Paloma Springs Healthcare LLC
For profit - Corporation
94 Beds
OPCO SKILLED MANAGEMENT
Data: November 2025
Trust Grade
28/100
#45 of 67 in NM
Photo by Paloma Springs Healthcare
Photo by Paloma Springs Healthcare
Photo by Ben Barreras
1 / 5 photos
Last Inspection: April 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Paloma Springs Healthcare LLC has received a Trust Grade of F, indicating significant concerns about the quality of care provided. It ranks #45 out of 67 nursing homes in New Mexico, placing it in the bottom half of facilities in the state, and #2 out of 2 in Sierra County, meaning there is only one other option that is better. The facility is improving, having reduced the number of issues from 17 in 2024 to 14 in 2025, yet it still faces serious challenges. Staffing is average, with a turnover rate of 44%, which is lower than the state average, but the overall rating is only 2 out of 5 stars. Recent inspections revealed critical issues, including failure to monitor and treat a resident's pressure ulcers properly, which worsened their condition, and inadequate food storage practices that could lead to foodborne illnesses.
- Trust Score
- F
- In New Mexico
- #45/67
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- 44% turnover. Near New Mexico's 48% average. Typical for the industry.
- Penalties ✓ Good
- $19,971 in fines. Lower than most New Mexico facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 29 minutes of Registered Nurse (RN) attention daily — below average for New Mexico. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 43 deficiencies on record. Higher than average. Multiple issues found across inspections.
28/100
Bottom 33%
Review needed
17 → 14 violations
★★☆☆☆
2.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★☆
4.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 17 issues
2025: 14 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (44%)
4 points below New Mexico average of 48%
Facility shows strength in quality measures, fire safety.
The Bad
2-Star Overall Rating
Below New Mexico average (2.9)
Below average - review inspection findings carefully
Staff Turnover: 44%
Near New Mexico avg (46%)
Typical for the industry
Federal Fines: $19,971
Below median ($33,413)
Minor penalties assessed
Chain: OPCO SKILLED MANAGEMENT
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 43 deficiencies on record
1 actual harm
Aug 2025
1 deficiency
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
Medical Records
(Tag F0842)
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 medical records were complete and accurate for 1 (R #1) of 3...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure medical records were complete and accurate for 1 (R #1) of 3 (R #1, R #2 and R #3) residents reviewed for documentation accuracy. This deficient practice has the potential to have a negative impact on the care staff provide to residents due to missing or inaccurate records and resident information. The findings are: A. Record review of R #1's admission record (no date) revealed the following: 1. R #1 was admitted to the facility on [DATE]. 2. R #1 had the following diagnoses: a. Chronic Obstructive Pulmonary Disease (COPD, a group of lung diseases that cause airflow obstruction and breathing problems) with acute exacerbation (a sudden worsening of symptoms in a chronic condition). b. Respiratory failure unspecified whether with hypoxia or hypercapnia (condition where you do not have enough oxygen in the tissues in your body [hypoxia] or when you have too much carbon dioxide in your blood [hypercapnia]. B. Record review of R #1's care plan dated 01/08/25 revealed the following: 1. Focus: R #1 has pain. Goal: R #1's pain will be kept to minimal (mild and barely noticeable). Approaches (actions taken by facility staff): Monitor/Record pain characteristics: Quality (nature of pain, describing how it feels, such as sharp, dull, throbbing, or burning), severity (intensity of pain, determine by 0-10 scale; 0 is no pain and 10 is the worst pain imaginable), anatomical location (where on the body the pain is occurring), onset (when the pain began), duration (how long the pain lasts), aggravating factors (what makes pain worse), relieving factors (what helps decrease pain). 2. Focus: R #1 has COPD. Goal: R #1's medical conditions will be managed on a daily basis. Approaches (actions taken by facility staff): administer PRN meds, listen to lungs sounds PRN, check oxygen saturation PRN, notify family and doctor of respiratory distress. C. Record review of R #1's nursing progress notes revealed the following: 1. 04/12/25 at 3:40 AM, R #1 complained of shortness of breath (SOB; not being able to get enough air, chest tightness or working harder to breathe). The nurse administered PRN albuterol inhaler (inhaled medication that relaxes muscles in the airways which helps to open them up an make it easier to breathe). 2. 04/12/25 at 3:41 AM, R #1 was given hydroxyzine (medication that helps relieve allergies and has a sedative effect that helps decrease anxiety) for complaints of shortness of breath. 3. 04/12/25 at 4:17 AM, albuterol inhaler and hydroxyzine effective (helped alleviate the symptoms).4. 04/12/25 at 4:21 AM, the resident reported shortness of breath and anxiety. The nurse administered PRN albuterol inhaler and hydroxyzine and notified the on-call provider. R #1 refused to go to the emergency room. 5. 04/12/25 at 7:08 AM, R #1 requested and was given acetaminophen (pain reliever and fever reducer used to treat mild to moderate pain and reduce fever) for complaint of headache. 6. 04/12/25 at 8:01 AM, acetaminophen effective resident reports no pain or discomfort at this time. 7. 04/12/25 at 4:19 PM, R #1 requested and was given acetaminophen. 8. 04/12/25 at 4:20 PM, R #1 requested and was given albuterol inhaler. 9. 04/12/25 at 5:21 PM, acetaminophen and albuterol inhaler effective resident reports no pain or discomfort at this time. Resident reports no SOB or discomfort at this time. 10. 04/12/25 at 11:54 PM, R #1 was given hydroxyzine. 11. 04/13/25 at 2:40 AM, hydroxyzine effective. 12. 04/13/25 at 4:53 AM resident was given acetaminophen. 13. 04/13/25 at 6:20 AM, acetaminophen effective. 14. 