Avir at Rose Trail

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs for 2 of 4 residents (Resident #34 and Resident #71) reviewed for care plans. 1. The facility failed to ensure that Resident #34's care plan included interventions for sexually inappropriate behavior. 2. The facility failed to ensure that Resident #71's care plan reflected the physician's order and intervention of enteral feedings. These failures could place residents at an increased risk of decline in physical or functional well-being, of not receiving necessary care or services, and having personalized plans developed/implemented to address their needs.The findings included: 1. A record review of an undated face sheet indicated Resident #34 was a [AGE] year-old male who admitted to the facility on [DATE]. He had diagnoses of senile…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning is 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 (Resident #60) reviewed for oxygen therapy, in that: Resident #60's oxygen was set to 3.5 LPM on 3 consecutive days instead of 2 LPM as ordered by the physician. Resident #60's medical record did not include documentation of oxygen saturation checks and oxygen administration. These failures could place residents who receive oxygen therapy at risk for respiratory distress and incomplete medical records.Findings included: A review of a face sheet dated 12/03/2025 indicated Resident #60 was admitted to the facility on [DATE] with a diagnosis of respiratory failure. A review of a quarterly MDS assessment dated [DATE] noted Resident #60 had a BIMS score of 15…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 2 of 5 residents (Resident #61 and Resident #74) reviewed for pharmacy services. MA-A failed to take action to acquire Resident #61s scheduled dose of Pantoprazole when she did not have it available for administration. MA-A failed to take action to acquire Resident #74's scheduled dose of Tegretol when she did not have it available for administration. MA-A incorrectly documented she administered a dose of Pantoprazole to Resident #61 and a dose of Tegretol to Resident #74 when she did not have the 2 (two) medications available for administration. These failures could place residents at risk of not receiving their medications as ordered, having adverse consequences due to inconsistent levels of medication in the body, and having incorrect medication administration records.Findings included: 1.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 observation, interview, and record review, the facility failed to ensure a medication error rate less than 5 percent. There were 2 errors out of 27 opportunities, resulting in a 7 percent medication error rate involving 2 of 5 residents (Resident #61 and Resident #74). MA-A failed to administer a scheduled medication, pantoprazole 40 MG tablet, to Resident #61 as ordered by the physician. MA-A failed to administer a scheduled medication, Tegretol 300 MG tablet, to Resident #74 as ordered by the physician. These failures could place residents at risk of not receiving the therapeutic effects of the mediations and could result in a decline in health status.Findings included: 1.A review of a face sheet and physician orders dated 12/02/2025 indicated Resident #61 admitted to the facility on [DATE] with diagnoses which included end stage kidney disease and GERD (gastroesophageal reflux disease, a condition where stomach acid flows back up into the esophagus). A review of the 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 residents were free from significant medication errors for 1 of 5 residents (Resident #74) reviewed for significant medication errors. MA-A failed to take action to acquire and administer a scheduled medication, Tegretol (to prevent seizures related to diagnosis of epilepsy). This failure could place resident at risk of not receiving the therapeutic effect of mediations and could result in a decline in health status.Findings included: A review of a face sheet and physician orders dated 12/02/2025 indicated Resident #74 admitted to the facility on [DATE] with diagnoses which included epilepsy (a chronic brain disorder characterized by recurrent, unprovoked seizures).A review of a quarterly MDS assessment dated [DATE] noted Resident #74 had a BIMS score of 5 indicating his cognition was severely impaired. The same MDS indicated Resident #74 was non-ambulatory and dependent on staff for most activities of daily living. A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the residents that meet professional standards of quality care within 48 hours of the residents' admission for 2 of 2 residents (Resident #1, Resident #2). The facility failed to ensure Resident #1, and Resident #2 had a baseline care plan.This failure could place residents at risk for not communicating appropriate treatment and services to meet their needs.Findings included: A Review of the physician's orders and face sheet dated [DATE] indicated Resident #1was a 58 -year-old female who admitted on [DATE] with diagnoses including acute respiratory failure, unspecified lack of coordination, scabies, urinary tract infection bacteremia muscle weakness, schizophrenia, borderline intellectual functioning, anemia, atrial fibrillation, mood disorder, pressure ulcer, rhabdomyolysis, acute kidney…

