Meridian Care Monte Vista

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the resident was not given a psychotropic drug unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 5 residents (Resident #4) reviewed for unnecessary medications, in that: The facility failed to ensure Resident #4 psychotropic medication, Atarax was prescribed no longer than 14 days PRN. Resident #4 was ordered PRN Atarax (an antihistamine medication with sedative and hypnotic effects used to treat anxiety disorders) on 1/15/2026 without a stop date. This failure could place residents at risk of receiving unnecessary psychotropic medications. The findings included: Record review of Resident #4's face sheet dated 2/12/2026 revealed a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses which included: moderate recurrent major depressive disorder, generalized anxiety disorder, and cyclothymic disorder (mood disorder with fluctuating highs/mania…

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, record reviews, and interviews, the facility failed to correct impairments during the inspection for 1 of 1 Fire Alarm System, inspected for regulatory requirements, failed to ensure outside areas, were maintained in good condition and kept free of conditions which constituted a fire or health hazard and failed to ensure the Emergency Preparedness Plan had been evaluated and updated annually. The Emergency Preparedness Plan was not updated at least annually. The Fire Alarm Control Panel was impaired indicating a low battery trouble signal. There were multiple trees on the back side of the facility leaning up against the roof which could constitute a fire hazard. These failures could affect the health and safety of residents dependent on staff to maintain the facility free of fire hazards, have a functioning alarm system and ensure staff were prepared to address emergency situations. Findings included:During an interview in the entrance conference, at 09:20 a.m. on 11/07/2025, the Administrator stated she was employed as the Administrator with the facility 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 maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 7 of 10 residents (Residents #2, #3, #5, #6, #7, #8 and # 9) reviewed for infection control, in that: 1. RT A was observed providing tracheotomy care to Resident #2 on 08/18/2025 at 10:05 a.m. without wearing a gown while Resident #2 was on enhanced barrier precautions. 2. RT D was observed providing a nebulizer treatment for Resident #3's tracheotomy on 08/18/2025 at 10:45 a.m. Resident #3 was on enhanced barrier precautions and RT D wore a face mask below her mouth and did not wear a gown. 3. Residents # 5,6,7,8, and 9 were observed with a tracheotomy and did not have enhanced barrier precaution signs on the entry to their doors to identify the residents required specific PPE for care. These failures placed residents at risk of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 4 of 10 residents (Residents #1, #2, #3, #4) reviewed for the allegation of abuse, neglect, exploitation and or mistreatment. 1. On 12/3/2024 the facility failed to report to the state agency an allegation of abuse and or mistreatment when Resident #1's Representative alleged a nurse treated 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 record reviews and interviews the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, had evidence that all alleged violations were thoroughly investigated, prevented further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress. for 4 of 10 residents (Resident #1, #2, #3, #4) reviewed for the allegations of abuse, neglect, exploitation and or mistreatment. 1. On 12/3/2024 the facility failed to investigate an allegation of abuse and or mistreatment when Resident #1's Representative alleged a nurse treated Resident #1 poorly and made Resident #1 cry. 2. On 12/23/2024 the facility failed to investigate an allegation of neglect and or mistreatment when Resident #2 alleged a nurse neglected to change a gastric tube stoma dressing. Resident #2 alleged the nurse handed her the gauze dressing and told her to do it herself. 3. On 3/12/2025 the facility failed to investigate an allegation of abuse with rough…

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 reviews the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 2 of 4 medication carts reviewed for security and control, in that: 1. LVN E left the 100-hall medication cart unattended, unsupervised, and unlocked. 2. RT K left the 200-hall respiratory therapy medication cart unattended, unsupervised, and unlocked. These failures could place residents at risk of misappropriation of property, not receiving the therapeutic effects of medications, and or adverse effects of medications. The findings included: During an observation and interview on 6/17/2025 at 12:34 PM revealed the medication cart for the 100-hall was unattended, unsupervised, and unlocked while parked on the hall, as evidenced by the protruding unlocked mechanism. The cart was observed for 10 minutes while residents and CNAs ambulated in the hall. Continued observation revealed the ADON approached the medication cart and locked the cart. The ADON…

