Avina on 32nd

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure that 1 of 1 resident (R100) reviewed for suprapubic catheters was provided with appropriate care. The facility did not have an indication for the catheter and failed to ensure there were physician orders for catheter care. In addition, the facility failed to ensure that R100's care plan included the appropriate type of catheter, and that the catheter had a privacy bag. Findings include: R100 was admitted to the facility on [DATE]. R100's hospital Medicine admission History and Physical, dated 11/08/24, included a history of .cystocele (prolapsed bladder) repair .suprapubic catheter, 09/23 . Review of hospital Patient Discharge Summary, dated 11/14/24 indicated, .Presenting for multiple days of progressive altered mental status per patient and family. Initial workup in the emergency department showed .a urinalysis concerning for possible UTI (Urinary Tract Infection) (patient does have a suprapubic catheter) .Urine culture…

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 ensure that 2 of 4 residents (R42 and R149) reviewed for pain management out of a total sample of 31 received pain medications consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. R42 rated pain at a 6.5 out of 10 and stated that anything over 4 was unacceptable for them. Nursing staff were alerted to R42's request for pain medication at 3:38 PM. R42 did not receive pain medication until 4:15 PM. During that time, R42 verbalized she had pain, and was observed to be moaning and rocking. R149 was experiencing pain rated at an 8 or 9 out of 10. R149 had requested pain medication and it took nursing staff over an hour to respond with the medication. When staff responded with the medication, R149's pain rating had increased to 10 out of 10. Findings include: Review of the facility's policy titled, Management of Pain, dated 10/12/22, indicated, .The purpose…

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, record review, and interview, the facility did not ensure that staff accurately administered medications for 1 of 31 sampled residents (R9). CMT M (Certified Medication Tech) did not mix compounded insulin for R9 prior to administering it. Failure to do so could result in an inaccurate proportion of short or long acting insulin being given. Findings include: Review of the Novolog 70/30 manufacturer's instructions, provided by the facility, revealed 70/30 insulin was a .mixture of 70% intermediate-acting insulin (isophane) and 30% short-acting insulin (regular). Before using, gently roll the vial or cartridge, turning it upside down and back 10 times to mix the medication. Do not shake the container . Review of the facility's undated policy titled, Registered Nurse (RN) Delegating Tasks to Medication Aides stated, .the responsibility and authority to decide what the aide can and cannot do. The RN may decide to delegate a task that was not taught to the aide (insulin injections, for example).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, record review, and facility policy review, the facility failed to complete catheter care, wound care, and/or medication administration in a manner to prevent cross contamination for 2 of 31 sampled residents (R35 and R100) on 4 separate occasions. Findings include: Review of the facility's policy titled, Hand Hygiene/Handwashing, dated 05/17/22, revealed no information related to when to don and doff gloves. The policy did state to perform hand hygiene after removing gloves. Review of the facility's policy titled, Dressing Change-(Clean/Non-Sterile, dated 05/17/22, revealed, .Bring supplies into resident's room. Individual resident supplies may be placed on the over bed table after it has been disinfected and/or a protective barrier placed on the table .Prepare/open any necessary supplies and place on top of clean barrier . 1. R35 was readmitted to the facility on [DATE] with diagnoses that included traumatic brain injury. R35's Care Plan dated 09/19/24 revealed a focus area for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility did not ensure that 1 (R1) out of 3 residents who currently had pressure injuries received the necessary care and treatment to promote the healing of the pressure ulcers. R1 was admitted with an unstageable pressure ulcer to her left thigh and left shin. R1 was also admitted wearing a brace to the lower left leg for the healing of a fracture. The facility did not update R1's plan of care to indicate when the use of the leg brace was to be discontinued. The facility also did not update R1's plan of care to include the use of heel boots to provide pressure relief and did not offer to place the heel boots on after wound treatment was performed. Findings include: 1.) R1 was admitted to the facility on [DATE] with diagnosis that included fracture of upper end of left tibia, type 2 diabetes, major depressive order, anxiety, unstageable pressure ulcer to the left thigh and an unstageable pressure ulcer to the left shin. R1 was also admitted with a brace 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 observations, record review and staff interviews, the facility did not ensure that they implemented Enhanced Barrier Precautions (EBP) for 2 (R1 & R2) out of 3 residents requiring EBP as recommended by the Center for Disease Control (CDC) and per the Facility's policy. Findings include: The facility's policy dated 3/25/24 and titled Enhanced Barrier Precautions documents: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Policy Explanation and Compliance Guidelines: (includes) 2.) Initiation of Enhanced Barrier Precautions: b. An order for enhanced barrier precautions (in accordance with the physician approved standing orders) will be initiated for residents with any of the following: i. Wounds ( e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes,…