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 records reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to ensure the comprehensive care plan described the services and interventions to be used to attain and maintain the resident's practicable physical, mental, and psychosocial well-being for 4 of 4 residents reviewed for care plans (Resident #1, Resident #2 Resident #3, and Resident #4).The facility failed to ensure Residents 1, 2, 3, and 4 had documented a completed Comprehensive Care Plan. This failure could place residents at risk for not communicating appropriate treatment and services to meet their needs.Finding included: A Review of the physician's orders and face sheet dated [DATE] indicated Resident #1was a 58 -year-old female who admitted on [DATE] with diagnoses including acute respiratory failure, unspecified lack of coordination, scabies, urinary tract infection bacteremia muscle weakness, schizophrenia, borderline intellectual 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 observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse, or mistreatment 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 4 residents (Resident #7 and Resident #6) reviewed for abuse and neglect. The facility failed to report to Health and Human Services Commission an alleged incident of verbal abuse by Resident #6 towards Resident #7 on or about 07/2025. This failure could place residents at risk for abuse, humiliation, intimidation, fear, shame, agitation, and a decreased quality of life.Findings include:Resident #7Record review of a face sheet dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 8 residents (Resident #4) reviewed for care plans. The facility failed to ensure a care plan was developed and implemented for Resident #4's use of a Foley catheter and leg band strap stabilizer. These failures could place residents at risk of not having individual needs met and a decreased quality of life.The findings include: Record review of a face sheet dated 09/29/25 indicated Resident #4 was a [AGE] year-old male initially admitted to the facility on [DATE] with diagnoses which included acute kidney failure and neuromuscular dysfunction of the bladder (problem due to disease or injury of the central nervous system or nerves involved 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 observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 2 of 8 residents (Resident #1 and Resident #4) reviewed for treatment and services related to indwelling catheters. 1. The facility failed to ensure Resident #1's foley catheter was secured on 09/11/2025. 2. The facility failed to ensure Resident #4 foley catheter was secured on 09/27/25, 09/28/25, 09/29/25, and 10/02/25. These failures could place residents at risk for urinary tract infections, dislodgment, potential complications and a decreased quality of life.Findings included:1. Record review of a face sheet dated 09/29/25 indicated Resident #1 was a [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included neuromuscular dysfunction of the bladder (problem due to disease or injury of the central nervous system or nerves involved in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review the facility failed to ensure that a resident who needs respiratory care, including tracheostomy (an opening through the neck into the trachea to provide and airway) care and tracheal suctioning, is provided such care, consistent with professional standards of practice for 1 of 2 residents (Resident #2) reviewed for tracheostomy care. The facility failed to ensure Resident #2 had replacement tracheostomy supplies (tracheostomy tubes (a curved tube inserted into the tracheostomy to keep the airway open)) in the facility or at the bedside. This failure could place residents at risk of respiratory distress and prolong emergency care being provided.Findings included:1. Record review of the face sheet dated 8/14/25 indicated Resident #2 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including anoxic brain damage (brain damage that occurs when the brain does not receive enough oxygen), epilepsy (seizure disorder), hypertension (elevated…

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 develop and implement a comprehensive person-centered care plan to meet each resident's medical needs for 1 of 6 residents (Resident #3) reviewed for care plans. The facility failed to ensure Resident #3's care plan was updated when she completed her vitamin C, multivitamin with minerals, and zinc (supplements for wound care). This failure could place the residents at increased risk of not having their individual needs met and a decreased quality of life. Findings Included: 1. Record review of the face sheet dated 3/25/25 indicated Resident #3 was admitted to the facility on [DATE] with diagnoses including pressure ulcer of the sacral region, dementia, and multiple sclerosis (a disease in which the immune system eats away at the protective covering of the nerves). Record review of the physician orders dated 3/25/25 indicated Resident #3 did not have an order for vitamin C, multivitamin with minerals, or zinc. Record review of 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 ensure the necessary treatment and services, in accordance with comprehensive assessment and professional standards of practice, to prevent development of pressure injuries was provided for 1 of 4 (Resident #1) reviewed for pressure injuries. The facility failed to ensure Resident #1's dressing to her sacrum was changed/re-applied after becoming saturated or dislodged per physician orders. This failure could place residents at risk for new development or worsening of existing pressure injuries, pain, and decreased quality of life. Findings included: 1. Record review of the face sheet dated 3/25/25 indicated Resident #1 was a [AGE] year-old female re-admitted to the facility on [DATE] with diagnoses including pressure ulcer of the sacral region (the lower portion of the spine, located at the base of the vertebral column), muscle weakness, heart failure, and hypertension (elevated blood pressure). Record review of the physician orders dated 3/25/25…

