Uptown Rehabilitation Center

Based on interview and record review, the facility failed to follow physician orders when staff did not enter an order for a nebulizer (device that turns liquid medication into a fine mist, allowing it to be inhaled directly into the lungs) treatment into the medical record for 1 (R #15) of 1 (R #15) resident. This deficient practice could likely result in a resident not receiving the treatment as ordered by the physician which could cause the resident's respiratory status to be compromised. The findings are: A. Record review of R #15's face sheet revealed an admission date of 05/26/24 with the following diagnoses: -Chronic Obstructive Pulmonary Disorder (COPD; lung disease). -Type II diabetes (DM2; a disease in which the body cannot make or properly use insulin). -Hodgkin lymphoma (type of cancer that affects the lymphatic system) -Asthma (chronic lung disease). -Cardiomegaly (a medical condition in which the heart becomes enlarged). B. Record review of R #15's encounter notes, dated 05/17/25 at 1:00 am and written by telehealth provider after hours, revealed R #15 experienced…

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 and interviews, the facility failed to secure medications and make them inaccessible to unauthorized staff for one medication cart on the 300 hall, creating a risk of unauthorized staff or residents taking a medication not prescribed to them. This deficient practice had the potential to affect all 25 residents residing on 300 hall as identified by the Resident Census provided by the Administrator on 07/29/25.A. On 07/29/25 at 1:05 pm, an observation was made of Nurse #9 walking away from the medication cart without locking it. Nurse #9 was observed to walk into a resident's room. Other (unidentified resident and staff members) were also present on the hall.B. On 07/29/25 at 1:08 pm, an observation was made of the Unit Manager (UM) #2 walking down the hall. UM stopped at the medication cart and locked it. She was observed telling Nurse #9 he needed to lock the medication cart every time he walks away from it. C. On 07/29/25 at 1:08 pm, during an interview with the UM #2 she stated the expectation is to lock the medication cart every time a nurse walks away from…

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

Based on observation, record review, and interview, the facility failed to ensure the nutritional needs and preferences were met for all 118 residents listed on the facility census provided by the Administrator on 04/28/25 when staff failed to: 1. Serve the food items listed on the menu. 2. Provide residents with the opportunity to select their choice from the menu or alternate menu in advance of meal service. If the facility is not providing meal as listed on the menu or offering residents the option to select their choice of meal in advance of meal service, then residents are likely to experience frustration, depression, weight loss, and feel unimportant. The findings are: A. Record review of posted lunch menu for 04/30/25 revealed the following: - Main menu item was sausage pizza with marinated cucumber salad. - Alternate menu item was crispy breaded chicken, corn with fresh herbs, and a dinner roll with margarine. - Dessert was a peanut butter cookie. B. On 04/30/25 at 12:24 pm, an observation of the lunch meal service revealed staff served R #19 a cubed pork with peppers…

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 all garbage and refuse containers had lids or were covered when not in use. This deficient practice could likely affect all 118 residents identified on the resident census list provided by the Administrator on 04/28/25. This deficient practice could likely result in the unintentional sheltering and feeding of pests. The findings are: A. On 04/28/25 at 9:23 am during an observation, the kitchen the garbage dumpster, located outside the back entrance of the kitchen, was full of garbage, uncovered, and not in use. B. On 05/02/25 at 10:01 am during an observation, the outside dumpster contained garbage, uncovered, and not in use. C. On 05/02/25 at 10:08 am during an interview, the Maintenance Director (MD) stated staff place all facility garbage, to include the kitchen trash, in the dumpster located outside the back entrance to the kitchen. D. On 05/02/25 at 10:29 A.M., during an interview, the Dietary Manager (DM) stated all garbage containers should be closed or covered. She stated it was the kitchen staff'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 interviews and record reviews, the facility failed to provide complete documentation of an infection surveillance plan (ISP, a system for tracking and monitoring infections) for identifying, tracking, monitoring, and reporting of infections, communicable diseases (an illness that can spread from one person to another), and outbreaks (the occurrence of more cases of disease than expected in a given area or among a specific group of people over a particular period of time) among residents and staff. This failed practice has the potential to affect all 118 residents in the facility. This deficient practice is likely to lead to a higher risk of patient harm, difficulty identifying and addressing outbreaks, and difficulty tracking the effectiveness of infection prevention measures (basic practices to stop the spread of germs). The findings are: A. Record review of the facility's Infection Prevention and Control Program (IPCP) documentation, undated, revealed it did not include the following: - A procedure on how staff monitored residents to identify possible infections and…

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

Based on record review and interview, the facility failed to ensure staff implemented a comprehensive Antibiotic Stewardship Program (ASP, a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use). This failed practice has the potential to affect all 118 residents in the facility. Residents identified on the matrix provided by the Administrator on 04/30/25. This deficient practice could likely result in the inappropriate use of antibiotics and lead to resistance of Multi-Drug Resistant Organisms (MDRO; a germ that is resistant to many antibiotics). The findings are: A. Record review of the facility's Antibiotic Stewardship policy, dated 12/16/24, revealed the purpose of the policy was to reduce inappropriate antibiotic use and prevent the development of antibiotic-resistant organisms. B. Record review of the facility's Infection Prevention and Control Program (IPCP), revealed the facility did not have a proper and adequate ASP that included: 1. Written antibiotic use protocols on antibiotic…

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 interviews, the facility failed to maintain a clean, safe, and comfortable environment for residents when staff failed to: 1) Repair damaged and broken blinds in resident rooms #103, #109, #206, #305, #309, and #311. 2) Repair broken wall tiles in resident bathrooms in rooms #103, #106, and #107. 3) Paint over unpainted drywall in resident rooms #101, #102, #103, #107, #302, #303, and #305. 4) Clean dust from ceiling fans above the dining room eating area. 5) Replace stained tablecloths in the dining room. 6) Ensure the cleanliness of vending machines in the common area. 7) Maintain the conference room in a clean, uncluttered, and hazard-free condition. Failure to maintain the building in a clean and comfortable manner is likely to result in unsafe conditions and prevent residents from enjoying everyday activities. These deficient practices could likely result in residents feeling frustrated, embarrassed, and unimportant. The findings are: Broken Blinds A. On 04/28/25 at…

