New Mexico State Veterans Home

Based on record review and interview, the facility failed to ensure that an MDS assessment was completed every three months for 1 (R #10) of 1 (R #10) residents reviewed for MDS assessments when they failed to complete a quarterly MDS assessment within 92 days of the previous assessment reference date (ARD; the specific end point for the look-back periods in the MDS assessment process, also called the observation or assessment period.). This deficient practice could result in residents' assessments being outdated and residents not receiving care and treatment that meets their current needs. The findings are: A. Record review of R #10's Significant Change MDS assessment revealed an ARD of 12/08/25. B. Record review of R #10's Quarterly MDS assessments revealed an ARD of 03/23/26 (105 days after 12/08/25). C. On 04/21/26 at 4:36 PM, during an interview, the MDS Coordinator confirmed staff did not complete R #10's MDS assessments within 92 days of R #10's Significant Change MDS.

Based on record review and interview, the facility failed to complete and transmit a MDS assessment within 14 days of completion (sign off by RN) for 1 (R #10) of 1 (R #10) residents reviewed for MDS assessments. This deficient practice could lead to the facility not reporting information in a timely manner (within 14 days) to the federal agency. The findings are: A. Record review of R #10's Quarterly MDS revealed a completion date of 03/31/26. B. Record review of R #10's Quarterly MDS revealed the facility transmitted the MDS to the federal agency on 04/15/26. C. On 04/21/26 at 4:36 PM, during an interview, the MDS Coordinator confirmed staff did not transmit R #10's Quarterly assessment to the federal agency within 14 days of completion.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to meet professional standards of practice for 1 (R #132) of 4 (R #1, R #9, R #132, R #133) residents reviewed for medical care, when staff failed to implement an order after a doctor visit. This deficient practice could likely lead to unnecessary discomfort, prolonged symptoms or worsening of medical conditions. The findings are: A. Record review of R #132's admission Record, no date, revealed R #132 was admitted to the facility on [DATE]. B. On 04/14/26 at 9:51 AM, during an interview, R #132 stated the following: 1. He has a cough with a lot of phlegm that has had for several weeks. 2. He was seen by the facility doctor approximately two weeks ago where he told the doctor he had a cough with phlegm. 3. R #1 stated the doctor told him he would prescribe cough syrup for him. 4. R #1 has not received any cough syrup yet. B. Record review of R #132's provider visit note dated 04/01/26 revealed the following: 1. R #1 has a cough with phlegm. 2. Will…

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 provide an ongoing program of activities designed to meet the interests for 2 (R #2, and R #5) of 4 (R #1, R #2, R #5, and R #29) residents reviewed for activities by not providing meaningful individualized activities based upon residents' interests. If residents are not provided or encouraged to attend/participate in activities that meet their interests, then they are likely to experience an increase in boredom, isolation, and depression. The findings are: R #2 A. Record review of R #2's admission Record, no date, revealed R #2 was admitted to the facility on [DATE]. B. Record review of R #2's Significant change MDS dated [DATE], revealed R #2's Activities Assessment preferences were coded as follows: 1. Staff documented code 2 (somewhat important) for R #2 to be around animals such as pets. 2. Staff documented code 1 (very important) for R #2 participate in religious services. C. Record review of R #2's care plan revision date 02/17/26…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide foot care for 1 (R #87) of 4 (R #1, R #11, R #78, and R #87) resident reviewed for Activities of Daily Living (ADL) care when staff failed to provide nail care for R #87's toenails. This deficient practice could likely cause residents to have podiatric complications (foot and toenail health issues such as ingrown toenails, fungal infections, and trauma-related injuries). The findings are: A. Record review of R #87's admission Record, no date, revealed the following: 1. R #87 was admitted to the facility on [DATE]. 2. R #87 had the following diagnoses: a. Onycholysis (the painless separation of the nail plate from the nail bed, frequently starting at the tip or sides). b. Type 2 Diabetes Mellitus with Unspecified Complications. B. On 04/14/26 at 8:46 AM, during an observation and interview with R #87, the following was revealed: 1. R #87's toenails appeared long and discolored. 2. R #87 confirmed that his toenails were very long.…

