La Vida Buena Healthcare

Inspectors wroteBased on record review and interviews, the facility failed to ensure psychotropic medication (medication used to treat mental health conditions) consent forms were signed by the resident or resident representative prior to medication administration for 1 (R #1) of 3 (R #1, #2, and #3) residents reviewed for unnecessary psychotropic drugs. This deficient practice is likely to put residents at increased risk for undesirable side effects (including but not limited to increased drowsiness, insomnia, fatigue, sexual dysfunction) associated with the use of these medications.

Inspectors wroteBased on record review and interviews, the facility failed to notify R #1's daughter and the hospice nurse for 1 (R #3) of 3 (R #1, 2 and 3) resident reviewed for falls. This deficient practice is likely to result in family and the hospice not being able advocate for residents and residents being at further risk of injury.

Inspectors wroteBased on record review and interview, the facility failed to provide a Facility Initiated Report (mandatory self-initiated facility report of an incident) and a five day follow up report to the State Survey Agency (SSA) after a fall with injury for 1(R#1) of 1 (R #1) resident reviewed for incidents,This deficient practice is likely to result in the State Survey Agency (SSA) not being aware of facility incidents and being unable to assure residents safety.

Inspectors wroteBased on record review and interview, the facility failed to thoroughly investigate a fall with injury involving 1 (R #1) of 1 (R #1). This deficient practice is likely to result in residents not getting the treatment/care needed if the facility is not thoroughly investigating incidents.

Inspectors wroteBased on record review and interview, the facility failed to accurately complete quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) assessments for 1 (R #1) of 3 (R #1, #2, and #3) residents reviewed for assessment accuracy and completion. This deficient practice is likely to result in residents not receiving care and treatment that meet their current needs.

Inspectors wroteBased on record review and interview, the facility failed to ensure that the Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) quarterly assessment was electronically transmitted within the required 14-day timeframe for 1 (R #1) out of 3 (R #1, #2, and #3) residents reviewed for MDS transmittal requirement. This deficient practice is likely to hinder the ability of regulatory bodies to oversee resident care and prevents the facility from accurately tracking clinical trends or declines in a resident's condition over time.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a comprehensive and accurate assessment was completed for 1 (R #1) out of 3 (R #1, #2, and #3) residents reviewed upon readmission to the facility following an acute care hospital stay. This deficient practice is likely to not accurately calculate the resident's Risk Score for skin breakdown or falls.

Inspectors wroteBased on record review and interview, the facility failed to report an incident of possible neglect to the State Agency for 1 (R #1) of 3 (R #1, R #2 and R #3) residents reviewed for abuse and neglect. If the facility fails to report allegations to the State Agency, then the State Agency is unable to ensure residents are free from abuse and neglect.

Inspectors wroteBased on record review and interview, the facility failed to notify the facility providers (Nurse Practitioner, Physician, and the facility Wound Care Nurse) and Guardian for 3 (R #'s 4, 9, 15) of 3 (R #'s 4, 9, 15) residents reviewed when:Guardian for R # 4 was not notified of a fall with injury above R #4's right eye on 05/28/25. The facility Registered Nurse Treatment Nurse (Wound Care Nurse) was not notified of R #9's scalp laceration (a tear or ragged cut in skin or flesh) with staples for 24 days after R #9 received scalp staples. Facility providers were not notified of R #15's worsening (becoming worse) pressure ulcer (skin wound) as soon as the wound was identified to be declining, so wound care treatment could be changed. This deficient practice is likely to result in a delay in treatment or inadequate treatment.

Inspectors wroteBased on record review and interview, the facility failed to make prompt (done without delay; immediate) efforts to resolve resident's grievances for 4 (R #'s 13, 14, 16, and 17) of 4 (R #'s 13, 14, 16, and 17) residents reviewed by:Not responding to grievances that involved allegations of abuse and neglect for several days after the grievance was reported. Failing to educate all nursing staff, including the nursing staff involved, for grievances with allegations of abuse and neglect. If the facility is not ensuring that grievances are responded to in a prompt manner and without delay, then residents are likely at risk of continued/repeat concerns and feeling as though their concerns are unimportant to the facility.

Inspectors wroteBased on record review and interview, the facility failed to report an investigation regarding allegations abuse and neglect within the required timeframe (2 hours) for 3 (R #'s 13, 14, and 17) of 4 (R #'s 13, 14, 16, and 17) residents reviewed for grievances. If the facility is not submitting the summary of the facility's investigation to the State Agency, then the State Agency is unable to appropriately triage (review) the allegation for further investigation.

