Avir at Sherman

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety for the facility's only kitchen in that: 1. The facility failed to ensure food items in the facility freezer were dated or labeled. 2. The facility failed to ensure during lunch service kitchen staff used proper hand hygiene while serving residents' trays on 6/3/25. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness if consumed and food contamination. Findings Include: Observation of freezer in the kitchen and interview with Dietary Manager on 06/03/25 beginning at 9:16 am: -clear opened to the air plastic bag with about 25 corn dogs, in an unsecured box labeled corn dogs. Dietary Manager stated the bag should be closed and proceeded to close it by making a knot on top. -clear opened to the air, plastic bag with about 30 1.5-inch circular disc inside…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for four (Resident #70, Resident #66, Resident #19, and Resident #61) of seven residents observed for infection control. 1. The facility failed to ensure LVN A used the required PPE for Resident #70, who was on enhanced barrier precautions due to her venous access device, while administering resident IV antibiotics on 06/04/25. 2. The facility failed to ensure LVN A and LVN B decontaminate the glucometers which were used to obtain a fingerstick blood sugar on Resident's #70 and Resident # 66 when they failed to allow the glucometer that was sanitized with a germicidal wipe to air dry before returning the glucometer to the medication cart and laying it on top other supplies inside the medication cart. 3. The Facility failed to…

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 therapeutic diet when ordered by the physician to maintain adequate nutritional status, to the extent possible to maintain acceptable parameters of nutritional status for 1 of 18 residents (Resident #227) reviewed for nutrition: The facility did not ensure Resident #227's diet was consistent with physician's order on 5/8/25 for Diabetic Diet. This failure could place the resident at risk for weight loss and further decline in health. Findings included: Review of Resident #227 admission Minimum Data Set (MDS) Assessment, dated 5/13/25, reflected she was a [AGE] year-old female with an admission date of 5/6/25. Resident #227 had no impairment to her cognition and had a BIMS score of 15. The resident was to have a therapeutic diet while a resident at the facility. She had the following diagnoses: Diabetes (a group of diseases that result in too much sugar in the blood), Malnutrition, Anemia (a condition marked by a deficiency of red…

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 residents who require dialysis receive such services, consistent with professional standards of practice, for one (Residents #177) of one resident reviewed for dialysis. The facility nursing staff failed to document and assess Resident #177's returning vital signs, access site, and mental status after Resident #177 returned from dialysis treatment on 05/27/25, 05/31/25, and 06/03/25. This failure places residents in the facility who received dialysis at risk of not receiving proper care and coordination of care. Findings included: Record review of Resident #177's Comprehensive MDS, dated [DATE], reflected she was a [AGE] year-old female admitted to the facility admitted on [DATE] with the diagnoses of anemia (low iron), kidney disease, heart failure, and diabetes (high blood sugar) with a BIMS score of 15 (intact cognition). Resident #177 required dialysis services. Record review of Resident #177's care plan, dated 06/03/25 reflected 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 ensure a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder, receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for one of two (Resident #43) reviewed for behavioral health services. The facility failed to ensure Resident #43 received his ongoing psychiatric services. Resident #43's last psychiatric appointment provided was on 01/29/25. This failure could place residents at risk for not receiving behavioral health services and a decline in quality of life. Findings Included: Record review of Resident #43 quarterly MDS assessment dated [DATE] reflected a [AGE] year-old male with an admission date of 12/01/19. Resident #43 had a BIMS of 15 which indicated he was cognitively intact. There were no behaviors, signs of delusions 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 observation, interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring and administering of all medications to meet the needs of each resident for one of five residents (Resident #70) reviewed for pharmacy services. The facility failed to ensure LVN A followed the manufacturer's instructions to prime (means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly) the Humalog pen (Insulin Lispro) (Hormone) prior to dialing in required amount of Insulin to be administered to Resident #70. These failures placed residents at risk of not receiving full dosage of medication. Findings included: Record review of Resident #70's, Face sheet, dated 06/05/25 reflected a [AGE] year-old female with a readmission date of 05/08/25. Resident #70 had a diagnosis which included Type 2 diabetes (condition where the body cannot control blood sugar and use it for energy)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure all drugs were only accessible by authorized personnel, for 1 of 6 residents (Resident #71) reviewed for medication storage. The facility failed to ensure Resident #71 did not have a medication named BioFreeze (a topical analgesic) at Resident #71's bedside table on 06/03/25. This failure could place residents at risk of having access to medications, resulting in harm, misuse of medication, drug diversions, and adverse reactions to medications due to improper storage. Findings included: Record review of Resident #71's Quarterly MDS, dated [DATE], reflected she was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure), dementia (loss of cognition), and cervical disc myelopathy disorder (compressed spinal cord in the neck), with a BIMS score of 14 (intact cognition). Record review of Resident #71's care plan revealed no indication regarding her ability to…

