Taos Healthcare

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure psychotropic medication (medication used to treat mental health conditions) consent forms were signed by the resident or resident representative prior to medication administration for 3 (R #'s 3, 6, and 8) of 3 (R #'s 3, 6, and 8) residents reviewed for unnecessary psychotropic drugs. This deficient practice is likely to put residents at an increased risk for undesirable side effects (including but not limited to; increased thoughts of suicide, insomnia, fatigue, sexual dysfunction) associated with the use of these medications.The findings are:R #3: A. Record review of R #3's face sheet revealed R #3 was admitted into the facility on [DATE]. B. Record review of R #3's physician orders dated October and November 2025 revealed the following: 10/08/25: Buspirone HCL (anti-anxiety medication), give 10 mg (milligrams) by mouth three times a day for anxiety. Order was discontinued on 11/04/25. 11/04/25: Buspirone HCL, give 15 mg by mouth three times…

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 residents were free from abuse for 1 (R #25) of 1 (R #25) resident reviewed, when:Facility nursing staff used threatening language via text messages to R #25 while on approved facility leave. A facility nurse inappropriately touched R #25's foot when he returned to the facility after approved facility leave. If the facility performs inappropriate use of text messaging and touching, then residents are at risk for physical injury and psychological harm, including fear or distress related to staff interactions. The findings are: A. Record review of R #25's face sheet revealed R #25 was admitted into the facility on [DATE]. B. Record review of R #25's nursing progress notes dated 12/28/25 revealed the following: 12/28/25 at 3:54 am: R #25 was not in his room, sign out log indicated R #25 signed out of the facility on 12/26/25 at 10:20 am to go home. R #25's cellphone was called, but R #25 did not answer. R #25's wife was called, and she stated she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR; a federal requirement to help ensure individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) Level 1 screening was completed accurately for 1 (R#6) of 1(R #6) resident reviewed, when the PASRR level 1 indicated no mental health diagnosis despite admission documentation identifying a diagnosis of bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). This deficient practice could result in the facility failing to identify and address residents' mental health needs and ensure appropriate screening and services at admission.The findings are:A. Record review of R # 6's face sheet revealed R #6 was admitted to the facility on [DATE] with the following diagnoses:Unspecified dementia, moderate, with agitation (a group of conditions characterized by impairment…

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 revise the care plan for 1 (R #11) of 1 (R #11) resident reviewed for oxygen (O2) use. If the facility is not updating the care plan to reflect the residents' current care areas and treatment, then the facility may not be providing the appropriate care and treatment to meet the residents' needs. The findings are:A. Record review of R #11's face sheet revealed R #11 was admitted into the facility on [DATE]. B. Record review of R #11's physician orders dated 12/16/25 revealed R #11 was prescribed O2 at 2 liters per minute (LPM) via nasal cannula (a small, flexible tube that delivers oxygen to the nose through soft prongs). C. Record review of R #11's care plan dated 12/23/25 revealed O2 use was not care planned for R #11. D. On 01/15/26 at 9:56 am during an interview with Certified Nursing Assistant (CNA) #2, he confirmed R #11 wears O2 every day. E. On 01/15/26 at 3:09 pm during an interview with the Regional Nurse Consultant (RNC), she confirmed 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 interview and record review, the facility failed to ensure pain management was provided in accordance with professional standards for 1 (R #25) of 3 (R #21, 25 and 60) when staff administered pain medication to a resident when the resident reported pain levels of 2 - 7, which did not meet the physician's ordered parameters of 8 or higher. If staff are not following physicians' orders then residents are at risk of being over medicated and may have inadequate pain control. The findings are:Based on interview and record review, the facility failed to ensure pain management was provided in accordance with professional standards for 1 (R #25) of 3 (R #25, #00 and 00) when staff administered pain medication to a resident when the resident reported pain levels of 00 - 00, which did not meet the physician's ordered parameters of 00 -00. If staff are not following physicians' orders then residents are at risk of being over medicated and may have inadequate pain control. The findings are:A. On 01/12/2026 at 3:09 pm during an interview, R #25 stated that sometimes the facility does…

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 interviews; the facility failed to acquire medications for 1 (R #61) of 9 (R 35, R #16, R #26, R #58, R #61, R #65, R #67, R #89, and R #103) residents. This deficient practice is likely to result in missed doses of medication continuing, and potentially lead to serious harm, exacerbation of disease process, or other adverse outcomes for residents.The findings are:A. On 01/12/26 at 4:18PM, during an observation of medication administration, Registered Nurse (RN) #1 administering medications for R #61, Symbicort aerosol 160-4.5 mcg (micrograms)/act (per actuation/puff) inhaler (budesonide [a bronchodilator]/formoterol [a steroid]; inhaled medication to expand lungs and airway) not administered.B. On 01/12/26 at 4:18PM during an interview with RN #1, she stated the medication is not available and is not present in Rx Now machine (a device for storing medications) as an emergency supply. RN #1 stated she spoke with pharmacy regarding inhaler for R #61, currently awaiting delivery of medication.C. Record review of R #61 medication administration…

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 results of all investigations of allegations of abuse, neglect, and injuries of unknown source were submitted to the State Agency within 5 working days for 1(R #1) of 1(R #1) resident. If the facility is not submitting the five-day follow-up, residents are likely to be at risk of further abuse/neglect. The findings are:A. Record review of the facility's investigations revealed that a 5 day follow up had not been submitted to the state agency. B. On 09/29/25 at 5:21 pm during an interview with the facility's Administrator, he confirmed that a five day follow up had not been submitted to the state agency.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to thoroughly investigate allegation of abuse for 1 (R #1) of 1 (R #1) resident reviewed for abuse. If staff do not thoroughly investigate allegations of abuse, then the other residents are at risk of abuse which may cause physical, emotional, and psychological harm. The findings are: A. Record review of R #1's face sheet revealed he was admitted to the facility on [DATE] and discharged to acute care hospital on [DATE] with multiple diagnoses including, but not limited to: -Acute (sudden onset) kidney failure (sudden loss of kidney function) -Hydroureter (swelling of the ureter [duct by which urine passes from the kidney to the bladder] due to urine buildup) -Obstructive (blockage) and reflux (the flow of a fluid through a vessel or valve in the body in a direction opposite to normal) uropathy (blockage in the urinary tract), unspecified -Need for assistance with personal care -Personal history of malignant (tern to describe active cancer cells or tumors)…

