Avir at Seguin

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review revealed residents has a right to a clean and comfortable and homelike environment, including but not limited to receiving support for daily living including clean bed for 1 of 8 Residents (Resident #56) for 3 of 4 survey days (6/2/24 to 6/5/24) whose environment was observed for clean linens. Nursing staff failed to ensure they changed Resident #56's bed sheets for 3 of 4 survey days (6/2/24 to 6/5/24. Resident #56's bed sheets were stained with brown spots and had residue all over them. This deficient practice could affect any resident and contribute to feelings of low self-esteem. The findings were: Review of Resident #56's quarterly MD'S assessment, dated 4/12/24, revealed Resident #56 was admitted to the facility on [DATE], with diagnoses including Hypertension (high blood pressure), ESRD (also called end-stage kidney disease or kidney failure, occurs when chronic kidney disease, the gradual loss of kidney function, reaches an advanced state. In end-stage…

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 Base d on observation, interview and record review the facility failed to provide Preadmission Screening for individuals with a mental disorder for 1 of 1 Resident (Resident #61) whose records were reviewed for PASRR services. The facility failed to recognize on the Level 1 PASRR screening that Resident #61 had a mental illness diagnosis of Bi-polar Disorder which would qualify her for a PASRR evaluation. This deficient practice could affect residents with a mental illness and could result in Resident's not receiving mental health services as needed. The findings were: Review of Resident #61's quarterly MDS assessment, dated 3/31/24, revealed she was admitted to the facility on [DATE] with diagnoses including Dementia, Anxiety Disorder, Manic Depression (Bi-polar disorder) and Seizure Disorder. Further review revealed Resident #61's BIMS was 6 out of 15 indicative of severe cognitive impairment. Review of Resident #61's Care Plan dated 3/31/24 read: Resident has bipolar disorder, current episode depressed,…

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 residents who needed respiratory care were provided such care, consistent with professional standards of practice, for 3 residents (Resident #4, Resident #43 and Resident #52) reviewed for oxygen therapy in that: 1. Residents #4 and #52's, nebulizer tubing was on the bedside table unbagged and undated. 2. Resident #43's filter on the oxygen concentrator had lint build up on it. These failures could place residents who received oxygen therapy at risk for an increase in respiratory complications and or infections. The findings were: 1. Record review of Resident # 4's face sheet dated 6/2/24 revealed an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with the diagnosis that included Peripheral vascular disease (is a chronic condition that affects blood vessels outside of the heart and brain), Dementia (a general term for the impaired ability to remember, think, or make decisions that interfere with…

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

Based on interview and record review, the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, for one of four quarters for 2024 (Quarter 3) reviewed for sufficient nursing staff. According to the PBJ report for Quarter 3 2024 (March 1 through May 31), the facility did not have sufficient staff on weekends. This failure could place residents at risk of diminished quality of life and quality of care. Findings: Record review of the CMS PBJ reports Quarter 3 2024 ( March 1 through May 31) indicated: the facility had a 1-star staffing rating. Record review of CMS PBJ report for Quarter 3 202 (March 1 through May 31) indicated the facility had excessively low weekend staffing. Record review of RN staffing hours for February 2024 - May 2024 revealed that there was no RN coverage on 3/16/24, 3/17/24,3/24/24,3/24/24,3/30/24/3/31/24,4/6/24, 4/7/24, 4/20/24,4/27/24,5/11/24,5/12/24,5/25/24 and 5/26/24. Interview on June 4,…

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

Based on interview, observation, 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 residents who eat in their rooms in halls 100 and 200. While passing lunch trays in hallways 100 and 200 staff did not sanitize or clean hands in between residents. This failure could place residents at risk for infection. Findings included: Observation of meal services on 06/02/2024 at 12:16 PM revealed the Business Office Manager (BOM) passing trays in the 100 and 200 halls. The BOM went from the rack of trays into resident's rooms with lunch trays then back to the rack of lunch trays in the hallway. The BOM pushed the rack of lunch trays down the hall and repeated the process for all residents eating in their rooms in halls 100 and 200. The BOM did not wash or sanitize her hands after pushing the rack of trays down the hallways or between passing each resident's trays. Interview on 06/02/2024 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs for 1 of 8 Residents (Resident #16) who were observed for call light placement. Nursing staff failed to ensure Resident #16's call light was within reach for use if she needed to ask for assistance. This deficient practice could affect any resident who used a call light and could contribute to resident's needs not being met. The findings were: Review of Resident #16's significant change MDS assessment, dated 3/20/24, revealed she was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease (brain disorder that causes problems with memory, thinking and behavior) and Dementia (group of symptoms affecting memory, thinking and social abilities). Further review revealed Resident #16's BIMS was 8 out of 15 indicative of moderate cognitive impairment, her vision was moderately impaired, she was dependent on staff from…

