Rio Grande Rehabilitation And Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to provide a rationale to act upon the pharmacist's recommendations in a timely manner for one (#15) of nine residents out of 31 sample residents. Specifically, the facility failed to provide a rationale for not acting upon the pharmacist's recommendations for Resident #15.Findings include: I. Facility policy and procedure The Medication Regimen Reviews policy and procedure, revised 2/25, was provided by the nursing home administrator (NHA) on 4/22/26 at 10:10 a.m. It revealed in pertinent part, Upon receiving the medication recommendation report (MRR) from the pharmacist, the physician reviews and responds to the report. The physician documents in the resident's medical record that the pharmacist's recommendation has been reviewed and what actions were taken to address them. II. Resident #15A. Resident status Resident #15, age less than 65, was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to establish an effective antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for one (#34) of four residents reviewed for antibiotic stewardship out of 31 sample residents. Specifically, the facility failed to ensure Resident #34's antibiotic therapy for a potential urinary tract infection (UTI) was discontinued in a timely manner after the facility received a negative urine culture and sensitivity (C&S - a test that identifies the organism in the urine and determines the most effective antibiotic therapy) report.Findings include:I. Professional referenceAccording to The Centers for Disease Control and Prevention's (CDC) Core Elements of Antibiotic Stewardship for Nursing Homes, (2024), retrieved on 4/27/26 from https://www.cdc.gov/antibiotic-use/hcp/core-elements/nursing-homes-antibiotic-stewardship.html, To track how and why antibiotics are prescribed, providers perform reviews on resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure the resident had the right to be free from involuntary seclusion not required to treat the resident's medical symptoms for one (#2) of one out of seven sample residents.Specifically, the facility failed to ensure Resident #2 was not told to go to her room or taken to her room as punishment for her behaviors. Findings include: I. Facility policy and procedureThe Resident Rights policy, revised December 2021, was provided by the nursing home administrator (NHA) on 7/24/2 at 3:20 p.m. It read in pertinent part, Federal and state laws guarantee certain rights to all residents of this facility. These rights include the resident's right to a dignified existence, to be treated with respect, kindness, and dignity, to be free from involuntary seclusion, to be supported by the facility in exercising resident rights, and to have equal access to quality care.II. Resident #2A. Resident statusResident #2, age greater than 65, was admitted on [DATE].…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to provide person-centered dementia care and services for two (#2 and #1) of seven residents reviewed for dementia care out of seven sample residents.Specifically, the facility failed to:-Implement appropriate person-centered dementia interventions for Resident #2; and,-Implement person-centered dementia interventions for Resident #1.Findings include: I. Facility policy and procedureThe Dementia Clinical Protocol policy, undated, was provided by the nursing home administrator (NHA) on 7/24/2 at 3:20 p.m. It read in pertinent part, For individuals with dementia, the interdisciplinary team (IDT) will identify a resident-centered care plan to maximize function and quality of life.Direct care staff will support the resident with initiating and completing activities and tasks of daily living. The IDT will identify and document resident condition and level of support needed during care planning and review changing needs as they arise. The physician will order…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for four of four staff reviewed. Specifically, the facility had not completed annual performance reviews and/or provided regular in-service education based on the outcome of the reviews for certified nurse aide (CNA) #2, CNA #3, CNA #4 and CNA #5. Findings include: I. Record review CNA #2 (hired on 5/24/19), CNA #3 (hired on 12/8/10), CNA #4 (hired on 7/22/10) and CNA #5 (hired on 4/29/14) did not have an annual performance review completed. The CNAs did not have an in-service education plan based on the outcome of the review. II. Interview The nursing home administrator (NHA) was interviewed on 3/21/24 at 1:10 p.m. She said she could not locate the performance reviews for CNA #2, CNA #3, CNA #4 and CNA #5. She said she was not aware the performance reviews needed to include a regular in-service plan based on the outcome of these reviews. She said going forward she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure three (#36, #40 and #49) of five residents were free from unnecessary psychotropic medications out of 23 sample residents. Specifically, the facility failed to: -Implement effective individualized behavior monitoring in the medical record to determine the efficacy