Sandia Ridge Center

Based on observation, record review, and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment (to prevent the development and transmission of communicable diseases and infections) for 1 (R #1) of 3 (R #1, #2 and #3) residents, when: The facility failed to post the required Enhanced Barrier Precautions (EBP; an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) signage for R #1.This deficient practice is likely to result in repeated and ongoing exposure of residents to increased risk of infection, cross-contamination, and injury. The findings are: A. Record review of R #1's face sheet revealed an admission date of 12/17/25 and included a diagnosis of gastronomy status (when a person has a surgically created opening in their abdominal wall that leads directly into the stomach which allows for nutrition, hydration, and medication administration). B. Record review of R…

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

Based on interview, observation, and record review, the facility failed to ensure meals were palatable and served at an appetizing temperature for 6 (R #1, R #2, R #3, R #4, R #5, and R #6) of 6 (R #1, R #2, R #3, R #4, R #5, and R #6) residents reviewed. This failed practice had the potential to affect all 128 residents identified on the resident census list provided by the Administrator on 02/19/26. If meals are not appetizing, then residents may not eat meals and lose weight. The findings are: A. On 02/19/26 at 3:12 p.m., during an interview, Resident #1 stated their meals were consistently cold. R #1 stated they ate only what they could tolerate because the food often arrived too cold to enjoy. B. On 02/19/26 at 3:17 p.m., during an interview, Resident #2 stated their meals were often cold when they were supposed to be hot. The resident stated the room trays sometimes took a long time to reach the rooms. C. On 02/19/26 at 3:24 p.m., during an interview, Resident #3 stated their meals were often not warm enough, and the food was sometimes already cold by the time the tray reached…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) assistance for 4 (R #'s 1, 41, 85 and 114) of 4 (R #'s 1, 41, 85 and 114) residents reviewed for ADL care by not: Providing baths/showers per the schedule for R #'s 1, 41, and 85. Providing nail care for R #114. This deficient practice is likely to affect the dignity and health of the residents. 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 shower schedule revealed R #1's baths/showers were scheduled for Mondays, Wednesdays, and Fridays. C. Record review of R #1's care plan dated 05/16/25 revealed R #1 is at risk for decreased ability to perform ADL(s) in bathing, grooming, personal hygiene, dressing. eating, bed mobility, transfer, locomotion & toileting related to physical and cognitive impairments. R #1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to protect 1 (R #2) of 1 (R #2) resident reviewed from the use of a physical restraint that was not required to treat a resident's medical condition. This deficient practice could likely result in resident feeling trapped and hopeless. The findings are: A. Record review of R #2's face sheet dated 03/26/25 revealed R #2 was admitted to the facility on [DATE] with the following diagnoses: -Dementia (a chronic progressive decline of mental abilities and memory). -Need for assistance with personal care. -History of Traumatic Brain Injury (an injury of the brain that may cause a decline in memory, thought, personality or motor skill). -Homelessness The face sheet further revealed R #2 was discharged on 03/24/25. B. Record review of R #2's Elopement (to leave or exit without permission or knowledge of staff) Risk Evaluation dated 02/17/25 revealed he was not a risk of elopement. C. Record review of R #2's daily care note dated 02/27/25, stated R #2 was found 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 and interview the facility failed to revise the care plan for 1 (R #2) of 1 (R #2) resident reviewed for care planning. This deficient practice has the potential for staff to fail to identify resident as an elopement risk. The findings are: A. Record review of R #2's face sheet dated 03/26/25 revealed R #2 was admitted to the facility on [DATE] with the following diagnoses: -Dementia (a chronic progressive decline of mental abilities and memory). -Need for assistance with personal care. -History of Traumatic Brain Injury (an injury of the brain that may cause a decline in memory, thought, personality or motor skill). -Homelessness The face sheet further revealed R #2 was discharged on 03/24/25. B. Record review of R #2's provider order dated 03/12/25 revealed an order for staff to place a Wander Guard elopement device due to poor safety awareness. C. Record review of R #2 care plan reviewed on 03/26/25 , revealed the care plan did not contain any documentation to include the risk of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure staff provided care in accordance with professional standards of practice for 1 (R #1) of 1 (R #1) resident. Nursing staff failed to maintain the scene of a suspcious death before calling the New Mexico Office of Medical Investigator. (OMI) (a New Mexico state agency that reviews and determines the need for investigation and autopsy when a person dies in a facility). This deficient practice could disturb the scene of a suspicious death so that it cannot be thoroughly assessed and reviewed by proper authorities. The findings are: A. Record review of OMI web page (hsc.unm.edu/omi/about/faq/reportable.html) reviewed on 03/27/25 at 11:30 am revealed the expectation to report any death suspected to be due to violence (suicidal, accidental or homicidal) and any death of a person in a nursing home should be reported to OMI. B. Record review of R #1 face sheet dated 03/28/25 revealed R #1 was admitted to the facility on [DATE] with the following…