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

Based on 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 2 of 3 residents (Resident #1 and #2) and 1 of 4 staff (Treatment Nurse) observed for infection control. The facility failed to ensure the Treatment Nurse changed gloves and performed hand hygiene while performing wound care and incontinent care on Resident #1 and Resident #2. This failure could place residents and staff at risk for cross-contamination, spread of infection, and could potentially affect all others in the building. Findings Included: 1. During an observation on 3/25/25 at 8:56 a.m. the Treatment Nurse performed wound care and incontinent care on Resident #1 with assistance from CNA A. The Treatment Nurse and CNA A performed hand hygiene and donned PPE (gown and gloves) prior to providing care to Resident #1. CNA A assisted with Resident #1's positioning during the care. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure accurate MDS assessments were completed for 4 of 6 Residents (#16, #50, #60, #61) reviewed for accuracy of MDS assessments. The facility failed to accurately code Residents #16's and #50's quarterly MDS assessments for dialysis. The facility incorrectly coded Residents # 60's and #61's comprehensive MDS assessments for ventilator use. These failures could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being. Findings included: 1.A review of Resident #16's face sheet and physician's orders for September 2024 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included end-stage renal disease (condition in which the kidneys lose their ability to remove wastes and balance fluids) and dependence on dialysis (process of removing water, solutes, and toxins from the blood in people whose kidneys can no longer perform these…

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 pharmaceutical services were provided to meet the needs of 3 of 5 residents reviewed for pharmacy services (Residents #45, #57, and #173). The facility failed to ensure the physician's order for Vitamin C included the dose of Vitamin C to be administered to Resident #45. The facility failed to ensure three (3) physician prescribed medications including Vitamin B12 (a vitamin present in foods of animal origin), Brimonidine tartrate ophthalmic (refers to the eye) solution (eye drops to treat glaucoma, a condition wherein the nerve connecting the eye to the brain is damaged and can result in blindness)), and Latanoprost ophthalmic eye drops (to treat glaucoma) were available for administration to Resident #57 as ordered by the physician. The facility failed to obtain a stop date for an antibiotic dated 9/16/2024 per the hospital discharge summary, resulting in Resident #173 receiving the medications beyond the intended stop date. These…

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 reviews, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review Level 1(PASRR) Screening for 2 of 5 residents reviewed for PASRR (Resident #36 and #57). The facility failed to ensure Resident #36 had an accurate PASRR Level 1 Screening indicating a diagnosis of mental illness on 9/20/2021. The facility failed to ensure Resident #57 had an accurate PASRR Level 1 Screening indicating a diagnosis of mental illness on 5/10/2023. These failures could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs. Findings included: 1. Record review of a face sheet dated 04/10/2024 indicated Resident #36 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), anxiety…

