Los Alamos Wellness & Rehabilitation

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 2 (R #3 and R #7) of 2 (R #3 and R #7) residents reviewed for accuracy of documentation, when staff failed to: 1. Ensure R #3's medications were ordered for the correct diagnoses or symptom. 2. Clarify what type of respiratory illness R #3 was being treated for. 3. Ensure that R #7's care plan documented accurate diagnosis.These deficient practices have the potential to negatively impact the care staff provide to meet residents' needs due to inaccurate records. The findings are: R #3 A. Record review of R #3's admission Record, no date, revealed the following: 1. R #3 was admitted to the facility on [DATE]. 2. R #3's diagnoses did not include a respiratory illness. B. On 03/24/26 at 2:06 PM, during an interview, R #3's Family Member (FM) stated that R #3 was diagnosed with pneumonia (a serious lung infection caused by bacteria, viruses, or fungi) and was started on antibiotics (powerful medications…

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 notify the provider timely of any skin condition changes for 1 (R #1) of 1 (R #1) resident reviewed when the facility's treatment nurse (TN) did not notify the provider of the worsening wound and lack of healing progress. This deficient practice is likely to result in a delay in treatment or inadequate treatment. The findings are: A. Record review of R #1's face sheet revealed R #1 was admitted into the facility on [DATE] and discharged to the emergency room [DATE]. B. Record review of R #1's medical diagnoses on face sheet dated 10/14/25 revealed the following (including but not limited to): -Muscle wasting and atrophy (waste away), not elsewhere classified, multiple sites. -Morbid (SEVERE) obesity (substantial accumulation of body fat) due to excess calories. -Developmental disorder of scholastic skills (a persons ability to learn core academic skills).-Disorder of adrenal (endocrine gland located on top of each kidney) gland.-Hypopituitary…

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 the wound was monitored weekly and order to refer to wound clinic was followed for 1(R #1) of 4(R #1-4) residents reviewed for wounds. This deficient practice likely resulted in the worsening of the wound. The findings are:Cross reference to findings in F580 A. Record review of R #1's wound report dated 06/07/25 through 09/01/25 revealed the following: - 06/07/25 - 06/14/25 = Date Identified 06/10/25 left lower leg front, Length (L) = N/A, Width (W) = N/A, Depth (D) = N/A). - 06/15/25 - 06/22/25 = (No weekly skin assessment documentation found) - 07/01/25 - 07/02/25 = (No weekly skin assessment documentation found) - 07/19/25 - 07/20/25 = (No weekly skin assessment documentation found) - 07/21/25 - 08/02/25 = Last assessed: 08/02/25 = Skin Tear left lower leg front, L=4.00 cm, W=4.50 cm, D=0.10 cm - 08/03/25 - 08/11/25 = (No weekly skin assessment documentation found) - 08/12/25 - 08/25/25 = Last assessed: 08/14/25 = Skin Tear left lower leg front, L=3.70 cm, W=5.00 cm, D=0.10 cm B. Record review of R #1's physician…

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

Based on observation and interview, the facility failed to: ensure medications were stored properly, medication carts were locked and secured when not in use. This deficient practice is likely to result in resident injury, through dosing with medications that have been improperly stored, having access to medications not prescribed for them, and possible overdose. A. On 11/18/25 at 2:00 pm, during random observation of the memory care unit and interview the medication cart was unlocked. Medication cart was in the back of the unit and standing next to the medication cart was R #5 and walking back and forth was R #6. Medication cart was unlocked from 2:00 pm to 2:33. Housekeeping Director was asked medication cart should be left unlocked and he stated No and proceeded to go look for Director of Nursing (DON) #2, and left cart unlocked. Certified Nurse Aide (CNA) #1 was asked if medication cart should be unlocked, she stated it should not be she also walked away to look for the Nurse. CNA #1 came back a few minutes later and locked the medication cart. B. On 11/18/25 at 2:32 pm, during…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview, the facility failed to ensure medical records were accurate for 2(R #2 and 4) of 4(R #104) residents reviewed. If the facility is not ensuring accurate medical records, then residents are likely at risk of not receiving the care needed to achieve optimal wellness. The findings are:R #2:A. Record review of R #2's admission assessment revealed R #2 was admitted into the facility on [DATE] from the local hospital with stage 2 (some of the outer surface of the skin is damaged) pressure ulcer to his coccyx (tailbone) measuring 2.3x4.2 centimeters. B. Record review of R #2's weekly wound report (tracking system the facility utilizes to tract and trend all residents skin concerns) dated 09/03/25 through 10/15/25 revealed the following: - 09/03/25 - 09/10/25 = Date last assessed 09/05/25 Coccyx, Deep Tissue Pressure Injury, Length (L) = 6.00, Width (W) = 6.60, Depth (D) = 0.00, Deep Maroon=75%, Bright Beefy Red=25%. - 09/11/25 - 09/17/25 = No weekly skin assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to store and serve food under sanitary conditions when staff failed to ensure: 1. All items were labeled and dated in the locked unit and room [ROOM NUMBER] refrigerators. 2. Daily temperatures of the locked unit and room [ROOM NUMBER] refrigerators were documented. These deficient practices are likely to affect all 20 residents in the locked unit, 2 residents in room [ROOM NUMBER] and is likely to cause foodborne illnesses in residents. The findings are: A. On 06/16/25 at 9:33 AM, during the initial walk through of the facility's locked unit, a refrigerator in the dining area and room [ROOM NUMBER]. The refrigerator contained the following food items and snacks for the residents. 1. Two containers of punch/juice, two containers of nutritional supplements, one container of salsa, all items were unlabeled and undated. 2. One uncovered container of punch/juice, dated 06/11/25, was expired and improperly stored. 3. Packaged frozen food items in the freezer…

