St. Anthony Healthcare and Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to keep residents free from physical restraints for 1 (R #4) of 1 (R #4) resident reviewed for restrictions when staff used a wander guard (wearable technology used to keep residents from wandering or eloping from the facility unattended) for a resident that no longer needs a wander guard. This deficient practice could likely result in R #4 being unnecessarily restricted. The findings are: A. Record review of R #4's admission Record revealed R #4 was admitted to the facility on [DATE], with the following diagnoses:1. Dementia in other diseases classified elsewhere, unspecified severity, with mood disturbance (marked by a severe decline in cognitive functions, such as thinking, reasoning, and remembering, to the extent that it interferes with the person's daily life), 2. Thyrotoxicosis, unspecified without thyrotoxic crisis or storm (too much thyroid hormone in your body. Common symptoms include unexplained weight loss, a rapid heart rate and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff revised the care plan for 1 (R #32) of 3 (R #9, R #32, and R #65) residents reviewed when staff failed revise R #34's care plan to include elopement risk and use of a wander guard (wearable technology used to keep residents from wandering or eloping from the facility unattended). This deficient practice is likely to result in residents' care and needs not being addressed. The findings are: A. Record review of R #32's face sheet revealed she was admitted to the facility on [DATE] with the following diagnoses: 1. Other pulmonary embolism (a blood clot that blocks blood flow to an artery in the lungs),2. Bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), 3. Schizoaffective disorder (a mental condition that causes both psychosis and mood problems),4. Essential (primary) hypertension (HTN; high blood pressure),B. On 08/10/25 at 11:00 am an observation of R #32…

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 post nurse staffing data daily, at the beginning of the shift that included the following: 1. Facility name. 2. The current date. 3. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: 1. Registered nurses. 2. Licensed practical nurses. 3. Certified nurse aides. 4. Resident census. This deficient practice could likely result in residents and visitors not having the staffing information readily available. The findings are:A. On 08/10/25 at 10:00 am, an observation of the main entrance revealed the nurse staffing data sheet was dated 08/08/25. B. On 08/13/25 at 1:22 pm, during an interview with the Administrator, she confirmed the nursing staffing data sheet should be posted daily and it was not.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based observation, record review, and interviews, the facility failed to ensure residents were free from significant medication errors by not administering medications as ordered for 1 (R #2) of 1 (R #2) resident reviewed for medication administration. This deficient practice could likely lead to severe negative effects on the residents. The findings are: A. Record review of R #2's admission Record revealed she was admitted to the facility on [DATE] with diagnoses of peripheral vascular disease (PVD; poor circulation) and heart failure. B. On 08/13/25 at 11:15 am, an observation and interview with R #2 revealed that she had not received her Lidocaine External Patch and she had no wraps on her legs. C. Record review of R #2's current physician orders revealed the following orders:1. Lidocaine external patch to be applied to her upper back topically in the morning for back pain, end date of 08/31/25.2. An order dated 01/03/25 to wrap R #2's bilateral legs with an ACE bandage daily for edema (swelling caused by…

