Las Palomas Center

Based on record review and interview, the facility failed to ensure medical records were updated and accurate for 1 (R #2) of 1 (R #2) resident reviewed. If resident medical records are not complete, accurate and up to date, then resident care may be delayed or duplicated. The findings are: A. Record review of R #2's face sheet dated 06/05/25 revealed he was admitted to the facility on on 04/01/25. B. Record review of R #2's provider order dated 04/25/25 stated: give Imodium A-D (a medication that treats diarrhea (a condition of frequent watery stools) 1 tablet by mouth every four hours as needed. C. Record review of R #2's daily medication administration record (MAR) dated June 2025 revealed that on 06/03/25, no Imodium A-D had been given as of 06/03/25 at 12:00 pm when the MAR was reviewed. D. On 06/03/25 at 12:10 pm during interview with Licensed Practical Nurse (LPN) 2, she stated that she had given R #2 a dose of Imodium A-D during the morning medication pass at about 8:00 am. She reviewed the MAR and acknowledged the dose of Imodium A-D had not been documented. She stated she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that there was a coordinated plan of care for 1 (R #2) of 1 (R #2) resident reviewed for hospice services. This deficient practice is likely to result in the resident not receiving the services that he needs. The findings are: A. Record review of R #2's admission Minimum Data Set (MDS), dated [DATE], Section O, Special Treatments, Procedures and Programs revealed the resident was on hospice care. B. On 06/02/25 at 12:25 PM during an interview with Hospice Registered Nurse (HRN) #1, he stated that hospice charting is done on a tablet and then printed and given to the facility. He further stated that a hospice binder was brought upon R #2's admission that contained the hospice coordinated plan of care and admitting documentation. C. On 06/03/25 at 8:34 AM during an interview with Licensed Practical Nurse (LPN) #3, she stated that the facility does not have hospice binders, and all hospice documentation is in the Electronic Medical Record (EMR). 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.

Based on record review and interview, the facility failed to ensure the results of all investigations of allegations of abuse, neglect, exploitation, misappropriation and injuries of unknown source were submitted to the State Survey Agency within 5 working days of the incident. This deficient practice likely affects all residents identified on the facility census list. If the facility is not timely investigating allegations of abuse, then residents are at risk of further abuse. The findings are: A. Record review of notice sent to the facility Administrator by the State Survey Agency dated 11/27/24 identified that the 5 day follow up investigations were still pending despite efforts to reach out to the Administrator for (26) facility self reports in which the 5 day follow up investigation was not received. B. On 03/05/25 at 12:56 pm during interview with the facility Administrator and record review of facility self reports and 5 day investigation reports, he confirmed that he is the abuse coordinator and he is the only one responsible for reporting allegations of abuse to the state…

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 a quality care that meets professional standards for 4 (R # 1, 2, 3 and 6) of 4 (R #1, 2, 3 and 6) residents when the facility failed to: 1. Ensure R #1's oxygen (O2) amount was provided as per physician orders. 2. Label and date O2 tubing per physician orders for R #1 and R #2. 3. Ensure there was a physician order for oxygen use before being provided to R #3. 4. Ensure there was a physician order before providing medication/treatment to R #6. If the facility is not following physician orders, then residents are at risk of adverse outcomes and inadequate monitoring of treatment. The findings are: R #1: A. Record review of R #1's face sheet revealed R #1 was admitted into the facility on [DATE]. B. Record review of R #1's physician orders dated [DATE] revealed an order for O2 at 5 liters per minute (LPM) via nasal cannula (thin, flexible tube that provides O2 through ones nose) continuously. C. Record review of R #1'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Extended Survey Based on record review and interview, the facility failed to ensure residents had a written, signed, and dated progress note from their physician after each visit for 8 ( R #'s 8, 9, 10, 11, 12, 13, 14, 15) of 8 ( R #'s 8, 9, 10, 11, 12, 13, 14, 15) residents reviewed for current physician progress notes and documentation. This deficient practice is likely to result in resident's records being incomplete and resident care not being documented and reviewed. The findings are: R #16 A. Record review of R #8 face sheet dated 04/09/25 revealed she was admitted to the facility on [DATE] with multiple diagnoses including: -Acute and Chronic Respiratory Failure. -Chronic Kidney Disease. -Difficulty walking. The face sheet also revealed that primary care provider (PCP) was a doctor of a senior service agency, not a provider connected to the facility. B. Record review of R #8 electronic medical record (EMR) for the past six months revealed there were no progress notes that had been submitted by the PCP or…

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 PAST NON-COMPLIANCE Based on record review and interview, the facility failed to ensure medications were monitored and administered as ordered for 1 (R #s 16) of 1 (R #s 16) resident reviewed for medications not given as ordered by the physician. This deficient practice can result in a resident receiving an excessive dose of the medications that could cause harm and possible death. The findings are: A. Record Review of R #16 face sheet dated 04/01/25 revealed she was admitted to the facility on [DATE] with multiple diagnoses including: -Parkinson's (a chronic, progressive disease of the nervous system) Disease -Age-Related Physical Debility (age related decline of physical function) B. Record review of R #16 provider orders revealed the following orders: -03/10/25 Morphine Sulfate (a narcotic pain relieving medication) 20 mg (milligrams) per 5 ml (milliliter) oral (by mouth) solution. Give 1.3 ml every 4 hours for pain. -03/10/25 Morphine Sulfate 20mg/5ml oral solution. give 1.3 ml every two hours 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 record review and interview, the facility administration failed to ensure a system of receiving timely response from the provider for 8 (R's #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18) of 8 (R's #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18) residents reviewed for physician communications. This deficient practice is likely to result in residents not receiving optimal care and the facility not have knowledge of physician plans and directives. Cross reference to F684 and F711 for further information A. Record review of R #8-15 revealed that each resident was being provided medical care through a senior service provider. B. On 04/02/25 at 12:10 pm during interview with the Director of Nursing (DON), stated that R #10 is one of several residents who are managed by a PCP who is not connected with the facility. She stated that the facility nurses must call this service for orders. DON stated that there have been times when the staff reported to her that the PCP from this service failed 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 observations, interviews, and record reviews, the facility failed to utilize enhanced barrier precautions (an infection control intervention) when performing wound care to 2 (R #4, #5) out of 2 (R #4, #5) residents. Failure to utilize enhanced barrier precautions when performing wound care has the potential to expose the residents to multidrug resistant organisms. The findings are: A. Review of Centers for Medicare and Medicaid Services' (CMS') Enhanced Barrier Precautions in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 03/20/24, revealed the following: - MDRO transmission is common in long term care (LTC) facilities. - Enhance Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of MDRO that employs targeted gown and glove use during high contact resident care activities. - EBP are indicated for residents with wounds, even if the resident is not known to be infected or colonized with a MDRO. B. Record review of R #4's medical record revealed the following: - admission date of 03/25/24. -…

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.

