Guadalupe Valley Nursing And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to determine that drug records were in order and that an account of all controlled substances was maintained and periodically reconciled for 8 of 17 residents (Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, and Resident #11) and 4 of 6 medication carts (MC #1, MC #2, MC #4 and MC #6) reviewed for pharmaceutical services. 1. The facility failed to ensure discontinued/expired medications were removed from the medication carts on (4) occasions.2. The facility failed to ensure the administration and count of controlled substances were reconciled on (3) occasions.3. The facility failed to ensure counts of controlled medications were completed/signed for on (28) occasions. These deficient practices could put residents at risk for diversion and reduced effectiveness of medications. Findings included: 1. Record review of Resident #4's admission Record, dated 9/26/25, revealed the resident was re-admitted…

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 medication error rate was not five percent or greater for 1 of 5 residents (Resident #12). The facility had a medication error rate of 45% based on 5 errors out of 11 opportunities. LVN D failed to administer medications as ordered to Resident #12 by administering Gabapentin (for neuropathy), Cyclobenzaprine (for pain), Colace (for constipation), Carboxymethylcellulose Sodium ophthalmic gel (dry eyes), and Rosuvastatin (for high cholesterol) 2 hours and 12 minutes before the scheduled time. This failure could place residents at risk of not receiving the desired therapeutic effect of their medications. Findings included: Record review of Resident #12's admission Record, dated 9/26/25, revealed the resident was re-admitted on [DATE] with diagnoses which included: Dry Eye Syndrome, Constipation, Hemiparesis (weakness or an inability to move one side of the body), Hemiplegia (paralysis or weakness to one side of the body) 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, interview and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 4 residents (Resident #11) reviewed for medication labeling. The facility failed to ensure medications were correctly labeled. These deficient practices could place residents at risk of medication misuse and drug diversion. Findings included: Record review of Resident #11's admission Record, dated 9/26/25, revealed the resident was admitted on [DATE] with diagnoses which included: Dementia (group of thinking and social symptoms that interferes with daily functioning). Record review of Resident #11's Order Summary Report, dated 9/26/25, revealed: Lorazepam oral concentrate 2mg/mL by mouth every 4 hours PRN. Observation on 9/25/25 at 2:15 pm revealed Resident #11's Lorazepam was in the refrigerator,…

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 medical records, in accordance with accepted professional standards and practices, that are complete; and accurately documented for 1 of 2 residents (Resident #1) reviewed for medical records:The facility failed to document wound care dressing changes on the Treatment Administration Record (TAR) for Resident #1 on 8/2/25, 8/3/25, 8/5/25, 8/8/25, 8/13/25, 8/14/25, and 8/16/25.These failures could place residents at risk for missed treatments and care which could result in the deterioration of the wound and/or development of an infection.The findings included:Record review of Resident #1's face sheet dated 10/7/25 revealed a [AGE] year-old male admitted to the facility on [DATE] and discharged on 8/18/25 with diagnoses that included sepsis (condition in which the body's response to infection causes widespread inflammation, leading to tissue damage, organ failure, or death), secondary malignant neoplasm of right lung (cancer has…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 5 residents (Resident #1) reviewed for resident rights.The facility failed to notify Resident #1's provider of his change in condition when the Wound Care Nurse identified the resident developed a Stage 2 pressure ulcer on 8/6/25.This failure could affect residents by placing them at risk for a delay in medical treatment, decline in health, and death.The findings included:Record review of Resident #1's face sheet dated 10/7/25 revealed a [AGE] year-old male admitted to the facility on [DATE] and discharged on 8/18/25 with diagnoses that included sepsis (condition in which the body's response to infection causes widespread inflammation, leading to tissue damage, organ failure, 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 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 includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 5 residents (Resident #1) reviewed for care plans:The facility failed to develop a person-centered care plan with interventions that addressed Resident #1's pressure wound, refusals for offloading and repositioning and wound care treatments.This failure could place residents at risk of not having their needs and preferences met.The findings included:Record review of Resident #1's face sheet dated 10/7/25 revealed a [AGE] year-old male admitted to the facility on [DATE] and discharged on 8/18/25 with diagnoses that included sepsis (condition in which the body's response to infection causes widespread inflammation, leading to tissue damage, organ failure,…

