The Rehabilitation Center of Albuquerque

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY PAST NON-COMPLIANCEBased on record review and interviews, the facility failed to ensure residents were free from misappropriation of property for 1 (R #2) of 1 (R #2) resident reviewed, when a transport driver took money from a resident. This deficient practice could result in financial loss, emotional distress, and compromise of resident trust and safety. The findings are: A. Record review of the facility's Code of Conduct revealed staff were not to ask for or accept tips, gifts, loans, and/or monetary transactions from residents or their family members. Further review revealed the facility has a zero tolerance for any type of misappropriation or exploitation. B. Record review of the facility's follow-up investigation report, dated 11/19/25, for misappropriation of resident property identified the following corrective actions: All drivers were re-educated of the facility's zero-tolerance policy against misappropriation of resident property. A sign was placed in each transportation van to indicate to residents…

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 report a medication error involving 1 (R #1) of 1 (R #1) to the State Agency as required. This failure limited regulatory oversight and placed the residents at risk for serious harm by delaying external review and corrective action.If a facility fails to report medication errors in accordance with abuse prevention and reporting requirements, then the facility limits the State Agency's ability to ensure resident safety, increasing the risk of unaddressed harm and repeated incidents.The findings are:A. Record review of the facility's Abuse Prohibition Policy revised 11/14/25, revealed the facility prohibits abuse, mistreatment, neglect, exploitation, misappropriation of patient property, and injuries of unknown source and requires immediate reporting, investigation, and protection of patients. The policy specifies that allegations resulting in serious bodily injury must be reported immediately but no later than two (2) hours, and allegations not…

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 prevent a significant medication error when staff administered a second dose of Mounjaro (GLP-1 Trizepatide) 12.5 milligrams (mg) within 24 hours to 1 (R#1) of (R #1). The facility also failed to ensure accurate medication administration practices consistent with the resident's prescribed regimen. The Findings are: A. Record review of the facility's Medication Administration policy, dated January 2025, revealed licensed nurses must administer medications in accordance with the written orders of the prescriber.B. Record review of R #1's Face Sheet revealed she was admitted on [DATE] with diagnoses including morbid obesity (severely overweight) and Type 2 diabetes mellitus (DM2, a disease in which the body cannot make or properly use insulin)C. Record review of the physician orders dated 08/01/25 showed an active order for Mounjaro (tirzepatide) 12.5 mg subcutaneous (under the skin) once weekly, and an active order for Emgality (migraine medication)120…

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 stored securely when a medication cart remained unlocked and unattended on the 200 Hall. This failure created the potential for unauthorized access to medications, including controlled substances, for 1 of 1 medication carts observed. The findings are: A. Record review of the facility's Medication Storage and Security Policy, revised January 2025, revealed the facility requires all medications to be kept secured at all times. The policy states medication carts must remain locked when not in the direct possession of licensed staff, and controlled substances must be stored in a separately locked, permanently affixed compartment. The policy further states staff must ensure medications are protected from unauthorized access by residents, visitors, or staff.B. On 12/12/25 at 9:17 a.m., observation of the 200 Hall revealed a medication cart positioned in the hallway with the top drawer unlocked. No staff were present in the immediate area, and the cart remained unattended and accessible to residents walking…

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 ensure: 1. Nurses and Certified Medication Aides (CMAs) dated opened insulin (a medication prescribed to help the body turn food into energy and manages blood sugar levels) pens and discarded them within 28 days of opening date for 5 (R #8, R #12, R #15, R #32 and R #66) of 5 (R #8, R #12, R #15, R #32 and R #66) residents reviewed. This deficient practice is likely to lead to all five residents receiving medications that are less effective or expired. 2. Staff secured medications and made them inaccessible to unauthorized staff for one medication cart in the 100 hall and one treatment cart in the 400 hall. Improperly stored medications could result in a resident, staff member, or visitor taking medications not prescribed to them. This deficient practice had the potential to affect all 60 residents in both halls as identified by the Resident Census provided by the Administrator on 06/22/25. The findings are: Insulin Pens A. Record review of the facility's Insulin Pens Policy, dated 05/01/25, revealed the…