Inspectors wroteBased on record review and interview, the facility failed to complete a thorough investigation and report the investigation findings within five working days, for allegations of abuse and neglect for 3 (R #'s 13, 14, and 17) of 4 (R #'s 13, 14, 16, and 17) residents reviewed for grievances. If the facility is not completing an accurate and thorough investigation and submitting the summary of the facility's investigation to the State Agency, then the State Agency (SA) is unable to appropriately triage (review) the allegation for further investigation.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide quality care that meets professional standards for 2 (R #'s 9 and 11) of 2 (R #'s 9 and 11) residents when the facility failed to:Remove R #9's scalp staples within 7 to 10 days as ordered by a physician. Provide physician orders for anticoagulant (blood thinner) complications (bruising, bleeding, pain, swelling, and dizziness) monitoring (daily nursing assessments) for R #11. If the facility is not following physician orders or providing medication monitoring orders, then residents are at risk of adverse outcomes and inadequate monitoring of treatment.

Inspectors wroteBased on record review and interview, the facility failed to provide a program of activities sufficient to meet each resident's capabilities, interests and needs, for 1 (R # 5) of 3 (R #s 1, 2 and 5) residents reviewed for activities. This deficient practice has the potential to cause residents feelings of boredom, isolation and depression.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents received the necessary treatment and services to prevent the development and worsening of pressure wounds (also called a pressure injury/pressure ulcer; skin damage which results from unrelieved pressure on the body) for 1 (R #15) of 1 (R #15) resident reviewed when staff failed to: Monitor for changes in R #15's coccyx (tailbone area; base of spine) pressure ulcer and timely notify the provider (physician and/or Nurse Practitioner) of R #15's pressure ulcer worsening and development of new pressure wound. Document and monitor wound progress (that includes measurements; to track effectiveness of wound care treatments and to prevent the progression of pressure ulcers) for R #15, so any pressure ulcer changes can be managed and/or treated without delay. [...]

Inspectors wroteBased on interview and record review, the facility failed to utilize Nursing Assistants (NAs) appropriately by using NAs for more than 4 months, on a full-time basis to provide nursing and nursing related services for 2 (NAs #1 and 2) of 3 (NAs #1, 2, and 3) reviewed for staffing. If the facility is staffing NAs for longer than 4 months, then residents are likely to not receive the appropriate care, services and may not meet the needs of all residents.

Inspectors wroteBased on record review and interview the facility failed to ensure a resident was treated with respect and dignity for 1 (R #5) of 3 (R #1, 2 and 5) residents reviewed for dignity by:1. Not allowing the resident to leave the facility per his preference.2. Re-directing the resident back to the facility when he has wanted to leave to go for a walk or shopping and not offering the resident an alternate solution/plan. This deficient practice created frustration and confusion for the resident because he did not understand why he was unable to leave.

Inspectors wroteBased on record review and interview, the facility failed to ensure staff revised the care plan for 1 (R #5) of 3 (R #1, 2 and 5) residents reviewed when staff failed to update the care plan to include R #5 not being able to leave the facility independently. This deficient practice is likely to result in residents' preferences and needs not being addressed if care plans are not updated.

Inspectors wroteBased on interview and record review, the facility failed to have competent (aware of each resident's current health status and regular activity) nursing staff that was aware of anticoagulant (blood thinner) use for 1 resident (R #11) of 1 resident's (R #11) reviewed for falls. If nursing staff are not aware of anticoagulant medications taken by residents; then this deficient practice is likely to result in medication administration errors, the lack of monitoring of the resident's condition, delays in treatment or interventions, and increased risk of serious injury or complications such as bleeding, following a fall.

Inspectors wroteBased on record review and interview, the facility failed to promote resident choices for 1 (R #3) of 2 (R #'s 2 and 3) residents reviewed for choices when staff failed to offer R #3 showers per her preference. If the facility does not honor residents' choices, then residents are likely to experience a loss of independence and self-worth leading to feelings of frustration and depression.

Inspectors wroteBased on record review and interview, the facility failed to notify the facility providers (Nurse Practitioner, Physician) when there was a change of condition for 1 (R #1) of 1 (R #1) residents reviewed. This deficient practice is likely to result in a delay in treatment or inadequate treatment.

