Avir at San Knoll

Based on observation, interview, and record review, the facility failed to provide an environment that maintained or enhanced each resident's respect and dignity for 5 of 19 residents observed in dining room. The facility failed to provide a dignified and respectful dining experience for each resident in the dining room by allowing residents to watch their tablemates eat or be fed, and/or have their meals placed in front of them but they were not able to feed themselves due to physical or mental handicaps for extended periods of time. This failure could place residents at risk of embarrassment, low self-esteem, anxiety, or potential weight loss.The findings include:During an observation on 04/22/2026 at 12:10 pm, the surveyor observed a plate of food in front of an unknown resident in dining room. The resident appeared to need assistance to eat. The food was uncovered in front of resident until 12:22 pm when a staff member sat down next to resident to feed them. CNA D confirmed resident needed feeding assistance.During an observation on 04/22/2026 at 12:17 pm, the surveyor observed…

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 staff had successfully completed a State-approved training course for feeding assistance before feeding resident who required staff to feed them for 3 of 7 unknown residents in the dining room over 3-day period of observations.The facility did not ensure that the Administrator and the Medical Records clerk completed a state approved training course for feeding assistance before assisting residents to eat.This failure could place residents who require assistance with eating at risk of aspiration and choking.Findings include:During an observation on 04/22/2026 at 12:10pm, the surveyor observed the MR clerk assisting an unknown resident to eat. Unknown resident appeared to have bilateral upper extremities weakness and contractures. CNA D confirmed unknown resident needed feeding assistance.During an observation on 04/22/2026 at 12:10 pm, the surveyor observed the ADMIN assisting an unknown resident to eat. Unknown resident was sitting upright in specialized chair. Unknown resident did not make any effort…

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

Based on observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible, and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 7 (hall 100 exit door) exit doors reviewed for accident hazards and supervision. The facility failed the ensure the exit door alarm on hall 100 was not turned off where 14 of 47 residents resided. This failure could place residents who are exit seeking at risk for elopement and possible injuries. The findings included: Record review of Resident List Report, dated 03/07/2026, revealed the facility had 14 residents located on 100 hall and a total of 47 residents. During an observation on 03/07/2026 from 11:55 a.m. to 12:49 p.m. hall 100 was observed to have two staff members working in the hallway and four (4) resident room doors open with two (2) residents in beds and two (2) residents in their wheelchairs. The residents observed were not self-ambulating (walking on their own) or moving their wheelchairs on their own. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 residents (Resident #1) and 1 of 1 staff (LPN A) reviewed for infection control. The facility failed to ensure LPN A wore appropriate PPE for EBP during wound care for Resident #1 on 03/07/2026. This failure could place residents at risk of exposure to infectious diseases due to improper infection control practices. The findings included: Record review of Resident #1's Face Sheet, dated 03/07/2026, reflected Resident #1 was initially admitted on [DATE] and readmitted on [DATE]. The face sheet indicated Resident #1 was [AGE] years old. Record review of Resident #1's Diagnosis Report, dated 03/07/2026, reflected Resident #1 diagnoses included cerebral infarction (a condition when blood supply to a part of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews the facility failed to ensure the resident had a right to a dignified existence, self-determination, and communication with and access to people and services inside and outside the facility for 1 resident (Resident #3) of 10 residents reviewed for dignity. The facility failed to ensure Resident #3 was checked on frequently and kept clean and dignified. This failure could affect residents who have incontinence and unsanitary behaviors and could result in diminished self-esteem.The findings included: Record review of Resident #3's electronic face sheet dated 12/17/2025 reflected he was a [AGE] year-old-male who was admitted to the facility on [DATE]. His diagnoses included: chronic obstructive pulmonary disease (condition involving constriction of the airways and difficulty or discomfort in breathing), muscle weakness (reduction in strength in one or more muscles, making it harder to move or perform tasks), major depressive disorder (serious mood disorder,…

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 the resident had a right to a safe, clean, comfortable, and homelike environment to receiving treatment and support for daily living safety for 1 resident (Resident #3) of 10 residents reviewed for safe and clean environment. The facility failed to ensure Resident #3's room which had urine and feces on the sticky floor was cleaned as required to provide a safe and clean environment. This failure could affect residents who have incontinence and unsanitary behaviors and could result in disease spread and accidents. The findings included: Record review of Resident #3's electronic face sheet dated 12/17/2025 reflected he was a [AGE] year-old-male who was admitted to the facility on [DATE]. His diagnoses included: chronic obstructive pulmonary disease (condition involving constriction of the airways and difficulty or discomfort in breathing), muscle weakness (reduction in strength in one or more muscles, making it harder to move or…

