The Neighborhood in Rio Rancho

Based on observation, record reviews, and interviews, the facility failed to ensure a call light was within reach for 1 (R #4) of 1 (R #4) resident. If the facility is not ensuring the call light is within residents' reach, then residents may be unable to request immediate assistance when needed.The findings are: A. Record review of the facility's Call Lights Policy, dated October 2024, revealed staff were instructed to place the call light within easy reach of the resident while in bed or a chair. B. On 08/11/25 at 11:27 am, observation revealed R #4's call light hung out of R #4's reach while the resident lay in bed watching TV. C. On 08/13/25 at 9:39 am, during an interview, Certified Nurse Assistant (CNA) #1 stated call lights should be within residents' reach. She stated R #4 needed the call light to request assistance when needed. D. On 08/13/25 at 11:50 am, during an interview, the Director of Nursing (DON) stated he expected all staff to check R #4's call light when they went into the resident's room. The DON stated if a call light hung off R #4's bed, then staff should pick…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure nursing staff were competent to provide nursing and related services. This deficient practice could affect all 53 residents in the facility (residents were identified by Resident Matrix provided by the Administrator on [DATE]). This deficient practice could likely result in CNA's (Certified Nurse Assistant) and RN's (registered nurses) working with residents without adequate knowledge to do so; likely resulting in injury or inappropriate care being provided to the residents. The findings are: A. Record review of the facility's Agency Use Policy (policy and procedures for using nursing staff who are contracted through a third-party agency) revised on 02/2023, revealed the facility will ask the agency to fax to the facility the completed LN (Licensed Nurse) competency evaluation on each individual. In addition, the verification of licensure and/or certification and background check results for all agency staff must be given/faxed to the facility.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that they did not impose a charge against the personal funds for items or services already being billed for (R #1 and R #3) of 3 (R #1, R #3 and R #4) residents reviewed when staff billed the residents instead of billing the hospice agency for supplies and medications. This deficient practice is likely to cause undue financial strain for the residents. The findings are: A. Record review of R #1's admission Record revealed R #1 was admitted to the facility on [DATE]. B. Record review of R #1's medical orders revealed an order dated 10/08/23 to admit R #1 to hospice effective 10/08/23. C. Record review of R #1's billing statements from the facility revealed the following: 1. A charge dated 06/01/24 for an oxygen concentrator (a medical device that delivers concentrated oxygen to a person via cannula (a medical device/plastic tube that delivers oxygen to a person through their nostrils) for $75.00, 2. A charge dated 07/01/24 for an oxygen…

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 Power of Attorney (POA; legal authorization for a designated person to make decisions about another person's property, finances, and/or medical care) for 1 (R #1) of 3 (R #1, R #2, and R #5) residents when injuries or incidents occurred. If the facility is not notifying the resident's POA when the resident has an injuries or incident occur, then the POA is not able to make decisions related to treatment and advocate for the resident's care. The findings are: A. Record review of R #1's admission Record revealed R #1 was admitted to the facility on [DATE], with the following diagnoses: 1. Chronic heart failure, 2. Anxiety (feelings of fear or apprehension) disorder due to known physiological condition, 3. Insomnia (disorder where a person has persistent difficulty falling asleep, staying asleep, or quality of sleep), unspecified, 4. Adjustment disorder (emotional or behavioral reaction to a stressful event or change in a person's lift) with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure staff revised the care plan for 3 (R #2, R #3 and R #5 ) of 4 (R #1, R #2, R #3, and R #5) residents reviewed when staff failed to update care plans to include hospice care or fall protocol . This deficient practice is likely to result in residents' care and needs not being addressed. The findings are: R #2 A. Record review of R #2's admission record revealed R #2 was originally admitted to the facility on [DATE], and readmitted on [DATE] after a hospital stay with the following diagnoses: 1. Hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body) and Hemiparesis (weakness or paralysis on one side of the body) following cerbral (brain) infarction (condition where blood flow to the brain is interrupted, causing brain tissue damage) affecting left non-dominant side. 2. Atherosclerotic heart disease (condition where the coronary arteries, which supply blood to the heart, become narrowed or blocked due to the buildup of plaque…