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 the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident#3) of 7 residents reviewed for ADLs. The facility failed to ensure Resident #3's nails were cleaned and trimmed on 04/16/2025. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Findings included: Record review of Resident #3's Face Sheet dated, 04/16/25, reflected a [AGE] year-old male admitted on [DATE] with diagnoses of myocardial infarction (heart attack), contracture ( the abnormal shortening of muscles, tendon, skin or ligaments leading to a fixed tightening that restricts normal movement), of left hand and left shoulder, and hemiplegia and hemiparesis (paralysis and weakness on one side of the body). Record review of Resident #3's MDS assessment 04/02/25, reflected…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 2 (Resident #1 and Resident #2) of 4 residents reviewed for infection control. 1. The facility failed to ensure LVN A disinfected the blood pressure cuff in between blood pressure checks for Residents #1 and #2 on 04/16/2025. This failure could place residents at-risk of cross contamination which could result in infections or illness. Findings included: Record review of Resident #1's Quarterly MDS assessment, dated 1/1/2025, reflected Resident #1 was an [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included coronary artery disease (Damage or disease in the heart's major blood vessel), Hypertension, and Diabetes. Resident #1 had a BIMS of 12 which indicated Resident #1 cognition was moderately impaired.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 (Resident #13, Resident #40) of 8 residents reviewed for ADLs. The facility failed to ensure: 1- Resident #13 had her fingernails cleaned and trimmed. 2- Resident #40 had his fingernails cleaned and trimmed. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Findings include: 1- Resident #13 Review of Resident #13's Annual MDS assessment dated [DATE]/2023 reflected Resident #13 was a [AGE] year-old female with initial admission date to the facility on [DATE]. Her diagnoses included coronary artery disease (chronic condition of plaque buildup in heart), hypertension (high blood pressure), heart failure (heart doesn't pump enough blood for body needs), Renal insufficiency (poor…

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 the facility's only kitchen: 1. The facility failed to ensure food items in the facility refrigerator, freezer and dry storage were covered and dated. 2. The facility failed to ensure [NAME] A used appropriate hair restraint in the kitchen. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness if consumed, and food contamination. Findings included: Observation in facility's walk-in refrigerator on 05/21/24 at 9:31 AM revealed a packet of hot dog did not had an expiration date on them. Observation in facility's dry storage on 5/21/24 at 9:36 AM revealed a packet of tortilla in plastic bag did not had used-by date and a packet of cornflakes that was left open without an use-by date marked on it. Observation in facility's freezer on 5/21/24 at 9:32 AM revealed a packet of bread did not had an expiration date.…

