Monte Vista Healthcare Center

Based on observation, interview, and record review, the facility failed to post nurse staffing information of actual hours worked by licensed and unlicensed nursing staff who were directly responsible for resident care, per shift daily, in a prominent location and make readily accessible to residents and visitors for viewing on 4/21/2026, 4/22/2026, 4/23/2026 and 4/24/2026. This deficient practice resulted in inaccurate nursing hours posted by the facility and had the potential to result in residents and family members obtaining misleading information posted.Findings:During an observation on 4/24/2026 at 12:35 PM, the facility's posted document titled Projected Census and Direct Service Hours Per Patient Day (DPHHD) on 4/21/2026, 4/22/2026, 4/23/2026, and 4/24/2026, the DPHHD indicated the projected hours for direct care staff for shifts 7 AM to 3 PM, 3 PM to 11 PM, and 11 PM to 7 AM. The DPHHD did not indicate the actual hours worked per shift.During an interview and concurrent record review with the Director of Staff Development (DSD), on 4/24/2026 at 12:41 PM, the facility'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident's (Resident 48) had two home medication bottle contents verified by a licensed pharmacist as indicated by the facility's policy and procedure (P&P) titled, Medications Brought to the Facility by the Resident/Family.This deficient practice had the potential for Resident 48 to receive medication and/or tablets other than what was indicated on the medication bottle labels and the potential to affect Resident 48's physical well-being.Findings: During a review of Resident 48's admission Record (AR), the AR indicated Resident 48 was admitted to the facility on [DATE] with multiple diagnoses including Alzheimer's disease (a condition that occurs late in life and worsens with time in which brain cells degenerate; it is accompanied by memory loss, physical decline, and confusion) and generalized muscle weakness.During a review of Resident 48's Minimum Data Set (MDS- a resident assessment tool), dated 3/2/2026,…

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 one of five sampled residents (Resident 4) had a consent (when a patient gives permission for something to happen) for the COVID-19 (Coronavirus Disease of 2019 - a highly contagious respiratory illness caused by the SARS-CoV-2 virus) vaccine (medications used to prevent diseases usually given by injection or by mouth) prior to being administered the vaccine and as indicated by the facility's policy and procedure (P&P) titled, Coronavirus Disease (COVID-19) - Vaccination of Residents.This deficient practice had the potential to result in Resident 4 not making informed decisions due to not being aware of the potential risks and benefits associated with the vaccine.Findings:During a review of Resident 4's admission Record (AR), the AR indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including chronic obstructive pulmonary disease (COPD - a long standing lung disease causing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a comprehensive care plan (CP, a person-centered plan that outlines a resident's specific health needs, goals, and tailored interventions required to achieve their highest level of physical, mental, and psychosocial well-being) for two of three sampled residents (Residents 1 and Resident 2), as evidenced by: 1.Resident 1's vaccine (a type of medicine that helps the body to fight a disease before getting it, so illness is prevented or stays mild) refusal was not addressed in the care plan. 2. Resident 2's influenza (a highly contagious respiratory illness caused by influenza viruses that infect the nose, throat, and the lungs) status was not addressed in the care plan. This failure had the potential to result in unmet individualized medical needs for Resident 1 and Resident 2 and had the potential to affect the residents' physical and psychosocial well-being.Findings:a.During a review of Resident 1's admission Record (AR), the AR indicated 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 failed to follow its Policy and Procedure (P&P) titled, Influenza Vaccine for one of three sampled employees (Licensed Vocational Nurse [LVN] 1) when the facility did not obtain LVN 1's influenza vaccine (an annual vaccine designed to protect against infection from influenza [a highly contagious respiratory illness caused by influenza viruses that infects the nose, throat, and the lungs] viruses) administration record to ensure tracking and documentation of employee influenza vaccination. This failure resulted in LVN 1's employee file being incomplete and had the potential for influenza transmission to vulnerable residents (in general), causing harm, and an inability to track vaccination records.Findings:During an interview on 3/4/2026 at 11:02 AM with LVN 1, LVN 1 stated LVN 1 received the influenza vaccine in August of 2025 but had not provided proof of vaccination to the facility. During a concurrent interview and record review on 3/4/2026 at 2:45 PM with the Director of Staffing Development (DSD), LVN 1's Personnel Action 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 interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation - Reporting and Investigating, dated 4/2021, for one of three sampled residents (Resident 3) on 1/30/2026 by failing to report Resident 3's allegation of abuse within two hours and failing to remove Certified Nursing Assistant (CNA) 1 from resident contact immediately after Resident 3 made an allegation of abuse involving CNA 1.These deficient practices had the potential for Resident 3 to feel unsafe and for Resident 3 to be subjected to abuse.Findings:During a review of Resident 3's admission Record (AR), the AR indicated Resident 3 was admitted to the facility on [DATE] with multiple diagnoses including dementia (a progressive state of decline in mental abilities) and urinary tract infection (UTI- an infection in the bladder/urinary tract).During a review of Resident 3's Minimum Data Set (MDS - resident assessment tool), dated 2/5/2026, the MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an injury of unknown origin for one of ten sampled residents (Resident 2) to the local Ombudsman (an official appointed to investigate individuals' complaints against facility administration), to the Police, and to the State Survey Agency within two (2) hours of obtaining Resident 2's right hip X-ray results, in accordance with facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating. This failure had the potential to place Resident 2 at risk for further injury and/or harm from abuse and/or other sources.Findings: During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis…