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 adequate supervision for 1 (R #2) of 1 (R #2) resident reviewed who were identified as a risk for elopement (leave facility without authorization or supervision potentially endangering themselves or others.) This deficient practice likely resulted in the resident being able to eloped from the facility for over 24 hours likely putting himself at serious risk of adverse outcomes. The findings are: A. On 03/26/25 at 11:00 am, during observation of the facility entrance the front door was locked. To enter the building required a doorbell be pushed and staff within the facility would then activate and unlock the door. Once inside the building there was a lounge area with a nurses station directly across from the entrance. There were chairs and multiple residents sitting in the area. Multiple staff sat at the nurses station. Staff, visitors and residents were further observed to walk up to the front door where they pushed a green button…

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 1 (R #1) of 1 (R #1) resident received prescribed intravenous (IV) (medications administered directly into the vein) medications on time in accordance with professional standards of practice. The facility failed to provide and administer antibiotic (antibacterial) medications as ordered by the prescriber. The findings are: A. Record review of R #1's face sheet revealed R #1 was admitted to the facility on [DATE] with multiple diagnoses including: -Acute (sudden onset) Infective Endocarditis (a serious, potentially life threatening bacterial infection of the heart) -Bacteremia (a serious bacterial infection of the blood stream) and was transferred to a local hospital on [DATE] and was discharged the same day. B. Record review of R #1's provider orders revealed the following: -10/19/24 Ampicillin (antibiotic medication used to treat bacterial infections) 2 GM (grams). Use 100 ml (milliliter) intravenously every four hours for Enterococcus…

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 resident injuries of unknown sources were reported to the State Agency within 24 hours to the state agency for 1 (R #4) of 2 (R #4 and R #5) residents reviewed. If the facility is not immediately investigating and reporting injuries of unknown sources residents are likely to be at risk of further injuries. The findings are: R #4 A. Record review of R #4's face sheet revealed R #4 was admitted to the facility on [DATE] with multiple diagnoses including: -Pain in Left Hip. -Dementia (a progressive disease that affects memory). -Lack of Coordination. Face sheet further revealed she was readmitted to the facility on [DATE] with new diagnoses including: -Fracture of Left Femur (large upper leg bone) with routine healing. -Fracture of left Patella (knee bone) B. Record review of R #4's X-ray report of the left leg dated 10/29/24 stated no acute fracture or dislocation. Prior fixation hardware (surgically placed metal supports and screws used to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to investigate and report within five working days, injuries of unknown origin for 1 (R #4) of 2 (R #4 and R #5) residents reviewed for incidents. If the facility is not completing an accurate and thorough investigation and submitting the summary of the facility's investigation to the State Agency, then the State Agency is unable to appropriately triage (review) the allegation for further investigation. The findings are: R #4 A. Record review of R #4's face sheet revealed R #4 was admitted to the facility on [DATE] with multiple diagnoses including: -Pain in Left Hip. -Dementia (a progressive disease that affects memory). -Lack of Coordination. Face sheet further revealed she was readmitted to the facility on [DATE] with new diagnoses including: -Fracture of Left Femur (large upper leg bone) with routine healing. -Fracture of left Patella (knee bone) B. Record review of R #4's X-ray report of left leg dated 10/29/24 stated no acute fracture 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 Based on record review and interview the facility failed to keep residents free from abuse for 1 (R #1) of 3 (R #1, R #2, and R #3) residents reviewed for abuse and neglect. This deficient practice likely resulted in staff to resident abuse in which R #1 had bruises to both hands. The findings are: A. Record review of R #1's face sheet, dated 07/23/24, revealed R #1 was admitted to the facility on [DATE] with multiple diagnoses including: -Type 2 diabetes mellitus (a chronic condition in which the body does nor properly process blood sugar) with foot ulcer (a wound of the foot). -Chronic respiratory failure (a chronic condition of the lungs) with hypoxia (low blood oxygen level). -Adjustment disorder (a mental health condition in which a person has difficulty adjusting to changes) with mixed anxiety (nervousness) and depressed mood (chronic sadness). -Chronic systolic heart failure (a chronic failure of the heart to adequately pump blood). B. Record review of R #1 daily nurses progress notes revealed a note,…

