Avir At Cowhorn Creek

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident had a right to organize and participate in resident groups in the facility for 1 of 8 residents reviewed for resident council. (Resident #39) The facility did not ensure Resident #39 was able to attend resident council meetings, as they were scheduled on her dialysis days. This failure could place residents at risk for decreased quality of life and resident rights not being honored.The finding included: Record review of the face sheet, dated 02/11/2026, reflected Resident #39 was a [AGE] year-old female who admitted to the facility on [DATE] with a primary diagnosis of stroke. Resident #39 had further diagnoses that included: end stage renal disease (final, permanent stage of kidney failure, were the kidney's no longer filter waste and balance fluids) and dependance on renal dialysis (life-sustaining medical treatment that filters blood to remove excess waste, toxins, and fluids when kidney's no longer work). Record…

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 each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of charges for those services, which included charges for services not covered under Medicare/Medicaid or by the facility's per diem rate for 1 of 3 residents (Resident #74) reviewed for Medicare/Medicaid coverage. The facility failed to ensure Resident #74 was given a SNF ABN (is document that informs a Medicare beneficiary that Medicare will no longer pay for skilled services) when discharged from skilled services at the facility prior to covered days being exhausted. This failure could place residents at risk for not being aware of changes to provided services.The findings included: Record review of the face sheet, dated 02/11/2026, reflected Resident #74 was an [AGE] year-old male who admitted to the facility on [DATE]. Resident #74 had a primary diagnosis of sepsis (blood infection). Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that each resident who experienced a significant change in status is comprehensively assessed using the CMS-specified Resident Assessment Instrument (RAI) process for 1 of 8 residents reviewed for significant changes in status (Resident #14). The facility failed to comprehensively assess Resident #14 when she elected hospice services using the CMS-specified RAI process. This failure could place residents at risk of not receiving needed care and services.Findings included: Record review of an undated face sheet revealed Resident #14 was a [AGE] year-old female admitted on [DATE] with diagnoses of malignant neoplasm of parotid (a cancerous tumor arising in the parotid gland), end stage heart disease (the most advanced, chronic phase where the heart pumps inefficiently, causing severe, persistent symptoms even at rest), and hemiplegia (a severe, often permanent, form of unilateral paralysis affecting one side of the body, caused by brain or spinal…

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 1 of 18 residents reviewed for MDS accuracy. (Resident #1) The facility failed to accurately code Resident #1's significant weight loss of 12.8% in 180 days. This failure could place residents at risk of not receiving needed care and services.Findings included: Record review of an undated face sheet revealed Resident #01 was a [AGE] year-old male, admitted on [DATE] with the diagnoses of cerebral infarction (a type of ischemic stroke where a blockage in a blood vessel disrupts blood flow, causing brain or retinal cell death (necrosis) due to lack of oxygen), pulmonary embolus (a sudden, often life-threatening blockage in one or more of the pulmonary arteries in the lungs, usually caused by a blood clot that travels from the legs or other parts of the body), gout (a disease in which defective metabolism of uric acid causes arthritis, especially in the smaller bones of the feet, deposition of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program to include all residents with newly evident or possible serious mental disorder for 1 of 5 residents (Resident #9) reviewed for the PASRR program.The facility failed to ensure Resident #9 was referred for a PASRR (Level II) evaluation when she received a new mental illness diagnosis.This failure could place residents at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs.Record review of the face sheet, dated 02/10/26, indicated Resident #9 was [AGE] years old. The face sheet indicated an admission date of 01/19/22 with an original admission date of 09/01/20. The face sheet indicated Resident #9 had diagnoses including dementia, paranoid schizophrenia with an onset date of 09/24/24, and pain.Record review of a hospital history and physical dated 01/16/22 indicated a problem 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 ensure necessary services to maintain grooming and personal hygiene were provided for 1 of 4 residents reviewed for ADLs. (Resident #39) The facility did not ensure Resident #39 was assisted with brushing her hair. These failures could place residents at risk of not receiving care or services, decreased quality of life, embarrassment, and decreased self-esteem.The findings included: Record review of the face sheet, dated 02/11/2026, reflected Resident #39 was a [AGE] year-old female who admitted to the facility on [DATE] with a primary diagnosis of stroke. Resident #39 had further diagnoses that included: end stage renal disease (final, permanent stage of kidney failure, were the kidney's no longer filter waste and balance fluids) and dependance on renal dialysis (life-sustaining medical treatment that filters blood to remove excess waste, toxins, and fluids when kidney's no longer work). Record review of the quarterly MDS assessment,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that 1 of 17 residents reviewed for vision services, received proper treatment and assistive devices to maintain vision abilities. (Resident #9)The facility failed to follow up on an eye doctor's recommendation to order glasses for Resident #9. This failure could affect residents by causing them to have decreased vision awareness when ambulating, difficulty seeing and participating in activities, and decreased self-esteem.Record review of the face sheet, dated 02/10/26, indicated Resident #9 was [AGE] years old. The face sheet indicated an admission date of 01/19/22 with an original admission date of 09/01/20. The face sheet indicated Resident #9 had diagnoses including dementia, paranoid schizophrenia (a chronic mental disorder dominated by intense, irrational delusions (false beliefs) and auditory hallucinations (hearing voices), and pain. Record review of quarterly MDS assessment, dated 10/24/25, indicated Resident #9 had 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 observation, interview, and record review, the facility failed to ensure adequate supervision and assistance devices to prevent accidents for 1 out of 2 residents (Resident #47) reviewed for transfers. The facility failed to ensure CNA D and CNA F performed a proper gait belt transfer on Resident #47 on 02/09/2026. This failure could place residents at risk of injuries, such as arm dislocation and fractures, during transfers.The findings included: Record review of the face sheet, dated 02/11/2026, reflected Resident #47 was a [AGE] year-old female who admitted to the facility on [DATE] with a primary diagnosis of hemiplegia (paralysis) and hemiparesis (weakness) following a brain bleed that affected the right-dominant side. Record review of the quarterly MDS assessment, dated 01/24/2026, reflected Resident #47 had unclear speech, was sometimes understood, and was able to understand others. Resident #47 had a BIMS score of 8, which indicated moderately impaired cognition. The MDS reflected Resident #47…