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 an in-dept investigation, correct the grievance allegations, and notify residents of the outcome of their grievances. These deficient practices have the potential to affect all 62 residents (residents were identified using the census provided by the Administrator on 05/28/25) residing in the facility. If the facility is not investigating, correcting, and notifying residents of their grievance allegations then residents are likely to feel unheard and unimportant. The findings are: A. On 05/28/25 at 10:45 am during an interview with R #1, he stated that he has filed several grievances with the facility regarding the food and has never received an outcome. B. On 05/28/25 at 11:15 am during an interview with R #2, he stated that he has filed several grievances with the facility regarding several issues and has never received an outcome. C. On 05/28/25 at 1:40 pm during an interview with R #6, she stated that she has filed a couple grievances with the facility regarding food and showers and has never received an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to secure medications in a medication cart and a treatment cart for all 62 residents living in the facility (residents were identified by the census list provided by the Administrator on 05/28/25). This deficient practice could result in residents obtaining medication not prescribed to them resulting in adverse side effects. The findings are: A. On 05/28/25 at 1:45 pm, an observation of the facility revealed the medication cart was located by room [ROOM NUMBER] and was unlocked. B. On 05/28/25 at 1:46 pm, during an interview Licensed Practical Nurse (LPN) #1, she confirmed that the medication cart was unlocked. C. On 05/29/25 at 10:11 am, an observation of the facility revealed the treatment cart was in the 200 hall near the nurse's station and was unlocked. D. On 05/29/25 at 10:13 am, during an interview LPN #2, she confirmed that the medication cart was unlocked. E. On 05/29/25 at 11:20 am, during an interview with the Director of Nursing (DON), she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and observation, the facility failed to serve food that is palatable, attractive, and at a safe and appetizing temperature. This deficient practice has the potential to affect all 62 residents' ability to eat and enjoy their meals, may decrease their quality of life, and could likely lose weight. The findings are: A. Record review of R #1's admission record revealed he was admitted to the facility on [DATE] with the following diagnoses: 1. Spinal Stenosis, cervical region, 2. Type 2 diabetes mellitus with hyperglycemia 3. Depression, unspecified, 4. Chronic diastolic (congestive) heart failure. B. Record review of R #1's quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) dated 10/18/24, revealed a Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) score of 15, cognitively intact. C. On 05/28/25 at 10:45 am, during an interview with R #1, he stated that the food does not taste good, food that 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 observation and interviews, the facility failed to provide a comfortable and homelike environment by: 1. Not repairing the peeling and chipped paint, 2. Not repainting areas of repair to match the rest of the wall, 3. Handrails in the 200-hall appeared worn and needed repair/refinishing, 4. Using an overhead paging system to announce phone calls for staff members and to call staff members to the office. These deficient practices could affect everyone that lives in the 200-hall as identified by the Daily Census provided by the Administrator (ADM) on 05/28/25 and will likely cause residents to feel like they are not living in a comfortable home-like environment and make them feel they are not valued. The findings are: A. On 05/29/25 at 9:36 am a random observation of the facility revealed the following: 1. Peeling and chipped paint on the walls throughout the 200-hall. 2. A section of the wall, close to the therapy entrance, approximately two feet wide and one foot tall, where it appears an object once hung on the wall is not repainted to match the rest of the wall. 3.…

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

Based on interview, the facility failed to have evidence that all allegations of abuse, neglect, exploitation or mistreatment were thoroughly investigated to prevent further incidents from occurring. This deficient practice could likely affect all 62 residents residing in the facility according to the census provided by the Administrator (ADM) on 05/28/25. If the facility is not thoroughly investigating and maintaining evidence of the investigations then residents are at a higher risk of being abused, neglected, exploited, or mistreated. The findings are: A. On 05/28/25 at 2:43 pm during an interview with the Administrator, she stated that she does not have evidence of any investigations conducted since 01/01/25 due to the previous Social Services Director taking the Reportable Binder (a binder the facility uses to keep all documentation and evidence of investigations) when she left. The ADM confirmed that she had to start a new binder as of 05/01/25.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure the comprehensive care plan was accurate for 2 (R #1 and R #7) of 2 (R #1 and R #7) residents reviewed for care plan accuracy. This deficient practice could likely result in staff not understanding and implementing the most appropriate interventions and treatments for the residents. The findings are: R #1 A. Record review of R #1's admission record revealed he was admitted to the facility on [DATE] with the following diagnoses: 1. Spinal Stenosis, cervical region (narrowing of one or more spaces within the spinal canal), 2. Type 2 diabetes mellitus with hyperglycemia (blood sugar levels rise significantly), 3. Depression, unspecified, 4. Chronic diastolic (congestive) heart failure. B. Record review of R #1's quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) dated 10/18/24, revealed a Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) score of 15, cognitively…

