Albuquerque Heights Healthcare and Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure dental services were obtained to replace dentures (removable plate or frame holding one or more artificial teeth) for 1 (R #5) of 1 (R #5) resident reviewed for dental care and services. This deficient practice could likely result in the residents not receiving dental care and services to meet their needs. The findings are: A. Record review of the facility's dental service policy dated 09/15/25, indicated the facility is responsible for the loss or damage of dentures when the loss or damage is due to the facilities staff's misplacement, inadvertent disposal, and/or destruction of the dentures. B. Record review of R #5's face sheet revealed R #5 was admitted into the facility on [DATE] with the following diagnosis: Severe protein calorie malnutrition (an imbalance between the nutrients your body needs to function and the nutrients it gets). C. Record review of R #5's Brief Interview of mental Status (BIMS; a screening for cognitive…

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 develop a comprehensive care plan that included interventions for transfer assistance consistent with the resident's assessed needs and physician orders for 1 (R #4) of 1 (R #4) resident reviewed. If the facility fails to develop and implement a comprehensive care plan regarding a resident's transfer requirements, then staff may attempt unsafe transfer methods that increase the risk of falls, fractures, and other serious injuries. The findings are: A. Record review of the facility's Transfer and Lift policy, dated 03/01/24, stated residents requiring extensive or total assistance with transfers must be transferred using a mechanical lift with the assistance of two trained staff members. B. Record review of R #4's face sheet showed she was admitted to the facility on [DATE], diagnosis of muscle weakness. C. Record review of R #4's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 07/03/2025, 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.

Based on observation and interview, the facility failed to maintain a homelike environment when the facility did not have enough bath towels and face cloths for the residents. This deficient practice could cause residents to miss a shower if there are not enough towels available. The findings are: A. On 06/09/25 at 10:55 am, during an interview, Certified Nursing Assistants (CNA) #15 stated the facility was always short on linens, such as sheets and towels. She stated there were times when they opened the linen storage closet, and there were not any linens at all. She stated she went to other units to get what they needed, but the other units did not have much either. B. On 06/09/25 at 11:22 am, during an interview, Family Member (FM) #1 stated she will try to clean up R #1, but there was often not any towels or facecloth for her to use. She stated the facility frequently did not have enough clean linens available. C. On 06/09/25 at 12:15 pm, during an interview, the Housekeeping Director (HD) stated they did not have enough linens. She stated the management staff ordered new towels…

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 ensure resident records were complete when staff did not document the evening meal percentages for 9 (R #1, #2, #3, #4, #5, #6, #7, #8 and #9) of 9 (R #1, #2, #3, #4, #5, #6, #7, #8 and #9) residents reviewed for meal intakes. This deficient practice could likely cause the Registered Dietician (RD) to not implement nutrition interventions if the meals were not documented for the RD's consideration during resident record reviews. The findings are: A. Record review of the meal intakes, dated 05/12/25 through 06/10/25 indicated staff did not document the evening meals for R #1, #2, #3, #4, #5, #6, #7, #8 and #9. B. On 06/10/25 at 7:21 am, during an interview, Registered Nurse #3 stated she was not sure which shift should document the dinner meal intakes. She stated the dinner meal trays were still coming out, and residents were still eating dinner during the staff shift change. She stated the dinner meal intake documentation should be done by the evening shift staff. C. On 06/10/25 at 7:28 am, during an interview, Registered…

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 ensure the Minimum Data Set (MDS; a federally mandated comprehensive assessment of a resident's functional, medical, psychosocial and cognitive assessment completed by facility staff) was accurate for 1 (R #61) of 1 (R #61) resident reviewed for MDS assessments. This deficient practice could result in failure to provide adequate care and treatment of the resident's needs. The findings are: Cognition A. Record review of R #61's face sheet revealed an admission date of 01/03/24 and included the following diagnoses: - Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgement.) - Other symptoms and signs involving cognitive function and awareness. This is not an all inclusive list. B. Record review of R #61's MDS, dated [DATE], revealed the following: - Brief Interview for Mental Status (BIMS; screening for cognitive impairment) was not completed due to resident was rarely or never…

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 observation, interview, and record review, the facility failed to provide a light meal or a snack for 1 (R #177) of 1 (R #177) before the resident left the facility to go to dialysis (a medical treatment which filters waste and excess fluid from the blood.) This deficient practice could potentially cause prolonged recovery time for the resident after dialysis. The findings are: A. Record review of the facility's Dialysis Policy, last revised on 08/07/23, revealed nutritional/fluid management included the provision of meals before, during, and after hemodialysis (dialysis) and monitoring intake and output measurements as ordered. B. Record review of R #177's face sheet revealed the resident was admitted to the facility 03/19/25, with the following diagnoses: - Non-st elevation (NSTEMI) myocardial infarction (a heart attack that happens when a part of the heart is not getting enough oxygen), - Congestive heart failure (the heart cannot supply enough blood to meet the body's needs), - Ischemic cardiomyopathy (a type of heart failure caused by low blood flow to the heart…

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 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 2 (R #6 and #38) of 2 (R #6 and #38) residents sampled for ADLs when staff failed to: 1) Change R #6's soiled brief prior to assisting him to bed. 2) Clean and change R #38's ileostomy (a surgically made opening that connects your small intestine to your abdominal wall) bag. These deficient practices could likely result in residents being at a higher risk for infection and to feel unimportant, embarrassed and undignified. The findings are: R#6 A. Record review of R #6's face sheet, dated 07/23/24, revealed an initial admission date of 03/25/24. B. Record review of R #6's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 03/22/25, indicated R #6 required substantial staff assistance for toileting hygiene. C. Record review…

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 observation and interview, the facility failed to ensure residents had a safe and functional environment for resident rooms 205, 206, 207, 208, 211, and 213 when staff failed to: 1) Replace a broken plastic disposable glove holder in room [ROOM NUMBER] and 208. 2) Repair ripped flooring near a resident bed in room [ROOM NUMBER]. 3) Repair the hand rail end piece outside of room [ROOM NUMBER]. 4) Repair or replace a broken closet, a broken dresser, missing dresser drawer, broken blinds, and ripped flooring near the resident's bed in room [ROOM NUMBER]. 5) Maintain the shower in room [ROOM NUMBER] free of the storage of random items. 6) Replace broken blinds, cleaning a wall, and ensuring the room was free from a pungent (strong) urine odor in room [ROOM NUMBER]. This deficient practice could likely result in residents living in an unsafe environment, could increase their risk for injuries, and decrease their quality of life. The findings are: A. On 04/08/25 at 11:20 am, observation of resident room [ROOM…

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 provide mental health services for 1 (R #57) of 1 (R #57) resident after the resident witnessed his roommate unconscious and unresponsive as staff performed life saving procedures on the roommate. If residents are not provided with mental health services, then residents are likely to experience a decline in their psychosocial well-being. The findings are: A. Record review of R #33's face sheet revealed R #33 was admitted on [DATE] with a diagnosis of major depressive disorder. B. Record review of R #33's progress notes, dated [DATE], revealed R #33 was found unconscious in the bathroom of a suspected overdose of street drugs. R #33's son and R #57 (roommate) were in the room. Registered Nurse (RN) #1 and Physician Assistant (PA) performed cardiopulmonary resuscitation (CPR; full code, an emergency procedure that combines chest compression with artificial ventilation) on R #33. C. Record review of R #57's face sheet revealed R #57 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.