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 all allegations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 2 residents (Resident #1 and #2) of 10 residents reviewed for neglect and misappropriation. 1. The facility failed to report Resident #1's missing Tramadol and Tylenol #3 while he was out on leave on Thanksgiving to the ADM who…

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 develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the residents that meet professional standards of quality care for 1 resident (Resident #2) of 10 residents reviewed for care plans. The facility failed to complete a baseline care plan within 48 hours of admission for Resident #2 that reflected she had a colostomy and required monitoring and care. This facility failure could affect residents who require care in the facility and could result in missed or inappropriate care.The findings included: Record review of Resident #2's electronic face sheet dated 12/17/2025 reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: type 2 diabetes mellitus (condition in which the body cannot use insulin correctly and sugar builds up in the blood), acute pain due to trauma (sudden or urgent pain that occurs as…

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 each resident received adequate supervision and assistance devices to prevent accidents for 1 resident (Resident #4) of 5 residents reviewed for smoking. The facility failed to ensure Resident #4 was provided with a smoking apron during a smoke break. This facility failure could affect residents who smoke at the facility and could result in injury and harm.The findings included: Record review of Resident #4's electronic face sheet dated 12/17/2025 reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: benign neoplasm of parotid gland (non-cancerous tumor), vascular dementia (caused by conditions such as stroke, resulting in problems with memory, thinking and behavior), and mild intellectual disabilities (general learning disability). Record review of Resident #4's quarterly MDS assessment dated [DATE] reflected he could understand and be understood. He scored 13 of 15 on his BIMS which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 resident (Resident #1) of 10 residents reviewed for pharmaceutical services. The facility failed to ensure Resident #1's Tramadol and Tylenol #3 were accounted for when he left to go out on pass on Thanksgiving (11/27/2025). This facility failure could affect residents who take narcotics for pain and could result in misappropriation of medications or drug diversion.The findings included: Record review of Resident #1's electronic face sheet dated 12/16/2025 reflected he was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included: acute respiratory failure with hypoxia (a condition where there is insufficient oxygen delivery to the tissues leading to low oxygen in the blood), muscle weakness (lack of 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 observations, interviews and record reviews, the facility failed to establish and maintain, an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 resident (Resident #2) of 10 residents reviewed for infection control. The facility failed to ensure Resident #2 had EBP implemented when she was admitted to the facility on [DATE] with a stage 4 wound to her coccyx which required treatment and dressing. This facility failure could affect residents with wounds and could result in cross contamination and infection of an MDRO.The findings included: Record review of Resident #2's electronic face sheet dated 12/17/2025 reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: type 2 diabetes mellitus (condition in which the body cannot use insulin correctly and sugar builds up in the blood), acute pain due to trauma…

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 with limited mobility receives appropriate services and equipment to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is unavoidable for 1 of 1 Resident (Resident #1) whose records were reviewed for motorized wheelchairs. The facility failed to obtain Resident #1's motorized wheelchair's specifications, to assess and ensure Resident #1 had a wheelchair that met his weight capacity for at least 3 months. This violation could place residents at risk of utilizing an unsuitable motorized wheelchair and contribute to unsafe mobility. The findings were: Review of Resident #1's face sheet, dated 10/24/25, revealed he was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia, muscle weakness (generalized), difficulty in walking not elsewhere classified, unspecified lack of coordination, adult morbid (severe) obesity due to excess…

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 adequate supervision and assistive devices to prevent accidents for 1 of 2 Residents (Resident #2) whose records were reviewed. Nursing staff failed to ensure Resident #2's bed was in the lowest position and staff provided Resident #2 with adequate supervision. This violation could place residents at risk for experiencing avoidable falls. The findings were:Review of Resident #2's face sheet, dated 10/26/25, revealed she was admitted to the facility on [DATE] with diagnoses including neurocognitive disorder with Lewy bodies (a progressive neurocognitive disorder characterized by the accumulation of Lewy bodies in the brain, leading to cognitive decline, movement issues, and various other symptoms), psychotic disorder with delusions due to known physiological condition (a psychotic disorder characterized by the presence of delusions that arise as a direct consequence of a known physiological condition),…