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 investigate an injury of unknown origin for one of ten sampled residents (Resident 2) after Resident 2's bilateral hip (involving both hips) X-ray (picture or digital image of the inside of the body) results, dated 12/21/2025 and timed at 9:14 am, indicated Resident 2 had a suspected acute right femur (thigh bone) fracture (a partial or complete break in the bone). Resident 2 was transferred and admitted to General Acute Care Hospital (GACH) 1 on 12/21/2025 at 4:44 pm. Resident 2's GACH 1 right hip X-ray results, dated 12/22/2025 and timed at 9:11 am, indicated Resident 2 had an acute right femur fracture. This failure had the potential to place Resident 2 at risk for further injury and/or harm from abuse and/or other sources. Findings: During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus (DM-a disorder characterized by difficulty in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 4 did an assessment including vital signs (VS - measurements of the body's basic functions, such as heart rate, breathing rate, blood pressure, and temperature) and documented the assessment and VS on the medical record for one of 10 sampled residents (Resident 2) before and after Resident 2 went to an outside doctor's appointment. This failure had the potential for Resident 2's change in condition to be unmonitored which could result in delayed care and services.Findings: During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness in the arm, leg, and face on one side of the body) following cerebral…

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 foods were stored, prepared, and distributed under sanitary conditions for all the residents who received food from the kitchen by failing to:1. Ensure food past the use-by date was not available for use in the kitchen.2. Ensure food stored in the kitchen had an open date.These failures placed all residents who received food from the kitchen at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages). During a concurrent observation and interview on 07/23/2025 at 9:15 a.m. with the Dietary Supervisor in the facility kitchen walk-in refrigerator, a clear plastic container of diced tomatoes was observed labeled with an open date of 07/16/2025. The Dietary Supervisor stated, That (diced tomatoes) should have been discarded three days after opening (7/19/2025). It looks like it was missed. A clear plastic container of grape jelly with no open date was also observed in the walk-in refrigerator. The Dietary Supervisor stated the container of grape jelly was…

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

Based on observation, interview, and record review, the facility failed to ensure one of two trash containers was closed with a tight-fitting lid and kept covered. This failure had the potential to attract insects and harbor pests in the refuse area that can cause a wide spread of diseases and affect the residents, staff, and visitors. During a concurrent observation and interview on 7/23/2025 at 9:17 AM with the Dietary Supervisor (DS) at the kitchen, a large white trash can was observed without a lid. The trash can was partially filled with food waste and positioned near clean food carts and meal preparation surfaces. The trash can was open to the environment and not covered in any way. The DS stated the lid of the trash container should be closed at all times. During a review of the facility's policy and procedure titled, Sanitization, undated, the policy indicated, All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects. The policy also indicated kitchen wastes not disposed of by…

