Las Palomas Center

Inspectors wroteBased on observation and interviews, the facility failed to ensure kitchen appliances (storage equipment) were maintained and food was stored properly, when the facility failed to:Ensure the South unit's nourishment room freezer seal was in good condition, and the freezer was free from excessive ice and frost buildup. This deficient practice is likely to affect all 52 residents on the South units identified on the resident census list provided by the Administrator on 07/15/26. If food is not stored properly and kitchen appliances are not maintained, residents are at increased risk of contracting foodborne illnesses.

Inspectors wroteBased on record review and interview, the facility failed to make prompt (done without delay; immediate) efforts to resolve resident's grievances for 1 (R # 6) of 1 (R # 6) resident reviewed by not responding/following up on grievances that involved resident to resident altercation after the grievance was reported to staff. If the facility is not ensuring that grievances are responded to and without delay, then residents are likely at risk of continued/repeaedt concerns and feeling as though their concerns are unimportant to the facility.

Inspectors wroteBased on record review and interviews, the facility failed to appropriately discharge 1 (R #1) of 1 (R #1) resident when the facility failed to re-admit R #1 from the hospital and ensure coordination with an appropriate receiving facility so R #1's needs could be met after discharge from the hospital. This deficient practice resulted in R #1 being discharged to the hospital without a plan for her return to the facility and without appropriate coordination to ensure R #1's wellbeing and continuity of care following the hospital stay.

Inspectors wroteBased on observation, record review and interview, the facility failed to properly intervene and prevent a Certified Nurse's Aide (CNA) from touching and interacting inappropriately with multiple residents over multiple times for 4 (R #17, 46, 96, and 120) of 4 (R #17, 46, 96, and 120) residents who were reviewed for possible abuse. If staff do intervene and take steps to prevent abuse, then other residents are at risk of abuse which may cause physical, emotional, and psychological harm.

Inspectors wroteBased on record review and interview, the facility failed to thoroughly investigate multiple allegations of abuse. The facility then failed to take steps to prevent any future abuse of 4 (R #17, 46, 96 and 120) out of 4 (R #17, 46, 96 and 120) residents reviewed for abuse. If staff do not investigate allegations of abuse and take steps to prevent abuse, then other residents are at risk of abuse which may cause physical, emotional, and psychological harm.

Inspectors wroteBased on record review and interviews, the facility failed to follow provider orders for 2 (R #3 and R#121) of 2 (R #3 and R#121) residents when staff failed:-Complete, relay and document weekly Prothrombin Time and International Normalized Ratio (PT/INR) (a test administered to monitor and manage blood levels of Warfarin-a blood thinning medication) laboratory results for R #3. -Follow physician order for oxygen use for R#121. These deficient practices are likely to result in residents not maintaining their optimal health as planned by their medical provider.

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) for 3 (R #'s 5, 15, and 9) of 3 (R #'s 5, 15, and 9) residents reviewed for ADL care by staff failing to: Providing assistance for baths and showers. This deficient practice is likely to affect the dignity and health of the residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure residents were treated with respect and dignity for 1(R #1) of 1 (R #1) resident when the facility failed to ensure the resident was not soiled while in the common areas for extended periods of time. This deficient practice is likely to result in residents feeling as if they were unimportant and not having privacy.

Inspectors wroteBased on record review and interview, the facility failed to provide the highest level of care for 1 (R #1) of 8 (R #1, 2, 3, 4, 5, 6, 7, 8) residents. The facility failed to provide consistent and adequate wound care (observation and care that promotes healing of wounds) to promote the healing of R #1's wounds. This deficient practice is likely to result in residents not receiving care that would promote the healing of resident's wounds.

Inspectors wroteBased on record review and interview the facility failed to assure that the physician/provider reviewed and entered all orders for 1 (R #1) of 1 (R #1) resident when the provider failed to review and enter an order upon admission to provide wound care. This deficient practice is likely to result in residents not having adequate review and submission of treatment and medication orders resulting in less-than-optimal care.

