Las Ventanas De Socorro

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 receives appropriate treatment and services to prevent urinary tract infections for 2 of 3 (Resident #67 and Resident #72) residents reviewed for urinary catheters. The facility failed to ensure Resident #72's Foley bag was off the floor and failed to ensure Resident #67 Foley tubing was draining urine into the Foley bag. This failure placed residents who had a urinary Foley at risk of contracting a UTI.Findings include:Record review of Resident #67's face sheet dated 2/18/2026 revealed the resident was an [AGE] year-old female with an admission date on 9/20/2023. Record review of Resident #67's of history and physical dated 10/11/2023 revealed the resident had a diagnosis of chronic congestive heart failure (heart is unable to pump blood efficiently), Age-related physical debility (muscular weakness because of age), and acute renal failure (rapid loss of kidney function). 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.

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 used in the facility was labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 2 residents (Resident #4) reviewed for pharmacy services enteral feedings .The facility failed to label Resident #4's enteral feeding (also known as tube feeding, is a method of delivering nutrition directly into the stomach when a person cannot eat safely or adequately by mouth) with staff initials and the date on 02/15/26.This failure could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects.The findings include:Record review of Resident #4's face sheet dated 02/16/2026 revealed a [AGE] year-old female with initial admission date 04/23/2018 and readmission date 01/11/2026.Record review of Resident #4's history and physical dated 02/17/2026…

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 on each resident that were complete and accurately documented for 1 of 4 residents (Resident #26) whose medical records were reviewed in that:The facility failed to accurately document on Resident #26's wound care on her Treatment Administration Record (TAR).This deficient practice affected one former resident and could place 14 residents with pressure sores at risk of inaccurate records.Record review of Resident #26's face sheet dated 02/16/2026 revealed an [AGE] year-old female with admission date 01/22/2026.Record review of Resident #26's history and physical dated 02/12/2026 revealed a medical history of the following: Chronic Kidney Disease (a condition meaning damage to the kidneys causing it to not filter the waste in the blood), Type II Diabetes Mellitus (metabolic condition that causes the body to become resistant to insulin or the pancreas fails to produce enough insulin), and had wounds on both legs.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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that the assessment accurately reflected the resident's status for 1 (Resident #2) of 14 resident reviewed for accuracy of MDS assessment, in that:The facility failed to ensure that Resident #2's Significant Change Assessment reflected Resident #2 required total assistance of two persons with bed mobility. The facility failed to ensure that Resident #2's Significant Change Assessment documented in Active Diagnoses resident had two types of autoimmune skin diseases. This failure could place residents at risk of not receiving appropriate interventions or care to meet their current needs. Findings included:Closed record review of Resident #2's Face Sheet dated 10/03/25 revealed, initial admission date 02/19/25, and re-admission date of 07/01/25. Review of History & Physical, dated 06/10/25, for Resident #2 revealed a [AGE] year-old male with past medical history of diabetes mellitus (a condition where the body has high blood sugar (glucose) because…

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 establish procedures for storing and disposing of drugs and biological in accordance with federal, state, and local laws. The facility failed to ensure medications pending return to the pharmacy were stored in a locked cabinet in the DON's office. This failure could place 68 residents living at the facility at risk of drug diversion. The findings included:During an observation on 10/01/25 at 9:26 AM revealed, the door to the DON's office was opened and unsupervised. There was an opened cardboard box that contained medication blister packets stored on the floor by a cabinet and several medication blister packets were visible from the entrance to DON's office. During an observation on 10/01/25 at 10:12 AM revealed, the DON was not in the office while the Housekeeper was vacuuming the office and the opened cardboard box that contained medication blister packets was still stored on the floor in the DON's office. During an observation on 10/01/25 at 10:14 AM revealed, the Corporate Clinical Service director was working in DON's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented, in accordance with accepted professional standards and practices, for 1 of 14 residents (Resident #2) reviewed for clinical records with transfer assistance. The facility failed to give access to the contracted agency CNA to document in the residents' electronic record the care provided to assigned residents in the 100-Hall. This failure place residents at risk of having incomplete and accurate clinical records. Findings included:Closed record review of Resident #2's Face Sheet dated 10/03/25 revealed, initial admission date 02/19/25; and re-admission date 07/01/25. Review of History & Physical, dated 06/10/25, for Resident #2 revealed a [AGE] year-old male with past medical history of diabetes mellitus (a condition where the body has high blood sugar (glucose) because it does not make enough insulin or cannot use it effectively), osteoarthritis (wear and tear…

