Avir at Adams

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, receiving, dispensing and administering of all drugs and biologicals, to meet the needs of each resident for 2 of 4 medication carts (MA B's Medication Cart #1 and Medication Cart #2) and 4 of 6 residents (Resident #5, Resident #7, Resident #10, and Resident #19) reviewed for pharmacy services. 1. The facility failed to ensure MA B accurately reconciled Resident #5's narcotic medication log for Medication Cart #1 when she administered Resident #5's tramadol (controlled medication used for pain) 1 tablet two doses and Codeine/Acetaminophen (controlled medication used for pain) 1 tablets two doses on 6/18/25. 2. The facility failed to ensure MA B accurately reconciled Resident #7's narcotic medication log for Medication Cart #1 when she administered Resident #7's oxycodone (controlled medication used for pain) 1.5 tablets and lorazepam (controlled…

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, interviews, and record reviews the facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety. 1.The facility failed to maintain proper kitchen sanitation when the [NAME] did not follow proper hand hygiene protocols. 2.The facility failed to ensure residents were safe from potentially contaminated food when staff did not sanitize their hands between giving residents food. The deficient practice could place residents who were served from the kitchen at risk for health complications and foodborne illnesses. Findings Include: 1. Observation on 6/18/2025, at 9:30 AM, revealed that the Cook, after donning sanitized gloves, continued to prepare pureed noodles. While still wearing the same pair of gloves, she used three different kitchen utensils, a spatula, a serving spoon, and a whisk. She also touched the puree menu book, made notations using a pen, and opened the top of the puree machine to add liquid to the noodles, all without changing her gloves or sanitizing her hands. Furthermore, the [NAME] 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 that the resident medical records for two of six residents reviewed for wound care documentation (Resident #7 and Resident #21) were complete and accurately documented. 1. The facility failed to ensure that documentation of dressing changes provided to Resident #7 was accurate and completed on 06/09/2025, 06/11/2025, 06/13/2025, and 06/16/2025. 2. The facility failed to ensure that documentation of dressing changes provided to Resident #21 was accurate and completed on 06/18/2025 and 06/19/2025. This deficient practice could put the resident at risk of having inaccurate medical records and not receiving the ordered treatments and care. Findings: Review of Resident #7's Face sheet reflected a [AGE] year-old, female admitted to the facility on [DATE]. Diagnoses included: Schizoaffective Disorder, bipolar type (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or 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 observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for 1 of 1 facility reviewed for pests. 1.The facility failed to ensure the facility was free of gnats, and 2 roaches throughout the facility including resident rooms and resident restrooms 2. The facility failed to ensure the facility was free of bedbugs for Resident # 9. These deficient practices placed residents at risk of exposure to pests, diseases, infections, and diminished quality of life. The findings included: Record review of Resident # 9's admission face sheet dated 6/18/25 reflected a [AGE] year old female admitted on [DATE] and readmitted on [DATE] with diagnoses of unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning), anxiety (intense, excessive, and persistent worry and fear about everyday situations), abnormalities of gait and mobility, low back pain, depression (a group 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.

Based on observation, interviews, and record reviews, the facility failed to ensure the resident's right to secure and confidential personal and medical records for one (unknown resident) of 28 residents . The facility failed to ensure the privacy of the unknown resident by not locking the laptop screen, so the resident's information could not be seen by someone walking by. This failure put residents at risk for confidential health information exposure, psychosocial harm and decreased quality of life. Findings included: Observation on 6/16/2025 at 12:05 PM during lunch service revealed that the tablet on the medication cart was open and the screen had the resident's information on the laptop screen. The surveyor was watching lunch service and walked around the corner, and the laptop was open. The surveyor waited five minutes, and the staff member did not return to the medication cart. The laptop screen timed out, and the screen went dark after five minutes. In an interview on 6/19/2025 at 1:53 p.m., MA A stated you cannot leave the laptop screen open with residents' information on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review the facility failed to ensure the resident assessments accurately reflected the resident's status for 2 (Resident # 10 and Resident #7) of 8 residents reviewed for accuracy of assessments. 1. The facility failed to ensure Resident #10's Significant Change MDS assessment, dated 12/31/2024, completed Resident #10's preferences for customary routine and activities. 2. The facility failed to ensure that Resident #7's Significant Change in Status MDS assessment on 05/21/2025 accurately reflected that she had an unhealed pressure ulcer at the time of the assessment. This deficient practice could have placed the residents at risk for inadequate care and diminish quality of life due to inaccurate assessments. Findings included: 1. Review of Resident #10's Face Sheet, dated 06/18/2025, reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses unspecified dementia, unspecified severity, with agitation ( a group of symptoms…