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 when staff failed to: 1. Ensure opened food items in the refrigerator, freezer, and dry storage room were dated and labeled. 2. Ensure staff utilized a sanitizing solution when cleaning various food related surfaces. 3. Ensure eggs and cheese were stored in a manner to prevent food borne pathogen growth when not in the refrigerator. 4. Ensure all storage areas are kept clean and free of debris. 5. Ensure kitchen staff wore their face mask appropriately. These deficient practices are likely to affect all 85 residents listed on the resident census list and are likely lead to foodborne illnesses if food is not being stored properly and safe food handling practices are not adhered to. The findings are: A. On 12/05/24 at 8:40 am, an observation of the facility kitchen revealed the following: - Eight eggs and a small package of sliced cheese sat on a cart next to the kitchen stove. The eggs and cheese sat for one hour and were not on ice. The eggs were warm to touch,…

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 give written notice for a room change, including the reason for the change, before the residents were moved for 2 (R #1 and R #3) of 2 (R #1 and R #3) residents. This deficient practice is likely to result in frustration and confusion for residents. The findings are: Findings for R #1: A. Record review of R #1's face sheet, dated 11/25/24, revealed the following: - admission date of 09/12/24. - Other drug induced secondary Parkinsonism (symptoms that may occur due to the side effects of taking certain medications.) - Dementia, mild, with other behavioral disturbance (a disease that causes loss of memory, language, problem-solving and other thinking abilities.) - Disorganized schizophrenia (a mental disorder characterized by speech, emotional expressions, thoughts, and actions that are disorganized or not in tune with what is expected or appropriate.) - Cognitive communication deficit (difficulty understanding and speaking with other people.) - Other symptoms and signs involving cognitive functions and awareness. B. Record…

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 ensure 3 (R #5, #6 and #7) of 3 (R #5, #6 and #7) residents reviewed had a working portable concentrator. This deficient practice is likely to have a resident become hypoxic (having too little oxygen in the blood). The findings are: R #5 A. Record review of physicians orders for R #5, dated 12/16/23, revealed oxygen (O2) administered at 2 liters per minute (LPM) continuous per nasal cannula (a medical device that consists of a small, flexible tube with two prongs that sit inside a patient's nostrils), face mask, or facial tent via O2 concentrator or tank. B. On 11/25/24 at 12:15 pm during an observation, Certified Nurse Aide (CNA) #1 checked R #5's portable O2 concentrator and stated there was not any oxygen coming out of the concentrator and not functioning. CNA #1 asked Minimum Data Set (MDS) Director #1 to check R #5's oxygen saturations, and R #5's oxygen saturation measured 82 percent (%; ideal oxygen saturations 95% to 100%). CNA #1 and MDS director were unsure as to how long R #5's concentrator had 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 notify the Providers (Physicians and Nurse Practitioners) of a change in condition in which a resident began to have behaviors for 1 (R #1) of 1 (R #1) residents reviewed for change of condition. If the physician is not notified of changes in residents status then residents are likely to not get the care needed. The findings are: A. Record review of R #1's face sheet, dated 11/25/24, revealed the following: - admission date of 09/12/24. - Other drug induced secondary Parkinsonism (symptoms that may occur due to the side effects of taking certain medications.) - Dementia In other diseases classified elsewhere, mild, with other behavioral disturbance (a disease that causes loss of memory, language, problem-solving and other thinking abilities.) - Disorganized schizophrenia (a mental disorder characterized by speech, emotional expressions, thoughts, and actions that are disorganized or not in tune with what is expected or appropriate.) - Cognitive communication deficit (difficulty understanding and speaking with other…

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 had been done for 1 (R #1) of 2 (R #1 and #8) residents reviewed for an allegation of abuse. If the facility fails to complete thorough investigations residents are likely to feel frustrated and unsafe. The findings are: R #1 and R #8 A. Record review of the facility's Follow Up Report to the State Agency, dated 10/29/24 at 5:19 pm, revealed the following: 1. R #1 was in the dining room with R #8 and waited for meal service. 2. Both residents held hands and kissed each other's hands. 3. R #1 leaned in and kissed R #8 on the lips as R #8's husband entered the dining room. 4. R #8's husband became upset and alerted staff to what happened. B. Record review of R #1's behavior charting, dated 10/24/24, revealed R #1 tried to encourage a female resident to come to his room or he tried to enter their rooms. Resident held hands with female residents and kissed their hands. Interventions attempted: Reminded…

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 include required information in the residents medical record for transfer or discharge for 1 (R #1) of 1 (R #1) residents reviewed for discharges. This deficient practice is likely to result in resident and residents family being unable to locate an appropriate placement putting the residents at risk of an unsafe discharge. The findings are: A. Record review of R #1's face sheet, dated 11/25/24, revealed the following: - admission date of 09/12/24. - Other drug induced secondary Parkinsonism (symptoms that may occur due to the side effects of taking certain medications.) - Dementia In other diseases classified elsewhere, mild, with other behavioral disturbance (a disease that causes loss of memory, language, problem-solving and other thinking abilities.) - Disorganized schizophrenia (a mental disorder characterized by speech, emotional expressions, thoughts, and actions that are disorganized or not in tune with what is expected or appropriate.) -…

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, record review, and an observation of the [NAME] Unit, the facility failed to ensure a medication cart remained locked when not in use. This deficient practice is likely to result in residents having access to the medications in the unlocked medication cart. The findings are: A. Record review of the facility's Security of Medication Cart Policy, dated April 2007, revealed medication carts must be securely locked at all times when out of the nurse's view. B. On 12/02/24 at 12:18 pm during an observation of the [NAME] Unit, the medication cart was unlocked and unattended. Further observation revealed nursing personnel were not present, and residents walked around and sat close to the unlocked medication cart. C. On 12/02/24 at 12:19 pm during an interview with Registered Nurse (RN) #1, he confirmed the medication cart should be locked at all times when not in use. RN #1 further stated he stepped away to assist another resident and was aware he should have locked the cart.

