Socorro Wellness & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to report allegations of misappropriation of resident funds (the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's money without the resident's consent) to the State Agency within 24 hours of allegation for 1 (R #36) of 2 (R #2 and R #36) residents reviewed for misappropriation of funds, when staff failed to report allegations of missing money. If the facility fails to report allegations of misappropriation of resident funds to the state agency within 24 hours of the allegation, then corrective action may not be taken, and residents may suffer increased anxiety and fear that their money is not being protected. The findings are: A. Record review of R #36's admission documents, no date, revealed R #36 was admitted to the facility on [DATE]. B. On 12/10/25 at 9:47 AM, during an interview, R #36's family member (FM) stated the following: 1. He gave Human Resources (HR) money to put in an account for R #36 shortly…

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 thoroughly investigate an allegation of misappropriation of resident funds (the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's money without the resident's consent) 1 (R #36) of 2 (R #2 and R #36) residents reviewed for misappropriation of resident funds when staff failed to have evidence of a thorough investigation of misappropriation of resident funds. If the facility does not adequately investigate allegations of misappropriation of resident funds, then corrective action is not implemented to protect other residents from misappropriation of resident funds, then residents may suffer increased anxiety and fear that their money is not being protected. The findings are: A. Record review of R #36's admission documents, no date, revealed R #36 was admitted to the facility on [DATE]. B. On 12/10/25 at 9:47 AM, during an interview, R #36's family member (FM) stated the following: 1. He gave Human Resources…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set Assessment (MDS; federally mandated assessment instrument completed by facility staff) was accurate for 1 (R #36) of 8 (R #4, R #5, R #6, R #7, R #10, R #17, R #36, and R #60) residents reviewed for dental care. This deficient practice could likely result in the facility not having an accurate assessment of the residents' needs. The findings are: A. Record review of R #36's admission documents, no date, revealed R #36 was admitted to the facility on [DATE]. B. On 12/10/25 at 9:59 AM, during an interview, R #36's family member (FM) stated that R #36 had top dentures when she came to the facility and was missing her bottom dentures prior to admission. C. On 12/12/25 at 9:43 AM, during an observation and interview of R #36, the following was revealed: 1. R #36 stated she did not have any teeth or dentures. 2. R #36 stated she had dentures, but she was not sure what happened to them. 3. R #36 was observed to 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 observation, record review, and interviews, the facility failed to meet professional standards of practice (established guidelines and expectations that ensure the delivery of high-quality care to residents) for 2 (R #5 and R #17) of 7 (R #5, R #6, R #7, R #17, R #36, R #69 and R #76) residents reviewed for neglect when staff failed to follow physician orders. If the facility is not providing care per physician's orders, and providing care that meets professional standards of practice, then residents are likely to experience adverse effects, worsening of their condition, and potential complications from not receiving the care ordered by the physician. The findings are: R #5 A. Record review of R #5's admission record, no date, revealed the following: 1. R #5 was admitted to the facility on [DATE]. 2. R #5's diagnoses include the following: a. Diastolic (congestive) heart failure (heart's main pumping chamber (left ventricle) becomes stiff and can't relax properly to fill with enough blood between…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to ensure appropriate treatment for urinary conditions (conditions affect the kidneys, bladder, and tubes connecting them, ranging from common issues like Urinary Tract Infections (UTIs), incontinence, and kidney stones to more complex problems like overactive bladder, interstitial cystitis, and prostate issues (in men) for 1 (R #2) of 4 (R #2, R #5, R #6, and R #76) resident's reviewed for urinary conditions, when staff failed to provide services for Foley Catheter tubing (soft plastic or rubber tube that is inserted to the bladder to drain the urine and is connected to a collecting bag) care for R #2.This deficient practice could result in residents being susceptible to worsening of infection or becoming septic (potentially life-threatening when the body responds to infection by damaging its own tissues) The findings are: A. Record review of R #2's admission documents, no date, revealed the following: 1. R #2 was admitted 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 record review and interview, the facility failed to ensure hospice services met professional standards for 2 (R #8 and R 69) of 2 (R #8 and R #69) residents reviewed for hospice services when staff failed to: 1. Ensure resident medical records had relevant communication indicating the delivery of hospice services (services provided for a person experiencing an advanced, life-limiting illness) for R #8 and R #69. 2. Ensure there was a coordinated plan of care in R #8's medical record delineating services that hospice was responsible for and services the facility was responsible for. These deficient practices could likely lead to residents not receiving the services needed due to lack of collaboration and communication between the facility and hospice provider. The findings are: R #8 A. Record review of R #8's admission documents, no date, revealed the following: 1. R #8 was admitted to the facility on [DATE]. 2. R #8 had a diagnosis of senile degeneration of brain (an outdated term for age-related…