Based on record review and interview, the facility failed to discontinue a duplicate order of carvedilol (a blood pressure medication used to prevent high blood pressure and strokes in persons with heart disease or hypertension) for 1 (R #61) of 1 (R #61) resident reviewed for unnecessary medications. This deficient practice is likely to result in a resident failing to obtain maximum wellness or suffering prolonged illness. The findings are: A. Record review of R #61's face sheet, undated, revealed an initial admission date of 01/03/24 and included the following diagnoses: - Cerebral infarction (stroke) due to embolism (obstruction in a blood vessel) of bilateral (both sides) middle cerebral (relating to the brain) arteries. - Paroxysmal (sudden occurrence or increase of symptoms) atrial fibrillation (Afib; a type of irregular heartbeat.) - Essential (primary) hypertension (high blood pressure.) B. Record review of R #61's Medication Administration Record (MAR), dated April 2025, revealed the following: - Start date 04/04/24, End date: None. Carvedilol tablet 3.125 milligrams (mg).…

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 observation and interview, the facility failed to protect a treatment cart (a movable piece of equipment used in healthcare facilities to store, transport, and dispense treatment supplies and tools) from unauthorized access when staff failed to lock the treatment carts while staff were away from the cart. This failure had the potential to affect all 48 residents on the 300 Unit, as identified by the Resident Census provided by the Administrator on 04/07/25. If staff fail to lock an unsupervised treatment cart, then residents could obtain medial equipment which could result in injury or death. The findings are: A. On 04/07/25 at 11:50 AM, during an observation of the 300 Unit, the intravenous (IV; in the vein) treatment cart was unlocked and opened. Further observations revealed the cart had sterile needles and intravenous catheters (a thin, flexible tube inserted into a vein to deliver fluids). Staff were not present in the area near the cart. B. On 04/07/25 at 11:55 AM, during an interview, Registered Nurse (RN) #1 stated the IV treatment cart was unlocked and opened. 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.

Based on observation and interview, the facility failed to serve a meal that had been at a palatable temperature for 1 (R #177) of 1 (R #177) resident when staff left the resident's lunch tray on the bedside table while the resident was at dialysis. This deficient practice could cause a resident to not eat her lunch and could cause weight loss. The findings are: Cross referenced to F658 A. Record review of R #177's face sheet revealed the resident was admitted to the facility 03/19/25 with the following diagnoses: - Non-st elevation (NSTEMI) myocardial infarction (a heart attack that happens when a part of the heart is not getting enough oxygen), - Congestive heart failure (the heart cannot supply enough blood to meet the body's needs), - Ischemic cardiomyopathy (a type of heart failure caused by low blood flow to the heart muscle), - Type II diabetes (means that your body does not use insulin properly), - End stage renal disease (kidneys reach advanced state of loss of function), - Dependence on renal dialysis (a blood purifying treatment given when kidney function is not optimum.)…

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 interview and record review, the facility failed to promptly notify the ordering provider of critical laboratory results for 1 (R #180) of 1 (R #180) resident reviewed for change in condition. This deficient practice could cause a delay in treatment, creating a potential for harm or death to the resident. The findings are: A, Record review of R #180's face sheet revealed an admission date of 02/27/25 with the following diagnoses: - Hepatitis C (inflammation of the liver), - Type II diabetes mellitus (DM2, a condition which results from insufficient production of insulin, causing high blood sugar), - Angina pectoris (a type of chest pain caused by reduced blood flow to the heart) with presence of aortocornonary bypass graft (heart bypass surgery; a procedure to restore blood flow to areas of your heart), - Right foot amputation (loss of foot), - Stage 4 severe chronic kidney disease (severe loss of kidney function), - Staphylococcus (bacteria that causes infection) - Psoas muscle (located in the pelvic area) abscess (collection of puss due to an infection.) B. Record review…

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 ensure ongoing communication and collaboration with the dialysis (clinical purification of blood as a substitute for the normal function of the kidney) facility regarding dialysis care and failed to monitor the resident before and after dialysis treatment for 2 (R #1 and R #2) of 2 (R #1 and R #2) residents reviewed for dialysis care. These deficient practices could likely result in the facility being unaware of the resident's condition, possible complications that arise during dialysis treatment, and residents may not receive the appropriate monitoring and care. The findings are: R #1: A. Record review of R #1's face sheet revealed an initial admission date of 07/24/24 with a diagnosis of end stage renal disease (ESRD; chronic irreversible kidney failure). B. Record review of R #1's physician orders revealed an order, revision date 10/30/24, for dialysis on Tuesdays, Thursdays, and Saturdays at 06:00 A.M. C. Record review of R #1'S Electronic Medical Record (EMR) revealed: 1. Dialysis Communication Record, dated 09/04/24,…

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 ensure the Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) was accurate for 1 (R #10) of 1 (R #10) resident when the MDS Nurse did not document the decline in R #10's weight to reflect R #10's status at the time of the assessment. This deficient practice is likely to result in R #10 not receiving the appropriate care and treatment she needs. The findings are: A. Record review of R #10's Comprehensive admission MDS, dated [DATE], revealed the MDS nurse documented R #10's weight as 180 pounds. B. Record review of R #10's discharge MDS, dated [DATE], revealed the MDS nurse documented the following: - R #10's weight as 163 pounds. - R #10 did not have a weight loss of 5 percent (%) or more in the last month. - R #10 did not have a weight loss of 10% or more in last 6 months. C. Record review of R #10's weight assessments revealed staff documented the following: - On 09/07/24, R #10 weighed 180.2 pounds. - On…

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 interviews and record review, the facility failed to identify a resident at nutritional risk or address the risk factors for impaired nutritional status for 1(R #10) of 1(R #10) resident. When the facility's staff failed to weigh R #10 weekly or when ordered by the facility's provider. This deficient practice could likely lead to the resident to suffer from unplanned weight loss. The findings are: A. Record review of R #10's facesheet dated 09/07/24, revealed the following: -R #10's admission date to the facility was 09/07/24. -R #10's discharge date to an assisted living facility (ALF) was 10/03/24. B. Record review of R #10's care plan dated 09/07/24, revealed Nurse #1 recorded R #10 was at nutritional risk for weight loss. C. Record review of R #10's provider's progress notes dated 09/26/24, revealed the following: 1. R #10 had a poor appetite and there was some concerns for possible weight loss. 2. R #10 had the following diagnoses: - Wedge compression fracture of second lumbar vertebra (a fracture in the spine), - Poor appetite, - Confusion (a decline in cognitive…

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 honor residents' choices for 3 (R #8, R #16 and R #17) of 3 (R #8, R #16 and R #17) residents reviewed for choices when staff failed to: 1. Ensure showers in resident rooms were in working order (including missing faucet knobs and having random items stored in them), which caused R #8 to utilize the community shower only on scheduled days/times rather than choosing the days and times she preferred to shower. 2. Ensure a female staff was available to provide showers per R #16 preference for female staff only for showers. 3. Ensure there were clean towels available for resident showers. These deficient practices are likely to cause frustration and diminish quality of life. The findings are: Resident #8 A. On 08/22/24 at 11:45 am, a random observation of resident shower in room [ROOM NUMBER] revealed there were items stored in the shower, and there was not a faucet knob on the shower. B. On 08/22/24 at 11:48 am during an interview, R #8 stated she would…

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 observation and interview, the facility failed to provide a homelike environment for all residents on the 300 units (residents were identified by the resident census provided by the Administrator on 08/19/24) when they failed to: 1. Repair damaged and broken blinds in rooms 302, 307, 308, 314, 322, and 325. 2. Repair a damaged thermostat that controlled the 300 unit. 3. Repair 11 broken floor tieles and broken toilets in the shower room. 4. Ensure handrails were secured to the wall. 5. Repair four outlet faceplates on the 300 unit which were loose and not secured. 6. Ensure bed frames were not stored in the 300 Hallway. 7. Ensure there were enough towels available for the residents during showers. 8. Repair areas in 12 resident rooms with unpainted patchwork. 9. Repair missing faucet knobs, running faucets, broken blinds, sticky floors, and ensure random items, including medical equipment, were not stored in resident showers. These deficient practices could likely result in residents feeling frustrated,…