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

Based on observation and interview, the facility failed to store and serve food under sanitary conditions when staff failed to ensure: 1. All items were labeled and dated in the locked unit refrigerator. 2. Daily temperatures of the locked unit refrigerator were documented. These deficient practices are likely to affect all 20 residents in the locked unit and could lead to foodborne illnesses in residents. The findings are: A. On 03/18/25 at 10:33 AM, during the initial walk through of the facility's locked unit, a refrigerator was in the dining area. The refrigerator contained food items and snacks for the residents. The refrigerator contained the following: 1. Two containers of punch/juice, one package of cheese, one head of lettuce, one package of turkey sandwich meat, one container of salsa, a partial loaf of bread, all items were unlabeled and undated. 2. One uncovered container of punch/juice dated 03/11/25. 3. Packaged frozen food items in the freezer that were unlabeled and undated. 4. Refrigerator temperature log was not available for review. B. On 03/18/25 at 10:44 AM,…

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

Based on observation and interview the facility failed to safeguard clinical record information by leaving Private Health Information (PHI) where unauthorized persons had access to the PHI for 1 (R #4) of 1 (R #4) resident reviewed during random observation. If resident's clinical information is not safe guarded, resident's PHI is likely to be viewed by unauthorized residents, visitors and staff. The findings are: A. On 03/19/25 at 5:40 PM during a random observation, the Admissions Coordinator (AC) left a clipboard with R #4's PHI face up and unattended in the facility lobby, visible to unauthorized residents, visitors and staff. B. On 03/19/25 at 5:42 PM, during an interview, the Human Resources Director (HR) confirmed the clipboard with R #4's PHI was left faced up and unattended in the facility lobby and PHI should not have been visible.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to keep residents free from abuse for 1 (R #1) of 3 (R #1, R #2, and R #3) residents reviewed for abuse when the facility failed to protect a resident. This deficient practice is likely to result in residents continuing to be at risk for abuse. The findings are: A. Record review of a complaint report for R #1 revealed on 12/30/24 an alleged incident of abuse had occurred as follows: a Certified Nurse Aide and another staff had witnessed a Registered Nurse (RN) #1 yell and push R #1. The incident had been reported to the Administrator. The unidentified reporter had not witnessed an investigation, and the nurse remained in the unit and the residents in the unit were at risk for further abuse by the accused nurse (RN) #1. B. Record review of R #1's face sheet, dated 03/18/25, revealed R #1 was admitted to the facility on [DATE] with the following diagnoses: - Personal history of Traumatic Brain Injury. - Unspecified dementia, unspecified severity, without…

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 an incident report to the State Survey Agency, for 1 (R #1) of 3 (R #1, #2, and #3) residents reviewed for abuse. If the facility fails to report incidents of possible abuse to the State Agency, then the State Agency is unable to ensure residents have a safe environment. The findings are: A. Record review of a complaint report for R #1 revealed on 12/30/24 an alleged incident of abuse had occurred as follows, a Certified Nurse Aide and and another staff had witnessed Registered Nurse (RN) #1 yell and push R #1. The incident had been reported to the Administrator and the unidentified reporter had not witnessed an investigation, and the nurse remained in the unit and the residents in the unit were at risk for further abuse by the accused nurse (RN). B. Record review of the facility's incident log dated 03/08/25 revealed the log did not contain any documentation of the incident for an allegation of of abuse toward R #1. C. On 03/19/25 at 2:42 PM during interview with the Administrator (ADM), she confirmed she is 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.

Refer to F-600 Based on record review and interview, the facility failed to thoroughly investigate an allegation of abuse. If the facility is not conducting thorough abuse investigations then residents are likely to continue to be at risk of abuse. The findings are: A. Record review of a complaint report for R #1 revealed on 12/30/24 an alleged incident of abuse had occurred as follows, a Certified Nurse Aide and another staff had witnessed a Registered Nurse (RN) #1 yell and push R #1. The incident had been reported to the Administrator. The unidentified reporter had not witnessed an investigation, and the nurse remained in the unit and the residents in the unit were at risk for further abuse by the accused nurse (RN) #1. B. On 03/19/25 at 2:42 PM during interview with the Administrator (ADM), she confirmed she is the Abuse Coordinator. ADM further stated the procedure of an abuse allegation is if a resident makes an accusation of abuse/neglect, if it is a specific allegation of abuse towards a staff member, we place that staff member on leave and start the investigation. 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 ensure the facility was free of accident hazards for 1 (R #2) of 2 (R #1 and #2) residents reviewed for accidents and hazards when staff failed to supervise a resident that was considered a fall risk and required the use of an ambulatory assistance device (walker, wheelchair) in the locked unit. This deficient practice is likely to result in residents experiencing avoidable falls. The findings are: A. Record review of R #2's face sheet revealed R #2 was admitted to the facility on [DATE] with the following diagnosis: - Fracture of Unspecified Part of Neck of Right Femur (Femur fracture). - Closed Right Femur Fracture with Routine (normal) Healing. - Cognitive Communication Deficit (problems with communication caused by impaired cognitive processes, such as attention, memory, language, and reasoning). B. Record review of R #2's Fall Risk Evaluation dated 03/12/25 revealed the following: - Chair bound and required assist with toileting. - Resident is not…

