Avir at Pecos

Based on interview and record review the facility failed to develop a QAPI (Quality Assurance and Performance Improvement) plan that described the process for conducting quality assessment and assurance activities, including the process on how the committee would identify and correct quality deficiencies. The facility failed to have documentation and evidence of its QAPI plan being ongoing and comprehensive.This failure could affect all residents and result in quality deficiencies not being recognized and corrected.Findings included: Record review of the Nursing Facility's QAPI plan, the Nursing Facility's meeting template documents for 02/2026, 03/2026, and 04/2026, revealed the areas documented: Goal, Interventions, and Progress, were blank. The PIP (Performance Improvement Plan) for the mentioned 3 months had the same handwritten notes that read, past LSC (Life Safety Code) and Annual Surveys from 03/25/25-03/28/25, all deficiencies were identified with no current issues. The PIP also included ANE in-services were completed for the months mentioned.In an interview and observation…

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 implement the facility's Quality Assessment and Performance Improvement (QAPI) plan and program, in which data was to be gathered and analyzed, and plans of action were to be developed, implemented, and evaluated to address adverse events related to potential deficient practice for 1 of 1 QAPI programs reviewed.The facility failed to conduct at least one performance improvement project (PIP) annually that focused on high risk or problem prone areas identified by the facility, through data collection and analysis.This failure could place residents of the facility at risk of the facility not developing, monitoring and implementing corrective actions for identified areas of improvement.Findings included: Record review of the Nursing Facility's QAPI plan, the Nursing Facility's meeting template documents for 02/2026, 03/2026, and 04/2026, revealed the areas documented: Goal, Interventions, and Progress, were blank. The PIP (Performance Improvement Plan) for the mentioned 3 months had the same handwritten notes that read, past…

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 report an injury of unknown source, immediately, but not later than 2 hours after the allegation was made, to other officials in accordance with State law, including to the State Survey Agency for 2 of 5 residents reviewed for falls. (Residents #7, #44)The facility investigated but failed to report to the State Survey Agency when Resident #7 had an unwitnessed fall on 05/02/2026 that resulted in a laceration on the left side of the resident's forehead, and left wrist.The facility failed to report to the State Survey Agency when Resident #44 sustained an unwitnessed bruise to right eye and a laceration to forehead and was unable to state how the injury occurred on 05/09/2026.The facility failed to report when a pipe burst, and the sprinkler system malfunctioned on 01/27/2026. These failures could place residents who require assistance with mobility at risk for non-reported serious bodily injury. Resident #44 Record review of Resident # 44'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 show evidence that all alleged violations were thoroughly investigated and failed to report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident for 2 of 5 residents (Resident #7 and #44) reviewed for injuries of unknown origin.The facility investigated but failed to report to the State Survey Agency when Resident #7 had an unwitnessed fall on 05/02/2026 that resulted in a laceration on the left side of the resident's forehead, and left wrist. The facility failed to investigate an injury of unknown origin for Resident #44 resulting in bruising around the right eye and a laceration above the right eyebrow on 05/09/2026. These failures could place residents in the facility with dementia at risk of not receiving timely investigations and reporting of injuries of unknown origin. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, 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 for 1 of 7 (Resident #4) residents reviewed for base line care plans.The facility failed to develop Resident #4's baseline care plan within 48 hours of admission.This failure placed newly admitted residents at risk of not receiving continuity of care and communication among nursing home staff, increase resident safety and safeguard against adverse events that are most likely to occur right after admission.Finding included:Record review of Resident #4's face sheet dated 05/13/2026, revealed the resident was a [AGE] year-old male with an admission date 04/24/2026.Record review of Resident #4's Physician progress note dated 05/04/2026 revealed a past medical history of the following: Wound to the right fingers, Peripheral Vascular…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that a resident who was unable to carry out activities of daily living, received the necessary services to maintain good grooming, and personal hygiene, for 1 Resident of 7 residents (Resident #4) reviewed for activities of daily living.The facility failed to provide Resident #4 with nail care on 05/12/2026.This failure could place residents at risk for embarrassment, injury, and infections.The findings included:Record review of Resident #4's face sheet dated 05/13/2026, revealed the resident was a [AGE] year-old male with an admission date 04/24/2026.Record review of Resident #4's Physician progress note dated 05/04/2026 revealed a past medical history of the following: Peripheral Vascular Disease (a condition that develops when the arteries that supply oxygen-rich blood to the internal organs, arms, and legs become completely or partially blocked).Record review of Resident #4's Comprehensive MDS dated [DATE], revealed Resident #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 observation, interview, and record review, the facility failed to ensure residents received proper treatment and care to maintain good foot health for 2 resident 12 residents (Resident #7 and Resident #49) reviewed for foot care.The facility staff CNAs and licensed nurses failed to provide foot care for Resident #7 and Resident # 49 on 05/12/2026This failure could affect residents by placing them at risk for poor foot health, decreased personal hygiene, and a decline in their quality of life.Findings included:Resident #7Record review of Resident #7's face sheet revealed resident was [AGE] year-old male with initial admission date 11/21/24 and re-admission date 10/10/25.Record review of Resident #7's Quarterly MDS dated [DATE], revealed a BIMS of 0, indicating Resident #7 was severely cognitively impaired. Under Section GG- Functional Abilities, it was noted Resident #7 was completely dependent with his personal hygiene, meaning the helper does all the effort to complete the task while the resident does…