Inspectors wroteBased on record review and interview, the facility failed to ensure medical records were updated and accurate for 1 (R #1) of 1 (R #1) resident reviewed, when the facility: 1. Failed to document a change in condition (CIC; sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains) that required R #1 to go to the emergency room (ER). 2. Failed to document the reason R #1 was sent to the ER, including documentation that indicated a facility provider was notified of R #1 being sent to the ER on [DATE]. This deficient practice is likely to result in residents having an inaccurate medical record, which could result in the residents receiving less than optimal care and treatment.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (R #1) of 3 (R #1, R #2, and R #3) residents reviewed for safe transfer when staff did not have two staff present while providing care of a resident. This deficient practice likely resulted in the resident experiencing an injury, pain, discomfort and less than optimal care. A. Record review of R #1's face sheet, dated 11/31/24, revealed R #1 was admitted to facility on 12/04/21 with the following diagnoses: - Unspecified lack of coordination. - Need for assistance with personal care (requires assistance when dressing, transferring positions, meal setup, showers). - History of traumatic brain injury (a sudden and significant injury of the brain). [...]

Inspectors wroteBased on record review and interview, the facility failed to conduct a through investigation and failed to report timely to the State Survey Agency for 1 (R #1) of 3 (R #1, 2, 3) residents reviewed for incidents/accidents. This deficient practice is likely to prevent the state agency from properly monitoring and investigating a facility and prevent such incidents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to deliver meals consistently and timely to 84 residents that received room trays or ate in the dining room, as identified on the facility census provided by the Administrator on 08/20/24. This deficient practice is likely to cause frustration and hunger.

Inspectors wroteBased on observation and interview, the facility failed to store and serve food under sanitary conditions when staff failed to: 1. Properly label and store food items. 2. Maintain the facility kitchen free of dirt and grime. This deficient practice is likely to affect all 83 residents listed on the resident census list, provided by the Administrator on 08/02/24, and could likely lead to foodborne illnesses in residents if food is not being stored properly, safe food handling practices are not adhered to.

Inspectors wroteBased on observation and interview, the facility failed to maintain proper infection prevention measures when the facility experienced an outbreak of coronavirus disease (COVID; a contagious viral disease) and staff failed to: 1. Properly dispose of used personal protective equipment (PPE; protective masks, gloves and gowns used and disposed of when staff is exposed to a contagious disease). 2. Exchange and dispose of protective mask after contact with each contagious resident. These deficiencies are likely to affect all 83 residents of the facility as listed on the census provided on 08/02/24.

Inspectors wroteBased on record review and interview, the facility failed to ensure 1 (R #1) of 3 (R #1, #2 and #3) residents reviewed for pressure ulcers (a wound caused by prolonged pressure occurring in boney area of the body) received the necessary treatment and services to promote healing and prevent new ulcers from developing, when staff failed to conduct consistent pressure ulcer wound assessments with measurements. If the facility is not consistently assessing and measuring wounds, then resident's wounds are likely to worsen without appropriate intervention.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents received care consistent with professional standards to promote the healing of pressure ulcers (a localized wound caused by prolonged pressure to an area above a prominent bone) for 1 (R #21) of 1 (R #21) resident reviewed when staff: 1. Delayed in implementing new interventions/treatment (antibiotic) when the wound started to deteriorate. 2. Failed to accurately document presence of wound on skin checks/showers sheets and wound staging on reports. 3. Failed to notify provider of changes in the wound. 4. Delayed in getting R #21 an appointment at the Wound Clinic for treatment (seen 21 days after order). These deficient practices likely resulted in the wound significantly worsening for R #21, exposing bone and osteomyelitis (bone infection).

Inspectors wroteBased on record review, interview, and observation, the facility failed to provide sufficient support staff to carry out the functions of food and nutrition services at the facility. This deficient practice is likely to result in the residents' dietary needs not being met, recieving food that is not stored approriately (open to air, not labeled and dated) and longer waits for meal service for all 80 residents residing at the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to deliver meals consistently and timely for all 80 residents in the facility. This deficient practice could potentially lead to frustration and hunger.

