Fiesta Park Wellness & Rehabilitation

Based on record review and interview, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR; a federal requirement to help ensure individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) was accurate for 9 (R #2, R #3, R #5, R #6, R #7, R #8, R #9, R #10, and R #11) out of 9 (R #2, R #3, R #5, R #6, R #7, R #8, R #9, R #10, and R #11) residents reviewed for PASARR accuracy. This deficient practice has the potential to result in the facility not providing the services needed for residents who are identified in the screening process as needing additional care and services. The findings are: R #2:A. Record review of R #2's Face Sheet revealed the following: admission date of 09/02/25,Diagnosis of major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). B. Record review of R #2's PASARR Level 1 Screening, dated 09/02/25, revealed staff documented the resident…

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

Based on record review, observation, and interviews, the facility failed to maintain a safe environment for all residents in the 200-unit when staff failed to ensure the facility oxygen (O2) storage room was secured to prevent unauthorized access. This deficient practice has the potential to lead to residents experiencing avoidable accidents.The findings are: A. Record review of the facilities Oxygen Administration Policy, dated 06/2020, revealed the following: Oxygen cylinders are to be secured in a cylinder cart or bracket at all times, Oxygen stored in clean, dry locations. B. On 02/18/26 at 1:59 pm, observation of the facility's 200-unit oxygen room revealed the following: The oxygen storage room keypad door lock was without power and nonoperational. The keypad screen remained blank and did not activate when touched. Further observation revealed occupants in the area could open the oxygen storage room door without entering an access code. Oxygen cylinders (portable medical oxygen tanks) sat on the floor and were not stored in the designated oxygen cylinder rack. C. On 02/18/26…

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 the Minimum Data Set (MDS; a federally mandated comprehensive assessment of a resident's functional, medical, psychosocial and cognitive assessment completed by facility staff) was accurate for 1 (R #2) of 1 (R #2) resident reviewed for MDS accuracy. This deficient practice could result in failure to provide adequate care and treatment of the resident's needs. The findings are:A. Record review of R #2's face sheet revealed R #2 was admitted into the facility on [DATE] with the following diagnoses: Guillain-Barre syndrome (a rare condition where the body's immune system attacks the nerves),Epilepsy (a long-term brain disorder that causes repeated, unprovoked seizures due to abnormal electrical activity in the brain),Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).R #2 was discharged to the hospital on [DATE]. B. Record review of R #2's Change in Condition (CIC) form, dated 10/16/25, revealed R #2 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 and interview, the facility failed to ensure residents where give prior notice and equal accommodations during a remodeling project for 4 (R #1, #2, #3, and #4) out of 4 residents. These deficient practices could result in residents feeling as if they were unimportant, restricted, did not have freedom to make their own choices, and did not have privacy. The findings are: A. On 01/15/26 at 1:15 pm, observation revealed the 400 hallway was under renovation. Multiple resident rooms did not have furniture or flooring, and construction workers were present laying flooring in the empty rooms. Residents were present in the 400 hallway and some resided in rooms 423, 424, 425, and 426. B. On 01/15/26 at 12:50 pm, during an interview, R #4 stated staff kicked me out of my room yesterday, and he had to sit in his wheelchair from 7:40 am to 6:00 pm. He stated the staff did not give him any notice, and they just told me to get out. The resident stated the facility made him leave his room so they could remove the carpet and replace it with flooring. R #4 stated he did not…

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 maintain a safe and comfortable environment for all residents and occupants during a remodeling project when staff failed to:- Maintain proper ventilation of construction flooring adhesive odors.- Maintain the means of egress (a continuous and unobstructed way of travel from any point in the building or structure to a public way) throughout the facility. If staff fail to maintain a safe environment, then the residents could find themselves in an emergency situation which could endanger their health and safety. The findings are:Construction Adhesive Fumes A. Record review of the facility's Safety Plan for the floor renovation project, dated 09/16/2025, revealed the following: - The resident units affected were Gila, [NAME], and Pecos. - Potential issues included unpleasant odors due to the materials in use. - Staff were instructed to contain the aerosol dust/debris with ventilation as needed, close doors where applicable to provide…