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 maintain medical records on each resident that were complete, accurately documented, readily accessible, and were systematically organized, for 1 of 8 residents (Resident #8) reviewed for consents for accurate medical records. Resident #8's November 2024 treatment administration report had no documentation for his prescribed daily wound care for the wound on his sacrum (a single bone comprised of five separate vertebrae. It is shaped like an upside-down triangle and sits at the bottom of the spinal column, connecting it to the pelvis) on the following dates: o 11/10/2024 , o 11/15/2024, o 11/20/2024, o 11/21/2024, and, o 11/24/2024. The failure could place residents at risk for inaccurate and unorganized medical records. The findings included: A record review of Resident #8's admission record dated 6/19/2025 revealed an admission date of 9/5/2024 with diagnoses which included Guillain-Barre disease (a condition in which the body's immune system…

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 promote and facilitate resident's self determination with support of resident choice and the right to refuse care for 1 of 4 (Resident #7) reviewed for resident rights. Resident #7 was unable to refuse care without the threat of calling his family member. This failure could affect the resident's psychosocial well-being and the ability to maintain highest level of independence. The findings included: Record review of Resident #7's face sheet dated 6/19/2025 revealed a [AGE] year-old male was admitted to the facility on [DATE] with the diagnoses: hypertension, chronic kidney disease, and coronary artery disease(narrowing or blockage of the artery leading to the heart). Record review of Resident #7's Quarterly MDS dated [DATE] revealed he had a BIMS score of 15 indicative of cognition intact. Record review of Resident #7's Care Plan dated 6/13/2025 revealed he was care planned per family member's request to be called with episodes of refusal of car with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to protect the rights of residents to be free from misappropriation of property for 2 of 8 residents (Resident #5, Resident #6) reviewed for misappropriation of medication. The facility failed to ensure Resident #5's and Resident #6's medications were secured and not diverted when delivered to the facility. The noncompliance was identified as past noncompliance. The noncompliance began on [DATE] and ended on [DATE]. This failure could place residents who receive pain medications at risk of diminished quality of life and distress. The findings included: Record review of Resident #5's face sheet dated [DATE] revealed a [AGE] year-old male admitted to the facility on [DATE] with the diagnoses: epilepsy, hypertension, joint derangement (a chronic condition that is a result of an underlying injury), and stiff man syndrome (autoimmune neurological disorder with muscle stiffness and painful spasms). He expired on [DATE] at the facility. 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 record reviews and interviews the facility failed to send a copy of the residents' discharge notice, prior to discharge, to the representative of the Office of the State Long-Term Care (LTC) Ombudsman of the residents' transfer or discharge and the reasons for the move, for 1 of 8 residents (Resident #8) reviewed for notifying the LTC Ombudsman of the residents' discharge. Resident #8 was discharged on 12/2/2024 without a notice to the LTC state ombudsman. This failure could place residents at risk of not knowing their rights or receiving the services of the state LTC Ombudsman. The findings included: A record review of Resident #8's admission record dated 6/19/2025 revealed an admission date of 9/5/2024 with diagnoses which included Guillain-Barre disease (a condition in which the body's immune system attacks the nerves. It can cause weakness, numbness, or paralysis), respiratory failure, and a tracheostomy (a hole that surgeons make through the front of the neck and into the windpipe, also known as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure its medication error rate was not 5% or greater. The facility had a medication error rate of 7.69%, based on 2 errors out of 26 opportunities, which involved 1 of 6 residents (Resident #1) reviewed for medication administration and medication errors. RN A administered Resident #1's medications: a 10 gram of carafate tablet (an anti-ulcer medication) and 30 milliliters of 10 gm/15mL enulose solution (a laxative used to treat constipation), scheduled at 04:00 p.m., at 05:29 p.m., one hour and twenty-nine minutes late. These deficient practices could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. The findings included: Record review of Resident #1's admission Record, dated 01/17/2025, reflected Resident #1 was admitted initially on 11/14/2024 and re-admitted on [DATE]. Resident #1 was noted to be [AGE] years old. Record review of Resident #1's Medical Diagnoses…