Inspectors wroteBased on observation and interview, the facility failed to ensure food was stored, prepared, distributed, and served to residents in accordance with professional standards of food service safety when staff failed to: 1. Ensure all food items in the kitchen were labeled, dated, and stored properly. 2. Ensure refrigerated and frozen food was put away after a delivery and not left out for an extended period of time. 3. Ensure the kitchen walls, floors, and freezer floor were clean from dirt, grime, and unknown liquid. These deficient practices are likely to affect all 80 residents identified on the resident census list provided by the Administrator on 06/10/24. If the facility does not follow food safety guidelines, then they are likely to expose residents to food borne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to provide reasonable accommodations of resident needs and preferences for 1 (R #12) of 1 (R #12) residents. If the facility is not honoring resident preferences then residents are not able to make choices about aspects of their lives which 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.

Inspectors wroteBased on observation and interviews the facility failed to provide a homelike environment for all 17 residents that ate their meals in the small dining room when staff failed to remove resident meals from the serving trays after they served the residents their meals. Residents were identified by the resident matrix provided by the Administrator on 06/10/24 and the seating chart for the small dining room provided by the Administrator on 06/12/24. This deficient practice could likely cause residents to feel depressed and anxious that they are not living in a comfortable home-like environment.

Inspectors wroteBased on record review and interview, the facility failed to complete a Minimum Data Set (MDS; a collection of health data that reflects a resident's functional capabilities) assessment for 1 (R #3) of 1 (R #3) residents reviewed for significant change resident assessments. This deficient practice could likely result in resident needs not being identified or treated, resulting in residents receiving less than optimal care.

Inspectors wroteBased on record review and interview, the facility failed to create an accurate baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) within 48 hours of admission for 3 (R #75, R #78, and R #386) of 3 (R #75, R #78, and R #386) residents reviewed for baseline care plans. This deficient practice could likely result in a decline in the residents' conditions due to staff not being aware of the residents' needs.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to develop a comprehensive care plan for 3 (R #58, R #78, and R #386) of 3 (R #58, R #78, and R #386) residents reviewed for care plans. This deficient practice could likely result in residents not receiving the care and treatment needed due to staff being unaware of the needs of residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) assistance for baths and showers by the facility staff for 2 (R #'s 15 and 31) of 2 (R #'s 15 and 31) residents reviewed for ADL care. This deficient practice is likely to affect the dignity and health of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from accident hazards for 3 (R #15, #42, and #45) of 3 (R #15, #42, and #45) residents, when they failed to: 1. Use appropriate number of staff members to assist R #15 and R #45 while using a Hoyer lift (a patient lift or portable total body lift is a mobility tool designed to help individuals with mobility challenges). 2. Implement interventions to prevent falls after R #42 had repeated falls with injury. These deficient practices could likely result in residents being at risk of serious harm or injury.

Inspectors wroteBased on record review and interview, the facility failed to conduct a monthly Drug Regime Review for 1 (R #1) of 5 (R #1, R #29, R #37,R #45 and R #74) residents reviewed for unnecessary medications. This deficient practice is likely to result in irregularities not being communicated in a timely manner to the physician for review, evaluation, and possible intervention, which could result in delay of assessment or appropriate treatment.

Inspectors wroteBased on record review and interview, the facility failed to monitor for the use of psychotropic medications (any medication that affects brain activity associated with mental processes and behavior) for 4 (R #'s 3, 11, 19, and 29) of 4 (R #'s 3, 11, 19, and 29) residents reviewed when staff failed to: 1. Attempt to gradually reduce the dose (lower dose/quantity of medication administered) for a psychotropic medication for R #3, #11, and #19. 2. Complete a psychotropic medication consent form prior to psychotropic medication use for R #29. These deficient practices are likely to result in residents being administered unnecessary medication or being over medicated.

Inspectors wroteBased on interview and record review, the facility failed to notify 2 (R #4 and #44) of 2 (R #4 and #44) residents when their balance was within or approached $200.00 of the maximum amount a Medicaid recipient could have in cash assets. If the facility is not notifying resident or residents' responsible parties when they are approaching the maximum amount then residents are likely to lose their eligibility of Medicaid benefits. A. Record review of the facility's Resident Statement Landscape (residents personal funds account) revealed R #4 and R #44 were above the eligible maximum amount. B. On 06/14/24 at 9:55 am during an interview with the facility Business Office Manager (BOM), he stated R #4's and R #44's accounts were above the maximum cash assets allowed amount for Medicaid recipients. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to meet professional standards of care related to the use of oxygen for 1 (R #21) of 1 (R #21) residents. This deficient practice is likely to cause resident to have upper respiratory infections if oxygen monitoring is not done.

