Red Rocks Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure an environment free from accident hazards and failed to provide adequate supervision to prevent accidents for 2 (R #5 and R #38) of 2 (R #5 and R #38) residents reviewed for accidents and supervision when: The facility did not ensure staff maintained a safe room temperature, exposing R #5 and R #38 to 32-degree Fahrenheit (F) outside temperatures, when staff opened a window without consent and left the window open for an extended period of time. This deficient practice is likely to lead to residents experiencing avoidable accidents and/or injuries. The findings are: R #5: A. Record review of R #5's face sheet revealed R #5 was admitted to the facility on [DATE] with diagnosis of unspecified dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment). B. Record review of R #5's Quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure ongoing communication and coordination with the resident's dialysis provider for 1 (R #4) of 1 (R #4) residents reviewed for dialysis. If the facility does not ensure consistent two-way communication with the dialysis center for every dialysis treatment, then the facility cannot ensure appropriate monitoring of the resident's dialysis-related condition, recognition of complications, or implementation of timely interventions. The findings are: A. Record review of the facility's Dialysis Policy dated 08/07/23 revealed facility nursing staff are required to complete ongoing assessments for the residents' condition and monitoring before and after dialysis treatments. B. Record review of R 4's face sheet revealed R #4 was admitted into the facility on [DATE] with the following diagnoses: Diagnosis of end stage renal disease,Dependence on renal dialysis. C. Record review of R #4's Care Plan, dated 04/22/23, revealed the following: Monitor dialysis…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to provide a diet in accordance with physician orders for 1 (R #4) of 1 (R #4) resident reviewed for nutrition when:The facility did not ensure therapeutic dysphagia care (the clinical treatment of swallowing disorders using rehabilitative and compensatory interventions to improve swallowing function and reduce the risk of aspiration) was followed and sent R #4 to dialysis with food items (sandwich) inconsistent with his ordered renal/dysphagia advanced diet.Dietary staff and nursing leadership lacked awareness of and oversight over the contents of dialysis sack lunches, placing the resident at risk for aspiration and inadequate nutritional management. These deficient practices are likely to negatively impact a resident's ability to eat, causing difficulty with swallowing during mealtimes. The findings are:A. Record review of R 4's face sheet revealed R #4 was admitted into the facility on [DATE] with the following diagnoses: End stage renal disease…

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 maintain accurate resident records for 5 of (R #'s 8, 37, 42, 90 and 95) of 5 (R #'s 8, 37, 42, 90 and 95) residents reviewed for accuracy of records by not: Ensuring weights were accurately documented for R #'s 8, 37, 42, and 90. Ensuring discharge documentation was updated and accurate for R #95. This deficient practice is likely to result in staff not having the information they need to provide competent, comprehensive care, and services to residents. The findings are: R #8: A. Record review of R #8's face sheet revealed an admission date of 11/08/23. B. Record review of R #8's weight tracking revealed the following: 11/01/2025, the resident weighed 214.5 pounds (lbs.). 12/01/2025, the resident weighed 253.5 lbs. C. On 12/04/2025 at 1:02 PM during an interview with the Director of Nursing (DON), she confirmed the documented weights for R #8 and stated R #8's one month weight gain appears to be an error and R #8 should be re-weighed immediately. 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 observation, record review, and interviews, the facility failed to ensure there was a functioning call light system that allowed residents to call for assistance for 5 (1B, 25A, 26A, 27A, and 29A) of 5 (1B, 25A, 26A, 27A, and 29A) resident rooms observed for call light functionality. If the facility does not have a functioning communication system, then residents are unlikely to get their immediate needs met by facility staff.The findings are: A. Record review of the facility's Call Lights policy, last revised on [DATE], revealed residents will have a call light or alternative communication device at each patient's bedside, toilet, and bathing room to allow residents to call for assistance when unattended. Further review of policy revealed staff will report problems with a call light or call system immediately to the supervisor and/or Maintenance Director and will provide immediate or alternative solutions until the problem can be remedied (examples include replacing call light, providing a bell or…