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. Eggs should be refrigerated, kept cold or on ice when out of the refrigerator. 3. Floor in the facility freezer was clean (spilled milk) and free of debris (paper) These deficient practices are likely to affect all 95 residents listed on the resident census list provided by the Administrator on 06/02/25 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 provide care that met professional standards for 1 (R #2) of 1 (R #2) resident when medications were administered which were contraindicated (medications that counteract each other) resulting in the resident experiencing diarrhea (a condition characterized by excessive and loose, watery bowel movements). This deficient practice is likely to result in residents being uncomfortable, developing skin damage and becoming dehydrated (a condition where the body loses more fluids than it takes in).

Inspectors wroteBased on 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 for 1 (R #2) of 1 (R #2) resident reviewed for ADL care. This deficient practice is likely to affect the dignity and health of the residents.

Inspectors wroteBased on observation and interview the facility failed to safeguard clinical record information by leaving Private Health Information (PHI) where unauthorized persons had access to it for the residents of Unit 1 and Unit 2 during random observations. If the resident's clinical information is not sufficiently safe guarded, resident's PHI is likely to be viewed by unauthorized residents, visitors, and staff.

Inspectors wroteBased on observation and interview, the facility failed to serve food at a safe and appetizing temperature for 1 (R #2) of 1(R #2) resident reviewed for food preference. This deficient practice is likely to result in residents consuming less food causing weight loss and malnutrition.

Inspectors wroteBased on record review and interview, the facility failed to ensure medical records were updated and accurate for 1 (R #2) of 1 (R #2) resident reviewed. If resident medical records are not complete, accurate and up to date, then resident care may be delayed or duplicated.

Inspectors wroteBased on record review and interview, the facility failed to ensure that there was a coordinated plan of care for 1 (R #2) of 1 (R #2) resident reviewed for hospice services. This deficient practice is likely to result in the resident not receiving the services that he needs.

Inspectors wroteFindings related to R #7 L. Record review of the complaint allegation received by the State Agency on 01/09/25 revealed that during the holiday (Christmas), three different family members visited R #7 either in person of via Zoom and all three mentioned that her eyes were red, irritated and making R #7 uncomfortable. The cousin who visited in person alerted staff to this and they brought some eye drops. The complainant stated that she specifically requested care for R #7's eyes via email on 12/24/24 and 12/31/24 however there was no response until 01/07/25. M. On 02/15/25 at 12:33 pm during interview with R #7 when asked about her eyes being irritated, she stated Only thing I remember was they were cutting grass and the window was open. She confirmed that her eyes were itchy but it wasn't painful. R #7 remembered the symptoms only lasting one day. N. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to notify the resident's physician for 2 (R #2 and #6) of 2 (R #2 and #6) residents reviewed when: 1. R #2 began having difficulty feeding herself with low meal intake percentages 2. R #6 developed a sacrum wound These deficient practices likely resulted in R #2 not getting the assistance she needed resulting in a decrease in meal intake and a delay in treatment and deterioration in R #6's wound likely resulting in the wound becoming septic.

Inspectors wroteBased on record review and interview, the facility failed to ensure the results of all investigations of allegations of abuse, neglect, exploitation, misappropriation and injuries of unknown source were submitted to the State Survey Agency within 5 working days of the incident. This deficient practice likely affects all residents identified on the facility census list. If the facility is not timely investigating allegations of abuse, then residents are at risk of further abuse.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide a quality care that meets professional standards for 4 (R # 1, 2, 3 and 6) of 4 (R #1, 2, 3 and 6) residents when the facility failed to: 1. Ensure R #1's oxygen (O2) amount was provided as per physician orders. 2. Label and date O2 tubing per physician orders for R #1 and R #2. 3. Ensure there was a physician order for oxygen use before being provided to R #3. 4. Ensure there was a physician order before providing medication/treatment to R #6. If the facility is not following physician orders, then residents are at risk of adverse outcomes and inadequate monitoring of treatment.