Based on record reviews and interviews, the facility failed to ensure the facility had sufficient staff to meet the needs of all 77 residents who resided in the facility when staff failed to: 1. Offer baths or showers to residents as scheduled and per resident preference. 2. Effectively communicate with residents to meet their needs. These deficient practices are likely to negatively impact resident comfort. The findings are: Resident Baths and Showers: A. Refer to F561 and F677 for related findings. B. On 09/25/24 at 1:23 pm during an interview with an anonymous staff member (ASM), they stated the facility did not have enough staff which resulted in resident baths or showers being missed often. C. On 09/25/24 at 3:34 pm during an interview with CNA #1, she stated sometimes the facility will experience short staffing, and resident baths and showers get missed when that happens. D. On 09/25/24 at 4:02 pm during an interview with CNA #2, she stated there was not enough staff to clean up resident beds and give residents baths and showers. CNA #2 also stated there is not any staff 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, interview, and record review, the facility failed to maintain the kitchen in a sanitary manner when staff failed to: - Store food in a manner that prevented cross contamination when staff did not label and date open food items. - Utilize hair restraints and beard guards in a manner which restrained all hair while in the kitchen. - Test the sanitizer level in a sanitizing bucket. - Failure to store ice scoop appropriately. 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. The findings are: Unlabeled and Undated Food Items: A. On 09/22/24 at 3:55 pm, observation of the Dietary Department refrigerators and freezers revealed the following: - One 6 ounce (oz) bowl of ice cream not labeled or dated. - One tray of 16 glasses of 8 oz. clear liquid not labeled or dated. - One 5 pound (lb) bag of radishes open to air, not dated. - One tray of unidentified food not labeled or dated. - One tray of 6 oz. glasses 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 interview, the facility failed to promote resident choices for 2 (R #72 and #175) of 2 (R #72 and #175) residents reviewed for choices when staff failed to: 1. Accommodate R #72's choice to have his pacemaker (a device that stimulates the heart rate when it is beating too slowly) monitor present in the facility. 2. Offer R #175 showers per his preference. These deficient practices are likely to result in the resident's personal choices not being honored. The findings are: R #72: A. Record review of R #72's face sheet revealed R #72 was admitted on [DATE] with a diagnosis of atrial fibrillation (an irregular and often very rapid heart rhythm). B. Record review of R #72's Care Plan Conference notes, dated 09/11/24, revealed R #72 had a pacemaker (a device surgically implanted in the body to deliver electrical pulses to the heart to help the heart beat in a regular rhythm) implanted in December, 2023 and had a pacemaker monitor at home. Family will bring it in and let them know to 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 interview, the facility failed to ensure residents received mail on Saturdays for all 77 residents who resided at the facility. 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 09/24/24 at 1:15 PM during the Resident Council meeting, the residents stated staff did not deliver mail to them on the weekends, but they thought staff should. B. On 09/26/24 at 9:06 AM during an interview with the Activities Director, she stated staff did not deliver mail on the weekends to the residents. She stated if the Post Office delivered mail to the front office on the weekend, then staff put it in the activities mail box for her to deliver on Monday. C. On 09/26/24 at 2:16 PM during an interview with the Administrator, she stated the expectation was for residents to get their mail on the weekends if that was when the Post Office delivered it to the facility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure staff revised the care plan for 4 (R #19, #39, #71, and #72) of 4 (R #19, #39, #71, and #72) residents reviewed when staff failed to: 1. Update the care plan to include a wander guard (wearable technology used to keep residents from wandering or eloping from the facility unattended) use for R #19 and #39. 2. Update the care plan to include family assistance with activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) care for R #71. 3. Update the care plan to include the use of a fall mat for R #72. 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 #19: A. On 9/22/24 at 5:12 PM during a random observation, R #19 wore a wander guard. B. Record review of R #19's care plan, dated 07/25/24, revealed staff did not care plan R #19's use of a wander guard. C. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) assistance for baths and showers by the facility staff for 1 (R #58) of 1 (R #58) residents reviewed for ADL care. This deficient practice is likely to affect the dignity and health of the residents. The findings are: A. Record review of R #58's face sheet revealed R #58 was admitted into the facility on [DATE]. B. Record review of R #58's care plan, dated 03/05/24, revealed the following: - Focus: R #58 had an ADL self-care deficit related to a history of fractures. - Interventions: Shower at least once a week and as needed. - R #58 was dependent on staff for bathing. C. Record review of the facility's bath and shower schedule revealed R #58 was scheduled to bathe or shower on Wednesdays and Saturdays. D. Record review of R #58's documentation survey report (Activities of Daily Living - ADL tracking form),…

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 restorative physical therapy service devices as recommended by the therapy department for 1 (R #37) of 1 (R #37) residents. This deficient practice is likely to result in residents having pain and a decrease in mobility, causing psychosocial harm and despair. The findings are: A. Record review of R #37's face sheet revealed R #37 was admitted into the facility on [DATE] with the following diagnoses: 1. Encephalopathy (a disease that affects brain structure or function and causes altered mental state and confusion). 2. Muscle weakness. 3. Quadriplegia (paralysis of all four limbs). B. Record review of R #37's care plan, dated 06/23/23, revealed R #37 required assistance to meet basic activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) care due to quadriplegia to include assistance with transfers and ensuring R #37's call light was in reach 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 Based on observation, record review, and interview, the facility failed to ensure 2 (R #12 and #62) of 2 (R #12 and #62) residents reviewed for behavioral health concerns received necessary behavioral health care to meet their needs when staff failed to ensure effective communication between the facility and psychiatric providers and provide consistent psychiatric services to meet R #12 and #62 psychiatric service needs. These deficient practices are likely to result in the residents not receiving the behavioral or mental health care and assistance needed to improve mood and reduce depression and anxiety. The findings are: R #12: A. Record review of R #12's face sheet revealed R #12 was admitted into the facility on [DATE]. B. Record review of R #12's care plan, dated 09/15/22, revealed R #12 had a diagnoses of depression, and facility staff should monitor R #12 for any signs of depression. C. Record review of R #12's nursing progress notes, dated 07/13/24, revealed Psychiatric Services Provider (PSP) #1 saw R…

