Amistad Nursing and Rehabilitation Center

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety, for 1 of 1 kitchen reviewed for food safety. Raisin bread and hamburger buns were stored in the facility's' kitchen pantry without labeled dates to indicate when the food was received and opened. Hamburger buns were stored in the facility's' kitchen pantry unsealed and open to air. The facility's' nutrition room refrigerator had resident foods which were not labeled to indicate when the food was received or when the food should be discarded. Food delivered by the food vendor was stored in cardboard cases upon the floor. These failures could place residents at risk for food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were provided a sanitary and comfortable environment for 1 of 3 shower areas (400-hall shower) reviewed for physical environment. The facility failed to ensure the 400-hall shower area was free from dirt and debris. This failure could result in decreased quality of life.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents had the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. These grievances included those with respect to care and treatment which had been furnished as well as those which had not been furnished, the behavior of staff and of other residents, and other concerns regarding their long term care (LTC) facility stay, for 3 of 8 residents (Residents #11, #12, and #30) reviewed for grievances. CNA A failed to file a grievance when Resident #11 reported to CNA G that someone stole $31 from her some days prior to 6/24/2026. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures, for 3 of 8 residents (Residents #11, #12, and #30) reviewed for reporting [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation were verified appropriate corrective actions must have been taken, for 3 of 8 residents (Residents #11, #12, and #30) reviewed for reporting suspicions of abuse, neglect, exploitation or mistreatment. The facility failed to investigate and provide the State Agency with a report no later than 5 days after the alleged abuse, neglect, exploitation, mistreatment, and misappropriation of property was received for:A reported allegation of misappropriation of property, when Resident #11 reported to CNA G that someone stole $31 from her. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure at the time each resident was admitted , the facility had physician orders for the resident's immediate care, for 1 of 8 residents reviewed (Resident #30) for medications needed upon admission. Resident #30 was discharged from the hospital and admitted to the facility on [DATE] with an immediate need for anticoagulant medication which was not prescribed per the physicians' and manufactures' recommendations and resulted in Resident #30 missing 4 doses. This failure could place residents at risk of not receiving medications upon admission.

Inspectors wroteBased 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 3 of 5 residents (Residents #5, #76, and #77) reviewed for transmission-based precautions. The facility failed to ensure staff wore required PPE when providing assistance for Residents #76 and #77. The facility failed to ensure staff performed proper hand-hygiene when providing personal care for Resident #5. This failure could lead to the spread of infection.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition, for 1 of 1 facility kitchen reviewed for essential equipment. The facility's 1 of 1 dishwashing machine had a faulty temperature gauge which indicated safe operating temperatures. The facility's 1 of 1 plate warmer was malfunctioning and not operational for longer than a week. This failure could place residents at risk for food borne illness and cold food.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the resident has a right to be treated with respect and dignity for 1 of 8 (Resident #51) residents reviewed for personal hygiene in that: Resident #51 had long strands of facial hair on upper lip and chin area, and she did wanted them shaved. This failure could affect all residents that did not want facial hair and could result in low self-esteem.

Inspectors wroteBased on interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 4 of 8 (Residents #10, #51, #62, #75) residents reviewed for care plans. The facility failed to ensure Resident #10's care plan had discharge plans. The facility failed to ensure Resident #51's care plan had discharge plans. The facility failed to ensure Resident #62's care plan had discharge planThe facility failed to ensure Resident #75's care plan had discharge plans. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain grooming, and personal and oral hygiene for 1 of 8 (Resident #51) residents reviewed for personal hygiene in that: 1. Resident #51 had long strands of facial hair on upper lip and chin area, that she wanted staff to shave her.2. Resident #51 had not cleaned her teeth in the last 3 days of surveyor observations. This failure could affect all residents that did not want facial hair, wanted to have clean teeth and could result in low self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs used in the facility were labeled in accordance with currently accepted professional principles for 1 of 4 medication carts (E-Hall medication cart) reviewed for medication storage. The facility failed to ensure 2 insulin pens in the E-Hall medication cart were labeled with the date opened. This failure could result in residents receiving expired insulin, leading to uncontrolled blood sugar levels.

Inspectors wroteBased on observations, interviews, and record reviews of the facility failed to ensure therapeutic diets must be prescribed by the attending physician for 1 resident of 1 (Resident #62) in that: Resident #62 did not have her ice cream cup with her meal tray. This could affect all residents that get a meal tray and could cause residents to lose weight.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure the facility must be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from Each resident's bedside for 1 of 8 (#51) resident with call system in that: Resident #51's call light was not working when she was lying in bed. This failure could affect all residents with call lights at bedside and could result in call light not being answered and causing further harm.

