The Neighborhood In Rio Rancho
Non profit - Corporation
72 Beds
Independent
Data: November 2025
Trust Grade
50/100
#22 of 67 in NM
Photo by The Neighborhood in Rio Rancho
Photo by The Neighborhood in Rio Rancho
Photo by The Neighborhood in Rio Rancho
1 / 7 photos
Last Inspection: May 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
The Neighborhood In Rio Rancho has received a Trust Grade of C, which means it is average compared to other nursing homes, sitting in the middle of the pack. It ranks #22 out of 67 facilities in New Mexico, placing it in the top half, and is the best option among three facilities in Sandoval County. The facility is showing improvement, decreasing from 11 issues in 2024 to 8 in 2025, but it still has concerning staffing turnover at 80%, which is significantly higher than the state average of 53%. On a positive note, there have been no fines recorded, indicating no compliance problems, and the facility has good RN coverage, which is important for catching potential health issues. However, there have been serious incidents, such as a resident lacking proper access to call lights for assistance and failing to recognize the resident’s significant health decline, which could lead to emotional distress. Overall, while the facility has strengths in certain areas, families should be aware of the staffing challenges and past incidents that could affect resident care.
- Trust Score
- C
- In New Mexico
- #22/67
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 80% turnover. Very high, 32 points above average. Constant new faces learning your loved one's needs.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most New Mexico facilities.
- Skilled Nurses ✓ Good
- Each resident gets 65 minutes of Registered Nurse (RN) attention daily — more than 97% of New Mexico nursing homes. RNs are the most trained staff who catch health problems before they become serious.
- Violations ⚠ Watch
- 46 deficiencies on record. Higher than average. Multiple issues found across inspections.
50/100
Top 32%
Needs review
11 → 8 violations
★★★★☆
4.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★★☆
4.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2024: 11 issues
2025: 8 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in staffing levels, quality measures, fire safety.
The Bad
Staff Turnover: 80%
33pts above New Mexico avg (46%)
Frequent staff changes - ask about care continuity
Staff turnover is very high (80%)
32 points above New Mexico average of 48%
The Ugly 46 deficiencies on record
2 actual harm
Mar 2025
6 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the assessment was accurate for 1 (R #2) of 1 (R #2) residen...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the assessment was accurate for 1 (R #2) of 1 (R #2) resident reviewed. This deficient practice could likely result in the residents' preferences and care needs not being met accurately. The findings are:
A. Record review of R #2's admission record revealed R #2 was originally admitted to the facility on [DATE] and readmitted on [DATE] after a hospital stay with the following diagnoses:
1. Hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body) and Hemiparesis (weakness or paralysis on one side of the body) following cerbral (brain) infarction (condition where blood flow to the brain is interrupted, causing brain tissue damage) affecting left non-dominant side.
2. Atherosclerotic heart disease (a condition where the coronary arteries, which supply blood to the heart, become narrowed or blocked due to the buildup of plaque [fatty deposits]).
3. Altered mental status, unspecified.
4. Strange and inexplicable behavior.
5. Cardiac (heart) Arrythmia (irregular heartbeat).
6. Major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities).
7. Vascular dementia (a type of cognitive decline caused by damage to the blood vessels in the brain), unspecified severity with other behavioral disturbances.
B. Record review of local police report dated 12/15/24 revealed that staff heard a loud scream and entered R #2's room to observe R #2 going after another staff member.
C. Record review of R #2's annual MDS assessment dated [DATE], section E0200 Behaviors, revealed R #2 had not exhibited any physical and verbal behavioral symptoms directed towards others.
D. On 03/19/25 at 1:00 pm during an interview with Minimum Data Set (MDS) Coordinator, she confirmed that any alteration in behavior should have be brought to her attention. She confirmed that the Annual MDS for R #2 dated 12/19/24 should have contain information on behaviors and that the MDS was not accurate.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0571
(Tag F0571)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that they did not impose a charge against the personal funds...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that they did not impose a charge against the personal funds for items or services already being billed for (R #1 and R #3) of 3 (R #1, R #3 and R #4) residents reviewed when staff billed the residents instead of billing the hospice agency for supplies and medications. This deficient practice is likely to cause undue financial strain for the residents. The findings are:
A. Record review of R #1's admission Record revealed R #1 was admitted to the facility on [DATE].
B. Record review of R #1's medical orders revealed an order dated 10/08/23 to admit R #1 to hospice effective 10/08/23.
C. Record review of R #1's billing statements from the facility revealed the following:
1. A charge dated 06/01/24 for an oxygen concentrator (a medical device that delivers concentrated oxygen to a person via cannula (a medical device/plastic tube that delivers oxygen to a person through their nostrils) for $75.00,
2. A charge dated 07/01/24 for an oxygen concentrator for $75.00,
3. Charges dated 07/28/24 for a cannula for $1.25 and a humidifier for $4.73,
4. A charge dated 08/05/24 for a cannula for $1.25,
5. A charge dated 08/11/24 for a cannula for $1.25,
6. A charge dated 08/18/24 for a cannula for $1.25,
7. A charge dated 09/01/24 for an oxygen concentrator for $75.00,
8. A charge dated 10/01/24 for an oxygen concentrator for $75.00,
9. A charge dated 12/01/24 for an oxygen concentrator for $75.00,
10. Charges dated 12/31/24 for three medications for a total amount of $19.56.
D. On 03/19/25 at 1:22 pm, during an interview with [NAME] Specialist (BS), she confirmed she billed R #1 for the oxygen concentrator, canula and medications. She further stated she was waiting for a list of items that are covered by hospice.
E. On 03/18/25 at 4:25 pm, during an interview with the Hospice Agency Clinical Services Director (HACSD), she confirmed hospice does cover oxygen concentrators, cannulas, humidifiers, and the medications that were charged to R #1 was because these items were relate to R #1's terminal diagnosis.
R #3
F. Record review of R #3's admission Record revealed R #3 was admitted to the facility on [DATE].
G. Record review of the hospice agency's admission form dated 10/22/24, revealed R #3 started hospice on 10/22/24.
H. Record review of R #3's billing statements from the facility revealed the following:
1. A charge dated 12/08/24 for wipes for $9.61,
2. A charge dated 12/16/24 for adult briefs for $23.04,
3. A charge dated 12/22/24 for a medication of $0.54.
I. On 03/19/25 at 1:22 pm, during an interview with [NAME] Specialist (BS), she confirmed she billed R #3 for wipes, adult briefs and medication. BS further stated she was waiting for a list of items that are covered by hospice.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the Power of Attorney (POA; legal authorization for a design...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the Power of Attorney (POA; legal authorization for a designated person to make decisions about another person's property, finances, and/or medical care) for 1 (R #1) of 3 (R #1, R #2, and R #5) residents when injuries or incidents occurred. If the facility is not notifying the resident's POA when the resident has an injuries or incident occur, then the POA is not able to make decisions related to treatment and advocate for the resident's care. The findings are:
A. Record review of R #1's admission Record revealed R #1 was admitted to the facility on [DATE], with the following diagnoses:
1. Chronic heart failure,
2. Anxiety (feelings of fear or apprehension) disorder due to known physiological condition,
3. Insomnia (disorder where a person has persistent difficulty falling asleep, staying asleep, or quality of sleep), unspecified,
4. Adjustment disorder (emotional or behavioral reaction to a stressful event or change in a person's lift) with depressed mood (feelings of sadness, loss of interest, and difficulty with thinking, memory, eating, and sleeping).
B. Record review of R #1's quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) dated 10/25/25 revealed a Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) score of 00, severe impairment.
C. On 03/18/25 at 10:33 am, during an interview with R #1's POA and daughter, she stated she went to the facility on [DATE] to visit R #1 when she noticed a bandage on R #1's wrist that went from her wrist to her elbow. She stated R #1 also had a bandaid on her face. R #1's POA stated that she was not informed of any new injuries, and she wanted to know the cause, so she asked the staff that were working that day, but nobody knew what happened. She said one staff member looked through the electronic medical record but could only tell her that a staff member documented that she bandaged R #1 on 01/31/25. R #1's POA stated the facility's communication used to be better, she said the staff at the facility would inform her of everything that happened, but since the new management company took over, things have gone downhill and she is not informed about anything anymore.
D. Record review of R #1's electronic health record (EHR) revealed the following:
1. A Change of Condition form dated 01/31/25 that listed a skin wound or ulcer as the change of condition, but no cause of injury is stated.
2. A Total Body Skin assessment dated [DATE] revealed R #1 has two new wounds.
E. On 03/19/25 at 3:00 pm, during an interview with the Director of Nursing (DON), she confirmed R #1's POA was not notified of the injuries that R #1 incurred on 01/31/25. The DON stated that the nurse on duty should notify POAs when residents are injured.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure staff revised the care plan for 3 (R #2, R #3 and R #5 ) of ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure staff revised the care plan for 3 (R #2, R #3 and R #5 ) of 4 (R #1, R #2, R #3, and R #5) residents reviewed when staff failed to update care plans to include hospice care or fall protocol . This deficient practice is likely to result in residents' care and needs not being addressed. The findings are:
R #2
A. Record review of R #2's admission record revealed R #2 was originally admitted to the facility on [DATE], and readmitted on [DATE] after a hospital stay with the following diagnoses:
1. Hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body) and Hemiparesis (weakness or paralysis on one side of the body) following cerbral (brain) infarction (condition where blood flow to the brain is interrupted, causing brain tissue damage) affecting left non-dominant side.
2. Atherosclerotic heart disease (condition where the coronary arteries, which supply blood to the heart, become narrowed or blocked due to the buildup of plaque [fatty deposits]).
3. Altered mental status, unspecified.
4. Strange and inexplicable behavior.
5. Cardiac (heart) Arrythmia (irregular heartbeat).
B. Record review of R#2's facility Nursing progress note revealed the following:
1. dated 02/25/25, revealed R #2 had a fall with injuries.
2. Dated 03/03/25 revealed R #2 returned from hospital after fall resulting in right hip fracture and surgical repair.
C. Record review of R #2's Care Plan dated 07/16/24 revealed .at risk for falls due to: Generalized Weakness. Care Plan did not include date of fall on 02/25/25 which resulted in hip fracture. There were no additional updates or interventions added.
D. On 03/19/25 at 3:15 pm, during an interview with the Director of Nursing (DON), she confirmed R #2's care plan was not revised to include the fall R #2 had sustained that caused R #2 to break her hip or added new interventions for the 02/25/25 fall, she confirmed after R #2's fall the care plan should have been updated to include a fall protocol with interventions and prevention.
R #3
E. Record Review of R #3's admission record revealed R #3 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with the following diagnoses:
1. Atherosclerotic heart disease (condition where the coronary arteries, which supply blood to the heart, become narrowed or blocked due to the buildup of plaque [fatty deposits]).
2. Chronic atrial fibrillation (heart rhythm disorder where the upper chambers of the heartbeat irregularly and rapidly that last for more than a week).
3. Acute congestive heart failure (a sudden, life-threatening condition where the heart struggles to pump enough blood to meet the body's needs, leading to fluid buildup and symptoms like shortness of breath and swelling).
4. Chronic Kidney disease (a condition in which the kidneys gradually lose their ability to filter waste products from the blood).
5. Type 2 Diabetes Mellitus (a chronic condition characterized by high blood sugar levels due to the body's inability to use insulin effectively or produce enough insulin).
6. Benign prostatic Hyperplasia (a non-cancerous condition where the prostate gland grows larger than normal, potentially causing urinary problems)
F. Record review of R #3's hospice admission order form (a form completed by a hospice nurse to identify diagnosis, activity, diet, allergies and medication orders) revealed resident was admitted to hospice on 10/22/24.
G. Record review of R #3 significant change Minimum Data Set (MDS) assessment dated [DATE] revealed R #3 receives hospice in the facility.
H. Record review of R #3's care plan dated 07/09/24 and revised on 01/02/25 revealed the care plan was not revised to reflect hospice care.
I. On 03/19/25 at 12:59 pm during an interview with the Director of Nursing (DON), she confirmed the following:
1. R #3 is currently receiving hospice services
2. R #3's care plan was not updated prior to 01/02/25 to include hospice services which originally began on 10/22/24.
3. R #3's care plan revised on 01/02/05 does not meet her expectations for interventions regarding R #3's care for hospice needs.
R #5
J. Record review of R #5's admission record revealed R #5 was admitted to the facility on [DATE] with the following diagnoses:
1. Alzheimer's disease,
2. Depression and anxiety disorders,
3. Generalized epilepsy and epileptic syndromes (seizure disorder),
4. Disorientation, unspecified,
5. Unspecified psychosis (mental disorder), not due to a substance or known condition.
K. Record review of R #5's electronic health record (EHR) revealed a Long Term Care Form dated 02/20/25 completed by the hospice agency stated routine hospice care to start on 02/20/25.
L. Record review of R #5's MDS assessment dated [DATE] revealed R #5 was receiving hospice care in the facility.
M. Record review of R #5's care plan dated last revised on 07/19//24 did not identify that R #5 was receiving hospice services.
N. On 03/19/25 at 3:00 pm, during an interview with the DON, she confirmed R #5's care plan did not contain any information regarding R #5 being on hospice. She stated her expectation is for all residents that are on hospice to have a comprehensive care plan that includes interventions for hospice.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0849
(Tag F0849)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure hospice services met professional standards for 2 (R #3 and ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure hospice services met professional standards for 2 (R #3 and R #5) of 3 (R #1, R #3, and R #5) residents reviewed for hospice services by:
1. Not having an order for hospice services for R #5
2. Not having a qualifying diagnosis for R #3.
3. Not having hospice plans of care for R #3 and R #5.
4. Not communicating with hospice regarding a change in condition for R #3.
These deficient practices are likely to result in the resident not receiving the services that she needs. The findings are:
R #3
A. Record review of R #3's admission record revealed R #3 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with the following diagnosis:
1. Atherosclerotic heart disease (condition where the coronary arteries, which supply blood to the heart, become narrowed or blocked due to the buildup of plaque [fatty deposits]).
2. Chronic atrial fibrillation (heart rhythm disorder where the upper chambers of the heartbeat irregularly and rapidly that last for more than a week).
3. Acute congestive heart failure (a sudden, life-threatening condition where the heart struggles to pump enough blood to meet the body's needs, leading to fluid buildup and symptoms like shortness of breath and swelling).
4. Chronic Kidney disease (a condition in which the kidneys gradually lose their ability to filter waste products from the blood).
5. Type 2 Diabetes Mellitus (a chronic condition characterized by high blood sugar levels due to the body's inability to use insulin effectively or produce enough insulin).
6. Benign prostatic Hyperplasia (a non-cancerous condition where the prostate gland grows larger than normal, potentially causing urinary problems)
B. Record review of R #3's hospice admission order form (a form completed by a hospice nurse to identify diagnosis, activity, diet, allergies and medication orders), revealed:
1. R #3 was admitted to hospice on 10/22/24.
2. R #3 was admitted to hospice care with a diagnosis listed as unspecified illness.
C. Record review of R #3's Electronic Health Record (EHR) revealed the hospice plan of care was not available.
D. Record review of nurse progress notes dated 12/29/24 revealed registered nurse (RN) #1 sent R #3 to the emergency room (ER) for unusual behavior and that RN #1 was unaware R #3 was on hospice.
E. On 03/18/25 at 11:07 am during an interview with R #3's family member, he confirmed RN #1 was not aware R #3 was on hospice and that the family member informed RN #1 of R #3's hospice care when he asked why hospice was not notified.
F. On 03/18/25 at 12:38 pm during an interview with R #3's hospice nurse, she stated the facility did not notify the hospice agency about R #3 condition prior to transporting him to the hospital on [DATE] and was notified from the family member.
G. Record review of R #3's Medical Record revealed R #3 returned to the facility on [DATE] with COVID as his hospice qualifying diagnoses.
H. Record review of R #3 EHR revealed a diagnosis of COVID dated 12/23/24 and resolved on 02/10/25.
I. Record review of the facility's End of life Guidelines revised 05/2023 revealed the following:
1 When hospice services are involved, the facility and hospice are jointly responsible for developing a coordinated plan of care (POC) for the residents that guides both providers and is based upon their assessments and the resident's needs and goals. The coordinated POC must identify which provider (hospice or facility) is responsible for various aspects of care. The facility is required to update its POC just as Hospices need to update their POC.
2. The hospice and the facility should have a process by which they can exchange information from their respective plans of care reviews, assessment updates, and patient and family conferences, when updating the plan of care (POC) and evaluating outcomes of care.
3 The facility's services must be consistent with the plan of care (POC) developed in coordination with the hospice. The facility continues responsibility for providing the residents' overall care and comfort.
4. The care plan incorporates the hospice philosophy of care. The care plan includes interventions and orders to manage pain and other uncomfortable symptoms. Procedures exist to ensure that the resident receives timely, pertinent nonpharmacologic and pharmacological interventions for optimal palliation. The hospice and facility need to collaborate to train facility staff in managing the residents' symptoms and utilizing any special equipment.
5. The facility should notify the hospice when the resident experiences a significant change in physical, mental, social, or emotional status, or needs to be transferred from the facility.
6. In order to ensure that each provider meets its responsibilities, it is essential the facility and hospice have a means to communicate how all needed services, professionals, medical supplies, Durable medical equipment (DME) drugs and biologicals will be made available to the resident 24 hours a day, seven days a week, including who may receive and/or write orders for care, in accordance with State/Federal requirements.
