Avir at Citizens Trail

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable environment for 2 of 8 residents (Resident #51 and Resident #2) reviewed for a homelike environment. 1. The facility failed to ensure Resident #51's pillow had a pillowcase on it on 09/22/25 and 09/24/25. 2. The facility failed to ensure Resident #2's fitted sheet did not have reddish-brownish particles and multiple brown stains on it on 09/23/2025 and 09/24/2025. These failures could place residents at risk for an uncomfortable, unhomelike environment, and a diminished quality of life. Findings included: 1. Record review of Resident #51's face sheet, dated 09/15/25, indicated an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #51 had diagnoses which included senile degeneration of the brain (progressive decline in cognition), impulse disorder (mental health disorder that makes it difficult to resist urges and behaviors), depressive disorder (group of conditions that lower…

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 transfer or discharge of a resident was documented in the resident's medical record and appropriate information was communicated to the receiving health care institution or provider for 2 of 4 residents (Resident #8, Resident #54) reviewed for discharge. The facility failed to provide transfer and discharge documentation in the EMR for Resident #8 and Resident #54 to include a physician's orders, reason for discharge or a discharge summary. This failure could place residents at risk of an unsafe discharge.The findings include: 1. Record review of Resident #8's electronic face sheet, dated 09/23/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with hospitalizations on 07/28/2025, 08/05/2025, 08/26/2025, and 09/18/25 and re-admissions on 07/30/2025, 08/06/2025, 08/29/2025, and 09/20/2025. Resident #8 had diagnoses which included: End stage renal disease (a condition in which the kidneys lose the 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, interviews, and record review, the facility failed to ensure the services provided, as outlined by the comprehensive care plan, met professional standards of quality, for 1 of 7 residents (Resident #2) reviewed for services provided to meet professional standards. The facility failed to ensure RN A administered Resident #2's Humalog KwikPen (insulin medication) according to the manufacturer's instructions. This failure could place residents at risk of inaccurate drug administration and not receiving the care and services to meet their individual needs. Findings included:Record review of Resident #2's face sheet, dated 09/23/25, reflected Resident #2 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included Type 2 diabetes mellitus (lifelong condition where the pancreas makes little or no insulin, which leads to high blood sugar levels) with diabetic nephropathy (complication of diabetes mellitus that affects the kidneys). Record review of Resident #2…

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 was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 1 of 2 residents (Resident #4) reviewed for ADLs. The facility failed to ensure Resident #4's facial hair was removed. This failure could place residents at risk of not receiving services and care, and a decreased quality of life.Findings included: Record review of Resident #4's face sheet dated 09/15/2025 indicated she was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included multiple fractures of the pelvis and dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life). Record review of Resident #4's Comprehensive MDS assessment dated [DATE] indicated she understood others and was understood. The MDS assessment indicated Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure based on the comprehensive assessment of a resident, the residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 2 (Resident #41) residents reviewed for quality of care. The facility failed to ensure the Treatment Nurse conducted a skin assessment on 09/22/2025, after she was notified that Resident #41 had newly identified redness under both breasts. This failure could place residents at risk for not receiving appropriate care and treatment, a decreased quality of life, and pressure ulcers. Findings included: Record review of Resident #41's face sheet dated 09/15/2025 indicated she was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Alzheimer's Disease (progressive disease that destroys memory and other important mental functions), cerebral palsy (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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this was not possible or resident preferences indicate otherwise for 2 of 14 residents (Resident #4 and Resident #57) reviewed for nutrition and hydration. 1. The facility failed to provide fluids for Resident #57 to ensure adequate nutrition. 2. The facility failed to ensure Resident #4's RD recommendation for Boost VHC (nutritional supplement) four times a day was implemented, after it was recommended due to weight loss on 08/22/2025. These failures could place residents at risk for compromised hydration, malnourishment, illness, skin breakdown, and decreased quality of life.Findings include: 1. Record review of Resident #57's electronic face sheet, dated 09/24/25, revealed an [AGE] year-old male originally admitted to the facility on [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 ensure, based on a resident's comprehensive assessment, a resident was fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 of 2 residents (Resident #17) reviewed for enteral nutrition. The facility failed to ensure Resident #17 received Isosource 1.5 (liquid nutrition tube-feeding formula) as ordered by the physician on 09/22/2025. This failure could place residents at risk of weight loss, nutritional imbalances, and health complications.Findings included: Record review of a face sheet dated 09/15/2025 indicated Resident #17 was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included cerebral infarction (damage to tissues in the 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 a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 residents (Residents #30) reviewed for respiratory care. 1. The facility failed to ensure Resident #30's oxygen filter was clean in the back of the concentrator on 09/22/25-09/24/25. 2. The facility failed to ensure Resident #30's oxygen tubing and water was dated, on 09/22/25. 3. The facility failed to ensure Resident #30 had an order in place to ensure oxygen tubing and water were changed and dated, and the filter was cleaned weekly on Sundays. These failures could place residents at risk for respiratory infections and exacerbation of respiratory disease. Findings included:1. Record review of Resident #30's face sheet, dated 09/15/25, indicated a [AGE] year-old-male who was admitted to the facility on [DATE]. Resident #30…