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 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 1 of 2 shower rooms reviewed for infection control. -The facility failed to ensure plastic urinal that was hanging in the community shower room/ bathroom in the 300 hall was not full of urine. This failure could place residents at risk for cross contamination and the spread of infection.Finding included: In an observation on 5/12/2026 at 10:27AM of community bathroom in the 300 hallway revealed a plastic urinal hanging from the grab bar next to the toilet, it contained yellow tinged urine. In an interview on 5/13/2026 at 10:17 AM with CNA A, she stated that urinals were emptied and rinsed out after each use and should not be left in the shower room. She stated that that it was the responsibility of the CNAs to ensure this was being done. She stated that the risk would be that residents might use 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 interview, and record review, the facility failed to provide training to their staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property; and procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property, for 1 of 8 staff (DON) reviewed for abuse, neglect exploitation training. The facility failed to ensure the DON had completed their mandatory abuse annual training.This failure could place residents at risk of being cared for by untrained staff.findings included:Record review of the DONs Personnel file revealed the DON did not have current Abuse trainings completed.Record review of Personnel documents on 05/14/2026 at 11:00 AM with Human Resources revealed the DON's hire date 11/23/2009.In an interview with Human Resources on 05/14/2026 at 11:00 AM, she stated Nursing Management was responsible for making sure nursing staff was up to date with their trainings.In an interview on 05/14/2026 at 5:40 PM with the DON, she stated all staff were responsible for their own…

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 provide the mandatory training on standards, policies, and procedures for an infection prevention and control program for 1 of 8 staff (the DON) reviewed for training, in that:The facility failed to ensure infection prevention and control training was provided to the DON.This failure could place residents at risk of illness due to lack of staff training. Findings included:In an interview and Record review of Personnel files with Human Resources on 05/14/2026 at 11:00 AM, it was revealed the DON did not have current Enhanced Barrier training completed. She stated Nursing Management was responsible for making sure nursing staff was up to date with their trainings.In an interview on 05/14/2026 at 5:40 PM with the DON, she stated all staff were responsible for their own trainings. The DON stated all staff were aware of the importance of being kept up to date with trainings. She stated she was responsible as the DON for nursing staff and self. The DON stated the potential risk of the Nursing Facility staff not having their…

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 were provided with reasonable accommodation of needs and preferences, including ensuring the call light was within reach to request assistance, for one (Resident #1) of four residents reviewed for resident rights.The facility failed to ensure Resident# 1 had the call light within reach.This failure placed Resident #1 at risk for unmet needs, delayed assistance, increased fall risk, and potential injury.Findings included:Record review of Resident #1's admission record dated 01/06/2026 revealed an [AGE] year-old male admitted [DATE].Record review of Resident #1's History and Physical dated 02/27/2025 revealed an [AGE] year-old male diagnosed with severe cognitive impairment (serious problems with memory and thinking), metabolic encephalopathy (brain dysfunction caused by illness or chemical imbalance), subclinical hypothyroidism (mild underactive thyroid), hypertension (high blood pressure), hyperlipidemia (high…

