Canyon Transitional Rehabilitation Center, LLC

Based on interviews and observations, the facility failed to provide a clean, homelike environment for all 21 residents who lived on the 400 hall. This deficient practice is likely to result in residents not feeling comfortable, which could affect their psychological well-being. The findings are: A. On 11/25/24 at 8:00 a.m., observation during the initial tour of the building revealed the 400 hall had a strong odor of urine and feces throughout. B. On 11/27/24 at 11:06 a.m., during an interview, R #266 stated she had a bedside commode. She stated she did not always put the lid down, because she frequently needed to use the bathroom. She stated she missed the bedside commode in the past while she tried to open the lid. C. On 11/237/24 at 11:06 a.m., it was observed that R#266 bedside commode sat next to the resident's bed, the lid was up, and urine was in the commode. D. On 11/27/24 at 11:15 a.m., during an interview with Certified Nursing Assistant (CNA) #1, she stated R #266 did not keep the lid on her bedside commode down after she used it, which made the 400-hallway smell of…

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 care that met professional standards for 1 (R #60) of 3 (R #23, #60 and #16) residents when the facility failed to maintain and care for R #60's gastrostomy tube (g-tube; a tube surgically inserted through the abdomen into the stomach and used to provide fluids, nourishment and medications.) This deficient practice is likely to result in residents not receiving proper nutritional needs and also places residents at risk for complications and infections that may affect their quality of life. The findings are: A. Record review of the facility's policy, Enteral Management, dated 03/01/22, revealed staff to provide safe and effective management of enteral tubes. B. Record review of the facility's policy, Enteral Tubes Medication Administration, dated 03/01/22, revealed guidelines for managing complications. Staff directed to do the following: 1. Check first to see the tube was not kinked. 2. If the feeding tube became clogged, then interventions…

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 ensure the medication error rate did not exceed 5 percent (%) for 7 residents (R #25, #32, #52, #130, #131, #132, and #317) of 11 residents (R #3, #16, #25, #31, #32, #45, #52, #130, #131, #132, and #317) reviewed during medication administration. Staff administered 80 medications with 39 errors, which resulted in a medication error rate of 48.75 %. If medications are administered in error, residents are likely to experience less than optimal results from their medication regimen. The findings are: R #25 A. Record review of R #25's physician orders, dated 12/2/24, revealed the following: - Potassium oral tablet (treats hypokalemia; a condition where the level of potassium in blood is lower than normal), 20 milliequivalents (meq). Give one tablet by mouth for hypokalemia at 8:00 am. - Sotalol oral tablet (manages blood pressure), 80 milligrams (mg). Give one tablet by mouth for high blood pressure at 8:00 am. - Sertraline oral tablet (treats depression; a mood disorder that causes a persistent feeling of…

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, observation, and interview, the facility failed to keep a resident free from significant medication errors for 1 (R #132) of 1 (R #132) residents when they failed to administer R #132's vancomycin (an antibiotic medication) intravenous (IV; a tube that is inserted into a blood vessel and used to administer medications, fluids, or nutrition into the bloodstream) medication in a timely manner as per the physician's order. This deficient practice is likely to cause R #132 to have adverse drug effects including but not limited to lowering the effectiveness of the antibiotic treatment and potentially contributes to antimicrobial resistance (when microorganisms, like bacteria, viruses, fungi, and parasites, change and are no longer affected by the drugs used to treat them). The findings are: A. Record review of R #132's face sheet, dated 11/12/24, revealed he was admitted to the facility on [DATE] with multiple diagnoses including but not limited to: - Osteomyelitis of vertebra, lumber region…