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

Based on observation, record review, and interview, the facility failed to ensure that the bed rail and bed were compatible for 1 (R #17) of 1 (R #17) resident reviewed for accidents. This deficient practice could likely result in serious injury if residents fall while attempting to transfer while using the bed rail. The findings are:A. On 12/10/25 at 1:37 PM, during an observation of R #17 in his bed, revealed that R #17's bed rail was loose. The bed rail moved side to side parallel to the length of the bed approximately 1 to 2 inches. The bed rail appeared to be an aftermarket attachment to the side of the bed. When R #17 reached for the bed rail to assist with getting up from lying down, the bed rail gave. B. Record review of R #17's medical record, no date, revealed that there was no documentation that the bed rail has been inspected for proper installation. C. On 12/10/25 at 4:26 PM, during an interview, the ADON confirmed that the bed rail was not sturdy. The ADON stated she did not know if the bed rail had been inspected for proper installation.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to protect 25 out of 25 residents on the secure unit and North Hall (residents were identified by the resident census report, dated 10/18/24, provided by the Administrator on 12/13/24) sampled for abuse and neglect, when a staff member: 1. Abandoned residents by frequently leaving the building to go to his car multiple times throughout the shift. 2. Wore air pods (wireless headphones for listening to music and answering phone calls) in both ears, which prevented him from hearing what was occurring on the unit. 3. Fell asleep on the unit couch during the dinner meal. 4. Used loud, foul, abusive language. These deficient practices could result in residents' needs not being met, staff not being unaware of urgent resident needs, and residents feeling unsafe in their home. The findings are. A. Record review of the Incident Report, dated 10/25/24, revealed the following: 1. An abuse and neglect type of incident occurred on 10/19/24 at 6:00 PM. 2. CNA #1 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to report alleged allegations of abuse and neglect to the State Agency for 25 out of 25 residents on the secure unit and north hall (residents were identified by the resident census report, dated 10/18/24, provided by the Administrator on 12/13/24) sampled for abuse and neglect, when they failed to report allegations of abuse and neglect by CNA #1 on 10/18/24 within two hours after the incident. If the facility fails to report allegations of abuse and neglect timely, then corrective action may not be taken, and residents could likely suffer serious bodily injury or a decline in their psychological well-being. A. Record review of the Incident Report, dated 10/25/24, revealed the following: 1. An abuse and neglect type of incident occurred on 10/19/24 at 6:00 PM. 2. CNA #1 was asleep on the job. 3. CNA #1 smelled of alcohol. 4. CNA #1 became belligerent, was cussing at staff, and threatened to kill staff. 5. CNA #1 got into an RN's space and threatened 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 record review and interview, the facility failed to provide abuse, neglect, and exploitation (ANE) training to 1 (CNA #1) of 3 (CNA #1, CNA #2, and CNA #4) staff sampled for training. This deficient practice could likely result in staff not knowing who, what, and when to report abuse, neglect, and exploitation. The findings are: A. Record review of CNA #1's training transcript, hire date 10/18/24, revealed CNA #1 did not take ANE training prior to working with residents on 10/18/24. B. On 12/11/24 at 1:58 PM, during an interview with the Scheduler, she revealed the following: 1. CNA #1 was staff member for an outside agency. 2. Agency staff do not complete facility trainings prior to working with residents at the facility. C. On 12/12/24 at 11:28 AM, during an interview with the DON, she stated the following: 1. Agency staff were required to have dementia training completed through the outside agency prior to working a shift at the facility. 2. Agency staff were not required to complete abuse, neglect, and exploitation training with the outside agency or the facility prior…