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

Based on observation and interview the facility failed to ensure medication carts were locked when unattended. This deficient practice is likely to negatively impact the health of residents if they were to ingest medications not intended for them. The findings are: A. On 03/18/25 at 10:25 AM during the initial walk through of the locked unit, the medication cart was unlocked and staff left the cart unattended. B. On 03/18/25 at 10:25 AM during interview with Registered Nurse (RN) #2, she confirmed the medication cart should not be left unlocked and unattended.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to maintain a comfortable water temperature in the resident shower rooms for all 63 residents listed on the census provided by the Administrator (ADM) on 12/02/24. If the water temperature is too cold, then this deficient practice is likely to negatively impact resident safety and comfort. The findings are: A. Record review of the facility resident council minutes, dated 10/15/24, revealed R #30 reported the showers were too cold. The resident council minutes stated the Maintenance Director (MD) would be contacted about the water temperature. B. On 12/04/24 at 1:06 pm during an observation of the water temperatures in the Shower room [ROOM NUMBER] and an interview, the MD turned on the water and allowed it to run for several minutes. The MD used a calibrated thermometer to checked the water temperature, and it measured 94.1 degrees (°) Fahrenheit (F). The MD stated the water was cold. C. On 12/04/24 at 1:17 pm during an observation of 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 provide residents a nourishing bedtime snack in order to ensure there was not more than 14 hours between a substantial evening meal and breakfast the following day for 8 (R #11, R #14, R #16, R #35, R#36, R #40, R#48 and R #50) of 8 (R #11, R #14, R #16, R #35, R#36, R #40, R#48 and R #50) residents reviewed for snacks. This deficient practice could likely cause frustration and lead to unnecessary hunger. The findings are: A. Record review of the facility's meal times, no date, revealed staff served dinner at 5:00 PM and breakfast at 8:00 AM (15 hours between meal services.) B. On 12/03/ 24 at 2:11 PM, during an interview with the Resident Council, residents stated they were not provided with a snack at bedtime and dinner was served at 5:00 PM. Residents stated they would like to have snacks at bedtime, because some residents got hungry. The residents stated the facility used to provide snacks at night, but snacks are not available any more. The resident stated they would like bedtime snacks again. C. On 12/ 04/24 at 2:04…

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

Based on observation and interview, the facility failed to store and serve food under sanitary conditions when staff failed to ensure: 1. Food items were sealed, labeled, and dated. 2. The kitchen and food related equipment were clean and free of grease and grime. 3. The trash can was covered when not in use. 4. Maintained food at temperatures out of the danger zone [between the temperatures of 45 degrees (°) Fahrenheit (F) and 135° F; the temperature range in which food-borne bacteria can grow.] This deficient practice is likely to affect all 63 residents listed on the resident census list provided by the Administrator on 12/02/24 and is likely 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 12/02/24 at 11:07 am, observation of the kitchen revealed the following: - A trash can was uncovered and not in use. - The stove was not clean with dried food stuck on the burners and side of the stove. - The steam table water wells were visibly soiled with food particles and calcium built…

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 there was a functioning call light system that allowed residents to call for assistance. This deficient practice likely affected all 63 residents identified on the resident census list provided on 12/02/24. 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 Resident Council meeting minutes revealed the following: 1. On 10/15/24: The residents had concerns with the call lights taking too long to answer. Resident Council minutes indicated the call light response times issue was not resolved. 2. On 11/16/24: Call lights were still taking too long to be answered. Resident Council minutes indicated the call light response times issue was not resolved and stated, Call lights are still taking too long to be answered. B. On 12/03/24 at 12:19 pm during an call light observation, Room (RM) #211's call light was activated, but it did not sound at the nurses station or unit to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to notify the resident's Power of Attorney (POA; authority to act for another person in specified or all legal or financial matters), the facility providers (Nurse Practitioner, Physician, Registered Dietitian), and the Director of Nursing (DON) when an resident experienced nausea and abdominal pain for 1 (R #12) of 1 (R #12) residents reviewed change of condition. If the facility does not notify the POA, facility providers, or DON when the resident experiences abdominal pain with nausea for multiple days, then the POA, facility providers, and DON are unable to make decisions related to treatment and advocate for the resident's care. The findings are: A. Record review of R #12's face sheet revealed R #12 was admitted into the facility on [DATE]. B. Record review of R #12's nursing progress notes revealed staff documented the following: 1. On 10/22/24 at 9:16 am: R #12 notified nursing staff she was nauseous throughout the night. Staff administered 12…

