The Suites Rio Vista

Based on record review and interview, the facility failed to ensure staff revised the care plan for 1 (R #60) of 1 (R #60) residents reviewed when staff failed update R #60's plan of care to include an accurate advanced directive code status. This deficient practice is likely to result in residents' care and needs not being addressed if care plans are not updated. The findings are: A. Record review of R #60's face sheet revealed an admission date of 12/12/25, with R #60's code status (information that lets the resident's medical team know what they want and do not want in the event of a medical emergency such as their heart stopping) being Do Not Resuscitate (DNR; lifesaving measures are not desired) status (lifesaving measures are not desired). B. Record review of R #60's New Mexico Medical Orders for Scope of Treatment (NM MOST; a legal document which outlines the care the resident wants when they become incapacitated and unable to speak for themselves) form dated 01/28/26, revealed R #60 was a DNR. C. Record review of R #60's Care Plan dated 01/26/26, revealed a code status of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure residents received the necessary treatment and services to promote healing of a surgical wound (a cut or incision in the skin that is usually made by a scalpel during surgery) for 1 (R #66) of 1 (R #66) resident reviewed when the facility failed to: Ensure hospital discharge orders for a wound VAC (vacuum-assisted closure; a medical device that uses negative pressure to promote wound healing) were implemented as prescribed. Prevent unauthorized modification of a wound VAC order without provider approval. These deficient practices resulted in R #66's wound care therapy not being delivered as intended, leading to ineffective wound care management. The findings are: Past Non-Compliance Compliance Date: 01/29/26 A. Record review of R #66's face sheet revealed R #66 was admitted into the facility on [DATE] with the diagnosis of an infection following a procedure, deep incisional surgical site. B. Record review of R #66's Care Plan dated 01/23/26…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide respiratory care in accordance with professional standards for 2 (R #15 and R #69) of 2 (R #15 and R #69) residents reviewed for respiratory care when the facility failed to: Administer oxygen (O2) therapy per physician orders for R #15.Provide the necessary respiratory equipment to ensure O2 was readily available for R #69.These deficient practices are likely to result in residents receiving too much or not enough oxygen and can lead to worsening of their conditions.The findings are: R #15: A. Record review of R #15's physician's orders dated 02/02/26 revealed a room air trial (test conducted by removing O2 from resident to determine O2 saturations in room air) to establish if R #15 was still in need of O2 use. There were not active or discontinued orders related to O2 use for R #15. B. On 02/02/26 at 9:19 AM during an observation of R #15 while outside of his room, R #15 was not observed wearing O2. C. On 02/02/26 at 9:20 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to ensure a resident had access to dental services and was seen for routine and emergency dental care for 1 (R #69) of 1 (R #69) residents reviewed for routine dental services.This deficient practice could likely result in residents experiencing tooth decay, tooth pain, and difficulty chewing. The findings are: A. Record review of the facility's Dental Services Policy dated 2018 revealed the following: Routine and emergency dental services are available to meet the resident's oral health services in accordance with resident's assessment and plan of care, Routine and 24-hour emergency dental services are provided to our residents through a contract agreement with a licensed dentist that comes to the facility monthly. B. Record review of R #69's Face Sheet revealed the resident was admitted into the facility on [DATE] with the following diagnoses: Parkinson's disease without dyskinesia, without mention of fluctuations (disorder caused by…

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

Based on record reviews and interviews, the facility failed to ensure medical records consistently reflected the correct code status for 1 (R #5) of 3 (R #5, #6, and #7) residents. If code status is not accurately documented in resident records, then the resident is at risk of a life-threatening medical error. The findings are: A. Record review of R #5's face sheet revealed an admission date of 06/11/25. Further review revealed the resident's code status was not documented in the record. B. Record review of R #5's hospital discharge documentation, dated 06/07/25, revealed a code status of Do Not Resuscitate (DNR; lifesaving measures are not desired). C. Record review of R #5's New Mexico Medical Orders for Scope of Treatment (NM MOST; a legal document which outlines the care the resident wants when they become incapacitated and unable to speak for themselves) form, dated 06/11/25, revealed a DNR code status. D. Record review of R #5's Care Plan, dated 06/23/25, revealed a Full Code Status. E. On 08/21/25 at 8:30 am, during an interview, Family Member (FM) #1 stated a nurse told her…

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 maintain the resident environment free from the potential for accidents and hazards when staff left: - An electrical junction box unsecured. - Electrical cords stretched across the hallway floor. - A fire alarm control panel open. These failures had the potential to affect all residents in the facility. If the facility fails to secure electrical panels and equipment and to remove tripping hazards from resident areas, then residents are at risk of injury. The findings are: A. Review of the facility’s Hazardous Areas, Devices, and Equipment policy, revised 2018, revealed the following: - All hazardous areas, devices, and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. - Hazard was defined as anything in the environment that has the potential to cause injury or illness. - Examples included: Equipment and devices left unattended or malfunctioning, Open areas or items that should be locked when not in use,…