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 establish and maintain an infection control program designed to provide a safe sanitary, and comfortable environment for 6 of 10 residents (Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8 and Resident #10) reviewed for infection control.The facility failed to ensure residents who lived on the 300/400 hallway of the facility received showers in a room that was free of potentially infectious debrisThe facility failed to ensure Resident #4, and Resident #6 were screened for tuberculosis prior to or upon admission to the facility and annually.These failures could cause the spread of infections from one resident to another, leading to sickness and a decreased quality of life. Findings included:Record review of Resident #3's admission record dated 11/18/2025 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE].Resident #3 had a diagnosis of Alzheimer's Disease with Late Onset,…

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 the resident's right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 1 resident (Resident #6) reviewed for accommodations of needs.The facility failed to ensure Resident #6 had the proper Bariatric bed and overhead trapeze to facilitate self-positioning, self-transfer and bed safety.This failure could cause residents to lose independent functioning as related to Activities of Daily Living, loss of dignity, and overall well-being. Findings included: Record review of Resident #6's admission record dated 11/19/2025 reflected Resident #6 was a [AGE] year-old male who was admitted to the facility on [DATE].Resident #6 had a diagnoses of Acute Respiratory Failure with Hypoxia (low levels of oxygen in muscle tissues); Muscle Weakness (Generalized); Difficulty in Walking, Not Elsewhere Classified; Unspecified Lack of Coordination, Mild Intermittent Asthma,…

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 residents had the right to receive visitors of his or her choosing at the time of his or her choosing, subject to the resident's right to deny visitation when applicable, and in a manner that does not impose on the rights of another resident.The facility failed to ensure door access to residents after 8:00PM daily for 1 of 10 residents (Resident #3) reviewed for visitation rights.This failure could lead to reduced communication and contact between residents, families and others, resident isolation and a decreased quality of life. Findings included: Record review of Resident #3's admission record dated 11/19/2025 revealed Resident #3 was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 had diagnoses of Alzheimer's Disease with late onset, Dysphagia, Oropharyngeal Phase (swallowing difficulties due to neurological or muscular impairments), Other Abnormalities of Gait and Mobility, Vascular Dementia…

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 residents had the right to reasonable access to the use of a telephone and a place in the facility where calls can be made without being overheard.The facility failed to protect and facilitate residents' right to communicate with individuals and entities within and external to the facility, including reasonable access to a telephone, for 2 of 10 residents (Resident #4 and Resident #10) reviewed for Resident Rights.Resident #4 had a personal cell phone but was unable to use it due to decline in visual impairment.Resident #10 did not have a personal cell phone and the only means of outside communication was through a facility-provided telephone.These failures could lead to reduced communication and contact between residents, families and others, resident isolation, and decreased quality of life. Findings Included: Record review of Resident #4's admission record dated 11/19/2025 revealed Resident #4 was a [AGE] year-old female who…

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 that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 10 residents (Resident #1) reviewed for smoking safety.The facility failed to ensure that a resident did not keep cigarettes and a lighter in their personal possession.This failure could lead to risk of injury, potential fire incidents and a decreased quality of life.Findings included:Record review of Resident #1's admission record dated 11/18/2025 reflected a [AGE] year-old female who was admitted to the facility on [DATE] with the following diagnosis: chronic obstructive pulmonary disease with (acute) exacerbation; other persistent atrial fibrillation; cough, unspecified; other hereditary and idiopathic neuropathies; other muscle spasm, and insomnia, unspecified. Record review of Resident #1's quarterly MDS dated [DATE] revealed Resident #1 had a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident for 1 of 10 resident (Resident #6) reviewed for Diet Meets the Needs of Each Resident.The facility failed to ensure Resident #6 received the prescribed therapeutic diet.This failure could place residents at risk of their nutritional needs not being met. Findings included:Record review of Resident #6's admission record dated 11/19/2025 reflected a [AGE] year-old male who was admitted to the facility on [DATE].Resident #6 had a diagnoses of Acute Respiratory Failure with Hypoxia (low levels of oxygen in muscle tissues); Muscle Weakness (Generalized); Difficulty in Walking, Not Elsewhere Classified; Unspecified Lack of Coordination, Mild Intermittent Asthma, Uncomplicated; Pain in Right Shoulder; Age-related Osteoporosis without Current…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 4 of 7 residents (Resident #23, Resident #9, Resident #37 and Resident #17) reviewed for accidents and hazards: 1. The facility failed to ensure Resident #23 did not have a disposable razor at the bedside.2. The facility failed to ensure Resident #9 did not have a pair of large nail clippers in her room.3. The facility failed to ensure Resident #37 did not have a pair of large nail clippers and a disposable razor in her room.4. The facility failed to ensure Resident #17 did not have a pair of scissors at the bedside.These failures could place residents at risk of harm or injury and contribute to avoidable accidents and a decline in health.The findings included:1. Record review of Resident #23's face sheet dated 7/22/25 revealed a [AGE] year old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that 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 observation, interview, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 6 of 8 residents (Resident #15, #18, #31, #19, #17 and #9) reviewed for infection control.1. The facility failed to ensure LVN A sanitized the blood pressure cuff when obtaining Resident #15, Resident #18, and Resident #31's blood pressure. 2. The facility failed to ensure LVN A wore gloves when applying a lidocaine patch to Resident #18's lower back. 3. The facility failed to ensure LVN C sanitized the blood pressure cuff when obtaining Resident #19, and Resident #17's blood pressure. 4. The facility failed to ensure LVN C wore a gown while administering a bolus of water to Resident #9's feeding tube who was on EBP (enhanced barrier precautions) on 7/23/25.These deficient practices could affect residents who require assistance and treatments…