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 did not provide a safe, comfortable and homelike environment which had the potential to affect a pattern of Residents who use the shower/bathing room on the 2nd & 5th units. * Wing 5 shower/bathing room has ceiling tiles that have been moved exposing ceiling pipes. In the tub area there are 2 tiles missing for the cove base on the right side and on the left side there is a wall tile missing. * Wing 2 shower/bathing room the toilet seat is loose and the call light in the shower area is not working. * There is a piece of floor tile missing on the floor by the door which leads to the smoking area outside. Findings include: The Preventative Maintenance Program policy not dated under Policy Explanation and Compliance Guidelines documents 1. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner. 1. On 2/7/24 at 9:02 a.m.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not develop and implement an effective discharge planning process for 4 (R9, R10, R11, and R12) of 5 Residents reviewed for discharge plans implemented to effectively transition the Residents to post-facility care. *R9 discharged home on [DATE] and the facility did not make the necessary referrals for home health so that services could be started after discharge and to assist with the transition of moving back into the community. The facility did not set up follow-up with a primary care physician(PCP). R9's discharge summary did not include all the pertinent information from all interdisciplinary team(IDT) , a final summary of R9's; status at the time of discharge and a post-discharge plan of care developed with the participation of the resident and/ or representative. *R10 discharged home on [DATE] and the facility did not make the necessary referrals for home health so that services could be started after discharge and to assist with the transition 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 did not provide notice of resident rights and services to prior to or upon admission both orally and in writing for 1 of 5 (R12) Residents reviewed. *R12 was admitted to the facility on [DATE] and admission paperwork including but not limited to consent to treatment was not offered to R12. R12 discharged from the facility on 1/26/24. Findings Include: Surveyor reviewed the Admission/readmission policy and procedure revised 10/03 which documents the following: .Policy: 2. A qualified staff member conducts the admission process involving the Resident and family. 3. Questions by the Resident or family receive immediate attention or are directed to the appropriate resource. R12 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, Essential Hypertension, Muscle Weakness, Polyneuropathy, and Type 2 Diabetes Mellitus. R12 was his own person while at the facility. R12 discharged from the facility on 1/26/24. R12's admission…

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 staff interview, the facility did not ensure all facility reported incidents involving potential abuse, neglect, and misappropriation of Resident property were thoroughly investigated for 1 (R5) of 2 sampled Residents (R). * R5 reported $500 missing on 11/17/23 and the facility only obtained 3 nursing staff statements from 1 shift. Other departments who would have had access to R5's room were not interviewed. Findings Include: Surveyor reviewed the undated facility's Abuse policy and notes the following applicable to completing a thorough investigation: .Abuse Policy This facility affirms the right of our Residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of Residents. In order to do so, the facility has attempted to establish a Resident sensitive and Resident secure environment. The purpose of this policy is to assure that…