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 resident's environment remains as free of accident hazards as is possible, for 1 of 1 resident (Resident #2), in the facility reviewed for accidents, in that:The facility failed to ensure Resident # 2 did not have disposable razors in his room.This failure could place residents at risk of injury and contribute to avoidable accidents and a decline in health.The findings include:Record review of Resident #2's face sheet dated 10/07/2025 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included diabetes, other sequelae following unspecified cerebrovascular disease (lingering affects due to a disruption in blood flow to the brain), major depressive disorder, anxiety disorder, chronic pain syndrome, gastro-esophageal reflux disease (frequent acid reflux), and long term us of insulin.Record review of Resident #2's MDS dated [DATE] documented a BIMS of 14 out of 15 indicating independent decision…

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 have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable, physical, mental, and psychosocial well-being for 1 of 1 nurse (Wound Care Nurse) reviewed for competent nursing care.The facility failed to ensure the Wound Care Nurse was aware of notification of changes to the RN Unit Manager or designee per facility policy when she identified Resident #1 with a Stage 2 pressure ulcer.These deficient practices affect residents who depend on nursing care and could place residents at risk for injury, infection and a decline in health. The findings included:Record review of Resident #1's face sheet dated 10/7/25 revealed a [AGE] year-old male admitted to the facility on [DATE] and discharged on 8/18/25 with diagnoses that included sepsis (condition in which the body's response to infection causes widespread inflammation, 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 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 (Residents #12) reviewed for infection control. The facility failed to ensure LVN D followed proper infection control practices during medication administration on 9/26/25. This deficient practice could place residents at risk for exposure to pathogens causing infection resulting in diminished quality of life. Findings included: Record review of Resident #12's admission Record, dated 9/26/25, revealed the resident was re-admitted on [DATE] with diagnoses which included: Dry Eye Syndrome, Constipation, Hemiparesis (weakness or an inability to move one side of the body), Hemiplegia (paralysis or weakness to one side of the body) and Hyperlipidemia (elevated cholesterol). Record review of Resident #12's Order…

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

Based on interview, record review, and observation, the facility failed to ensure residents have a right to personal privacy for 1 of 2 resident (Resident #6) reviewed for privacy, in that: CNA A and CNA B did not close Resident #6's privacy curtain while providing incontinent care on 06/05/2025. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy. The findings included: Record review of Resident #6's face sheet, dated 06/06/2025, revealed an admission date of 06/03/2023 and, a readmission date of 04/10/2024, with diagnoses which included: Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills), Type 2 diabetes mellitus (high level of sugar in the blood), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to the brain.), Anxiety (A group of mental illnesses that cause constant fear and worry), Chronic kidney disease (gradual loss of 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, 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 disease and infection for 1 of 2 residents (Resident #6) reviewed for infection control, in that: While providing incontinent care for Resident #6, CNA A did not change her gloves or wash her hands after cleaning the resident and before touching the clean draw sheet and clean brief on 06/05/2025. This deficient practice could place residents at-risk for infection due to improper care practices. Findings included: Record review of Resident #6's face sheet, dated 06/06/2025, revealed an admission date of 06/03/2023 and, a readmission date of 04/10/2024, with diagnoses which included: Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills), Type 2 diabetes mellitus (high level of sugar in the blood), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Vascular dementia…