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 had the right to be informed in advance of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options for 1 of 6 residents (Resident #39) reviewed for informed consent.The facility failed to ensure a psychotropic medication consent was included in the medical record for Resident #39's Olanzepine (an atypical antipsychotic medication).This failure could place residents at risk of receiving care/treatment without consent and knowledge of adverse side effects.The findings included: Review of Resident #39’s face sheet with an original date of 12/23/24 and a readmission date of 4/2/25, documented a [AGE] year-old female with diagnoses including Type 2 Diabetes Mellitus, Paranoid Schizophrenia (a mental health disorder that affects how a person thinks, feels, and behaves with symptoms that include delusions and auditory hallucinations), and Celiac Disease (a disorder that causes a reaction in your…

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 1 of 8 residents (Resident #2) received services in the facility reviewed for reasonable accommodation of resident needs related to call lights. The facility failed to ensure the call light was within reach for Resident #2. This deficient practice could affect any resident and place them at risk of not being able to ask for help as needed.The findings were: Record review of Resident #2's face sheet revealed she was admitted to the facility on [DATE] with diagnoses which included: catatonic disorder (person experiences significant disruptions in movement and behavior), Neoplasm of uncertain behavior of parathyroid gland (growth in the parathyroid gland), Sick sinus syndrome (heart's natural pacemaker doesn't work properly). Record review of Resident #2's MDS assessment, dated 05/07/2025, revealed the resident's BIMS score was 99, which indicated severe cognitive impairment. The MDS assessment further revealed Resident #2 required…

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 is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding for 1 of 3 resident (Resident #9) reviewed for enteral feeding:The facility failed to ensure Resident #9's feeding formula and water containers were labeled with the appropriate identifiers and did not discard the feeding containers after the feeding was completed.This deficient practice could place residents who received enteral nutrition at risk of infection, and bloating discomfort.The findings included:Record review of Resident #9's face sheet dated 7/21/25 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included nausea, aphasia (medical condition that affects a persons' ability to communicate) following cerebral infarct (a type of stroke that prevents blood flow to a part of the brain), dysphagia(condition that involves…

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 discharge of Resident #1 was documented in the EMR for one resident (#1) of four residents reviewed for discharge. The facility failed to provide Resident #1 with a 30-day discharge notice when he was sent to the hospital for a change in condition and the facility refused to take him back. Documentation of discharge was not present in Resident #1's EMR to include physician's orders or a discharge summary. This failure could affect residents who go to the hospital for a change in condition and result in an unsafe discharge. The findings included: Record review of Resident #1's electronic face sheet dated 06/25/2025 reflected he was a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included: Pressure ulcer (a localized injury to the skin and underlying tissue) of other cite, unstageable (depth of wound could not be determined), neurogenic bladder (condition where nerve damage disrupts…