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 the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to choose health care and providers of health care services consistent with his or her interests, assessments, and plan of care for 1 of 8 Residents (Resident #61) whose records were reviewed for health care services. Resident #61 expressed her desire to find a psychiatrist within the community. The SS worker told Resident #61 she could select a psychiatrist of her choice but because the facility provided in house psychiatry services, she would have to secure her own transportation. This deficient practice could affect any resident exercising their rights to choose their own health care providers and result in a direct violation of the resident's right to autonomy. The findings were: Review of Resident #61's quarterly MDS assessment, dated 3/31/24, revealed she was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents had the right to personal privacy and confidentiality of his or her personal and medical records for one of five residents (Resident # 15) reviewed for privacy. The facility failed to ensure CMA E locked the computer, which exposed Resident #15's morning medication list after she walked away and left the computer unattended. This failure could place residents at risk of having medical information exposed to others and cause residents to feel uncomfortable and disrespected. The findings include: Record review of Resident # 15's face sheet, dated 6/4/24, revealed a [AGE] year-old male was admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses that included Acute Kidney Failure ( occurs when your kidneys suddenly become unable to filter waste products from your blood) , aphagia (The loss of the ability to swallow) and Right hemiplegia ( is a condition that causes paralysis on the right side of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to 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 3 (Resident #71) residents reviewed for comprehensive assessments. The facility failed to ensure that Resident #71's care plan documented interventions for the diagnosis of General anxiety disorder. This failure could place residents at risk of not receiving proper care and services related to the disease process. The findings were: Record review of Resident # 71's face sheet, dated 6/4/24, revealed a [AGE] year-old female was admitted to the facility on [DATE] and readmitted on [DATE] with the diagnosis that Included General anxiety disorder (involving a persistent feeling of anxiety or dread that interferes with how you live your life),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 1 of 8 Residents (Resident #56) whose records were reviewed for ADL care. Nursing staff failed to ensure Resident #56 received a shower on 6/3/24 and on 6/5/24. This deficient practice could affect any resident and contribute to feelings of low self-esteem. The findings were: Review of Resident #56's quarterly MDS assessment, dated 4/12/24, revealed Resident #56 was admitted to the facility on [DATE], with diagnoses including Hypertension (high blood pressure), ESRD (also called end-stage kidney disease or kidney failure, occurs when chronic kidney disease, the gradual loss of kidney function, reaches an advanced state. In end-stage renal disease, your kidneys no longer work as they should to meet your body's needs) and PVD (a condition that affects the blood vessels outside of the heart and brain).…

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 8 Residents (Resident #12) reviewed for falls. Nursing staff failed to provide adequate supervision for Resident #12 which resulted in her experiencing a fall on 6/3/24. On 6/5/24 nursing staff failed to ensure the fall mats were next to her bed to cushion her fall in an effort to prevent injuries related to having a history of frequent falls. These deficient practices could affect residents at risk for falls and could result in avoidable falls and injuries. The findings were: Review of Resident #12's quarterly MDS, dated [DATE], revealed she was admitted to the facility on [DATE] with diagnoses including Hypertension (high blood pressure), Alzheimer's Disease (causes the brain to shrink and brain cells to eventually die. Alzheimer's disease is the most common cause of dementia, a gradual decline in memory) and Hemiplegia (is a 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 interview and record review the facility failed to ensure the attending physician documented in the resident's medical record that the identified irregularity made by the pharmacist had been reviewed and what, if any, action had been taken to address it. If there was to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record for 1 of 3 Residents (Resident #25) whose records were reviewed for unnecessary medications. The DON and ADON failed to identify the pharmacist addressed identified medication irregularities to the wrong physician when completing the pharmacy review for Resident #25. This resulted in a delay in the physician's response to the medication irregularity including Zyrtec (used for allergies) and Hydrocodone (used for pain). This deficient practice could affect any resident, delay a physician's response and result in a decline in the residents health. The findings were: Review of Resident #25'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.