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

Based on record review and interview, the facility failed to ensure 4 (R #13, #21, #48, and #6) out of 5 residents (R #13, #21, #48, #6 and #14) reviewed for immunizations had completed and signed consent/refusal forms on file to show they consented to or declined the pneumococcal (for pneumonia, an infection in one or both lungs) and influenza (flu) vaccines. If residents are not vaccinated as appropriate against pneumonia and influenza they have a higher likelihood of contracting that illness and spreading it to other residents and staff in the facility. The findings are: A. Record review of facility's Policies and Procedures for Pneumococcal and Influenza Prevention and Control, revised on 06/2020, revealed the resident's medical record should include documentation to indicate, at minimum, the resident consented or refused vaccinations. Findings for R #13 B. Record review of R #13's immunization record revealed the resident received the flu vaccination on 09/30/23, but the medical record did not contain documentation of the provision of education regarding the benefits 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 ensure Certified Nurse Aides (CNAs) received the required in-service training of at least 12 hours per year for 2 (CNAs #3 and #4) of 5 (CNAs #3,#4, #5, #6, and #7) CNAs randomly reviewed for required in-service training. This deficient practice is likely to result in the nurses aides not receiving the necessary training to meet the care needs of the residents. The findings are: CNA #3: A. Record review of the facility staffing list revealed CNA #3 was hired on 06/17/19. B. Record review of CNA #3's annual in-service training, dated 06/17/23 through 06/17/24, revealed CNA #3 did not complete at least 12 hours of required in-service training. C. Record review of the facility staffing schedule, dated 08/01/24 through 08/31/2,4 revealed CNA #3 worked seven CNA shifts in the facility during that timeframe. D. On 09/26/24 at 3:28 pm during an interview with the Administrator (ADM), she confirmed CNA #3 did not complete the required 12 hours of in-service training but should have. CNA #4: E. Record review 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 promote care with dignity and respect for 1 (R #19) of 1 (R #19) residents reviewed for residents' rights by placing a WanderGuard (a bracelet that sets off an alarm when the person wearing it attempts to exit the building) on a resident who did not attempt to leave the facility grounds. This deficient practice is likely to result in residents feeling as if they were kept in the facility against their will. The findings are: A. On 9/22/24 at 5:12 PM during a random observation, R #19 wore a wander guard. B. Record review of R #19's physicians orders revealed the resident did not have an order for a wander guard. C. Record review of #19's care plan, dated 07/25/24, revealed staff did not care plan the resident's wander guard. D. Record review of R #19's Elopement Risk Evaluation, dated 7/25/24, revealed the following: - Score of 6, moderate risk; - No Risk section: If yes to question A1 or A2, the assessment is complete. - Section A1: Resident was able to make decisions regarding task of daily living? 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, record review, and interview, the facility failed to prevent an accident for 1 (R #75) of 1 (R #75) residents reviewed for falls: 1. When the facility failed to routinely assess R #75 to check for injuries following the first fall. 2. When the facility failed to follow post-fall protocols after R #75's first and second falls. These deficient practices likely resulted in R #75 having falls with injuries that required treatment at the hospital. The findings are: A. Record review of the facility's Response to Fall policy, undated, revealed guidance for staff regarding post-fall assessment and monitoring: Following each resident fall, the licensed nurse to complete an incident report and perform a post-fall assessment and investigation. B. Record review of the facility's neurological assessment policy, dated 02/2019, revealed nursing staff should complete a neurological assessment after a resident fall as follows: - Every 30 minutes four times; - Every hour four times; - Every four hours four…

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 that ileostomy [a surgical procedure in which the last part of the small intestine (ileum) is connected to the abdominal wall and an opening (stoma) is created in the abdominal wall to allow waste to leave the body] care was consistent with professional standards of practice for 1 (R #13) of 1 (R #13) resident when the ostomy bag and the abdominal binder (wide compression belt that encircles the abdomen) was not consistently offered/applied per physician order. This deficient practice could likely result in skin breakdown/infection around the ostomy opening. The findings are: A. Record review of R #13''s face sheet revealed she was admitted to the facility on [DATE]. B. Record review of R #13's physician's orders revealed the following: 1. Dated 12/21/23, change ileostomy bag per wound orders. When resident refused ostomy (ileostomy) bag or continually removed bag, cleanse skin surrounding ostomy two times per shift daily. Cleanse…

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 Elopement Risk Evaluation was accurate for 1 (R #19) of 1 ( R #19) residents reviewed when staff did not accurately complete R #19's evaluation to reflect the resident's elopement risk. This deficient practice is likely to result in resident not receiving the appropriate care and treatment he may need. The findings are: A. Record review of R #19's Elopement Risk Evaluation, dated 7/25/24, revealed the following: - Score of 6, moderate risk; - No Risk section: If yes to question A1 or A2, the assessment is complete. - Section A1: Resident was able to make decisions regarding task of daily living? Staff answered no. - Section A2: Resident was unable to ambulate or mobilize wheelchairs? Staff answered yes. - Moderate Risk section: Resident was cognitive impaired and staff entered the following information: - Resident ambulated or propelled self; - Resident may go outdoors on occasion but did not make an attempt to leave grounds. - Action: Implement Elopement Risk Care Plan. - Imminent Risk section: Staff 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.

Based on observation and interview, the facility failed to ensure the bedroom for 1 of (R#3) of 1 (R #3) residents was clean, without food debris and used medical equipment on the floor. This deficient practice is likely to make the resident feel as if he was not important and he did not matter to the facility. The findings are: A. On 09/23/24 at 11:03 am during an observation and interview, R #3's room floor was dirty and sticky. There were food crumbs present by R #3, who sat in a wheelchair by the television, and there was an unknown yellow colored liquid on the floor next to R #3. Two of R #3's urinals lay on the nightstand, and the other one urinal lay on the floor near his bed. R #3's roommates side of the room was clean. R #3 stated the staff cleaned his room every now and then when they get a chance. R #3 stated there were times when his room was not cleaned by housekeeping staff. B. On 09/23/24 at 11:07 am during an interview with Licensed Practical Nurse (LPN) #3, she stated R #3's room was dirty and should be cleaned. LPN #3 stated she did not know why R #3's room was so…

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 residents' choices for 2 (R #4 and #5) of 2 (R #4 and #5) residents reviewed for choices when staff placed a bladder control pad (products made for incontinence control to pull moisture away from your skin) in the briefs of residents. These deficient practices are likely to result in the resident's personal choices, needs, and preferences not being honored. The findings are: A. On 05/09/24 at 2:58 pm during an interview with an anonymous former staff member, they stated Certified Nursing Assistants (CNAs) sometimes put a bladder control pad in the resident's brief so it did not leak. The former staff stated residents wear bladder control pads in their briefs a lot, because the CNAs did not want to change the residents as often. The former staff also stated CNAs would utilize the bladder control pads without asking for the residents' permission sometimes. B. On 05/10/24 at 10:24 am during an interview with CNA #2, she stated the facility 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 revise the care plan for 1 (R #1) of 3 (R #1, 2, 3) residents reviewed for falls. If the facility is not updating the care plan to reflect the resident's current care needs and treatments, then the facility may not be providing the appropriate care to meet the resident's needs. The findings are: A. Record review of R #1's face sheet revealed he was admitted to the facility on [DATE] with multiple diagnoses to include: - Urinary tract infection. - Personal history of transient ischemic attack (small minor stroke of unknown cause with short duration). - Cerebral infarction (a blood vessel located in the brain that is blocked reducing or stopping blood flow to that area) without residual deficits (no lasting effects). - Unspecified fall. - Cognitive communication deficit (inability to effectively speak with and understand others). B. Record review of R #1's daily care notes revealed staff documented the following: - On 10/04/23, a Certified Nurses Aide…