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

Based on observation, interview, and record review the facility failed to ensure the low temperature dishwasher (low temperature dishwashers utilize chemicals for sanitation) worked properly to sanitize the dishes and was repaired timely. If the facility is not properly sanitizing the dishes, then there was the potential for foodborne illnesses which could affect all of the 116 residents listed on the resident census provided by the Administrator on 06/22/25. The findings are: A. Record review of the temperature log for the low-temperature dishwasher showed staff documented 200 parts per million (PPM; a unit used to express the concentration of a substance in a solution) for each meal on 06/23/26. B. On 06/24/25 at 10:27 am, during a kitchen observation, Kitchen Staff #2 checked the low-temp dishwasher's sanitizer level. Kitchen Staff #2 tested the sanitizing solution three times, but the test strips did not show any sanitizer passing through the machine. C. On 06/24/25 at 10:43 am, during an interview, the Kitchen Manager (KM) stated the test strips did not register any sanitizer…

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: Lock a treatment cart (a movable piece of equipment used in healthcare facilities to store, transport, and dispense treatment supplies and tools) on the 400 Unit when not in use and unattended. Lock a wound care treatment cart on the 100 Unit when not in use and unattended. These deficient practices had the potential to affect all residents on the 400 and 100 Units. If staff fail to lock unsupervised treatment carts, then residents could obtain medical equipment which could result in injury or death. The findings are: A. Record review of the facility's Storage of Medication policy, dated January 2025, revealed the following: Medications are stored properly, following manufacturer's or provider pharmacy recommendations, to keep their integrity and to support safe, effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. 400 Treatment Cart B. On 06/22/25 at 5:43 am, 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.

Based on interview and record review, the facility failed to: - Ensure appropriate treatment and services for 1 (R #26) of 1 (R #26) resident who had urinary retention (a condition that occurs when a person is unable to empty their bladder, either partially or completely) and an indwelling urinary catheter (a thin, flexible tube which drains urine from the bladder). - Ensure an indwelling urinary catheter was used only when clinically necessary for 1 (R #1) of 1 (R #1) resident. These deficient practices could place the residents at risk for infection or diminished quality of life. The findings are: R #26 A. Record review of R #26's face sheet showed an admission date of 10/06/17 with the following diagnoses: - Tremors (a neurological condition that included shaking or trembling movements in one or more parts of the body), - Spastic quadriplegic cerebral palsy (a type of cerebral palsy), - Congenital hydrocephalus (an abnormal buildup of cerebrospinal fluid in the brain), - Spinal stenosis cervical region (a bone disease involving the narrowing of the spinal canal at the level 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 reviews and interviews, the facility failed to: 1. Ensure a resident received a prescribed anticoagulant (AC, blood thinner) medication at admission to the facility for 1 (R #69) of 1 (R #69), when staff failed to administer warfarin (blood thinner) as ordered by the provider. This deficient practice is likely to lead to increased R #69's risk of blood clot formation. 2. Ensure a resident received prescribed antipsychotic medication (used to treat mental health conditions that involve psychosis) in a timely manner for 1 (R #1) of 1 (R #1) resident, when staff failed to administer the antipsychotic medication as ordered by the provider. These failures have the potential to lead to the reduction of the medication's effectiveness and potentially lead to a return or worsening of the symptoms. The findings are: Warfarin A. Record review of R #69's Face Sheet, undated, revealed R #69 was admitted to the facility on [DATE] with multiple diagnoses including: -Venous thrombosis (blood clot) and embolism…

