old male who admitted to the facility on [DATE] and readmitted [DATE]. Resident #46 had diagnoses of anxiety, unspecified psychosis (mental disorder characterized by disconnection from reality), depression (persistent depressed mood), and Alzheimer's disease (progressive disease that destroys memory and other mental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 21 residents (Resident #59) reviewed for ADL (activities of daily living) care. The facility failed to provide facial hair removal/shaving for dependent female Resident #59 on 09/09/2024. This failure could place residents at risk of not receiving care and services to meet their needs. Findings include: Record review of the face sheet, dated 09/11/2024, revealed Resident #59 was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included Encephalopathy unspecified (damage or disease that effects the brain), Schizophrenia, unspecified, (affects how people think, feel and behave. It may result in a mix of hallucinations, delusions, and disorganized thinking and behavior. Hallucinations involve seeing things or hearing voices…

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 laboratory services were obtained to meet the needs of 1 of 21 residents reviewed for laboratory services (Residents #46). The facility failed to obtain ordered Depakote level (level obtained to ensure medication is in therapeutic range) for Resident #46. This failure could place residents at risk of not receiving timely diagnoses, treatment, and services to meet their needs. Findings included: Record review of Resident #46's face sheet dated 09/11/24, indicated an [AGE] year-old male who admitted to the facility on [DATE] and readmitted [DATE]. Resident #46 had diagnoses of anxiety, unspecified psychosis (mental disorder characterized by disconnection from reality), depression (persistent depressed mood), and Alzheimer's disease (progressive disease that destroys memory and other mental functions). Record review of Resident #46's quarterly MDS assessment dated [DATE], indicated he was rarely/never understood and rarely/never understood others.…

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, and comfortable homelike environment for 1 of 3 bathrooms reviewed for physical environment. The facility failed to ensure Resident #1's bathroom was clean and free of odors. This failure could place residents at risk for a decreased quality of life and an unsanitary environment. The findings included: Record review of the face sheet, dated 07/23/24, revealed Resident #1 was a [AGE] year-old male who admitted to the facility on [DATE] with a diagnosis of cerebral infarction (stroke). Record review of the quarterly MDS assessment, dated 06/28/2024, revealed Resident #1 had clear speech and was understood by others. The MDS revealed Resident #1 was able to understand others. The MDS revealed Resident #1 had a BIMS score of 15, which indicated no cognitive impairment. The MDS revealed Resident #1 had no behaviors or refusal of care. The MDS revealed Resident #1 usually required setup or clean-up assistance with 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 observations, interviews, and record review the facility failed to maintain an effective pest control program so that facility is free of pests and rodents for the 1 of 3 bathroom's reviewed for pests. The facility did not maintain an effective pest control program to ensure the facility was free of roaches in Resident #2's bathroom on C Hall. These findings could place residents at risk for an unsanitary environment and a decreased quality of life. The findings included: Record review of the face sheet, dated 07/23/2024, revealed Resident #2 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnosis of bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). Record review of the admission MDS assessment, dated 06/28/2024, revealed Resident #2 had clear speech and was understood by others. The MDS revealed Resident #2 was able to understand others. The MDS revealed Resident #2 had a BIMS score of 13, 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 develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and establish policies and procedures to report and investigate such allegations, for 3 of 11 residents (Resident's #37, #49 and #69) reviewed for abuse. 1.The facility did not implement policy on reporting abuse for bruise of unknown origin for Resident #37 to the abuse coordinator (Administrator). 2.The facility did not implement policy on reporting abuse timely for Resident #49 and Resident #69. These failures could place the residents at increased risk for abuse and neglect. The findings included: Record review of the facility policy for Abuse Prevention Program dated 01/09/23, indicated, Policy Statement:1. The Administrator is responsible for the overall coordination and implementation of our Center's abuse prevention program policies and procedures in accordance with the Elder Justice Act. 2. Our residents have the right…

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 all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source were reported immediately, but no later than 2 hours after the allegation was made, for 3 of 3 residents (Resident #37, Resident #49 and Resident #69) reviewed for abuse and neglect. 1. The facility failed to report Resident #37's left cheek bruise, an injury of unknown origin, timely to HHS. 2.The facility failed to report Resident #49's bruised eye and nose, an injury of unknown origin, timely to HHS. 3.The facility failed to report Resident #69 and Resident #37 resident -to-resident altercation timely to HHS. These failures could place the residents at increased risk for further potential abuse due to unreported and uninvestigated allegations of abuse and neglect. Findings included: 1.Record review of Resident #37's face sheet, dated 08/10/23, indicated Resident #37 was an [AGE] year-old male admitted to 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 that licensed staff were able to demonstrate the specific competencies and skill sets necessary to care for resident's needs for 3 of 4 licensed staff (LVN D, LVN F, ADON/LVN O). The facility failed to ensure that LVN D, LVN F, and ADON/LVN O, who were charge nurses for a resident with a central venous line catheter, were competent in providing medication administration via the central venous line catheter (a catheter placed in a large vein up near the heart). This failure had the potential to affect residents by placing them at an increased and unnecessary risk of exposure to staff who lack the appropriate skills competencies to provide care that is safe and capable of minimizing accidents from procedural errors, infections, and errors in medication administration. Findings included: Record review of the personnel file revealed there were no competencies for ADON/LVN O . Record review of the in-service records dated 2023 did not reveal any in-services provided or skills check off on central venous…