J. Record review of R #3 hospice agreement
1. Section 3.1.2 Hospice shall assess the resident in accordance with hospice's criteria for admission to the hospice program and shall notify the resident and facility whether the resident meets such criteria.
a. Exhibit E hospice criteria for admission is the terminal prognosis of six months or less if the disease follows its normal course.
2. Section 3.2.13 The facility shall immediately notify hospice when a significant change in a patients physical, mental, social or emotional status occurs, a life threatening condition has appeared, a need to transfer the patient from the facility arises, or the patient dies.
3. Section 3.31 Hospice and facility shall jointly develop and agree upon the patient's Plan of Care (POC). Hospice and facility each shall maintain a copy of each patients' POC in the respective clinical records maintained by each party. Hospice and facility shall designate a registered nurse responsible for coordinating the implementation of the POC for each patient.
K. On 03/19/25 at 12:59 pm during an interview with the Director of Nursing (DON), she confirmed the following:
1. R #3 is currently receiving hospice services
2. R #3's current hospice admission order form dated 01/02/24, COVID diagnoses does not meet her expectations as a qualifying diagnosis for hospice care.
3. The facility does not have a record of R #3's hospice POC.
4. R #3's care plan was not updated prior to 01/02/25 to include hospice services which originally began on 10/22/24.
5. R #3's care plan revised on 01/02/05 does not meet her expectations for interventions regarding R #3's care for hospice needs.
R #5
L. Record review of R #5's admission record revealed R #5 was admitted to the facility on [DATE] with the following diagnoses:
1. Alzheimer's disease,
2. Depression and anxiety disorders,
3. Generalized epilepsy and epileptic syndromes, (seizures-uncontrolled jerking and loss of consciousness)
4. Disorientation, unspecified,
5. Unspecified psychosis, not due to a substance or known condition.
M. Record review of R #5's electronic health record (EHR) revealed a Long Term Care Form dated 02/20/25 completed by the hospice agency stated routine hospice care to start on 02/20/25.
N. Record review of R #5's Electronic Health Record (EHR) revealed there was no hospice plan of care.
O. Record review of R #5's current medical orders revealed there is no order for hospice services.
P. On 03/19/25 at 3:00 pm, during an interview with the DON, she confirmed R #5's EHR did not contain any information regarding R #5 being on hospice. She stated that her expectation is for all residents that are on hospice to have an order for hospice, a pertinent diagnosis, a coordinated care plan, and it should be included in the agency's care plan and confirmed none of that is in place for R #5.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure nursing staff were competent to provide nursing and related ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure nursing staff were competent to provide nursing and related services. This deficient practice could affect all 53 residents in the facility (residents were identified by Resident Matrix provided by the Administrator on [DATE]). This deficient practice could likely result in CNA's (Certified Nurse Assistant) and RN's (registered nurses) working with residents without adequate knowledge to do so; likely resulting in injury or inappropriate care being provided to the residents. The findings are:
A. Record review of the facility's Agency Use Policy (policy and procedures for using nursing staff who are contracted through a third-party agency) revised on 02/2023, revealed the facility will ask the agency to fax to the facility the completed LN (Licensed Nurse) competency evaluation on each individual. In addition, the verification of licensure and/or certification and background check results for all agency staff must be given/faxed to the facility. The facility must provide the necessary orientation to enable the registry personnel to carry out their responsibilities.
B. On [DATE] at 3:17 pm during an interview with Certified Nurse Aid (CNA) #3, he confirmed he is a contracted agency staff. He stated he did not receive any training's or orientation from the facility prior to working at the facility.
C. On [DATE] at 3:41 pm during an interview with CNA #5, she confirmed she is a contracted agency staff. She stated she did not receive any trainings or orientation from the facility prior to working at the facility.
D. On [DATE] at 12:30 pm during an interview with Registered Nurse (RN) #3, he confirmed he is a contracted agency nurse. RN #3 confirmed he was working his first shift since 6:30 am [[DATE]]. He reported that he did not have any training or orientation with the facility prior to starting his shift and was only given a brief tour when he arrived. RN #3 stated he was given a code to sign into a tablet, but did not have access to the residents' electronic health records until approximately 12:30 pm [[DATE]]. RN #3 confirmed he was working on the floor as the only nurse with a Certified Medication Aide (CMA) and he was dependent upon the CMA to access resident medical records for him due to not having access.
E. On [DATE] at 1:00 pm during an interview with the administrator (ADM), she confirmed the facility does not complete any training or orientation for agency staff prior to working their first shift. The ADM stated the expectation is that the contracting agency completes all required verifications and trainings. The agency staff should arrive at the facility ready to work. The Administrator confirmed that she did not have any record of staff training or background checks for agency staff.
F. On [DATE] at 2:25 pm during an interview with the scheduler and central supply (S/CS), she confirmed the facility does not provide any training or orientation to agency contracted staff.
G. [DATE] at 2:23 pm during interview with Human Resources (HR), she confirmed that the facility did not have to keep records for agency staff.
Findings for R #2:
H. Record review of R #2's admission record revealed R #2 was originally admitted to the facility on [DATE], and readmitted on [DATE] after a hospital stay with the following diagnoses:
1. Hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body) and Hemiparesis (weakness or paralysis on one side of the body) following cerbral (brain) infarction (condition where blood flow to the brain is interrupted, causing brain tissue damage) affecting left non-dominant side.
2. Atherosclerotic heart disease (condition where the coronary arteries, which supply blood to the heart, become narrowed or blocked due to the buildup of plaque [fatty deposits]).
3. Altered mental status, unspecified.
4. Strange and inexplicable behavior.
5. Cardiac (heart) Arrythmia (irregular heartbeat).
I. Record review of R #2's care plan dated [DATE] revealed R #2 was at risk for falls due to generalized weakness. Interventions include staff to assist as needed with transfers and ADLs (activities of daily living).
J. Record review of Minimum Data Set (MDS) assessment dated [DATE], revealed that R #2 has upper and lower extremity impairment on one side. Assessment also indicated that R #2 needed substantial/maximal assistance (helper does more than half the effort) for upper body dressing and dependent (helper does all the effort) for lower body dressing.
K. Record review of a written statement by CNA #6, acquired by facility during an investigation conducted on [DATE], revealed CNA #6 was not aware that R #2 had left-sided weakness and had told R #2 to put her arms in the sleeves of her shirt by herself. R #2 began to cry an stated that she couldn't [dress herself] and that's why she needed help. R #2 began to swing at the CNA. CNA #6 wrote in her statement that she didn't know the resident wasn't able to dress herself.
L. Record review of the employee record for CNA #6 confirmed that she was agency staff. The record also identified that training for abuse, neglect and misappropriation had not been completed, dementia care assessment 1 was expired, enhanced barrier precautions training not started, long term care essential clinical assessment was not started, CNA acute care training was expired, psychiatric and mental health nursing was expired.
Findings related to R #3:
M. Record review of R #3's admission record revealed R #3 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with the following diagnoses:
1. Atherosclerotic heart disease (condition where the coronary arteries, which supply blood to the heart, become narrowed or blocked due to the buildup of plaque [fatty deposits]).
2. Chronic atrial fibrillation (heart rhythm disorder where the upper chambers of the heartbeat irregularly and rapidly that last for more than a week).
3. Acute congestive heart failure (a sudden, life-threatening condition where the heart struggles to pump enough blood to meet the body's needs, leading to fluid buildup and symptoms like shortness of breath and swelling).
4. Chronic Kidney disease (a condition in which the kidneys gradually lose their ability to filter waste products from the blood).
5. Type 2 Diabetes Mellitus (a chronic condition characterized by high blood sugar levels due to the body's inability to use insulin effectively or produce enough insulin).
6. Benign prostatic Hyperplasia (a non-cancerous condition where the prostate gland grows larger than normal, potentially causing urinary problems)
N. Record review of R #3's hospice admission order form (a form completed by a hospice nurse to identify diagnosis, activity, diet, allergies and medication orders) revealed resident was admitted to hospice on [DATE].
O. Record review of the nurse progress note dated [DATE], revealed Sent patient to hospital this morning, Was acting aggressive, confused and lethargic. He did slap one of the techs and refused a blood sugar and medication. Ambulance took patient to [Name of hospital]. Note was written by RN #1.
P. On [DATE] at 2:59 pm during interview with the Administrator, she confirmed that the nurse that sent R #3 to the hospital was unaware that he was on hospice and he should not have been sent out. The Administrator confirmed that RN #1 was an agency nurse.
Jan 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to prevent an accident for 1 (R #1) of 1 (R #1) residents reviewed for...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to prevent an accident for 1 (R #1) of 1 (R #1) residents reviewed for falls when the facility failed to ensure proper use of mechanical lift (a device designed to help staff move a resident from one place to another within a room or from one position to another) which resulted in R #1 falling and sustaining injuries that required treatment at the hospital. The findings are:
A. Record review of R #1's face sheet revealed R #1 was admitted to the facility on [DATE] with multiple diagnoses including:
1. Acute kidney failure,
2. Inclusion body myositis (a progressive muscle disease that causes muscle inflammation, weakness, and atrophy),
3. Permanent atrial fibrillation (abnormal heartbeat despite previous attempts to restore normal heart rhythm),
4. Muscle weakness, generalized.
5. Other reduced mobility.
B. Record review of R #1's quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) dated 10/18/24, revealed the following:
1. A Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) score of 15, cognitively intact.
2. R #1 was dependent and required the assistance of two or more staff to complete transfer activities.
C. Record review of R #1's Change of Condition Note, dated 10/23/24, revealed the resident was transferred to the emergency room by Emergency Medical Services (EMS) for an evaluation related to a fall from a Hoyer sling.
D. Record review of the facility's Initial Incident Report, dated 10/23/24, revealed staff used a Hoyer lift to transfer R #1, and the hoyer sling broke which caused R #1 to fall.
E. Record review of R #1's Post Fall Evaluation, dated 10/25/24, revealed the following:
1. On 10/23/24 at 7:50 am, R #1 had a witnessed fall in his room while being transferred by staff.
2. R #1 suffered a skin tear and bruising from the fall.
F. Record review of the facility's Follow-Up Report, dated 10/24/24, revealed the conclusion that the Certified Nurses Aides (CNAs) should have used two staff members while using the Hoyer lift to transfer R #1. Staff also documented there was some negligence (failure to take proper care in doing something).
G. On 01/02/25 at 2:15 pm during an interview with R #1, he stated he remembered falling from the Hoyer sling, and he was glad he wasn't really hurt.
H. On 01/03/25 at 11:45 am during an interview with the Administrator (ADM), she stated she was the only staff member that would remember the incident. She stated the Hoyer sling was not visibly worn at the time of the incident, but there was only one CNA operating the lift when R #1 fell on [DATE]. The ADM stated there should always be two staff members operating the mechanical lift.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure patient care equipment was in safe operating condition for 1...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure patient care equipment was in safe operating condition for 1 (R #1) of 1 (R #1) residents reviewed. This deficient practice likely resulted in a Hoyer sling (a specialized fabric that connects onto the mechanical lift and supports a person's weight when transferring from one position to another using a mechanical lift) breaking and causing R #1 to fall and sustain injuries. The findings are:
A. Record review of R #1's face sheet revealed R #1 was admitted to the facility on [DATE] with multiple diagnoses including:
1. Acute kidney failure,
2. Inclusion body myositis (a progressive muscle disease that causes muscle inflammation, weakness, and atrophy),
3. Permanent atrial fibrillation (abnormal heartbeat despite previous attempts to restore normal heart rhythm),
4. Muscle weakness, generalized.
5. Other reduced mobility.
B. Record review of R #1's quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 10/18/24, revealed the following:
1. A Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) score of 15, cognitively intact.
2. R #1 was dependent and required the assistance of two or more staff to complete transfer activities.
C. Record review of R #1's Change of Condition Note, dated 10/23/24, revealed the resident was transferred to the emergency room by Emergency Medical Services (EMS) for an evaluation related to a fall from a Hoyer sling.
D. Record review of the facility's Initial Incident Report, dated 10/23/24, revealed staff used a Hoyer lift to transfer R #1, and the Hoyer sling broke which caused R #1 to fall.
E. Record review of the facility's policy and procedure for Patient Care-Related Electrical Equipment, revised October 2024, revealed the Maintenance Manager was to develop a maintenance schedule based on manufacturer and regulatory requirements, as well as, perform regular inspections and testing.
F. On 01/03/25 at 11:45 am during an interview with the Administrator (ADM), she stated the Hoyer sling was not visibly worn at the time of the incident on 10/23/24. She confirmed that the Hoyer sling did break which caused R #1's fall on 10/23/24. The Administrator confirmed that Maintenance staff was suppose to be checking the condition of equipment but was not able to indicate when the hoyers were last checked prior to this incident.
May 2024
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure the comprehensive care plan was updated for 1 (R #28) of 1 (R #28) residents reviewed for care plan accuracy. This deficient practic...
Read full inspector narrative →
Based on interview and record review, the facility failed to ensure the comprehensive care plan was updated for 1 (R #28) of 1 (R #28) residents reviewed for care plan accuracy. This deficient practice could likely result in staff not understanding and implementing the most appropriate interventions and treatments for the resident. The findings are:
A. Record review of R #28's Electronic Medical Record (EMR) revealed R #28 was admitted to hospice services on 01/17/24 and received these services.
B. Record review of R #28's care plan, reviewed on 04/24/24, revealed the care plan did not contain information about hospice services.
C. On 05/22/24 at 2:34 PM during an interview, the facility's Social Services Director (SSD) stated R #28's care plan did not include hospice services, and staff should have updated the resident's care plan to include hospice services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Repeat deficiency.
Based on record review and interview, the facility failed to meet professional standards of quality when staff failed to notify the Pharmacist and the Director of Nursing (DON) of ...
Read full inspector narrative →
Repeat deficiency.
Based on record review and interview, the facility failed to meet professional standards of quality when staff failed to notify the Pharmacist and the Director of Nursing (DON) of a morphine spill and a missing fentanyl patch for 2 (R #1 and #13) of 2 (R #1 and #13) residents reviewed for medications. This deficient practice could cause a resident to not receive the pain medication that was prescribed and could also cause confusion when reconciling medications. The findings are:
R #1
A. Record review of the physician orders for R #1 indicated an order for a fentanyl patch, 25 micrograms (mcg), every 72 hour; amount: one patch transdermal (absorbed through skin into bloodstream). Special Instructions: Apply transdermal patch onto lower back once every 72 hours. Start date 09/13/23.
B. Record review of R #1's nursing progress notes, dated 01/21/24, indicated the writer applied a new fentanyl patch to the resident's right shoulder with protective cover and dated it. The writer and the other Licensed Practical Nurse (LPN) on staff did not find the old patch.
C. On 05/23/24 at 10:08 am, during an interview with Nurse (N) #5, she stated she was not aware the nurses did not find and destroy R #1's fentanyl patches. She stated she thought the Assistant Director of Nursing (ADON) was aware of the January 2024 incident, but none of them were aware of it. N #5 stated the management staff could not find any documentation about the January 2024 incident. N #5 stated the nurse managers should be aware of missing fentanyl patches if staff cannot find the patches.
D. On 05/23/24 at 12:17 pm, during an interview with the Assistant Director of Nursing (ADON), he stated staff notified him in the past if they could not find a fentanyl patch. He was not aware of a missing patch for R #1 on 01/21/24.
E. Record review of the Medication Administration: Topical Patch Procedure, revised 10/2023, indicated if staff determined a patch to be missing, then the nursing staff should investigate and attempt to find the missing patch to dispose of properly. Staff should notify the Director of Nursing Services if they do not locate the patch.
R #13
F. Record review of the current physician orders for R #13 indicated an order for morphine concentrate solution, administer 0.5 to 1 ml orally, as needed for shortness of breath or pain. Start date 05/09/23.
G. Record review of the narcotic log sheet for R #13, dated 05/20/24, indicated 4 ml of morphine were wasted.
H. On 05/23/24 at approximately 9:30 am, during an interview with the Pharmacist, she stated she expected staff to notify her if there was a waste of morphine medication. She stated staff did not notify her that R #13's morphine was spilled on 05/13/24. She stated she expected a new order for the morphine, and the old bottle to be destroyed after the new one had come in.
I. On 05/23/24 at 10:07 am, during an interview with the Director of Nursing (DON), she stated she was not aware staff spilled R #13's morphine. She stated they found documentation of the spill on the Narcotic log sheet, and the morphine bottle was still in the medication cart.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to meet professional standards of care for 1 (R #30) of ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to meet professional standards of care for 1 (R #30) of 1 (R #30) resident reviewed for respiratory care by not changing the oxygen tubing. This deficient practice could likely lead to respiratory infections by the oxygen tubing becoming clogged due to condensation (a process where water vapor becomes liquid) or becoming dirty, leading to the reduced oxygen flow. The findings are:
A. Record review of the face sheet indicated R #30 was admitted to the facility on [DATE]. Resident had a diagnosis of pneumonia on 02/22/24 and on 03/06/24.
B. Record review of the physician orders for R #30, dated 06/07/23, revealed an order for oxygen, 1 to 4 liters per minute (LPM) via nasal cannula (thin tube that supplies oxygen through your nose), as needed (PRN) to maintain oxygen saturation (the amount of oxygen in the blood) above 90 percent (%). Further review revealed the orders did not indicate how often staff should change the resident's oxygen tubing.