of psychoactive medications for Residents #36, #40 and #49; and, -Ensure consents to review the risks versus benefits were in place prior to administration of psychotropic medications for Residents #40 and #49. Findings include: I. Facility policy The Psychopharmacological policy, dated July 2022, was provided by the nursing home administrator (NHA) on 3/25/24 at 11:57 a.m. It read in pertinent part: Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: -Anti-psychotics, antidepressants, anti-anxiety medications; and hypnotics. Residents, families and/or the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to incorporate recommendations from the preadmission screening and resident review (PASRR) level II determination and evaluation from the State Mental Health Agency in the case of residents with serious mental illness or a related condition for one (#31) of three residents reviewed for PASRR out of 23 sample residents. Specifically, the facility failed to arrange and incorporate recommendations from the PASRR level II notice of determination for Resident #31. Findings include: I. Resident status Resident #31, age [AGE], was admitted on [DATE]. According to the March 2024 computerized physician orders (CPO), diagnoses included bipolar disorder, anxiety and Huntington's disease (a genetic disease causing progressive degeneration of the nerve cells in the brain). The 1/7/24 minimum data set (MDS) assessment revealed the resident had a moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. The assessment revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure proper treatment and assistive devices to maintain vision and hearing abilities for two (#54 and #40) of three residents reviewed for vision and hearing out of 23 sample residents. Specifically, the facility failed to ensure: -Resident #54 had an eye exam; and, -Resident #40 obtained necessary hearing devices. Findings include: I. Facility policy and procedure The Care of Visually Impaired Resident policy, revised March 2021, was received by the nursing home administrator (NHA) on 3/25/24 at 11:56 a.m. It revealed in pertinent part, Residents with visual impairment will be assisted with activities of daily living as appropriate. Assistive devices to maintain vision include glasses, contact lenses, magnifying lenses and any other devices used by the resident to assist with visual impairment. While it is not required that our facility provide devices to assist with vision, it is our responsibility to assist the resident and representatives in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for one (#26) of three residents reviewed for accidents/hazards out of 23 sample residents. Specifically, the facility failed to ensure Resident #26 had an order for a medication (icy hot) found at his bedside. Findings include: I. Resident status Resident #58, age below 65, was admitted on [DATE]. According to the March 2024 computerized physicians orders (CPO), diagnoses included autistic disorder, dementia and fibromyalgia. The 1/12/24 minimum data set (MDS) assessment revealed the resident's cognitive status was intact with a brief interview for mental status (BIMS) score of 15 out of 15. II. Observation and interview The icyhot was at the bedside on 3/20/24 at 9:45 a.m. The icy hot was at the bedside on 3/21/24 at 10:00 a.m. Registered nurse (RN) #2 said icyhot was considered a medication. She said Resident #26 did not have an order for the icy hot nor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to assist a resident in obtaining routine or emergency dental services, as needed for one (#54) of three residents reviewed for dental care out of 23 sample residents. Specifically, the facility failed to ensure dental services were offered to Resident #54. Findings include: I. Facility policy and procedures The Dental Services policy, revised December 2016, was received by the nursing home administrator (NHA) on 3/25/24 at 11:56 a.m. It revealed in pertinent part, Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. Routine and 24 hour emergency dental services are provided to our residents through: -A contract agreement with a licensed dentist that comes to the facility monthly; -Referral to the resident's personal dentist; -Referral to community dentists; or -Referral to other health care organizations that provide dental services. All dental…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to develop and implement policies and procedures related to pneumococcal immunizations for one (#17) of three residents reviewed for vaccinations of 23 sample residents. Specifically, the facility failed to ensure Resident #17 was offered the secondary pneumococcal immunization. Findings include: I. Professional reference The Centers for Disease Control and Prevention (CDC), Pneumococcal Vaccine Recommendations website, revised 9/21/23, retrieved on 3/27/24 from https://www.cdc.gov/vaccines/vpd/pneumo/hcp/recommendations.html read in pertinent part, CDC recommends routine administration of pneumococcal conjugate vaccine (PCV15 or PCV20) for all adults 65 years or older who have never received any pneumococcal conjugate vaccine