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, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two of eight residents (Resident# 46, and Resident #59) reviewed for ADL care. The facility failed to ensure Resident #46's and Resident # 59's nails were cleaned, and did not have any rough edges. These failures could place residents at risk of not receiving services or care, diminished quality of life, and decreased self-esteem. Findings included: Review of Resident #46's face sheet, dated, 06/18/2025, reflected a [AGE] year-old male who was admitted on [DATE]. Resident #46 had diagnoses which included need for assistance with personal care ( helping individuals with activities of daily living like bathing, dressing, toileting, grooming, and eating), personal history of traumatic brain injury (occurs when external force impacts the head, causing damage to 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 observations, interviews, and record reviews the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive care plan for one (Resident #21) of one resident reviewed for nephrostomy care. The facility failed to ensure dressing changes were done for Resident #21's surgical sites on 06/18/2025 and 06/19/2025 and completed per the physician orders and with sterile technique per the facility policy. This failure puts residents at risk for infection and deterioration of the stoma site (a surgically created opening on the outside of your body that connects to an organ on the inside). Findings: Review of Resident #21's Face sheet revealed a [AGE] year-old, female admitted on [DATE]. Diagnoses included: Hydronephrosis (swelling of the kidneys from blockage of the flow of urine), Urinary Tract Infection, Chronic Kidney Disease, and Type 2 Diabetes (chronic disorder of abnormal blood sugar levels). Review of Resident #21'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 observations, interviews, and record reviews, the facility failed to ensure residents received services in the facility with reasonable accommodations of each resident's needs for 1 of 9 residents (Residents #1) reviewed for resident rights in that: The facility failed to ensure Residents #1's call light was answered in a timely manner. This failure could affect residents who needed assistance with activities of daily living and could result in needs not being met. Findings included: Record review of Resident #1's admission record dated 06/13/2025 documented a [AGE] year-old female admitted on [DATE]. Resident #1 had diagnoses which included: epilepsy (abnormal electricity activity in the brain), chronic obstructive pulmonary disease (group of lung disease that clock airflow and make it difficult to breathe), major depressive disorder(serious mental illness characterized by persistent sadness, loss of interest in activities and significant impairment in daily functioning), anxiety(intense, excessive,…

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 permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the discharge was necessary for the resident's welfare and the resident's needs could not be met in the facility for 1 of 9 residents (Resident #2) reviewed for discharge requirements. The facility failed to ensure Resident #2 was readmitted to the facility, after being sent to the hospital for behaviors. This failure could place discharged residents and residents residing in the facility at risk of being discharged and not allowed to return to the facility causing a disruption in their care and/or services. Findings included: A record review of Resident #2's face sheet dated 06/13/2025 reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2's diagnosis was Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), Unspecified asthma (a chronic disease in 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 observation, interview and record review the facility failed to provide, based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable for 3 of 8 resident (Residents #1, #2, and #3) reviewed for activities of daily living. The facility failed to ensure Residents #1, #2, and #3 were provided care and services for hygiene. This failure could place residents at risk for poor self-esteem, infections, socialization, ADL decline and diminished quality of life. Findings included: Record review of Resident #1's face sheet dated 01/17/2025, revealed Resident #1 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1 was diagnosed with Encephalopathy, unspecified (a brain disorder that affects brain function or structure, but the…

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

Based on observations, interviews, and record reviews, the facility failed to treat each resident with respect and dignity and care in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality, for 9 (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9) of 24 secure unit residents reviewed for dignity. The facility failed to ensure LVN A treated Residents #1, #2, #3, #4, #5, #6, #7, #8 and #9 who were sitting in the dining area in the memory care unit with dignity and respect when she referred to the residents' clothing protectors as bibs to CNA B. This failure could place residents at risk for psychosocial harm due to diminished self-esteem and quality of life. Findings included: An observation of the memory care unit's dining area on 12/11/24 at 5:00 p.m. revealed there were 9 residents sitting in the dining area and about to be served their dinner meal trays. LVN A was at the nursing station in the memory care unit's dining area where the 9 residents were sitting. CNA B was standing in the hallway…