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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: 1. The facility failed to store plastic storage containers to allow for air-drying in the dish room. 2. The facility failed to store, label and date a container of chopped beef brisket in the walk-in cooler. 3. The facility failed to store and label French fries in the reach-in freezer. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: 1. Observation on 11/03/2024 at 9:58 AM revealed three opaque plastic containers stacked on top each of each other on a plastic tray in the clean side of the dish machine. There was an air-drying net separating the bottom container from the tray. There was no separation between the containers to allow for air circulation and drops of moisture were visible inside and between all three containers. During an interview on 11/03/2024 at 10:00 AM, the FSD…

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 residents have a right to personal privacy for 1 of 5 residents (Resident #46) reviewed for privacy, in that: CNA A and CNA B did not close completely Resident #46's privacy curtain while providing catheter care. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy. The findings include: 1. Record review of Resident #46's face sheet, dated 11/06/2024, reflected an admission date of 10/14/2024 with diagnoses which included: Dysphagia (difficulty swallowing), Type 2 diabetes mellitus (high level of sugar in the blood), Cerebral palsy (group of movement disorders that appear in early childhood) and, Spina bifida (birth defect in which there is incomplete closing of the spine). Record review of Resident #46's admission MDS assessment, dated 10/20/2024, reflected the resident had memory problems and was severely cognitively impaired. Resident #46 was dependent for his activities of daily living, had an indwelling catheter and, was always incontinent of bowel.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and time frames to meet residents' mental, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and to ensure that the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including the right to refuse treatment for 1 of 8 residents (Resident #56) reviewed for care plans. Resident #56's cognitive communication deficit was not addressed in his comprehensive care plan. This failure could affect residents who have care areas not addressed by the care plan by not having their needs met and putting them at risk of not receiving appropriate care. The findings included: Record review of Resident #56's electronic face sheet dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 (Resident #8) of 18 reviewed for environment, in that: Resident #8's bathroom contained potentially hazardous materials. This deficient practice could result in residents, staff, and/or the public coming into contact with potentially hazardous materials. The findings were: Record review of Resident #8's face sheet, dated 11/06/2024, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Unspecified Dementia Moderate with Psychotic Symptoms, Legal Blindness as Defined in USA, and Anxiety Disorder. Record review of Resident #8's quarterly MDS, dated [DATE], revealed a BIMS score of 0 which indicated severe cognitive impairment. Record review of Resident #8's care plan, undated, revealed [Resident #8] has delusions, hallucinations, auditory or visual related to dementia or other psychiatric disorder.…

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 provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 (Resident #48) of 18 residents reviewed, in that: Resident #48 displayed signs and symptoms of depression and was not offered mental health services. This deficient practice could place residents with mental health concerns at risk of diminished psychosocial well-being. The findings were: Record review of Resident #48's face sheet, dated 11/06/2024, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Malignant Neoplasm of Overlapping Sites of Right Bronchus and Lung, Type 2 Diabetes Mellitus, and Unspecified Dementia. Record review of Resident #48's quarterly MDS, dated [DATE], revealed a BIMS score of 9 which suggested moderate cognitive impairment. Further review revealed the resident responded affirmatively when asked if felt down, depressed, or hopeless. 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 observation, interview, and record review, the facility failed to ensure all drugs and biological were stored in locked compartments for 1 of 3 medication carts (Hall 200 Medication Cart) reviewed for storage, in that: During medications administration, RN C left Hall 200 Medication cart unlocked on 1 occasion. This deficient practice could place residents at risk of misappropriation of medications or harm due to accidental ingestion of unprescribed medications. The findings were: Observation on 11/05/2024 at 9:25 a.m. revealed RN C was administering medications to residents. RN C was seen entering room [ROOM NUMBER] and closed the door. The medication cart was left unlocked and out of sight of RN C. Inside the unlocked cart were blister packs, bottles, and vials of medications for the residents. During an interview with RN C on 11/05/2024 at 9:30 a.m., RN C confirmed the medication cart was left unlocked while she was administering medications in the resident's room. RN C confirmed she knew she had 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.