C. On 05/20/24 at 12:10 pm, an observation of R #30's oxygen tubing revealed the tubing was dated 03/31/24.
D. On 05/20/24 at 12:16 pm during an interview, Nurse (N) #6 stated the oxygen tubing was dated 03/31/24 date. She stated there should be orders to change the tubing, and it should be changed weekly.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interview, the facility failed to provide quality of care when they did not provide wound care for 1...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interview, the facility failed to provide quality of care when they did not provide wound care for 1 (R #17) of 1 (R #17) residents review for skin conditions. This deficient practice could likely result in the resident not receiving appropriate and timely wound care resulting in discomfort and infection. The findings are:
Findings for R #17
A. Record review of R # 17's face sheet revealed the resident was admitted on [DATE] with diagnoses that included but was not limited to:
- Malignant melanoma (skin cancer) of skin of breast,
- History of unspecified open wound of right front wall of thorax (area of the body situated between the neck and the stomach) without penetration into thoracic cavity,
- Surgical removal of right breast and nipple.
B. Review of R #17's Medication Administration Record (MAR), revealed the following:
1. Wound Care for wound on right breast:
a. Cleanse with cleaning agent.
b. Pat Dry.
c. Apply antibiotic ointment.
d. RN will apply dry dressing, cover with 4 by 4 foam. Measure length, width, and depth of wound of the breast area.
e. Notify physician if wound increased in size. Every day shift related to malignant melanoma of skin of breast.
f. Start date 05/14/24.
2. Wound Care to front wall of thorax:
a. Hospice provided wound care to wound, as needed, every three days. Started 05/14/24.
C. Record review of R #17's MAR, dated 05/14/24 through 05/23/24, revealed staff completed wound care treatment two out of 10 times, as follows:
- On 05/14/24, staff did not provide treatment,
- On 05/15/24, staff did not provide treatment,
- On 05/16/24, staff provided treatment,
- On 05/17/24, staff provided treatment,
- On 05/18/24, staff did not provide treatment,
- On 05/19/24, staff did not provide treatment,
- On 05/20/24, staff provided treatment,
- On 05/21/24, staff provided treatment,
- On 05/22/24, staff did not provide treatment,
- On 05/23/24, staff did not provide treatment.
D. Record review of R #17's Hospice Care notes, dated 05/14/24 through 05/23/24, revealed hospice completed wound care treatment, as follows:
- On 05/14/24, hospice provided treatment.
- The notes did not contain any more documentation regarding wound care.
E. On 05/22/24 at 10:50 a.m., during an interview, the Assistant Director of Nursing (ADON) stated he was responsible for the resident's wound care every Thursday. The ADON stated the facility did not have a designated wound care staff who provided wound care, but they ensured the care was provided by the RN's that were on shift. The ADON stated R #17's wound seemed to clear up for a day or two then the wound would appear again due to breast cancer.
F. On 5/23/24 at 2:00 p.m., during an interview with Interim Director of Nursing (IDON), she stated the first order stated the wound care would be completed daily, and the second order stated Hospice would provide wound care, as needed, every three days. She stated the expectation was for the nurse on the floor, the Director of Nursing (DON), or the ADON to discontinue an order due to there being two orders that contradicted one another.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to:
1. Ensure the medication carts did not contain loose medications....
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to:
1. Ensure the medication carts did not contain loose medications.
2. Ensure expired supplies were not kept with unexpired supplies in the medication room.
3. Fentanyl patches were destroyed immediately after removal and not stored in the medication cart.
These deficient practices are likely to result in all 31 residents of the 200 and 300 halls, as identified on the census list provided by the facility Administrator on [DATE], receiving expired medication, having expired medical supplies used in their treatments, and in the mishandling or misuse of narcotic drugs.
The findings are:
Findings for loose medications found in medication carts.
A. On [DATE] am at 9:10 am, during observation of the 300 hall medication cart, one white, circular tablet was loose under the medication cards (vertical cardboard and foil cards pre-filled with prescription medications for easy storage and dispensing) in the drawer of the cart.
B. On [DATE] at 9:26 am, during an interview with Certified Medication Aide (CMA) #1, she stated loose medications should not be in the medication cart under the medication cards. CMA #1 further stated whoever is using the medication cart should check the cart for loose medicationsat the beginning of each shift.
Findings for expired supplies stored with unexpired supplies.
C. On [DATE] at 9:30 am, during observation of the 300 hall medication storage room, the following supplies were expired and stored with unexpired supplies:
1. Twenty Med Stream intravenous (IV) start kits expired [DATE].
2. One hundred [NAME] Prevent HT safety needles, 18 gauge, expired [DATE].
D. On [DATE] at 9:33 am, during an interview with Licensed Practical Nurse (LPN #1), she stated the IV start kits and the needles were expired and should not be stored with unexpired supplies. LPN #1 further stated all employees should check the medication storage room for expired supplies. She stated staff should remove expired supplies from the storage room and give them to the charge nurse or Director of Nursing.
Findings for fentanyl patches.
E. Record review of the facility's Medication Administration: Topical Patch Procedure, revised 10/2023, indicated the following:
- Removal and disposition of a controlled medication transdermal (the application of a medicine or drug through the skin, typically by using an adhesive patch, so that it is absorbed slowly into the body) patch: Fold patch in half with the sticky sides together and dispose in a secured pharmaceutical wastes container per appropriate medical wastes management regulations and applicable federal/state law. Do not flush the patch down the toilet.
F. On [DATE] at 10:45 am, during an interview with Nurse #4 she stated she just removed a fentanyl patch and put it in the medication cart until she was able to destroy it. She said there was not a second nurse available to destroy the patch immediately. Nurse #4 stated there was a form that nurses signed when they destroyed fentanyl patches, and two nurses had to sign and date the form when they destroyed the patch.
G. On [DATE] at 10:58 am, during an interview with Assistant Director of Nursing (ADON), he stated it was not okay to store a fentanyl patch in the medication cart while the patch waited to be destroyed. He stated he was always available to assist a nurse with the destruction of a fentanyl patch, and the Director of Nursing (DON) was also available. The ADON stated there was a form they used when the nurses destroyed a fentanyl patch, and the two nurses should sign and date it. He stated they used the drug buster (deactivates and contains the active ingredients in non-hazardous medications) to destroy the patches.
H. On [DATE] at 8:30 am, during an interview with the DON, she stated the for removing a fentanyl patch was for two nurses to sign and date the form, and then they put the patch in the drug buster. The DON stated that once the nurses removed a patch, they should destroy it immediately. She said they should not lock the fentanyl patch in the medication cart. She stated she was always available if a second nurse was needed to destroy a patch.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation and interview, the facility failed to store food in accordance with professional standards when staff stored expired food in the facility's walk-in refrigerator. This deficient pr...
Read full inspector narrative →
Based on observation and interview, the facility failed to store food in accordance with professional standards when staff stored expired food in the facility's walk-in refrigerator. This deficient practice had the potential to negatively impact all 47 residents listed on the census provided by the Director of Nursing on 05/20/24. If the facility fails to adhere to safe food storage practices, residents could likely to be exposed to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins). The findings are:
A. On 05/20/24 at 9:52 AM during an observation of the facility's walk-in refrigerator, three packages of tofu had an expiration date of 05/18/24.
B. On 05/20/24 at 9:52 AM during an interview, the facility's chef stated staff should throw out the expired tofu and not store it in the walk-in refrigerator.
C. On 05/23/24 at 1:02 PM during an interview, the facility's Director of Dining Services stated staff used the food stored in the walk-in refrigerator for the facility's residents, and the kitchen staff should check the refrigerator daily for expired foods. He stated staff should throw out expired foods when they discover them.
Apr 2024
5 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the power of attorney (POA; a designation given to an agent ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the power of attorney (POA; a designation given to an agent to handle financial or medical acts on someone else's behalf) and the Nurse Practitioner (NP) of a fall for 1 (R #1) of 3 (R #1, #2, and #3) residents reviewed for falls. This deficient practice could likely cause a breakdown in resident care if the NP is not notified of all falls and the family is left feeling uninformed and frustrated about their loved ones care. The findings are:
A. Record review of the face sheet for R #1 revealed he was admitted to the facility on [DATE]. Further review revealed the resident's POA was Family Member #3.
B. Record review of the nursing progress note for R #1, dated 11/07/23 at 3:53 pm, revealed the nurse reported R #1 fell in the dining room while playing Bingo. The nurse stated she checked R #1. R #1 did not hit his head and did not complain of any pain. The resident's range of motion (the extent or limit to which a apart of the body can be moved around a joint or a fixed point) was fine. R #1's family member #1 and family member #2 were with him when he fell.
C. Record review of R #1's medical record revealed the staff did not notify the resident's POA or the Nurse Practitioner of the fall on 11/07/24.
D. On 04/02/24 at 11:30 am, during an interview with the Director of Nursing (DON), she stated staff should always inform the POA of any falls. She stated staff should notify the POA even if a family member was present when a fall occurred, if that family member was not the POA.
E. On 04/02/24 at 11:05 am, during an interview with Nurse Practitioner (NP) she stated she did not write any notes about R #1's fall on 11/07/23, which indicated staff did not make her aware of R #1's fall.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to follow a physician's order for 1 (R #2) of 1 (R #2) residents revie...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to follow a physician's order for 1 (R #2) of 1 (R #2) residents reviewed for medication administration. This deficient practice could likely cause staff to administer a medication to a resident when the medication is not necessary.
The findings are:
A. Record review of R #2's quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 03/01/2024, revealed the following:
- The resident was admitted to the facility on [DATE];
- The resident was diagnosed with Parkinson's disease (a neurodegenerative disorder that affects the brain and worsens over time as cells in the brain that produce dopamine stop working or die).
B. Record review of R #2's Hospice admission Orders, dated 03/23/24, revealed an order for morphine sulfate, 20 milligrams (mg)/millilters (ml), 0.25 ml by mouth every four hours as needed for pain or shortness of breath.
C. Record review of R #2's medical record revealed a physician order, dated 03/23/24, for morphine sulphate 20 mg/ml, 0.25 ml liquid: 20 mg. Amount to administer 0.25; orally. Frequency: Every four hours. Special instructions: Administer every four hours as needed for pain or shortness of breath. Diagnosis: pain.
D. Record review of the Medication Administration Record (MAR) for R #1 revealed the following:
- On 03/23/24, staff administered morphine sulphate to the resident at 4:00 pm and at 8:00 pm.
- On 03/24/24, staff administered morphine sulphate to the resident at 12:00 am, 4:00 am, and at 8:00 am.
E. Record review of nursing notes, dated 03/24/24, revealed .daughter is extremely upset due to the fact that resident has been given morphine every 4 hours instead of PRN . writer removed the order for morphine with the scheduled times and left the PRN order.
B. On 03/28/24 at 9:21 am during an interview with the daughter of R #2, she reported that due to her father's condition, he began hospice services on 03/23/24, which included a PRN order for morphine when he experienced pain or shortness of breath. She stated she called the facility on 03/24/24 to check on her father, and the nurse informed her that he was resting due to the administration of morphine.
G. On 03/29/24 at 10:23 am, during an interview with the Director of Nursing (DON), she stated R #2's initial order is for morphine sulfate was 20mg/ml by mouth every four hours as needed for pain or shortness of breath; however, the agency nurse transcribed the order incorrectly. She stated the agency nurse entered the order as every four hours scheduled, and staff administered the morphine to R #2 as scheduled, every four hours. The DON stated staff administered three doses before they found the order was supposed to be as needed and not scheduled. She stated the resident should not have received any doses of morphine.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0740
(Tag F0740)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide behavioral health treatment for 1 (R #1) of 3 (R #1, R #2, ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide behavioral health treatment for 1 (R #1) of 3 (R #1, R #2, and R #3) residents reviewed for insomnia. This deficient practice could likely cause a resident to have increased agitation, restlessness, and falls. The findings are:
A. Record review of the face sheet for R #1 revealed R #1 was admitted to the facility on [DATE] with a diagnosis of dementia (a condition where the patient experiences the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) with agitation and schizophrenia (thoughts or experiences that seem out of touch with reality, disorganized speech or behavior, and decreased participation in daily activities). Further review revealed R #1 discharged the facility on 11/21/23.
B. Record review of the nursing progress notes for R #1 revealed the following:
1. On 10/30/23, staff documented staff monitored the resident frequently throughout the night. The resident slept for few hours but was awake most of the night.
2. On 11/04/23, staff documented R #1 was combative and did not sleep through the night. R #1 screamed for help while he was in bed. The resident kicked and hit staff.
3. On 11/08/23, staff documented staff monitored R #1 at the nurses station, because he continued to try and get out of his wheelchair and cussed at staff. R #1 requested to go bed at 10:00 pm. R #1 slept for 3 hours and started screaming. Staff responded and found R #1 naked. The resident urinated in his bed. When staff tried to change him, the resident started kicking, yelling, and telling staff to get out of his room.
4. On 11/11/23, staff documented the resident was verbally abusive and slept in chair all night.
5. On 11/13/23, staff documented R #1 was very easily agitated frequently. He self-propelled in his wheel chair. Staff constantly redirected throughout shift. Resident stayed awake most of the shift in agitated manner. Resident tried to self-propel himself into other resident's rooms, he became very angry, and cursed loudly as CNAs gently wheeled him out of the resident's rooms.
6. On 11/21/23, staff documented the resident was rude and combative with staff in the evening. R #1 was up throughout the night.
C. Record review of the current physician orders for R #1 revealed the resident did not have an order to address his lack of sleep or behaviors throughout the night.
D. On 03/28/24 at 5:21 pm during an interview with Nurse #1, she stated R #1 was aggressive, restless, and would not sleep well through the night.
E. On 04/02/24 at 11:05 am during an interview with the Nurse Practitioner, she stated she was not aware R #1 had insomnia issues and often did not sleep through the night.
F. On 04/02/24 at 11:35 am during an interview with the Director of Nursing (DON), she stated R #1 did not have a referral for a behavioral health consult while he was at the facility; but when R #1 was at his previous facility, behavior health was part of the care R #1 received. She stated R #1 did not have an order for anything to treat for his insomnia.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to monitor behaviors for 1 (R #1) of 3 (R #1, R #2, and R #3) resident...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to monitor behaviors for 1 (R #1) of 3 (R #1, R #2, and R #3) residents reviewed for the use of psychotropic medications. This deficient practice could likely result in residents continuing to exhibiting behaviors of agitation that are not remedied. The findings are:
A. Record review of the face sheet for R #1 revealed R #1 was admitted to the facility on [DATE] with a diagnosis of dementia (a condition where the patient experiences the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) with agitation and schizophrenia (thoughts or experiences that seem out of touch with reality, disorganized speech or behavior, and decreased participation in daily activities). Further review revealed R #1 discharged the facility on [DATE].
B. Record review of R #1's nursing progress notes revealed the following:
1. On [DATE], staff documented staff monitored the resident frequently throughout the night. The resident slept for few hours but was awake most of the night.
2. On [DATE], staff documented R #1 was combative and did not sleep through the night. R #1 screamed for help while he was in bed. The resident kicked and hit staff.
3. On [DATE], staff documented staff monitored R #1 at the nurses station, because he continued to try and get out of his wheelchair and cussed at staff. R #1 requested to go bed at 10:00 pm. R #1 slept for 3 hours and started screaming. Staff responded and found R #1 naked. The resident urinated in his bed. When staff tried to change him, the resident started kicking, yelling, and telling staff to get out of his room.
4. On [DATE], staff documented the resident was verbally abusive and slept in chair all night.
5. On [DATE], staff documented R #1 was very easily agitated frequently. He self-propelled in his wheel chair. Staff constantly redirected throughout shift. Resident stayed awake most of the shift in agitated manner. Family was aware of resident's behaviors and inability to sleep at night often per day staff, but they did not want him taking any as needed (PRN) medications despite his constant agitated yelling and cursing outburst behaviors, which could be stressful on himself and potentially lead to an even more increased risk for falls. Resident tried to self-propel himself into other resident's rooms, he became very angry, and cursed loudly as CNAs gently wheeled him out of the resident's rooms. Resident continued to be monitored closely by staff as he was a very high risk for falls and has reportedly fallen in the past.
6. On [DATE], staff documented R #1 fell out of a recliner as he attempted to stand up unassisted.
7. On [DATE], staff documented the resident was rude and combative with staff in the evening. R #1 was up throughout the night.
C. Record review of the current physician orders for R #1 revealed the following:
1. Physician order, dated [DATE] to [DATE], for gabapentin capsule (an anticonvulsant and nerve pain medication); 100 milligrams (mg). Amount to administer: one orally, three times a day. For schizophrenia.
2. Physician order, dated [DATE] to [DATE], for olanzapine tablet (an antipsychotic medication, often used to treat schizophrenia); 2.5 mg. Amount to administer: one tablet orally at bedtime. For schizophrenia.
3. Physician order, dated [DATE] to [DATE], for Prozac capsule (a selective serotonin reuptake inhibitor; a type of medication that can treat depression by by increasing levels of serotonin in the brain); 10 mg. Amount to administer: one tablet orally once a day. For depression.
D. Record review of R #1's care plan revealed the following entries:
1. An entry dated [DATE].
- R #1 received antipsychotic medication related to dementia with delirium/agitation.