or whose previous vaccination history is unknown: If PCV15 is used, this should be followed by a dose of PPSV23 one year later. The minimum interval is 8 weeks and can be considered in adults with an immunocompromising…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record review and staff interviews, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in one of one kitchen and for one (#41) of 21 sample residents. Specifically, the facility failed to ensure: -Appropriate hand hygiene by food service staff; -The freezer temperature was below zero degrees Fahrenheit; and -Outdated ready-to-eat foods were removed from Resident #41's room in a timely manner. Findings include: I. Improper hand hygiene A. Professional references According to the Food and Drug Administration (FDA) Food Code (2017), pp. 48-50, foodservice staff shall use the following handwashing procedures: -Rinse under clean, running warm water; -Apply an amount of cleaning compound recommended by the cleaning compound manufacturer; -Rub together vigorously for at least 10 to 15 seconds while paying particular attention to removing soil from underneath the fingernails and creating friction on the surfaces of the hands and arms fingertips, and areas between the fingers; -Thoroughly rinse under clean, running warm water;…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to conduct and document a facility-wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies. Specifically, the facility failed to have a comprehensive facility assessment. Findings include: I. Facility assessment Review of the facility assessment (FA) revealed it was not a comprehensive assessment of the facility's resources necessary to provide daily care to the resident population. The FA was updated on 8/8/19 and reviewed by the quality assurance (QA) committee on 8/23/19. The FA failed to identify the staff competencies necessary to provide the level and types of care needed for the resident population; the physical environment, equipment, services, and other physical plant considerations necessary to care for this population; any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility including, but not limited to, activities and food and nutrition services; the facility's resources,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to maintain readily accessible medical records for each resident. Specifically, the facility failed to have access to all electronic records during the recertification survey. Findings include: I. Notification Upon arrival to the facility on [DATE] at 9:20 a.m, the nursing home administrator (NHA) informed the survey team the electronic medical records (EMRs) system used by the facility had been hacked and were being held for ransom across the country. She said all facilities that utilized the EMR system the facility utilized were experiencing the same problem. On 11/18/19 at 9:46 a.m. the NHA informed the survey team the virtual control program interface (VCPI) had been breached and it prevented the facility from accessing all EMRs and emails. She assured the team the facility would continue to work and provide quality of care to the residents. She explained the system went down sometime in the early morning on 11/14/19. She said the medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interviews, the facility failed to provide training to all staff, at a minimum, on dementia management and abuse prevention. Specifically, the facility failed to: -Ensure one of two registered nurses (RNs) reviewed received dementia management training and abuse prevention training; -Ensure two of three certified medication aide (CMAs) reviewed received dementia training and one of three received abuse training; and -Ensure four of six certified nurse aides (CNAs) reviewed received dementia management training, and one of six received abuse prevention training. Findings include: I. Training review The November 2019 staffing schedule was provided on 11/18/19 by the nursing home administrator (NHA). A sample of two RNs, three CMAs and six CNAs included on the schedule were reviewed for compliance with training requirements. Training records revealed: -RN #2 did not have current dementia management training and RN #1 did not have current abuse prevention training. -CMAs #1 and #3 did not have current dementia management training and CMA #2 did not have…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to inform four (#21, #100, #37, and #99) of four residents reviewed for liability notices and beneficiary appeal rights, out of 23 sample residents, both orally and in writing in a language that the residents understood, of their rights and all rules and regulations governing resident conduct and responsibilities during their stay in the facility. Specifically, the facility failed to: -Obtain a signature from the residents' authorized representatives on liability notices provided for Residents #21 and #100, who were unable to understand the information due to severe cognitive impairment; and -Provide notification of Medicare Non-Coverage letters to the beneficiary/representative after verbal notification of Medicare