Based on observation, record review, and interview, the facility failed to maintain an environment that was clean, in good condition, and free from clutter for 1 (R #1) of 1 (R #1) residents sampled for a homelike environment by facility staff leaving a bag of soiled linens on the floor in front of the residents doorway. 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. Record review of R #1's care plan dated 07/16/24 revealed R #1 required assistance with ADL (Activities of Daily Living) care such as bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, and toileting due to chronic disease related to Congestive Heart Failure (CHF- when your heart can't pump blood well enough to give your body a normal supply). B. On 02/14/25 at 11:55 am during an observation of R #1's room, a plastic bag filled with soiled linen was left on the floor in front of R #1's doorway. C. On 02/14/25 at 12:01 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 Cross reference to F684 and F686. Based on record review and interview, the facility failed to ensure the discharge Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) was accurate for 1 (R #6) out of 1 (R #6) residents. If staff do not accurately reflect a resident's status in the MDS, then residents are at risk of not receiving the necessary care to maintain or improve their conditions. The findings are: A. Record review of R #6's admission MDS, dated [DATE], revealed the following: - admission date of 11/13/24 from hospital. - Brief Interview of Mental Status (BIMS; a screening for cognitive impairment) score of 15, cognitively intact. - Diagnoses of end stage renal disease (ESRD; chronic irreversible kidney failure), dependence on renal dialysis renal dialysis (the process of removing extra fluid and waste products from the blood when the kidneys are not able to function properly), and depression. - The resident was at risk of developing pressure ulcers (PU; 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 create an accurate baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) within 48 hours of admission for 1 (R #3) of 1 (R #3) resident reviewed for baseline care plans. This deficient practice could likely result in residents not receiving the appropriate care and may place residents at risk of an adverse event (undesirable experience, preventable or non-preventable, that caused harm to a resident because of medical care or lack of medical care) or worsening of current condition after admission. The findings are: A. Record review of R #3's face sheet revealed R #3 was admitted into the facility on [DATE] and was discharged on 01/28/25. B. Record review of R #3's care plan dated 01/23/25 revealed the following care areas were care planned: 1. R #3 had an infection related to a Mutlidrug-resistant Organisms (MDRO). 2. R #3 was at nutritional risk due to inadequate…

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 1 (R #6) of 1 (R #6) resident reviewed for pressure ulcers (a wound caused by prolonged pressure occurring in bony areas of the body) received the necessary treatment and services to promote healing and prevent new ulcers from developing when staff failed to perform wound care for multiple days. Failure to provide treatment for pressure ulcer could cause the wound to worsen and develop sepsis or osteomyelitis (bone infection.) The findings are: A. Record review of R #6's admission Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 11/19/24, revealed the following: - admission date of 11/13/24 from hospital. - Brief Interview of Mental Status (BIMS; a screening for cognitive impairment) score of 15, cognitively intact. - Diagnoses of end stage renal disease (ESRD; chronic irreversible kidney failure), dependence on renal dialysis renal dialysis (the process of removing extra fluid and waste products from the blood when the kidneys are not able to function properly),…

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 provide the required assistance for 1 (R #1) of 1 (R #1) resident reviewed during a random observation of meal time. This deficient practice could likely result in R #1 being at risk for aspiration (accidental inhale food or liquid into the lungs) and choking. The findings are: A. On 12/02/25 at 9:50 am during observation. R #1 ate his breakfast in bed. Staff were not present. B. On 12/02/25 at 10:04 am during an interview with Licensed Practical Nurse (LPN) #1, he stated R #1 was able to feed himself; however, staff check on him to monitor his swallowing. LPN #1 stated R #1 did not require supervision while he ate. C. Record review of R #1's Care Plan, initiated 11/25/24, revealed R #1 was a nutritional risk due to need for thickened liquids and dependence on staff for feeding. Interventions included the following: 1. Feeding assist with all means in upright position. 2. Monitor for signs/symptoms of aspiration. D. Record review of R #1's Nutritional Assessment revealed the following: 1. Dated 08/05/24,…

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.

Based on observation, record review, and interview, the facility failed to ensure 1 (R #1) of 1 (R #1) resident reviewed maintained acceptable parameters of nutritional status when they did not: 1. Monitor R #1's meal intakes, 2. Ensure R #1 received his ordered nutritional supplement. This deficient practice could likely result in resident weight loss and adverse effects. The findings are: A. On 12/02/25 at 9:50 am during observation, R #1 ate breakfast in bed, and staff were not present. R #1 struggled to reach his tray, put food on the utensil, and move his beverage to his mouth. B. On 12/02/25 at 10:04 am during interview with Licensed Practical Nurse (LPN) #1, he stated R #1 was able to feed himself; however, staff check on the resident to monitor his swallowing. LPN #1 stated R #1 did not require supervision while he ate. C. Record review of R #1's Care Plan, initiated 11/25/24, revealed R #1 was at nutritional risk due to the need for thickened liquids and dependence on staff for feeding. Interventions included the following: 1. Encourage resident to chew and swallow 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.

PAST NON-COMPLIANCE Based on record review and interview, the facility failed to ensure residents were free from misappropriation of property for 2 (R #2 and #3) of 2 (R #2 and #3) residents reviewed when a nurse removed the residents' oxycodone (narcotic pain medication) from the medication card for her own personal use. This deficient practice could likely result in a delay or residents not getting the care and treatment needed. The findings are: A. Record review of the facility's self-report for medication diversion, dated 10/24/24, revealed a nurse removed discharged meds [medications] from the med cart and stated she would give them to the DON [Director of Nursing]. B. On 01/02/25 at 2:01 pm during interview with the Administrator and DON, they stated a nurse contacted the former DON regarding Registered Nurse (RN) / Wound Care Nurse #1 taking medications out of the medication cart. The Administrator and DON stated the nurse reported RN #1 told him the medications were discontinued, and she was going to give them to the DON. The Administrator and DON stated the nurse asked 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 interview, the facility failed to ensure call light were in working order for 1 (R #1) of 1 (R #1) resident reviewed during random observation. If the facility is not ensuring a working call light system, then residents and staff are unable to request immediate assistance when needed. The findings are: A. On 01/02/25 at 9:50 am during observation, R #1 sat upright in bed and ate breakfast. R #1 mouthed the word help. Surveyor pressed the call light pinned to the side of R #1's bed. B. On 01/02/25 at 9:51 am during observation, the call light was pressed again, but there was not an audible sound or a light outside R #1's room above the door way. C. On 01/02/25 at 10:04 am during interview with the Licensed Practical Nurse (LPN) #1, he stated R #1 was unable to use his call light. He stated they considered getting the resident a pad (call light trigger), but did not do it yet. LPN #1 confirmed that he was unaware the call light for R #1 was not functional.