Based on observations, interviews, and record review, 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 one medication cart out of two carts reviewed for medication storage , in that : 1. LVN B left the medication cart unsecured on 100 Hallway while administering medications. These deficient practices could place residents at risk for misappropriation, misuse or tampering of medications. The findings included: Observation on 06/04/2024 at 08:28 a.m. on the 100 Hall revealed that the medication cart was left unattended and not locked. During an interview on June 4, 2024, at 08:28 with LVN B, it was revealed that she had left the medication cart unlocked, which was a practice she claimed to have never done before. Her focus on checking a resident led to this oversight. She acknowledged the potential for misappropriation, misuse, and harm if someone were to gain unauthorized access to the cart and acquire medications, including insulin. In an interview…

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 and ensure safe and sanitary storage of residents' food items for 2 (refrigerators in resident room [ROOM NUMBER] and room [ROOM NUMBER]) of 5 residents' refrigerators reviewed in that: The personal refrigerators in two residents' rooms contained food items that were unlabeled and undated. This deficient practice could place residents at risk of foodborne illness due to consuming foods which are spoiled. The findings were: Observation on 06/01/2024 at 10:02 a.m. revealed the personal refrigerator in resident room [ROOM NUMBER] contained a burrito with expiration date of 2/12/24, which was unlabeled and undated. Observation on 06/01/2024 at 10:48 a.m. revealed the personal refrigerator in resident room [ROOM NUMBER] contained bologna that was unlabeled and undated. Further observation on 06/01/2024 at 11:54 a.m. revealed the bologna was still present. On June 1, 2024, at 10:37 a.m. during an interview with CNA A, it was confirmed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for two (Hall 400 and 500) of six halls and one resident shower rooms on Hall 400 observed for environment. The facility failed to ensure resident rooms on Halls 400 and 500 and the resident shower room on Hall 400 were clean, safe, and in good repair. This failure could place residents at risk for diminished quality of life due to the lack of a well-kept environment. Findings included: An unidentified complainant had notified the surveyor that several months prior to this investigation, one of the rooms on 500 Hall had been closed off due to the collapse of the ceiling and a smell of mold. Upon investigation on 05/14/24 at 12:00 pm, room [ROOM NUMBER] was observed to have a large hole in the ceiling approximately 3 feet square with an adjacent piece of ceiling about the same size with the drywall to the ceiling removed and covered only by insulation.…

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 professional staff were licensed, certified, or registered in accordance with applicable State laws for 1 of 3 staff (Staff A) reviewed for staff qualifications. The facility failed to ensure Staff A completed the appropriate educational requirements of a bachelor's degree in social work and was appropriately licensed to practice social work in the State of Texas. This failure could place residents at risk of not receiving care and services from staff who were properly trained and supervised. The findings included: Record review of staff Roster (undated) revealed Staff A had a job title listed as Social Services with a hire date of 07/01/2022. Record Review of a job description titled Social Service Director dated 7/02/2022 signed by Staff A revealed: Job Requirements: Education Experience: bachelor's degree in social work. During an interview on 3/21/2024 at 4:00 p.m., Staff A stated she was hired as the facility Social Worker approximately 1.5 years ago. She stated she had completed a bachelor's degree…

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

Based on interview and record review, the facility failed to ensure a registered nurse was present in the facility for at least eight consecutive hours per day and seven days per week, and designate a registered nurse to serve as the director of nursing, for 1 of 1 facility reviewed for registered nursing coverage and presence of a director of nursing, in that: A registered nurse was not present in the facility for at least eight consecutive hours per day and seven days per week, and the facility did not have a director of nursing in its employ for approximately five months prior to the survey period. This failure could affect all residents receiving care from facility staff who did not have the advanced training of a registered nurse. The findings were: Record review of the facility staff posting, dated 05/02/2023, revealed a registered nurse was not scheduled at anytime during the twenty-four hour period. During an interview with the Regional RN on 05/05/2023 at 1:42 p.m., the Regional RN stated that the facility had not employed a registered nurse serving as director of nursing…