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

Based on record review and interview, the facility failed to provide activities of daily living ADL; (activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) assistance for baths and showers for 1 (R #7) of 1 (R #7) dependent resident sampled for ADLs. If the facility is not assisting the residents to bathe or shower, then residents are likely to feel unimportant, dirty and could develop further or worsening health issues. The findings are: A. Record review of R #7's Document Survey Report (documentation showing ADL support/care completed), dated 11/28/24 through 04/28/25 revealed the following: 1. On 12/30/24 R #7 received a bed bath. 2. On 01/11/25 R #7 received a bed bath. 3. On 01/19/25 R #7 received a bed bath. 4. On 01/26/25 R #7 received a bed bath. 5. On 02/02/25 R #7 received a bed bath. 6. On 02/08/25 R #7 received a bed bath. 7. On 02/15/25 R #7 received a bed bath. 8. On 03/03/25 R #7 received a bed bath. 9. On 03/10/25 R #7 received a bed bath. B. On 05/29/25 at 12:20 pm during an interview with the Director of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to keep residents free from accidents for 2 (R #5 and R #7) of 2 (R #5 and R #7) residents reviewed for accidents when staff failed to: 1. Put interventions in place to reduce the risk of falls for R #5. 2. Implement appropriate post-fall interventions (ensure the health and safety of residents after a fall by completing actions such as neurochecks) for R #5 and R #7. These deficient practices could likely result in residents getting injured during falls or injuries going unnoticed after a fall. The findings are: R #5 A. Record review of R #5's admission record revealed she was admitted to the facility on [DATE] with the following diagnoses: 1. Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgement), 2. Major depressive disorder (depression; a mood disorder that causes a persistent feeling of sadness and loss of interest), severe with psychotic symptoms, 3. Reduced…

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 respiratory care in accordance with professional standards for 3 (R #2, R #3, and R #4) of 3 (R #2, R #3, and R #4) residents reviewed for respiratory care when staff failed to change the oxygen concentrator (a medical device that provides extra oxygen) tubing. If the facility fails to provide new, clean tubing for oxygen concentrators then residents are at risk of becoming ill. The findings are: R #2 A. Record review of R #2's admission record revealed R #2 was originally admitted to the facility on [DATE] with the following diagnoses: 1. Chronic obstructive pulmonary disease (CODP; lung disease), 2. Quadriplegia (paralysis of all four limbs), 3. Type 2 diabetes mellitus (DM2; a condition results from insufficient production of insulin causing high blood sugar), 4. Morbid obesity (severely overweight). B. Record review of R #2's current medical orders revealed the following: 1. An order, dated 08/15/24, for oxygen at three liters…

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 update the resident's medical chart and to ensure the resident's current advance directive and New Mexico Orders for Scope of Treatment (MOST) form (a document which provides an individual's wishes for emergency and lifesaving care) matched the order in the electronic health record (EHR) for 1 (R #7) of 2 (R #1 and R #7) residents reviewed for advance directives when staff failed to update the resident's code status. This deficient practice is likely to result in confusion, delay, and residents not having their wishes honored if a life-threatening event occurred. The findings are: A. Record review of R #7's face sheet revealed R #7 was admitted into the facility on [DATE]. B. Record review of R #7's physician orders dated [DATE], revealed R #7 chose a do not resuscitate (DNR; does not want to have CPR attempted on them if their heart or breathing stops) for her advanced directive code status. C. Record review of R #7's current advance directive and the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop an accurate, person-centered comprehensive care plan for 1 (R #1) of 3 (R #1, R #2, and R #3) residents reviewed. If the facility is not updating the care plan to reflect the treatment needs for wound care, then the residents could likely experience a worsening of existing wounds or the development of new wounds. The findings are: A. Record review of R #1's admission Record revealed R #1 was admitted to the facility on [DATE] with the following multiple diagnosis: 1. Unspecified fracture of shaft humerus (break in the long bone of the upper arm), unspecified arm, subsequent encounter for fracture with routine healing. 2. Type 2 diabetes mellitus without complications. 3. Long term (current) use of insulin (a hormone that regulates blood sugar levels by moving glucose from the blood into cells). 4. Long term (current) use of anticoagulants (a substance that is used to prevent and treat blood clots). 5. Pressure ulcer (an injury to skin and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide a discharge summary that included a recapitulation (a summary describing the resident's course of treatment while residing in the facility) and a reconciliation of all medications at the time of discharge for 1 (R #1) of 1 (R #1) resident reviewed for discharge. This deficient practice could likely lead to the receiving facility, community agency, or family member not knowing what the current care needs and/or current medications are for the resident. The findings are: A. Record review of R #1's admission Record revealed R #1 was admitted to the facility on [DATE] with the following diagnoses: - Unspecified fracture of shaft humerus (break in the long bone of the upper arm), unspecified arm, subsequent encounter for fracture with routine healing. - Type 2 diabetes mellitus without complications. - Long term (current) use of insulin (a hormone that regulates blood sugar levels by moving glucose from the blood into cells). - Long term (current)…

