Avamere Rehabilitation At Park West

Based on interview and record review the facility failed to ensure 1 (Resident 12) of 5 residents and 1 supplemental resident (Resident 31) whose medication regimens were reviewed, were free of unnecessary psychotropic medications. This failure left residents at risk for unnecessary medications, adverse side effects and other negative health outcomes. Findings included . <Facility Policy>The facility's revised July 2020 Psychotropic Medication Use policy showed to improve residents' quality of life, residents with specific diagnoses would be provided psychotropic medication at the lowest effective dose and documented in resident's medical record. The policy showed the facility would use nonpharmacological interventions to minimize and allow discontinuation of the need for medication. Residents on psychotropic medications would receive gradual dose reduction (GDR), unless contraindicated, to discontinue these medications.<Resident 12> According to a 06/09/2025 Quarterly Minimum Data Set (MDS – an assessment tool) Resident 12 had multiple medically complex diagnoses including…

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

Based on observation, interview and record review, the facility failed to ensure assessments accurately reflected residents' health status and/or care needs for 1 (Resident 26) of 19 reviewed for assessments. The failure to accurately assess residents' cognitive patterns placed residents at risk for unidentified and unmet care needs and a diminished quality of life.Findings included .<Facility Policy>According to the facility's revised November 2018 Dementia Protocol, the facility would review the current physical, functional, and psychosocial status of individuals with dementia, and would summarize the individual's condition, related complications, and functional abilities and impairments. The Interdisciplinary team would evaluate individuals with new or progressive cognitive impairment and help identify symptoms and findings that differentiate dementia from other causes. <Resident 26>According to the 06/08/2025 modified Quarterly Minimal Data Set (MDS - an assessment tool) Resident 26 had diagnoses of severe vascular dementia with behavioral disturbance, a mood disorder, 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 provide baseline Care Plans (CP) to 2 (Residents 5, & 79) of 8 residents reviewed for care planning and 1 supplemental resident (Resident 99). The failure to provide residents and/or their representatives with a summary of their baseline CP placed residents and/or their representatives at risk for not being informed of their initial plan for the delivery of care and services, and placed residents at risk for unmet care needs.Findings included .<Resident 5>According to a 06/11/2025 admission Minimum Data Set (MDS - an assessment tool), Resident 5 admitted to the facility on [DATE] with multiple complex diagnoses including fractures, end stage kidney disease, and respiratory failure.In an interview on 07/22/2025 at 2:16 PM, Resident 5 stated they did not have a meeting with staff to discuss their CP, were unsure what their current care goals were, and stated they did not get copies of any paperwork after admission.Review of a 06/05/2025 Baseline CP…

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/or implement comprehensive Care Plans (CPs) for 4 of 19 sample residents reviewed (Residents 99, 26, 77 & 1). This failure placed residents at risk of unmet care needs, frustration, and diminished quality of life. Findings included . <Facility Policy>According to the facility's March 2022 Comprehensive Person-Centered CP policy, the facility would develop a comprehensive, person-centered CP for each resident. The CP would be consistent with each resident's assessed needs, and should include objective, measurable goals.According to the facility's November 2018 Dementia - Clinical Protocol, the facility would identify and document the resident's condition and level of support needed during care planning to maximize remaining function and quality of life.<Resident 99> According to a 07/15/2025 admission MDS, Resident 99 had adequate hearing with the use of hearing aids or other hearing appliances. Review of Resident 99's revised…