Based on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 3 of 9 residents (Residents #162, #4, and #46) reviewed for infection control, in that: 1. RN D did not sanitize the blood pressure cuff between Resident #162 and Resident #4. 2. CNA A and CNA B did not wear a gown while providing care to Resident #46 who had been place on enhanced barrier precautions. These deficient practices could place residents at-risk for infection due to improper care practices. The findings include: 1. Observation on 11/05/24 at 9:54 a.m. revealed RN D was seen returning to his medication cart with a blood pressure cuff in hand after measuring Resident #4's blood pressure. He placed the blood pressure cuff on the medication cart and documented the blood pressure he had just taken. He, then, went to Resident #162 to take his blood pressure with the same blood pressure cuff…

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 that all alleged violations involving abuse or neglect, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation result in serious bodily injury for 1 of 4 Residents (Resident #3) whose records were reviewed for abuse and neglect., in that; The facility failed to report to the state reporting agency (HHSC) an injury of unknown origin when Resident #3 suffered a fracture to her left tibia (lower leg). This deficient practice could affect any resident and could contribute to further abuse and neglect. The findings were: Record review of Resident #3's face sheet dated [DATE] revealed an admission date of [DATE] and a readmission date of [DATE] with diagnoses which included: moderate intellectual disabilities, autistic disorder, and unspecified fracture of upper end of tibia, initial encounter for closed fracture (break in one 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 interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 6 residents (Resident #3) reviewed for care plans, in that The facility failed to ensure Resident #3's comprehensive care plan included: -LIDDA representative name/office and contact information and next scheduled IDT meeting -Adult Day Care Services three days a week including the name of the facility and the name and phone number of their contact person at the ADC and interventions for continuity of care between the two facilities. -Community bus (rideshare) information to the ADC including schedule, interventions/preparation for transport, who to contact to schedule or cancel transportation and contact information. These deficient practices could…

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 comprehensive person-centered care plan for each that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs that are identified in the comprehensive assessment, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 of 16 resident (Resident #25, Resident #33, Resident #35, and Resident #44) reviewed for care plans. 1. The facility failed to ensure smoking was included on Resident #25's care plan. 2. The facility failed to ensure smoking was included on Resident #33's care plan. 3. The facility failed to ensure smoking was included on Resident #35's care plan. 4. The facility failed to ensure Resident #44's side rail use was care planned. This deficient practice place residents at risk for not receiving proper care and services due to inaccurate care plans. The findings included: 1. 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 observation, interview, and record review the facility failed to ensure residents who need respiratory care were provided such care, consistent with professional standards of practice for 4 of 17 residents (Resident #40, Resident #44, Resident # 47, and Resident #49) reviewed for respiratory care. 1. The facility failed to replace the oxygen concentrator humidification reservoirs in a timely manner. 2. Facility failed to ensure Resident #44 and Resident #49 nebulizer supplies were bagged and dated to prevent cross contamination. These deficient practices could affect residents who receive oxygen therapy and nebulizer treatments which could contribute to respiratory infections. The findings included: 1. Record review of admission record dated 9/22/2023, revealed Resident #47 was a [AGE] year-old man originally admitted to the facility on [DATE]. Record review of the comprehensive MDS assessment dated [DATE], revealed Resident #47's primary medical condition category for admission was related to acute 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 observation, interviews and record reviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for three residents (Residents #31, #36, and #54) out of 5 residents reviewed for medication administration in that: 1. Resident #31 had metoprolol (a medication for high blood pressure) administered outside the parameters as ordered by the physician. 2. Resident #36 had ibrutinib (a medication for cancer) administered without a pharmacy label. 3. Resident #54 had midodrine (a medication low blood pressure) administered outside of the parameters as ordered by the physician and Resident #54 missed administration of hydralazine (a medication for elevated blood pressure). This failure could place residents at risk for not receiving the intended therapeutic effects of their medications and possible adverse reactions. The findings include: 1. 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 observation, interviews and record reviews, the facility failed ensure residents are free of any significant medication errors for three residents (Residents #31, #36, and #54) out of 5 residents reviewed for medication administration in that: 1. Resident #31 had metoprolol (a medication for high blood pressure) administered outside the parameters as ordered by the physician. 2. Resident #36 had ibrutinib (a medication for cancer) administered without an appropriate label. 3. Resident #54 had midodrine (a medication low blood pressure) administered outside of the parameters as ordered by the physician. Resident #54 missed administration of hydralazine (a medication for elevated blood pressure). This failure could place residents at risk for not receiving the intended therapeutic effects of their medications and possible adverse reactions. The findings include: 1. Record review of the admission record, dated 9/19/2023, revealed Resident #31 was a [AGE] year-old male originally admitted on [DATE]. 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.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: The facility failed to ensure all foods in the refrigerator were labeled and dated with use by dates. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings were: During an observation and interview with the Food Service Director on 09/19/2023 at 10:51 a.m., revealed an unlabeled storage bag with ground meat and meat links dated 9/19/23 and an unlabeled storage bag of a yellow substance dated 9/19/23. The FSD called out to [NAME] H and reeducated that all items must be labeled. [NAME] H revealed the items to be pan sausage, sausage links and scrambled eggs from that morning which had been saved for the following days puree. The FSD instructed the [NAME] to discard the items. Further tour of the kitchen revealed a storage bag with a substance labeled as Pizza Mix dated 9/15/23. [NAME] H was asked if…