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 documentation review, the facility failed to ensure food was stored and served in a sanitary manner. This had the potential to result in the spread of infections and food born illnesses for 59 of 59 residents residing in the facility. Findings include: 1. During an observation on 07/23/24 at 9:30 AM, the temperature of the walk-in refrigerator was 49 degrees Fahrenheit (F) on both the outside and inside thermometers. The refrigerator contained two large roasts; two large bags of lettuce; an open, partially used gallon container of mayonnaise; an open container of alfredo sauce; two large bags of cut up potatoes; two cases of margarine; and two boxes of angel food cake. The bags of lettuce did not have a use-by date on them because they had been removed from their original box. The lettuce in one of the bags was turning brown. On 07/23/24 at 10:13 AM, the refrigerator temperature remained at 49 degrees F. The Dietary Manager (DM) verified the temperature was 49 degrees F and stated they had been having problems with the refrigerator maintaining…

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 review of facility documents and policies, the facility failed to maintain the walk-in refrigerator to ensure it functioned properly and maintained a safe operating temperature. This had the potential to result in food-borne illness as the result of not holding food at a safe temperature level. This had the potential to affect 59 of 59 residents in the facility. Findings include: During an observation on 07/23/24 at 9:30 AM, the temperature of the walk-in refrigerator was 49 degrees Fahrenheit (F) on both the outside and inside thermometer. The refrigerator contained two large roasts; two large bags of lettuce; an open, partially used gallon container of mayonnaise; an open container of alfredo sauce; two large bags of cut up potatoes; two cases of margarine; and two boxes of angel food cake. On 07/23/24 at 10:13 AM, the refrigerator temperature remained at 49 degrees F. The Dietary Manager (DM) verified the temperature of 49 degrees F and stated they had been having problems with the refrigerator maintaining its' temperature for the past four…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to ensure restorative services were provided as ordered by the physician for five of eight residents (Residents (R) 47, R54, R46, R11, and R34) reviewed for restorative services out of a total sample of 23. This had the potential to cause avoidable decline in the residents' functional abilities. Findings include: 1. Review of R37's Face Sheet, located in the Profile tab of the electronic medical record (EMR,) revealed R37 was admitted to the facility on [DATE] with diagnoses including quadriplegia, contracture of the right and left hand, and obesity. Review of R37's Restorative Nursing Referral, dated 03/27/24 and located in the restorative nursing binder in therapy, revealed R37 was to receive exercises of passive range of motion (ROM) five times a week to the upper extremities by the Restorative Nursing Assistant, who was Certified Nursing Aide (CNA)1. Review of R37's Restorative Nursing Care Plan, dated 03/27/24…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to provide an ongoing program of activities to meet the needs and interests of five of six residents (Resident (R) 43, R38, R47, R22, and R42) reviewed for activities out of a total sample of 23. This failure had the potential to cause diminished quality of life for all residents who resided on the dementia care unit. Findings include: Review of R43's quarterly Minimum Data Set (MDS), located under the MDS tab of the electronic medical record (EMR) and with an Assessment Reference Date (ARD) of 05/27/24, revealed R43 was admitted to the facility on [DATE]; had diagnoses of schizophrenia, dementia with other behavioral disturbances, and cognitive communication deficit; and was coded as being severely impaired for cognitive skills for daily decision making. Review of R43's Care Plan, revised 06/06/24 and located under the Care Plan tab of the EMR, recorded it was important for R43 to have the opportunity to engage 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, record review, and facility policy review, it was determined the facility failed to maintain an environment free of flies. Flies were observed in resident rooms, dining rooms, hallways, and in the therapy room, landing on residents and their food. This had the potential to affect 59 of 59 residents who resided at the facility, and the potential to result in food borne illness and the spread of infection and diseases. Findings include: 1. Review of Resident (R) 29's Face Sheet, located under the Profile tab of the electronic medical record (EMR), revealed R29 was admitted to the facility on [DATE] with diagnoses including dementia. Review of R29's admission Minimum Data Set (MDS), located under the MDS tab of the EMR and with an Assessment Reference Date (ARD) of 06/14/24, revealed R29 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. During a dining observation on 07/23/24 at 12:30 PM, where R29 was present,…