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 hospice services met professional standards for 2 (R #3 and R #5) of 3 (R #1, R #3, and R #5) residents reviewed for hospice services by: 1. Not having an order for hospice services for R #5 2. Not having a qualifying diagnosis for R #3. 3. Not having hospice plans of care for R #3 and R #5. 4. Not communicating with hospice regarding a change in condition for R #3. These deficient practices are likely to result in the resident not receiving the services that she needs. The findings are: R #3 A. Record review of R #3's admission record revealed R #3 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with the following diagnosis: 1. Atherosclerotic heart disease (condition where the coronary arteries, which supply blood to the heart, become narrowed or blocked due to the buildup of plaque [fatty deposits]). 2. Chronic atrial fibrillation (heart rhythm disorder where the upper chambers of the heartbeat irregularly 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 ensure the assessment was accurate for 1 (R #2) of 1 (R #2) resident reviewed. This deficient practice could likely result in the residents' preferences and care needs not being met accurately. The findings are: A. Record review of R #2's admission record revealed R #2 was originally admitted to the facility on [DATE] and readmitted on [DATE] after a hospital stay with the following diagnoses: 1. Hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body) and Hemiparesis (weakness or paralysis on one side of the body) following cerbral (brain) infarction (condition where blood flow to the brain is interrupted, causing brain tissue damage) affecting left non-dominant side. 2. Atherosclerotic heart disease (a condition where the coronary arteries, which supply blood to the heart, become narrowed or blocked due to the buildup of plaque [fatty deposits]). 3. Altered mental status, unspecified. 4. Strange and inexplicable behavior. 5.…

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 prevent an accident for 1 (R #1) of 1 (R #1) residents reviewed for falls when the facility failed to ensure proper use of mechanical lift (a device designed to help staff move a resident from one place to another within a room or from one position to another) which resulted in R #1 falling and sustaining injuries that required treatment at the hospital. The findings are: A. Record review of R #1's face sheet revealed R #1 was admitted to the facility on [DATE] with multiple diagnoses including: 1. Acute kidney failure, 2. Inclusion body myositis (a progressive muscle disease that causes muscle inflammation, weakness, and atrophy), 3. Permanent atrial fibrillation (abnormal heartbeat despite previous attempts to restore normal heart rhythm), 4. Muscle weakness, generalized. 5. Other reduced mobility. B. Record review of R #1's quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) dated 10/18/24,…

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 patient care equipment was in safe operating condition for 1 (R #1) of 1 (R #1) residents reviewed. This deficient practice likely resulted in a Hoyer sling (a specialized fabric that connects onto the mechanical lift and supports a person's weight when transferring from one position to another using a mechanical lift) breaking and causing R #1 to fall and sustain injuries. The findings are: A. Record review of R #1's face sheet revealed R #1 was admitted to the facility on [DATE] with multiple diagnoses including: 1. Acute kidney failure, 2. Inclusion body myositis (a progressive muscle disease that causes muscle inflammation, weakness, and atrophy), 3. Permanent atrial fibrillation (abnormal heartbeat despite previous attempts to restore normal heart rhythm), 4. Muscle weakness, generalized. 5. Other reduced mobility. B. Record review of R #1's quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility…

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

Based on observation and interview, the facility failed to store food in accordance with professional standards when staff stored expired food in the facility's walk-in refrigerator. This deficient practice had the potential to negatively impact all 47 residents listed on the census provided by the Director of Nursing on 05/20/24. If the facility fails to adhere to safe food storage practices, residents could likely to be exposed to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins). The findings are: A. On 05/20/24 at 9:52 AM during an observation of the facility's walk-in refrigerator, three packages of tofu had an expiration date of 05/18/24. B. On 05/20/24 at 9:52 AM during an interview, the facility's chef stated staff should throw out the expired tofu and not store it in the walk-in refrigerator. C. On 05/23/24 at 1:02 PM during an interview, the facility's Director of Dining Services stated staff used the food stored in the walk-in refrigerator for the facility's residents, and the kitchen staff should check the refrigerator…