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 it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 8.0%, based on 3 errors out of 25 opportunities, which involved 2 of 4 residents (Resident #15, Resident #59) reviewed for medication administration. 1. The facility failed to administer Resident # 15's Basaglar Insulin (a long-acting insulin injected once daily to improve blood sugar control in adults with type 2 diabetes and adults/children (6+ years) with type 1 diabetes) 20 Units every morning. 2. The facility administered (2) sprays per nostril of fluticasone propionate nasal spray (a corticosteroid used to relieve nasal symptoms like congestion, sneezing, itching, and a runny nose caused by seasonal allergies, year-round allergies, or non-allergic rhinitis) instead of the (1) spray per nostril ordered and the facility failed to check the expiration date on Resident #59's loratadine (to temporarily relieve indoor 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 each resident received and the facility provided food that accommodates resident allergies, intolerances, and preferences 1 of 8 residents (Resident #32) reviewed for resident food preferences. The facility failed to ensure Resident #32's dislike of pork was honored during the breakfast meal on 02/10/2026 and the lunch meal on 02/11/2026. This failure placed residents at risk for not having their nutritional needs met and a decreased quality of life.The findings included: Record review of the face sheet, dated 02/11/2026, reflected Resident #32 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of acute embolism (blockage) and thrombosis (blood clot) of deep veins of right upper extremity, ovarian and anal cancer, and obesity. The face sheet reflected Resident #32's allergies were penicillin, grapefruit extract, mango flavor, onions, and latex. Pork was not listed as an allergy. Record review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 2 of 5 resident personal refrigerators reviewed for food safety (Resident #12 and Resident #63). The facility failed to ensure the refrigerator for Resident #12 and Resident # 63 were clean and did not contain expired food. This failure could place residents at risk for food borne illnesses. Findings include: Record review of an undated face sheet indicated Resident #12 was a [AGE] year-old female, admitted on [DATE] with diagnoses including major depression (a serious, common mental health condition characterized by persistent sadness, hopelessness, and loss of interest in activities lasting at least two weeks), chronic kidney disease (a long-term, progressive loss of kidney function, often causing waste to build up in the body), and diabetes type II (a chronic condition where the body resists insulin or fails to produce enough, causing high blood sugar). Record…