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 staff interviews, the facility failed to ensure the physical environment was free of hazards when staff failed to: - Ensure the electrical cord and cord protector for an electronic game table in a common area were secured to prevent tripping. - Ensure an outlet casing box was secured to the wall without electrical wires exposed. - Ensure a medication treatment cart was locked. If the facility fails to maintain a hazard-free environment, then residents are at increased risk for injury and compromised well-being. The findings are: Cord Protector A. On 07/16/25 at 10:13 a.m. and 07/17/25 at 8:05 a.m., an observation of the common area revealed an electronic, touchscreen game table. Further observation revealed the electrical cord to the game table was enclosed in a cord protector which stretched across the room. The cord protector measured 3 inches in diameter, was flipped on its side, and did not lie flat on the ground. B. On 07/17/25 at 11:25 a.m., during an interview, the Assistant Director of Nursing (ADON) stated the cord should not stretch across 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 interviews, the facility failed to report a significant medication-related event to the State Survey Agency (SSA) for 1 (R #1) of 1 (R #1) resident, when R #1 experienced a suspected opioid overdose which required an emergency administration of Narcan and Code Blue activation. If a facility fails to report suspected overdoses and life-threatening incidents to the State Survey Agency (SSA), then the SSA cannot ensure the health and safety of the residents. The findings are: A. Record review of R #1's face sheet revealed an admission date of 06/02/25 with a diagnosis of long-term use of opiate analgesics (ongoing use of opioid medications for pain management). B. Record review of R #1's progress notes, dated 06/11/2025, revealed R #1 sat on the edge of her bed and swayed back and forth. The resident had low and unstable oxygen saturation (the amount of oxygen in the blood) in the low to mid-80s (normal oxygen saturation 95 to 100). The provider increased oxygen to five liters with minimal effect. Narcan (naloxone; medication used to reverse opioid overdose)…

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 provide a written discharge notice, including the reason for discharge, effective date, location, appeal rights, and contact information for the State Ombudsman to 1 (R #1) of 1 (R #1) resident. If the facility fails to provide a complete, written discharge notice to the resident, then the resident may be unable to appeal the discharge, lose access to their rights and due process protections, experience abrupt care discontinuity, or suffer from unsafe or uncoordinated transitions of care. The finding are: A. Record review of R #1's face sheet revealed an admission date of 06/02/25. B. Record review of R #1's progress notes, dated 06/11/25, the resident was transferred to the hospital on [DATE], following administration of Narcan for a suspected overdose. The facility did not enter a discharge summary, discharge plan, or written discharge notice into the medical record. C. Record review of R #1's electronical medical records revealed there was not any…

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 residents were free from abuse for 1 (R #1) of 3 (R #1, #2 and #3) residents reviewed for abuse when facility staff pushed R #1 back inside the facility and swatted (hit) his hands as the resident tried to exit to the parking lot. This deficient practice likely caused R #1 to feel unimportant and to fear staff. The findings are: Findings for R #1 A. Record review of R #1's Face Sheet, dated 03/26/24, revealed this as an initial admission date and included the following diagnoses: - Paraplegia (loss of voluntary muscle movement that affects the legs due to damage to the brain or spinal cord), - Depression (mood disorder that causes persistent feelings of sadness and loss of interest), - Post Traumatic Stress Disorder (PTSD; mental health condition that is caused by an extremely stressful or terrifying event). B. Record review of the Facility's Reported Incident, dated 12/12/24, revealed R #1 called police to report abuse at about midnight when he was going out to the front parking lot, and a nurse refused to let him…

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

Based on record review and interview, the facility failed to complete an accurate investigation regarding allegations of abuse for 1 (R #1) of 3 (R #1, #2, and #3) residents reviewed for abuse. If the facility is not completing an accurate and thorough investigation of allegations of abuse, then the State Agency is unable to appropriately review the allegation for further investigation. The findings are: A. Record review of R #1's face sheet revealed an initial admission date of 03/26/24. B. Record review of the facility's Facility Reported Incident, dated 12/14/24, revealed R #1 called police to report abuse when a nurse tried to stop R #1 from exiting the facility, as he went out to the front parking lot on 12/14/24 at midnight. Resident was assessed and did not have any injuries. The nurse, who tried to prevent R #1 from exiting the building, was placed on administrative leave pending an investigation. C. Record review of the facility's Five Day Follow-Up Report (a report sent to the State Survey Agency which includes the results of the facility's investigation into alleged…

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 Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) was accurate for 1(R #1) of 3 (R #1, R #2 and R #3) residents reviewed for accuracy of assessments. If the MDS assessment is not accurate, then residents are likely to not receive the services they need. The findings are: A. Record review of R #1's Face Sheet dated 03/26/24 revealed this as an initial admission date and included a diagnosis of Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). B. Record review of R #1's annual Minimum Data Set, dated [DATE], revealed the following: - R #1 did not have any behavioral concerns. - R #1 did not have any physical, verbal or sexually inappropriate behavioral symptoms directed toward others. - R #1 did not have any suicidal (thoughts or ideas about harming oneself or killing oneself) or homicidal ideations (thoughts about harming or killing another person). - 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 observation and interview, the facility failed to protect a treatment cart (a movable piece of equipment used in healthcare facilities to store, transport, and dispense treatment supplies and tools) from unauthorized access when staff failed to lock the treatment cart while staff were away from the cart. This deficient practice had the potential to affect all 48 residents on the 600 Unit, as identified by the Resident Census provided by the Administrator. If staff fail to lock an unsupervised treatment cart, then residents could obtain medical equipment, which could result in injury or death. The findings are: A. On 04/24/25 at 11:43 AM, during an observation of the 600 Unit, the wound care treatment cart was unlocked and opened. Further observations revealed the cart had wound care items, such as mineral oil, tweezers, and scissors. Staff were not present in the area near the treatment cart. B. On 04/24/25 AM at 11:46 AM, during an interview, Registered Nurse (RN) #1 stated wound care staff and all nurses on duty were responsible for the treatment cart, and staff should…

