Arc At El Paso

Based on interview and record review the facility failed to ensure prompt communication between Hospice Services and the facility for one resident (R6) of three residents reviewed for Hospice Services in a total sample of thirty eight. The Facility's Hospice Services Agreement signed and dated 8/1/2023 documents Hospice personnel shall provide all necessary oversight of services provided to Residents in accordance with the Hospice Plan of Care. Hospice shall review documentation of such services and shall communicate weekly Facility personnel to ensure that the needs of Residents are met in a comprehensive, coordinated fashion twenty-four hours a day. Such communication shall be documented pursuant to Hospice Policy. R6's Medical Record documents she was admitted to the facility on Hospice Services on 12/10/2024. R6's diagnosis include but are not limited to Congestive Heart Failure, Atrial Fibrillation, and history of Myocardial Infarction. R6's Medical Record documents she cognitively impaired and has short term memory problems. On 5/27/2026 V17 (Certified Nurse Aide) stated…

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 resident rooms in a clean and safe manner for four residents (R6, R8, R12, and R13) of four reviewed for safe, clean and homelike environment in a sample of 15.Findings Include:Facility's Maintenance Director Job Description dated 3/2024 documents: The primary purpose of the Maintenance Director is to plan, organize, develop, and direct the overall operation of the Maintenance Department in accordance with current, federal, state and local standards, guidelines, and regulations governing our facility, and as may be directed by the Administrator, to assure that our facility is maintained in a safe and comfortable manner.On 9/3/25 at 1:30 PM V1 stated he is unable to locate a policy for cleaning the air conditioner units in resident rooms.On 9/3/25 at 9:35 AM The AC (Air Conditioner) units in R6 and R13's room is located in the wall under the window. There are foam tubes around AC unit with a quarter sized hole where daylight can be seen. The vent slats of AC unit have multiple pinpoint black spots on…

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 obtain physician ordered weekly weights for one resident of three residents (R1) reviewed for weights in a sample of 15. Findings Include:The facility's Significant Weight Gain or Loss Policy dated 02/2025 documents, All residents will be weighed monthly unless physician order indicates differently.R1's physician's orders, dated 9/5/25, document weekly weights were ordered to begin for R1 on 6/23/25. R1 also has orders to receive the following medications for the diagnosis of congestive heart failure: Torsemide 20mg (milligrams) by mouth daily, Diltiazem 300mg by mouth daily, Metoprolol Succinate ER 50mg by mouth daily, and Aldactone 12.5mg by mouth.On 9/3/25 at 11:17 AM, R1 stated she has not been getting weighed because the machine used to weigh her has been broken.R1's Weight and Vitals Summary dated 9/3/25 documents from 6/23/25 to 8/17/25 weights were only obtained on the following dates: 6/23/25 (419.8 pounds), 7/1/25 (416 pounds), and 7/7/25 (415 pounds).On 9/3/25 at 9:38 AM, V1 (Administrator) verified the facility has…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to implement new interventions after falls and failed to complete a thorough post fall assessment for three of three residents (R2, R4 and R5.) reviewed for falls in a sample of 15. Findings include: 1. R2's medical record documents that R2 was admitted on [DATE] with diagnosis to include but not limited to unspecified dementia, moderate without behavioral disturbance, cerebral infarction and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. R2's documentation Un-witnessed fall dated 8/13/25 filled out by V2 (Director of Nursing) documents resident self-transferred from toilet resulting fall. Resident lying on left side of shower room floor. R2's documentation Un-witnessed fall dated 8/13/25 filled out by V2 (DON) documents under Mental status that resident was disoriented, but wnl (within normal limits) for this resident, oriented to person and oriented to situation were marked. The areas of resident did…