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

Based on observations, interviews and record review, the facility failed to: 1. Ensure medication refrigerators did not contain medications that belonged to discharged residents. 2. Ensure nurses and CMAs dated opened insulin (a medication prescribed to help the body turn food into energy and manages blood sugar levels) vials and discarded them within 28 days of opening. 3. Ensure medication carts did not contain medications that belonged to discharged residents. These deficient practices are likely to result in residents receiving medications that are less effective or expired for all 70 residents who reside in the facility, as identified on the census list provided by the facility Administrator on 11/25/24. The findings for the medication refrigerator: A. On 11/26/24 at 10:50 am, during observation of medication refrigerator located inside the medication room, revealed the following: 1. Lispro 10 milliliter multiple-dose vial insulin (a short-acting insulin) vial was open and did not have an opening date. The insulin vial belonged to R #8. 2. Vancomycin (an antibiotic medication)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure advance directives (a document which provides an individual's wishes for emergency and life saving care) were complete for 1 (R #45) of 1 (R #45) resident reviewed for advance directives when staff failed to ensure the resident signed the advance directive. This deficient practice is likely to result in residents receiving unwanted or unplanned treatment during a medical emergency. The findings are: A. Record review of R #45 electronic medical record (EMR) revealed R #45 elected a code status of do not resuscitate [DNR; a medical order that instructs healthcare providers not to perform cardiopulmonary resuscitation (CPR) if a patient's heart stops beating or breathing stops.] B. Record review of R #45's Medical Orders for Scope of Treatment (MOST; an advance directive) form, dated [DATE], revealed the resident did not sign it. C. On [DATE] at 3:48 PM during an interview, the Director of Nursing (DON) stated R #45's MOST form should be signed by…

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 ensure staff completed the comprehensive care plans for 2 (R #23 and R #166) of 2 (R #23 and R #166) residents reviewed for care plans, when staff failed to: 1. Complete care plans for R #23 for the following areas: Activities of daily living (ADL; basic self-care tasks) care, psychotropic medications (medications that affect behavior, mood, thoughts and perception), and respiratory complications; and 2. Complete care plans for R #166 for the following areas: ADL care, cardiovascular (heart) symptoms or complications, oral health, diabetes (high blood sugar levels), anemia (not having enough healthy red blood cells), and anticoagulant (medication that thins the blood) medication use. This failure has the potential to adversely affect staff's ability to implement preventative measures for the residents' health and well-being. The findings are: Resident #23 A. Record review of face sheet for R #23 revealed an admission date of 07/31/24 and included the following diagnoses: - Muscle weakness; - Lack of coordination; -…

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 adequate and timely pain relief for 1 (R #29) of 2 (R #29 and #132) residents reviewed for pain. This deficient practice likely resulted in R #29 to be in significant pain. The findings are: Resident #29 A. On 11/25/24 at 11:14 am, during an observation and interview of R #29, she rubbed her hand and cried. R #29 stated she was in a lot of pain. She stated staff gave her Tylenol a little bit ago, but it did not help. She asked the Certified Nursing Assistant (CNA) #6 to ask the nurse to bring her the medication for her nerve pain, and the CNA stated he would tell the nurse. R #29 stated that sometimes the Tylenol worked and sometimes it did not. She stated her pain level was an 11. B. Record review of the physicians orders for R #29 indicated an order for Tylenol extra strength, oral tablet 500 milligrams (mg). Give two tablets by mouth every eight hours as needed for generalized pain. C. Record review of the medical record for R #29 indicated staff documented the resident's pain level to be a 10 (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 observation and staff interview, the facility failed to maintain proper infection prevention practices when a staff did not perform hand hygiene prior to and after handling medications for 1 (R #132) of 1 (R #132), This deficient practice could likely result in the spread of infectious agents (viruses and bacteria) between the 23 residents in 100 hall. The findings are: A. On 11/25/24 at 9:53 am, during an observation of Nurse #1, she did not perform hand hygiene (a general term that applies to hand washing, antiseptic handwash, and alcohol-based hand rub) prior to administering medications to R #132. B. On 11/25/24 at 9:55 am, during an interview with Nurse #1, she stated she should have performed hand hygiene prior to and after administering medications to R #132.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain an environment that was clean and homelike for 2 (R #7, R #8) of 2 (R #7, R #8) residents reviewed for homelike environment. This failure had the potential to affect all 69 residents identified on the resident census provided by the administrator on 10/30/31. If the facility fails to maintain resident rooms in a safe and homelike environment then residents are likely to feel uncomfortable and could exacerbate (make worse) health issues. The findings are: A. On 10/30/23 at 1:38 pm, during an interview, Family Member (FM) #1 expressed concerns about the the physical environment of R #7's room. FM #1 stated the temperature in R #7's room was too high, and R #7 was completely soaked in sweat. She stated R #7 asked her to turn down the thermostat, but that did not seem to affect the temperature. FM #1 also stated the second concern was a problem with the sink. There was an odor, and it appeared that sewage was backing up. Things were not draining…