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 medication error rate less that 5 percent. There were 3 errors out of 31 opportunities, resulting in a 9 percent medication error rate involving 2 of 4 residents (Residents #45 and #57) reviewed for medication administration. MA C administered Vitamin C to Resident #45 without verifying the dose to be given. RN D failed to administer Vitamin B12 and Brimonidine ophthalmic solution 2% to Resident # 57 as ordered by the physician. These failures could place residents at risk for inaccurate drug administration resulting in a decline in health and decreased quality of life. Findings included: 1.A review of Resident #45's face sheet and physician orders dated 09/24/2024 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included epilepsy, systemic lupus erythematosus (an illness that occurs when the immune system attacks healthy tissues and organs) cerebral infarction (stroke),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to implement infection prevention and control practices 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 4 residents (Residents #57) reviewed for medication administration procedures. RN D obtained a syringe sealed in a plastic bag from the floor of Resident #57's room and used it for administration of water and medications through a gastrostomy tube after contaminating the syringe plunger by placing it on the plastic bag that had been lying on the floor. This failure could place residents who receive medications, water, or liquid nutrition via a gastrostomy tube at risk for exposure to possible transmission of communicable diseases and infections. Findings included: A review of Resident #57's face sheet and physician orders dated for 09/24/2024 indicated she was a [AGE] year-old female who admitted to the facility 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 provide or obtain laboratory services to meet the needs of residents for 1 of 5 residents (Resident #1) reviewed for laboratory services. The facility did not obtain UA labs as ordered by the physician for Resident #1. This failure could place residents at risk of not receiving treatment and services to meet their needs. Findings included: Record review of Resident #1's face sheet, printed on [DATE], reflected he was a [AGE] year-old male who originally admitted to facility on [DATE], readmitted to facility on [DATE] and expired in the facility on [DATE] with diagnoses which included Type 2 diabetes mellitus diabetic neuropathy (A chronic condition that affects the way the body processes blood sugar (glucose);With type 2 diabetes, the body either doesn't produce enough insulin, or it resists insulin) Diabetic neuropathy, which affects people with diabetes, causes pain or numbness in the hands, feet or limbs because the nerves are damaged.); Peripheral…

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

Based on record review and interview, the facility with more than 120 beds failed to employ a qualified social worker on a full-time basis for 1 of 1 facility reviewed for social worker qualifications. The facility did not have a qualified social worker since May 05/10/2024. This failure could affect residents in need of social services and place them at risk of psycho-social decline and poor-quality of life. Findings included: Record review of the Facility Summary Report dated 7/8/2024 revealed the facility had a maximum capacity of 172. In an interview with the Administrator, on 07/10/2024 at 9:30 AM, said, the Social Worker's last day at the facility was May 10, 2024 and there was not a current full time Social Worker and there has been an attempt to hire a new Social Worker with no success. In an interview with the DON, on 7/10/2024 at 10:30 AM, she said the Social Worker's last day at the facility was May 2024 and there was not a current full time Social Worker. DON said she had been attempting to do what she could in the Social Worker's absence, but she was not a licensed…

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 have evidence that all alleged violations were thoroughly investigated for 1 of 7 residents (Resident #2) reviewed for abuse and neglect. The facility failed to conduct a thorough investigation when Resident #2 alleged LVN A slapped at her hand and cursed at her during wound care. This failure could place residents at risk of abuse and neglect. Findings included: Record review of Resident #2's face sheet, dated 5/17/24, reflected she was a [AGE] years old admitted to the facility on [DATE], with diagnoses which included COPD (chronic obstructive pulmonary disease is a group of lung diseases that block airflow and make it difficult to breathe), dysphagia (difficulty swallowing foods or liquids, arising from the throat or esophagus), heart disease, muscle weakness and atrophy (wasting or thinning of muscle mass) unspecified open wound of the abdominal wall, chronic pain and depression. Record review of the MDS dated [DATE] indicated…

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 had a urinary catheter received appropriate treatment and services to prevent urinary tract infections and pain for 1 of 7 (Resident #2) residents reviewed for urinary catheters. The facility did not ensure Resident #2's urinary catheter (a tube inserted into the bladder to drain urine) bag was not lying in the floor . This failure could place residents at risk for urinary catheter bags busting by being stepped on or wheeled over by a wheelchair allowing bacteria into the catheter tubing, pain, and infection. Findings included: 1. Record review of the face sheet dated 4/3/24 indicated Resident #2 was a [AGE] year-old female re-admitted to the facility on [DATE] with diagnoses including muscle weakness, dementia, overactive bladder, chronic kidney disease, hypertension (elevated blood pressure), and lack of coordination. Record review of the MDS dated [DATE] indicated Resident #2 was understood others and was usually…