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 properly store medications for 2 (R #46 and R #85) of 2 (R #46 and R #85) residents randomly sampled for medication storage, when staff failed to ensure medications were not expired in treatment cabinet for R #46, and R #85. This deficient practice could likely result in residents obtaining medications not prescribed to residents, and that are no longer effective, resulting in adverse side effects. The findings are: A. On 04/15/26 at 2:14 PM, during an observation of house #1's Treatment Cabinet, revealed one medication of Diclofenac sodium Tropical gel, 1% expired on February 2026. B. On 04/15/26 at 2:14 PM, during an interview with LPN #28 confirmed the following: 1. Nurses are to check daily and make sure the medications are not expired. 2. Nurses are to follow facility process for expired medications. 3. LPN #28 stated she did not know who the Diclofenac sodium Tropical gel was prescribed to because there was no name on medication. 4. LPN #28 confirmed the medication Diclofenac sodium Tropical gel, 1%…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to maintain an infection prevention and control program for 1 (R #107) of 2 (R #9 and R #107) residents reviewed for Transmission Based Precautions (additional infection control measures used in healthcare settings alongside Standard Precautions. They prevent the spread of known or suspected pathogens) when staff failed to follow enhanced barrier precautions (EBP, an infection control intervention) for R #107. If the facility fails to maintain an effective infection control program, then infections could spread to residents throughout the facility, resulting in illness. The findings are: A. Record Review of the [Name of Federal Agency] Enhanced Barrier Precautions in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 03/20/24, revealed the following: 1. MDRO transmission is common in long term care (LTC) facilities. 2. EBP refers to an infection control intervention designed to reduce transmission of MDRO that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents were educated on and offered the influenza (Flu: highly contagious respiratory illness caused by the influenza viruses that infection the nose, throat and sometimes the lungs leading to mild and potentially severe illness) and pneumococcal (moderate to highly contagious respiratory illness caused by bacteria that infect the nose throat and sometimes the lungs and can lead to severe illness such as pneumonia) immunizations and ensure that residents who completed and signed a consent form received the vaccination for 2 (R #112, R #132) of 5 (R #2, R #28, R #112, R #124, and R #132) residents reviewed for immunizations. If residents are not vaccinated appropriately for influenza and pneumococcus then they have a higher likelihood of contracting the illness and spreading the infection to other residents in the facility. The findings are:R #112A. Record review of R #112's admission Record, no date, revealed R #112 was admitted to the…

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

Based on record review and interview, the facility failed to offer COVID-19 (an acute respiratory disease in humans characterized mainly by fever and cough, capable of progressing to severe symptoms and in some cases death) vaccinations to 2 (R #2 and R #132) of 5 (R #2, R #28, R #112, R #124, and R #132) residents reviewed for COVID-19 vaccinations. This deficient practice could likely result in residents having a higher likelihood of contracting COVID-19 and spreading the infection to other residents in the facility. The findings are:R #2A. Record review of R #2's Immunization Report revealed the last COVID-19 vaccination that R #2 received was on 01/20/22. B. Record review of R #2's medical record revealed the record did not contain any COVID-19 vaccine forms which indicated staff offered or administered the COVID-19 vaccine to the resident.R #132C. Record review of R #132's medical record revealed the following:1. R #132 did not have any immunization consent forms on file. 2. Staff did not document regarding R #132 being offered COVID-19 vaccine. D. On 04/21/26 at 3:39 PM,…

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 promote resident self-determination (the ability to make your own choices and decisions without being controlled by others) for 1 (R #18) of 3 (R #18, R #69 and R #256) residents reviewed for choices when staff did not allow the resident to go out into the community on their own. If the facility is not honoring resident's choices, then residents are likely to feel a loss of independence and self-worth leading to feelings of frustration and depression. The findings are: A. Record review of R #18's admission Minimum Data Set (MDS; a standardized, comprehensive assessment of an adult's functional, medical, psychosocial, and cognitive status) assessment, dated 09/06/24, revealed: 1. Brief Interview for Mental Status (BIMS; screening tool used to identify a resident's current cognitive function) evaluation score of 15, cognitively intact. B. Record review of R #18's progress notes revealed the following: 1. Social services note, dated 09/04/24, Talk (sic) to [name of R #18] regarding him leaving the facility. He say he will…

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 care plan requirements were met for 11 (R #4, R #6, R #18, R #48, R #49, R #51, R #57, R #62, R #78, R #87 and R #256) of 14 (R #4, R #6, R #18, R #48, R #49, R #51, R #57, R #62, R #69, R #73, R #76, R #78, R #87 and R #256) residents reviewed for care plans when they failed to: 1. Have the required Interdisciplinary Team (IDT, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) members participate in the care plan meeting for R #4, R #6, R #18, R #51, R #57, R #78, and R #87. 2. Ensure the care plan meeting was held within seven days of completion of the admission Minimum Data Set Assessment (MDS; a standardized, comprehensive assessment of an adult's functional, medical, psychosocial, and cognitive status) for R #256. 3. Revise the care plan with the most current resident information for R #48, R #49, R #51, and R #62. These…