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, the facility failed to ensure that residents and resident representatives have a right to voice grievances to the facility without fear of discrimination or retaliation (the act of hurting someone or doing something harmful to someone, because they have done or said something harmful to you) for 7 (Anonymous residents/representatives) identified during random review. This deficient practice could likely result in residents not getting the care and assistance needed or feel like they must discharge from the facility to get the care needed/desired which may be further away from family support. The findings are: A. During interview, Anonymous Family (AF) Member #1 stated there have been several issues with their family member regarding showers, wound care, and food while at the facility. However, when she brought her concerns to the former Head Nurse, he/she was told they could take their family member somewhere else. B. During interview, AF #2 stated they had concerns about their family member's/resident's care regarding wounds, showers, feeding assistance, pain,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure staff updated the care plan to reflect the current conditions for 2 (R #5 ad 14) of 2 (R #5 and 14) residents reviewed during random observation. If the care plan is not updated to reflect the residents current conditions, then residents may not get the care and assistance needed. The findings are: Findings related to R #5 A. On 09/19/23 at 4:00 pm, during interview, the State Ombudsman (SO) reported that during a recent onsite visit on 09/08/23, she observed R #5 was on the edge of the bed, leaning and ready to fall over. She said staff told her this [leaned over at edge of bed] was the way R #5 preferred to sleep. The SO verified that it [position of sleeping] was not in the resident's care plan. B. Record review of R #5's face sheet revealed she was admitted to the facility on [DATE] and had the following diagnosis: - Unspecified dementia (a group of symptoms that affects memory, thinking and interferes with daily life) -…

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 an ongoing activity program to meet the residents' interests and support residents' psychosocial well-being for 5 (R #1, 4, 11, 12 and 13) of 5 (R #1, 4, 11, 12 and 13) residents reviewed for activities and during random observation. If the facility is not providing engaging activities to residents then residents are at risk of boredom, depression, and decrease in quality of life. The findings are: A. On 09/20/23 at 10:23 am, during an interview, R #1 stated, I like to play bingo, but we have not played BINGO in about 3 weeks and they don't offer any other activities. B. On 09/20/23 at 10:45 am, during observation, Today's Activities Schedule, posted on bulletin board in Dining Room Hallway, was dated 9/7/23. C. On 09/21/23 at 12:14 pm, Please clarify the time during an interview, R #13 stated, I like to draw and paint and play bingo, but no activities were offered yesterday or today. D. On 09/21/23 at 12:17 pm, during an interview, Certified Nurse Aide (CNA) #2 stated, There are no activities planned…

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 staff monitor anxiety symptoms and the effectiveness of anxiety medications being administered for 1(R #4) of 1(R #4) resident identified during random observation. If the facility is not monitoring for the use of psychotropic medications then resident may not be getting adequate relief and treatment from symptoms. The findings are: A. Record review of R #4's face sheet identified she was admitted to the facility on [DATE] and had the following diagnoses: - Encephalopathy (disease that affects brain structure and functioning causing altered mental state and confusion), - Epilespy (neurological disorder that causes seizures or unusual sensation and behaviors), - Quadriplegia (loss of motor functioning and sensation from the neck down) and chronic pain. - This is not all inclusive. B. Record review of the Medication Administration Record (MAR) for R #4, dated September 2023, identified R #4 has available Lorazepam (antianxiety) medication,…

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 the medical record accurately reflected resident's level of assistance and advanced directives for 6 (R #2, 7, 9, 14, 15 and 16) of 16 (R #1-16) residents reviewed for feeding assistance and during random observation. If resident medical records are not accurate, then there is not an accurate history of residents care. The findings are: Findings related to Advanced Directives: A. Record review of R #7's face sheet revealed she was admitted to the facility on [DATE]. B. Record review of R #7's progress notes, dated 08/10/23 at 1:00 pm, revealed Code Status: DNR (Do Not Resuscitate) - No CPR (Cardio Pulmonary Resuscitation) Do Not Attempt Resuscitation (allow natural death). C. Record review of R #7's New Mexico Medical Orders For Scope of Treatment (MOST) form, dated 06/03/22, also known as an advanced directives (a written statement of a person's wishes regarding medical treatment created to ensure those wishes are carried out…

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 call light functioned for 2 (R #4 and R #8) of 4 (R #2, #4, #8 and #13) resident reviewed for call lights within reach and during random observation. If residents are unable to request staff assistance when needed then residents are likely not able to get their needs met. The findings are: Findings related to R #4: A. Record review of R #4's Care Plan, dated 06/23/23, revealed, [Name of R #4] requires assistance to meet basic ADL self care and performance r/t (related to) dx (diagnosis) of quadriplegia. Interventions included Be sure call light is within reach and encourage to use it for assistance. Respond promptly to all requests for assistance. B. On 09/20/23 at 12:17 pm, during observation and interview, R #4 laid in bed. Her right and left arm were contracted (permanent tightening of the muscles, tendons, skin and surrounding tissue that causes the joints to be shorten and stiffen) and bent in a fixed position at the wrist, with fingers bent inward. R #4 stated she wanted to take her pressure…

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

Based on record review, observation, and interview, the facility failed to provide accommodation of residents needs for 1(R #4) of 4 (R #2, 4, 8 and 13) residents reviewed for call lights within reach and during random observation, when the call light/pressure pad call light was not within resident's reach. This deficient practice is 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 #4's Hospice RN (Registered Nurse) Assessment, dated 09/13/23, identified limited mobility/ROM (range of motion), quadriplegia (loss of motor functioning and sensation from the neck down), chair bound and painful to be up in wheelchair, stayed in bed for meals. under the Skilled Observation Musculoskeletal (the human body system that provides our body with movement, stability, shape, and support) section. B. Record review of R #4's Care Plan, dated 06/23/23, revealed [Name of R #4] requires assistance to meet basic ADL (activities of daily living) self care 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 notify the resident representative of resident change in conditions which required hospital transfer for 2 (R #1 and 8) of 2 (R #1 and 8) residents reviewed for wound care and during random observations. This deficient practice could likely result in the resident representative unable to provide advocacy and make medical decision when needed. The findings are: Findings for R #1: A. On 09/20/23 at 10:23 am during interview, R #1 reported she was recently sent to the emergency room due to pain in her foot and later flown to another hospital. B. Record review of Nursing Progress Notes for R #1 revealed: 1. 08/23/23, At approx. 10 am, [Name of Physician #1] examined pts (patients) right foot and found it cold to the touch and requested her to be sent to the [Name of Hospital ER]. Report called to ER and ambulance called. 10:40 transferred [Initials of Hospital]. Note did not identify that R #1's POA (Power of Attorney) was notified. 2. 08/30/23 She was sent out 8/23/23 with severe right foot pain, right foot was cold 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 upon record review, observation, and interview the facility failed to ensure that 1 (R #4) of 1 (R #4) resident observed during random observation was free from neglect when facility staff failed to respond to R #4's cries/yelling out. This deficient practice could likely result in residents going without the assistance, care, or treatment needed and/or experiencing feelings of helplessness and not being cared for, resulting in mental anguish (a degree of mental pain and suffering that arises from another person's negligence - failure to exercise the care that a reasonably sensible person would exercise in like circumstances). The findings are: A. On 09/19/23 at 4:00 pm, during interview, State Ombudsman (SO) reported that during recent onsite visits at the facility, she observed R #4 laid in bed and slept throughout the visit. SO reported she asked the Director of Nursing (DON) to move R #4 closer to the nurse's station so staff could watch her more closely. B. Record review of R #4's Hospice RN (Registered Nurse) Assessment, dated 09/13/23, identified limited mobility/ROM…

