Avir At Monahans

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop a comprehensive person-centered care plan for each resident , consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment which were to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 4 of 4 residents (Resident #3, Resident #4, Resident #5, Resident #6) reviewed for care plans. 1. The facility failed to implement a comprehensive person-centered care plan for Resident #3's physical altercation with Resident #4 on 07/10/24. 2. The facility failed to implement a comprehensive person-centered care plan for Resident #4's incident on 07/10/24 with Resident #3 in which Resident #3 physical hit Resident #4. 3. The facility failed to implement a comprehensive person-centered care plan for Resident #5's physical altercation with…

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

Based on observation, interview and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 washing machine and 1 of 4 resident wheelchair brakes reviewed for essential equipment. 1. The facility did not provide necessary repairs for 1 industrial washing machines. 2. The facility failed to ensure Resident #1's wheelchair brakes were not broken These failures could place residents at risk of not having clean clothes to wear and place residents at risk of function mobility and injuries. Findings include: Observation and interview on 02/24/25 at 8:40 AM with Resident #1 revealed the right wheelchair brake would not disengage, and the handle was observed loose. Resident #1 was observed trying to move his wheelchair with his right arm/hand and moving slowly and veins in his arm could be seen popping out of his right arm/hand. Resident #1 did not have any legs as they were amputated. During an interview on 02/24/25 at 2:31 PM Resident #1 stated he told RN on 02/23/25 in the evening that his wheelchair…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 2 of 2 (Broken blinds), 2 warped tiles, 3 holes in the walls, 1 exit door missing sweep of 4 exit doors, and 1 of 1 maintenance log reviewed for environment. 1. The facility failed to ensure the blinds were not broken. 2. The facility failed to ensure floor tiles were not warped. 3. The facility failed to ensure there were not holes in hallway 3 and a hole in the hall leading to the back smoking patio/laundry room. 4. The facility failed to ensure the hallway 1 Exit door was not missing a sweep and created a seal on the mid-top side of the door to not expose the outside elements. 5. The facility staff failed to input broken items into the maintenance work order log. These failures could residents at risk of living, working and visiting in an unsafe, unsanitary, and uncomfortable environment. Findings include: Observation on 02/24/25 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 provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible and includes ensuring that the resident could receive care and services safely and that the physical layout of the facility maximized resident independence and did not pose a safety risk for 1 of 4 hallways (hall 100) and 1(Resident #2) of 3 residents reviewed for clean homelike environment. 1. The facility failed to ensure Hallway 1 did not smell of urine. 2. The facility failed to ensure Resident #2 did not have a dirty bed linens. These failures could place residents at risk of residing in an unsafe, unsanitary, and uncomfortable environment. Findings include: 1. Observation on 02/24/25 at 8:14 AM, with the Administrator, revealed her coming down hallway 1 to get state agency. Walking down the hallway smelled of urine. During an interview on 02/25/25 at 4:50 PM, with the Administrator, she stated the day the state survey agency was in hallway 1 and went to get him…