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 the allegations of possible neglect/abuse for 3 (R #'s 1, #2 and #3 ) of 3 (R #'s 1, #2 and # 3) residents reviewed for incidents. If the facility is not submitting the summary of the facility's investigation to the State Agency (SA), then the State Agency is unable to appropriately triage (review) the allegation for further investigation. The findings are: A. Refer to F0610 for related findings. B. On 02/12/25 at 2:30 pm during interview with Administrator (ADM), he stated he was aware of each of the allegations of neglect/abuse. He stated the incident with R #2 did not indicate any sexual contact occurred between Certified Nurse Aide (CNA) #1 and R #2, therefore, a report was not submitted to the state agency. He stated the medication errors involving R #1 and R #3 were reported and investigated within the facility. He stated that these investigations did not indicate to him that the incidents rose to the level of abuse, neglect or mistreatment. The ADM further stated that he generally over-reports 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 record review and interview, the facility failed to complete a thorough investigation and report the investigation findings within five working days for allegations of abuse and mistreatment for 3 (R #'s 1, 2, and 3) of 5 (R #'s 1, 2, 3, 4, and 5) residents reviewed for incidents. If the facility is not completing an accurate and thorough investigations and submitting the summary of the facility's investigation to the State Agency, then the State Agency (SA) is unable to appropriately review allegations for further investigation. The findings are: R #1 A. Record review of New Mexico Health Care Authority Complaints revealed a complaint dated 01/02/25, which alleges possible neglect, a medication error which involves R #1. B. Record review of R #1's daily progress notes revealed a note dated 12/26/24 at 12:50 pm that stated a medication error occurred when nurse gave Imatinib (an oral medication prescribed to treat certain kinds of cancer) and Creon (an oral medication prescribed to replace pancreatic enzymes (chemicals that break down other chemicals)) to the wrong 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain the kitchen in a sanitary manner when staff failed to: - Label and date open food items in the kitchen and in the unit nourishment refrigerators. - Store frozen food in the freezer in the kitchen. These failures have the potential to result in cross contamination, the growth of foodborne pathogens, and foodborne illness. This failure had the potential to affect all residents who ate food from the kitchen and unit nourishment refrigerators/freezers. The findings are: Kitchen Findings: A. On 11/05/24 at 11:29 am during an initial kitchen observations, the following was observed: - 1- 3.5 L (liter) container sliced tomatoes was not labeled or dated and stored in the kitchen refrigerator. - 1 plastic container of sliced onions was not labeled or dated and stored in the kitchen refrigerator. - 3 packages of Conestoga Pioneer 6 extra crisp English muffins was not dated and stored in the kitchen refrigerator. - 2 packages of Hilltop…

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 it for residents of the 300 unit, 500 unit and R #78 during random observations. If resident's clinical information is not sufficiently safe guarded, resident's PHI is likely to be viewed by unauthorized residents, visitors, and staff. The findings are: A. On 11/06/24 at 11:19 am during random observation of the 500 wing nurses station a vital sign sheet sat face up on the counter containing all vital signs for all residents residing on the 500 wing able to be observed by all unauthorized persons coming to the nurses station. B. On 11/06/24 at 11:20 am during an interview with Certified Nurse Aide (CNA) #1 confirmed that vital sign sheet should not be left sitting on the counter for all to view, and if it is it should be face down. C. On 11/14/24 at 9:20 pm during a random observation of the 300 unit Registered Nurse (RN) #2 was observed walking away from his medication cart leaving his computer open 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 maintain an environment that was clean, in good condition, and free from clutter for 3 (R #'s 31, 68, and 71) of 3 (R #'s 31, 68, and 71) residents sampled for a homelike environment by facility staff leaving used resident meal trays in residents rooms. Failure to maintain the building in a clean and comfortable manner is likely to result in unsafe conditions and prevent residents from enjoying everyday activities. The findings are: A. Record review of the facility meal service times revealed residents were served meals during the following times: - Breakfast: 7:30 am to 9:00 am. - Lunch: 12:00 pm to 1:30 pm. - Dinner: 5:00 pm to 6:30 pm. B. On 11/06/24 at 11:20 am during an observation of R #'s 68 and 71's room, R #'s 68 and 71's breakfast meal trays with trash and with old food still present on the tray were observed to still be in the residents rooms and on their dressers. R #71 became frustrated and stated the facility staff never collects used trays on time and it upsets him because it's gross. R #68…

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 facility failed to complete a resident centered, comprehensive care plan for 2 (R #45 and 195) of 2 R #45 and 195) residents. The facility failed to provide a plan for activities and the resident's perferred activities. This deficient practice is likely to result in residents mental and psychosocial needs not being met and residents being bored and uninterested. The findings are: R #45 A. Record review of R #45's face sheet dated 11/14/24 revealed she was admitted to the facility on [DATE] with multiple diagnoses including but not limited to: -Metabolic Encephalopathy (A disease of the brain that causes confusion, memory loss) -Depression (a state of sadness) -Chronic Kidney Disease (disease that causes disruption of the functions of the kidneys) -Generalized Anxiety Disorder (a condition of fear and concerns) B. Record review of R #45 activities assessment dated [DATE] revealed preferences for religious services, being outside to enjoy fresh air and listen to music. C.…