04/13/25 at 4:53 PM, R #1 has been short of breath throughout my shift, progressively worsening. Unable to get oxygen above 83-84% (95%-100% oxygen level is considered normal for most adults) this evening, with crackles (abnormal breath sounds that may be heard in the lungs of people with raspatory diseases) in both lower lung bases (bottom of each lung). R #1 also has increased weakness noted this evening. Primary care provider responded with the following feedback: Send to local emergency room via emergency medical services (ambulance). 15. Further record review of R #1's progress notes revealed staff did not document the quality, severity, onset, duration, aggravating factors or relieving factors of pain when they administered acetaminophen for complaints of pain on 04/12/25 at 7:08 AM, 04/12/25 at 4:19 PM, and on 04/13/25 at 4:53 PM. D. On 08/19/25 at 11:42 AM, during an interview, RN #1 stated the following: 1. She was the day shift nurse that worked with R #1 on 04/13/25. 2. On 04/13/25 after lunch (unable to remember the exact time) approximately 12:30 R #1 complained of shortness of breath and anxiety. 3. RN #1 stated this was not an uncommon complaint for R #1, RN #1 further stated R #1 would have increased anxiety related to diagnosis of COPD which causes her to have difficulty breathing. 4. RN #1 stated she administered hydroxyzine to R #1 at approximately 12:30 to help decrease her anxiety and help her to breathe easier. 5. RN #1 stated R #1 received her scheduled nebulizer treatment at approximately the same time (12:30 PM). 6. RN #1 stated she returned to check on R #1 after she had given her the hydroxyzine and scheduled ipratropium-albuterol (combination medication with two bronchodilators [inhaled medication that relaxes muscles in the airways which helps to open them up an make it easier to breathe]) nebulizer (approximately 1:00 PM) and resident reported the medication had helped. 7. RN #1 stated she checked on R #1 again at approximately 4:00 PM, R #1 complained of shortness of breath. RN #1 administered the PRN albuterol nebulizer treatment. 8. RN #1 stated she checked on R #1 at approximately 4:45 PM. R #1 still complained of shortness of breath and at that time also had increased weakness. RN #1 stated she contacted the on-call provider and received orders to send the resident to the emergency room via ambulance. E. Record review of R #1's administration record (spreadsheet where nurses initial to indicate the completion of a treatment or administration of medication), dated April 2025, revealed the following: 1. RN #1 did not document that she administered PRN hydroxyzine on 04/13/25 at 12:30 PM. 2. RN #1 did not document that she administered PRN albuterol nebulizer treatment on 04/13/25 at 4:00 PM. F. On 08/19/25 at 1:24 PM, during an interview with the DON, the following was confirmed: 1. RN #1 did not document her assessments of R #1 throughout the day that prompted her to administer PRN medications. 2. Staff are expected to document all resident assessments. 3. RN #1 did not document the administration of the PRN medications she administered on 04/13/25 4. Staff are expected to document all medications administered on the administration record when they are given. 5. Staff did not document the pain characteristics as indicated on R #1's care plan. 6. Staff are expected to document at minimum the pain levels for which they are administering PRN pain medications.
Apr 2025
12 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to provide a comfortable and homelike environment for 1 (R #1) of 3 (R #1, R #45, and R #78) residents sampled for environment, when staff faile...
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Based on observation and interview, the facility failed to provide a comfortable and homelike environment for 1 (R #1) of 3 (R #1, R #45, and R #78) residents sampled for environment, when staff failed to do the following:
1. Keep the residents' floor free of trash and orange peels.
2. Remove the residents' lunch tray after they had finished.
3. Empty and remove full urinal from the tray table.
These deficient practices could likely cause residents to feel like they are not living in a comfortable home-like environment and like they are not valued.
The findings are:
A. On 04/21/25 at 2:15 PM, during an observation of R #1's room, revealed there were orange peels on the R #1's floor. There were food crumbs on the floor around R #1's bed. R #1's floor also had paper trash on the floor. On R #1's tray table, there was a lunch tray from lunch service (lunch was served at 12:00 pm). There was a full urinal on R #1's lunch tray.
B. On 04/21/25 at 2:21 PM, during an interview, CNA #8 confirmed that there were orange peels, trash, and spills on the floor. CNA #8 confirmed that R #1's lunch tray was still in R #1's room. CNA #8 also confirmed that there was a full urinal on the resident's lunch tray. CNA #8 said R #1's tray should have been picked up. CNA #8 said that the urinal should be emptied and that it should not be on R #1's tray or tray table.
C. On 05/02/25 at 9:11 AM, during an interview, the Administrator said that orange peels should have been cleaned up and the lunch tray should be picked up when R #1 is done eating. The Administrator said that the urinal should have been emptied and taken off of R #1's tray table.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Recite from 02/12/24
Based on record review and interview, the facility failed to ensure residents, or their representatives rec...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Recite from 02/12/24
Based on record review and interview, the facility failed to ensure residents, or their representatives received a written notice of the bed hold policy which indicated the duration the bed would be held for 2 (R #32 and R #90) of 2 (R #32 and R #90) residents reviewed for hospitalization. This deficient practice could likely result in the residents and/or their representative being unaware of the bed hold policy upon return from the hospital. The findings are:
R #32
A. Record review of R #32's transfer notification, dated 04/16/25, revealed R #32 was sent to the hospital for cough and congestion.
B. Record review of R #32's medical record, no date, revealed staff did not complete a written bed hold notification for R #90's transfer to the hospital on [DATE].