Based on personnel file review, interview, and facility policy review, the facility failed to ensure the Activities Director (AD) was a qualified professional who was a therapeutic recreation specialist. This failed practice had the potential to affect all the residents of the facility and not meet the interests of the residents. Findings include: Review of the facility's policy titled, Program Design, revised 08/07/23 revealed, Policy: Centers/Communities must provide, based on the comprehensive assessment and care plan and the preferences of each patient/resident (hereinafter patient), an ongoing program to support residents/patients in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each patient, encouraging both independence and interaction in the community. Recreation services will be designed to meet the individual's interests, abilities, and preferences through group and individual programs and independent leisure…

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, interview, and policy review, the facility failed to ensure staff were taking meal temperatures to ensure they were served at safe temperatures before each meal was served. This had the potential for food borne illnesses and could affect all the residents of the facility who consume food from the kitchen. There were two residents in the sample that were nothing by mouth (NPO). Findings include: Review of the facility's policy titled Food: Preparation, revised 02/2023 revealed, All foods will be held at appropriate temperatures, greater than 135 degrees Fahrenheit (F) (or as state regulation requires) for hot holding, and less than 41 degrees F for cold food holding. Temperature for foods will be recorded at time of service, and monitored periodically during meal service periods. Review of the food temperature logs provided by the Dietary Manager (DM) revealed for the months of April, May, June, and July 2024 revealed April only had documented temperatures from 04/01/24 until 04/14/24. There were no documented meal temperatures for the months 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 interview and policy review, the facility failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) program by not having the Medical Director attend the meetings. This had the potential for the Medical Directors responsibilities to provide care and direction to the facility and residents to go without direct oversite, and the potential to affect all the residents of the facility. Findings include: Review of the facility policy titled, Center QAPI Process, revised 02/13/16 revealed, Policy: The Center is committed to incorporating the principles of Quality Assurance and Performance Improvement (QAPI) into all aspects of the center work processes, service lines and departments. All staff and stakeholders are involved in QAPI to improve the quality of life and quality of care that our patients and residents experience. 2.2 Is composed of the following individuals: 2.2.7 CED, 2.2.2 Center Nurse Executive, 2.2.3 Medical Director. During an interview on 07/19/24 at 2:30 PM, the Medical Director was asked about an incident in which a progress note from…

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, review of maintenance audits, interviews, and review of facility policy, the facility failed to ensure a comfortable and safe environment throughout the building. Broken/shattered windows and windows without screens were observed in a main hallway and in 18 resident rooms (room [ROOM NUMBER], 111, 115, 117, 118, 119, 120, 121, 122, 123, 126, 128, 130, 132, 139, 143, 153, and 161). This failure created the potential for residents to be injured related to broken glass and created the potential for pests to enter the facility through windows without screens. A total of 46 residents were reviewed in the sample. Findings include: Review of the facility's Preventative Maintenance Policy, most recently revised 01/08/24, read, in pertinent part, Each site will have a program in place that schedules preventative maintenance on equipment and the physical plant. Review of an email exchange between the MD and the facility's corporate office dated 04/02/24 was provided to the survey team and read, in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure eight residents (Resident (R)86, R11, R33, R81, R209, R20, R44 and R70) of eight reviewed for oxygen administration out of a total sample of 46 residents received oxygen per nasal cannula according to the physician's order. They failed to ensure there was an order in place for a resident receiving oxygen. This failure had the potential for the resident to receive increased oxygen causing hyperoxia (cells, tissues and organs are exposed to an excess supply of oxygen.) Findings include: 1. Review of R86's admission Record, located in the Profile tab of the electronic medical record (EMR) revealed admission to the facility on [DATE] with diagnoses of Pulmonary Hypertension, Chronic Obstructive Pulmonary Disease (COPD), Acute Respiratory failure with Hypercapnia. Review of R86's quarterly Minimum Data Set (MDS) under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 05/07/24, revealed the Brief Interview for Mental…

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 an effective pest control program within the facility. Flies were observed in multiple areas of the building during the survey. This failure created the potential for cross contamination related to the fly infestation. A total of 46 residents were reviewed in the sample. Findings include: A request for the facility's policy related to pest control was requested by the survey team on 07/18/24, however one was not provided prior to survey exit on 07/19/24. During observations of Resident (R) 80 revealed two flies buzzing around the resident's head and food while she was eating her lunch on 07/15/24 at 1:44 PM, two flies buzzing around the resident's head and landing on her left leg and foot on 07/16/24 at 10:26 AM, one fly buzzing around the resident on 07/16/24 at 1:32 PM, and two flies buzzing around the in the hallway immediately outside of the resident's room on 07/16/24 at 4:15 PM. During an interview with R80 on 07/16/24 at 10:26 AM, the resident swiped at a fly buzzing around her head and stated, They (flies) are…

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, interview, and facility policy review, the facility failed to ensure one of two residents (Resident (R)81) out of a total sample of 46 residents observed was cared for in a dignified way by allowing his Foley catheter bag to be viewed from the doorway of his room. This deficient practice had the potential to cause the resident to be treated and cared for in an undignified manner. Findings include: Review of the facility policy titled, Treatment: Considerate and Respectful, revised on 07/01/19, revealed, Policy: Centers will promote respectful and dignified care for patients in a manner and in an environment that promotes maintenance or enhancement of their quality of life while recognizing each patient's individuality. Purpose: To provide patients the rights to a quality of life that supports independent expression, decision making, and respect. 1.9 Demeaning practices: Staff will refrain from practices that are demeaning to patients such as: 1.0.1 Keeping urinary catheter…

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, interview, and facility policy review, the facility failed to ensure medications were not being left at the bedside for one of two residents (Resident (R)78) observed who was not assessed to self-administer medications out of 46 sampled residents. This had the potential for the resident not to receive their ordered medications and create unmet care needs. Findings include: Review of the facility's policy titled, Medications: Self-Administration, revised 03/01/22, revealed, Policy: Patients who request to self-administer medications will be evaluated for safe and clinically appropriate capability based on the patient's functionality and health condition. If it is determined that the patient is able to self-administer, A physician/advanced practice provider (APP) order is required. Self-administration and medication self-storage must be care planned. When applicable, patient must be provided with a secure, locked area to maintain medications. Patients must be instructed in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review, the facility failed to ensure Code Status was correct throughout the electronic medical record (EMR) for one (Resident (R) R209) out of four residents reviewed for Advance Directives/Code Status. Physician's orders in the EMR indicated the resident's code status as Full Code rather than his preferred Do Not Resuscitate (DNR) in the event the resident was found not breathing and/or without a pulse. This failure created the potential for Cardiopulmonary Resuscitation (CPR) to be performed on the resident when it was not desired. A total of 46 residents were reviewed in the sample. Findings include: Review of the facility's policy titled Code Status Orders Policy dated [DATE] read, in pertinent part, Patient identification mechanisms and information about each patient's code status (Full Code vs. Do Not Resuscitate (DNR) will be easily accessible to the clinical staff for all patients; and Upon admission/re-admission, a code status order is required as…