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 transport residents to physician appointments for 1 (R #8) of 1 (R #8) resident reviewed for follow up appointments. This deficient practice could likely cause delays in needed care and/or treatment prolonging the healing process. The findings are: A. Record review of R #8's face sheet revealed he was admitted to the facility on [DATE]. B. Record review of R #8's History and Physical Note, dated 09/13/23, revealed, New admission to facility 9/9/2023 .Admitting diagnosis: aftercare following right knee prosthetic explant (devices or tissues that are placed inside or on the surface of the body) and an articulating antibiotic spacer implant (device used to treat infection after a total knee replacement). Chronic septic arthritis (infection of the joint). C. On 09/21/23 at 12:45pm, during an interview, R #8 stated, These people (the facility) cancelled my post op (operation) appointment for my knee (right) on Tuesday (09/19/23). D. On 09/21/23 at 2:43pm,…

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

Based on interviews the facility failed to ensure that they had sufficient staff to guarantee the needs of all 88 residents residing in the facility. 1. Offering baths/showers to residents; 2. Changing residents briefs timely; 3. Having enough facility staff to meet the needs of the residents. These deficient practices are likely to negatively impact resident safety, comfort, and to impede processes such as timely incontinence care (assisting residents to the bathroom or changing adult briefs), regular turning schedules (moving or turning residents that need assistance and are unable to move on their own), timely showers and appropriate assistance with meals. Baths/Showers Findings: A. On 08/09/23 at 10:30 PM, during an interview, Certified Nurse Assistant (CNA) #5 stated sometimes it is tough with the showers. Sometimes they do not get finished with showers, because the facility does not have enough CNA's. B. On 08/09/23 at 10:35 PM, during an interview, CNA #4 stated there are many times there is not enough staff to complete all the tasks that need to get done. (For example…

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 nutritional needs and preferences were met for all 88 residents, listed on the resident census provided on 08/07/23. If staff do not follow the menu and do not have the specified menu items on hand to meet this requirement then residents are not likely to not receive the appropriate nutrition. The findings are: A. On 08/07/23 at 5:10 PM, during observation of the dinner meal, staff served the residents a bologna and cheese sandwich. B. Record review of the menu for 08/07/23 identified ham and cheese sandwiches to be served for dinner. C. On 08/07/23 at 5:13 PM, during an interview, the Dietary Manager (DM) stated bologna was served instead of ham, because the ham was not available. D. Record review of the facility menu for 08/13/23 revealed staff to serve scrambled eggs and bacon for breakfast and taco salad for dinner. E. On 08/13/23 at 11:08 AM, during an interview, Kitchen [NAME] (KC) #1 stated, We had no coffee and no scrambled eggs. Sometimes we do not have ingredients, and we run out of food for Sundays…

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

Based on interviews, the facility failed to: 1. Provide hydration between meals; 2. Provide coffee during breakfast meal. These deficient practices are likely affect all 88 residents listed on the census as provided by the Director of Nursing (DON) on 08/07/23 and likely result in residents becoming at increased risk for dehydration. The findings are: A. On 08/07/23 02:38 PM, during an interview, R #37 stated, There is no fresh water, and it is 4:00 in the afternoon. R #37 stated staff had not delivered fresh water on 08/07/23, and it was late into the day. B. On 08/08/23 at 9:11 AM, during Resident Council Meeting, R #2 stated, We have not been getting water between meals for a while now, especially on weekends. C. On 08/08/23 at 2:23 pm, during an interview, R #35 stated she had not been getting water between meals. D. On 08/13/23 at 11:04 AM, during interview, Assistant Director of Nursing (ADON) stated staff had not provided water/hydration to the residents last night [08/12/23] or this morning [08/13/23], because they were short on staff. E. On 08/13/23 at 10:57 AM during an…

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

Based on observation, interview, and record review the facility failed to deliver meals consistently and timely for all 88 residents in the facility. This deficient practice could potentially lead to frustration and hunger. The findings are: A. Record review of meal times revealed: - Breakfast scheduled at 7:30 AM - Lunch scheduled at 11:30 AM - Dinner scheduled at 5:00 PM B. On 08/07/23 at 12:30 PM, during dining observation of lunch meal, residents were observed sitting at tables and had not received their meal. C. On 08/09/23 at 8:33 AM, during dining observation of the breakfast meal, staff began to pass hall trays to the residents at 8:30 AM, and they passed the last hall tray at 8:49 AM. D. On 08/15/23 , during an interview, Dietary Manager stated they have a delay on getting the meals served on time to the residents, because CNA's (Certified Nurse Assistants) are not available.

Based on record review and interview, the facility failed to ensure staff implemented a comprehensive antibiotic stewardship program (a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use). This deficient practice has the potential to affect any of the 88 residents identified on the census provided by the Director of Nursing (DON) on 08/07/23, and who might be placed on antibiotics, which could result in the inappropriate use of antibiotics and that can lead to resistance of multi-drug resistant organisms. The findings are: A. Record review of the facility's Antibiotic Stewardship Program Policies and Procedures, dated 06/2020, revealed, Leadership: The facility's leadership team will identify an Infection Preventionist (IP) who will collaborate with the Medical Director to oversee the Antibiotic Stewardship Program (ASP) for the facility. 1. The facility's leadership team will communicate the mission, goals, and expectations of the ASP with attending physicians and staff. 2. If indicated,…