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 complete an initial skin assessment for 1 (R #1) of 3 (R #1, #2 and #3) residents reviewed for skin assessments, during the initial admission. If the facility fails to complete a skin assessments then facility is unable to provide proper care and treatment for the residents. The findings are: A. Record review of the State Agency complaint received on 05/13/25 stated that R #1 had been discharged AMA (against medical advice) from facility on 05/12/25 for physical abuse by facility staff and had been transported by [name of transport service] to [name of local hospital] at 6:00 pm with bruising, swollen genitals and penile bleeding along with various bruising on the body. B. Record review of R #1's facesheet revealed R #1 was admitted on [DATE]. C. On 05/14/25 at 11:17 am during a telephone interview with R #1's daughter, she stated that she believed her father was physically abused by the facility staff due to the amount of bruising present when she took…

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 medical records were updated with necessary documents and are accurate for 1 (R #4) of 1 (R #4) resident reviewed, when the facility failed to update and upload hospital discharge orders into the electronic medical record (EMR). This deficient practice is likely to result in residents not receiving accurate care and having an inaccurate medical record. The findings are: A. Record review of R #4's face sheet revealed she was admitted on [DATE]. B. On 05/14/25 at 10:23 AM, during an interview with R #4, she stated that intravenous (IV) antibiotics had been discontinued earlier than her hospital discharge orders indicated. She explained that the antibiotics should have continued for four weeks after her hospital discharge. C. On 05/15/25 at 10:28 AM, during an interview with the Nurse Practitioner (NP) #1, she stated that R #4 had been on IV antibiotics for a severe infection. She noted that R #4's hospital discharge orders dated 03/25/25 clearly…

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 and interview, the facility failed to store and serve food under sanitary conditions when staff failed to ensure: 1. Food items were labeled and dated in the kitchen refrigerator and freezer. 2. Food items were stored off the kitchen floor and appropriately in the dry storage. 3. Dietary staff were wearing appropriate hairnets while in the kitchen. 4. Frozen meats were thawed in a safe manner (under running water and not in stagnate water). These deficient practices are likely to affect all 107 residents listed on the resident census list provided by the Administrator on 01/06/25 and are likely lead to foodborne illnesses in residents if food is not being stored properly and safe food handling practices are not adhered to. The findings are: A. On 01/06/25 at 9:59 am, observation of the kitchen revealed the following: - Six plastic bags of diced potatoes were not dated and stored in the kitchen refrigerator. - Six plastic bags of salad mix (iceberg lettuce, carrots, and purple cabbage) were not dated and stored in the kitchen refrigerator. - Two plastic packages…

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 staff revised the care plan for 2 (R #'s 11 and 112) of 2 (R #'s 11 and 112) residents reviewed when staff failed to: 1. Conduct a quarterly care plan meeting as required for R #11 in accordance with his admission date and Minimum Data Set (MDS)assessment. 2. Update R #11's plan of care to include Libre2 ([NAME] based glucose monitor embedded in the skin) use for diabetic management. 3. Update R #112's plan of care to include oxygen (O2) use. These deficient practices are likely to result in residents' care and needs not being addressed if care plans are not updated. The findings are: Care Plan Meeting: R #11: A. Record review of R #11's face sheet revealed R #11 was admitted into the facility on [DATE]. B. Record review of R #11's social service progress notes dated 10/06/24 revealed R #11's Emergency Contact (EC) was notified of the scheduled care plan meeting, but it did not contain a date of the schedule care plan meeting. C. Record review…

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 provide a quality care that meets professional standards for 1 (R # 11) of 1 (R #11) resident when the facility failed to: 1. Communicate with a provider (Physician Assistant- PA, Nurse Practitioner- NP) the discontinuation of a medication (sodium zirconium- medication that binds potassium and treats Hyperkalemia- elevated potassium). 2. Review and implement R #11's Nephrologist (a doctor who specializes in diagnosing and treating kidney conditions) medication recommendations. 3. Follow physician orders to utilize R #11's Libre2 ([NAME] based glucose monitor embedded in the skin) when performing diabetic management. These deficient practices are likely to result in residents not receiving the appropriate medications and treatments if facility staff is not communicating with providers, ordering the appropriate medications for residents, and following physician orders. The findings are: Provider Communication and Medication Implementation: A. Record…