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 a clean, safe, sanitary, and homelike environment for the following by failing to: a) One of one sampled resident's bathroom (Resident 29) did not have a clogged toilet. b) Maintain Seven of Seven resident bathrooms (Bathrooms 1, 2, 3, 4, 5, 6, and 7) affecting 18 residents (Resident 3, Resident 4, Resident 5, Resident 7, Resident 8, Resident 11, Resident 15, Resident 20, Resident 24, Resident 27, Resident 30, Resident 31, Resident 32, Resident 33, Resident 36, Resident 39, Resident 49, and Resident 211). c) Maintain Four of Four resident rooms (Rooms A, B, C and D) affecting six residents (Resident 3, Resident 4, Resident 5, Resident 8, Resident 20, and Resident 36). These deficient practices had the potential for Residents 3, 4, 5, 7, 8, 11, 15, 20, 24, 27, 30, 31, 32, 33, 36, 39, 49, and 211 to be exposed to dirt, mold, rust and drywall dust, which can lead to a decline in the residents' health and result in irritation of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure, one of one sampled resident (Resident 25), received proper care by failing to follow Resident 25's physician's order that included parameters (specific instructions that can be measured) indicating when to hold (not give) the administration of Losartan Potassium (medication used to treat high blood pressure [hypertension]) for) as indicated in the facility's policy and procedure (P&P), titled, Administering Medications. This deficient practice could potentially result in Resident 25's blood pressure to drop too low (hypotension) and result in a medical emergency due to not enough oxygen (02 - colorless, odorless, tasteless gas essential for life) and nutrients to Resident 25's vital organs. Findings: During a review of Resident 25's admission Record (AR), the AR indicated, Resident 25 was admitted to the facility on [DATE] with multiple diagnoses including acute respiratory failure (when the lungs can't release enough oxygen into your blood)…

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 two of four sampled residents (Resident 41 and Resident 22), were provided treatment consistent with professional standards of practice to promote the healing of Resident 41's existing pressure ulcer/injury (PI - localized, pressure related damage to the skin and/or underlying tissue usually over a bony prominence) and to prevent the development of PI to Resident 22 by failing to ensure: a. Resident 41's low air loss mattress (LAL - a mattress attached to a blower pump designed to circulate a constant flow of air to remove excess moisture and regulate the pressure levels, thereby improving blood flow to the wound site) was set correctly on 2/19/2025. b. Resident 22 was turned and repositioned in accordance with Resident 22's care plan (CP). These deficient practices could potentially result in delayed healing of Resident 41's existing PI and the potential for development of a new PI to Resident 22. Findings: a. During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure, three of three sampled residents (Resident 21, 52, and 111), were provided appropriate respiratory care and services in accordance with the facility's policy and procedures (P&P) by failing to ensure: a. One of three sampled resident's (Resident 21) nebulizer (a medical device that turns liquid medications into a mist, which is then inhaled through a mouthpiece or a mask) was changed timely. b. Two of three sampled resident's (Resident 52 and 111) oxygen (02 - colorless, odorless, tasteless gas essential for life) tubing and breathing treatment's humidifier (a device that adds moisture to the air to prevent dryness) were labeled with a date to ensure the equipment was changed timely. Additionally, the facility failed to ensure there was a physician's order for the administration of oxygen for one of two sampled residents (Resident 52). These deficient practices could potentially result in the growth of harmful bacteria (living…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the facility medication error rate was not 5 percent or greater for one of three sampled residents (Resident 28). There were 3 errors observed during medication administration with 31 opportunities for errors which yielded a 9.68 % error rate. On 2/20/2025, the facility failed to administer the full dose of 3 out of 13 medications for Resident 28 via Resident 28's gastrostomy tube (G-Tube - tube that is placed directly into the stomach through an abdominal wall incision for the administration of food, fluids, and medications). This deficient practice could potentially result in Resident 28 not getting the full efficacy (the ability to produce a desired or intended result) and benefits of the medications. Findings: During a review of Resident 28's admission Record (AR), the AR indicated, Resident 28 was admitted to the facility on [DATE] with multiple diagnoses including encounter for attention to gastrostomy and type 2 diabetes…