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 2 (R #'s 43, 58 and 88) of 2 (R #'s 43, 58 and 88) residents reviewed when staff failed to: 1. Update the care plan to include the amount of staff assistance required for activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) care for R #43. 2. Update the care plan to include hospice services (a home providing care for the sick or terminally ill for R #'s 58 and 88. 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 #43: A. Record review of R #43's face sheet revealed R #43 was admitted into the facility on [DATE] with the following diagnoses: 1. Aphasia (acquired communication disorder) 2. Dysphagia (difficulty swallowing) 3. Traumatic Brain Injury R #43 was discharged to the emergency room (ER) on [DATE]. B. Record review of Minimum…

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 quality care that meets professional standards for 2 (R #'s 71 and 195) of 2 (R #'s 71 and 195) residents when the facility failed to: 1. Complete an assessment and provide physician orders to allow R #71 to check his own blood sugar and inject his own insulin with staff supervision. 2. Administer antiviral (medication that is meant to treat viral infections) on time and as ordered by the resident provider for R #195. This deficient practice is likely to result in residents not receiving antibiotics in a timely manner prolonging their infection and the physical effects (temperature, pain, discomfort) caused by the infection; and residents becoming at risk for improper medication administration without the proper self-administering assessments and orders provided. The findings are: R #71: A. Record review of R #71's face sheet revealed R #71 was admitted into the facility on [DATE] with the following diagnoses: 1. Diabetes. B.…

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 assure that physicians responded to recommendations submitted during the pharmacist's written monthly review or obtain physician rational specific to the resident to agree or disagree with the pharmacist's monthly recommendations for 6 (R #7, R #20, R #26, R #27, R #42, R #43) of 6 (R #7, R #20, R #26, R #27, R #42, R #43) residents. This deficient practice is likely to cause resident medication regimen to not be properly evaluated resulting in possible over medication. A. Record review of documents submitted by the facility pharmacist consultant on 06/17/24 for review and action by each resident's provider: 1. R #26 Recommendation for additional lab testing of resident. The document indicates no Physician/Prescriber Response and is signed and dated on 09/03/24 by the former Director of Nursing (DON). The recommendation had a handwritten note-ordered. 2. R #67 Recommendation Gradual Dose Reduction of Mirtazapine (a psychotropic medication prescribed to manage depression). The document indicates no Physician/Prescriber…

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 medication error rate did not exceed 5% for 1 (R #74) of 5 (R #33, 71, 74, 75, 80) residents reviewed during medication administration. 34 medications were observed administered with 6 errors resulting in a medication error rate of 14.71%. If medications are administered in error, residents are likely to experience less than optimal results from their medication regimen (a prescribed systematic form of treatment for a course of drugs). The findings are: A. On 11/13/24 at 9:37 am during observation of Certified Medication Aide (CMA) #1 she drew, poured and administered all morning medication to R #74 including the following: -Amoldipine 10 mg (milligrams) (a medication prescribed to manage blood pressure) -Aspirin Tablet Delayed Release 81 mg (a medication prescribed to prevent blood clots) -Colecalciferol Oral Tablet 25 mcg (micrograms) (Vitamin C a medication to provide vitamin supplement) -Hydrochlorothiazide Oral Tablet 25 mg (a medication prescribed to manage blood pressure) -Lisinopril Oral…

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 reasonable accommodations of resident needs and preferences for 1 (R #47) of 1 (R #47) residents reviewed by not ensuring R #47 had access to her call light. These deficient practices are likely to result in residents being unable to request assistance, such as needing help with transferring, after falling or other acute distress. The findings are: A. Record review of R #47's face sheet revealed R #47 was admitted into the facility on [DATE]. B. Record review of R #47's care plan 12/05/23 revealed R #47 experienced left sided hemiplegia (paralysis or weakness on one side of the body) and impaired gait, which required a call light pad and her call light to be within reach. C. On 11/06/24 at 1:09 pm during an observation and interview with R #47, R #47 was observed sitting in a wheelchair next to her bed and her call light pad was placed on the opposite side of her bed and not in reach. R #47 stated that she could not reach her call…

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 Pre-admission Screening and Resident Review (PASRR; a screening to help ensure that individuals are not inappropriately placed in nursing homes for long term care) assessment was accurate for 1 (R #71) of 1 (R #71) residents reviewed for PASRR accuracy. This deficient practice is likely to result in the facility not providing the services needed by residents. The findings are: A. Record review of R #71's PASRR Level 1 Identification Screen Section C: Identification of Mental Illness Evaluation Criteria dated 11/30/23 revealed R #71 required referral to PASRR prior to admitting into the nursing facility. B. Record review of R #71's face sheet revealed R #71 was admitted into the facility on [DATE]. C. Record review of R #71's Electronic Health Record (EHR) revealed no documentation was present for R #71's PASRR Level 2 referral. D. On 11/14/24 at 2:43 pm during an interview with the Social Services Director (SSD), she stated R #71 did 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents received proper treatment to maintain vision 1 (R #71) of 1 (R #71) residents reviewed for vision. If the facility is not assisting residents in accessing treatment to maintain their vision, then residents are likely to lose their ability to see, which will compromise their quality of life. The findings are: A. Record review of R #71's face sheet revealed R #71 was admitted into the facility on [DATE]. B. Record review of R #71's physician orders dated 09/13/24 revealed R #71 required an optometry appointment for eye glasses. C. Record review of R #71's Electronic Health Record (EHR) revealed no optometry appointment had been scheduled and/or completed for R #71. D. On 11/06/24 at 11:14 am during an interview with R #71, he stated that he has been waiting a long time for glasses and he has not had a vision appointment for them yet, which has made him upset. R #71 also stated that he needs them to see and he really needs help with this…