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 facility policy review, the facility failed to have written documentation of the Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNFABN) CMS [Centers for Medicare and Medicaid Services]-10055 and the Notice of Medicare Non-coverage (NOMNC) CMS-10123 for two of three for two of three residents (Resident (R)40 and R86) out of a sample of 46 residents. This had the potential for the residents to be unable to make an informed decision and to be unaware of additional costs and services when skilled services are ending and their right to appeal decisions. Findings include: Review of an undated list of Beneficiary Notice- Residents discharged Within the Last Six Months, document provided by the Administrator, listed residents who were discharged from Medicare covered Part A services with benefit days remaining who either were discharged home or chose to remain in the facility. On the list R40 and R86 were marked as Remaining in the facility. 1. Review of an undated document titled SNF Beneficiary Notification Review for R40,…

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, interview and facility policy review, the facility failed to ensure two out of three sampled residents out of a total sample of 46 residents reviewed for hospitalization (Resident (R)19, and R81) and/or their representatives were provided with written transfer notices upon emergent transfer to the hospital. Also, notification was not provided to the ombudsman. This deficient practice could allow a resident to be transferred without knowing their rights. Findings include: Review of the facility policy titled, Discharge and Transfer, revised on 11/14/22 revealed, Policy. For patients transferred to the hospital: 5.1 For unplanned acute transfers for the patient must be permitted to return to the Center. Prior to the transfer, the patent and the patient representative will be notified verbally followed by written notification using the Notice of Hospital or state specific transfer form. 5.2.1 Written notice must also be provided to the Ombudsman. 1. Review of R19's significant change Minimum…

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, record review, and review of facility policy, the facility failed to ensure two of two residents (Resident (R) 19 and R81) and/or their representatives out of a sample of 46 residents reviewed for hospitalization were given a written copy of a bed hold notice prior to or within 24-hours of transfer to the hospital. This failure creates the potential for residents and responsible parties not to have the information needed to safeguard their return to the facility. Findings include: Review of the facility policy titled Bed Hold Notice-Deliver Upon Transfer, revised August 2022, revealed, Process. Prior to a resident's transfer out of the center to a hospital for therapeutic leave, the staff member conducting the transfer out will provide both the resident and representative, if applicable, with the Bed Hold Policy Notice & Authorization form. Notice must be given regardless of payer. Resident copy is given directly to the resident prior to transfer and noted in the medical 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) Level I assessment was completed accurately for two residents (Resident (R)16 and R46) out of two residents reviewed for PASARR screenings out of a total sample of 46 residents. This had the potential for the residents to prevent or delay additional services to the residents that should have had a Level II PASARR completed. Findings include: 1. Review of R16's admission Record, located in the Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses including depression, obsessive compulsive disorder, schizophrenia, bipolar disorder, post-traumatic stress disorder (PTSD), anxiety disorder, pseudobulbar affect, and psychosis. All of these diagnoses were present upon admission to the facility. Review of R16's quarterly Minimum Data Set (MDS) located under the MDS tab of the EMR, with an Assessment Reference Date (ARD) 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 review of facility policy, record review, and interview, the facility failed to ensure two Residents (R) R18 and R80 of four residents reviewed for activities were provided with an appropriate ongoing program of activities to meet their needs. This failure created the potential for both residents to experience social isolation related to the lack of activity involvement. A total of 46 residents were reviewed in the sample. Findings include: Review of the facility's policy titled Recreation Services Policy and Procedure, dated most recently revised on 08/07/23, read, in pertinent part, Center/Communities must provide, based on the comprehensive assessment and care plan and the preferences of each patient/resident (hereinafter patient), an ongoing program to support residents/patients in their choice of activities, both facility sponsored group and individual activities and independent activities, designed to meet the interests of an support the physical, mental, and psychosocial well being 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview, the facility failed to ensure one Resident (R) 80 of one resident reviewed for vision services had glasses available to her per her plan of care. This failure created the potential for the resident to experience negative effects related to not being able to see adequately. A total of 46 residents were reviewed in the sample. Findings include: The facility's policy related to the provision of ancillary services, including vision services, was requested by the survey team on 07/18/24. The policy was not provided to the survey team prior to exit on 07/19/24. Review of R80's admission Record dated 07/19/24 and found in the Electronic Medical Record (EMR) under the Admissions tab, indicated the resident was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis following a stroke. Review of R80's quarterly Minimum Data Set (MDS) with an Assessment Reference (ARD) date of 04/06/24 and found in the EMR under the MDS tab indicated a Brief Interview…

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, interview, and review of facility policy, the facility failed to ensure one (Resident (R) 80) of one resident reviewed for side rail use had appropriate physicians orders, provided informed consent form, and was appropriately assessed for her use of side rails. This had the potential for possible injury to the resident. A total of 46 residents were reviewed in the sample. Findings include: Review of the facility's policy titled, Bed Rails Policy dated most recently revised on 09/01/22 read, in pertinent part, Centers will only use bed rails as mobility enablers .The Bed Rail Evaluation will be completed upon admission, re-admission, quarterly, change in bed or mattress, and with a significant change in condition. Prior to use/installation of a bed rail, staff will attempt the use of appropriate alternatives. If the alternatives were not adequate to meet the patient's needs, the patient will be evaluated for the use of bed rails; and After appropriate alternatives have been attempted 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 record review, observation, interview, and facility policy review, the facility failed to ensure a medication error rate of less than 5%. Two errors were made with a total of 25 opportunities for error, resulting in an 8.0% error rate. The errors involved one (Resident (R) 58) of four residents observed during medication administration. This had the potential for R58 to experience negative effects related to errors with their medication administration. A total of 46 residents were reviewed in the sample. Findings include: Review of the facility policy titled, Medication Errors dated most recently revised on 07/01/24 read, Medication Error means the observed or identified preparation or administration of medication or biologicals which is not in accordance with the prescriber's order; manufacturer's specifications (not recommendations) regarding the preparation and administration of the medication or biological; or accepted professional standards and principles which apply to professional providing services. Types of errors include; medication omission; wrong patient, dose,…

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, record review, and review of facility policy, the facility failed to ensure staff were trained in regard to enhanced barrier precautions (EBP) for two of six sampled residents (Resident (R)212 and R208) who had indwelling urinary catheters out of sample of 46 residents. The facility further failed to ensure infection control was maintained related to catheters being observed on the floor for R208 and R212, and lastly the facility failed to properly store respiratory equipment when not in use for R33 and R86. This had the potential for all the residents to acquire infections. Findings include: Review of the facility's policy titled, Procedure: Enhanced Barrier Precautions, revised 05/01/24, revealed, 1. Post the appropriate Enhanced Barrier Precautions (EBP) sign on the patient's room door. 1.1 Enhanced Barrier Precautions (EBP) are to be utilized for the duration of the patient's stay. 1.1.1 Gown and gloves would not be required for patient care activities other than those listed…