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 staff maintained accurate medical records for 1 (R # 3) of 7 (R # 1, R # 2, R # 3, R #4, R #5, R #6, and R #7) reviewed for charted pain medications in the electronic medication administration record (EMAR). This deficient practice could likely result in residents receiving more narcotic [a drug that in moderate doses dulls the senses, relieves pain, and induces profound sleep, but in excessive (more than necessary) doses causes coma (a deep state of not being awake or aware of things around you), convulsions (a medical condition in which muscles contract and relax rapidly and repeatedly resulting in uncontrolled shaking), or seizures (sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness)]. The findings are: A. Record review of R # 3's face sheet revealed she was admitted to the facility on [DATE]. B. Record review of R #3's Physician orders revealed: 1. Oxycodone…

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 the Ombudsman (long term care advocate for residents) in writing with the reason for the transfer/discharge to the hospital for 1 (R #61) of 1 (R #61) residents. This deficient practice is likely to cause the resident the inability to make informed decisions about the resident's care and not have access to an advocate who can inform them of their options and rights. The findings are: A. Record review of R #61's face sheet, dated 08/12/23, revealed an initial admission date of 07/12/23 and included the following diagnoses: - Metabolic Encephalopathy (chemical imbalance in the brain. Caused by a chemical imbalance in the blood); - Hypo-osmolality (condition where the levels of electrolytes, proteins, and nutrients in the blood are lower than normal); - Weakness; - Difficulty walking; - Dysphagia, Oral phase (swallowing difficulties); - Cognitive communication deficit (difficulty with thinking and how someone uses language); - Unspecified Asthma (condition in which your airways narrow and swell and may produce extra…

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, observation, and interviews, the facility failed to provide services that meet professional standards for 3 (R #18, R #63, and R #135) of 3 (R #18, R #63 and R #135) by: 1. Staff did not follow physician orders (R #135), 2. Staff did not document urine output for a resident with severe chronic kidney disease (R #63); 3. Staff did not provide a swallow evaluation and treatment services for a resident with swallowing difficulties/dysphagia (R #18) when indicated. These deficient practices may cause aspiration of a liquid causing the resident to choke if staff do not follow physicians' orders, progressing kidney failure could be occur without staff or the physician being aware if resident urinary outputs are not documented, and choking and aspiration if swallowing difficulties are not screened and treated. The findings are: R #135 A. Record Review of R #135 diet order, dated 08/10/23, read, Consistent carbohydrate (CCD) diet, dysphagia advanced texture, thick liquids-nectar consistency. B.…

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 serve food under sanitary conditions by: 1. Not ensuring all food items of residents' plated meals were covered while being transported from the the meal cart in the hallway into residents' rooms for in-room dining. 2. Not using proper handling techniques when handling cups and glasses when drinks were distributed to residents dining in their rooms. 3. Gloves not being removed and hands not being sanitized by staff. These deficient practices are likely to affect all 70 residents listed on the resident census list provided by the Administrator on 08/14/23 and could likely lead to foodborne illnesses in residents if safe food handling practices are not adhered to. The findings are: A. On 08/14/23 at 12:06 pm, during an observation of the lunch meal in the dining room, Certified Nursing Assistant (CNA) #4 was observered adjusting R #29's wheelchair lock at his table. After adjusting the locks, CNA #4 continued to pour juice and water from pitchers 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 interview, observation, and record review, the facility failed to provide infection control practices by not: 1. Performing hand hygiene between residents 2. Changing out gloves between direct care 3. Not Donning (applying personal protective equipment) and Doffing (taking off PPE) between residents on isolation 4. Cleaning the glucometer (an instrument used to measure sugar in the blood) after resident use. These deficient practices could likely result in the spread of infectious agents (viruses and bacteria) between the residents and/or staff. The findings are: Hand Hygiene: A. Record review of the facility's policy control titled, Hand hygiene, revealed Adherence to hand hygiene practices is maintained by all center personnel. Purpose: To improve hand hygiene and reduce the transmission of pathogenic microorganisms (bacterium, virus, or other microorganisms). Process: 1. Perform hand hygiene: 1.1 Before patient/resident care; 1.4 After patient care; 1.5 After contact with the patient's environment.…