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 observation and interview the facility failed to ensure call lights in the residents' rooms were within reach of the resident while in bed or were accessible to them if they were in their wheelchair in the room for 6 residents (R #4, #5, #6, #7, #9 and #10) out of 7 (R #4, #5, #6, #7, #9, #10 and #11) reviewed for call lights. If the call lights are not accessible to the residents then their needs could likely go unidentified. The findings are: A. On 08/20/24 at approximately 12:30 pm, observations of the 300 unit revealed the following: - R #4 was in his wheelchair, and the call light was on the floor by the wall out of reach. - R #5 was asleep in bed, and the call light was observed on the floor out of reach. - R #6 was in bed and ate her lunch. The call light was on the desk behind her where she could not reach it. - R #7 was in her wheelchair by the bed, and the call light was on the floor by the curtain out of reach. - R #9 was in bed and ate lunch. The call light was wrapped around the bed rail behind her where she could not reach it. - R #10 lay in bed and her call…

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 notify the physician or on call physician when facility staff had problems with a wound vacuum (wound vac; a type of therapy to help wounds heal, the device decreases air pressure on the wound and helps it heal more quickly.) functioning properly for 1 (R #3) of 2 (R #3 and R #18) residents reviewed for wound vac care. This deficient practice of not notifying the physician and receiving further orders on how to continue with wound care could cause the wound to worsen or become infected. The findings are: A. Record review of the face sheet for R #3 revealed she was admitted on [DATE] with the following diagnoses: - Third degree burns (a serious injury that destroys all three layers of the skin: the epidermis, dermis, and hypodermis) of multiple sites on the right lower leg, foot, and ankle; - Seizures; - Cellulitis (serious bacterial infection of the skin) of right lower limb. B. Record review of the discharge hospital orders for R #3, dated 06/01/24,…

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 follow physician orders when facility staff were having problems with a wound vacuum (wound vac; a type of therapy to help wounds heal, the device decreases air pressure on the wound and helps it heal more quickly) functioning properly for 1 (R #3) of 2 (R #3 and R #18) residents reviewed for wound vacuum care. This deficient practice of not following physician orders could likely cause the wound to go untreated, worsen, or become infected. The findings are: A. Record review of the face sheet for R #3 revealed she was admitted on [DATE] with the following diagnoses: - Third degree burns (a serious injury that destroys all three layers of the skin: the epidermis, dermis, and hypodermis) of multiple sites on the right lower leg, foot, and ankle; - Seizures; - Cellulitis (serious bacterial infection of the skin) of right lower limb. B. Record review of the discharge hospital orders for R #3, dated 06/01/24, indicated R #3 was discharged from the hospital…

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 observation and interview, the facility failed to keep the residents free from accidents failing to safely secure the arm of his wheelchair for 1 (R #12) of 1 (R #12) residents observed for falls. This deficient practice likely resulted in R #12 falling from R #12's wheelchair that could of resulted in injury. The finding are: A. On 08/20/24 during record review, shows that R #12, facesheet indicated that he suffered from Aphsia following a non-tramaumatic intracerebral hemorrhage (stroke) affecting his right side. B. On 08/20/24 during record review, shows that R #12 has new onset weakness per the residents care plan on 05/16/24. B. On 08/20/24 at 10:40 am, during an interview with Family Member (FM) #1, she expressed concern about R #12's wheelchair arm being broken and not clipping in to the wheelchair correctly when he was in it. She stated the wheelchair was not the proper wheelchair for him, and he did not received his custom wheelchair yet. C. On 08/20/24 at 3:17 pm, during an observation of the 300 unit, nine residents sat in the TV area and yelled out about an…

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 update a resident's care plan for 1 (R #2) of 2 ( R #2 and R #3) residents reviewed for a change in condition. This deficient practice could likely result in residents not receiving the care or treatment needed to ensure their overall safety or ability to maintain their highest practicable well being. The findings are: A. Record review of R #2's face sheet revealed R #2 was admitted to the facility on [DATE] with the pertinent diagnoses of unspecified dementia and other behavioral disturbance. B. Record review of R #2's physician notes, dated 04/14/24, revealed R #2 began to display a new symptom of increased phlegm (a specific type of mucus that originates in your lungs and throat). C. Record review of R #2's physician orders, dated 04/15/24, revealed an order for a suction machine at bedside as needed. D. Record review of R #2's care plan, last reviewed on 03/25/24, revealed staff did not document the need for a suction machine at bedside. E. On…

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 observation and interview, the facility failed to ensure food was stored, prepared, distributed, and served to residents in accordance with professional standards of food service safety when staff failed to: 1. Ensure all food items in the kitchen refrigerator and freezer were stored properly. 2. Ensure the kitchen pots, pans, and cooking utensils were cleaned properly. 3. Ensure the sanitizer sink water had the appropriate amount of sanitizer. 4. Ensure all food items are served at the appropriate temperature. These deficient practices are likely to affect all 127 residents identified on the resident census list provided by the Administrator on 1/22/24. These deficient practices are likely to expose residents to food borne illnesses. The findings are: Food Storage findings: A. Observation on 01/22/24 at 1:10 pm, during initial observation of the facility's food storage area, revealed the following: 1. One pack of 12 count (ct) flour tortillas opened to air and not dated. 2. One pack of French toast (6 ct.) opened to air and not dated. 3. One 30 pound (lb) box of vegetables…

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 observation, record review, and interview, the facility failed to promote care with dignity and respect for 5 (R #'s 18, 23, 47, 53, and 65) of 5 (R #'s 18, 23, 47, 53, and 65) residents reviewed during random observation when staff failed to : 1. Serve all residents who were sitting at the same table in the 300 unit a meal at the same time. 2. Ensure Spanish speaking resident had proper intervention for their language barrier in place. These deficient practices are likely to result in residents feeling as if their feelings and preferences are unimportant to the facility staff. The findings are: Findings related to meals A. On 01/26/24 at 6:20 pm during a dinner observation in the 300 unit: 1. R #'s 18, 47, 53, and 65 sat at the same table. 2. At 6:25 pm, staff served R #47 her dinner tray, and R #'s 18, 53, and 65 watched her eat. 3. At 6:49 pm, staff served R #65 his dinner tray, and R #'s 18 and 53 watched R #47 and #65 eat. 4. At 6:51 pm, R #53 was served her dinner, and R #18 watched R #47, 53, and 65 eat. 5. At 6:53 pm staff served R #18 her dinner tray. B. On…

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 observation, record review, and interview, the facility failed to provide reasonable accommodation of needs for 7 (R #'s 11, 20, 23, 39, 55, 68 and 89) of 7 (R #'s 11, 20, 23, 39, 55, 68, and 89) residents when staff failed to: 1. Ensure call light were within residents' reach for R #'s 11, 20, 39 and 68. 2. Ensure residents attended medical appointments for R #'s 23, 55, and 89. These deficient practices are likely to result in the residents not being able to call for help when needed, and residents not receiving the appropriate medical care as desired resulting in an exacerbation (to make worse) of current medical conditions. The findings are: Call lights A. Record review of the care plan for R #11, revised on 05/01/21, revealed staff to place the call light within resident's reach while in bed or close proximity to the bed. B. Record review of the care plan for R #20, revised on 10/21/16, revealed staff to place the call light within resident's reach while in bed or close proximity to the bed. C. On…

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 notify residents of the findings of their grievances. This deficient practice could likely result in the facility not considering the needs of the residents and lead to a decrease in resident quality of life. The findings are: A. On 01/26/24 at 11:14 AM during an interview with Resident's Council members, residents stated the facility sometimes notified them of the results of their grievances in writing, sometimes verbally, and sometimes not at all. The residents said the facility was not consistent. B. Record review of the resident grievance forms for the last three months months revealed the forms were blank under the resolution of grievance section for all grevience forms filed. C. On 01/26/24 at 8:56 AM during an interview with Activities Director (AD), he stated he verbally took resident council grievances to the department heads. He said the department heads gave him a verbal response, and he discussed the responses at the following month's resident council meeting. The AD stated there was not a written follow-up for…