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 label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 (200 hall nurses' medication cart) of 3 medication carts reviewed for pharmacy services. The facility failed to ensure the 200 Hall medication cart had: 1- 1 insulin pen for Resident #175 with an expired opened date. 2- 1 insulin pen for Resident #17 with an expired opened date. These failures could affect residents resulting in diminished effectiveness, and not receiving the therapeutic benefits of the medications. The findings include: 1- Record review of Resident #175's Comprehensive MDS, dated [DATE], revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses included type 2 diabetes mellitus and hyperlipidemia (too many lipids and fats in the blood). She had a BIMS score…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for one of five residents (Resident #24) observed for infection control. Facility failed to ensure CNA D performed hand hygiene while providing incontinence care to Resident # 24. This failure could place the residents at risk for infection. Findings include: A record review of Resident #24's Quarterly MDS assessment, dated 04/30/2024, reflected Resident #24 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included type 2 diabetes mellitus, need for assistance with personal care, and dementia (condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). Resident #24 had a BIMS of 07 which indicated Resident #24's cognition was severely impaired.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received necessary services to maintain good personally hygiene for 4 out of 5 residents (#1, #3, #4, and #5) reviewed for ADL care. The facility failed to provide timely incontinence care every two hours or as needed for Resident #1 on 4/22/24. The facility failed to provide timely incontinence care on a regular basis for residents #1, #3, #4, and #5. This failure could place residents at risk of skin breakdown, urinary tract infections, and loss of dignity. Findings included: 1) Record review of Resident #1's face sheet revealed a [AGE] year-old female, admitted on [DATE]. Diagnoses included: Blindness of right eye category 3, blindness of left eye category 5, ankylosing spondylitis (autoimmune disease that includes pain and stiffness in the spine and may affect other joints), atrophic disorder of skin (a reduction in epidermal and dermal thickness of skin), mild…

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 notify the resident and the resident's representative of the discharge with the reasons for the discharge in writing, send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman; and failed to record the reasons for the discharge in the resident's medical record for 1 (Residents #1) of 3 residents reviewed for transfer and discharge requirements. 1. The facility failed to initiate a 30-day discharge notice to Resident #1 and ombudsman on 08/28/23 when facility made decision based on inability to meet resident's needs not to readmit Resident #1 to the facility from the hospital. 2. The facility failed to have written documentation of facility's decision to not readmit Resident #1 from the hospital in resident's medical record. This failure could result in residents being discharged without appropriate reasons and documentation communicated to help with the transition of care. Findings included: Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to establish and follow a written policy on permitting residents to return to the facility after they were hospitalized for 1 (Resident #1) of 3 residents reviewed for transfer/discharge requirements. The facility failed to establish and follow a policy to address Resident #1's request to return to the facility after a hospitalization when facility initiated discharge on [DATE]. This failure could result in residents being discharged without appropriate reasons and documentation communicated to help with the transition of care. Findings included: Review of Resident #1's face sheet printed 09/20/23 reflected Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of cirrhosis of liver (permanent scarring that damages liver), diabetes, arthritis, uropathy (blockage in urinary tract), and kidney failure. Resident #1 was his own responsible party and had been discharged from the facility. Review 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 interview and record review, the facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, for 2 of 2 residents who were involved in reportable incidents where there was an abuse or neglect allegation (Resident #47, and #56). The facility did not implement their abuse/neglect policy related to reporting and investigating allegations within time frames required by federal requirements when 2 residents were involved in altercations with other residents (Residents #47 and #56). This failure could place residents in the facility at risk for abuse and neglect. The findings included: Resident #47 Review of an undated face sheet revealed that Resident #47 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of stroke, high cholesterol, left-sided paralysis, contracture of left hand and shoulder, generalized muscle weakness, lack of coordination, 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 record review and interview, the facility failed to ensure that all alleged violations involving abuse or neglect were reported immediately, but not later than 24 hours after the allegation was made for 2 of 2 residents who were involved in reportable incidents where there was an abuse or neglect allegation (Residents #47, and #56). The facility failed to timely report an allegation of resident abuse after the allegation was made to the administrator. This failure could affect all residents by placing them at risk of abuse if the reportable allegations are not reported timely after they are discovered. The findings included: Resident #47 Review of an undated face sheet revealed that Resident #47 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of stroke, high cholesterol, left-sided paralysis, contracture of left hand and shoulder, generalized muscle weakness, lack of coordination, vascular dementia (reduced blood flow to brain causing impaired memory and thinking), major…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that all alleged violations involving abuse and neglect were thoroughly investigated, and failed to report the results of all investigations to HHSC within 5 working days of the incident for 2 of 2 residents who were involved in reportable incidents where there was an abuse or neglect allegation Residents #47, and #56). The facility failed to properly investigate allegations of abuse or neglect for Residents #47, and #56. This failure could place residents at risk of allegations not being investigated. The findings included: Resident #47 Review of an undated face sheet revealed that Resident #47 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of stroke, high cholesterol, left-sided paralysis, contracture of left hand and shoulder, generalized muscle weakness, lack of coordination, vascular dementia (reduced blood flow to brain causing impaired memory and thinking), major depressive disorder, non-pressure ulcers 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, interview and record review, the facility failed to develop and implement comprehensive person-centered care plans for each resident 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 three (Residents #26, #44 and #52) of 24 residents reviewed for comprehensive care plans. 1. The facility failed to ensure Resident #26's contractures (permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) in her legs and preference to stay in bed were care planned for Resident #26. 2. The facility failed to ensure Resident #44's lower extremities impairment was care planned for Resident #44. 3. The facility failed to ensure Resident #52's right side limited range of motion was care planned for Resident #52. These failures could place residents at risk of not receiving individualized care and services to meet…