covered services ended for Residents #37 and #99. Findings include: I. Notice of non-coverage regulatory reference The Notice of Medicare Provider Non-Coverage (form CMS-10123) letters, also called Non-Coverage letters, Expedited Appeal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observation and interviews, the facility failed to inform residents on how and to whom a grievance or complaint could be filed. Specifically, the facility failed to: -Provide information to the residents on how to file a grievance; -Ensure the residents had access to the information on how to file a grievance; and -Inform the residents of the name and role of the grievance official. Findings include: I. Facility policy and procedure The Lost, Misplaced or Damaged Items policy, undated, was provided by the nursing home administrator (NHA) on 11/20/19 at 1:22 p.m., and read in part: It is the policy of the facility to maintain all personal belongings for each resident in good condition and located in the appropriate storage areas. When an item or article of clothing is lost, misplaced or damaged, the facility will investigate the problem until the item is found, relocated or repaired when necessary. When a resident, family member, friend, or staff member discovers something missing, the following procedure should be followed: Report missing items to social…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to protect from and prevent abuse for seven (#38, #18, #8, #22, #21, #40 and #5) of seven residents reviewed of 23 sample residents. Specifically, the facility: -Failed to protect Resident #38 from abuse by Resident #46; and -Failed to protect Residents #18, #8, #22, #21 and #40 from verbal and physical abuse from Resident #5, and Resident #5 from bullying and potential retaliatory abuse by other residents. Cross-reference F610, the facility failed to report to state authorities and investigate incidents and allegations of verbal and physical abuse. Cross-reference to F943, the facility failed to provide training to all staff at a minimum on abuse prevention and dementia management. Findings include: I. Resident #38 A. Resident status Resident #38, age [AGE], was admitted on [DATE]. According to the November 2019 computerized physician orders (CPO), diagnoses included type II diabetes mellitus (DMII) and insomnia. The 8/26/19 minimum data set (MDS)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to have evidence that all alleged abuse/neglect violations were thoroughly investigated for nine (#46, #38, #98, #5, #18, #8, #22, #21 and #40) of nine residents reviewed of 23 sample residents. Specifically, the facility: -Failed to thoroughly investigate two altercations caused by Resident #46 towards Residents #38 and #98; and -Failed to investigate verbal and physical abuse by Resident #5 towards Residents #18, #8, #22, #21 and #40. Cross-reference to F600, the facility failed to protect residents from verbal and physical abuse. Cross-reference to F943, the facility failed to provide training to all staff at a minimum on dementia management and abuse prevention. Findings include: I. Resident #46 A. Resident status Resident #46, age [AGE], was admitted on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included depression and malignant neoplasm of prostate. The [DATE] minimum data set (MDS) assessment revealed the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record reviews and interviews, the facility failed to ensure all drugs and biologicals were properly stored in one (AB hall cart) of two medication carts. Specifically, the facility failed to: -Ensure there were no expired medications in the AB hall medication cart; and -Ensure the AB hall medication cart was free from loose tablets at the bottom of the cart. Findings include: I. Facility policy and procedure The Medication policy and procedure, undated, provided by the nursing home administrator (NHA) on 11/19/19 at 11:55 a.m., read in part medication storage shall be properly and safely maintained in accordance with the security requirements of federal, state, and local laws. Individual medications ordered for the patient by the physician shall be dispensed by the pharmacy, and identified with the patient's name, dosage, frequency and date on these containers. II. Loose tablets On 11/19/19 at 9:59 a.m. the AB hallway medication cart was reviewed with certified medication aide (CMA) #3, and the following was observed: -Three loose white oval half tablets were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews, the facility failed to ensure a sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to: -Ensure proper hand hygiene while cleaning residents' rooms; and -Ensure proper hand hygiene during medication administration. Findings include: I. Facility policy and procedure The Infection Control Hand Washing policy and procedure, undated, was provided by the environmental director (ED) on 11/20/19 at 10:08 a.m. It read in part, all personnel working in the facility are required to wash their hands before and after resident contact, before and after performing procedures, and when hands become soiled. II. Housekeeping observations