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 and spices in accordance with professional standards of food service safety for all 43 residents (residents were identified on the resident census provided by the Administrator on 08/26/24) who ate food prepared in the kitchen when they failed to: 1. Label open food in the refrigerator. 2. Properly seal open food in the refrigerator. 3. Ensure spices were labeled with open dates. 4. Remove expired seasoning. These deficient practices could likely lead to foodborne illnesses. The findings are: A. On 08/26/24 at 11:54 AM, during an observation of the kitchen, a bag of chicken nuggets was opened and did not have an open date. The bag of chicken nuggets was not properly sealed. The bag appeared to have been rolled closed, and it unrolled and was open. B. On 08/26/24 at 11:55 AM, during an interview, the Lead [NAME] confirmed the bag of chicken nuggets was open and not sealed properly. The Lead [NAME] also confirmed the bag of chicken nuggets did not have an open date. The lead [NAME] confirmed staff should seal and…

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

Based on record review and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections when they failed to have a water management program to minimize the risk of Legionella [a bacteria that can grow in parts of building water systems that are continually wet (e.g., pipes, faucets, water storage tanks, decorative fountains) and cause a serious type of pneumonia] and other opportunistic pathogens (bacteria that do not usually cause diseases in healthy people but may become extremely injurious to unhealthy individuals) in the building's water system. This failure could potentially affect all 43 residents who lived in the facility (residents were identified by the Resident Matrix provided by the DON on 08/26/24). If the facility fails to maintain an effective infection control program, then infections could spread to residents throughout the facility, resulting in illness. The findings are: A. Record review of the…

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

Based on record review and interview, the facility failed to ensure pharmaceutical services (the direct, responsible provision of medication-related care) were met for 1 (R #10) of 4 (R #10, R #22, R #29, and R #36) residents reviewed for medications when they failed to provide routine medication for a resident. This deficient practice could likely lead to unresolved medical issues. The findings are: A. Record review of R #10's Physician orders revealed an order dated 06/27/24 for turmeric tablet (common spice often taken as a supplement which might reduce swelling). Give 1500 mg (strength of tablet) by mouth one time a day for supplement. B. Record review of R #10's MAR for August 2024 revealed staff documented the drug was not available from 08/14/24 through 08/28/24. C. On 08/29/24 at 11:16 AM, during an interview, CMA #1 stated the turmeric was not available, because R #10's family did not bring the turmeric to the facility. D. Record review of R #10's progress notes, no date, revealed staff did not document any communication with the pharmacy or with R #10's family regarding…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop an accurate, person-centered comprehensive care plan for 2 (R #13 and R #25) of 7 (R #10, R #12, R #13, R #23, R #25, R #29 and R #32) residents reviewed for care plans. This deficient practice could likely result in staff being unaware of the current and actual needs of the residents. The findings are: R #13 A. Record review of R #13's admission Record, no date, revealed the following: 1. R #13 was admitted to the facility on [DATE]. 2. R #13 diagnoses: a. Fibromyalgia [disorder characterized by widespread musculoskeletal (involving both muscle and bones) pain accompanied by fatigue, sleep, memory and mood issues.] b. Cramp (sudden, unexpected tightening of one or more muscles that can be very painful) and spasm (sudden, twitching contractions that are not usually painful.) c. Unspecified osteoarthritis (inflammation of one or more joints that occur without a known cause resulting in pain, stiffness, and loss of mobility.) d. Pain unspecified…