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

Based on observation and interview, the facility failed to safeguard residents' personal health information when the facility mailed a notice of involuntary discharge to an unauthorized entity for 2 (R #3 and #4) of 3 (R #3, #4 and #7) residents. If the facility fails to ensure the confidentiality, security, and proper management of resident records, then residents are at risk of unauthorized persons accessing their personal and medical information. The findings are: A. Record review of R #3's Notice of Involuntary Discharge, dated 03/06/25, revealed the facility sent the resident's notice to the State Long-Term Care Ombudsman in another state. The facility did not send the discharge notice to the State Long-Term Care Ombudsman in New Mexico. B. Record review of R #4's Notice of Involuntary Discharge, dated 03/05/25, revealed the facility sent the resident's notice to the State Long-Term Care Ombudsman in another state. The facility did not send the discharge notice to the State Long-Term Care Ombudsman in New Mexico. C. On 06/12/25 at 10:31 am during an interview, the New Mexico…

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 and submit a Five Day Report (a report sent to the State Survey Agency which includes the results of the facility's investigation into alleged violations) to the State Agency regarding allegations of neglect (the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress) for 1 (R #5) of 1 (R #5) residents. If the facility does not submit follow-up reports, then the State Agency cannot assure the residents are safe and free of neglect. The findings are: A. Record review of the facility's Reportable Incidents and Conditions policy, dated 06/01/15, revealed the following: - Staff will report, review, and investigate all reportable incidents and conditions which occurred, or allegedly occurred, on the property and involved, or allegedly involved, a resident who received services. - The Executive Director, Resident Care Director, or designee will review all reportable incidents and…

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

Based on record review and staff interview, the facility failed to provide a copy of the planned Involuntary Discharge Notice to the State Long-Term Care Ombudsman for 2 (R #3 and #4) of 3 (R #3, #4 and #7) residents. This deficient practice could result in residents being discharged without necessary advocacy or support from the Ombudsman's office. The findings are: R #3 A. Record review of R #3's Notice of Involuntary Discharge, dated 03/06/25, revealed the facility sent the resident's Involuntary Discharge Notice to the State Long-Term Care Ombudsman in another state. The facility did not send the discharge notice to the New Mexico Long-Term Care Ombudsman. B. On 06/12/25 at 10:31 am during an interview, the New Mexico Long-Term Care Ombudsman stated she did not receive R #3's Notice of Involuntary Discharge, dated 03/06/25. C. On 06/12/25 at 12:46 pm during an interview, the Social Services Director (SSD) stated she sent R #3's Notice of Involuntary Discharge, dated 03/06/25, to the Long-Term Care State Ombudsman in the wrong state. R #4 D. Record review of R #4's Notice of…

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

Based on record review and interview, the facility failed to ensure residents or the guardians were aware of and understood the reason they took a medication, the risks, and the benefits of the medication for 2 (R #19 and R #66) of 2 (R #19, R #66) residents reviewed for unnecessary medications. If the residents or their guardians are not informed of the risks of benefits of the medication, they are not able to make informed decisions. The findings are: R #19 A. Record review of R #19's physician's orders revealed an order for quetiapine fumarate oral tablet (used to treat certain mental/mood disorders), 50 mg (milligrams). Give one tablet orally at bedtime for agitation. Start date: 05/09/24. B. Record review of R #19's medical record revealed the record did not contain a consent form for quetiapine fumarate oral tablet, 50 mg. C. On 08/29/23 at 2:30 pm, during an interview, the Director of Nursing (DON) stated R #19's medical record did not contain consent forms for quetiapine fumarate oral tablet, 50 mg, and staff did not monitor R #19's behaviors while taking the quetiapine from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a homelike environment for 4 (R # 21, 63, 67 and 201) out of 4 (R # 21, 63, 67 and 201) residents reviewed when staff failed to replace the shower bed mattress that had a large hole all the way through the mattress which exposed the white pipe frame; to replace the curtain rods for multiple rooms; and to fix a broken door into the shower room. If residents do not have a homelike environment, they may become depressed and anxious about things in disrepair. The findings are: Shower bed mattress findings: A. On 07/22/24 at 2:02 pm, during an interview with R #67, she stated the shower bed she used for showers had a large hole in it. She stated the bed hurt her back when she lay on it, and the hole kept getting bigger. She stated it has been like that for months. B. On 07/24/24 10:41 am, during an interview with Certified Nursing Assistant (CNA) #5, she stated the shower bed has been like this for probably a couple of months. 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.

