Avir at Winnsboro

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review the facility failed to ensure residents were free from abuse for 2 of 6 residents (Resident #5 and Resident #2) reviewed for resident abuse. 1. The facility did not ensure Resident #5 was free from abuse when Resident #6 attempted to choke and struck Resident #5 on the middle of his back on 12/25/24. 2. The facility did not ensure Resident #2 was free from abuse when Resident #3 slapped Resident #2 on his left upper arm on 12/20/24. The noncompliance was identified as PNC. The noncompliance began on 12/20/24 and ended on 12/26/24. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: 1.Record review of Resident #5's face sheet dated 03/06/25 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses Schizophrenia (mental health condition that affects everything from how you think to how you…

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 right to be free from misappropriation of resident property for 1 of 6 residents reviewed for misappropriation of resident property. (Resident #4) The failed to ensure CNA/Van Driver K did not take Resident #4's debit/credit card and use it for her personal use. The noncompliance was identified as PNC. The noncompliance began on 08/12/24 and ended on 08/12/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for decreased quality of life, misappropriation of property, misappropriation of physician ordered medications and dignity. Findings included: 1.Record review of Resident #4's face sheet dated 03/06/25 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnosis of dementia (memory loss), depression, and anxiety. Record review of Resident #4's quarterly MDS dated [DATE] indicated he had clear speech, understood others, and was 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.

Based on observation, interview, and record review, the facility failed to consider the views of a resident group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life and failed to demonstrate their response and rationale for such response 3 of 3 groups. There was no documentation of the facility's effort to resolve grievances concerning beds not being made daily and cold food collected at Resident Council meetings on 2/29/2024, 3/27/2024, and 4/18/2024. This failure placed residents at risk of not having grievances addressed or provided a rational for facility decisions for issues identified Findings included: Record review of a Resident Council Meeting Form dated 2/29/2024 indicated the group council voiced their beds were not made daily and hot foods should be hot. The form failed to address how the grievances would be managed. The AD signed the Resident Council meeting form on 2/29/2024. Record review of a Resident Council Meeting Form dated 3/27/2024 indicated the group council voiced their beds were still not…

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 residents received mail delivered to the facility for 5 of 5 confidential residents reviewed for right to communication The facility failed to ensure residents received their mail on the weekend. This failure could affect residents in the facility who receive mail at risk for not receiving mail in a timely manner that could result in a decline in resident's psychosocial well-being and quality of life. Findings included: Record review of a Resident Council Meeting Form dated 2/29/2024 indicated the council was asked, Do you receive mail timely and on weekends?. The resident council answered no. Record review of a Resident Council Meeting Form dated 3/27/2024 indicated the council was asked, Do you receive mail timely and on weekends?. The resident council answered no. Record review of a Resident Council Meeting Form dated 4/18/2024 indicated the council was asked, Do you receive mail timely and on weekends?. The resident council answered no. During a confidential group interview on 5/07/2024 at 2:00 p.m., 5 of 5…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents had the right to formulate an advanced directive for 1 of 22 residents (Resident #10) reviewed for advance directives. The facility failed to accurately update Resident #10's comprehensive care plan with her code status. This failure could affect residents of the facility by not addressing their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, psychosocial outcome and inaccurate medical records. Findings included: Record review of Resident #10's face sheet dated [DATE], indicated a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included Alzheimer's (a progress disease that destroys memory and other important mental functions), atrial fibrillation (irregular often rapid heart rate that commonly causes poor blood flow), depression (persistent depressed mood), and anxiety. Record review of Resident #10's significant change in status 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 provide a safe, clean, and comfortable environment for 1 of 9 residents (Resident #9's) and 1 of 1 dining rooms reviewed for a homelike environment. The facility failed to ensure Resident #9's bathroom was free of offensive odors and unbroken and misshaped tiles around the base of the toilet. The facility failed to ensure the dining room did not have plastic, folding tables used as dining tables. This failure could place residents at risk for an uncomfortable, unhomelike environment, and a diminished quality of life. Findings included: 1. Record review of a face sheet dated 05/07/2024 indicated, Resident #9 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included unspecified dementia with other behavioral disturbance (a condition in which a person loses the ability to think, remember, learn and make decisions and solve problems), weakness, vitamin D deficiency, major depressive disorder (mental…