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 assessment accurately reflected the resident's status for 1 of 4 residents (Resident #3) reviewed for accuracy of MDS assessment. The facility failed to ensure Resident #3's quarterly MDS, dated 01/2025, accurately reflected the residents' behaviors. This deficient practice could place residents at risk of not receiving adequate care. Findings include: Record review of Resident #3's face sheet, dated 02/25/25, revealed an admission to the facility on [DATE] and re-admission on [DATE] to the facility. Record review of Resident #3's hospital history and physical, dated 07/05/24, revealed a [AGE] year-old male with diagnoses which included Wernicke-Korsakoff disorder (a life-threatening brain disorder caused by a severe deficiency of thiamine, or vitamin B1), Dementia, and anxiety disorder. Record review of Resident #3's MDS, dated 01/2025, revealed a moderate cognitive impairment BIMS score of 12 to recall and or make daily decisions. Behaviors…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 5 (Resident #3) reviewed for pharmacy services. The facility failed to record Tramadol-50 mg Schedule IV tablet was given to Resident #3 at 7:30 AM per physician orders in the narcotic logbook. This failure could place residents at risk for being over mediated which could result in medical complications and drug diversion. Findings include: Record review of Resident #3's face sheet, dated 02/25/25, revealed admission to the facility on [DATE] and re-admission on [DATE]. Record review of Resident #3's hospital history and physical, dated 07/05/24, revealed a [AGE] year-old male with diagnoses which included Wernicke-Korsakoff disorder (a life-threatening brain disorder caused by a severe deficiency of thiamine, or vitamin B1), Dementia and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for three of eight residents (Resident #1, #2, and #3) reviewed for infection control. 1. MA A touched Resident #3's pills with her bare hands during medication administration. 2. LVN B failed to prevent cross contamination between Residents #1 and #2 by brining in uncleaned diabetic supplies from one room to another. These failures could place resident's risk for cross contamination and the spread of infection. Finding included: Review of Resident #3's CCD dated 11/01/23, revealed a 90- year- old female admitted to the facility on [DATE] with diagnoses including chronic atrial fibrillation (heart does not beat with a regular beat all the time) and acute respiratory failure (person cannot get enough oxygen). Review of Resident #3's MDS…

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

Based on observation, interview, and record review, the facility failed to ensure the residents' right to a safe, clean, comfortable, and homelike environment for the residents on the 300 Hall reviewed for resident rights in that: The facility failed to ensure resident's room hand sinks maintained functioning hot water. This failure could place residents at risk for living in an uncomfortable, and unhomelike environment which could cause a diminished quality of life. The findings included: Observations on 06/11/2024 through 06/13/2024revealed the hand sinks in the rooms on hall 300 had no hot water. The hot water did not turn on at all. Interview on 06/12/24 at 01:33 PM with the Administrator revealed that Hall 300 did not have hot water for approximately 2 months due to a broken pipe. The Administrator stated the residents in hall 300 used the showers on Hall 200 and 400 which had hot water. The Administrator stated she had gotten several quotes and was waiting for approval from corporate. The Administrator stated she had received approval that morning, 06/12/24, to have the hot…

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

Based on interview and record review, the facility failed to use the services of a RN for at least 8 consecutive hours a day, 7 days a week for 16 days in Quarter 2 2024 reviewed for Licensed Nursing coverage from January 2024, February 2024 reviewed for nursing services. The facility did not have the required 8 consecutive hours of RN coverage during the month of January 2024 (11 days) and February 2024 (5 days). This failure could place residents at risk for not having their nursing care and medical needs met. Findings included: Review of PBJ [Payroll Based Journal] Staffing Data Report, with a run date of 06/06/2024 revealed Failed to have Licensed Nursing Coverage 24 Hours/Day was triggered for the fiscal year Quarter 2 2024 (January 1 - March 31). The infraction dates were 01/01 (MO); 01/02 (TU); 01/03 (WE); 01/04 (TH); 01/05 (FR); 01/08 (MO); 01/16 (TU); 01/17 (WE); 01/18 (TH); 01/24 (WE); 01/25 (TH); 02/02 (FR); 02/08 (TH); 02/16 (FR); 02/21 (WE); 02/22 (TH). Record review of the January 2024 schedule/time sheets indicated no 24-hour licensed nursing coverage for any 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 observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 (Residents #4 and #17) of 12 residents reviewed for infection control. The facility failed to ensure: The facility failed to ensure CNAs A and B washed or sanitized their hands prior to putting on gloves and change their gloves after they became contaminated during incontinent care while assisting Resident #4. The facility failed to ensure CNA C changed her gloves after they became contaminated during incontinent care while assisting Resident # 17 This failure could place resident's risk for cross contamination and the spread of infection. Finding include: RESIDENT #4 Record review of Resident #4's face sheet dated 06/11/2024 indicated she was admitted to the facility on [DATE] with diagnoses which included 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.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that ensure the accurate administering of all drugs to meet the needs of the residents, for 1 of 1 medication rooms inspected for medication storage. The facility failed to ensure the medication room did not have an expired vial of Tuberculin (TB) medication in the refrigerator. (TB formula is used to test people for tuberculosis). This failure could place residents at risk of receiving medications that were expired and not produce the desired effect. The findings were: During an observation on 06/12/24 at 09:29 AM, the medication room was inspected with CMA D present. Inside the refrigerator was a 1 ml vial of TB formula with an open date of 04/29/24. The TB formula box indicated Discard opened product after 30 days. CMA D said she did not administer TB tests, so she was not aware of the expired formula. During an interview on 06/12/24 at 09:39 AM, the DON said the TB formula was supposed to be dated when opened and discarded or returned to pharmacy when…