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, observation and record review, the facility failed to file a grievance report and investigate the grievances reported by a resident for 1 of 13 residents (Resident #1) reviewed for grievances. The facility failed to investigate Grievances/concerns when Resident #1 reported to the DON by emails on 7/05/25, 7/09/25, 7/12/25, 7/21/25, 7/22/25, 8/02/25, 8/03/25, 8/04/25, 8/07/25 and 8/08/25 related to not answering her call light timely, staff mistreatment, the lack of care she was receiving, and not being fed completely/timely.The facility failed to document Resident #1's grievances/concerns on the Grievance/Concerns log forms for the reported dates of 7/05/25, 7/09/25, 7/12/25, 7/21/25, 7/22/25, 8/02/25, 8/03/25, 8/04/25, 8/07/25 and 8/08/25.These failures could place residents at risk for abuse, neglect, and not having their needs met.Findings included:Record review of Resident #1's face sheet dated 8/12/25 indicated she was [AGE] years old and was admitted to the facility on [DATE]. 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 promote resident self-determination through support of resident choice for 1 of 7 residents reviewed for resident rights. (Resident #2)The facility failed to assist Resident #2 out of bed as often has she preferred. This failure could place dependent residents at risk for feelings of depression, lack self-determination and decreased quality of life. Record review of a face sheet dated 08/12/25 revealed Resident #2 was [AGE] years old and admitted to the facility on [DATE]. Resident #2 had diagnoses which included hemiplegia and hemiparesis affecting the left side (medical conditions that cause weakness or paralysis on one side of the body), generalized muscle weakness, vitamin deficiency, and recurrent depressive disorder (a disorder characterized by repeated episodes of major depression, separated by periods of remission). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #2 was understood and understood others.…

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 provide the necessary services to maintain personal hygiene for 1 of 4 residents reviewed for ADLs. (Resident #2)The facility failed to provide Resident #2 with her scheduled showers.This failure 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.Record review of a face sheet dated 08/12/25 revealed Resident #2 was [AGE] years old and admitted to the facility on [DATE]. Resident #2 had diagnoses which included hemiplegia and hemiparesis affecting the left side (medical conditions that cause weakness or paralysis on one side of the body), generalized muscle weakness, vitamin deficiency, and recurrent depressive disorder (a disorder characterized by repeated episodes of major depression, separated by periods of remission).Record review of a quarterly 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure food was provided that accommodated the preferences of 1 of 7 residents reviewed for preferences. (Resident #2) The facility did not honor Resident #2's food preferences after she made a request to the Dietary Manager on 08/04/25 that her meat be chopped. This failure could place residents at risk for dissatisfaction, poor intake, and/or weight loss.Record review of a face sheet dated 08/12/25 revealed Resident #2 was [AGE] years old and admitted to the facility on [DATE]. Resident #2 had diagnoses which included hemiplegia and hemiparesis affecting the left side (medical conditions that cause weakness or paralysis on one side of the body), generalized muscle weakness, vitamin deficiency, and recurrent depressive disorder (a disorder characterized by repeated episodes of major depression, separated by periods of remission). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #2 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 interviews and record review, the facility failed to ensure the facility assessment was reviewed and updated as necessary, and at least annually, to include the resident population, diseases, conditions, physical and behavioral health needs, cognitive status, acuity of the resident population, and other pertinent information for 1 of 1 facility.The facility failed to include Resident #1's diagnosis of Amyotrophic Lateral Sclerosis (ALS) (a nervous system disease that causes muscle weakness and paralysis (unable to move) and impacts physical function, ability to talk and breathe).These failures could affect residents by not having the necessary resources to ensure appropriate care was provided. Findings included:Record review of the facility assessment dated [DATE] did not address Amyotrophic Lateral Sclerosis (ALS).Record review of Resident #1's face sheet dated 8/12/25 indicated she was [AGE] years old and was admitted to the facility on [DATE]. Resident #1 had diagnoses which included ALS, muscle…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 1 of 7 residents (Resident #1) reviewed for resident rights. The facility failed to ensure Resident #1 was treated with respect, dignity, and provided with care that enhanced her quality of life when: * CNA B told Resident #1 she wished she would tell her not to come back in her room and she guessed she would not be back in on that day. * CNA C hid a can of air freshener and sprayed the top of Resident #1's top of bed, pillow, and her head and then told Resident #1 It stank up in here, it stank up in here. * CNA D told Resident #1 she had 10 minutes; he would be in her room [ROOM NUMBER] minutes or less; it was frustrating for the both of them; and she should be thankful for the care she did receive. * CNA D did not provide Resident #1 with privacy while providing incontinent care. * CNA E…

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, observation and record review, the facility failed to file a grievance report and investigate the grievance reported by a resident's representative for 1 of 7 residents (Resident #1) reviewed for grievances. The facility failed to investigate Grievances/concerns when Resident #1 reported to ADON A by emails on 1/05/25, 2/03/25, and 2/06/25 related to the lack of care she was receiving and not answering her call light. The facility failed to document Resident #1's grievances/concerns on the Grievance/Concerns log forms for the reported dates of 1/05/25, 2/03/25, and 2/06/25. These deficient practices could place residents at risk for abuse, neglect, and not having their needs met. Findings included: Record review of Resident #1's face sheet dated 4/08/25 indicated she was [AGE] years old and was admitted to the facility on [DATE]. Resident #11 had diagnoses which included ALS (Amyotrophic Lateral Sclerosis-progressive neurodegenerative disease that affects nerve cells in the brain and spinal…