- Approaches: Assess if the resident's behavioral symptoms presented a danger to the resident or others. Intervene as needed. Monitor resident's behavior and response to medication: Monitor for drowsiness /over sedation, delayed reaction, impaired cognition/behavior, disturbed balance/gait/positioning ability, slurred speech, sleep disturbance, tardive dyskinesia symptoms symptoms (repetitive, involuntary movements, such as grimacing and eye blinking caused by long-term use of some psychiatric drugs). Every shift. Monitor resident's functional status, document change, and report to provider. Review for continued need at least quarterly. Every shift.
E. Record review of Treatment Administration Record (TAR), for the month of [DATE], revealed the following physician orders:
1. Dated [DATE]: Monitor resident's behavior and response to medication. Monitor for drowsiness/over sedation, delayed reaction, impaired cognition/behavior, disturbed balance/gait/positioning ability, slurred speech, sleep disturbance, tardive dyskinesia. Every shift.
-Staff initialed the TAR to indicate they monitored R #1 for behaviors; however, the TAR did not contain documentation to indicate if a behavior occured or not.
2. Dated [DATE]: Anti-psychotic medication use olanzapine. Observe closely for significant side effects. Common side effects: Sedation, drowsiness, dry mouth, constipation, blurred vision, extra pyramidal reaction (involuntary movements that you cannot control), weight gain, edema (swelling caused by too much fluid trapped in the body's tissues), postural hypotension (when a person's blood pressure drops when they move from lying down to sitting up, or from sitting to standing), sweating, loss of appetite, urinary retention. Every shift. Diagnosis: depression, unspecified.
- Special attention for: Tardive dyskinesia, seizure disorder, chronic constipation, glaucoma, diabetes, skin pigmentation, jaundice (may occcur if the liver cannot efficeintly process red blood cells as they break down. Symptoms include yellowing of the skin and whites of the eyes.)
- Document 0 if none noted, document 1 if side effect(s) noted. If side effects present indicate in progress note with follow-up.
- Staff documented 0 for all observations on [DATE] through [DATE].
3. Dated [DATE]: Monitor and document any of the following behaviors every shift: Tearfulness, self-isolation related to use of psychotropic medication.
- Document Frequency. 0: Behaviors did not occur, 1: Behaviors occurred once, 2: Behaviors occurred more than once.
- Staff documented 0 for all behaviors on [DATE] through [DATE].
- Document the ability to redirect. 0: Redirection did not occur, E: Resident was easy to re-direct, D: Resident was difficult to re-direct.
- Staff documented 0 for all redirection on [DATE]-[DATE].
4. The TAR did not contain documentation staff monitored the resident for agitation, yelling, cursing, and combativeness.
F. On [DATE] at 5:21 pm during an interview with Nurse #1, she stated R #1 was aggressive, restless, and would not sleep well through the night.
G. On [DATE] at 9:22 am during an interview with Nurse #2, she stated R #1 was noncompliant. The nurse said the resident would try to get up and walk around. R #1 would try to get out of bed unassisted. R #1 would try to leave the unit. She said some days he would take his medications, and some days he would refuse. Nurse #2 said sometimes the resident would bother other residents. She stated most of the resident's falls occurred when he tried to get up unassisted.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure resident furnature was in operable working condition when they continued to use a broken recliner for 1 (R #1) of 3 (R...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to ensure resident furnature was in operable working condition when they continued to use a broken recliner for 1 (R #1) of 3 (R #1, 2, 3) residents reviewed for falls. This deficient practice could likely result in an injury if the reclining chairs are not in good operable condition.
The findings are:
A. On 03/29/24 at 11:32 am, during an observation of the recliners near the nurse's station, one recliner was broken. The foot rest was not attached to the mechanism that extended to raise and support the feet.
B. On 03/29/24 at 11:35 am and 04/02/24 at 11:30 am, during an interview, the Director of Nursing (DON) stated there were recliners in the memory care unit for the residents to use. She said the foot rest on one of the recliners did not lock when in the elevated position, and the foot rest would fall from the elevated position. The DON stated staff would place a foot stool under the foot rest so it would stay in the elevated position while a resident sat in the chair. The DON confirmed the broken recliner should not be on the floor for resident use.
Feb 2023
9 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
Based on interview, the facility failed to make prompt efforts to resolve resident grievances for 1( R #5) of 1(R #5) resident reviewed. This deficient practice is likely to result in the issue contin...
Read full inspector narrative →
Based on interview, the facility failed to make prompt efforts to resolve resident grievances for 1( R #5) of 1(R #5) resident reviewed. This deficient practice is likely to result in the issue continuing and resident's rights not being honored. The findings are:
A. On 01/31/23 at 12:02 PM during an interview with R #5, R #5 stated. Three weeks ago my phone cord and the adapter went missing and I told the nurses. It's bright colors and they said they were looking for it. R #5 was asked if they had returned her phone cord or adapter. She stated she had not heard anything more about it and it was not replaced.
B. On 02/03/23 at 11:58 AM during an interview with the SSD (Social Services Director), he stated. They (staff, residents) fill out a grievance usually, sometimes families don't do that. We will go buy it or reimburse the family. I don't why the families don't do the grievance. She chose to have it (the price of the phone charger) taken out of her bill. SSD further stated, there should have been a grievance or nursing note filled out and there wasn't one.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0602
(Tag F0602)
Could have caused harm · This affected 1 resident
Based on interview, the facility failed to ensure that a resident's belongs will be safeguarded from loss for 1 (R #5) of 1 (R #5) resident reviewed for personal property when they failed to follow up...
Read full inspector narrative →
Based on interview, the facility failed to ensure that a resident's belongs will be safeguarded from loss for 1 (R #5) of 1 (R #5) resident reviewed for personal property when they failed to follow up on an missing item that had been reported to staff. This deficient practice is likely to result in unaccounted property with no resolve for the resident and family regarding the loss resulting in frustration and not feeling heard. The findings are:
A. On 01/31/23 at 12:02 PM during an interview with R #5, R #5 stated. Three weeks ago my phone cord and the adapter went missing and I told the nurses. It's bright colors and they said they were looking for it. R #5 was asked if they had returned her phone cord or adapter. She stated she had not heard anything more about it and it was not replaced.
B. On 02/02/23 at 4:50 PM during an interview with Certified Nurse Aide (CNA) #1, she stated. I heard that she (R #5) lost her phone charger. It was a nice long one. We turned it (the issue of the missing phone cord) into Nurse [name of RN (Registered Nurse) #1], and they give it to [name of Social Services Director (SSD). I am not sure when this happened.
C. On 02/02/23 at 4:51 PM during an interview with CNA #2, she stated. I looked through every part of the room. I reported it to the nurse.
D. On 02/03/23 at 11:58 AM during an interview with the SSD, he stated. They (staff, residents) fill out a grievance usually, sometimes families don't do that. We will go buy it or reimburse the family for most missing items. I don't why the families don't do the grievance. She chose to have it taken out of her bill (the price of the phone cord). SSD further stated, there should have been a grievance or nursing note filled out and there wasn't one.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to report and provide follow up report within 5 working days from the date of the incidents to the State Survey Agency, for 1 (R's #160) of 1 ...
Read full inspector narrative →
Based on record review and interview, the facility failed to report and provide follow up report within 5 working days from the date of the incidents to the State Survey Agency, for 1 (R's #160) of 1 (R's #160) residents reviewed for incidents. If the facility fails to report incidents to the State Agency, then the State Agency will be unable to assure residents a safe and hazard free environment.
A. On 02/01/23 at 4:05 PM during an interview with R #160's granddaughter she stated, that one of the Certified Nurse Aides provided a shower for her grandmother and wrapped a wound on her leg in toilet paper and paper towels and it had stuck to the wound. She (R #160) had to be taken to [name of local hospital] emergency room to get the toilet paper out and get the wound cleaned.
B. Record review of [name of local hospital notes] dated 03/21/22 revealed: Open wound of left lower extremity, .Wounds do not appear acutely infected. Distalmost (furthest from the origin) wound appears to have suffered from some minor trauma and has some minor ecchymosis (discoloration of the skin resulting from bleeding underneath) and bleeding
C. On 02/02/23 at 11:41 am during an interview with Certified Medication Aide (CMA), she stated, that she had put toilet paper over R #160's wound because it was oozing (slow trickle or seep out of something). CMA further stated that she didn't know there needed to be a dressing on before she gave R #160 a shower.
D. On 02/02/23 at 4:07 pm during an interview with The Director of Nursing, she stated, she had done correction action with the CMA. She further stated that it was a big deal and it should have been reported.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to meet professional standards of quality for 1 (R #160) of 1 (R #160) resident reviewed by not administering a hydration packet (electrolyte ...
Read full inspector narrative →
Based on record review and interview, the facility failed to meet professional standards of quality for 1 (R #160) of 1 (R #160) resident reviewed by not administering a hydration packet (electrolyte supplement) in accordance with the physician's orders. If the facility is not administering treatments as prescribed, the residents are likely to not get the therapeutic results needed. The findings are:
A. On 02/01/22 at 4:05 pm during an interview with R #160's granddaughter, she stated, that her grandmother had dysphasia (difficulty speaking) and she was to be on a puree diet (mechanically altered) and everything but water was to be thickened. She further stated that her grandmother had been to the local ER (emergency room) several times for dehydration and was to be on IV (Intravenous) powder drinks through her IV daily, and it was not given daily.
B. Record review of face sheet revealed she (R #160) was admitted with the following diagnosis:
Moderate protein-calorie malnutrition, Dysphasia, along with several other diagnosis not mentioned here. Facesheet also revealed the following alerts:Make sure family is notified of any changes!!!!!!!!! CALL PCP (Primary Care Physician) with ANY CHANGES!!!!!!!!
1. Limited Additional Interventions: May include medical treatment, IV fluids, and cardiac monitoring (monitoring the electrical activity of the heart) as indicated Do Not Intubate, (process when a tube is inserted into a patients body for artificial ventilation transfer to hospital if indicated. Avoid Intensive care
2. Long term artificial nutrition/hydration (medical treatment that allows a person to receive nutrition and hydration when they are no longer able to take them by mouth)
C. Record review of Physicians orders dated 03/21/22 revealed: Make and give [name of R #160] the IV drinks (powder in room) and give 4 oz (ounces) qd (every day) DOCUMENT INTAKE OF THIS IN CC (cubic centimeters). Once a day 06:00- 18:00 (6:00 pm)
D. Record review of Treatments Administration History dated 03/21/22 to 03/31/22 revealed IV drink was given 6 out of 11 opportunities. No CC's documented.
E. Record review of Treatments Administration History dated 04/01/22 to 04/30/22 revealed IV drink was given 19 out of 30 opportunities. No CC's documented 12 out of 19 times administered.
F. Record review of Treatments Administration History dated 05/01/22 to 05/31/22 revealed IV drink was given 19 out of 31 opportunities. No CC's documented 16 our of 19 times administered.
G. On 02/01/23 at 2:37 pm during an interview with the Director of Nursing (DON). When asked if the IV drinks should have been documented each time they were administered, DON responded, that the IV drinks should have been documented each time they were administered.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview, the facility failed to ensure the enteral tube feeding [a device utilized to provide liquid nutrition and medications, via a tube into the stomach o...
Read full inspector narrative →
Based on observation, record review, and interview, the facility failed to ensure the enteral tube feeding [a device utilized to provide liquid nutrition and medications, via a tube into the stomach or intestine] nutritional supplement bottle for 1 (R #214) of 1 (R #214) resident reviewed, was labeled and dated to reflect when the feeding was started. The findings are:
A. Record review of R #214's care plan dated 01/27/23 revealed: Problem:
1. Clear liquid diet and Tube feeding due to Cancer of tongue with graft.
2. Hospital discharge diagnosis of severe malnutrition.
3. Skin Alteration with increased Nutrient Needs related to Peptic Ulcer (lesion in the lining of the digestive tract) on admit to follow.
a. Stable weight
b. Tolerance of TF (total fat) and wound healing.
c. Tolerance of PO (by mouth) intake with progression as able per Speech Language Pathologist (SLP)
Progress to PO intake as SLP determines.
Approach:
1. Provide TF per order and suggest increase to 35 milliliters (unit of measurement) per hour of TF 1.5 kilocalories/milliliters and continue same Fluid flush of 150 milliliters every four hours.
2. SLP to evaluate and progress to PO intake as able.
3. CDM (Certified Dietary Manager) and RD (Registered Dietician) to follow for TF tolerance and adequacy to meet nutritional needs.
B. Record review of Physician orders dated 01/27/23 revealed: Osmolite 1.5 (a therapeutic nutrition that provides complete, balanced nutrition for long- or short-term tube feeding for patients) at 55 milliliters per hour via J-Tube (a small, flexible tube inserted into the second/middle part of the small bowel, used to provide medications and nutrition) every shift 06:00 (6:00 am) - 18:00 (6:00 pm), 18:00 - 06:00.
C. On 01/30/23 at 1:44 pm during an observation, R #214 was observed actively receiving enteral feeding and R #214's nutritional supplement bottle was not dated or initialed to note when the feeding was started.
D. On 01/30/23 at 2:00 pm during an interview with Registered Nurse (RN) #1, she stated, The night nurse is supposed to replace everything [R #214's feeding supplement] at night. I've just been told when it's [R #214's feeding supplement] done [changed]. When anything [feeding supplement and/or tubing] is replaced, you should date and initial it. RN #1 confirmed that R #214's tube feeding was not initialed or dated, and should have been.
E. On 02/03/23 at 12:47 pm during an interview with the Director of Nursing (DON), she stated, It [R #214's feeding supplement] should be documented when it was started, when it [feeding supplement] was going, and when the equipment was changed. DON confirmed that R #214's feeding supplement should be time stamped and initialed by the RN when started.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that 2 (R #'s 48 and 53) of 2 (R #48 and 53) resident's New ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that 2 (R #'s 48 and 53) of 2 (R #48 and 53) resident's New Mexico Medical Orders For Scope of Treatment (MOST) reviewed was completed to reflect medical interventions (Advanced Directives-legal documents that allow you to spell out your decisions about end-of-life care ahead of time). This deficient practice is likely to affect residents' fulfillment of their end-of-life medical care choices and could result in unnecessary suffering for the resident. The findings are:
Findings for R #48:
A. Record review of R #48's face sheet revealed R #48 was admitted into the facility on [DATE].
B. Record review of the New Mexico Medical Orders For Scope of Treatment (MOST) form in R #48's electronic medical chart was signed by Physician on 09/28/22, however, no information was identified in the following sections: Medical interventions and Artificially Administered Hydration/Nutrition.
Findings for R #53:
C. Record review of R #53's face sheet revealed R #53 was admitted into the facility on [DATE].
D. Record review of the New Mexico Medical Orders For Scope of Treatment (MOST) form in R #53's electronic medical chart was not signed by a Physician.
E. On 02/01/23 at 2:16 pm during an interview with the Admissions Coordinator, she confirmed R #48's and R #53's MOST forms were incomplete.
F. On 02/02/23 at 3:47 pm during an interview with the Director of Nursing (DON), she verified that the MOST forms for R #48 and R #53 were incomplete, and the expectation is that resident MOST forms be complete with appropriate signatures.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure that 2 of (R #32 and 37), of 2 (R #32 and 37) resident's revi...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure that 2 of (R #32 and 37), of 2 (R #32 and 37) resident's reviewed for Minimum Data Set (MDS) assessments were accurate and reflected the resident's status. This deficient practice is likely to result in residents not receiving the appropriate care and treatment they need. The findings are:
Findings for R#32
A. Review of record of R #32's MDS revealed a discharge MDS assessment was not completed and sent out timely. R #32 expired on [DATE]. Last MDS (quarterly) completed was on [DATE].
Findings for R# 37
B. Review of record of R #37's MDS revealed a discharge MDS assessment was not completed and sent out timely. R #37 was discharged to Independent Living Facility on [DATE]. Last MDS completed was an admission MDS on [DATE]
C. On [DATE] at 9:18 AM during an interview with MDS Coordinator/Case Manager she confirmed there was no discharge MDS assessment completed for R #32 or R #37 sent out and there should have been.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that wound care for 1 (R #160) of 1 (R #160) residents revie...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that wound care for 1 (R #160) of 1 (R #160) residents reviewed was in accordance with professional standards of practice when the facility allowed resident's family to provide and implement wound care orders and was not monitoring the wound status and not in communication with the Home Heath Agency staff providing the wound care. If the facility is not monitoring resident care, then residents are likely to not get the care they need. The findings are:
A. Record review of R #160's face sheet revealed R #160 was admitted into the facility on [DATE].
B. Record review of care plan dated 09/20/20 revealed [Name of R #160] is at high risk for skin tears and bruising also secondary to aspirin use, nutritional status and very frail skin and has history of bruising and skin tears.
C. Record review of Progress Notes for R #160 revealed the following:
1. 12/30/21 at 1:05 am Late In the evening CNA (Certified Nurse Assistant) from 3rd floor come to 2nd floor to drop-off medication and report a resident had a scab come off while she was transferring the patient.