Inspectors wroteBased on interviews and record review, the facility failed to effectively manage pain for 1 (R #386) of 1 (R #386) residents reviewed for pain when staff did not provide pain treatment. This deficient practice likely resulted in R #386 experiencing pain without sufficient relief.

Inspectors wroteBased on record review and interview, the facility failed to ensure 1 (R #29) of 1 (R #29) residents reviewed for behavioral health concerns received necessary behavioral health care to meet their needs when staff failed to: 1. Ensure effective communication between the facility and psychiatric (psych) providers and provide consistent psychiatric services regarding R #29's psych service needs. 2. Document when facility Social Services Director (SSD) offered psych talk therapy to residents. 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: 1. Ensure all medications were stored properly and in the original, labeled packaging. 2. Ensure medical supplies in the medication storage room were not expired. These deficient practices were likely to negatively impact the health of all residents, if staff administered or used potentially compromised or contaminated medications and medical supplies due to inappropriate storage.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide food that accommodated resident preferences for 1 (R #15) of 1 (R #15) residents observed for food preferences. This deficient practice is likely to result in weight loss due to the resident not eating or an allergic reaction to the food being served to the resident.

Inspectors wroteBased on observation and interview, the facility failed to store foods under sanitary conditions by not: 1. Ensuring food items in the refrigerator and freezer were properly labeled and dated. 2. Ensuring food items in the refrigerator and freezer are properly covered. 3. Ensuring dry food items were properly stored, sealed, labeled, and dated in the dry storage room. 4. Ensuring raw eggs were kept on ice during preparation of meal service These deficient practices are likely to affect all 78 residents listed on the resident census list provided by the Director of Nursing (DON) on 04/03/23 and are likely to 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, observation, and interview, the facility failed to ensure that the care plan was developed and implemented for 2 (R #40 and #70) of (R #40 and #70) residents reviewed when: 1. The motion sensor alert was not turned on when R #70 was in bed per the care plan 2. The care plan did not identify that R #70 had glasses. 3. The care plan did not include the injury to R #40's leg If the facility is not developing and implementing resident care plans, resident may not get the care and assistance needed.

Inspectors wroteBased on record review and interview the facility failed to revise the care plan for 3 (R #40, 46 and 70) of 3 (R #40, 46 and 70) residents reviewed by not: 1. Not ensuring that care plan was revised to include R #40's injury to her right leg. 2. Not ensuring that care plan was revised to reflect R #46 was no longer receiving hospice services 3. Not ensuring the use of adaptive equipment was included in R #70's care plan If the facility is not updating the care plans to reflect the resident's current care areas and treatments, then the facility may not be providing the appropriate care and treatment to meet the residents' needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure that 1 (R #70) of 1 (R #70) resident reviewed for vision, received proper assistive devices to maintain her vision. If the facility is not assisting residents is accessing treatment and devices to maintain their vision, then residents could likely lose their ability to see and read.

Inspectors wroteBased on record review and interview, the facility failed to 1. Ensure that residents received a safe transfer(without injury) using a hoyer lift (mechanical device designed to lift patients safely) during transfer for R #14 2. Ensure R #52's ordered wing mattress (mattress that is used to keep residents from rolling out of bed) was placed on his bed to prevent falls. These deficient practices are likely to result in residents suffering further injury. Findings for R#14 A. Record review of R #14's care plan dated 02/24/23 revealed: Focus: Resident has Cerebral Palsy (a disorder that affect movement, muscle tone, balance, and posture) and needs extensive assistance for all her ADLs (Activities of Daily Living). She is hard to understand but is able to communicate her needs. Goals: Resident will have all ADL's done with assistance from staff. Interventions: Two person assist for transfers. [...]

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure that residents maintain acceptable parameters of body weight for 1(R #45) of 1(R #45) resident reviewed for weight loss by not implementing new intervention to address continued weight loss over 6 month period and by not ensuring that R #45 received healthshake as ordered. This deficient practice could likely result in continued weight loss and poor clinical condition of residents.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure that food was prepared in a form to meet the residents needed for 2 (R #5 and #82) of 2 (R #5 and 82) resident observed during random observation by ensuring that: 1. Mechanical Soft Diet was provided as ordered by a physician for R #5 2. R #82 was served pureed consistency. If the facility fails to provide foods in a consistency that residents are able to consume then residents are at risk for choking.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide food that accommodates resident allergies intolerance's and preferences for 3 (R #40, 52 and 81) of 3 (R #40, 52 and 81) resident's observed for food preferences. This deficient practice is likely to result in, an allergic reaction to the food being served to the resident and resident food preferences not being honored.