Based on record review and interview, the facility failed to ensure comprehensive Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) assessments were accurate for 2 (R #70 and #84) of 2 (R #70 and #84) residents reviewed for accurate MDS Assessments. If resident assessments are not complete and accurate, the facility could misidentify clinical complications and fail to provide adequate care to treat the resident's medical condition. The findings are: A. Record review of R #70's admission MDS Assessment, dated 05/21/24, indicated the resident was not on dialysis. B. Record review of R #84's admission MDS Assessment, dated 07/16/24, indicated the resident was not on dialysis. C. On 07/22/24 at 12:11 pm, during an interview with the MDS Coordinator, she verified R #70 was on dialysis at admission, and staff coded his MDS Assessment inaccurately. She also verified R #84 was on dialysis at admission, and staff coded her MDS Assessment inaccurately.

Based on interview and record review, the facility failed to ensure two (R #11 and R #66) of two (R #11 and R #66) residents had complete comprehensive care plans for their care, when staff failed to: 1. Include hospice on R #11's care plan. 2. Ensure R #66's care plans for delirium (a serious change in mental abilities that causes confused thinking and lack of awareness of surroundings), oral health, and use of psychotropic drugs (drugs that affect a person's mental state) were complete and included time frames. This failure had the potential to adversely affect staff's ability to implement preventative measures for the residents' health and well-being. Findings include: Resident #11 A. Record review of R #11's comprehensive Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 04/22/24, revealed the resident was on hospice. B. Record review of R #11's comprehensive care plan, dated 05/30/24, did not include R #11 was on hospice. C. Record review of R #11's physician orders showed R #11 started hospice on 04/12/24. D. During an…

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

Based on observation, record review, and interview the facility failed to maintain proper infection prevention measures when the facility failed to ensure the shower bed was free of a hole and several other cuts that exposed the foam for 4 (R #21, 63, 67 and 201) of 4 ( R # 21, 63, 67 and 201) residents that used the shower bed. Failure to replace items that required cleaning multiple times per day for infection control purposes could likely cause the spread of infections and illness to the residents who use the shower bed equipment. The findings are: A. On 07/22/24 at 2:02 pm, during an interview with R #67, she stated the shower bed she used for showers had a large hole in it, and it kept getting bigger. She stated it has been like that for months. B. On 07/24/24 at 10:55 am, during an observation of the shower room, the shower bed had multiple cracks on the shower bed mattress. The shower bed also had a large hole that went all the way through the mattress and exposed the pipe frame. The foam in the mattress was exposed in several places. The foam was a pourous suface that…

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 pressure ulcer interventions as ordered for R #10. This deficient practice could likely result in the resident not receiving appropriate and timely pressure ulcer relieving interventions, which could result in wounds becoming worse. The findings are: Findings for R #10 A. Record review of R #10's electronic medical record showed the resident was admitted on [DATE] with a diagnosis of pressure ulcer of sacral region, Stage 4 (pressure injuries that extend to muscle, tendon, or bone). This is not an all inclusive list. B. Record review of R #10's physician orders, dated 05/19/24, showed an order for a pressure-redistribution cushion to chair and a pressure-redistribution mattress to bed. C. Record review of R #10's physician orders from the wound clinic, dated 07/16/24, showed orders to offload (reduction or redistribution of pressure on a specific area to promote healing and prevent complications) patient every two hours, order a pressure…