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 residents obtained dental services for 1 (R #62) of 1 (R #62) residents sampled for dental services, when staff failed to schedule dental services for R#62's broken tooth. This deficient practice is likely to cause the resident unnecessary pain, embarrassment over the condition and/or appearance of teeth, and potential dental or oral complications. The findings are: A. Record review of R #62's admission record, no date, revealed R #62 was admitted to the facility on [DATE]. B. On 11/19/24 at 10:16 AM, an observation and interview with R #62 revealed the following: 1. R #62's bottom front tooth was broken. 2. The broken tooth was not causing any pain, but was annoying. 2. When he first arrived at the facility, R #62 told staff he had a broken tooth on one of his bottom front teeth (incisor tooth that is one of the most visible teeth when looking at a person) when he first arrived at the facility. 3. He told staff he wanted to see…

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 interview, observation, and record review, the facility failed to ensure residents were aware of changes to their rights for 2 (R #69 and R #256) of 3 (R #48, R #69 and R #256) resident reviewed for smoking. If the facility does not inform residents of their rights, then residents are likely to be unaware of their rights offered at the facility. The findings are: A. Record review of the facility's Smoking Policy, dated 01/22/24 revealed: 1. Smoking is not a resident right, it is a privilege extended to residents. The privilege can be revoked for unsafe practices, non-adherence to the policies or the facility becoming a non-smoking facility. 2. Upon admission staff will acclimate residents to smoking areas and hand them the smoking schedule. 3. Upon admission and duration of stay, residents will give all smoking items to the nurse and at no time will a resident have their cigarettes/cigars or lighter on their person. R #69 B. Record review of R #69's admission record revealed an admission date 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 notify the resident and the resident's representative of a transfer in writing for 1 (R #12) of 1 (R #12) residents sampled for hospitalizations when they failed to: 1. Notify the resident or the resident's representative of the transfers to the hospital in writing and in a language and manner they understand. 2. Ensure the contents of the notice included the following: -The name, phone number, and address (mailing and email) of the Office of the State Long-Term Care Ombudsman on the transfer notification form. -Statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request. 3. Send a written copy of the Transfer Notices to the Ombudsman. These deficient practices could likely result in the resident and/or their representative not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents and their representatives received a written notice of the bed hold policy which indicated the duration the bed would be held for 1 (R #12) of 1 (R #12) residents reviewed for hospitalization. This deficient practice could likely result in the resident and/or their representative being unaware of the bed hold policy upon return from the hospital. The findings are: A. On 11/19/24 at 11:04 AM, during an interview with R #12, he stated the following: 1. He was transferred to the hospital because he was having trouble breathing. R #12 was unable to remember the date of the transfer. 2. Staff did not give him a bed hold policy notification before he was transferred to the hospital or when he returned to the facility. B. Record review of R #12's admission documents, no date, revealed R #12's son was his emergency contact. C. Record review of R #12's progress note, dated 10/29/24, revealed R #12 was transferred to the hospital on [DATE] 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 record review the facility failed to ensure the annual Minimum Data Set assessment (MDS; a standardized, comprehensive assessment of an adult's functional, medical, psychosocial, and cognitive status) was finalized (transmitted and accepted) within 7 days for 1 (R #25) of 4 (R #18, R #25, R #51 and R #87) residents reviewed for MDS assessments. If MDS assessments are not finalized in a timely manner, it could likely lead to staff being unaware of resident's current status and needs. The findings are: A. Record review of R #25's admission record (no date) revealed an admission date of 03/09/2024. B. Record review of R #25's annual MDS assessment, dated 10/10/24, revealed the following: 1. The Assessment Reference Date (ARD; specific end point for the observation and assessment period in the MDS assessment process) was 10/10/24. 2. The MDS/RN Coordinator did not sign off on the annual assessment until 11/20/24. C. Record review of R #25's electronic medical record indicated the 10/10/24 annual assessment was export ready (assessment ready for electronic transmission) 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 and record review, the facility failed to ensure the Minimum Data Set Assessment (MDS; a standardized, comprehensive assessment of an adult's functional, medical, psychosocial, and cognitive status) was accurate for 3 (R #18, R #69 and R #256) of 6 (R #18, R #51, R #69, R #76, R #87, and R #256) residents reviewed for accurate MDS assessments. These deficient practices could likely result in the facility not having an accurate assessment of the resident's needs. The findings are: R#18 A. On 11/19/24 at 4:07 PM, during an interview, R #18 stated he had pain and a burning feeling to his feet daily. B. Record review of R #18's admission record revealed the following: 1. admission date of 08/26/24. 2. Diagnoses included carpal tunnel syndrome of unspecified upper limb (pain, numbness, tingling caused by pressure on the median nerve in of either wrist), unilateral primary osteoarthritis of unspecified knee (pain, swelling, and tenderness caused by wear and tear on a joint, that primarily affects one side of the body), and pain in unspecified (either left or right)…