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 observation, record review, and interview, the facility failed to maintain an environment that was clean, in good condition, and free from wall debris for 8 (R #'s 5, 22, 24, 45, 67, 80, 81, and 87) of 8 (R #'s 5, 22, 24, 45, 67, 80, 81, and 87) residents sampled for a homelike environment. 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. The findings are: A. On 01/23/24 at 11:17 am during an observation of resident occupied room [ROOM NUMBER], a scrape, which measured approximately 2 foot (ft) in length and 1 ft in height, had exposed drywall and was located by the baseboard on a wall near the bathroom. There were also eight unpainted drywall patches in various sizes on the wall. B. On 01/31/24 at 9:02 am during an observation of resident occupied room [ROOM NUMBER], a scrape, which measured approximately 2 ft in length and 7 inches in height, had exposed drywall and was located by 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 record review and interview, the facility failed to ensure the care plan was revised for 2 (R #22 and #27) out of 2 (R #22 and #27) residents reviewed when staff failed to: 1. Update a care plan to reflect CPAP (continuous positive airway pressure; a machine that keeps your airways open while you sleep so you can receive oxygen) use for R #22. 2. Conduct quarterly care plan meetings as required for R #27. These deficient practices are likely to result in staff not being aware of residents' care needs and preferences, and residents not receiving the needed care. The findings are: Findings for R #22: A. Record review of R #22's face sheet revealed R #22 was admitted into the facility on [DATE]. B. Record review of R #22's physician orders dated 05/04/21 revealed an order for CPAP back-up rate: pending evaluation. Oxygen liter flow at two liters (L). Apply at bedtime and remove in morning. Interface type: Nasal pillow/mask/full face mask. Humidification, if appropriate, heated or cool fill humidifier with…

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 observation, record review, and interview, the facility failed to meet professional standards of quality for 2 (R #4 and #62) of 2 (R #4 and #62) residents when staff failed to: 1. Change R # 4's empty oxygen (O2) humidifier. 2. Change O2 tubing per physician orders for R #62. If the facility is not changing and labeling oxygen tubing then residents are likely to not receive the therapeutic benefits and care needed. The findings are: Findings for R #4: A. Record review of R #4's face sheet revealed R #4 was admitted into the facility on [DATE]. B. Record review of R#4's physician orders, dated 01/31/2024, revealed an order for oxygen at one to six liters (L) per minute via nasal cannula (a small, flexible tube that delivers oxygen to the nose through soft prongs). C. On 1/30/24 at 10:53 am during an observation, R #4's O2 humidifier bottle was empty. D. On 01/30/24 at 10:56 am during an interview with the Director of Nursing (DON), she confirmed R #4's O2 humidifier bottle was empty and should 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 observation, record review, and interview, the facility failed to provide an ongoing program of activities designed to meet the interests and well-being for 3 (R #78, #128 and #143) of 3 (R #78, #128, #143) residents reviewed for activities when staff failed to: 1. Provide meaningful individualized activities based upon residents' interests as identified on their individual care plans. 2. Encourage activities in a convenient community setting. If residents are not provided or encouraged to attend and participate in activities that meet their interests, are enjoyable, and enhance their social and emotional well-being, then they are likely to experience an increase in boredom, isolation, and depression. The findings are: A. On 01/22/24 during observation of the 100 skilled care unit, between the hours of 1:30 pm and 3:30 pm, activity staff were not present and did not offer activities. B. Record review of the daily activity calendar, dated January 2024, revealed the following activities scheduled for…

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 complete an annual performance review of Certified Nurses Aides (CNAs) for 5 (CNAs) #1, #3, #4, #5, and #6) of 5 (CNAs #1, #3, #4, #5, and #6) randomly reviewed. If the facility is not maintaining the annual performance reviews then residents are likely to not receive the appropriate care and services, and the CNA's may not meet the needs of all residents. The findings are: CNA #1 Findings: A. Record review of the facility staffing log revealed CNA #1 was hired on 08/03/21. B. Record review of CNA #1's annual clinical competency validation (annual performance review) could not be completed due to the facility did not provide CNA #1's annual performance review. C. Record review of the facility staffing schedule, dated January 2024, revealed CNA #1 worked 15 days throughout the month. CNA #3 Findings: D. Record review of the facility staffing log revealed CNA #3 was hired on 08/16/22. E. Record review of CNA #3's annual clinical competency validation, dated 02/04/23, revealed a proctor did not sign and validate 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 record review and interview, the facility failed to ensure 2 (R #'s 27 and 53) of 2 (R #'s 27 and 53) residents reviewed for behavioral health concerns received necessary behavioral health care to meet their needs when staff failed to: 1. Ensure R #27 was seen soon by a psychiatric provider after experiencing suicidal ideations while in the facility. 2. Ensure effective communication between the facility and psychiatric (psych) providers and consistent psychiatric services regarding R #53's psych service needs. These deficient practices are likely to result in the residents not receiving the behavioral or mental health care and assistance needed to improve mood and reduce depression and anxiety. The findings are: Findings for R #27: A. Record review of R #27's face sheet revealed R #27 was admitted into the facility on [DATE] with the following diagnoses: 1. Suicidal Ideations (thinking about or planning suicide) 2. Major depressive disorder (a mental health disorder characterized by persistently…

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 ensure Certified Nurse Aides (CNAs) received the required in-service training of no less than 12 hours per year for 3 (CNA #4, #5, and #6) of 5 (CNA #1, #3, #4, #5, and #6) CNAs randomly reviewed for required in-service training. This deficient practice is likely to result in the nurses aides not receiving the necessary training to meet the care needs of the residents. The findings are: CNA #4 Findings: A. Record review of the facility staffing log revealed CNA #4 was hired on 11/21/19. B. Record review of CNA #4 yearly required in-service training, dated 11/21/22 through 11/22/23, revealed CNA #4 completed 6 hours and 28 minutes of training for the year, not the required 12 hours. C. Record review of the facility staffing schedule, dated January 2024, revealed CNA #4 worked 14 days throughout the month. CNA #5 Findings: D. Record review of the facility's staffing log revealed CNA #5 was hired on 06/10/21. E. Record review of CNA #5 yearly required in-service training, dated 06/10/22 through 06/10/23, revealed CNA #5…

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 promote resident choices when staff did not assist residents with a new medication per their request and preference or communicate the status of the medication request for 1 (R #21) of 1 (R #21) residents reviewed for choices. This deficient practice is likely to result in the resident's personal choices, needs, and preferences not being honored. The findings are: A. Record review of R #21's face sheet revealed R #21 was admitted into the facility on [DATE] with the following diagnoses: 1. Parkinson's disease (a disorder of the central nervous system that affects movement) with dyskinesia (uncontrolled jerking, dance-like or wriggling movements). 2. Major depressive disorder. 3. Post-traumatic stress disorder (PTSD; a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event.) B. Record review of R #21's psychiatric progress note, dated 10/30/23, revealed R #21 was found sitting in chair at bedside. 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 record review and interview, the facility did not ensure 1 (R #83) of 3 (R #s 80, 83, and 328) residents reviewed for timely Beneficiary Protection Notification received the correct notifications. This deficient practice can result in confusion for the resident or their representative as to what services they have or do not have financial coverage for under Medicare A. The findings are: A. Record review of Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review for R #83 revealed the record did not contain documentation to show staff issued CMS (Center for Medicare/Medicaid Service) form 10055: Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) to R #83 who intended to continue services. The facility provider initiated the discharge from Medicare Part A services when benefit days were not exhausted. B. On 01/30/24 at 12:13 pm during an interview with the Facility Administrator, he stated staff did not provide CMS 10055 to R #83 prior to discharge, but they should have.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop an effective discharge plan that included a facility provider (Nurse Practitioner (NP), Physician's Assistant (PA), and Physician) for 1 (R #149) of 1 (R #149) residents reviewed for discharge planning (the process of transitioning a resident from one level of care to the next). This deficient practice is likely to result in complicated or unsafe transitions from the facility to the residents' post-discharge settings. The findings are: A. Record review of R #149's face sheet revealed R #149 was admitted into the facility on [DATE] and discharged to a private residence with no home health services on 11/24/23. B. Record review of R #149's physician progress note, dated 11/08/23, revealed the resident had a history of alcohol dependence and was recently admitted to the hospital for confusion, subdural hematoma (a type of brain bleed that occurs within the skull but outside the actual brain tissue) and a mechanical fall (a fall caused by gravity…