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 review of personnel records, interview, and review of facility policy, the facility failed to ensure three employees (Activities Assistant (AA), Certified Nursing Assistant (CNA) 22 and CNA 23) of 31 staff members reviewed for the completion of required training were trained related to the facility's abuse processes and procedures prior to working in direct contact with residents. This failure created the potential for residents to be abused and/or for facility policies and procedures to not be followed in the event of potential abuse. A total of 46 residents were reviewed in the sample. Findings include: Review of the facility's Abuse Prohibition Policy and Procedures most recently dated revised on 10/24/22 read, in pertinent part, Purpose: To ensure the Center staff are doing all that is within their control to prevent occurrences of abuse, mistreatment, neglect, exploitation, involuntary seclusion, injuries of unknown source, and misappropriation of property for all patients; and Training 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to inquire about residents' dietary preferences for 6 (R#'s: 15, 18, 26, 27, 28, and 29) of 13 (R #'s: 15, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, and 29) residents reviewed for food preferences. This deficient practice could likely result in residents feeling frustrated and possible weight loss due to a lack of dietary options. The findings are: A. Record review of NM consumer complaint number 71279 revealed R #15 had not been eating. R #15 did not like the food at the facility, and staff did not ask her if she had any preferences on what to eat. B. Record review of R #15's Electronic Helath Record (EHR) revealed she was sent to the hospital on [DATE] and then discharged from the facility on 12/22/23. C. On 03/07/24 at 11:13 am during an interview with R #18, she stated, I have colitis so I can't eat 75 percent (%) of the food that they serve. I can't eat tomato sauce or spicy food. I can't eat green chili. I don't like fish. I still sometimes get…

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 sanitary and comfortable environment for all of the 110 residents identified by the facility census provided by the Administrator In Training (AIT) on 03/04/24, when staff failed to: 1. Ensure the facility did not smell like urine; 2. Ensure resident rooms were free of trash, floors are clean with no spots of dried liquids, and privacy curtains were clean and not soiled; 3. Replace a shattered window on the northwest hall; 4. Ensure hallways were clear of clutter. This deficient practice is likely to cause all residents to be exposed to environmental hazards and to not feel comfortable in their environment. The findings are: Urine Smell A. On 03/04/24 at 1:00 pm during an observation, as you walk into the building there was a smell of urine. On the north side of the building, there was a stronger smell of urine than on the south side of the building. There was not one room that the urine smell centered around. B. On 03/05/24 at 8:15 am, a walk…

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 staff treated a resident with respect and dignity for 1 (R #3) of 1 (R #3) resident when staff left a resident lying in bed naked after receiving care. This deficient practice could result in residents feeling frustrated and devalued. The findings are: A. On 03/04/24 at 1:30 pm during an observation, R #3 lay in bed with a sheet partially over her body, but her breasts were visible. B. On 03/04/24 at 1:30 pm during an interview with R #3, she stated she wanted a gown and waited for one since yesterday. C. On 03/05/24 at 3:40 pm during an interview with Certified Nursing Assistant (CNA) #1, she stated she changed R #3 at some point on 03/05/24 and forgot to get her a gown. CNA #1 stated she was not sure how long R #3 went without a gown, but it was a while.

Based on record review and interview, the facility failed to report an incident for 1 (R #17) of 3 (R #21, R #22, and R #23) residents reviewed for falls. This deficient practice could likely result in the State Survey Agency not being aware of facility incidents and unable to assure residents have a safe and hazard free environment. The findings are: A. Record review of New Mexico consumer complaint number 71790, revealed staff transported R #17 to an outside appointment. The resident was strapped into wheelchair, but the wheelchair was not secured in van. The resident fell over and hit her head. The resident sustained three bumps to head and bruising to chest. B. Record review of R #17's nursing notes, dated 01/02/24, revealed the facility's van driver reported to the nurse that the resident fell backward and hit her head on the floor in the van during transportation. The resident complained of pain and discomfort to the back of her head. Staff administered tylenol and noticed bumps on the back of the resident's head. Provider and family member notified. Transferred the 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 observation and interview, the facility failed to ensure medications were not left on a beside table in a resident's room for 1 (R #3) of 1 (R #3) resident. This failure could likely result in resident injury if staff do not confirm residents take their medications. The findings are: A. On 03/04/24 at 1:15 pm during an observation, two pills sat on the bedside table. One was pinkish and maroon in color. The other pill was white, oval, and slightly dissolved. B. On 03/04/24 at 1:15 pm, during an interview with R #3, she stated she was unaware of what the pills were or where they came from. C. On 03/04/24 at 1:30 pm during an interview with Registered Nurse (RN) #1, he stated he did not see the pills on the resident's bedside table this morning (03/04/24) when he took R #3 her medications. He stated staff should not leave the pills sitting on the resident's beside table, and it was a problem. D. On 03/04/24 at 2:15 pm during an interview with RN #1, he stated he spoke with Certified Nursing Assistant (CNA) #1 who worked with R #3 RN #1 stated the CNA told him she saw 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 interview, the facility failed to assure staff properly stored medications in a locked container. This deficient practice had the potential to affect all 110 residents identified on the facility census list provided by the Director of Nursing (DON) on 03/04/24. Improperly stored medications could result in a resident, staff member or a visitor taking the medications. The findings are: Medication in the Director of Nursing (DON) Office A. On 03/04/24 at 2:20 pm during an observation, a large trashcan was full of medications, did not have a lid, and sat in the DON's office. The DON was not in her office, and her office door was open. B. On 03/04/24 at 3:12 pm during an interview with the DON, she stated she did not know if the medications needed to be locked up or not. She stated the narcotics were locked up, and she pointed to a locked container mounted on the wall. She stated the medications in the trashcan needed to be logged and destroyed. C. On 03/04/24 at 3:50 pm during an interview with the DON, she stated she spoke with her pharmacist. She said 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, observation, and interview, the facility failed to follow the menu, and honor resident preferences. These deficient practices have the potential to affect all 104 residents listed on the census presented by the Administrator on 11/06/23 and could likely result in reduced food intake, weight loss, and a decline in a resident's psychosocial health (the health of someone's emotions, behaviors, and social abilities) due to developing feelings of frustration and/or unsatisfaction with meal options, anxiety (an excess feeling of fear, dread, and uneasiness), and disappointment. The findings are: A. On 11/06/23 at 10:10 am, during an initial tour and observation of the facility, the following observations were made: -Week 3 Week-At-A-Glance Menu was posted in the Skilled Care unit hallway, and in the Long-Term Care hallway of the facility. No other signage regarding menu options was posted. -Week 3 Week-At-A-Glance Menu was posted outside the main dining area. A daily menu for Thursday breakfast, lunch, and dinner was posted. The current day of the week was Monday.…

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 meals were served at an appetizing temperature, were attractive, and palatable (pleasant to taste). This deficient practice has the potential to affect all 104 residents identified on the census provided by the Administrator on 11/06/23 and could likely reduce residents' ability to eat and enjoy meals, decrease their quality of life, and cause weight loss due to feelings of frustration, anxiety (an excess feeling of fear, dread, and uneasiness), and disappointment. The findings are: A. On 11/03/23 at 2:50 pm, during an interview, Power of Attorney (POA-a person who has the authority to make legal or financial decisions for a person they represent) #1 for R #2, stated R #2's food was always cold and the food was not the right kind of food for a diabetic. B. On 11/06/23 at 10:23 am, during an interview, R #12 stated the food was awful quality. It was not cooked appropriately, meat would be dried out and not tender. The food was not really warm, not hot, and it does not look good. He stated a cucumber…