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 prevent staff to resident verbal abuse for two of three residents (R2 and R3) reviewed for abuse in a sample of three. Findings include:The facility's 24-hour Abuse Investigation Report, dated 7/16/25, documents V1, Administrator, was informed V4 (Certified Nursing Assistant), alleged cussing and yelling at a resident (R3) during care. V4 was suspended immediately pending investigation.V10's, Certified Nursing Assistant, signed statement, dated 7/17/25, documents R3 put on her call light. V4 said, Why did you have me pull you the F K up in the bed? This form also documents V4 is rough towards residents.On 8/19/25 at 3:00pm, V10, Certified Nursing Assistant, stated V4 answered R3's call light and wanted to be pulled up. V10 stated he heard V4 say Why the F k do you want me to pull you up, when all you do is slide right back down? V4 stated he used several other curse words while he was in the room. V10 stated he told the nurse right away. On 8/19/25 at 12:30pm, V1, Administrator verified he did not consider V4 cussing at R3…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a resident's haircut was done safely for 1 of 5 residents (R1) reviewed for safety in the sample of 5. The findings include: On 7/8/25 at 9:17 AM, R1 was seated in a wheelchair in his room. R1 had a full beard and partially bald head. R1 stated he received a hair and beard cut a couple of weeks ago and was all cut up during the process. R1 said a female staff member (name unknown) wheeled him into the beauty shop and just started in on me with hair clippers. R1 said the staff member took the guard piece off the clippers during the process and cut him under his chin. R1 said he hollered and yelled quit!. R1 said the staff member 'kept right on with what she was doing', and he felt like she didn't care. R1 said she moved to the back of his head with the clippers, and it was hurting him there too. On 7/8/25 at 9:39 AM, V1 (Administrator) stated R1 was given a haircut a few weeks ago by a CNA. V1 said when the facility beautician was out on medical…

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 eight consecutive hours of a Registered Nurse, daily. This failure has the potential to affect all 49 residents residing in the facility. Findings include: The facility's Facility Assessment Tool, dated 7/1/2024, documents the facility will provide a Registered Nurse (RN) as required with CMS (Centers for Medicare and Medicaid Services) minimum staffing requirements (eight consecutive hours per day). The facility's nursing staff schedule for March 2025, documents on 3/23/25 the facility did not have eight hours of an RN staffed in the facility. The facility's daily staff posting documents on 3/23/25, the facility was staffed with Licensed Practical Nurses (LPN) and documents no Registered Nurses provided resident care throughout 24 hours. On 3/25/25 at 1:45 PM, V1 (Administrator) confirmed the daily staff postings provided for March 2025 are accurate. On 3/26/25 at 11:16 AM, V13 (LPN/ Infection Control Preventionist) confirmed that she has been doing some nursing assistant schedules and Director of Nursing duties…

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 prepared refrigerated foods were labeled and dated with an expiration date, opened foods were stored in covered containers to prevent contamination, the kitchen floor/dry storage room floor were kept clean and free of debris, and kitchen surfaces were kept free from dust and debris. These failures have the potential to affect all 49 residents in the facility. Findings include: The facility's Food and Supplies: Storage Policy, dated 1/2024, documents, Policy: Food and supply storage areas shall be maintained in a clean, safe and sanitary manner. Procedures: 1. Food services will maintain clean food storage areas. 4. Prepared foods stored in the refrigerator until service will be covered, labeled, and dated with an expiration date. 6. All foods will be covered, labeled, and dated. If there is no expiration date on the package or container, a use-by date must be written on the product. The facility's Dry Storage Policy, dated 3/2025, documents, Dry storage areas will be kept neat, orderly, and in 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 interview and record review, the facility failed to offer Covid-19 vaccinations and vaccination education to all employees. This failure has the potential to affect all 49 residents residing in the facility. Findings include: The facility's Interim Covid-19 Vaccination Guidelines - Residents and Employees policy, dated 10/2024, documents, To minimize the risk of residents acquiring, transmitting, or experiencing complications from Covid-19. The facility maintains documentation related to staff Covid-19 vaccination that includes at minimum the following: That staff were provided education regarding the benefits and potential risks associated with Covid-19 vaccine; Staff were offered the Covid-19 vaccine or information on obtaining the Covid-19 vaccine. On 3/26/25 at 10:40 AM V13 (Licensed Practical Nurse/ Infection Control Preventionist) stated she doesn't have documentation to show Covid-19 vaccinations are offered to all employees or to show they are given education related to the Covid-19 vaccination. V13 stated, Staff are told to go to the local pharmacy to get 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 ensure Certified Nursing Assistants (CNA) were provided and completed Dementia training in a 12 month period. This failure has the potential to affect all 49 residents residing in the facility. Findings include: The facility's Facility Assessment tool, dated 7/1/24, documents the facility cares for residents with Cognitive loss/ Dementia. This policy also documents, Required in-service training for nurse aides. In-service training must: Be sufficient to ensure the continuing competence of nurse aides but must be no less than 12 hours per year. Include dementia management training and resident abuse prevention training. On 3/25/25 at 11:45 AM, V1 (Administrator) provided a 12 month yearly training report for V18, V19 and V20 (Certified Nursing Assistants, CNA). These reports do not include documentation that V18, V19 or V20 have completed Dementia training from March 2024- March 2025. On 3/25/25 at 1:45 PM, V1 confirmed several residents in the facility have a diagnosis of Dementia and he does not have documentation to show…