R #90
C. On 04/21/25 at 3:33 PM, during an interview, R #90 stated the following:
1. R #90 was sent to the hospital on [DATE], because the staff thought he was having heart issues.
2. Staff did not provide him with a written bed hold notification.
D. Record review of R #90's progress note, dated 04/16/25, revealed the following:
1. R #90 was sweating, had nausea, and chest pain.
2. R #90 was transferred to the hospital by ambulance.
E. Record review of R #90's medical record, no date, revealed staff did not complete a written bed hold notification for R #90's transfer to the hospital on [DATE].
F. On 04/25/25 at 9:45 AM, during an interview, the DON confirmed the following:
1. Staff did not complete a bed hold notification for R #32's transfer to the hospital on [DATE].
2. Staff did not complete a bed hold notification for R #90's transfer to the hospital on [DATE].
3. Staff are expected to complete a written bed hold notification and give it to the resident or their representative at the time of the transfer to the hospital.
CONCERN
(D)
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 interview and record review, the facility failed to ensure the Minimum Data Set Assessment (MDS; a standardized, compre...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Minimum Data Set Assessment (MDS; a standardized, comprehensive assessment of an adult's functional, medical, psychosocial, and cognitive status) were accurate for 2 (R #9 and R #46) of 5 (R #9, R #29, R #46, R #62 and R #78) residents reviewed for accurate MDS assessments. This deficient practice could likely result in the facility not having an accurate assessment of the residents' needs. The findings are:
R #9
A. On 04/22/25 at 09:20 AM, during an interview, R #9 stated she did not have any teeth and needed dentures.
B. Record review of R #9's admission record revealed R #9 was admitted on [DATE].
C. Record review of R #9's admission MDS dated [DATE] revealed:
1. Section L0200, Dental, check all that apply
a. Staff did not check that R #9 had no natural teeth or tooth fragments (edentulous; the state of being without teeth).
D On 04/25/25 at 11:03 AM, during an interview, the MDS Coordinator stated that she was unaware that R #9 was edentulous.
E. On 04/25/25 at 12:15 PM, during an interview, the MDS Coordinator confirmed that R #9 was edentulous and that she did not enter R #9's accurate dental status on the admission MDS.
R #46
F. Record review of R #46's physician's orders revealed the following:
1. An order dated 12/06/24: haloperidol oral concentrate (antipsychotic medicine that is commonly used to treat schizophrenia [serious mental health condition that affects how people think, feel and behave]) 2 MG/ML, give 0.5 ml by mouth one time a day for agitation.
G. Record review of R #46's medication administration records (MAR; a form used to document medication administration) revealed the following:
1. R #46 received 0.5 ml of haloperidol at 3:00 PM daily from 01/01/25 through 01/31/25.
2. R #46 received 0.5 ml of haloperidol at 3:00 PM daily from 02/01/25 through 02/28/25.
3. R #46 received 0.5 ml of haloperidol at 3:00 PM daily from 03/01/25 through 03/31/25.
4. R #46 received 0.5 ml of haloperidol at 3:00 PM daily from 04/01/25 through 04/24/25.
H. Record review of R #46's Quarterly MDS, dated [DATE], revealed the following:
1. Section N0450 Antipsychotic Medication (drugs that treat symptoms of psychosis such as delusions, hallucinations, paranoia, and confusion) Review
a. Did the resident receive antipsychotic medications since admission/entry or reentry? facility staff documented No, Antipsychotics were not received
I. On 04/25/25 at 11:09 AM, during an interview, the MDS Coordinator confirmed that R #46 was receiving haloperidol daily and that she did not accurately enter this information for R #46's Quarterly MDS.
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** Recite from 02/12/24.
Based on record review and interview, the facility failed to develop an accurate, person-centered comprehe...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Recite from 02/12/24.
Based on record review and interview, the facility failed to develop an accurate, person-centered comprehensive care plan for 1 (R #90) of 2 (R #32 and R #90) residents reviewed for care plans. This deficient practice could likely result in staff being unaware of the current and actual needs of the residents. The findings are:
A. Record review of R #90's admission record (no date) revealed the following:
1. R #90 was admitted to the facility on [DATE].
2. Diagnosis of Edema (swelling caused by too much fluid trapped in the body's tissues).
B. Record review of R #90's physician order dated 03/11/25, revealed an order for Furosemide (diuretic medication used to treat fluid retention (edema) and swelling caused by congestive heart failure, liver disease, kidney disease, and other medical conditions) 40 mg, once a day for edema.
C. Record review of R #90's admission Minimum Data Set Assessment, dated 03/17/25, revealed Section N- Medications: N0415 High-Risk Drug Classes; Staff selected diuretic (medication that increases the removal of water from the body, through the kidneys).
D. Record review of R #90's care plan, revised on 03/24/25, revealed staff did not document the following:
1. R #90 had a diagnosis of edema.
2. R #90 had an order for the high-risk medication furosemide for edema.
E. On 04/25/25 at 9:48 AM, during an interview, the DON confirmed the following:
1. R #90 had an order for furosemide, which is a high-risk medication.
2. R #90's care plan did not include that he was taking furosemide.
3. High-risk medications should be included on resident care plans.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Recite from 02/12/24.
Based on record review and interview, the facility failed to ensure medical records were complete and accu...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Recite from 02/12/24.
Based on record review and interview, the facility failed to ensure medical records were complete and accurate for 1 (R #90) of 1 (R #90) residents reviewed for documentation accuracy. This deficient practice has the potential to negatively impact the care staff provide to meet residents' needs due to missing or inaccurate records and resident information. The findings are:
A. Record review of R #90's admission record (no date) revealed the following:
1. R #90 was admitted to the facility on [DATE].
2. R # 90 had the following diagnoses:
a. Diarrhea (loose, watery stools that occur more frequently than usual).
b. Noninfective gastroenteritis and colitis (involves inflammation of your stomach and intestines).
c. Cellulitis of abdominal wall (a rare sign of acute appendicitis that presents as aggressive intra-abdominal inflammation).
d. Acquired absence of other parts of digestive tract (missing parts of your digestive organs due to an injury or operation).