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

Based on observation, record review, and interview, the facility failed to ensure staff revised the care plans for 2 (R #7 and R #24) of 2 (R #7 and R #24) residents reviewed. Staff failed to update the care plans to reflect each resident's current needs regarding the use of appropriate utensils during mealtime. Appropriate utensils refer to those assessed as safe and suitable for the resident based on their physical and mental condition (e.g., plastic utensils instead of metal for residents with a history of self-harm). If care plans are not updated to reflect residents' current needs, then staff may provide inappropriate items or assistance, which could result in unmet care needs and safety risks. The findings are: R #7 A. Record review of R #7's face sheet revealed an admission date of 05/26/25 with the following diagnoses: - Unspecified dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), -Muscle weakness (reduction in the power exerted by muscles.) B. Record review of R #7's Care Plan, dated 03/04/25,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to ensure a safe environment free of the potential for accidents and hazards for all residents when staff failed to: - Ensure accurate smoking supervision assessments were completed for R #7; - Ensure residents did not have lighters in their rooms; - Ensure staff did not store personal belongings in resident rooms; - Prevent unsecured bleach cleaning wipes from being left in resident bathrooms. This deficient practice placed residents at risk for burns, fire-related injuries, chemical exposure, and ingestion of unsafe substances. The findings are: R #7 A. Record review of facility's Smoking Safety policy, dated 04/10/24, revealed all smoking supplies (to include tobacco, matches, lighters, and lighter fluid) must be labeled with the resident's name, room number, and bed number; maintained by staff; and stored in a suitable cabinet at the nurses station. Lighters are not permitted in resident rooms due to fire risk, especially when oxygen is…

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

Based on observations, interviews and record review, the facility failed to ensure 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 the opening date for 5 (R #5, R #27, R #47, R #71, R #82) of 5 (R #5, R #27, R #47, R #71, R #82) residents reviewed. This deficient practice is likely to result in all five residents receiving medications that are less effective or expired. The findings are: A. Record review of the facility's Medication Storage Policy, dated January 2023, revealed the following: - Note the date on the label for insulin vials and pens when first used. - The policy did not address discarding insulin pens within 28 days of opening. B. Record review of the manufacturer's instructions for Insulin Glargine multiple dose vial, dated 2022, revealed staff were instructed to throw away all opened vials after 28 days of use, even if there was insulin left in the pen. C. Record review of the manufacturer's instructions for…

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

Based on observation and interviews, the facility failed to ensure food was stored, prepared, and served under sanitary conditions when they failed to: - Ensure food was stored in a manner to prevent cross contamination and outdated use. - Maintain the kitchen in a clean and sanitary manner. - Ensure employees wore hair restraints. - Ensure staff did not serve drinks with their hands on the rim of the cup. This deficient practice could likely affect all 118 residents identified on the resident census list provided by the Administrator on 04/28/25. If food was not stored, prepared, and served under sanitary conditions then residents are at an increased risk of contracting food born illness, having weightloss, and may feel unimportant. The findings are: Food Storage A. On 04/28/25 at 9:53 am, an observation of the facility's kitchen revealed the walk-in refrigerator contained three large serving trays with uncovered, unlabeled, and undated beverages. B. On 04/28/25 at 9:55 am during an interview, the Corporate Dietary Manager (CDM) stated there should not be any uncovered, unlabeled,…

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 reviews, and interviews, the facility failed to: - Ensure call lights were in working order when staff failed to report and repair two broken call lights on the 400 hall shower room; - Ensure a call light was within reach for 1 (R #120) of 1 (R #120). If the facility is not ensuring a working call light system or maintaining the call light is not within residents' reach, then residents are unable to request immediate assistance when needed. The findings are: A. Record review of the facility's Call Lights Policy, dated 02/01/23, revealed all residents will have a call light or alternative communication device within their reach at all times when unattended. 400 Hall Shower Room B. Record review of a Work Order, dated 04/03/25, revealed staff reported the 400 hall shower room call lights did not have strings. C. Record review of Nurse call system test via TELS, dated 05/01/25, revealed the Maintenance Director inspected 400 hall call lights, including the shower room, on 03/31/25 and 04/28/25. The call lights passed both inspections. D. On 04/29/25 at 3:10…

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 Ceiling Tiles H. Record review of the facility's policies and procedures revealed the facility did not have a policy regarding the maintenance of ceiling tiles. I. On 05/02/25 at 01:25 P.M., observation of the 100 hallway revealed the following: - A ceiling tile located near resident room [ROOM NUMBER] had open space. - A ceiling tile located outside the business office had a 1 inch triangular hole. - A ceiling tile located in the dining room near the exit door had a 1/2 inch hole. - A ceiling tile located in hallway 100, at the entrance doors, had two 1 inch circular holes. J. On 05/02/25 at 12:05 P.M., observation of the Dining Room revealed the following: - A cracked ceiling tile with unsealed space around a sprinkler head. - A cracked ceiling tile with a 1/4 inch unsealed space around the base of a ceiling fan. K. On 05/02/25 at 1:50 P.M., during an interview, the MD stated he was in charge of the life safety and maintenance of the facility. He stated he did not change out the broken ceiling tiles unless…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the resident's current advance directive (a document which provides an individual's wishes for emergency and lifesaving care) was properly documented for 1 (R #42) of 1 (R # 42) resident reviewed for advance directives. This deficient practice is likely to cause confusion and delay potentially lifesaving procedures. The findings are: A. Record review of R #42's face sheet, undated, revealed the following: - admission date of [DATE]. - Advanced directive was Do Not Resuscitate [DNR; does not want to have cardiopulmonary resuscitation (CPR; an emergency procedure that combines chest compression with artificial ventilation) performed if their heart or breathing stops.] C. Record review of R #42's New Mexico Medical Orders For Scope of Treatment (MOST), dated [DATE], revealed R #42 advanced directive was a Full Code (desired life saving procedures, such as CPR.) D. On [DATE] at 02:58 PM during an interview with Unit Manager (UM) #1, she stated 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 record review and interview, the facility failed to ensure the Minimum Data Set (MDS; a federally mandated comprehensive assessment of a resident's functional, medical, psychosocial and cognitive assessment completed by facility staff) was accurate for 1 (R #42) of 1 (R #42) resident reviewed for MDS assessments. This deficient practice could result in failure to provide adequate care and treatment of the resident's needs. The findings are: A. Record review of R #42's face sheet revealed an admission date of 08/22/20 and included the following diagnoses: - Alcohol use, unspecified with alcohol-induced persisting amnestic (memory deficit). - Cognitive functions and awareness. -Alcohol abuse. B. Record review of R # 42's MDS, dated [DATE], revealed the following: - Brief Interview for Mental Status (BIMS; screening for cognitive impairment) score of 14, moderately impaired cognition. - The resident did not have an acute change in mental status from resident's baseline (starting mental status.) - 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 date the oxygen tubing for 1 (R #325) of 1 (R #325) residents reviewed for oxygen. If the facility is not dating and initialing the oxygen tubing and humidifiers (provide moisture when delivering oxygen) then staff may be unaware as to when the tubing and humidifier should be changed and could cause the tubing to become dirty leading to reduced oxygen flow. The findings are: R #325 A. Record review of R #325's physician orders, dated May 2025, revealed the following: - Oxygen at 2 liter (L) per minute via nasal cannula (a device that delivers extra oxygen through a tube and into your nose), continuously. Every day and night shift. Start date 05/02/25. - Oxygen tubing change weekly. Label each component with date and initials. Start date 05/02/25. B. On 05/02/25 at 12:08 pm, during an observation, R #325's oxygen tubing and humidifier bottle did not have the staff initials or date. C. On 05/02/25 at 12:18 pm, during an interview with Certified Nursing Assistant (CNA) #8, she confirmed staff did not label R…