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 podiatry (the medical care and treatment of the human foot) services for 1 (R #65) of 1 ( R #65) resident reviewed for toenail care. This deficient practice could likely result in functional decline, pain, and infections. The findings are: A. Record review of R #65's face sheet indicated she was admitted on [DATE]. She had a diagnosis of type 2 diabetes (when the body does not use insulin properly), morbid obesity (overweight), Guillan-Barre syndrome (a condition in which the body's immune system attacks the nerves. It can cause weakness, numbness or paralysis) and dementia (symptoms affecting memory, thinking and social abilities severely enough to interfere with daily life). This is not an all inclusive list. B. On 07/21/24 at 6:45 pm, during an interview with R #65, she stated she needed her toenails cut and to see podiatry. She stated she requested this from the nursing staff for awhile now. C. On 07/21/24 at 6:45 pm, an…

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

Based on observation and interview, the facility failed to put a resident in her bed when she was asleep, and the resident slumped forward in her wheelchair for 1 (R #13) of 1 (R #13) resident viewed during random observation. This deficient practice could likely cause the resident to fall forward out of her wheelchair and get hurt. The findings are: A. On 07/24/24 at 10:45 am, an observation of R #67 revealed the resident was asleep in her wheelchair in room off of the nursing station. She was slumped forward in her chair with one of her arms hanging off the side of the chair and appeared that she may fall out of the wheelchair. B. On 07/24/24 at 11:00 am, observation of R #67 revealed the resident slumped forward and asleep in her wheelchair. Certified Nursing Assistant (CNA) #5 and CNA #6 sat in the room with R #67, but neither CNA assisted R #67. C. On 07/24/24 at 11:03 am, during an interview and observation of CNA #5, the CNA did not answer any questions from the surveyor regarding R #67. CNA #5 got up and asked R #67 if she wanted to lay down in her bed. R #67 stated yes, 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 observation and interview, the facility failed to provide a sanitary and comfortable environment for all 93 residents, as identified by the facility census provided by the Administrator In Training (AIT) on 12/26/23, by failing to maintain and replace water damaged and stained ceiling tiles. This deficient practice is likely to cause all residents in this facility to be exposed to environmental hazards and to not feel comfortable, which could likely affect their psychosocial well-being. The findings are: A. On 12/28/23 at 8:33 am, during an interview and observation, the Maintenance Director stated there was a ceiling tile that had mold. The tile was located at the nurses' station. During an observation of the ceiling tiles in the nursing station area, a ceiling tile was observed to have a circular stain approximately 2 feet in circumference. The center section of the stain was spongelike and black in appearance. The tile bowed out and curved towards the floor. During an observation, a 4 inch water…

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

Based on observation and interview, the facility failed to maintain a homelike environment in good condition for 2 (R #101 and R #102) of 4 (R #101, R #102, R #104, and R #105) residents reviewed for homelike environment. This deficient practice could likely cause residents to feel they are not living in a comfortable environment, and they are not valued. The findings are: A. On 12/20/23 at 5:24 pm, during an interview, R #101's family member stated the beds in R #101's room were old. The family member also stated the door to the bigger cabinet in R #101's room and to the little cabinet were broken. She stated on the little cabinet, the whole door was broken. She stated she had not been to the facility in a while because it was depressing. B. On 12/27/23 at 9:00 am, an observation of R #101's and R #102's room, revealed the following: 1. A chest of drawers in the resident's room was missing a strip of the laminate veneer from the left, front face of the drawers, which measured approximately ¾ inch by 4 feet in size and left the press board beneath exposed. The chest of drawers was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the care plan was revised and updated for 1 (R #101) of 5 (R #101, R #102, R #103, R #104, R #105) residents reviewed for revised care plans. 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 #101's face sheet revealed R #101 was admitted to the facility on [DATE] with the following diagnoses: - Neoplasm (a new and abnormal growth of tissue in some part of the body, especially as a characteristic of cancer) of uncertain behavior of the brain, infratentorial (the area of the brain located below the tentorium cerebelli); obstructive hydrocephalus (fluid buildup in the brain); - Adult failure to thrive; - Constipation, unspecified; - Unspecified astigmatism, bilateral (the front surface of the eye or the lens, inside the eye, is curved differently in one direction than the other in both eyes). - A diagnosis which indicated progressive…