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 housekeeping services necessary to maintain a sanitary, orderly, and comfortable interior for 1 of 1 shower room (300 hall) and 5 of 5 resident rooms (#312, #314, #315, #316 and #506) whose rooms were observed for housekeeping services. 1. Nursing staff failed to clean and sanitize the 300-hall shower room after each resident shower. 2. The facility failed to ensure Resident Rooms #312, #314, #315, #316 and #506 were thoroughly cleaned and sanitized. These deficient practices could place any residents at risk of living in an unclean and unsanitary environment and result in feelings of dissatisfaction. The findings were: 1. Review of Resident Council Meetings from July 2024 to [DATE] revealed concerns about CNA's not cleaning the 300-hall shower, leaving towels and other linens on the floor and sometimes poop. Interview on 1/14/25 at 10:11 AM during a group meeting with 12 residents including Resident #24, Resident #85 and 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 failed to ensure the resident environment remained as free of accident hazards as was possible in 1 of 4 shower rooms (300-hall shower room) and in 2 of 2 Resident rooms (#308 and #516) observed for safety hazards. 1. Nursing staff failed to ensure razors were disposed of after used in the 300-hall shower room and to ensure an oxygen tank was returned to a resident room. 2. Nursing staff failed to ensure a razor was secured and not left in resident room [ROOM NUMBER]. 3. Nursing staff failed to ensure multiple sharp devices/scissors were secured and not left in resident room [ROOM NUMBER]. These deficient practices could affect resident who had access to sharps materials and could result in an avoidable accident. The findings were: 1. Observation and interview on 1/14/25 at 11:25 AM in the 300-hall shower room revealed a razor on top of a shower chair and an oxygen cylinder in a stand sitting in the middle of the shower room. CNA J stated she had…

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 and handle, store, process, and transport linens to prevent the spread of infection for 2 of 5 resident halls (300-hall & 500-hall) and in 2 of 2 resident rooms (#308 and #506) reviewed for infection control. 1. A dirty linen barrel on 500-hall had dirty linen spilling over the edges and the lid was sitting approximately 2.5 inches above the barrel on top of the dirty linen. 2. Dirty towels with feces were left on the floor in the shower stall and there was a lump of feces on the floor in the 300-hall shower room. 3. There were drops of blood by bed B in room [ROOM NUMBER]. 4. There were drops of blood on the floor by bed A in room [ROOM NUMBER]. There was a soiled dressing with blood on the floor, a clean bag of linens stacked on…

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

Based on interview and record review the facility failed to develop, implement, and maintain an effective training program for all new and existing staff for 8 (Food Service Manager, Cook, Housekeeper, Maintenance Assistant, CNA B, CNA C, CNA D, and CNA E) of 29 employees reviewed for training requirements. The facility failed to ensure required trainings were provided to Food Service Manager, Cook, Housekeeper, Maintenance Assistant, CNA B, CNA C, CNA D, and CNA E annually. This failure could place residents at risk of being cared for by staff who have been insufficiently trained. Findings include: Record review of the personnel records for the Food Service Manager revealed a hire date of 10/23/2021. Further review of a training log, provided by the HR Manager revealed no evidence of resident rights training being provided annually. Record review of the personnel records for the [NAME] revealed a hire date of 11/16/2023. Further review of a training log, provided by the HR Manager revealed no evidence of communication training, resident rights training, abuse/neglect training,…

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

Based on interview and record review, the facility failed to provide mandatory effective training on communications training for 3 of 29 employees (Cook, CNA B, and CNA D) reviewed for training, in that: The facility failed to ensure effective communication training was provided to Cook, CNA B, and CNA D annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. The findings include: Record review of the personnel records for the [NAME] revealed a hire date of 11/16/2023. Further review of a training log, provided by the HR Manager revealed no evidence of communication training. Record review of the personnel records for CNA B revealed a hire date of 03/08/2022. Further review of a training log, provided by the HR Manager revealed no evidence of communication training. Record review of the personnel records for CNA D revealed a hire date of 07/24/2017. Further review of a training log, provided by the HR Manager revealed no evidence of communication training. Interview with the HR Director, on 01/16/2025 at 12:05 PM…

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

Based on interview and record review, the facility failed to provide mandatory effective training on rights of the resident training for 4 of 29 employees (Food Service Manager, Cook, CNA B and CNA D) reviewed for training, in that: The facility failed to ensure effective rights of the resident training was provided to Food Service Manager, Cook, CNA B and CNA D annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. The findings include: Record review of the personnel records for the Food Service Manager revealed a hire date of 10/23/2021. Further review of a training log, provided by the HR Manager revealed no evidence of resident rights training being provided annually. Record review of the personnel records for the [NAME] revealed a hire date of 11/16/2023. Further review of a training log, provided by the HR Manager revealed no evidence of resident rights training. Record review of the personnel records for CNA B revealed a hire date of 03/08/2022. Further review of a training log, provided by the HR Manager…