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 ensure staff revised the care plan for 3 (R #11, #12, and #27) of 3 (R #11, #12, and #27) residents reviewed when staff failed to: 1. Conduct a quarterly care plan meeting as required for R #11. 2. Update R #12's plan of care when the resident returned from the ER with a diagnoses of gall stones (an abnormal stone-like mass in the gallbladder, which causes sudden severe pain in upper right side of the abdomen). 3. Update the care plan to include positioning a resident's bed to prevent sleeping all day for R #27. These deficient practices are likely to result in residents' care and needs not being addressed if care plans are not updated. The findings are: R #11: A. Record review of R #11's face sheet revealed R #11 was admitted into the facility on [DATE]. B. Record review of R #11's nursing progress notes revealed R #11's last care plan meeting occurred on 07/09/24. C. Record review of R #11's care plan conference (meeting) assessment,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to monitor and provide appropriate interventions for 1 (R #12) of 1 (R #12) residents reviewed for illness when staff failed to send R #12 to the emergency room (ER) after several days of experiencing nausea, vomiting, and abdominal pain without relief. These deficient practices likely resulted in R #12's nausea, vomiting, and abdominal pain becoming worse. The findings are: A. Record review of R #12's face sheet revealed R #12 was admitted into the facility on [DATE]. B. Record review of R #12's nursing progress notes revealed staff documented the following: 1. On 10/22/24 at 9:16 am: R #12 notified nursing staff she was nauseous throughout the night. Staff administered 12 milliliters (ml) of Pepto-Bismol to R #12. 2. On 10/22/24 at 12:15 pm: R #12 refused pain medication, because she was still nauseous. 3. On 10/22/24 at 12:44 pm: R #12 reported the Pepto-Bismol helped some, but she was still nauseous. Staff gave Zofran (anti-nausea medication) to R…

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

Based on record review and interview, the facility failed to ensure physicians reviewed and responded to recommendations submitted by the pharmacist's written monthly review for 5 (R #3, 16, 33, 34, 38) of 5 (R #3, 16, 33, 34, 38) residents. This deficient practice is likely to cause resident medication regimen to not be properly evaluated resulting in possible over medication. The findings are: R #03 A. Record review of pharmacist recommendations for R #3 revealed the following: - On 05/24/24, consider fall risks related to medications prescribed: Resident had recent fall. Gabapentin (medication administered to reduce pain) and quetiapine (medication administered to treat several psychiatric disorders) increase risk of falls. Consider medication changes. The recommendation was not signed, and there was not any evidence it was reviewed and considered by the physician. - On 08/26/24, consider fall risks related to medications prescribed: resident had recent fall. Gabapentin , melatonin (medication administered to induce sleep), venlafaxine (medication to manage depression) 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, interview, and record review, the facility failed to dispose of a controlled substance (a medication that is at high risk for abuse) that was discontinued for 1 (R #38) of 1 (R #38) resident reviewed for medication storage. Failure to properly dispose of a discontinued controlled substance can result is mishandling or theft of medications. The findings are: A. Record review of R #38's provider orders revealed the following prescriptions for Ativan: - Dated 10/02/23, lorazepam (generic name for Ativan) oral tablet, 0.5 mg. Give one tablet by mouth every four hours as needed. Discontinued on 01/13/24. - Dated 10/21/24, lorazepam, 0.5 mg oral tablet to be taken every six hours as needed for anxiety. Discontinued on 11/06/24. - The record did not contain a current order for Ativan. B. On 12/03/24 at 4:03 pm during observation of the medication cart located in the Dementia Unit (a unit that serves residents who are experiencing loss of memory and mental decline), three bubble pack cards (a large card containing multiple plastic bubbles, each bubble contains a single…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the resident's current advance directive (a document which provides an individual's wishes for emergency and life saving care) and the resident's Electronic Health Record (EHR) revealed the same resident wishes for 1 (R #11) of 1 (R #11) residents reviewed for advance directives. This deficient practice is likely to cause confusion and delay potentially life saving procedures. The findings are: A. Record review of the face sheet in R #11's EHR revealed R #11 was admitted into the facility on [DATE], and her current advanced directive was listed as do not attempt resuscitation (DNR; lifesaving measures are not desired.) B. Record review of R #11's Medical Orders For Scope of Treatment (MOST; a legal document which outlines the care the resident wants when they become incapacitated and unable to speak for themselves) forms revealed the following: - Dated [DATE], R #11's advanced directive was DNR. - Dated [DATE], R #11's advanced directive was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure residents received necessary behavioral health care to meet their needs for 1 (R #49) of 1 (R #49) residents when staff failed to ensure effective communication between the facility and psychiatric providers and to provide consistent psychiatric services to meet R #49's psychiatric needs. These deficient practices are likely to result in the residents not receiving the behavioral or mental health care and assistance needed to improve mood and reduce depression and anxiety. The findings are: A. Record review of R #49's face sheet revealed R #49 was admitted into the facility on [DATE] with the following diagnoses: - Dementia, severe with agitation. - Depression. - Dementia with behavioral disturbance. B. Record review of R #49's physician order, dated 10/23/24, revealed R #49 was to be referred to a psychiatric provider to evaluate and treat. C. Record review of R #49's Psychiatric Consent for Services form, dated 10/23/24, revealed…