Inspectors wroteExtended Survey Based on record review and interview, the facility failed to ensure residents had a written, signed, and dated progress note from their physician after each visit for 8 ( R #'s 8, 9, 10, 11, 12, 13, 14, 15) of 8 ( R #'s 8, 9, 10, 11, 12, 13, 14, 15) residents reviewed for current physician progress notes and documentation. This deficient practice is likely to result in resident's records being incomplete and resident care not being documented and reviewed.

Inspectors wrotePAST NON-COMPLIANCE Based on record review and interview, the facility failed to ensure medications were monitored and administered as ordered for 1 (R #s 16) of 1 (R #s 16) resident reviewed for medications not given as ordered by the physician. This deficient practice can result in a resident receiving an excessive dose of the medications that could cause harm and possible death.

Inspectors wroteBased on record review and interview, the facility administration failed to ensure a system of receiving timely response from the provider for 8 (R's #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18) of 8 (R's #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18) residents reviewed for physician communications. This deficient practice is likely to result in residents not receiving optimal care and the facility not have knowledge of physician plans and directives. Cross reference to F684 and F711 for further information A. Record review of R #8-15 revealed that each resident was being provided medical care through a senior service provider. B. On 04/02/25 at 12:10 pm during interview with the Director of Nursing (DON), stated that R #10 is one of several residents who are managed by a PCP who is not connected with the facility. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to utilize enhanced barrier precautions (an infection control intervention) when performing wound care to 2 (R #4, #5) out of 2 (R #4, #5) residents. Failure to utilize enhanced barrier precautions when performing wound care has the potential to expose the residents to multidrug resistant organisms.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain an environment that was clean, in good condition, and free from clutter for 1 (R #1) of 1 (R #1) residents sampled for a homelike environment by facility staff leaving a bag of soiled linens on the floor in front of the residents doorway. Failure to maintain the building in a clean and comfortable manner is likely to result in unsafe conditions and prevent residents from enjoying everyday activities.

Inspectors wroteCross reference to F684 and F686. Based on record review and interview, the facility failed to ensure the discharge Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) was accurate for 1 (R #6) out of 1 (R #6) residents. If staff do not accurately reflect a resident's status in the MDS, then residents are at risk of not receiving the necessary care to maintain or improve their conditions.

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 1 (R #3) of 1 (R #3) resident reviewed for baseline care plans. This deficient practice could likely result in residents not receiving the appropriate care and may place residents at risk of an adverse event (undesirable experience, preventable or non-preventable, that caused harm to a resident because of medical care or lack of medical care) or worsening of current condition after admission.

Inspectors wroteBased on record review and interview, the facility failed to ensure 1 (R #6) of 1 (R #6) resident reviewed for pressure ulcers (a wound caused by prolonged pressure occurring in bony areas of the body) received the necessary treatment and services to promote healing and prevent new ulcers from developing when staff failed to perform wound care for multiple days. Failure to provide treatment for pressure ulcer could cause the wound to worsen and develop sepsis or osteomyelitis (bone infection.)

Inspectors wroteBased on observation and interview, the facility failed to have the most recent survey results and any plan of corrections available in a place that was readily accessible to residents, family members, legal representatives and visitors. This deficient practice likely affects all resident identified on the census list provided by the Administrator on 02/14/25. If residents are unable to locate the latest survey results conducted by State Surveyors then residents, representatives, and visitors are unable to know how the facility is doing and make placement decisions accordingly.

Inspectors wroteBased upon observation and interview, the facility failed to ensure that food was prepared and served to prevent cross contamination when kitchen aides were not wearing hairnets during the lunch meal services. This deficient practice could likely affect all residents identified on the facility census provided by the Administrator on 02/14/25.

Inspectors wroteBased on record review, observation, and interview, the facility failed to provide the required assistance for 1 (R #1) of 1 (R #1) resident reviewed during a random observation of meal time. This deficient practice could likely result in R #1 being at risk for aspiration (accidental inhale food or liquid into the lungs) and choking.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure 1 (R #1) of 1 (R #1) resident reviewed maintained acceptable parameters of nutritional status when they did not: 1. Monitor R #1's meal intakes, 2. Ensure R #1 received his ordered nutritional supplement. This deficient practice could likely result in resident weight loss and adverse effects.