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

Based on interview and record review the facility failed to include as part of its QAPI program mandatory training that outlines and informs staff of the elements and goals of it's QAPI program for 4 (Cook, CNA C, CNA D, CNA E) of 29 employees reviewed for training requirements. The facility failed to ensure required trainings were provided to Cook, CNA C, CNA D, CNA E annually. This failure could place residents at risk of being cared for by staff who have been insufficiently trained. Findings include: Record review of personnel records for the [NAME] revealed a hire date of 11/16/2023. Further review of a training log, provided by the HR Manager revealed no evidence of communication training, resident rights training, abuse/neglect training, dementia training, QAPI training, infection control training, ethics training, behavior health training, HIV training, fall prevention training, restraint training, or emergency preparedness training being provided annually. Record review of personnel records for CNA C revealed a hire date of 06/01/2021. Further review of a training log,…

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

Based on interview and record review, the facility failed to provide mandatory effective training on standards, policies, and procedures for an infection prevention and control program training for 3 of 29 employees (Cook, CNA B and CNA D) reviewed for training, in that: The facility failed to ensure effective standards, policies, and procedures for an infection prevention and control program training was provided Cook, CNA B and CNA D annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. The findings include: Record review of personnel records for the [NAME] revealed a hire date of 11/16/2023. Further review of a training log, provided by the HR Manager revealed no evidence of communication training, resident rights training, abuse/neglect training, dementia training, QAPI training, infection control training, ethics training, behavior health training, HIV training, fall prevention training, restraint training, or emergency preparedness training being provided annually. Record review of personnel records for CNA B…

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

Based on interview and record review, the facility failed to provide mandatory effective training on behavioral health for 3 of 29 employees (Cook, Maintenance Assistant, CNA C) reviewed for training, in that: The facility failed to ensure effective behavioral health training was provided Cook, Maintenance Assistant, and CNA C annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. The findings include: Record review of personnel records for the [NAME] revealed a hire date of 11/16/2023. Further review of a training log, provided by the HR Manager revealed no evidence of communication training, resident rights training, abuse/neglect training, dementia training, QAPI training, infection control training, ethics training, behavior health training, HIV training, fall prevention training, restraint training, or emergency preparedness training being provided annually. Record review of personnel records for the Maintenance Assistant revealed a hire date of 04/25/2023. Further review of a training log, provided by the HR…

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 received services in the facility with reasonable accommodation of resident needs for 1 of 8 Residents (Resident #8) who was observed for call light placement. The facility staff failed to ensure the call light was within reach for Resident #8. This failure could affect any resident and keep them from calling for help as needed. The findings were: Record review of Resident #8's face sheet, dated 01/14/2025, revealed the resident was admitted to the facility on [DATE] with diagnoses which included: spastic hemiplegic cerebral palsy. Record review of Resident #8's Annual MDS assessment, dated 10/18/2024, revealed the resident's BIMS score was 09, which indicated moderate cognitive impairment. The Annual MDS assessment further revealed Resident #8 was dependent (helper does all of the effort) with rolling left and right, chair/bed to chair transfer, tub/shower transfer, toileting hygiene, shower/bathing, upper body dressing,…