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 all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse, to the administrator of the facility and to other officials including to the State Survey Agency where state law provides for jurisdiction in long-term care facilities in accordance with State law through established procedures for 2 of 4 residents (Residents #1 and #2), reviewed for freedom from abuse, neglect, and exploitation. 1. Facility failed to report incident of suspected abuse from Monday 04/12/2025 when Resident #1 stated she had been fondled by man. 2. Facility failed to report an incident of suspected physical abuse from Monday 04/12/2025 when Resident #2 stated he had been hit by a female resident. These failures could put the residents at risk of abuse, allegations of abuse not being reported immediately, and could result in physical 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 have evidence all allegations of abuse, neglect or mistreatment were thoroughly investigated and documented for 2 of 4 residents (Resident #1 and Resident #2) reviewed for abuse. 1. The Facility failed to ensure an allegation of Resident #1 being fondled by a man was thoroughly investigated. 2. The Facility failed to ensure an allegation of Resident #2 having been hit by a female resident was thoroughly investigated. These failures could place residents at risk for abuse and neglect by not investigating allegations of abuse, neglect, exploitation, or mistreatment. The findings were: Record review of Resident #1's face sheet, dated 06/21/2025, revealed she was admitted on [DATE] and the latest admission being 04/02/2025 with diagnoses which included: muscle weakness (generalized), cognitive communication deficit, and paranoid schizophrenia .( subtype of schizophrenia characterized by prominent symptoms of paranoia, including delusions and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident had a right to a safe, clean, comfortable, and homelike environment for 1 (Resident #1 room) of 4 resident reviewed for resident rights, in that: A pile of yellow liquid was seen on the restroom floor of Resident #1's room. This failure could result in physical and psychosocial harm due to diminished quality of life and increased risk for falls. The findings were: Record review of Resident #1's face sheet, dated 04/06/23, noted the resident was admitted to the facility on [DATE] with diagnoses including: Depression, Anxiety, Tremor, Lack of Coordination, Type 2 Diabetes Mellitus, Hyperlipidemia, Chronic Obstructive Pulmonary Disease (a lung disease that blocks airflow and makes it difficult to breath), Cognitive Communication Deficit (difficult with communication caused by an impairment in cognitive processes), Unsteadiness on Feet, Paranoid Schizophrenia, Seizures, and Abnormalities of Gait and Mobility. Record review…

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 reviews, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys, for 1 of 2 medication carts (Medication Cart 2), reviewed for security, in that, An unassigned medication cart was unattended and unlocked with medication blister packs inside of the medication cart. This failure placed residents at risk for harm by misappropriation of property of their medications. The findings included: During an observation on 01/23/2025 at 10:51 AM, it was revealed that a medication cart near the nurses' station at the corner of the 100 and 200 hallways, was unattended and unlocked. The medication cart was observed to have the lock button unengaged and unlocked. During an interview and observation on 01/23/2025 at 11:08 AM, LVN A stated he was not assigned to the med cart and was not sure why it was unlocked. LVN A stated that the medication cart should have been locked and that he had not gone into the med cart that day. 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 employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition services for 1 of 1 dietary manager reviewed for qualified dietary staff. The facility failed to employ a certified dietary manager as required. This failure could place residents who consumed food prepared by staff in the kitchen at increased risk of food borne illness and not receiving adequate nutrition. The findings were: Record Review of the Employee Service List, undated, revealed the Dietary Manager with an initial hire date of 06/17/21. During an interview with the Human Resources Director on 06/06/24 at 10:00a.m., she stated she was not aware the Dietary Director had to have completed a certified Dietary manager course. She stated she along with the Administrator would have been responsible for ensuring the department heads met their certification requirements. During an interview on 06/6/24 at 10:15a.m., the Dietary Manager revealed she had not taken the Dietary Manager Certification course and was…

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

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 for 1 of 1 kitchen, in that: 1. A plastic bag of cheese in the refrigerator was not labeled or dated. 2. A plastic bag of beets in the refrigerator was not labeled or dated. 3-A one gallon plastic container of pudding was not labeled or dated 4. The temperature gauge on the dish machine in the dish room was not working as the temperature reading would not advance on the gauge. 5. Snacks in the Nourishment Rooms were not labeled or dated. These deficient practices could place residents who received meals and snacks from the kitchen at risk for food borne illness from improper infection control, from a lack of food label date monitoring, from a lack of equipment maintenance, and improper sanitation in the kitchen area. The findings included: Observation on 06/04/24 from 9:10 am to 9:40 am, during the kitchen tour with the Dietary Manager revealed the following: a. There was a plastic bag of cheese 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 1 facility reviewed for environmental concerns. The facility failed to secure a resident's bathroom ceiling fan, replace a resident's bedroom light, fix a resident's window blinds, repair a penetration in a resident's bedroom wall, replace a hallway ceiling panel cover, repair water discoloration marks around a hallway ceiling vent, fix a section of resident hallway floor molding, and replace the light bulbs in a hallway ceiling light unit. This deficient practice could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe. The findings included: During an observation on 06/4/24 from 10:20 a.m. to 11:10 a.m. revealed the following the following: 1. Resident room [ROOM NUMBER] had a bathroom ceiling fan which measured approximately 1 foot in diameter…