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 ongoing communication and collaboration with the dialysis (clinical purification of blood as substitute for normal kidney functioning) facility regarding dialysis care and services for 1 (R #51) of 1 (R #51) resident reviewed for dialysis. If the facility is unaware of the status, condition or complications that arise during dialysis treatment, then residents are likely to not receive the appropriate monitoring and care they need. The findings are: A. Record review of the facility's dialysis care policy dated 06/2020, revealed facility nursing staff will utilize dialysis communication records or similar forms to convey information regarding dialysis care to the dialysis provider, and keep those documents in the residents Electronic Health Record (EHR). B. Record review of R #51's face sheet revealed R #51 was admitted into the facility on [DATE]. C. Record review of the physician order dated 12/11/24, revealed R #51 received dialysis on Mondays,…

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

Based on observation, record review and interview, the facility failed to ensure that medications were administered with an error rate less than 5%. Medications were observed being administered to 2 (R #61 and R #97) of 4 (R #61, R #97, R #192, and R #365) During observation there were 26 medications administered with 13 medication errors observed. This resulted in a medication error rate of 50%. If medications are not administered at the scheduled ordered times, the treatment may be less effective and residents will receive less than optimal care. The findings are: A. On 01/09/24 at 8:40 am during an observation of R #61's medication administration, Certified Medication Aide (CMA) #1 administered the following medications: -Aspirin (an over the counter medication administered to manage blood coagulation and pain) 81 mg (milligrams). -Furosemide (a prescribed medication to reduce fluid and water from the body) 80 mg. -Gabapentin (a prescribed medication to reduce pain) 100 mg. -Sertraline (a prescribed medication to mange symptoms of depression) 25 mg. B. Record review of R #61'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 record review and interview, the facility failed to maintain accurate and complete records in accordance with accepted professional standards and practices for 7 (R #'s 34, 54, 69, 193, 194,195, and 196) of 7 (R #'s 34, 54, 69, 193, 194,195, and 196) residents. The facility failed to properly document that pharmacist recommendations were reviewed by the facility providers. this could adversely impact resident medication needs by not have accurate information. A. Record review of the monthly pharmacist reviews dated December 2023 to December 2024 of R #'s 34, 54, 69, 193, 194,195, and 196 medications revealed the following recommendations: -Note to Attending Physician/Prescriber dated 12/21/23 for R #34 recommended Paroxetine (medication for symptoms of depression) 40 mg (milligrams) and Trazodone (medication for symptoms of depression and sleep disturbance) 50 mg be reviewed for benefit versus risk and consider for periodic dose reduction trials. The response to the recommendation stated that patient has a good response to treatment and requires dose for conditions…

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 investigate an allegation of missing money for 1 (R #121) of 1 (R #121) resident reviewed for missing money. This deficient practice is likely to result in resident financial hardship. The findings are: A. On 01/14/25 at 2:07 PM during an interview with R #121, she stated she had $150.00 in a green baggie under her mattress and it was missing. She further stated that she did not remember the exact date that the money went missing but it was sometime in December 2024. She did not file a formal grievance but she verbally reported the missing money to the Administrator. B. Record review of the facility's incidents and grievances for the months of August 2024 through January 2025 revealed there was not any documentation of R #121's missing money. C. On 01/15/25 at 2:04 PM during an interview with the Administrator, she stated she was aware of the alleged missing money. She was told about the missing money by R #121. She further stated she had asked R #121 if she wanted to file a police report or file a formal grievance 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 record review and interview, the facility failed to provide sufficient preparation for 1 (R #81) of 1 (R #81) resident reviewed by not ensuring that referral for services had been received, accepted and was scheduled to provide care for the resident upon her discharge home. This deficient practice could likely result in resident not receiving needed services and having to navigate referral process for services unassisted. The findings are: A. Record review of R #81's Face Sheet dated revealed R #81 was admitted to the facility on [DATE] with multiple diagnoses including: -Spina Bifida (a birth defect that causes the spinal column to not develop properly usually leaving an open hole to the spinal cord) with hydrocephalus (fluid collecting at the base of the brain). -Pressure Ulcer (a wound that develops over a boney area of the body) of Sacral (lower back just above the buttocks) Region. Face sheet also revealed R #81 was discharged from facility on 01/07/25 B. Record review of R #81's skin assessments…