At 2330 (11:30 pm) nurse from 3rd floor coming and asking for steri-strlp as a resident on 3rd floor has a skin tear. Took some steri-strlp with wound care supplies. Resident appeared sleeping in her bed. Removed the blanket and found resident with large skin tear (8cm) to her right lateral shin. Cleansed the wound with normal saline, dry and applied steri-strlp, Applied 4 x 4 and wrap with kerllx as resident continue wiping scant amount of sanguineous drainage. Resident is not on any bleeding thinner and she is on Aspirin 81mg daily .POA was notified, and the POA who is resident daughter was upset because no one has any idea how it happened and at what time it had happened.
2. 12/30/21 at 11:23 am Wound Care/Assessment: Notified of skin tear during morning meeting, Visualized Nursing skin tear, it is well approximated with small amount of blood, Measured at 6cm
open to air sterl-strlps were placed by night RN (Registered Nurse).
3. 12/30/21 at 2:30 pm Residents granddaughter called to speak to writer re [again] skin tear resident received last night. Advised the Social Worker sent her a picture that she forwarded to [Name of R #160's Primary Care Physician (PCP)] and that she [R #160's PCP] 'didn't like the look of the steri strips' [wound closure tape] so callers cousin who is an ER [Emergency Room] nurse would be coming to remove the steri strips and apply a dressing like [Name of R #160's PCP] requested.
4. 01/03/22 Residents [R #160] daughter visited today, she [R #160's daughter] brought her niece who is ER nurse, she [R #160's daughters niece] did the dressing on the Rt [right] leg, and they were complaining about the dressing on her Left leg, that she did not had this redness in the last visit As they mentioned, they had a picture and sent a picture to [Name of R #160's PCP]. The ER nurse would be coming EOD [end of day] to remove the steri strips and apply a dressing like [Name of R #160's PCP] requested. So, the family coming on EOD to do wound care, as her daughter stated.
D. Record review of R #160's medical record did not provide any additional information regarding the status of the wound to the right shin including treatment provided between 01/03/22 and 03/20/22.
E. Record review of R #160's Home Health Agency (HHA) Visit Note Report dated 01/12/22 revealed, PT [patient (R #160)] WAS REFERRED TO HOME HEALTH FOR WOUND CARE TO BLE [bilateral lower extremity] SKIN TEARS AFTER WOUNDS WERE FOUND BY FAMILY AND FACILITY UNABLE TO APPROPRIATELY CARE FOR WOUNDS. RT [right] LATERAL LOWER LEG WOUND WAS FOUND TO BE INFECTED AND DX [diagnosed] W [with] CELLULITIS [infection in the skin] AT TELEHEALTH VISIT W [with Name of R #160's PCP] ON 1/7 [2022]. ABX [antibiotics] WAS STARTED AND FINISHED YESTERDAY. PT REQUIRES 2 PERSON TRANSFERS AND SKIN TEARS ARE BELIEVED TO BE CAUSED BY CG [caregiver] STAFF DURING TRANSFERS. WOUNDS WERE NEVER REPORTED AND WOUNDS WERE NEGLECTED CAUSING INFECTION. FAMILY HAS FILED POLICE REPORT AND THE STATE IS INVOLVED IN SITUATION. UPON EVALUATION OF RT LATERAL WOUND, ERYTHEMA AND EDEMA IS NOTED TO PERI-WOUND. PT [R #160's] GRANDDAUGHTER HAS BEEN PERFORMING WOUND CARE PRIOR TO TODAYS VISIT AND PER [Name of R #160's daughter] WOUNDS ARE NOT TO BE CARE FOR BY LNF [long term nursing facility]. LT [left] ANTERIOR WOUND IS FOUND TO HAVE A RAISED SCAB AND PT REFUSING ANY WOUND CARE TO WOUND. PT [R #160] WAS D/C [discontinued] FROM IN PATIENT THERAPY SERVICES D/T [due to] MAX POTENTIAL MET. WOUND CARE TO RT LATERAL LOWER LEG WOUND, MONITOR FOR WOUND INFECTION, EDUCATE PT/CG [R #160/caregiver] ON KEEPING BANDAGE DRY DURING SHOWERING, CARDIOPULMONARY ASSESS, SKIN ASSESSMENT, EDUCATE CG ON PROPER TRANSFERS W [with] IMPORTANCE OF PREVENTING SKIN BREAKDOWN AND ASSESS FOR ADEQUATE HYDRATION/NUTRITION FOR OPTIMAL WOUND HEALING. PCP APPROVES POC [plan of care].
F. On 02/01/23 at 2:37 pm during an interview with the Director of Nursing (DON), she stated, The [R #160's] family asked [Name of R #160's Primary Care Physician] for Home Health for wound care and therapy. We [facility staff] were told not to touch it [R #160's wounds] by the family. I would ask the wound home health nurse [for R #160 wound care updates]. I would go up there [R #160's room] during wound rounds to make sure there was a dressing on there. I would tell the nurse to call home health [if there were any issues with R #160's wounds and/or dressings]. This person [R #160's wound care nurse] was a relative and reporting everything to the family and not me. I have no control over that. I kept saying, I don't get any information from these people [R #160's family and HHA] and I don't know what's going on. In the future, I would never let that go on. I couldn't get hold of [Name of R #160's PCP] and that happened a lot. DON confirmed the facility staff should have documented R #160's wound in the Wound Management Report, even if the HHA was treating the wound.
G. On 02/01/23 at 2:59 pm during an interview with the Social Services Director (SSD) regarding R #160's shin wound, he stated They [facility nursing staff] weren't allowed to touch it [R #160's wounds]. SSD described that the Home Health Agency would communicate with R #160's family regarding the wound but not to the facility.
H. On 02/01/23 at 4:05 pm during an interview with R #160's granddaughter, she stated that her grandmother [R #160] had some wounds and no one at the facility could tell her how the wounds had happened and it was not documented. She further stated that the family had an outside Home Health Agency coming into the facility to care for R #160's wounds because they could not get any information from the facility on the wound care or on how the wound occurred. She also stated that on 03/21/22 there was an incident where her grandmother was given a shower and the wound was packed with toilet paper and covered with paper towels and it was stuck on her wound. R #160 was totally dependent on the facility to care for her other than care for the wounds. R #160 was sent out to the local hospital on [DATE] to have the wound cleaned out (toilet paper and paper towels) and to ensure there was no infection.
I. Record review of R #160's HHA Visit Note Report dated 03/21/22 revealed, UPON SN [skilled nurse] ARRIVAL, PT (Patient) HAD LLE [left lower extremity] PANT LEG SOILED W [with] BLOOD. WHILE LIFTING LLE PANT LEG, A PAPER TOWEL WAS LAYING OVER WOUND. REMOVED PAPER TOWEL TO FIND TOILET PAPER STUCK ON WOUND BED. PT [R #160] REPORTED SEVERE PAIN WHILE TRYING TO REMOVE TISSUE AND SMALL NECROTIC TISSUE NOTED TO 5 O CLOCK OF WOUND BED AND INCREASED REDNESS AND INFLAMMATION TO PERI-WOUND. NOTIFIED [R #160's Power of Attorney (POA)], FLOOR NURSE AND DOCTOR. PT [R #160] WAS ADVISED TO SEEK EMERGENCY TX [treatment] FOR POSSIBLE WOUND INFECTION. [Name of R #160's daughter] PRESENT AND TOOK PT [R #160] TO [Name of local hospital]. CG [caregiver] HAVE BEEN ADVISED, INSTRUCTED AND LEFT NOTES IN PT [R #160's] ROOM ABOUT LEAVING WOUND ALONE AND WRAPPING BLE [bilateral extremities] W [with] PLASTIC WHILE SHOWERING. SN [skilled nurse] PHONE NUMBER HAS BEEN PLACED IN SEVERAL AREAS IN PT [R #160's] ROOM TO CALL SN IF BANDAGES ARE SOILED, DISLODGED OR REMOVED AS FAMILY ONLY WANTS HHC [Home Health Care] TO CARE FOR WOUND D/T MULTIPLE ISSUES W FACILITY CARING FOR WOUND.
J. Record review of the photo of the wound to R #160's left shin dated 03/21/22 revealed a very raw open wound, bleeding/oozing with red with dark bruising and various pieces of toilet paper sticking out of the wound bed.
K. On 02/02/23 at 11:41 am during an interview with Certified Medication Aide (CMA), she stated, that she had put toilet paper over R #160's wound because it was oozing (slow trickle or seep out of something). She further stated her intention was to stop the oozing. At that time, she was not aware [to not touch R #160's wounds]. I was in the wrong to do that. CMA further stated that she didn't know there needed to be a dressing on before she gave R #160 a shower. CMA was unaware that there was an outside nurse [HHA] coming in [to perform wound care on R #160].
L. Record review of R #160's Progress Notes dated 03/21/22 revealed, [Name of R #160] is being sent to hospital/ER [Name of local hospital] for further evaluation on her wound to the left lower leg per daughter.
M. Record review of [name of local hospital notes] dated 03/21/22 revealed: Open wound of left lower extremity, .Wounds do not appear acutely infected. Distalmost (furthest from the origin) wound appears to have suffered from some minor trauma and has some minor ecchymosis (discoloration of the skin resulting from bleeding underneath) and bleeding
N. Record review of R #160's PCP [Primary Care Provider] Letter dated 03/22/22 revealed, The person allowed to care for and address [Name of R #160's] wound is the wound care nurse. The preferred nurse is [Name of Home Health Agency (HHA) Registered Nurse (RN).
O. On 02/02/23 at 3:56 pm during an interview with the facility Administrator, she stated, she should have been made aware that there was a Home Health Agency coming into the facility and providing treatments to a resident. She also stated she was not made aware of the fact that a facility staff had put toilet paper on a residents wound and she should have been aware of the incident.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to store foods under sanitary conditions by not:
1. Ensuring food items ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to store foods under sanitary conditions by not:
1. Ensuring food items in the refrigerator and freezer were properly labeled and dated.
2. Ensuring food items in the refrigerator are properly covered.
3. Ensuring vent over mixing machine was free of debris and debris was not falling on items below
These deficient practices are likely to affect all 55 residents listed on the resident census list provided by the Administrator on 01/30/23, and are likely to lead to foodborne illnesses in residents if food is not being stored properly and safe food handling practices are not adhered to.
The findings are:
A. On 01/30/23 at 9:50 am during the initial tour of facility kitchen the following was observed in freezers and kitchen refrigerators:
1. 1 box of Patuxent Farms 10.5 pounds chicken left open to air
2. 1 plastic storage bag of sausages not labeled or dated
3. 1 box [NAME] Spunkmeyer Sugar Frozen Cookie Dough 20 pounds left open to air
4. 2- 6 count hoagie rolls bag not labeled or dated
5. 1- 6 count everything bagel bag not labeled or dated
6. 16 - 6 count English muffins not labeled or dated
7. 1 metal tray with 17 uncooked strips of bacon not labeled or dated
8. 1 metal container of blueberry with use by date of 01/28/23
9. 1 plastic bag of spinach not labeled or dated and left open to air
B. On 01/30/23 10:20 AM during interview with Dietary Manager (DM), DM confirmed the above findings.
C. On 02/02/23 at 8:09 AM during an interview and follow up tour of the facility kitchen the following was observed: A vent under the range hood was observed to be dirty and debris was noticed on a covered tilt kettle and on a tray holding labels and alcohol wipes. [NAME] (CK) #1 stated that there was some pooling in the ceiling and it was dripping unto the vent and unto the tilt kettle and the tray below and that is why there was debris on the items.
D. On 02/03/23 at 12:11 PM during an interview with the facility Executive Director, he stated he was aware of the issue (debris on the vent and on the items kept below the vent) and it would be resolved.
Feb 2022
18 deficiencies
2 Harm
SERIOUS
(H)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0558
(Tag F0558)
A resident was harmed · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure residents had adequate (satisfactory or accept...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure residents had adequate (satisfactory or acceptable) access to request staff assistance from the resident room for 1 (R #50) of 1 (R #50) residents reviewed for call light access. This deficient practice likely resulted in the resident feeling as if he were a burden to the staff and was not able to notify staff of his needs or alert staff during emergent (calling for prompt action, emergency) situations because he felt as if staff did not care about his well-being. The findings are:
A.
Record review of R #50's face sheet revealed R #50 was admitted into the facility on [DATE] with the following diagnoses:
1. Multiple Sclerosis (MS) (a disease in which the immune system eats away at the protective covering of nerves resulting in nerve damage that disrupts communication between the brain and body)
2. Other muscle spasm
3. Urinary Tract Infection,(an infection in any part of the urinary system, kidneys, bladder or urethra) site not specified
4. 2019-nCoV acute respiratory disease (COVID-19, acute respiratory illness caused by a coronavirus)
5. Major depressive disorder, single episode, unspecified
6. Irritant contact dermatitis, unspecified cause (condition where the skin becomes red, swollen, and sore)
7. Encounter for testing for latent tuberculosis infection (condition where bacteria is in active)
8. Hordeolum externum left upper eyelid (a red painful lump near the edge of the eyelid)
9. Pain, unspecified
10. Personal history of other diseases of the nervous system and sense organs
11. Dependence on wheelchair
12. Difficulty in walking, not elsewhere classified
13. Neuromuscular dysfunction of bladder,(lack of bladder control) unspecified
14. Essential (primary) hypertension (high blood pressure)
15. Unspecified mood [affective] disorder
16. Quadriplegia, unspecified (paralysis of all four limbs)
17. Constipation, unspecified
B.
Record review of R #50's Care Plan dated 01/15/22 revealed, Problem Start Date: 01/15/2022, Category: ADL [Activities of Daily Living] Functional/Rehabilitation Potential: [Name of R #50] has potential for deterioration (become progressively worse) in ADLs (transfer, walk in room, walk in corridor, dress, eat, toilet, maintain personal hygiene, bathing) related to diagnosis MS and quadriplegia (paralysis of all four limbs). Approach: Provide 1 person assistance in ADLS such as feeding, dressing, grooming and 2 person hoyer lift (assistive device that allows residents to be transferred between surfaces) for transfers.
C.
Record review of R #50's progress notes dated 02/14/22 revealed, [NAME] [Name of R #50's electronic assistive device] charger come off the wall and resident unable to reach the nurse station or his call light. Heard resident calling out for help. Plug [NAME] back on the wall and he was able to communicate with [NAME]. Resident continue [sic] having issue communicating with nurse station, the phone at the nurse station was not working. Resident contact his wife and she called the nurse station. Resident request to be check on his [sic] every 30 minutes (requested that staff check on resident every 30 minutes). CNA [Certified Nursing Assistant] continue checking on resident and reposition him in bed as resident request. Call security and had the phone fix at the nurses station. Informed resident the phone is back on and he should able to contact the nurses. Resident also has difficulty using the call button.
D.
On 02/14/22 at 1:02 pm during an interview with R #50 and observation of R #50's room, R #50 stated, Sometimes I'm not treated like I'm welcome [in the facility]. They treat me like I am a burden to the facility and staff. R #50 is observed to have a gray call light pad on his bed (resident is unable to use the gray call light pad because he has lost his strength to be able to trigger the light). R #50 confirmed that he is no longer able to use the call light and he has not been able to use it for approximately one week.
E.
On 02/16/22 at 11:41 am during an interview with R #50 and R #50's wife, she stated, he [R #50] can't lift his arms to use his call light and I don't think they [facility] check on him enough. He [R #50] said he was in pain last night [02/15/22], but he [R #50] couldn't get anyone to assist him.R #50 confirmed he was in pain and could not get assistance because he was unable to use the call light. and stated he used his [NAME], but could not get assistance. ([NAME] communicates with facility phone)
F.
On 02/16/22 at 1:54 pm during a random observation, R #50 is heard shouting [NAME] HELP from his room. R #50 is observed stating, [NAME], help! R #50's call light is not activated and no staff is present near R #50's room. R #50's electronic assistive device did not call the nursing station. R #50 is observed to be frustrated and telling his device Never mind then. Staff was not observed entering R #50's room after this. Staff was observed entering R #50's room approximately 10 minutes later.
G.
On 02/16/22 at 6:04 pm during an interview and observation with R #50, R #50 is observed telling [NAME] call [Name of Licensed Practical Nurse (LPN) #1. R #50's electronic assistive device replied, That name [LPN #1] is not in number in your contacts. R #50 then stated, [NAME] call nurse. [NAME] is observed not calling LPN #1. R #50 stated, I don't know why [NAME] didn't call [Name of LPN #1]. [NAME] wasn't working the other day because her [LPN #1] phone didn't have power. Now [NAME] is not working, unless she [LPN #1] doesn't have her phone on her. I can't get a hold of anybody [nursing staff]. R #50 is observed to be visibly distressed due to his electronic assistive device not being able to contact staff.
H.
On 02/16/22 at 6:08 pm during an interview with Temporary Nursing Aide (TNA) #1, he stated, If he [R #50] calls [Name of LPN #1], [NAME] will call her [LPN #1] phone. She [LPN #1] works the memory unit [first floor] and this floor [second floor] tonight. I will call IT [Information Technology] in the morning and let them know [NAME] is not working]. He [R #50] needs to call the front because [NAME] might not have went to [Name of LPN #1's phone] because there's spots [in the facility] with bad [cell phone] service. TNA #1 further stated, [NAME] call [Name of LPN #1]. [NAME] replied, I cannot find that contact. TNA #1 confirmed [NAME] was not working. LPN #1's phone is one of the phone numbers that is connected to R #50's.
I.