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 and 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, recognizing each resident's individuality for 1 of 4 residents (Resident #15).The facility failed to ensure resident call lights were within reach for 1 resident (Resident #15).This failure placed residents at risk of having their needs unmet when they are unable to contact staff.Findings included:Record review of Resident #15's admission record, dated 10/01/2025, revealed an [AGE] year-old female with an original admission date of 06/30/2023.Record review of Resident #15's history and physical data, dated 09/24/2025, revealed the resident was diagnosed with dementia (a degenerative disease that alters an individual's cognition and functional capabilities), anxiety (a psychiatric disorder that makes an individual feel restless, nervous, and/or uneasy), and heart…

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 comprehensive care plan to include measurable objectives and timeframes to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being for 1 of 14 (Resident #2) residents reviewed for comprehensive care plans in that: The facility failed to revise or update Resident #2's care plan to reflect the need for two people for bed mobility due to pain caused by autoimmune skin disease. The facility failed to revise or update Resident #2's care plan to reflect physician's orders to treat autoimmune skin disease. This failure could place residents at risk of not receiving appropriate interventions or care to meet their current needs. The findings included:Closed record review of Resident #2's Face Sheet dated 10/03/25 revealed, initial admission date 02/19/25; and re-admission date 07/01/25. Review of History & Physical, dated 06/10/25, for Resident #2 revealed a [AGE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan for 1 (Resident #1) of 1 reviewed for quality of care.The facility failed to ensure that Resident #1 received an initial neurological check and continued neurological checks for 72 hours following an unwitnessed fall as per the facility's policy on fall management and and neurological checks, from 09/25/2025 to 09/27/2025. This failure could place residents at risk of head related injuries, decrease cognitive and functional abilities and not receiving the necessary care and services. Findings included:Record review of Resident #1's care plan, dated 09/16/2025, revealed Resident #1 has a history of falling related to age-related cognitive decline, unspecified dementia, unspecified severity, with other behavioral disturbance and has difficulty focusing attention/ understanding others due 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 establish and 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 one of fourteen residents (Resident #2) reviewed for Enhanced Barrier Precautions. The facility failed to implement their policy on Enhanced Barrier Precautions for Resident #2 who had wounds, indwelling medical devices and was incontinent of bowel and bladder. This failure could place residents at risk for healthcare associated cross-contamination and at risk of the transmission of multi-drug-resistant organisms (MDROs). The findings included:Closed record Review of Resident #2's Face Sheet dated 10/03/25 revealed, initial admission date 02/19/25; and re-admission date 07/01/25. Review of History & Physical, dated 06/10/25, for Resident #2 revealed a [AGE] year-old male with past medical history of pemphigus…

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 the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 2 (Residents #1 and Resident #4) of 4 residents reviewed for accommodation of needs. The facility failed to ensure that Residents #1's call light was within reach. The facility failed to ensure that Resident #4's call light was within reach. This failure placed residents at risk of not being able to call have their needs met. Findings included: Resident #1 Record review of Resident #1's face sheet dated 05/16/25, revealed, admission on [DATE] and re-admission on [DATE] to the facility. Record review of Resident #1's hospital history and physical dated 05/03/25, revealed, an [AGE] year-old male diagnosed with hypertension, congestive heart failure, Parkinson's Disease (progressive neurodegenerative disorder that affects movement, primarily due to a loss of brain cells that produce dopamine, a…

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

Based on interview and record review, the facility failed to implement written policies that prohibit and prevent abuse for 2 of 4 employees (Van Driver & ADON) reviewed for development of abuse policy. The facility failed to conduct the annual EMR check for the Van Driver. The facility failed to conduct the annual EMR check for the ADON. This failure could place residents at risk of potential abuse or ongoing abuse. Findings included: Record review on 05/13/25 at 2:10 PM, revealed, the Van Driver's annual EMR dated 03/22/24, was not conducted. Record review on 05/13/25 at 2:12 PM, revealed, the ADON's annual EMR dated 03/22/24, was not conducted. During an interview on 05/13/25 at 3:09 PM, the Administrator stated corporate had informed him that they did not have an EMR Policy, and they followed state guidelines. During an interview on 05/16/25 at 9:06 AM, with HR, he stated that EMRs are to be conducted annually. HR stated the purpose of conducting the EMR checks was to check that staff were still eligible to work at the facility. HR stated the negative outcome of not conducting…