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

Based on observations, record reviews, and interviews, the facility failed to meet professional standards of quality for 4 (R #18, R #48, R #51 and R #87) of 4 (R #18, R #48, R #51 and R #87) residents when staff failed to: 1. Notify the physician when medication was not available for R #18 and R #48. 2. Administer medications according to physician's orders for R #51 and R #87. 3. Notify the physician when R #51 refused medication. If the facility is not providing care that meets professional standards of quality, then residents are likely to experience adverse effects, worsening of their condition, and potential complications from not receiving the care ordered by the physician. The findings are: R #18 A. Record review of R #18's admission record, no date, revealed R #18 was admitted to the facility 08/26/24. B. Record review of R #18's physician orders revealed an order, start date of 08/18/24, for amitriptyline 25 mg. Give one tablet by mouth one time a day for neuropathy (nerve damage that affects the hands and feet and causes pain, tingling, and burning sensation.) C. 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 interview and record review, the facility failed to develop the resident's individualized discharge goals and needs for 1 (R #100) of 1 (R #100) resident 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: A. Record review revealed R #100 was discharged from the facility on 09/27/24. A. Record review of R #100's medical record, no date, revealed staff did not develop a discharge plan for R #100's discharge goals and needs. Record review revealed that the discharge summary, recapitulation of stay, and medications were not documented in the resident's medical record. B. On 11/21/24 at 9:38 am, during an interview, the DON confirmed R #100's discharge goals or needs were not documented in the residents' charts.

Based on record review and interview, the facility failed to ensure staff completed a discharge summary that included a recapitulation (a summary describing the resident's course of treatment while residing in the facility) and a reconciliation of all medication at the time of discharge for 1 (R #100) of 1 (R #100) residents sampled for discharge from the facility. This deficient practice could likely lead to the receiving facility, community agency, or family member not knowing what the current care needs and/or current medications are for the resident. The findings are: A. Record review of R #100's Electronic Medical Record (EMR) revealed the following: 1. R #100 was discharged from the facility on 09/27/24 to his home. 2. The record did not contain a recapitulation for of the resident's stay, medication list, or a discharge summary. 3. There is no documentation that R #100 was provided a discharge discharge summary. B. On 11/21/24 at 9:38 am, during an interview, the DON confirmed staff did not complete R #100's discharge summary at the time of discharge. The DON also stated…

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

Based on interview and record review, the facility failed to ensure residents received proper treatment to maintain hearing for 1 (R #78) of 3 (R #69, R #73, and R #78) residents reviewed for vision and hearing. This deficient practice could likely result in residents losing some independence if they cannot hear, which would compromise their quality of life. The findings are: A. On 11/19/24 at 9:20 am, during an interview, R #78 said he needed hearing aids, but he did not know why he did not have any hearing aids. R #78 said he had an appointment a year ago. R #78 said that he was supposed to get hearing aids but he never heard anything about them after the appointment. R #78 said he told staff several times that he needed hearing aids. B. Record review of R #78's progress note, dated 10/17/24, revealed R #78 complained that he needed hearing aids and had trouble getting them. The progress note did not include any intervention by staff to obtain hearing aides for the resident or refer the resident for an appointment to assess his hearing. C. On 12/02/24 at 2:50 pm, during an…

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

Based on observation, record review, and interview, the facility failed to maintain proper infection prevention measures when they failed to initiate transmission-based precautions (used to prevent the spread of infectious agents from individuals who are suspected to be infected, such as gloves, facemasks, and gowns) for residents diagnosed with COVID-19 (an acute respiratory disease in humans characterized mainly by fever and cough and capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions). Failure to adhere to an infection control program is likely to cause the spread of infections and illness to all 12 residents on the D Unit (residents were identified by the resident matrix provided by Administration on 09/09/24). The findings are: A. On 9/9/24 at 10:55 AM, during an interview with Guide #16, the following was revealed: 1. There were residents who had COVID-19 in the D Unit. 2. All staff must wear surgical masks in the building and N95 masks (a respiratory protective device designed to achieve a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to create an accurate baseline care plan (a document with the minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) within 48 hours of admission for 1 (R #8) of 3 (R #8, R #9, and R #10) residents reviewed for resident neglect. This deficient practice could likely result in residents not receiving the appropriate care and may place residents at risk of an adverse event (an undesirable experience, preventable or non-preventable, that caused harm to a resident because of medical care or lack of medical care) or worsening of current condition after admission. The findings are: A. Record review of R #8's face sheet, no date, revealed R #8 was admitted into the facility on [DATE]. B. Record review of R #8's physician's orders revealed the following: 1. Dated 09/06/24, a bland diet, no food by mouth, fluid restrictions, and Jevity 1.2 (calorically dense, fiber-fortified therapeutic nutrition…