On 02/16/22 at 6:19 pm during an interview with Certified Nursing Assistant (CNA) #1, she stated, He [R #50] doesn't have her [LPN #1] contact, but I'll add it now. CNA #1 confirmed R #50 did not have the correct contact information for LPN #1.
J.
On 02/16/22 at 6:36 pm during an interview with CNA #1, she stated, I check on him [R #50] every hour to 1.5 hours because he calls the front so often.
K.
On 02/16/22 at 6:32 pm during an interview with LPN #1, she stated, This is not the first time [R #50's] [NAME] has gone out. It [R #50 not being able to use his electronic assistive device] happened a few days ago as well. LPN #1 confirmed that R #50's [NAME] does not work sometimes due to poor service in the facility and the nurses cell phone was not charged before.
L.
On 02/17/22 at 4:31 pm during an interview with R #50, he stated, They [nursing staff] pull me over to adjust me. It's [R #50's pain] usually an 8 out of 10 [10 being the worst amount of pain]. I haven't been in this situation in the past. R #50 confirmed he uses his call light and electronic assistive device because he is in constant pain.
M.
On 02/18/22 at 11:46 am during an interview with the Director of Nursing (DON) she stated, He's [R #50] had [NAME] since he came over from AL [Assisted Living]. I've seen him use it [gray call light pad] and I saw him use it [gray call light pad] maybe 10 days ago. He uses his [NAME] a lot. The nurse should have notified me and maintenance to see if we could get him [R #50] another call light if he needed it. I didn't know he [R #50] couldn't use that call light anymore or I would have fixed it. DON confirmed R #50 should have access to a call light at all times.
SERIOUS
(H)
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to prevent neglect for 1 (R #50) of 1 (R #50) residents ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to prevent neglect for 1 (R #50) of 1 (R #50) residents by:
1. Not providing R #50 with proper access to a call light/ability to request assistance from staff while in his room.
2. Failing to recognize and treat a significant decline experienced by R #50 which likely resulted in resident's inability to use the call light.
This deficient practice likely resulted in R #50 feeling mental anguish (a feeling of hurt and anger) and emotional distress, which also affected the dignity and health of the resident. The findings are
A.
On [DATE] at 1:02 pm during an interview with R #50 and observation of R #50's room, R #50 stated, Sometimes I'm not treated like I'm welcome [in the facility]. R #50 is observed to have a gray call light pad on his bed. R #50 is observed not being able to use gray call light pad R #50 stated that since he had COVID-19 ([DATE]) (acute respiratory illness in humans) which had been a couple weeks he had lost his ability to use his arms and the call light does require the use of his hands or arm. R #50 stated he knows he has declined. R #50 further stated that he would like to eat in his room because he is weak and feels like he is more comfortable in his room and is only allowed to eat in his room if his wife comes in to assist him. I have begged staff to let me stay in my room to eat and I am told there is not enough staff to assist me with dining in my room. Recently the staff was asking wife to assist with feeding him in his room with dining, otherwise he was going to have to go to the dining room. Resident also stated that he call several times using [NAME] or yelling to get staff to go re-position him because of the pain due to his Multiple Sclerosis. Many times they do not come or [NAME] is not working, I yell out for help sometimes they hear me and come.
B.
Record review of R #50's care plan dated [DATE] revealed, Problem- Category: Behavioral Symptoms: [Name of R #50] is having behaviors: He is using his call light or calling the nurses station approximately every 10-15 minutes an hour and at times 15 - 20 times an hour and becomes verbally abusive with the staff such as yelling and cursing at them. Refusing to come out to DR [Dining Room] for meals due to being dependent with this ADL [Activities of Daily Living] as agreed before coming to HC [Health Care]. Goal- [Name of R #50] will understand about the schedule on the floor such as meal times and understand that he can not be placed in or out of bed at these times. That he will come out to DR for meals. Approach- [Name of R #50] has agreed to get OOB [out of bed] at 0730 [am] and with the understanding that 2 staff members are needed for hoyer (device used to transfer residents between a bed and a chair or other similar resting places) transfers. [Name of R #50] will come out to DR for meals due to other Residents being dependent with meal intake. It has been explained that the staff may be busy with other Residents and he may have to wait for his wants to be addressed.
C.
Record review of R #50's progress notes dated [DATE] revealed, Resident [NAME] [Name of R #50's electronic assistive device] charge come off the wall and resident unable to reach the nurse station or his call light. Heard resident calling out for help. Plug [Name of R #50's electronic assistive device] back on the wall and he was able to communicate with [Name of R #50's electronic assistive device]. Resident continue having issue communicating with nurse station, the phone at the nurse station was not working. Resident contact his wife and she called the nurse station. Resident request to be check on his [sic} every 30 minutes. CNA [Certified Nursing Assistant] continue checking on resident and reposition him in bed as resident request. Call security and had the phone fix at the nurses station. Informed resident the phone is back on and he should able to contact the nurses. Resident also has difficulty using the call button.
D.
On [DATE] at 9:54 am during an interview with R #50's Wife, she stated, Staff only came to his room when I was in the room or when he yelled out for help or when he called through [NAME] them to check on him as much as they could. He [R #50] could use it [call light] up until like last Thursday [[DATE], when R #50 began to lose the ability to use his call light] his MS (multiple sclerosis- chronic disease affecting the central nervous system) when he gets tired in the evening he has to use [Name of R #50's electronic assistive device]. He [R #50] has gone downhill really fast in the past three weeks. I could tell he was slowing down and he wasn't feeling well. On Monday and Tuesday [[DATE] and [DATE]], he [R #50] was calling me at home and he was saying he couldn't move and he was in so much pain. I called the nurse station and they would say he's not calling us. He would call again and say he can't get a hold of the nurses. One of the nurses said the battery in the phone died. One time he [R #50] said I'm tired of trying. They refuse to take him to the toilet. They refuse to do it. He [R #50] can't project his voice right now. He [R #50] told me that he doesn't feel welcome here. He [R #50] says he feels like he's a bother here and they act like I'm a bother too and I understand. I came in one time and he [R #50] was crying because they wouldn't help him.
E.
On [DATE] at 10:42 am during an interview with Registered Nurse (RN) #1, she stated, I hadn't been on this floor this week and he [R #50] was using it [call light] last time. RN #1 confirmed she was not aware of R #50's decline and thought R #50 could still use his call light.
F.
On [DATE] at 10:42 am during an interview with Certified Nursing Assistant (CNA) #1, she stated it has been approximately 5-7 days since R #50 could use his call light. CNA #1 also confirmed this decline began on R #50 returned from the hospital. CNA confirmed she had reported the decline to the nurse.
G.
On [DATE] at 11:47 am during an interview with the Director of Nursing (DON), she stated, I didn't know he [R #50] could no longer use it [call light]. The nurse should have notified me and maintenance to see if we could get him another call light if he needed it. We would have approached it if I would have known that. The nurses know they can call me or text me. DON confirmed she was unaware of R #50's decline.
H.
On [DATE] at 12:35 pm during an interview with the Social Services Director (SSD), he stated, Our expectation is to give him [R #50] the service he needs. The customer is always right is the expectation we have here (facility). Nobody should feel that way [unwanted in the facility]. It [R #50's care plan] should be re-addressed or re-worded because it shouldn't read like that (that resident is a burden to the facility or staff. SSD confirmed no resident should feel unwanted in the facility. SSD also confirmed R #50's care plan should be written so it doesn't make R #50 seem like a burden to the facility.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to conduct an accurate comprehensive assessment for each resident's fu...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to conduct an accurate comprehensive assessment for each resident's functional capacity (capability of performing tasks and activities that people find necessary in their lives) for 1 (R #161) of 1 (R #161) resident reviewed for required comprehensive assessments. This deficient practice is likely to result in residents receiving less than optimal care and treatment. The findings are:
A.
Record review of R#161 face sheet dated 02/15/22 revealed she was admitted to the facility on [DATE] with multiple diagnosis.
B.
Record review of Minimum Data Set (a comprehensive review of resident condition and needs)(MDS) record of submissions dated 02/15/22 revealed that on 12/10/21 an MDS was to have been completed and submitted. The resident record revealed this MDS was in process and had not been submitted as required.
C.
Record review of MDS record of submissions dated 02/15/22 revealed that no 5 day follow-up report (a comprehensive review of resident needs to be completed within 5 days after admission to a long term care facility) assessment of the resident's needs had not been started or submitted.
D.
On 02/16/22 at 5:46 pm during phone interview with MDS Coordinator (MDSC) she reviewed R#161's facility record and noted that the MDS dated [DATE] was not completed and submitted as was required. She also stated that there was no 5 day follow-up MDS and confirmed this should have been completed and submitted within 5 days of her admission to the facility.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to develop an accurate baseline care plan for 1 (R #162) ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to develop an accurate baseline care plan for 1 (R #162) of 5 (R #19, 38, 39, 50, and 162) residents reviewed for baseline care plans. This deficient practice is likely to result in staff not providing needed care and may not be aware of resident's needs and concerns. The findings are:
A.
Record review of R #162 face sheet revealed R #162 was admitted into the facility on [DATE].
B.
Record review of R #162 progress notes dated 02/12/22 revealed, Pt [patient] is confused wanders unit and goes into other pts [patients] rooms. Appetite good, no GI [Gastrointestinal] distress. She has voiced no complaints of pain.
C.
Record review of progress notes dated 02/14/22 revealed, Resident here for hospice respite (short-term relief for in-home hospice caregivers). Resident is alert and oriented to self only, and confused. No calling out for help thus far but requires reorientation routinely as to why she's here. Her behaviors (wandering) are decreased when she at the dinner table with other residents around her. She is polite and calm. Takes her meds [medications] whole.
D.
Record review of R #162's base line care plan dated 02/12/22 revealed, Problems: Category: Nutritional Status-1. Poor intake<25% [less than 25 percent] and weight loss with BMI [Body Mass Index] of 17 and now on Hospice.
E.
On 02/14/22 at 12:07 pm during an observation of the second floor, R #162 is observed going into RM #207. Registered Nurse (RN) #3 is observed taking R #162 out of RM #207 and walking R #162 to her room in RM #206.
F.
On 02/16/22 at 4:58 pm during an interview with the Social Services Director (SSD), he stated R #162's baseline care plan was not accurate or as complete as the baseline care plan should have been to address all the issues noted on progress notes.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to develop and implement a comprehensive person-centered care plan for ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to develop and implement a comprehensive person-centered care plan for 1 (R # 161) of 1 (R #161) residents. Failure to develop and implement a resident centered care plan is likely to result in staff's failure to understand and implement the needs and treatments of residents resulting in decline in abilities and a failure to thrive. The findings are:
A.
Record review of R #161 face sheet dated [DATE] revealed she was admitted to the facility on [DATE] with multiple diagnoses including:
Prior fracture of right tibia (broken bone of the leg)
Macular Degeneration (disease of the eye that may result in blurred vision and blindness)
Expressive language disorder (difficulty forming and speaking words)
Other specified anxiety disorders
Post Traumatic Stress Disorder (an anxiety condition resulting from some past injury or condition)
Rheumatic disease of endocardium (heart disease caused by past disease)
Osteoporosis (a condition of brittle bones that could be subject to breaks)
B.
Record review of R#161's care plan dated [DATE] revealed care plans for two problems including use of pain medication for Rheumatoid arthritis and review of her chosen status to be full-code (requesting that in a medical emergency she would be provided all possible interventions to revive her).
C.
On [DATE] at 10:50 am during interview with R #161, she stated that she has multiple conditions that require staff assistance including movement from bed to wheelchair and back, incontinence (loss of bladder control) assistance, special medications, a history of Rheumatoid arthritis (a painful disease of the joints and bones)
D.
On [DATE] at 5:15 pm during interview with Minimum Data Set Coordinator (MDSC) she confirmed R #161 has been a resident of the facility since [DATE]. She reviewed R #161's care plan and noted that it was not comprehensive and was incomplete in its assessment and description of R #161's care needs and should have addressed all R #161's needs.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that the care plan had been revised for 2 (R #'s 39 and 161)...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that the care plan had been revised for 2 (R #'s 39 and 161) residents of 2 (R #'s 39 and 161) residents reviewed by:
1. Not conducting a care plan meeting for R #39 in a timely manner.
2. Not creating a care plan that accurately reflects residents diagnoses and needs for R #161.
These deficient practices are likely to result in staff not being aware of residents care needs, preferences, and residents not receiving the needed care. The findings are:
Findings for R #39:
C.
Record review of R #39's face sheet revealed R #39 was admitted into the facility on [DATE].
D.
Record review of R #39's Electronic Health Record (EHR) Care Conference Report revealed R #39 had not had a care conference since being admitted into the facility.
E.
On [DATE] at 3:03 pm during an interview with R #39, she stated, I don't think I've been invited [to a care conference].
F.
On [DATE] at 4:58 pm during an interview with the Social Services Director (SSD), he confirmed R #39 did not have a care conference occur in a timely manner (quarterly) as required and should have had a meeting and resident should be invited.
Findings for R #161:
G.
Record review of R #161 face sheet dated [DATE] revealed she was admitted to the facility on [DATE] with multiple diagnoses including:
Prior fracture of right tibia (broken bone of the leg)
Macular Degeneration (disease of the eye that may result in blurred vision and blindness)
Expressive language disorder (difficulty forming and speaking words)
Other specified anxiety disorders
Post Traumatic Stress Disorder (an anxiety condition resulting from some past injury or condition)
Rheumatic disease of endocardium (heart disease caused by past disease)
Osteoporosis (a condition of brittle bones that could be subject to breaks)
H.
Record review of R #161's care plan dated [DATE] revealed care plans for two problems including use of pain medication for rheumatoid arthritis and review of her chosen status to be full-code (requesting that in a medical emergency she would be provided all possible interventions to revive her).
I.
On [DATE] at 2:34 pm during interview with R #161, she stated that she did not recall having attended or participated in a care plan meeting. She stated she had not met with anyone to discuss her care needs.
J.
On [DATE] at 5:15 pm during interview with Social Services Director (SSD) he stated that he was aware of R #161 and was aware that she had been admitted to the facility in [DATE]. After reviewing R #161's medical record he stated that there was no record of there being a care plan meeting to discuss her needs and stated that her current care plan was incomplete and did not reflect all of her needs.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to meet professional standards of care for 1 (R #211 ) o...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to meet professional standards of care for 1 (R #211 ) of 1 (R #211) residents reviewed for the use of oxygen (O2). If the facility is administering O2 without physician orders and not labeling and dating O2 tubing then residents are likely to not get the therapeutic results of medication/treatment needed and/or resident should. The findings are:
A.
Record review of R #211's face sheet revealed R #211 was admitted into the facility on [DATE].
B.
Record review of R #211's physician orders dated 02/16/22 revealed no physician orders for oxygen (O2) use.
C.
On 02/17/22 at 4:46 pm during an interview with Certified Nursing Assistant (CNA) #1 and an observation of the second floor, R #211 is observed wearing O2 while in the dining room. CNA #1, stated, O2 tubing should be labeled and dated and it is not.
D.
On 02/17/22 at 4:47 pm during an interview with Licensed Practical Nurse (LPN) #3, she stated, As far as I know she [R #211] does [wear O2]. LPN #3 confirmed R #211 wears O2.
E.
On 02/18/22 at 11:25 am during an interview with the Director of Nursing (DON), confirmed O2 use must have orders and O2 tubing should be labeled and dated.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0661
(Tag F0661)
Could have caused harm · This affected 1 resident
Based on record review and interview the facility failed to ensure that the discharge summary's for 2
(R #15 and R #41) of 2 (R #15 and R #41) residents reviewed for discharge were completed and docu...
Read full inspector narrative →
Based on record review and interview the facility failed to ensure that the discharge summary's for 2
(R #15 and R #41) of 2 (R #15 and R #41) residents reviewed for discharge were completed and documented in the resident's medical record. This deficient practice is likely to result in unsafe and ineffective discharge. The findings are:
Resident #15
A.
Record review of R #15 closed medical chart did not reveal a discharge summary or a discharge note.
B.
On 02/16/22 at 4:02 pm during an interview with the Social Services Director (SSD) he stated that [name of R #15] had discharged to the assisted living section of the same facility. He further stated that person responsible for the discharge of [name of R #15] no longer was employed by the facility and it did not appear that she had written a discharge summary and should have and it should have been placed in the medical record.
Resident #41
C.
Record review of R #41's closed medical chart did not reveal a discharge summary, a discharge note was documented by the Minimum Data Set Coordinator (MDSC).
D.
Record review of progress note dated 01/21/22 revealed the following: Discharge planning: Call placed to [initials of medical supply store] in regards to w/c (wheelchair) ordered for discharge date of 01.29.22. [initials of medical supply store] awaiting face to face visit. Face to face visit by [name of certified nurse practitioner] dated 1.18.22 faxed to [initials of medical supply store and phone number].
E.
Record review of MDS [Minimum Data Set-Assessment of all residents information] dated 01/29/22 revealed discharge return not anticipated (resident was not returning to facility).
F.
On 02/17/22 at 4:53 pm during an interview with SSD, he stated. [Name of R #41] had gone home with her husband and there should have been some kind of note and discharge summary completed, this resident was also part of the case load assigned to the staff member that no longer worked at the facility. He further stated that a discharge meeting had taken place on 01/21/22 and the only note in the chart was completed by the MDSC. The process as explained by the SSD is to meet with the family, a discharge summary is started and all disciplines will assist in the safe discharge and all necessary equipment is ordered and put into place. SSD confirmed that there was no discharge summary completed for R #41 and there should have been.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected 1 resident
Based on observation and interview the facility failed to accurately post the actual number of nursing staff scheduled to provide direct patient care. This deficient practice is likely to prevent resi...