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 an interview, record review, and facility policy review, the facility failed to ensure the resident's right to participate in the care planning process for two of two residents (Resident (R) 32 and R48) reviewed for care plans out of a total sample of 23. This failure placed the residents at risk for unmet care needs due to a lack of resident involvement in their care. Findings Include: 1. Review of R32's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R32 was admitted to the facility on [DATE] with diagnoses that included bipolar disease. It was recorded R32 was her own representative. Review of R32's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/16/24 and located under the MDS tab of the EMR, revealed R32 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated the resident was cognitively intact. Review of R32's Progress Note, dated 07/18/24 at 2:35 PM and located under the Progress Notes…

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, record review, and review of facility policy, the facility failed to administer medications in a manner to prevent cross contamination for five of eight residents (Resident (R) 18, R43, R9, R42, and R5) residents observed receiving medications out of a total census of 59 and failed to complete wound care in a manner to prevent cross contamination for one of one resident (R11) reviewed for pressure ulcers out of a total sample of 23. The failure had the potential to cause residents to be exposed to pathogens and increased the risk of infection. Findings include: 1. During an observation of the medication administration pass on 07/25/24 at 7:06 AM, Licensed Practical Nurse (LPN) 1 completed a blood pressure check for R18, gave the resident her medication, and returned to the medication cart. LPN1 did not sanitize or wash her hands after resident contact. Continuing with the medication administration observation on 07/25/24 at 7:17 AM, LPN1 prepared the medications for R43, completed a blood pressure check, gave the resident her medication, and went…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that staff reviewed Resident's Rights during the resident's stay or Resident Council Meetings for 11 (R #1, R #5, R #6, R #13, R #14, R #18, R #19, R #32, R #35, R #41, and R #42) of 11 (R #1, R #5, R #6, R #13, R #14, R #18, R #19, R #32, R #35, R #41, and R #42) residents sampled during a Resident's Council meeting. This deficient practice could likely result in residents feeling uninformed, not respected, vulnerable and susceptible to abuse or neglect. The findings are: A. On 06/12/23 at 9:30 am, during interview with R #6, R #5, R #13, R #41, R #18, R #1, R #35, R #32, R #19, R #14, and R #42 during a Resident Council meeting, it was revealed that resident rights are not being reviewed with residents. B. Record review of the prior six (6) months of Resident Council Minutes ([DATE] to June 2023) did not show documentation that resident rights had been discussed during the meetings. C. On 06/13/23 at 3:45 pm, during an interview with the…

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

Based on observation and interview, the facility failed to ensure that the most recent survey results completed by Federal and State Surveyors and any plans of correction in effect is readily and easily accessible for residents, visitors, and their legal representatives. This deficient practice has the potential of affecting all 49 residents identified on the facility census list provided by the Administrator on 06/11/23. The findings are: A. On 06/11/23 at 10:00 am, during a facility observation, a sign in the entrance stated the survey book (book that contains the most recent Federal and State surveys and plans of correction) was only available if you checked with the Administrator. B. On 06/12/23 at 9:30 am, interview with R #5, R #6, R #13, R #14, R #18, R #19, R #32, R #35, R #41, and R #42 during a Resident's Council meeting, it was revealed that the survey book was not readily available to the residents, their visitors, staff, or the general public. Residents stated they had to get the book from the Administrator. C. On 06/14/23 at 2:25 pm, during an interview with 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 ensure that five (5) Certified Nursing Aides (CNA's) (CNA's #2, #3, #5, #7 and #8) of 5 (CNA's #2, #3, #5, #7 and #8) CNA's had documented and demonstrated competencies (ability of an individual to do a job properly), before they worked with the residents. All 49 residents, as identified by the facility census provided by the Administrator on 06/11/23, residents could likely be affected by this deficient practice, which could lead to the residents not receiving the care and services as described on their care plan and making them susceptible to improper care. The findings are: A. Record review of staff personnel and training files revealed the following: 1. CNA #2- No competencies (testing/observations conducted to ensure proper job skills) were in employee file. 2. CNA #3- No competencies were in employee file. 3. CNA #5- No competencies were in employee file. 4. CNA #7- No competencies were in employee file. 5. CNA #8- No competencies were in employee file. B. Record review of facility Nursing Services policy, dated…