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 the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 3 (Resident #13, Resident #45, Resident #54) of 8 residents reviewed for ADLs. The facility failed to ensure: 1- Resident #13 had his fingernails trimmed. 2- Resident #45 had his fingernails trimmed and cleaned. 3- Resident #54 had his fingernails cleaned This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Findings include: 1- Review of Resident #13's Quarterly MDS assessment dated [DATE] reflected Resident #13 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses included dementia (loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), muscle weakness, and lack 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 observations, interviews, and record reviews the facility failed to ensure a medication error rate below 5% for t of six Residents (Resident #60 and #62) reviewed for medication administration errors. Facility failed to ensure the medications were administered per the physician orders for Resident #60 and #62. 28 medications were administered, two of the medications administered were late. This failure could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. The findings included: A record review of Resident #60's Quarterly MDS assessment dated [DATE], revealed Resident #60 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including elevated blood pressure, muscle weakness, and dementia. Resident #60 had a BIMS of 12 which indicated Resident #60 was cognitively moderately impaired. A record review of Resident #60's physician's orders dated 3/29/23 revealed Resident #60 was to receive metoprolol tartrate tablet; 25…

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

Based on observation, interview and record review the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, administering, and securing of medications for 1 medication carts (300 hall medication aide cart) of 2 medication carts reviewed for pharmacy services in that: The facility failed to ensure medications in unsecure containers were immediately removed from stock. These failures could place residents at risk of not having the medication available due to possible drug diversion and at risk of not receiving the intended therapeutic benefit of the medication. Findings Included: An observation on 03/28/2023 at 11:45 AM of the Medication Aide Cart Hall 300 revealed the blister pack for Resident #12's clorazepate 15 mg tablet (controlled medication used for anxiety) had 1 blister seal broken and the pill was still inside the broken blister and taped over. In an observation and interview on 03/28/23 at 11:45 AM, MA C stated she was unaware when the blister pack seal was broken, and she was not aware of who might have damaged the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for one of five residents (Resident #17) observed for infection control. Facility failed to ensure CNA E perform hand hygiene while providing incontinence care to Resident # 17. This failure could place the residents at risk for infection. Findings include: A record review of Resident #17's Comprehensive MDS assessment dated [DATE], revealed Resident #17 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including elevated blood pressure, dementia, and depression. Resident #17 had a BIMS of 14 which indicated Resident #17 was cognitively intact. Resident #17 was incontinent of bowel and bladder. Observation on 03/29/23 at 9:58 AM revealed CNA E providing incontinent care to Resident #17. CNA E was observed completing hand hygiene before care, then she informed the resident she was providing incontinent care.…

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.