Avina on 32nd

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to report an allegation of misappropriation of property for one of 12 sampled residents (Resident (R) 8). The failure to report allegations of misappropriation created the potential for additional misappropriation to have occurred for other residents.Findings include:Review of the admission Record located under the Profile tab in the electronic medical record (EMR) revealed R8 was admitted on [DATE] with diagnoses that included flaccid hemiplegia affecting left nondominant side.Review of R8's quarterly Minimum Data Set (MDS), located under the MDS tab in the EMR, with an Assessment Reference Date (ARD) of 08/20/25, revealed R8 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R8 was cognitively intact.During a resident group interview on 10/01/25 at 2:00 PM with four alert and oriented residents (R8, R9, R10, and R11), R8 said she had an antenna stolen from outside her room where it had been magnetically mounted. R10…

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, interviews, and review of facility policy, the facility failed to ensure 13 residents [(R)4, R16, R17, R18, R19, R20. R21, R22, R23, R24, R25, R26, and R27] out of a census of 43 Resident reviewed for misappropriation was free from abuse in the sample of fifteen residents. This failure had the potential for psychosocial impairment from the loss of resident funds by a staff member. Findings include: Review of the facility's reported incident revealed that the former Business Office Manager (FBOM) was alleged to have been taking monies out of the resident trust for personal gain; at which time the BOM was immediately removed from the facility and all access to resident trust was suspended. The report also revealed that the facility reported the incident timely and conducted a thorough investigation identifying thirteen residents that had discrepancies with their trust account. The review also revealed that residents that maintained funds in the resident trust account had not had any issues with receiving money when requested. During an interview on 05/28/25 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 observations, interviews, and facility policy review, the facility failed to ensure food was properly labeled and dated as to when they expired, and all expired foods were disposed of in accordance with professional standards for food service safety as required for 51 census residents who received meals from the facility kitchen. These failures had the potential to lead to food-borne illness among all facility residents. Findings include: Review of a facility's policy titled, Food Storage, dated March 2022, revealed Food will be purchased in quantities that can be stored properly, and arranged in food groups for organized storage and inventory .Old stock is always used first .Food should be dated as it is placed on the shelves .Date marking will be visible on all high-risk food to indicate the date by which a ready-to-eat .All containers must be legible and accurately labeled and dated. During an initial kitchen observation with DA O (Dietary Aide) and DM P (Dietary Manager) on 11/16/24 from 10:29 AM to 10:50 AM, it was revealed: -The walk-in refrigerator had six one-quart…

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 facility policy review, the facility failed to ensure 6 of 28 resident rooms on 2 of 4 halls had been maintained in a safe and homelike manner. Findings include: Review of facility's policy titled, Safe and Homelike Environment, revised 11/19/24, revealed no procedure for the upkeep of the resident rooms. During an observation and interview on 11/16/24 at 11:00 AM, in room [ROOM NUMBER], an area of unpainted dry wall plaster was noted behind the resident's bed. R37 stated he did not remember how long the unpainted area had been there. He stated he would like the area painted. During an observation on 11/16/24 at 12:45 PM, room [ROOM NUMBER] was noted to have a hole in the wall to the left of the window. The hole was approximately four inches wide by two feet long. CNA F (Certified Nursing Assistant) and CNA G stated they had not noticed the hole in the wall. An observation and interview on 11/16/24 at 11:32 AM revealed wall damage in resident room [ROOM NUMBER]. There was a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, the facility failed to ensure 1 of 1 resident (R3) reviewed for self-administration of medications out of a total sample of 31 had been assessed for self-administration of medications, had a physician's order for the self-administrator, and had care plan interventions identified and implemented related to self-administration of medications. Failure to assess and care plan residents for self-administration of medications increases the potential of medication errors for residents. Findings include: Review of the facility's policy titled, Self-Administration of Medications, revised January 2018, indicated, .In order to maintain the resident's high level of independence, residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the residents and other residents of the facility and there is a prescriber's order to self-administer. Procedures: A. If the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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.