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 medical records, in accordance with accepted professional standards and practices, were maintained on each resident that were accurately documented for 1 of 4 residents (Resident #9) reviewed for medical records. The facility failed to ensure documentation was being done for showers being given to Resident #9 or being refused by Resident #9. This deficient practice could place residents at risk of records being inaccurate due to documentation errors. Finding included: Record review of Resident #9's face sheet dated 05/16/25, revealed, admission on [DATE] to the facility. Record review of Resident #9's hospital history and physical dated 05/02/25, revealed, a [AGE] year-old female diagnosed with osteopenia (a condition characterized by reduced bone density, meaning your bones are weaker than normal, but not as severely weakened as in osteoporosis), right hip arthroplasty (a surgical procedure where the hip joint on the right side is…

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 a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one resident (Residents #1) who was provided incontinence care by two (CNA A and CNA B) of two CNAs observed. 1. CNA A and CNA B failed to perform hand hygiene during incontinent care for Resident #1. 2. CNA A failed to clean Resident #1 from vagina to buttocks. These failures can place residents at risk for urinary tract infections. Findings include : In an observation on 02/20/25 at 4:43PM revealed CNA A and CNA B prepared Resident #1 CNA B disposed of the dirty brief and the dirty gloves in the trashcan. CNA B was observed putting on new gloves without performing hand hygiene. CNA A cleaned Resident #1's genitalia area with a clean wipe from rectum to perineum (the area between the anus and the vulva) and perineum to rectum . CNA A cleaned the resident's buttocks from front to back and disposed of the wipe. CNA A and CNA B disposed of the dirty wipes and dirty gloves into the…

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

Based on 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 one of one resident (Resident #1) reviewed for infection control. -CNA A failed to perform hand hygiene before providing perineal care to Resident #1. -CNA A and CNA B failed to perform hand hygiene after disposing of dirty wipes and briefs, and before applying new briefs on Resident #1. These failures can place residents at risk for urinary tract infections. Findings include : In an observation on 02/20/25 at 4:43PM revealed CNA A and CNA B prepared Resident #1 CNA B disposed of the dirty brief and the dirty gloves in the trashcan. CNA B was observed putting on new gloves without performing hand hygiene. CNA A cleaned Resident #1's genitalia area with a clean wipe from rectum to perineum (the area between the anus and the vulva) and perineum to rectum . CNA A cleaned the resident's buttocks from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record reviews, the facility failed to maintain clinical records that were complete and accurate, in accordance with accepted professional standards and practices, for 1 of 2 residents (Resident #2) whose closed medical records were reviewed in that: -The Facility failed to have Resident #2's hospital documentation from her injury to her left eyebrow and under her left eye on 2/03/25 in her facility medical records. This deficient practice could affect residents and result in errors in care and treatment. The findings include: Record review of Resident #2's Face Sheet, dated 2/24/25, revealed the resident was admitted on [DATE] with diagnoses: Age-related physical debility, Ataxic gait (staggering movements), Dementia (term used to describe a group of symptoms affecting memory, thinking and social abilities). Record review of Resident #2's Quarterly MDS dated [DATE] revealed a BIMS revealed Resident #2 was not able to answer questions. BIMS is a structured evaluation aimed at evaluating…

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 Resident #10 FTag Initiation 12/03/24 03:53 PM During observation on 12/03/2023 at 9:09 AM #10 [NAME] peri care observed with [NAME] CNA, one person assist stated resident should be a 2 person assist, but it was only her. She did not ask for help. She turned resident on side with wedges in place toward wall. Bed was locked.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident #79 Respiratory Care 12/02/24 01:49 PM Ms. [NAME] was in bed at this time. Her brother was visiting they both stated that the staff from the facility are very professional and they are very respectful. Ms. [NAME] had no complaints from the facility or staff and said she had no concerns. Scrapes on wall. She was wearing her nasal cannula and there was no oxygen sing posted outside the room. Posting of cautionary and safety signs indicating the use of oxygen policy was provided and it stated in part. Respiratory Policies and Procedures: Oxygen Therapy. Procedures- C. Check the patient's/resident's room to make sure it's safe for oxygen administration, place oxygen precautions sign on the door of the patient's/resident's room. 12/03/24 12:51 PM Observation 210 [NAME]. Call light was pressed at this time to interview on Oxygen. [NAME] MDS stated that she believed there is supposed to be an oxygen sign. She stated that the risk of a resident who needs oxygen not having a sign outside their room was that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 CNA (CNA-A) staff observed during incontinent care. The facility failed to ensure CNA-A performed proper hand hygiene for Resident #4, Resident #10, and Resident #52. These failures placed residents of the facility at risk of infections from improper incontinent care and hand hygiene while performing incontinent care. Findings included: Resident #4 Record review of Resident #4's face sheet dated 12/04/2024 revealed, the resident was a [AGE] year-old male admitted to the facility on [DATE]. Resident #4's medical diagnoses included Type 2 diabetes, atrial fibrillation (irregular heartbeat), myocardial infarction (heart attack), embolism and thrombosis deep veins of unspecified lower extremity (blood clots in his legs),…