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 ensure the resident's ability to perform activities of daily living (ADLs) was maintained for 1 (R # 25) of 1 (R # 25) resident when staff failed to ensure R #25 received restorative therapy (therapy in which a patient trains on abilities they already have to perfect them and helps maintain physical abilities to perform ADLs.) If the facility does not ensure that residents receive restorative services, then the residents are likely to experience a decrease in their ability to walk, transfer, and do other activities of daily living. The findings are: A. Record review of R #25's face sheet revealed R #25 was admitted into the facility on [DATE]. B. Record review of R #25's Occupational Therapy (OT) Discharge summary, dated [DATE], revealed, the resident had good range of movement, to receive restorative range of motion program and therapy band- resistance band routine, per written handout and as needed. C. Record review of R #25's physician orders,…

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 observation, record review, and interview, the facility failed to provide activities of daily living (ADL) assistance for facial hair shaving for 1 (R #27) of 1 (R #27) residents reviewed for ADL care when staff failed to: 1. Offer to shave R #27's facial hair. 2. Provide the correct facial hair shaving equipment for R #27. This deficient practice is likely to affect the dignity and health of the residents. The findings are: A. Record review of R #27's care plan, dated 05/11/23, revealed the following: - Focus: [Name of R #27] was at risk for decreased ability to perform ADLs. - Interventions: Provide cueing for safety and sequencing to maximize current level of function. Arrange resident/patient environment as much as possible to facilitate ADL performance. B. On 01/23/24 at 5:03 pm during an interview with R #27, he stated he did not like his beard, but he did not have anybody to shave him. The resident said he asked a Certified Nursing Assistant (CNA) before to shave him. R #27 had a beard and mustache which measured approximately 1 to 2 inches in length. R #27 stated he…

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 ensure ongoing communication and collaboration with the dialysis (mechanical purification of blood in place of normal kidney function) facility regarding dialyses care and services for 1 (R #23) of 2 (R #23 and #45 ) residents reviewed for dialysis. If the facility is unaware of the status, condition, or complications that arise during dialysis treatment then residents are likely to not receive the appropriate monitoring and care they need. The findings are: A. Record review of R #23 face sheet, dated 01/31/24, revealed he was admitted to the facility on [DATE] with multiple diagnoses to include: - End stage renal disease (advanced disease and failure of the kidneys), - Heart failure, - Dependence on renal (kidney) dialysis, B. Record review of R #23 provider revealed an order, dated 01/17/24, for dialysis at (name of dialysis provider) every Monday, Wednesday, Friday at 6:00 am. C. Record review of a dialysis folder, held at the nurses station,…

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 schedule an appointment for dental services for 1 (R #19) of 1 (R #19) residents sampled for dental services. This deficient practice could likely result in continued dental pain or infection for the resident. The findings are: A. Record review of R #19's Hospital Transfer Orders dated 01/13/24 revealed the following: Other special instructions: Patient needs to see dentistry for evaluation. B. On 01/22/24 at 4:18 PM, during an interview with R #19, she stated she was waiting for staff to schedule a dental appointment for her after her recent hospital stay due to dental problems. C. On 01/26/24 at 1:00 PM, during an interview with the Scheduler, she stated that nursing reviewed the resident's transfer or admitting orders, and they let her know what appointments need to be scheduled for the residents. She further stated she did not receive a request to schedule a dental appointment for R #19. D. On 01/30/24 at 3:43 PM, during an interview with the Director of Nursing (DON), she stated the admitting nurse or unit manager…

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 ensure the medical record was accurate for 1 (R #228) of 1 (R #228) resident reviewed. This deficient practice is likely to result in staff confusion as to the services and treatment provided. The findings are: A. Record review of R #228's face sheet revealed he was admitted to the facility on [DATE] with multiple diagnoses to include: - Sepsis (a life-threatening complication of an infection. Occurs when chemicals released in the bloodstream to fight an infection trigger inflammation throughout the body), - Dementia (a progressive condition in which a person's mental abilities declines), - The resident was discharged from the facility on 12/08/23 at 6:37 pm., to an acute care hospital. B. Record review of New Mexico Department of Health complaint #71174 revealed emergency medical providers (EMT) responded to a call at the facility regarding R #228 on 12/08/23 at 7:30 pm. EMT's transported R #228 to hospital. C. Record review of R #228's 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.

Based on record review and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (R #1) of 3 (R #1-3) residents reviewed for hypoglycemia [a condition in which your blood sugar levels drop below the specified limits (less than 70)] by not ensuring meals are served timely. This deficient practice is likely to result in residents experiencing a change in condition. The findings are: A Record review of progress note for R #1, dated 10/29/2023 at 4:13 PM, revealed R #1 had a hypoglycemic episode at 2:41 PM as lunch was being served. Resident was noted to be awake but slowly leaning to one side and responses slow. The resident's capillary blood glucose (CBG; the amount of glucose/sugar in your blood. Normal is between 70 and 100) test result was 49 CBG. The resident was immediately administered yogurt, orange juice, small amount of ice cream, and glucose gel (medication used to treat very low blood sugar) per standing order. The resident's CBG rebounded to 106 CBG within about 15 minutes. 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.

Based on record review, observation and interview, the facility failed to deliver meals consistently and timely to all 127 residents that receive room trays or eat in the dining room. This deficient practice is likely to cause frustration, hunger, and hypoglycemic episodes [a condition in which your blood sugar levels drop below the specified limits (less then 70)] for residents with diabetes [a chronic medical condition where your blood sugar (glucose) levels are consistently high]. The findings are: A. Record review of meal service times, as posted in the facility, revealed: - Unit 400: Breakfast 6:45 to 6:55 AM, lunch 11:30 to 11:40 AM, dinner 4:30 to 4:40 PM, - Unit 100: Breakfast 6:56 to 7:06 AM, lunch 11:41 to 11:51 AM, dinner 4:41 to 4:51 PM, - Dining room: Breakfast 7:07 to 7:17 AM, lunch 11:52 AM to 12:02 PM, dinner 4:52 to 5:02 PM, - Unit 200 Breakfast 7:18 am to 7:28 AM, lunch 12:03 PM to 12:13 PM, dinner 5:03 to 5:13 PM - Unit 300: Breakfast 7:29 to 7:39 AM, lunch 12:14 to 12:24 PM, dinner 5:14 to 5:30 PM. B. On 11/02/23 at 6:08 PM, during dining observation of the main…

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, interview, and observation, the facility failed to provide sufficient support staff to carry out the functions of food and nutrition services at the facility. This deficient practice is likely to result in the residents' dietary needs not being met and longer waits for meal service for all 127 residents residing at the facility. The findings are: A. On 10/30/23 the following was observed in the facility kitchen: 1. Food items were expired and stored in the facility refrigerators. 2. Food items were not properly labeled and dated. 3. Temperature logs were not utilized 4. Facility was not kept free of dirt/grime/debris. 5. Ice machine was not cleaned according to cleaning schedule. 6. Hand wash sink was not clean and available for use by dietary staff. 7. Correct menu was not posted for the day. 8. Snacks were not available for diabetic residents. 9. Meal services were not delivered on a timely manner B. Record review of dietary schedule, dated 10/22/23 to 10/02/2,3 revealed there were 3 full-time employees and a Dietary Manager scheduled in the kitchen 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.