Inspectors wroteBased on record review and interview, the facility failed to ensure that there was collaboration between the facility and hospice services for 1 (R #46) of 1 (R #46) residents reviewed for hospice services by not developing a coordinated plan of care for the resident. This deficient practice is likely to result in the resident not receiving the services that she needs.

Inspectors wroteFindings related to catheters: F. On 04/03/23 at 12:32 pm during observation, R #58 was being pushed in his wheelchair from the dining room to the hallway. Under the wheelchair the catheter bag was dragging directly on the floor. Registered Nurse (RN) #1 confirmed that the catheter bag should not be touching the floor. G. On 04/03/23 at 5:51 pm during observation, R #58 was sitting in his wheelchair near the Nurse's station. His catheter bag was observed to be dragging on the floor. H. Record review of the care plan for R #70 dated 03/14/23 identified [Name of R #70] has a foley catheter and is at risk for increased urinary tract infections. I. On 04/06/23 at 8:56 am and 10:38 am during observation, R #70 was laying in bed sleeping. His catheter bag was observed laying directly on the floor under the bed. J. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure that there is an appropriate diagnosis for the use of psychotropic medications for 1 (R #19) of 5 (R #15, 19, 32, 70 and 82) residents evaluated for unnecessary medications. If residents are prescribed psychotropic medications without proper diagnosis, then residents are likely to be administered unnecessary medications likely resulting in adverse side effects.

Inspectors wroteBased on interview, observation, and record review, the facility failed to manage hydration for 1 (R #52) of 1 (R #52) resident reviewed for hydration. This deficient practice is likely to result in serious health complications for any resident without adequate hydration.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide assistive devices (special eating equipment and utensils) for 1 (R #50) of 1 (R #50) resident reviewed for use of assistive devices. This deficient practice is likely to result in residents not being able to eat meals independently unable to perform activities of daily living which could likely result in consuming less food.

Inspectors wroteBased on observation and interview, the facility failed to ensure that residents receive information on how to contact the state survey agency to file a complaint or seek advocacy. This deficient practice could likely affect all 78 residents residing in the facility as identified on the census list provided by the Director of Nursing (DON) on 04/03/23. If the facility is not ensuring that residents are able to contact the state survey agency, then residents have limited their advocacy option if there are concerns.

Inspectors wroteBased on record review, observation, and interview, the facility failed to provide the necessary care to effectively manage pain for 1 (R # 33) of 2 (R # 33, 52) residents reviewed for pain. This deficient practice likely resulted in R #33 experiencing significant (long) periods of pain without sufficient relief.

Inspectors wroteBased on observation and interview, the facility failed to store and serve food under sanitary conditions by not: 1. Ensuring food items in the refrigerator and freezer were properly labeled and dated. 2. Ensuring food items in the freezer were properly stored. 3. Ensuring food items weren't stored on the kitchen and freezer floor. These deficient practices are likely to affect all 69 residents listed on the resident census list provided by the Administrator (ADM) on 02/28/22. If the facility fails to adhere to safe food handling practices residents are likely to be exposed to foodborne illnesses.

Inspectors wroteBased on observation, interview and record review, the medical director of the facility failed to manage and coordinate resident care in a manner that would enable each resident to attain or maintain his or her highest practicable physical, mental, and psychosocial well being, which resulted in 3 (three) citations related to Pain Management, Physician visits, and Quality of Care. The cumulative effect of these systemic deficient practices resulted in contributing to poor resident outcomes with respect to quality-of-life, quality-of-care, health, safety and comfort.

Inspectors wroteBased on observation and interview the facility failed to maintain proper infection prevention measures for 2 (R #67's and R #64) of 2 (R #67's and R #64) residents identified during random observation when R 67 and R #64's 's Foley Catheters were resting on the bare floor. Failure to adhere to an infection control program is likely to cause the spread of infections and illness.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide a homelike environment, for 2 (R #'s 63 and 67) of 2 (R #'s 63 and 67) residents reviewed for homelike environment, by not maintaining an environment that is clean and free of clutter. If the facility fails to maintain resident rooms in a homelike environment, then residents are likely to feel uncomfortable and could exacerbate (make worse) health issues.