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 updated with necessary documents and accurate for 1 (R #11) of 1 (R #11) residents reviewed, when the facility failed to complete an accurate smoking assessment for R #11. This deficient practice is likely to result in residents not receiving accurate assessments and having an inaccurate medical record, which could result in the residents receiving less than optimal care and treatment. The findings are: A. Record review of R #11's face sheet revealed R #11 was admitted to the facility on [DATE]. B. Record review of R #11's smoking assessment revealed the following: - Dated 07/08/24, the resident was a safe smoker with minimal supervision. - Dated 10/02/24, the resident did not smoke. C. Record review of R #11's care plan, last reviewed on 12/04/24, revealed R #11 was assessed as a safe smoker and could smoke independently. D. On 12/04/24 at 10:41 am during an interview with R #11, she stated she was a smoker and could smoked…

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 residents received treatment and care in accordance with professional standards of practice for 1 (R #1) of 3 (R #1, #2 and #3) resident reviewed for medication administration when staff did not obtain and provide prescribed medications. This deficient practice is likely to result in residents experiencing pain, discomfort, and less than optimal care. The findings are: A. Record review of R #1's face sheet revealed he was admitted to the facility on [DATE] with multiple diagnoses including: - Low back pain. - Chronic pain syndrome. - Intervertebral (the space between each bone of the back) disc (the soft liquid filled sac between each bone of the back) degeneration (gradual deterioration). - The resident discharged from the facility on 05/07/24. B. Record review of R #1's provider orders revealed an order, dated 05/01/24, for Pregabalin capsule 50 mg. Give 50 mg by mouth three times a day for pain-no end date noted C. Record review of R #1's…

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

Based on record review and interview, the facility failed to ensure residents were bathed according to their preference for 1 (R #3) of 1 (R #3) resident reviewed for showers. This deficient practice is likely to result in the residents' personal choices not being honored, poor hygiene, and loss of dignity. The findings are: A. On 07/19/24 at 1:54 PM during an interview with R #3's daughter, she stated her mother rarely got showers and her hair was always greasy at the facility. She further stated her mother was able to make choices about her care and voiced that she did not refuse showers when they were offered to her. The daughter also stated her mother was very private and embarrassed about asking for care. B. Record review of shower schedule revealed R #3's shower days were Wednesdays and Saturdays. C. Record review of shower sheets and documentation survey reports (a detailed report that included tasks, interventions, frequency, documentation details, and responses), dated 3/20/24 through 04/17/24, revealed R #3 had one shower on 03/23/24 out of nine opportunities. D. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to ensure staff monitored residents for side effects of medication for 1 (R #3) of 1 (R #3) residents reviewed for unnecessary medications. If the facility is not adequately monitoring for the side effects of the medications prescribed to their residents then residents are likely to be at risk of adverse outcomes. The findings are: A. On 07/19/24 at 1:54 PM during an interview with R #3's daughter, she stated her mother had unresolved diarrhea. B. Record review of R #3's medical record revealed R #3 was admitted on [DATE] for skilled services with the primary diagnosis of metabolic encephalopathy (a disorder that affects the brain and causes altered mental status). Further review revealed the resident had a Brief Interview for Mental Status (BIMS; a tool used to measure a person's ability to think, problem-solve, and process information) score of 7, severe impairment. C. Record Review of R #3's care plan, dated 03/26/24, revealed R #3 was…

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

Based on observation, record review, and interview, the facility failed to meet professional standards of quality for 1 (R #1) of 1 (R #1) residents when staff failed to implement a resident's care plan for fall precautions. If fall prevention measures are not implemented then residents are likely to sustain falls that can result in serious harm or injury and the resident's decline in health and quality of life. The findings are: A. Record review of R #1's face sheet revealed resident was admitted to facility on 04/07/23 with the following diagnoses which made the resident a high fall risk: 1. Senile degeneration of brain, not elsewhere classified. 2. Muscle weakness (a decrease of strength in muscles.) 3. Muscle wasting and atrophy (the wasting or thinning of muscle mass.) 4. Type II diabetes mellitus (a condition results from insufficient production of insulin, causing high blood sugar.) 5. Hypertension (high blood pressure.) 6. Respiratory failure, hypoxia (a condition in which a person's lungs have difficulty exchanging oxygen and carbon dioxide with the blood). B. Record review…

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

Based on observation, record review, and interview, the facility failed to provide activities of daily living (ADL) assistance with bathing and showers for 1 (R #1) of 1 (R #1) resident reviewed for ADL care. This deficient practice is likely to affect the dignity and health of the resident. The findings are: A. On 03/18/24 at 11:50 am during observation, R #1 lay in bed asleep. Her brief was soiled, her hair was disheveled, and her fingernails were long with heavy debris under her nails. B. Record review of the shower schedule revealed R #1's showers were scheduled for Saturday and Wednesday. C. On 03/18/24 at 11:58 am during an interview with LPN #1, she stated R #1's fingernails were dirty with debris under the nails. D. Record review of the [NAME] Hall shower book on 03/18/24 at 12:13 pm revealed the book did not contain documentation to show R #1 had a shower since 03/13/24. E. On 03/18/24 at 12:40 pm during interview LPN #1 stated the last documented shower for R #1 was dated Wednesday 03/13/24.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility staff failed to follow proper infection prevention protocols when they did not ensure staff utilized personal protective equipment (PPE; i.e., gown and gloves) when they entered the room of a resident (R #1) confirmed positive for COVID 19 (infectious disease). Failure to adhere to an infection control program is likely to cause infections and illness to all residents and staff within the facility. The findings are: A. On 03/14/24 at 1:48 pm during an observation, R #1 lay in bed in their room. In the hallway beside R #1's doorway was a container with PPE (indicating that PPE must be put on before entering the room). Further observation at 1:50 pm revealed the Administrator and the Regional Administrative Officer ([NAME]) entered the resident's room without donning (put on) PPE. B. On 03/14/24 at 1:52 pm during an interview with RN #1, she stated any staff who entered R #1's room should put on PPE. She stated R #1 was COVID 19 positive. RN #1…

