Mesa Vista Inn Health Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to respect the residents' right to confidentiality in his or her personal and medical records for 1 (Resident #2) of 13 residents reviewed for dignity. The facility failed to ensure Resident #2's shared bathroom door remained closed during wound care. This failure could cause a decrease in feelings of self-worth by being exposed during care. Findings included: Record review of Resident #2's face sheet, dated 4/24/26, revealed the resident was a [AGE] year-old female, initially admitted to the facility on [DATE], readmitted on [DATE], with diagnoses including sacral spina bifida with hydrocephalus (a congenital condition in which the spinal column does not close completely and is accompanied by excess cerebrospinal fluid accumulation in the brain), pressure ulcer of contiguous site of back, buttock, and hip, stage 4 (full-thickness tissue loss with exposed bone, tendon, or muscle), cellulitis (bacterial skin infection), neuromuscular…

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 MDS assessment accurately reflected the resident's status for 2 of 33 residents (Residents #88 and #113) reviewed for assessments: Resident #88's Quarterly MDS dated [DATE] did not indicate she was receiving hospice services. Resident #113's Quarterly MDS dated [DATE] did not indicate she was receiving hospice services. These failures could place residents at risk for inadequate care due to inaccurate assessments.Findings included: Record review of Resident #88's admission Record dated 04/24/26 documented a [AGE] year-old female originally admitted to the facility on [DATE] and the last admission on [DATE]. The diagnoses included Alzheimer's disease (a progressive irreversible neurodegenerative disorder and the most common cause of dementia, characterized by memory loss, cognitive decline, and behavioral changes), unspecified severe protein calorie malnutrition (a critical medical condition indicating extreme muscle wasting,…

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 the Pre-admission Screening and Resident Review (PASRR) Level 1 residents with mental illness were provided with a PASRR Level II assessment accurately 1 of 6 residents (Resident #6) whose records were reviewed for PASRR services. The facility failed to conduct a Level 1 PASRR screening for Resident #6 after a diagnosis of PTSD and coordinate with the Local Authority to conduct a Level 2 PASRR evaluation to determine the need for specialized services. This deficient practice could place residents at risk of a diminished quality of life related to not receiving or benefiting from specialized PASRR services to meet their needs.The findings included: Record review of Resident #6's admission sheet dated 9/12/2025 with an original admission date of 3/01/2024 documented an [AGE] year-old male resident with a diagnosis of PTSD on admission [DATE]). Record review of Resident #6's MDS assessment dated [DATE] documented a BIMS score of 7 indicating…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality of care for 1 of 6 residents (Resident #128) whose medical records were reviewed for accuracy, in that: The facility failed to develop a baseline care plan within 48 hours of Resident #128's admission to the facility. This failure could place residents at risk of not receiving needed care and treatment.The findings included: Record review of Resident #128's admission sheet dated 4/17/2026 documented a [AGE] year-old male resident with diagnoses including encephalopathy (a group of conditions that cause brain dysfunction), type 2 diabetes mellitus, cognitive communication deficit, disorientation (a state of mental confusion where a person is unsure about time, place, identity, or situation), hyperlipidemia (high cholesterol), alcoholic cirrhosis 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 observations, interviews, and record review, the facility failed to ensure residents who need respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice for 1 of 1 resident (Resident #5) reviewed for quality of care. The facility failed to ensure Resident #5's sterile water was dated on the oxygen concentrator. This failure could place residents at risk for infection. The findings include: Record review of Resident #5's face sheet, dated 04/21/2026, revealed a [AGE] year-old female readmitted to the facility on [DATE], with an original admission date of 01/02/2023, with a primary diagnosis of aftercare following joint replacement surgery and chronic obstructive pulmonary disease, unspecified (progressive lung disease that makes it difficult to breathe) Record review of Resident #5's MDS assessment, dated 03/14/2026, revealed that a BIMS could not be obtained, but the resident's cognition was severely impaired. 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 that residents who required dialysis received such services, consistent with professional standards of practice for 1 of 1 resident (Resident #9) reviewed for quality of care: The facility did not maintain communication, coordination, or collaboration with the dialysis facility for Resident #9. This failure could affect residents who received dialysis treatments and place them at risk of complications and not receiving proper care and treatment to meet their needs. The findings included: Record review of Resident #9's care plan, dated 4/22/26, revealed a [AGE] year-old female, admitted on [DATE], with diagnosis with diagnoses including end stage renal disease (a permanent kidney condition in which the kidneys have lost nearly all ability to function, requiring renal replacement therapy such as dialysis), anemia, unspecified (a condition characterized by a decreased number of red blood cells or hemoglobin, commonly associated with chronic kidney…