Read full inspector narrative →
Based on observation and interview the facility failed to accurately post the actual number of nursing staff scheduled to provide direct patient care. This deficient practice is likely to prevent residents and visitors from having access to accurate and current staffing information. The findings are:
A.
On 02/17/22 during random observation it was observed that staffing information was not posted and visible for residents and visitors to view.
B.
On 02/17/22 at 11:30 am during an interview with the Social Services Director (SSD), he confirmed that the facility daily staffing list was not posted and to his knowledge had never been posted and was not aware that it should have been posted.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure that the consultant pharmacist recommendations were implemented or acted upon by the facility for 1 (R #60) of 5 (R# 38, 46, 55, 59,...
Read full inspector narrative →
Based on record review and interview, the facility failed to ensure that the consultant pharmacist recommendations were implemented or acted upon by the facility for 1 (R #60) of 5 (R# 38, 46, 55, 59, and 60) residents reviewed for unnecessary medication review. If consultant pharmacist recommendations are not implemented in a timely manner, residents are likely to experience a potential for unnecessary drug interactions and adverse side effects. The findings are:
A.
Record review of the Medication Regimen Review (MRR) dated 01/09/22 revealed the following: Pharmacist recommendation stating that Lorazepam (medication used to treat anxiety) can not have an open ended stop date (did not have a date as to when the medication should be stopped).
B.
Record review of the physicians order dated 01/17/22 revealed that R #60 was ordered 0.5 mg (milligrams) of Lorazepam with a start date of 01/17/22 and no stop date.
C. On 02/16/22 at 10:48 am during an Interview with the Director of Nursing (DON), she confirmed that the Lorazepam order dated 01/17/22 was open ended and should have had a stop date as recommended by the Pharmacist. All MRR recommendations should be given to the physician and acted upon.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure the resident was given a diet as ordered by the physician for 1(R #38) of 1 (R#38) resident reviewed for having a therapeutic diet (...
Read full inspector narrative →
Based on record review and interview, the facility failed to ensure the resident was given a diet as ordered by the physician for 1(R #38) of 1 (R#38) resident reviewed for having a therapeutic diet (a meal plan that controls the intake of certain foods or nutrients) If the facility is not following physicians dietary orders, then residents are likely to experience weight loss, frustration, and depression. The findings are:
A.
Record review of Physicians orders dated 09/01/21 revealed: Diet: Dysphasia Level 7(normal everyday foods of various textures) Regular/easy to chew. Resident was observed to be getting an RCS diet (reduced concentrated sweets- diet used for an individual diagnosed with diabetes-a chronic condition that affects the way the body process blood sugar) Please provide date as to when this observation occurred.
B.
Record review of Consistency Census Report (list of residents diets) dated 02/14/22 revealed RCS 1800 calorie diet (diet plan that call for three meals and three snacks each day to provide the body with essential nutrients for sustained energy).
C.
On 02/17/22 at 10:13 am during an interview with the facility Dietary Manager (DM), she stated, The process is when the nurse gets the order the nurse writes on a diet communication and the communication is given to me and I go into the system and I insert it to the meal tickets, and that is how the meals are served according to the meal tickets I provide. We have been giving [name of R #38] an RCS diet daily because that is what is ordered for her. Review of Physicians order dated 09/01/21 revealed Dysphasia Level 7 Regular/easy to chew.
D.
On 02/17/22 at 11:13 am during interview per DM's request, DM had a Diet Order and Communication dated 09/01/21 that revealed a Regular/Easy to chew diet. DM stated that [name of R #38] was not to be on a RCS diet and the diet that had been provided to [name of R #38] was incorrect. R #38 should have been on a regular diet not on a RCS diet.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
Based on observation, record review, and interview, the facility failed to promote care with dignity and respect for 2 (R #'s 21 and 50) of 4 (R #'s 10, 21, 24, and 50) residents reviewed during rando...
Read full inspector narrative →
Based on observation, record review, and interview, the facility failed to promote care with dignity and respect for 2 (R #'s 21 and 50) of 4 (R #'s 10, 21, 24, and 50) residents reviewed during random observation by:
1. Not serving residents a meal at the same time while sitting at the same table in the memory unit.
2. Referring to residents that require dining assistance as feeders.
These deficient practices are likely to result in residents feeling as if their feelings and preferences are unimportant to the facility staff. The findings are:
Meal Service:
A.
On 02/14/22 at 11:45 am during a lunch observation in the memory unit, R #10, #21, and #24 were observed to be sitting at a dinning table together. R #10 and R #24 had already finished their meal while R #21 was waiting at the table to be served.
B.
On 02/14/22 at 12:17 pm during a lunch observation in the memory unit, R# 21 was observed to receive her meal.
C.
On 02/16/22 at 10:24 am during an interview with Registered Nurse (RN) #2, she stated all residents sitting at a table should be served at the same time first before staff moves on to serve a different table.
D.
On 02/17/22 at 9:58 am during an interview with the Dietary Manager (DM), she stated, Everyone [residents] should be fed at the same time and receiving their plates at the same time. Everyone [residents] should be eating at the same time.
Referring to Residents as Feeders:
E.
Record review of R #50's progress notes dated 02/11/22 revealed, This CNA [Certified Nursing Assistant] and Nurse went to answer call light at 10:52 am. [Name of R #50] wife stated 'He ready to lay back down.' This CNA stated 'I'm sorry we can't do that right now we are getting ready to start lunch and we have a couple of feeders. [Name of R #50] Wife stated 'YOUR STARTING LUNCH NOW!' This CNA stated ' yes, we are, we will be back to lay him down after lunch.' This CNA and nurse left the room quietly.
F.
On 02/17/22 at 9:57 am during an interview with the Dietary Manager (DM), she stated, All of the feeders need to be in the dining room for the CNA's to do that [assist with meals], but if they are in their room, the CNA's can't assist. When asked who she referred to when using the term Feeders DM stated Feeders are the residents that need to be fed (assisted with dining) that is what we call them.
G.
On 02/17/22 at 6:12 pm during an interview with CNA #1, she stated, He [R #50] prefers [to eat in] his room but he's a feeder and I have three others to feed. My main priority is [R #50] he's a choking hazard. We keep all the chokers out here [in the dining room].
H.
On 02/18/22 at 11:48 am during an interview with the Director of Nursing (DON), she stated, There's a lot of feeders on all of the floors. DON refers to residents needing assistance in the facility as feeders.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to promote resident self determination through support o...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to promote resident self determination through support of resident choice for 2 (R #'s 38 and 50) of 2 (R #'s 38 and 50) residents reviewed for choices, by:
1. Not assisting R #38 to her room after meals which is her preference.
2. Not allowing R #50 to eat meals in his room or go to bed when he would like per his preferences.
If the facility is not honoring resident's choices, then residents are likely to experience frustration and depression. The findings are:
Findings For R #38:
A.
Record review of R #38's face sheet revealed R #38 was admitted into the facility on [DATE].
B.
On 02/15/22 from 9:45 am to 10:43 am during random observation R #38 is observed sitting alone at a dining room table with no other residents or staff present.
C.
On 02/15/22 at 9:46 am during and interview with R #38, she stated, I have a bad torso (main part of the body) and they [nursing staff] sit me here from breakfast (8:00 am) to lunch (11:30 am to 1:00 pm). They don't know what I'm going through and I don't like doing that (sit in wheelchair for hours). R #38 stated that she has informed staff that she does not like to sit in her wheelchair from breakfast to lunch and that she would like to go to her room .
D.
On 02/16/22 at 11:23 am during a random observation, R #19 is overheard telling a dietary staff, I'm [R #19] going to sit by [Name of R #38] today because I think she [R #38] gets lonely.
E.
On 02/17/22 at 5:28 pm during an interview with Licensed Practical Nurse (LPN) #3, she stated, That's her [R #38] preference [to sit in dining room alone all morning].
F.
On 02/18/22 at 9:10 am during an interview with Registered Nurse (RN) #1, when asked about R #38 sitting in the dining room alone, she stated,We try to keep her [R #38] out of bed because she has breakdowns.
Findings for R #50:
G.
Record review of R #50's face sheet revealed R #50 was admitted into the facility on [DATE].
H.
Record review of R #50's care plan dated 02/12/22 revealed, Problem- Category: Behavioral Symptoms: [Name of R #50] is having behaviors: He is using his call light or calling the nurses station approximately every 10-15 minutes an hour and at times 15 - 20 times an hour and becomes verbally abusive with the staff such as yelling and cursing at them. Refusing to come out to DR [Dining Room]for meals due to being dependent with this ADL [Activities of Daily Living] as agreed before coming to HC [Health Care]. Goal- [Name of R #50] will understand about the schedule on the floor such as meal times and understand that he can not be placed in or out of bed at these times. That he will come out to DR for meals. Approach- [Name of R #50] has agreed to get OOB [out of bed] at 0730 [am] and with the understanding that 2 staff members are needed for hoyer (device used to transfer residents between a bed and a chair or other similar resting places) transfers. [Name of R #50] will come out to DR for meals due to other Residents being dependent with meal intake. It has been explained that the staff may be busy with other Residents and he may have to wait for his wants to be addressed.
I.
Record review of R #50's progress notes dated 02/11/22 revealed, This CNA [Certified Nursing Assistant] and Nurse went to answer call light at 10:52 am. [Name of R #50] wife stated 'He ready to lay back down.' This CNA stated 'I'm sorry we can't do that right now we are getting ready to start lunch and we have a couple of feeders.' [Name of R #50] Wife stated 'YOUR STARTING LUNCH NOW!' This CNA stated ' yes we are we will be back to lay him down after lunch.' This CNA and nurse left the room quietly.
J.
Record review of R #50's progress notes dated 02/11/22 revealed, This CNA and Nurse [Name of Nurse] assisted [Name of R #50] into wheelchair at 3:50 pm. This CNA Stated 'I'll be back for you at 5 pm to eat in the dining room.' [Name of R #50] Stayed quiet. This CNA continued to do rounds with other patient care and assist to dining as well as feeding. Nurse [Name of Nurse] went to assist [Name of R #50] for dinner at 5 PM. [Name of R #50] stated 'I want to go to bed now.' Nurse stated ' we can't right now. We are in the middle of feeding.' [Name of R #50] stated 'he didn't care' and started to verbally abuse the nurse.
K.
Record review of R #50's progress notes dated 02/16/22 revealed, [Name of R #50] called the DON [Director of Nursing] office phone and could not hear what he was saying so went to his room. He stated he wanted to go to bed, explained to him that it is meal time and the CNA was getting ready to assist another resident to eat. I asked if there was anything I could do at this time to help him get more comfortable. He asked to be tilted back in his chair. I was trying to do this when the CNA came for him to take him to DR for breakfast.
L.
On 02/14/22 at 1:01 pm during an interview with R #50 and R #50's wife, R #50's wife stated, They make him [R #50] get up with everyone else and there's no work around anymore. Every single time I'm here, they ask me to feed him every time. R #50's wife confirmed R #50 is required to go to the dining room for each meal, even when he does not want to.
M.
On 02/17/22 at 9:57 am during an interview with the Dietary Manager (DM), she stated, All of the feeders need to be in the dining room for the CNA's to do that [assist with meals], but if they are in their room, the CNA's can't assist. Feeders are the residents that need to be fed.
N.
On 02/17/22 at 5:28 pm during an interview with LPN #3, she stated, We do prefer it if he's [R #50] out here [in the dining room] because he's [R #50] a choking hazard.
O.
On 02/17/22 at 6:12 pm during an interview with CNA #1, she stated, He [R #50] prefers [to eat in] his room but he's a feeder and I have three others to feed. My main priority is he's a [R #50] choking hazard. We keep all the chokers out here [in the dining room].
P.
On 02/18/22 at 11:42 am during an interview with the DON, she stated, He [R #50] would prefer to eat in his room. The nurses are probably busy and probably can't reach him [R #50] if he's choking.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to ensure there is sufficient staff to meet the needs of the residents without residents having to wait for care and assistance. This deficien...
Read full inspector narrative →
Based on record review and interview, the facility failed to ensure there is sufficient staff to meet the needs of the residents without residents having to wait for care and assistance. This deficient practice is likely to affect all 8 residents residing on the second floor, that were identified on the census list provided by the Administrator on 02/14/22. If the facility is not ensuring that there is enough staff to meet the residents needs, then resident are likely to not get the services they need. The findings are:
Cross reference findings from F0550: Resident Rights/ Exercises of Rights, F0558: Reasonable Accommodations Needs/Preferences, and F0600: Free From Abuse and Neglect.
A.
On 02/18/22 at 11:42 am during an interview with the Director of Nursing (DON), she stated, If there's only two people [nurses] on the floor, then there's only two people [nurses] to watch everyone [residents on the second floor]. If the census is higher, we would have three [nurses and/or Certified Nursing Assistants (CNA)] and it would still be impossible to watch, for example during dining to watch all those residents that are on a mechanically altered diet.
B.
On 02/18/22 at 12:37 pm during an interview with the Social Services Director (SSD), he stated, The resident is always right and sometimes we don't have the staff to do so [allow residents to eat in their rooms or get out of bed when they want to].
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
Based on observation, record review, and interview, the facility failed to ensure the medication error rate did not exceed 5% for 5 (R #4, 22, 38, 53 and 54) of 5 (R #4, 22, 38, 53 and 54) residents r...
Read full inspector narrative →
Based on observation, record review, and interview, the facility failed to ensure the medication error rate did not exceed 5% for 5 (R #4, 22, 38, 53 and 54) of 5 (R #4, 22, 38, 53 and 54) residents reviewed during medication administration. 29 medications were observed administered with 13 errors resulting in a medication error rate of 44.83%. If medications are administered in error, residents are likely to experience less than optimal results from their medication regimen (a prescribed systematic form of treatment for a course of drugs). The findings are:
R #38
A.
On 02/16/22 at 6:32 pm during observation of medication administration by Licensed Practical Nurse (LPN) #1 she prepared medications for R #38. She was observed as she prepared the following medications:
Aspirin (an over-the-counter medication used to thin blood) 81 mg (milligram) 1 tablet
Amiodarone (a medication used to reduce blood pressure) 200 mg 1 tablet
Atorvastatin (a medication used to reduce fats in the blood) 40 mg 1 tablet
Eliquis (a medication used to reduce the occurrence of blood clots) 5 mg 1 tablet
Hydralazine (a medication used to reduce blood pressure) 10 mg 1 tablet
Keppra (a medication used to reduce the occurrences of seizure) 500 mg 1 tablet
Each pill was placed into a small plastic cup. As she picked up the cup, she dropped the pills into an open drawer of her medication cart (a large lockable, mobile cart with multiple drawers used to hold and secure resident medications). LPN #1 then set the cup down on her top counter. The cup was noted to contain 4 pills. LPN #1 then removed a disposable glove from a box, placed a glove on her hand and reached to the bottom of the drawer and found 1 pill which she then placed into the cup. When asked if there was a pill missing, she counted and stated that she had none missing and all pills were in the cup.
LPN #1 then went to R #38 and administered her the 5 remaining medications that was in the cup. LPN #1 prepared 6 medications and was only observed to administer 5 medications.
B.
On 02/18/22 at 11:53 am during interview with Director of Nursing (DON), she stated that a medication that is dropped should be wasted (thrown) and replaced and should not have been administered to the resident. She further confirmed that all 6 medications should have been administered not just 5. She also stated the nurse should have counted the medications to confirm they were all in the medication cup.
R #22
C.
Record review of R #22's Medication Administration Record (MAR) dated February 2022 revealed R #22 was to receive a Lydoderm patch (a prescription pain medication in a patch form that is applied to an area of pain) applied each morning and removed each evening.
D.
On 02/16/22 at 6:45 pm during interview with LPN #1 she stated that a Lydoderm patch had been ordered but never applied because of problems with insurance. She stated she had contacted the provider and notified them of the problem. LPN #1 stated she had told higher ups (nurse administrators) that Lydoderm patches were not available but did not know what had been done. She acknowledged the medication was not administered but still ordered.
E.
On 02/18/22 at 11:53 pm during interview with Director of Nursing (DON) she stated that the Lydoderm patch had not been administered and that the order to administer should have either been discontinued or a substitute provided.
R #4
F.
On 02/17/22 at 8:32 am, LPN #2 was observed as he administered medications to R #4. LPN #2 was observed as he drew Aspirin 81 mg 1 tablet from the medication cart. As other medications were drawn, he (LPN #2) stated that the cart did not have Tylenol (an over-the-counter medication that is used to relieve pain and swelling) in the appropriate dose to administer to the resident.
G.
Record review of R #4 physician order dated 11/04/21 revealed an order for Aspirin 81 mg given daily at 7:00 am.
H.
Record review of R #4 physician order dated 02/02/22 revealed an order to administer Tylenol 650 mg every Tuesday and Thursday at 9:00 am.
I.
Record review of R #4 MAR dated February 2022 revealed that Tylenol 650 mg was not administered on Tuesday 02/15/22 Item unavailable.
J.