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 recognize, investigate, and respond to the grievance of 1 (R #1) of 5 (R #1, #2, #3, #4, and #5) residents. This deficient practice is likely to result in residents feeling that their concerns do not matter, and their rights are not being honored. The findings are: A. Record review of a face sheet, dated 05/06/24, revealed R #1 was admitted to the facility on [DATE] with multiple diagnoses including: - Sepsis (a serious condition in which the body responds improperly to an infection) unspecified organism, - Altered mental status (a change in a person's ability to recall and reason), - Disorientation, - Difficulty walking. B. Record review of R #1's nursing daily notes, dated 04/15/24 at 6:20 pm, revealed staff documented the resident's wife and daughter spoke with the evening nurse on duty. They were upset and said the resident's brief was very soaked and smelly when they arrived. C. Record review of facility reported grievances for the month of April…

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

Based on observation and interview, the facility failed to maintain proper food temperatures for all 126 residents listed on the census as provided by the facility Director of Nursing on 11/27/23. This deficient practice could likely result in bacterial growth and foodborne illness. The findings are: A. On 11/27/23 at 12:19 pm, during an observation of the steam table, lunch for the day was hot grilled ham and cheese sandwiches and cold ham and cheese (ground ham and ground cheese, mixed together for texture purposes) sandwiches. All sandwiches were placed on the steam table. The cold sandwiches sat in a pan in the first well. The grilled sandwiches sat in a pan in the second and third well. B. On 11/27/23 at 12:19 pm, during an interview, [NAME] #1 took the temperature of the sandwiches. The grilled sandwiches measured 113 degrees (°) Fahrenheit (F), and the cold sandwiches measured 77.8 ° F. [NAME] #1 stated the hot sandwiches should be maintained above 135° F, and the cold sandwiches should be maintained below 41° F. [NAME] #1 said he only measured the temperature of the hot…

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 past noncompliance deficiency. Based on record review and interview, the facility failed to initiate treatment of a pressure wound for 1 ( R#1) of 6 (R #1, R #4, R #6, R #7, R #8, and R #9) residents reviewed for wound care. This deficient practice could likely result in residents not receiving wound care in a timely manner after a wound has been identified. The findings are: A. Record review of R #1's Electronic Health Record (EHR) revealed she was admitted to the facility on [DATE] with the pertinent diagnoses of: - Personal history of uterine cancer, - Adult failure to thrive (a syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function, and low cholesterol), - Kidney stones, - Unspecified dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) with other behavioral disturbances, - Dysphagia (difficulty swallowing). B. Record review of R…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and policy review, the facility failed to ensure an individualized program of activities was implemented for one of one resident (Resident (R) 38) reviewed for activities out of a total sample of 28 residents. This failure had the potential to cause boredom and isolation for R38. Findings include: Review of the facility's policy titled, Recreation Services Policies and Procedures, revised 04/01/18, documented Purpose: To create opportunities for each person to have a meaningful life by supporting his/her domains of wellness: identity, growth, autonomy, security, connectedness, meaning, and joy. To provide an ongoing person-centered recreation program that incorporates the individual's interests, hobbies, and cultural preferences which are integral to maintaining and improving a resident's physical, mental, and psychological well-being and independence. Record review of R38's undated admission Record, located in the Profile tab of the Electronic Medical…

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

Based on interviews, record review, and policy review, the facility failed to provide a meal to cover the lunch hour dialysis treatment three days a week for one of one resident (Resident (R)86) reviewed for dialysis out of a total sample of 28 residents. This failure had the potential to create altered nutritional status and weight loss for R86. Findings include: Record review of the facility policy titled Dialysis: Hemodialysis (HD) Provided by a Certified Dialysis Facility, revised 06/01/21, under the Shared Communication Between the Center and the Certified Dialysis Facility section documented The communication process should include: Nutritional/Fluid management including documentation of weights, compliance with food/fluid restrictions, or the provision of meals before, during, and/or after HD, and monitoring intake and output measurements as ordered. Record review of R86's admission Record, found in the Profile Tab in the Electronic Medical Record (EMR), revealed an admission date of 05/05/21 with diagnoses including end stage renal disease, hemiplegia and hemiparesis…