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 quality of care when they did not provide wound care for 1 (R #17) of 1 (R #17) residents review for skin conditions. This deficient practice could likely result in the resident not receiving appropriate and timely wound care resulting in discomfort and infection. The findings are: Findings for R #17 A. Record review of R # 17's face sheet revealed the resident was admitted on [DATE] with diagnoses that included but was not limited to: - Malignant melanoma (skin cancer) of skin of breast, - History of unspecified open wound of right front wall of thorax (area of the body situated between the neck and the stomach) without penetration into thoracic cavity, - Surgical removal of right breast and nipple. B. Review of R #17's Medication Administration Record (MAR), revealed the following: 1. Wound Care for wound on right breast: a. Cleanse with cleaning agent. b. Pat Dry. c. Apply antibiotic ointment. d. RN will apply dry dressing, cover with 4 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 observations and interviews, the facility failed to: 1. Ensure the medication carts did not contain loose medications. 2. Ensure expired supplies were not kept with unexpired supplies in the medication room. 3. Fentanyl patches were destroyed immediately after removal and not stored in the medication cart. These deficient practices are likely to result in all 31 residents of the 200 and 300 halls, as identified on the census list provided by the facility Administrator on [DATE], receiving expired medication, having expired medical supplies used in their treatments, and in the mishandling or misuse of narcotic drugs. The findings are: Findings for loose medications found in medication carts. A. On [DATE] am at 9:10 am, during observation of the 300 hall medication cart, one white, circular tablet was loose under the medication cards (vertical cardboard and foil cards pre-filled with prescription medications for easy storage and dispensing) in the drawer of the cart. B. On [DATE] at 9:26 am, 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 interview and record review, the facility failed to ensure the comprehensive care plan was updated for 1 (R #28) of 1 (R #28) residents reviewed for care plan accuracy. This deficient practice could likely result in staff not understanding and implementing the most appropriate interventions and treatments for the resident. The findings are: A. Record review of R #28's Electronic Medical Record (EMR) revealed R #28 was admitted to hospice services on 01/17/24 and received these services. B. Record review of R #28's care plan, reviewed on 04/24/24, revealed the care plan did not contain information about hospice services. C. On 05/22/24 at 2:34 PM during an interview, the facility's Social Services Director (SSD) stated R #28's care plan did not include hospice services, and staff should have updated the resident's care plan to include hospice services.

Repeat deficiency. Based on record review and interview, the facility failed to meet professional standards of quality when staff failed to notify the Pharmacist and the Director of Nursing (DON) of a morphine spill and a missing fentanyl patch for 2 (R #1 and #13) of 2 (R #1 and #13) residents reviewed for medications. This deficient practice could cause a resident to not receive the pain medication that was prescribed and could also cause confusion when reconciling medications. The findings are: R #1 A. Record review of the physician orders for R #1 indicated an order for a fentanyl patch, 25 micrograms (mcg), every 72 hour; amount: one patch transdermal (absorbed through skin into bloodstream). Special Instructions: Apply transdermal patch onto lower back once every 72 hours. Start date 09/13/23. B. Record review of R #1's nursing progress notes, dated 01/21/24, indicated the writer applied a new fentanyl patch to the resident's right shoulder with protective cover and dated it. The writer and the other Licensed Practical Nurse (LPN) on staff did not find the old patch. C. 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 observation, record review, and interview, the facility failed to meet professional standards of care for 1 (R #30) of 1 (R #30) resident reviewed for respiratory care by not changing the oxygen tubing. This deficient practice could likely lead to respiratory infections by the oxygen tubing becoming clogged due to condensation (a process where water vapor becomes liquid) or becoming dirty, leading to the reduced oxygen flow. The findings are: A. Record review of the face sheet indicated R #30 was admitted to the facility on [DATE]. Resident had a diagnosis of pneumonia on 02/22/24 and on 03/06/24. B. Record review of the physician orders for R #30, dated 06/07/23, revealed an order for oxygen, 1 to 4 liters per minute (LPM) via nasal cannula (thin tube that supplies oxygen through your nose), as needed (PRN) to maintain oxygen saturation (the amount of oxygen in the blood) above 90 percent (%). Further review revealed the orders did not indicate how often staff should change the resident's oxygen…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the power of attorney (POA; a designation given to an agent to handle financial or medical acts on someone else's behalf) and the Nurse Practitioner (NP) of a fall for 1 (R #1) of 3 (R #1, #2, and #3) residents reviewed for falls. This deficient practice could likely cause a breakdown in resident care if the NP is not notified of all falls and the family is left feeling uninformed and frustrated about their loved ones care. The findings are: A. Record review of the face sheet for R #1 revealed he was admitted to the facility on [DATE]. Further review revealed the resident's POA was Family Member #3. B. Record review of the nursing progress note for R #1, dated 11/07/23 at 3:53 pm, revealed the nurse reported R #1 fell in the dining room while playing Bingo. The nurse stated she checked R #1. R #1 did not hit his head and did not complain of any pain. The resident's range of motion (the extent or limit to which a apart of the body can be moved…