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

Based on observation and interview, the facility failed to ensure that 1 (R #3) of 1 (R #3) residents reviewed was free from accidents and hazards by not securing an electric cord that is in a direct path to the residents bed. This deficient practice is likely to put residents at risk of unsafe situations. The findings are: A. On 11/13/24 at 10:22 AM during an interview with R #3 he stated that staff was repositioning him and the Certified Nursing Assistant (CNA) on his left side tripped on the electric cord connected to the bed. The CNA was able to catch herself and did not fall to the floor but bumped the side of his bed. B. On 11/13/24 at 10:24 AM a black electric cord was observed to be unsecured and in the direct walking path to R #3's bedside. C. On 11/13/24 at 10:37 AM Licensed Practical Nurse (LPN) #1 verified that the electrical cord to R #3's bed was unsecured and a tripping hazard.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to assure that 1 (R #195) of 1 (R #195) resident was provided respiratory care including provider orders to monitor, clean, use a C-PAP (Continuous Positive Airway Pressure) or Bi-PAP (Bilevel positive Airway Pressure) (a non-invasive devices that provide assistive breathing usually during rest and sleep). If the facility fails to assist, manage and maintain equipment as ordered then resident are likely to not get the therapeutic results needed. The findings are: A. Record review of R #195 face sheet revealed he was admitted to the facility on [DATE] with multiple diagnoses including but not limited to: -Chronic Obstructive Pulmonary Disease (COPD) (a chronic, progressive disease of the lungs which causes a reduction of respiratory function especially during sleep and rest) -NonTraumatic Intracerebral hemorrhage (stroke) -Vascular Dementia with Agitation (a chronic and progressive disease of the brain the disrupts memory and brain functions)…

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 11/14/24 at 9:23 PM during an observation of the 300 wing medication cart, RN #2 was observed walking away from the medication cart without locking it. B. On 11/14/24 at 9:25 PM during interview with RN #2, he confirmed that medication carts should not be left unlocked and unattended. C. On 11/14/24 at 9:24 PM during an observation of the 500 wing medication cart, the cart was unlocked and staff left the cart unattended, also observed on top of the medication cart was a cup with four unidentified medication and five lancets (a small medical implement used for blood sampling). D. On 11/14/24 at 9:30 PM during interview with RN #1, she confirmed that medication carts should not be left unlocked and unattended. RN #1 picked up the medication cup and walked away again leaving the medication cart unlocked. F. On 11/15/24…

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 interviews, the facility failed to ensure residents obtained routine dental care for 1 (R #36) of 1 (R #36) residents reviewed for dental services. This failure is likely to result in the resident experiencing pain, embarrassment over condition of teeth, and potential weight loss. The findings are: A. Record review of R #36's face sheet revealed R #36 was admitted into the facility on [DATE]. B. Record review of R #36's physician orders dated 10/20/24 revealed R #36 required referral for in-house dentist for dental pain and recurrent gingivitis (inflammation of the gums). C. Record review of R #36's Electronic Health Record (EHR) revealed no indication that R #36 was seen by a dentist after the 10/20/24 physician order. D. On 11/06/24 at 11:45 am during an interview with R #36, she stated that she has not had a dental appointment in sometime and she has several teeth that need to be pulled, and she experiences pain in her gums often. R #36 confirmed she told the facility nursing staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain proper infection prevention measures for 2 (R #'s 71 and 75) of 6 (R #'s 33, 39, 44, 71, 75 and 80) residents observed when the facility: 1. Failed to store R #71's nebulizer mask (a drug delivery device used to administer medication in the form of mist) appropriately in a bag. 2. During medication administration when the Certified Medication Aide (CMA) used her bare fingers to pour mediations. This deficient practices are likely to result in the spread of infectious diseases. The findings are: R #71: A. Record review of R #71's face sheet revealed R #71 was admitted into the facility on [DATE]. B. Record review of R #71's physician orders revealed the following: 1. 01/23/24: Albuterol inhalation solution (medication used to open airways in the lungs). 2. 10/26/24: Ipratropium inhalation solution (medication used to open airways in the lungs). C. On 11/06/24 at 11:18 am during an observation and interview with R #71, R #71'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that medical records were complete and accurate for 1 (R #1) of 1 (R #1) resident reviewed. This deficient practice will likely result in staff not knowing residents' daily care events, changes, and needs. The findings are: A. Record review of R #1's face sheet dated 07/05/24 revealed R #1 was admitted to the facility on [DATE] with multiple diagnoses including but not limited to: -Diabetes (a chronic disease in which the body fails to process blood sugars) Type 2 -Spinal Stenosis (Deterioration of the backbones and spinal discs) Cervical (neck) region -Spinal Stenosis Lumbar (lower back) region -Flaccid (not firm) Neuropathic (nerve) Bladder (condition of the bladder due to nerve damage) -Retention (holding or having difficulty passing) of Urine -Repeated Falls -R #1 was discharged from the facility on 06/10/24. B. Record review of R #1's physician orders revealed the following: 06/07/24 A physician ordered to admit R #1 to the facility for…