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 date oxygen tubing and bag when not in use, place an oxygen sign on resident doors, and ensure a nebulizer facemask and tubing was changed weekly for four of five residents (R2, R6, R7, R11) reviewed for respiratory care in a sample of 36. Findings include: The facility's Oxygen and Respiratory Equipment-Changing/Cleaning Policy, dated 10/2024 documents Purpose: 1. To provide guidelines to employees for changing all disposable respiratory supplies. 2. To ensure the safety of residents by providing maintenance of all disposable respiratory supplies. 3. To minimize the risk of infection transmission. Procedure: 1. Handheld Nebulizer and Mask, if applicable: a. The handheld nebulizer should be changed weekly and as needed. b. A clean plastic bag with a zip lock or draw string, etc. (etcetera). should be changed weekly and as needed. 2. Nasal Cannula. a. Nasal cannulas are to be changed once a week and as needed. b. Whenever possible, residents…

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, observation, and record review, the facility failed to ensure Enhanced Barrier Precautions were implemented for five of five residents (R2, R10, R17, R47, and R51) reviewed for infection control in a sample of 36. The facility's Enhanced Barrier Precautions Policy, dated 3/2024, documents, Statement of Purpose: Enhanced Barrier Precautions (EBP): recommendations now include use of EBP for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status. Personnel: Personnel providing direct care. Personal Protective Equipment: Gown and gloves. Policy: EBP may be considered and implemented for: Wounds and/or indwelling medical devices (central line, feeding tube, tracheostomy, drains etc. (Etcetera). Infection or colonization with a novel or targeted multi-drug resistant organism when contact isolation does not apply. At discretion of the Infection Preventionist. Personal Protective Equipment.…

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 resident with new diagnoses of mental illness after admission was referred to the state agency for a level II PASARR (Preadmission Screening and Resident Review) evaluation for one of two residents (R7) reviewed for PASARR screening in the sample of 36. Findings include: The facility's Preadmission Screening and Annual Resident Review (PASARR) Policy, dated 3/2024, documents, It is the policy to screen all potential admissions on an individualized basis. As part of the preadmission process, the facility participates in PASARR level I for all new and readmissions per requirements to determine if the individual meets the criterion for mental disorder (Severe Mental Illness/Severe Mental Disability), intellectual disability or related condition. Annually and with any significant change of status, the facility will complete the PASARR level one screen for those individuals identified per the Level II screen requiring specialized services. R7's…

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

Based on observation, interview, and record review the facility failed to follow a Physician's Wound Order for one of two residents (R47) reviewed for wound care in a sample of 36. Findings Include: The Facility's Pressure Injury and Skin Condition Assessment Policy, dated/revised 01/2018, documents, Physician ordered treatments shall be initialed by the staff on the electronic Treatment Administration Record after each administration. Other nursing measures not involving medications shall be documented in the weekly wound assessment or nurses noted. R47's Physician Order Sheet, dated 3/19/2025, documents Non-Pressure Wound of the Right Second toe. Dressing Treatment Plan, Primary Dressing: Betadine apply once daily for 23 days. Secondary Dressing: Gauze Island with border apply once daily for 23 days. On 3/25/2025 at 11:06 AM, V11 (RN/Registered Nurse) entered R47's room. V11 removed R47's right foot sock. A pea sized black, dry, and crusted area was noted to R47's right 2nd toe knuckle. V11 used 4x4 gauze saturated with normal saline and cleansed R47's wound. V11 then opened a…

