Avir at New Braunfels

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of needs and preferences for one (1) of eight (8) residents (Resident #1) reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #1's room was in a position accessible to the resident on 12/29/2025. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.The findings included: Record review of Resident #1's admission Record, dated 12/30/2025, revealed a [AGE] year-old male admitted on [DATE] and re-admitted on [DATE]. Record review of Resident #1's Diagnosis Report, dated 12/30/2025, revealed diagnoses including cerebral ischemia (a condition in which a blockage in an artery restricts the blood flow to the brain resulting in damage to brain tissue), unspecified lack of coordination, muscle wasting and atrophy…

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 post the required signage acknowledging the use of oxygen in resident room per resident care policies and procedures. The polices and procedures for respiratory care and services provided include, but are not limited to, the posting of cautionary and safety signs indicating the use of oxygen for 1 of 1 Resident's for hall. The facility failed to post cautionary and safety signs indicating the use of oxygen on 12/29/2025 for Resident #1's room. This failure could put residents, family members, and all visitors at risk for potential harm due to the flammability of oxygen.The findings included: Record review of Resident #1's admission Record, dated 12/30/2025, revealed a [AGE] year-old male admitted on [DATE] and re-admitted on [DATE]. Record review of Resident #1's Diagnosis Report, dated 12/30/2025, revealed diagnoses including cerebral ischemia (a condition in which a blockage in an artery restricts the blood flow to the brain resulting in…

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 over the counter medications in accordance with currently accepted professional principles for medication storage room in secure Co-ed unit. The facility failed to ensure that the medication storage room held no expired medications per state and federal guidelines. This failure could cause adverse reactions to residents when ingesting expired medications. The findings included: Observation of 4 expired supplemental shakes within the medication room, each with an expiration date of 09/10/2025. Observation of the medication storage room in the secured Co-ed unit on 12/30/2025 at 8:51a.m. revealed 4 expired supplemental shakes on the counter, with expiration dates of 09/10/2025. Interview with CMA on 12/30/2025 at 8:51 surveyor asked CMA where expired liquids, such as medications and supplements, were stored. CMA responded that they are usually taken out of here and stored somewhere else. Surveyor then asked CMA What expiration date do you see on this supplement? CMA responded It says it expires September…

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, to store all drugs and biologicals under proper temperature controls in 1 of 1 central supply storage room reviewed for medication storage. The facility failed to store their over-the-counter medications (8 bottles of Acetaminophen 325 mg.) in the central supply storage room maintained within 68 to 77 degrees Fahrenheit per medication recommendations. This deficient practice could place residents at risk of the medications not being as effective as they were designed to work. The findings were:Observation and interview on 11/18/25 at 2:01 PM with CNA A in the central supply storage room revealed she was assigned as the charge person for ordering and storing medications in the central supply storage room as of 10/1/25. She stated when she started organizing the storage room, she noted it was hot in the storage room and there was no ventilation. CNA A stated they stored nursing supplies including over the counter medications, enteral feedings and med pass. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 1 of 8 Residents (Resident #2) who were reviewed for homelike environment. The facility failed to ensure Resident #2's shower remodeling project was completed and the floor in the resident room was leveled and safe to walk across. This deficient practice could place residents at risk of unsafe living conditions and avoidable accidents. The findings were:Review of Resident #2's face sheet, dated 11/24/25, revealed she was admitted to the facility on [DATE] with diagnoses including unspecified Dementia (decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities), lack of coordination, weakness, pain in right hip and difficulty in walking. Review of Resident #2's quarterly MDS, dated [DATE], revealed her BIMS score was 15 of 15 reflecting she was alert and oriented without 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 incorporate the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care 1 of 2 residents (Resident #1) reviewed for PASARR services. The nursing facility failed to submit a completed (NFSS) application to ensure Resident #1 received a specialized motorized wheelchair based on her rehabilitation assessment. This deficient practice could place residents at risk for not receiving specialized equipment and result in the decline in their physical condition. The findings were: Review of Resident #1's face sheet, dated 11/24/25, revealed she was admitted to the facility on [DATE] with diagnoses including severe intellectual disabilities, unspecified lack of coordination, muscle weakness (generalized), other specified disorders of muscles and unspecified Dementia (a general term for declining mental abilities, like memory, thinking, and reasoning,…