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

Based on record review observation and interviews, the facility failed to ensure residents obtained routine dental care for 2 (R #15 and R #48) of 2 (R #15 and R #48) residents reviewed for dental services. This deficient practice is likely to cause the resident unnecessary pain, embarrassment over the condition/appearance of teeth, and potential dental or oral complications. The findings are: R # 15: A. On 04/28/25 at 12:15 PM, during an observation and interview, R #15 did not have visible teeth or dentures. R #15 said she needed to be seen by the dentist, because her dentures did not fit properly. B. Record review of R #15 Oral Health Evaluation, dated 12/10/23, revealed R #15 was at risk for oral health and dental care problems. R #15's last dentist appointment was on 08/22/22. The resident required an follow-up dental appointment for proper fitting dentures. C. Record review of R #15's Electronic Health Record (EHR) revealed the following - Physician order, dated 11/14/24, dental referral. - R #15 did not have a follow-up dentist appointment. R #48: D. On 04/28/25 at 11:57 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 ensure that a resident received treatment and care in accordance with professional standards of practice by not following physician orders for 1 (R #2) of 3 (R #2, 3 and 4) residents reviewed for diabetic medications. Failure to follow physician orders is likely to cause residents to not receive the care and treatment they require. The findings are: A. Record review of R #2's face sheet revealed he was admitted on [DATE] with the following diagnoses: - Type II diabetes mellitus (DM2, a condition which results from insufficient production of insulin, causing high blood sugar), - Diabetic neuropathy (a type of nerve damage that occurs as a complication with diabetes), - Diabetic ophthalmic complication (damage to eyes caused by diabetes), - Blindness in left eye. - This is not all inclusive list. B. Record review of R #2's physician orders revealed the following orders: - Glipizide (oral diabetes medicine that helps control blood sugar levels) oral…

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 treated residents with dignity and respect for 1 (R #1) of 3 (R #1, #2, and #3) residents reviewed when staff failed to consider a resident's feelings due to her pain levels. This deficient practice could likely cause the resident to feel like she was not being heard and did not matter. The findings are: Cross reference with F697. A. Record review of R #1's face sheet revealed she was admitted on [DATE] and discharged on 01/09/25, with the following diagnoses: - Quadriplegia (paralysis of all four limbs), - Traumatic brain injury (TBI is the result from a violent blow or jolt to the head or body), - Neurogenic bladder (the lack of bladder control due to brain, spinal cord, or nerve problems), - Cognitive communication deficit (consequence of brain injuries that affects a person's ability to communicate effectively), - Cervical subluxation (partial misalignment or displacement of the vertebrae in the neck), - Traumatic nondisplaced…

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 (SSA) an allegation of staff to resident abuse for 1 (R #1) of 1 (R #1) resident reviewed for abuse. If the facility fails to report allegations of abuse to the SSA, then corrective measures may not be acted on and the SSA will not be unable to ensure residents are free from abuse. The findings are: A. Record review of R #1's face sheet revealed she was admitted on [DATE] and discharged on 01/09/25, with the following diagnoses: - Quadriplegia (paralysis of all four limbs), - Traumatic brain injury (TBI is the result from a violent blow or jolt to the head or body), - Neurogenic bladder (the lack of bladder control due to brain, spinal cord, or nerve problems), - Cognitive communication deficit (consequence of brain injuries that affects a person's ability to communicate effectively), - Cervical subluxation (partial misalignment or displacement of the vertebrae in the neck), - Traumatic nondisplaced spondylolisthesis…

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 manage a resident's pain for 1 (R #1) of 1 (R #1) resident reviewed for pain management. This deficient practice could likely cause a resident to experience a decline physical and emotional health if the resident's pain was not managed and effectively controlled. The findings are: A. Record review of R #1's face sheet revealed she was admitted on [DATE] and discharged on 01/09/25, with the following diagnoses: - Quadriplegia (paralysis of all four limbs), - Traumatic brain injury (TBI is the result from a violent blow or jolt to the head or body), - Neurogenic bladder (the lack of bladder control due to brain, spinal cord, or nerve problems), - Cognitive communication deficit (consequence of brain injuries that affects a person's ability to communicate effectively), - Cervical subluxation (partial misalignment or displacement of the vertebrae in the neck), - Traumatic nondisplaced spondylolisthesis of cervical vertebra (a condition in which one…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to provide a podiatry consult and care for 1 (R #1) of 3 (R #1, R #2, and R #3) residents reviewed for foot care. This deficient practice likely caused R #1 not to receive foot care as ordered by a physician which could result in more serious foot problems. The findings are: A. Record review of R #1's face sheet revealed an initial admission date of 11/26/18. The resident went to the hospital for a fall on 05/30/24 and was readmitted to the facility on [DATE] with the following list of diagnoses (not all-inclusive): - Right femur fracture (break in the thigh bone). - Dementia with agitation (loss of cognitive function with issues such as sleeping or having hallucinations). - Mood disturbance and anxiety (emotional disturbance that impacts emotional health). - Neuropathies (affects the nerves in your body and can be painful). - Dysphagia (difficulty swallowing). B. Record review of R #1's nursing progress notes, dated 05/05/24, revealed R #1…