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 discharge was appropriately communicated and documented in the medical record for 1 of 4 discharged residents (Resident #1) reviewed for discharge requirements. 1. The facility refused to re-admit Resident #1 from the hospital on 2/22/2024. 2. Resident #1's clinical record had no physician documentation to address why the resident was being discharged , what needs of the resident the facility could not meet, and how the resident posed a danger to the existing resident population. These failures could place residents at risk of not receiving the necessary care and services to meet their physical and psychological needs. Findings included: Record review of Resident #1's face sheet dated 03/18/24 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses of Huntington's disease (an uncurable neurodegenerative disease that is mostly inherited), encephalopathy (disease that alters the brain), depression, 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 notify the Office of the State Long-Term Care Ombudsman of the transfer or discharge and the reasons for the transfer or discharge in writing for 1 of 4 residents (Residents #1) reviewed for transfer and discharge. The facility initiated a discharge for Resident #1 due to a change of condition and did not notify the State Long-Term Care Ombudsman by phone or in writing. This failure could place residents at risk of improper discharge planning and diminished quality of life. Findings included: Record review of Resident #1's face sheet dated 03/18/24 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses of Huntington's disease (an uncurable neurodegenerative disease that is mostly inherited), encephalopathy (disease that alters the brain), depression, and traumatic brain injury. The face sheet also indicated Resident #1 was his own responsible party. Record review of Resident #1's admission MDS assessment dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to establish and follow written policy on permitting residents to return to the facility after they were hospitalized for 1 (Resident #1) of 4 residents reviewed for transfer/discharge. 1. The facility failed to admit Resident #1 back to facility after he was sent to the hospital on [DATE]. 2.The facility failed to give Resident #1 a 30-day discharge notice. These failures could place residents at risk of not receiving the care and services to meet their needs and could affect their mental and emotional well-being. The findings included: Record review of Resident #1's face sheet dated 03/18/24 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses of Huntington's disease (an uncurable neurodegenerative disease that is mostly inherited), encephalopathy (disease that alters the brain), depression, and traumatic brain injury. The face sheet also indicated Resident #1 was his own responsible party. Record review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 12 residents (Resident #1, Resident #2, and Resident #4) reviewed for infection control. 1. The facility failed to ensure a resident COVID-19 outbreak that included one hospitalization, Resident #4, was reported to state regulatory authority. 2. The facility failed to ensure the OTA G, CNA D, and PT R maintained proper donning of facemasks for source control in the hallway and within 3 feet of Resident #1 and Resident #2 during a COVID-19 outbreak. These failures could place residents at risk for development and spread of infection. Findings include: 1. Record review of Resident #4's, undated, face sheet reflected a [AGE] year-old female with an initial admission date of 12/05/2022. Resident #4 had diagnoses 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 interview and record review the facility failed to maintain evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision for 1 of 1 grievance book reviewed for clinical records. The facility failed to follow their policy and maintain the grievance records for a period of no less than 3 years from January 2020 to October 31, 2023. This failure could place residents at risk for unresolved grievances which could lead to miscommunication, a delay in services or a potential decline in resident 's health. Findings included: Record review of facility's undated grievance binder revealed no documentation from January 2020 to October 31, 2023. During an interview 12/15/23 at 3:48 p.m., the Administrator said someone from housekeeping tossed the previous grievance binder with all the grievances in the trash and he had to start over and made a new grievance binder and only had grievance records for November 2023. During an interview on 12/18/23 at 12:20 p.m., the Housekeeping Supervisor said he did not remember 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 assist residents in obtaining routine and emergency dental care for 2 of 7 (Resident #1 and Resident #2) residents reviewed for dental services. The facility failed to provide emergency dental services for Resident #1 after complaints of mouth pain, orders for dental referrals were received, and being prescribed antibiotics for a mouth infection. The facility failed to provide dental services for Resident #2's broken teeth. This failure could affect residents by placing them at risk for oral complications and diminished quality of life. Findings included: 1. Record review of the face sheet dated 11/2/23 indicated Resident #1 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including COPD, diabetes, schizoid personality disorder (a condition in which people avoid social activities and interacting with others), and hypertension (elevated blood pressure) Record review of the MDS dated [DATE] indicated Resident #1…