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 observation, the facility failed to respond to resident grievances, regarding another resident yelling and cussing, for 1 (R #61) of 1 (R #61) resident reviewed. If the facility fails to respond to residents' grievances then residents are likely to feel uncomfortable and could exacerbate (make worse) health issues. The findings are: A. On 08/08/23 at 10:35 AM, during an interview, R #61 stated her neighbor yells and uses foul language all day and night, and it is very disturbing. She further stated she has complained to nursing staff and filed a grievance (unsure of date) and nothing has been done. B. On 08/08/23 at 10:40 AM, during observation and interview with R #6, this writer heard R #61's neighbor yell in a very loud voice, and R #61 stated That's what I'm talking about. C. On 08/15/23 at 9:30 AM, during interview, the Director of Nursing (DON) stated she was familiar with R #61's neighbor. She stated he had behaviors and yelled. She further stated staff could move R #61's neighbor, but staff had not initiated the move. The DON confirmed she was unaware…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the care plan was revised for 4 (R #'s 14, 37, 59 and 91) out of 5 (R #'s 1, 14, 37, 59, and 91) residents reviewed by: 1. Not conducting quarterly care plan meetings as required for R #'s 14, 37, and 59; 2. Not updating a care plan to reflect oxygen (O2) use for R #59 and hospice (health care that focuses on the palliation of a terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) services for R #91. These deficient practices are likely to result in staff not being aware of residents care needs and preferences, and residents not receiving the needed care. The findings are: Findings for R #14: A. Record review of R #14's face sheet revealed R #14 was admitted into the facility on [DATE]. B. Record review of R #14's Care Conference Assessment revealed R #14's last care conference occurred on 08/31/22. C. On 08/08/23 at 12:48 pm, during an interview, R #14 stated, It's been a long time…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to meet professional standards of quality for 2 (R #'s 57 and 59) of 2 (R #'s 57 and 59) residents by not 1. Changing R #57's oxygen (O2) weekly as ordered; 2. Labeling, dating, and changing O2 for R #59. If the facility is not changing and labeling oxygen tubing then residents are likely to not receive the therapeutic benefits and care needed. The findings are: Findings for R #57: A. Record review of R #57's face sheet revealed R #57 was admitted into the facility on [DATE]. B. Record review of R #57's physician orders, dated 11/29/22, revealed, 2L [liters] NC [nasal cannula- device used to deliver O2 to the patients face] to keep sats [saturations] > [greater than] 88% [percent]. Sats daily and PRN [as needed] for dyspnea [shortness of breath]. C. On 08/07/23 at 3:03 pm, during an interview and observation, R #57 confirmed she wore O2 daily. R #57 was observed wearing O2 with the tubing, dated 07/28/23, connected to a concentrator. D. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide ADL (Activities of Daily Living) assistance for 2 (R #'s 1 and 32) of 2 (R #'s 1 and 32) residents reviewed for ADL care by not: 1. Changing R #1's wet brief; 2. Providing baths/showers for R #32. These deficient practices are likely to affect the dignity and health of the residents if they are left in wet briefs or are not offered a bath or shower on a regular basis. The findings are: R #1: A. On 08/07/23 at 4:59 PM, during an interview, R #1's Power of Attorney (POA) stated she came to visit and found R #1 sitting in a wet brief. She reported it to the nurse on duty, and the nurse sent the Certified Nursing Assistant (CNA) to change R#1. The POA stated she will change the resident if they take too long. POA stated this has happened multiple times. B. On 08/15/23 at 12:17 PM, during interview, Registered Nurse (RN) #1 stated the POA for R #1 complained about finding the resident in a wet brief. He further stated he will check the resident and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to assure physicians responded to the pharmacist's recommendations submitted during the pharmacist's monthly medication review and obtain physician rational, specific to the resident, which agreed or disagreed with the pharmacist's recommendations for 1 (R #2) of 6 (R #'s 1, 2, 6, 14, 35, and 79) residents reviewed for unnecessary medications. This deficient practice is likely to cause resident medication regimen to not be properly evaluated resulting in possible over medication. The findings are: A. Record review of R #2's face sheet revealed R #2 was admitted into the facility on [DATE]. B. Record review of R #2's physician orders, dated 03/30/21, revealed, Clonazepam tablet, 0.5 MG [milligrams], *Controlled Drug,* Give 0.5 mg by mouth two times a day for anxiety. C. Record review of R #2's note to attending physician/prescriber (Pharmacy Review), dated 03/21/23, revealed, This resident [R #2] has been taking the anxiolytic Clonazepam 0.5 mg twice daily…

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 psychotropic medication (medication used to treat mental health conditions) consent forms were signed by the resident or resident representative prior to medication administration for 5 (R #'s 6, 9, 45, 52, and 56) of 5 (R #'s 6, 9, 45, 52, and 56) residents reviewed for unnecessary psychotropic drugs. This deficient practice is likely to put residents at an increased risk for undesirable side effects (increased thoughts of suicide, insomnia, fatigue, sexual dysfunction) associated with the use of these medications. The findings are: Findings for R #6: A. Record review of R #6's face sheet revealed R #6 was admitted into the facility on [DATE]. B. Record review of R #6's physician orders, dated 06/28/23, revealed, Escitalopram Oxalate oral tablet, 5 MG [milligrams]. Give 5 mg by mouth one time a day for depression/anxiety. C. Record review of R #6's pharmacist recommendations, dated 07/18/23, revealed, The resident [R #6] has an order 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.

Based on observation and interview, the facility failed to: 1. Ensure expired medications are discarded and not stored in the cart; 2. Ensure expired medications were not stored with unexpired medications; 3. Ensure medications, stored on medication cart for 200 and 300 halls, were kept in their original labeled packaging and in a manner that maintains the sterility of the product. These deficient practices are likely to negatively impact the health of residents if they received expired, potentially ineffective/compromised, or contaminated medications and medical supplies due to inappropriate storage. The findings are: A. On 08/08/23 at 9:21 AM, during observation of the medication cart for the 200 and 300 halls,one half pill was loose on the bottom of the second drawer. B. On 08/08/23 at 9:34 AM, during observation of the medication storage room for the 100 and 200 units', the following expired medications were located on the wound cart; 1. One tube containing Tretinoin Cream 0.025, which expired on 07/23 and belonged to R # 54; 2. One tube containing Diclofenac Sodium 1% (percent)…

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 Certified Nurse Aides (CNA's) received the required in-service training of not less than 12 hours per year for 7 (CNA #13, CNA #14, CNA #15, CNA, #16, CNA #17, CNA #18, and CNA #19) of 7 (CNA #13, CNA #14, CNA #15, CNA, #16, CNA #17, CNA #18, and CNA #19) CNA's randomly reviewed for required in-service training. This deficient practice is likely to result in the nurses aides not receiving the necessary training to meet the care needs of the residents. The findings are: A. Record review of the facility personnel files revealed the following: 1. CNA #13 was hired on 06/17/19. 2. CNA #14 was hired on 02/27/07. 3. CNA #15 was hired on 09/04/20. 4. CNA #16 was hired on 07/21/17. 5. CNA #17 was hired on 08/18/22. 6. CNA #18 was hired on 01/17/08. 7. CNA #19 was hired on 08/23/22. B. Record review of the facility staffing schedule, dated July 2023, revealed the following: 1. CNA #13 worked on 07/03-07/07 and 07/24-07/28. 2. CNA #14 worked on 07/03-07/07 and 07/24-07/28. 3. CNA #15 worked on 07/24-07/28. 4. CNA #17 worked…