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 ensure a call light was within reach for 2 (R #5 and #22) of 2 (R #5 and #22) residents observed. If the facility is not ensuring the call light is within residents' reach, then residents are unable to request immediate assistance when needed. The findings are: A. On 06/22/25 at 9:54 am, during an observation, Certified Nursing Assistant (CNA) #8 left R #5's room with a vital machine (a machine used to take blood pressure, oxygen, and temperature), and R #5's call light was on the floor out of the resident's reach. B. On 06/22/25 at 10:15 am, observation revealed R #22's call light was on the floor, and R #22 lay in bed watching TV. C. On 06/22/25 at 11:00 am, during an interview, CNA #8 confirmed R #22's call light was on the ground. CNA #8 stated R #22 was not her resident, did not pick up R #22's call light, and left the room. CNA #8 stated R #5's call light was on the ground. She stated she was in the resident's room taking vitals, and she did not remember if the resident's call light was on the ground. CNA #8 stated…

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 a resident's right to retain his personal property for 1 (R #34) of 1 (R #34) resident when staff removed a resident's Christmas lights from his room and failed to put them back up after the safety rating was approved for use. If staff do not respect a resident's right to personal property, then the resident may become angry, frustrated, and disrespected. The findings are: A. Record review of R #34's face sheet revealed an admission date of 08/22/23 with diagnosis of depression and post-traumatic stress. B. Record review of R #34's Minimum Data Set, dated [DATE], indicated R #34 had a Brief Interview of Mental Status (BIMS; a screening for cognitive impairment) score of 15, cognitively intact. C. On 06/22/25 at 7:30 am, observation revealed Christmas lights hung around R #34's room. D. Record review of the manufacturer's instructions for R #34's Christmas lights revealed the lights were 4-[NAME] (measurement of electricity) string…

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 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 2 (R #60, #86) of 2 (R #60, #86) residents reviewed for Baseline Care Plans. This deficient practice could likely result in a decline in the residents' condition due to staff not being aware of the care residents' need, and residents may not attain or maintain their highest level of well-being. The findings are: A. Record review of the facility's Person-Centered Care Plan policy, last revised 10/24/22, revealed staff must develop and implement a baseline person-centered care plan within 48 hours of admission/readmission for each resident, which included the instructions needed to provide effective and person-centered care that meets professional standards of quality care. Resident #60 B. Record review of R #60's face sheet revealed an initial admission date of 05/12/25 with the following diagnoses: - Other acute…

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 reviews and observations, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1(R #1) of 1(R #1) residents observed, when staff failed to report or repair a broken wall inside R #1's room. This deficient practice is likely to lead to the following: 1. Creating an environment conducive to mold and mildew growth. 2. Mice can enter through the broken wall and cause significant damage, spread diseases, and create unpleasant odors. They can chew through insulation, wiring, and other building materials, potentially leading to fires or structural problems. The findings are: A. Record review of R #1's Face Sheet, undated, revealed R #1 was admitted to the facility on [DATE]. B. Record review of the facility's Work Orders Report dated 11/01/24 through 04/22/25 showed staff did not report the broken wall in R #1's room. C. On 04/21/25 at 9:00 am, during observation of R #1's room, part of the wall was broken and had a hole. D. On 04/21/25 at 9:05 am,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to follow a physician's order and professional standards of practice for 1 (R #1) of 1 (R #1) residents reviewed for medication administration. This deficient practice could likely cause staff to incorrectly administer a medication, which could cause the gastronomy tube (g-tube; a tube inserted through the belly that brings nutrition directly to the stomach) to clog and or incompatible medications to be administered together. The findings are: A. Record review of R #1's quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 02/19/24, revealed the following: - The resident was admitted to the facility on [DATE]; - The resident was diagnosed with traumatic brain injury (TBI; injury to the brain caused by an outside force, usually a violent blow to the head), cerebrovascular accident (CVA; stroke), and transient ischemic attack (TIA; when blood flow to part of the brain stops for a brief period 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, record review, and observation, the facility failed to ensure staff served meals that were attractive and palatable (pleasant to taste) for 6 (R #'s 2, 7, 29, 36, 49, and 309) of 10 (R #'s 2, 7, 15, 29, 36, 37, 39, 49, 104 and 309) residents reviewed for meal quality. This deficient practice reduces residents' ability to eat and enjoy meals, may decrease their quality of life, and could likely lose weight. The findings are: A. On 03/25/24 at 11:05 AM during an interview, R #309 stated the food was not always hot and arrived to her room cold. B. On 03/25/24 at 11:15 AM during an interview, R #2 stated the food was regularly cold and unappetizing by the time it arrived to her room. C. On 03/25/24 at 11:21 am during an interview, R #29 stated the food was often unidentifiable, there was not much variety, and the food tasted awful. D. On 03/25/24 at 12:30 PM during an interview, R #49 stated she was served raw chicken on several unknown dates. She said most of the time her food was cold when staff delivered it to her room . E. On 03/25/24 at 1:26 PM during 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.