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 care plan revision occurred for 1 (R #30) of 4 (R #5, R #7, R #11, and R #30) residents reviewed for care plans, when they failed to update R #30's care plan to document that her lower dentures were lost. This deficient practice could likely result in the care plan not being updated with the most current resident conditions and appropriate interventions, staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are: A. On 08/26/24 at 2:30 PM, during an interview, R #30's said she lost her bottom dentures. R #30 said she did not remember when she lost them. B. Record review of R #30's progress notes, dated 06/12/24, revealed R #30 wore full dentures. C. Record review of R #30's care plan, dated 06/21/24, did not document R #30's bottom dentures were missing. D. On 08/27/24 at 10:59 AM, during an interview, the Business Office Manager (BOM) confirmed R #30's bottom dentures are lost. The BOM said she was not…

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

Based on record review and interview, the facility failed to meet professional standards of practice for 1 (R #36) of 4 (R #10, R #22, R #29, and R #36) residents reviewed for medication administration, when staff did not administer R #36's blood pressure medication regardless of specific parameters (numerical or another measurable factor) from the medical provider. This deficient practice could likely lead to the resident having adverse (unwanted, harmful, or abnormal result) side effects or not receiving the desired therapeutic effect of the medication due to it not being administered. The findings are: A. Record review of R #36's Physician orders revealed: 1. Order date 08/29/23: amlodipine besylate (medication used to treat high blood pressure) tablet. Give 5 mg by mouth one time a day. Hold for systolic blood pressure (SBP; top number of blood pressure reading) less than 100. 2. Order date 08/30/23: lisinopril (medication used to treat high blood pressure) tablet. Give 10 mg by mouth one time a day. Hold for SBP less than 100. B. Record review of R #36's MAR for July 2024…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the resident's ability to perform activities of daily living (ADLs) was maintained or improved for 1 (R #12) of 2 (R #12 and R #25) residents reviewed for functional ability (the actual or potential capacity of an individual activity and tasks that can be normally expected). If the facility does not ensure that residents maintain or improve their functional abilities, then the residents are likely to experience a decrease in their ability to walk, transfer, and do other activities of daily living. The findings are: A. Record review of R #12's admission record, no date, revealed the following: 1. R #12 was admitted on [DATE]. 2. R #12 had the following diagnoses: a. Unspecified dementia (term used to describe a group of symptoms affecting memory, thinking and social abilities.) b. Other displaced fracture of upper extremity. c. Polyosteoarthrities (any type of arthritis that involves five or more joints simultaneously.) d. History of falling. e.…

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 a resident received restorative rehabilitation (focuses on maximizing an optimal level of functioning, enabling clients to regain/retain their independence following the debilitating effects of illness or injury) services as ordered by the physician for 2 (R #9 and #37) of 2 (R #9 and #37) residents reviewed for rehabilitation services. This deficient practice is likely to result in a decrease in residents functional mobility. The findings are: R #9 A. On 08/26/24 at 1:54 PM, during an interview with R #9, he stated he did not have any therapy services, but the nurses helped him move his arms and legs. B. Record review of R #9's physical (PT) and occupational therapy (OT) Discharge summary, dated [DATE], revealed R #9 to discharge to same the skilled nursing facility (SNF) with right upper extremity (region of the body that includes the arm, forearm, wrist and hand) range of motion program [ROM; the movement potential of a joint from full…

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 did not receive psychotropic medications (antidepressants, anti-anxiety medications, stimulants, antipsychotics, and mood stabilizers) unless the medication was necessary to treat a specific psychiatric diagnosis for 1 (R #25) of 5 (R #5, R #11, R #12, R #13, and R #25) residents reviewed for unnecessary medications. This deficient practice could likely result in residents receiving medications without a medical reason and being at a higher risk of adverse side effects (unwanted, harmful, or abnormal result). The findings are: A. Record review of R #25's admission Record, no date, revealed the following: 1. R #25 was admitted to the facility on [DATE]. 2. R #25 diagnoses as follows: a. Alzheimer's disease (a progressive disease that destroys memory and other important mental functions.) b. Unspecified dementia (term used to describe a group of symptoms affecting memory, thinking and social abilities.) c. Neurocognitive disorder 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.