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 provide follow up reports within five (5) working days from the date of the incidents to the State Survey Agency, for 2 (R #9 and R #10) of 5 (R #6, R #7, R #8, R #9, and R #10) residents reviewed for incidents. If the facility fails to provide a five (5) day follow-up report to the State Agency then the State Agency will be unable to assure residents are safe and have a hazard free environment. The findings are: A. Record review of New Mexico Health Facility Licensing and Certification (NMHFL&C) report revealed a Facility Initiated Report (FIR), received 08/18/2023, regarding alleged abuse of R #9. The record did not contain a five (5)-day follow up report received regarding this incident. B. Record review of New Mexico Health Facility Licensing and Certification (NMHFL&C) report revealed a Facility Initiated Report (FIR), received 09/26/2023, regarding alleged neglect of R #10. The record did not contain a five (5)- day follow up report received regarding this incident. C. On 11/07/23 at 1:21 pm, during interview,…

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 have the Interdisciplinary Team (IDT(consists of a team of professionals of various roles within the facility who review and determine resident needs and abilities)) determine if residents could self-administer medication for 1 (R #1) of 4 (R #1, R #2, R #3 and R #4) residents reviewed. If the facility is not assessing the residents to determine if a resident is capable of self-administering medications, then this deficient practice is likely to result in residents self-administering medications inappropriately and or incorrectly, likely causing harm (overdose, missed medications, and another resident taking the medication.) The findings are: Findings for R #1 A. On 10/06/23 at 2:15 pm, during an interview, R #1 revealed she had an inhaler at bedside. R #1 stated the night nurse from the night before had brought the inhaler in and tossed it to her. He never came back to retrieve it. B. On 10/06/23 at 2:17 pm, during an observation of R #1 medication revealed an inhaler, Proair (albuterol used to treat…

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 effectively manage pain for 1 (R #2) of 4 (R #1, R #2, R #3, and R #4) residents reviewed for pain by not providing pain treatment. This deficient practice could likely result in residents experiencing a significant (long) period of pain without sufficient relief for pain. The findings are: A. Record review of facility's Policy for Pain management, revised 11/01/23, revealed, Policy: Staff will continually observe and monitor patients for comfort and presence of pain and will implement strategies in accordance with standards with professional standards of practice, the patient -centered plan of care, and the patient's choices related to pain management. Purpose: To maintain possible level of comfort for the patients by providing a system to identify, assess, treat, and evaluate pain. B. Record review of R #2 admission record revealed he was admitted to the facility on [DATE] his diagnosis includes, but are not limited to the following: Acquired absence…

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 ensure that all residents that have a personal funds account with the facility are able to access their funds on weekends/evenings. This deficient practice is likely to affect all residents having an account with the facility. If residents are unable to access their funds when desired, then residents are likely to not be able to participate in activities and purchase food or personal items when they choose. The findings are: A. On 08/17/23 at 10:32 a.m., during an interview, the Business Manager (BM) stated currently, residents are unable to access their personal funds during evening or weekend hours. She stated after COVID (a viral infection that resulted in a pandemic) started the facility stopped providing this service and has not re-started this service since. The BM stated that she could and would reinstate the availability of after hours and weekend access to personal funds today.

Based on observation and interview, the facility failed to maintain consistent meal service times for residents and serve snacks between meals. This deficient practice has the potential to affect all 113 residents listed on the facility census provided by the Center Executive Director on 08/13/23. This deficient practice could likely result in residents becoming frustrated and/or residents not receiving meals if meals are not served at consistent meal times, and could affect the physical and mental health of residents. The findings are: A. On 08/13/23 at 12:29 pm during a random observation, revealed posted at the entrance of the dining room was a sign with the following information: Meal Times: Breakfast - 7:30 am, Lunch - 12:30 pm, and Dinner - 5:30 pm. B. On 08/13/23 at 12:32 pm, a random observation of the lunch meal service revealed several residents sat in the dining room and waited for lunch to be served. R #37 appeared to be falling asleep at her table. At 12:44 pm, staff served beverages to residents. One staff member asked R #37 if she was tired and wanted to go to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure food stored in the facility refrigerators was properly labeled, dated, and/or disposed of based on the use by date. This deficient practice could likely affect the 109 residents listed on the facility census provided by the Administrator on 08/13/23 that receive food or meals from the kitchen and could likely lead to foodborne illnesses (an infection or irritation of the gastrointestinal tract - a pathway by which food enters the body and solid wastes are expelled - caused by food or beverages that contain harmful bacteria) amongst residents, if safe food handling practices are not adhered to. The findings are: A. Record review of the facility policy titled Refrigerated/Frozen Storage, dated 05/01/23, revealed: - 1.4 All foods are labeled with the name of the product and the date received and use by date once opened. Manufacturer 'use by' dates are used until opened. - 1.5 Prepared foods are labeled and dated with the name of 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, interview, and observation, the facility failed to provide proper infection control practices when staff failed to ensure glucometers (a medical device to measure glucose {sugar} levels in the blood). utilized by the facility for more than one resident, were disinfected per manufacturer's instructions after each time one is used, for 4 (R #260, R #103, R #157, R #48) of 4 (R #260, R #103, R #157, R #48) residents that receive capillary (small blood vessels) blood glucose (CBG, capillary blood glucose) monitoring with glucometers. The facility also failed to ensure staff conducted proper hand hygiene between residents while serving meals to residents. These deficient practices may likely result in the spread of infection agents (viruses and bacteria) between residents and or staff who utilize glucometers, between residents and staff during meals, and if staff are not using proper hand hygiene procedures after touching residents or surfaces before serving meals. The findings are: A. On 08/13/23 at 12:28 PM, an observation revealed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that staff maintain the right for residents to preserve personal items for 1 (R #71) of 1 (R #71) resident reviewed for personal items. This deficient practice is likely to cause the resident to feel isolated and unable to join activities that they enjoy, because they do not have their prescription glasses. The findings are: A. On 08/13/23 at 3:51 PM, during an interview, R #71 stated he verbally reported he was missing some of his clothing and his glasses several times to nursing staff since his admission on [DATE]. R #71 stated, since 08/13/23, he has received a small box of clothing from the other facility, but his prescription glasses are still missing. He said he cannot see well without his glasses and feels frustrated with the facility. R#71 stated he cannot enjoy any activities and has been getting headaches. B. On 08/15/23 at 2:28 PM, during an interview with Social Services (SS #2), SS#2 tried to contact R #71's previous facility to get…