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 provide reasonable accommodations of resident needs and preferences for 2 (R #7 and 66) of 2 (R #7 and 66) residents reviewed by: 1. Not accommodating R #7's preference for what time she gets up in the morning; 2. Not accommodating R #66's preference of using pull-up's (disposable underwear) for incontinence (loss of bladder control). If facility is not honoring resident preferences then residents are not able to make choices about aspects of their lives which are important to them. This deficient practice is likely to result in the resident's life style, personal choices, needs, and preference not being met. The findings are: R #7 A. On 08/08/23 at 1:54 PM, during an interview with R #7, when asked if she is able to make choices about when she gets up in the morning and when she goes to bed at night, she stated, No, I'm told when to get up. I would like to get up at 7:00 am, and staff get me up between 5:00 AM and 5:30 AM. B. On 08/15/23 at 11:11 AM, during an interview with Registered Nurse (RN) #1, he stated R #7…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to notify the resident's Power of Attorney (POA) when an accident occurred for 1 (R #1) of 1 (R #1) residents reviewed for falls. If the facility does not notify the POA when the resident has a fall then the POA is unable to make decisions related to treatment and advocate for the resident's care. The findings are: A. Record review of progress note, dated 9/22/22, RN #2 wrote R #1 had an unwitnessed fall with injury. RN #2 did not document the POA was notified. B. On 08/07/23 at 4:06 PM, during an interview, R #1's POA stated R #1 had a fall a few months ago (unsure of the date), and the staff did not notify her. She found out about the fall when she went to visit R #1 and saw a bump on her forehead. C. On 08/15/23 at 12:15 PM, during an interview, Registered Nurse (RN) #1 stated R #1 had a fall a few months ago, and she obtained a bump on her forehead. She stated, It was not on my shift, but all falls should be documented in her progress notes. D. On…

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

Based on interview, observation, and record review, the facility failed to develop a discharge plan that focused on the resident's individualized discharge goals and needs for 3 (R #'s 35, #88 and #89) of 3 (R #'s 35, #88 and #89) residents reviewed for discharge planning. This deficient practice is likely to prevent a safe transition from the facility to the resident's post-discharge setting. The findings are: Findings for R #88 and R #89 A. On 08/08/23 at 10:40 AM, during an interview, R #88 and R #89 (husband and wife residing in facility) stated they wanted to go home, and the facility was not allowing them to go home. R #89 stated they had a meeting the week prior (08/02/23), and at that time, they voiced they would like to discharge home. R #89 further stated she did not feel the facility was making any effort to assist them in making the transition. R #89 stated the facility told them they would have to leave AMA (Against Medical Advice), because they received therapy services and had not been discharged from therapy. B. On 08/09/23 at 10:58 am, during an interview, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that 1 (R #50) of 1 (R #50) resident, reviewed during random observation, received the appropriate supervision to prevent or minimize the risk of elopement (an unauthorized departure of a patient from an around-the-clock care setting) when the facility failed to notify facility leadership of an elopement attempt and revise the elopement risk assessment and the plan of care. This deficient practice could likely put residents at risk of unsafe situations. The findings are: A. Record review of R #50's face sheet revealed R #50 was admitted into the facility on [DATE]. B. Record review of R #50's elopement risk assessment, dated 06/17/23, revealed R #50 was a Moderate Risk (an identified concern, without mitigation is likely to cause the resident to experience injury) for elopement. C. Record review of R #50's care plan, dated 06/29/23, revealed, Focus: At Risk for elopement r/t [related to] (specify): Disoriented to place, Impaired safety…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to maintain oxygen (O2) equipment according to professional standards for 2 (R #'s 59 and 76) of 2 (R #'s 59 and 76) residents reviewed for respiratory care by applying R #59's O2 saline and concentrator on R #76 in error. This deficient practice could likely result in oxygen tubing not being changed according to the date of install or the previous replacement and using humidifier bottles without physician instruction. The findings are: A. Record review of R #59's face sheet revealed R #59 was admitted into the facility on [DATE]. B. Record review of R #59's physician orders, dated 08/10/22, revealed, Oxygen via NC [nasal cannula- tubing device used to deliver O2 to a patient's face] @ [at] 2L [liters]/min [minute]. Titrate to keep 02 sats [SA, saturations] > [greater than] 88% [percent]. C. Record review of R #76's face sheet revealed R #76 was admitted into the facility on [DATE]. D. Record review of R #76's physician orders, dated 06/22/23, revealed,…

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

Based on observation and interview, the facility failed to: 1. Ensure safe serving temperatures (cold foods: equal to or less than 40 degrees Fahrenheit and hot foods: equal to or greater than 135 degrees Fahrenheit) were maintained for room trays awaiting to be distributed to the residents; 2. Ensure cups of milk were maintained temperature below 40 degrees. These deficient practices are likely to cause resident to suffer from food borne illnesses if food is not served at the proper temperature. The findings are: A. On 08/15/23 at 12:34 pm, during a meal time observation of the 600 unit room tray food cart, the following temperatures were observed: Chicken tortilla soup was 130 degrees (°) Fahrenheit (F), Spanish rice was 120° F, broccoli was 120° F, Jell-O (lemon) was 45° F, and lemonade drink was 52° F. B. On 08/15/23 at 12:42 pm, during observation and interview, Dietary Manager (DM) used a food grade thermometer to take the temperatures of the food on trays. DM confirmed the temperature of food items and stated the food items were not at the appropriate temperatures. C. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview the facility failed to maintain proper infection prevention measures for 1(R #59) of 1(R #59) resident reviewed during random observation by: 1. Facility staff storing R #59's Oxygen (O2) tubing non-covered and on a chair and R #59's O2 tubing being on the floor. The findings are: A. Record review of R #59's face sheet revealed R #59 was admitted into the facility on [DATE]. B. Record review of R #59's physician orders dated 08/10/22 revealed, Oxygen via NC [nasal cannula- tubing device used to deliver O2 to a patient's face] @ [at] 2L [liters]/min [minute]. Titrate to keep 02 sats > [greater than] 88% [percent]. C. On 08/07/23 at 3:29 pm during an interview, R #59, confirmed he wears O2 daily. R #59 was not currently wearing O2. O2 tubing including prongs (end of tubing that goes in the patient's nose) was also on the floor. R #59's back up O2 tubing was observed to be stored on a chair and not sealed. D. On 08/07/23 at 3:37 pm during an interview, 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.