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 did not ensure 1 (R7) of 1 dependent Residents reviewed received required assistance with their ADL's (activities daily living). R7 did not receive incontinence cares according to his plan of care and did not receive oral care . Findings include: The Oral Hygiene and Dental Care policy and procedure with an effective date of 8/12/22 under Policy Statement documents To ensure all residents receive appropriate oral hygiene, including dental care to provide a clean and fresh mouth. R7's diagnoses includes quadriplegia, cerebral palsy, diabetes mellitus, and hypertension. The bowel and bladder incontinence care plan initiated 9/23/22 and revised 10/12/22 includes an intervention of Check and change every 2-3 hours and prn (as needed). Initiated & revised 10/12/22. The quarterly MDS (minimum data set) with an assessment reference date of 11/17/23 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. R7 is assessed as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility did not ensure 1 of 1 Resident (R1) reviewed for abuse was provided medically related social services to assist R1 in attaining or maintaining their mental and psychosocial health. *On 1/7/24, R1 reported that R2 touched R1 sexually inappropriately. A follow-up trauma assessment and psychological referral was not completed to determine R1's psychosocial status. Findings Include: R1 was admitted to the facility on [DATE] with diagnoses of Anxiety Disorder, Major Depressive Disorder, Obsessive Compulsive Disorder, and Hyperlipidemia. R1 is his own person. On 2/7/24 at 8:21 AM, Surveyor reviewed R1's Quarterly Minimum Data Set(MDS) dated [DATE] which documents R1's Brief Interview for Mental Status(BIMS) score to be 15, indicating R1 is cognitively intact for daily decision making. R1's Patient Health Questionnaire(PHQ-9) score is 1, indicating minimal depression. On 3/29/22, an admission trauma assessment was completed with no triggers. On 1/22/24,…

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 staff interviews, and record review, the facility did not ensure therapy services were provided in a timely manner for 1 resident (R) (R3) of 1 Resident reviewed for therapy services. *R3 was admitted into the facility on [DATE]. R3 was referred to therapy based on R3's comprehensive care plan along with physician orders dated 12/22/23 for evaluation and treatment and R3 was not evaluated until 12/26/23 for speech (ST), and physical (PT) therapy, and was first evaluated for occupational (OT) therapy on 12/27/23. Findings Include: The facility's Admission/readmission policy and procedure revised 10/03 documents that .therapy orders are communicated to the therapy department. The policy also documents .Information about Resident admission is communicated in a timely manner to the appropriate departments. R3 was admitted to the facility on [DATE] with diagnoses of Atherosclerotic Heart Disease of Native Coronary Artery, Hyperlipidemia, Muscle Weakness, Unsteadiness on Feet, and Type 2 Diabetes Mellitus. R3…

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 review of daily staff postings, staffing schedules, and interview, the facility did not use the services of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week. * On 8/5/23 and 8/19/23 there was no RN who worked for 8 consecutive hours. This deficient practice has the potential to affect all 57 residents residing in the facility on 8/5/23 and all 62 residents residing in the facility on 8/19/23. Findings include: On 10/25/23 at 12:45 PM, Surveyor interviewed Human Resources (HR)-I regarding the facility staffing patterns. Surveyor asked if there was a time when the facility had no RN for 8 consecutive hours. HR-I reported that the Payroll Based Journal (PBJ) triggered for no RN for 8 consecutive hours on 8/6/23 and on 8/19/23. Surveyor and HR-I reviewed the Daily Staffing Census and schedule and it was determined there was an RN working for 8 consecutive hours on 8/6/23 and HR-I stated she would be fixing the information so that the PBJ report would accurately reflect an RN as working 8 consecutive hours on 8/6/23. Surveyor reviewed the Daily…

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 did not maintain an effective pest control program so that the facility is free of pests. During the survey, residents complained of the facility having gnats, which were observed by Surveyors. The facility hired an exterminator in the spring of 2023 however the facility continues to have gnats. This deficient practice has the potential to affect all 50 of 50 residents residing in the facility at the time of the survey. Findings include: 1. On 10/24/23 at 11:00 am, Surveyor conducted a resident group meeting in the facility's small dining room with 6 residents in attendance (R11, R12, R28, R30, R37, and R41.) 4 of the 6 residents in attendance reside on the 200 unit. The residents from the 200 unit reported if you have food in your room you will have gnats. R28 who is the President of Resident Council reported when dinner trays are not picked up right away this will cause gnats. One of the residents who resides on the 200 unit indicated there were gnats in his room right now. Residents stated some trays are left…