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 were free from abuse for 1 of 7 residents (Resident #1) reviewed for resident abuse. 1. The facility failed to ensure Resident # 1 was free from abuse when CNA C hid a can of air freshener and sprayed the top of Resident #1's top of bed, pillow, and her head on 12/26/24. 2. The facility failed to ensure Resident #1 was free from abuse when CNA E abruptly grabbed Resident #1 by both shoulders and roughly positioned her more upright in bed and spoke to her in a loud rude tone on 12/27/24. These failures could place residents at risk of physical harm, mental anguish, and/or emotional distress. The findings included: Record review of Resident #1's face sheet dated 4/08/25 indicated she was [AGE] years old and was admitted to the facility on [DATE]. Resident #11 had diagnoses which included ALS (Amyotrophic Lateral Sclerosis-progressive neurodegenerative disease that affects nerve cells in the brain and spinal cord, 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.

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. 1. The facility failed to ensure the sugar was stored in a bin with a closed lid. 2. The facility failed to ensure all food items were labeled and dated in Freezer #1. 3. The facility ensure the deep fryer was clean free of grease splashes and food particles. 4. The facility failed to ensure the doors of Freezer #1, Refrigerator #1 and the lid of the milk cooler was clean and free of food smears. These failures could place residents at risk of foodborne illness and food contamination. Findings include: During an observation on 12/02/24 at 8:48 a.m., there were white smears on the door of the refrigerator. On the lid of the milk cooler there was a brown smear. During an observation on 12/02/24 at 8:50 a.m., the sugar bin stored inside the pantry was open to air. During an observation on 12/02/24 at 8:51 a.m., the deep fryer was covered in greasy residue. The greasy residue 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 ensure that the residents and/or representatives had the right to participate in the development and implementation of his or her person-centered plan of care, and to ensure that the planning process facilitated the inclusion of the residents and/or representatives for (AR #1, AR #2, AR #44, AR #6, and AR #8). The facility failed to ensure , AR #1, AR #2, AR #44, AR #6, and AR #8, were involved in the review of the comprehensive assessment and were able to discuss their individualized care needs for services to include their need for medical and nursing care, medications, therapy, psychological and dietary needs. The failure could affect residents by placing them at risk for not receiving adequate or individualized care. Findings include: During a confidential group interview on 12/03/2024 at 2:00 p.m., Anonymous Resident's #1, #2, #44, #6, and #8 stated they had not been invited to or attended a care plan meeting about their care within the last 6…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure each resident received and the facility provided food and drink that was palatable, attractive, and at a safe and appetizing temperature for 8 of 17 residents (Resident #4, Resident #19, Resident #27, Resident #29, Resident #36, Resident #38, Resident #54, and Resident #64) and 4 anonymous residents reviewed for palatable food. 1. The facility failed to ensure residents received food that tasted good. 2. The facility failed to ensure residents did not receive cold food. 3. The facility failed to provide condiments such as salad dressing, sugar, and coffee creamer to residents. These failures could place residents at risk of weight loss, altered nutritional status and diminished quality of life. Findings included: 1. Record review of a face sheet dated 12/02/24 revealed Resident #4 was an [AGE] year-old female and was admitted to the facility on [DATE] with diagnoses of diabetes, chronic kidney disease, and anxiety disorder. Record…

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

Based on interview, and record review, the facility failed to ensure there were no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack was served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span for 6 of 8 residents (confidential residents in group) reviewed for frequency of meals. The facility failed to ensure residents were offered snacks at bedtimes as required due to mealtimes being more than 14 hours apart. This failure could affect all residents who received meals served from the facility's only kitchen by placing residents at risk for, unplanned weight loss, and side effects from medication given without food, and diminished quality of life. Findings included: Record review of the posted Meal Service Times in the dining room revealed the following: Breakfast - 8:00 AM Lunch - 12:00 PM Evening meal 5:00 PM- There was no posting to advise any resident a snack or availability of type of snack after specified times.…