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 assessments accurately reflected the resident status for 2 of 7 (Resident #1 and Resident #2) residents reviewed for MDS assessment accuracy. The facility failed to accurately reflect Resident #1 and Resident #2's dental oral/dental on the MDS assessment. This failure could place residents at risk for not receiving care and services to meet their needs. Findings included: 1. Record review of the face sheet dated 11/2/23 indicated Resident #1 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including COPD, diabetes, schizoid personality disorder (a condition in which people avoid social activities and interacting with others), and hypertension (elevated blood pressure) Record review of the MDS dated [DATE] indicated Resident #1 understood others and was understood by others. The MDS indicated Resident #1 had a BIMS of 12 and was moderately cognitively impaired. The MDS indicated Resident #1 did not have…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights for 1 of 7 (Resident #1) residents reviewed for care plans, The facility failed to ensure Resident #1's oral/dental health problems were care planned prior to surveyor intervention. This failure could place the residents at increased risk of not having their individual needs met and a decreased quality of life. 1. Record review of the face sheet dated 11/2/23 indicated Resident #1 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including COPD, diabetes, schizoid personality disorder (a condition in which people avoid social activities and interacting with others), and hypertension (elevated blood pressure) Record review of the MDS dated [DATE] indicated Resident #1 understood others and was understood by others. The MDS indicated Resident #1 had a BIMS of 12 and was moderately cognitively impaired. 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 observations, interviews, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promotes maintenance or enhancement of his or her quality of life for 2 of 5 residents (Resident #1 and Resident #2) reviewed for resident rights. The facility did not ensure Resident #1 and Resident #2's catheter bag (urine reservoir bag) had a privacy bag in place. This failure could place residents at risk for diminished quality of life, loss of dignity and self-worth. The findings included: Record review of the face sheet for Resident #1 indicated he was re-admitted to the facility on [DATE] with diagnoses including high blood pressure, COPD (chronic obstructive pulmonary disease is a group of lung diseases that block airflow and make it difficult to breathe), heart disease, history of heart attack, and history of stroke. Record review of the MDS dated [DATE] indicated Resident #1 sometimes understood others and rarely/never made himself 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 a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 2 of 5 residents (Resident #1 and Resident #2) reviewed appropriate treatment and services related to indwelling catheters. The facility failed to ensure Resident #1's catheter bag was placed below the level of the bladder. The facility failed to ensure Resident #1's catheter bag and catheter tubing was kept off the floor. The facility failed to ensure Resident #1 had a catheter secure device in place. The facility failed to ensure Resident #1 and Resident #2's catheter tubing was free of dependent loops (a configuration of catheter tubing where the drainage tubing dips below the entry point into the catheter bag). These failures could place residents at risk for urethral injury and urinary tract infections. Findings include: Record review of the face sheet for Resident #1 indicated he was re-admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the appropriate treatment and services to prevent complications was provided for 1 of 2 residents reviewed for feeding tube management. (Resident #3) The facility did not ensure Resident #3 had his dressing removed/changed around his gastrostomy tube site after his return from the hospital and did not assess the site as ordered. These failures could place residents with gastrostomy tubes at risk for skin irritation, insertion site infections and associated complications. Findings included: Record review of the face sheet for Resident #3 indicated he was re-admitted to the facility on [DATE] with diagnoses cellulitis (common, potentially serious bacterial skin infection) of the right leg, high blood pressure, heart failure, type 2 diabetes, morbid obesity, history of stroke, kidney cancer, and stage 3 chronic kidney disease. Record review of the MDS dated [DATE] indicated Resident #3 understood others and made himself 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 sure each resident had a right to a safe, clean, comfortable, and homelike environment in the facility and failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior in the central bath and 8 of 35 resident rooms (106, 211,226,.227,.228,.229,315 and 329) reviewed for environment., The facility failed to ensure resident used common areas and rooms were clean and did not need repair. These failures could place residents at risk for living in an unsafe, unclean, uncomfortable, and unhomelike environment which could cause a decline in resident psychosocial well-being. Findings include: Observation on 8/14/2023 at 9:08 AM in room [ROOM NUMBER], revealed resident's wheelchair was dirty with brown residue in the seat and toilet paper around the wheels of the wheelchair. The seat of the wheelchair smelled of feces and observed feces on the seat. The over the bed table was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure an accurate MDS was completed for 6 of 12 residents (Residents #9, 25, 33, 50, 94, and 97) reviewed for MDS assessment accuracy. The facility did not accurately code Resident #9's quarterly MDS assessment for assistance with eating and diuretic use. The facility did not accurately code Resident # 25's annual MDS assessment for antipsychotic medication use. The facility did not accurately code Resident #33's annual MDS assessment for Pressure Ulcer and insulin use, opioid use, antidepressant use, antibiotic use, and antianxiety use. The facility did not accurately code Resident #50's quarterly MDS assessment for assistance with eating and diuretic use, opioid use, antidepressant use, and anticoagulant use. The facility did not accurately code Resident #94's quarterly MDS assessment for antipsychotic use. The facility did not accurately code Resident #97's admission MDS assessment for antianxiety use and anticoagulant use. This…

