Avir at San Antonio

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to promptly notify the ordering physician of laboratory results that fell outside of clinical reference ranges for 1 (Resident #91) of 16 residents whose medical records were reviewed for lab work. Facility staff failed to identify, respond, and act upon Resident #91's critical lab, glucose (blood sugar) level of 40 received on 8/14/25. This deficient practice could affect any resident and could contribute to the decline of the resident's health statuses. The findings were:Record review of Resident #91's face sheet, dated 8/28/25, revealed he was admitted to the facility on [DATE] with diagnoses including Type 2 diabetes mellitus (the body cannot use insulin correctly and sugar builds up in the blood) without complications and Major depressive disorder, recurrent, mild ( pervasive low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities). Record review of Resident #91's admission MDS assessment, dated…

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

Based on observation and interview the facility failed to dispose of garbage and refuse properly for 1 of 1 dumpster reviewed for disposal of garbage. The facility's dumpster presented with 1 30-gallon bag of trash besides the garbage dumpster and scattered garbage surrounding the dumpster area. This failure could place residents at risk for reduced health status and degraded morale. The findings included: During an observation on 8/28/2025 at 10:13 AM revealed the facility's dumpster concrete pad had a large steel dumpster with the sliding doors opened. Further observation revealed a 30-gallon plastic bag filled with garbage on the concrete besides the dumpster. Further review revealed scattered trash surrounding the dumpster. During an interview on 8/28/2025 at 10:22 AM the HK manager stated the dumpster was utilized by the dietary staff, nursing staff, and the housekeeping staff. The HK manager stated the expectation for the staff was for all trash to be placed in the dumpster and for the dumpster doors to be closed when not in use. The HK manager stated the surrounding area…

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 immediately consult with the resident's physician when there was a significant change in the resident's physical status (that is, a deterioration in health status, (status in either life-threatening conditions or clinical complications) for 1 of 6 Residents (Resident #91) whose records were reviewed. LVN W failed to notify Resident #91's physician on 8/14/25 when he received a critical lab reflecting Resident #91's blood sugar was 40. This deficient practice could place residents at risk for a delay in treatment and a decline in the resident's physical condition. The findings were:Review of Resident #91's face sheet, dated 8/28/25, revealed he was admitted to the facility on [DATE] with diagnoses including Type 2 diabetes mellitus (the body cannot use insulin correctly and sugar builds up in the blood) without complications and Major depressive disorder, recurrent, mild (pervasive low mood, low self-esteem, and loss of interest or pleasure in normally…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 6 Residents (Resident #76) whose MDS records were reviewed.MDS Coordinator/LVN T failed to include in Resident #76's MDS assessment that she had lost weight in the last 6 months. This deficient practice could place residents at risk of not receiving the care and services as needed.The findings were:Record review of Resident #76's face sheet, dated 8/30/25, revealed she was admitted to the facility on [DATE] with diagnoses including muscle weakness (generalized), unsteadiness on feet and other lack of coordination. Record review of Resident #76's quarterly MDS, dated [DATE], revealed her BIMS score was 12 of 15 reflective of moderate cognitive impairment and she was dependent on staff for all ADL's. Further review revealed it did not reflect she had lost weight during July 2025. Record review of Resident #76's Care Plan, dated 7/16/25, revealed she had a significant…

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 within 48 hours of a resident's admission and failed to include the minimum healthcare information necessary to properly care for a resident including, but not limited to, initial goals based on admission and physician orders for 1 of 6 residents (Resident #104), reviewed for comprehensive resident centered care plans. Resident #104's baseline care plan dated 8/23/25 did not include her diagnoses, contact isolation for MRSA (Methicillin-resistant Staphylococcus Aureus bacteria) to her wound, and did not have interventions and goals for 5 of 5 days during the survey period. This failure could place residents at risk of not receiving their individualized needed care and services.The findings were: Record review of the facility…

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 a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 6 Residents (Resident #76 and Resident #91) reviewed for care plans . The facility failed to include in Resident #76's comprehensive care plan that she had a self-performance deficit, and she was dependent on staff for all activities of daily living.The facility failed to include in Resident #91's comprehensive care plan that he had diabetes mellitus and received insulin on a regular basis. This deficient practice could place residents at risk of not receiving the care and services as needed. The findings were: 1. Record review of Resident #76's face sheet, dated 8/30/25, revealed she was admitted to the facility on [DATE] with diagnoses including muscle…