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 maintain an effective pest control program for 1 of 1 facility in that: 1. Numerous gnats were observed in a resident room on the 200 hall. 2. Numerous flies were observed on the 200 hall. 3. Observed a cockroach in the conference room This deficient practice could place residents at risk of residing in an environment with pests. The findings were: 1. Observation on 06/04/2024 at 9:34 a.m. revealed the presence of numerous flies on the 200 hall. 2. Observation on 06/04/2024 at 9:39 a.m. revealed the presence of gnats in and around residents' room in the 200 hall. 3. Observation on 06/05/2024 at 3:21 pm revealed the presence of a cockroach in the conference room. Records review revealed that the pest control company had been to the facility twice in May 2024 to treat for ants and insects. During an Interview on 06/06/2024 at 1:14 pm with the Administrator stated the maintenance person for the facility quit on 06/04/2024. He stated the facility should not have pests. He stated the facility does have a contract with a pest…

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 reviews the facility failed to develop and implement 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 1 of 19 residents (Resident #48) reviewed for care plans. The facility failed to develop a care plan to address Resident #48's anti-coagulant medication use. This failure could have placed residents at risk of not having their needs identified and met. The findings were: Record review of Resident #48's face sheet, dated 6/26/24, revealed an admission date of 2/06/2024 with diagnosis that included: unspecified dementia ( a condition in which a person can experience memory loss, poor judgement, and confusion), anxiety disorder( a condition in which there are strong feelings of worry, anxiety, or fear), and chronic pain syndrome( a condition in which pain can last for weeks or longer). Record review of Resident's #48'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 observation, interview and record review the facility failed to provide housekeeping and maintenance services necessary to maintain a safe, sanitary, orderly, and comfortable interior for 4 of 5 Resident's (Resident #2, Resident #3, Resident #6, and Resident #7) reviewed for environment. 1. The facility failed to prevent Resident #2's bathroom from having a black substance caked over the interior of the toilet bowl and the air conditioning unit was covered in dust. 2. The facility failed to ensure the wall on the back of Resident #3's bed did not have peeling drywall. 3. The facility failed to ensure Resident #6's room floor was cleaned near/under furniture and in the closet. 4. The facility failed to ensure Resident #7's room floor was cleaned. These failures could affect any resident and place them at risk for a diminished quality of life and a diminished clean, homelike environment. The findings included: 1. Record review of Resident #2's face sheet, dated 4/11/24 revealed a [AGE] year-old male…

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, 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 2 of 4 residents (Resident #1 and Resident #5) reviewed for care plans. 1. The facility failed to care plan Resident #1's refusal eating in the dining room for supervision with meals. 2. The facility failed to care plan Resident #5's use or refusal to use fall mats. This failure could place residents at risk of not having their needs met. Finding Included: 1. Record review of Resident #1's face sheet dated 4/10/24 revealed a [AGE] year-old male, admitted on [DATE] and readmitted on [DATE] with diagnoses of seizures, cerebrovascular disease, aphasia following cerebral infarction (a person may be unable to comprehend or unable to formulate language because of damage to specific brain regions),…

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 drugs and biologicals used in the facility must be labeled and stored in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions and the expiration date when applicable for 1 of 4 resident rooms (Resident #4's room) reviewed for medication storage. The facility failed to ensure Resident #4's medications were stored properly in the facility. This deficient practice could affect residents who received medications for treatments and could result in less potent or an adverse effects and drug diversion. The findings included: Record review of Resident #1's face sheet, dated 4/10/24 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included fracture of shaft of fibula (lower leg bone that extends from the knee to the outside of the ankle), closed fracture with routine healing, pain, type 2 diabetes (a long-term condition 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews, the facility failed to ensure each resident received and the facility provided food prepared in a form designed to meet individual needs for 1 of 3 residents (Residents #1) reviewed for food and nutrition services. The facility failed to ensure Resident #1 received a mechanical soft diet in the proper consistency. This deficient practice could place residents who received pureed meals at risk of dissatisfaction, poor intake, choking, and/or weight loss. The findings included: Record review of Resident #1's face sheet dated 4/10/24 revealed a [AGE] year-old male, admitted on [DATE] and readmitted on [DATE] with diagnoses of seizures, cerebrovascular disease, aphasia following cerebral infarction (a person may be unable to comprehend or unable to formulate language because of damage to specific brain regions), contracture right elbow (shortening of muscles, tendons, skin, and nearby soft tissues that causes the joints to shorten and become very stiff,…

