Asistencia Villa Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure adequate supervision for one (1) of four (4) sampled residents (Resident 1), when Resident 1 left the facility without staff knowledge. Resident 1 was found five hours later in an adjacent building. This failure had the potential to result in serious injuries/accidents or death of Resident 1 due to lack of supervision.A review of Resident 1's Face Sheet (contains resident demographic), the Face Sheet indicated, Resident 1 was admitted on [DATE], with diagnoses that included spinal stenosis cervical region (the bony tunnel (spinal canal) in the neck gets too narrow squeezing the spinal cord), abnormalities of gait and mobility (your usual way of walking is off).During an interview on December 12, 2025, at 2:52 PM, with the License Vocational Nurse (LVN 1), LVN 1 stated that during the shift change, she received a communication from LVN 2 that on December 12, 2025, around 5:00 AM they could not locate Resident 1, prompting a search. LVN 1 further…

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 blood pressure medication was not administered in duplicated dose for one of three sampled residents (Resident 1). This failure had the potential for Resident 1 to receive an excessive dosage of the medication which could jeopardize her health and safety. Findings: During a review of Resident 1's admission record (information about the patient's personal details, reason for admission, and medical history), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included cardiac arrest (the heart suddenly and unexpectedly stops pumping blood to the brain and other vital organs). During a review of the facility provided document titled Progress Notes, for Resident 1, dated May 24, 2025, at 2:18 AM, the Progress Notes indicated an entry from Licensed Vocational Nurse (LVN 1) stating: Double dose given, MD [Doctor of Medicine] notified, and receive the order for continually monitor for Hypotensive [low 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 provide the necessary care and services to ensure residents received care and services with activities of daily living (ADL) when two out of three residents (Resident 1 and Resident 2) waited a long time to be cleaned and changed. This failure had the potential to place two clinically compromised Residents (Resident 1 and Resident 2) ' s health and safety at risk, when the residents ' activities of daily living were not met in timely manner. Findings: 1. During review of Resident 1 ' s admission Record (general demographics), the document indicated Resident 1 was last admitted to the facility on [DATE], with diagnoses that included chronic respiratory failure (a condition when the lungs cannot get enough oxygen into the blood or get rid of the waste product from the blood), morbid obesity (a condition with too much body fat), dependence on respirator (a condition when one cannot breath on their own and needs a machine) , and quadriplegia…

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 reviews, the facility failed to follow its policy and procedure regarding medication error and adverse drug reaction reporting, for one of four sampled residents (Resident 1) when Resident 1 did not receive Pirfenidone (a medication to treat pulmonary fibrosis – a disease that damages the lung tissue, making it difficult to breathe) on December 21, 2024. This failure resulted in Resident 1 not receiving one dose of Pirfenidone and had the potential to adversely affect the health and safety of Resident 1 by causing a decline in lung function (when lung tissues cannot expand enough). Findings: During a review of Resident 1's admission Record (It contains demographic information), the admission Record indicated, Resident 1 was admitted to the facility on [DATE], with a diagnosis that included acute respiratory failure (is a serious condition that occurs when the body's respiratory system is unable to meet the body's need for oxygen or remove carbon dioxide). During a…

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

Based on observations, interviews, and record review, the facility failed to maintain a sanitary kitchen when: 1. There was a cabinet that stored a juice dispenser, the door to the cabinet had a sticky residue. Inside the cabinet there was a red juice spill. The cabinet under the steam table had food crumbs and trash. There was food residue around the floor sink under the steam table. This had the potential to attract pests and for microorganisms' growth. 2. The industrial mixer was stored with white food residue on the mixer. This had the potential to contaminate food being mixed in the mixer. 3. The ice machine had some brown build-up in the area where ice is formed. This had the potential to contaminate the ice. The facility failures had the potential to attract pests and cause foodborne illness to a population of 59 residents eating facility prepared meals. Findings: 1. During an observation on October 14, 2024, at 08:02 AM, on the stainless-steel counter there was a juice dispenser and below there was a cabinet. The handle to open the cabinet had a sticky residue. When the…