Inspectors wrotePAST NON-COMPLIANCE Based on record review and interview, the facility failed to ensure residents were free from misappropriation of property for 2 (R #2 and #3) of 2 (R #2 and #3) residents reviewed when a nurse removed the residents' oxycodone (narcotic pain medication) from the medication card for her own personal use. This deficient practice could likely result in a delay or residents not getting the care and treatment needed.

Inspectors wroteBased on observation and interview, the facility failed to ensure call light were in working order for 1 (R #1) of 1 (R #1) resident reviewed during random observation. If the facility is not ensuring a working call light system, then residents and staff are unable to request immediate assistance when needed.

Inspectors wrote2. Review of the admission Record for R36 found in the EMR located under the Profile tab indicated R36 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Chronic Respiratory Failure with Hypoxia (an absence of oxygen in the tissues to sustain bodily function), and Obstructive Sleep Apnea. Review of the admission MDS admission assessment found in the EMR located under the MDS tab revealed an ARD of 04/22/24. The BIMS score was 15 out of 15, revealing intact cognition. Review of the Care Plan for R36 found in the EMR located under the Care Plan tab revealed a care plan for smoking dated 07/10/24 with an intervention of Monitoring patients' compliance to smoking policy. [...]

Inspectors wroteBased on personnel file review, interview, and facility policy review, the facility failed to ensure the Activities Director (AD) was a qualified professional who was a therapeutic recreation specialist. This failed practice had the potential to affect all the residents of the facility and not meet the interests of the residents.

Inspectors wroteBased on observation, record review, interview, and policy review, the facility failed to ensure staff were taking meal temperatures to ensure they were served at safe temperatures before each meal was served. This had the potential for food borne illnesses and could affect all the residents of the facility who consume food from the kitchen. There were two residents in the sample that were nothing by mouth (NPO).

Inspectors wroteBased on interview and policy review, the facility failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) program by not having the Medical Director attend the meetings. This had the potential for the Medical Directors responsibilities to provide care and direction to the facility and residents to go without direct oversite, and the potential to affect all the residents of the facility.

Inspectors wroteBased on observation, review of maintenance audits, interviews, and review of facility policy, the facility failed to ensure a comfortable and safe environment throughout the building. Broken/shattered windows and windows without screens were observed in a main hallway and in 18 resident rooms (room [ROOM NUMBER], 111, 115, 117, 118, 119, 120, 121, 122, 123, 126, 128, 130, 132, 139, 143, 153, and 161). This failure created the potential for residents to be injured related to broken glass and created the potential for pests to enter the facility through windows without screens. A total of 46 residents were reviewed in the sample.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure eight residents (Resident (R)86, R11, R33, R81, R209, R20, R44 and R70) of eight reviewed for oxygen administration out of a total sample of 46 residents received oxygen per nasal cannula according to the physician's order. They failed to ensure there was an order in place for a resident receiving oxygen. This failure had the potential for the resident to receive increased oxygen causing hyperoxia (cells, tissues and organs are exposed to an excess supply of oxygen.)

Inspectors wroteBased on observation and interview, the facility failed to ensure an effective pest control program within the facility. Flies were observed in multiple areas of the building during the survey. This failure created the potential for cross contamination related to the fly infestation. A total of 46 residents were reviewed in the sample.

