Bloomfield Nursing and Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and interviews, the facility failed to ensure nursing services were provided in accordance with professional standards of practice for 1 (R #25) of 1 (R #25) resident reviewed, when: The facility nursing staff administered oxygen (O2) without physician orders. The facility nursing staff did not document R #25's O2 use.The facility did not notify the physician when R #25 experienced O2 desaturation (a drop in a person's oxygen level in the blood below normal, meaning the body is not getting enough oxygen). If nursing staff initiate and continue O2 therapy for a resident without a physician order, fail to document oxygen use, and do not notify the physician when a resident experiences O2 desaturation, then residents are at risk for receiving unauthorized treatment without appropriate medical oversight. These deficient practices are likely to lead to delayed or inappropriate medical intervention, and potential adverse outcomes related to untreated or improperly managed medical…

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

Based on record reviews and interviews, the facility failed to ensure the accuracy and completeness of the electronic health record (EHR) for 1 (R #66) of 1 (R #66) resident reviewed for accuracy of resident information by: Inaccurately documenting R #66's communication and hearing impairments. This deficient practice is likely to create the potential for inaccurate or incomplete documentation within the electronic health record, which may negatively impact the resident's ability to receive the care and services needed. The findings are: A. Record review of R # 66's Face Sheet revealed an admission date of 05/18/23 and the following diagnoses: Expressive language disorder (a condition where a person has trouble using words and sentences to communicate),Sensorineural hearing loss, bilateral (hearing loss in both ears caused by damage to the inner ear (cochlea) or auditory nerve, leading to reduced ability to hear and understand sounds, especially speech),Dysphagia (difficulty or discomfort in swallowing, as a symptom of disease),Other drug induced secondary Parkinsonism (movement…

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 provide wound care as ordered by the physician for 1 (R #25) of 1 (R #25) resident reviewed for wound care. This deficient practice could likely cause wounds to worsen or become infected which could lead to sepsis (a serious condition in which the body responds improperly to an infection) and hospitalization. The findings are: A. Record review of R #25's face sheet revealed R #25 was admitted to the facility on [DATE]. She was admitted with the following diagnoses: Atrial Fibrillation (A-Fib; irregular heart rhythm), Type II diabetes (a disease in which the body cannot make or properly use insulin), Chronic venous hypertension with ulcer and inflammation of the left lower extremity (venous ulcers are open skin lesions that occur in an area affected by venous hypertension caused by poor blood flow and circulation), Pulmonary hypertension (condition characterized by high blood pressure in the arteries of the lungs, leading to various…

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 accurately record (document what actually occurred) the wound care for 1 (R #25) of 1 (R #25) resident reviewed for wounds. This deficient practice is likely to cause confusion about wound care, when wound care documentation is inaccurate and indicates wound care treatments as being completed when they were not. The findings are: A. Record review of the R #25's face sheet revealed R #25 was admitted to the facility on [DATE]. She was admitted with the following diagnoses: Atrial Fibrillation (A-Fib; irregular heart rhythm), Type II diabetes (a disease in which the body cannot make or properly use insulin), Chronic venous hypertension with ulcer and inflammation of the left lower extremity (venous ulcers are open skin lesions that occur in an area affected by venous hypertension caused by poor blood flow and circulation), Pulmonary hypertension (condition characterized by high blood pressure in the arteries of the lungs, leading to various…

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 review, the facility failed to ensure a resident's Level 1 Preadmission Screening and Resident Review (PASRR; a federal requirement to help ensure individuals with a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) were reviewed for accuracy and completion for 1 (R #1, R #2 and R #3) of 3 (R #1, R #2 and R #3). If the facility fails to review PASRR screenings for accuracy and completion, then residents with serious mental illness or intellectual disability may receive inappropriate placement and care. The findings are: A. Record review of R #1's admission Record, dated 05/12/15, revealed an admission date of 05/12/15 with the following diagnoses:- Dementia. (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment)- Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). B. Record review of R #1's New Mexico PASRR Level 1 Identification Screen, dated 05/08/15 and completed by the previous…

