Mirador

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation and food storage. The facility failed to ensure the hot chocolate and latte dispenser nozzle was clean and free from corrosion. The facility failed to ensure all expired foods were discarded. The facility failed to ensure all foods were securely closed, labeled, and dated. The facility failed to ensure staff did not enter the kitchen without a hairnet. The facility failed to ensure the ice machine was clean. The facility failed to ensure all chemicals in the cleaning and chemical storage area in the kitchen were appropriately labeled. These failures placed residents at risk for cross contamination and food-borne illness.

Inspectors wroteBased on interview and record review the facility failed to ensure the comprehensive careplan was developed and implemented for each resident consistentwith resident rights; to include measurable objectives and timeframes to meet residentsmedical, nursing, mental, and psychosocial needs identified in the comprehensiveassessment for 1 of 5 residents (Resident #16) reviewed for care plans. The facility failed to implement Resident #16's care plan for fallinterventions. The failure could place the residents at risk of not receiving adequate or required careThe

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure thatresidents who needed respiratory care were provided with such care consistent withprofessional standards of practice, the comprehensive person-centered care plan, and theresidents' goals and preferences to include Oxygen in Use sign posted at the door to resident's room for 1 (Resident #16) of 5 residents reviewed for respiratorycare.1. The facility failed to ensure Resident #16's Nasal Cannula, (a small, flexibleplastic tube worn under the nose that delivers supplemental oxygen therapy), wasfree of kinks. (A kink in the Nasal Cannula restricts the flow of prescribed oxygen tothe patient).2. The facility failed to ensure Resident #16's oxygen concentrator, (a medicaldevice that.delivers concentrated oxygen.to patients with respiratory conditions),was set at the oxygen liters ordered by the physician. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from any significant medication errors for 1 of 5 residents (Resident #25) reviewed for medication errors. The facility failed to hold Resident #25's carvedilol (medication that lowers blood pressure and heart rate) when Resident #25's heart rate was outside of physician's parameters twice on 06/27/26 and once on 06/28/26. These failures could place residents at risk for complications such as decreased blood pressure, decreased heart rate, exacerbation of symptoms, and potential hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles for medications stored in 1 of 4 medication carts (Side 2 Medication Aide Cart) reviewed for storage. The facility failed to ensure the timolol eye drops (lowers pressure in the eye) for Resident #5 in the Side 2 Medication Aide Cart were labeled with the date they were opened. This failure could place residents in the facility at risk of receiving expired medications from staff.

Inspectors wroteBased observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #18) reviewed for infection control practices. The facility failed to ensure the ADON knew the proper techniques and practices to keep the wound from becoming contaminated by a dirty brief during wound care on 07/01/2026. The facility failed to ensure the ADON performed proper or adequate hand hygiene while performing wound care on 07/01/2026. The facility failed to ensure the ADON donned (to put on) proper PPE during wound care on 07/01/2026. The facility failed to ensure CNA-C donned proper PPE during wound care on 07/01/2026. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served under sanitary conditions for 1 of 1 kitchen reviewed for food served under sanitary conditions. The handwashing sink's water drainage box was dirty with a black substance and the drainage plug was loose. A large frying pan was on the kitchen floor beneath a cooking table and near the cooking stoves. These failures could place residents at risk for food contamination, food borne illness and a diminished quality of life.

Inspectors wroteBased on the interview and record review, the facility failed to ensure that residents are free from chemical restraints related to PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order, for 1 of 3 residents (Resident #132) reviewed for chemical restraint, in that: The facility failed to ensure Resident #132 was prescribed a psychotropic drug for anxiety, no longer than 14 days PRN (as needed). This failure could place residents at risk of receiving unnecessary psychotropic medications.