Based on observation, and interview, the facility failed to store medications properly for all 17 residents in the East Unit (residents were identified by the Resident Matrix provided by the Administrator on 08/26/24), when they failed to ensure the medication cart did not contain loose medications. This deficient practice could likely result in residents obtaining or being administered medication not prescribed to them, receiving medications that are less effective, and may result in adverse side effects. The findings are: A. On 08/28/24 at 12:05 PM, during an observation of the medication cart assigned to the East Unit with rooms 101-114, one white round tablet was loose in the second drawer of the medication cart and located towards the back of the medication cards (cardboard and foil packaging prefilled with prescription medication.) B. On 08/28/24 at 12:06 PM, during an interview, CMA #24 confirmed white round tablet was loose and not in bubble pack or pill container.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (R #2) of 3 (R #1, R #2, and R #3) residents reviewed for hospitalizations, when they failed to continue the administration of antibiotics for treatment of urinary tract infection (UTI; infection of the urinary system). This deficient practice could likely lead to residents needs not being met and/or a worsening of their medical condition. The findings are: A. Review of R #2's medical record revealed: 1. R #2 was sent to the emergency room (ER) on 08/19/23 due to low blood pressure, elevated temperature, and urinary urgency (an immediate unstoppable urge to urinate). 2. R #2 returned to the facility after being seen in the ER, was diagnosed with UTI, and started on antibiotics. 3. R #2 was sent to the ER again on 08/22/23 due to lethargy (decrease in consciousness, drowsiness, or sleepiness) and abnormal vital signs. 4. R #2 was admitted to the…

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

Based on record review and interview, the facility failed to ensure that residents receive mail on Saturday's for all 35 residents identified on the census provided on 07/10/23 by the Administrator. This deficient practice is likely to result in residents not receiving timely communication which could result in feelings of isolation. The findings are: A. On 07/12/23 at 10:38 am, during an interview with Resident Council members: R #2, R #3, R #6, R #7, R #13, R #31, R #32, and R #34, revealed that the resident's mail is not delivered on Saturday's because it goes to a Post Office box and there is no one to pick it up on the weekend and deliver it to the residents. B. On 07/03/23 at 11:03 AM, during an interview, the Receptionist revealed that the mail is not delivered on Saturday's because the Activity's Assistant has been out and there is no one to pick it up at the post office on the weekends and deliver it. C. Record review of Resident Council minutes dated 04/18/23, 05/16/23, and 06/30/23 revealed that no information related to Resident Council members regarding residents' mail…

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 that licensed nurses (RN's and LPN's) and CNA's are able to demonstrate competency in skills and techniques necessary to care for residents' needs. This could affect all 35 residents in the facility (residents were identified by Resident Matrix provided by the Administrator on 07/10/23). This deficient practice could likely result in Nurses and CNA's working with residents without adequate competencies to do; likely resulting in injury or inappropriate care being provided to the residents. The findings are: A. Record review of the personnel files revealed no competencies (the measurement of an individual's knowledge and skills as related to safe, competent performance) evaluations for the following staff: RN #11, RN #12, CNA #12, CNA #13, and CNA #14. B. On 07/14/23 at 10:45 AM, during an interview, the Administrator confirmed that there were no competencies on file for RN #11, RN #12, CNA #12, CNA #13, and CNA #14. C. On 07/14/23 at 11:09 AM, during an interview with the DON, she stated that they did not have…