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 pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 6 residents (Resident #57) reviewed for pain management. The facility failed to monitor and record pain levels per physician's order for Resident #57. This deficient practice could place residents at risk of experiencing pain, undue pain and mental distress.The findings were: Record review of Resident #57's electronic face sheet, dated 09/24/25, revealed an [AGE] year-old male originally admitted to the facility on [DATE]. Resident #57 had diagnoses which included Alzheimer's dementia (most common form of dementia characterized by progressive cognitive decline), atherosclerotic heart disease (a condition characterized by build-up of plaque in the arteries), hypertension (high blood pressure), hyperlipidemia (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 observation, interview, and record review, the facility failed to ensure that licensed staff were able to demonstrate the specific competencies, and skill sets necessary to care for resident's needs for 1 of 1 resident (Resident #2) and 2 of 2 nursing staff (RN A and CNA K) reviewed for competencies.1.The facility did not perform RN A's annual skill checkoffs on obtaining a fingerstick glucose level and insulin administration. 2. The facility failed to conduct CNA K's competency assessment to ensure she demonstrated competency in the use of the mechanical lift. These failures could place the residents at risk of receiving care from staff who do not have the training and competency needed for providing care.Findings included: 1.During an observation and interview on 09/22/25 at 11:42 a.m., RN A performed hand hygiene, applied a set of gloves and prepared to obtain fingerstick blood sugar for Resident #2. RN A gathered a glucometer (measures the amount of sugar in the bloodstream at a specific time),…

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 dispensing and administering of all drugs and biologicals to meet the needs of each resident and determined that drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for 3 of 20 residents (Resident #2, Resident #33, and Resident #62) reviewed for pharmacy services. 1. The facility failed to ensure there was not a delay in administering Resident #33's Lasix (diuretic removed fluid) and Potassium when they were ordered on 09/15/2025 and not administered until 09/19/2025. 2. The facility failed to ensure Resident #62's daptomycin (antibiotic) was administered on 04/02/2025. 3. The facility did not ensure RN A administered Resident #2's Humalog KwikPen (insulin medication) according to the manufacturer's instructions. These failures could place the residents at risk of not having medications available for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review the facility failed to ensure that residents were free of significant medication errors for 1 of 1 resident (Resident #2) reviewed for insulin administration. The facility did not ensure RN A administered Resident #2's Humalog KwikPen (insulin medication) according to the manufacturer's instructions. This failure could place residents at risk of medical complications and not receiving the therapeutic effects of their medications.Findings included:Record review of Resident #2's face sheet, dated 09/23/25, reflected Resident #2 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included Type 2 diabetes mellitus (lifelong condition where the pancreas makes little or no insulin, which leads to high blood sugar levels) with diabetic nephropathy (complication of diabetes mellitus that affects the kidneys). Record review of Resident #2 quarterly MDS assessment, dated 07/14/25, reflected Resident #2 made herself understood, 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 accommodate residents' food preferences for 1 of 3 residents (Resident #21) reviewed for preferences. The facility failed to honor Resident #21's preference for double meat for the lunch meals on 09/22/2025 and 09/23/2025. This failure could place residents at risk for a decrease in resident choices, diminished interest in meals, and weight loss. Findings included: Record review of Resident #21's face sheet dated 09/15/2025 indicated he was a [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included schizoaffective disorder, bipolar type (mood disorder with symptoms such as hallucinations, delusions, depression) and profound intellectual disabilities (significant limitations in cognitive function and limits abilities to live independently). Record review of Resident #21's Comprehensive MDS assessment dated [DATE] indicated he was able to make himself understood and understood…