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 notify and give written notification to residents for 2 (R #7 and R #48) of 2 (R #7 and R #48) residents reviewed for notification of room change. This deficient practice could likely result in a resident being unprepared for the room change and may lead to feelings of helplessness, anxiety, and frustration. The findings are: R #7 A. On 08/15/23 at 12:30 PM, during an interview, R #7 stated, I didn't know they (the facility) can keep changing my rooms. I was surprised when I came over here (to his current room), and they did not tell me before (moving him and his belongings). R #7 stated he came back from lunch one day and all his things were not in his room. His things had been moved to his current room. R #7 stated he was not made aware that he would be changing rooms, prior to his belongings being moved by the facility. B. On 08/21/23 at 12:29 PM, during an interview, the Director of Nursing (DON) stated residents should be informed prior to being moved to another room, and it should be documented 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 and record review the facility failed to prevent staff to resident exploitation by staff members using a resident's bank debit card to make unauthorized (without the account holders permission) money withdrawal or purchases for 2 (R #50 and #134) of 3 ( R #50, 134 and 136) residents looked at for abuse/neglect. This deficient practice caused undue stress and anxiety for the residents when it was discovered that they had money missing. The findings are: A. Record review of a complaint received on 07/10/23, with allegations of misappropriation (wrongful use of another's belongings, money, etc.) of property, revealed the alleged Perpetrator (a person who commits an illegal or harmful act) was the Business Office Manager Assistant (BOMA) of (name of facility), and she had stolen up to $9000 from the alleged victim R #50. An assignment by the State of NM complaints team was made, and the complaint was investigated along with a re-certification survey starting on 08/14/23. B. On 08/14/23 at 11:30 am, during an interview, R #50 stated she did remember something about her…

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

Based on observations, record review, and interview the facility failed to provide a safe environment free of hazards for 4 (R #31, 29, 121, and 164) of 4 (R #31, 29, 121, and 164) residents reviewed for accident hazards due to: 1. A floor mat that was on the floor in a residents room while the resident wasn't in bed R #164, 2. A wheelchair weight machine not being folded and in it's locked position taking up a large portion of the hallway; 3. By not providing one resident with her helmet when she was out of bed for R #121. These deficient practices could likely cause residents to trip and fall causing bruising, scratches, lacerations (a cut on the skin thought to be a wound) or even broken bones and had the potential to cause R #121 to suffer severe brain damage if she wasn't wearing her helmet and fell, hitting her head where she currently has a soft spot because a portion of her skull was removed. The findings are: R #31 A. On 08/14/23 at 3:56 pm, an observation was made of the wheelchair weight machine being in the down position; meaning a wheelchair could be rolled onto 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 upon observation, record review, and interview, the facility failed to meet professional standards of care for 4 (R #11, R # 39, R #166, and R #168) of 4 (R #11, R # 39, R #166, and R #168) residents reviewed for respiratory care by: 1. Not properly dating and monitoring the oxygen delivery tubing for R #166, R #11, and R #39; and dating the humidifier bottle (bottle of water that provides water to the oxygen to prevent the air from being too dry) for R #168 and R #166. These deficient practices could lead to hypoxia (decreased oxygen to the body) by not supplying enough oxygen and could lead to possible respiratory infections by the oxygen tubing becoming clogged, filled with water condensation, or becoming dirty leading to the reduced flow of oxygen. R #168 A. On 08/15/23 at 10:37 AM, during an observation, R #168 was observed to be taking oxygen. No date was observed on the humidifier bottle (bottle of water that provides water to the oxygen to prevent the air from being too dry). B. Record review of…