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 unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene that promotes maintenance or enhancement of his or her quality of life, for Resident (Resident #34) review for activities of daily living The facility failed to provide Resident #34 with personal grooming for nail care These failures could place residents at risk for poor hygiene, dignity issues and decreased quality of life. Findings included: Record review of Resident #34's admission record dated 12/28/2021 reflected Resident #34 was a [AGE] year-old male. Resident #34's diagnoses included full code, Chronic Obstructive Pulmonary Disease(refers to a group of diseases that cause airflow blockage and breathing-related problems) Type 2 diabetes Mellitus with foot ulcer, morbid obesity due to excess calories, major depressive disorder, single episode, presence of cardiac pacemaker. Record review…

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 all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury for 2 of 7 (Resident #1 and Resident #2) residents reviewed for abuse and neglect. The facility did not report the allegations of verbal and physical abuse of Resident #1 and Resident #2 by CNA B to the state agency. This failure could place residents at risk of injuries, abuse, and/or neglect. Findings Include: 1. Record review of the face sheet orders dated 8/08/23 indicated Resident #1 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including dementia, abnormalities of gait and mobility, amputation…

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 electronically transmit encoded, accurate, and complete MDS data to the CMS System within 14 days after the facility completed the resident's assessment for 2 of 2 residents reviewed for MDS assessments. (Resident #32 and 65) The facility failed to transmit to the CMS system Resident #32 's discharge MDS assessment dated [DATE]. The facility failed to transmit to the CMS system Resident #65 's discharge MDS assessment dated [DATE]. This failure could place the residents at risk for not having the MDS assessment transmitted as required. Findings included: A review of Resident #65's face sheet dated 08/16/23 reflected a [AGE] year-old female. She was re-admitted to the facility on [DATE]. #65 was discharged on 4/12/2023 which reflected that the MDS record was over 120 days old. A review of Resident #32's face sheet dated 08/16/23 reflected a [AGE] year-old female. She was admitted to the facility on [DATE]. Resident #32 was discharged on 4/13/23 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 interview and record review, the facility failed to implement their written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents for 1 of 7 new hire staff reviewed for criminal history checks. (Staff B) The facility employed Staff B who was not eligible for hire and retained the employee from hire on 5/19/23 through to 7/13/23. This failure could place residents at risk for abuse, neglect, exploitation, and misappropriation of property. Findings included: Record review of the facility staff roster, undated indicated Staff B was hired on 5/19/23 and listed as CNA in training. Record review of criminal history conviction name search history printed on 5/31/23 indicated search date of 5/23/23 for Staff B had 1 hit. Record review criminal history conviction name search dated 7/12/23 for Staff B indicated the criminal history review documented an offense that made Staff B ineligible for hire. Record review of undated and untitled document listing offense penal codes provided by the HR Clerk on 7/14/23 indicated staff B 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.

Based on interview and record review, the facility failed to implement their written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents for 1 of 7 new hire staff reviewed for criminal history checks. (Staff B) The facility failed to follow the A/N/E policy and procedure with regard to failing to screen applicants prior to hire. This failure could place residents at risk for abuse, neglect, exploitation, and misappropriation of property. Findings included: Record review of the facility staff roster, undated indicated Staff B was hired on 5/19/23 and listed as CNA in training. Record review of criminal history conviction name search history printed on 5/31/23 indicated search date of 5/23/23 for Staff B had 1 hit. Record review criminal history conviction name search dated 7/12/23 for Staff B indicated the criminal history review documented an offense that made Staff B ineligible for hire. Record review of undated and untitled document listing offense penal codes provided by the HR Clerk on 7/14/23 indicated staff B was determined 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.