B. Record review of R #90's physician orders, multiple dates, revealed the following:
1. An order dated 03/24/25 for fiber oral tablets; give two tablets by mouth at bedtime for colon health.
2. An order dated 03/25/25, discontinued on 04/27/25, for Questran 4 grams; give one packet by mouth for diarrhea, two times a day for 10 days.
3. An order dated 03/27/25 for Questran (can provide relief of diarrhea caused by surgery or disease of the small bowel) 4 grams; give one packet by mouth for diarrhea, three times a day for 10 days.
C. Record review of R #90's medication administration record (MAR; a form used to document medication administration), dated March 2025, revealed staff documented the following:
1. On 03/25/25 at 9:00 PM, Questran, staff documented not administered, see progress note (Code 7).
2. On 03/26/25 at 8:00 PM, fiber, staff documented other, see nurses note (Code 9).
3. On 03/27/25 at 12:00 PM, Questran, staff documented code 7.
4. On 03/27/25 at 8:00 PM, fiber, staff documented Code 9.
5. On 03/28/25 at 8:00 PM, fiber, staff documented Code 9.
6. On 03/29/25 at 8:00 PM, fiber, staff documented Code 9.
D. Record review of R #90's medication administration record, dated April 2025, revealed staff documented the following:
1. On 04/01/25 at 8:00 PM, fiber, staff documented Code 9.
2. On 04/02/25 at 8:00 PM, fiber, staff documented Code 9.
3. On 04/03/25 at 4:00 PM, Questran, staff documented Code 7.
4. On 04/03/25 at 8:00 PM, fiber, staff documented Code 9.
5. On 04/04/25 at 12:00 PM, Questran, staff documented Code 7.
6. On 04/04/25 at 4:00 PM, Questran, staff documented Code 7.
7. On 04/04/25 at 8:00 PM, fiber, staff documented Code 9.
8. On 04/05/25 at 8:00 AM, Questran, staff documented Code 7.
9. On 04/05/25 at 12:00 PM, Questran, staff documented Code 7.
10. On 04/05/25 at 4:00 PM,Questran, staff documented Code 7.
11. On 04/05/25 at 8:00 PM, fiber, staff documented Code 9.
12. On 04/10/25 at 8:00 PM, fiber, staff documented Code 9.
13. On 04/11/25 at 8:00 PM, fiber, staff documented Code 9.
14. On 04/12/25 at 8:00 PM, fiber, staff documented Code 9.
E. Record review of R #90's entire medical record, no date, revealed staff did not document that the provider was notified about R #90 missing Questran or fiber medication doses.
F. On 04/25/25 at 9:21 AM, during an interview with the DON, she confirmed the following:
1. R #90 missed several doses of Questran and fiber medications in March and April 2025.
2. She stated that staff contacted the on-call provider through the facility communication application on 04/05/25 at 6:45 AM to notify them that R #90 did not have any Questran medication, and the provider ordered another medication to be added to R #90's treatment.
3. Staff did not document communication with the on-call provider on 04/05/25 in R #90's medical record.
4. Staff were expected to document all communication with providers in the resident's medical record.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to ensure residents and/or their representatives were informed in advance of what medications they received and understood the reasons, risks,...
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Based on record review and interview, the facility failed to ensure residents and/or their representatives were informed in advance of what medications they received and understood the reasons, risks, and benefits of the medications for 1 (R #62) of 5 (R #9, R #45, R #46, R #62 and R #90) residents reviewed for unnecessary medications. If the residents or their representatives are not informed of the risks and benefits of the medication or treatment alternatives, they are not able to make informed decisions regarding residents' care. The findings are:
A. Record review of R #62's physician's orders revealed the following:
1. An order for fluvoxamine oral tablet (psychotropic medication; any drug that affects brain activities associated with mental processes and behavior), 50 milligrams (mg) Give one tablet by mouth two times daily for post-traumatic stress disorder (PTSD; mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback, and avoidance of similar situations). Start date: 08/23/24.
B. Record review of R #62's medical record revealed staff did not document consent for fluvoxamine.
C. On 04/25/25 at 10:47 AM, during an interview, the Director of Nursing (DON) confirmed that staff did not obtain the consent form for the fluvoxamine for R #62. The DON confirmed that staff are expected to complete the psychotropic medication consent form prior to the resident starting psychotropic medications.
CONCERN
(E)
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 provider of missed medication doses for 1 (R #90) of 1 (...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the provider of missed medication doses for 1 (R #90) of 1 (R #90) resident reviewed for diarrhea, when they failed to notify the provider that R #90 missed 8 doses of Questran (medication that can provide relief of diarrhea caused by surgery or disease of the small bowel) and 12 doses of fiber (can be used to relieve mild-to-moderate diarrhea. Soluble fiber soaks up water in the digestive tract, which makes stool firmer and slower to pass) medication. This deficient practice could likely result in residents not receiving necessary care or worsening medical condition due to lack of treatment. The findings are:
A. Record review of R #90's admission record (no date) revealed the following:
1. R #90 was admitted to the facility on [DATE].
2. R #90 had the following diagnoses:
a. Diarrhea (loose, watery stools that occur more frequently than usual).
b. Noninfective gastroenteritis and colitis (involve inflammation of your stomach and intestines).
c. Cellulitis of abdominal wall (a rare sign of acute appendicitis that presents as aggressive intra-abdominal inflammation).
d. Acquired absence of other parts of digestive tract (missing parts of your digestive organs due to an injury or operation).