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 Past non-compliance Based on interview, record review, and observation, the facility failed to ensure patient care equipment was in safe operating condition for 1 (R #2) of 1 (R #2) resident reviewed. This deficient practice likely resulted in the collapsing of the shower gurney (a special bed made to be used in a shower) while R #2 was on the gurney and being transferred from his room to the shower room. If the facility does not ensure that residents' equipment is safe and operating, then residents are at risk of injury. The findings are: A. Record review of R #2's face sheet revealed R #2 was admitted to the facility on [DATE] with multiple diagnoses including: -Quadriplegia (limited use of all limbs) -Traumatic Brain Injury (injury of the brain causing significant brain damage) B. On 07/09/24 at 4:00 pm during interview with Licensed Practical Nurse (LPN) #1, she stated that on 07/09/24 during the early afternoon, R #2 had fallen. She stated R #2 was being assisted to the shower by his assigned CNA (Certified…

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 meet professional standards of quality for 1 (R #1) of 3 (R #'s 1, 2, and 3) residents when staff: 1. Did not know where the gastrostomy tube (G-Tube; a tube inserted through the belly that brings nutrition directly to the stomach) equipment for R #1 was located. 2. Did not provide R #1 with proper hydration for 22 hours via a G-Tube. 3. Did not provide R #1 medications upon admission for 17 hours via G-Tube. 4. Did not document R #1's blood glucose (sugar) levels checks. If the facility is not providing hydration and medications via resident G-Tubes then residents are likely to not receive the therapeutic benefits and care needed. The findings are: A. Record review of R #1's Certified Nursing Assistant (CNA) admission Flow Sheet, dated 12/15/23, revealed R #1 was admitted into the facility on [DATE] at 4:30 pm. B. Record review of R #1's nursing progress notes, dated 12/15/23 at 6:00 pm, revealed staff looked for pump and tubing compatible together.…

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 to the State Survey Agency for 2 (R #'s 8 and 91) of 2 (R #'s 8 and 91) residents reviewed for abuse and neglect related incidents. If the facility fails to provide a 5 day follow-up report to the State Agency for abuse and neglect related incidents, then the State Agency will be unable to assure residents are safe and have a hazard free environment. 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 Grievance Concern Report, dated 10/10/23, revealed, - Describe in detail the concern: I feel bad about having to say this. A big guy from therapy creeps me out. He was playfully pulling my mom's chin hairs. He was talking about changing her, which as I believe is inappropriate. I do not want this therapist working with my mom anymore. - Findings of Investigation:…

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 complete and document a thorough investigation and implement corrective actions regarding allegations of physical and verbal abuse (any type of harm including physical or emotional injuries, sexual assault, or financial exploitation experienced by residents) and neglect (failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness) for 2 (R #'s 8 and 91) of 2 (R #'s 8 and 91) residents reviewed for abuse/neglect allegations by not: 1. Completing a thorough investigation and documenting that investigation for R #8. 2. Completing a thorough investigation, documenting that investigation, and implementing corrective actions for R #91. If the facility fails to implement preventive and corrective actions necessary to prevent and correct the incident from happening again, it is likely residents will not enjoy living to their highest practicable well-being. The findings are: Findings for R #8: A. Record review of 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 observation, record review, and interview, the facility failed to provide activities of daily living (ADL) assistance for baths and showers for 2 (R #39 and 91) of 2 (R #39 and 91) residents reviewed for ADL care. This deficient practice is likely to affect the dignity and health of the residents. The findings are: Findings for R #39: A. Record review of R #39's face sheet revealed R #39 was admitted into the facility on [DATE]. B. Record review of R #39's care plan, dated 10/02/23, revealed, R #39 was admitted to long term care (LTC) related to a need for assistance with ADLs and medication administration. C. Record review of R #39's Documentation Survey Report (an ADL tracking documentation located in the Electronic Health Record- EHR), dated 11/01/23 through 11/30/23, revealed staff provided R #39 three bed baths or showers out of five opportunities, and her last bed bath or shower was on 11/16/23. D. Record review of R #39's Shower Sheets dated 11/01/23 through 11/30/23 revealed staff provided R #39…

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 an on-going program of activities designed to meet the interests and well-being for 2 (R #'s 22 and 25) of 4 (R #'s 22, 25, 49, and 83) residents reviewed for activities when staff failed to: 1. Offer one-to-one activities to residents that stay in their rooms. 2. Provide meaningful individualized activities based upon residents' interests. If residents are not provided or encouraged to attend or participate in activities that meet their interests, are enjoyable, and enhance their social and emotional well-being, then they are likely to experience an increase in boredom, isolation, and depression. The findings are: Findings for R #22: 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 care plan, dated 09/18/23, revealed the resident preferred independent activities or spending time with her family rather than doing things in groups. Interventions included…