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 promote and facilitate resident self-determination through support of resident choice, including but not limited to choose health care and providers of health care services consistent with his or her interests for 1 of 8 Residents (Resident #184) who was reviewed for services. The facility failed to meet and discuss with Resident #184, a new admission, Medicaid coverage and options for healthcare providers. This deficient practice could affect any resident who was a new admission to the facility and could result in residents not having the opportunity to participate in making decisions for health coverage and choosing health providers. The findings were: Review of Resident #184's face sheet, dated 1/16/25, revealed he was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses including Hemplegia and Hemiparesis following Cerebral Infarction affecting right dominant side, Other Sequelae of Cerebral Infarction and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to immediately consult with the resident's physician when there was a need to alter treatment significantly or to commence a new form of treatment for 1 of 8 Residents (Resident #24) whose records were reviewed for medications. Nursing staff failed to contact Resident #24's PCP/NP on 1/14/25 when realizing medication insulin Toujeo was not available for night administration per physician orders. This deficient practice could affect any resident and could contribute to resident's not receiving medications per physician orders and result in a decline in condition. The findings were: Review of Resident #24's face sheet, dated 1/16/25, revealed he was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus (According to Mayo clinic Diabetes mellitus refers to a group of diseases that affect how the body uses blood sugar (glucose)) with Diabetic chronic kidney disease, Type 2 Diabetes Mellitus with Hyperglycemia (According to Mayo…

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 routine and emergency drugs and biologicals for 1 of 8 Residents (Resident #24) whose records were reviewed for pharmacy services. LVN G failed to notify LVN H, the ADON or the DON that Resident #24's insulin medication, Toujeo was not delivered by the facility pharmacy and not available for administration on 1/14/25 to avoid further delay in delivery. Resident #24 did not receive his nighttime dose (80 units) of Toujeo insulin per physician orders. This deficient practice could affect any resident and could contribute to resident's not receiving medications per physician orders and result in a decline in condition. The findings were: Review of Resident #24's face sheet, dated 1/16/25, revealed he was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus (According to Mayo clinic Diabetes mellitus refers to a group of diseases that affect how the body uses blood sugar (glucose)) with Diabetic 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 interview and record review, the facility failed to provide mandatory effective training on abuse, neglect, exploitation, and misappropriation training for 2 of 29 employees (Cook, CNA D) reviewed for training, in that: The facility failed to ensure effective abuse, neglect, exploitation, and misappropriation training was provided to [NAME] and CNA D annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. The findings include: Record review of personnel records for the [NAME] revealed a hire date of 11/16/2023. Further review of a training log, provided by the HR Manager revealed no evidence of communication training, resident rights training, abuse/neglect training, dementia training, QAPI training, infection control training, ethics training, behavior health training, HIV training, fall prevention training, restraint training, or emergency preparedness training being provided annually. Record review of personnel records for CNA D revealed a hire date of 07/24/2017. Further review of a training log, provided…

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

Based on interview and record review, the facility failed to provide mandatory effective training on ethics training for 1 of 29 employees (Cook) reviewed for training, in that: The facility failed to ensure effective ethics training was provided [NAME] annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. The findings include: Record review of personnel records for the [NAME] revealed a hire date of 11/16/2023. Further review of a training log, provided by the HR Manager revealed no evidence of communication training, resident rights training, abuse/neglect training, dementia training, QAPI training, infection control training, ethics training, behavior health training, HIV training, fall prevention training, restraint training, or emergency preparedness training being provided annually. Interview with the HR Director, on 01/16/2025 at 12:05 PM revealed annual trainings are available to employees in Health Stream and assigned by corporate. The HR Director stated employees receive emails informing them of assigned…

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

Based on interview and record review, the facility failed to provide mandatory effective in-service training for nurse aides on dementia for 1 of 5 nurse aides (CNA C) reviewed for training, in that: The facility failed to ensure effective dementia training was provided CNA C annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. The findings include: Record review of personnel records for CNA C revealed a hire date of 06/01/2021. Further review of a training log, provided by the HR Manager revealed no evidence of dementia training, QAPI training, behavior health training, or emergency preparedness training being provided annually. Interview with the HR Director, on 01/16/2025 at 12:05 PM revealed annual trainings are available to employees in Health Stream and assigned by corporate. The HR Director stated employees receive emails informing them of assigned trainings and it is up to department heads to ensure employees complete trainings in Health Stream. The HR director also stated employees that do not complete their…