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

Based on observation, record review, and interview, the facility failed to ensure the nutritional needs and preferences were met for all 57 residents listed on the facility census provided by the Administrator on 10/23/23 by: 1. Not making an alternative meal available to residents. 2. Not providing resident's with an alternate meal menu. If the facility is not providing an alternative meal or offering an alternate meal menu to residents, then residents are likely to experience weight loss, frustration, and depression. The findings are: Alternative Meal Findings: A. Record review of the facility's week at a glance Spring/Summer and Fall/Winter 2023/24 menu revealed the facility provided one meal for each breakfast, lunch, and supper. The facility did not offer an alternative meal/choice with each meal. B. On 10/23/23 at 3:43 pm during an interview with R #23, he stated, It [facility food] was good for awhile, and then it got bad. The new company cut the budget on the kitchen. We [resident's] used to have two menus, and now we only have one. It's a shame, because resident's have to…

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

Based on observation, record review, and interview, the facility failed to store and serve food under sanitary conditions by not ensuring: 1. Food items stored in the kitchen refrigerators/freezers were labeled, dated, stored appropriately, and not expired. 2. The kitchen and freezer floors were free from debris (large pieces of ice in the freezer) and trash. 3. Food was left open above the food prep stations in the kitchen with multiple flying insects near it. 4. Food temperature records were completed for each meal prior to serving. This deficient practice is likely to affect all 57 residents listed on the resident census list provided on 10/23/23 and could likely lead to forborne illnesses in residents if food is not being stored properly and safe food handling practices are not adhered to. The findings are: Kitchen Refrigerator, Freezer, Dry Storage, Floor, and Prep Station Findings: A. On 10/23/23 at 9:19 am during the initial tour of facility kitchen, the following was observed in the kitchen freezers, kitchen refrigerators, kitchen dry storage, kitchen floors, and kitchen…

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 adequately establish, maintain, and implement an infection prevention and control program for all residents by failing to provide proof of monitoring water system for Legionella (bacteria in water) and other opportunistic waterborne pathogens. This deficient practice could likely affect all 57 residents in the facility as identified on the census list provided by the Administrator on 10/23/23. Failure to plan and implement an infection control program could likely cause the spread of infections and illness to residents and staff within the facility. The findings are: A. Record review on 10/26/23 of the facility's Infection Control Program revealed staff could not locate the water management plan which addressed monitoring for Legionella and other waterborne pathogens. B. On 10/26/23 at 4:12 pm during an interview with Maintenance Director (MD), he stated the county tests the water every six months and the sewer. He did not know if they checked for Legionella. He further added he never checked for Legionella…

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 have the most recent survey results in a place that was readily accessible for all 57 residents that reside in the facility (such as a lobby or other area frequented by most residents, visitors, or other individuals where individuals wishing to examine survey results do not have to ask to see them). If residents are unable to locate the latest survey results conducted by State Surveyors then residents, representatives, and visitors are unable to know how the facility is doing and make decisions accordingly. The findings are: A. On 10/25/23 at 12:37 PM, during a resident council meeting, R #8, R #10, R #23, R #61, R #63 and R #64 said they did not know where to find the latest survey results conducted by State Surveyors. B. On 10/25/23 and 10/26/23 during random observation of the front reception area and sign-in table, the survey results binder nor signage (indicating location of survey results binder) were visible. C. On 10/26/23 at 1:06 PM during interview with Social Services Director (SSD), she stated the results 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 record review and interview the facility failed to: 1. Ensure the resident's advance directive (a document which provides an individual's wishes for emergency and life saving care) and the Physicians orders revealed the same resident wishes. 2. Ensure current advance directives were included in the residents medical record. 3. Ensure advance directives were complete. for 5 (R #1, #8, #16, #32 and #62) of 5 (R #1, #8, #16, #32 and #62) residents reviewed for advance directives. These deficient practices are likely to cause residents to receive unwanted or unplanned treatment during a medical emergency. The findings are: Resident #1 A. Record review of R #1's medical record revealed her advance directive status to be full code (all life saving measures during a medical emergency) according to her New Mexico Medical Orders for Scope of Treatment form (MOST; an advanced directive). B. Record review of R #1's physicians orders, dated [DATE], revealed Do Not Resuscitate (DNR; revive from unconsciousness 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide ADL (Activities of Daily Living) assistance for baths/showers and nail care for 2 (R #'s 15 and 19) of 2 (R #'s 15 and 19) residents reviewed for ADL care by not: 1. Offering R #15 at least two showers a week. 2. Providing nail care for R #19. This deficient practice is likely to affect the dignity and health of the residents. The findings are: Findings for R #15: A. Record review of R #15's face sheet revealed R #15 was admitted into the facility on [DATE]. B. Record review of R #15's care plan, dated 09/11/23, revealed, Category: ADLs Functional Status/Rehabilitation Potential- [Name of R #15] CNA [Certified Nursing Assistant] needs are as follows: Approach- BATHING ABILITY: Set up assist, and Walking Ability: Not safe to ambulate/ only with therapy on short distances. C. Record review of R #15's Point of Care History (Electronic Health Record ADL Care Tracking Form), dated 09/01/23 through 09/30/23, revealed staff offered R #15…