Inspectors wroteBased on the interview and record review, the facility failed to ensure, in accordance with accepted professional standards and practices, that medical records were accurately maintained for each resident, as documented for 1 of 4 residents (Resident #132) reviewed for the accuracy of their medical records. The facility failed to ensure that documentation on Resident #132's chart accurately reflected an allergy to Azithromycin (an Antibiotic). This failure could place residents at risk of receiving improper care.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a person-centered comprehensive care plan to include measurable objectives and timeframes to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being for 2 of 5 (Resident #1 and #2) residents reviewed for comprehensive care plans in that: The facility failed to revise or update Resident #1's care plan to reflect the need and order for Enhanced Barrier Precautions (EBP). The facility failed to revise or update Resident #2's care plan to reflect the need and order for Contact Precautions. This failure could affect the residents by placing them at risk for not receiving appropriate interventions or care to meet their current needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan, for one (Resident #1) of three residents reviewed for injuries. The facility failed when CNA A did not ensure Resident #1 was medically assessed before picking up Resident #1 off the floor after she fell off the bed and CNA A left her unattended and misaligned in bed on 09/07/2024. Resident #1 sustained a femur fracture and her feeding tube was dislodged as a result of the fall. An Immediate Jeopardy (IJ) was identified as past non-compliance on 04/25/25. The non-compliance began on 09/07/24 and ended on 09/07/24. The facility had corrected the non-compliance before the investigation began on 04/11/25. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of four residents reviewed for accident hazards and supervision on 09/07/24. The facility failed to identify and eliminate a foreseeable fall. CNA A left Resident #1 unattended and did not ensure her body was positioned in a safe manner when providing incontinent care resulting in Resident #1 falling off her bed, sustaining a femur fracture, and her feeding tube to be dislodged. An Immediate Jeopardy (IJ) was identified as past non-compliance on 04/25/25. The non-compliance began on 09/07/24 and ended on 09/07/24. The facility had corrected the non-compliance before the investigation began on 04/11/25. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, including hand hygiene, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for one (Resident #1) of 4 residents reviewed for infection control practices. The facility failed to ensure CNA A wore a gown before entering a contact isolation room to perform incontinent care on 09/07/24. The facility failed to ensure CNA A wore his face mask properly while in a contact isolation room for a communicable disease on 09/07/24. The facility failed to ensure CNA A performed hand hygiene before putting on gloves to perform incontinent care on 09/07/24. [...]

Inspectors wroteBased on interviews and record review, the facility failed to consult/ notify the physician when the resident experienced a significant change in their physical status for one (Resident #1) of five residents reviewed for physician notification of changes. The facility failed to consult with/notify the physician after Resident #1 displayed significant changes in condition on 05/06/24 such as lethargy, vomiting, a decrease of oxygen saturation of 85%, irregular lung sounds and after requiring resuscitation efforts. Resident #1 expired on 05/06/24. On 05/24/24 at 4:45 PM, an immediate jeopardy was identified. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to respect the resident's right to personal privacy and confidentiality of his or her personal and medical records for four (Residents #1, Resident #2, Resident #3, and Resident #4) of four Residents reviewed for privacy issues, in that: 1. RN A did not lock her electronic health record computer screen on 07/06/2024, exposing Resident #1, Resident #2, Resident #3, and Resident #4's medical records to the community residents and visitors. This failure could place residents at risk for embarrassment, poor self-esteem, and unmet needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. The facility failed to ensure dietary staff facial hair was fully covered by beard restraints. The facility failed to ensure dietary staff used proper hand hygiene during meal preparation. The facility failed to ensure refrigerated food items were dated and properly sealed. The facility failed to ensure pantry food items when opened were dated and properly sealed. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure the assessment accurately reflected the resident's status for 1 resident (#6) out of 24 residents reviewed for MDS assessments. Resident #6's quarterly MDS assessment dated [DATE] did not accurately reflect he had Hospice as a service provider and he was not on a therapeutic diet. This deficient practice could affect residents with MDS assessments and could result in inaccurate care.

Inspectors wroteBased on interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 residents (Resident #6, Resident #10) of 12 residents reviewed for care plans. 1. The facility failed to ensure Resident #6's bowel status was reflected in the resident's care plan (undated). 2. The facility failed to ensure Resident #10's code status was not reflected in resident's care plan. These deficient practices could place residents at risk of not receiving proper care and services.

Inspectors wroteBased on interview and record review the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments person-centered care plan to reflect the current condition for 2 of 12 residents (Resident #8 and Resident #88) reviewed for care plan revisions. 1. The facility failed to ensure Resident #8's care plan was updated to reflect she was not on contact isolation for shingles. 2. The facility failed to ensure Resident #88's care plan was updated to reflect DNR (do not resuscitate) code status. This deficient practice could place residents at risk of not receiving appropriate interventions to meet their current needs.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for one of one facility treatment cart observed. The facility failed to ensure the treatment care was secured when unattended. This deficient practice could affect residents and visitors and result in misappropriation of medications and injury. The finding was: Observation on 03/26/24 at 10:44 a.m. the facility treatment cart left unsecured During observation and an interview with LVN E on 03/26/2024 at 10:46 a.m., who then secured the cart, stated the cart was not supposed to be left unsecured Items in the cart included: antibiotic ointment, syringes and needles, and wound care cleanser and dressing supplies. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 2 of 4 residents (Resident #10 and #85) reviewed for infection control, in that: 1. The facility failed to keep Resident #10's indwelling urinary catheter drainage bag from touching the floor, and CNA F placed it onto Resident #10's bed after it was on the floor when she performed catheter care for the resident. 2. The facility failed to keep Resident #85's indwelling urinary catheter bag from touching the floor and CNA G placed the bag which touched the floor onto the bed and then into the resident's lap when she transferred her from the bed to her wheelchair. [...]