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

Based on interview and record review, the facility failed to provide effective Communications Mandatory Training for 16 of 16 employees (Laundry M, CNA N, CNA O, Transporter P, MA B, CNA Q, Dietary R, DM, AD, LVN S, LVN, A, MDS, RN T, LVN C, LVN F, and SS) reviewed for training, in that: The facility failed to ensure Laundry M, CNA N, CNA O, Transporter P, MA B, CNA Q, Dietary R, DM, AD, LVN S, LVN, A, MDS, RN T, LVN C, LVN F, and SS completed effective communication training. These failures could place residents at risk of miscommunication and social isolation due to lack of staff training. The findings were: a. Record review of Staff Roster, dated 12/13/2022, revealed CNA M was hired on 09/12/1998. Record review of Laundry M's training history revealed Laundry M had not completed communication training in the last year. b. Record review of Staff Roster, dated 12/13/2022, revealed CNA N was hired on 06/24/2002. Record review of CNA N's training history revealed CNA N had not completed communication training in the last year. c. Record review of Staff Roster, dated 12/13/2022,…

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 ensure Quality Assurance and Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program for 16 of 16 employees (Laundry M, CNA N, CNA O, Transporter P, MA B, CNA Q, Dietary R, DM, AD, LVN S, LVN, A, MDS, RN T, LVN C, LVN F, and SS) reviewed for training, in that: The facility failed to ensure Laundry M, CNA N, CNA O, Transporter P, MA B, CNA Q, Dietary R, DM, AD, LVN S, LVN, A, MDS, RN T, LVN C, LVN F, and SS completed QAPI training within the last year. These failures could affect residents and place them at risk of poor care or victimization due to lack of staff training. Findings included: a. Record review of Staff Roster, dated 12/13/2022, revealed CNA M was hired on 09/12/1998. Record review of Laundry M's training history revealed Laundry M had not completed QAPI training in the last year. b. Record review of Staff Roster, dated 12/13/2022, revealed CNA N was hired on 06/24/2002. Record review of CNA N's training history revealed CNA N had not…

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 purchase a surety bond to assure the security of all personal funds of residents deposited with the facility for 1 of 1 resident trust account reviewed, in that: The amount on deposit in the resident trust fund was less than the amount of the surety bond. This failure could affect all residents with funds on deposit in the resident trust fund and cause a lack of security of resident personal funds. The findings were: Record review of the facility's surety bond, dated 08/24/2022, revealed the bond amount was $40,000.00. Record review of the resident trust fund as of 05/05/2023, revealed the balance was $51,125.39. During an interview with the BOM on 05/05/2023 at 3:05 p.m., the BOM confirmed the amount of the surety bond was greater than the amount on deposit in the resident trust fund. During an interview with ADON C on 5/05/2023 at 6:27 p.m., ADON C stated the residents' funds on deposit in the resident trust fund should be secured. During an interview with the Regional RN on 05/05/2023 at 4:07 p.m., the Regional RN…

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' right to formulate an advance directive for 5 of 39 residents (Resident #4, Resident #20, Resident #66, Resident #28 and Resident #33) reviewed for advanced directives, in that: 1. Resident #4's OOH-DNR was executed by two physicians and the resident had family members. 2. Resident #20's OOH-DNR was not witnessed and had no accompanying physician order. 3. Resident #66's OOH-DNR was not signed twice by her qualified relative. 4. The facility failed to ensure Resident #28's and Resident #33's OOH-DNR's were signed at the bottom, by either the nearest living relative or the resident. These failures could place residents at-risk for residents' rights not being honored and having CPS performed against the residents' will. The findings were: 1. Record review of Resident #4's face sheet, dated [DATE], revealed the resident was admitted to the facility on [DATE] with diagnoses including: encephalopathy, unspecified dementia, and…

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

Based on interview and record review, the facility failed to implement their written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents for 5 of 21 staff (MA I, [NAME] J, Hskg K, AD and MDS Coordinator ) reviewed for abuse and neglect, in that: 1. The facility failed to follow their abuse policy when a criminal background check and the EMR was not completed in a timely manner prior to their hired dates for MA I, [NAME] J, and Hskg K. 2. The facility failed to follow their abuse policy when the AD's and the MDS's annual EMR was not completed within the past year. These failures could place residents at risk for abuse and neglect. The findings were: Record review of facility policy titled Abuse Prevention Program, revised 08/2006, which read Policy Interpretation and Implementation. 1. Our facility is committed to protecting out residents from abuse by anyone including but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members,…