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 interview and record review, the facility failed to ensure ongoing communication and collaboration with the dialysis (clinical purification of blood as substitute for normal kidney functioning) facility regarding dialysis care and services for 1 (R #134) of 1 (R #134) resident reviewed for dialysis. If the facility is unaware of residents status, current condition, or any barriers or complications, then residents are likely to not receive the appropriate monitoring and care they need. The findings are: A. Record review of R #134's face sheet indicated that he was re-admitted to the facility on [DATE]. B. Record review of the hospital medical records dated 08/04/23 indicated that R #134 was placed permanently on dialysis. C. Record review of the physician orders indicated that R #134 Dialysis days were: (M/W/F) Monday, Wednesday and Friday Pick up: 1100 Transport to: [name of company] D. Record review of the Medical Records Documents Section indicated that there was one dialysis communication form in 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 observation, interview, and record review, the facility failed to maintain records of controlled substances (drugs that are subject to strict government control because they may cause addiction) on each medication cart. This deficient practice could case the likelihood of controlled substances being diverted (a medical and legal concept including the transfer of any illegal prescribed controlled substances from the individual for whom it was prescribed to another person for any illicit use) and expired medication was found in the medication storage room. The findings are: Narcotic (controlled substance) Logbook: A. On 08/14/23 at 11:35 am during an observation of the 400-medication cart Narcotic book (This is a book used to manually track inventories of prescription medications. This tracks resident prescription intake. It will record when the facility receives the medication for each schedule 2 controlled substance received from the pharmacy, and shift pages to count at the beginning and end of each…

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 obtain laboratory testing for 1 (R #6) of 1 (R #6) residents reviewed for laboratory services. If the facility fails to obtain labs that have been ordered, this could likely cause a delay in services related to her anticoagulant therapy, (commonly known as blood thinners) causing harm to the resident. The findings are: A. Record review R #6's Physicians order dated 01/23/23 revealed she was on Enoxaparin Sodium Injection (is an anticoagulant that helps prevent the formation of blood clots) 40 milligram (MG) two times a day, everyday for DVT (deep vein thrombosis, blood clots in the legs) with no stop date. B. Record review of R #6's pharmacy recommendations revealed she (R #6) had accepted recommendations from her physician on 05/18/23 for the following: Monitor a CBC (Complete blood count is a blood test. It's used to look at overall health and find a wide range of conditions, including anemia, infection and leukemia.) and BMP (basic metabolic panel is a test that measures eight different substances in your blood) 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 and interview, the facility failed to promote care with dignity and respect, for 1 (R #36) of 1 (R #36) resident reviewed, by attempting to restrict R #36's interactions with another resident (R #50) under threat of discharge from facility. This deficient practice could likely result in feelings of living in a hostile environment and feelings of helplessness and fear. The findings are: A. On 08/21/23 at 9:43 am, during an interview R #36 stated he was approached by a previous resident about R #50's problems with her bank account. He stated he was given permission by R #50 to talk to her bank about her account. He stated R #50 was looking for her checks and debit card, which were physically missing from her possession. He stated the representative from R #50's bank later reached out to him to ask if R #50 was still living at the facility. The representative from R #50's bank called R #36, because the bank representative wanted to talk to R #50 about money missing from her account. The bank represented informed R #36 the money missing was from ATM withdrawals. R…

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 residents were aware of and/or understood the risks and benefits of medication they were receiving for 1 (R #11) of 1 (R #11) residents by not informing residents of why a medication was being prescribed and administered and what diagnosis/condition it was treating. This deficient practice could likely result in residents feeling anxious and potentially receiving unnecessary treatment/medication. The findings are: A. Record review of Physicians Orders, dated 08/03/23, for R #11 revealed: - Risperidone (used to treat certain mental/mood disorders) oral tablet, 1 milligram (mg), give 1 tablet at bedtime every day for delusional disorder (is a type of serious mental illness. One can't tell what's real from what is imagined); - Quetipine Fumarate [a medication used for schizophrenia (false beliefs, seeing or hearing things that don't exist, unusual physical behavior, and disorganized thinking and speech), acute manic episodes, and adjunctive treatment for major depressive disorder] oral tablet 50 mg, give 1 tablet…