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 accommodate residents' food preferences and allergies for 1 of 3 (Resident #1) residents reviewed for food preferences and allergies, in that: The facility failed to ensure that Resident #1's daily dietary form reflected the residents allergy to mushrooms. These failures could cause an allergic reaction, a decrease in resident choices, and diminished interest in meals. The findings were: The findings included: Record review of Resident #1's face sheet dated 4/10/24 revealed a [AGE] year-old male, admitted on [DATE] and readmitted on [DATE] with diagnoses of seizures, cerebrovascular disease, aphasia following cerebral infarction (a person may be unable to comprehend or unable to formulate language because of damage to specific brain regions), contracture right elbow (shortening of muscles, tendons, skin, and nearby soft tissues that causes the joints to shorten and become very stiff, preventing normal movement), contracture right…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide drinks, including, water and other liquids, consistent with resident needs and preferences for 1 (Resident #1) of 4 Residents observed for meal service. The facility failed to provide water during lunch on 04/10/24 for Resident #1. This failure could place residents at risk for thirst, dehydration, and decreased quality of life. Findings included: Record review of Resident #1's face sheet dated 4/10/24 revealed a [AGE] year-old male, admitted on [DATE] and readmitted on [DATE] with diagnoses of seizures, cerebrovascular disease, aphasia following cerebral infarction (a person may be unable to comprehend or unable to formulate language because of damage to specific brain regions), contracture right elbow (shortening of muscles, tendons, skin, and nearby soft tissues that causes the joints to shorten and become very stiff, preventing normal movement), contracture right wrist, hemiplegia (weakness of one entire side of the body) 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 observations, interviews, and record reviews the facility failed to provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals for 1 (Resident #1) of 3 residents reviewed for special eating equipment and assistance when consuming meals, in that: The dietary staff failed to provide Resident #1 with a divided plate to meet Resident #1's need for assistance with eating. This failure could place residents at risk for harm by weight loss, diminished independence, and self-esteem. The findings included: . Record review of Resident #1's face sheet dated 4/10/24 revealed a [AGE] year-old male, admitted on [DATE] and readmitted on [DATE] with diagnoses of seizures, cerebrovascular disease, aphasia following cerebral infarction (a person may be unable to comprehend or unable to formulate language because of damage to specific brain regions), contracture right elbow (shortening of muscles,…

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 a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 6 residents (Resident #44) reviewed for incontinent care, in that: CNA A failed to separate Resident #44's labia to clean between the labia during incontinent care. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices. The findings were: Record review of Resident #44's face sheet, dated 04/27/2023, revealed an admission date of 04/24/2023, with diagnoses which included: Atelectasis (collapse or closure of a lung), Bipolar disorder(mental disorder characterized by periods of depression and periods of abnormally elevated mood) and, Guillain-Barre syndrome( rare disorder in which the body's immune system attacks the nerves). Record review of Resident #44's MDS Log revealed there was no completed MDS. Record review of Resident #44's care plan, dated 04/25/2023,…

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 development and transmission of communicable diseases and infection for 1 of 6 residents (Resident #44) reviewed for infection control, in that: CNA A failed to wash or sanitize his hands or change his gloves after touching the bed's remote and head of the bed and before starting incontinent care. This deficient practice could place residents at-risk for infection due to improper care practices. The findings include: Record review of Resident #44's face sheet, dated 04/27/2023, revealed an admission date of 04/24/2023, with diagnoses which included: Atelectasis (collapse or closure of a lung), Bipolar disorder(mental disorder characterized by periods of depression and periods of abnormally elevated mood) and, Guillain-Barre syndrome( rare disorder in which the body's immune system attacks the nerves). Record review of Resident #44's MDS Log 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.