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 reasonable accommodation of resident needs 2 of 8 resident rooms (Resident #42 and Resident #44) reviewed for call lights. The facility failed to ensure Resident #42 and Resident 44's call lights were within reach and placed for easy access. The deficient practice could place residents at risk of not receiving care or attention needed. Findings included: Record review of Resident #42's face sheet, dated 09/21/2023, revealed the resident was originally admitted to the facility on [DATE] with diagnoses which included: benign neoplasm of prostate, dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, unspecified macular degeneration, legal blindness, hypertension, senile degeneration of brain, chronic atrial fibrillation, and hearing loss. Record review of Resident #42's admission MDS assessment, dated 07/14/2023, revealed the resident's BIMS score was 00, which indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 2 of 8 residents (Residents #10 and #25) whose assessments were reviewed, in that: The facility failed to ensure Resident #10 and #25's Quarterly MDS Assessments were coded correctly for bed rails. This failure could place residents at-risk for inadequate care due to inaccurate assessments. The findings were: 1. Record review of Resident #10's face sheet, dated 09/22/2023, revealed the resident was admitted to the facility on [DATE] with diagnoses that included end stage renal disease, diabetes, bipolar disorder, and mild cognitive impairment. Record review of Resident #10's Quarterly MDS, dated [DATE], revealed the resident's BIMS score was 11, which indicated moderate cognitive impairment. Further review of the assessment indicated Resident #10 had a bed rail; coded as (1) used less than daily. Record review of Resident #10's care plan with last review completed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 of 8 residents (Resident #25) for care plan revisions, in that: The facility failed to ensure bed rails were removed from Resident #25's care plan. This failure could place residents at risk of receiving inappropriate care. The findings include: Record review of Resident #25's face sheet dated 09/22/2023 revealed an initial admission date of 03/21/2019 with a recent admission of 04/20/2021 and diagnoses which included major depressive disorder, generalized anxiety disorder, low back pain, and muscle weakness. Record review of Resident #25's Quarterly MDS, dated [DATE], revealed the resident's BIMS score was 04, which indicated severe cognitive impairment. Further review of the assessment indicated Resident #25 had a bed rail; coded as (1) used less than daily. Record review of Resident #25's Care Plan with last 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 observations, interviews, and record reviews, the facility failed to ensure an incontinent resident who had a urinary catheter received appropriate treatment and services to prevent urinary tract infections for 1 of 1 resident (Resident #29) reviewed for catheter care in that; The facility failed to ensure Resident #29 was provided catheter care to professional standards to prevent infections. This deficient practice could place residents at-risk for exposure to pathogens causing infection resulting in diminished quality of life. The findings included: Record review of the admission record, dated 9/22/2023, revealed Resident #29 was a [AGE] year-old-male, originally admitted to the facility on [DATE]. Record review of the discharge MDS assessment, dated 9/02/2023, revealed Resident #29's active diagnoses included unspecified retention of urine. Resident #29 had severely impaired cognitive skills for daily decision making. Resident #29 had an indwelling catheter and was always incontinent. Resident #29…