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 facility policy review, the facility failed to ensure they had a certified infection prevention nurse hired at least part time onsite. This failure has the potential to increase infection rates due to the lack of active surveillance and staff education. Findings include: Review of the facility's policy titled, Infection Prevention and Control Program Description, and dated 01/09/04 with a revision date of 07/01/24 indicated, The IP [Infection Preventionist] must work at least part time. Under the Goals section the following was documented: The IPCP [Infection Prevention Control Policy] has been developed to provide staff with a coordinated organizational structure, technical procedures, comprehensive work practices, and guidelines to reduce the risk of transmission of infection or communicable disease. During an interview on 09/18/24 at 2:08 PM, Registered Nurse (RN)1 stated her last day of employment at the facility was 09/13/24. RN1 stated she received a text message from the Director of Nursing (DON) informing her that was her last day due to the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to provide one of two residents (Resident (R)79) reviewed for hospital transfers out of a total sample of 30 residents a written bed hold when R79 was transferred to the hospital. Findings include: Review of the facility's policy titled Bed-Holds revised date 01/12/23, read in part .When a resident/patient (resident) is transferred out of the service location to a hospital or on therapeutic leave, the designee will provide the resident and his/her representative, if applicable with the written Bed Hold Policy and Authorization form. If the resident representative is not present to receive the written notice upon transfer, the notice is delivered via e-mail, fax or hard copy via mail. Review of R79's admission Record located in the electronic medical records (EMR) section titled Profile revealed the resident was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, dementia 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 observations, record review, and interview, the facility failed to provide services based on acceptable standards of practice by specifically failing to accurately check a finger stick glucose level for three of three residents (Resident (R)14, R49, and R 52) reviewed for professional standards of 30 sample residents. This failure had the potential to affect the blood glucose levels for three of three residents reviewed. Findings include: Review of the revised facility's policy titled, Procedure: Fingerstick Blood Glucose Monitoring dated 06/15/22 did not address discarding the first drop of blood prior to obtaining the blood sample. 1. Review of R52's Face Sheet, located under the Resident tab of the electronic medical record (EMR), documented R52 was admitted to the facility on [DATE] with a diagnosis of type two diabetes mellitus with hyperglycemia. Review of R52's annual Minimum Data Sheet (MDS) with an Assessment Reference Date (ARD) of 08/07/24, located under the MDS tab of the EMR, documented R52…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to send a referral for a barium swallow study within an appropriate time frame for one of 30 sampled residents (Resident (R) 76). This failure placed the resident at risk of not having pleasurable items. Finding include: Review of R76's undated admission Record, located in the resident's electronic medical record (EMR) under the Resident Summary tab revealed the resident was admitted to the facility on [DATE] with diagnoses which included aftercare following surgery on nervous system, post-traumatic hydrocephalus and encephalitis and encephalomyelitis. Review of R76's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/13/24 located in the resident's EMR under the MDS tab revealed the resident did not have a Brief Interview for Mental Status (BIMS) and was rarely/never understood. Review of R76's Medication Order Summary located under the Orders tab of the EMR, dated 09/13/24, revealed an order for R76 to the hospital for a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, facility policy review, and review of manufacturer's instructions, the facility failed to provide respiratory care in accordance with professional standards for two of two residents (Residents (R) 16, R18 and R31) reviewed for respiratory care out of 30 sampled residents. This failure has the potential for the residents to be subjected to contaminated respiratory equipment and to not receive proper airflow. Findings include: Review of the facility's policy titled, Respiratory Equipment/Supply Cleaning/Disinfection, dated 06/01/21, documented, .cleaning and disinfection of respiratory equipment is performed by a respiratory therapist, licensed nurse, or equipment technician. All respiratory equipment which cannot be immersed in water is cleaned with a disinfecting solution and allowed to dry. Disinfection is performed on all equipment on a scheduled basis and upon discontinuation from service between patients. Review of the policy titled, Procedure: Respiratory…

