Fiesta Park Wellness & Rehabilitation

Inspectors wroteBased on record review and interviews, the facility failed to provide adequate oversight of nursing students in accordance with professional standards of practice for 1 (R #1) of 1 (R #1) resident reviewed, which resulted in a nursing student providing R #1 a meal tray despite R #1 having an active nothing by mouth (NPO) dietary order. If staff serve food to a resident with an NPO order, then the resident is at risk for aspiration, choking, respiratory distress, and other preventable adverse outcomes.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident was free from abuse for 1 (R #2) of 1 (R #2) resident, when a facility Certified Nursing Assistant (CNA) engaged in unwanted physical contact with the resident and ate food from the resident's meal tray. This deficient practice resulted in R #2 experiencing fear, anxiety, tearfulness, sleep disturbance, emotional distress, and concern regarding retaliation.

Inspectors wroteBased on record review and interview, the facility failed to submit the required incident summary report for multiple days to the State Agency (SA) for 1 (R #1) of 1 (R #1) resident. If the facility does not submit the incident summary to the State Agency without delay, then the State Agency cannot appropriately triage (review) the allegation for further investigation.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident was free from neglect for 1 (R #131) of 1 (R #131) resident, when:The facility van driver failed to completely secure R #131's wheelchair in the van prior to transport. The facility van driver failed to contact emergency medical services (EMS) after the resident sustained a fall with injury during transport to an appointment. If the facility fails to properly secure residents in the transport van and contact EMS providers after a resident experiences a fall with injury, then residents are at risk for delayed treatment or worsening injury.

Inspectors wroteBased on observation and interview, the facility failed to ensure the outdoor trash dumpster was covered to minimize odors and prevent pests or rodents. If staff fail to keep outdoor trash bins closed, the environment may become unsanitary, increasing the risk of pest infestation and disease transmission to residents.

Inspectors wroteBased on interviews and record reviews, the facility failed to properly complete consent forms for 5 (R #3, R #12, R #13, R #74, and R #129) of 5 (R #3, R #12, R #13, R #74, and R #129) residents, when: Vaccination consent forms were not signed by residents or resident representatives for R #12, R #74, and R #129. Psychotropic medication (medication used to treat mental health conditions) consent forms were not signed by residents or resident representatives for R #3 and R #13. This deficient practice is likely to result in residents and/or their representatives not being consulted and informed of the risks and benefits of medications and treatments being provided to them.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) was accurate for 2 (R #4 and R #7) of 2 (R #4 and R #7) residents reviewed for MDS accuracy, when: R #4's MDS indicated she had clear speech when she was non-verbal (a person that does not speak). The facility staff did not complete R #7's mood assessment section of the MDS.This deficient practice is likely to result in a failure to provide adequate care and treatment of residents' needs.

Inspectors wroteBased on record review and interviews, the facility failed to develop and implement an adequate baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) for 1 (R #11) of 1 (R #11) residents reviewed for baseline care plans, when: R #11's baseline care plan was incomplete and inaccurate due to the baseline care plan failing to include foley catheter (a thin, sterile tube inserted into the bladder to drain urine) use with interventions. If the facility fails to develop and implement an adequate baseline care plan within 48 hours of admission for residents, then staff may lack necessary guidance to provide appropriate care which could lead to an adverse event (undesirable experience, preventable or non-preventable, that causes harm to a resident due to medical care or lack of medical care).

Inspectors wroteBased on observations and interviews, the facility failed to ensure the proper storage and security of medications located in the medication carts, when: The 200-unit narcotic (controlled medication used for the management of pain) box located in a medication cart was left unlocked. Medications were pre-poured (the practice of preparing and pouring medications in advance of their scheduled administration time, which carries significant risks) prior to administration and left in the medication cart located in the 400-unit. A medication tablet was left out of the packaging and on the floor in the 200-unit. This deficient practice is likely to increase the risk of unauthorized access to medications, medication diversion, contamination, and administration of medications to the wrong resident.

Inspectors wroteBased on record review and interview, the facility failed to ensure care plan interventions were implemented for 1 (R #5) of 1 (R #5) resident reviewed for falls. If the facility does not ensure care plan interventions for falls are implemented, then residents are at risk for continued falls and potential injury.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure staff revised the care plan for 1 (R #74) of 1 (R #74) resident reviewed, when:Facility staff failed to update R #74's plan of care to include R #74's use of a Hoyer lift (equipment used to safely transfer residents with limited mobility) for transfers. This deficient practice is likely to result in residents' care and needs not being addressed if care plans are not updated.