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, record review, and review of facility policy, the facility failed to administer oxycodone as ordered by the physician and requested by the resident for one resident (Resident (R)236) of one resident reviewed for pain management in a total sample of 28 residents. This failure increased the potential for R236 to have unrelieved pain. Findings include: Record review of the facility provided policy for pain management revealed, .Staff will .implement strategies in accordance with professional standards of practice, the patient-centered plan of care, and the patient's choices related to pain management An individualized. interdisciplinary, person-centered care plan will be developed and included .pharmacological approaches .Using specific strategies for preventing or minimizing sources of pain or pain related symptoms . If a patient has a change in pain status, complete an e-lnteract Change in Condition assessment and Pain Evaluation . Record review of R236's undated admission RECORD, located 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 interviews, observations, and review of records, the facility failed to ensure the staff were competent with skills and knowledge to provide care for one of one resident (Resident (R) 236) reviewed for care of a chest tube out of a total sample of 28 residents. The facility's deficient practice likely resulted in the chest tube being blocked and unable to be removed. Findings include: During an interview 01/12/23 at 5:22 PM, Clinical Lead Corporate (CLC)1 confirmed the facility did not have a staff competency policy. Record review of facility-provided binder titled In-Service 2022 for 01/2022 through 12/2022 revealed no in-service or competency training for the facility staff for chest tubes. Record review of R236's undated admission RECORD, located in the Electronic Medical Record (EMR), revealed he was admitted to the facility on [DATE] with multiple diagnosis to include abscess of the lung with pneumonia. Record review of R236's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD)…

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 administer antibiotic medication as ordered for to two of two residents (Resident (R) 234 and R230) reviewed for antibiotic use in a total sample of 28 residents. This failure could likely increase the risk of ineffective treatment for infection resulting in worsening infection. Findings include: 1. Record review of R234's undated admission RECORD, located on her Electronic Medical Record (EMR) revealed she was admitted to the facility on [DATE] with multiple diagnosis to include bacterial meningitis (Meningitis is an infection of the membranes (meninges) that protect the spinal cord and brain) and osteomyelitis (inflammation of bone or bone marrow, usually due to infection) of the lumbar (lower back) spine. Record review of R234's comprehensive Care Plan, under the Care Plan tab in the EMR, revealed .has actual colonization/ infection with MSSA [Methicillin sensitive Staphylococcus aureus-bacteria] and is at risk for sepsis [injury to tissues 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 ensure that an Advance Directive (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) for 3 [R #'s 39, 58, and 471] of 5 [R #'s 24, 39, 58, 90, 471] residents' electronic records: 1. Had accurate Advance Directive wishes information on file and in different areas in the resident electronic record that was conflicting and 2. Did not complete an Advanced Directive in a timely manner. This deficient practice could likely cause confusion with the residents advance directives and can likely result in the end of life wishes not being met. The findings are: Findings for R #58: A. Record review of R #58's electronic medical record revealed an Advance Directive/MOST (Medical Orders for Scope of Treatment) form dated [DATE] on file stating Do Not Resuscitate (DNR) (instructs health care providers not to do…

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 create a baseline care plan for 1 (R #78) of 2 (R #s 44 and 78) residents sampled for baseline care plans completed within 48 hours of admission. If the facility fails to include care, treatment, services, and goals the residents may not receive the appropriate care. This deficient practice could potentially result in residents not being able to achieve their highest practical abilities, could result in a decline, and staff not being aware of the residents needed care. The finding are: A. Record review of Face Sheet dated 05/21/20 for R #78 revealed this is the initial admission date and included the following diagnoses: Type 2 Diabetes Mellitus (high blood sugar) with Diabetic Chronic Kidney Disease (loss of kidney function), Kidney Failure (when your kidneys stop functioning), Legal Blindness (inability to see things including light), Acute Systolic Congestive Heart Failure (disease that affects pumping action of the heart muscles, which causes fatigue and shortness of breath), Contact with (suspected) Exposure to other…