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 reviews the facility failed to ensure a medication error rate below 5% for 2 of 3 residents (Residents #31 and #36), in that; During medication administration observations, LVN A administered medications erroneously resulting in a 7.59% (2 errors out of 26 opportunities) medication administration error rate: 1. LVN A administered metoprolol (a medication for high blood pressure) to Resident #31 outside the parameters as ordered by the physician. 2. LVN A administered ibrutinib (a medication for cancer) to Resident #36 without a pharmacy label. This failure could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. The findings include: 1. Record review of the admission record, dated 9/19/2023, revealed Resident #31 was a [AGE] year-old male originally admitted on [DATE]. Record review of the quarterly MDS assessment, dated 6/30/2023, revealed Resident #31's primary medical condition for admission was acute…

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 all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys in 1 medication carts of 6 medication carts (First Floor Treatment Cart) reviewed for medication storage, in that; The facility failed to ensure the First Floor Treatment Cart was locked when left unattended in the hallway. This deficient practice could place residents at risk of medication misuse or drug diversion. The findings were: In an observation on 9/19/2023 at 10:25 AM, the First Floor Treatment Cart was observed to be unlocked and unattended in the hallway near room [ROOM NUMBER]. The drawers were facing out into the hallway. The hall was a common area hallway; the pathway to the dining, television room, elevator and main facility exit. There were ambulatory and self-mobilizing residents, visitors and staff in the immediate vicinity. The First Floor Treatment Cart…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to implement establish policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, and smoking safety for 3 (Residents #25, #33 and #35) of 3 residents reviewed did not have their smoking assessment. 1. The facility failed to ensure a smoking assessment was completed for Resident #25 quarterly. 2. The facility failed to ensure a smoking assessment was completed for Resident #33 upon admission. 3. The facility failed to ensure a smoking assessment was completed for Resident #35 quarterly. This failure could affect smoking residents and could result in harm if policies were not followed. The findings included: 1. Record review of Resident #25's face sheet dated 09/22/2023 revealed an initial admission date of 03/21/2019 with a recent admission of 04/20/2021 and diagnoses which included major depressive disorder, generalized anxiety disorder, low back pain, and muscle weakness. Record review of Resident #25's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record reviews, the facility failed to maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized for 1 of 4 residents (Resident #1), reviewed for resident records, in that: The facility failed to ensure Resident #1's physician orders reflected the resident's Advance Directive code status after Resident #1's Out of Hospital Do Not Resuscitate form was provided to the facility. This deficient practice could affect all residents whose records are maintained by the facility and could place them at risk for errors in care and treatment. The findings included: Record review of Resident #1's face sheet, dated [DATE], revealed he was admitted to the facility on [DATE] with diagnoses which included malignant neoplasm of prostate (prostate cancer), muscular dystrophy (genetic disease that causes breakdown of the muscles), tracheostomy (surgical opening in the neck to administer oxygen), gastrostomy (surgical opening into…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 1 resident (Resident #1) reviewed for incontinence/perineal care, in that: CNA A and CNA B used multiple passes with the same wipe while providing incontinence/perineal care to Resident #1. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices. The findings were: Record review of Resident #1's face sheet, dated 8/24/23 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included benign prostatic hyperplasia with lower urinary tract symptoms (non-cancerous condition in men in which the prostate gland is enlarged causing blockage of urine flow out of the bladder), chronic kidney disease stage 3 (damage to kidneys affecting how blood is filtered), and type 2…

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 an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 resident (Resident #1) and 2 of 2 staff (CNA A and CNA B) reviewed for infection control in that: CNA A and CNA B placed clean gloves into their pockets used during incontinence/perineal care CNA A and CNA B did not perform hand hygiene between glove changes CNA A did not change her soiled gloves after cleansing Resident #1's buttock area, before touching the clean brief and before applying barrier cream to the resident's scrotal and buttock area CNA B did not change her soiled gloves after cleansing Resident #1's thighs, before touching This deficient practice could affect residents and place them at risk for infection. The findings were: Record review of Resident #1's face sheet, dated 8/24/23 revealed an [AGE]…

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.