Based on observation and interviews, the facility failed to provide hydration between meals by not: 1. Ensuring there was process or a responsible department to pass out clean water pitchers/water during the day/night. 2. Ensuring there were water pitchers available for residents use. These deficient practices are likely to affect all 127 residents residing in the facility resulting in residents becoming at increased risk for dehydration. The findings are: A. On 10/26/23 at 11:00 am during initial tour of the facility, water pitchers were not available at residents' bedside tables in several of the residents rooms (rooms 205, 316, 320, 305, 411, 302, 301 and 105). B. On 10/26/23 at 11:20 am during an interview with the Dietary Manager (DM), he stated. We do send out hydration on the meal carts, but other then that, I am not sure how hydration is given. I do not know if every resident has a water pitcher. I have not gotten any water pitcher in the kitchen to be changed out. I need to get a head count so I can order water pitchers. The process would be that the nursing staff would…

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 observation and interview, the facility failed to store and serve food under sanitary conditions.This deficient practice is likely to affect all 127 residents listed on the resident census list provided by the Administrator on 10/26/23 and is likely to lead to foodborne illnesses, if food is not being stored properly and safe food handling practices are adhered to. The findings are: On 10/30/23 at during 11:40 am during initial tour of facility kitchen the following was observed: 1. Expired food items left in the facility refrigerators. 2. Food items stored in the facility refrigerator were not properly labeled and dated. 3. Food service employees did not wear hair restraints (Dietary Manager) and beard restraints at all times while in the facility kitchen (dietary aide). 4. Personal food items stored in the facility refrigerators not dated or labeled. 5. Frozen food items were not properly thawed out (not under running cool water). 6. Cold food items were not kept on ice during meal service. 7. Dirty trash cans uncovered and with trash stored next to food prep stations. 8.…

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 observation, record review, and interview, the facility failed to meet professional standards of quality for 1 (R #1) of 1 (R #1) resident reviewed by not obtaining physicians orders to treat, monitor, and document an injury of unknown origin on R #1's right arm. If the facility is not documenting or monitoring an injury of unknown origin then the resident is likely to not receive the necessary treatment needed to heal the wound. The findings are: A. Record review of R #1's Face sheet identified the resident was admitted to the facility on [DATE] with the following diagnosis: Seizures, contusion, history of falls, anxiety disorder, dysphagia (impaired production of speech resulting from brain disease or damage), and benign prostatic hyperplasia age-related enlarged prostate gland). B. Record review of R #1's care plan, dated 05/06/23, identified resident was dependent for mobility, related to weakness, and required assistance/was dependent for ADL (activities of daily living) care with total assist of 2…

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 ensure documents in resident records were complete and accurate for 1 (R #1) of 2 (R #'s 1 and 2) residents, when they failed to accurately document resident's completed/offered baths/showers. This deficient practice could likely result in staff not having the information they need to provide competent, comprehensive care and services if vital information is missing from the resident's medical documents. The findings are: A. Record review of R #1's face sheet revealed R #1 was admitted to the facility on [DATE] and discharged [DATE]. B. Record review of R #1's care plan dated 03/12/23 revealed, Focus: [Name of R #1] is dependent for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting) related to: debility 2/2 [2 of 2] BLE [bilateral left extremity] weakness and prolonged hospitalization w/ [with] chronic pain. Interventions: Provide resident/patient with total assist of 2 (specify #) for…

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 and interviews, the facility failed to maintain an effective pest control program by not ensuring the facility was free from pests. This deficient practice is likely to expose all 88 residents residing in the facility to the spread of disease/infection by way of carrier (cockroaches, spiders). The findings are: A. Record review of pictures provided by R #2's sister dated 06/26/23, revealed R #2's restroom with cockroaches in his shower. B. On 08/01/23 at 11:34 am during an interview with R #2's sister, she confirmed she saw cockroaches in R #2's shower and took pictures of the insects. R #2's sister also confirmed she informed the Administrator (ADM) of the insect issue. C. On 08/02/23 at 8:09 am during an observation of room [ROOM NUMBER]-A, a spider was observed in room [ROOM NUMBER]-A's shower. D. On 08/03/23 at 10:34 am, during an interview with Maintenance Director (MD), he stated, This problem [with insects] has been on going. Recently, I reached out to our Pest Company to come to 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 interview the facility failed to consistently offer snacks to all 125 residents residing in the facility. This deficient practice is likely to cause frustration and unnecessary hunger with the residents. The findings are: A. On 01/09/23 at 1:46 pm during an interview with R #37, he stated that snacks are not offered during the day or at night and he would like to have a snack. B. On 01/09/23 at 2:56 pm during an interview with R #12 he stated that he is not offered snacks and would like snacks. C. On 01/09/23 at 3:55 pm during interview with R #174 he stated that the facility does not offer snacks. D. On 01/17/23 at 3:50 pm during interview with Registered Dietitian she stated that she puts in orders for evening diabetic snacks. She further stated that residents can request snacks if they would like a snack. The kitchen closes at 7 pm and ordered diabetic snacks are passed out at 10 am, 2 pm and 5 pm. E. On 01/18/23 at 7:49 PM during an interview with Registered Nurse (RN) #2, he stated. All available snacks are for residents that have snacks ordered such as any 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 observation and interview, the facility failed to store and serve food under sanitary conditions by not: 1. Ensuring food and beverage items in the refrigerator, freezer, and kitchen were properly labeled and dated. 2. Ensuring food items in the refrigerator and freezer were properly stored. 3. Ensuring food and beverage items are labeled, dated, and stored appropriately in the 300 unit nourishment refrigerators and freezers. 4. Ensuring food items were not expired in the kitchen refrigerator. 5. Ensuring food items were not stored on the floor. 6. Ensuring the kitchen floor was clean and free from trash and debris. These deficient practices are likely to affect all 125 residents listed on the resident census list provided by the Administrator (ADM) on 01/09/23. If the facility fails to adhere to safe food handling practices residents are likely to be exposed to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins). The findings are: A. On 01/09/23 at…

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 observation, record review, and interview, the facility failed to promote care with dignity and respect for 12 (R #'s 8, 10, 15, 30, 32 ,34, 37, 40, 45, 88, 91, and 175) of 12 (R#'s 8, 10, 15, 30, 32, 34, 37, 40, 45, 88, 91, and 175) residents reviewed during random observation by: 1. Referring to residents that require dining assistance as feeders. 2. Not removing meals from serving trays during meal times for any residents eating in the main facility dining room making it a non homelike environment. These deficient practices are likely to result in residents feeling as if their feelings and preferences are unimportant to the facility staff. The findings are: Dining Assistance/Feeders Findings: A. On 01/11/23 at 4:51 pm during a 300 unit observation, a dry erase board posted at the unit nursing station revealed, Feeders/Cueing: 302B (R #8), 306A (R #88), 307B (R #40), 311B (R #175), 313B (R #37), 315A (R #30), 318A (R #45), 322B (R #10), 323A (R #32), 323B (R #91), 324A (R #15), 325B (R #34). B. On 01/11/23 at 5:42 pm during an interview with Licensed Practical Nurse (LPN)…

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 observation, record review, and interview, the facility failed to provide reasonable accommodations of resident needs and preferences for 2 (R #'s 12 and 15) of 3 (R #'s 12, 15, and 41) residents reviewed by not: 1. Ensuring R #12 had access to his call light. 2. Ensuring R #15 was dressed in his own clothing and not in a hospital gown. These deficient practices are likely to result in residents feeling embarrassed and that their preferences are not important to the facility; and residents being unable to request assistance, such as needing help with transferring, after falling or other acute distress. The findings are: R #12 Call Light Findings: A. Record review of R #12's care plan dated 09/29/22 revealed, Focus: [Name of R #12] is at risk for falls d/t [due to] LLE [left lower extremity] tibia/fibula fracture, (front lower leg) impaired mobility, history of falls/lowering to floor. Interventions: Place call light within reach while in bed or close proximity to the bed. B. On 01/09/23 at 3:03 pm during an observation and interview with R #12, R #12's call light is…

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 ensure that 4 (R #12, 98, 103, and 182) of 4 (R #12, 98, 103 and 182) resident's records reviewed for advanced directives (legal documents that allow you to spell out your decisions about end-of-life care ahead of time) were complete. This deficient practice could likely affect residents' fulfillment of their end of life medical care choices and could likely result in unnecessary suffering for the resident. The findings are: A. Record review of R #12's MOST form (Medical Orders for Scope of Treatment) revealed section C (Artificially Administered Hydration/Nutrition) and section D (who was it discussed with) were left blank. B. Record review of R #98's MOST form revealed section B (Medical interventions), section C (Artificially Administered Hydration/Nutrition) and section D (who was it discussed with) were left blank. C. Record review of R #103's MOST form revealed section B (Medical interventions), section C (Artificially Administered Hydration/Nutrition) and section D (who was it discussed with) were left blank. D.…