Based on observation and interview record review, the facility failed to serve food under sanitary conditions in accordance with professional standards of food service safety when staff failed to monitor the internal temperature of food to ensure it is safe for consumption. This deficient practice is likely to result in residents getting a food borne illness and could likely affect all 115 residents identified on the census list provided by the Administrator on 02/12/24. The findings are: A. On 03/25/24 at 10:58 AM during an interview, R #39 stated his food was always served cold. B. On 03/25/24 at 11:05 AM during an interview, R #309 stated the food was not always hot and arrived to her room cold. C. On 03/25/24 at 11:15 AM during an interview, R #2 stated the food was regularly cold and unappetizing by the time it arrived to her room. D. On 03/25/24 at 12:30 PM during an interview with R #49, she said she was served raw chicken on several unknown dates. She said most of the time when her food was delivered to her room it was cold. E. On 03/25/24 at 1:26 PM during an interview with…

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

Based on observation, interview, and record review, the facility failed to ensure that Minimum Data Set (MDS; a federally mandated standardized assessment tool completed by facility staff, that measures health status in nursing home residents) assessments included accurate insulin use information for 2 (R #2 and R #3) of 2 (R #2 and R #3) residents reviewed for MDS accuracy. This deficient practice could likely result in residents not receiving the most optimal and personalized care required to meet their highest practicable outcomes. The findings are: R #2 A. Record review of R #2's quarterly MDS assessment, dated 01/19/2024, Section N, indicated R #2 received seven insulin injections during the seven day look back period (The time period over which staff observe a resident to capture the resident's condition or status for the MDS assessment. Unless otherwise stated, the look back period is seven days, and only those occurrences during the look back period will be captured on the MDS.) B. Record Review of R #2's physician's order summary, dated January 2024, did not include 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 observation, interview, and record review, the facility failed to support residents in activities of daily living by not offering showers to residents in accordance with a pre-planned and agreed upon schedule and not answering call lights in a timely manner for 3 (R #2, R #73, and R #309) of 3 (R #2, R #73, and R #309) residents sampled for ADLs. These deficient practices are likely to negatively impact resident safety, comfort, and to impede processes such as timely incontinence care (assisting residents to the bathroom or changing adult briefs) and showers. The findings are: Finding related to showers: R #309 A. Record review of R #309's care plan, revised on 03/17/24, revealed R #309 was admitted to the facility on [DATE] and required activities of daily living (ADL) assistance in bathing, grooming, personal hygiene, dressing, transfers, locomotion, and toileting. B. Record review of R #309's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) assessment,…

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 properly store medications in medication carts by allowing loose medications under the medication cards (cards that contain individually sealed tablets in which the medication must be pushed through the foil in order to take the medication). This deficient practice has the likelihood to result in all residents on hall 300 and 400, as identified on the census list provided by the administrator on [DATE], to receive expired or improperly temperature-controlled medications that have either lost their potency or effectiveness. The findings are: A. On [DATE] at 8:33 am, during an observation of the 400 hall medication cart, a loose round, white tablet lay under the medication cards. B. On [DATE] at 8:44 am, during observation of the 300 hall medication cart, loose medications lay under the medication cards. The loose medications included one white oval tablet, two pink oval tablets, one liquid capsule, and two white circular tablets. C. On [DATE] at 10:22 am,…