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 for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs, for 4 of 6 (Resident #40, Resident #33, Resident #4 and Resident #23) residents reviewed for the care plan. 1. The facility failed to care plan Resident #40 needs to be in the secure unit 2. The facility failed to care plan or write an order for Resident #33's to be in the secure unit. The facility failed to care plan Resident #33 was a smoker. 3. The facility failed to ensure Resident #4's comprehensive care plan addressed she received a prophylactic antibiotic. 4. The facility failed to ensure Resident #23's comprehensive care plan was person-centered to include his diagnosis of PTSD and any triggers he had. These failures could affect residents by placing them at risk of not receiving appropriate interventions to meet their…

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 resident environment remained as free of accident hazards as possible for 3 of 6 residents (Resident #38, Resident #12, and Resident #33, ) reviewed for accidents and hazards. 1. The facility failed to ensure the fall mat was in place for Resident #38. 2. The facility failed to ensure Resident #12 and Resident #33 had a smoking assessment done monthly per facility policy. These failures could place residents at risk for injury. Findings included: Record review of Resident #38's face sheet, dated 05/07/24, indicated Resident #38 was a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #38 had diagnoses which included Dementia (loss of memory), anxiety (a feeling of fear, dread, and uneasiness), and depression(sadness). Record review of Resident #38's quarterly MDS assessment, dated 01/19/24, indicated Resident #38 usually understood and was usually understood by others. Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 4 of 8 residents (Residents #11, #54, #50, and #55) reviewed for pharmacy services. 1. The facility failed to ensure MA K administered Resident #11's Clindamycin (antibiotic), Eliquis (anticoagulant), Keppra (antiseizure), and Vimpat (antiseizure) timely as ordered at 8:30 a.m. 2. The facility failed to ensure MA K administered Resident #54's Tylenol (pain medication), Coreg (blood pressure), Gabapentin (used to treat pain), and Isosorbide (blood pressure) timely as ordered at 8:30 a.m. 3. The facility failed to ensure MA K administered Resident #50's Tylenol (pain reliever), timely as ordered at 8:30 a.m. 4. The facility failed to ensure MA K administered Resident #55's oxcarbazepine (antiseizure) timely as ordered at 9:00 a.m. This failure could place residents at risk of medical complications 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 interviews and record reviewss, the facility failed to ensure residents who used psychotropic drugs were not given those drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 5 residents (Resident #62) reviewed for unnecessary psychotropic drugs. The facility failed to follow the pharmacy recommendation to discontinue Resident #62's Seroquel/quetiapine (antipsychotic medication) on 04/25/24 therefore Resident #62 received 13 more doses of Seroquel. This failure could place residents at risk for adverse consequences such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status. Findings included: Record review of Resident #62's face sheet dated 05/08/24, indicated an [AGE] year-old male who admitted to the facility on [DATE], with diagnoses which included dementia (memory loss), insomnia (problems with falling and staying asleep), left femur fracture (left thighbone break),…

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 38% based on 16 errors out of 42 opportunities, which involved 4 of 8 residents (Residents #11, #54, #50, and # 55) reviewed for pharmacy services. The facility failed to ensure Residents 11, 54, 50, and 55 medications were administered during the scheduled time. This failure could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders. Findings included: 1) Record review of a face sheet dated 5/08/2024 indicated Resident #11 was a [AGE] year-old female who admitted on [DATE] with the diagnoses of seizures, anxiety, high blood pressure and depression. Record review of a Quarterly MDS dated [DATE] indicated Resident #11 was sometimes understood and usually understood others. Resident #11's BIMS score was a 5 indicating she 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.