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, record review, and interview the facility failed to ensure resident Care Plans (CPs) were updated as needed for 2 (Residents 11 & 28) of 19 sample residents, and failed to ensure the Interdisciplinary Team (IDT) attended resident care conferences to ensure residents could express their preferences and goals for 2 of 8 residents (Resident 39, & 5) reviewed for care conferences. These failures placed residents at risk for unmet care needs, and frustration. Findings included . <Facility Policy>According to the facility's March 2022 Comprehensive Person-Centered Care Plans, the IDT, in collaboration with the resident and their representative, would develop, implement, and revise a CP for each resident to address their physical, psychosocial, and functional needs. The policy showed the IDT would review and update the CP and conduct care conferences with the residents and their representatives at least quarterly (every 3 months). The policy showed residents were to be informed of their right to participate and given advance notice of conferences. If participation 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: nurses only signed for tasks completed for 1 of 19 sample residents (Resident 2), physician's orders were clarified as needed for 4 (Residents 7, 1, 12, & 5) of 19 sample residents, and failed to follow physician's orders for 1 of 19 sample residents (Resident 5). These failures placed residents at risk for medication errors, delayed treatment, receiving unnecessary medications, and adverse outcomes. Findings included . <Facility Policy>According to the facility's July 2016 Medication and Treatment Orders policy, staff were to administer medications in accordance with prescribers' written orders and, if necessary, staff would contact the prescriber for clarification. Staff were to document all interactions and order clarifications in the medical record, as appropriate.<Signing for Orders Not Completed> <Resident 2> Record review showed a 06/07/2025 pharmacist's recommendation for staff to obtain bloodwork for Resident 2. 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 ensure residents were assessed, monitored, refusals were documented, the provider was notified of changes, and they received the treatment they were assessed to require for 2 of 3 (Residents 28 & 1) who were reviewed for edema (swelling) management. The failure to monitor, document, implement interventions, and to follow the physician orders for edema management, placed residents at risk for decline in medical status, decreased quality of life, and unmet care needs and discomfort.Findings included .<Facility Policy>The Facility did not provide Edema Management policy. On 07/25/2025 the facility Administrator stated the facility did not have an Edema Management policy.<Resident 28> According to the 06/15/2025 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 28 admitted to the facility on [DATE] with multiple medically complex conditions including left side of body weakness, heart failure, and kidney failure. The MDS showed…

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 facility failed to maintain an environment that was free from accident hazards. The failure to secure chemicals in 1 of 3 soiled utility rooms and 1 of 2 storage rooms placed residents at risk for accident hazards, and diminished safety.Findings included .<2nd Floor>Observation on 07/22/2025 at 8:40 AM showed the door to the second floor soiled utility room was unlocked. One bottle of a bleach urine stain/odor remover was unsecured. The warning label on the bottle showed the chemical was an eye irritant. The bottle was one quarter full. The soiled utility room also contained a bag of fingernail polishes and a bottle of nail polish drying spray. The drying spray had a warning label that cautioned the user to prevent contact with the skin and eyes. The soiled utility room also contained a a bottle of rapid dissolving disinfectant spray with a caution warning on the front label to keep away from children.Observation on 07/22/2025 at 8:42 AM showed second floor…

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 monitor and report on nutritional care, provide weight monitoring, and obtain supplements as ordered for 3 (Resident 79, 26, & 1) of 11 residents reviewed for nutrition. The failure to offer meal replacements and monitor residents who consumed less than 50% of their meals and collect timely and accurate weights as ordered and per facility policy, placed residents at risk for nutrition-related complications, unplanned weight fluctuations, inaccurate assessments and delayed interventions of nutritional status, fluid overload, and other negative health outcomes.Findings included .<Facility Policy>According to the facility's revised 2017 Nutrition Impaired/Unplanned Weight Loss-Clinical Protocol policy, staff would monitor and document weight and intake of resident's in a format which permitted comparison over time and the provider would be notified of any abrupt or persistent change from baseline appetite or food intake. The policy showed…

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 and interview, the facility failed to ensure medications were discarded when expired, and/or returned to the pharmacy upon a resident's discharge for 1 of 3 medication rooms (First Floor Unit) observed. The facility failed to ensure resident rooms were free of unsecured medication for 1 of 19 sample residents (Resident 31) observed. The failure to ensure unneeded medications were returned to the pharmacy, discarded when expired, and were stored securely, placed residents at risk for receiving unauthorized, compromised, and/or ineffective medications.Findings included.<Facility Policy>According to the facility's Revised November 2020 Storage of Medications policy, drugs and biologicals must be locked with only authorized persons given access. The policy showed discontinued and outdated drugs must be returned to the dispensing pharmacy or destroyed.<First Floor Unit Medication Room> Observations of the First Floor Unit Medication room on 07/23/2025 at 9:18 AM with Staff AA (Licensed Practical…