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 for 1 of 8 Residents (Resident #3) reviewed for sanitary conditions. The facility failed to ensure the damaged linoleum tile was replaced, the walls were painted, the baseboard behind the bed was sanded and painted in Resident #3's room for a period of approximately 2 months. This deficient practice could place residents at risk of living in uncomfortable and unsanitary conditions. The findings were:Review of Resident #3's face sheet, dated 11/24/25, revealed he was admitted to the facility on [DATE] with diagnosis including unspecified Dementia (decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities). Review of Resident #3's BIMS assessment dated [DATE] revealed his score was 7 of 15 reflective of moderate cognitive impairment. Observation on 11/20/25 at 5:12 PM in Resident #3's room revealed there…

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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the transmission of communicable diseases and infections for 3 of 3 laundry carts. The facility failed to ensure laundry staff handled and delivered linens in a manner to ensure cleanliness and protect from dust and soil to prevent cross-contamination and the spread of infections. This failure could place residents at risk for development of communicable diseases and infections that could diminish a residents' quality of life. Findings included:Observation on 8/26/25 at 11:15 AM revealed linens being delivered on a laundry cart being pushed down the hall by LS B with a green fitted sheet thrown over the top of the cart. The sheet left the lower part of the hanging clothes, the clothes down in the basket section, and both ends of the hanging clothes exposed to the open air with visitors and staff passing on the same hall. Observation on 8/27/25 at 1:30 PM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents had the right to retain and use personal possessions including cigarettes for two (Resident #13 and Resident #37) of four residents reviewed for the right to use personal possessions.The facility failed to return the residents personal cigarettes for Resident #13 and Resident #37 on 08/13/2025.This failure could place residents at risk of having their rights infringed upon and could lead to the residents not being able to use their personal cigarettes when resident were off facility grounds.Record review of Resident #13's face sheet, dated 08/27/2025, reflected he was a [AGE] year-old male, who admitted to the facility on [DATE], with diagnoses including Nicotine Dependence (regularly smokes cigarettes), cognitive communication deficit (difficulties in communication stemming from impairments in the cognitive processes), generalized anxiety disorder (a mental health condition characterized by excessive, uncontrollable worry…

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 assess a resident using the quarterly review (every 3 months) instrument specified by the State and approved by CMS for 1 of (Resident #92) of 5 residents reviewed for quarterly MDS assessments. The facility failed to complete a quarterly MDS assessment for Resident #92 every 3 months (04/19/2025 through 08/22/2025). This failure could place residents at risk of not having accurate assessments completed timely which could result in the residents not receiving necessary care or receiving inappropriate care for their conditions.Findings included: Record review of Resident #92's face sheet dated 08/28/2025 reflected a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis that included Alzheimer's Disease (progressive brain disease that causes memory loss and other cognitive impairments), Major Depressive Disorder (mental disorder characterized by a persistent low mood and loss of interest or pleasure in activities), Psychotic Symptoms…

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 in accordance with state and federal laws, all drugs and biologicals were discarded before the expiration date for 2 medications stored in 1 of 2 medication rooms observed for medications. The facility failed to ensure that Med room [ROOM NUMBER] did not have expired OTC medications in the drawer/room.The failures could result in residents receiving ineffective, expired medications which could be harmful. An observation and audit were conducted 08/28/2025 at 10:21 AM of Med room [ROOM NUMBER] which was located in the main lobby revealed that inside a mini fridge were expired insulin and Bisacodyl. The insulin had an expiration date of 08/21/2025. The Bisacodyl had an expiration date of 04/29/2025. An interview was conducted on 08/28/2025 at 4:38PM with the ADM who reported working at the facility for 2.5 months. The ADM stated the ADON and DON provided training for labeling/dating medication. The ADM stated that the policy 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.