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 label food in accordance with professional standards of food service safety. This could affect all 35 residents in the facility who eat food prepared in the kitchen (residents were identified Resident Matrix provided by the Administrator on 07/10/23), when they failed to ensure food items in the kitchen labeled and dated. If the facility fails to adhere to safe food handling practices, hygiene practices, and safe food storage, residents are likely to be exposed to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins). The findings are: A. On 07/10/23 at 1:10 PM, during an observation of the kitchen revealed the following: 1. Quaker Oats with no open date or expiration date 2. Completes Instant Mashed potatoes with no open date or expiration date B. On 07/10/23 at 1:20 PM, during interview, the [NAME] confirmed that there was not an open date or expiration date on the Quaker Oats or Completes Instant Mashed Potatoes. C. On 07/12/23 at 11:30 AM, during an interview with the…

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

Based on observation, interview, and record review, the facility failed to keep residents free from physical restraints for 2 (R #27 and R #33) of 3 (R #25, R #27, and R #33) residents randomly sampled, when staff used the bed rails on R #27 and R #33's bed. This deficient practice could likely result in physical restraints being used for discipline or staff convenience; unnecessarily preventing residents from freedom, movement, or activity. The findings are: R #27: A. On 07/11/23 at 8:34 am during an observation and interview with R #27, it was observed resident was laying down on his bed and his bed had rails that were up. R #27 said that the bed rails have always been on his bed. B. Record review of R #27's physician orders revealed no orders for bed rails. C. Record review of R #27's assessments revealed no bed rail assessment was done. R #33: D. On 07/11/23 at 9:30 am, during an observation, R #33's bed had bed rails. E. Record review of R #33's physician orders revealed no orders for bed rails. F. Record review of R #33's assessments revealed no bed rail assessment was done.…

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 meet professional standards of quality for 1 (R #12) of 5 (R #12, R #25, R #27, R #29 and R #35) residents reviewed for unnecessary medications when they failed to: 1. Have parameters (numerical values) in place to determine when to administer or when to hold (not provide) blood pressure medication 2. Consistently measure blood pressure to determine effectiveness of medication or changes in blood pressure due to missed doses of medication 3. Report to physician when missed medication several days in a row These deficient practices could likely lead to the resident having adverse (unwanted, harmful, or abnormal result) side effects or not receiving the therapeutic (desired) effect of the medication due to it not being administered. The findings are: A. Record review of R #12's Physician's orders revealed: Order Date 12/07/22 Atenolol (medication used to help lower blood pressure) Tablet 50 MG (milligram) Give 1 tablet by mouth one time a day (8 PM) for hypertension (high blood pressure)(no parameters included in order) 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 ensure that 1 (R #29) of 2 (R #12 and R #29) residents are receiving restorative therapy (a therapy in which a patient trains on abilities they already have to perfect them). If the facility does not ensure that residents receive restorative services, then the residents are likely to experience a decrease in their ability to walk, sit, stand, and perform other ADL's (Activities of Daily Living). The findings are: A. Record review of R #29's face sheet revealed an admission date 07/14/21. B. On 07/12/23 at 9:08 am during an interview with R #29, she revealed that she is not getting restorative interventions. C. Record review of R #29's Care Plan dated 06/28/23 revealed: 1. [name of resident] has a need for restorative intervention to increase ADL and mobility functions. 2. Resident will improve current level of function in ADL's and Mobility with restorative. 3. RESTORATIVE; Assistance ADL's, Lay out clothes for each day. D. On 07/13/23 during an interview with the DON, she confirmed that the facility does 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.