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 an effective Antibiotic (ABO) Stewardship Program to promote appropriate use of ABO's, reduce the risk of unnecessary ABO use, and decrease the development of an ABO resistance for 2 of 3 residents (Resident 9 & 53) reviewed for ABO Stewardship.<Policy>According to the facility policy titled, ABO Stewardship, dated December 2016, ABOs would be prescribed and administered to residents under the guidance of the facility's ABO Stewardship Program. The policy showed when an ABO was prescribed to a resident the primary care practitioner would assess the resident within 72 hours. The policy showed diagnostic results would be communicated with the resident's primary care provider to determine if ABO therapy should be continued, modified, or discontinued. Findings included.In an interview on 07/28/2025 at 9:19 AM Staff D (Infection Preventionist) stated the facility used the McGeers criteria (a tool used for infection surveillance activities and management of ABO usage). Staff D stated when a resident 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 and interview, the facility failed to ensure residents where provided with a home like environment for 2 of 3 floors (the 200 Floor and 300 Floor) and 1 of 2 elevators. The failure to ensure resident rooms were free of walls with gouges/missing paint and stained ceiling tiles and the elevator was free of broken trim left residents at risk for a less-than-homelike environment. Findings included . <Facility Policy> The facility's February 2021 Homelike Environment policy showed residents would be provided a safe, clean, comfortable, and homelike environment. The policy showed the facility environment should be clean and sanitary. <Resident Rooms> Observations on 04/15/2024 at 8:39 AM showed bed 1 in room [ROOM NUMBER] had deep gouges and exposed drywall on the wall at the head of the resident's bed and a ceiling tile falling down on one side above the resident's bed. In an interview and observation on 04/22/2024 at 3:19 PM, Staff S (Central Supply) confirmed the damage to the wall 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.

Based on interview and record review, the facility failed to transmit the required Minimum Data Set (MDS - an assessment tool) data to the Center for Medicare and Medicaid Services (CMS) within the required time frames for 6 (Resident 33, 69, 57, 17, 73, & 51) of 20 sample residents reviewed for resident assessments. This failure placed residents at risk for delays in care planning, unmet care needs, and a diminished quality of life. Findings included . Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, revised in October 2023, showed Significant Change, Quarterly, and Annual MDS assessments must be completed no later than 14 days after the Assessment Reference Date (ARD), and it must be submitted/transmitted within 14 days of the MDS completion date to the database as required. <Resident 33> Review of Resident 33's records showed a 07/18/2023 Significant Change MDS was not completed or transmitted by staff as required to CMS until 08/07/2023, six days after the required due date. Resident 33's 02/02/2024 Quarterly MDS was not completed or…

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 failed to ensure Pre-admission Screening and Resident Review (PASRR - a mental health screening required before transfer to a nursing home) assessments were revised to reflect mental health changes for 3 of 6 residents (Residents 37, 30, & 13) reviewed for PASRRs and one supplemental resident (Resident 69). This failure left residents at risk for risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health care needs. Findings included . <Facility Policy> The facility's 03/22/2024 PASRR policy showed the purpose of a PASRR assessment was to ensure residents with mental health or intellectual disabilities were appropriately placed and received the services they required. The policy showed PASRRs would be reviewed periodically for potential changes and the Social Services was responsible. <Resident 30> According to the 03/22/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 30 had medically complex diagnoses including anxiety, dementia, a psychotic disorder. Record…

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

Based on observation, interview, and record review the facility failed to ensure: Physician's Orders (POs) were clarified as needed for 6 (Residents 17, 33, 13, 57, 9, & 83) of 20 sample residents; followed for 2 (Residents 69 & 57) of 20 sample residents; nurses did not sign for incomplete tasks for 1 (Resident 69) of 20 sample residents reviewed; and orthostatic blood pressure (a process where a resident's blood pressure is taken while lying down, then sitting, then standing as practical to assess for changes in blood pressure caused by changes in elevation for safety) was monitored as required for 1 (Resident 2) of 5 residents reviewed for psychotropic medications. These failures placed residents at risk for medication errors, delayed treatment, and adverse outcomes. Findings included . <Clarification of Orders> <Resident 17> Review of Resident 17's April 2024 Medication Administration Records (MAR) showed the resident had a 07/25/2023 PO for a powdered laxative medication to be given once daily for constipation. A second 03/28/2024 PO for the same powdered laxative was also…

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

Based on observation, interview, and record review the facility failed to ensure residents who were dependent on staff for assistance with Activities of Daily Living (ADLs - i.e. grooming, bathing, eating, etc.) received the assistance they required for 4 of 9 sample residents (Residents 61, 51, 58, & 73) and 1 supplemental resident (Resident 55). The failure to provide nailcare, bathing, and eating assistance left residents at risk for embarrassment, poor personal hygiene, and other negative health outcomes. Findings included . <Facility Policy> The facility's March 2018 ADLs Policy showed residents who could not perform ADLs independently should be provided the care, treatment, and services they required. The policy showed residents' ADL needs including bathing and hygiene would be assessed and provided accordingly. <Resident 61> According to the 04/03/2024 admission Minimum Data Set (MDS - an assessment tool) Resident 61 had impaired vision, no rejection of care, and required substantial to maximal assistance with bathing and personal hygiene. The MDS showed Resident 61 had two…