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 a comprehensive Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) was completed within 14 calendar days after admission for 1 (R #1) of 4 (R #1, R #2, R #31, and R #32) residents reviewed. This deficient practice could likely result in residents' preferences and care needs not being met. The findings are: A. Record review of R #1's admission record revealed an admission date of 03/22/24 for R #1. B. Record review of R #1's medical record revealed an admission MDS assessment was in progress (assessment has been started but all sections have not been completed) on 05/08/24. C. On 05/08/24 at 4:05 PM, during an interview, LPN #1 confirmed the following: 1. R #1 was admitted to the facility on [DATE]. 2. R #1's Annual MDS assessment was still in progress and was not completed within 14 days of admission.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to complete a baseline care plan within 48 hours of admission, that includes the instructions needed to provide effective and person-centered care to residents for 1 (R #1) of 5 (R #1, R #2, R #3, R #31, and R #32) residents reviewed for Care Plans. This deficient practice could likely result in residents not receiving the appropriate care and services and may place residents at risk of an adverse event (an event that caused harm to a patient as a result of medical care or lack of medical care) or worsening of current condition after admission. The findings are: A. Record review of R #1's face sheet revealed, R #1 was admitted to the facility on [DATE]. B. Record review of R #1's physician's orders revealed: 1. Order date of 03/22/24; Seroquel (antipsychotic medication used to treat serious mental and mood disorders) oral tablet give 25 milligrams (mg) by mouth two times a day. 2. Order date of 03/22/24; Sertraline (antidepressant medication used to treat…

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 medications were administered as ordered by the physician for 1 (R #2) of 2 (R #1 and R #2) residents reviewed for medication administration. This deficient practice is likely to result in a resident failing to obtain therapeutic effects of medication treatment or worsening of condition. The findings are: A. Record review of R #2's face sheet revealed R #2 was admitted to the facility on [DATE] with diagnosis of Parkinson's disease (a chronic and progressive movement disorder that causes tremors/shaking, stiffness or slowing of movement). B. Record review of R #2's physician orders revealed: Order date of 07/11/22, Sinemet (combination medication is used to treat symptoms of Parkinson's disease) 25-100 mg give 1 tablet by mouth four times a day (scheduled at 8:00 AM, 12:00 PM, 5:00 PM and 8:00 PM) for Parkinson's disease. C. Record review of R #2's care plan, dated 07/11/22, revealed the following: - Focus: resident has Parkinson's and receives…

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 appropriate staffing levels to meet the needs of the residents. This failure has the potential to affect all 53 residents (residents were identified by the resident matrix as provided by the Administrator on 08/21/23). This deficient practice could likely affect direct patient care and limit residents' abilities to obtain the best possible care while in the facility. The findings are: A. On 08/21/23 at 1:42 PM, during an interview R #2 stated: They have problems with staff, they don't have enough. B. On 08/23/23 at 3:37 PM, during Resident Council meeting, R #2 stated that there is a lot of turn around with staff and they (staff) are always different. C. On 08/21/23 at 12:22 PM, during an interview, R #8 stated that his brief is not changed in a timely matter due to staff shortage. D. On 08/21/23 at 1:06 PM, during an interview, R #13 stated, They don't have enough staff. The ones that are working are always working overtime. E. On 08/21/23 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that residents and representatives were informed of and participate in their treatment for 2 (R #2, R #33) of 2 (R #2, and R #33) residents reviewed for documentation, when: 1) R #2 or R #2's power of Attorney (POA) did not sign the MOST form (advanced directive), and 2) Consent for R #33's medications was not obtained. These deficient practices could like result in residents or their representatives not being able to participate in their treatment or make their own decisions. The findings are: R #2 A. Record review of R #2's face sheet revealed R #2 was admitted into the facility on [DATE]. R #2 is the responsible party and R #2's daughter is his emergency contact. B. Record review of R #2's MDS Section C0200 dated 06/20/23, revealed a BIMS (Brief Interview for Mental Status mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility) score of 15 (13 to 15 suggests the patient is…

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 a comprehensive assessment (complete assessment that includes not only the traditional care of the resident, but also the prevention and early detection of disease and rehabilitation) was completed and accurate for 2 (R #33, and R #35) of 3 (R #6, R #33, and R #35) residents reviewed for completion of a comprehensive MDS assessment. When they failed to: 1. Include R #33's diagnosis of PTSD (Post Traumatic Stress Disorder; mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback, and avoidance of similar situations), and 2. Complete the pain management section of the MDS assessment for R #35. This deficient practice could likely result in residents' preferences and needs not being met. The findings are: R #33 A. Record review of R #33's Electronic Medical Record (EMR) revealed: Progress Note DOS (Date of Service) 04/17/23, Plan: Major Depressive…