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 all drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles for 1 of 7 medication carts (100/400 hall nurse cart) reviewed for medication storage and labeling. The facility failed to ensure all insulins located inside the 100/400 hall nurse cart were properly labeled with opened dates. This failure could place residents who receive medications at risk for not receiving the intended therapeutic effects of their prescribed medications.The findings included: During an observation of the 100/400 hall nurse cart on 4/23/2026 at 9:39 AM, revealed it contained two insulins which had no opened date. During an interview with LVN J on 4/23/2026 at 9:39 AM, LVN J stated it was important to have the opened date on the insulins so it is known when they will expire, because if expired medications were given to residents, it would be unknown what the effect could be. During an interview with the DON on 4/23/2026 at 10:41 AM, the DON stated 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 4 residents (Resident #82) reviewed for accuracy of records: The facility failed to ensure Resident #82's hospice binder was accurate with their DNR status. These failures could affect residents whose records were maintained by the facility and could place the residents at risk of errors in care and treatment.The findings include: Record review of Resident #82's face sheet, dated [DATE], revealed a [AGE] year-old male readmitted to the facility on [DATE], with an original admission date of [DATE], with a primary diagnosis of Alzheimer's disease, unspecified (progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior). Record review of Resident #82's MDS assessment, dated [DATE], revealed the resident's BIMS score was a 3 out of 15 which indicated the resident's cognition was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain 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 3 residents (Resident #3) reviewed for infection control in that: LVN A did not wash his hands between removing soiled gloves and putting on clean gloves when providing direct care to Resident #3 who had a skin tear and was on enhanced barrier precautions (EBP). The DON did not wash her hands after touching a window blind, bed controls, and bed linens prior to providing direct care to Resident #3 who had a skin tear and was on EBP. This deficient practice could affect residents who are receiving wound care or were on enhanced barrier precautions placing them at risk for infection.The findings were: Record review of Resident #3's admission record printed on 12/23/2025 revealed she was a [AGE] year-old female who admitted to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made for 1 of 4 Residents (Resident #1) whose records were reviewed for suspicious injuries. The facility failed to report an injury of unknown injury to HHSC when Resident #1 was noted with bruising to right temple and was sent out to the hospital on 9/2/25 about 11:30 PM. This deficient practice could place the residents at risk for further abuse or neglect.The findings were: Review of Resident #1's face sheet, dated 9/25/25, revealed she was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction (Stroke) and Unspecified Dementia (often indicating a decline in cognitive function without a clear underlying cause). Review of Resident #1's quarterly MDS assessment, dated 9/10/25, revealed her BIMS score was 4 out of 10 reflective of severe…

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 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 3 of 5 residents (Resident #2, Resident #3, and Resident #4) reviewed for infection control. The facility failed to ensure staff wore PPE during wound care for Resident #2 who was on enhanced barrier precautions. The facility failed to ensure LVN A and ADON B appropriately doffed (removed) PPE after providing care to Resident #3 and Resident #4. This deficient practice could put residents at risk for infection. Findings included: 1. Record review of Resident #2's admission Record, dated 10/17/25, revealed the resident was re-admitted to the facility on [DATE] with diagnoses which included: Type 1 Diabetes (condition in which the pancreas makes little/no insulin, resulting in high blood sugar) and Peripheral Vascular Disease…

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 treat each resident with respect, dignity, and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 2 of 4 residents (Resident #2 and Resident #3) reviewed for dignity. The facility failed to ensure residents' privacy/dignity was maintained during wound observations/care on (2) occasions. These failures could affect residents by contributing to poor self-esteem, decreased self-worth and quality of life. Findings included: Record review of Resident #2's admission Record, dated 10/17/25, revealed the resident was re-admitted to the facility on [DATE] with diagnoses which included: Type 1 Diabetes (condition in which the pancreas makes little/no insulin, resulting in high blood sugar) and Peripheral Vascular Disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Record review of Resident #2's quarterly MDS assessment, 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 develop and implement a comprehensive person-centered care plan, 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 one of 12 residents (Resident #6), in that: Resident #6's care plan did not include a focus area or interventions for Resident #6's ordered hospice care diagnosis. This failure placed residents at risk of not receiving appropriate end of life care, a decreased quality of life, mismanagement of medications, and hospitalization. The findings included: Record review of Resident #6's admission Record dated 08/29/2025, reflected a [AGE] year-old female resident admitted to the facility on [DATE]. Record review of Resident #6's Medical Diagnosis report dated 08/29/2025 reflected diagnoses including senile degeneration of the brain (the brain's cells are damaged, leading…