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 ensure 3 (Residents 57, 69, & 51) of 6 residents reviewed for Restorative Nursing Program (RNP) services received the care and services they were assessed to require. These failures placed residents at risk for a decline in Range of Motion (ROM), increased dependence on staff, and a decreased quality of life. Findings included . <Facility Policy> The facility's July 2017 Restorative Nursing Services Policy showed residents would receive restorative nursing care as needed to help promote optimal safety and independence. The policy showed restorative goals and objectives should be resident-centered and outlined in the resident's Care Plan (CP). <Resident 57> According to a 02/01/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 57 was cognitively intact and had multiple medically complex diagnoses including stroke with impairment of functional limitation in ROM to the upper arm on one-side and both lower legs. This MDS showed Resident 57 was dependent on staff for dressing and transfers from…

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 ensure the facility was free of accident hazards. The failure to: ensure appropriate supervision and storage of smoking materials for 1 of 1 (Resident 83) sample residents who smoked; ensure 1 of 1 Central Supply rooms was secured; and 2 of 3 soiled utility rooms were secured, placed residents at risk for smoking accidents, accident hazards, and diminished safety. Findings included . <Smoking> <Facility Policy> The facility's revised October 2023 Smoking Policy showed smoking was only allowed in designated smoking areas. The policy showed residents who were assessed to smoke independently may store their own cigarettes but all other residents who smoked were required to store their cigarettes with the facility. <Resident 83> According to the 03/20/2024 Quarterly Minimum Data Set (an assessment tool) Resident 83 had impaired vision and used a wheelchair. The MDS showed Resident 83 required substantial to maximal assistance with transfers, toileting, showering, and personal hygiene and had medically complex…

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 nursing staff had the appropriate competencies and skill sets to provide nursing care and related services that assured resident safety and attained or maintained resident's highest practicable physical, mental, and psychosocial well-being as identified by resident assessments and according to individual plans of care, in consideration of the number, acuity and diagnoses of the facility's resident population, and in accordance with the facility assessment and facility policies. The facility failed to verify skills competency for 5 of 5 Certified Nursing Assistants (CNA) (Staff AA, BB, CC, DD, EE, & FF) whose training documents were reviewed, 5 of 5 CNAs (Staff GG, FF, HH, II, and W) and 1 of 1 Registered Nurses (Staff O) interviewed for special focused training for tracheostomy and stoma care. The facility's failure to validate their nursing staff's knowledge, skills, abilities, behaviors, and other characteristics necessary perform…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to implement an effective Infection Prevention and Control Program. The failure to develop and implement a water management program, ensure resident equipment and the facility environment was free of uncleanable surfaces, urinary catheter (tubing to facilitate urinary drainage) bags were secured, and Hand Hygiene (HH) was performed before, during, and after resident care left residents at risk for waterborne illness, exposure to communicable diseases, sickness, and other negative health outcomes. Findings included . <Water Management Program> In an interview on 04/17/2024 at 2:30 PM Staff E (Environmental Director) was asked to provide documentation to support the facility had a water management program that included monitoring and prevention of Legionella (bacteria that can cause severe lung infections) and other waterborne pathogens. Staff E stated the water management program should be discussed with Staff A (Administrator) because there…

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 revise infection prevention and control policies and develop and implement an updated Antibiotic (ABO) Stewardship program to comply with the 10/24/2023 federal requirements. The facility failed to; implement protocols and a system to monitor, document, and analyze the appropriate use of ABOs; failed to include leadership support and accountability for 3 of 3 months (January, February, & March 2024) reviewed. The failure to implement an infection surveillance process that included gathering data on the resident's symptoms, type of infectious organism, assessment of infections to meet specific criteria for ABO treatment, and track the spread of infection through tracing similar organisms, placed residents at risk for potential adverse outcomes associated with the inappropriate/unnecessary use of ABOs and an increased risk for ABO resistant organisms. Findings included . Review of the facility policy Surveillance for Infections (revised 09/2017) showed the facility would conduct ongoing surveillance of infections, including…