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 safe and sanitary storage of resident's food items for 1 of 2 residents reviewed for personal food safety. (Residents #30) The facility did not develop or implement the personal food policy related to personal refrigerators for Residents #30. This failure could place residents at risk for food borne illnesses. Findings included:1.Record review of Resident #30's face sheet, dated 09/15/25, indicated he was a [AGE] year-old-male who admitted to the facility on [DATE] with the diagnoses chronic systolic congestive heart failure (disease in which the heart muscle cannot pump blood effectively), sleep apnea (sleep disorder in which breathing stops and starts repeatedly), atrial fibrillation (an irregular often rapid heart rate that causes poor blood flow), and high blood pressure. Record review of Resident #30's admission MDS assessment, dated 08/25/25, indicated he was understood by others and made himself understood. The MDS also…

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 medical records were kept in accordance with professional standards and practices and were complete and accurately documented for 2 of 5 residents (Resident #6 and Resident #5) review for accuracy of records. The facility failed to ensure Resident #6's diet order was updated to reflect resident signed waivers and matched the dietary meal ticket. The facility failed to complete admission assessments for Residents #5 within 24 hours following their admission to the facility on [DATE] and 08/15/25.This failure could place residents at risk of improper care due to inaccurate records and identifying information.Findings included: 1.Record review of Resident #6's face sheet, dated 09/15/25, revealed a [AGE] year-old male admitted [DATE] with no hospitalizations. Review of diagnoses revealed dysphagia (difficulty swallowing), dementia (a group of conditions that cause a decline in cognitive abilities), bipolar disorder (a mental health…

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 follow established policy regarding smoking areas, and smoking safety for 1 of 1 facility. The facility did not ensure staff kept their smoking material stored properly on 09/22/25. This failure could place residents and staff at risk of unsafe smoking and injury.Findings included: During an observation and interview on 09/22/25 at 9:49 a.m., a 1/2 smoked cigarette was observed next to the toaster in the kitchen. [NAME] Q stated the cigarette belonged to her and it should not be at the workstation next to the toaster. [NAME] Q stated her personal belonging should be stored in her bag. [NAME] Q stated it was important that cigarettes were stored in her bag to prevent a fire. During an observation and interview on 09/22/25 at 10:59 a.m., a cigarette was observed in a filing cabinet in the laundry room. The Housekeeping Supervisor stated the cigarette belonged to a PRN staff that will no longer come back. The Housekeeping Supervisor stated cigarettes should be stored in a cigarette cart in their personal bag.…

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 promote resident self-determination through support of resident choice for 1 of 11 residents (Resident #10) reviewed for resident rights. The facility failed to ensure Resident #10 was provided a shower per his preference instead of bed baths. This failure could place dependent residents at risk for feelings of depression, lack self-determination and decreased quality of life. Findings included: Record review of the face sheet dated 04/19/23 indicated Resident #10 was an [AGE] year old male admitted on [DATE] with diagnoses including Vascular Dementia (a chronic condition that affects memory, thinking, and behavior), Hypertension (a common condition that occurs when the pressure in your blood vessels is consistently too high), Muscle Weakness (a lack of muscle strength that can make it difficult for muscles to contract or move as easily as usual). Record review of the Quarterly MDS dated [DATE] indicated Resident #10 was understood and understood…