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 all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys, for one (Treatment Cart) of 3 medication carts reviewed for drug storage. The facility failed to ensure the treatment cart was not left unlocked and unsupervised. This failure could place clients at risk for drug diversion or accidental ingestion. The findings included: During an observation on 06/11/24 at 09:38 AM, the treatment cart was seen unlocked and unattended. Inside the cart were several types of medications such as antifungal creams, triple antibiotic ointments, scissors, nail clippers and several other medicated bandages. During an interview on 06/11/24 at 10:15 AM, the DON was made aware of the observation of the unlocked treatment cart. The DON said the cart was supposed to be locked when unattended. The DON said if the cart was left opened some of the residents could get into the cart. The DON said she was not sure who left it open and proceeded to lock it. The DON said 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 interview and record review, the facility failed to ensure a written notice of room change was received, including the reason the room was changed, for 2 (Residents #7 and #15) of 3 residents reviewed for notification of room change. -The facility failed to provide Resident #7 and/or their RP a written notice of a room change before the resident was moved. -The facility failed to provide Resident #15 and/or their RP a written notice of a room change before the resident was moved. This failure could place all residents at risk for being displaced without notice and/or reason and decrease quality of life being in a new environment. Findings Included: Resident #7: Record review of Resident #7's face sheet dated 12/27/2023, revealed an [AGE] year-old female who was admitted on [DATE] with diagnoses including cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) and corticobasal degeneration (rare condition that can cause gradually worsening problems with movement, speech,…

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 1 (Resident #15) of 6 residents reviewed for resident rights. The facility failed to ensure Resident #15's bedroom entrance door and door to the restroom were not partially blocked by a dresser. This failure could place the resident at risk of decreased quality of life due to the lack of a well-maintained environment. Findings included: Record review of Resident #15's face sheet dated 12/27/2023, revealed a [AGE] year-old female who as admitted on [DATE] with diagnoses including fracture of lumbar vertebra, rheumatoid arthritis (chronic progressive disease causing inflammation in the joints and resulting in painful deformity and immobility, especially in the fingers, wrists, feet, and ankles), and osteoporosis (bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes). Record review of Resident #15's…

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

Based on interview and record review, the facility failed to ensure it received registry verification for 1 (CNA K) of 5 employees reviewed for registry verification prior to allowing an applicant to serve as a nurse aide in that: The facility failed to ensure CNA K had a current nurse aide certification while employed at the facility while actively providing care for residents. This failure could place residents at risk for receiving care from someone unqualified to provide care. Findings included: Review of a staff roster dated 12/20/2023 reflected CNA K had a hire date of 3/31/2023. During an interview and record review on 12/22/2023 at 10:45 a.m., the BOM reviewed CNA K's employee file which revealed CNA K's certification expired 11/08/2023, and she had worked since the expiration dated. The BOM said she was unaware that the certification was expired and did not know why CNA K had not renewed her certification. The BOM said the facility did not have a system to track the expiration dates and it was the responsibility of the department head to ensure certifications were up to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections for one (Resident #1) of two residents reviewed for infection control practices in that: CNA A failed to perform proper hand hygiene and glove changes while providing incontinence care to Resident #1. This failure could place residents at risk for the spread of infection. Findings included: Review of Resident #1's face sheet dated 02/04/21, revealed a 70- year- old male admitted to the facility on [DATE] with diagnoses including muscle weakness, muscle wasting and atrophy, contracture of muscle, hemiplegia (partial or total paralysis) and hemiparesis (slight weakness) dementia, and diabetes mellitus. Review of Resident #1's MDS assessment dated [DATE] revealed Resident #1 required extensive assistance with most activities of daily…