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 a therapeutic diet as ordered by a physician for 2 (R #'s 19 and 33) of 2 (R #'s 19 and 33) residents reviewed during random dining observations. If the facility fails to provide a diet as ordered, then residents are likely to experience weight loss due to not receiving their prescribed nutritional caloric intake. The findings are: Findings for R #19: A. Record review of R #19's face sheet revealed R #19 was admitted into the facility on [DATE]. B. Record review R #19's care plan, dated 09/12/23, revealed, Category: Nutritional Status [Name of R #19] current dietary order is: Regular Diet/Puree texture. Nectar thickened liquids. He has supplement(s) Including shakes with his lunch and dinner meals. He is at risk for aspiration, encouraged to slow down while eating. C. Record review of R #19's physician orders, dated 10/03/23, revealed, Regular diet. Puree texture. Moderately thick consistency. D. Record review of R #19's lunch meal…

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 2 (R #'s 8 and 33) of 2 (R#'s 8 and 33) residents by not: 1. Documenting communication with a provider for new symptoms of pain experienced for R #8. 2. Ensuring all orders were transferred over from the previously used charting system to the new charting system for R #33. 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: Findings for R #8: A. Record review of R #8's face sheet revealed R #8 was admitted into the facility on [DATE]. B. Record review of R #8's nursing progress notes, dated 10/11/23, revealed, PT [Physical Therapy] reported resident [R #8] reporting shooting pain that radiates down medial (middle) thigh. Reports pain to lower back. Will notify provider. The record did not contain any other documentation that indicated the provider was made aware of R #8's pain.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, the facility failed to ensure a resident's belongs was safeguarded from loss for 1 (R #9) of 1 (R #9) resident reviewed for personal property when they failed to offer R #9 a safe place for her belongings until after theft occurred. This deficient practice is likely to result in unaccounted property for the resident and family resulting in frustration. The findings are: A. Record review of R #9's face sheet revealed R #9 was admitted into the facility on [DATE]. B. Record review of R #9's nursing progress notes, dated 08/29/23, revealed, SSD [Social Services Director] walked into [Name of R #9's] room, and she was crying and talking on the phone with her [name of credit card] company. She [R #9] was in the process of canceling it and having them send her a replacement card, because someone had stolen two of her cards out of her wallet. She [R #9] stated once she was off the phone that someone is trying to make charges on her cards. We [facility] called the police together and they came 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 report and provide follow-up report within 5 working days from the date of the incident (burn on head) to the State Survey Agency, for 1 (R #22) of 1 (R #22) residents reviewed for incidents. If the facility fails to provide a 5 day follow-up report to the State Agency then the State Agency will be unable to assure residents are safe and have a hazard free environment. A. Record review of R #22's face sheet revealed R #22 was admitted into the facility on [DATE]. B. Record review of R #22's nursing progress notes, dated 10/19/23, revealed, Family has requested that resident's [R #22] hair not be curled anymore as there is a burn on her forehead from curling iron yesterday. C. Record review of facility incident reports, dated 10/19/23-10/26/23, revealed staff did not document an incident report for R #22's 10/19/23 incident. D. On 10/24/23 at 5:32 pm during an interview with R #22's son, he stated, The other day [10/19/23] they [facility staff] curled…

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 ensure staff revised the care plan for 1 (R #22) of 1 (R #22) residents reviewed by not updating the care plan to include various fall prevention interventions. This deficient practices 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 #22's face sheet revealed R #22 was admitted into the facility on [DATE]. B. On 10/25/23 and 10/26/23, observations of the locked unit revealed: 1. 10/25/23 at 9:51 am, R #22 sat in a wheelchair in the TV area of the locked unit with other residents. 2. 10/25/23 at 12:09 pm, R #22 sat in a wheelchair in the locked unit dining room and ate lunch. 3. 10/25/23 at 2:32 pm, R #22 sat in a wheelchair in the locked unit activity room next to the unit nurse. 4. 10/26/23 at 10:11 am, R #22 sat in a wheel chair and slept. C. Record review of R #22's care plan, dated 10/24/23, revealed, Focus: Resident is at risk for falls due to…

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

Based on interviews, observation, and record review, the facility failed to ensure that services provided to residents met professional standards for 1 (R #33) resident out of 1 (R #33) residents reviewed for therapeutic diets. If the facility is not following physician orders residents are likely to not get the intended therapeutic results. The findings are: A. Record review of R #33 face sheet revealed resident was admitted to facility on 07/28/21. B. Record review of R #33's medical record revealed there was not a order for R #33 to receive a health shake C. Observation on 10/22/23 at 1:00 PM revealed, a health shake sat on the the bedside table in R #33's room D. On 10/25/23 at 3:50 PM during an interview with CNA #2, she stated she provided R #33 with a health shake every day she worked with her. E. On 10/25/23 at 4:12 PM during an interview with Assistant Director of Nursing (ADON), she stated if a resident received a health shake it needed to be listed under their physician orders.