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

Based on observation, interview, and record review, the facility failed to implement their infection control program to help prevent the spread of COVID-19 (Corona Virus Disease, a highly infectious disease caused by the SARS-CoV-2 virus) when the facility did not have any tracking and documentation of staff COVID-19 vaccination status. This failure had the potential to cause harm to the 95 residents residing within the facility by causing cross contamination of the environment and increasing the risk of exposure and spread of the COVID-19 virus. Findings: During a concurrent interview and record review on October 17, 2024, at 9:40 AM, with the Infection Control Preventionist (ICP) nurse, the ICP nurse was asked to review the staff COVID-19 vaccination status. The ICP nurse was not able to provide a document that indicated a tracking system of staff members and their COVID-19 vaccination status. The ICP nurse stated she was unaware of her responsibility to maintain a system for documenting staff COVID-19 vaccination. The ICP nurse further stated she realized this duty only after…

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

Based on observations, interviews, and record review, the facility failed to ensure their equipment was maintained in safe operating condition when: The countertop water dispenser was found leaking and collecting standing water in the drain. This facility's failure to ensure a safe, operating equipment has the potential to increase risk of resident harm and attract pests due to the standing water which can affect the population of 59 residents who receive food from the kitchen. Findings: During an observation on October 14, 2024, at 08:04 AM, there was a leaking water dispenser on the countertop, with sitting water in the drain underneath the cover. During an interview on October 14, 2024, at 08:09 AM, with [NAME] 1, she stated they do not use it and it that it looks like it is leaking and needs to be fixed. During an interview on, October 16, 2024, at 3:10 PM, with Registered Dietitian Nutritionist (RDN 1), and Registered Dietitian Nutritionist (RDN 2), RDN 2 stated that it was her expectation that the water dispenser should be fixed as soon as possible. During a review 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 the observation, interview and record review, the facility failed to ensure a Significant Change of Status Assessments (SCSA) of the Minimum Data Set (MDS-a computerized assessment instrument) was completed within 14 days for one resident (Resident 36) when Resident 36 had a significant change in the nutrition route from enteral (nutrition delivered directly to the stomach or intestines) to oral (nutrition taken by mouth) after gastric tube (g-tube is a small tube that is placed through the skin into the stomach, used to give food, water, or medicine to people who can't eat by mouth) removal and a changed in the level of eating assistance. This failure resulted in Resident 36's care plan not being updated and revised to reflect his current status, which had the potential to delay the implementation of care and support needs. Findings: During a review of Resident 36's admission Record (a document that contains demographic and clinical data), indicated, Resident 36 was admitted to the facility on [DATE],…

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 Minimum Data Set (MDS- a computerized assessment instrument) Assessments were completed accurately to reflect the resident's status, care, and services for one of two sampled residents (Resident 68) reviewed for restraints (tools used to keep a patient safe by limiting their movement. They can be things like special belts, mittens, or straps that prevent a person from hurting themselves or others, or from pulling out important medical equipment). This failure had the potential to cause inaccuracy in identifying Resident 68's care and support needs. Findings: During a review of Resident 68's admission Record (a document that contains demographic and clinical data), the admission Record indicated, Resident 68 was admitted to the facility on [DATE], with diagnoses which included metabolic encephalopathy (a brain problem caused by issues with how the body uses food and energy) and attention of tracheostomy (tube helps people breathe when they can't…