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

Based on observation, interview, and record review, the facility failed to provide care and services in a manner that maintained and promoted resident rights and dignity for 4 (Residents 37, 3, 76, & 69) of 20 sample residents. The failure to obtain consent prior to psychotropic medication treatment (Resident 37) and the failure to provide adequate privacy during the provision of care (Residents 3, 76, & 69) placed residents at risk for unwanted psychotropic medications, a diminished sense of self-worth, and wellbeing. Findings included . <Consent> <Facility Policy> According to the facility's 08/25/2020 Psychotropic Medication policy when a resident received a new order for a psychotropic medication the facility would obtain informed consent (a process where a resident is informed of the risks and benefits of a treatment before they agree to receive it) prior to administration of the medication. <Resident 37> According to the 02/27/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 37 was assessed with severe memory impairment and showed verbal behaviors towards…

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 system by which residents received required written notices at the time of transfer/discharge, or as soon as practicable, for 3 of 4 residents (Residents 30, 66, & 97) reviewed for hospitalization. Failure to ensure a written notification was provided to the resident and/or representative of the reasons for the discharge and in a language and manner the resident and/or representative understood, placed residents at risk for a discharge that was not in alignment with the resident's stated goals for care and preferences. Findings included . <Facility Policy> According to the facility's March 2021 Transfers and Discharges Notice policy residents should be informed in writing and in a language and format of their choice of the reason for and date or the transfer or discharge. The policy showed for emergent transfers the notification should be provided as soon as practical, and a copy provided to the State Long-Term Care Ombuds (an advocacy group).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the resident and/or the resident's representative a written notice of the facility's bed hold (a process allowing residents who transfer from a facility temporarily to return to the same bed) policy, at the time of transfer or within 24 hours, for 2 of 4 sample residents (Resident 66 & 97) reviewed for hospitalization. This failure placed the residents and their representatives at risk of not being informed of their right to, and the cost of, holding the resident's bed while hospitalized that was necessary for decision-making. Findings included . <Facility Policy> The facility's October 2022 Bed Hold and Returns policy showed all residents and/or their representatives would be provided written information regarding the facility's bed hold process both upon admission and at the time of transfer. The policy showed in the case of an emergent transfer the facility would provide this notification within 24 hours. <Resident 66> According 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.

<Resident 81> According to the 03/21/2024 admission MDS Resident 81 was assessed with intact memory and was able to understand and be understood in conversation. The MDS showed Resident 81 showed no rejection of care during the assessment's seven-day lookback period. The section of this MDS addressing Resident 81's mood included instructions for staff to conduct a mood interview with the resident unless the resident was rarely or never understood in conversation. Instead, staff completed a staff assessment of Resident 81's mood. The section of this MDS addressing pain included instructions for staff to conduct a pain interview with Resident 81 unless the resident was rarely or never understood in conversation. This section was incomplete showing a - (dash) for four questions discussing with what frequency Resident 81's pain interfered with different aspects of their life, instead of including a value indicating a frequency. The MDS showed Resident 81 had obvious or likely cavity or broken natural teeth. In an interview on 04/16/2024 at 9:53 AM Resident 81 stated all their teeth were…

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 failed to ensure a person-centered comprehensive Care Plan (CP) was developed and implemented for 4 of 20 sample residents (Resident's 37, 73, 66, & 91) whose CPs were reviewed. Failure to address the individualized care needs for each resident placed residents at risk for inconsistent and/or inadequate care, and a decreased quality of life. <Facility Policy> According to the facility's [DATE] Comprehensive Person-Centered CP policy, the facility would develop a comprehensive, person-centered CP for each resident. The CP would be consistent with each resident's assessed needs, and should include objective, measurable goals. <Resident 66> According to the [DATE] Quarterly Minimum Data Set (MDS - an assessment tool) Resident 66 admitted to the facility on [DATE] and had medical diagnoses including kidney and heart failure, and high blood pressure. The assessment showed Resident 66 had no broken teeth. Observation on [DATE] at 2:33 PM and [DATE] at 8:12 AM…

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.