On 11/20/19 at 8:09 a.m., environmental aide (EA) #3 was observed cleaning room E4 and the following observations were made: -After cleaning the toilet of room E4, EA #3 did not remove gloves to perform hand hygiene. -After cleaning the toilet of room E4, while still gloved, EA #3 went into the hallway and opened the housekeeping cart to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure residents were free from physical restraints imposed for purposes of convenience and the least restrictive alternatives were used for one (#5) of three residents reviewed for assistive devices out of 23 sample residents. Specifically, the facility: -Failed to re-evaluate the ongoing use of a personal restraint; and -Failed to have a comprehensive care plan addressing the use of the restraint. Findings include: I. Facility policy and procedure The Restraint and Position Change Alarm Use Policy, revised November 2017, provided by the regional clinical consultant (RCC) on 6/3/19 at 3:13 p.m., included: The use of a physical restraint required consultation with an appropriate health professional such as an occupational or physical therapist. The use of less restrictive devices must be documented in the medical record prior to using the physical restraint. -A restraint shall not be used for discipline, as punishment, for the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY II. Resident #21 A. Resident status Resident #21, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the November 2019 computerized physician orders (CPO), diagnoses included adult failure to thrive, depressive episodes, and chronic kidney disease. The 9/16/19 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of six out of 15. Depressed mood with behavior symptoms were noted. He required extensive assistance for bed mobility and toileting. He required limited assistance with transfers and personal hygiene. B. Record review The care plan, initiated 10/1/18 and revised 7/15/19, identified depression and negative statements and requires antidepressant and antipsychotic medication. Interventions included: medication review quarterly for possible reduction or discontinuance, monitor behavior of self-isolation, and pharmacy consultant review monthly. The October 2019 CPO revealed the following: -Seroquel…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure qualified staff persons in accordance with each resident's written plan of care provided care for one (#5) of three residents reviewed for accidents out of 23 sample residents. Specifically, the facility failed to have a registered nurse (RN) assess Resident #5 following an unwitnessed fall. Findings include: I. Professional reference According to the Scope of Practice-Registered Nurse (RN) and Licensed Practical Nurse (LPN), Title 12, Professions and Occupations, Article 38, Nurses, Colorado Revised Statutes (July 1, 2013) retrieved from https://www.colorado.gov/pacific/[NAME]/Nursing_Laws: -Delegation of nursing function is limited to patients that are stable and where the outcome of the task is predictable. -Assessment function of an LPN includes collecting, reporting and recording objective/subjective data, observing condition or change of condition, and collecting and reporting signs and symptoms of deviation from normal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible, and adequate supervision and assistance devices to prevent accidents were provided, for one (#46) of three residents reviewed for falls out of 23 sample residents. Specifically, the facility failed to keep the room door open, when care was not being provided, for Resident #46 who had a high risk for falls. Findings include: I. Resident status Resident #46, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the November 2019 computerized physician orders (CPO), diagnoses included dementia, anxiety, and depressive disorder. The 11/4/19 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of one out of 15. Extensive assistance was needed for transfers, bed mobility, dressing, toileting, and personal hygiene. II. Record review The care plan,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure no unnecessary psychotropic medication usage for one (#3) of five residents reviewed out of 23 sample residents. Specifically, the facility failed to assess for the continued use of Lorazepam as needed (PRN) drug for Resident #3. Findings include: I. Facility policy and procedure The Chemical and Physical Restraint policy and procedure, undated, provided by the nursing home administrator (NHA) on 11/20/19 at 2:00 p.m., read in part, the resident has the right to be free from any physical restraints imposed and psychoactive drugs administered. Orders for restraints shall not be enforced for longer than 12 hours unless the resident's condition worsens and the care plan should indicate the specific period of time for the use of the chemical restraint. Assessment of the restraint rationale would be continually documented. II. Resident #3 status Resident #3, age [AGE], was admitted on [DATE]. According to the November 2019 computerized physician…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.