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. Based on observation, record review, and interview, the facility failed to take into consideration food preferences (choices) for 2 (R #36 and R #49) of 2 (R #36 and R #49) residents by not providing an alternative meal substitution as per resident request. This deficient practice could likely affect all 116 residents identified on the facility census provided by the Administrator (ADM) on 03/25/24 and could likely result in residents feeling frustrated that staff do not support their rights and choices. The findings are: Resident #36 A. Record review of posted lunch menu for 03/27/24 revealed staff to serve the following for lunch: Country fried steak with mushroom gravy or fish tacos with flour tortilla, dinner roll, pineapple tidbits, seasoned potato wedges, and seasoned green beans or Mexican street corn. B. Record review of Available Daily Lunch and Dinner Menu revealed the following items were available: Grilled cheese sandwich; peanut butter and jelly sandwich; ham and cheese sandwich; chef salad with vinaigrette (a type of salad dressing); 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 observation, interview, and record review, the facility failed to meet professional standards of care for 1 (R #309) of 1 (R #309) resident reviewed for oxygen therapy when staff failed to: - Ensure physician orders for oxygen therapy were entered into the resident's medical record. - Ensure O2 tubing was properly dated and labeled with the last equipment change. This deficient practice could likely result in residents not getting the therapeutic results required for optimal health. The findings are: A. Record review of R #309's face sheet revealed she was admitted to the facility on [DATE] with multiple diagnoses including (not an all-inclusive list): - Acute and chronic respiratory failure with hypoxia (not enough oxygen is delivered to maintain the body's normal functions), - Hemiplegia (paralysis affecting one side of the body) and hemiparesis (weakness affecting one side of the body) following cerebral infarction (stroke) affecting right dominant side, - Asthma, unspecified, - Chronic diastolic…

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. Based on interview, observation, and record review, the facility failed to serve food according to the presented menu. This deficient practice has the potential to affect all 116 residents listed on the census presented by the Administrator (ADM) on 03/25/24 and could likely result in resident frustration and/or dissatisfaction with meal options and therefore residents' may not receive required nutrition to maintain their best health. A. On 03/26/24 at 9:42 am during an interview, R #37 stated there was not much variety, and the menu was not followed. R#99 B. Record review of posted lunch menu for 03/27/24 revealed staff to serve the following for lunch: Country fried steak with mushroom gravy or fish tacos with flour tortilla, dinner roll, pineapple tidbits, seasoned potato wedges, and seasoned green beans or Mexican street corn. C. On 03/27/24 at 11:57 am during a random meal observation, staff served R #99 a plate of Salisbury steak, mashed potatoes with brown gravy, and a small bowl of salad. Staff did not serve the resident the items on the posted…

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 ensure a resident's call light was functioning as intended for 1 (R #3) of 1 (R #3) resident reviewed for call system functioning. This deficient practice could likely result in residents being unable to notify staff when they are in need of assistance. The findings are: A. On 03/25/24 at 1:48 PM during an observation, R #3 was in her bed with a bed side commode (BSC) next to her bed. A call light button was attached to the BSC. B. On 03/25/24 at 1:50 PM during an interview, R #3 stated her call light did not work and has not worked for several days. She added she notified multiple staff members, and nothing has been done about it. C. On 03/25/24 at 1:52 PM, during an observation, R #3 pressed the call light button two separate times. The hallway indicator light did not activate on either attempt. D. Record review of facility's maintenance work orders revealed the record did not contain an open or resolved work order for R #3's call light. E. On 03/27/24 at 1:00 PM, the Administrator stated R #3's call light…