<Care Plan Revision> <Resident 83> According to the 03/20/2024 Quarterly MDS Resident 83 had diagnoses including coronary artery disease and heart failure. The MDS showed Resident 83 did not receive an anticoagulant medication. The MDS showed Resident 83 had an above knee left leg amputation. Review of Resident 83's Physician's Orders (POs) showed no orders for an anticoagulant medication. The 09/16/2023 Deep Vein Thrombosis (DVT - a condition where blood clots form in veins located deep inside the body, often the legs) CP included an intervention for nursing staff to monitor laboratory values to monitor/document effect of anticoagulant therapy [ .] report values outside desired range. In an interview on 04/22/2024 at 2:23 PM Staff I (Resident Care Manager - RCM) stated Resident 83 did not receive an anticoagulant medication. Staff I reviewed Resident 83's DVT CP and stated the CP was inaccurate and should be updated.Based on observation, interview, and record review the facility failed to ensure Care Plans (CP) were updated and/or revised as needed for 2 of 20 (Residents 83 and 51)…

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 implement care for 1 (Resident 69) of 1 resident reviewed for Tube Feeding (TF - nutrition delivered into the stomach by tube) management including: failure to provide a consistent formula or rate of administration; failure to document the total intake provided over 24 hours; failure to clarify and administer the amount of water flushing required by the resident; and failure to label and date the TF formula. These failures placed Resident 69 at risk for TF complications, inadequate or excessive calorie or protein intake and/or hydration. Findings included . <Facility Policy> Review of a revised November 2018 facility, Enteral (directly to the intestine) Nutrition policy showed the nurse would confirm TF orders were complete and included: the nutritional product; delivery site; the specific access device; administration method (continuous, bolus [give large doses of formula several times a day], intermittent); volume and rate of administration .; and instructions for flushing (solution, volume, frequency,…

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 staff timely acted on irregularities identified by the consultant pharmacist for 1 of 5 residents (Resident 33) reviewed for medications. The failure to act on medication-related irregularities identified by the consultant pharmacist placed the residents at risk for medication-related complications. Findings included . <Resident 33> According to a 02/02/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 33 had multiple medically complex diagnoses including high blood pressure and hyperlipidemia (high levels of fat particles in the blood). Review of Resident 33's Physician Orders (PO) showed a 12/23/2022 order for a medication to be given daily for hyperlipidemia. A 10/23/2023 pharmacy consultation report revealed recommendations to facility to obtain a lipid panel blood test with the next routine lab draw for periodic monitoring. This recommendation was signed by the provider on 10/25/2023 with agree indicated. Review of the pharmacy November 2023 and December 2023 recommendations pending response…

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 1 of 1 sample residents (Resident 58) was reviewed for Antibiotic (ABO) use. Failure to follow provider's recommendations and to schedule appointments to adjust medications placed residents at risk for inadequate treatment of medical conditions and the potential for adverse side effects of unnecessary medications. Findings included . <Resident 58> According to the 02/10/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 58 admitted to the facility on [DATE] and had diagnoses including kidney failure and shortness of breath. The MDS showed Resident 58 received ABO medications during the assessment period. Review of the April 2024 Medication Administration Record showed Resident 58 received a steroid medication (an anti-inflammatory medication) daily for kidney disease since 01/11/2024. Resident 58 received an ABO medication every 48 hours for long term use of systemic steroids since 11/16/2023. According to 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.

Based on observation, interview, and record review the facility failed to ensure residents were free of unnecessary medications for 1 of 5 (Residents 37) sample residents. The failure to ensure residents had an appropriate diagnosis in place prior to administration left residents at risk for adverse side effects, unnecessary psychotropic medications, and other negative health outcomes. Findings included . <Facility Policy> The facility's 08/25/2020 Psychoactive Medication Treatment policy showed in order to improve residents' quality of life, residents with supporting diagnoses would be provided psychoactive medications at the lowest effective dose. <Resident 37> According to the 02/27/2024 Quarterly Minimum Data Set Resident 37 was assessed with severe memory impairment and showed verbal behaviors towards others on one-to-three days of the assessment's 7-day look back period. The MDS showed Resident 37 had medically complex diagnoses including dementia and an adjustment disorder with mixed anxiety and depressed mood. Review of the physician's orders showed Resident 37 had a…

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

Based on observation and interview, the facility failed to ensure drugs and biologicals were secured and expired medications and biologicals were disposed of timely in accordance with professional standards in 1 of 2 medication rooms and 2 of 4 medication carts reviewed. This failure placed residents at risk for receiving expired medications and at risk for medication errors. Findings included . Facility Medication Rooms <First Floor Medication Room> Observation of the first floor medication room on 04/17/2024 at 9:53 AM, showed two ostomy pouches (external devices that collect waste from the body) expired on 11/24/2022, Intravenous (IV) tubing expired on 07/18/2023, and one bag of IV fluid 1000 expired on 01/2024. The medication room refrigerator contained one bag of IV antibiotic medication that expired on 03/01/2024 and a liquid antacid medication which expired on 02/01/2024 for a discharged resident. The medication room refrigerator contained four insulin pens, immunization injections for pneumonia, and one antianxiety liquid medication for five residents who discharged from the…