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 had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 20 residents (Resident #31) reviewed for reasonable accommodations. The facility failed to ensure Resident #31's, call button was within reach while in bed. This failures could place residents at risk for a delay in assistance and decreased quality of life, self-worth, and dignity. Findings include: Record review of Resident #31's face sheet dated 12/2/2024 revealed a [AGE] year-old male admitted on [DATE] with diagnoses that included Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (stroke that occurs on the right side of the brain affecting the left side of the body), Acute ischemic heart disease (refers to a range of conditions related to reduced blood flow to the heart) and age-related physical debility (a condition of decreased physiological…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to send a copy of the notice of facility-initiated discharge to a representative of the Office of the State Long-Term Care Ombudsman for 1 of 3 residents (Resident #59) reviewed for discharge. The facility failed to send a transfer or discharge notice in writing to the facility's Ombudsman as soon as practicable when Resident #59 was discharged to another facility on 11/15/2024. This failure could place residents at risk of being discharged and not having access to available advocacy services, discharge/transfer options, and the appeal processes. The findings include: Record review of Resident #59's, undated face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Resident #59 had diagnoses which included insomnia (inability to sleep), repeated falls, and schizophrenia (mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech, and behavior. The face sheet indicated Resident #59 was discharged 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 interview and record review, the facility failed to ensure the baseline care plan that included the instructions for resident care needed to provide effective and person-centered care was completed and provided to the resident and/or their representative for 2 of 6 residents reviewed for new admissions (Residents #28 and #177). The facility did not ensure the baseline care plan that included the instructions for resident care needed to provide effective and person-centered care was provided to the resident and/or their representative for Resident #28. The facility did not ensure the baseline care plan that included the instructions for resident care needed to provide effective and person-centered care was completed and provided to the resident and/or their representative for Resident #177. These failures could place residents at risk of not receiving care and services to meet their needs. Findings included: 1.Record review of a face sheet dated 12/02/2024 revealed Resident #28 was a 73- year-old-…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that 1 of 17 residents reviewed for vision services, received proper treatment and assistive devices to maintain vision abilities. (Resident #47) The facility failed to transport Resident #47 to an appointment with an ophthalmologist on 10/02/24 and 12/04/24. This failure could affect residents by causing them to have decreased vision awareness when ambulating, difficulty seeing and participating in activities, and decreased self-esteem. Findings included: Record review of a face sheet dated 12/02/24 revealed Resident #47 was a [AGE] year-old female, was admitted on [DATE] with diagnoses including dementia, glaucoma with increased episcleral venous pressure (an eye disorder with increased pressure in the eye and veins), anxiety and depressive episode (periods of depression). Record review of the most recent MDS dated [DATE] indicated Resident #47 had moderately impaired vision and required corrective lenses. The MDS indicated Resident #47 had a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents received appropriate treatment and services to prevent further decrease of ROM for 1 of 4 residents reviewed for limited range of motion. (Resident #68) The facility did not ensure Resident #68 had a contracture prevention services in place for the treatment of his left sided hemiplegia with decreased range of motion. This failure could place residents at risk for decrease in mobility, range of motion, and contribute to worsening of contractures. Findings included: 1. Record review of an undated face sheet revealed Resident #68 was a [AGE] year-old male admitted to the facility on [DATE] with the diagnoses of hemiplegia (one-sided paralysis), diabetes mellitus type II (condition affecting blood glucose levels), and cerebral infarction (stroke). Record review of Resident #68's quarterly MDS dated [DATE] revealed he had a BIMS score of 10 which indicated moderate cognitive impairment. Resident #68 had upper and lower ROM impairment 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 observations, interviews, 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 demonstrated that this was not possible or resident preferences indicated otherwise for 1 of 20 residents (Resident #72) reviewed for nutrition. The facility failed to follow the facility's weight policy of weighing Resident #72 after a 11.3-pound weight loss from admission on [DATE] to 11/1/2024 indicating a 5.51% weight loss. There was no weight obtained within 24 hours after signification weight loss >5 % on 11/1/2024. This failure could place residents at risk for malnourishment, weight loss, skin breakdown, and decreased quality of life. Findings included: Record review of Resident #72's face sheet dated 12/03/2024 revealed he was [AGE] year-old male who was admitted to the facility on [DATE]. Resident #72 had diagnoses which included neuromuscular…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure a gradual dose reduction was attempted for 1 of 3 residents (Resident #39) reviewed for unnecessary medications/ gradual dose reduction. The facility failed to ensure a gradual dose reduction (GDR) was attempted or document contraindication for a gradual dose reduction for Resident #39's ordered Abilify (antipsychotic medication used to treat certain mental/mood disorders) 5 milligrams orally daily ordered 06/29/23. This failure could place residents at risk for possible psychotropic medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications. Findings included: Review of a face sheet dated 12/04/24 revealed Resident #39 was an [AGE] year-old female that admitted to the facility on [DATE] with the diagnoses of stroke, Schizophrenia (a chronic mental disorder that affects a person's ability to think, perceive reality, and interact socially) and muscle weakness. Review of the quarterly 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.