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

Based on observation, record review, and interview, the facility failed to ensure that bathing/showering assistance was provided for 3 (R #14, 115, and 271) of 3 (R #14, 115, and 271) 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: Findings for R #14 A. Record review R #14's face sheet revealed, admission date 04/07/21, and diagnoses included: encephalopathy (injured or damaged brain), hydronephrosis with renal and ureteral calculous obstruction (swelling of the kidney, which is the organ responsible for filtering blood and removing waste from the body due to inability to drain urine), moderate protein-calorie malnutrition (not eating enough protein calories), dysphasia oropharyngeal phase (swallowing difficulties), exposure to covid-19 (highly infectious viral disease), pressure ulcer of sacral region (bottom of the spine) stage 4 (has reached through the skin to…

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

Based on observation and interview, the facility failed to provide an ongoing activity program for all 24 residents on the secure unit [is defined as a special care unit in a designated, separate area for individuals with Alzheimer's disease or dementia that is locked, or secured to prevent or limit access by a resident outside the designated or separated area] that were identified on the resident census that the facility Center Executive Director provided on 10/18/21. If the facility is not ensuring that all residents are receiving an ongoing activity program, documenting resident refusals and making in room activity accommodations, then residents are likely to experience increased feelings of isolation [social separation from others] and depression [feelings of sadness or loss of interest in doing activities]. The findings are: A. On 10/18/21 at 8:45 am, during an interview with Certified Nursing Assistant [CNA] #5 she stated that the activities department are hardly ever back here [on the secure unit] doing any activities [with the residents]. She stated that the staff do 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, record review, and interview, the facility failed to ensure that a resident with a diagnosis of diabetes mellitus (a disease of impaired glucose metabolism) was offered foods to help maintain a healthy blood glucose level for 1 [R #17] of 6 [R #s 17, 44, 58, 67, 223, 272] residents reviewed for nutrition. This deficient practice has the potential to result in dangerously high blood glucose levels in a diabetic resident. The findings are: A. Record review of the face sheet for R #17; revealed she was admitted to the facility with Dementia with Behavioral Disturbance [behavioral disturbances can be grouped into four categories: mood disorders (e.g., depression, apathy, euphoria); sleep disorders (insomnia, hypersomnia, night-day reversal); psychotic symptoms (delusions and hallucinations); and agitation (e.g., pacing, wandering, sexual disinhibition, aggression)],Type II Diabetes Mellitus, Major Depression Disorder, other Hallucinations and Delusional Disorders [an experience involving the apparent perception of something not present]. This is not all of R #17's…

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

Based on interview and record review, the facility failed to ensure that staff members follow their established scope of practice (the services that a qualified health professional is deemed competent to perform, and permitted to undertake in keeping with the terms of their professional license) for all the residents residing on the 200 hall on 10/24/21 by allowing an uncertified staff member to administer medications without the supervision of a licensed nurse. This deficient practice is likely to allow the opportunity for a medication error. The findings are: A. On 10/24/21 at 1:30 pm, during an observation of the number of licensed and certified nursing staff on the weekend, information was gained that Certified Nursing Assistant (CNA) # 6, who had completed the nursing board-approved medication administration program in July, was waiting to take the medication aide examination. CNA #6 had been assigned to administer the scheduled medications to the 19 residents that reside on the 200 hall, without the supervision of a Registered Nurse (RN) due to a licensed nurse calling in for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that medically-related social services were provided for 1 [R #265] of 1 [R #265] mentally incompetent residents that were identified as needing assistance in obtaining health care agents [such as a Power of Attorney [POA] or a Guardian [a trusted person appointed legally to to make medical decisions on the residents behalf]. This deficient practice could lead to the residents receiving inconsistent services and not having their best interests served within the facility. The findings are: A. Record review of the hospital records for R #265 dated 03/19/21 indicated the following: per CM [Case Manager] note: in process to apply to Office of Guardianship .Recommended discharge to skilled nursing facility. He would not be a safe discharge to his home where he lives alone. He would not be able to identify and or resolve any unsafe situations or hazards in the home. Like forget the stove was on, burn himself while cooking or take medications wrong. B.…