Based on observations, interviews, and record review, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 7 of 7 confidential residents reviewed for food and nutrition services. The facility failed to ensure dietary staff provided food that was palatable and appetizing temperature on 5/08/2024 for confidential residents. These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. Findings included: During an initial tour interview on 5/06/2024 between 9:28 a.m. - 4:00 p.m., 2 confidential residents voiced their meal trays, when received, were cold. During a confidential group interview on 5/07/2024 at 2:00 p.m., 5 residents said the food trays served on the halls were cold. Record review of the food temperature log dated May 8,2024 indicated the Regular meat's temperature at the time of serving was 188 degrees Fahrenheit, the cooked vegetables were 170- and 171-degrees Fahrenheit, and the dessert was 33 degrees Fahrenheit. During an observation on 5/08/2024 at 11:50 a.m., 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 interview and record review, the facility failed to ensure the medical record was complete and accurately documented for 1 of 22 residents (Resident #10) reviewed for resident records. The facility failed to accurately update Resident #10's comprehensive care plan with her code status. This failure could affect residents of the facility by not addressing their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, psychosocial outcome and inaccurate medical records. Findings included: Record review of Resident #10's face sheet dated [DATE], indicated a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included Alzheimer's (a progress disease that destroys memory and other important mental functions), atrial fibrillation (irregular often rapid heart rate that commonly causes poor blood flow), depression (persistent depressed mood), and anxiety. Record review of Resident #10's significant change in status 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 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 22 residents (Resident #14, Resident #17) and laundry services reviewed for infection control practices. 1. The facility failed to ensure Resident #14's catheter bag was not touching the floor. 2. The failed to ensure CNA H wiped correctly and performed hand hygiene while providing incontinent care for Resident #17. 3. The facility failed to ensure laundry staff handled infectious laundry using the appropriate PPE. 4. The facility failed to ensure soiled laundry was transported to prevent the spread of infection. These failures could place residents and staff at risk for cross contamination and the spread of infection. Findings included: 1.Record review of a face sheet dated 05/09/2024 indicated Resident #14 was an [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 treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 2 of 22 residents reviewed for dignity. (Residents #14 and #36). The facility did not ensure Resident #14's catheter drainage bag was covered for one day. The facility failed to ensure CNA C did not feed Resident #36 while standing. These failures could place residents at risk of a diminished quality of life, loss of dignity and self-worth. Findings included: 1.Record review of a face sheet dated 05/09/2024 indicated Resident #14 was [AGE] years old, re-admitted on [DATE] with diagnoses including encounter for surgical aftercare - surgery on skin and subcutaneous tissue (deepest layer of the skin), urinary tract infection, schizoaffective disorder(mental health disorder that is marked by a combination of schizophrenia symptoms such as hallucinations 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 residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 22 residents (Residents #4) reviewed for reasonable accommodations. The facility failed to ensure Resident #4's call light was accessible. This failure could place residents at risk of injuries, health complications and decreased quality of life. Findings included: Record review of Resident #4's face sheet dated 05/07/24, indicated a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE]. Resident #4's diagnoses included dementia (memory loss), depression (persistent depressed mood), and urinary tract infection (an infection in any part of the urinary system). Record review of Resident #4's comprehensive care plan dated 03/18/24, indicated Resident #4 has had an actual fall and has potential for injury related to falls due to unsteady gait, history of previous…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the resident's representative immediately when there was an accident or significant change in the resident's physical, mental, or psychosocial status that is, a deterioration of health, mental, or psychosocial status in either life-threatening conditions or clinical complications for 2 of 9 residents (Resident #9 and Resident #39) reviewed for notification of changes. The facility failed to notify Resident #9's representative when Resident #9 sustained a fall on 02/18/2024. The facility failed to notify Resident #39's representative when Resident #39 sustained a fall on 03/31/2024. This failure placed residents' at risk of not having their representative being aware of any changes in their conditions and could result in delay in treatment and decline in residents' health and well-being. Findings included: 1. Record review of a face sheet dated 05/07/2024 indicated, Resident #9 was an [AGE] year-old female admitted to the facility on [DATE] with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure resident rights of confidentiality of medical records for 2 of 23 residents (Resident #'s 1 and 35) reviewed for medical record confidentiality. The facility failed to ensure MA E closed the EMR of Resident #'s 1 and 35's medication regimen prior to her walking away from the medication cart during the passing of medications. This failure could place residents at risk of their medical information being provided to unauthorized personnel, other residents, or visitors. Findings included: 1)Record review of a face sheet dated 5/08/2024 indicated Resident #1 was a [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnoses of heart failure, and keratoconjunctivitis (inflammation of both the cornea and the conjunctiva, which can be infectious or non-infectious causing ocular dryness, burning, and foreign-body sensation and grittiness). Record review of the comprehensive care plan dated 1/19/2024 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 interview and record review, the facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. The facility failed to follow their policy on abuse for 2 of 22 residents (Resident #'s 10 and 36) reviewed for abuse. The facility failed to report Resident #10's injury of unknown to HHSC when bruising was found to her perineum. The facility failed to report Resident #36's injury of unknown to HHSC when bruising was found to his bilateral buttocks and left chest. These failures could place residents at risk of being abused and neglected. Findings included: Record review of the facility's policy titled, Abuse/Reportable Events dated 12/1/2018, indicated . All residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation . The facility will provide and ensure the promotion and protection of resident rights. It is everyone's responsibility to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews 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, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result 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 2 of 22 resident (Residents #'s 10 and 36) reviewed for abuse. The facility failed to report Resident #10's injury of unknown to HHSC when bruising was found to her perineum. The facility failed to report 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 interviews and record reviews the facility failed to ensure assessments accurately reflected the resident status for 1 of 22 residents (Resident #41) reviewed for MDS assessment accuracy. The facility inaccurately coded Resident #41 as having had a weight loss on his quarterly MDS assessment dated [DATE]. This failure could place residents at risk for not receiving care and services to meet their needs. Findings included: Record review of Resident #41's face sheet dated 05/08/24, indicated a [AGE] year old male who admitted to the facility on [DATE] with diagnoses which included quadriplegia (paralysis that affects all limbs and body from the neck down), dysphagia (difficulty swallowing), anemia (a condition in which the blood does not have enough healthy red blood cells, to carry oxygen all through the body), and neurofibromatosis (a condition that causes tumors to form in the brain, spinal cord, and nerves). Record review of Resident #41's comprehensive care plan dated 01/10/24, indicated Resident #41…