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 a medication error rate below 5% for 5 of 10 Residents (Residents #25, #48, #19, #50, and #35) reviewed for medication administration errors, in that: The Facility staff administered 45 medications of which 25 were administered to Residents #25, #48, #19, and #50, outside of acceptable parameters for safe medication administration; and one medication at the wrong dosage for Resident #35, which resulted in a 57% medication error rate. This failure could place residents at risk for not receiving the intended therapeutic effects of their medications and possible adverse reactions. The findings included: Residents #25 Record review of the Face Sheet dated 5/05/2023 revealed Resident #25 was a [AGE] year-old female admitted [DATE]. Record review of the quarterly MDS assessment dated [DATE] revealed Resident #25 was admitted with non-traumatic brain dysfunction related to unspecified psychosis [not related to substance or physiological…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were accurately documented for 1 of 39 Residents (Resident #174) reviewed for medical records, in that: The facility failed to ensure Resident #174's Schizoaffective disorder, bipolar type diagnoses was listed throughout the residents EHR. This failure could place residents at risk for improper care due to inaccurate records. The findings were: Record review of Resident #174's face sheet, dated 05/04/2023, revealed the resident was admitted on [DATE] with diagnoses that included: dementia, anxiety, mood disturbance, unspecified psychosis. Further record review did not reveal a diagnosis of schizoaffective disorder, bipolar type Record review of Resident #174's clinical notes, entered on 04/19/2023 at 12:44 pm by RN E, which read Patient admitted to [Facility Name] at 0800 from [State Hospital Name]. Transported by State Hospital facility van with medications…

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

Based on record review and interview the facility failed to ensure the Arbitration Agreement contained all the required elements for all current residents. The facility failed to ensure the arbitration agreement contained the required element: The right to rescind within 30 calendar days of signing. This failure could place the residents and their representatives at risk of being uninformed about their rights regarding binding arbitration and less able to defend their rights related to disputes, controversy or claims arising out of or related to the services provided by the nursing facility. Findings included: During the entrance conference on 5/02/2023 at 8:45 AM with the ADM, a blank copy of the facility's admission packet and of the facility's binding Arbitration Agreement were requested and these were received by the survey team on 5/02/2023 by 5:00 PM. Record review of the facility's admission agreement, dated June 2020, revealed an Arbitration Agreement dated Jan[uary] 2014. The Arbitration Agreement did not state that the resident had the right to rescind the binding…

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

Based on interview and record review, the facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, for 5 (Resident #4, Resident #20, Resident #66, Resident #28 and Resident #33) of 39 residents reviewed, in that: The Advanced Directives of five residents were incorrectly executed and were therefore invalid. The Social Services Director was unaware of the Advanced Directive errors, the Social Services Director was unaware that her department was responsible to ensure the accuracy of Advanced Directives, the Social Services Director was unaware of how to correctly execute an OOH-DNR, and the Social Services Director was not a licensed Social Worker. This failure could affect all residents and lead to a decline in mental and psychosocial well-being, and residents' wishes not being honored. The findings were: During an interview with the Social Services Director on 05/05/2023 at 12:36 p.m., the Social Services Director stated she was currently enrolled in a Social Work…

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 (room [ROOM NUMBER]) of 67 resident restrooms reviewed, 1 (400/500 hall) of 2 resident shower rooms reviewed, and 1 (500 hall) of 2 public restrooms reviewed, in that: 1. The sink in resident room [ROOM NUMBER] was loosely affixed to the wall. 2. The resident shower room serving 400 and 500 halls had a foul odor and had soiled briefs in two trashcans. 3. The public restroom located on 500 hall had clothing and trash in the floor and there was brown liquid in the commode. 4. Resident #68 was not provided a safe, functional, sanitary, or comfortable environment due to non-functional window blinds. 5. Resident # 74 was not provided a safe, functional, sanitary, or comfortable environment due to the smell of cigarette smoke in her room from the smoking area outside her closed window. These failures could lead to residents living in,…

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

Based on interview and record review, the facility failed to provide the required education on the rights of the resident and the responsibilities of a facility to properly care for its resident for 3 of 16 employees (the DM, the AD, RN T) reviewed for training, in that: The facility failed to ensure the DM, the AD, and RN T completed resident rights training within the previous year. These failures could affect residents and place them at risk of being uninformed due to lack of staff training. The findings were: a. Record review of Staff Roster, dated 12/13/2022, revealed the DM was hired on 09/06/2011. Record review of the DM's training history revealed the DM had not completed resident rights training in the last year. b. Record review of Staff Roster, dated 12/13/2022, revealed the AD was hired on 06/20/2022. Record review of the AD's training history revealed the AD had not completed resident rights training in the last year. c. Record review of Staff Roster, dated 12/13/2022, revealed RN T was hired on 07/23/2020. Record review of RN T's training history revealed RN T had not…