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 and 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 kitchen sanitation. 1. The facility failed to ensure stored foods were properly labeled and dated. 2. The facility failed to ensure expired foods were discarded. This places residents at risk of receiving outdated foods. The findings included: Observation of the dry storage on 4/18/23 at 8:15 AM revealed the following: - 1, 1-lb bag jet puffed mini marshmallows expired 1/17/23 - 6 white plastic bags with very small labels that read banana cake mix, no expiration date - 4, 1-gallon containers of Golden Italian dressing with packaged date of 11/19/19, no expiration date - 2, 1-gallon containers of Orange French dressing with packaged date of 12/20/18, no expiration date - 1, 5-lb container of Lite Chili Powder with expiration date of 9/9/16 - 1, 1-gallon container of dill relish with packaged date of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 7 of 15 residents (Residents #13, #15, #16, #21, #26, #30, and #142) reviewed for care plans in that: 1. Resident #13 did not have a care plan to address cognitive ability or delirium, psychosocial well-being/ mood state, behavioral symptoms including the use of a wander guard, falls, nutritional status, or medication use including antidepressant, anticoagulant or diuretic use), diagnosis of seizures, anxiety, or stroke. 2. Resident #15 did not have a care plan for pain/neuropathy, presence of a pacemaker, intermittent explosive disorder, or wheelchair use. 3. Resident #16 did not have a care plan for dementia care, diabetic monitoring, limited vision, psychoactive medication use or blood thinner use. 4.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review the facility failed to ensure that 2 of 4 (Resident #3 and #142) residents reviewed for respiratory care was provided care consistent with professional standards of practice in that: Resident # 3's water bottle, oxygen tubing and plastic bag was not changed, labeled and dated according to policy. Resident #142's water bottle, oxygen tubing and plastic bag was not changed, labeled and dated according to policy. This deficient practice could affect residents who received oxygen treatments and result in respiratory infection. Record review of Record review of Resident #3's face sheet revealed admission date of 11/10/22 with diagnoses of Congestive Heart Failure, Chronic Kidney Disease, Diabetes Mellitus. She was [AGE] years of age. Record review of Resident #3's care plan dated 05/11/2023 failed to mention use of oxygen. Record review of Resident #3's medication profile dated 11/10/22 revealed an order for oxygen via nasal cannula continuously on 3 liters to keep…

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 medication error rates of 5 percent or greater. The facility had a medication error rate of 7.14 %, based on 2 errors out of 28 opportunities, which involved 2 of 8 residents (Resident #19 and Resident #25) reviewed for medication administration. The facility failed to ensure Resident #19 and Resident #25 received prescribed Senna-Docusate 8.6/50 mg (stimulant laxative/stool softener combination medication) verses administered Senna 8.6mg (stimulant laxative only). This failure could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders. Findings included: Record review of Resident #19's face sheet indicated an [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses which included Huntington's Disease (a condition that stops parts of the brain working properly over time), and constipation (having fewer than 3…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to maintain an infection control program designed to prevent the development and transmission of infections for 1 of 3 residents (Resident #19) reviewed for infection control. CNA A failed to wash her hands before or after incontinent care and did not change her gloves during incontinent care for Resident #19. This failure could place incontinent residents at risk for transmission of diseases and organisms. The findings included: Review of Resident #19's Resident Face Sheet dated 4/18/23 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Huntington's Disease (a condition that stops parts of the brain working properly over time. It gets gradually worse over time), Gastrostomy (feeding tube) status, pain, muscle spasms, aphasia (could not speak), contractures, stroke, lung cancer, dementia, repeated falls, and adult failure to thrive. Review of Resident #19's Significant Change MDS, dated [DATE],…

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