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 medical records were updated with necessary documents and accurate for 2 (R #1 and #2) of 2 (R #1 and #2) residents reviewed for foot care. This deficient practice could likely result in staff not knowing residents' daily care events, changes, and their needs. The findings are. R #1 A. Record review R #1's nursing progress notes, dated 05/05/24, indicated R #1 requested to see a podiatrist but refused to allow the nurse to see her feet. B. Record review of R #1's physician order, dated 05/14/24, indicated a podiatry consult was ordered. C. Record review of R #1's electronic medical record (EMR) revealed the records did not contain documentation a podiatrist saw R #1 after 5/14/24 or that R #1 refused podiatry care. D. On 11/14/24 at 10:29 am, during an interview, the Administrator confirmed R #1's chart did not contain updated podiatry documentation. The Administrator stated R #2 frequently refused care, to include monthly podiatrist visits, and was now scheduled to see the podiatrist yearly. The Administrator…

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, observations, and interviews, the facility failed to ensure the facility had sufficient staff to meet the needs of all 116 residents who resided in the facility when staff failed to offer baths or showers to residents as scheduled. These deficient practices are likely to negatively impact resident comfort. The findings are: A. Refer to F0677 for findings related to baths/showers. B. On 08/16/24 at 10:32 am during an interview with Licensed Practical Nurse (LPN) #1, she stated there was a shortage of staff at times. She stated she saw most bath or shower problems during the night shift and not the day shift. C. On 08/16/24 at 11:14 am during an interview with an anonymous staff member (ASM), they stated the facility was understaffed and a lot of the staff wasburnt out due to it. The ASM stated residents went without bathsor showers frequently due to the lack of staff, and nurses had to give baths or showers most of the time to make up for the lack of staff available. The ASM confirmed the residents' needs are not met because of the lack of staffing. D. On…

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

Based on observation, record review, and interview, the facility failed to maintain an environment that was clean, in good condition, and free from clutter for all residents who resided on the 400 Unit and were sampled for a homelike environment. Failure to maintain the building in a clean and comfortable manner is likely to result in unsafe conditions and prevent residents from enjoying everyday activities. The findings are: A. On 08/14/24 at 9:48 am during a 400 unit observation, three mattresses and an oxygen (O2) concentrator (machine used to deliver O2) were observed on the floor, against the hallway railings and by room (RM) #401. B. On 08/14/24 at 11:45 am during an interview with Registered Nurse (RN) #3, she confirmed the above findings and stated those should not have been left in the Unit hallway by RM #401. C. On 08/15/24 at 4:43 pm during a 400 unit observation, a bedside commode (portable toilet) was observed to be outside of RM #408, against the wall and below the hand rail. D. On 08/16/24 at 9:37 am during a 400 unit observation, a bedside commode (portable toilet)…

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 meet professional standards of quality for 2 (R #7 and R #9) of 4 (R #5, #7, #8 and #9) residents when staff: 1. Did not provide care or assess R #7 for several hours upon admission. 2. Did not offer R #7 hydration or a snack for several hours upon admission. 3. Nursing staff did not obtain physician orders for R #9's Peripherally Inserted Central Catheter (PICC; a long, thin tube that is inserted through a vein in your arm and passed through to the larger veins near your heart) line care, monitoring, and dressing changes. 4. Nursing staff did not provide PICC line care, monitoring, and dressing changes for R #9 until R #9 was discharged from the facility If the facility is not providing care, hydration, or assessing a resident after an admission, then residents are likely to not receive the therapeutic benefits and care needed. The findings are: R #7 A. Record review of R #7's face sheet revealed R #7 was admitted into the facility on [DATE] and was…

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 activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) assistance for baths and showers by the facility staff for 5 (R #5, #8, #9, #10, and #11) of 5 (R #5, #8, #9, #10, and #11) residents reviewed for ADL care. This deficient practice is likely to affect the dignity and health of the residents. The findings are: R #5: A. Record review of R #5's face sheet revealed R #5 was admitted into the facility on [DATE]. B. Record review of R #5's care plan dated 06/13/24 revealed the following: - Focus: Resident/Patient requires assistance, was dependent for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting related to recent illness, fall, hospitalization. - Interventions: Arrange resident environment as much as possible to facilitate ADL performance. C. Record review of the facility'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 observation, record review, and interview, and the facility failed to ensure the medical records for residents were accurate and complete for 2 (R #1 and R #7) of 2 (R #1 and R #7) residents randomly selected and reviewed when staff failed to ensure residents' medication was available and documented they administered prescribed medications when the medications were not available or when resident refused. This deficient practice is likely to result in staff confusion as to when or if residents have consistently received prescribed medications and if residents are receiving their intended medication effectiveness. The findings are: Findings for R #1: A. Record review of R #1 Medications Administration Record (MAR), dated August 2024, revealed staff documented they administered the following medications: - Breyna inhaler [budesonide (a bronchodilator)/formoterol (a steroid); generic; an inhaled medication to expand lungs and airway.] Give two puffs inhaled orally, two times a day. - On 08/01/24 thru…

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 a resident's belongs were safeguarded from loss for 1 (R #2) of 1 (R #2) residents reviewed for personal property when they failed to offer R #2 a safe place for her belongings until after theft occurred. This deficient practice is likely to result in unaccounted property for the resident and family resulting in frustration. The findings are: A. Record review of R #2's face sheet revealed R #2 was admitted into the facility on [DATE]. B. Record review of R #2's complaint narrative investigation report, dated 07/12/2, revealed R #2 reported on 07/12/24 that a check in the amount of $800.00 was missing out of her dresser. C. Record review of R #2's complaint narrative investigation report, dated 07/12/2, revealed Facility Actions: Business Office Manager (BOM) immediately reviewed resident trust account and found the check was cashed on 07/05/24 via mobile deposit into a bank account. The BOM immediately notified the facility's bank and filed 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.