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 1 of 1 water dispenser reviewed for physical environment. The facility failed to ensure:A. The water dispenser that was used for the residents was clean and not soiled. B. The floors in the area where the water dispenser was housed were free of dirt.C. The floor tiles in the area where the water dispenser was housed were free of cracks. This failure could affect the residents by placing them at risk for diminished quality of life due to the lack of a well-kept environment. Findings included: In an observation on 12/9/25 at 11:18 am, revealed a locked closet area off of the dining room with a water dispenser that was used for the residents. The water dispenser was soiled with dirt and dust on the top and sides of the unit. The interior portion of the water dispenser was soiled with dust and white spots. The base had standing water. There was a cup 1/2 filled with water sitting on top of the dispenser. The floors had dirt covering them 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.

Based on observations, interviews, 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 food was stored in a manner that was not open to the air. 3. The facility failed to remove potatoes in the dry storage when they were beginning to show signs of rot. 4. The facility failed to ensure expired food items were discarded by the expiration date. 5. The facility failed to maintain cleanliness in the kitchen. The dry storage had food particles on the floor, drawers had crumbs and a gritty substance in the bottom, the refrigerator had dried sticky substances on the bottom shelf, the floor in the dishwashing area had trash and debris in a corner and the juice spout had a sticky, reddish-brown substance build up on it. These failures could place residents who received prepared meals from the kitchen at risk for food borne illness 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.

Based on observations, interviews, and record review the facility failed to maintain all mechanical and electrical quipment in safe operating condition for 1 of 1 kitchen reviewed for kitchen sanitation. The spray nozzle above the rinsing sink in the dishwashing room leaked, and the oven did not work. These failures could place residents who received prepared meals from the kitchen at risk for food borne illness or undercooked food. The findings included: During the initial tour of the kitchen on 3/25/25 from 10:00 am to 11:00 am in the dishwashing room, the spray nozzle above the rinsing sink had a steady flow of water coming out and flowing into the sink while in the off position. In an interview on 03/25/25 at 11:00 a.m., the Chef stated the oven is not working and the spray nozzle in the dishwashing room has leaked for several months. The Chef stated the ADM is aware of both. In an interview on 3/27/25 at 6:12 p.m., the ADM stated the request for the oven to be repaired was approved, now waiting for the service company. The ADM said the spray nozzle in the dishwashing area had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were free from abuse for 1 of 6 residents (Resident #8) reviewed for abuse, neglect, and exploitation. The facility failed to ensure Resident #8 was free of abuse on 03/20/25 when Resident #8 was hit on the arm and shoulder by CNA C. This failure was determined to be Past Non-Compliance (PNC). The non-compliance began on 03/20/25 and ended on 03/21/25. The noncompliance was corrected by the facility before the survey began on 03/25/25. This failure could place residents at risk of physical harm, mental anguish, or emotional distress. The findings included: Review of Resident #8's face sheet revealed he was a [AGE] year-old male originally admitted to the facility on [DATE] with a most recent admission date of 01/06/2025. He had diagnoses which included moderate dementia with behavioral disturbances, schizoaffective disorder, severe manic bipolar disorder with psychotic features, generalized anxiety disorder, intermittent explosive,…

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 receive medication or feeding through a gastrostomy tube receive the appropriate treatment to prevent complications for 1 of 1 resident (Resident 44) reviewed for percutaneous endoscopic gastrostomy (PEG) feeding tube ( A PEG is a tube that is inserted through the abdominal wall and into the stomach and used to administer nutrition). The facility failed to ensure CNA A did not lower the head of Resident #44's bed flat while the PEG tube feeding pump was still infusing the formula, during personal care. This failure could place residents of aspiration. The findings: Record review of Resident #44's electronic face sheet dated 03/27/2025 indicated he was admitted to the facility on [DATE] with diagnoses of stroke, muscle weakness and dysphagia (difficulty swallowing). He was [AGE] years of age. Record review of Resident #44's care plan revised 03/26/25 indicated in part: Problem: Dependent on tube feeding for nutrition…