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 the observation, interview and record review, the facility failed to store all drugs and biological in accordance with currently accepted professional principles and the facility's policies and procedures when one of four medication carts (200's hall medication cart ) reviewed for medication storage found to be unsanitary on October 16, 2024. This failure had the potential increase the risk of infection to a resident's receiving medications with unwanted chemical reactions and decreased efficacy. Findings: During an observation on October 16, 2024, at 10:50 AM with License Vocational Nurse 2 (LVN 2), LVN 2 inspected the contents of the 200's hall medication cart. The left bottom drawer, was noted with yellow moist build up. LVN 2 stated the drawer contains the as needed over the counter medications and acknowledged there was a yellow build up on the paper towel used to wipe inside of the 200's hall medication cart left bottom drawer. During a concurrent observation and interview on October 16, 2024, at 11:10 AM with Infection Control Preventionist (ICP) nurse. The ICP nurse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to implement its policy and procedure on antibiotic stewardship (a set of practices aimed at ensuring the safe and effective use of antibiotics [medications used to treat infections]) for one of fourteen sampled residents (Resident 47) reviewed for antibiotic used, when the Infection Control Preventionist (ICP) nurse did not accurately assess and collect data to indicate the rationale and common clinical conditions necessary to ensure the appropriate use of antibiotic therapy for Resident 47. This failure had the potential to placed Resident 47 at risk for adverse events, including the development of anti-biotic resistant organisms, from unnecessary or inappropriate antibiotic use. Findings: During a review of Resident 47's admission Record (a document that contains demographic and clinical data), the admission Record indicated, Resident 47 was admitted to the facility on [DATE], with diagnoses which included metabolic encephalopathy (a brain problem…

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 their policy and procedure to ensure the removal of medication from the medication cart immediately upon receipt of a physician order to discontinue an order to prevent error in administration of medication for one of four sampled residents (Resident 1). This failure had the potential to place a clinically compromised Resident 1's health and safety at risk when Resident 1 was administered a medication that had already been discontinued. Findings: During a review of Resident 1 ' s admission record, the face sheet (contains demographic and medical information), indicated Resident 1 was admitted on [DATE], with a diagnosis that included polyneuropathy, unspecified ( is a damage or disease affecting peripheral nerves [made of fibers that send messages from the brain and spinal cord] roughly the same areas on both sides of the body, featuring weakness, numbness, and burning, pain). During a review of the clinical record for Resident 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow policy and procedure to ensure the call lights were answered in a timely manner to provide care and services for two of three residents (Resident 1 and Resident 2). This failure had the potential to place two clinically compromised Residents (Resident 1 and Resident 2) health and safety at risk when residents call lights were not answered promptly to assist with their activities of daily living. Findings: 1.During a review of Resident 1's clinical record, the face sheet (contains demographic and medical information), indicated Resident 1 was admitted on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD - is a common lung disease causing restricted airflow and breathing problems). During a review of the clinical record for Resident 1's the Brief Interview for Mental Status (BIMS- screening tool to identify and monitor cognitive decline), dated March 4, 2024, indicated, Resident 1's score was a 15,…

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 adequate supervision was provided to prevent avoidable accidents when one of four residents (Resident 4) was unsupervised and fell on the floor. This failure contributed to Resident 4 falling and hitting his head and sustaining a subdural hematoma (a collection of blood between the covering of the brain after an injury to head). Findings: During a review of Resident 4 ' FACE SHEET (general demographics) on May 16, 2024, the document indicated Resident 4 was originally admitted to the facility on [DATE], with diagnoses that include repeated falls, seizures (a condition that causes a sudden uncontrolled body movements and changes in the brain), dementia (a condition with the loss of thinking, remembering and reasoning) and other abnormalities of gait and mobility (a condition that causes abnormal walking and balance). A review of Resident 4 ' s History and Physical dated, October 13, 2023, indicated, . Other . CAPACITY: This 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.