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 control and labeled in accordance with currently accepted professional principles for 2 (medication cart #1 and medication cart #3) of 4 medication carts reviewed for medication storage. The facility failed to ensure that MC #1 did not have loose unknown NARC medications in the drawer. The facility failed to ensure that MC #1 and MC #3 did not have medications that were undated in the drawer. This failure could put residents at risk for missed medications and/or receiving unidentified medications. An observation and audit conducted on 08/27/2025 at 12:50 PM revealed Med Cart #1 which was stationed on the 50 hall, contained loose and unlabeled medications. The observation revealed half of a white circle tablet loose in the locked narcotics bin. It was identified by INV and LVN G that the medication was not a current medication in the narcotics bin. Med Cart #1 contained undated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public on 4 of 4 resident hallways (Hallway A, Women's Unit, Hallway C, and Men's Unit) reviewed for environmental concerns. 1. The facility failed on 8/13/25 to ensure the ceiling lights were replaced and the ceiling vent cleaned in the therapy bathroom located at the end of the A- hallway.2. The facility failed on 8/13/25 to ensure the ceiling vents/panels were cleaned/repaired and a shower room in room # 32 cleaned on the Women's Unit.3. The facility failed on 8/13/25 to repair a bedroom light in room [ROOM NUMBER] and clean a shower room in room # 70 on the C-hall.4. The facility failed on 8/13/25 to repair a bathroom floor molding in room # 89 on the Men's Secure Unit. These failures could place residents at risk of a diminished quality of life due to exposure to an environment that was unpleasant, unsanitary, and unsafe. 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, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs that were identified in the comprehensive assessment, and described services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 8 residents (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1's care plan reflected his bowel incontinence and included a care plan regarding how to take care of his bowel incontinence. These deficient practices could place residents at risk for not receiving proper care and services due to inaccurate care plans. The findings included: Record review of Resident #1’s face sheet, dated 07/09/2025, revealed Resident #1 was [AGE] years old male, admitted to the facility on [DATE], and re-admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder and bowel received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 2 residents (Resident #1) reviewed for incontinence care. When CNA-A was providing incontinent and bladder indwelling catheter care to Resident #1 on 07/10/2025, CNA-A did not clean the resident's suprapubic area (the area of the abdomen located below the umbilical region), left groin area, right groin area, and scrotum. These failures could place residents who required incontinence care at risk for cross contamination and the development of new or worsening urinary tract infections. The findings included: Record review of Resident #1's face sheet, dated 07/09/2025, revealed Resident #1 was [AGE] years old male, admitted to the facility on [DATE], and re-admitted to the facility on [DATE] with the diagnosis of major depressive disorder (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.

Based on observation, interview, and record review, the facility failed to provide an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being for residents 1 of 1 secure unit reviewed for activities, in that: The facility failed to ensure there were organized activities available to residents. The failure placed residents at risk for a diminished quality of life, isolation, and lack of stimulation. Findings included: During observation of men's secure unit (MSU) on 3/4/2025 at 1:30 PM, the centrally located group activities board was observed to have a large print February 2025 calendar posted with red themed decorations. There were no additional postings to include activities for March on the activities board. On 3/5/2025 as observed at 1:30 PM, the group activities board contained new decorations in a green theme but did not have a calendar or notes of daily or monthly activities. 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 and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #1) observed for infection prevention. The facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented and used when CNA-A provided peri and catheter care for Resident #1. This deficient practice could place residents at-risk for spread of infection. Findings include: Record review of Resident #1's face sheet dated 01/30/2025 revealed she was a [AGE] year-old woman, with an initial admission date of 04/04/2024, with re-admission on [DATE] and with diagnoses which included: Non-traumatic subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain); Gastrostomy status (presence of surgically created opening in stomach through which a feeding tube…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide pharmaceutical services including procedures that assured accurate administering of all drugs to meet the needs of residents for 1 of 11 residents (Resident #3) reviewed for pharmaceutical services, in that: 1. MA A administered Resident #9's Gabapentin to Resident #3 when Resident #3 did not have the medication available on 12/14/2024. 2. The facility did not reorder Resident #3's Lyrica, Gabapentin and Clonazepam timely, resulting in Resident #3 missing 3 doses of Lyrica, 5 doses of Gabapentin and 2 doses of Clonazepam. 3. LVN A received an Ativan prn order from NP A on 12/14/2024 for Resident #3 and did not add the medication to Resident #3's physician orders or order the medication from the pharmacy. 4. LVN C documented LVN C administered an Ativan prn to Resident #3 on 12/15/2024 that had not been administered. These failures could place residents who receive medications administered by the facility at risk of not receiving the intended…

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 implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet residents' physical, mental, and psychosocial needs that were identified in the comprehensive assessment and to ensure that the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including the right to refuse treatment for 4 of 30 residents (Residents #24, #59, #88 and #97) reviewed for care plans. 1. The facility failed to implement a comprehensive person-centered care plan to address Resident #24's diagnosis of depression. 2. The facility failed to implement a comprehensive person-centered care plan to address Resident #59's diagnosis of depression. 3. The facility failed to implement a comprehensive person-centered care plan to address Resident…