B. Record review of R #90's physician orders revealed the following:
1. An order dated 03/24/25, for fiber oral tablets; give two tablets by mouth at bedtime for colon health.
2. An order dated 03/25/25, discontinued on 03/27/25, for Questran 4 grams; give one packet by mouth for diarrhea, two times a day for 10 days.
3. An order dated 03/27/25, for Questran 4 grams; give one packet by mouth for diarrhea three times a day for 10 days.
4. An order dated 04/04/25, for Imodium A-D (medication used to treat diarrhea) 2 mg; give two tablets by mouth every 6 hours as needed for diarrhea.
C. Record review of R #90's medication administration record (MAR; a form used to document medication administration), dated March 2025, revealed staff documented the following:
1. On 03/25/25 at 9:00 PM, Questran, staff documented not administered, see progress note (Code 7).
2. On 03/26/25 at 8:00 PM, fiber, staff documented other, see nurses note (Code 9).
3. On 03/27/25 at 12:00 PM, Questran, staff documented code 7.
4. On 03/27/25 at 8:00 PM, fiber, staff documented Code 9.
5. On 03/28/25 at 8:00 PM, fiber, staff documented Code 9.
6. On 03/29/25 at 8:00 PM, fiber, staff documented Code 9.
D. Record review of R #90's medication administration record, dated April 2025, revealed staff documented the following:
1. On 04/01/25 at 8:00 PM, fiber, staff documented Code 9.
2. On 04/02/25 at 8:00 PM, fiber, staff documented Code 9.
3. On 04/03/25 at 4:00 PM, Questran, staff documented Code 7.
4. On 04/03/25 at 8:00 PM, fiber, staff documented Code 9.
5. On 04/04/25 at 12:00 PM, Questran, staff documented Code 7.
6. On 04/04/25 at 4:00 PM, Questran, staff documented Code 7.
7. On 04/04/25 at 8:00 PM, fiber, staff documented Code 9.
8. On 04/05/25 at 8:00 AM, Questran, staff documented Code 7.
9. On 04/05/25 at 12:00 PM, Questran, staff documented Code 7.
10. On 04/05/25 at 4:00 PM, Questran, staff documented Code 7.
11. On 04/05/25 at 8:00 PM, fiber, staff documented Code 9.
12. On 04/10/25 at 8:00 PM, fiber, staff documented Code 9.
13. On 04/11/25 at 8:00 PM, fiber, staff documented Code 9.
14. On 04/12/25 at 8:00 PM, fiber, staff documented Code 9.
E. Record review of R #90's progress notes for March and April 2025, revealed staff documented the following for R #90's fiber and Questran medications:
1. On 03/25/25 at 10:38 PM, Questran, staff documented, on order, notify nurse.
2. On 03/26/25 at 9:19 PM, fiber, staff documented, waiting for delivery. Nurse aware.
3. On 03/27/25 at 9:15 PM, fiber, staff documented, waiting for delivery. Nurse aware.
4. On 03/28/25 at 9:08 PM, fiber, staff documented, waiting for delivery. Nurse aware.
5. On 03/29/25 at 8:39 PM, fiber, staff documented, waiting for delivery. Nurse aware.
6. On 04/01/25 at 10:43 PM, fiber, staff documented, on order.
7. On 04/02/25 at 9:13 PM, fiber, staff documented, waiting for delivery. Nurse aware.
8. On 04/03/25 at 4:03 PM, Questran, staff documented, waiting on pharmacy delivery.
9. On 04/03/25 at 9:36 PM, fiber, staff documented, waiting for delivery. Nurse aware.
10. On 04/04/25 at 8:50 AM, Questran, staff documented, waiting on pharmacy delivery.
11. On 04/04/25 at 11:21 AM, Questran, staff documented, waiting on pharmacy delivery.
12. On 04/04/25 at 3:19 PM, Questran, staff documented, waiting on pharmacy delivery.
13. On 04/04/25 at 8:51 PM, fiber, staff documented, waiting for delivery. Nurse aware.
14. On 04/05/25 at 9:28 AM, Questran, staff documented, waiting on pharmacy delivery.
15. On 04/05/25 at 1:20 PM, Questran, staff documented, waiting on pharmacy delivery.
16. On 04/05/25 at 3:02 PM, Questran, staff documented, waiting on pharmacy delivery.
17. On 04/05/25 at 9:10 PM, fiber, staff documented, waiting for delivery. Nurse aware.
18. On 04/10/25 at 11:25 PM, fiber, staff documented, waiting for delivery. Nurse aware.
19. On 04/11/25 at 8:52 PM, fiber, staff documented, waiting for delivery. Nurse aware.
20. On 04/12/25 at 8:13 PM, fiber, staff documented, waiting for delivery. Nurse aware.
21. Staff did not document that the provider was notified about R #90 missing doses of fiber and Questran medications.
F. Record review of R #90's entire medical record, no date, revealed the medical record did not contain documentation that the provider was notified about R #90 not receiving doses of Questran or Fiber medications.
G. On 04/24/25 at 2:23 PM, during an interview, LPN #16 stated the following about regular processes regarding missing medication:
1. When the CMA's notify her that a medication is not available, she checks the facility medication management system to see if the medication is available there.
2. If the resident will miss any doses, she notifies the provider and documents the communication with the provider and enters any order changes in the resident's medical record.
H. On 04/25/25 at 9:21 AM, during an interview, the DON confirmed the following:
1. R #90 missed several doses of Questran and fiber medications in March and April 2025.
2. She stated staff contacted the on-call provider through the facility communication application on 04/05/25 at 6:45 AM, to notify them that R #90 did not have any Questran medication, and the provider ordered Immodium A-D to be added to R #90's treatment.
3. Prior to 04/05/25, staff had not contacted the on-call provider regarding R #90's missed doses of fiber or Questran medication.