Inspectors wroteBased on record review, observation, interview, and facility policy review, the facility failed to ensure one of two residents (Resident (R)81) out of a total sample of 46 residents observed was cared for in a dignified way by allowing his Foley catheter bag to be viewed from the doorway of his room. This deficient practice had the potential to cause the resident to be treated and cared for in an undignified manner.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure medications were not being left at the bedside for one of two residents (Resident (R)78) observed who was not assessed to self-administer medications out of 46 sampled residents. This had the potential for the resident not to receive their ordered medications and create unmet care needs.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure Code Status was correct throughout the electronic medical record (EMR) for one (Resident (R) R209) out of four residents reviewed for Advance Directives/Code Status. Physician's orders in the EMR indicated the resident's code status as Full Code rather than his preferred Do Not Resuscitate (DNR) in the event the resident was found not breathing and/or without a pulse. This failure created the potential for Cardiopulmonary Resuscitation (CPR) to be performed on the resident when it was not desired. A total of 46 residents were reviewed in the sample.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to have written documentation of the Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNFABN) CMS [Centers for Medicare and Medicaid Services]-10055 and the Notice of Medicare Non-coverage (NOMNC) CMS-10123 for two of three for two of three residents (Resident (R)40 and R86) out of a sample of 46 residents. This had the potential for the residents to be unable to make an informed decision and to be unaware of additional costs and services when skilled services are ending and their right to appeal decisions.

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to ensure two out of three sampled residents out of a total sample of 46 residents reviewed for hospitalization (Resident (R)19, and R81) and/or their representatives were provided with written transfer notices upon emergent transfer to the hospital. Also, notification was not provided to the ombudsman. This deficient practice could allow a resident to be transferred without knowing their rights.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to ensure two of two residents (Resident (R) 19 and R81) and/or their representatives out of a sample of 46 residents reviewed for hospitalization were given a written copy of a bed hold notice prior to or within 24-hours of transfer to the hospital. This failure creates the potential for residents and responsible parties not to have the information needed to safeguard their return to the facility.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) Level I assessment was completed accurately for two residents (Resident (R)16 and R46) out of two residents reviewed for PASARR screenings out of a total sample of 46 residents. This had the potential for the residents to prevent or delay additional services to the residents that should have had a Level II PASARR completed.

Inspectors wroteBased on review of facility policy, record review, and interview, the facility failed to ensure two Residents (R) R18 and R80 of four residents reviewed for activities were provided with an appropriate ongoing program of activities to meet their needs. This failure created the potential for both residents to experience social isolation related to the lack of activity involvement. A total of 46 residents were reviewed in the sample.

Inspectors wroteBased on record review, and interview, the facility failed to ensure one Resident (R) 80 of one resident reviewed for vision services had glasses available to her per her plan of care. This failure created the potential for the resident to experience negative effects related to not being able to see adequately. A total of 46 residents were reviewed in the sample.

Inspectors wroteBased on record review, interview, and review of facility policy, the facility failed to ensure one (Resident (R) 80) of one resident reviewed for side rail use had appropriate physicians orders, provided informed consent form, and was appropriately assessed for her use of side rails. This had the potential for possible injury to the resident. A total of 46 residents were reviewed in the sample.

Inspectors wroteBased on record review, observation, interview, and facility policy review, the facility failed to ensure a medication error rate of less than 5%. Two errors were made with a total of 25 opportunities for error, resulting in an 8.0% error rate. The errors involved one (Resident (R) 58) of four residents observed during medication administration. This had the potential for R58 to experience negative effects related to errors with their medication administration. A total of 46 residents were reviewed in the sample.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to ensure staff were trained in regard to enhanced barrier precautions (EBP) for two of six sampled residents (Resident (R)212 and R208) who had indwelling urinary catheters out of sample of 46 residents. The facility further failed to ensure infection control was maintained related to catheters being observed on the floor for R208 and R212, and lastly the facility failed to properly store respiratory equipment when not in use for R33 and R86. This had the potential for all the residents to acquire infections.

Inspectors wroteBased on review of personnel records, interview, and review of facility policy, the facility failed to ensure three employees (Activities Assistant (AA), Certified Nursing Assistant (CNA) 22 and CNA 23) of 31 staff members reviewed for the completion of required training were trained related to the facility's abuse processes and procedures prior to working in direct contact with residents. This failure created the potential for residents to be abused and/or for facility policies and procedures to not be followed in the event of potential abuse. A total of 46 residents were reviewed in the sample.

Inspectors wroteBased on record review and interview, the facility failed to inquire about residents' dietary preferences for 6 (R#'s: 15, 18, 26, 27, 28, and 29) of 13 (R #'s: 15, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, and 29) residents reviewed for food preferences. This deficient practice could likely result in residents feeling frustrated and possible weight loss due to a lack of dietary options.