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, interviews, and facility policy review, the facility failed to ensure an appropriate diagnosis for the use of an anti-depressant was clarified by the Medical Director for one of five residents (Resident (R) 64) reviewed for unnecessary medications in a total sample of 30 residents. This failure resulted in the Medical Director and/or his nurse practitioner not responding to the consultant pharmacist recommendations for Gradual Dose Reduction (GDR) for psychotropic medications and providing clarification of diagnoses for an anti-depressant. Findings include: Review of the facility's policy titled, Medication Management, dated 01/24, indicated Policy-Each resident's drug regimen is reviewed to ensure it is free from unnecessary drugs. This includes any drug .without adequate indications for its use .In order to optimize the therapeutic benefit of medication therapy and minimize or prevent potential adverse consequences, facility staff, the attending physician/prescriber, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and facility policy review, the facility failed to implement a 14 day stop date for the as needed (PRN) use of an anti-anxiety medication and/or provide a rationale for the continued use of the medication for one of two residents reviewed for anti-anxiety medications (Resident (R) 69), out of a total sample of 30 residents. The facility also failed to implement a gradual dose reduction (GDR) for one of five reviewed for an antipsychotic GDR (R 16). Failure to provide evidence of the physician rationale for continued use of the medication had the potential to result in unnecessary medication use. Findings include: A review of the facility's policy titled, Medication Regimen Review and Reporting dated 01/24 indicated, 6 .Resident specific MRR [Medication Regimen Review] recommendations and findings are documented and acted upon by the nursing care center and/or physician.7 . a record of the consultant pharmacist's observations and recommendations is made available in an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, and the facility policy review, the facility failed to assist one of one (Resident (R) 54) reviewed for dental services in obtaining routine dental services out of a sample of 30 residents. Findings include: Review of the facility's policy titled, Dental Services revised date 09/01/23 read in part .Centers will provide or obtain from an outside resource routine and emergency dental services, including 24-hour emergency dental care, to meet the needs of each patient. Review of R54's admission Record located in the electronic medical records (EMR) section titled Profile revealed the resident was admitted to the facility on [DATE] with diagnoses that included bipolar disorder, anxiety disorder and dysphagia. Review of R54's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/05/24, located in the resident's EMR under the MDS tab indicated the facility assessed R54 to have a Brief Interview for Mental Status (BIMS) score was 15 out of 15, indicating…