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

Based on interviews and record review, the facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care, and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required. The Dietary Manager (DM) did not have the appropriate certification, education, or qualifications to serve as the Director of Food and Nutrition Services. This deficient practice could place the residents who consume food prepared from the kitchen at risk of food borne illness and not receiving adequate nutrition. The findings included: Record review of the employee personnel file provided by the facility revealed the hire date for the DM was 03/22/2023. Further review of this personnel file, which included the DM's resume, did not reveal the DM was: (A) A certified dietary manager; or (B) A certified food service manager; or (C) Had similar national certification for food service management and safety…

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

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: 1. The DM wore a facial hair restraint that did not cover all his facial hair. 2. The facility failed to store, label and date food items properly in the walk-in cooler and dry storage room. 3. In the dish room there were multiple trays of plastic cups stored on trays without air-drying nets separating them from the trays. 4. One of the two reach-in freezers in the dining room (Freezer #1) failed to maintain temperatures at a level to keep frozen food solid. 5. DAs G and H were not wearing hair restraints during food preparation in the kitchen. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: 1. Observation on 06/25/2024 at 11:00 AM in the kitchen revealed the DM walked through the food preparation area of the kitchen during the preparation of the lunch meal. The DM wore a cloth…

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 2 reach-in freezers (Freezer #1) reviewed for essential equipment. The facility did not ensure Freezer #1 was in safe operating condition. This failure could place the residents at risk of foodborne illness for consuming food not stored at a safe temperature. Findings included: Observation on 06/25/2024 at 11:28 AM of the analogue thermometer inside Freezer #1 revealed the reading fluctuated between 40 and 42 degrees Fahrenheit. Further observation of several food items in Freezer #1 (two 6.5-lb. containers of sliced strawberries, a sample of biscuit dough from a closed case, and a sealed, uncooked pork loin of unknown weight) were all in a completely thawed state. Record review of the temperature log attached to Freezer #1 revealed the temperature of Freezer #1 was 1.4 in the AM on 06/25/2024, 1.5 the PM on 06/24/2024, 1.4 the AM on 06/24/2024, and -1 the PM on 06/24/2024. During an interview on 06/25/2024 at…

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

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 1 facility reviewed for environmental concerns. The facility failed to repair a gap surface on a wall in a resident's room, repair a penetration in a resident's bathroom wall, replace light bulbs in a shower stall in a hallway shower room, repair a cracked corner surface of a shower stall in a hallway shower room, clean the dirt/dust particles a bathroom ceiling vent in two residents' rooms, and remove mold from the floor surface of a shower stall in a hallway shower room. This deficient practice could place residents at risk of not living in a safe, functional, sanitary, and comfortable environment. The findings included: During an observation on hallway A from 10:20 a.m., to 11:30 a.m., revealed the following: 1. Resident room # 51 on the B-side had a 4 foot gap in the wall surface behind the resident's headboard. 2. Resident room# 51 had a 6- inch round wall penetration in the bathroom. 3. 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 develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care, in that: Resident #276's baseline care plan did not include her prescribed diet, food allergies, or code status. This deficient practice could result in newly admitted residents receiving improper care. The findings were: Record review of Resident #276's face sheet, dated 06/28/2024, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Type 2 diabetes mellitus without complications, Gastro-esophageal reflux disease without esophagitis, and Diverticulitis of intestine, part unspecified, without perforation or abscess without bleeding. Record review of Resident #276's clinical record as of 06/28/2024 revealed her initial MDS had not yet been completed. Record review of Resident #276's care plan, dated 06/27/2024,…

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 infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #385), reviewed for infection control. LVN B failed to sanitize or wash her hands between glove changes during wound care for Resident #385. This failure could place residents at risk of cross contamination, infection, delayed wound healing, and illness. The findings were: Record review of Resident #385's face sheet dated 6/28/24 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included osteomyelitis (inflammation of the bone caused by an infection, which may spread to the bone marrow, and tissues near the bone), surgical amputation of toes to right foot (surgical removal of toes), and type 2 diabetes mellitus with diabetic peripheral angiopathy…