Inspectors wroteBased on observation and interview, the facility failed to provide a sanitary and comfortable environment for all of the 110 residents identified by the facility census provided by the Administrator In Training (AIT) on 03/04/24, when staff failed to: 1. Ensure the facility did not smell like urine; 2. Ensure resident rooms were free of trash, floors are clean with no spots of dried liquids, and privacy curtains were clean and not soiled; 3. Replace a shattered window on the northwest hall; 4. Ensure hallways were clear of clutter. This deficient practice is likely to cause all residents to be exposed to environmental hazards and to not feel comfortable in their environment.

Inspectors wroteBased on observation and interview, the facility failed to ensure staff treated a resident with respect and dignity for 1 (R #3) of 1 (R #3) resident when staff left a resident lying in bed naked after receiving care. This deficient practice could result in residents feeling frustrated and devalued.

Inspectors wroteBased on record review and interview, the facility failed to report an incident for 1 (R #17) of 3 (R #21, R #22, and R #23) residents reviewed for falls. This deficient practice could likely result in the State Survey Agency not being aware of facility incidents and unable to assure residents have a safe and hazard free environment.

Inspectors wroteBased on observation and interview, the facility failed to ensure medications were not left on a beside table in a resident's room for 1 (R #3) of 1 (R #3) resident. This failure could likely result in resident injury if staff do not confirm residents take their medications.

Inspectors wroteBased on observation and interview, the facility failed to assure staff properly stored medications in a locked container. This deficient practice had the potential to affect all 110 residents identified on the facility census list provided by the Director of Nursing (DON) on 03/04/24. Improperly stored medications could result in a resident, staff member or a visitor taking the medications.

Inspectors wroteBased on record review, observation, and interview, the facility failed to follow the menu, and honor resident preferences. These deficient practices have the potential to affect all 104 residents listed on the census presented by the Administrator on 11/06/23 and could likely result in reduced food intake, weight loss, and a decline in a resident's psychosocial health (the health of someone's emotions, behaviors, and social abilities) due to developing feelings of frustration and/or unsatisfaction with meal options, anxiety (an excess feeling of fear, dread, and uneasiness), and disappointment.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure meals were served at an appetizing temperature, were attractive, and palatable (pleasant to taste). This deficient practice has the potential to affect all 104 residents identified on the census provided by the Administrator on 11/06/23 and could likely reduce residents' ability to eat and enjoy meals, decrease their quality of life, and cause weight loss due to feelings of frustration, anxiety (an excess feeling of fear, dread, and uneasiness), and disappointment.

Inspectors wroteBased on record review and interview, the facility failed to provide follow up reports within five (5) working days from the date of the incidents to the State Survey Agency, for 2 (R #9 and R #10) of 5 (R #6, R #7, R #8, R #9, and R #10) residents reviewed for incidents. If the facility fails to provide a five (5) day follow-up report to the State Agency then the State Agency will be unable to assure residents are safe and have a hazard free environment.

Inspectors wroteBased on observation, record review, and interview, the facility failed to have the Interdisciplinary Team (IDT(consists of a team of professionals of various roles within the facility who review and determine resident needs and abilities)) determine if residents could self-administer medication for 1 (R #1) of 4 (R #1, R #2, R #3 and R #4) residents reviewed. If the facility is not assessing the residents to determine if a resident is capable of self-administering medications, then this deficient practice is likely to result in residents self-administering medications inappropriately and or incorrectly, likely causing harm (overdose, missed medications, and another resident taking the medication.)

Inspectors wroteBased on record review and interview, the facility failed to effectively manage pain for 1 (R #2) of 4 (R #1, R #2, R #3, and R #4) residents reviewed for pain by not providing pain treatment. This deficient practice could likely result in residents experiencing a significant (long) period of pain without sufficient relief for pain.