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 ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 6 Residents (Resident #54) whose records were reviewed. Nursing staff failed to apply a splint on Resident #54's right arm/wrist as tolerated for a right-hand contracture for 5 days, during the survey process. This deficient practice could affect residents with range of motion deficits and could contribute and result in a resident's decrease in their range of motion. The findings were: Review of Resident #54's face sheet, dated 8/30/25, revealed she was admitted to the facility on [DATE] with diagnoses including Vascular dementia (describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain), moderate, withoutbehavioral disturbance, psychotic disturbance, mood disturbance,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews the facility failed to ensure food was stored, prepared, distributed and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for expired foods. The facility stored 13, 46 ounce, containers of thickened orange juice which were expired by 17 days. This deficient practice could place residents at risk for food borne illnesses. The findings included:During an observation on 8/26/2025 at 9:15 AM revealed the facility's kitchen pantry stored 13 46 oz. containers of thickened orange with manufactures labeling which included, best if used by [DATE]. During an interview on 8/26/2025 at 9:18 AM [NAME] G stated the thickened orange juice was stored in the pantry and was available for residents. The cook stated all staff were responsible for reviewing foods for expiration dates. The cook reviewed the thickened orange juice and stated the juice was expired and should not be stored and available for service. During an interview 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 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 4 residents (Resident #30), reviewed for infection control, in that: Resident #30 was provided high contact care and transferred from her bed to her wheelchair without the use of the appropriate EBP (Enhanced Barrier Precautions) on 8/27/25. This failure could place residents at risk of cross contamination. The findings were: Record review of Resident #30's face sheet dated 8/27/25 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with readmission on [DATE]. Resident #30's diagnoses included Sacral spina bifida with hydrocephalus (a neural tube defect where the spinal column doesn't close completely, and buildup of excess cerebrospinal fluid in the brain), colostomy status (surgical…

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 record reviews and interviews, the facility failed to ensure all necessary information, including a resident's discharge summary or a 30-day written discharge notice was completed to ensure a safe and effective transition of care for 1 (Resident #1) of 4 residents reviewed for safe transfer or discharge. 1. The facility failed to provide a notification of transfer notice in written form and in a manner that Resident #1 and Resident #1's RP/POA could understand prior to Resident discharge on [DATE]. 2. The facility failed to record the reasons for the transfer in Resident #1's medical record when discharged on 05/16/2025. 3. The facility failed to provide a 30-day written notice of transfer to Resident #1 and to the facility's ombudsman prior to Resident #1's discharged from the facility on 05/16/2025. This failure could result in residents experiencing psychosocial harm (feelings of anger and sadness) due to inappropriate discharges and placed residents at risk of being discharged without alternate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 4 of 4 residents (Resident #2, Resident #3, Resident #4, Resident #5) reviewed for accurate assessments: Resident #2's BIMS & PHQ assessment dated [DATE] were completed during the time when resident was hospitalized , and resident interview was not completed. Resident #3's BIMS & PHQ assessments dated 10/15/2024 were completed during the time when resident was hospitalized , and resident interview was not completed. Resident #4's BIMS & PHQ assessments dated 03/03/2025 were completed during the time when resident was hospitalized , and resident interview was not completed. Resident #5's BIMS & PHQ assessments dated 03/31/2025 were completed during the time when resident was hospitalized , and resident interview was not completed. This failure could place residents at risk for inaccurate assessments due to completing assessments without resident interview. The findings included: 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 on observation, interview, and record review, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 7 (Residents #6-12) of 9 residents reviewed for infection control. 1. The facility failed to implement the required elements for transmission based precautions, including signage and readily available PPE, for Residents #6-11. 2. The facility failed to don appropriate PPE while performing an invasive procedure on Resident #12. These failures could cause the spread of infection and illness. Findings included: Record review of Resident #6's face sheet reflected a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included dementia (a progress disorder that impairs the thought processes, such as memory, thinking, reasoning, and decision-making); colostomy (a surgically created opening in the abdomen for output of stool) status; viral hepatitis C (a viral infection causing liver…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (100/200 hall crash cart) out of 2 crash carts and 1 (Resident #18) out of 5 residents reviewed for medical records. 1. Facility night nurses did not initial on the crash cart supply verification sheet after checking supplies inside the 100/200 hall crash cart on 04/08/2025, 04/09/2025, 04/10/2025, 04/16/2025, 04/17/2025, and 04/18/2025. 2. Facility medication aide-C did not document exact times when she administered Resident #18's medications on the resident's medication administration record. This failure placed residents at risk for missed treatment and medications which could result in decline in heal and well-being. Findings included: 1. Observation on 05/06/2025 at 4:00 p.m. revealed there were two crash carts located at the 100/200 hall nursing station and 300/400 hall nursing station, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to provide treatment and care in accordance with the comprehensive person-centered care plan and in accordance with professional standards of practice for 2 of 4 residents (Resident #3 and Resident #4) reviewed for quality of care. 1. The facility failed to ensure Resident #3 received wound care on 3/18/2025 and 3/19/2025 when the Treatment Nurse failed to re-approach or assess the reason for a refusal to complete wound care throughout the shift and failed to pass along to the next shift when a dressing change was refused on 3/18/2025. In addition, the Treatment Nurse failed to attempt wound care the following day which resulted in missed wound care on 3/18/2025 and 3/19/2025. 2. The facility failed to ensure Resident #4 received wound care on 3/18/2025 when the Treatment Nurse failed to attempt wound care multiple times and failed to pass along to the next shift when Resident #4 missed wound care on 3/18/2025. These deficient practices…