Inspectors wroteBased on record review and interview, the facility failed to provide an incident or a follow-up report to the State Survey Agency, for 2 (R #33 and R #67) of 2 (R #33 and #67) residents reviewed for falls and R #67 for not receiving her meal for dinner. If the facility fails to report incidents and/or falls with injury to the State Agency, then the State Agency is unable to ensure residents have a safe and hazard-free environment.

Inspectors wroteBased on record review and interview the facility failed to develop and implement a comprehensive person-centered care plan for 2 (R #10, 51) of 6 (R #10, 18, 22, 33, 47, and 51) residents reviewed for care plans. Failure to develop and implement a resident-centered care plan is likely to result in staff's failure to understand and implement the needs and treatments of residents, resulting in decline in abilities and a failure to thrive.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents have a written, signed, and dated progress note from their physician after each visit, and physician appointments were scheduled for residents 13 ( R #'s 4, 13, 16, 18, 26, 33, 37, 46, 48, 51, 52, 54 and 118) of 44 ( R #'s 1, 2, 4, 5, 6, 9, 10, 12, 13, 16, 18, 19, 20, 21, 22, 24, 25, 26, 29, 30, 32, 33, 34, 36, 37, 39, 41, 42, 43, 46, 47, 48, 50, 51, 52, 53, 54, 55, 57, 58, 64, 66, 68, and 118) residents reviewed for current physician progress notes and documentation. This deficient practice is likely to result in resident's needs not being accurately determined and met due to the lack of current documentation. A. Record review of the Facility Medical Director (FMD) resident tracking form dated 03/01/22 revealed the following residents with past due Physician Progress Notes/ History and Physicals: 1. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure that PRN (as needed) orders psychotropic medications were limited to 14 days unless the prescribing practitioner provided written rationale for extending the order for 2 (R #18 and 22) of 5 (R #18, 22, 33, 47, and 67) residents reviewed with PRN psychotropic medications ordered. This deficient practice is likely to result in residents being administered unnecessary medication and being over medicated.

Inspectors wroteBased on observation and interview the facility failed to: 1. Ensure that medications in the medication cart were not expired. 2. Ensure that all medications were properly labeled and stored. These deficient practices are likely to affect all 69 residents listed on the resident census list provided by the Administrator(ADM) on 02/28/22 by dosing with expired medications and dosing with medications that have been improperly stored.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure resident had access to call light for 1 (R #59) of 1 (R #59) residents reviewed for call light access. This deficient practice is likely to result in the residents not being able to notify staff of their needs or alert staff during emergent (urgent) situations.

Inspectors wroteBased on observation, record review, and interview, the facility failed to revise the care plan for 1 (R #67) of 1 (R #67) residents reviewed for Foley catheter (flexible tube inserted through the urethra and into the bladder to drain urine) use. If the facility is not updating the care plan to reflect the resident's current care areas and treatment, then it is likely the facility may not be providing the appropriate care and treatment to meet the residents' needs.

Inspectors wroteBased on record review and interview, the facility failed to provide ADL (Activities of Daily Living) assistance for baths/showers for 1 (R #54) of 3 (R #'s 33, 54, and 67) residents reviewed for ADL care. This deficient practice is likely to affect the dignity and health of the residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that 1 (R #44) of 1 (R #44) resident received proper assistive devices to maintain his vision. If the facility is not assisting residents in accessing treatment and devices to maintain their vision, then residents could likely lose their ability to see and read.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident specific physician orders and ongoing communication and collaboration (different persons/groups working together) with the dialysis (clinical purification of blood as substitute for normal kidney functioning) facility regarding dialysis care and services for 1 (R #42) of 1 (R #42) residents 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 record review and interview, the facility failed to ensure there was collaboration between the facility and hospice services (services provided for a person that is experiencing an advanced, life-limiting illness) for 1 (R #18) of 1 (R #18) resident reviewed for hospice services, by not having documentation in the resident's record indicating the delivery of hospice services, and for hospice failing to visit the resident as often as required. This deficient practice of not ensuring that there was an appropriate collaboration between the facility and hospice services is likely to result in the resident not receiving the services that they need.

Inspectors wroteBased on record review, observation, and interview, the facility failed to: 1. Display nurse staffing information in a clear and visible place. 2. Maintain the posted information for a minimum of 18 months. These deficient practices are likely to result in residents and visitors not having access to accurate staffing information.