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 facility policy review, the facility failed to ensure two residents observed of a sample of 33 residents (Resident (R) 94 and (R)20) had emergency calling devices or alternative communication devices accessible while in their beds. These failures had the potential to delay needed assistance and negatively impact the quality of life. Findings include: A. Review of the facility's Call Lights policy, dated 10/24/21, revealed, Patients will have a call light or alternative communication device within their reach at all times when unattended. B. Review of R94's undated admission Record, located in the Profile tab of the Electronic Medical Record (EMR), revealed R94 was admitted to the facility on [DATE]. C. Review of R94's Brief Interview for Mental Status (BIMS) located in the quarterly Minimum Data Set (MDS) with an assessment reference date of 10/18/22, located in the MDS tab of the EMR, revealed R94 scored three out of 15 which indicated R94 had severe cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to report to the State Survey Agency an incident resulting in an injury for one (Resident (R) 516) of 3 residents sampled for falls. This deficient practice could likely result in preventing staff from determining the cause of the incident and identifying the need for staff training and implementing interventions to address such incidents in the facility. The findings are: A. Review of the Accidents/Incidents policy dated 10/24/22 provided by the facility revealed, Center staff will report, review, and investigate all accidents/incidents which occurred, or allegedly occurred, on or off Center property and involving, or allegedly involving, a patient who is receiving services .The licensed nurse will: Report accidents/incidents and assist with completion of a timely investigation to determine root cause; Take immediate post-accident/incident measures as deemed appropriate; Implement appropriate interventions based on conclusions; Update the care plan 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 conduct a thorough investigation for one (Resident (R) 516) of 3 residents sampled for falls. This deficient practice could likely result in preventing staff from determining the cause of the incident and identifying the need for staff training and implementing interventions to address such incidents in the facility. The findings are: A. Review of the Accidents/Incidents policy dated 10/24/22 provided by the facility revealed, Center staff will report, review, and investigate all accidents/incidents which occurred, or allegedly occurred, on or off Center property and involving, or allegedly involving, a patient who is receiving services .The licensed nurse will: Report accidents/incidents and assist with completion of a timely investigation to determine root cause; Take immediate post-accident/incident measures as deemed appropriate; Implement appropriate interventions based on conclusions; Update the care plan and communicate with the patient 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 observation, interview, record review and facility policy review, the facility failed to ensure two of 33 sampled resident's (Resident (R) 27 and R70) care plan interventions were implemented for R27's nutritional risk monitoring of meal intakes, and failed to ensure a care plan was developed for R70's prescribed neck brace, oxygen therapy and C-PAP [a method of respiratory therapy in which air is pumped into the lungs through the nose or nose and mouth during spontaneous breathing, used in the treatment of sleep apnea and other respiratory disorders]. The facility's failure had the potential to increase R27's risk of insufficient nutritional intake and R70's risk for potential of respiratory and neck brace complications. Findings include: A. Review of facility provided policy titled Person-Centered Care Plan dated 10/24/22 revealed The Center must . develop .implement .care plan .for each patient/resident .instructions to provide effective and person-centered care that meet professional standards…

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, interviews, and record reviews, the facility failed to provide quality care in accordance with physician orders for one (Resident (R) 517) out of 33 sampled residents. The facility failed to notify the physician of elevated blood sugars in accordance with physician's orders. This had the potential for the resident to not receive timely care and services related to her high blood sugars. Findings include: A. Review of the undated admission Record, in the Electronic Medical Record (EMR) under the Profile tab, revealed R517 was admitted to the facility on [DATE] with a diagnosis of type 2 diabetes. B. Review of the Care Plan dated 11/28/22 in the EMR under the Profile tab, revealed R517 has a diagnosis of diabetes with insulin dependency and will be free of all signs and symptoms of hypo/hyperglycemia such as: sweating, trembling, thirst, fatigue, weakness, blurred vision for 90 days .R517 has diabetes creating a potential for hypo or hyperglycemia and other complications .Fingerstick sugars…