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

Based on interview and record review, the facility failed to address and respond to the resident concerns and grievances (an official statement of a complaint over something believed to be wrong or unfair) for 1 (R #421) of 3 (R #24, 90 and 421) residents. This deficient practice could likely result in residents feeling that their issues or concerns are not taken seriously, leading to feelings of helplessness, and frustration. The findings are: A. Record review of R #421's progress note dated 01/09/21 revealed the following: 1/9/2021 15:32 pm General Note: Resident filed a grievance about nursing staff due to other resident. Resident gave a grievance to the primary nurse, so she can escalate it to the manager. Resident stated They always do this to him. And I will escalated more. I'm not gonna leave it. The primary nurse gave a grievance to the house supervisor. Will continue to monitor. B. On 10/26/21 at 11:03 am, during an interview, the Interim Director of Nursing (DON) stated she could not find the grievance on file for R #421 that the Registered Nurse (RN) #1 filed for him…

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 accurately assess dialysis (medical treatment that filters and purifies the blood using a machine when your kidneys do not function correctly) needs for 1 (R #78) of 2 (R #s 44 and 78) residents sampled for Dialysis needs. The deficient practice could likely to result in residents not receiving needed care and treatment. The findings are: A. Record review of Face Sheet dated 05/21/20 for R #78 revealed this is the initial admission date and included the following diagnoses: Type 2 Diabetes Mellitus (high blood sugar) with Diabetic Chronic Kidney Disease (loss of kidney function), Kidney Failure (when your kidneys stop functioning), Legal Blindness (inability to see things including light), Acute Systolic Congestive Heart Failure (disease that affects pumping action of the heart muscles, which causes fatigue and shortness of breath), Contact with (suspected) Exposure to other Viral Communicable Diseases (highly infectious disease that is easily spread…

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 (put into place) a comprehensive person-centered care plan for 1 (R #67) of 3 (R #s 44, 67 and 78) residents reviewed for care plans. Failure to develop and implement a resident centered care plan is likely to result in staff's failure to understand and implement the needs and treatments of residents. The findings are: A. Record review of face sheet dated 08/19/21 for R #67 revealed an initial admission date of 05/19/20 and included the following diagnoses: Encephalopathy (disease that affects brain structure or function), Hypoxemia (low oxygen levels in the blood), Schizoaffective Disorder (a combination of psychotic and mood symptoms and can affect a person's thinking, emotions, and behaviors), Anxiety Disorder (excessive and persistent worry and fear about everyday situations), Muscle Weakness, Central Pontine Myelinolysis (brain cell dysfunction), Paranoid Schizophrenia (a chronic mental illness in which a person loses touch…

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

Based on record review and interview, the facility failed to ensure that care plans had been revised, updated, and reflected up-to-date goals, and interventions for 1 [R #42] of 3 [R # 16, 42 and 97] residents reviewed for care plans. This deficient practice could likely result in residents not receiving the care and assistance they need to maintain their highest practicable well being. The findings are: A. Record review of the care plan dated 07/23/21 indicated that there were no goal or interventions initiated in the care plan for R #42's behaviors. B. Record review of the nursing progress notes dated 10/04/21 indicated that R #42 had returned from [name of hospital] a behavioral health facility. R #42 was sent to the behavioral health facility for medication review and behaviors. C. Record review of the nursing progress notes dated 10/08/21 indicated that R #42 had physical behaviors that occur up to five days per week, verbal behaviors that occur up to five days per week, and rejection of care that occurs up to five days per week. Pt. [patient] is experiencing…

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

Based on interview and record review the facility failed to ensure that 1 (R #278) of 1 (R #278) resident with a gastronomy tube (G-Tube- a tube inserted through the abdomen that delivers nutrition directly to the stomach) received continuous (24-hour) nutrition feed as prescribed by a physician to commence (start) the day resident was admitted into the facility. This deficient practice could likely cause R #278 to be starved of food and become dehydrated (harmful reduction in the amount of water in the body) from lack of fluids/water due to the facility's delay in administering (giving)/initiating (beginning) nutritional feed delivery. The findings are: Findings for R #278: A. Record review of R #278's Face Sheet date of admittance 04/02/21. B. Record review of R #278's physicians orders dated 04/02/21. The physician order states one time a day, Pour 5 cans of twoCalHN (Jevity) (nutrition formula) into bag to hang. TwoCal HN: Administer Continuous 45 mL (milliliter)/hr (hour) x 24 hours. Total volume 1080 mL/24 hours, the order state to commence the day resident was admitted into…