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

Based on interview and record review, the facility failed to provide the required compliance and ethics training for 5 of 16 employees (CNA O, DM, AD, MDS, and RN T) reviewed for training, in that: The facility failed to ensure CNA O, DM, AD, MDS, and RN T completed compliance and ethics within the previous year. These failures could affect residents and place them at risk of poor care or victimization due to lack of staff training. Findings included: a. Record review of Staff Roster, dated 12/13/2022, revealed CNA O was hired on 03/21/2022. Record review of CNA O's training history revealed CNA O had not completed ethics training in the last year. b. Record review of Staff Roster, dated 12/13/2022, revealed the DM was hired on 09/06/2011. Record review of the DM's training history revealed the DM had not completed ethics training in the last year. c. Record review of Staff Roster, dated 12/13/2022, revealed the AD was hired on 06/20/2022. Record review of the AD's training history revealed the AD had not completed ethics training in the last year. d. Record review of Staff Roster,…

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

Based on interview and record review, the facility failed to provide mandatory effective behavioral health training for 8 of 16 employees (CNA O, DM, AD, MDS, RN T, LVN C, LVN F, and SS) reviewed for training, in that: The facility failed to ensure CNA O, the DM, the AD, the MDS, RN T, LVN C, LVN F, and the SS completed behavioral health training within the previous year. These failures could place residents at risk of not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being due to lack of staff training. The findings were: a. Record review of Staff Roster, dated 12/13/2022, revealed CNA O was hired on 03/21/2022. Record review of CNA O's training history revealed CNA O had not completed behavioral health training in the last year. b. Record review of Staff Roster, dated 12/13/2022, revealed the DM was hired on 09/06/2011. Record review of the DM's training history revealed the DM had not completed behavioral health training in the last year. c. Record review of Staff Roster, dated 12/13/2022, revealed the AD was hired on 06/20/2022.…

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 facilitate the inclusion of the resident or resident representative in the care planning process for 3 (Resident #68, #4, and #10) of 8 residents care plans reviewed, in that: The facility failed to include Resident's #68, #4, and #10 or resident representative in their Care Conference meeting. This failure could affect residents and place them at-risk by contributing to inadequate care. The findings included: Resident #68 Record review of the admission MDS assessment dated [DATE] revealed Resident #68 was a [AGE] year-old male admitted [DATE] with the primary admitting diagnosis of other neurological conditions related to stroke and dementia. Resident #68's summary BIMS score was 9, indicative of moderately impaired cognition. Record review of the Progress Note written by SS for Resident #68 dated 3/13/2023 at 11:25 AM revealed an attempt to reach Resident #68's responsible party but no indication that the care plan meeting was held, an attendance…

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 comprehensive care plan was reviewed and revised by the interdisciplinary team after there was an update for 1 of 39 residents (Resident #16) whose care plan was reviewed, in that: The facility failed to ensure Resident #16's care plan reflected full code instead of DNR. This failure could place residents at risk of receiving the incorrect care and cause health complications with subsequent illness. The findings were: Record review of Resident #16's face sheet, dated 05/04/2023, revealed the resident was re-admitted on [DATE] with diagnoses that included: schizoaffective, bipolar type, shortness of breath, dementia, and Parkinson's disease. Further record review revealed Do Not Resuscitate (DNR) as Yes. Record review of Resident #16's quarterly MDS assessment, dated 04/03/2023, revealed the resident had a BIMS score of 09, which indicated moderate cognitive impairment. Record review of Resident #16's care plan, reviewed 12/09/2021,…

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 residents were free of any significant medication errors for 1 (Resident #35) of 10 residents reviewed for safe administration of medications, in that: Resident #35 was administered 3, 300 mg capsules of Gabapentin when 1, 300 mg capsule of Gabapentin was ordered. This failure could place residents at risk of not receiving the intended therapeutic benefit of drugs and biologics, worsening or exacerbation of chronic medical conditions such as physiological and/or psychological addiction. The findings include: Record review of the quarterly MDS assessment dated [DATE] revealed Resident #35 was a [AGE] year-old female admitted [DATE] with traumatic brain dysfunction associated with cerebral infarction [stroke] as the primary medical condition category for admission. Her current BIMS summary score of 10 was indicative or moderately impaired cognition. Active diagnoses included anxiety disorder, depression. Pain assessment interview…

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.