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 keep a resident free from significant medication errors for 1 (R #148) of 1 (R #148) resident randomly sampled, when they failed to administer R #148's Cefazolin (an antibiotic medication) intravenous (IV; a tube that is inserted into a blood vessel and used to administer medications, fluids, or nutrition into the bloodstream) medication in a timely manner as per physician's order. This deficient practice is likely to cause R #148 to have adverse side effects such as injury of the liver and kidneys and reduce the effectiveness of the antibiotic medication. The findings are: A. Record review of R #148's face sheet dated 12/10/23 revealed she was admitted to the facility on [DATE] with multiple diagnoses including but not limited to: - Encounter for other orthopedic (bone and bone structure) aftercare, - Infection and inflammatory reaction due to internal left hip prosthesis (a device surgically placed in the hip to replace and repair the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure medications were stored properly and not left on beside tables in residents' rooms. These deficient practices is likely to affect all 100 residents as identified by the facility census, dated 12/08/23, and 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. The findings are: Medications stored improperly. A. On 12/08/23 at 11:09 am during review of the medication cart that served the 700 hallway, a medication cup sat in the top drawer and contained four tablets of unidentified medications. The cup had the number 702 B written on the side. B. On 12/08/23 at 11:09 am during interview with Licensed Practical Nurse (LPN) #3, he stated another nurse had poured the medications into the cup and placed the cup in the medication cart earlier in the morning. He stated this nurse had been reassigned to another area 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 observations and interviews, the facility failed to ensure staff served meals at preferred temperature for 6 (R# 15, 39, 49, 53, 63 and 83) of 6 (R# 15, 39, 49, 53, 63 and 83) residents reviewed meal temperatures. If food is not served at preferable temperature for the resident (hot foods are served hot and cold foods are served cold and in accordance with resident preferences). Residents are likely to not eat their meals and be at risk for weight loss. The findings are: A. On 12/05/23 at 12:25 am during an interview with R #63, she stated the food was frequently cold. The resident said if she asked the staff to warm it up then they took too long to bring it back to her. B. On 12/07/23 at 10:15 am during an interview with R #83, she stated her food was always cold, and she would like it to be hot. C. On 12/07/23 at 10:33 am during an interview with R #49's daughter, she stated the food was not served hot. She said most of the time it was cold, and her mother was not able to ask staff to warm it up. Daughter further stated she was often at the facility at meal time, and the…

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

Based on observation and interview, the facility failed to provide food that accommodated resident allergies, intolerances, and preferences for 3 (R #34, 83 and 148) of 3 (R #34, 83, and 148) residents observed during dining food service. This deficient practice is likely to result in weight loss due to residents not eating or experiencing allergic reactions. The findings are: R #83 A. On 12/07/23 at 12:38 PM during lunch observation, R #83's Lunch Meal Ticket indicated R #83 was not to receive any meat. The staff served the resident pork enchiladas. B. On 12/07/23 at 12:41 PM, Assistant Director of Nursing (ADON) confirmed R#83's meal ticket stated no meat, and staff served R #83 pork enchiladas. R #148 C. On 12/11/23 at 12:08 PM record review of R #148's Breakfast Meal Ticket indicated R #148 was not to receive any milk or milk products. D. On 12/11/23 at 12:44 PM during an interview with the Dietary Manager (DM), he confirmed the ticket reflected lactose intolerance, and staff served R #148 an 8 ounce glass of whole milk. R #34 E. On 12/11/23 at 12:45 PM, a record review of 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, observation, and interview, the facility failed to store and serve food under sanitary conditions by not ensuring: 1. Staff wore beard guards or hair restraints when in the facility kitchen. 2. Kitchen was clean and sanitary. This deficient practice was likely to affect all 100 residents listed on the resident census list provided by the Administrator on 12/04/23. This failure was likely to cause foodborne illnesses in residents if the kitchen was not clean or hair in the food if staff are not wearing proper hair restraints in the food preparation areas of the facility kitchen. The findings are: Hair Restraints - A. On 12/04/23 at 2:19 pm during observation of the facility kitchen, the Dietary Manager (DM) and Dietary Aide #1 did not wear a hair restraint while unwrapping food for the supper meal in the food preparation area of the facility kitchen. B. On 12/11/23 at 11:26 AM during an interview with the Dietary Manager, he stated hair nets should always be worn while handling food . Kitchen Cleanliness C. On 12/11/23 at 10:55 am, a tour of 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.

Based on observation, record review, and interview the facility failed to maintain proper infection prevention measures for 3 (R #22, 62 and 89) of 3 (R #22, 43, and 89) residents when staff failed to: 1. Ensure oxygen tubing was labeled and dated. 2. Ensure urinary catheter tubing did not drag on the bare floor. 3. Ensure staff changed the dressing on a PICC line (peripherally inserted central catheter; a distinctive long tube inserted into a blood vessel of the arm then passed to the larger vessels near the heart to allow the administration of IV medications) in a timely manner. If the facility is not adhering to infection control practices then residents are likely to be at risk for infections and other illnesses. The findings are: Resident #62 A. On 12/11/23 at 12:38 PM during random observation of the facility dining room, R #62 sat at the table and ate his lunch. The resident's catheter tubing lay on the bare floor. B. On 12/11/23 at 12:40 PM during interview, CNA #3 confirmed R #62's catheter tubing lay on the bare floor, and it should not. Resident #83 C. On 12/04/23 at…

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 promote care with dignity and respect for 1 (R #14) of 1 (R #14) resident found sitting in a hallway in her wheelchair through the entire night. This deficient practice likely resulted in resident feeling sore, stiff, and as if their feelings and preferences are unimportant to the facility staff. The findings are: A. Record review of R #14 face sheet, dated 12/11/23, revealed R #11 was admitted to the facility on [DATE] with multiple diagnoses to include: - Pulmonary embolism (a blood clot lodged near the lungs), - Dysphasia (difficulty swallowing), - History of falls, - Difficulty walking, B. Record review of facility grievance, dated 08/13/23, revealed staff left R #14 sitting in her wheelchair in the hallway outside her room through the entire night. C. Record review of Facility Reported Incident, five day report revealed on 08/13/23, staff left R #14 sitting in her wheelchair for the night until 4:00 am. Per the report, an agency (a contracted…