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 1 of 1 resident (Resident #10) received adequate supervision to prevent accidents CNA-A failed to perform a 2 person assist for Resident #10 during incontinent care after precautions were put in place after a fall while performing resident care. This failure could place residents at risk for being provided care or treatment different from the plan of care. Findings included: Resident #10 Record review of Resident #10's face sheet dated 12/04/2024 revealed the resident was a [AGE] year-old female initially admitted to the facility on [DATE] and was recently readmitted on [DATE] with medical diagnoses of dementia, syncope (fainting), convulsions, hemiplegia (paralysis of one side of the body), aphasia (inability to speak), cerebral infarction (stroke), history of falls, weakness, and tremors. Record review of Resident #10's 5-day scheduled assessment MDS, dated [DATE] revealed the residents Brief Interview for Mental Status Section…

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 residents who are incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 2 of 2 residents (Resident #4 and Resident #5), The facility failed to ensure CNA-A performed proper peri-care (incontinent care) Resident #4, and Resident #52. These failures placed residents of the facility at risk of infections from improper incontinent care and hand hygiene while performing incontinent care. Resident #4 Record review of Resident #4's face sheet dated 12/04/2024 revealed, the resident was a [AGE] year-old male admitted to the facility on [DATE]. Resident #4's medical diagnoses included Type 2 diabetes, atrial fibrillation (irregular heartbeat), myocardial infarction (heart attack), embolism and thrombosis deep veins of unspecified lower extremity (blood clots in his legs), and weakness. Record review of Resident #4's Optional State Assessment MDS, dated [DATE] revealed; Section C,…

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 comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 2 (Resident #1 and Resident #2) of 6 reviewed for care plans. The facility failed to develop a comprehensive care plan to address Resident #1 minced/ moist texture diet. The facility failed to develop a comprehensive care plan to address Resident #2 regular diet consistency on 12/15/23. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed to address their needs. Findings included: Resident #1 Record review of Resident #1's face sheet dated 02/07/2024 revealed a [AGE] year-old male who was admitted on [DATE] with diagnoses of dementia (impaired ability 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 observations, interview and record review , the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, are reported immediately, but no later than 2 hours after the event, if the events result in serious bodily injury, or no later than 24 hours if the events do not 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 2 (Resident #1 and Resident #2) of 5 residents reviewed for abuse. CNA K failed to immediately notify the Administrator on 01/13/2024 of allegations of abuse by CNA L and involving Resident #1 and Resident #2. This was determined to be past non-compliance at a pattern of potential for more than minimal harm due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the inspection This failure could place…

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

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for professional standards for food service safety. -The facility kitchen was observed on 01/24/2024 with 1 bag of frozen French fries located in the walk-in freezer that was removed from the original package, dated 1/21/24 and was not sealed. -The facility kitchen was observed on 01/24/2024 with 1 bag of tater tots located in the walk-in freezer was found out of original package, was not sealed, or labeled. -Cook O was observed on 01/24/2024 with - with a beard and was not wearing a beard net while preparing food in the kitchen. These failures could place residents at risk of food-borne illness. Findings included: Observation on 1/24/2024 at 9:30 a.m., of the walk-in freezer revealed a gallon sized zipper storage bag of frozen French fries removed from the original package and that was open. The bag was labeled 01/21. Observation on 01/24/2024 at 9:30 a.m., of walk-in freezer…