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 store and maintain foods under sanitary conditions by not ensuring food items in the dry storage, refrigerator, and freezer were properly labeled and/or dated. These deficient practices are likely to affect all 49 residents listed on the resident census list provided by the Director of Nursing (DON) on 06/11/23, and could lead to 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 06/11/23 at 10:24 am, during an observation of the facility kitchen, the following was noted in the kitchen freezers, kitchen refrigerators, and kitchen dry storage: 1. Diced potatoes in a box (undated) 2. Watermelon in a box (undated) 3. Fruit in a box (undated) 4. Ground meat in a box in the refrigerator (undated) 5. Multiple pitchers of red fluid in the refrigerator (undated) 6. Clear cups of fruit, pudding in the refrigerator (undated) 7. Open gallon of milk in the refrigerator (undated) 8. Multiple spices to include cumin, basil, 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 observation, record review, and interview, the facility failed to provide a safe, functional, and comfortable environment for all 49 residents, as identified by the facility census provided by the Administrator on 06/11/23, by failing to maintain, repair and resurface building/walls and the hand rail system. This deficient practice is likely to affect their safety and psychosocial well being. The findings are: A. On 06/12/23 at 4:14 pm, during an observation of the facility environment revealed: 1. All Hand rails had a very worn finish and were in need of repair/refinishing 2. A fly light (blue light that attracts flies to a stick paper) at end of 200 hallway was unplugged and cord was hanging down/loose (possible resident choking/entanglement hazard) 3. The main dining area was monochrome in color and was lacking homelike quality/bright cheerful decoration. 4. The receptionist entry (little area off of the dining room that residents have access to) had items stacked and was cluttered and unsightly. B. Record review of facility resident rights policy, dated 11/28/16, page…

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 notify residents of the findings of their grievances. This deficient practice could likely affect all 49 residents who reside at the facility grievances. If the facility does not provide responses to grievances, then residents may not feel that their concerns are being resolved or important to the facility administration. The findings are: A. On 06/12/23 at 9:30 am during an interview with Resident's Council members, residents stated they were not being notified of the results of their grievances. The members said they were all aware of how to file a grievance and many stated they had filed written grievances to the facility. Three of the members, (R #1, R #5 and R #32) stated they had filed grievances in the past but could not recall the dates and never received a response to their grievances, notifying them of the outcome. B. Record review of the resident grievance logs did not indicate that residents were being notified of the results of their grievances. C. On 06/14/23 during an interview with the Social Services…

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 develop a comprehensive care plan and implement a comprehensive care plan for 3 (R #7, 22, and 47) of 4 (R #7, 22, 47, and 49) residents reviewed for comprehensive care plans: Develop a comprehensive care plan for R #7 and R #47 residents; Implement a comprehensive care plan for R #22. This failure is likely to delay residents in receiving benefits from, or improving, related to plans of care that are effective for their optimal well-being. The findings are: Resident #7: A. Record review of facility face sheet for R #7, dated 04/26/23, revealed admitting diagnoses which included: Atherosclerotic Heart Disease (hardening of the arteries), Heart failure, Hypertension (high blood pressure), Type 2 Diabetes (high blood sugar), Hypothyroidism (low hormones), and Diverticulitus of intestine (swelling of intestine). B. Record review of progress notes, dated 05/15/23, for R #7 revealed that she was to have 2 LPM (liters per minute) of oxygen (O2) via nasal cannula (device to supply oxygen to the nostrils of a person)…

