Ventana by Buckner

Inspectors wroteBased on observations, interviews, and record review, the facility failed to make information on how to file a grievance or complaint available t the resident for 2 of 2 confidential residents reviewed for grievances. The facility failed to notify residents or their representatives either individually or through prominent postings throughout the facility on how to file a grievance or complaint in an anonymous manner. These failures could affect resident's ability to file a grievance without the fear of discrimination, reprisal, retribution, and their right to anonymously file their grievance.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 1 (300 Hall) out of 2 hallways reviewed for accidents and hazards. 1. The facility failed to ensure that the mechanical lift in Resident #58's bathroom on 300 Hall was locked and secured when not in use. This failure could place residents at risk of falls and/or injuries. Findings Included:Record review of Resident #58's admission face sheet dated 03/18/26 reflected she was a [AGE] year-old female admitted to the facility on [DATE] with active diagnoses that included: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders for 1 of 3 (Resident #90) residents reviewed for parenteral fluids. The facility did not ensure Resident #90's midline dressing was changed per the physician orders. This failure could place residents at risk for receiving care that is not safe and at risk for infectionReview of Resident #90's face sheet dated 03/18/26 reflected she was a [AGE] year old female, and she was admitted to the facility on [DATE]. Admitting diagnoses included, pressure-induced deep tissue damage of left heel, dementia, chronic ulcer of heel and midfoot. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents received proper treatment and care to maintain mobility and good foot health for 1 Resident (Resident #1) of 6 residents reviewed for foot care. The facility failed to provide adequate foot care for Resident #1 who had a standing order for podiatric services. Resident #1's toenails were chipped, thick, and long. This failure could put residents at risk for infection, impaired mobility, and poor foot health as well as a decline in their quality of life.

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 infection of communicable diseases and infections for one of one resident (Resident #1) reviewed for infection control. The facility failed to ensure CNA A performed hand hygiene with gloves change, while providing incontinence care to Resident # 1. These failures could place residents at-risk of cross contamination which could result in infections or illness.

Inspectors wroteBased on interview and record review, the facility failed to assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months for one (Resident #36) of six residents reviewed for quarterly assessments. The facility did not ensure Resident #36's Quarterly MDS Assessment, dated 10/28/24, was completed withing 92 days of the previous assessment. These failures could place residents at-risk of not having their assessments completed timely.

Inspectors wroteBased on interviews and record review, the facility failed to ensure assessments accurately reflected the resident's status for one (Resident #36) of six residents reviewed for accuracy of assessments. The facility failed to ensure that Resident #36's Quarterly MDS Assessment included interviews conducted within the required timeframes. These failures could place residents at risk for not receiving care and services to meet their needs.

Inspectors wroteBased on interview and record review the facility failed to develop and implement an effective discharge planning process that focused on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions for one (Resident #67) of 3 residents reviewed for discharge planning. The facility failed to develop and implement a discharge plan for Resident #67 who's goal was to return to the community. This failure could place residents at risk of not receiving care and services to meet their needs upon discharge.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had a discharge summary that included a recapitulation of the resident's stay, medication reconciliation, and a post-discharge plan of care for one (Resident #67) of 3 residents reviewed for discharge summaries. The facility failed to complete a discharge summary for Resident #67 when he discharged home from the facility. This failure could place residents at risk of a recapitulation of the stay being unavailable to help ensure continuity of care once they went back home.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure its medication error rates were not 5% or greater. The facility had a medication error rate of 23% based on 10 errors out of 43 opportunities which involved 1 of 4 residents (Resident #32) and 1 of 3 staff (LVN A) reviewed for medication error, in that: LVN A crushed medication and mixed all the fourteen (14) medications together and administered through a gastrostomy tube (surgically placed to provide direct access to a human's stomach for supplemental feeding, hydration, or medication) to Resident #32 These failures could place residents at risk of incomplete therapeutic outcomes, increased negative side effects, and decline in health.

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 infection of communicable diseases and infections for one of six residents (Resident #1) reviewed for infection control. CNA Z failed to perform hand hygiene during while providing incontinence care to Resident # 1. This failure could place the residents at risk for infection.

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 the facility's only kitchen reviewed for food safety. 1. The facility failed to ensure two of the four handwashing sinks had a garbage receptacle next to the sink. 2. The facility failed to ensure food items in the refrigerators (4), freezers (4) and dry storage room were labeled and stored in accordance with the professional standards for food service. 3. The facility failed to discard items stored in refrigerator, freezers or dry storage that were not properly labeled or past the 'best buy', consume by or expiration dates. 4. The facility failed to ensure the ice machine filters and vent/grate and outer surface was free from dirt and dust. 5. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and described the services that are to be provided to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Resident #62) of four residents reviewed for care plan. The facility failed to implement Resident #62's care plan to address nutrition and, anticoagulant therapy. This failure could affect residents by placing them at risk for not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the LTC facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, for 2 of 4 residents (Resident #32 and Resident #43) reviewed for care plans. The facility did not update Resident #32's care plan to reflect specific instructions for hospice and end of life. The facility did not update Resident #43's care plan to reflect specific instructions for hospice and end of life. This failure could place residents at risk for not receiving appropriate care and intervention to meet their current needs.