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 residents receive treatment and care in accordance with professional standards of practice for 1 of 6 (Resident #44) residents reviewed for quality of care. The facility failed to ensure Resident #44's diabetic wound was being monitored for improvement or worsening. This failure could place residents at risk of complications which include worsening of existing wounds, development of new wounds, and infection. Findings included: Record review of Resident #44's face sheet dated 05/08/24, indicated a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #44 had diagnoses of metabolic encephalopathy (problems with the metabolism that causes brain dysfunction), dementia (memory loss), history of diabetic foot ulcer (an open sore or wound on the foot that develop in patients type 1 or type 2 diabetes), and type 2 diabetes mellitus (long-term condition in which the body has trouble…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 22 residents (Resident #23) reviewed for quality of care. The facility did not ensure Resident #23's trauma screening was completed upon admission to the facility. This failure could put residents at an increased risk for severe psychological distress due to re-traumatization. The findings included: Record review of Resident #23's face sheet dated 05/08/23, indicated a [AGE] year-old male who admitted to the facility on [DATE] with diagnosis which included type 2 diabetes mellitus (long-term condition in which the body has trouble controlling blood sugars and using it for energy), post-traumatic stress disorder (disorder in which a person has…

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, the facility failed to ensure drugs and biologicals used in the facility were stored and secured properly for 1 of 1 medication storage refrigerators, and 1 of 6 medication carts (Zone 7 medication cart) 1. The facility failed to provide a separately locked, permanently affixed compartment for storage of controlled drugs in the refrigerator of the medication room. 2. The facility failed to ensure MA E locked her medication cart and secure the keys to the medication cart during medication pass. These failures could place residents at risk for a drug diversion of their medications. Findings included: During medication pass observation on 5/07/2024 at 9:25 a.m., MA E left the medication cart to administer medications to Resident #6 in room [ROOM NUMBER] leaving the medication cart unlocked, with the keys to the cart on the top right-hand side. During an interview on 5/07/2024 at 9:25 a.m., MA E said she should have locked her cart and taken the keys with her when she…

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 a policy identifying those cirumstances when the loss or damage of dentures was the facility's responsibility and failed to provide or obtain dental services to meet the needs of each resident for 1 of 9 (Resident #30) residents reviewed for dental services. The facility failed to provide dental services when Resident #30 lost his dentures. The facility failed to have policies and procedures for lost dentures. This failure could affect residents by placing them at risk for oral complications and diminished quality of life. Findings included: Record review of the face sheet dated 05/08/2024 indicated Resident #30 was an [AGE] year-old male re-admitted to the facility on [DATE] with diagnoses including encounter for surgical aftercare following surgery of genitourinary system (organs of the reproductive and urinary system), colitis (inflammation of the colon), calculus (stone) of kidney, hematuria(blood in urine), weakness, astigmatism (a curvature…