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 provide appropriate interventions for 1 (R #241) of 1 (R #241) residents reviewed for injury when the facility did not send R #241 to the emergency room (ER) for several hours after R #241 fell and experienced a head laceration (a tear or ragged cut in skin or flesh) with bleeding from her head, and was taking blood thinners. This deficient practice could likely result in R #241's head laceration becoming worse with additional bleeding. The findings are: A. Record review of R #241's face sheet revealed R #241 was admitted into the facility on [DATE] and was discharged on 11/04/24. B. Record review of R #241's physician orders dated 10/16/24, revealed R #241 was ordered Apixaban Oral Tablet (blood thinner) 2.5 mg (milligrams) by mouth two times a day. C. Record review of R #241's nursing progress notes revealed the following: -10/20/24 at 6:01 am: R #241 was found on the floor after R #241's called for help. R #241 stated she was getting out of bed…

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

Based on observation, record review, and interview, the facility failed to ensure the nutritional needs and preferences were met for 1 (R #11)of 1 (R #11) resident reviewed, when staff failed to serve the food items listed on the meal ticket. If the facility is not providing a meal as listed on the meal tickets, then residents are likely to experience weight loss, frustration, and depression. The findings are: A. Record review of R #11's meal ticket dated 01/07/25, revealed R #11 was on a Consistent Carbohydrate (CCHO) diet (Spreading carbohydrate consumption throughout the day to prevent blood sugar spikes) and was to be served salad with his dinner. B. On 01/07/25 at 1:32 pm during an interview with R #11, he stated that the kitchen staff does not always follow instructions and he is supposed to be getting a side salad with his dinner, but that does not happen. R #11 confirmed he had mentioned this to the nursing staff, who informed the dietary staff, but he still does not receive a side salad. C. On 01/07/25 at 5:08 pm during a dinner observation, R #11 was served a meatball sub…

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 and interviews, the facility failed to ensure staff served meals at an appetizing temperature for 6 (R#'s 28, 2, 47, 30, 53, 2) of 6 (R#'s 28, 2, 47, 30, 53, 2) residents reviewed for meal temperatures. If the facility is not serving meals at residents desired temperatures then residents are likely to not eat their meals and be at risk for weight loss.The findings are: A. On 11/07/23 at 10:33 am, during an interview with R #2, she stated she preferred to eat her meals in her room. She stated the food was not hot. It's cold. The resident said if she asked the staff to warm it up then they take too long to bring it back to her. B. On 11/07/23 at 10:33 am, during an interview with R #47, she stated she preferred to eat her meals in her room. She stated the food was not hot . It's always cold. The resident said she did not ask the stafff to warm it up, because it took too long. C. On 11/07/23 at 10:33 am, during an interview with R #30, she stated she preferred to eat her meals in her room. She stated the food was not hot , it's cold. D. On 11/07/23 at 10:33 am,…

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

Based on record review and interview, the facility failed to provide reasonable accommodations of resident needs and preferences for 2 (R #30 and 77) of 2 (R #30 and 77) residents reviewed by: 1. Not accommodating R #30's preference to have a refrigerator in her room. 2. Not accommodating R #77's preference for showers instead of bed baths as often as she would prefer. If facility is not honoring resident preferences then residents are not able to make choices about aspects of their lives that are important to them. This deficient practice is likely to result in the resident's life style, personal choices, needs and preference not being met which could result in loss of dignity and resident rights. The findings are: Concerning the refrigerator: A. On 11/07/23 at 10:05 AM during an interview with R #30, she stated she would like a refrigerator in her room. She further stated maintenance told her there was not an issue with her having a refrigerator in her room. She ordered a refrigerator on-line, and it was delivered to the facility. R #30 said the administrtor came and informed her…