Based on observation, interview, and record review, the facility failed to provide proper infection control practices for 2 (R #5 and R #6) of 2 (R #5 and R #6) residents reviewed for wound care when staff failed to: 1. Change gloves after cleaning a wound and before placing a clean bandage on wound. 2. Ensure clean bandages and gloves did not touch a non-clean surface (bed, bedside tray table). 3. Dispose of soiled bandages in a receptacle for items that contained biohazards waste. If the facility is not using proper infection control practices the residents are likely to acquire infections. The findings are: Findings for R #5 A. On 08/14/24 at 1:32 pm, observation of wound care for R #5 revealed the following: 1. LPN #2 placed the clean bandages on R #5's bedside table (a non-clean surface.) 2. LPN #2 did not change her gloves and perform hand washing after cleaning R #5's wound and before she applied the clean bandages from R #5's bedside table to the wound. Findings for R #6 B. On 08/14/24 at 2:30 pm observation of wound care for R # 6 revealed the following: 1. The Wound Care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to notify a resident's Power of Attorney (POA) before transferring 1 (R #5) of 2 (R #5 and R#1) residents to a different facility. This deficient practice could likely result in the resident's POA not being aware of the resident's location. The findings are: A. Record review of R #5's face sheet revealed he was admitted to the facility on [DATE] and transferred on 03/01/24. B. Record review of a progress note for R #5, dated 02/29/24, indicated R #5 exited the back door, and staff spotted him walking around with his front-wheel walker. Facility staff brought the resident back into the building and asked R #5 about going outside. R #5 stated, I was just going to get some fresh air. The resident was placed on one-to-one observation until he was transferred out to another facility with a secured locked unit on 03/01/24. C. On 03/25/24 at 11:30 am, during an interview with the Guardian for R #5, she stated, the resident called her on 03/01/24 and that is when…

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 discard food after it reached its shelf life or after it expired. This failure was likely to affect all 122 residents listed on the census provided by the Director of Nursing (DON) on 02/16/24. This deficient practice could likely lead to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) in residents if food is not being discarded timely. The findings are: A. On 02/12/24 at 8:22 am, an observation of the kitchen revealed the following: - A container of limes dated 12/26/23 and a container of lemons dated 12/22/24. Both containers of the fruits appeared old, brown in color, and moldy. - A large container of something, that looked like pudding, did not have a date. - Desserts on the cart uncovered and did not have a date. - Deli ham opened and did not have a date. - Six gallons of whole milk in the refrigerator had an expiration of 02/10/24. B. On 02/12/24 at 8:32 am, during an interview with the Dietary Manager (DM), she confirmed staff should have thrown out the container…

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 an environment that was homelike, free of clutter and broken items for residents eating in the dining room and living on 100 hall. This deficient practice could likely result in any of the 122 residents identified on the facility census provided by the Center Nursing Executive on 02/12/24 feeling like their environment was filled with unusable items that needed to be disposed of, causing frustration. The findings are: A. On 02/12/24, at 8:30 am, an observation was made of boxes up against the glass side panel of the door, and a hospital bed sat to the left of the boxes. Further observation revealed an old transport van was used to store unusable items, such as beds, other furniture, and old supplies. The van had tumbleweeds and trash around and under it. B. On 02/12/24, at 12:35 pm, an observation of the outside patio area off of the dining room revealed several pieces of broken furniture, side tables, chairs, a bed, and a medication cart all on the patio area. C. On 02/12/24, at 12:41 pm, during an interview with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and interview, the facility failed to meet professional standards of quality for 5 (R # 26, 55, 84, 102, and 165) of 5 (R #26, 55, 84, 102, and 165) residents sampled for nutrition and skin issues, when staff failed to: 1. Maintain accurate weights for R #26, R #84, and R #165; 2. Float the resident's heels per physician orders while in bed for R #102. 3. Ensure a resident on dialysis received a meal per physician orders prior to leaving to their appointments for R #55. These deficient practices could likely result in resident nutrition not being accurately assessed, causing a potential for weight gain or weight loss to go unnoticed, the deterioration (worsening) of overall health and well-being of residents, and places the resident at risk of developing a pressure sore which could lead to infection. The findings are: Accurate Weights R #26 A. Record review of R #26's weight log revealed staff documented the following weights: - On 02/01/24, 157.2 pounds (lbs). - On…

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

Based on record review and interview, the facility failed to conduct annual performance reviews for 2 Certified Nurse Assistants (CNAs; CNA #1 and CNA #2) of 3 (CNA #1, CNA #2, and CNA #3) CNAs. This deficient practice could likely result in staff not maintaining the competencies to perform their daily tasks and may lead to inappropriate care, service, and a failure to meet the needs of all residents. The findings are: A. On 02/16/24 at 10:27 am, during an interview with the Director of Nursing (DON), she stated she did not have an annual performance evaluation for CNA #1 and CNA #2. She said CNA #1 and CNA #2 were overdue for an annual performance evaluation. She stated the previous Human Resource staff member did not keep track of annual evaluation due dates.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to: 1. Ensure the medication carts did not contain loose medications. 2. Ensure expired supplies were not kept with unexpired supplies in the medication room. These deficient practices are likely to result in all 31 residents residing in hall 200, as identified on the census list provided by the facility Administrator on [DATE], receiving expired medication and having expired medical supplies used in their treatments. The findings are: Findings for loose medications found in medication carts. A. On [DATE] am at 8:25 am, during observation of the 200 hall medication cart, one yellow oval tablet was loose, under the medication cards (vertical cardboard and foil cards pre-filled with prescription medications for easy storage and dispensing) in the drawer of the cart. B. On [DATE] at 8:26 am, during an interview with Licensed Practical Nurse (LPN) #1, she stated loose medications should not be in the medication cart under the medication cards. Findings for…

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

Based on interview, observation, and record review, the facility failed to follow dietary orders for double entree's and include all items on the resident's meal ticket for 1 (R #105) of 1 (R #105). The findings are: Resident #105 A. Record review of R #105's meal ticket, dated 02/14/24, stated R #105 was to receive double entrees for breakfast, lunch, and dinner. B. On 02/12/24 at 12:15 pm, during observation of R #105's meal tray, he received a single entree and not a double. The resident received the same amount of entree as the other residents at his table, and those residents received single portion entrees. C. On 02/14/24 at 12:47 pm, during observation of R #105's meal tray, he received one entree of chicken fried steak, instead of the two. According to his meal ticket, he was also missing green beans, milk, and margarine, which were on his meal ticket but not his meal tray. D. On 02/14/24 at 1:00 pm and 2:34 pm, during an interview with the Dietary Manager (DM), she stated R #105 should receive double entrees. The DM stated she put a note on the serving line to remind the…