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 complete a MDS (Minimum Data Set- a collection of health data that reflects a resident's functional capabilities) assessment for 2 (R #19 and 94) of 4 (R #'s 6, 19, 70, and 94) residents reviewed for resident assessments. This deficient practice could likely result in the facility receiving monies they are not entitled to and resident needs not being identified and/or treated, resulting in residents receiving less than optimal care. The findings are: Findings for R #94 A. Record review of R #94's EHR (Electronic Health Record) revealed that R #94 was admitted to the facility on [DATE] and was discharged from the facility on 03/23/23. B. Record review of R #94's MDS assessment, dated 03/23/23, revealed that the discharge assessment was in progress. C. On 08/16/23 at 12:37 pm, during an interview, the MDS nurse said staff realized during a recent audit R #94's discharge assessment was missing, and they are now in the process of completing it. Findings…

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 administer medications for 1 (R #66) of 2 (R #'s 23 and 66) residents reviewed for medication regimen. This deficient practice could likely result in a resident not feeling well due to the lack of treatment. The findings are: A. On 08/13/23 at 2:52 pm, during an interview, R #66 reported that there have been a few times when his mediation was not given to him. B. Record review of R #66's face sheet revealed that R #66 was admitted to the facility on [DATE] with the following pertinent diagnoses: Nondisplaced fracture ( the bone cracks or breaks but retains its proper alignment) of right radial styloid process (Radial Styloid Process- the end of the radius, the thicker and shorter of the two long bones in the forearm, that meets the bones of the hand), abrasion of right ear, depression, and rheumatoid arthritis with rheumatoid factor (an immune system protein that attacks healthy cells in the body). C. Record review of physician orders revealed the…

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

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 #157) of 1 (R #157) resident reviewed. These deficient practices have the potential to affect the dignity and health of the residents. The findings are A. Record review of R #157 face sheet revealed she was admitted to the facility on [DATE] with multiple diagnoses to include: - Idiopathic (unknown cause); - Aseptic (not caused by viral/bacterial infection); - Necrosis (dead/dying cells) of unspecified toes; - Morbid obesity (severely overweight) due to excess calories; - Paroxysmal Atrial Fibrillation (abnormal heart rhythm). B. Record review of R #157 Multiple Data Survey (MDS; a series interviews and assessments to determine a residents needs and abilities), Section C (a section of the MDS that indicates a persons ability to remember and recall, indicating a resident's level of dementia), revealed a BIMS score (Brief Interview of Mental Status; score range between 0 and 15,…

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 store medications in their proper container in a medication cart. The findings are: A. On 08/13/23 at 12:56 PM, during observation of the front hall medication cart, two round yellow tablets, one green oval tablet, one blue oval tablet, and one green circular tablet were found loose under the medication cards. Licensed Practical Nurse (LPN) #1 confirmed the medication was loose under the medication cards. B. On 08/13/23 at 1:10 PM, during observation of the south east hall medication cart, four round white tablets, one large round orange tablet, one blue round tablet, and one white oval tablet were found loose under the medication cards. LPN #2 confirmed the medication was loose under the medication cards. C. On 08/13/23 at 1:15 PM, during an interview, LPN #2 stated loose medications, when found in the medication cart, should be destroyed and not left in the carts.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview the facility failed to ensure that 1 (R #48) of 1 (R #48) resident was treated in a respectful manner that preserved the residents' dignity. This deficient practice has the potential to reduce residents' quality of life, through feelings of frustration, humiliation, and anxiety. The findings are: A. Record review of R #48's face sheet revealed he was admitted to the facility on [DATE] for multiple diagnoses including: hemiplegia (one sided paralysis of the body and/or face), hemiparesis (one sided muscle weakness), cerebral infarction (stroke, ruptured and bleeding blood vessel of the brain) affecting the left side; acquired absence of left leg below the knee (amputation of left leg, below the knee). B. Record review of R #48's physician orders revealed an order, dated 08/11/23, to ensure CNAs (certified nurses aide) turn and reposition for pressure relief. C. On 08/13/23 the following observations were made: - At 1:00 p.m., R #48 was observed in his room lying…

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 of missed medication administrations for 1 (R #66) of 2 (R #'s 23 and 66) residents reviewed for medication regimen. This deficient practice could likely result in a stalled improvement in condition due to the lack of medication and/or not receiving an alternative treatment. The findings are: A. On 08/13/23 at 2:52 pm, during an interview, R #66 reported there have been a few times where his mediation was not given to him. B. Record review of R #66's face sheet revealed R #66 was admitted to the facility on [DATE] with the following pertinent diagnoses: Nondisplaced fracture of right radial styloid process, abrasion of right ear, depression, and rheumatoid arthritis with rheumatoid factor. C. Record review of physician orders revealed the following pertinent medication orders: - Physician order dated, 07/01/23-07/03/23: Ciprofloxacin HCl [type of antibiotic] Ophthalmic Ointment .3% instill 5 drops in right eye two times a day 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 record review and interview, the facility failed to ensure that grievances (complaints over something believed to be wrong or unfair) filed by residents were tracked, followed up on, and resolved to the satisfaction of the resident for 1 (R #50) of 1 (R#50) resident reviewed for grievances. This deficient practice could likely result in continued issues or concerns not being addressed appropriately or in a timely manner by staff and residents feeling as though their concerns are not important to the staff. A. Record review of R #50's face sheet revealed that he was admitted to the facility on [DATE]. B. On 08/13/23 at 4:28 pm, during an interview, R #50 stated about a month ago (mid July 2023) he filed a grievance with Social Services (SS) #2 about his call light not being answered timely, and he never heard back from anyone about the status of the grievance. R #50 stated, We can fill out a grievance (form) and drop it (the grievance form) in the grievance box, but there is no follow up by the staff. We…

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 and implement a comprehensive person-centered care plan for 1 (R #48) of 1(R #48) residents. Failure to develop and implement a person-centered care plan may result in staff's failure to understand the needs and implement treatments for residents possibly resulting in decline in abilities and a failure to thrive. The findings are: A. Record review of R #48's face sheet revealed he was admitted to the facility on [DATE] for multiple diagnoses including: - Hemiplegia (one sided paralysis of the body and/or face), hemiparesis (one sided muscle weakness); - Cerebral infarction (stroke, ruptured and bleeding blood vessel of the brain) affecting left side; - Acquired absence of left leg below knee (amputated left leg below the knee). B. Record review of R#48's medical record revealed the care plan was developed and initiated on 07/12/23, but the plan did not address the residents activities. C. On 08/16/23 at 9:31 am, during an interview, 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 interviews, the facility failed to provide necessary discharge planning services for 1 (R #41) of 1 (R #41) resident reviewed for discharge planning. This deficient practice resulted in the resident being discharged without adequate planning. The findings are: A. Record review of R #48 History and Physical, dated 06/09/23, revealed he was a patient of an outpatient medical service (OMS) who was admitted to the facility for respite care (a temporary placement of a patient into a controlled setting to allow family and home care givers a break from care. The document was signed by the physician of the outpatient medical service. B. Record review of R#48 face sheet revealed R #48 was admitted to the facility on [DATE] with multiple diagnoses including: - End stage renal disease (progressive failure of the kidneys); - Dependence on renal dialysis (requirement to mechanically filter blood of toxic chemicals). C. Record review of R #48 daily care notes revealed: - 05/23/23 General: Pt.…