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 right to be free from misappropriation of property was provided for 1 of 9 residents (Resident #9) reviewed for misappropriation and exploitation, in that: The facility did not prevent Resident #9's personal belongings from being lost when he discharged to the hospital. This failure could affect residents and their responsible party by preventing them from having access to their personal effects and belongings. The findings included: Record review of Resident #9's face sheet, dated [DATE], revealed the resident was admitted on [DATE] with diagnoses that included: dementia, anxiety, and mood disorder. The resident was a male age [AGE]. The RP was listed as a family member. Record review of Resident #9's quarterly MDS, dated [DATE], revealed the resident had BIMS score of 01 (severe cognitive impairment). Record review of facility's discharge list, dated [DATE], revealed Resident #9 expired in the facility on [DATE] under hospice care. Record…

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 interview and record review the facility failed to immediately inform the resident's responsible party and physician when there was a significant change in the resident's physical, mental or psychological status for one resident (Resident #1) reviewed for notification of change of condition, in that: The facility failed to notify Resident #1's responsible party and physician when Resident #1 sustained a burn injury after spilling hot coffee on himself. The non-compliance was identified as past non-compliance. The non-compliance began on 08/28/2023 and ended on 09/01/2023. The facility had corrected the non-compliance before the survey began. This failure placed residents' caregivers at risk of not being aware of any changes in their conditions and could result in a delay in treatment and decline in residents' health and well-being. Findings included: Record review of Resident #1's face sheet revealed a [AGE] year-old male who was admitted on [DATE] and readmitted on [DATE]. His diagnoses included…

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 comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 7 residents (Reident #1), reviewed for care plan revisions, in that: Resident #1's care plan was not revised a total of four times changes were made to the MDS specific to eating assistance. This deficient practice could place residents at risk for lack of coordination of services and confusion as to eating assistance. The finding included: Record review of Resident #1's face sheet, dated 11/30/23, and EMR revealed the resident was admitted on [DATE] with diagnoses that included: Alzheimer's disease (primary) (progressive mental deterioration), abnormal gait and mobility, lack of coordination, stroke affecting right side of face; and hospice. Further review revealed the resident was a male; age [AGE], Advanced Directive was DNR, and the resident's Responsible Party…

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 that licensed nurses had the appropriate competencies and skill sets to provide nursing and related services to assure resident safety for 2 of 29 licensed staff (LVN A and LVN B) reviewed for competent staff, in that: 1. The facility failed to ensure LVN A completed an incident report and notified Resident #1's RP and physician after he sustained a burn incident. 2. The facility failed to ensure LVN B documented care provided to Resident #1 in his EMR. The non-compliance was identified as past non-compliance. The non-compliance began on 08/28/2023 and ended on 09/01/2023. The facility had corrected the non-compliance before the survey began. These failures could place residents at risk for not receiving the appropriate care and services to maintain their health and safety. The findings included: 1. Record review of Resident #1's face sheet, dated 11/08/2023, and EMR revealed a revealed a [AGE] year-old male admitted to the facility on [DATE] and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain medical records, in accordance with accepted professional standards and practices, which were complete and accurate for one resident (Resident #1) reviewed for accuracy of records, in that: The facility did not document in Resident #1's electronic medical record (EMR) an incident report or care that was provided after the resident sustained a burn injury. The non-compliance was identified as past non-compliance. The non-compliance began on 08/28/2023 and ended on 09/01/2023. The facility had corrected the non-compliance before the survey began. These failures could place residents at risk of not having accurate medical records and could create confusion in services provided or needed to be provided. The findings included: Record review of Resident #1's face sheet, dated 11/08/2023, and EMR revealed a revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included Alzheimer's disease (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to follow menus for 1 of 1 resident meals (lunch meal on 04/11/2023) reviewed for menus in that: 1. Residents on a regular diet were served lunch items on 04/11/2023 that did not reflect what was on the menu. 2. Residents on modified diets were served lunch items on 04/11/2023 that did not reflect what was on the menu. These failures could place residents who consume food prepared by the facility kitchen at risk of not having their nutritional needs met and/or weight loss. The findings included: 1. Observation on 04/11/2023 at 10:15 a.m. in the dining room revealed the lunch meal posted for that day was: Cheeseburger, French Fries, Tomato/Lettuce/Pickles/Onion, Hot Spiced Apples, Iced Tea or Punch and Water. There was no weekly menu posted. Record review of the current week's menu provided by facility labeled, Week 5 revealed the lunch meal scheduled for Tuesday, 04/11/2023, for residents on a regular diet was: Pot Roast, Roasted New…