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

Based on record review and interview, the facility failed to revise the care plan for 1 (R #84) of 3 (R #'s 31, 55 and 84) residents reviewed for care plan revisions by not revising a care plan after there was documented significant weight loss for R #84. This deficient practice could likely result in residents not receiving the care or treatment needed to ensure their overall safety or ability to maintain their highest practicable well being. The findings are: Resident #84 A. Record review of Face Sheet for R #84 revealed an admission date of 8/01/23. B. Record review of Nutrition Progress Notes, dated 10/11/23 at 3:17 PM, for R #84 revealed significant weight change. Weight Changes: - 20.9%, lost 44 pounds (lbs) over thirty days. On 10/5/23, the resident weighed 166.7 pounds. On 9/4/23, the resident weighed 210.5 pounds. On 8/1/23, the resident weighed 215.0 pounds. Will request reweigh to verify amount of weight loss. C. Record review of Weight Tracking form for R #84 revealed the following: - On 08/01/23 - 216.0 lbs; - On 09/04/23 - 210.5 lbs; - On 10/12/23 - 159.9 lbs; - On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure quality care and treatment for 3 (R #84, 87 and 262) of 3 (R #84, 87 and 262) residents reviewed for appointments, activities of daily living (ADL) care, and following dietary orders to obtain weekly weights. This deficient practice could likely result in a resident not receiving the care and services that were ordered and did result in a resident feeling embarrassed and frustrated due to not being assisted to the bathroom and going in her brief. The findings are: Resident #87 A. On 02/15/24, at 3:30 pm, during an interview with R #87, she stated she requested the Unit Manger (UM) #1 to make an appointment with a pulmonary specialist (specializes in lung and breathing issues) at least four times. She stated the doctor had an order in for a pulmonary specialist appointment, and that it still has not been made. She stated that she was very upset. B. Record review of the physician order, dated 12/27/23, indicated an order to refer to Pulmonologist…

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 oxygen equipment according to safety precautions and prohibitions for oxygen use for 1 (R #4) of 3 (R #4, R #20, and R #48) residents reviewed for respiratory care when staff failed to post caution and safety signs indicating the use of oxygen in the resident's room. This deficient practice could likely result in staff not recognizing that oxygen is being used in a resident's room, and this could result in a dangerous (able or likely to cause harm or injury) fire hazard (material, substance, or action that increases the likelihood of an accidental fire occurring). Resident #4 A. Record review of physician's orders for R #4 revealed the following orders related to oxygen use: Physician order, dated 02/08/24, oxygen at 1 to 6 liters per minute (L/min) via nasal cannula (flexible tubing that delivers oxygen from the source into the resident nose). B. On 02/12/24 at 11:20 am, during an observation, R #4's room door did not have a Oxygen in use sign posted. C. On 02/14/24 at 7:54 am, during an observation, R #4's room…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to maintain proper infection prevention measures when staff did not: 1. Wear the proper personal protective equipment (PPE; protective clothing, face masks, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection) before entering the room of a resident under covid precautions (set of measures to prevent the transmission of bacteria and viruses that are spread through respiratory liquid). This deficient practice could likely result in the spread of infectious agents (viruses and bacteria) between the 28 residents in the 400 hall. The findings are: Findings: A. Review of the CDC guidance, titled Use Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19, dated 06/03/2020, health care workers shall wear N95 mask (a mask that filters at least 95% of airborne particles that have a mass median aerodynamic diameter of 0.3 micrometers), face shield, or goggles,…

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: 1. Serve food in a timely manner according to established meal times; 2. Maintain the holding temperature of cooked food (greater than 140 degrees Fahrenheit) . These deficient practices are likely to affect all 119 residents listed on the census provided by the Director of Nursing (DON) on 01/03/24. These deficient practices could likely lead to: 1. Foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) if food is not held at a temperature outside the danger zone (the temperature range where bacteria grows at a rapid rate, between 40 degrees (°) Fahrenheit (F) and 140° F); 2. Residents feeling frustrated as they wait for meals to be served and/or receive cold food. The findings are: Food served in a timely manner A. Record review of New Mexico complaint #71278 revealed on 12/17/23, residents received breakfast at 11:40 am. B. Record review of the food menu, as posted in the dining room, revealed staff regularly served breakfast at 7:30 am. C. On 01/03/24 at…

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

Based on observation, record review, and interview, the facility failed to ensure medications were not left on a beside table in a resident's room for 1 (R #2) of 1 (R #2) resident. This failure could likely result in resident injury if staff do not confirm residents take their medications. The findings are: A. Record review of R #2's orders and electronic medical record revealed R #2 was not allowed to self-administer medications, and he was prescribed Lisinopril to be administered once daily in the morning. B. On 01/03/24 at 1:53 pm, during observation of R #2's room a pink tablet (identified as Lisinopril using the pill description and identifiers) sat on the resident's bedside table and not in a cup. C. On 01/03/24 at 1:54 pm, during an interview, R #2 stated sometimes the nurse waited until he took his medications before they left the room, and sometimes the nurse left before he took his medications. R#2 further stated the Lisinopril belonged to him. R #2 did not know how long the Lisinopril was on his bedside table or which nurse gave him the Lisinopril. D. On 1/04/24 at 10:10…

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

Based on record review, observation, and interview, the facility failed to provide pericare (the cleaning of a patient's private area) in a timely manner for 3 (R#1, R #2, and R #10) of 4 (R#1, R #2, R #10, and R #14) residents reviewed for brief maintenance. This deficient practice could likely result in residents feeling upset as they must sit in a soiled brief longer than expected. The findings are: Findings for R #1 A. On 01/03/24 at 9:28 am, during an interview with R #1's POA (Power of Attorney), she stated she was dissatisfied with the care R #1 received at the facility. She said she found the resident one morning (date unknown) with dried feces in his brief (disposable underwear). Findings for R #2 B. On 01/03/24 at 1:53 pm, during an interview with R#2, he stated he was dissatisfied with his care. The resident said one day (date unknown), a CNA changed his brief, because he had a bowel movement. The resident said later in the day he began to feel uncomfortable and itchy in his perineum (the area between the anus and the scrotum). The resident said he asked a nurse to check…