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 establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for 1 (MA C) of 3 staff reviewed for authorized drug destruction personnel. The facility failed to ensure a licensed professional was a witness to the drug destruction. MA C witnessed and handled controlled and non-controlled medications during the drug destruction process with the DON. This failure could place residents at risk of drug diversion. Findings included: Record review of the facility's staff roster, dated 12/11/24, reflected MA C was a medication aide. Record review of the facility's controlled and non-controlled drug destruction forms, from 06/01/24 through 12/11/24, reflected the following: -MA C signed as a witness and the DON signed as a nurse to the non-controlled and over the counter drug destruction process on 10/08/24. There was no signature from the Pharmacist. -MA C signed as a witness and the DON signed as a nurse to the non-controlled drug destruction process…

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 food in accordance with professional standards for food service safety for 1 of 1 kitchens reviewed for kitchen sanitation. The facility failed to ensure dietary staff stored disposable plates and cups away from chemicals and cleaning supplies. This failure could place residents at risk of cross-contamination, food contamination, and foodborne illness. Findings included: An observation of the kitchen's cleaning supply room on 12/11/24 at 10:35 a.m., revealed there was an open box of Styrofoam cups next to a rack that had cleaning supplies stocked on each shelf. The room door was propped wide open with 1 gallon-sized bottle of concentrated alkaline degreaser and 1 gallon-sized bottle of concentrated alkaline floor cleanser. There was no dietary staff in or near the cleaning supply room. From top to bottom, the first shelf had 1 quart spray bottle of heavy duty degreaser and 1 quart spray bottle of bio-enzymatic odor eliminator hanging on the edge of the shelf. The second shelf had 1 open and half…

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, prepare, distribute, and serve food in accordance with professional standards for food service safely for 1 of 1 kitchen reviewed for food storage and labeling in that: 1.The facility failed to ensure food and beverages were safely stored, labeled, and dated. in refrigerator #1, refrigerator #2, and freezer #1, freezer #2 and in the dry storage area on 05/14/24. 2.The facility failed to ensure kitchen staff DC #2 and DC #3 were properly wearing hair nets and properly wearing and changing gloves on 05/14/2024 and 05/15/2024. These deficient practices could place residents at risk of foodborne illness. The findings included: Observation of Refrigerator #1: At 8:35am on 5/14/2024 revealed a one gallon of milk labeled with an expiration date of 5/21/2024 did not contain an opened-on date. At 8:35am on 5/14/2024 revealed a one-gallon plastic container of dill pickles that did not contain an opened-on and use-by date. At 8:35am on 5/14/2024 revealed a white plastic container with plastic wrap placed…

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 treat residents with respect and dignity and care for them in a manner and in an environment that promoted maintenance or enhancement of their quality of life for 3 (Residents #5, #28, and #29 ) of 16 residents reviewed for resident rights. 1.The facility failed to treat Resident #28 with respect and dignity on 5/14/2024 during the Hoyer transfer to keep her body covered. 2.The facility failed to treat Resident # 5 with respect and dignity on 5/14/2024 during wound care, by not closing the door to the room or pulling the privacy curtain. 3.The facility failed to treat Resident's # 5 on 5/14/2024 and # 29 on 5/17/2024 by always keeping a privacy bag on the foley drainage bag. These failures could place residents at risk for decreased quality of life, decreased self-esteem and increased anxiety. Findings included: Review of Resident # 5's face sheet dated 5/16/2024 revealed a [AGE] year-old-female admitted [DATE] with diagnosis that…