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 did not ensure a clean, comfortable and homelike environment which had the potential to affect 1 of 7 (R20) resident rooms observed and 18 of 18 residents residing on wing 1. *R20's room was observed to have wall scrapping with plaster gouges and the metal door frame was heavily scrapped. * On 10/24 and 10/25/23, a strong persistent urine odor was noted in the 100 unit hallway which had the potential to affect all 18 residents residing in this unit. Findings include: 1. On 10/24/23 at 9:27 am., Surveyor observed R20's bedroom. Surveyor noted heavy wall scrapping and plaster gouging on the wall behind R20's bed and along the length of the wall along the side of R20's bed. Surveyor also noticed the metal door frame was heavily scrapped on both sides. Surveyor attempted to interview R20 regarding his room however, R20 was not able to respond to the questions posed. Surveyor noted a reasonable person would not want a room with heaving wall scraping and gouges into 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 record review and interview, the facility did not ensure written notification of Medicare Non-Coverage was signed by the resident and/or the resident's representative acknowledging receipt and understanding of the notification and of their appeal rights for 3 of 3 residents (R101, R1, and R36) reviewed whose Medicare coverage was ending, and had remaining Medicare eligible days and remained residing in the facility. Findings include: 1. Surveyor reviewed R101's Notice of Medicare Non-Coverage (CMS 10123- NOMNC) form which indicated R101's Medicare coverage would end 6/24/2023. The notice included appeal rights. The form includes the following, Please sign below to indicate you received and understood this notice. I have been notified that coverage of my service will end on the effective date indicated on this notice and that I may appeal this decision by contacting my Quality Improvement Organization (QIO). There is an area for Signature of Patient or Representative and Date. Surveyor noted there is no Resident or Resident Representative signature or date on this form.…

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 did not provide respiratory care consistent with professional standards of practice for 1 (R44) of 2 Residents reviewed for respiratory care. * R44 was observed not to have his oxygen administered per order, the oxygen was not signed out as administered and his oxygen tubing was not labeled with the date it was changed. R44 also did not have a care plan for oxygen use. Finding include: R44 was admitted to the facility on [DATE] with diagnosis that included End stage renal disease and recent history of pneumonia. On 10/25/23 R44's admission Minimum Data Set (MDS) dated [DATE] was reviewed and indicated R44 was assessed to have a Brief Interview for Mental Status score of 15 indicating fully intact long and short term memory. On 10/24/23 at 1:30 PM R44 was observed in his recliner chair in his room with his oxygen on. The oxygen concentrator was set at 5 liters per minute. R44 indicated he had been using oxygen continuously in his room since 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 did not provide pharmaceutical services, including services that assure the accurate storage, dispensing and administering of all drugs and biological's to meet the needs of residents for 1 (R31) of 3 residents investigated for proper medication administration. *R31 was observed to be left 2 doses of a nebulizer treatment for her to self-administer. R31 was observed also to have an albuterol inhaler in her bedside dresser. R31 did not have an assessment or care plan to self-administer these medications. Findings include: On 10/26/23 the facility's policy titled, Self-Administration of Medications dated 1/2018 was reviewed and read: If a resident desires to self-administer medications, an assessment is conducted of the resident's cognitive, physical and visual ability to carry out the responsibility. If the resident demonstrates the ability to safely self-administer medications, a further assessment of the safety of bedside medication storage is conducted. R31 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, staff interviews, and record review, the facility did not ensure it stored, prepared or served food, in accordance with food safety practices. This had the potential to effect 62 residents that receive food from the facility kitchen. Facility kitchen observations include: Open food was not dated. Open food was not stored in a sanitized manner. Canned food storage was not managed effectively to ensure effective rotation. The kitchen was not maintained in a clean and organized manner to prevent contamination. The kitchen equipment was not utilized to ensure proper food temperatures were maintained to prevent contamination. The facility's policy and procedure for Food Temperatures (undated) was reviewed by Surveyor. The procedures indicate that all hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 degrees Fahrenheit. Foods should be transported as quickly as possible to assure hot foods stay above 135 degrees Fahrenheit. Food…