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

Based on observation, interview, and record review, the facility failed to ensure prompt dental services were provided for 1 (Resident 57) of 4 sample residents reviewed for dental services. This failure placed the residents at risk for unmet dental needs and a diminished quality of life. Findings included . <Facility Policy> Review of a revised December 2016 facility, Dental Services policy showed routine and emergency dental services were available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. This policy stated social services representatives would assist residents with appointments and transportation arrangements. <Resident 57> According to a 05/03/2023 admission Minimum Data Set (an assessment tool), Resident 57 was cognitively intact, had no rejection of care, and was identified with obvious or likely cavities or broken natural teeth. In an interview on 04/16/2024 at 9:41 AM, Resident 57 stated they had broken teeth, oral pain, and difficulty with chewing at times. Resident 57 stated a dentist had, come by about a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to implement their policy and procedures for accurate billing practices and imposed charges for services covered under Medicare for 1 of 3 residents (Resident 1) reviewed for billing accuracy. The failure to follow insurance verification for out-of-pocket (OOP) requirements, ensure accuracy of resident billing statements, failure to correctly bill insurance copays, and failure to follow established processes for collections of past due balances placed residents at risk for undue stress and worry of their personal financial obligations, overpayment for insurance covered services, and potential diminished quality of life. Findings included . In an interview on 10/06/2023 at 1:05 PM, Resident 1's Representative (RR) stated the facility billed Resident 1 for services that were covered by Resident 1's Medicare managed insurance provider. RR stated Resident 1 met the maximum OOP requirement and the insurance provider was required to cover the services but the…

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

Based on interview and record review the facility administration failed to implement and monitor billing office staff and billing practices. The failure to identify billing office failures through ongoing monitoring of resident accounts placed residents at risk of overpayment for insurance covered services and Medicare billing fraud. Findings included . Review of the 01/13/2022 facility policy Managed Care/Commercial Verification directed admission staff to verify insurance deductibles and out-of-pocket (OOP) maximum, and if OOP maximum had been met. Review of the 01/13/2022 facility policy Financial Verification and Documentation directed admission staff to complete the first step of insurance verification then notify the billing office staff of the verification details. The policy stated then the Business Office Manager would review the verification for accuracy and complete the second step of the verification process. Review of the 01/22/2018 document called SNF BOM Non-negotiables (Skilled Nursing Business Office Non-negotiable) showed a list of tasks required of the Business…

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 assistance with Activities of Daily Living (ADL) care for dependent residents with for 3 (Residents 88, 31 & 41) of 5 dependent residents reviewed for ADLs. Facility failure to provide ADL assistance placed residents at risk for poor hygiene, embarrassment, and diminished quality of life. Findings included . Facility Policy According to the facility's revised 03/2018 Activities of Daily Living (ADLs) policy, appropriate care and services will be provided for residents who are unable to carry out ADLS independently, with consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: (a) Hygiene (bathing, dressing, grooming, and oral care) Resident 88 According to the 01/17/2023 Annual Minimum Data Set (MDS - an assessment tool) Resident 88 admitted to the facility on [DATE] and had diagnoses including quadriplegia (paralysis of four limbs), and an unspecified injury of cervical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to implement their non-smoking policy for 2 (Residents 86 & 9) 2 of sample residents and 1 supplemental resident (Resident 34) reviewed for smoking. Facility failure to effectively implement their policy left residents at risk of frustration, burns, other smoking injuries, and other negative health outcomes. Findings included . In an interview on 01/31/2023 at 9:11 AM Staff A (Administrator) stated the facility was non-smoking since converting from a smoking facility after the onset of the COVID-19 pandemic. Staff A stated there were four residents who admitted when the facility permitted smoking on the campus. The facility permitted these residents to continue to smoke off campus. Staff S stated there was one additional resident (Resident 34) for whom the facility provided smoking cessation treatments. Facility Policy Record review showed the facility's policy binder did not include a non-smoking policy. The binder included an undated…