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 medical records were complete and accurate for 3 (R #101, R #102, and #103) of 3 (R #101, R #102 and R #103) residents reviewed for accuracy of documentation. This deficient practice has the potential to negatively impact the care staff provide to meet resident needs due to missing or inaccurate records. The findings are: Findings for R #101: A. Record review of R #101's face sheet revealed the following: R #101 was admitted to the facility on [DATE] on hospice care (a type of health care that focuses on the relief of a terminally ill patient's distress and symptoms and attending to their emotional and spiritual needs during the final stages of life) with the diagnoses of neoplasm (a new and abnormal growth of tissue in some part of the body, especially as a characteristic of cancer) of uncertain behavior of the brain, infratentorial (the area of the brain located below the tentorium cerebelli); obstructive hydrocephalus (fluid buildup in 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 provide Foley catheter (a flexible tube inserted into the bladder and anchored by a balloon to allow the free flow of urine into an attached bag) care for 2 (R #1 and 2) of 3 (R #s 1, 2 and 3) residents found to have an indwelling (fixed in a person's body for a long time) Foley catheter. This deficient practice is likely to result in a resident's catheter becoming unclean and unsanitary leading to urinary tract infections (an infection in any part of the urinary system) and other diseases. The findings are: Resident #1 A. Record review of face sheet, dated 11/10/23, for R #1 revealed an initial admission date of 03/15/23 and included the following diagnoses: - Paraplegia (the impairment in motor or sensory function of the lower extremities), - Peritoneal abscess (a collection of pus or infected material in the abdomen), - History of urinary tract infections (UTI - an infection of any part of the urinary tract), - Neuromuscular dysfunction of bladder…

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

Based on record review, observation, and interviews, the facility failed to deliver consistently, and timely (to be prompt, be on time, and follow the times provided to the facility) lunch meals to 89 residents that receive trays in the dining rooms, and room trays, as identified on the facility matrix provided by Center Executive Director on 05/01/23. This deficient practice could potentially lead to resident frustration and hunger. The findings are: A. Record review of the facility posted times revealed that the following times for the meal pass. 1. Breakfast will be served at 7:30 am. 2. Lunch will be served at 12:30 pm. 3. Supper will be served at 5:30 pm. B. On 05/04/23 during an observation of the lunch meal pass, the following was noted. 1. Meal trays passed in the South dining room at 12:50 pm for a 12:30 pm mealtime. (20 min delay) 2. Meal trays passed on the North side dining room at 12:56 pm for a 12:30 pm mealtime. (26 min delay) 3. Meal trays arrived in the hallway at 1:15 pm for at 12:30 pm mealtime. (45 min delay) 4. Meal tray pass completed for hallway A, B, C and D…

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

Based on observation, interview and record review, the facility failed to 1. Follow policy procedure for sanitizing (method of reducing or eliminating pathogenic agents, such as bacteria, on the surfaces of something) food preparation areas and; 2. Serve a room tray at safe food temperatures (hot foods should be held and served at 135 degrees Fahrenheit) These deficient practices could likely result in residents receiving food that may be contaminated due to unsanitized prep surfaces and poor handling/serving of food trays served in resident rooms. The findings are: Findings related to sanitizing technique: A. Record review of the facility policy Cleaning and Sanitizing, not dated, revealed the following; Sanitizer solution should be tested for correct PPM (parts per million- the ratio of chemical to water) frequently . You must change your sanitizing solution every two hours or when it becomes soiled [dark, cloudy, or with debri] . B. On 05/01/23 at 11:05 am, during an observation of the kitchen prep area, sanitizer solution was observed in a bucket sitting on a nearby cart. 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 update a residents care plan to reflect new diagnosis and treatment plans for 2 (R #15 & R #92) of 2 (R #15 & R #92) residents reviewed for comprehensive care plans. This deficient practice could likely result in resident care not being closely monitored and managed to meet the needs of the resident. The findings are: A. Record review of the facility policy Person Centered Care Plan, last revised 10/24/22, revealed the following: 4. A comprehensive person-centered care plan must be developed for each patient and must describe the following: 4.1 Services that are to be furnished; . 6.1 The care plan must be customized to each individual patient's preferences and needs. Findings for R #15: B. Record review of R #15's EHR (Electronic Health Record) revealed that he was admitted to the facility on [DATE] for the following diagnosis: epilepsy (a disorder in which nerve cell activity in the brain is disturbed and causes seizures- temporary abnormalities 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.