Inspectors wroteBased on interview, the facility failed to ensure that all residents that have a personal funds account with the facility are able to access their funds on weekends/evenings. This deficient practice is likely to affect all residents having an account with the facility. If residents are unable to access their funds when desired, then residents are likely to not be able to participate in activities and purchase food or personal items when they choose.

Inspectors wroteBased on observation and interview, the facility failed to maintain consistent meal service times for residents and serve snacks between meals. This deficient practice has the potential to affect all 113 residents listed on the facility census provided by the Center Executive Director on 08/13/23. This deficient practice could likely result in residents becoming frustrated and/or residents not receiving meals if meals are not served at consistent meal times, and could affect the physical and mental health of residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food stored in the facility refrigerators was properly labeled, dated, and/or disposed of based on the use by date. This deficient practice could likely affect the 109 residents listed on the facility census provided by the Administrator on 08/13/23 that receive food or meals from the kitchen and could likely lead to foodborne illnesses (an infection or irritation of the gastrointestinal tract - a pathway by which food enters the body and solid wastes are expelled - caused by food or beverages that contain harmful bacteria) amongst residents, if safe food handling practices are not adhered to.

Inspectors wroteBased on record review and interview, the facility failed to ensure that staff maintain the right for residents to preserve personal items for 1 (R #71) of 1 (R #71) resident reviewed for personal items. This deficient practice is likely to cause the resident to feel isolated and unable to join activities that they enjoy, because they do not have their prescription glasses.

Inspectors wroteBased on record review and interview, the facility failed to complete a MDS (Minimum Data Set- a collection of health data that reflects a resident's functional capabilities) assessment for 2 (R #19 and 94) of 4 (R #'s 6, 19, 70, and 94) residents reviewed for resident assessments. This deficient practice could likely result in the facility receiving monies they are not entitled to and resident needs not being identified and/or treated, resulting in residents receiving less than optimal care.

Inspectors wroteBased on record review and interview, the facility failed to administer medications for 1 (R #66) of 2 (R #'s 23 and 66) residents reviewed for medication regimen. This deficient practice could likely result in a resident not feeling well due to the lack of treatment.

Inspectors wroteBased on record review and interview, the facility failed to provide ADL (activities of daily living) assistance with showering for 1 (R #157) of 1 (R #157) resident reviewed. These deficient practices have the potential to affect the dignity and health of the residents.

Inspectors wroteBased on observation and interviews the facility failed to store medications in their proper container in a medication cart.

Inspectors wroteBased on record review, observation, and interview the facility failed to ensure that 1 (R #48) of 1 (R #48) resident was treated in a respectful manner that preserved the residents' dignity. This deficient practice has the potential to reduce residents' quality of life, through feelings of frustration, humiliation, and anxiety.

Inspectors wroteBased on record review and interview, the facility failed to notify the physician of missed medication administrations for 1 (R #66) of 2 (R #'s 23 and 66) residents reviewed for medication regimen. This deficient practice could likely result in a stalled improvement in condition due to the lack of medication and/or not receiving an alternative treatment.

Inspectors wroteBased on record review and interview, the facility failed to ensure that grievances (complaints over something believed to be wrong or unfair) filed by residents were tracked, followed up on, and resolved to the satisfaction of the resident for 1 (R #50) of 1 (R#50) resident reviewed for grievances. This deficient practice could likely result in continued issues or concerns not being addressed appropriately or in a timely manner by staff and residents feeling as though their concerns are not important to the staff. A. Record review of R #50's face sheet revealed that he was admitted to the facility on [DATE]. B. On 08/13/23 at 4:28 pm, during an interview, R #50 stated about a month ago (mid July 2023) he filed a grievance with Social Services (SS) #2 about his call light not being answered timely, and he never heard back from anyone about the status of the grievance. [...]

Inspectors wroteBased on record review and interview, the facility failed to develop and implement a comprehensive person-centered care plan for 1 (R #48) of 1(R #48) residents. Failure to develop and implement a person-centered care plan may result in staff's failure to understand the needs and implement treatments for residents possibly resulting in decline in abilities and a failure to thrive.