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 follow a physician's order for 1 (R #2) of 1 (R #2) residents reviewed for medication administration. This deficient practice could likely cause staff to administer a medication to a resident when the medication is not necessary. The findings are: A. Record review of R #2's quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 03/01/2024, revealed the following: - The resident was admitted to the facility on [DATE]; - The resident was diagnosed with Parkinson's disease (a neurodegenerative disorder that affects the brain and worsens over time as cells in the brain that produce dopamine stop working or die). B. Record review of R #2's Hospice admission Orders, dated 03/23/24, revealed an order for morphine sulfate, 20 milligrams (mg)/millilters (ml), 0.25 ml by mouth every four hours as needed for pain or shortness of breath. C. Record review of R #2's medical record revealed a physician order,…

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 behavioral health treatment for 1 (R #1) of 3 (R #1, R #2, and R #3) residents reviewed for insomnia. This deficient practice could likely cause a resident to have increased agitation, restlessness, and falls. The findings are: A. Record review of the face sheet for R #1 revealed R #1 was admitted to the facility on [DATE] with a diagnosis of dementia (a condition where the patient experiences the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) with agitation and schizophrenia (thoughts or experiences that seem out of touch with reality, disorganized speech or behavior, and decreased participation in daily activities). Further review revealed R #1 discharged the facility on 11/21/23. B. Record review of the nursing progress notes for R #1 revealed the following: 1. On 10/30/23, staff documented staff monitored the resident frequently throughout the night. The resident slept for few hours…

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 behaviors for 1 (R #1) of 3 (R #1, R #2, and R #3) residents reviewed for the use of psychotropic medications. This deficient practice could likely result in residents continuing to exhibiting behaviors of agitation that are not remedied. The findings are: A. Record review of the face sheet for R #1 revealed R #1 was admitted to the facility on [DATE] with a diagnosis of dementia (a condition where the patient experiences the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) with agitation and schizophrenia (thoughts or experiences that seem out of touch with reality, disorganized speech or behavior, and decreased participation in daily activities). Further review revealed R #1 discharged the facility on [DATE]. B. Record review of R #1's nursing progress notes revealed the following: 1. On [DATE], staff documented staff monitored the resident frequently throughout the night. The resident…

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 resident furnature was in operable working condition when they continued to use a broken recliner for 1 (R #1) of 3 (R #1, 2, 3) residents reviewed for falls. This deficient practice could likely result in an injury if the reclining chairs are not in good operable condition. The findings are: A. On 03/29/24 at 11:32 am, during an observation of the recliners near the nurse's station, one recliner was broken. The foot rest was not attached to the mechanism that extended to raise and support the feet. B. On 03/29/24 at 11:35 am and 04/02/24 at 11:30 am, during an interview, the Director of Nursing (DON) stated there were recliners in the memory care unit for the residents to use. She said the foot rest on one of the recliners did not lock when in the elevated position, and the foot rest would fall from the elevated position. The DON stated staff would place a foot stool under the foot rest so it would stay in the elevated position while a resident sat in the chair. The DON confirmed the broken recliner…

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 foods under sanitary conditions by not: 1. Ensuring food items in the refrigerator and freezer were properly labeled and dated. 2. Ensuring food items in the refrigerator are properly covered. 3. Ensuring vent over mixing machine was free of debris and debris was not falling on items below These deficient practices are likely to affect all 55 residents listed on the resident census list provided by the Administrator on 01/30/23, and are likely to 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 01/30/23 at 9:50 am during the initial tour of facility kitchen the following was observed in freezers and kitchen refrigerators: 1. 1 box of Patuxent Farms 10.5 pounds chicken left open to air 2. 1 plastic storage bag of sausages not labeled or dated 3. 1 box [NAME] Spunkmeyer Sugar Frozen Cookie Dough 20 pounds left open to air 4. 2- 6 count hoagie…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that 2 (R #'s 48 and 53) of 2 (R #48 and 53) resident's New Mexico Medical Orders For Scope of Treatment (MOST) reviewed was completed to reflect medical interventions (Advanced Directives-legal documents that allow you to spell out your decisions about end-of-life care ahead of time). This deficient practice is likely to affect residents' fulfillment of their end-of-life medical care choices and could result in unnecessary suffering for the resident. The findings are: Findings for R #48: A. Record review of R #48's face sheet revealed R #48 was admitted into the facility on [DATE]. B. Record review of the New Mexico Medical Orders For Scope of Treatment (MOST) form in R #48's electronic medical chart was signed by Physician on 09/28/22, however, no information was identified in the following sections: Medical interventions and Artificially Administered Hydration/Nutrition. Findings for R #53: C. Record review of R #53's face sheet revealed R…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure that 2 of (R #32 and 37), of 2 (R #32 and 37) resident's reviewed for Minimum Data Set (MDS) assessments were accurate and reflected the resident's status. This deficient practice is likely to result in residents not receiving the appropriate care and treatment they need. The findings are: Findings for R#32 A. Review of record of R #32's MDS revealed a discharge MDS assessment was not completed and sent out timely. R #32 expired on [DATE]. Last MDS (quarterly) completed was on [DATE]. Findings for R# 37 B. Review of record of R #37's MDS revealed a discharge MDS assessment was not completed and sent out timely. R #37 was discharged to Independent Living Facility on [DATE]. Last MDS completed was an admission MDS on [DATE] C. On [DATE] at 9:18 AM during an interview with MDS Coordinator/Case Manager she confirmed there was no discharge MDS assessment completed for R #32 or R #37 sent out and there should have been.