Based on interview and record review the facility failed to ensure one of three clinically compromised residents (Resident 2) was provided transportation for her medical appointment. This failure had the potential to result in a delay of treatment that could adversely affect and further compromise Resident 2. Findings: During a review of Resident 2's Face Sheet (general demographics) on December 4, 2023, the document indicated Resident 2 was last admitted to the facility April 22, 2023, diagnoses that include respiratory failure (a condition that make it difficult to breathe), hemiplegia (a condition with loss of strength on one side of the body), 2 diabetes mellitus (a condition that affects the way the body process blood sugar) and hypertension (a condition with blood pressure that is higher than normal). During a review of Resident 2's History and Physical on December 4, 2023, the document indicated Resident 2 diagnoses include Thyroid nodules (a condition of a growth and enlargement of the thyroid gland or the front of the neck), respiratory failure (a condition of the lungs).…

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 comfortable and homelike environment for one of three residents (Resident 1), when Resident 1 ' s overhead light located on the wall, at the head of the bed, had the light shining directly at him. The light setting couldn ' t be adjusted or turned off since the beaded cord was stuck. This failure has the potential to negatively impact Resident 1 ' s sense of well-being and comfort. Findings: A review of Resident 1 ' s Face sheet (a document with clinical and demographic data) indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included, other sequelae of cerebral infraction (stroke), nontraumatic intracerebral hemorrhage (a common subtype of stroke with a poor prognosis, high mortality, and long-term morbidity), and abnormal posture. During an observation on September 12, 2023, at 11:50 AM, in Resident ' s room, Resident 1 was lying in bed, with his eyes closed. The overhead light that was located…

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 maintain professional standards for food service safety when the [NAME] (Cook 2) was not wearing a facial hair restraint while serving food during lunch on August 8, 2023. This failure had the potential to expose 90 medically compromised residents who receive food from the kitchen to foodborne illness due to food contamination. Findings: During an observation on August 8, 2023, at 12:14 PM, in the kitchen, [NAME] 2 did not wear a facial hair restraint during lunch tray line (when cook serves food on plates for each resident). [NAME] 2 had visible facial hair. During an interview on August 9, 2023, at 10:28 AM, with the Dietary Services Supervisor (DSS 1), the DSS 1 stated it was her expectation that the cook wears a facial hair restraint during tray line. During an interview on August 9, 2023, at 2:36 PM, with the Registered Dietitian (RD), the RD stated it was her expectation that facial hair restraints be worn if the cook has facial hair. During a review of facility's policy and procedure (P&P) titled,…

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 follow the approved menus when: 1. Residents on CCHO (Consistent Carbohydrate diet, diet for diabetic residents, residents who have elevated blood sugar levels) received a larger portion of red roasted potatoes than was indicated on the menu for lunch on August 8, 2023. (1/2 cup was served and the menu indicated ¼ cup of potato) 2. There was no planned vegan (food containing no animal product) menu for one resident (Resident 353) on a vegan diet. 3. Resident 10 on a fortified (extra calories) full liquid diet (fluids and foods that are normally liquid and foods that turn into liquid when they are at room temperature) did not receive the correct lunch on August 8, 2023. These failures resulted in lower calorie content of meals served, a potential to contribute to a decline in nutritional status and undesirable weight loss when menus are not planned and followed, for 17 residents on CCHO diet who are medically compromised residents. Findings: 1. During a tray line (when cook serves food on plates for each…

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 maintain kitchen equipment in operating condition when three pieces of equipment (steamer, convection oven, and industrial mixer) were not functioning. These failures led to equipment accumulating dust and grime and providing a source for bacterial growth that could be inadvertently transferred to food and can affect 90 medically compromised residents receiving food from the kitchen. Findings: During the tour of the kitchen, on August 8, 2023, at 7:53 AM, a steamer, convection oven, and one industrial mixer had signs on the equipment stating, out of service and there was dust collecting on the bottom of the convection oven and dust collecting on the cover of the industrial mixer. During an interview with the Dietary Services Supervisor (DSS 1), on August 8, 2023, at 10:00 AM, in the kitchen, the DSS 1 stated the equipment needed to be repaired and were waiting for outside vendor quotes. During an interview with the Registered Dietitian (RD), on August 9, 2023, at 2:56 PM, the RD stated it was her expectation…