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 1 of 2 physicians (Physician R) signed and dated resident physician orders for physicians reviewed for physician visits. The facility failed to have Physician R electronically sign physician orders. The Medical Records Director was instructed by Administrator O to electronically sign Physician R orders in the EMR using Physician R's username and password. This failure could place residents assigned to Physician R at risk for not receiving appropriate physician ordered care. Findings included: Record review of a facility document titled, Investigation Summary, provided by Administrator N, revealed Administrator N had a meeting with the Medical Records Director on 05/05/2025 regarding an audit of the EMR conducted by the Regional Medical Records Director that revealed unsigned physician orders. Administrator N stated the Medical Records Director said she had been instructed by Administrator O, to sign Physician R's physician orders in the EMR. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 11 (Resident #4) reviewed for care plans. 1. The facility failed to ensure a care plan was developed and interventions put in place to address Resident#4 physical and verbally aggressive behaviors toward others. This deficient practice could place residents with behaviors at risk for injury to themselves or others. The findings included: Record review of Resident #4's face sheet revealed Resident #4 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease (a progressive disease that affects memory and other important mental functions) and Type 2 Diabetes (a chronic condition that occurs when the…

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

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 disease and infection for 1 of 3 residents (Resident #3) reviewed for infection control: The facility failed to ensure CNA A changed her gloves and washed or sanitized her hands after they became contaminated during incontinent care, before touching Resident #3's clean linen and clean brief. This failure could place residents at-risk for infection due to improper care practices. The findings included: Record review of Resident #3's admission Record (face sheet) dated 03/30/2025, revealed she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia (a progressive decline in memory, thinking, reasoning and problem-solving that interferes with daily life activities), vitamin D deficiency…

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 develop and implement written policies and procedures that prohibit and prevent abuse and neglect for 1 of 1 facility in that: The ADM did not follow the ANE policy and procedures by not reporting a serious injury of unknown source to HHSC when: Resident #1 fell, went to the hospital, and received 6 sutures to her forehead. This could affect all resident that had a fall and could result in further injuries. The Findings were: Record review of policy Abuse/Neglect dated 2003 reflected The resident had the right to be free of abuse, neglect misappropriation of resident property and exploitation. E: Reporting, Facility employees must report all allegations of abuse, neglect exploitation mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report the allegation to HHSC. 1. If the allegations involve abuse or result in serious…

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 that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, 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, to the administrator of the facility and to other officials (including to the State Survey Agency) in accordance with State law through established procedures for 1 of 1 facility in that: Resident #1 had an unwitnessed fall, went to the emergency room, and received 6 sutures to her forehead. This was not reported by the ADM to HHSC. This deficient practice could result in the delay of investigating the residents' circumstances after sustaining a serious injury of unknown source. The findings were: Record Review of Resident #1's admission Record dated 3/18/2025 reflected she was [AGE] years old, she was admitted on [DATE] and she had Hospice…

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 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 and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 7 (Resident #2) residents in that: Resident #2's fall mat was not on the ground near her bed as specified in her care plan. Resident #2 had a fall and had behaviors and required a fall mat to prevent injury. This deficient practice could place residents at risk for not receiving proper care and services due to incomplete care plans. The Findings were: Record Review of Resident #2's admission Record dated 3/17/2025 reflected she was admitted on [DATE] and readmitted on [DATE]. Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility must ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 7 residents (Resident #2) reviewed for pressure sores, in that: The facility failed to ensure Resident #2's air mattress was was dialed to the correct weight. This failure could affect residents with skin injures and wounds and could place the residents at risk for worsening of pressure ulcers. The findings were: Record Review of Resident #2's admission Record dated 3/17/2025 reflected she was admitted on [DATE] and readmitted on [DATE]. Resident #2's diagnoses included dementia (a general term for a decline in mental ability that interferes with daily life, encompassing various conditions affecting memory, thinking, and reasoning), repeated falls, pressure ulcer of sacral region (is at the bottom of the spine and lies…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the observations, interviews, and record review the facility failed to ensure that the resident's environment remained free of accidents and hazards as was possible and each resident received adequate supervision to prevent accidents for 1 (Resident #60) of 2 residents reviewed for accidents. The facility failed to make sure Resident #60's environment was free of sharp devices that could harm the resident such as a pair of nail clippers. This failure could place the resident at risk of self-injury and complications with resident's diabetic condition. Findings included: Record review of Resident #60's admission Record dated 01/30/25, documented a [AGE] year-old male admitted to facility's secure unit on 05/30/24. His diagnoses included unspecified dementia (impaired ability to remember, think or make decisions that interferes with doing everyday activities), senile degeneration of the brain (gradual decline in cognitive function that involves the deterioration of brain cells and connections, leading to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder and bowel received appropriate treatment and services to prevent urinary tract infections for 1 of 2 residents (Resident #31) reviewed for incontinent care: The facility failed to ensure CNA A and CNA B properly cleaned Resident #31's vaginal and buttock area after an incontinent episode. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices. The findings included: Record review of Resident #31's face sheet dated 1/29/25 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included dementia (a decline in cognitive abilities severe enough to interfere with daily life), diabetes (chronic condition when the body cannot produce enough insulin or effectively use the insulin the body produces leading to elevated blood sugar levels) with complications and hydronephrosis…