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

Based on record review and interview the facility failed to ensure that 1 [R #97] of 7 [R #'s 4, 45, 58, 66, 68, 87, and 97] residents reviewed for psychotropic medications (medications used to treat psychiatric conditions by altering perception, mood, consciousness, cognition or behavior) were not given medications longer than necessary. This deficient practice could likely result in residents continuing to receive medications that are inappropriate for use in the elderly population due to having a high mortality [state of being subjected to death] rate. The findings are: A. Record review of the face sheet for R #97 indicated the following: major depressive disorder [frequent feelings of sadness or loss of interest in doing activities]. Dementia with behavioral disturbance [Dementia refers to a group of symptoms that together affect the memory, normal thinking, communicating and the reasoning ability of a person, the behaviors associated with Dementia are mood disorders (e.g., depression, apathy, euphoria); sleep disorders] and anxiety disorder [intense, excessive, and persistent…

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

Based on observation, record review and interview, the facility failed to ensure that residents were bathed according to the facility schedule and their preferences for 2 (R #38 and 93) of 3 (R #21, 38, and 93) resident reviewed for choices. This deficient practice has the potential to prevent residents from maintaining personal hygiene per their personal preference. The findings are: A. On 10/19/20 at 2:42 pm, an observation was made R #38 had not been bathed. Her sheets had not been washed and they were stained and very dirty. She had food under her nails and her hands appeared dirty. B. Record review of the Activities of Daily Living/bathing indicated that for R #38 for the month of June 2020 R #38 had two showers and three documented refusals. For the entire month of July 2020 R #38 did not have any showers or bed baths documented. For August 2020 R #38 had two showers documented and two refusals documented. September 2020 indicated that R #38 received 6 showers. For the month of October 2020 ADL/Bathing documentation indicated that R #38 received 4 showers from 10/01/20-…

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 for 4 (R #s 67, 106, 178 and 179) of 10 (R #s 19, 67, 73, 76, 84, 89, 106, 178, 179,and 183) new and re-admitted residents whose records were reviewed for Advance Directives (legal documents that allow you to spell out your decisions about end-of-life care ahead of time) were filled out and updated timely. This deficient practice could cause confusion with the residents' advance directives resulting in the end of life wishes not being met. The findings are: Findings for R #179 A. Record review of the face sheet for R #179 indicated that he was admitted to the facility on [DATE]. B. Record review on 10/19/20 of the electronic medical record for R #179, indicated that there was no advance directive in the electronic medical chart miscellaneous section, and there was nothing on the electronic medical record dashboard. C. Record review on 10/19/20 of the paperchart for R #179 indicated that the NM MOST (Medical Orders for Scope of Treatment)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the assistance needed for 2 (R #8 and R #103) of 2 (R #8 and R #103) residents reviewed for receiving restorative nursing services, [Restorative nursing programs aim is to keep residents from declining once rehabilitation therapy {such as physical therapy (PT), occupational therapy (OT) and speech therapy (ST)} has ended, a program provides a wide range of services to augment residents strengths and prevent declines if possible] was provided. This deficient practice could likely affect any of the 22 residents noted to have restorative nursing needs, from list provided by the Center Nurse Executive on 10/21/20. If an organized and supervised program is not in place it will likely result in residents affected not gaining or maintaining their optimal state of well-being while living in the facility. The findings are: A. Record review of facility policy titled, . Restorative Nursing, last revised 03/31/20 revealed, A registered nurse (RN) or licensed…

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

Based on observation, interview and record review, the facility failed to provide a substantive program of activities for 4 [R # 18, 41, 66, and 93] out of 4 [R # 18, 41, 66, and 93] residents looked at for activities. Some residents stated that they were bored and depressed and don't have enough to do. This deficient practice has the potential to diminish residents' quality of life through lack of engagement, lack of socialization, and boredom. The findings are: A. On 10/20/20 at 9:08 am, during an interview with R #93, she stated that she is bored and she is sitting in her room like she is grounded. She stated that the only thing there is do, is to go out for smoke break. R #93 stated that it is the best thing that happens during the day. She stated that she feels bad for those residents that don't smoke because they don't get outside. B. On 10/20/20 at approximately 1:30 pm, during an interview with R #18, he stated that he got some money from the government and he bought himself an Ipad with it. He stated that it is the only thing that keeps him from going crazy. C. On 10/21/20…