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 a private space for residents' monthly council meetings for 9 of 9 confidential residents reviewed for resident council. The facility did not provide a private space for resident council meeting. This failure could place residents, who attended resident council meetings, at risk of not being able to voice concerns due to a lack of privacy. Findings include: During an observation on 08/08/2023 at 3:05 p.m., CNA M, LVN C, Treatment Nurse, Social Worker, and the DON disturbed the resident council meeting that was held in the dining room by walking in and out of the side door that was connected to the dining room. During a confidential group interview on 08/08/2023 at 3:15 p.m., nine residents stated the resident council meetings were held monthly in the dining room. Residents stated staff disturbed the meetings by going in and out of the side door of the dining room or dietary staff coming in and out of the kitchen. Residents stated they would like a more private place for more privacy and the ability 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 provide a safe, functional, sanitary, and comfortable environment for 1 of 1 (Resident #42) residents' bathrooms reviewed for environment. 1. The facility failed to ensure Resident #42 did not a have sticky floor near the toilet in the bathroom. This failure could place residents at risk of an unsafe or uncomfortable environment and a decrease in quality of life and self-worth. Findings included: Record review of Resident #42's face sheet dated 08/10/23 indicated that he was a 66year old male who admitted to the facility on [DATE] with the diagnoses of schizophrenia (mental disorder), respiratory disease, depression, hallucinations, and chronic obstructive pulmonary disease (lung disease). Record review of Resident #42's MDS dated [DATE] indicated that he had a BIMS score of 10 which indicated he had moderately impaired cognition. The MDS also indicated that Resident #42 required supervision with all ADLs. Record review of Resident #42's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure all alleged violations of abuse and neglect were thoroughly investigated for 1 of 3 residents (Resident #37) reviewed for abuse and neglect. The facility did not thoroughly investigate when Resident #37 had a bruise of unknown origin on his left cheek. This failure could place residents at risk for abuse and neglect. Findings included: Record review of the facility policy for Abuse prevention Program dated 01/09/23, indicated, Policy Statement 1. The Administrator is responsible for the overall coordination and implementation of our Center's abuse prevention program policies and procedures in accordance with the Elder Justice Act. 1.Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat 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 implement a person-centered care plan to meet resident's medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment for 1 of 25 residents (Resident # 55) reviewed for care plans. The facility failed to care plan Resident #55's need for contact isolation related to a contagious urinary tract infection with ESBL from July 5, 2023 - July 11, 2023. This failure could place residents at risk for injuries, inaccurate care plans and decreased quality of care. Findings included: Record review of an undated face sheet indicated Resident #55 was a [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnosis of acute and chronic respiratory failure (a serious condition that makes it difficult to breath on your own), and diabetes. Record review of a Quarterly MDS dated [DATE] indicated Resident #55 understood others and was understood by others. Resident #55's BIMS was 15, and she had no cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received services to maintain grooming and personal hygiene for 1 of 3 (Resident #69) residents reviewed for ADLs. The facility failed to ensure Resident #69's fingernails were clean and free from a brown colored material. This failure cold place residents at risk for not receiving services/care and decreased quality of life. Findings included: Record review of an undated face sheet indicated Resident #69 was an [AGE] year-old male who admitted on [DATE] with the diagnose of dementia. Record review of the admission MDS dated [DATE] indicated Resident #69 understood others and was understood. The MDS indicated Resident #69's BIMS score was 4 indicating severe cognitive impairment. The MDS indicated Resident #69 had inattention and disorganized thinking. The MDS indicated Resident #69 had not rejected care during the assessment period. The MDS indicated Resident #69…