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 meals were served at an appetizing temperature and were attractive and palatable (pleasant to taste) for 5 (R #'s 8, 14, 15. 28 and 31) of 5 (R's #'s 8, 14, 15, 28 and 31) residents reviewed for meal quality. This deficient practice reduces residents' ability to eat and enjoy meals, may decrease their quality of life, and they could likely lose weight. The findings are: Resident #14 A. Record review of the facility grievance book revealed R #14 wrote a grievance on 05/03/23 stating the food served by the facility staff was cold on multiple occasions, and it was tasteless. On the grievance, the dietary manager wrote she apologized for the cold food, and she would work closely with her staff to correct the issue. B. On 10/24/23 at 10:48 am, during an interview, R #14 stated they still received cold and tasteless food from the facility. Resident #15 C. Record review of facility grievance book revealed that R #15 wrote a grievance on 05/03/23 stating the food served by the facility staff was cold on multiple occasions…

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 an environment that was free of flies for 3 (R #26, 27 and 28) of 3 (R #26, 27 and 28) looked at for environment and pest control. This deficient practice could likely result in residents feeling frustrated and uncomfortable if the facility fails to maintain an effective management of flies in the building. The findings are: A. On 10/23/23 at 9:55 am during an interview with R #28, she stated there have been issues with flies. She stated the flies have not been controlled and have really been a problem. She stated they were so bad in her room that an unidentified Certified Nursing Assistant (CNA) brought in the sticky fly strips for her and hung them up in her room. B. On 10/23/23 at 9:55 am, during an observation, R #28's room revealed two fly strips hung by R #28's bed. Both strips had a lot of flies stuck to the entire fly strip. C. On 10/23/23 at 10:57 am, during an interview, Registered Nurse (RN) #1 stated flies have been an issue in the building. RN #1 stated over the last couple of months the flies were…

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 nursing staff followed the process for monitoring medications in the treatment cart for all 30 residents residing in the 400 hall, as listed on the resident census on 10/20/23. This deficient practice could likely result in resident medications not being monitored and at risk for misappropriation. The finding are: A. Record review of New Mexico complaint #67860, dated 07/11/23, revealed a concern nursing staff did not perform a count of the narcotic medication during shift change. B. On 10/20/23 at 12:16 pm, during an observation of the 400 hall med cart, the narcotic book did not have a signature for the morning of 10/20/23. C. On 10/20/23 at 12:16 pm during an interview, RN #2 explained she did perform a count of the medications during shift change; however, she did not sign off on it in the narcotic book. D. On 10/20/23 at 12:30 pm, during an interview with the director of nursing (DON), she stated all treatment carts must be locked, and two nurses must sign-off on the narcotic count twice a day 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, record review, and interview, the facility failed to provide quality care for 1 (R #30) of 1 (R #30) resident reviewed for pain management. This deficient practice could likely cause the resident to not have her pain adequately controlled if she is not receiving all prescribed pain medications. The findings are: A. Record review of the Electronic Health Record (EHR) dashboard revealed R #30 was currently on hospice and staff were to call hospice for all controlled medications. B. Record review of the nursing progress notes for R #30, dated 09/06/23, indicated resident continues on bed bound with severe contractions to BLE (bi-lateral lower extremity) and BUE (bi-lateral upper extremity). Minimal assist with meals. Total assist with ADL's (activities of daily living). C. Record review of the current physician's orders indicated R #30 had an order for the following: - Oxycodone, 2.5 milligrams (MG) Three times per day at 7:00 am, 1300 (1:00 pm), and 1900 (7:00 pm) for pain last ordered 09/12/23. - Morphine 20 mg/milliliters (ML) Give 0.25 ml by mouth every 4…

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 all residents at risk of elopement (residents who have been identified as a danger to themselves if they exit the facility unattended) remained in the facility after a wander guard (a medical device/bracelet that alarms when residents attempt to exit the building) alarm was activated. This deficient practice affected 1 (R #6) of 6 (R #'s 1, 2, 3, 4, 5, and 6) residents reviewed for elopement risk. This deficient practice could likely result in residents exiting the building unattended without the ability to return. The findings are: A. Record review of New Mexico complaint #68034, dated 07/19/23, revealed R #6 was assigned a wander guard but eloped from the building. B. Record review of R #6's Electronic Health Record (EHR) revealed R #6 was admitted to the facility on [DATE] with the following pertinent diagnoses: - Insomnia (a sleeping disorder where individuals are unable to sleep at night), - Unspecified dementia ( a group of conditions-…

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, interview, record review and policy review, the facility failed to ensure the kitchen was maintained in a sanitary manner to prevent the potential spread of foodborne illness to 114 out of 115 residents (one resident received nutrition via a feeding tube and took nothing orally). Specifically, staff failed to change gloves between tasks when serving meals; the dish machine area was unsanitary and not adequately maintained; refrigerator temperatures were too high; and food was not stored in a manner to prevent cross contamination. Findings include: Review of the Proper Hand Hygiene: Dining Services Employees checklist dated 2020 and provided by the facility revealed, Proper Glove Usage - Gloves are not meant to be used as a replacement for handwashing. They are only effective if proper handwashing is completed . You must wear gloves when: touching any foods (raw or cooked) without utensils . When to change or remove your gloves: when they are dirty, torn, damaged, discolored or contaminated . when changing tasks. Review of the Food Storage: Cold Foods policy…

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 policy review, the facility failed to ensure the dumpster area remained free of garbage to prevent the harborage of pests and rodents on three of three days in which observations were made during the survey. This had the potential to affect staff, visitors, and all 115 residents residing in the facility. Findings include: Review of the Dispose of Garbage and Refuse policy dated August 2018 and provided by the facility revealed, All garbage and refuse will be collected and disposed of in a safe and efficient manner . The Dining Services Director coordinates with the Director of Maintenance to ensure that the area surrounding the exterior dumpster area is maintained in a manner free of rubbish or other debris. 1. On 11/14/22 at 9:32 AM, the dumpster area was observed with the Dietary Manager (DM) and the area contained a significant amount of garbage/refuse as follows: multiple pieces of paper and cardboard, fourteen disposable gloves, a yogurt container, a face shield, numerous pieces of plastic, a partially eaten sandwich, several soda cans, 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, review of resident council minutes, and policy review, the facility failed to ensure the menus were followed for residents attending the resident council, and for 11 (Resident (R)262, R68, R39, R8, R35, R53, R76, R85, R7, R91, and R38) out of 35 sampled and supplemental residents, creating the potential for dissatisfaction and decreased nutritional intake. Specifically, tray tickets were not followed; residents were served less food or smaller portions than what the menu/tray tickets called for. Foods were omitted without replacements being made. Findings include: Review of the Dining and Food Preferences policy dated September 2017 and 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 72 hours of admission. The purpose of this interview will be to identify…