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 and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1of 5 residents (Residents #2) reviewed for dignity. The facility failed to ensure CNA B did not feed Resident #2 while standing on 10/23/2024. The failure could place residents at risk for a diminished quality of life, loss of dignity and self-worth. Findings: Record review of Resident #2's, undated, face sheet reflected a 49-years-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included amyotrophic lateral sclerosis (progressive muscle weakness leading to difficulties with moving, speaking, breathing and swallowing), muscle weakness, other abnormalities of gait and mobility, other speech disturbances, pain, nasal congestion, anxiety disorders (characterized by significant 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 had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 5 residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #3 did not verbally abuse Resident #1 on 10/14/2024. This failure could place residents at risk of abuse, physical harm, mental anguish and emotional distress. Findings include: 1. Record review of Resident #1's, undated, face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included myocardial infarction (heart attack), muscle wasting, zosters (a viral infection that causes pain and blisters), convulsion (seizures), ocular pain (eye), renal disease (kidney), hypertension (high blood pressure), lack of coordination, Type 2 diabetes mellitus (high blood sugar), anxiety (characterized by significant and uncontrollable feelings of anxiety and fear such that a person's social,…

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 all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 5 residents (Resident #1) reviewed for abuse and neglect. The facility failed to report to Health and Human Services Commission Resident #1's family member's allegation that Resident #3 was verbally abused by Resident #1 on 09/29/2024. This failure could place residents at risk for abuse, humiliation, intimidation, fear, shame,…

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 all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 5 residents (Resident #1) reviewed for abuse and neglect. The facility failed to investigate Resident #1's family member's allegation that Resident #3 was verbally abused by Resident #1 on 09/29/2024. This failure could place residents at risk for abuse, humiliation, intimidation, fear, shame, agitation and a decreased quality 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 ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 (Resident #4) residents reviewed for accidents. The facility failed to ensure CNA E used two-person assistance to transfer Resident #4 out from the recliner to the bed which resulted in a fall without injury on 10/10/2024. This failure could place residents at risk of injuries, falls and hospitalizations. Findings include: Record review of Resident #4's, undated, face sheet reflected an 89-years-old who was readmitted to the facility on [DATE]. Resident #4 had diagnoses which included parkinsonism (a disorder of the central nervous system that affects movement, often including tremors), depression, hypertension, (high blood pressure) open wound of the buttocks, shortness of breath, urinary incontinence, dementia (a group of thinking and social symptoms that interferes with daily functioning) , abnormalities of gait (walking) and lack of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #2) reviewed for infection control practices and transmission-based precautions. The facility failed to ensure LVN A performed hand hygiene after he removed his gloves when he provided incontinent care to Resident #2 on 10/24/2024. This failure could place residents at risk for cross-contamination and the spread of infection. Findings include: Record review of Resident #2's care plan, revised on 03/06/2024, reflected Resident #2 required assistance with ADLs with the intervention of use of a bedpan for bowel and bladder with staff assistance. Record review of Resident #2's, undated face sheet reflected a [AGE] year-old female, who was admitted to the facility on [DATE]. Resident #2 had…

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 a resident had the right to a dignified existence and was treated with respect for 1 of 4 residents reviewed for rights. ( Resident #1) The facility failed to ensure CNA A provided Resident #1 with care when she activated her said staff often come into her room and turn the call light, CNA A entered the room turned the call light off and left the room. without providing any care or consideration due to her speech impairment and them not wanting to take the time and listen. CNA A was seen in a video turning off Resident #1's call light without providing her assistance. This failure placed residents at risk of deficient practice could cause the resident not receiving needed care and services, loss of dignity and self-worth. Findings included: Record review of Resident #1's undated face sheet indicated the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included amyotrophic lateral sclerosis (ALS- a muscular…

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 receives and the facility provides food prepared in a form that meet the resident needs for 1 of 4 residents reviewed for puree food. (Resident #1) The facility failed to ensure Resident #1's pureed breakfast meal was the correct consistency and not bland. This deficient practice could place residents at risk for weight loss. Findings included. Record review of Resident #1's significant change MDS dated [DATE] indicated intact cognition. The resident required substantial to maximum assist with eating toileting, and upper body dressing. The resident was occasionally incontinent of bowel and bladder. Record review of a care plan with a problem start date of 12/8/23 and last edited on 3/6/24 indicated the resident exhibited depressive/maladaptive behaviors and agitation with staff as evidenced by refusing ADL care, medication's, eating, likewise, she refused to use the communication board to enable staff to meet her needs.…