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 food complaints recorded on the Facility's grievance log, Resident council meetings, the resident group meeting held with a Surveyor, and current observations and interviews with Residents, the Facility did not resolve Resident food grievances. This has the potential to affect all Residents who receive food from the Facility's kitchen. Findings include: The January 2022 grievance log includes 4 food concerns. The February 2022 grievance log includes 2 food concerns. The March 2022 grievance log includes 3 food concerns. The April 2022 grievance log includes 5 food concerns. The May 2022 grievance log includes 4 food concerns. The June 2022 grievance log includes 7 food concerns. The Resident Council minutes dated 1/6/22, include food concerns of food choices and food being too salty. The Resident Council minutes dated 1/12/22, include food concern of not enough food on the plate, cold food, food tasting bland, residents aren't getting food they ordered on their ticket and the hash browns have a lot of grease. The Resident Council minutes dated 2/16/22, include food concerns…

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, staff interviews, and record review the facility did not ensure 4 out of 7 residents with pressure ulcers (R3,R42, R29, R39) received the necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing. * R3 was readmitted to the facility with unstageable pressure ulcers to both the sacrum and left posterior thigh. The facility did not updated that plan of care to include interventions to assist in the healing of these wounds. The facility also continued to provide treatment to the left posterior thigh even though the area was said to be healed. * R42 developed a Deep Tissue Injury to the left heel while at the facility. The facility did not update the plan of care with interventions to assist in the healing of the Deep Tissue Injury and R42 was also observed with her feet planted directly on the floor without any pressure relief. * R29 was observed to not have her heels off-loaded for assisting in the healing of the pressure ulcer and per 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 food complaint from R25, R29, R39, R18, R21, R34 and testing R26's lunch tray food items on 7/12/22, the Facility did not ensure Resident's food was palatable. This has the potential to affect 62 Residents who receive their meals from the Facility's kitchen. Findings include: 1. On 7/11/22 9:12 a.m. Surveyor asked R25 how the food is at the Facility. R25 informed Surveyor breakfast is terrible, it's not prepared & served correctly. R25 informed Surveyor lately there has been no meat served at breakfast which is very irritable to her. Surveyor asked R25 if she has spoken to anyone about her food complaints. R25 informed Surveyor she complained three or four weeks ago as they were serving liquid eggs which smelled. R25 also informed Surveyor the frozen chicken patties are dried and crunchy like a cracker. On 7/11/22 at 12:47 p.m. Surveyor observed R25 in bed with the lunch tray on a over bed table next to R25's bed. R25 informed Surveyor she can't eat the pork as it's like leather and the white stuff on the plate is potatoes. R25's roommate informed R25 it's noodles. R25…

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 the facility did not ensure a resident obtained a requested copy of their medical record. This was discovered with 1(R20) of 1 residents requesting a copy of their medical record. R20 requested a copy of their medical record in June 2022 and has not yet received it by the end of the onsite survey on 7/14/22. Findings include: The facility's policy and procedure, entitled: Health Information Management- Release of Information, dated 1/2021 was reviewed by Surveyor. The facility procedures indicate a request for health information from a resident should be provided upon request and within 2 working days with advance notice. On 7/11/22, at 9:47 AM, Surveyor spoke with R20. R20 indicated he requested copies of his medical record in June of 2022 and has not yet received them. On 07/12/22, at 9:33 AM, Surveyor spoke with MR-D (medical record staff). MR-D indicated R20 requested copies of his entire medical record. MR-D indicated they have not gotten around to copying the record yet. MR-D stated R20's request came sometime between June 6th thru 20th and MR-D had off 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview & policy review, the Facility did not ensure 3 (R25, R27, & R34) of 4 allegations of mistreatment were immediately reported to the State Survey Agency &/or the Administrator. * R25's allegation of verbal abuse was not reported immediately to the Administrator & State Survey Agency. * R27's allegation of a CNA (Certified Nursing Assistant) pulling out the call light so he could not request help was not reported to the State Agency. * R34's allegation of verbal abuse was not reported to the Administrator immediately. Findings include: The Facility's policy entitled, Abuse Prevention Program not dated under section IV Internal Reporting Requirements and Identification of Allegations documents Employees are required to report any incident, allegation, or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it 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.