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

Based on interview and record review the facility failed to ensure they employed a qualified social worker on a full-time basis for eight of eight weeks reviewed. The facility, licensed for 126 beds, failed to have a full time Social Worker for eight weeks, from 11/27/2023 to 01/24/2024. This failure could place residents at risk of unmet psychosocial needs and poor quality of life. Findings included: Record review of the Facility Summary Report revealed the facility was licensed for 126 bed capacity. Record review of Employee Job History revealed SW P last date worked was 11/26/2023. During an interview on 01/24/2024 at 10:47 a.m., the Administrator said she started working at the facility on 01/02/2024. The Administrator said the facility does not currently have a Social Worker (SW). The Administrator said the former SW last worked at the facility on 11/26/2023. The Administrator said that a Social Services Contingency Plan was put into effect. The Administrator said she was the grievance officer, the MDS nurses are helping with discharges, and nursing was handling assessments…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews, the facility failed to allow residents the right to reside and receive services in the facility with reasonable accommodation of needs and preferences for 2 residents (Resident #35 and Resident #241) of 6 reviewed for resident rights. The facility failed to ensure Resident #35, and Resident #241 were not found with their call lights out of reach on 10/17/23 and 10/19/23. This failure could cause a decline in health in residents if their call lights are not within reach, preventing them from calling for assistance. Findings included: Record review of Resident #35's face sheet dated 10/20/2023 revealed an [AGE] year-old female with an admission date to the facility of 10/10/17. Record review of Resident #35's History and Physical dated 05/31/2023 revealed she had a diagnosis of Alzheimer's Disease, muscle weakness, and was bedbound. It also revealed Resident #35 required assistance with ADLs. Record review of Resident #35's Comprehensive 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.

Based on interview, and record review, the facility failed to make residents and residents family members aware of the grievances process and allowing them to exercise their right to file a grievance leading to the facility not addressing the grievances of residents for resident reviewed who attended Resident council Meetings (9 residents). 1. The facility failed to make residents and family members aware of how to file a grievance These failures put residents and family members at risk of decreased opportunities to present grievances and recommendations. Findings included: In a confidential interview on 10/18/2023 at 11:19 am with a group of residents from the facility they all stated that they were not aware of how to file a formal grievance. A resident stated he was under the impression the residents from the facility had to present their complaint to the resident council president and he would inform the social worker of any concerns. However, residents stated that they were not aware there was a grievance form that could be filled out if they wished to place a formal written…

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 review, the facility failed to store biologicals under proper temperature controls for 1 medication cart (300 Hall) of 3 medication carts reviewed for medication storage. -The facility failed to ensure that a container of thickened water was kept under appropriate temperatures after it was opened. This failure could cause a decline in health in residents if medications were to be given after not being stored at correct temperatures. Findings included: Observations on 10/19/23 at 9:37 AM of the 300 hall medication cart with CMA Q revealed a container of Ready Care Thickened Water dated as opened on 10/17/23. The container was stored in the last drawer and was not refrigerated. Directions on the side of the container that read .After opening, may be kept up to 7 days under refrigeration. An interview on 10/19/23 at 9:41 AM with MA Q revealed she checked the medication cart once a week to make sure the medication carts did not have expired medications, ensure they were clean. She stated the thickened water containers, once they are opened,…

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 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 in 2 out of 6 residents reviewed for infection control. The facility failed to ensure CNA F and CNA I maintained proper hand hygiene and use gloves while performing perineal care for Resident #30 and Resident #15. This failure could place other residents who receive perineal care at risk of cross-contamination. Findings included: Resident #30 Record review of Resident #30's face sheet undated revealed a [AGE] year-old female was admitted on [DATE]; re-admitted [DATE]. Record Review of Resident #30's History & Physical dated 08/21/2023 revealed history of left distal tibia (lower leg near the ankle) fracture, anxiety disorder, Parkinson's disease, Major Depressive disorder, muscle wasting and atrophy, unsteadiness 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 interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation were thoroughly investigated for 1 (Resident #242) of 6 residents reviewed for neglect. -The facility failed to thoroughly investigate an incident on 08/12/23 when Resident #242 complained of leg pain and was found to have a broken femur. This failure could place residents at risk of abuse and neglect if incidents are not thoroughly investigated. Findings included: Record review of Resident #242's face sheet dated 10/20/2023 revealed a [AGE] year-old female with an initial admission date to the facility of 05/11/2021 and re-admission date of 07/06/2023. Record review of Resident #242's History and Physical dated 09/06/2022 revealed a diagnosis of osteoarthritis and vitamin D deficiency. She also had a history of right femur fracture which she got surgery intervention for. Record review of Resident #242's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 3 indicating 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 send a copy of the notice of discharge and the reasons for the move in writing to a representative of the Office of the State Long-Term Care Ombudsman for one (Resident #294) of 18 residents reviewed for admission/transfer/discharge rights. The facility failed to ensure the Long-Term Care Ombudsman was notified that Resident #294 was denied readmission after being sent to the hospital. This failure could put residents at risk of not having the opportunity to appeal discharge, not having their rights honored regarding facility-initiated discharges, and homelessness. Findings included: Closed record review of Resident #294's face sheet dated 10/18/2023 revealed he was [AGE] years old, was admitted to the facility on [DATE] and discharged to a local hospital on [DATE]. Record review of Resident #294's clinic referral dated 08/23/2023 revealed he was alert, oriented only to person, unable to follow directions and delusional.? He had diagnoses including…