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 two of two medications (Senna and Docusate Sodium [medications used to treat constipation and were labeled properly in one of two sampled medication carts (Med Cart 2) in accordance with the facility's policy and procedure (P&P), titled, Administering Medications. This deficient practice had the potential for residents to be administered ineffective and contaminated medications and the potential to compromise the health, safety, and well-being of the residents. Findings: During an observation and interview on [DATE] at 9:26 AM with Licensed Vocational Nurse (LVN) 1, during the medication administration, an opened bottle of Senna and an opened bottle of Docusate Sodium did not have an opened date label and were stored inside Med Cart 2. LVN 1 stated, the bottles of Senna and Docusate Sodium were the facility's house supply (medications stocked at the facility). LVN 1 stated, the house supply medications should be dated once opened…

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 fortified diets were provided for two of two sampled residents (Resident 29 and Resident 112). This deficient practice had the potential for Residents 29 and 112 not to get the caloric intake ordered by the physician. Findings: During a review of Resident 29's admission Record, (AR), the AR indicated the facility admitted Resident 29 on 1/19/2022 with diagnoses that included cerebral infarction (stroke - occurs when blood flow to a part of the brain stops, the brain cannot get nutrients and oxygen. Brain cells can die, causing lasting damage), hemiplegia and hemiparesis (weakness and paralysis to one side of the body). During a review of Resident 29's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 10/9/2024, the MDS indicated Resident 29 had intact cognition. The MDS indicated Resident 29 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact…

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 there were no expired items, in one of one kitchen's (Kitchen 1) storage. This deficient practice had the potential to cause food-borne illnesses (illness caused by food contaminated with infectious organisms) among the residents consuming food at the facility. Findings: During a concurrent observation and interview on 2/18/2025 at 8:22 AM, with the Dietary Aide (DA), the following items were expired and still kept in Kitchen 1's dry storage. 1. 1 open package of corn meal, a quarter full had an expiration date of 9/2024. 2. 1 open package of baking powder, half full had an expiration date of 7/2023. The DA stated the expired items needed to be discarded right away. During an interview on 2/18/2025 at 2:30 PM, with the Dietary Supervisor (DS), the DS stated expired food items needed to be discarded right away so kitchen staff did not use it. The DS stated every kitchen staff member was responsible for checking if any food items were expired. The DS did not answer when asked for the reason why 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow infection control practices for 20 of 20 sampled residents (Residents 112, 13, 17, 42, 25, 9, 10, 21, 40, 162, 6, 35, 161, 50, 56, 53, 111, 29, 30, and 114) by failing to ensure, a.&b. two of eight sampled residents (Residents 29 and 30) who exhibited signs and symptoms of norovirus (a highly contagious virus that can cause vomiting, diarrhea and dehydration) were asymptomatic (did not have signs and symptoms [S/S]) prior to discontinuing contact (microorganisms spread through the direct and indirect contact) isolation (staying away/kept away from others) precautions. c. Ensure staff were wearing appropriate personal protective equipment (PPE - protective items or garments worn to protect the body or clothing from hazards that can cause injury and to protect residents from cross-transmission) during contact with residents and/or the resident's environment who were on transmission-based precautions (infection control precautions in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure: 1) A call light was functional for 1 of 1 sampled resident (Resident 7). 2) 7 out of 7 bathrooms were in good repair. 3) 1 of 1 sampled resident's (Resident 13) bed control was functional. These deficient practices had the potential for Residents 7, 13, and residents in Rooms A-D to be placed at risk for injury, a decline in the resident's health, and a delay in meeting the resident's needs for toileting and assistance. Cross Reference F584 and F919. Findings: 1) During an interview on 2/18/25 at 12:50 p.m. with Resident 7, Resident 7 stated Resident 7's call light was not working since last night (2/17/25). Resident 7 stated he was told by the night shift Certified Nursing Assistant (no name given) to Yell for me. Resident 7 stated he was upset that he would have to yell for help. Resident 7 stated he requested staff to fix his call light on 2/18/25. During a concurrent observation and interview on 2/18/25 at 12:55 p.m. with…