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 a safe, functional, sanitary, and comfortable environment for 5 (Rooms 28, 32, 34, 36, and 64) of 20 resident rooms reviewed for environment. The facility failed to ensure the ceiling tiles in rooms [ROOM NUMBERS] were free from stains and drooping on 05/14/24, 05/15/24, and 05/16/24. The facility failed to ensure the blinds in rooms 28, 32, 36, and 64 were free from missing slats on 05/14/24, 05/15/24, and 05/16/24. These failures could place residents at risk of living in an unsafe, unsanitary, and uncomfortable environment, lack of privacy, and diminished quality of life. Findings included: Observation of room [ROOM NUMBER] on 05/14/24 at 9:02 AM revealed slats missing from the blinds. During an observation and interview on 05/14/24 at 11:57 AM, room [ROOM NUMBER] revealed three ceiling tiles with stains and one of the tiles was drooping. LVN A stated when she saw a problem, she reported it to the maintenance man but if it 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 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 of 4 (Residents # 5, Resident # 10, Resident # 24 and Resident # 58) of 24 reviewed for comprehensive care plans. 1.The facility failed to ensure Resident # 5's care plan dated 5/3/2024 was resident by behaviors, mood and medication documented brief and generic. 2.The facility failed to ensure Resident # 10's care plan dated 4/11/2024 reflected his pain and interventions to ensure resident had the best possible quality of life. 3.The facility failed to ensure Resident # 24's care plan dated 4/11/2024 was individualized to meet resident needs and preferences. 4.The facility failed to ensure Resident # 58's care plan dated was individualized to resident needs 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 interview and record review the facility failed to ensure the resident's drug regimen was free from unnecessary psychotropic medications for 1 of 5 residents (Resident #58) reviewed for unnecessary psychotropic medications. The facility failed to ensure Resident #58's order, dated 05/03/24, for the psychotropic medication lorazepam (an anti-anxiety medication) PRN was not ordered beyond 14 days without an end date. The facility failed to ensure Resident #58 was monitored for side effects and behaviors related to the use of Abilify (an antipsychotic medication) from 04/23/24 through 05/17/24, and lorazepam (an anti-anxiety medication) from 05/03/24 through 05/17/24. These failures could place residents at risk for receiving unnecessary medication, unwanted side effects, and decreased quality of life. Findings included: Review of Resident #58's admission MDS assessment dated [DATE], Section A (Identification Information) reflected a [AGE] year-old female admitted to the facility 04/12/24. Section I…

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 that residents were free of a medication error rate of 5% or greater (10.34%) for 3 (Resident #1, Resident #50, and Resident #54) of 5 residents reviewed for medication administration. 1) The facility failed to ensure LVN A primed the insulin pen prior to administering insulin to Resident #1 on 05/14/24. 2) The facility failed to ensure MA E administered Senna 8.6mg as ordered instead she gave Senna-S 8.6mg/50mg to Resident #50 on 05/15/24. 3) The facility failed to ensure LVN B primed the insulin pen prior to administering insulin to Resident #54 on 05/15/24. These failures placed residents at risk of incorrect doses and not receiving the intended therapeutic benefit of the medications prescribed by the physician. Findings included: 1) Review of Resident #1's quarterly MDS assessment dated [DATE] Section A (Identification Information) reflected a [AGE] year-old female admitted to the facility 07/12/06. Section I (Active…

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 in accordance with state and federal laws, all drugs and biologicals were stored in locked compartments, under proper temperature control and labeled in accordance with currently accepted professional principles for 1 (medication room [ROOM NUMBER]) of 2 medication storage rooms and 2 (medication cart #1 and medication cart #2) of 4 medication carts reviewed for medication storage. Medication cart # 1 was left unattended and unlocked on 05/15/2024. Medication Cart #2 was left unattended and unlocked on the secure unit on 05/14/2024. An expired, opened and accessed, medication was stored in the medication room [ROOM NUMBER] refrigerator on 05/15/2024. This failure could allow residents unsupervised access to prescription and over the counter medication and can result in the resident receiving ineffective medication due to expired medications. Findings included: Observation on 5/14/2024 at 10:11 am revealed Medication cart # 2 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 observations and interviews, the facility failed to prepare food and drink that are palatable, attractive and at a safe and appetizing temperature for two of three meals sampled in that: The facility failed to provide food that was palatable (vegetables with no flavor or seasoning) at a safe and appetizing temperature (sample tray was luke warm.] . This failure could place residents at risk of not being satisfied with their food, decreased food intake, unintended weight loss, hunger, poor nutrition, impeded recovery from illness and injury and diminished quality of life. Findings included: An observation on 5/15/2024 at 12:05pm in the kitchen revealed a tray of pre-seasoned garlic bread cooked in the oven. Sitting beside a toast oven, was another metal tray which contained stacks of toasted, white bread, which was over-cooked and was deep brown/black in color. An interview on 5/15/2024 at 12:10pm DC #2, said they did not have enough of the frozen, pre-seasoned garlic bread and had substituted 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 observation, interview, and record review, the facility failed to provide food prepared in a form designed to meet individual needs for two of three meals sampled. The facility failed to ensure the puree texture was in a form (pudding like consistency that was smooth) to meet resident needs for two of three lunch meals on (5/14/2024 and 5/15/2024) sampled by two (Surveyor # 2 and Surveyor #3) of four survey team members . These failures could place residents at risk of decreased food intake, choking and aspiration. . The finding included: On 5/14/2024 @ 1:10pm an observation of pureed sample meal by two (Surveyor #2 and Surveyor #3) of four survey team members . The pureed meal consisted of Cajun sausage and beans, white rice, breaded okra, a baked roll, and bread pudding. Both team members agreed the sausage and beans had a good flavor but contained small pieces of sausage that required chewing prior to swallowing. The rice had a suitable texture and lacked flavor or seasoning. The okra, bread, and dessert had appropriate puree texture. On 5/14/2024 @ 1:30pm 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 establish and maintain an infection prevention and control program, designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable disease and infections in 14 ( Residents # 5,#9,#10, #23,#26,#28,#29,#31,#33, #41, # 58, # 61, and # 66) of 23 residents that were reviewed for infection control and transmission-based precautions policies and practice in that: 1.The facility failed to ensure CNA I, MA J, MA K, CNA L and ST did not grab Resident's 9 (Resident #9, # 23. #26, # 29 #31, # 33, #41, #61, and #69) of 23, cup by the rim with bare hands, contaminating the tops of the rims, during the meal service on the secure unit on 5/12/2024 and 5/13/2024 at lunch time. 2.The facility failed staff failed to follow hand hygiene 3(resident # 5, 10, and 28) of 23 A. on 5/14/2024 at 11:00 am ADON did not use Proper hand hygiene and wound care techniques while performing wound care on Resident # 5. B.…