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

Based on observation, record review, and interview, the facility failed to have physician orders for 1 (R #7) of 1 (R #7) resident by administering oxygen without a physician's order. If the facility fails to obtain orders for the administering of oxygen, it could likely cause the resident to not receive the therapeutic benefits, resulting in possible harm to the resident. The findings are: A. Record review of facility face sheet, dated 04/26/23, for R #7 revealed admitting diagnoses which included: Arteriosclerotic Heart Disease (hardening of the arteries), Heart failure, Hypertension (high blood pressure), Type 2 Diabetes (high blood sugar), Hypothyroidism (low hormones), and Diverticulitus of intestine (swelling of intestine). B. Record review of progress notes, dated 05/15/23, for R #7 revealed that she was to have 2 LPM (liters per minute) of oxygen (O2) via nasal cannula (device to supply oxygen to the nostrils of a person) as needed during sleep to keep her O2 levels above 90%. C. On 06/11/23 at 3:57 pm, during an observation of R #7's room revealed an oxygen concentrator…

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 kitchen equipment is in safe operating condition. This failure is likely to cause residents to not receive meals as scheduled, or be served at appetizing temperatures, or be stored in accordance with industry standards. The findings are: A. On 06/11/23 at 10:24 am, during an observation of the facility kitchen, the following was noted: 1. Ice machine was out of order. 2. Coffee machine was broken. 3. Electrical outlets on east wall of the kitchen and half of north wall were not functioning 4. Gas ovens were not functioning at full capacity, as one oven and the broiler were not working. 5. Sink used for dishwashing was leaking from drain pipe onto the floor. 6. Dishwasher took three (3) cycles to reach 120 degrees Fahrenheit. B. On 06/11/23 at 10:45 am, during an interview with the Dietary Services Director, she confirmed the problems with the electricity, the oven, as well as the ice machine and the coffee machine.

Based on record review and interview, the facility failed to ensure that a care plan had been revised for 1 (R #21) of 1 (R #21) resident reviewed for care plans. The facility failed to update the care plan to include removal of a catheter (device used to drain the bladder). 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 facility face sheet, dated 03/10/23, for R #21 revealed admitting diagnoses which included: Heart Failure, Sepsis (blood poisoning), Urinary Tract Infection (UTI), Atrial Fibrillation (abnormal heart rhythm), Respiratory Failure, Hypoxia (low oxygen in blood), Hyperlipidemia (high cholesterol), Hypothyroidism (underactive thyroid), Asthma (trouble breathing), Chronic Kidney Disease, Claustrophobia (fear of confined spaces), Type 2 Diabetes (high blood sugar), Congenital Malformation Of Intestine (bowel obstruction), Multiple Sclerosis (disease that affects the nervous system), Osteoporosis (weak bones), Rheumatoid Arthritis (joint disease), Neuromuscular…

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 a Wanderguard (a device worn by a resident used to notify the facility of resident trying to leave the facility) to prevent accidents for 1 (R #45) of 1 (R #45) resident reviewed for accidents. If the facility does not implement safety devices, accidents could occur, resulting in injury to residents. The findings are: A. Review of R #45's care plan, dated 04/20/2023, revealed R #45 had diagnoses including: Metabolic Encephalopathy (abnormal chemical balance affecting the brain, that adversely affects brain function), Dementia (a group of symptoms changing memory, thinking and social abilities of daily life), Psychotic Disturbance (confusion), Mood Disturbance (feelings of distress, sadness, depression, and anxiety), Transient Ischemic Attack (a stroke that lasts a short time), Cerebral Infarction (a stroke where cells of the brain die), Hypertensive Heart Disease (an effect of high blood pressure causing heart damage), Altered Mental Status (confusion, forgetfulness), Cognitive Communication Deficit…

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 garbage can lids on garbage cans were closed completely or had a lid within the kitchen area. A. On 06/17/23 at 11:00 am, during observation of the kitchen, a trash can on wheels was sitting uncovered in the kitchen area, by the back door. B. On 06/17/23 at 11:01 am, during an interview with Dietary Services Director (DSD), when asked if the garbage cans in the kitchen needed to be covered, she replied yes. She then picked up the lid from next to the trash can and placed it on the trash can. C. Record review of Trash Removal policy dated 07/15/22 revealed the following: Policy Title: Trash Removal . Process: . 2.Covered trash containers are used for collection. 5. Trash containers and lids are cleaned when visibly soiled and disinfected at least monthly. 6. The loaded trash container is covered and taken directly to the disposal area .