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 call lights (a device that triggers a visual and/or auditory cue when a resident needs assistance) were accessible for use to provide assistance to meet the needs of three Residents 66, 79, and 10 of 33 sampled residents' when: 1. Resident 66 could not reach their call light while lying in bed. 2. Resident 79's call light was found on the floor while Resident 79 was in bed. 3. Resident 10 was provided a call light that is not working properly for her to use. These failures had the potential to affect the health and safety of Residents' 66, 79, and 10 in case of an emergency. Findings: 1. A review of Resident 66's clinical record titled, Face Sheet (contains demographic and medical information), it indicated Resident 66 was admitted on [DATE] to the facility with diagnoses, which included hypertensive heart disease (high blood pressure) with heart failure (a condition that develops when your heart does not pump enough blood 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, interview, and record review, the facility failed to ensure one of eight sampled resident (Resident 505), Physician Orders for Life-Sustaining Treatment (POLST - a mobile medical order form that communicates choice of life sustaining treatment in an emergency situation) was filled out in its entirety in accordance with the facility's policy and procedure. This failure has the potential to imply full treatment without taking Resident 505's wishes or current medical condition into consideration. Findings: During a review of Resident 505's Face Sheet (contains demographic and medical information), indicated Resident 505 was admitted to the facility on [DATE], with diagnoses that included craniectomy right (removal of the skull without replacement of the bone), bilateral subdural hematoma (brain bleed to both sides of brain), and left tibial fracture (broken left lower leg bone). During a concurrent interview and record review on [DATE], at 12:24 PM, with the Minimum Data Set Resource Nurse…

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 a care plan for a resident with an identified medical condition related to peripheral neuropathy (a medical condition that involves the damaged nerves causing pain, numbness, and weakness mostly felt in the hands and feet). This failure had the potential to limit the services and provision of individualized care necessary for one of eight sampled residents (Resident 304). Findings: During an interview on August 10, 2023 at 12:10 PM with Resident 304, Resident 304 stated she was experiencing pain on her lower legs usually in the early mornings and described the pain as shooting pain or like pins and needles. A review of Resident 304's Face Sheet (a document containing a resident's basic information), dated August 9, 2023, indicated Resident 304 was admitted to the facility on [DATE]. A review of Resident 304's admission History and Physical (H&P- a reference document that provides concise information about a patient's history and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to follow their policy and procedure when the SBAR (Situation, Background, Assessment and Recommendation- a standardized tool used by a facility to make detailed observations and gather relevant information to improve clinical communication about a resident) was not completed for a change of condition for one of eight sampled residents (Resident 8) who sustained an injury following an accident. This failure had the potential to cause negative physical, mental or psychosocial outcome for Resident 8. Findings: During an interview on August 11, 2023 at 10:46 AM with Resident 8, Resident 8 stated there was a time when she was being transferred from bed to chair using an electric lift that did not lock, causing the lift to tilt and hit her on the forehead. Resident 8 further stated Certified Nursing Assistant 1 (CNA 1) and Certified Nursing Assistant 2 (CNA 2) were present when the incident occurred. During an interview on August 11, 2023 at 10:55 AM with CNA…

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 essential services to increase range of motion (measurement of how far you can move a body part) or to prevent further decrease in range of motion for one of three sampled residents (Resident 465). Resident 465 was not assessed for or provided access to a Restorative Nursing Assistance program (RNA- a program aimed to help residents in the long-term care to maintain the highest level of functioning like bed mobility, transfer, walking, dressing, etc.) after Physical Therapy (PT- a branch of rehabilitative health that uses specially designed exercise to help regain or improve their physical abilities) and Occupational Therapy (OT-a branch of rehabilitative health that focuses on improving the ability to perform activities of daily living such as bathing, toileting, eating, personal hygiene, etc.) programs were discontinued for Resident 465. This failure had the potential to worsen Resident 465's already decreased range of motion…