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, interviews, and facility policy review, the facility failed to ensure food preferences were honored for two of two residents (Residents (R) 29 and R44) out of a sample of 30 residents. By not ensuring food preferences are being honored, residents may be at risk for potentially adverse effects such as weight loss and preferring not to eat what is being served. Findings include: Review of the facility's policy titled, Food Preferences, revised May 2014, indicated Policy: It is the center policy that individual food preferences are identified for all residents. It further indicated, Action Steps: The Food Services Director or designee will complete a Food Preference Interview within 72 hours of admission for the purpose of identifying individual food and beverage preferences .Food dislikes .will be entered into the resident profile in menu management software system. The individual tray assembly ticket will identify all food items appropriate for the resident based on diet…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and review of facility policy, the facility failed to ensure staff used a protective barrier for blood glucometer supplies while preparing to check blood glucose readings at the resident's bedside for four or four residents (Resident (R)14, R37, R49 and R52) and failed to wear personal protective equipment (PPE) while administering medications through a gastrostomy tube for one of one resident (R38). The facility staff also failed to only take the needed supplies into each room. Failure to use a protective barrier and taking all resident supplies into each room can lead to cross contamination. Failure to use appropriate PPE for residents on enhanced barrier precautions (EBP) could contribute to the spread of microorganisms. Findings include: Review of the facility's provided policy titled, Procedure: Enhanced Barrier Precautions revised on 01/08/24, documented, Enhanced barrier precautions applies to chronic wounds and/or indwelling medical devices (e.g., central line,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide resident care that met acceptable standards of professional practice for 3 (R #3, R #6 and R #7) of 3 (R #3, R #6 and R #7) residents by not conducting weekly skin checks and weekly skin evaluations. This deficient practice could likely result in residents not receiving all the appropriate care needed to ensure they reach or maintain their optimal well-being. The findings are: Findings for R #3: A. Record review of R #3's face sheet revealed he was admitted to the facility on [DATE] and diagnosed with quadriplegia (a condition in which both the arms and legs are paralyzed - the loss of the ability to move and sometimes to feel anything in part or most of the body) on 03/25/20. B. Record review of R #3's care plan, initiated 04/11/23, revealed, [First name of R #3] is noncompliant and sits in his wheelchair for extended periods of time causing an old area on his coccyx (tailbone) to reopen . and Weekly wound assessment to include measurements…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the resident's representative when the resident was discharged from the facility for 1 (R #4) of 2 (R #4 and R #5) residents reviewed for discharges. This deficient practice could likely result in the resident's representative being unable to provide assistance with coordinating care and/or making medical decisions as needed. The findings are: A. Record review of R#4's face sheet revealed she was admitted to the facility on [DATE] and discharged on 08/16/23 to Private home/apt. (apartment) no home health services. The face sheet also revealed R #4's niece was listed as her medical Power of Attorney (POA) and Emergency Contact #1. B. On 10/12/23 at 7:56 am, during an interview, R #4's niece/POA reported the facility staff did not notify her that R #4 had discharged on 08/16/23. She reported R #4 called her 3 days (on 08/19/23) after R #4 left the facility and told her she had gone home. R #4's niece/POA reported she received a call from someone…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to conduct a MDS assessment (minimum data set - a standardized assessment tool that measures health status in nursing home residents) following a significant change in condition for 1 (R #2) of 1 (R #2) reviewed for hospice (a type of health care that focuses on the quality of life of person with a serious illness who is approaching the end of life). This deficient practice could likely result in residents not receiving the appropriate care and services they need. The findings are: A. Record review of R#2's face sheet revealed she was admitted to the facility on [DATE]. B. Record review of R #2's Consent for Election of Medicare Hospice Benefit revealed R #2 began hospice services on 10/03/23. C. Record review of R #2's electronic medical record revealed staff did not conduct a change of condition MDS after R #2 began hospice. D. On 10/12/23 at 1:25 pm, during an interview, the Director of Nursing (DON) confirmed staff did not conduct a change in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure staff maintained accurate medical records for 1 (R #3) of 1 (R #3) resident reviewed for quality of care and discharges. This deficient practice could likely result in residents not receiving the care and services they need. The findings are: Findings for R #3: A. Record review of R #3's face sheet revealed he was admitted to the facility on [DATE] and diagnosed with quadriplegia (a condition in which both the arms and legs are paralyzed - the loss of the ability to move and sometimes to feel anything in part or most of the body) on 03/25/20. B. Record review of R #3's physician progress note titled History and Physical (H&P), dated 09/28/23 and under the Physical Exam section, revealed, Extremities (arms, hands, legs and feet): FULL ROM (range of motion - limit to which a part of the body can be moved around a joint or a fixed point.) C. On 10/11/23 at 7:17 pm, during an interview, the Director of Nursing (DON) reported R #3 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.

Based on record review, observation, and interview, the facility failed to ensure the nutritional needs and preferences were met for all 81 residents list on the resident census list provided on 07/17/23 by the facility Administrator by: 1. Not following the posted menu 2. Not providing an alternative meal These deficient practices could prevent residents from eating well, meeting their nutritional needs, and lead to weight loss. The findings are: A. On 07/19/23 at 4:45 pm during an interview with the District Manager (DM), when asked if there should be an alternative meal, he stated. There should be two meal options. One would be the meal offered and the other would be the alternative meal. An always available menu is offered [food items that are available for resident consumption every day] but it is not like offering an alternative meal. B. On 07/19/23 during record review of the menu and observations of meals available to be served, there was not an alternate menu offered or served.

Based on observation, record review, and interview, the facility failed to: 1. Ensure cold foods were served at the appropriate temperature 2. Ensure food trays were served at posted meal times 3. Ensure food trays were served at the same time to all residents sitting at the same table 4. Ensure food items are labeled These deficient practices are likely to result in residents being served food not at the appropriate temperature and not being served in a timely manner causing residents frustration and feeling as if they do not matter. The findings are: Cold food items: A. On 07/17/23 at 11:59 AM during observation of the lunch meal service the following was observed: 1. One large sheet pan with fruit in individual bowls was not labeled, was not ice, and was sitting on the countertop ready to be served for the lunch meal. Temperature of fruit sitting on the tray was 47.6 degrees. (appropriate temperature is 41 degrees or below). 2. One large sheet pan with assorted pre-poured juice glasses were not labeled, juice glasses were not on ice, and were sitting on the countertop ready to be…