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 a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 1 resident (Resident's #2) reviewed for respiratory care. The facility failed to ensure Resident #2's oxygen tubing and nasal cannula was handled by qualified staff. This failure could place residents who receive respiratory care at risk of developing respiratory complications and a decreased quality of care. Findings included. Record review of Resident #2's face sheet, dated 12/11/24 revealed an [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included heart failure, cough, need for assistance with personal care and morbid obesity due to excess calories. Record review of Resident #2's most recent quarterly MDS assessment, dated 10/25/24 revealed the resident 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 ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 1 of 5 resident rooms (Resident #1), 1 of 5 hallways, 300 hall, and 1 of 1 medication cart. 1. The facility failed to ensure medications were not left at the bedside or on the floor for Resident #1. 2. The facility failed to ensure there were no medications found on the floor and the medication cart on the 300 hall was left unlocked and unattended. This deficient practice could place residents at risk of medication misuse or drug diversion. The findings included: 1. Record review of Resident #1's face sheet, dated 12/11/24 revealed a [AGE] year old female admitted to the facility on [DATE] with diagnoses that included cerebral infarction (stroke; occurs when blood flow to part of the brain is interrupted/reduced resulting in lack of oxygen to the brain), pain in right shoulder, pain in right knee, non-displaced fracture 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 observation, interviews, and record reviews the facility failed to ensure each resident had the right to personal privacy for 1 of 2 residents (Resident #2) reviewed for dignity. Resident #2's bedroom door was not closed, and the privacy curtain was not completely drawn during catheter care on 8/29/24. This failure 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 8/30/24, revealed the resident was readmitted to the facility on [DATE] with diagnoses that included: UTI, Type 2 Diabetes (chronic condition that affects the way the body processes blood sugar), Morbid Obesity (disorder that involves having too much body fat) , Hemiplegia (paralysis of one side of the body) , Anxiety Disorder (feeling of dread, fear, or uneasiness) , Major Depressive Disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities), Obstructive and Reflux…

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 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 5 residents (Resident #2) reviewed for quality of care. The facility failed to ensure Resident #2 was provided catheter care according to professional standards; keeping the catheter anchored to prevent excessive tension on the catheter, which can lead to trauma due to urethral tears or dislodging the catheter. This failure could place residents at risk for trauma resulting in diminished quality of life. Findings included: Record review of Resident #2's admission Record, dated 8/30/24, revealed the resident was readmitted to the facility on [DATE] with diagnoses that included: UTI, Type 2 Diabetes (chronic condition that affects the way the body processes blood sugar), Morbid Obesity (disorder that involves having too much body fat) , Hemiplegia…

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 nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 2 of 2 staff (CNA B and CNA C) reviewed for nurse aide competencies. 1. The facility failed to ensure CNA B performed perineal care for Resident #1, on 8/29/24, according to facility policy. 2. The facility failed to ensure CNA C performed catheter care for Resident #2, on 8/29/24, according to professional standards. This failure could place residents at risk for trauma and/or infection. The findings included: 1. Record review of Resident #1's admission Record, dated 8/30/24, revealed the resident was admitted to the facility on [DATE] with diagnoses which included: Dementia (group of thinking and social symptoms that interferes with daily functioning), Hyperlipidemia (high levels of fat in the blood), and Hypertension (high blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review, the facility failed to ensure resident medical records were kept in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete and accurately documented for 1 of 5 residents (Resident #2) reviewed for clinical records. The facility failed to ensure Resident #2's vital signs were accurately documented in the EMR on 8/28/24. This failure could place residents at risk for improper care due to inaccurate records. Findings included: Record review of Resident #2's admission Record, dated 8/30/24, revealed the resident was readmitted to the facility on [DATE] with diagnoses that included: UTI, Type 2 Diabetes (chronic condition that affects the way the body processes blood sugar), Morbid Obesity (disorder that involves having too much body fat) , Hemiplegia (paralysis of one side of the body) , Anxiety Disorder (feeling of dread, fear, or uneasiness) , Major Depressive Disorder (mental health…