4. Staff should have notified the provider at the time of each missed dose to see if the provider wanted to change R #90's treatment.
CONCERN
(E)
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** Recite from 02/12/2024
Based on record review and interview, the facility failed to ensure care plan revisions and care plan mee...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Recite from 02/12/2024
Based on record review and interview, the facility failed to ensure care plan revisions and care plan meeting requirements occurred for 7 (R #1, R #9, R #15, R #37, R #45, R #89 and R #90) of 8 (R #1, R #9, R #15, R #37, R #45, R #62, R #89 and R #90) residents when the staff failed to:
1. Have the required Interdisciplinary Team (IDT, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) members participate in the care plan meeting for R #9, R #15, R #45, R #89, and R #90.
2. Ensure the care plan meeting was held within 7 days from the completion of the MDS assessment when creating the care plan for R #1, R #9, and R #45.
3. Revise the care plan with the most current resident information for R #1, R #45, and R #90.
These deficient practices could likely result in the care plan not being updated with the most current resident conditions and appropriate interventions, staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are:
IDT Team
R #9
A. Record review of R #9's Care Plan Conference form, dated 02/11/25, revealed the following:
1. Staff documented the individuals that were present at the meeting were: R #9's representative and the Social Services Director (SSD).
2. Staff documented not applicable for the RN, MDS case manager, Nurse Aide, food service staff, Physician, Activity Director as contributors.
B. On 04/25/25 at 11:30 AM, during an interview, the SSD stated that the required IDT did not attend the meeting because the meeting that was held on 02/11/25 was not a scheduled care plan meeting. The SSD stated the meeting was held because R #9's representative was at the facility on 02/11/25.
R #15
C. Record review of R #15's Care Plan Conference form, dated 01/14/25, revealed the following:
1. The individuals that were contributors to the meeting were: R #15, R #15's representative, an RN, the activity director, the social services director, the director of rehabilitation, and two ombudsmen.
2. Staff documented not applicable for Nurse Aide and Physician as contributors.
R #37
D. Record review of R #37's Care Plan Conference form, dated 03/16/25, revealed the following:
1. The individuals that were present to the meeting were: R #37's representative, the RN, the Food Service Staff, the Activities Director, and the Social Services Director.
2. Staff documented not applicable for MDS Coordinator, Nurse Aide and Physician as contributors.
R #45
E. Record review of R #45's care plan assessment, dated 02/11/25, revealed the individuals that were present at the meeting were: the RN, the MDS Coordinator, Food Service Staff, and the Social Services Director (SSD).
R #89
F. Record review of R #89's care plan assessment, dated 03/27/25, revealed the individuals that were present at the meeting were: R #89, R #89's POA (Power of Attorney), the RN, the Activity Director (AD), and the Social Services Director (SSD).
R #90
G. Record review of R #90's Care Plan Conference form, dated 03/26/25, revealed the following:
1. The individuals that were contributors to the meeting were: R #90, an RN, food services staff, the activity director, and the social services director.
2. Staff documented not applicable for Nurse Aide and Physician as contributors.
H. On 04/25/25 at 9:55 AM, during an interview, the DON confirmed the following:
1. The provider does not usually attend care plan meetings.
2. Staff do not usually contact the provider to ask for input prior to each resident's care plan meeting.
3. CNA's do not usually attend care plan meetings.
4. CNA's do not usually provide input for the care plan meetings.
Timing
R #1
I. Record review of R #1's Annual MDS, dated [DATE], revealed the assessment was signed by the Registered Nurse (RN) on 02/15/25.
J. Record review of R #1's entire medical record, no date, revealed staff did not document that a care plan meeting took place within seven days after the completion of R #1's Annual MDS on 02/15/25.
K. On 04/24/25 at 9:23 AM, during an interview with the Social Services Director, she confirmed that there was no care plan meeting after R #1's Annual MDS was completed.
R #9
L. Record review of R #9's admission MDS, dated [DATE], revealed the assessment was signed by the Registered Nurse (RN) on 01/26/25.
M. Record review of R #9's Care Plan Conference form, dated 02/11/25, revealed that the care plan meeting was not held within 7 days of the completion of R #9's admission MDS.
N. On 04/25/25 at 11:30 AM, during an interview with the SSD, she confirmed that R #9's care plan meeting was not held within 7 days of the completed of R #9's admission MDS.
R #45
O. Record review of R #45's Quarterly MDS, dated [DATE], revealed the assessment was signed by the Registered Nurse (RN) on 02/21/25.
P. Record review of R #45's Care Plan Conference, dated 02/11/25, revealed that the care plan meeting was held before the completion of R #45's Quarterly MDS on 02/21/25.
Q. On 04/24/25 at 9:23 AM, during an interview, the Social Services Director confirmed that R #45's care plan meeting was held before his Quarterly MDS was completed.
Revisions
R #1
R. Record review of R #1's admission documents, no date, revealed R #1 was admitted to the facility on [DATE].
S. Record review of R #1's physician order, dated 04/14/25 revealed an order to apply lotion to R #1's upper and lower extremities daily (arms, including everything from the shoulders to the hands, and legs, including everything from the hips to the feet).
T. Record review of R #1's care plan, dated 02/17/25 revealed staff did not revise R #1's care plan to include applying lotion to R #1.
R #90
U. Record review of R #90's admission record (no date) revealed the following:
1. R #90 was admitted to the facility on [DATE].
2. R #90 had the following diagnoses:
a. Diarrhea (loose, watery stools that occur more frequently than usual).
b. Noninfective gastroenteritis and colitis (involves inflammation of your stomach and intestines).
c. Cellulitis of abdominal wall (a rare sign of acute appendicitis that presents as aggressive intra-abdominal inflammation).
d. Acquired absence of other parts of digestive tract (missing parts of your digestive organs due to an injury or operation).