Based on observation, record review, and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (R #13) of 1 (R #13) residents reviewed for edema (swelling caused by too much fluid trapped in the body's tissues). This deficient practice is likely to result in residents experiencing pain or a worsened condition. The findings are: A. Record review of progress note, dated 08/12/23, by Medical Doctor (MD) #1, revealed a physical exam, and in the cardiovascular section noted lymphedema (a condition that results in swelling of the leg or arm) of lower legs, non-pitting (no dimples), taught skin with sock indentation. B. Record review of progress note, dated 08/17/23, by Nurse Practitioner #1 revealed under physical exam, in the cardiovascular section, both noted lymphedema of lower legs, non-pitting, taught skin with sock indentation. C. On 10/23/23 at 4:30 PM during observation and interview, R #13 had edema to her right lower leg and foot. R #13 stated she sometimes had swelling to both legs and feet. 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 record review and interview, the facility failed to ensure 1 (R #47) of 1 (R # 47) resident reviewed for weight loss received care and treatment that met the resident's needs by not following Dietician recommendations to weigh the resident weekly. This deficient practice is likely to result in weight loss or continued weight loss. The findings are: A. Record review of Progress Note, dated 10/10/23, revealed note by Registered Dietitian (RD) stated, Monthly weight - Problem: unplanned weight loss related to inadequate oral intake as evidenced by -5.5% weight loss in 1 month. Intervention: add Med Pass [name of medication drink that delivers more nutrition than water, juice or milk, with added protein and calories.] 4 ounces twice a day, weekly weight. B. Record review of weights and vitals revealed staff weighed R #47 on 09/06/23, and the resident weighed 148.4 lbs. (pounds). Staff weighed R #47 on 10/04/23, and the resident weighed 140.3 lbs. Staff did not record any other weights. C. Record review of Physicians Orders, dated 10/15/23, revealed the following: Weekly vital…

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 implement pharmacist recommendation in a timely manner for 1 (R #9) out of 5 residents (R #2, R #23, R #42, R #43). This deficient practice is likely to result in more than minimal harm to R #9 by failing to ensure resident was free of any abnormal signs and symptoms of bleeding. The finding are: A. Record review of R #9 face sheet revealed resident was admitted on [DATE]. B. Record review of R #9 orders, dated 09/04/22, revealed an order for Eliquis (medication used to prevent blood clots) tablet, 5 mg, twice daily. C. Record review of pharmacist recommendations, dated 02/01/23, revealed the pharmacist made following recommendations for R #9: The resident has an order for Eliquis. Please add observation order: Monitor for signs and symptoms of bleeding and thromboembolism [obstruction of blood vessel] during each shift . D. Record review of R #9 orders, dated 06/02/23, revealed the following order: Monitor for signs and symptoms of bleeding, such as…

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: 1. Personal items were not stored in the medication storage room. 2. Items were not stored under the sink in the medication storage room. 3. Medications stored on the East Medication Cart were kept in their original labeled packaging and in a manner that maintains the sterility of the product. These deficient practices is likely to negatively impact the health of all 57 residents that reside in the facility. They are likely to receive compromised or contaminated medications and medical supplies due to inappropriate storage. The findings are: A. On 10/24/23 at 3:45 pm during observation of the medication storage room, staff stored various personal items under the sink such as: one open bag of pretzels, one can of doctor pepper, one bottle of wine unopened which was not labeled with a resident identifier, seven unopened cups of applesauce, one curling iron, one perfume spray, paper cups, and plates. B. On 10/24/23 at 3:50 pm during interview with Certified Medication Aide (CMA) #1, she stated the bottle of wine belongs…

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 ensure facility hallways were clear of any obstructions and hallway handrails were not blocked for all 57 residents who wished to use handrails to self-propel or as a support when ambulating. This deficient practice is likely to cause residents to receive injuries related to tripping and falls. The findings are: A. On 10/23/23 at 10:16 AM during the initial tour and observation of the facility, seven storage bins sat in the hall next to the wall and blocked the handrail, between the entrances to rooms [ROOM NUMBERS]. B. On 10/26/23 at 4:31 PM during a walk through of the facility, the same storage bins sat in the same area and blocked the handrail between rooms [ROOM NUMBERS]. C. On 10/26/23 at 4:38 PM during an interview with the Administrator (ADM), she stated the facility was small, and that was the only place they had to store the bins. ADM confirmed the bins blocked the residents' access to the handrail.

Based on record review and interviews, the facility failed to ensure 1 Certified Nurse Aide (CNA) out of 5 sampled CNA's had completed required annual skills competencies. This deficient practice is likely to result in the nurses aides not receiving the necessary training to meet the care needs of the residents. The findings are: A. Record review of the five sampled CNA personnel files revealed CNA #1 did not have annual skill competencies completed for year 2023. B. On 10/26/23 at 11:19 AM during an interview with Human Resources Director (HRD), she stated CNA #1 started in June of 2023 and should have already completed her annual skill competencies. C. On 10/26/23 at 5:00 PM during an interview with Assistant Director of Nursing (ADON), she acknowledged CNA #1 had not completed her annual skills competencies. She further stated, I'd assume competencies would be completed the same day CNA is hired.