Inspectors wroteBased on record review and interview, the facility failed to provide quality care that meets professional standards for 1 (R #25) of 1 (R #25) resident reviewed, when staff failed to: Update R #25's physician orders to reflect a new dialysis (a medical treatment which filters waste and excess fluid from the blood) schedule. This deficient practice is likely to result in residents not maintaining their optimal health as planned by their medical provider.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to maintain a safe and sanitary environment to prevent the transmission of infectious agents and communicable diseases for 1 (R #10) of 3 (R #10, #52, and #62) residents, when the facility: Failed to prevent a urinary catheter (a thin, flexible tube which drains urine from the bladder) bag and tubing from touching the floor. These deficient practices have the potential to expose staff and other residents to infectious diseases.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR; a federal requirement to help ensure individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) was accurate for 9 (R #2, R #3, R #5, R #6, R #7, R #8, R #9, R #10, and R #11) out of 9 (R #2, R #3, R #5, R #6, R #7, R #8, R #9, R #10, and R #11) residents reviewed for PASARR accuracy. This deficient practice has the potential to result in the facility not providing the services needed for residents who are identified in the screening process as needing additional care and services.

Inspectors wroteBased on record review, observation, and interviews, the facility failed to maintain a safe environment for all residents in the 200-unit when staff failed to ensure the facility oxygen (O2) storage room was secured to prevent unauthorized access. This deficient practice has the potential to lead to residents experiencing avoidable accidents.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Minimum Data Set (MDS; a federally mandated comprehensive assessment of a resident's functional, medical, psychosocial and cognitive assessment completed by facility staff) was accurate for 1 (R #2) of 1 (R #2) resident reviewed for MDS accuracy. This deficient practice could result in failure to provide adequate care and treatment of the resident's needs.

Inspectors wroteBased on observation and interview, the facility failed to ensure residents where give prior notice and equal accommodations during a remodeling project for 4 (R #1, #2, #3, and #4) out of 4 residents. These deficient practices could result in residents feeling as if they were unimportant, restricted, did not have freedom to make their own choices, and did not have privacy.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain a safe and comfortable environment for all residents and occupants during a remodeling project when staff failed to:- Maintain proper ventilation of construction flooring adhesive odors.- Maintain the means of egress (a continuous and unobstructed way of travel from any point in the building or structure to a public way) throughout the facility. If staff fail to maintain a safe environment, then the residents could find themselves in an emergency situation which could endanger their health and safety.

Inspectors wroteBased on record review and interview the facility failed to complete an initial skin assessment for 1 (R #1) of 3 (R #1, #2 and #3) residents reviewed for skin assessments, during the initial admission. If the facility fails to complete a skin assessments then facility is unable to provide proper care and treatment for the residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure medical records were updated with necessary documents and are accurate for 1 (R #4) of 1 (R #4) resident reviewed, when the facility failed to update and upload hospital discharge orders into the electronic medical record (EMR). This deficient practice is likely to result in residents not receiving accurate care and having an inaccurate medical record.

Inspectors wroteBased on observation and interview, the facility failed to store and serve food under sanitary conditions when staff failed to ensure: 1. Food items were labeled and dated in the kitchen refrigerator and freezer. 2. Food items were stored off the kitchen floor and appropriately in the dry storage. 3. Dietary staff were wearing appropriate hairnets while in the kitchen. 4. Frozen meats were thawed in a safe manner (under running water and not in stagnate water). These deficient practices are likely to affect all 107 residents listed on the resident census list provided by the Administrator on 01/06/25 and are likely lead to foodborne illnesses in residents if food is not being stored properly and safe food handling practices are not adhered to.

Inspectors wroteBased on record review and interview, the facility failed to ensure staff revised the care plan for 2 (R #'s 11 and 112) of 2 (R #'s 11 and 112) residents reviewed when staff failed to: 1. Conduct a quarterly care plan meeting as required for R #11 in accordance with his admission date and Minimum Data Set (MDS)assessment. 2. Update R #11's plan of care to include Libre2 ([NAME] based glucose monitor embedded in the skin) use for diabetic management. 3. Update R #112's plan of care to include oxygen (O2) use. These deficient practices are likely to result in residents' care and needs not being addressed if care plans are not updated.

Inspectors wroteBased on record review and interview, the facility failed to provide a quality care that meets professional standards for 1 (R # 11) of 1 (R #11) resident when the facility failed to: 1. Communicate with a provider (Physician Assistant- PA, Nurse Practitioner- NP) the discontinuation of a medication (sodium zirconium- medication that binds potassium and treats Hyperkalemia- elevated potassium). 2. Review and implement R #11's Nephrologist (a doctor who specializes in diagnosing and treating kidney conditions) medication recommendations. 3. Follow physician orders to utilize R #11's Libre2 ([NAME] based glucose monitor embedded in the skin) when performing diabetic management. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure ongoing communication and collaboration with the dialysis (clinical purification of blood as substitute for normal kidney functioning) facility regarding dialysis care and services for 1 (R #51) of 1 (R #51) resident reviewed for dialysis. If the facility is unaware of the status, condition or complications that arise during dialysis treatment, then residents are likely to not receive the appropriate monitoring and care they need.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure that medications were administered with an error rate less than 5%. Medications were observed being administered to 2 (R #61 and R #97) of 4 (R #61, R #97, R #192, and R #365) During observation there were 26 medications administered with 13 medication errors observed. This resulted in a medication error rate of 50%. If medications are not administered at the scheduled ordered times, the treatment may be less effective and residents will receive less than optimal care.