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, review of resident council minutes, record review, and policy review, the facility failed to ensure the food was palatable for 10 (Resident (R)262, R9, R165, R68, R51, R100, R462, R43, R20, R263) out of 35 sampled and supplemental residents, and residents attending resident council meetings. Specifically, the food was poorly prepared, did not taste or look appetizing, and was not at an acceptable temperature when residents received their meals. Findings include: Review of the Food: Quality and Palatability policy dated September 2017 and provided by the facility revealed, Food will be prepared by methods that conserve nutritive value, flavor and appearance. Food will be palatable, attractive, and served at a safe and appetizing temperature . The Dining Services Director and Cook(s) are responsible for food preparation. Menu items are prepared according to the menu, production guidelines, and standardized recipes. 1. Residents expressed concerns with the palatability of the food…

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, and staff interviews, the facility failed to ensure staff followed adequate transmission-based precautions (TBP) to prevent the spread of COVID-19. Five Certified Nurse Aides (CNAs) entered the rooms of residents (Resident (R) 25 and R33) out of six residents on TBP for COVID-19 without adequate use of personal protective equipment (PPE). These five CNAs were assigned to provide care to residents with COVID-19 and residents without. These failures placed the 21 residents and staff on the 400 unit at risk for transmission of COVID-19. The facility further failed to ensure proper hand hygiene was implemented when completing a dressing change for one (R9) out of one observation of a dressing change. Findings include: Per the Centers for Disease Control and Prevention (CDC) COVID Data Tracker website, accessed on 11/14/22 at https://covid.cdc.gov/covid-data-tracker, the facility's community transmission rate of COVID-19 was high. During Entrance Conference with the Administrator…

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 resident and staff interviews, record reviews, and facility policy review, the facility failed to ensure an allegation of misappropriation of property for one (Resident (R) 68) of one resident reviewed for personal property was thoroughly investigated. This failure had the potential to contribute to a feeling of helplessness and anxiety over a lost wheelchair and further misappropriation of property in the facility. Findings include: 1. Review of R68's undated admission Record, located in the Profile tab of the electronic medical record (EMR) revealed R68 was admitted to the facility on [DATE] with diagnoses which included: left and right leg amputations below the knee, dependence on wheelchair, morbid obesity, reduced mobility, anxiety, and depression. Review of R68's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 08/16/22, located in the MDS tab of the EMR, revealed he scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. R68…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to ensure the comprehensive assessment assessed the pain status for one resident (Resident (R) 68) of 28 sampled residents. This failure had the potential to lead to a lack of adequate interventions to address and control the presence, location, intensity, and effects of R68's pain. Findings include: Review of R68's undated admission Record, found in the Profile tab of the Electronic Medical Record (EMR), revealed R68 was admitted to the facility on [DATE] with diagnoses including morbid obesity, osteoarthritis, anxiety, depression, bilateral leg amputations below the knee, and history of opioid and alcohol abuse. Review of R68's quarterly Minimum Data Set (MDS) assessment, with an assessment reference date of 08/16/22, revealed he scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. R68 received a scheduled pain medication regimen but no non-medication pain interventions. Though the 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 staff interviews, record review, and facility policy review, the facility failed to develop a comprehensive care plan related to oxygen use directing measurable goals and interventions for one (Resident (R) 100) of a total sample of 35 residents. This failure placed the resident at risk for unmet care needs and the inability meet their maximum practicable level of functioning related to use of oxygen. Findings include: Review of R100's undated admission Record located in the Profile tab of the Electronic Medical Record (EMR), revealed R100 was admitted to the facility on [DATE]. Review of R100's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/10/22, located in the resident's EMR under the MDS tab, revealed the resident used oxygen. Throughout the survey from 11/14/22 to 11/17/22, R100 was observed in her room on quarantine for a diagnosis of COVID-19. R100 was observed to receive oxygen continuously via nasal cannula during all observations. During an investigative review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interview, the facility failed to ensure two (Resident (R) 68 and 99) of six sample residents reviewed for rehabilitation/restorative services received appropriate treatment and services as ordered to maintain, restore, or improve the functional ability This failure had the potential to lead to increasing disabling effects of chronic conditions for R68 and R99. Findings include: 1. Review of R99's undated admission Record, located in the Profile tab of the Electronic Medical Record (EMR) revealed he was admitted to the facility on [DATE] with diagnoses including lymphoma, malnutrition, repeated falls, muscle weakness, and a need for assistance with personal care. Review of R99's admission Minimum Data Set (MDS) assessment in the MDS tab of the EMR, with an assessment reference date (ARD) of 10/19/22, documented he scored a 12 out of 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. R99 required limited assistance with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review the facility's policy, the facility failed to ensure one of 35 sample residents (Resident (R)9) received assistance with activities of daily living (ADLs), including personal hygiene, baths and/or showers. This failure had the potential to contribute to a lack of good personal hygiene and an overall sense of well-being. Findings include: Review of R9s undated admission Record located in the Profile tab of the Electronic Medical Record (EMR), revealed R9 was admitted to the facility on [DATE]. R9's diagnoses included unstageable pressure ulcer to the left hip, stage 3 pressure ulcer of sacral region, protein calorie malnutrition, spondylosis with myelopathy (compression of the spinal cord) and spinal stenosis at cervical region, diabetes mellitus, falls, and weakness. Review of R9's admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 10/31/22 located in the MDS tab of the EMR, revealed R9 scored a 15 out of 15 on the Brief…

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 assure a physician's order was in place for the use of oxygen for one (Resident (R) 100) of a total sample of three residents reviewed for oxygen use. This failure placed the resident at potential risk due to no parameters of how much oxygen to administer, or if it needed to be continuous, or as needed. Findings include: Review of R100's undated admission Record located in the Profile tab of the Electronic Medical Record (EMR), revealed R100 was admitted to the facility on [DATE] with diagnoses including pulmonary hypertension, asthma, and history of lung cancer. The diagnosis of COVID-19 was added to the record on 11/08/22. Throughout the survey on 11/14/22 at 2:30 PM, 11/15/22 at 9:49 AM, and 11/16/22 at approximately 9:00 AM, R100 was observed in her room on isolation related to COVID-19. She was using oxygen via a nasal canula at 2 liters/minute Review of R100's October 2022 and November 2022 O2 [Oxygen] Saturation records, 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.