Inspectors wroteBased on interviews and record review, the facility with more than 120 beds failed to employ a qualified social worker on a full-time basis, for 1 of 1 social services staff reviewed for qualifications of Social Worker. The facility, licensed for 200 beds, did not employ a full-time social worker. This failure could place residents at risk of social service and psychosocial needs not being met.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to send and receive mail, and to receive letters, package and other materials delivered to the facility or the resident through a means other than a postal service, including the right to privacy of such communications for 1 of 5 residents (confidential resident) reviewed for resident rights. The facility failed to ensure staff distributed mail received on Saturdays to the residents. This deficient practice could result in residents not receiving mail in a timely manner and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had a right to personal privacy and confidentiality in his or her personal and medical records for 1 of 1 resident (Resident #52) reviewed for residents' rights. The facility failed to ensure LVN D locked the medication cart computer screen and left Resident #52's information exposed. This failure could place residents at risk of resident-identifiable information being accessed by unauthorized persons.

Inspectors wroteBased 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 and to restore continence to the extent possible for 2 of 2 residents (Resident #68 and #40) reviewed for indwelling urinary catheter care/incontinence care: 1. The facility failed to ensure Resident #68's indwelling urinary catheter drainage bag was not touching the floor and failed to provide proper incontinence care. 2. The facility failed to ensure Resident #40's indwelling urinary catheter drainage bag was not touching the floor. This failure could place residents with indwelling urinary catheter devices at risk for the development of new or worsening urinary tract infections.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles for one of six medication carts (200 hall nurse cart) assessed for medication storage and labeling. The facility failed to ensure all medications located inside the 200 hall nurse cart were stored in labeled containers. This failure could place residents at risk of receiving inadequate treatments or ingesting medications for which they were not prescribed.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health and safety of the resident or others for 1 of 8 residents (Resident #4) reviewed for call light placement. The facility failed to ensure the call light was within reach for Resident #4. This deficient practice could place residents at risk of not receiving help as needed.

Inspectors wroteBased on observation and interview, the facility failed to provide a safe, clean, comfortable and homelike environment for daily living for 3 of 6 residents rooms (Resident rooms [ROOM NUMBER]) reviewed for environmental concerns in that: 1. Resident rooms for Residents #39, #52 and #46 had many scratches and removed paint changing the appearance of the door making them look dirty and damaged. 2. Resident #52's room had multiple scratches on the walls. These failures could affect residents who resided at the facility and could put them at risk of living in an unsafe, unclean, and uncomfortable and an un-homelike environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. 1. There was a box with an opened clear plastic bag containing items identified as frozen fish, by the DM, partially opened exposing the fish to air and possible other contaminants in the freezer. 2. There was a clear large plastic bag of items identified as cut up sausage links, by the DM, with no label or date in the freezer. 3. There was one large plastic bag of a yellow substance identified as a bag of eggs with no label or date in refrigerator A. 4. There was a plastic container identified as a container of chorizo partially used with no opened date in refrigerator B. 5. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure the right to receive written notice of a room change before the change was made for 1 of 1 resident (#46) reviewed for right to receive written notification. The facility did not provide evidence that Resident #46 was given a written notice of a room change before the resident was moved. This deficient practice could affect residents in the facility that are moved without required notification. Record review of Resident #46's face sheet dated 02/27/2024 revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included polyosteoarthritis, lack of coordination, difficulty walking, mild cognitive impairment, anxiety disorder, and presence of a cardiac pacemaker. [...]

Inspectors wroteBased on observation and interview the facility failed to ensure drugs and biologicals were stored in accordance with currently accepted professional principles, in 1 of 7 (100 hall medication cart) medication carts observed: The facility failed to assure that 100 hall medication cart was secure and inaccessible to unauthorized staff and residents. This deficient practice could place residents at risk of medication misuse and diversion.

Inspectors wroteBased on record review and interviews a facility with more than 120 beds, failed to employ a qualified social worker on a full-time basis, for 1 of 1 social services staff reviewed: The facility, licensed for 200 beds, did not employ a full-time social worker. This failure could place residents at risk of social service and psychosocial needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 8 residents (Resident #1) reviewed for accidents. The facility failed to safely provide ADLs including bed mobility for Resident #1 and prevent injury during incontinent care or dressing the resident. This failure could place ADL dependent resident at risk for accidents, injuries, and hospitalization.