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 2 of 2 residents (Residents #1 and Resident #2) reviewed for infection control. 1. The facility failed to ensure CNA B followed proper infection control practices during perineal care for Resident #1 0n 8/29/24. 2. The facility failed to ensure CNA C followed proper infection control practices during catheter care for Resident #2 on 8/29/24. These failures could place residents at risk for exposure to pathogens causing infection resulting in diminished quality of life. Findings included: 1. Record review of Resident #1's admission Record, dated 8/30/24, revealed the resident was admitted to the facility on [DATE] with diagnoses which included: Dementia (group of thinking and social symptoms that interferes with 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, interviews and record reviews, the facility failed to ensure the assessment must accurately reflect the resident's status for 1 (Resident #40) out of 8 residents reviewed for MDS assessments in that: Resident #40's MDS assessment reflected her to be frequently incontinent of bladder when she was always incontinent of bladder. This failure could affect residents who required MDS assessments and result in lack of care. The findings included: Review of Resident #40's electronic face sheet dated 12/14/2023 reflected she was admitted to the facility on [DATE]. Her diagnoses included: cerebral vascular accident ( an interruption in the flow of blood to cells in the brain), atrial fibrillation (an irregular and often very rapid heart rhythm. An irregular heart rhythm is called an arrhythmia. AFib can lead to blood clots in the heart. The condition also increases the risk of stroke, heart failure and other heart-related complications) and hemiplegia ( paralysis on one side of the body). Review 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 observation, interviews and record reviews, the facility failed to provide food prepared in a form designed to meet individual needs for 1 (Resident #85) of 12 residents observed during dining observations in that: Resident #85 was served a regular consistency diet when he was ordered a pureed. This failure could affect residents with eating and swallowing disorders and result in choking. The findings included: Record review of Resident #85's electronic face sheet dated December 12, 2023 reflected he was originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included: dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety (a feeling of fear, dread, and uneasiness) and dysphagia (difficulty swallowing foods or liquids, arising from the throat and esophagus, ranging from mild difficulty to complete…

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 4 of 25 residents (Resident #4, Resident #5, Resident #6, and Resident #7) reviewed for infection control in that: LVN A did not perform hand hygiene between passing the lunch meal trays of Resident #4, Resident #5, Resident #6, and Resident #7. This deficient practice could affect all residents and place them at risk for infection. The findings were: Record review of Resident #4's face sheet, dated 9/8/23, revealed Resident #4 was admitted to the facility on [DATE] with diagnoses of Parkinson's disease [a disorder of the nervous system that affects movement, often including tremors], muscle wasting and atrophy [shrinking of muscle or nerve tissue], not elsewhere classified, multiple sites, difficulty in walking, not elsewhere…

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 they had evidence that all alleged violations involving abuse were thoroughly investigated, failed to take corrective action and prevent further potential abuse for 1 of 25 residents (Resident #1 and Resident #2) reviewed for abuse and neglect, in that: The facility did not conduct an investigation after being informed Resident #2 struck Resident #1 on the back of the head. This deficient practice could place residents at risk for abuse and placed them at risk for continued and/or unrecognized abuse, injury, and emotional distress. The findings were: Record review of Resident #1's face sheet, dated 9/6/23, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease [a progressive disease that affects memory and other important mental functions] with late onset, atherosclerotic heart disease of native coronary artery [buildup of fats in the arteries that supply blood to the heart muscle] without angina…

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 person-centered care plan that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 25 residents (Resident #3) reviewed for comprehensive care plans in that: Resident #3's care plan was not updated to reflect the aggressive behavior after he struck Resident #8 on 5/4/23. This deficient practice could affect all residents and place them at risk for not receiving appropriate treatment and services or activities: The findings were: Record review of Resident #3's face sheet, dated 9/6/23, revealed Resident #3 was admitted to the facility on [DATE] with diagnoses of vascular dementia [brain damage typically caused by multiple strokes], moderate, with psychotic disturbance, COVID-19, muscle wasting and atrophy [shrinking of muscle or nerve tissue], not elsewhere classified, multiple sites, unsteadiness of feet, and weakness. Record review 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.