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 acceptable parameters of nutrition status for one resident (Resident 6), when Resident 6 lost 10 pounds (lbs.) and the Registered Dietitian (RD) was not notified and did not assess (evaluate) Resident 6. This failure had the potential to result in Resident 6 to decline medically and nutrionally. Findings: During a review of Resident 6's Face Sheet (contains demographic information), it indicated, Resident 6 was admitted to the facility on [DATE], with the diagnoses of chronic respiratory failure with hypercapnia (airways in lungs become narrow and damaged and too much carbon dioxide in the blood), paraplegia (paralysis that occurs in the lower half of the body), and anoxic brain damage (complete loss of oxygen flowing to the brain causing damage). During a review of Resident 6's History and Physical, dated November 11, 2022, indicated, Resident 6, .This resident does NOT have the capacity to understand and make decisions.…

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 safe medication administration to meet the needs of one of seven residents, (Resident 41), when Resident 41 was provided a stool softener (medication for easier passage and less strain) without being assessed for loose stools, as directed by the physician order. This failure had the potential for placing Resident 41 at risk for fluid volume deficit (when fluid output exceeds fluid intake from diarrhea and causing dehydration). Findings: During an observation on August 10, 2023, at 9:00 AM in Resident 41's room, with Licensed Vocational Nurse 1 (LVN 1), LVN 1 was observed administering medication to Resident 41. LVN 1 was observed giving stool softener medication without assessing Resident 41 for loose stool, as indicated in the Medication Administration Record (MAR - a record of medication detailing the drugs administered to a patient by a healthcare professional in the nursing home), as a parameter for holding the medication. During an interview on August 10, 2023, at 9:10 AM, with LVN 1, LVN 1, was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain infection control practices when: 1. One Certified Nursing Assistant 4 (CNA 4) entered a transmission-based precaution room (a separate room that keep residents with certain medical conditions or infections separate from other people while they receive medical care) with contact precautions (require anyone entering the room to wear a gown and gloves) without wearing a gown or gloves for Resident 2. 2. Two Certified Nursing Assistants (CNA 7 and 8) entered a transmission-based precaution room with contact precautions without wearing a gown or gloves for Resident 462. 3. One Certified Nursing Assistant (CNA 6) opened a trash bin with his bare hands and entered Resident 46's room without performing hand hygiene (washing hands with use of soap and water, or using a hand sanitizing gel to prevent spread the spread of germs). These failures had the potential to cause cross-contamination (the unintentional physical movement or transfer…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a medication was administered and or prescribed for a current medical condition for one of three residents (Resident 1). This failure had the potential to affect the Resident 1's kidney function and her overall health and safety. Finding: An abbreviated survey was conducted on July 18, 2023, at 11:28 AM to investigate a complaint related to quality of care. During a review of Resident 1's clinical record, the face sheet indicated Resident 1 was admitted on [DATE], with diagnoses, which included Urinary retention, and gastrointestinal hemorrhage (bleeding). A review of the IV (intravenous, into the vein) Administration Record for Resident 1, dated June 2023, indicated IV Vancomycin (to treat serious or severe bacterial infections) for Osteomyelitis (infection in the bone) of right great toe to be given every twelve hours. The medication was given from June first to the third and from June 8th to the 23rd. During review of the clinical record 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.

Based on interview and record review, the facility failed to provide a mattress that fit the bedframe for one of three sampled residents (Resident 1). Resident 1 fell to the floor requiring a transfer to a general acute care hospital for evaluation. This failure placed Resident 1 a clinically compromised, health and safety at risk for severe injuries due to falls. Findings: During a review of Resident 1's admission Record ( general demographics), admitted to facility on October 18, 2022, with diagnosis (DX) hemiplegia following cerebral infarction affecting right dominant side ( right side paralysis after stroke), chronic respiratory failure (condition when the lungs cannot get enough oxygen into the blood or eliminate carbon dioxide from the body ), tracheostomy ( an opening surgically created through the neck into the windpipe to allow air to fill the lungs), Gastrostomy ( An opening into the stomach from the abdominal wall, made surgically for the introduction of food), Dependent on Ventilator ( need for mechanical ventilation , unable to breath independently ), Vegetative State…

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.