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 medical records, in accordance with accepted professional standards and practices, that are complete; and accurately documented for 1 of 8 residents (Resident #31) reviewed for medical records: The facility failed to ensure staff obtained a written order for Resident #31's use of a left arm sling. This failure could result in residents not having an accurate overall view of their care and services. The findings included: Record review of Resident #31's face sheet dated 1/29/25 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included ataxia following cerebrovascular disease (a neurological condition characterized by a lack of muscle coordination, including difficulty with fine motor tasks and unsteady walking). Record review of Resident #31's most recent annual MDS assessment dated [DATE] revealed the resident was severely cognitively impaired for daily…

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 establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 2 or 4 residents (Residents #31 & #33) reviewed for infection control. 1. The facility failed to identify and implement interventions for Resident #33 on Enhanced Barrier Precaution who had a colostomy. 2. The facility failed to ensure CNA A and CNA B used appropriate infection control principles including during catheter care, incontinent/peri care, and hand hygiene/glove changes for Resident #31. These deficient practices could affect residents who were on EBP and required assistance with incontinent/peri care and could place residents at risk for cross contamination and infections. The findings included: 1. Review of Resident #33's electronic face sheet dated 1/31/2025 revealed she was admitted to the facility on [DATE] with diagnoses 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 observations, interviews, and record reviews the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member or to a centralized staff work area from each resident's bedside, toilet, and bathing facilities, for 1 of 2 residents (Resident #41) reviewed for call light accessibility and functionality. On 01/28/25 at 10:05 am, Resident #41 was observed to have utilized his call light which did not illuminate the nurse call light directly outside and above his room door. This failure could place residents at risk for harm by not receiving care and attention when their nurse call light system malfunctioned and/or was out of reach. The findings included: Record review of Resident #41's admission Record dated 01/30/25 documented an [AGE] year-old male admitted to the facility 04/15/24. His diagnoses included unspecified dementia (impaired ability to remember, think, or make decisions that interferes…

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 review, the facility failed to ensure the resident had the right to be informed of the risks, and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives, or treatment options and to choose the alternative or options he or she preferred, for 1 (Resident #1) of 5 reviewed for resident rights. 1. The facility failed to obtain a signed consent for antipsychotic medication, Escitalopram Oxalate (Lexapro) which was administered to Resident #1. 2. The facility failed to provide Resident #1's Responsible Party with the benefits, risks, and options available after a Psychiatric Nurse Practitioner's recommendation of an increase in Escitalopram Oxalate (Lexapro) on 03/01/2024. These failures could place residents at risk of receiving medications without their, or that of their responsible party's prior knowledge or…