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 1 of 11 residents reviewed for environment. (Resident #35) The facility failed to provide Resident #35 with a pillowcase. These failures could place residents at risk of an unsafe or uncomfortable environment and a decrease in quality of life and self-worth. Findings included: Record review of the face sheet dated 06/18/23 indicated Resident #35 was a [AGE] year-old male admitted on [DATE] with diagnoses including Hyperlipidemia (a condition where there are abnormally high levels of lipids or lipoproteins in the blood), Chronic Fatigue (a serious and often long-lasting illness that keeps people from doing their usual activities), Hypomagnesemia (a condition where the body has a lower-than-normal level of magnesium in the blood). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #35 was understood and understood others. The MDS indicated a BIMS…

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 Baseline Care Plan that included the instructions for resident care needed to provide effective and person-centered care for 1 of 5 residents reviewed for new admissions. (Resident #29) The facility failed to develop and implement a Baseline Care Plan for Resident #29 within 48 hours of admission. This failure could place residents at risk of not receiving care and services to meet their needs. Findings included: Record review of Resident #29's face sheet dated 8/19/24 indicated she was [AGE] years old and admitted to the facility initially on 5/04/24 and re-admitted on [DATE] with diagnoses including hypoxic ischemic encephalopathy (lack of oxygen causing damage to brain), dementia (forgetfulness) with mood disturbance, major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), dysphagia (difficulty swallowing), weakness, cognitive communication deficit, heart disease, chronic…

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 to maintain personal hygiene for residents who are unable to carry out activities of daily living for 1 of 16 residents reviewed for ADL's. (Resident #22) The facility failed to remove facial hair from female Resident #22. This failure could place residents who required assistance from staff for ADL's at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health. Findings included: Record review of a face sheet dated 08/20/24 revealed Resident #22 was an [AGE] year-old female and was admitted on [DATE] with diagnoses including Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), major depressive disorder (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure each residents' drug regimen was free from unnecessary psychotropic drugs (without adequate behavior monitoring) for 1 of 7 residents (Resident #39) whose medications were reviewed in that: 1. The facility failed to ensure Resident #39 had side effect monitoring (monitoring for unintended responses to medication) for his prescribed Quetiapine (an antipsychotic medication used to treat several types of mental health conditions) during the months of July and August 2024. 2. The facility failed to ensure Resident #39 had behavior monitoring for his prescribed Quetiapine during the months of July and August 2024. These failures could place residents at risk of not receiving the intended therapeutic benefits of their psychotropic medications. Findings included: Record review of Resident #39's face sheet dated 8/19/24 indicated he was [AGE] years old and admitted to the facility initially on 11/29/22 and re-admitted on [DATE] with diagnoses including…

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 to meet each resident's medical, nursing, mental and psychosocial needs for 1 of 4 residents reviewed for care plans. (Resident# 7) The facility failed to place Resident #7's bed in the lowest position per her care plan, after she had recently returned (02/15/24) from the hospital after a fall with injury (02/09/24). This failure could place residents at risk of not having individual needs met and cause residents not to receive needed services. Findings included: Record review of Resident #7's face sheet printed on 02/15/24 indicated Resident #7 was a [AGE] year-old female and admitted on [DATE] and latest return on 02/15/24 with diagnoses including nontraumatic intracranial hemorrhage (a brain bleed), flaccid hemiplegia affecting left side non dominant (the affected extremity exhibits decreased muscle tone and cannot be actively moved by the patient), legal blindness, 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 provide services by sufficient numbers of other nursing personnel, which included but not limited to nurse aides, on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans for 6 of 20 residents (Residents #38, Resident #33, Resident #37, Resident #44, Resident #10, and #17) reviewed for care and services. The facility failed to provide sufficient staff on the 6a-2pm, 2pm-10pm,10pm-6am on Friday- Sunday from 04/09/2023 to 07/09/2023 to meet the needs of the residents who required assistance with activities of daily living. This failure could place residents at risk of injury, skin breakdown, low self-esteem, depression, embarrassment, and psychological harm. Findings included: Record review of the PBJ staffing Data Report dated 04/01/2023 to 06/30/2023 indicated the facility triggered for one star staff rating. Record review of the Facility Assessment Tool updated 04/10/2023 indicated the average…