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

Based on observation, interview and record review, the facility failed to promote dignity and privacy during patient care for one of one sampled resident (Resident 22). This deficient practice had the potential to affect Resident 22's psychosocial wellbeing. Findings: During a review of Resident 22's admission Record (AR), the AR indicated the facility admitted Resident 22 on 7/30/2019, with diagnoses that included malignant neoplasm of the left lung (lung cancer) and retention of urine (is a condition in which your bladder doesn't empty completely even if it's full). During a review of Resident 22's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 10/31/2024, the MDS indicated Resident 22 had severe cognitive impairment and sometimes understands verbal content and sometimes able to express ideas and wants. The MDS indicated Resident 22 was dependent in toileting hygiene, shower/bathe self and required maximum assistance (helper does more than half the effort) with personal hygiene. During an observation on 2/21/2025 at 9 AM while in Resident 22's room,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a proper assessment was conducted for the self-administration (take or do something for yourself that would normally be done by someone else) of Pepto Bismol Ultra (medication used to treat occasional upset stomach, heartburn, and nausea), for one of one sampled resident (Resident 53). On 2/18/2025, there was an almost empty bottle of Pepto Bismol Ultra in Resident 53's room. The facility failed to obtain a consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) from Resident 53 and a physician's order for the self-administration of the medication as indicated in the facility's policy and procedures (P&P), titled, Administering Medications and Self-Administration of Medications. This deficient practice had the potential to harm Resident 53 as a result of overmedicating, improper medication dosage, and a adverse drug event (injuries…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a care plan for one of one sampled resident (Resident 32) after receiving positive lab results for clostridium difficile (C. diff- a highly contagious bacteria that causes severe diarrhea). This deficient practice had the potential to negatively affect the provision of care and services for Resident 32. Findings: During a review of Resident 32's admission Record (AR), the AR indicated, Resident 32 was admitted to the facility on [DATE] with diagnoses that included atherosclerotic heart disease (plaque buildup in artery walls), type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), gastro-esophageal reflux disease (stomach acid repeatedly flows back up into the tube connecting the mouth and stomach), and dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). During a review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure toileting was offered to one of one sampled resident (Resident 14) every two hours as indicated in Resident 14's care plan (CP), titled, At Risk for Falls. This deficient practice had the potential to result in falls and injury to Resident 14. Findings: During a review of Resident 14's admission Record (AR), the AR indicated the facility admitted Resident 14 on 9/15/2023, with diagnoses that included dementia (a progressive state of decline in mental abilities), repeated falls. During a review of Resident 14's CP, titled At Risk for Falls, initiated on 7/14/2024, the CP included an intervention to meet Resident 14's toileting needs every two hours. During a review of Resident 14's Minimum Data Set (MDS - a resident assessment tool) dated 12/2/2024, the MDS indicated Resident 14 had a memory problem and had severely impaired cognitive skills for daily decision making. The MDS indicated Resident 14 required moderate assistance…

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 licensed nurse followed the physician's order for indwelling catheter care for one of one resident (Resident 22). This deficient practice had the potential to result in Resident 22 experiencing complications with the use of an indwelling catheter and to affect Resident 22's physical wellbeing. Findings: During a review of Resident 22's admission Record (AR), the AR indicated the facility admitted Resident 22 on 7/30/2019, with diagnoses that included malignant neoplasm of the left lung (lung cancer) and retention of urine (is a condition in which your bladder doesn't empty completely even if it's full). During a review of Resident 22's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 10/31/2024, the MDS indicated Resident 22 had severe cognitive impairment and sometimes understands verbal content and sometimes able to express ideas and wants. The MDS indicated Resident 22 was depended in toileting hygiene, shower/bathe self and required maximum assistance (helper does…

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 one of one sampled resident (Resident 28), received appropriate care and services during gastrostomy tube (G-Tube - tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) medication administration. On 2/20/2025, Licensed Vocational Nurse (LVN) 1 used apple sauce to mix Resident 28's medications during administration via Resident 28's G-Tube. This deficient practice had the potential to cause tube-associated complications such as feeding tube occlusions (risk of clogging) to Resident 28's G-Tube. Findings: During a review of Resident 28's admission Record (AR), the AR indicated, Resident 28 was admitted to the facility on [DATE] with multiple diagnoses including encounter for attention to gastrostomy and type 2 diabetes mellitus (DM2- adult-onset disorder characterized by difficulty in blood sugar control and poor wound healing) with diabetic…