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 medications were administered as ordered for 2 (R #s 40 and 111) of 2 (R #s 40 and 111) residents reviewed for medications not given as ordered by the physician. This deficient practice is likely to result in a resident failing to obtain maximum wellness and/or suffering prolonged illness. The findings are: Findings for R #40: A. Record review of facility, admission Record, revealed, his most recent admission was on 10/07/20 with diagnosis that included, Diffuse Traumatic Brain Injury [injury to head from some external force, affecting more than one area of the brain] as a primary diagnosis and Conduct Disorder [A behavioral and emotional disorder that presents as repetitive, disruptive behavior.] unspecified as secondary. B. Record review of Medication Administration Record (MAR) for October 2020 revealed, Chart Codes .NN= [indicates] NO/See Nurse Notes and ZZ= In Progress. C. On 10/21/20 at 11:25 am during interview with Licensed Practical…

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: 1. Communicate and maintain menu options 2. Update resident preferences for 7 (R#'s 41, 96, 103, 111, 120, 324, and 325) of 7 (R#'s 41, 96, 103, 111, 120, 324, and 325) residents reviewed during dining observations. This deficienct practice could likely result in a decline in the psychosocial health of the residents as the residents develop feelings of frustration, anxiety, and disappointment. The findings are: Findings for R# 96: A. On 10/19/20 at 02:46 pm, during an interview with R# 96, when asked to describe the food served by the facility, R# 96 stated they refuse to serve correct food to people. They served us French Toast and a cube of ham about an inch and a half big. They never toast the bread. Once they served me chicken and it hurt my tooth when I bit into it. It snapped like a piece of wood. They don't serve nutritious meals. I have repeatedly talk to the dietician and 2 dietary managers. They had a poor attitude about my concerns. The nutritionist believes that the residents do not deserve snacks.…

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

Based on record review, observation, and interview, the facility failed to ensure that meals were served at an appetizing temperature and palatable, for 10 (R # 15, 18, 38, 41, 50, 55, 91,103, 120, and 325) of 10 (R # 15, 18, 38, 41, 50, 55, 91,103, 120, and 325 ) residents reviewed for meal quality. This deficient practice reduces residents' ability to make choices about important aspects of their lives and may decrease their quality of life by not having nutritious palatable food and food served at the proper temperature. The findings are: A. Record review of the meal times indicated that meal times can vary 10 minutes or so due to the complexity of the meal. On the 200 hall breakfast is served at 7:40 am, 12:40 pm, and dinner is served at 5:40 pm. B. On 10/19/20 at 1:10 pm, during ongoing observation revealed lunch had still not been served on the 200 hall. Observation had not been made of when breakfast was served on 10/19/20. C. On 10/19/20 at 1:13 pm, an observation was made of the food carts being loaded by Dietary Aide #1 [DA]. During observation it was asked by one DA #1 to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to implement all recommended transmission-based precautions for residents newly admitted and readmitted to the facility. While caring for residents suspected of having COVID-19 [is a new illness that can affect your lungs and airways. It's caused by a virus called coronavirus] during the 2020 public health emergency, these failed practices put all 128 residents in the facility at increased risk for infection with COVID-19. On the date of this survey, 10/19/20, recommended /nationally recognized transmission-based precautions included staff caring for residents newly admitted or readmitted to wear gowns, gloves, an N95 face mask (or higher-level protection) and goggles or face shield and for residents to be placed in a private room (if available) with the door closed for 14 days. If all recommended standard and transmission-based precautions are not consistently adhered to, safe resident care that inhibits transmission of infections from person to person is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that medications were stored safely, which has the potential to affect any of the facility's 22 residents listed on the facility census as living on the 200 unit provided by the Administrator on [DATE]. Un-labeled, altered labeled and medications labeled for residents that no longer on the unit/in the facility were stored with current residents medications. Medications were left in an unlocked unattended treatment cart on a behavioral health care unit. These deficient practices have the potential to result in resident injury, through use of expired product, potentially contaminated product, or self administration of medication by a confused resident. The findings are: A. On [DATE] at 9:19 am during observation in the 200 unit the treatment cart was noted to be unlocked. In the cart were insulin pens and vials glucose monitoring supplies. The following were noted on the cart for residents no longer residing on the unit: 1. For R #113,…

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.