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

Based on interview and record review, the facility failed to develop and implement an Antibiotic Stewardship Program (ASP) to promote the safe usage of antibiotics and collect outcome data. Facility failure to develop and implement an ASP placed all residents prescribed antibiotics at risk for antibiotic resistance and poor health outcomes. Findings included . Review of the facility's Infection Control Program policies and procedures showed no of evidence of an annual review of the ASP or any policies related to the ASP. In an interview on 02/02/2023 at 2:22 PM, Staff C (Regional Nurse Consultant) confirmed that due to a management change at the facility, infection prevention and control documentation was not available for review and there was no current policy related to ASP. Staff C confirmed the facility lacked an effective ASP, including tracking and trending of resident infections, and potential identification of resident infections as the facility's Electronic Chart system was not functional at that time, and the dashboard feature the facility utilized for ASP analysis was 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide residents and/or their representative with written notification of a facility-initiated transfer for 1 (Resident 62) of 1 residents reviewed for hospitalization, and failed to provide notification of transfer to the Ombudsman. These failures placed residents and/or their representatives at risk of not being informed of their condition, unmet care needs and a diminished quality of life. Findings included . Record review showed Resident 62 was sent to the hospital on [DATE] for emergent care and returned to the facility on [DATE]. There was no documentation in the record indicating Resident 62 and/or their representative were provided with written notification of the transfer. In an interview on 02/02/2023 at 2:23 PM Staff C (Regional Nurse Consultant) confirmed the facility failed to provide Resident 62 and/or the resident's representative and the Ombudsman a copy of the notice at the time of the emergent transfer. Staff C confirmed the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the resident and/or representative information regarding a Bed Hold for 1 (Resident 62) of 1 sampled residents reviewed for hospitalization. Facility failure to provide information regarding bed holds left residents at risk for lack of knowledge regarding their right to hold their bed while out of the facility Findings included . Review of Resident 62's record showed they admitted to the facility on [DATE]. The record showed Resident 62 discharged to the hospital on [DATE] for emergency care and returned to the facility on [DATE]. Resident 62's record included no indication the facility provided the facility's bed hold policy to Resident 62 or their repesentative. In an interview on 02/02/2023 at 2:23 PM, Staff C (Regional Nurse Consultant) confirmed the facility failed to provide Resident 62 and/or their representative with the facility's bed hold policy. Staff C confirmed the facility lacked policies and procedures for providing the bed hold…

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 Level 2 Preadmission Screening and Resident Review (PASARR) recommendations were followed for 2 Residents (Residents 79 & 3) of 7 residents reviewed for PASSAR. Facility failure to implement mental health services recommended the Level 2 PASARRs left residents at risk for unmet mental health needs and a diminsihed quality of life. Findings included . The facility's 07/28/2015 Preadmission Screening and Resident Reviews (PASARR) policy showed the PASARR program is an advocacy program mandated by the Centers for Medicare and Medicaid Services (CMS) to ensure that nursing home applicants and residents with mental illness/developmental disabilities are appropriately placed and receive necessary services to meet their needs. The policy showed recommendations made in level 2 evaluations will be incorporated into the resident's care plan by the IDT [Interdisciplinary team - senior staff/department managers who oversee clinical care] team. Resident 79…

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 routine dental services were provided for 1 (Resident 31) of 1 resident reviewed for dental services. Facility failure to provide routine dental services left residents at risk for poor dental health and diminished quality of life. Findings included . In an interview on 02/03/2023 at 3:20 PM, Staff C (Regional Nurse Consultant) stated the facility did not have a policy related to the provision of routine dental services. According to the 12/06/2022 quarterly Minimum Data Set (MDS - an assessment tool) Resident 31 admitted to the facility on [DATE] and was cognitively intact. The MDS indicated Resident 31 had no dental concerns. Record review showed Resident 31's comprehensive Care Plan did not address their dental status. According to an 11/30/2022 Oral Health Dental Screening Resident 31 had no natural teeth or tooth fragments. The oral health screening indicated Resident 31 did not have dentures. According to an a 10/14/2022 Dental…

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 infection control during personal care provided to 1 resident of 1 samle residents (Resident 38) observed during personal care and failed to ensure staff wore appropriate personal protective equipment (PPE) while administering an inhaled medication on the COVID-19 unit for 1 of 7 sample residents (Resident 80) observed during medication pass. These failures placed residents at risk for the development and transmission of communicable disease and infection. Findings included . Facility Policy According to the facility's 09/19/2022 Infection Prevention, Control and Surveillance (IPC) policy faciilty staff would perform hand hygiene as indicated by national guidelines and per the facility's Hand Hygiene policy. The Hand Hygiene policy directed staff to use alcohol-based hand rub (ABHR) before providing care, and when moving from a contaminated body site to clean body site such as when changing a brief. The facility's updated…

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.