Based on record review and interview the facility failed to ensure residents maintained personal grooming for 2 (R #13 and 23) of 3 (R #13, 23 and 34) residents reviewed for Activities of Daily Living (ADLs)/nail grooming. These deficient practices could likely affect the health of the residents, causing pain in their feet and issues with their shoes not being comfortable. The findings are: R #13 A. On 05/01/23 at 11:30 am, during an interview with R #13, he stated that he is not diabetic but needs his toenails cut. They don't cut them here and they are too long and it hurts when I have my shoes on. B. Record review of the physician orders indicated that an order on 10/21/22: Refer to Podiatry: Right Great toe nail dislocated. C. Record review of R #13's medical chart did not reveal that an appointment was made for podiatry. D. Record review of the physician orders indicated that an order on 01/03/23: Referral to Podiatry: to get toenails clipped. E. Record review of R #13's medical chart did not reveal that an appointment was made for podiatry. R #23 F. On 05/05/23 at 1:40 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 record review and interview, the facility failed to notify the physician that nursing staff did not obtain and administer medications for 2 (R #48 and #92) of 3 (R #15, #48, #92) residents reviewed for medication regimen. This deficient practice could likely result in residents not receiving medication as ordered for treatment of infection and disease. The findings are: A. Record review of job aid titled 5 Step Medication Order Quick Reference Guide, not dated, 1. Determine Time Next Dose Due . 2. Determine Estimated Delivery Time (EDT)- . If EDT is > [later that] time dose is due, go to next step. 3. Pull From On-site Inventory (eKit/Omnicell)- Determine if the med [medicine] is available on-site in the eKit or Omnicell. If not, go to next step 4. Urgent Action Needed -Call the prescriber to get the med changed to something in the Omnicell/eKit or call the pharmacy to request the med be delivered STAT [immediately]. Be sure to inform the pharmacy when the next dose is due . 5. Enter RMS Pharmacy Alert…

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

Based on observation, interview, and record review the facility failed to ensure that glucometer's (a medical device to measure glucose {sugar} levels in the blood) utilized by the facility for more than one resident, was disinfected per manufacturer's instructions after each time one is used, for 2 (R #5 and R #10) of 17 (R #4,R #5, R #10, R #20, R #26, R #35, R #36, R #37, R #39, R #56, R #67, R #68, R #92, R #197, R #200, R #204, and R #205) residents that receive capillary (small blood vessels) blood glucose (CBG capillary blood glucose) monitoring with glucometers. Nursing staff should be doing hand hygiene before and after each resident. This deficient practice may likely result in the spread of infection agents (viruses and bacteria) between residents and or staff who utilize glucometers. The findings are: A. On 05/02/23 at 8:40 am, during an observation of Registered Nurse (RN) #1 checking R #5 CBG. RN #1 pulled glucometer from caddy without disinfect the glucometer before use. RN #1 did not perform hand hygiene prior to donning gloves (putting gloves on), and after the CBG…