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 within 48 hours of a resident's admission for one (Resident #294) of 18 residents reviewed for baseline care plans. The facility failed to develop and implement a baseline care plan within 48 hours after admission for Resident #294. This failure could put residents at risk of not having their care needs identified and met. Findings included: Record review of Resident #294's face sheet dated 10/18/2023 revealed he was [AGE] years old, was admitted to the facility on [DATE] and discharged to a local hospital on [DATE]. Record review of Resident #294's clinic referral dated 08/23/2023 revealed he was alert, oriented only to person, unable to follow directions and delusional.? He had diagnoses including memory deficit. Record review of Resident #294's clinical records revealed no baseline care plan. Record review of Resident #294's progress note dated 9/05/2023 at 02:00 AM revealed he had behaviors including…

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 comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 2 of 12 residents (Resident #89 and Resident #241) reviewed for care plans in that: 1. The facility failed to ensure that Resident #89's comprehensive care plan included his behavior of pulling out his G-Tube. 2. The facility failed to ensure that Resident #241's comprehensive care plan included her ADL needs. These failures could place residents in the facility at risk of not receiving the necessary care or services and not having personalized plans developed to address their needs. Findings included: Resident #89 Closed record review of Resident #89's face sheet dated 10/21/2023 revealed he was [AGE] years old, was admitted to the facility on [DATE] and discharged on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 (Resident #9 and Resident #15) of 6 residents observed for assistance with ADL's. The facility failed to ensure Resident #9 and Resident # 15, who required assistance with ADLs, and were not observed to have long nails. This failure could affect residents who were dependent on assistance with ADLs and could result in poor care, lack of dignity, and skin tears due to long nails. Findings included: Record review of Resident #9's face sheet dated 10/20/2023 revealed a [AGE] year-old male with an initial admission date to the facility of 07/13/2017 and re-admission date of 03/02/2023. Record review of Resident #9's History and Physical dated 08/17/2023 revealed a diagnosis of cerebral infarction (stroke) and contracture of muscle. It also revealed he required…

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 needs respiratory care is provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan for one (Resident #33) of 5 residents reviewed for respiratory care. The facility failed to ensure that Resident #33's oxygen concentrator was delivering oxygen at the physician-ordered rate (liters per minute). This failure could put residents at risk of oxygen toxicity. Findings included. Record review of Resident #33's face sheet dated 10/18/2023 revealed she was [AGE] years old and admitted to the facility on [DATE]. Record review of Resident #33's History and Physical dated 08/18/2023 revealed that the resident had medical history including lung cancer and diagnoses including chronic obstructive pulmonary disease (COPD - disease that blocks airflow in the lungs). She was receiving breathing treatments and was dependent on supplemental oxygen via nasal cannula (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 maintain clinical records that were complete and accurately documented for 1 (Resident #30) of 18 residents reviewed for clinical records. 1. The facility failed to document on 08/13/23 when CNA reported resident #30 had a swollen left ankle. 2. The facility failed to document a pain assessment on 08/13/23 when Resident #30 complained of pain to left ankle. 3. The facility failed to document the administration of Diclofenac Sodium Gel that was administered to Resident #30 on 08/13/23 for pain to left ankle. This failure could put residents at risk of not receiving prescribed pain medications as ordered. Findings include: Record review of undated face sheet revealed Resident #30 [AGE] year-old female was admitted on [DATE]; re-admitted [DATE] from hospital. Review of Hospital Records for Resident #30 revealed: Encounter Date 08/14/23. Encounter Diagnosis: Fracture of distal end of left tibia. Unwitnessed fall. Dementia. Safety Awareness: Impaired due 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.