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

Based on record review and interview, the facility failed to ensure that 19 (R #1, R #3, R #5, R #7, R #10, R #12, R #13, R #15, R #17, R #19, R #20, R #22, R #23, R #24, R #28, R #32, R #38, R #39, R #40) of 19 (R #1, R #3, R #5, R #7, R #10, R #12, R #13, R #15, R #17, R #19, R #20, R #22, R #23, R #24, R #28, R #32, R #38, R #39, R #40) residents reviewed for Minimum Data Set assessments, have MDS documents completed, and finalized in a timely manner. If MDS assessments are not completed and finalized in a timely manner, it could likely cause residents to receive less than optimal care. The findings are: A. Record review of R #1, R #3, R #5, R #7, R #10, R #12, R #13, R #15, R #17, R #19, R #20, R #22, R #23, R #24, R #28, R #32, R #38, R #39, and R #40 MDS assessments revealed they all had been exported but not accepted. B. On 08/23/23 at 1:30 PM, during an interview the Facility Contractor (FC) confirmed that R #1, R #3, R #5, R #7, R #10, R #12, R #13, R #15, R #17, R #19, R #20, R #22, R #23, R #24, R #28, R #32, R #38, R #39, and R #40 MDS assessments had been exported but…

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 develop and implement a comprehensive person-centered care plan for 3 (R #18, R #25 and R #35) of 7 (R #1, R #6, R #18, R #25, R #33, R #35 and R #191) residents reviewed for Comprehensive Care Plans. Failure to develop a person-centered care plan could likely result in staff's failure to understand the needs, preferences, and treatments for residents to achieve their highest level of well-being. The findings are: R #18 A. Record review of R #18's Care Plan dated 06/20/23 revealed the following: [name of R #18] is a High risk for falls r/t (related to) Confusion, Poor communication/comprehension, Unaware of safety needs, Wandering . Fall risk assessment quarterly and PRN. B. Record review of R #18's Medical Record revealed the last fall assessment was conducted on 07/30/21. C. On 08/24/23 at 11:44 AM, during an interview House Supervisor (HS) #1 confirmed that R #18's last fall assessment was conducted on 07/30/21. HS also confirmed that the fall assessments should be done quarterly. R #25 D. Record review of R #25's…

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

Based on record review and interview, the facility failed to revise the care plan for 2 (R #35 and R #242) of 6 (R #1, R #6, R #33, R #35, R #191 and R #242) residents reviewed for care plan revisions. This deficient practice could likely result in staff being unaware of changes in care being provided and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are: R #35 A. On 08/22/23 at 12:39 PM, during an interview, R #35 stated his dentures were stolen and he was waiting on getting his new dentures. B. On 08/23/23 at 10:11 AM, during an interview, CNA #1 and CNA #2 confirmed that R #35 did not currently have dentures. C. Record review of R #35's MDS (comprehensive assessment) dated 07/11/23 revealed Section L Oral/Dental Status. Question LO2OO Dental: No natural teeth or tooth fragment(s) (edentulous [without any teeth]) was marked off. D. Record review of R #35's Care Plan dated 08/14/20, revealed ORAL CARE: (name of R #35) has dentures. Ensure dentures are clean daily. E. On 08/25/23 at 12:34 PM, during a joint…

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

Based on observation, interview, and record review the facility failed to ensure residents received care that meets professional standards for 1 (R #1) of 1 (R #1) resident sampled for limited range of motion, when they failed to use neck support and wedge (are used for trunk stabilization to maintain positioning) for proper positioning. This deficient practice could likely result in worsening of resident's trunk control (ability to control your upper body [trunk or torso]) or unnecessary pain and discomfort. The findings are: A. On 08/21/23 at 12:16 PM, during an observation, R #1 was sitting in his wheelchair in the dining area, R #1 was leaning to his right and had no positioning devices in place. B. On 08/25/23 at 8:35 AM, during an observation of R #1 in the common area, revealed resident in his wheelchair with a travel neck pillow (Pillow shaped like a horseshoe to fit around the neck, mostly used by travelers to keep their necks straight while sleeping sitting up on board planes or other vehicles) and no additional device used for positioning. Resident was slumped over right…