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

Based on observation, interview, and record review, the facility failed to provide sufficient staff to care for dependent residents. This failure has the potential to affect all 60 residents residing in the facility. Findings include: The Facility Assessment Tool dated 08/2024-07/2025, documents, Indicate the number of residents you are licensed to provide care for: 65. Average Daily Census Analysis states the average residents are 60, the minimum is 55, and the maximum is 64. This same document states that staffing units per shift should have one Registered Nurse (RN), one Licensed Practical Nurse (LPN), and six Certified Nursing Assistants (CNA's) for days. Evenings, one RN, one LPN, and six CNA's. Nights, one LPN, and five CNA's. The facility's Resident List Report, dated 1/13/25, documents that 60 residents reside in the facility. The facility's Daily Staffing Sheet, dated 1/13/25, documents that for 1st shift the facility staffed one RN and one LPN and five CNAs. The same sheet documents that for 2nd shift the facility staffed two LPN's and five CNAs. On 1/13/25 at 9 A.M., V4…

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 restorative services were being provided for 3 of 3 residents (R1, R2, R3) reviewed for restoratives and range of motion in a total sample of three. Findings include: The facility's Restorative Nursing Program policy revised on 01/2019 documents, Purpose: to promote each residents ability to maintain or regain the highest degree of independence as safely as possible. Includes, but is not limited to, programs in walking/mobility, dressing and grooming, eating and swallowing, transferring, bed mobility, communication, splint or brace assistance, amputation care and continence programs. Guidelines: Documentation of the interventions and the resident's response will be completed with each implementation. 1. R1's Restorative: Active ROM (Range of Motion) done every shift dated 1/13/25 look back on the last 14 days show the following dates documented as not done. 12/31/24-1/13/25 only done on two shifts instead of three. R1's Restorative: Dressing/grooming done every shift dated 1/13/25 look back on the last…

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 post the facility Daily Staffing Report daily and, in an area, visible to all residents and visitors. This failure has the potential to affect all 58 residents residing in the facility. Findings include: The facility's Midnight Census report, dated 11/6/24, documents there are currently 58 residents residing in the facility. On 11/6/24 at 8:35 am, the facility's Nurse Staffing posting was located near the Receptionist desk, on the wall, behind a portable stand that held instructions for visitors to sign in on the facility's visitor log. This posting is not easily visible to staff, residents, or visitors. This Nurse Staffing posting was last completed on 10/29/24. On 11/8/24 at 10:20 am, 10:22 am, 10:24 am, and 10:25 am, R2, R9, R10, and R12 respectively stated they do not know where the Nursing Staff posting is located. On 11/6/24 at 9:12 am, V2 DON (Director of Nursing) walked with this writer to the Receptionist desk and confirmed the location of the Nurse Staffing posting on the wall behind a portable stand…

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 accurately report the PBJ (pay-roll based journal) staffing information. This failure affects all 58 residing in the facility. Findings include: The facility's PBJ (pay-roll based journal) Staffing Data Report, fiscal year Quarter 3 2024, dated April 1 through June 30, 2024, documents Excessively Low Weekend Staffing was triggered due to facility submission of excessively low staffing worked on the weekends. The facility's Midnight Census report, dated 11/6/24, documents there are currently 58 residents residing in the facility. On 11/6/24 and 11/7/24 at 7:30 am through 4:00 pm, there were six CNAs (Certified Nursing Assistants), two RNs (Registered Nurses) and one LPN (Licensed Practical Nurse) working on the day shift. On 11/6/24 at 11:05 am and 11:21 am, and on 11/7/24 at 7:45 am and 9:40 am R2, R10, R6 and R9 respectively stated the facility has two to three CNAs and a Nurse for each hallway in the facility and their needs are being met. On 11/8/24 at 8:30 am, R12 stated she is the President 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.