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 store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. 1. The facility failed to ensure 3 sheet pans were free from a brown colored grease like build up on the inside corners of the sheet pans. 2. The facility failed to ensure 2 cast iron skillets were free from a carbon build up not covering the inside walls and the outside of the skillet. 3. The facility failed to ensure the juice machine was free from dusty like material on the front and sides. These failures could place residents at risk for food borne illness. Findings included: During observations on initial tour on 5/06/2024 at 9:28 a.m., the following was found: *2 cast iron skillets with a large amount of black encrusted carbon buildup on the inside and the outside. *3-1/4 sheet pans with dark brown build up appears to be caked on grease material was on the inside corners of each pan. *Juice machine 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 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 3 residents (Resident #40 and Resident # 18) reviewed for hospice services. The facility failed to maintain Resident #40's hospice binder containing information related to hospice services provided for the resident. The facility failed to obtain Resident #18's most recent hospice plan of care. These deficient practices 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 #40's face sheet, dated 05/07/24 indicated he was an [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 interview and record review, the facility failed to promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy and providing written rationale, by the provider, when an antibiotic Zithromax was used despite criteria, to determine the appropriate use of an antibiotic for 1 of 6 residents (Residents #44) reviewed for antibiotic use. The facility failed to ensure Resident #44 had documented signs and symptoms and diagnosis to support the use of prescribed antibiotic Zithromax. This failure could place residents receiving antibiotics at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased antibiotic-resistant infections. Findings included: Record review of Resident #44's face sheet dated 05/08/24, indicated a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #44 had diagnoses of metabolic encephalopathy (problems with the metabolism that causes brain dysfunction), dementia (memory loss), history of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the resident environment remained free of accident and hazards for 2 of 7 residents (Residents #1 and #2) reviewed for accident hazards. CNA B and CNA C failed to ensure Resident #2's Hoyer lift (an assistive lift device that allows for transfer using electrical power) transfer was performed correctly. CNA D did not lock Resident #1's bed during incontinent care. These failures could place dependent residents at risk for falls, significant injuries and decreased quality of life. Findings included: 1. Record review of the face sheet dated 1/9/24 indicated Resident #2 was [AGE] years old, admitted to the facility on [DATE] with diagnoses including, dementia, high blood pressure and COPD (chronic obstructive pulmonary disease - group of lung diseases that block airflow and make it difficult to breathe). Record review of the MDS dated [DATE] indicated Resident #2 had unclear speech, rarely made herself understood and rarely 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 interview and record review the facility failed to immediately inform the resident's responsible party when there was a significant change in the resident's physical, mental or psychological status for one resident (Resident #41) reviewed for notification of change of condition, in that: The facility failed to notify Resident #41's responsible party when Resident #41 sustained a fractured finger after an incident where Resident #41 had another resident sit in a chair and caught Resident #41's finger in between chairs. This failure placed residents' caregivers at risk of not being aware of any changes in their conditions and could result in a delay in treatment and decline in residents' health and well-being. Findings included: Record review of Resident #41's face sheet dated 11/29/23 indicated she was a [AGE] year-old female who was admitted on [DATE] and readmitted on [DATE] with the diagnoses atrial flutter (a common abnormal heartbeat), Pneumonia (lung inflammation caused by bacterial or viral infection…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 4 of 8 residents (Resident #31, Resident # 32, Resident #33, and Resident #41) reviewed for comprehensive person-centered care plans. 1. The facility failed to include Resident #31's behavior to take others food and drinks in her care plan after she was involved in a resident-to-resident altercation for taking another resident's milk on 06/26/2023. 2. The facility failed to care plan Resident #32's and Resident #33's risk for resident-to-resident altercations after an altercation that occurred between them on 07/19/2023. 3. The facility failed to care plan Resident #41's right finger fracture (diagnosed on [DATE]). These failures could place the residents at…

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 pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 4 of 4 residents (Residents #34, Resident #35, Resident #36, and Resident #37) reviewed for pharmacy services. 1. The facility failed to ensure MA C (no longer employed) documented on Resident #36's narcotic record the time of administration for 1 dose of hydrocodone-acetaminophen (a narcotic medication used for pain) given on 06/16/2023. 2. The facility failed to ensure MA B documented on Resident #37's narcotic record the time of administration for 1 dose of hydrocodone-acetaminophen given on 10/17/2023. 3. The facility failed to ensure MA B documented on Resident #35's narcotic record the time of administration for 1 dose of hydrocodone-acetaminophen given on 11/23/2023. 4. The facility failed to ensure MA A documented on Resident #34's narcotic record the time 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, in accordance with accepted professional standards and practices, maintain clinical records on each resident that were complete and accurately documented for 1 of 15 residents (Resident #42) reviewed for clinical records. The facility failed to ensure Resident #42's electronic record reflected the residents accurate skin conditions during her respite stay from 10/04/23-10/08/23. This failure could place residents at risk of worsening skin integrity and decline in comfort level. The findings included: Record review of Resident #42's face sheet dated 11/29/23 indicated she was an [AGE] year-old female who admitted to the facility on [DATE] and discharged on 10/08/23. Resident #42 had diagnoses which included heart disease( a heart condition that includes diseased blood vessels, structural problems, and blood clots), chronic kidney disease stage 4(disease in which the kidneys do not function as they should to filter waste from the body), chronic diastolic…