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 Pre-admission Screening and Resident Review (PASRR; a screening to help ensure that individuals are not inappropriately placed in nursing homes for long term care) assessment was accurate for 1 (R #56) of 1 (R #56) residents reviewed for PASRR accuracy. This deficient practice is likely to result in the facility not providing the services needed by residents. The findings are: A. Record review of R #56's most recent PASRR, dated 12/28/20, revealed the following: - Section B listed schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech, and behavior) as a pertinent diagnoses. - Section C,1 asked if there was a diagnosis or suspected mental illness, and staff answered No. Staff did not enter the diagnosis of schizophrenia. B. Record review of R # 56's Minimum Data Set (MDS; a complete assessment of each resident's functional capabilities and helps nursing home staff identify health problems), dated 09/16/23, Section I, Active Diagnoses revealed R #56 had a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure staff revised and updated the care plan for 1 (R #39) of 1 (R #39) residents reviewed for revising care plans when staff failed to remove the use of CPAP/Bi-PAP (continuous positive airway pressure//bilevel positive airway pressure; a machine that used mild air pressure to keep breathing airways open while you sleep) from the resident's care plan. This deficient practice is likely to result in residents care and needs not being addressed if care plans are not updated. The findings are: A. Record review of R #39's face sheet revealed R #39 was admitted into the facility on [DATE]. B. Record review of R #39's care plan, dated 10/02/23, revealed, - Focus: The resident had potential for sleep pattern disturbance related to sleep apnea (a sleep disorder where breathing is interrupted repeatedly during sleep.) - Interventions: BIPAP machine. C. Record review of R #39's physician orders, as of 12/11/23, revealed R #15 did not have a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure 1 (R #56) of 1 (R #56) residents received proper assistive devices to maintain her vision. If the facility is not assisting residents in accessing treatment and devices to maintain their vision, then residents could likely lose their ability to see. The findings are: A. Record review of R #56's face sheet revealed that she was admitted on [DATE]. B. On 12/04/23 at 3:34 PM during observation, R #56 did not wear glasses. The resident stated she did wear glasses and needed glasses to be able to read. R #56 further stated she communicated to unidentified staff that her glasses were missing, was unsure as to when they went missing, and that she needed them to be able to read. She also stated she has not had an eye exam since admission to the facility, even though she told facility staff she needed glasses. C. Record review of R #56's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), Section…

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 complete an annual performance review of one Certified Nurses Aide (CNA #8) of 5 (CNA's #1, 6, 7, 8, and 9) randomly reviewed. If the facility is not maintaining the annual performance reviews then residents are likely to not receive the appropriate care and services, and the CNA's may not meet the needs of all residents. The findings are: A. Record review of the facility staffing list revealed CNA #8 was hired on [DATE]. B. Record review of CNA #8's Annual Skills Competency Checklist revealed CNA #8's last annual performance review occurred on [DATE]. C. Record review of the facility staffing hours revealed CNA #8 worked shifts on the following dates: [DATE], [DATE], [DATE], 11/11,23, [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. D. On [DATE] at 2:41 pm during an interview with the Director of Nursing (DON), she confirmed CNA #8's annual performance review expired. DON also confirmed…

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 an interview the facility failed to employ a Certified Dietary Manager (CDM) that met the requirements as follows: (A) A certified dietary manager; or (B) A certified food service manager; or (C) Has similar national certification for food service management and safety from a national certifying body; or (D) Has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; or (E) Has 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting and has completed a course of study in food safety and management, by no later than October 1, 2023, that includes topics integral to managing dietary operations including, but not limited to, foodborne illness, sanitation procedures, and food purchasing/receiving. This deficient practice is likely to affect all 100 residents living at the facility. Residents are likely not to receive the dietary nutritional services needed to thrive and their…

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 food was prepared in a form that met a resident's required textured diet (an appropriate consistency of food that can be easily chewed and swallowed) for 2 (R #33 and 49) of 2 (R #33 and 49) resident observed during random observation. This deficient practice could likely result in a choking incident. The findings are: R #33 A. Record review of R #33's lunch meal ticket, dated 12/11/23, revealed R #33 was on a regular diet with meat cut to dime size. B. Record review of R #33's physician order, dated 11/06/23, revealed a regular diet with chopped meat texture. Staff to chop meat into dime-size pieces with no other mechanical alterations. C. On 12/11/23 at 12:35 PM, during an observation and interview, R #33 received her lunch meal, and staff did not cut up the meat. The resident stated, I can't eat that, I need help cutting it into smaller pieces. R #49 D. Record review of R #49's lunch meal ticket, dated 12/11/23, revealed R #49 received a regular pureed meal. E. On 12/11/23 at 12:38 PM, 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 observations and interviews, the facility failed to provide milk per resident preference or as ordered by physician for 4 (R# 33, 35, 49 and 51) of 4 (R# 33, 35, 49 and 51) residents reviewed. If the facility is not providing drinks as per resident preference or as ordered residents, then are likely to not meet their nutritional needs. The findings are: A. On 12/11/23 at 12:40 PM, during an interview, R #35 stated she had not been getting 8 ounce (oz.) whole milk with meals, and she would like to get milk with her meals. She further stated she asked facility staff to provide milk with her meals. The resident said staff told her they did not always serve milk because not all the residents like or can drink milk. Resident #33 B. On 12/11/23 at 12:38 PM, during an interview, R #33 stated she is supposed to get an 8 oz. glass of milk on her tray, and there was not an 8 oz glass of milk on her tray. C. Record review of R #33's meal ticket revealed the staff should serve the resident an 8 oz. glass of milk three times a day. D. Record review of R #33 Physician's order, dated…

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