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 observation, record review, and interview, the facility failed to maintain an environment that is safe and at a comfortable temperature by not ensuring a functioning thermostat for 1 (R #12) of 2 (R #12 and #28) residents reviewed for room temperatures. This deficient practice is likely to result in residents feeling unsafe or uncomfortable if the facility fails to maintain the building in a safe and homelike environment. The findings are: A. Record review of R #12's face sheet revealed R #12 was admitted into the facility on [DATE] and resided in Room (RM) #304-A. B. On 01/09/23 at 2:55 pm during an interview and observation with R #12, R #12's room (RM #304-A) was noted to be uncomfortably hot. R #12 stated, Its too hot. I don't like it. It's been like this for awhile and I've told them about it. R #12's room thermostat is observed to be at 88 degrees Fahrenheit. R #12 stated he had told various facility staff but was unable to recall staff names. C. On 01/09/23 at 3:07 pm during an interview with…

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 ensure that grievances by residents are responded to timely for 2 (R #3 and #12) of 2 (R #3 and #12) residents reviewed. If the facility is not ensuring that grievances are responded to timely, then residents are likely at risk of continued/repeat concerns and feeling as though their concerns are unimportant to the facility. The findings are: Findings for R #3: A. Record review of R #3's face sheet revealed R #3 was admitted into the facility on [DATE]. B. Record review of R #3's progress notes dated 10/11/22 revealed, Resident c/o [complains of] to Dietary someone had taken money from her wallet, $80 missing since few weeks ago, Per sister [Name of R #3's sister] resident did want some cash on hand and also warned resident you don't need money, I bring you stuff you ask for, resident persistent and given $100 cash, resident went to appt [appointment] yesterday with sister and only had $20 cash in wallet. Call placed to sister and stated she probably…

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 revise the care plan for 1 (R #9) of 1 (R #9) residents reviewed. If the facility is not updating the care plan to reflect the resident's current care areas and treatment, then the facility may not be providing the appropriate care and treatment to meet the residents' needs. The findings are: A. On 01/11/23 at 11:13 am during record review of R #9's medical record revealed: 1. Care Plan dated 04/25/22 identified that resident requires an indwelling Foley catheter (a hollow, flexible tube that is inserted into the bladder through the urinary opening) due to retention (when a person is unable to empty their bladder). 2. Physicians Orders dated 07/14/22 at 5:20 pm revealed that the order for Foley catheter care (orders to clean catheter, empty drainage bag, and to change the catheter if it becomes clogged) were discontinued (removed or stopped). B. On 01/11/23 at 2:29 pm during interview with Certified Nursing Assistant (CNA) #4, she stated. Resident does not have a catheter, she is able to toilet herself and wears briefs,…

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 observation, record review and interview, the facility failed to meet professional standards of quality for 2 (R #'s 8, 59) of 2 (R #'s 8, 59) residents by: 1. Providing oxygen (O2) to R #8 without physician orders. 2. Not labeling, dating, and changing O2 tubing in accordance with physician orders for R #59 If the facility is providing O2 without physician orders, or not changing and labeling oxygen tubing per physician orders, then residents are likely to not receive the therapeutic benefits and care needed. The findings are: Findings for R #8: A. Record review of R #8's face sheet revealed R #8 was admitted into the facility on [DATE]. B. On 01/09/23 at 12:13 pm during a dining observation, R #8 is observed wearing portable O2. C. Record review of R #8's physician orders revealed no order present for O2 use. D. Record review of R #8's O2 Sats (Saturations) Summary dated 01/01/23-01/19/23 revealed R #8 wearing O2 on 18 out of 19 days. E. On 01/09/23 at 12:14 pm during an interview with Certified…

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 provide ADL (Activities of Daily Living) assistance with showering for 1 (R #66) of 2 (R #'s 66 and 78) resident reviewed for showers. This deficient practice is likely to affect the dignity and health of the residents. The findings are A. Record review of R #66's face sheet revealed R #66 was admitted into the facility on [DATE] and resided in Room (RM) #311-B. B. Record review of R #66's care plan dated 10/03/22 revealed, Focus: [Name of R #66] requires assistance/is dependent for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to: Limited mobility. Interventions: Provide resident/patient with total assist of 2 for transfers. C. Record review of the Unit 300 Shower Sheet dated 12/15/22 revealed R #66 should be offered a shower on Tuesday and Friday nights. D. Record review of R #66's Documentation Survey Report dated 12/01/22-12/31/22 revealed R #66 was offered 6 baths/showers…

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 interview the facility failed to ensure that 2 (R #'s 9 and 51) of 2 (R #'s 9 and 51) residents reviewed received care and treatment that met the resident's needs by not updating hospice binders to include hospice notes/records and documenting hospice communication. If the facility fails to communicate with other entities that are providing care it is likely residents physical, mental, and psychosocial well being may decline. The findings are: Findings for R #9: A. Record review of R #9's physician order dated 07/15/22 revealed, Admit to Hospice [Name of Hospice Provider] DX [diagnosis]: Systolic heart failure with protein calorie malnutrition.(heart is not pumping enough blood throughout the body) B. On 01/12/23 at 12:43 pm during an observation, R #9's hospice communication binder was not present at the 300 unit nursing station. (Unit R #9 resides in) C. On 01/12/23 at 12:44 pm during an interview the Unit Manager (UM) #1, she stated, I don't have it [R #9's hospice documentation] up here [300 unit nursing station]. UM #1 confirmed R #9's…

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 complete an annual performance review of 2 Certified Nurses Aide (CNA #5 and #6) of 5 (Certified Nurses Aide #5, #6, #7, #8, #9) randomly reviewed. If the facility is not maintaining the annual performance reviews then residents are likely to not receive the appropriate care, services and may not meet the needs of all residents. The findings are: A. During record review of CNA #5's employee personnel file it was revealed that the last annual performance review was completed on 06/11/21 B. During record review of CNA #6's employee personnel file it was revealed that the last annual performance review was completed on 08/10/18 C. On 01/20/23 at 4:50 pm during an interview with the Director of Nursing, she stated, it would be her expectation that all annual performance reviews be up to date. D. Record review of Nurse Aide Nursing and Certification Policy dated 10/24/22 revealed: 7. The service location must complete a performance review of every nurse aide at least once every 12 months.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure that 1 (R #'s 41) of 2 (R #'s 37 and 41) residents reviewed for behavioral health concerns were receiving necessary behavioral health care to meet their needs by not: 1. Ensuring R #41 was seen by Psychiatry on a regular basis. 2. Ensuring medications recommended by Psychiatry were reviewed and documented as to why R #41 was not provided or administered the medication. This deficient practice is likely to result in the residents not receiving the behavioral or mental health care and assistance they require that has the potential to improve mood and reduce depression and anxiety. The findings are: Psychiatry Visits Findings: A. Record review of R #41's face sheet revealed R #41 was admitted into the facility on [DATE] with the following diagnoses: 1. ADULT FAILURE TO THRIVE 2. SUICIDAL IDEATIONS 3. UNSPECIFIED MOOD [AFFECTIVE] DISORDER 4. RESTLESSNESS AND AGITATION 5. MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED B. Record…

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 ensure monitoring for efficacy (effectiveness) /proper dosing of medication for 1 (R #51) of 1 (R #51) resident reviewed for pain. This deficient practice is likely to result in residents receiving unwarranted medications, with an increased likelihood of negative side effects or drug interactions. The findings are: A. On 01/18/23 8:05 PM , during observation of R #51, she was observed ambulating (walking) throughout the unit via wheelchair, resident did not appear to be in any distress (pain or discomfort). B. On 01/18/23 at 8:08 PM during observation Registered Nurse (RN) #1 asked R #51 if she had pain. R #51 stated that she had a headache and was administered Tylenol extra strength tablet 1000 mg (milligrams) (medication used to treat pain) at 19:52 (7:52 pm). R #51 was not asked her pain level, at 19:56 (7:56 pm) it is documented that medication was effective. C. Record review of Physicians orders with a start date of 07/29/22 revealed Tylenol Extra strength tablet 500 mg (milligram) give 1000 mg by mouth as needed for…