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 food in the texture as ordered by the physician for 1 (R #258) of 1 (258) residents reviewed for meal textures. This deficient practice could likely result in residents not eating or experiencing difficulty swallowing during meal times. The findings are: A. On 08/14/23 at 10:32 am, during an interview, R #258 explained her meals are not consistent. Sometimes she receives broths only and sometimes she receives pureed food. B. Record review of R #258's physician order, dated 08/03/23, revealed Full Liquid diet, Regular Texture. C. Record review of R #258's Speech Therapy evaluation, dated 07/20/23, revealed R #258 is experiencing GI (gastrointestinal- the organs in your body that aid in food digestion) issues. She is able to tolerate thin liquids and puree without signs of aspiration; however, she is waiting for clearance from her GI specialist for a diet texture change. Further review revealed the following recommendation: thin liquids and no solids by mouth. D. Record review of R #258's care plan,…

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

Based on record review and interviews, the facility failed to ensure that residents received treatment [surgical/medical physician appointment] and care in accordance with professional standards of practice for 2 (R #28 and #281) of 7 (R #1, #28, #33, #78, #169, #281 and #282) residents who were reviewed for having transportation needs. This deficient practice could likely result in residents feeling frustrated with not receiving their scheduled treatments, including transportation to and from appointments. Residents could also have worsened medical conditions due to a delay in attending their scheduled surgical/medical physician appointments. The findings are: Findings related to R #28: A. Record review of R #28's admission Record dated 02/03/22, included the following diagnoses: metabolic encephalopathy (a problem in the brain, caused by a chemical imbalance in the blood), End-Stage Renal Disease (ESRD) (a medical condition in which a person's kidneys cease to function on a permanent basis), dependence on renal dialysis (a process of removing excess water, and toxins from 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 This is a repeat deficiency from a survey that was conducted on 06/30/21. Based on observation, interview, and record review the facility failed to ensure that 1 (R #165) of 1 (R #165) resident noted to have cognitive [thinking] impairment with behavioral symptoms [persistent or repetitive behaviors that are disruptive {troublesome, uncontrolled} or inappropriate] received all necessary person centered interventions to maintain or improve her well-being while admitted into the facility by: 1. by failing to provide sufficient and consistent monitoring of behaviors by leaving her alone in a room with the door closed and 2. by failing to plan and implement interventions to address her behaviors noted. These deficient practices may likely have contributed to the resident's decline in health leading to her readmission to an acute care facility. The findings are: A. Record review of admission record revealed, R #165 was admitted on [DATE] with a primary diagnosis of metabolic encepholopathy [disease that affects brain…

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 This is a repeat deficiency from a survey that was completed on 12/16/20. Based on record review and interview, the facility failed to develop and implement (put into place) a comprehensive person-centered care plan for 2 (R #31 and #78) of 5 (R #8, #31, #72, #77 and #78) residents reviewed for care plans. This deficient practice could likely result in staff's failure to understand and implement the needs and treatments of the residents. The findings are: Findings related to R #31: A. Record review of Face Sheet dated 02/05/22 for R #31 revealed this as an initial admission date and included the following diagnoses: Hemiplegia (paralysis on one side of the body after a stroke) and hemiparesis (weakness on one side of the body) and metabolic encephalopathy (an alteration of brain function or consciousness due to failure of other internal organs). B. Record review of Minimum Data Set (MDS) dated [DATE] for R #31 revealed, Section G - Bathing - Activity did not occur; Section V - Care Area Assessment - ADL…

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 bathing/showering assistance was provided for 1 (R #31) of 3 (R #s 31, 49 and 72) residents reviewed for ADLs (activities of daily living). This deficient practice could likely result in residents in need of this specialized care to experience a decline in their ability to perform hygiene tasks and/or maintain good personal hygiene. The findings are: A. Record review of Face Sheet dated 02/05/22 for R #31 revealed this as an initial admission date and included the following diagnoses: Recurrent Dislocation Left Shoulder (an injury in which your upper arm bone pops out of the cup-shaped socket that is part of your shoulder blade), Hemiplegia (paralysis on one side of the body) and Hemiparesis (weakness or the inability to move on one side of the body), Metabolic Encephalopathy (abnormalities of the water, electrolytes, vitamins, and other chemicals that adversely affect brain function), Chronic Pain, Morbid (Severe) Obesity (Overweight),…

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.

This is a repeat deficiency from a survey that was completed on 12/16/20. Based on observations, interviews, and record review, the facility failed to: 1) Ensure that opened/accessed multi-dose vials (a vial of liquid medication that contains more than one dose of the medication) of medications that had been accessed were dated; 2) Ensure that medical supplies were stored in an appropriate place, not under the sink; 3) Ensure that expired medical supplies were not stored with current medical supplies that were ready and available for use; and 4) Ensure that treatment/medication carts were kept locked when not in use. These deficient practices could likely affect all 108 identified residents listed on the facility's Resident Alphabetical Census list provided by the Center Executive Director (CED) on 04/11/22. The findings are: Findings related to multi-dose vials opened and undated, medical supplies being stored under the sink and expired medical supplies stored with active current medical supplies: A. On 04/26/22 at 9:27 am, during an observation of the Rapid Recovery Services (RRS)…

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 residents received pneumococcal (pneumonia an infection in one or both lungs) vaccines according to current vaccine recommendations with their consent for 1 (R #3 ) of 5 (R #s 3, 7, 11, 31 and 78) residents reviewed for immunizations. If residents are not vaccinated as appropriate against pneumonia they have a higher likelihood of contracting that illness and spreading it to other residents and staff in the facility. The findings are: A. Record review of facility policy titled, IC 601 Pneumococcal Vaccination - Prevnar 13 (PCV13) [a type of pneumococcal vaccine, protecting against 13 types of pneumonia causing bacteria] or Pneumovax (PPSV23) [a type of pneumococcal vaccine protecting against 23 types of pneumonia causing bacterial], last review date 09/02/20 revealed, provide the opportunity to receive the pneumococcal vaccine to all patients .In adherence with current recommendations of the Advisory Committee on Immunization Practices…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and observations, the facility failed to provide a comfortable and clean bathroom environment for 2 roommates (R #28 and #78) who share the restroom with an adjoining room. This deficient practice of not maintaining a clean bathroom, is likely to result in the two residents becoming very upset and embarrassed of this daily occurrence. The findings are: A. On 04/25/22 at 11:41 am, during an interview, R #78 discussed a situation that was occurring for herself and her roommate R #28. They reside in room [ROOM NUMBER]. R #78 stated that the resident in the next room, room [ROOM NUMBER] when she defecates (discharge feces from the body)in the bathroom on the toilet, there is fecal matter all over the bathroom. R #78 stated when she needs to use the restroom, she first has to clean up the mess that R #276 has made. R #78 stated that this has been occurring for quite awhile. She stated that between herself and her roommate R #28, they have expressed their frustrations and concerns to the nursing…

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.