Based on observation and interview, the facility failed to provide an ongoing activity program for 9 (R #9, R #14, R #16, R #22, R #23, R #24, R #25, R #33 and R #191) of 9 (R #9, R #14, R #16, R #22, R #23, R #24, R #25, R #33 and R #191) residents reviewed for activities in the secured memory care unit. This deficient practice could likely cause boredom, isolation, anxiousness, and feeling helpless. The findings are: A. On 07/11/23 at 9:00 am, during an observation of the secured unit, the television was on, but the picture was fuzzy, not clear, and the volume was turned down and so low that the residents couldn't hear it R#23 and R #24 were sitting in front of it. No other activities were going on. B. On 07/11/23 at 11:28 am, during an observation of the secured unit, the television was on, the picture was fuzzy and the volume was not audible. R #23 was sitting in front of it. No other activities were going on. C. On 07/11/23 at 11:29, during an interview, CNA #13 confirmed that the television picture was fuzzy and that it had been that way for weeks. CNA #13 also said that 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.

Based on observation, record review, and interview, the facility failed to provide respiratory care (breathing support) consistent with professional standards for 1 (R #12) of 2 (R #12 and R #13) residents reviewed for respiratory care when the facility failed to monitor R #12's oxygen levels. If the facility fails to monitor the resident's oxygen levels, they may fail to provide the resident with supplemental oxygen (additional oxygen to maintain oxygen levels above 90%) as needed. The finding are: A. On 07/11/23 at 2:37 pm, during an observation and interview, R #12 was sitting in her wheelchair, resident did not have her oxygen on and stated, I always use oxygen, the girls (CNA's) always put it on me, but I forgot to remind them. B. Record review of R #12's Physician's orders revealed: Order date 12/07/22 Oxygen via nasal cannula (tubing) 2 liters per minute as needed for Dyspnea (shortness of breath) Hypoxia (low oxygen levels) or Acute Angina (chest discomfort or shortness of breath caused when heart muscles receive insufficient oxygen-rich blood). C. Record review of R #12's…

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

Based on record review and interview, the facility failed to provide Dementia (group of symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function, caused by the permanent damage or death of the brain's nerve cells) Care training, to 1 (LPN #11) of 3 (LPN #11, RN #11, and RN #12) staff sampled for training. This deficient practice could likely result in residents not receiving the services necessary to attain or maintain their physical, mental, and psychosocial (involving both psychological and social aspects) well-being. The findings are: A. Record Review of annual staff trainings revealed no training completed for Dementia Care for LPN #11. B. On 07/14/23 at 10:45 AM, during an interview, the Administrator confirmed that there was no Dementia Care training for LPN #11.

Based on record review and interview, the facility failed to provide Behavioral Health (the emotions and behaviors that affect your overall well-being) training, to 2 (LPN #11 and RN #12) of 3 (LPN #11, RN #11, and RN #12) staff sampled for training. This deficient practice could likely result in residents not receiving the services necessary to attain or maintain their physical, mental, and psychosocial (involving both psychological and social aspects) well-being. The findings are: A. Record Review of annual staff trainings revealed no training completed for Behavioral Health for LPN #11 and RN #12. B. On 07/14/23 at 10:45 AM, during an interview, the Administrator confirmed that there was no Behavioral Health training for LPN #11 and RN #12.

Based on record review, observation, and interview, the facility failed to implement a comprehensive person-centered care plan for 1 (R #13) of 4 (R #7, R #13, R #19, and R #33) residents reviewed for dental care. Failure to implement a resident-centered care plan may result in staff's failure to understand and implement the needs of residents, likely resulting in residents not receiving the care and/or treatment needed. The findings are: A. On 07/11/23 at 2:08 pm during an interview, R #13 revealed that she needs a dental appointment to address her missing teeth. B. On 07/11/23 at 2:08 pm during observation of R #13 revealed several missing teeth. C. Record review of R #13's Care Plan revised date 03/03/23 revealed: 1. The resident has oral/dental health problems. She is missing some teeth. 2. Resident will be free of infection, pain or bleeding in the oral cavity by/through review. D. On 07/12/23 at 02:14 PM during an interview, the Social Worker revealed that she had not set up an appointment for R #13 because she was not aware of any issues.