Inspectors wroteBased on record review and interview, the facility failed to maintain accurate and complete records in accordance with accepted professional standards and practices for 7 (R #'s 34, 54, 69, 193, 194,195, and 196) of 7 (R #'s 34, 54, 69, 193, 194,195, and 196) residents. The facility failed to properly document that pharmacist recommendations were reviewed by the facility providers. this could adversely impact resident medication needs by not have accurate information. A. Record review of the monthly pharmacist reviews dated December 2023 to December 2024 of R #'s 34, 54, 69, 193, 194,195, and 196 medications revealed the following recommendations: [...]

Inspectors wroteBased on interview and record review, the facility failed to investigate an allegation of missing money for 1 (R #121) of 1 (R #121) resident reviewed for missing money. This deficient practice is likely to result in resident financial hardship.

Inspectors wroteBased on record review and interview, the facility failed to provide sufficient preparation for 1 (R #81) of 1 (R #81) resident reviewed by not ensuring that referral for services had been received, accepted and was scheduled to provide care for the resident upon her discharge home. This deficient practice could likely result in resident not receiving needed services and having to navigate referral process for services unassisted.

Inspectors wroteBased on record review and interview, the facility failed to provide appropriate interventions for 1 (R #241) of 1 (R #241) residents reviewed for injury when the facility did not send R #241 to the emergency room (ER) for several hours after R #241 fell and experienced a head laceration (a tear or ragged cut in skin or flesh) with bleeding from her head, and was taking blood thinners. This deficient practice could likely result in R #241's head laceration becoming worse with additional bleeding.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the nutritional needs and preferences were met for 1 (R #11)of 1 (R #11) resident reviewed, when staff failed to serve the food items listed on the meal ticket. If the facility is not providing a meal as listed on the meal tickets, then residents are likely to experience weight loss, frustration, and depression.

Inspectors wroteBased on observations and interviews, the facility failed to ensure staff served meals at an appetizing temperature for 6 (R#'s 28, 2, 47, 30, 53, 2) of 6 (R#'s 28, 2, 47, 30, 53, 2) residents reviewed for meal temperatures. If the facility is not serving meals at residents desired temperatures then residents are likely to not eat their meals and be at risk for weight loss.

Inspectors wroteBased on record review and interview, the facility failed to provide reasonable accommodations of resident needs and preferences for 2 (R #30 and 77) of 2 (R #30 and 77) residents reviewed by: 1. Not accommodating R #30's preference to have a refrigerator in her room. 2. Not accommodating R #77's preference for showers instead of bed baths as often as she would prefer. If facility is not honoring resident preferences then residents are not able to make choices about aspects of their lives that are important to them. This deficient practice is likely to result in the resident's life style, personal choices, needs and preference not being met which could result in loss of dignity and resident rights.

Inspectors wroteBased on interview and record review, the facility failed to give the resident council feedback on their concerns for 5 (R #28, 30, 47, 53 and 64) residents interviewed in the resident Council Meeting. If the facility is not ensuring the Resident Council grievances are responded to and resolved then residents are likely to feel that their issues and concerns are not taken seriously.

Inspectors wroteBased on record review and interview, the facility failed to provide activities of daily living (ADL) assistance for baths/showers for 2 (R #'s 29 and 76) of 2 (R #'s 29 and 76) residents reviewed for ADL care. This deficient practice is likely to affect the dignity and health of the residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure 1 (R #55) of 1 (R #55) residents reviewed for behavioral health concerns received necessary behavioral health care to meet their needs by not: 1. Ensuring effective communication between the facility and psychiatric (psych) providers regarding R #55's psych service needs. 2. Ensuring R #55's behavioral health/psych progress notes were documented for facility staff. These deficient practices are likely to result in the residents not receiving the behavioral or mental health care and assistance needed to improve mood and reduce depression and anxiety.

Inspectors wroteBased on observation and interview, the facility failed to ensure that medications stored in medication storage rooms and inside of the emergency medication kits (e-kit) were not expired. This deficient practice is likely to result in all residents who receive these medications that have lost their potency and effectiveness more vulnerable to acquiring infections.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Smoking Assessment was accurate for 1 (R #57) of 1 (R #57) residents reviewed for smoking. If the facility is not accurately assessing residents it is likely that the residents needs are not being met.