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 pain management was provided to residents who require such services, consistent with professional standards of practice, pain management services for 1 of 6 residents reviewed for pain. (Resident #10) The facility failed to ensure Resident # 10 received his scheduled Oxycodone 5mg every 4 hours for 5/11/2024 at noon to 5/13/2024 at 12:00am for a total of 13 doses. The facility failed to obtain an alternative medication for Resident #10's pain, until 5/12/2024 with the initial dose being given at 7:32 pm leaving Resident #10 in pain for over 24 hours. This failure placed residents at risk of increased pain and decreased quality of life. Findings included: Review of Resident # 10 face sheet dated 5/16/2024 revealed a [AGE] year-old male, admitted on [DATE] with diagnosis that include Chronic Obstructive pulmonary disease (a group of lung disease that block airflow and [NAME] if difficult to breathe), Pain unspecified (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 provide routine dental services to 1 of 2 (Resident #1) residents reviewed for dental services. The facility failed to provide routine dental services for Resident #1, since admission on [DATE], who was being treated for an oral infection. This failure could place residents at risk for decline in oral health, oral infections, and decreased quality of life. Findings included: Review of Resident #1's quarterly MDS assessment dated [DATE] Section A (Identification Information) reflected a [AGE] year-old female admitted to the facility 07/12/06. Section I (Active Diagnoses) reflected diagnoses including diabetes mellitus (a condition that affects the way the body processes blood sugar), anemia (lack of red blood cells in the blood), hypertension (high blood pressure), dementia, anxiety (intense and excessive worry and fear), and schizophrenia (a disorder that is marked by a combination of symptoms, such as hallucinations or 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 care for residents in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for one of one resident (Resident #1) reviewed for resident rights. The facility failed to ensure Resident #1's bed was moved, per request, as outlined in his care plan, to allow him for more space. This failure could place the residents at risk for depression and unmet needs. Findings include: Review of Resident #1 quarterly MDS assessment, dated 10/26/2023, reflected an [AGE] year-old male who was admitted on [DATE] and had a BIMS score of 14, which indicated cognitive intactness . Review of Resident #1's care plan, last reviewed and revised 10/19/2023, reflected the following: Problem Start Date: 06/01/2022 Resident requests that his bed be against the wall to allow for more space in room. Edited: 10/19/2023 Goal Target Date: 01/20/2024 Requests will be honored. Edited: 10/19/2023 Approach Start Date: 06/01/2022…

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 follow their policy and ensure five (5) of five (5) residents (Resident #1, Resident #2, Resident #4, Resident #5 and Resident #6) reviewed for notification of room change, received written notice prior to a room change. The facility failed to ensure Resident #1, Resident #2, Resident #4, Resident #5 and Resident #6 received written notice prior to a room change. This facility failure placed all residents at risk for being displaced without notice and/or reason in order to accommodate other individuals. Findings included: Review of Resident #1's Face Sheet dated [DATE], revealed a [AGE] year-old women admitted on [DATE] with diagnoses that included: vascular dementia (progressive loss of intellectual functioning), Hypertension (high blood pressure), Insomnia (sleeping disorder), Anxiety disorder, Hyperlipidemia (high cholesterol) and senile degeneration of brain (a decrease in the ability to think, concentrate or remember). Revie of Resident #1's MDS…