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

Based on observation, record review, and interview the facility failed to ensure that 1 [R #195] of 2 [R #74 and 195] residents reviewed for falls were free from accident hazards by not providing sufficient supervision for one resident. This deficient practice could likely result in injuries or hospitalizations. The findings are: Resident #195 A. On 05/02/23 at 2:04 pm during a random interview, an unknown CNA (Certified Nursing Aide) stated that R #195 has fallen a couple of times since being in the facility and she is now on 1:1 (requires one on one supervision). B. On 05/03/23 at 8:31 am during a random observation revealed R #195 was seated in her wheelchair. She was observed to have a C shaped bruise on the outer corner of her right eye. She was appropriately dressed and appeared clean and comfortable. C. Record review of Face Sheet dated 04/23/23 for R #195 revealed this as an initial admission date and included the following diagnoses: Traumatic Subdural Hemorrhage (a type of bleed inside your head), Hypothyroidism (low thyroid hormone), Dementia (a group of symptoms…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to conduct a urinary and bowel incontinence assessment for 1 (R #15) of 1 (R #15) residents reviewed for falls. This deficient practice could likely result in denying the resident of assessment and services that might restore normal bladder function and allow the resident to return to the highest practicable well being. The findings are: A. Record review of the facility's policy Continence Management, last revised 06/15/22, revealed the following: Patients will be assessed for the need for continence management as part of the nursing assessment process. A urinary incontinence assessment and/or bowel incontinence assessment will be completed upon admission or re-admission and with a change in condition or change continence status (the ability to control movements of the bowels and bladder). Continence status will be reviewed quarterly (every 3 months) as part of the care plan process . 1. Identify patient's continence status and need for continence…

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

Based on observation, interview, and record review, the facility failed to properly document the administration of a narcotic medication (a drug that produces analgesia, narcosis, and addiction. It is also known to produce euphoria in some people) for 1 resident (R #81) of 1(R #81) residents record of compliance of record keeping in the controlled substance log (A book that allows on coming nurses to count narcotics medications in the nursing cart). If the facility is not ensuring that controlled drugs are not appropriately documented at the time of administration, it could cause a narcotic medication discrepancy. The findings are: A. On 05/02/23 at 9:46 am, during an observation of med pass it was noted that the Controlled Substance book was missing a signature for 04/23/23 for R# 81. B. Record Review for R #81 physicians order revealed an order for LORazapam (abenzodiazepine used to treat anxiety disorders) 0.5 MG (milligrams) 1 time a day for Anxiety (Feeling nervous or tense. impending doom). C. On 05/02/23 at 09:26 am, during an interview with Certified Medication Assistant…

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 the the pharmacist recommendations, which were documented as responded to by the Center Nursing Executive (CNE) were followed through for 1 (R #74) of 3 (R #s 74, 94 and 197) residents sampled for drug (medication) regimen review (thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences [undesirable effects of medication]) by not completing a lab screening for INR levels (blood test that that determines how well a person is responding to Warfarin - a blood thinning medication). This deficient practice could likely result in residents receiving medications that may have adverse consequences, receiving medications longer than needed or at a higher or incorrect dose. The findings are: A. Record review of Face Sheet dated 08/13/22 for R #74 revealed this as an initial admission date and included the following diagnoses: Long Term Use of Anticoagulants (blood thinning medications) and Atherosclerotic Heart Disease (a condition where…

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 interviews, the facility failed to: 1) Ensure that opened and accessed (if [NAME]-dose vial has been opened or accessed {e.g needle puntered} the vial should be dated with the last date that the product should be used {expiration date} and discarded with in 28 days unless the manufacturer specifies a different use by date) multi-use vials (a vial of liquid medication that contains more than one dose of the medication) were dated as to when they were initially opened/assessed, by nursing staff. 2) Ensure that expired medications were not stored with unexpired medications, that were readily available for resident use; and 3) Ensure that treatment carts are kept locked when not in use. These deficient practices have the likelihood to result in the 19 residents that were identified on daibetis list provided by the ADON on 05/05/02, to receive expired medications that have either lost their potency, or effectiveness; medications that were undated continued to be accessed and stored with…

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