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 comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 8 residents (Resident #50, Resident #74 and Resident #138) reviewed for comprehensive care plans in that: 1. The facility failed to ensure Resident #50 had an order for bed rails and was care planned for the rails on her bed. 2. The facility failed to ensure Resident #74 care plan reflected he had a catheter. 3. The facility failed to ensure Resident #138 care plan reflected he had a catheter. This deficient practice could place residents at risk of not being provided with the necessary care or services and having personalized plans developed to address their specific needs. The findings included: 1. Record Review of Resident #50's admission record, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to ensure correct installation, use, and maintenance of bed rails for 3 residents of 8 residents (Resident #16, Resident #50, and Resident #138) reviewed for use of side or bed rails in that: The facility did not ensure Resident #16, #50, and #138 were assessed for risk of entrapment from bed rails before they were installed and did not have a signed informed consent from his responsible party for the bed rails. This failure could affect residents who use bed or side rails as enablers and could result in entrapment. The findings included: 1. Record Review of Resident #16's admission record, dated 7/25/24, revealed a [AGE] year-old female initially admitted [DATE] and with diagnoses including myocardial infarction, dislocation of internal left hip prosthesis, major depressive disorder recurrent severe without psychotic features, seizures, and need for assistance with personal care. Record Review of Resident #16's quarterly MDS assessment,…

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 its medication error rates were not 5% or greater. The facility had a medication error rate of 62.96%, based on 17 errors out of 27 opportunities which involved 3 of 8 residents (Resident #16, Resident #63 and Resident #79) reviewed for medication administration and medication errors. 1. The facility failed to ensure Resident #16 received her medications on time. 2. The facility failed to ensure Resident #63 received her medications on time and received her bumetanide (used to reduce extra fluid in the body (edema) caused by conditions such as heart failure, liver disease, and kidney disease) as ordered. 3. The facility failed to ensure Resident #79 received his medications on time. These deficient practices could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. The findings included: 1. Record Review of Resident #16's admission record, dated 7/25/24, revealed a [AGE]…

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 one of one laundry room reviewed for environment. The facility failed to properly dispose and maintain the lint accumulation in the facility dryers in a timely manner. This failure could put residents at risk for an unsafe and unsanitary environment. Findings included: Observation on 7/25/24 at 10:50 AM of facility's laundry room revealed there were three (3) dryers that were in use at that time. Observation of the lint collector area beneath two (2) dryers revealed a layer of thick lint about 1 inch thick accumulated on the top of lint trap and some lint at the bottom of the dryers. Interview on 7/25/24 at 11:50 AM with the laundry aide stated there was no laundry log for tracking cleaning the laundry lint traps. The [NAME] aide stated she last cleaned the lint traps at 6:00 a.m. that morning. The Laundry aide stated she is supposed to clean them after every two loads,…

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 record review and interview, the facility failed to complete an assessment which accurately reflected the resident's status for 2 of 8 residents (Residents #52 and #138) reviewed for assessments. 1. The facility failed to indicate Resident #138 had an indwelling catheter on their MDS. 2. The facility failed to indicate Resident #52 was receiving Dialysis and oxygen services on her MDS. These failures could result in inadequate care due to an incomplete assessment of the residents' physical status. The findings included: 1. Record review of Resident #138's face sheet dated 7/23/2024, revealed the resident was a [AGE] year old male admitted to the facility on [DATE] with diagnoses that included, pressure ulcer of sacral region stage 4, unspecified hydronephrosis, acute kidney injury, and acute cystitis with hematuria. Record review of Resident #138's care plan, revised 07/16/2024, revealed the resident was at risk for impaired skin integrity related to bowel incontinence with interventions to check 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 coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort for 2 of 8 residents reviewed for PASRR (Resident #8 and Resident #35). 1. The facility failed to ensure Resident #8 had an accurate PASRR Level 1 Screening indicating diagnoses of mental illness and refer the residents to the state local authority for an evaluation. 2. The facility failed to ensure Resident #35 had an accurate PASRR Level 1 Screening indicating diagnoses of mental illness and refer the resident to the state local authority for an evaluation. This failure could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs. Findings included: 1. Record Review of Resident #8's admission record, dated 7/23/24, revealed a [AGE] year-old female initially…