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 record review and interviews, the facility failed to use the services of a registered nurse (RN), for at least 8 consecutive hours a day, 7 days a week for 1 of 3 months (October 2024, November 2024, December 2024) reviewed for RN coverage. The facility failed to ensure RN coverage on 10/12/2024 and 10/26/2024. This failure placed the residents at risk for not having decisions made that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring of the direct care staff. Findings include: Record review on 03/26/25 at 4:05 pm of the Payroll Based Journal report (nurse staffing and non-nurse staffing datasets provide information submitted by nursing homes including rehabilitation services on a quarterly basis), run date of 3/21/25, for Fiscal Year 2025 Quarter 1 (October 1, 2024, through December 31, 2024) revealed no evidence of RN coverage on 10/12/24, 10/26/24, 11/9/24, and 12/21/24. Review of nurse staffing schedules for October 2024, November 2024, and December 2024 on 03/26/25 at 4:45 pm revealed no RN coverage…

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 one (Resident #44) of two residents reviewed for incontinent care in that; CNA A failed to wash or sanitize her hands between glove changes while assisting Resident #44. This failure could place resident's risk for cross contamination and the spread of infection. Finding included: Record review of Resident #44's electronic face sheet dated 03/27/2025 indicated he was admitted to the facility on [DATE] with diagnoses of stroke, muscle weakness and dysphagia (difficulty swallowing). He was [AGE] years of age. Record review of Resident #44's care plan revised 03/26/25 indicated in part: Problem: Resident is incontinent of bladder and bowel resident cognition is: unable to recall daily forgetfulness. GOAL: resident will be maintained…

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 adequate supervision and assistance devices was provided for 1 of 3 residents reviewed for transfers (Resident #1). The facility failed to assess Resident #1 for safe transfer practices as she was non-weight bearing. This deficient practice has the potential to affect residents in the building who required extensive assistance which could result in residents having pain, falls or injuries. The findings included: Review of Resident #1's Resident Face Sheet, dated 10/24/24, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included heart failure, arthritis, dementia, muscle weakness, and limitation of activities due to disability. Review of Resident #1's Quarterly MDS Assessment, dated 8/12/24, revealed: She had a mental status score of 9 of 15 (indicating moderate cognitive impairment) She was dependent on staff for transfers from bed to chair. Review of current MDS did not indicate how…

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 the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed in that: 1.The facility failed to label and date food items. 2.The facility failed to discard expired food items. These deficient practices could place residents who received prepared meals from the kitchen at risk for food borne illness and cross-contamination. Findings include: Observation on 02/20/2024 at 11:30 AM of the refrigerator revealed: Red gelatin dated 2/11/24, shelf life 3 days. Peanut butter and jelly mixture dated 2/16/24, shelf life 3 days. 5 pounds of ground beef in plastic zip lock bag, unlabeled, undated, no use by date. 20 corn tortillas in asealed bag unlabeled, undated no use-by date. 20 flour tortillas in a sealed bag unlabeled, undated, no use-by date. Observation on 02/20/2024 at 11:45 AM of dry pantry revealed: 10 oz sprinkles unlabeled undated, no use-by date. 16 fluid oz bottle of red food coloring expired 10/02/2020. 1 gallon of Karo Syrup expired 02/12/2022. 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 interviews and record reviews the facility failed to ensure the resident's had the right to be informed of the risks, and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 2 of 14 residents (Resident #21, Resident # 35) reviewed for resident rights . The facility failed to obtain informed consent based on information of the benefits, risks, and options available from Resident #21 prior to administering Zoloft, an antidepressant used to treat depression. The facility failed to obtain informed consent based on information of the benefits, risks, and options available from Resident #35 prior to administering Paxil, an antidepressant used to treat depression. The facility also failed to obtain informed consent based on information of the benefits,…