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 deliver meals consistently and timely to all 81 residents that receive room trays or eat in the dining room. This deficient practice is likely to cause frustration and hunger. The findings are: A. On 07/19/23 at 10:55 am, during an interview with R #2 and R #21, both stated that meals are often delivered late, delivered cold, and sometimes they (facility staff) will not warm the food for the residents. B. On 07/19/23 at 12:28 pm during observation R #30 was served a lunch tray and a table mate had not been served his meal tray at 12:46 pm. C. On 07/19/23 during random observation of lunch dining service, R #45 was served his lunch tray at 12:20 pm and R #75 was served at 12:50 pm. Both residents were sitting at the same dining table. D. On 07/19/23 at 8:03 am during an interview with R #5's daughter she stated, she is at the facility every day for breakfast and lunch and the food trays are not delivered timely. She often has to ask the dietary department to give her her mother's tray so that she can assist her with dining,…

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 store and serve food under sanitary conditions by not: 1. Ensuring records of the refrigerator and freezer temperatures not pre-documented 2. Ensuring 5 gallon buckets of sanitizer were not stored on the bare floor. 3. Ensuring cold food/beverages being served for lunch were on ice and at appropriate temperature (40 degrees or below). These deficient practices are likely to affect all 81 residents listed on the resident census list provided by the Administrator on 07/17/23, and are likely to cause foodborne illnesses in residents if food is not being stored properly and safe food handling practices are not adhered to. The findings are: A. On 07/17/23 at 11:59 am during the initial tour of facility kitchen the following was observed: 1. One 5 gallon bucket of Sanitizer was stored on the bare floor in the storage room. 2. One large plastic container of diced turkey was not labeled or dated and open to air on kitchen back table. 3. One large sheet pan with fruit in individual bowls was not labeled and was not on ice was 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 provide an ongoing activity program for 1 (R #7) of 1 (R #7) resident reviewed for activities. If the facility does not ensure that all residents are receiving an ongoing activity program, documenting resident refusals, and making in-room activity accommodations, then residents are likely to demonstrate an increase in isolation and depression. The findings are: A. Record review revealed R #7 was admitted on [DATE] with the primary diagnosis of paraplegia unspecified (unable to move the legs and lower body). B. On 07/18/23 at 10:37 am during an interview with R #7 when asked if he participated in activities he stated, No, I just watch television here in my room. I would like to participate in activities. He further stated that he likes watching movies, playing games, and any activity with music. C. Record review of Activities/Recreation Progress Notes for R #7 dated 10/22/19 to 07/20/23 revealed that he participated in one activity of nail care, coffee,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to: 1. Ensure that medications were not expired and were labeled as to when they were opened 2. Ensure Medication carts were locked and not left unattended. These deficient practices are likely to result in residents receiving medications that have lost their potency and effectiveness leaving them vulnerable to acquiring infections. Leaving medication carts unlocked and unattended gives residents access to potentially dangerous medications kept in the unlocked medication carts. The findings are: Findings for 100 Unit: A. On [DATE] at 9:31 am during observation of Unit 100's medication storage room, the following was observed inside the medication refrigerator: One 1 mL (milliliter) multidose vial of TB (tuberculosis (purified protine used to screen for TB and for tuberculosis diagnosis) opened and not dated to indicate the date the vial was first opened. B. On [DATE] at 9:35 am during interview, Certified Medication Aide (CMA) #1 confirmed the vial (TB)…