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 store, prepare, distribute and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for food service safety. The Dietary Manger failed to ensure all items were stored properly, labeled, dated, and discarded prior to their expiration date. The Dietary Manger failed to ensure the handwashing sink was stocked with paper towels. CK J failed to properly wash her hands between tasks. These failures placed residents at risk of foodborne illness. Findings included: An observation on 3/21/2023 at 10:00 a.m. revealed the kitchen's handwashing sink was not stocked with paper towels. Observations of the reach-in refrigerator on 3/21/2023 from 10:02 a.m. - 10:14 a.m. revealed the following: At 10:02 a.m., the reach-in refrigerator contained a plastic sealable bag of unidentifiable meat patties dated 3/20/2023. At 10:03 a.m., the reach-in refrigerator contained a plastic storage container of mixed fruits without a label or date. At 10:04 a.m., the reach-in refrigerator…

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 a homelike environment for ten (Resident #3, Resident #11, Resident #13, Resident #15, Resident #20, Resident #23, Resident #44, Resident #49, Resident #55, and Resident #58) of 24 residents reviewed for a clean, comfortable, and organized environment. Window blind slats were missing from the blinds for residents #3, #11, #13, #15, #20, #23, #49, #55, and number 58. The Smoking area for residents #13, #44, and #55 was not cleaned and organized Ceiling tiles were missing from the outside hallway to the main central nurse's station. The failure could result in a diminished quality of life and prevent these residents from attaining their highest practicable well-being. Findings included: A record review of Resident #3's face sheet dated 3/23/2023 reflected an [AGE] year-old male admitted to the facility on [DATE] with diagnoses of vascular dementia (memory loss), lumbago with sciatica (lower back pain), acute kidney failure,…

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 follow the menu for three (Resident #15, Resident #17, and Resident #41) of eight residents reviewed for portion size adequacy. CK J served Resident #15, Resident #17, and Resident #41 pureed food items using scoops smaller than required per the facility's menu. This failure placed residents at risk of poor intake, weight loss, and malnutrition. Findings included: A record review of Resident #15's face sheet dated 3/23/2023 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of fracture of right femur (broken thigh), unspecified dementia (memory loss), Alzheimer's disease (type of dementia), moderate protein-calorie malnutrition (low body weight), abnormal weight loss, gastro-esophageal reflux disease (acid reflux), muscle wasting (muscle loss), chronic kidney disease, dysphagia (difficulty swallowing), major depressive disorder (depression), hyperlipidemia (high cholesterol), cachexia (unintentional weight…

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 all residents received food and drinks that accommodated their preferences for four (Resident #11, Resident #14, Resident #17, and Resident #41) of eight residents reviewed for food and drink preferences. 1. TNA H failed to provide coffee requested by Resident #11. 2. Dietary staff failed to provide Resident #14 with ice cream per his tray ticket and physician's order. 3. LVN B failed to offer Resident #41 an additional helping of food when he finished his plate and was still hungry. 4. Nursing staff failed to offer Resident #17 an additional helping of food when she finished her plate and appeared still hungry. These failures placed residents at risk of hunger and not receiving their food and drink preferences. Findings included: A record review of Resident #11's face sheet dated 3/24/2023 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of vascular dementia (memory loss), hypertension (high blood…

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 was treated with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for two of two residents (Residents #17 and Resident #15) reviewed for resident rights. The facility failed to ensure Resident #15 and Resident #17 were fed by a staff member sitting at eye level rather than standing over them. This failure could place residents at risk for a diminished quality of life, loss of dignity and self-worth. Findings included: A record review of Resident #15's face sheet dated 3/23/2023 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of fracture of right femur (your thigh bone), unspecified dementia (memory loss), Alzheimer's disease (type of dementia), moderate protein-calorie malnutrition (low body weight), abnormal weight loss, gastro-esophageal reflux disease…

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 and prevention control program that included, at a minimum, a system for preventing and controlling infections for 1 of 2 residents reviewed for medication administration (Resident #62) and for 1 of 1 resident (Resident #169) reviewed for incontinent care as indicated by: MA E failed to properly sanitize blood pressure cuff when moving from one resident to another resident when administering medications and obtaining blood pressure for Resident #62. CNA G failed to wash or sanitize her hands while going from a dirty to clean surface when performing incontinent care on Resident #169. This deficient practice placed all residents identified at risk for cross contamination and the spread of infection. Findings included: Record Review of Resident #62's face sheet dated 03/23/23 reflected Resident #62 was a [AGE] year-old male with an admission date of 09/27/22. Resident #62's diagnoses included Parkinson's Disease (long…

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.