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 record review and interview the facility failed to provide the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week, for 14 of 92 days in July 2023 - September 2023 The facility had no Registered Nurse coverage on dates 07/15/2023, 07/16/2023, 07/22/2023,07/29/2023, 08/12/2023, 08/19/2023, 08/20/2023, 08/26/2023, 08/27/2023, 09/03/2023, 09/16/2023, 09/17/2023, 09/24/2023, 09/30/2023. This failure could affect all residents and put them at risk of their care not being overseen properly. The findings were: Record Review of the facility's time sheets from July 01, 2023- September 30, 2023 - on 02/22/2024 at 01:00 PM revealed there was no Registered Nurse coverage on 07/15/2023, 07/16/2023, 07/22/2023,07/29/2023, 08/12/2023, 08/19/2023, 08/20/2023, 08/26/2023, 08/27/2023, 09/03/2023, 09/16/2023, 09/17/2023, 09/24/2023, 09/30/2023. During an interview on 02/22/2024 at 01:21 PM with the Director of Nurses confirmed there was no RN coverage for the date listed above. The DON stated the facility has been trying to hire new RNs by having competitive…

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 medication rooms had an expired Tuberculin (TB) vial medication in the refrigerator. 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 and interview on 02/20/24 at 03:12 PM the medication room was inspected with LVN C present. There was a small refrigerator that contained several medications to include an open box that contained a 5ml vial that contained Tuberculin. The date on the box indicated it was opened on 12/22/23. The box indicated Discard opened product after 30 days. LVN C said she was an agency nurse and was not sure who was responsible for making sure expired medications were removed from the medication room. LVN C said she had not noticed the TB medication had expired. During 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 observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 4 medication carts ( Hall 100 nurse medication cart) reviewed for medication storage and failed to ensure all controlled drugs and biologicals were stored in separately locked and permanently affixed compartments for 1 of 1 medication storage compartments reviewed for labeling/storage of drugs and biologicals. The facility failed to ensure the hall 100 nurse medication cart did not contain expired insulin pens and had open dates after they were put into use. The facility failed to ensure stored discontinued controlled medications and biologicals were separately locked and in a permanently affixed compartment kept in the DON's office. This failure failures could place residents at risk of not receiving the therapeutic benefit of medications or adverse reactions to medications…

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 2 residents (Resident #43) reviewed for infection control. CNA A failed to wash hands or use hand sanitizer between glove changes during incontinent care while assisting Resident #43. This failure could place residents at risk for cross contamination and the spread of infection. Finding include: Record review of Record review of Resident #43's face sheet revealed admission date of 09/07/23 with diagnoses of hemiplegia of right side (one-sided paralysis), Type 2 Diabetes Mellitus (condition where pancreas does not produce enough insulin), cerebrovascular disease (blood flow to brain is affected), He was [AGE] years of age. Record review of Resident #43's MDS dated [DATE] indicated in part: BIMS 09 -moderately impaired.…

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 an infection prevention and control program designed to help prevent the development and transmission of communicable diseases for 2 of 15 (Resident #1 and Resident #2) residents reviewed for infection control. Three facility staff (MT, HA A, and HSKG) failed to follow the facility's infection prevention protocol for COVID-19 by failing to wear appropriate PPE. MT entered the hot zone with N95 mask and no other PPE. HA A did not wear appropriate PPE for the warm unit. HSKG did not wear appropriate PPE going into hot zone and shower room. Shower room was not sanitized after Resident #1, who was on isolation for exposure to COVID-19. This failure has the potential to affect residents by placing them at an increased and unnecessary risk of exposure to communicable diseases and infections, particularly COVID-19. Findings include: Record review of Resident #1's face sheet, dated 1/26/24, revealed a female resident with an admission date of 12/10/20 and diagnosis that included dementia, anxiety, and type 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.

Based on interview, and record review the facility failed to consult with the physician when the resident experienced a change in condition for 1 of 2 residents (Residents #3) reviewed for a notification of a change of condition, in that: Resident #3 was known to be covid-19 negative but roomed with Resident #4 who was known to be covid-19 positive. Facility failed to report to Physician that his patient Resident #3 was being roomed with a covid positive Resident #4. This deficient practice could place residents at risks of not having the physician contacted when they have a change of condition, and it could result in delay of medical treatment and hospitalization. Findings included: Record review of Resident #3's face sheet, dated 1/26/24, revealed a male resident with an admission date of 3/17/23 and diagnosis that included type 2 diabetes mellitus, muscle wasting, muscle weakness, and repeated falls. Record Review of the facility's covid-19 testing log dated 1/25/24 indicated Resident #3 was tested for covid on 1/21/24, 1/24/24, and 1/25/24 which all resulted as negative. 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.