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

Based on observation and interview, the facility failed to provide food that accommodates resident allergies, intolerances, and preferences for 1 (R #26) of 1 (R #26) resident observed for food allergies. This deficient practice is likely to result in weight loss due to residents not eating or experiencing allergic reactions. The findings are: A. On 07/19/23 at 9:00 am during a breakfast observation, R #26's Breakfast Meal Ticket indicated that R #26 is to receive 1/2 C (cup), of oatmeal for breakfast. B. On 07/19 at 1:38 pm during an interview with the Dietary District Manager (DM), he confirmed that R #26's ticket does not reflect an oat allergy and it should. DM further stated that R #26 should not be getting any type of oats with his meals.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that 1 (R #26) of 1 (R #26) resident's New Mexico Medical Orders For Scope of Treatment (MOST) reviewed was completed to reflect medical interventions (Advanced Directives-legal documents that allow you to spell out your decisions about end-of-life care ahead of time). This deficient practice is likely to affect residents' fulfillment of their end-of-life medical care choices and could result in unnecessary suffering for the resident. The findings are: A. Record review of R #26's face sheet revealed R #26 was admitted into the facility on [DATE]. B. Record review of the MOST form in R #26's electronic medical chart was signed by Physician on 09/25/03. However, no information was identified in the Section D: discussed with patient, Healthcare Decision Maker, Court Appointed Guardian or Other. C. Record review of the MOST form in R #26's electronic medical chart was not signed by a Healthcare Decision Maker or by R #26. D. On 07/19/23 at 3:47 pm…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete the Minimum Data Set (pertinent resident health information) (MDS) quarterly for 1 (R #42) of 1 (R #42) resident reviewed for current comprehensive assessment. This deficient practice is likely to result in residents not receiving the optimal care needed. The findings are: A. Record review of the medical record for R #42 revealed that R #42 had been admitted to the facility on [DATE] and no Quarterly MDS had been completed for this resident, which was due on 05/27/23. B. On 07/19/23 at 2:08 pm during an interview with the Director of Nursing (DON), she confirmed that R #42 should have had an MDS completed on 05/27/23. C. On 07/19/23 at 2:35 pm during an interview with Minimum Data Set (MDS) Coordinator, she confirmed that the quarterly MDS for R #42 was 40 day's overdue and should have been completed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure that the resident's care plan had been revised for 1 (R #26) of 1 (R #26) resident reviewed by not updating the care plan to include a food allergy. This deficient practice is likely to result in residents' care and needs not being addressed if care plans are not updated. The findings are: A. Record review of R #26's face sheet revealed R #26 was admitted into the facility on [DATE]. B. Record review of R #26's physician orders dated 06/27/23 revealed R #26 is allergic to oats. C. Record review of R #1's care plan dated 10/18/22 revealed that an oat allergy was not care planned. D. On 07/19/23 at 9:00 am during a breakfast observation, R #26's Breakfast Meal Ticket indicated R #26 was to receive 1/2 C (cup) of oatmeal for breakfast. E. On 07/19 at 1:38 pm during an interview with the Dietary District Manager (DM), he confirmed that R #26's meal ticket does not reflect the oat allergy, and the care plan does not reflect that R #26…

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 complete an annual performance/competency review for two Certified Nurse Assistants (CNA)'s (CNA #2 and #3) of 3 (CNA #1, CNA #2, and CNA #3) CNA's randomly reviewed for annual performance/competency trainings. This deficient practice is likely to result in staff not maintaining the competencies to perform their daily tasks needed to provide the care and service to meet the needs of all residents. The findings are: A. Record review of personnel files revealed the annual competency reviews of CNA's #2 and #3 were not completed. No documentation was available to confirm that CNA #2 and CNA #3 had been evaluated during the past 12 months nor that each was able to demonstrate competent skills in providing care to residents. B. On 07/20/23 at 12:49 pm during an interview with Human Resources, (HR) she confirmed that there was no documentation to confirm that CNA's #2 and #3 had been evaluated for their skills and competencies at any time during the past 12 months.

Based on observation and interview, the facility failed to provide proper infection control practices by not: 1. Ensuring that the door between the soiled utility room, containing clothing items that were soiled with body fluids, and the clean laundry room (where clothing items are cleaned and laundered) was kept closed. 2. Ensuring alcohol wipes were readily available for use in the facility kitchen to wipe thermometer probe used to take temperature of prepared food items before food service. 3. Ensuring that sanitizer buckets used to clean food preparation areas had sanitizer in them. These deficient practices are likely to cause the spread of infections and illness to residents and staff within the facility. The findings are: A. On 07/20/23 at 10:20 am during observation of laundry services, upon entering the clean side of the laundry room it was observed that the door between the soiled utility room which contains soiled clothing items and the clean laundry area was open. B. On 07/20/23 at 10:21 AM during interview with Laundry Worker #1, she confirmed that the door was open 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.