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 give the resident council feedback on their concerns for 5 (R #28, 30, 47, 53 and 64) residents interviewed in the resident Council Meeting. If the facility is not ensuring the Resident Council grievances are responded to and resolved then residents are likely to feel that their issues and concerns are not taken seriously. The findings are: A. On 11/07/23 at 10:33 am during a meeting with R #28, R #30, 47, 53 and 64, the residents stated there have been concerns about meals served late and cold, and the concerns have not been resolved. The residents said it was an ongoing issue, and it has been brought up many times in the meetings with the Dietary Manager. The other concern is that there are not any snacks delivered or available at night. B. Record review of Quality Assurance Resident Council form, dated 08/23/23 at 1:30 PM, revealed the residents had dietary concerns and documented they still received cold food and coffee. There were no responses from Administration or Dietary Department. C. Record review of Quality…

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 provide activities of daily living (ADL) assistance for baths/showers for 2 (R #'s 29 and 76) of 2 (R #'s 29 and 76) residents reviewed for ADL care. This deficient practice is likely to affect the dignity and health of the residents. The findings are: Findings for R #29: A. Record review of R #29's face sheet revealed R #29 was admitted into the facility on [DATE]. B. Record review of the facility shower schedule revealed R #29 was to be offered a bed bath or shower every Tuesday and Friday. C. Record review of R #29's Documentation Survey Report (ADL tracking in the Electronic Health Record- EHR), dated 10/06/23 to 10/31/23, revealed R #29 received a bed bath/shower for 4 out of 7 opportunities for the entire month. D. Record review of R #29's facility shower sheets revealed R #29 received a bed bath/shower for 4 out of 7 opportunities for the entire month of October. E. Record review of R #29's Documentation Survey Report, dated 11/01/23 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 record review and interview, the facility failed to ensure 1 (R #55) of 1 (R #55) residents reviewed for behavioral health concerns received necessary behavioral health care to meet their needs by not: 1. Ensuring effective communication between the facility and psychiatric (psych) providers regarding R #55's psych service needs. 2. Ensuring R #55's behavioral health/psych progress notes were documented for facility staff. These deficient practices are likely to result in the residents not receiving the behavioral or mental health care and assistance needed to improve mood and reduce depression and anxiety. The findings are: A. Record review of R #55's face sheet revealed R #55 was admitted into the facility on [DATE] with the following diagnoses: 1. Major depressive disorder, 2. Anxiety disorder. B. Record review of R #55's care plan, dated 08/03/23, revealed: - Focus: R #55 used antidepressant medication related to depression. - Interventions: Monitor/document/report to doctor as needed. Ongoing signs…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure that medications stored in medication storage rooms and inside of the emergency medication kits (e-kit) were not expired. This deficient practice is likely to result in all residents who receive these medications that have lost their potency and effectiveness more vulnerable to acquiring infections. The findings are: Findings for Pecos Unit Medication Room E-Kit A. On 11/08/23 at 09:47 AM, observation of the Pecos Unit's medication storage room revealed the ekit contained the following: 1. Four glass vials of Ceftazidime (used to treat a wide variety of bacterial infections) contained 1 gram (basic unit for measurement of weight and mass) for injection,was expired on 09/2023. 2. Two glass single dose vials of Piperacillin and Tazobactam (used to treat a wide variety of bacterial infections) contained 3.375 grams for injection expired on 07/2023. B. On 11/08/23 at 10:00 am, during an interview, Certified Medication Aide (CMA) #1 confirmed all…

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

Based on record review and interview, the facility failed to ensure the Smoking Assessment was accurate for 1 (R #57) of 1 (R #57) residents reviewed for smoking. If the facility is not accurately assessing residents it is likely that the residents needs are not being met. The findings are: A. On 11/06/23 at 3:08 PM, during an interview, R#57 stated she was a smoker. B. Record review of R #57's Safe Smoking Evaluation, dated 09/02/2023, documented the resident was not a smoker. C. Record review of R #57's Care Plan dated 05/02/23 revealed: - Focus: The resident wished to smoke despite facility non-smoking policy. At risk for/potential for burns and for impaired gas exchange, related to history of smoking and strength. The resident understood the center's smoking policy. Date Initiated: 05/02/23 - Goal: Staff educated the resident about safety while smoking against policy. - Interventions: Educate resident on facility smoking policy. Encourage resident not to smoke to prevent injuries. Instruct and educate resident about the facility was a non-smoking facility. The staff offered 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.