Based on record review and staff interviews, the Facility did not ensure an allegation of possible mistreatment was investigated for 1(R27) of 4 allegations. R27's allegation of a CNA (Certified Nursing Assistant) pulling out the call light so he couldn't ask for help reported on 2/17/22 was not thoroughly investigated. Findings include: The facility's policy entitled, Abuse Prevention Program not dated, under section VI (6) Internal investigation documents 1. All incidents will be documented, whether or not abuse, neglect, exploitation, mistreatment or misappropriation of resident property occurred, was alleged or suspected. 2. Any incident or allegation involving abuse, neglect, exploitation, mistreatment or misappropriation of resident property will result in an investigation. 4. Investigation Procedures. The appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident, if interviewable. Any written statements that have been submitted will be reviewed, along with any…

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 did not ensure 1 (R25) of 17 Residents were given the opportunity to participate in the care planning conference and 1 (R29) of 17 Resident's care plan were reviewed & revised . * R25 was admitted to the facility on [DATE]. R25 did not have a care conference until 5/13/22. * R29's falls care plan was not revised to remove the floor mat after it was determined R29 no longer required this intervention. Findings include: The facility policy entitled, Care Plan - Reviews/Conference, dated April 1, 2008 documents under policy, The facility will conduct a care plan review/conference at least quarterly, and as needed, that is interdisciplinary, provides an in-depth review of the resident's plan of care, and provides an opportunity for resident and family discussions/input. 1.) R25 was admitted to the facility on [DATE]. The quarterly MDS (minimum data set) with an assessment reference date of 5/12/21 has a BIMS (brief interview mental status) score of 14…

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 did not ensure 1 of 1 residents (R20) reviewed who are on a theraputic diet received established menu food items. * R20 has Celiac disease and Kidney failure and requires a special diet. On 07/11/22 R20 did not receive their designated food items based on their therapeutic menu. Findings include: On 07/11/22 at 09:42 AM Surveyor spoke with R20 in their room at the end of breakfast. R20 indicated they only got pancakes today. R20 indicated they did not get raspberries and almond milk. R20 indicated there is always a mistake. RD-K (Registered Dietician) is good at making their menu and purchasing the food. R20 indicated they received glutton food a couple days in a row. R20 indicated they have celiac disease. R20 showed their therapeutic menu to Surveyor, which indicated raspberries and almond milk. R20 has no cognitive impairment and is independent with activity of daily living. On 07/12/22 at 09:54 AM Surveyor spoke with RD-K regarding menu planning for R20. RD-K started the menu planning on 11/18/2021. RD-K reviewed glutton free…