On 02/18/22 at 11:53 am during interview with DON, she stated that medications due at 7:00 am should be administered between 6:00 am and 8:00 am. She confirmed that Aspirin was administered late. DON also confirmed that R #4 should have received Tylenol 650 mg, but did not receive Tylenol 650 mg as ordered.
R #53
K.
On 02/17/22 at 8:41 am LPN #2 was observed as he administered medications to R #53
He drew the following medications:
Aspirin 81 mg
Hydrochlorothiazide (medication to reduce fluids in the blood flow) 25 mg
Vitamin D3 (a vitamin supplement) 1 tablet
and administered them.
L.
Record review of R #53 physician orders each dated 01/19/22 revealed:
Aspirin 81 mg once daily at 7:00 am
Hydrochlorothiazide 25 mg daily at 7:00 am
Vitamin D3 1 tablet daily at 7:00 am
M.
On 02/18/22 at 11:53 am during interview with DON, she stated that medications due at 7:00 am should be administered between 6:00 am and 8:00 am. DON confirmed that Aspirin 81 mg, Hydrochlorothiazide 25 mg and Vitamin D3 1 tablet were all administered late.
R #54
N.
On 02/17/22 at 8:45 am LPN #2 was observed as he administered medications to R #54. He drew the following medications:
Aspirin 81 mg
Docusate (medication prescribed to prevent constipation) 1 tablet
Baclefen (medication prescribed to reduce muscle spasms) 1 tablet
Duloxetine (trade name Cymbalta) (medication prescribed to relieve symptoms of depression) 30 mg
Reglan (medication prescribed to relieve symptoms of heart burn) 10 mg
Peradex (mouthwash prescribed to reduce bacteria in the mouth) 15 ml (milliliter) swish/spit
and administered each medication.
O.
Record review of R #54 physician orders revealed the following:
Aspirin 81 mg daily at 7:00 am dated 12/18/21
Docusate 1 tablet twice daily at 7:00 am and 7:00 pm dated 12/18/21
Baclofen 10 mg three times daily at 6:00 am, 2:00 pm and 10:00 pm dated 12/18/21
Duloxetine 30 mg daily at 7:00 am dated 12/18/21
Reglan 10 mg twice daily at 7:00 am and 7:00 pm dated 12/18/21
Peridex mouthwash 15 ml twice daily at 7:00 am and 7:00 pm dated 09/09/21
P.
On 02/18/22 at 11:53 am during interview with DON, she stated that medications due at 7:00 am should be administered between 6:00 am and 8:00 am. DON confirmed that Aspirin 81 mg, Docusate 1 tablet, Baclofen 10 mg, Duloxetine 30 mg, Reglan 10 mg and Peridex Mouthwash were all administered late.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Findings for R #50:
C.
Record review of R #50's physician orders dated 01/15/22 revealed, Irrigate supra pubic [Foley Catheter] with 60-`120 cc [cubic centimeter] sterile N.S. [Normal Saline] q 3 [ev...
Read full inspector narrative →
Findings for R #50:
C.
Record review of R #50's physician orders dated 01/15/22 revealed, Irrigate supra pubic [Foley Catheter] with 60-`120 cc [cubic centimeter] sterile N.S. [Normal Saline] q 3 [every 3] days and PRN [as needed].
D.
On 02/14/22 at 1:29 pm during an observation of R #50's room, a used 20 ml (milliliter) syringe was left out on R #50's room window sill.
E.
On 02/14/22 at 1:35 pm during an interview with Registered Nurse (RN) #3, she stated, That [used syringe] should not have been left out. RN #3 confirmed used syringes should not be left out in the open in residents rooms.
F.
On 02/17/22 at 12:19 pm during an interview with the Infection Preventionist (IP), she confirmed used syringes should not be left in residents room.
G.
On 02/18/22 at 11:31 am during an interview with the Director of Nursing (DON), she stated, No, it [used syringe in R #50's room] should not be left laying around.
Based on observation and interview, the facility failed to maintain proper infection prevention measures for 2 (R #38 and 50) of 2 (R #38 and 50) residents reviewed by:
1. Not disposing and replacing medications that dropped into an unclean area for R #38.
2. Leaving used Foley catheter care equipment in R #50's room.
Failure to adhere to an infection control program is likely to cause the spread of infections and illness. The findings are:
Findings for R #38:
A.
On 02/16/22 at 6:32 pm during observation of medication administration by Licensed Practical Nurse (LPN) #1, she prepared medications to be administered to R #38. LPN #1 was observed as she prepared the following medications:
Aspirin (an over-the-counter medication used to thin blood) 81 mg (milligram) 1 tablet
Amiodarone (a medication used to reduce blood pressure) 200 mg 1 tablet
Atorvastatin (a medication used to reduce fats in the blood) 40 mg 1 tablet
Eliquis (a medication used to reduce the occurrence of blood clots) 5 mg 1 tablet
Hydralazine (a medication used to reduce blood pressure) 10 mg 1 tablet
Keppra (a medication used to reduce the occurrences of seizure) 500 mg 1 tablet
Each pill was placed into a small plastic cup. As she picked up the cup, she dropped pills into an open drawer of her medication cart (a large lockable, mobile cart with multiple drawers used to hold and secure resident medications). LPN #1 then set the cup down on her top counter and removed a disposable glove from a box, placed a glove on her hand and reached to the bottom of the drawer and found 1 pill which she then placed into the cup. LPN #1 then went to R #38 and administered all medications contained in the cup.
B.
On 02/18/22 at 11:53 am during interview with DON she stated that a medication that is dropped should be disposed and replaced. She confirmed the medication should not be provided to the resident.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to store and serve food under sanitary conditions by not:
1. Ensuring fo...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to store and serve food under sanitary conditions by not:
1. Ensuring food items in the refrigerator and freezer were properly labeled and dated in both the main kitchen and kitchenettes on each floor.
2. Ensuring food items in the refrigerator and freezer were properly stored and not expired.
3. Ensuring food items were not stored on the kitchen floor.
4. Ensuring staff wore hair nets in the main kitchen
5. Ensuring the main kitchen was clean and free from dirt and grime.
These deficient practices are likely to affect all 55 residents listed on the resident census list provided by the Administrator (ADM) on 02/14/22. If the facility fails to adhere to safe food handling practices, residents are likely to be exposed to foodborne illnesses. The findings are:
A.
On 02/14/22 at 8:55 am during an initial tour of the facility kitchen, the following was observed:
1. 2-Cross Valley Farms 8 lb (pound) Cantaloupe chunks in light syrup with a best before 02/09/22 was stored in the main kitchen refrigerator.
2. 1-Plastic bag of spring mix was not labeled or dated and stored in the main kitchen refrigerator.
3. 3- Large plastic bins containing a meat product marinating was not labeled or dated and stored in the main kitchen refrigerator.
4. 1-Plastic bag of chicken was not labeled or dated and stored in the main kitchen freezer.
5. 1-Plastic bag of breaded shrimp was not labeled or dated and stored in the main kitchen freezer.
6. 1-Plastic bag of frozen biscuits was not labeled or dated and stored in the main kitchen freezer.
7. 1-Plastic bag of frozen cookie dough was not labeled or dated and stored in the main kitchen freezer.
8. 1- Aluminum tray of possible lasagna was left open to air and stored in the main kitchen freezer.
9. 2- Large plastic bags of frozen fried okra was not labeled or dated and stored in the main kitchen freezer.
10. Approximately 1/4 of a 5 lb bag of Monarch Frozen Mango cubes was not dated and stored in the main kitchen freezer.
11. 1- Box of Brickfire Bakery Cookies was left open to air and stored in the main kitchen freezer.
12. 1- Box of Rich's Sugar Free Cookies was left open to air and stored in the main kitchen freezer.
13. 1- Plastic wrapped sheet of pie crust was not labeled and stored in the main kitchen freezer.
14. 3 -Plastic packages of dinner rolls was not labeled or dated and stored on the main kitchen bread rack.
15. 1- 4 count (ct) hoagie rolls was not labeled or dated and stored on the main kitchen bread rack.
16. 1- Package of sliced white bread was not labeled or dated and stored on the main kitchen bread rack.
17. 1- Plastic storage bag of croissants was not labeled or dated and stored in the main kitchen reach in refrigerator.
18. 1- Package of Grandma's tortillas was left open to air and stored in the main kitchen reach in refrigerator.
19. 1- Box of approximately 20 croissants was not labeled or dated and stored in the main kitchen reach in refrigerator.
20. 1- Plastic condiment squeeze bottle with peach colored substance was not labeled or dated and stored in the main kitchen reach in refrigerator.
21. 2- Bags of tater tots, both were not labeled or dated and one was left open to air, stored in the main kitchen reach in freezer.
22. 1- Box of Tyson Italian Seasoned Chicken Breast Fillets was left open to air and stored in the main kitchen reach in freezer.
23.1- Bag of sweet potato fries was not labeled or dated and stored in the main kitchen reach in freezer.
B.
On 02/14/22 at 9:10 am during an interview with the Cook/Manager (C/M), he confirmed all findings and stated all food should be stored appropriately, not expired, and labeled and dated.
C.
On 02/18/22 at 7:41 am during a follow-up observation of the main kitchen, the following was observed:
1. 3- Boxes of Glenview Farms Liquid Margarine was stored on the entrance floor of the main kitchen.
2. 4- 1 gallon jug box of Monarch flavored dressing was stored on the entrance floor of the main kitchen.
3. 2- Boxes of Cross Valley Farms mashed potatoes was stored on the entrance floor of the main kitchen.
4. 2- 6 lb box of Monarch frozen vegetables was stored on the entrance floor of the main kitchen.
5. 2- Boxes of [NAME] Sheet Cake was stored on the entrance floor of the main kitchen.
D.
On 02/18/22 at 7:45 am during an interview with the C/M, he stated,Yeah, it [boxes of food] kind of has to be there [main kitchen floor] to bring everything up (to be able to fit all product in the kitchen area at one time). C/M confirmed food boxes are always placed on the main kitchen floor after each delivery.
E.
On 02/18/22 at 7:55 am during a follow-up observation of the main kitchen, [NAME] (CK) #2 was observed walking throughout the entire kitchen while not wearing a hair net.
F.
On 02/18/22 at 7:56 am during an interview with CK #2, he stated, I always wear one [hair net], but I took it off. I'm so sorry, I forgot. CK #2 confirmed he was not wearing a hair net and should have been.
G.
On 02/18/22 at 8:19 am during an observation of the Memory Unit Nourishment Refrigerator/ Kitchenettes the following was observed:
1. 3- Plastic containers of cake labeled [Name of R #55] was not labeled or dated and stored in kitchenette refrigerator.
2. 4- plastic containers labeled [Name of R #55] Thickened ice cream was not dated and stored in the kitchenette freezer.
H.
On 02/18/22 at 8:25 am during an interview with Dietary Aide (DA) #1, she confirmed all kitchenette findings and stated all food should be labeled and dated.
I.
On 02/18/22 at 8:30 am during an observation of the second floor nourishment refrigerator/ kitchenette, the following was observed:
1. 2- Loaves of bread was not labeled or dated and stored in the kitchenette refrigerator.
J.
On 02/18/22 at 8:35 am during an interview with DA #2, she confirmed the finding for second floor kitchenette and stated, We never label or date them [loaves of bread] and I just got it [loaves of bread] out of the [main] kitchen.
K.
On 02/18/22 at 11:13 am during random observation of the facility's main kitchen and interview with the Kitchen Manager the following was observed:
1. 2 bottles of lemon juice,
2. 1 case of cherry tomatoes
3. 1 case cottage cheese
4. 6 1/2 gallon of milk
5. 1 case of 20 ounce hot cups
6. 1 five gallon bucket of liquid detergent were all observed to be set on the bare floor.
When kitchen manager was asked about the boxes being stored on the bare floor he picked them up and placed them on top of an ice cream freezer that had several opened 5 gallon tubs of ice cream.
7. There were no food temperature logs available for the month of February 2022.
8. Kitchen Manager was unable to take accurate food temperatures because he stated that the thermometers had not been calibrated properly.
9. Personal cups were stored in the food preparation area.
Kitchen Manager verified that the food truck delivery had just been made that morning and they had not had time to store the items because they were preparing for the lunch meal. He also verified that there were no food temperature logs available for the month of February and there should have been and that there should not be any personal cups stored in the food preparation areas. He further stated that food temperatures should be recorded and that the thermometers should be in good working condition.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0886
(Tag F0886)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure 100% (percent) facility testing for COVID-19 (a contagious n...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure 100% (percent) facility testing for COVID-19 (a contagious new strain of a viral disease causing mild to severe disease) infection according to regulatory requirements after 3 (R #19, 38, and 50) of 3 (R #19, 38, and 50) residents tested positive for COVID-19. Failure to comply with testing requirements is likely to result in infections in residents and staff that might have been prevented. The findings are:
Findings for R #19:
A.
Record review of R #19's face sheet revealed R #19 was admitted into the facility on [DATE].
B.
Record review of R #19's progress notes dated 02/02/22 revealed, Resident given rapid Covid test per direction from DON [Director of Nursing].Test result--Positive. R #19's progress note confirmed R #19 tested positive for COVID-19.
C.
Record review of R #19's progress notes dated 02/03/22 revealed, Received report resident is [sic] test positive for COVID and resident is on isolation.
Findings for R #38:
D.
Record review of R #38's face sheet revealed R #38 was admitted into the facility on [DATE].
E.
Record review of R #38's progress noted dated 02/03/22 revealed, Resident hospital return. Resident is COVID positive and on isolation. R #38's progress note confirmed R #38 tested positive for COVID-19.
Findings for R #50:
F.
Record review of R #50's face sheet revealed R #50 was admitted into the facility on [DATE].
G.
Record review of R #50's progress notes dated 01/30/22 revealed, Resident return from hospital with COVID position [sic] and UTI [Urinary Tract Infection].
H.
Record review of the COVID-19 Employee Testing Log provided by the facility Infection Preventionist (IP) revealed the facilities last COVID-19 testing occurred on 12/13/21. No later COVID-19 testing dates were provided (100% facility wide COVID-19 testing should have occurred weekly after each positive resident).
I.
On 02/17/22 at 12:10 pm during an interview with the Infection Preventionist (IP), she confirmed the facility did not perform 100% facility COVID-19 testing after R #'s 19, 38, and 50 tested positive for COVID-19.
J.
On 02/17/22 at 12:11 pm during an interview with the Unit Assistant (UA), she stated, It's been awhile since we've done 100% testing. We were doing 100% [facility testing] and then we got the clearance we didn't have to do that again. Then we got the 3 [COVID-19] positive residents. UA confirmed the facility did not perform 100% facility COVID-19 testing after R #'s 19, 38, and 50 tested positive for COVID-19. UA confirmed she did not know who told her the facility no longer had to perform 100% facility wide testing after having COVID-19 positive residents.
K.
On 02/17/22 at 4:58 pm during and interview with the Social Services Director (SSD), he stated, The last one [facility-wide testing] we did was in December [2021]. It [responsibility for COVID-19 testing after a positive resident] would be Infection Control [IP]. SSD confirmed the facility should have completed 100% testing for COVID-19 and the facility did not.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most New Mexico facilities.
Concerns
- • 46 deficiencies on record, including 2 serious (caused harm) violations. Ask about corrective actions taken.
- • Grade C (50/100). Below average facility with significant concerns.
- • 80% turnover. Very high, 32 points above average. Constant new faces learning your loved one's needs.
Bottom line: Mixed indicators with Trust Score of 50/100. Visit in person and ask pointed questions.
✓ Report will be sent to your email
About This Facility
What is The Neighborhood In Rio Rancho's CMS Rating?
CMS assigns The Neighborhood In Rio Rancho an overall rating of 4 out of 5 stars, which is considered above average nationally. Within New Mexico, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is The Neighborhood In Rio Rancho Staffed?
CMS rates The Neighborhood In Rio Rancho's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 80%, which is 33 percentage points above the New Mexico average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 88%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at The Neighborhood In Rio Rancho?
State health inspectors documented 46 deficiencies at The Neighborhood In Rio Rancho during 2022 to 2025. These included: 2 that caused actual resident harm and 44 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates The Neighborhood In Rio Rancho?
The Neighborhood In Rio Rancho is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 72 certified beds and approximately 45 residents (about 62% occupancy), it is a smaller facility located in Rio Rancho, New Mexico.
How Does The Neighborhood In Rio Rancho Compare to Other New Mexico Nursing Homes?
Compared to the 100 nursing homes in New Mexico, The Neighborhood In Rio Rancho's overall rating (4 stars) is above the state average of 2.9, staff turnover (80%) is significantly higher than the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.
What Should Families Ask When Visiting The Neighborhood In Rio Rancho?
Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's high staff turnover rate.
Is The Neighborhood In Rio Rancho Safe?
Based on CMS inspection data, The Neighborhood In Rio Rancho has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in New Mexico. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at The Neighborhood In Rio Rancho Stick Around?
Staff turnover at The Neighborhood In Rio Rancho is high. At 80%, the facility is 33 percentage points above the New Mexico average of 46%. Registered Nurse turnover is particularly concerning at 88%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was The Neighborhood In Rio Rancho Ever Fined?
The Neighborhood In Rio Rancho has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is The Neighborhood In Rio Rancho on Any Federal Watch List?
The Neighborhood In Rio Rancho is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.