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 residents received care and treatment in accordance with professional standards of care (reasonable degree of care a person should provide to another person, typically in a professional or medical setting) for 1 (R #35) of 2 (R #35 and R #191) reviewed for hospitalizations by: Not continuing antibiotic orders for continued treatment of Pneumonia for R #35 as per hospital discharge instructions resulting in rehospitalization for Pneumonia. These deficient practices could likely lead to unnecessary pain, suffering, hospitalization, and death. The findings are: A. Record review of R #35's Medical record revealed R #35 was admitted on [DATE]. B. On 08/22/23 at 12:42 PM, during an interview, when asked about hospitalizations R #35 stated Yes, I had Pneumonia then I got double Pneumonia (lung infection that affects both lungs) because they didn't give me my medicine when I got out of the hospital. C. Record review of R #35's Electronic Medical…

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

Based on interview and record review, the facility failed to ensure residents were receiving rehabilitative services, PT (Physical therapy is the treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise), OT (Occupational therapy is a form of therapy that encourages rehabilitation through the performance of activities required in daily life), and ST (Speech therapy is a form of therapy to improve speaking and swallowing, enabling clients to regain/retain their independence following the debilitating effects of illness or injury.) services as ordered by the physician for 1 (R #241) of 1 (R #241) resident reviewed for rehab services. This deficient practice is likely to result in a decrease in resident's functional mobility. The findings are: A. On 08/22/23 at 9:18 AM, during an interview, R #241 reported that her therapy had not started because she just got there. She stated she had a stroke and was supposed to be in therapy. B. Record review of R #241's Facesheet revealed the following: 1. admission date of 08/02/23. 2. Diagnosis…

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

Based on record review and interview, the facility failed to ensure that the physician reviewed and addressed pharmacy recommendations for 2 (R #25 and R #35) of 5 (R #8, R #18, R #25, R #33, and R #35) residents reviewed for unnecessary medications. This deficient practice could likely result in residents being at a higher risk of adverse side effects (unwanted, harmful, or abnormal result). The findings are: R #25 A. Record review of R #25's Pharmacy Recommendations dated 07/08/23 revealed: 1. [name of resident] is taking Seroquel (used to treat schizophrenia, bipolar disorder, and depression.) 50 mg .evaluate the current dose and consider a dose reduction. B. Record review of R #25's Orders dated 07/29/23 revealed: 1. SEROquel Oral Tablet 50 MG: Give 1 tablet by mouth at bedtime related to PSYCHOTIC DISORDER WITH HALLUCINATIONS DUE TO KNOWN PHYSIOLOGICAL CONDITION Start date 01/25/23 with no end date. C. On 08/25/23 at 12:46 PM during an interview, the DON confirmed that the pharmacy recommendations were not followed and no rational was given. R #35 D. Record review of Pharmacy…

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

Based on record review and interview, the facility failed to ensure residents did not receive antipsychotic (drug primarily used to treat psychotic disorders such as schizophrenia [mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech, and behavior. that impairs daily functioning]) medications unless the medication is necessary to treat a specific condition or diagnosis and is documented in the medical record for 1 (R #33) of 5 (R #8, R #18, R #25, R #33, and R #35) residents reviewed for unnecessary medications. This deficient practice could likely result in residents receiving medications without a clinical indication (medical reason) and being at a higher risk of adverse side effects (unwanted, harmful, or abnormal result). The findings are: A. Record review of R #33's physician's orders revealed: 1. Order start date 04/20/23, Abilify (antipsychotic medication) 5 mg by mouth one time daily related to mixed receptive-expressive language disorder (communication disorder when a person has difficulties with speaking to and understanding others). 2.…

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

Based on observation, record review, and interview, the facility failed to ensure that the medication error rate was 5% or less when medications were given late or not given at all for 3 (R #5, R #6, and R #242) of 12 (R #5, R #6, R #8, R #14, R #16, R #23, R #24, R #27, R #91, R #92, R #242 and R #243) residents observed during medication pass. Resulting in a medication error rate of 28.21%. This deficient practice could likely result in residents being at a higher risk of adverse side effects (unwanted, harmful, or abnormal result). The findings are: R #5 A. On 08/24/23 at 9:04 AM, during observation of medication pass, CMA #1 administered Carbamazepine 100 mg (antiseizure medication), Escitalopram (depression medication) 10 mg, Gabapentin (medication used to control nerve pain) 800 mg, Lisinopril (blood pressure medication) 10 mg and Rivaroxaban (medication to prevent blood clot formation) 10 mg to R #5. CMA #1 stated R #5 takes her medication whenever she is up, out of bed and ready for the day. B. Record review of R #5's Physician Orders revealed the following: 1. carBAMazepine…