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 observation and interview, the facility failed to: 1. Ensure that medications and supplies are stored securely (locked) and out of reach of residents and visitors on the 100, 300 and 400 units medication and treatment carts. 2. Ensure that expired medications were not being stored with unexpired medications on the 200 units medication cart. 3. Ensure that medications were stored properly and not found out of package and laying in bottom of drawer inside of medication cart on the 200 unit. 4. Ensure that expired medications were not being stored with unexpired medications in the 100 and 300 units medication storage rooms. 5. Failed to label and lock alcoholic beverages for residents found stored inside the medication storage room on the 300 unit. 6. Failed to secure discarded medications by not locking the discarded medications box inside of the 300 units storage room These deficient practices are likely to negatively impact the health of all the residents on the 100, 200,300 and 400 units. Unsupervised…

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 observation, record review, and interview, the facility failed to provide assist devices (3 compartment plate) for 2 (R #11 and 91) of 2 (R #11 and 91) residents reviewed. This deficient practice is likely to result in residents consuming less food resulting in weight loss. Findings for R#11: A. Record review of R #11's Nutritional assessment dated [DATE] and completed by the Registered Dietitian, revealed a recommendation for a 3-compartment plate. (a plate with 3 different eating divided areas) B. On 01/09/23 at 12:22 pm during random lunch meal observation and an interview with the Dietary Manager he confirmed that R #11 should have her meals served on a 3-compartment plate as noted on her meal ticket and she was not. Findings for R #91: C. Record review of R #91's care plan dated 12/12/22 revealed, Focus: [name of R #91] is at nutritional risk r/t [related to]: dysphagia [difficulty swallowing] advanced diet texture, enteral feeds to meet needs when po [by mouth] intake is poor, wt [weight] loss,…

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 promote resident choices for 1 (R #3) of 2 (R #'s 3 and 78) residents reviewed for choices by not assisting residents showers per their requested schedule and preference. This deficient practice is likely to result in the resident's personal choices, poor hygiene and needs and preference not being met. The findings are: A. Record review of R #3's face sheet revealed R #3 was admitted into the facility on [DATE] and resides in Room (RM) #310-B. B. Record review of R #3's care plan dated 08/02/22 revealed, Focus: While in the facility, [name of R #3] states that it is important that she has the opportunity to engage in daily routines that are meaningful relative to her preferences. Interventions: It is important for me to choose between a tub bath, shower, bed bath or sponge bath. C. Record review of the Unit 300 Shower Sheet dated 12/15/22 revealed R #3 should be offered a shower on Tuesday's and Friday's. D. Record review of R #3's Documentation Survey…

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 ensure Pre-admission Screening and Resident Review (PASRR) screening tool had been fully completed for 1 (R #38) of 1 residents (R #38) reviewed for PASRR clearance, prior to admission. This deficient practice is likely to result in residents with physical or intellectual disabilities not receiving needed services. The findings are: A. Record review of R #38 PASRR Level 1 screening tool, completed at an area hospital,(tool needed prior to admission to facility on 06/23/21), Section C, question 1 identified R #38 as having a diagnosis or suspected mental illness. Question 2 was incomplete. Which required an answer to be able to determine if R #38 would need a referral to PASRR prior to nursing facility admission. B. On 01/18/23 at 11:19 am, during an interview with the Social Services Director (SSD), she confirmed all sections should be completed to determine if further services were needed prior to admission, and they were not completed. C. On 01/19/23 at 1:53 PM, during an interview with the Director of Nursing,(DON), 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.

Based on record review and interview, the facility failed to develop and implement a comprehensive person-centered care plan that reflects a dementia diagnosis for 1 (R #37) of 1 (R #37) residents. Failure to develop and implement a resident centered care plan may result in staff's failure to understand and implement the needs and treatments of residents possibly resulting in decline in abilities and a failure to thrive. The findings are: A. Record review of R #37's face sheet revealed R #37 was admitted to facility on 09/09/22 with the diagnosis of UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITH OTHER BEHAVIORAL DISTURBANCE. B. Record review of R #37's care plan dated 10/23/22 revealed no care plan created that addressed R #37's dementia diagnosis. C. On 01/19/23 at 1:59 pm during an interview with the Director of Nursing (DON), she stated, I don't see dementia [in R #37's care plan]. DON confirmed dementia was not care planned for R #37 and should have been.

Based on record review and interview, the facility failed to ensure that 1 (R #56) of 1 (R #56) resident reviewed for hearing assisted devices, received proper interventions and/or appointments to maintain their hearing. If the facility is not assisting residents in accessing treatment and devices to maintain their hearing, then residents are likely to lose their ability to hear compromising their quality of life. The findings are: A. Record review of R #56's care plan dated 03/04/22 revealed, Focus: [Name of R #56] has impaired communication as evidenced by impaired hearing. Interventions: Auditory amplifier to be used as needed for communication, Involve in activities which do not depend on hearing, Provide emotional support and encouragement. B. On 01/12/23 at 2:15 pm during an interview with R #56, she stated, If they [facility] would fix the hearing aides, I'd be able to wear them. I told [Name of Dementia Program Director (DPD)] about it [R #56's hearing aides not working] and the Psychiatrist they [R #56's hearing aides] don't work. These [R #56's hearing aides] don't work…

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 observation, record review, and interview, the facility failed to: 1. Provide dining assistance for R #91 who is triggered for significant weight loss 2. Document/track meal intake percentages for every meal for R #91 for 1 (R #91) of 1 (R#91) resident reviewed for weight loss This deficient practice is likely to result in malnutrition, dehydration, weight loss and decline in resident's well-being. The findings are: A. Record review of R #91's face sheet revealed R #91 was admitted into the facility on [DATE]. B. Record review of R #91's care plan dated 12/12/22 revealed, Focus: [Name of R #91] is at nutritional risk r/t [related to]: dysphagia [difficulty swallowing], advanced diet texture, (food that is nearly regular texture) enteral feeds to meet needs when po [by mouth] intake is poor, wt [weight] loss, request for adaptive equipment at meal times. Interventions: Please administer a bolus feed of Jevity 1.5 [nutritional supplement] if meal completion is [less than] <50% [percent], and…

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 interview, observation, and record review the facility failed to provide meals that taste good, looked appetizing, and were served at the correct temperature. This failed practice has the potential to affect all 125 residents identified on the resident census list provided by the Administrator on 01/09/23. This deficient practice is likely to cause residents to not eat meals which could lead to weight loss. The findings are: A. On 01/09/23 at 1:29 pm during an interview with R #19, he stated, that he felt like he had lost weight because the food was not very good and it was always cold. He further stated that he had asked to get his food warmed up but, he was told that they would come back and warm it up and it was rare that they ever came back to re-warm his food. B. On 01/10/23 at 8:36 am during an interview with R #63 she stated, that the food was often cold when it was brought to her room. C. On 01/11/23 at 10:26 am during observation and an interview with R #78. R #78's breakfast tray was observed to be sitting on the bedside table. R #78 stated, that he had just…

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 observation and interview the facility failed to maintain proper infection prevention practices by not ensuring that aseptic technique (using practices and procedures to prevent contamination from a bacteria, virus, or other microorganism that can cause disease) were followed when administering wound care. This deficient practices are likely to result in contamination, infection and worsening of the wound. The findings are: A. On 01/12/23 at 8:29 am during observation of wound care RN #4 was observed doing a dressing change on R #101 wound, RN #4 was not observed changing her gloves after cleaning the wound and prior to applying a new bandage. B. On 01/20/23 at 3:59 pm during interview with DON when asked is it appropriate for a nurse not to change gloves after cleaning a wound and before placing a new bandage? DON replied No, new gloves should be used after cleaning a wound.