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 food served to the residents was served at a temperature that was safe and appetizing. This deficient practice had the potential to result in food that was not appetizing or palatable to the residents consuming the food and result in resident caloric goals not met. Findings: During an observation on 2/20/2025 at 1:15 PM, the licensed nurses and the certified nursing assistants (CNA's) were distributing food trays to the residents, the last cart sent out from the kitchen was sampled. During a review of th e facility's Cycle 1 2025 Winter Menu, last approved 5/11/2025, the menu indicated on Thursday, 2/20/2025, the following food items would be served for lunch: baked chicken, mashed potatoes/gravy, green beans, bread/margarine, snickerdoodle, cake/icing, and water. During a review of the facility's Resident Council Minutes, dated 12/2024 and 1/2025, the Resident Council Minutes indicated in December 2024, a resident complained food was always cold by the time food was received. The January 2025, minutes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a functioning call light for one of one sampled resident (Resident 7). This deficient practice had the potential for delay in care and services to meet Resident 7's needs for hydration, toileting, and activities of daily living. Findings: During a review of Resident 7's admission Record (AR), the AR indicated, Resident 7 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side) following cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it), epilepsy (a chronic brain disorder in which groups of nerve cells, or neurons, in the brain sometimes send the wrong signals and cause seizures), and muscle weakness (lack of muscle strength). During an interview on 2/18/25 at 12:50 p.m. with Resident 7, Resident 7 stated his call light was not working since last night (2/17/25). Resident 7…

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 one of one kitchen (Kitchen 1) area was kept free of pest. On 2/18/2025, two dead cockroaches were found in Kitchen 1. This deficient practice had the potential to result in food-borne illnesses (illness caused by food contaminated with infectious organisms) due to harboring of pest. Findings: During a tour of the Kitchen 1 on 2/18/2025 at 8:45 AM, there were two dead cockroaches at the back of the walk-in freezer, the roaches were visible when checking the 3- inch gap located between the walk-in freezer and the wall. The Dietary Aide (DA) used a broom to sweep the cockroaches from the back wall. The broom used had dust and green beans that were swept together with the dead roaches. During an interview on 2/18/2025 at 8:47 AM, with the DA, the DA stated it was dead cockroaches. During an interview on 2/18/2025 at 2:40 PM, with the Dietary Supervisor (DS), the DS stated the cockroaches could have come out of hiding after the monthly pest control visit more than a week ago. The DS stated kitchen staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement person-centered care-plans for 3 of 3 (Resident 46, Resident 35 and Resident 38) sampled residents when: a. There was no care plan created for Resident 46 who was diagnosed with abdominal distension (swollen belly, enlarged). b-c. For Resident 35 and Resident 38, the facility did not follow an existing care plan's intervention to trim, and clean Resident 35's and Resident 38's nails on bath day and as necessary. These failures had the potential to result in inconsistent implementation of care and had the potential to result in physical declines to Residents 46, 35, and 38 and result in infections to Residents 35 and 38. Cross Reference: F677 Findings: a.During a review of Resident 46's admission Record (AR), the AR indicated Resident 46 was re-admitted to the facility on [DATE] with diagnoses that included end stage renal disease (last stage of kidney loss) and hypertension (high blood pressure). During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure necessary grooming services were provided for three of six sampled Residents (Residents 3, 35, and 38) as indicated in the facility's policy and procedure (P&P) titled Fingernails/Toenails, Care of, by failing to: 1. Ensure Resident 3, who had a left contracted (condition of shortening and hardening of muscles, tendons, or other tissues, often leading to deformity and rigidity of joints) hand, had trimmed and clean fingernails. 2. Ensure Resident 35's fingernails and toenails (hard, smooth covering that protects the upper part of the end of a toe) were kept trimmed and clean. 3. Ensure Resident 38's fingernails were kept trimmed and clean. The failures resulted in Resident 3's fingernails pressing into Resident 3's left palm (part of hand between the bases of the fingers and the wrist), causing pain and discomfort to Resident 3. The failures had the potential to result in the development of infections and injuries to Resident's 3,…