Inspectors wroteBased on record review and interviews, the facility failed to provide necessary discharge planning services for 1 (R #41) of 1 (R #41) resident reviewed for discharge planning. This deficient practice resulted in the resident being discharged without adequate planning.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide food in the texture as ordered by the physician for 1 (R #258) of 1 (258) residents reviewed for meal textures. This deficient practice could likely result in residents not eating or experiencing difficulty swallowing during meal times.

Inspectors wroteBased on observation and interview, the facility failed to maintain an environment that is clean and sanitary. This deficient practice has the potential to affect the 113 residents listed on the facility census as provided by facility administrator on 08/13/23. If the facility fails to maintain resident rooms and common areas in a homelike environment, residents are likely to be exposed to environmental hazards which may result in unsafe conditions and exacerbate (make worse) health issues.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that residents received treatment [surgical/medical physician appointment] and care in accordance with professional standards of practice for 2 (R #28 and #281) of 7 (R #1, #28, #33, #78, #169, #281 and #282) residents who were reviewed for having transportation needs. This deficient practice could likely result in residents feeling frustrated with not receiving their scheduled treatments, including transportation to and from appointments. Residents could also have worsened medical conditions due to a delay in attending their scheduled surgical/medical physician appointments.

Inspectors wroteThis is a repeat deficiency from a survey that was conducted on 06/30/21. Based on observation, interview, and record review the facility failed to ensure that 1 (R #165) of 1 (R #165) resident noted to have cognitive [thinking] impairment with behavioral symptoms [persistent or repetitive behaviors that are disruptive {troublesome, uncontrolled} or inappropriate] received all necessary person centered interventions to maintain or improve her well-being while admitted into the facility by: 1. by failing to provide sufficient and consistent monitoring of behaviors by leaving her alone in a room with the door closed and 2. by failing to plan and implement interventions to address her behaviors noted. These deficient practices may likely have contributed to the resident's decline in health leading to her readmission to an acute care facility.

Inspectors wroteThis is a repeat deficiency from a survey that was completed on 12/16/20. Based on record review and interview, the facility failed to develop and implement (put into place) a comprehensive person-centered care plan for 2 (R #31 and #78) of 5 (R #8, #31, #72, #77 and #78) residents reviewed for care plans. This deficient practice could likely result in staff's failure to understand and implement the needs and treatments of the residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure that bathing/showering assistance was provided for 1 (R #31) of 3 (R #s 31, 49 and 72) residents reviewed for ADLs (activities of daily living). This deficient practice could likely result in residents in need of this specialized care to experience a decline in their ability to perform hygiene tasks and/or maintain good personal hygiene.

Inspectors wroteThis is a repeat deficiency from a survey that was completed on 12/16/20. Based on observations, interviews, and record review, the facility failed to: 1) Ensure that opened/accessed multi-dose vials (a vial of liquid medication that contains more than one dose of the medication) of medications that had been accessed were dated; 2) Ensure that medical supplies were stored in an appropriate place, not under the sink; 3) Ensure that expired medical supplies were not stored with current medical supplies that were ready and available for use; and 4) Ensure that treatment/medication carts were kept locked when not in use. These deficient practices could likely affect all 108 identified residents listed on the facility's Resident Alphabetical Census list provided by the Center Executive Director (CED) on 04/11/22.

Inspectors wroteBased on record review and interview, the facility failed to ensure that residents received pneumococcal (pneumonia an infection in one or both lungs) vaccines according to current vaccine recommendations with their consent for 1 (R #3 ) of 5 (R #s 3, 7, 11, 31 and 78) residents reviewed for immunizations. If residents are not vaccinated as appropriate against pneumonia they have a higher likelihood of contracting that illness and spreading it to other residents and staff in the facility.

Inspectors wroteBased on interviews and observations, the facility failed to provide a comfortable and clean bathroom environment for 2 roommates (R #28 and #78) who share the restroom with an adjoining room. This deficient practice of not maintaining a clean bathroom, is likely to result in the two residents becoming very upset and embarrassed of this daily occurrence.