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 in 1 of 1 kitchen reviewed for food service safety. The facility failed to ensure cardboard boxes were not stored on the floor. The facility failed to ensure all food items were labeled and dated in Refrigerator #1, walk-in cooler, Freezer #1 and Freezer #2. The facility failed ensure all food items were properly stored in Refrigerator #1. The facility failed to safely thaw meat. The facility failed to ensure spoiled food items were removed from the pantry and walk-in cooler. The facility failed to ensure the chlorine test strips for the dishwasher were not expired. The facility failed to ensure an air conditioner, food carts, and areas of the stove top were clean. These failures could place residents at risk of foodborne illness and food contamination. Findings include: Record review of a blank Daily Cleaning Schedule indicated, .wash & sanitize prep tables/countertops .wash & sanitize beverage table .clean stovetop/grill…

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 reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 4 of 20 residents (Residents #17, #36, #56, and #15) reviewed for reasonable accommodations. The facility failed to ensure Residents #17, #36, #56, and #15's call lights were accessible. This failure could place residents at risk of injuries, health complications and decreased quality of life. Findings included: 1. Review of Resident #17's undated electronic face sheet revealed she was admitted to the facility on [DATE] with diagnoses of rheumatoid arthritis (an autoimmune and inflammatory disease, which means that your immune system attacks healthy cells in your body by mistake, causing inflammation (painful swelling) in the affected parts of the body), diabetes mellitus type 2 (group of diseases that result in too much sugar in the blood (high blood glucose), and depression (a common 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 provide a safe, functional, sanitary, and comfortable environment for 3 of 10 residents reviewed for environment. (Resident #60, Resident #57, and Resident #28) The facility failed to control Resident #60's odor and provide a comfortable environment. These failures could place residents at risk of an unsafe or uncomfortable environment and a decrease in quality of life and self-worth. Findings included: 1. Record review of a face sheet dated 01/14/2023 revealed Resident #60 was a [AGE] year-old male admitted on [DATE] with diagnoses including dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), psychotic disturbance (A mental disorder characterized by a disconnection from reality), Psychotic disorder with delusions (Paranoid delusion and delusions of grandeur are two examples of psychotic delusions), Anxiety disorder…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 3 of 20 residents reviewed for care plans. (Resident #270, Resident #47, and Resident #36) The facility failed to develop a comprehensive person-centered care plan including an active problem of diabetes mellitus for Resident #270. The facility failed to develop a comprehensive person-centered care plan including an active problem of pain for Resident #47. The facility failed to develop a comprehensive person-centered care plan for a significant change in status for Resident #36. These failures could place residents at risk of not having individual needs met, a decreased quality of life, and cause residents not to receive needed services Findings include: 1. Record review of a face sheet dated 03/20/2023 revealed Resident #270 was [AGE] years old female and was admitted on [DATE] with diagnoses including Type 2…

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 to maintain personal hygiene for 5 of 20 residents reviewed for ADLs (Resident #2, Resident #33, Resident #37, Resident #10, and Resident #44). The facility failed to remove facial hair from female Resident #2 and female resident #37. The facility failed to clean the fingernails of Resident # 33. The facility failed to provide scheduled baths/showers for Resident #10 and Resident #44. These failures could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health. Findings included: 1. Review of Resident #2's electronic face sheet dated 03/20/2023 revealed that she was admitted to the facility on [DATE] with diagnoses of senile degeneration of brain (severe cortical atrophy and cell loss as well as a high index of dementia as…

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

Based on observations, interviews, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the appropriate accessory and cautionary instructions, and the expiration date when applicable for two of three medication carts reviewed for medications storage (A Wing Nurse Medication Cart and C Wing Nurse Medication Cart). 1. The facility failed to remove expired over the counter medications from the A Wing Nurse Medication Cart. 2. The facility failed to remove expired over the counter medications from the C Wing Nurse Medication Cart. These failures could place residents at risk for not receiving the therapeutic benefit of medications or adverse reactions to medications. Findings included: During an observation on 07/12/23 at 9:53 AM, this surveyor reviewed the A Wing Nurse Medication Cart with RN C and found these medications: *1 stool softener docusate sodium 100mg, Expired April 2023 *1 calcium carbonate 500mg, Expired December 2022 *1 nasal spray oxymetazoline HCL…