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 facility policy review, the facility failed to ensure one (Resident (R)516) of three sample residents reviewed for falls received adequate supervision and assistive devices to prevent accidents. The facility failed to maintain adequate documentation concerning R516's injury and determine the root cause of the accident. Findings include: A. Review of the Accidents/Incidents policy dated 10/24/22 provided by the facility revealed, Center staff will report, review, and investigate all accidents/incidents which occurred, or allegedly occurred, on or off Center property and involving, or allegedly involving, a patient who is receiving services .The licensed nurse will: Report accidents/incidents and assist with completion of a timely investigation to determine root cause; Take immediate post-accident/incident measures as deemed appropriate; Implement appropriate interventions based on conclusions; Update the care plan and communicate with the patient and appropriate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff interview, and facility policy review, the facility failed to ensure one of three sample residents (Resident (R) 1) reviewed for catheters and urinary tract infections (UTIs) received appropriate catheter treatment and services to potentially prevent UTIs. Findings include: A. Review of the facility's Catheter: Indwelling Urinary-Care of policy, updated 06/01/21, revealed, .Secure catheter tubing to keep the drainage bag .off the floor. B. Review of R1's undated admission Record, located in the Profile tab of the Electronic Medical Record (EMR), revealed R1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including severe sepsis, urinary tract infection (UTI), and COVID-19. C. Review of R1's Brief Interview for Mental Status (BIMS) located in the annual Minimum Data Set (MDS), with an assessment reference date (ARD) of 11/01/22, located in the MDS tab of the EMR, revealed R1 scored a 15 out of 15 which indicated R1 was cognitively intact.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, resident and staff interviews, the facility failed to ensure the menu was followed regarding portion size for one resident of six reviewed for meal portions. (Resident (R)324). The had the potential for the resident's nutrition not being met. Findings include: A. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/13/22 located in the Electronic Medical Record (EMR) under the MDS tab indicated R324 was admitted to the facility on [DATE] and had a Brief Interview of Mental Status (BIMS) score of 15 out of 15 indicating he was cognitively intact. B. Review of the EMR in the Med Diag tab revealed R324 had a diagnosis of Moderate Protein-Calorie Malnutrition. C. Review of physician's Orders in the Orders tab of the EMR revealed an order dated 12/07/22 for regular texture and double portion entrée and sides. D. Review of the Diet Order and Communication Form located in the EMR under the Misc tab dated 12/07/22 indicated R324 would receive a…

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, interviews, record review, and policy review, the facility failed to offer food according to diet orders for two out of 33 sampled residents (Resident (R)516 and R518). This failure had the potential to place R516 and R518 at risk for nutritional issues. Findings include: A. Review of the undated Dining and Food Preferences policy provided by the facility revealed, Individual dining, food, and beverage preferences are identified for all residents/patients.The Dining Services Director, or designee, will interview the resident or resident representative to complete a Food Preference Interview within 48 hours of admission. The Registered Dietitian/Nutritionist (RDN) or other clinically qualified nutrition professional will review, and after consultation with the resident, adjust the individual meal plan to ensure adequate fluid volume and appropriate nutritional content for residents that do not consume certain foods or food groups. B. Review of the undated admission Record in the Electronic…

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 the call light was operating for one out of 33 sampled residents (Resident (R)516). The call light had been inoperable for at least two months and although it had been reported to staff, it had not been repaired. This had the potential for the resident's needs not being met in a timely manner. Findings include: A. Review of the undated admission Record in the Electronic Medical Record (EMR) under the Profile tab revealed R516 was admitted to the facility on [DATE] with a discharge of 11/24/22 home and then she was readmitted to the facility on [DATE]. Diagnoses included history of falls, type 1 diabetes, hypertension, hyperlipidemia, hypothyroidism, heart failure, atrial fibrillation, and obstructive sleep apnea. B. Review of the Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/11/22 in the EMR under the MDS tab revealed R516 was cognitively intact with a Brief Interview for Mental Status Score (BIMS) of 14 out…

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.