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 assistive hearing devices were available for one of one sampled resident (Resident 15) who was hard of hearing (HOH). Resident 15 was not provided with audiology (health care professionals who identify, assess, and manage disorders of hearing, balance, and other neural systems) services to address Resident 15's hearing impairment. This failure had the potential to result in further hearing loss and a psychosocial decline to Resident 35 and the potential to affect Resident 15's quality of life. Findings: During a review of Resident 15's admission Record (AR), the AR indicated Resident 15 was admitted to the facility on [DATE] with diagnoses that included hearing loss of unspecified ear, subsequent (occurring) falls, and dementia (a decline in mental ability severe enough to interfere with daily life). During a review of Resident 15's Admission/readmission Data Tool (ARDT), dated 9/15/23, the tool indicated Resident 15's ability to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the medication error rate was not 5 percent (%) or greater during medication administration observation. The facility had 25 medication administration opportunities observed and two of the 25 medications administered resulted in a medication error rate of 8%. The errors consisted of: a. For Resident 33, who had a gastrostomy tube (GT- tube inserted through the belly that brings nutrition directly to the stomach) and who could not receive solid textures by mouth, the facility failed to ensure the physician's order indicated administration of Bactrim by GT, the order indicated an incorrect route to administer by mouth to Resident 33. b. For Resident 4, the facility failed to administer Peridex (a medication that treats gum disease) as indicated by pharmacy recommendations to Resident 4. These failures had the potential to result in adverse drug events (injuries resulting from medication use including physical and mental harm, or loss…

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 a Minimum Data Set (MDS, a standardized assessment and care-screening tool) was accurate for one of one sampled resident (Residents 54). Resident 54's MDS incorrectly indicated Resident 54 was dehydrated (a dangerous loss of body fluid caused by illness, sweating, or inadequate intake). This failure had the potential to result with inadequate treatments and/or services to Resident 54. Findings: During a review of Resident 54's admission Record (AR), the AR indicated Resident 54 was admitted to facility on 1/12/24 with multiple diagnoses including acute respiratory failure (when the lungs can't get enough oxygen into the blood, sudden) with hypoxia (low levels of oxygen in your body tissues), epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), and cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture). During a review of Resident 54's MDS, dated 1/18/24, the MDS indicated Resident 54 was severely (never/rarely made…

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 post actual worked nursing hours at the start of each shift in one of one Nursing Stations (Nursing Station 1) as indicated in the facility's Policy and Procedure (P&P) titled, Posting Direct Care Daily Staffing Numbers, revised August 2022. This failure had the potential to result inaccurately reflecting the actual nurses providing direct care to the residents. Findings: During a concurrent interview and record review on 2/10/24 at 4:44 p.m. with the Director of Staff Development (DSD), the facility's Daily Direct Care Staffing, dated 2/10/24 was reviewed. The DSD stated a Daily Direct Care Staffing was posted at Nurses Station 1. The DSD stated a Licensed Vocational Nurse (LVN) from the night shift, or the Director of Nursing (DON) posted the document in Nurses Station 1. The DSD stated the Daily Direct Care Staffing only indicated the projected staffing level and did not reflect accurate staffing levels if a staff person called off. During a review of the facility's P&P titled, Posting Direct Care Daily Staffing…

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 infection prevention and control practices were included in the facility's, Water Management Program (WMP, a program develop to identify hazardous conditions and taking steps to minimize the growth and transmission of Legionella [bacteria that causes severe lung inflammation called Legionnaires' disease, LD]) and other waterborne pathogens [living thing that causes disease]) by failing to: Develop specific control measures per facility risk area used to control the introduction and/or spread of Legionella. These failures could potentially result in the growth of Legionella and other opportunistic waterborne pathogens and had the potential to result in the development and transmission of LD which could compromise the health and safety of all residents residing at the facility. Findings: During a concurrent interview and record review on 2/11/24 at 12:51 pm, with the Maintenance Supervisor (MS), the facility's, Water Management Program (WMP), 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.