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 an accurate MDS assessment was completed for 2 of 20 residents reviewed for MDS accuracy. (Resident # 36 and #17) 1. The facility failed to accurately document Resident #36's significant weight change 2. The facility failed to accurately document Resident #17's upper extremity contractures. These failures could place residents at risk for not receiving needed care and services. Findings included: 1. Review of Resident #36's undated electronic face sheet revealed that she was admitted to the facility on [DATE] with diagnoses of dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), hypothyroidism (a common condition where the thyroid doesn't create and release enough thyroid hormone into your bloodstream), and insomnia (having trouble falling asleep, staying asleep, or getting good quality sleep). Record review of Resident #36's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities in accordance with the comprehensive assessment to meet the interests and the physical, mental, and psychosocial well-being for 2 of 10 residents reviewed for activities. (Residents # 7 and Resident # 36.) The facility failed to provide Resident # 7 and Resident #36 with consistent, scheduled activities. This failure could place residents at risk for not having activities to meet their interests or needs and a decline in their physical, mental, and psychosocial well-being. Findings included: 1. Record review of a face sheet dated 11/07/2023 revealed Resident #7 was a [AGE] year-old female admitted on [DATE] with diagnoses Chronic obstructive pulmonary disease (group of diseases that cause airflow blockage and breathing-related problems), Muscle wasting and atrophy (the wasting or thinning of muscle mass), Dysuria (Discomfort when urinating can have causes that aren't due to underlying 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 ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 4 residents, (Resident #4) reviewed for skin integrity in that: The facility failed to provide Resident #4 with proper wound care. This failure could place residents at risk of wound deterioration, increased pain, infection, and a decline in health. The findings were: Record review of Resident #4's face sheet dated 7/12/2023 revealed Resident # 4 was a [AGE] year-old-female with an admission date of 03/17/2023 with diagnoses that included quadriplegia (a symptom of paralysis that affects all a person's limbs and body from the neck down), morbid obesity (a complex chronic disease in which a person has a body mass index (BMI) of 40 or higher or a BMI of 35 or higher and is experiencing obesity-related health conditions), and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure an acceptable parameter of nutritional status was maintained for 1 of 20 residents (Resident #36) who was reviewed for nutritional status, in that: 1. Resident #36 had a significant weight loss of 21.5 pounds, a 22% loss, in less than 180 days. The facility did not follow RD recommendations or provide nutritional supplements as ordered. This failure could place residents at risk for further weight loss and decline in health due to nutritional needs not being met. Finding included: 1.Review of Resident #36's undated electronic face sheet revealed that she was admitted to the facility on [DATE] with diagnoses of dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), hypothyroidism (a common condition where the thyroid doesn't create and release enough thyroid hormone into your bloodstream), and insomnia (having trouble…

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 that pain management was provided to residents who require such services, consistent with professional standards of practice for 1 of 20 residents reviewed for pain management. (Resident #47) The facility failed to manage Resident #47's pain by not administering an ordered as needed pain medication. This failure placed residents at risk for increased pain, decline in mobility, functioning, inability to perform activities of daily living and decreased quality of life. Findings Include: Record review of a face sheet dated 07/10/23 revealed Resident #47 was [AGE] years old and was admitted on [DATE] with diagnoses including dementia, muscle spasms, and Parkinson's Disease (a disorder of the central nervous system that affects movement, including tremors). Record review of current physician's orders indicated an open-ended order with a start date of 06/27/23 for Tylenol #3 (an opioid pain medication), 1 tab every 4 hours as needed for pain. 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 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 2 of 5 residents (Residents #7, Resident #60) reviewed for infection control practices. The facility failed to ensure Resident #7 and Resident #60's room was sanitized and free from soiled adult briefs. These failures placed residents at risk for cross contamination and infection. Findings included: 1. Record review of a face sheet dated 11/07/2023 revealed Resident #7 was a [AGE] year-old female admitted on [DATE] with diagnoses Chronic obstructive pulmonary disease (group of diseases that cause airflow blockage and breathing-related problems), Muscle wasting and atrophy (the wasting or thinning of muscle mass), Dysuria (Discomfort when urinating can have causes that aren't due to underlying disease), Personal history 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.