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 implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs, for 4 of 21 (Residents #38, #29, #59 and #49) residents reviewed for care plans. 1. The facility failed to ensure Resident #38's comprehensive care plan addressed that she required Lasix (a diuretic medication used to reduce extra fluid in the body (edema) caused by conditions such as heart failure, liver disease, and kidney disease). 2. The facility failed to ensure Resident #29's left-hand contracture (a permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen) was care planned. 3. The facility failed to ensure Resident #59's diagnosis of PTSD (post-traumatic stress disorder - a mental health condition that develops following a traumatic event characterized by intrusive thoughts…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were seen by a physician at least once every 30 days for the first 90 days after admission for 4 of 21 residents (Resident #'s 38, 59, 31 and 4) reviewed for physician services. The facility failed to ensure Resident #38, Resident #59, Resident #31, and Resident #4 were seen by a physician within the first 30 days of their admission to the facility. These failures could place the residents at risk for medical conditions not being identified, care needs not being met, and a decline in health status. The findings included: 1.Record review of Resident #38's face sheet, indicated she was an [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included acute embolism and thrombosis (both blood clots that reduce or block blood flow inside your blood vessels), Hypernatremia (a medical term used to describe having too much sodium in the blood), dementia (the loss of cognitive functioning -…

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 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 3 of 21 residents (Resident #13, Resident #31, and Resident #39) reviewed for infection control practices and transmission-based precautions. The facility failed to follow their policy for testing residents and staff following a COVID-19 outbreak in the facility after Resident #13 and Resident #31 tested positive for COVID-19. The facility failed to ensure LVN G performed hand hygiene and glove change while providing wound care for Resident #39. These failures could place residents and staff at risk for cross-contamination and the spread of infection. Findings included: 1.Record review of Resident #31's face sheet dated 11/16/23 indicated he was a [AGE] year-old male who originally admitted to the facility on [DATE] 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 assessments accurately reflected the resident status for 2 of 21 residents (Resident #59 and Resident #24) reviewed for MDS assessment accuracy. 1. The facility failed to accurately code Resident #59's diagnosis of schizophrenia (mental illness that causes delusions, or fixed beliefs that seem real, and hallucinations, or hearing voices that are not real) on his quarterly MDS assessment. 2. The facility inaccurately coded Resident #24 taking an anticoagulant medication on her quarterly MDS assessment dated [DATE]. These failures could place residents at risk for not receiving care and services to meet their needs . Findings included: 1.Record review of Resident #59's face sheet dated 11/15/23, indicated a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident # 59's diagnoses included paranoid schizophrenia. Record review of Resident #59's quarterly MDS assessment dated [DATE], indicated he 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 ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR) Screenings for 1 of 2 residents (Resident #59) reviewed for resident assessments. The facility failed to refer Resident #59 for PASRR review following new mental illness diagnoses for paranoid schizophrenia (mental illness that causes delusions, or fixed beliefs that seem real, and hallucinations, or hearing voices that are not real) and PTSD (post-traumatic stress disorder)(mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress anxiety, flashback and avoidance of similar situations). This failure could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs. Findings included: Record review of Resident #59's face sheet dated 11/15/23, indicated a [AGE]…

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 carryout activities of daily living received services to maintain grooming and personal hygiene for 2 of 6 residents (Resident #'s 26 and 117) reviewed for quality of life. The facility failed to provide Residents #26 and #117 with a routine shower and shave. These failures could place residents at risk for and a decreased quality of life. Findings included: 1) Record review of a face sheet dated 11/16/2023 indicated Resident #26 was a [AGE] year-old male who admitted on [DATE] with the diagnoses of incontinence and stroke with hemiplegia (paralysis of one side of the body). Record review of the Quarterly MDS dated [DATE] indicated Resident #26 was usually understood and understands others. The MDS indicated Resident #26's BIMS score was 10, indicating he had moderately impaired cognition. The MDS in the section of Behaviors failed to indicate Resident #26 rejected care. The MDS in section Functional…