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 residents received proper treatment and assistive devices to maintain or enhance vision abilities for 1 of 1 resident reviewed for vision services. (Resident #55). The facility failed to schedule Resident #55 for a consult for cataract surgery. This failure could affect resident in need of referrals for vision evaluations and place them at risk of not receiving necessary treatment and services. Findings included: Record review of an undated face sheet indicated Resident #55 was a [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnoses of acute and chronic respiratory failure (a serious condition that makes it difficult to breath on your own), diabetes, and diabetic complications of diabetic cataract. Record review of a Quarterly MDS dated [DATE] indicated Resident #55 understood others and was understood by others. Resident #55's BIMS was 15, and she had no cognitive problems. The MDS indicated…

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 environment remained as free of accident hazards as possible, and each resident received adequate supervision to prevent accidents for 5 of 28 residents (Resident #'s 11, 33, 42, 54 and 63). The facility failed to ensure a safe environment to prevent accidents and hazards when Resident #33 hit Resident #11, put her hand in Resident #63's shorts, and served other residents drinks, including Resident #62 who was on thickened liquids. The facility failed to ensure a safe environment to prevent accidents and hazards for Residents #63 and #54, and #42, with the razors in the bathroom not stored securely. This failure could place residents at risk for injury. Findings included: 1). Record review of the physician's orders dated 7/7/23 - 8/7/23 indicated Resident #33 admitted [DATE], was a [AGE] year old female with diagnoses that included: Seizures (interruption in the normal connections between nerve cells in the brain),…

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 consistently with professional standards of practice for 1 of 4 residents reviewed for respiratory care. (Resident #22) The facility failed to ensure Resident #22's CPAP (continuous positive airway pressure) had the correct setting to ensure proper respiratory exchange. This failure could place residents at risk for shortness of breath and increased sleep apnea. Findings included: Record review of an undated face sheet indicated Resident #22 was a [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnoses of chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and heart failure. Record review of the physician orders dated 8/01/2023 - 8/31/2023 indicated the physician for Resident #22 had ordered on 6/29/2023 CPAP: apply at hour of sleep via a face mask. Record review of the comprehensive care plan…

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, observation, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 25 residents (Resident #122) and 1 of 3 medication carts (C Hall) reviewed for pharmacy services. The facility did not remove expired medications from C Hall nurse cart. The facility failed to administer Resident #122's prescribed sodium chloride tablets. These failures could place residents at risk for not receiving the therapeutic benefit of medications or adverse reactions to medications. Findings included: 1. During an observation on 08/10/2023 at 8:11 a.m., C Hall nurse cart was observed with LVN A present. Inside the medication cart, there was 1 insulin lispro Kwik pen (a product used to lower blood sugar) with expiration date 07/17/2023. During an interview on 08/10/2023 at 9:24 a.m., LVN A stated the nurse was responsible for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure psychotropic medications were not given unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 5 residents reviewed for unnecessary medications. (Resident #23) The facility failed to have an appropriate diagnosis or adequate indication for the use of Resident #23's Seroquel (antipsychotic medication used to treat certain mental/mood disorders such as schizophrenia, and bipolar disorder). This failure could place residents at risk of receiving unnecessary psychotropic medications with possible medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications. Findings included: Record review of Resident #23's face sheet, dated 08/11/23, indicated Resident #23 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included Dementia (impaired ability to remember, think, or make decisions…

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, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 2 of 3 medication carts (medication and nurse carts) reviewed for storage of medications. The facility failed to ensure Hall C medication cart and Hall A, B, and D nurses' cart was secured and unable to be accessed by unauthorized personnel. This failure could place residents at risk of medication misuse and diversion. Findings include: 1. During an observation on 08/08/2023 at 9:20 a.m., LVN P was preparing to give Resident #20's medications. LVN P gathered Resident #20 medications, a cup of water and closed the cart. LVN P then entered the room of Resident #20 and left Hall C medication cart unlocked, and out of sight, while administering Resident #20's medications. During an interview on 08/09/2023 at 11:30 a.m., LVN P stated the medication cart should be locked anytime she walked away from it,…

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 laboratory services were obtained to meet the needs of 2 of 28 residents reviewed for laboratory services (Residents #'s 41 and 10). The facility failed to obtain ordered CBC (Complete Blood Count), CMP (Complete Metabolic Panel), B12/Folate, Stool Culture, Vitamin D, Lipids, TSH (Thyroid Stimulating Hormone, and FER (Ferritin) levels for Resident #41. The facility failed to obtain ordered A1C for Resident #10. These failures could place residents at risk of not receiving timely diagnoses, treatment, and services to meet their needs. Findings included: 1.Record review of the physician's orders dated 7/9/23 - 8/9/23 indicated Resident #41 was an [AGE] year old female that admitted [DATE] with diagnoses that included: Acute Myocardial Infarction (heart attack, a blood clot blocks blood flow to the heart), Dementia (cognitive impairment characterized by memory loss and impaired judgement, Atrial fibrillation (rapid and irregular beating 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.