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 residents' had the right to formulate an advanced directive for 1 of 24 residents (Resident #5) reviewed for advance directives. Resident #5's OOH-DNR form was invalid because the attending physician's license number, physician's date signed, and physician's printed name were missing from the form. This failure could result in a resident's DNR not being executed. The findings included: Record review of Resident #5's face sheet dated, 12/14/2023, reflected a [AGE] year-old female most recently admitted on [DATE] and diagnoses included: Dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities). Record review of Resident #5's comprehensive person-centered care plan, dated 12/15/2023 reflected [Resident #5] had an order for Do Not Resuscitate with an initiated date of 12/12/2023. Record review of Resident #5's clinical records reflected a OOH-DNR, dated 11/28/23, lacking 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 included measurable objectives and timeframes to meet residents' mental, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and to ensure 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 for 2 of 20 residents (Resident #20 and #57) reviewed for care plans in that: The facility failed to develop a comprehensive care plan that addressed Resident #20 and #57's need to want to sleep in each other's bed when residing in the memory/secure care unit. This failure could place residents at risk of not receiving appropriate care. The findings included: Record review of Resident #20's face sheet, dated 12/15/23 revealed a [AGE] year old female admitted to the facility 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 provide treatment and care in accordance with the comprehensive person-centered care plan and in accordance with professional standards of practice for 1 of 2 Residents (Resident #69) reviewed for quality of care. The facility failed to obtain medical information needed to monitor the parameters of the cardiac pacemaker for Resident #69. This failure could place residents with cardiac pacemakers at risk for not having care and services provided to meet their needs. The findings included: Record review of Resident #69's face sheet dated 12/15/23 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), seizures (disorder in which brain activity becomes abnormal, causing seizures or periods of unusual behavior, sensations and sometimes loss of awareness), heart failure chronic condition 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, observation, and interview the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 1 of 24 residents (Resident #17) reviewed for respiratory care, in that: Resident #17 did not have sufficient oxygen flow based on the physician's order. This failure could place residents at-risk of inadequate oxygen availability. The findings included: Record review of Resident #17's face sheet, dated 12/14/23, reflected a [AGE] year-old male with an admission date of 12/08/2023 with diagnoses which included acute on chronic diastolic (congestive) heart failure. Record review of Resident #17's comprehensive person-centered care plan, dated 12/15/2023, reflected The resident has PRN Oxygen Therapy r/t CHF. Record review of Resident #17's Physician Order Summary of all orders,…

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 it received registry verification for 1 (CNA C) of 5 employees reviewed for registry verification prior to allowing an applicant to serve as a nurse aide in that: The facility failed to ensure CNA C had a current nurse aide certification while employed at the facility while actively providing care for residents. This failure could result in residents being provided care by staff who have not provided documentation of training and competency in providing care. The findings included: Review of CNA F's personnel file reflected a date of hire of [DATE]. The last Employability Status Check Search that was completed on [DATE] reflected CNA C's NAR status expired on [DATE]. Review of the nursing staff schedule, A Unit for [DATE] reflected CNA C worked on [DATE] on shift 6A-2P (6:00 AM - 2:00 PM) under the CNAs section. Review of CNA C Iso-Quality Testing, Inc Certificant Registry (no date) reflected CNA C's NAR expired on [DATE]. Interview on [DATE] at…

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 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 1 of 3 Residents (Resident #78) reviewed for medication administration. LVN L administered insulin to Resident #78 without cleaning the rubber seal on the insulin pen prior to injection. These deficient practices could affect residents who received medication and place them at risk of an adverse reaction or a decline in health. The findings included: Record review of Resident #78's face sheet, dated 12/15/23 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included type 2 diabetes (a chronic, long-lasting health condition that affects how your body turns food into energy), hypertension (high blood pressure), chronic hepatitis (an inflammatory condition affecting the liver) 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 record review and interviews, the facility failed to ensure residents were given psychotropic medications to treat specific diagnoses for 1 (Resident #31) of 24 Residents, reviewed for unnecessary psychotropic medications in that: The facility failed to ensure the medication (Seroquel) was administered to treat a specific diagnosis for Resident #31. This failure could affect residents who received psychotropics in the facility and put them at risk for adverse consequences such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status. The findings included: Record review of Resident #31's face sheet reflected a [AGE] year-old with an admission date of 06/01/2023 a primary diagnosis of Unspecified Sequelae of Unspecified Cerebrovascular Disease (a group of conditions that affect blood flow and the blood vessels in the brain), depression, and generalized anxiety disorder. Record review of Resident #31's physician orders dated 12/14/2023 reflected an…

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 clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 19 residents (Resident #85) reviewed for accuracy of medical records. The facility failed to accurately document the implementation of the physician's orders for Resident #85. This deficient practice could affect 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 #85's face sheet, dated 12/14/23 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), repeated falls, dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and chronic pain. Record review of Resident #85's most recent…

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 infections for 1 of 3 staff (LVN L) reviewed for infection control. LVN L administered insulin to Resident #78 without cleaning the rubber seal on the insulin pen prior to injection. These deficient practices could place residents who received care at-risk for infections. The findings included: Record review of Resident #78's face sheet, dated 12/15/23 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included type 2 diabetes (a chronic, long-lasting health condition that affects how your body turns food into energy), hypertension (high blood pressure), chronic hepatitis (an inflammatory condition affecting the liver) and heart failure. Record review of Resident #78's most recent quarterly MDS assessment,…

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.