Based on interview, the facility failed to make prompt efforts to resolve resident grievances for 1( R #5) of 1(R #5) resident reviewed. This deficient practice is likely to result in the issue continuing and resident's rights not being honored. The findings are: A. On 01/31/23 at 12:02 PM during an interview with R #5, R #5 stated. Three weeks ago my phone cord and the adapter went missing and I told the nurses. It's bright colors and they said they were looking for it. R #5 was asked if they had returned her phone cord or adapter. She stated she had not heard anything more about it and it was not replaced. B. On 02/03/23 at 11:58 AM during an interview with the SSD (Social Services Director), he stated. They (staff, residents) fill out a grievance usually, sometimes families don't do that. We will go buy it or reimburse the family. I don't why the families don't do the grievance. She chose to have it (the price of the phone charger) taken out of her bill. SSD further stated, there should have been a grievance or nursing note filled out and there wasn't one.

Based on interview, the facility failed to ensure that a resident's belongs will be safeguarded from loss for 1 (R #5) of 1 (R #5) resident reviewed for personal property when they failed to follow up on an missing item that had been reported to staff. This deficient practice is likely to result in unaccounted property with no resolve for the resident and family regarding the loss resulting in frustration and not feeling heard. The findings are: A. On 01/31/23 at 12:02 PM during an interview with R #5, R #5 stated. Three weeks ago my phone cord and the adapter went missing and I told the nurses. It's bright colors and they said they were looking for it. R #5 was asked if they had returned her phone cord or adapter. She stated she had not heard anything more about it and it was not replaced. B. On 02/02/23 at 4:50 PM during an interview with Certified Nurse Aide (CNA) #1, she stated. I heard that she (R #5) lost her phone charger. It was a nice long one. We turned it (the issue of the missing phone cord) into Nurse [name of RN (Registered Nurse) #1], and they give it to [name 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 report and provide follow up report within 5 working days from the date of the incidents to the State Survey Agency, for 1 (R's #160) of 1 (R's #160) residents reviewed for incidents. If the facility fails to report incidents to the State Agency, then the State Agency will be unable to assure residents a safe and hazard free environment. A. On 02/01/23 at 4:05 PM during an interview with R #160's granddaughter she stated, that one of the Certified Nurse Aides provided a shower for her grandmother and wrapped a wound on her leg in toilet paper and paper towels and it had stuck to the wound. She (R #160) had to be taken to [name of local hospital] emergency room to get the toilet paper out and get the wound cleaned. B. Record review of [name of local hospital notes] dated 03/21/22 revealed: Open wound of left lower extremity, .Wounds do not appear acutely infected. Distalmost (furthest from the origin) wound appears to have suffered from some minor trauma and has some minor ecchymosis (discoloration of the skin resulting…

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 enteral tube feeding [a device utilized to provide liquid nutrition and medications, via a tube into the stomach or intestine] nutritional supplement bottle for 1 (R #214) of 1 (R #214) resident reviewed, was labeled and dated to reflect when the feeding was started. The findings are: A. Record review of R #214's care plan dated 01/27/23 revealed: Problem: 1. Clear liquid diet and Tube feeding due to Cancer of tongue with graft. 2. Hospital discharge diagnosis of severe malnutrition. 3. Skin Alteration with increased Nutrient Needs related to Peptic Ulcer (lesion in the lining of the digestive tract) on admit to follow. a. Stable weight b. Tolerance of TF (total fat) and wound healing. c. Tolerance of PO (by mouth) intake with progression as able per Speech Language Pathologist (SLP) Progress to PO intake as SLP determines. Approach: 1. Provide TF per order and suggest increase to 35 milliliters (unit of measurement) per hour of TF 1.5 kilocalories/milliliters and continue same Fluid flush of 150…

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.