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 care plan for 1 (R #6) of 1 (R #6) residents. Failure to develop and implement a person-centered care plan could likely result in staff's failure to understand the needs and implement the appropriate treatments for residents; possibly resulting in decline in abilities and failure to thrive. The findings are: A. Record review of Physician's orders, dated 01/24/23, states, Oxygen at 1-6 liters per minute via nasal cannula (tubing placed in the nose) continuously. B. Record review of care plan, dated 01/24/23 and last revised on 07/12/23, revealed the care plan did not address R #6's oxygen use. C. On 08/21/23 at 11:59 am, during an interview, the Director of Nursing (DON) stated oxygen use should be care planned.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This is cited at Past Non-compliance Based on record review and interview the facility failed to initiate a change in condition prompting the physician to be notified for 1 (R #63) of 5 (R # 29, 34, 47, 63 and 120) residents looked at for change in condition. This deficient practice could likely contribute to residents suffering a decline in their health, hospitalization, and death if a change in condition is not identified timely. The findings are: While on survey the facility provided sufficient evidence that the facility corrected the non-compliance and was in substantial compliance at the time of the survey on 08/14/23. On 06/02/23 the facility identified deficient practice, on 06/05/23 the facility began auditing, and initiated a PIP (Performance Improvement Plan) around the facility failing to identify a change in condition (CIC). R #63 passed away on 06/02/23 and there was evidence of ongoing monitoring conducted on a monthly basis and reviewed during the monthly Quality Assessment Performance Improvement…

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 a residents feeding tube was properly taken care of for 1 (R #121) of 1 (R #121) reviewed for feeding tubes. This deficient practice could likely cause infection at the site of the feeding tube if there are no physician orders to continue to clean the area around the feeding tube; and the order to remove the feeding tube had not been followed through with. The findings are: A. On 08/15/23 at 9:22 am, during an interview with Family Member, she stated that her mother's (R#121) feeding tube is not always cleaned. She stated that she is not currently using the feeding tube and it is supposed to be removed. It hasn't been removed yet and it's not getting cleaned as often as it should. B. Record review of the care plan updated on 07/31/23 indicated to continue cleaning peg tube (feeding tube) until removed. C. Record review of the physician orders indicated that on 08/03/23 to remove PEG tube and apply compression dressing. D. Record review of the progress notes dated 08/03/23 at 15:34 (3:34 pm) faxed to [name of…

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 ensure that food was prepared in a form that met a resident's required textured diet (an appropriate consistency of food that can be easily chewed and swallowed) for 1 (R #18) of 1 (R #18) resident observed during random observation. This deficient practice could likely result in a choking incident. The findings are: A. On 08/14/23 at 1:02 pm, during an observation and interview, R #18 received her lunch meal. She stated I can't eat that. I need it shredded. I'm missing part of my dentures and can't chew that good . It was observed that she had a breaded chicken fillet patty on a roll. B. Record review of R #18's meal ticket for 08/14/23 lunch meal, revealed the following: R #18 is on a regular (one that does not include any dietary restrictions)/liberalized (a diet that takes into account not only the person's state of health, physician's orders, and treatments, but also the individual's food preferences) with a dysphagia advanced texture (dysphagia advanced diet includes food that is nearly regular textures…

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 interview and record review the facility failed to have complete and up to date resident records for 1 (R #62) of 1 (R #62) resident looked at for discharge. This deficient practice could cause confusion if minimal documentation is found in the chart for a resident who left Against Medical Advice (AMA). The findings are: A. Record review of medical record indicated that R #62 was admitted on [DATE] and discharged on 06/24/23. B. Record review of the nursing progress notes dated 06/24/23 at 11:34 am indicated that R #62 left Against Medical Advice (AMA) .with meds this morning, all personal items taken by resident. Left facility at approx. 1115H (11:15 am) with sister, denied any pain or discomfort. C. On 08/21/23 at 2:44 pm, during an interview with Licensed Practical Nurse (LPN) #3, he stated that he does remember her (R #62) and that he did discharge her that day 06/24/23. He stated that he doesn't know why she discharged that day but he doesn't remember her being angry. He thinks she was just ready…

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.