Based on interview and record review, the facility failed to protect residents from misappropriation of resident property for nine residents (R7, R8, R9, R10, R11, R12, R13, R14 and R15) of nine residents reviewed for missing medications, in a sample of 15. FINDINGS INCLUDE: The facility policy, Abuse Prevention and Reporting, dated (reviewed) 08/2023 directs staff, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. Misappropriation of resident property means the deliberate misplacement, exploitation or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. The facility Preliminary 24-Hour Abuse Investigation Report dated 8/30/24 documents, We (facility) have received all allegation (of) Theft. On 8/29/24 (the facility) made aware of alleged misappropriation of resident property. Investigation initiated. Staff member identified (V6/RN) and suspended pending investigation. Follow up report will be sent.…

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 keep medications secure for nine residents (R7, R8, R9, R10, R11, R12, R13, R14 and R15) of nine residents reviewed for medication storage, in a sample of 15. The facility policy, Narcotic/Controlled Substances- Counting, dated (reviewed) 11/2023 directs staff, To count controlled substances with a partner and to verify the accuracy of the log sheets. General Guidelines: Always participate in the counting of the controlled substances at the beginning and ending of your shift. If you do not observe the medication that you sign as being present, you may be implicated if the medications are later missing. Follow your facilities specific guidelines and use their specific log sheet. The facility form, Shift Change Controlled Substance Inventory Count Sheet directs staff, Nurse coming on to shift must verify count of all controlled substances with nurse coming off shift or any time the medication cart keys are exchanged. Nurses must count total (number) of cards/containers and total (number) count sheets, both for individual…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure a staff member treated a resident with respect for one of six residents (R1) reviewed for resident rights in the sample of five. Findings include: The facility's Resident Rights policy dated 02/2024 documents, Purpose: To promote the exercise of rights for each resident, including any who face barriers in the exercise of these rights. Exercising rights means that residents have autonomy and choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care, subject to the facility's rules, as long as those rules do not violate a regulatory requirement. The facility's Concern/Compliment Form dated 7-1-24 documents, Nature of complaint: (R1) concerned that night shift CNA/Certified Nursing Assistant (V28) was acting weird. Correction action taken: Education to employee (V28) on resident rights and customer service. R1's MDS (Minimum Data Set) assessment dated [DATE] documents R1 is cognitively intact. On…

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: 1) implement an antibiotic stewardship program that included assessing and monitoring residents for signs and symptoms of infections; 2) ensure antibiotic usage was appropriate, and 3) use of a nationally recognized surveillance criteria to define infections for 3 of 3 (R34, R57, R58) residents reviewed for the Antibiotic Stewardship Program in the sample of 37. Findings include: The Antibiotic/Antimicrobial Stewardship Program-Mission Statement & Guidelines dated 11/2017 documented, The Consultant Pharmacist will review the use of antibiotics by performing medication regimen review, reviewing the clinical record and laboratory results, and making recommendations regarding antibiotic use. Tracking and Monitoring Review the clinical record for new antibiotic starts to determine whether the clinical assessment, prescription documentation and antibiotic selection were in accordance with the antibiotic stewardship practices. When conducted over time, monitoring process monitors can assess whether antibiotic prescribing…

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 sufficient staffing to meet the needs of the residents for four residents (R1, R2, R4, and R5) out of five residents reviewed for activities of daily living and call lights in a sample of five. Findings include: The facility's Bathing - Shower and Tub Bath policy dated 8/2023 documents, A shower, tub bath or bed/sponge bath will be offered according to resident's preference, no less than once per week or according to the resident's preferred frequency and as needed or requested. The facility's Call Light policy dated 7/2023 documents Purpose: To respond to resident's requests and needs in a timely and courteous manner. Guidelines: 1. Answer light (signal) promptly. 3. Turn off call light. 5. Respond to request, if item is not available, or request questionable, get assistance from charge nurse. Return to resident with prompt reply. 6. Offer further assistance before leaving resident's room. The facility's Facility Assessment dated 8/2020 through 7/2024 documents the following direct care staffing numbers: Six CNAs…

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.