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 review and revise Resident Care Plans after each assessment for 2 of 8 Residents (Resident #68 and Resident #71) whose records were reviewed. 1. Resident #68's Care Plan was not updated after his significant change MDS reflected he was dependent on staff for ADL care. 2. Resident #71's Care Plan was not updated after he experienced a change of condition and developed a venous ulcer to his left shin. These deficient practice could affect any resident and contribute to Residents not receiving the care and services they needed. The findings were: 1. Review of Resident #68's face sheet, dated 7/25/24, revealed he was admitted to the facility on [DATE] with diagnoses including Cerebral infarction (Stroke), unspecified and Local infection of the skin and subcutaneous tissue, unspecified, Review of Resident #68's significant change MDS assessment, dated 5/14/24, revealed Resident #68 was dependent on staff for all ADL care. Review of 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 ensure each resident received assistance devices to prevent accidents for 1 of 8 Residents (Resident #69) whose records were reviewed for falls. CNA E and CNA F failed to use a gait belt properly by applying a gait belt over Resident #69's breast instead of around her waistline during a bed to wheelchair transfer. LVN G failed to use a gait belt while transferring Resident #69 from the wheelchair to the bed. These deficient practices could affect any residents who required assistance with transfers and could contribute to an avoidable fall/injury. The findings were: Review of Resident 69's face sheet, dated 7/25/24 revealed she was admitted to the facility on [DATE] with diagnoses including Vascular Dementia with other behavior disturbance, Chronic Kidney Disease, and Congestive Heart Failure. Review of Resident #69's quarterly MDS, dated [DATE] revealed Resident #69 was unable to complete the BIMS assessment; was dependent on staff for sit…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 2 resident (Resident #74's and #138) reviewed for indwelling urinary catheter. 1. The facility failed to ensure Resident #74's catheter was off the floor and protect from potential contaminants on the floor and from staff stepping on the catheter bag and tubing. 2. The facility failed to ensure Resident #138 had physician orders to care for his catheter and daily care was performed and documented. This deficient practice could place residents with in dwelling urinary catheters at-risk for urinary tract infections and/or pain. The findings were: 1. Record Review of Resident #74's admission record, dated 7/26/24, revealed a [AGE] year-old male initially admitted [DATE] and readmitted on [DATE] with diagnoses including metabolic encephalopathy, pressure ulcer…

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 DM's personnel file revealed the hire date for the DM was 10/02/23. 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 from a national certifying…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 2 of 6 residents (Resident #2 and Resident #138) reviewed for hospice services, in that: 1. The facility failed to ensure Resident #2's most recent Physician Certification of Terminal Illness and Hospice election form were completed and part of the hospice documents. 2. The facility failed to ensure Resident #138's Physician Certification of Terminal Illness was completed, the most recent plan of care was available at the facility, and hospice physician orders were available and at the facility. This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to 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 maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of infections for 2 of 8 residents care (Resident #74 and Resident #81) reviewed for infection control, in that: 1. The facility failed to ensure Resident #74's fall mat was clean. 2. The facility failed to ensure LVN E performed hand hygiene between glove changes while administering Resident #81's bolus tube feeding. These deficient practices could place residents at-risk for infections. The findings included: 1. Record Review of Resident #74's admission record, dated 7/26/24, revealed a [AGE] year-old male initially admitted [DATE] and readmitted on [DATE] with diagnoses including metabolic encephalopathy, pressure ulcer of the sacral region, urinary tract infection, need for assistance with personal care, and hemiplegia and hemiparesis following cerebral infarction…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 2 nutrition rooms (South Hall nutrition room) reviewed for kitchen sanitation in that: The facility failed to remove expired food from the South Hall nutrition room. This failure could place residents at risk for cross-contamination and foodborne illnesses. The findings included: Observation on 5/31/23 at 3:22 PM revealed 1 jar of peanut butter dated EXP 08/17/21, 1 box of snack chips dated SELL BY [DATE], 3 sodas dated [DATE], an additional 2 bags of potato chips each dated 1 [DATE], a bag of cookies dated [DATE], and an additional food container dated [DATE] within the cabinets of the nourishment room by the nurse's station in the south hall. Interview on 5/31/23 at 3:29 PM, the DON stated the responsibility of the nourishment rooms was shared between nursing and dietary where the refrigerators, daily snacks being…

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.