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

Based on record review and interview, the facility failed to provide food that accommodates resident preferences for 7 (R #2, R #8, R #20, R #34, R #35, R #91 and R #244) of 7 (R #2, R #8, R #20, R #34, R #35, R #91, and R #244) resident's reviewed for food preferences. This deficient practice is likely to result in the resident having less than optimal nutritional health outcomes and resident food preferences not being honored. The findings are: R #20 A. On 08/21/23 at 12:43 PM, during an interview, R #20 stated that they serve the same thing a lot. He also stated there is a lot of chicken. R #35 B. On 08/22/23 at 12:24 PM, during an interview, R #35 stated We eat a lot of chicken, we get it over and over. R #91 C. On 08/21/23 at 12:34 PM, during an interview R #91 stated that she doesn't like the food, It is same thing over and again. R # 244 D. On 08/21/23 at 1:24 PM, during an interview, R #244 stated that the food isn't what he is used to and they serve the same thing all the time. E. On 08/23/23 at 3:28 PM, during Resident Council meeting revealed the following: a. R #34…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents were treated with respect and dignity for 1 (R #23) of 1 (R #23) residents randomly sampled, when the facility failed to ensure staff are not removing resident's personal property without their knowledge, This deficient practices are likely to result in residents feeling angry, and that their feelings and preferences are unimportant to the facility staff. The findings are: A. Record review of R #23's Medical Records revealed: 1. Initial admission date of 06/02/20, 2. MDS dated [DATE]: Brief Interview for Mental Status (BIM) score of 15. (scores 13-15 suggests the patient is cognitively intact). B. Record review of R #23's Care Plan dated 07/24/23 revealed: 1. Diagnosis: POST-TRAUMATIC STRESS DISORDER (PTSD a mental health condition triggered by experiencing or witnessing a traumatic event). 2. Trauma Informed Care: R #23 has a history of trauma that affects him negatively, 3. Triggers will be avoided that may cause re-traumatization…

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 reasonably accommodate residents needs for 1(R #35) of 2 (R #1 and R #35) reviewed for medical appointments. If the facility is not honoring resident's preferences and/or requests for medical appointments the resident may feel like their preferences and requests are being ignored and lead to feeling like their needs do not matter. The findings are: A. On 08/22/23 at 12:27 PM, during an interview, R #35 stated he has something on his skin that could be cancer and the facility canceled his dermatology appointment on 08/21/23 because the van needed an oil change. R #35 stated I don't know when it is rescheduled for. B. Record review of R #35's Electronic Medical Record revealed Physicians Assistant progress note Chronic Care Management 08/04/23. Patient has a lesion (abnormal skin growth or appearance compared to the skin around it) in his left upper chest, he has an appointment with [name of clinic] dermatology August 21. He states they are going to do a biopsy (medical procedure that involves removal of a small sample 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 notify the physician for 1 (R #191) of 2 (R #35 and R #191) residents reviewed for hospitalization, when they failed to notify R #191's physician about her abdominal pain, fever, or low blood pressure. This deficient practices could likely result in residents not receiving necessary care or delay in treatment if the Physician is not notified of new or worsening symptoms. The findings are: A. Record review of R #191's Medical record revealed the following: 1. admitted [DATE]. B. Record review of R #191's Progress Notes revealed: 1. 02/04/23 3:18 AM Nurse Administration Note: ANTACID LIQUID (medication is used to treat the symptoms of too much stomach acid such as stomach upset, heartburn, and acid indigestion) Give 30 ml (milliliters) orally every 2 hours as needed for Heartburn; Indigestion. RUQ (right upper quadrant, upper right side of abdomen) hyperactive (louder sounds related to increased intestinal activity which can occur after eating or when…

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

Based on observation, record review and interview, the facility failed to ensure that 1 (R #14) of 3 (R #14, R #23, and R #36) residents reviewed for behavioral-emotional health were receiving necessary behavioral health care to meet their needs. This deficient practice likely resulted in R #14 experiencing prolonged symptoms including depression (persistent feeling of sadness and loss of interest), paranoia (unjustified mistrust of other people and their actions) thoughts and hallucinations (perception of something not present). The findings are: A. Record review of R #14's admission record with an admission date of 02/09/17 revealed: 1. Diagnosis: MAJOR DEPRESSIVE DISORDER, RECURRENT, SEVERE WITH PSYCHOTIC SYMPTOMS (a mental disorder in which a person has depression along with loss of touch with reality). B. Record review of R #14's Active Orders revealed the following: 1. 05/12/23 DULoxetine HCl (Oral Capsule Delayed Release Particles-used to treat depression and anxiety) Give 60 mg by mouth two times a day for depression. 2. 07/28/23 traZODone HCl Oral Tablet 100 MG (Trazodone…

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.