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 did not ensure pharmaceutical services including accurate acquiring and administering of medications to meet the needs of each Resident for 2 (R29 & R39) of 8 Residents reviewed. * R29's order for SPS (Sodium Polystyrene Sulfonate), which is used to treat high potassium was not picked up and R29 did not receive this medication. * R39's order from the hospital ER (emergency room) to receive Magnesium Oxide 400 mg (milligrams) for three days was not transcribed correctly. Findings include: 1. R29's NP (nurse practitioner) note dated 5/2/22 under assessment and plan documents E87.5 Hyperkalemia: 5/1/2022 potassium 5.6. Order 1 dose of SPS powder and potassium supplement on hold. Per hospice, no longer following patient's labs. Surveyor reviewed R29's physician orders and May MAR (medication administration record) and was unable to locate an order for SPS powder or the SPS powder was administered to R29. On 7/13/22 at 11:22 a.m. Surveyor informed DON (Director of Nursing)-B Surveyor noted R29's NP note dated 5/2/22 documents order 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not act timely or did not act on recommendations by the pharmacist for 2 (R45 and R21) of 5 residents reviewed for unnecessary medications. *R45 had a pharmacist recommendation for stopping an (as needed) Trazadone order because the limit for a PRN psychotropic medication is 14 days that was not completed. *R21 had pharmacist recommendations for a gradual dose reduction for Sertraline that was not completed. Findings include: Surveyor reviewed facility's Consultant Pharmacy Reports policy with a revision date of January 2018. Documented was: IIIA1. Medication Regimen Review The consultant pharmacist performs a comprehensive review of each resident's medication regimen and clinical record at least monthly. The medication regimen review (MRR) includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and preventing or minimizing adverse consequences 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 interview and record review the facility did not ensure Residents who receive anti-psychotic drugs were assessed for the potential side effects of the anti-psychotic drugs for 2 (R45 and R50) of 3 residents reviewed for unnecessary medications. R45 and R50 did not have an Abnormal Involuntary Movement Scale (AIMS) assessment completed at least every 6 months while on anti-psychotic medication. Findings include: On 7/13/22 the facility's policy titled, Psychotropic Medication dated 2/1/18 was reviewed and read: Residents on anti-psychotic drug therapy will be monitored for tardive dyskinesia every 6 months through use of the AIMS scale. 1. R45 was admitted to the facility on [DATE] with diagnosis that included Anoxic Brain Damage and Insomnia. On 7/12/22 R45's current and discontinued physicians orders were reviewed and read: Risperdal 1 milligram (mg) one time a day with a start date of 5/4/22, Risperdal 1.5 mg twice a day with a start date of 6/22/22. Risperdal is an anti-psychotic medication. R45's…

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

Based on observation, record review and interview, the facility did not ensure food was prepared and served in a nutritional and balanced manner. The dietary staff was observed preparing the lunch meal on 7/11/22 and not following a recipe. A recipe will identify the specific portions of an ingredient needed for a meal in order to preserve the nutritional adequacy of the meal. During the meal preparation, Dietary Manager (DM) -G, Cook-C and Cook-E were observed estimating the amount of ingredients needed to make the meal and when plating the food. This deficient practice has the potential to effect 3 of 3 puree diets and 9 of 9 ground diets in the facility. The facility kitchen did not serve 3 of 3 puree diets, 9 of 9 ground diets, in a nutritional and balanced manner. Findings include: The facility's policy and procedure Meat and Vegetable Preparation (undated) was reviewed by Surveyor. The policy indicates that meats and vegetables will be prepared to conserve maximum nutritive value, to develop and enhance flavor and appearance, and to prevent foodborne illness. On 07/11/22 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.

Based on interview and record review, the facility did not ensure hospice documentation of care and services was available for facility staff. This was discovered with 1 (R38) of 1 hospice resident's reviewed. R38 is receiving hospice care and services in the facility and there was no documentation of the hospice services provided available at the facility. Findings include: The facility's policy and procedure entitled: Hospice Services dated 5/17/22, was reviewed. The procedures includes in part: All hospice staff will write a progress note for each resident visit indicating treatment provided and pertinent information related to the resident's condition which is available for all interdisciplinary staff to access. All treatments and services are documented in accordance with the facility's medical record policies and nursing procedures. R38's medical record was reviewed by Surveyor. R38 has a PN (progress note) on 6/6/2022, at 12:12 PM, which documents: Hospice called regarding need for new communication book and that POA (Power of Attorney) stated wanted to bring her home. Call…

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.