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 with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 6 residents (Resident #4) reviewed for quality of care. The facility failed to ensure Resident #4's low air loss mattress (designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) was on the correct settings. These failures could place residents at risk for deterioration of wound. Findings included: Record review of a face sheet dated 11/15/2023 indicated Resident #4 was an [AGE] year-old male who originally admitted on [DATE] and readmitted on [DATE] with the diagnoses of fracture to left femur (upper leg bone), dementia, pressure ulcer right buttock, unstageable, and pressure ulcer to left buttock stage 2. Record review of an Annual MDS assessment dated [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 a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 6 residents reviewed for quality of care. (Resident #29) The facility did not provide interventions for Resident #29's left hand contracture. This failure could place residents who had contractures at risk of not attaining/or maintaining their highest level of physical, mental, and psychosocial well-being. Findings included: Record review of Resident #29's face sheet dated 11/15/23, indicated an [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #29 had diagnoses that included senile degeneration of the brain (memory loss), anxiety, depression, and high blood pressure. Record review of Resident #29's quarterly MDS assessment dated [DATE], indicated she rarely/never made herself understood or 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 residents were offered sufficient fluid intake to maintain proper hydration and health for 2 of 5 residents (Residents #4 and #38) reviewed for hydration. 1. The facility failed to ensure Resident #4 received adequate nutrition for wound healing. 2. The facility failed to ensure Resident #38 received adequate hydration. These failures could place residents at risk for dehydration, electrolyte imbalance, slow healing of pressure injuries, and continued poor skin health. Findings included: 1. Record review of a face sheet dated 11/15/2023 indicated Resident #4 was an [AGE] year-old male who originally admitted on [DATE] and readmitted on [DATE] with the diagnoses of fracture to left femur (upper leg bone), dementia, pressure ulcer right buttock, unstageable, and pressure ulcer to left buttock stage 2. Record review of an Annual MDS dated [DATE] indicated Resident #4 was usually understood, and usually understands others. The 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to have adequate monitoring in place for side effects associated with the use of psychotropic medications and documented in the clinical record for 1 of 5 residents reviewed for unnecessary psychotropic drugs (Resident #13). The facility failed to adequately monitor Resident #13's behaviors regarding his psychotropic medications, including valium (an antianxiety medication), buspirone (antianxiety medication), and paroxetine (an antidepressant medication). These failures could place residents at risk of receiving unnecessary psychotropic medications with possible medication side effects, adverse consequences, decreased quality of life, and dependence on unnecessary medications. Findings included: Record review of Resident #13's face sheet dated 11/16/23 indicated that he was a [AGE] year-old male who originally admitted on [DATE] and re-admitted [DATE] with the diagnoses of Alzheimer's disease (a common and devastating form of dementia that affects memory,…

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

Based on observation and interview the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 1 of 2 medication carts (300/400 Hall nurse cart) reviewed for cleanliness. The facility failed to ensure the Medication Cart #1 (300/400 nurse medication cart) was free from a dried, tacky substance in the 3rd large drawer, and #4 and #5 small drawers. This failure could result in residents not receiving an accurate dose of medication as not being maintained at their best therapeutic level. Findings included: During an observation on 11/15/2023 at 3:30 p.m., ADON E assisted the surveyor with reviewing the Medication Cart #1 (300/400 nurse medication cart). During the review the 3rd large drawer, and the 4th and 5th small drawers had a brown colored material which was dry but tacky feeling. The ADON said the nurses were responsible for ensuring the medication cart was clean. The ADON said the substance could contaminate the medications stored in these drawers. During an interview on 11/16/2023 at 3:21 p.m.,…

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 collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure the quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 2 of 2 residents (Resident #42 and Resident #20) reviewed for hospice services. The facility failed to maintain Resident #42 and Resident #20's hospice binder. This deficient practice could place residents who receive hospice services at risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs. The findings included: 1.Record review of Resident #42's face sheet, indicated she was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease {COPD}( a 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.

Based on interview and record review, the facility failed to develop, implement, and maintain annually an effective training program for existing staff, consistent with their expected roles for 5 of 21 employees (Speech Therapist, Occupational Therapist, Physical Therapist, CNA K, and CNA M) reviewed for required trainings. The facility failed to ensure the Speech Therapist, the Occupational Therapist, and the Physical Therapist received restraint training annually. The facility failed to ensure CNA K, CNA M, the Speech Therapist, and the Physical Therapist received HIV training annually. These failures could place residents at risk for the inappropriate use of restraints and exposure to HIV. Findings included: Record review of the employee files indicated the following: *Speech Therapist (hire date 11/08/21), *Occupational Therapist (hire date 10/01/21), *Physical Therapist (hire date 08/12/22), *CNA K (hire date 09/14/18), *CNA M (hire date 03/04/20). During an interview on 11/16/23 at 11:00 AM the Administrator said staff that received the training were printed on the list 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.