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

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: 1. There was a zip-locked bag in the reach in cooler with diced ham that was past its use-by date. 2. There was an open bag of flour in the dry storage room that was not stored in a closed or tightly covered container. 3. The tabletop can opener blade, bar, and base were covered in sticky black and brown grime. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: 1. Observation on 04/11/2023 at 10:20 a.m. in the reach-in cooler revealed there was a zip-locked bag on a shelf with the words, Diced ham. Also written on the bag was the date 3/23 and OP 3/28. Interview on 04/11/2023 at 10:30 a.m. with the DM revealed the dates meant the ham was received by the facility on 3/23/2023 and opened on 3/28/2023. The DM stated that the ham had been in the cooler for 14 days by 04/11/2023 and should…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 3 of 6 residents (Residents #44, #94 and, #114) reviewed for infection control, in that: 1. LVN X did not wash or sanitize her hands or change her gloves after touching Resident #44's environment and before starting wound care for Resident #44. 2. CNA Y and CNA D did not wash or sanitize their hands or change their gloves after touching Resident #94's environment and before starting incontinent care for Resident #94. 3. LVN A did not wash or sanitize her hands between change of gloves during colostomy care for Resident #114. These deficient practices could place residents at-risk for infection due to improper care practices. The findings include: 1 .Record review of Resident 44's face sheet, dated 04/13/2023, revealed an…

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 Quality Assurance Performance Improvement (QAPI) Training that outlines and informs staff of the elements and goals of the facility's QAPI program for 13 of 23 staff (CNAs E, F, G, H, I, J, K, L, and LVNs N, Q, and ST, PT, and OT, reviewed for training, in that: The facility failed to ensure that 13 of 23 staff (CNAs E, F, G, H, I, J, K and LVN's N, Q, and ST, PT, OT staff had completed their mandatory QAPI annual training. This failure could place residents at risk for care by CNA, LVN, and therapy staff who have been insufficiently trained while working in the facilit The findings included: Record review of the annual CNA, LVN, and therapy staff training information revealed that: CNA E (hired-11/1/18), CNA F (hired-5/5/20), CNA G (hired-8/2/20), CNA H (hired-11/1/18), CNA I (hired-11/1/18), CNA J (hired-11/1/18),CNA-K((hired- 11/1/18),CNA-L(hired-3/3/20), LVN N (hired-5/28/19), LVN-Q (hired-2/20/19), and ST (hired-9/1/20), and PT (hired-9/21/20) and OT (hired-3/15/22) had not completed their mandatory QAPI…

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 have a right to personal privacy for 2 of 6 resident (Residents #44 and, #114) reviewed for privacy, in that: 1. LVN X did not completely close Resident #44's privacy curtain while providing wound care for the resident. 2. LVN A did not completely close Resident #114's privacy curtain while providing colostomy care for the resident. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy. The findings include: 1. Record review of Resident 44's face sheet, dated 04/13/2023, revealed an admission date of 10/03/2022, with diagnoses which included: Cerebral aneurysm (weak spot in an artery of the brain that bulges out), Hypertension (High blood pressure), Depression (feeling of severe despondency), Hyperlipidemia (too much lipids (fat) in the blood), Anxiety (a feeling of worry, nervousness or unease) Record review of Resident #44's Quarterly MDS, dated [DATE], revealed the resident 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.

Based on interview and record review, the facility failed conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity within 14 days calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition for 1 of 7 resident (Resident #423) reviewed for Comprehensive Assessments and timing. The facility failed to ensure an MDS Assessment for Resident #423 was completed within 14 days after admission. This failure could place residents at risk for improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. Findings include: Record review of Resident #423's face sheet dated 04/13/2023, revealed an admission date of 03/15/2023, Record review of Resident #423's medical record revealed as of 04/14/2023 no admission assessment MDS had been completed. Interview with the MDS Coordinator on 04/14/23 at 2:52 p.m. revealed the time frame for an initial MDS to be completed was 14 days from admission 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 interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident's rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 47 residents (Resident #2) whose care plan was reviewed, in that: The facility failed to ensure Resident #2's care plan included insulin This deficient practice could place residents at risk of receiving the incorrect care and cause health complications with subsequent illness. The findings were: Record review of Resident #2's face sheet, dated 04/14/2023, revealed the resident was re-admitted on [DATE] with diagnoses that included: vascular dementia, type 2 diabetes, anxiety and psychotic disturbance. Record review of Resident #2's quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 08, which indicated moderate 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.