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, and interviews the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in 3 of 3 showers (Whispering Lane shower, Park Place shower, and Texas Boulevard shower), and 1 of 3 public restrooms (nursing station area public restroom) observed. 1. The facility failed to ensure the three common shower rooms were free of black and green substances growing in the grout, towels lying on the floor, and a pink slimy substance growing on the undersurface of the shower chairs. 2. The facility failed to ensure the bathtub in the public restroom was free of a black substance . These failures could place residents at risk of infections and a loss of dignity. Findings included: During an observation on 04/04/2023 at 11:50 a.m., clean and folded towels and wash cloths were sitting exposed on the half wall petition in the communal shower room on Park Place Hall; used and un-labeled toothpaste was on the sink; and the dirty linen and trash barrels were stored in the shower. During an observation and interview 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 observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 1 resident (Resident #12) reviewed for activities of daily living. The facility failed to remove Resident #12's facial hair. This failure could place residents at risk of embarrassment, decreased self-esteem, or decreased quality of life. Findings included: Record review of Resident #12's face sheet, dated 04/05/23, indicated an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included dementia(symptoms affecting memory), respiratory failure(disease that makes it difficult to breathe), heart failure(the heart does not pump the way it should), osteoarthritis(cartilage at ends of bones wear down), and anxiety(excessive worrying causing increased heart rates and breathing). Record review of Resident #12's 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 the residents environment remained free of accident hazards for 1 of 2 resident (Resident #5) reviewed for transfers. The facility failed to ensure Resident #5 was transferred using a gait belt. This failure could place residents at risk for injuries and falls. Findings include: Record review of Resident #5's face sheet, dated 04/04/23, indicated a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia with behavioral disturbance (memory loss with behaviors), essential hypertension (high blood pressure), hemiplegia (paralysis) and hemiparesis (muscle weakness) following cerebral infarction affecting left non-dominant side (stroke affecting left side), and diabetes (a chronic condition that affects the way the body process blood sugar). Record review of Resident #5's comprehensive care plan, dated 07/08/22, indicated he had a self-care deficit related to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that medication error rates of 5 percent or greater. The facility had a medication error rate of 7.14 %, based on 2 errors out of 28 opportunities, which involved 1 of 7 residents (Resident #23) reviewed for medication administration . The facility failed to ensure Resident #23 received aspirin (non-steroidal anti-inflammatory) and magnesium oxide (supplement) at the correct dosage. This failure could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders. Findings included: Record review of Resident #23's face sheet indicated an [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses which included Alzheimer's disease (memory loss), and atrioventricular block (heart beats more slowly). Record review of Resident #23's consolidated physician's orders, dated 03/04/2023, indicated she was prescribed aspirin delayed…

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, in accordance with State and Federal laws, ensure all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 1 of 6 medication carts (main street medication cart) reviewed for medication storage. The facility failed to ensure the main street hall medication cart was locked when the ADON left the floor and left the cart unattended. This failure could place residents at risk of taking medications not intended for them with adverse outcomes; risk of loss/interruption in receiving medications. Findings included: During an observation on 04/03/23 from 11:46 a.m. to 11:57 a.m., the main street hall medication cart was left on the main street hall unlocked and unattended while nurse had left it to go to the dining room. During an observation and interview on 04/03/23 at 11:57 AM, the Corporate Clinical Nurse walked up to the cart and tried to hide her hand while she locked the medication cart. The Corporate…

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 2 of 16 residents (Residents #5 and #23) reviewed for infection control practices. 1. CNA A failed to wash or sanitize her hands before, in between glove changes, and after performing peri care to Resident #5. 2. The facility failed to ensure the ADON used gloves when she administered Resident #23's eye medication. 3. The facility failed to ensure the ADON did not dry Resident #23's eyes with the same tissue used to clean Resident #23's nose. These failures could place residents at risk for infections. Findings included: 1. Record review of Resident #5's face sheet, dated 04/04/23, indicated a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included…

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.