V. Record review of R #90's physician's orders, revealed the following:
1. An order dated 03/24/25, for fiber (can be used to relieve mild-to-moderate diarrhea. Soluble fiber soaks up water in the digestive tract, which makes stool firmer and slower to pass) oral tablets; give two tablets by mouth at bedtime for colon health.
2. An order dated 03/24/25 (discontinued on 03/26/25) for Imodium A-D (medication that can treat diarrhea) 2 mg; give two tablets by mouth every 12 hours as needed for loose stools.
3. An order dated 03/25/25 for Acidophilus Probiotic (a probiotic that is used to help maintain the number of healthy bacteria in your stomach and intestines) oral tablet; give one tablet by mouth two times a day for gastrointestinal health for 14 days.
4. An order dated 03/27/25 for Questran (can provide relief of diarrhea caused by surgery or disease of the small bowel) 4 grams; give one packet by mouth for diarrhea, three times a day for 10 days.
5. An order dated 04/04/25 for Imodium A-D 2 mg; give two tablets by mouth every 6 hours as needed for diarrhea.
6. An order dated 04/12/25 for Imodium A-D 2 mg; give two tablets by mouth for diarrhea four times a day until 04/15/25.
7. An order dated 04/14/25, for a consultation with a gastroenterologist (a specialist with expertise in the disorders and diseases that affect the digestive system).
8. An order dated 04/17/25 for Imodium A-D 2 mg; give two tablets by mouth four times a day for diarrhea for three days.
W. Record review of R #90's care plan, dated 03/12/25, revealed staff did not revise R #90's care plan to include his diagnosis of diarrhea or the interventions in place to treat his diarrhea.
X. On 04/25/25 at 9:43 AM, during an interview, the DON confirmed the following:
1. R #90 had diarrhea over a prolonged period of time.
2. R #90 had several orders in place to treat his diarrhea.
3. R #90 had an order to see the gastroenterologist due to frequent diarrhea.
4. Staff should have included R #90's diagnosis of diarrhea and the interventions in place to treat his diarrhea.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to meet professional standards of quality for 1 (R #90) of 1 (R #90)...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to meet professional standards of quality for 1 (R #90) of 1 (R #90) resident when staff failed to administer medications according to physician's orders. If the facility is not providing care that meets professional standards of quality, then residents are likely to experience adverse effects, worsening of their condition, and potential complications from not receiving the care ordered by the physician. The findings are:
A. Record review of R #90's admission record (no date) revealed the following:
1. R #90 was admitted to the facility on [DATE].
2. R # 90 had the following diagnoses:
a. Diarrhea (loose, watery stools that occur more frequently than usual).
b. Noninfective gastroenteritis and colitis (involve inflammation of your stomach and intestines).
c. Cellulitis of abdominal wall (a rare sign of acute appendicitis that presents as aggressive intra-abdominal inflammation).
d. Acquired absence of other parts of digestive tract (missing parts of your digestive organs due to an injury or operation).
B. Record review of R #90's physician orders, multiple dates, revealed the following:
1. An order dated 03/24/25 for fiber (can be used to relieve mild-to-moderate diarrhea. Soluble fiber soaks up water in the digestive tract, which makes stool firmer and slower to pass) oral tablets; give two tablets by mouth at bedtime for colon health.
2. An order dated 03/25/25, discontinued on 03/27/25, for Questran (can provide relief of diarrhea caused by surgery or disease of the small bowel) 4 grams; give one packet by mouth for diarrhea two times a day for 10 days.
3. An order dated 03/27/25 for Questran 4 grams; give one packet by mouth for diarrhea, three times a day for 10 days.
C. Record review of R #90's medication administration record (MAR; a form used to document medication administration), dated March 2025, revealed staff documented the following:
1. On 03/25/25 at 9:00 PM, Questran, staff documented not administered, see progress note (Code 7).
2. On 03/26/25 at 8:00 PM, Fiber, staff documented other, see nurses note (Code 9).
3. On 03/27/25 at 12:00 PM, Questran, staff documented code 7.
4. On 03/27/25 at 8:00 PM, Fiber, staff documented Code 9.
5. On 03/28/25 at 8:00 PM, Fiber, staff documented Code 9.
6. On 03/29/25 at 8:00 PM, Fiber, staff documented Code 9.
D. Record review of R #90's medication administration record, dated April 2025, revealed staff documented the following:
1. On 04/01/25 at 8:00 PM, Fiber, staff documented Code 9.
2. On 04/02/25 at 8:00 PM, Fiber, staff documented Code 9.
3. On 04/03/25 at 4:00 PM, Questran, staff documented Code 7.
4. On 04/03/25 at 8:00 PM, Fiber, staff documented Code 9.
5. On 04/04/25 at 12:00 PM, Questran, staff documented Code 7.
6. On 04/04/25 at 4:00 PM, Questran, staff documented Code 7.
7. On 04/04/25 at 8:00 PM, Fiber, staff documented Code 9.
8. On 04/05/25 at 8:00 AM, Questran, staff documented Code 7.
9. On 04/05/25 at 12:00 PM, Questran, staff documented Code 7.
10. On 04/05/25 at 4:00 PM, Questran, staff documented Code 7.
11. On 04/05/25 at 8:00 PM, Fiber, staff documented Code 9.
12. On 04/10/25 at 8:00 PM, Fiber, staff documented Code 9.
13. On 04/11/25 at 8:00 PM, Fiber, staff documented Code 9.
14. On 04/12/25 at 8:00 PM, Fiber, staff documented Code 9.
E. Record review of R #90's progress notes for March and April 2025, revealed staff documented the following for R #90's fiber and Questran medications:
1. On 03/25/25 at 10:38 PM, Questran, staff documented, on order, notify nurse.
2. On 03/26/25 at 9:19 PM, Fiber, staff documented, waiting for delivery. Nurse aware.
3. On 03/27/25 at 9:15 PM, Fiber, staff documented, waiting for delivery. Nurse aware.
4. On 03/28/25 at 9:08 PM, Fiber, staff documented, waiting for delivery. Nurse aware.
5. On 03/29/25 at 8:39 PM, Fiber, staff documented, waiting for delivery. Nurse aware.
6. On 04/01/25 at 10:43 PM, Fiber, staff documented, on order.
7. On 04/02/25 at 9:13 PM, Fiber, staff documented, waiting for delivery. Nurse aware.
8. On 04/03/25 at 4:03 PM, Questran, staff documented, waiting on pharmacy delivery.
9. On 04/03/25 at 9:36 PM, Fiber, staff documented, waiting for delivery. Nurse aware.
10. On 04/04/25 at 8:50 AM, Questran, staff documented, waiting on pharmacy delivery.
11. On 04/04/25 at 11:21 AM, Questran, staff documented, waiting on pharmacy delivery.
12. On 04/04/25 at 3:19 PM, Questran, staff documented, waiting on pharmacy delivery.
13. On 04/04/25 at 8:51 PM, Fiber, staff documented, waiting for delivery. Nurse aware.
14. On 04/05/25 at 9:28 AM, Questran, staff documented, waiting on pharmacy delivery.
15. On 04/05/25 at 1:20 PM, Questran, staff documented, waiting on pharmacy delivery.
16. On 04/05/25 at 3:02 PM, Questran, staff documented, waiting on pharmacy delivery.
17. On 04/05/25 at 9:10 PM, Fiber, staff documented, waiting for delivery. Nurse aware.
18. On 04/10/25 at 11:25 PM, Fiber, staff documented, waiting for delivery. Nurse aware.
19. On 04/11/25 at 8:52 PM, Fiber, staff documented, waiting for delivery. Nurse aware.
20. On 04/12/25 at 8:13 PM, Fiber, staff documented, waiting for delivery. Nurse aware.
21. Staff did not document what was done to try to get the fiber or Questran medications for R #90.
22. Staff did not document that the provider was notified about R #90 missing doses of fiber and Questran medications.
F. On 04/24/25 at 2:23 PM, during an interview with LPN #16, she stated the following:
1. When the CMA's notify her that a medication is not available, she checks the facility medication management system to see if the medication is available there.
2. If the medication management system does not have the medication, she contacts the pharmacy to see when the medication will arrive.
3. If the medication is an over-the-counter medication, she notifies the staff member that orders supplies so she can go to the local grocery store to pick it up.
4. If the resident will miss any dose, she notifies the provider and documents the communication with the provider and enters any order changes in the resident's medical record.
G. On 04/25/25 at 9:21 AM, during an interview with the DON, she confirmed the following:
1. R #90 missed several doses of Questran and fiber medications in March and April 2025.
2. Staff are expected to contact the pharmacy to see when the medication will arrive.
3. If the medication is an over-the-counter medication, staff are expected to notify the staff member that orders supplies so she can go to the local grocery store to pick up the medication.
4. Staff are expected to notify the provider at the time of each missed dose to see if the provider wants to change the resident's treatment.
5. She stated that staff contacted the on-call provider through the facility communication application on 04/05/25 at 6:45 AM to notify them that R #90 did not have any Questran medication.
6. Prior to 04/05/25, staff had not contacted the on-call provider regarding R #90's missed doses of fiber or Questran medication.
7. She was unable to determine if staff notified the staff member who ordered supplies to pick up fiber medication from the local grocery store.
8. She was unable to determine if staff contacted the pharmacy regarding R #90's Questran medication.
H. Record review of the facilities Medication Ordering and Receiving From Pharmacy Provider: Medication Shortages policy, dated January 2023 revealed the following instructions:
1. Nursing staff shall, if the shortage will impact the patient's immediate need of the ordered product:
a. Notify the attending physician of the situation, explain the circumstances, expected availability and optional therapy(ies) that are available.
b. Obtain a new order and cancel/discontinue the order for the non-available medication.
c. Notify the pharmacy of the replacement order.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Recite from 02/12/24
Based on record review and interview, the facility failed to ensure the consultant pharmacist's recommendat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Recite from 02/12/24
Based on record review and interview, the facility failed to ensure the consultant pharmacist's recommendations were reviewed and implemented by the physician and/or the physician provided documentation of a rationale (a set of reasons or a logical basis for a course of action or a particular belief) for not following the consultant pharmacist's recommendation in the residents' medical record for 2 (R #45 and R #46) of 5 (R #9, R #45, R #46, R #62, and R #90) residents reviewed for unnecessary medications. This deficient practice could likely result in residents receiving medications that are no longer necessary and may cause unnecessary drug interactions (changes to medication action caused by being combined with other foods, beverages, or drugs) or adverse side effects (unwanted, undesirable effects from medication). The findings are:
R #45
A. Record review of R #45's face sheet no date revealed the following:
1. R #45 was admitted to the facility on [DATE],
2. R # 45 was diagnosed with the following diagnosis
a. Major Depressive Disorder (mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), recurrent, mild.
b. Sleep disorder (a condition that disrupts normal sleep patterns, affecting the quality, timing, and duration of sleep).
c. Post Traumatic Stress Disorder (PTSD) (mental health condition that can develop after a person has experienced or witnessed a traumatic event).
d. Nightmare Disorder (sleep disorder characterized by recurrent, vivid, and frightening dreams that cause distress and impairment).
B. Record review of R #45's physician's orders revealed the following orders:
1. An order dated 10/07/24 for Doxepin (used to treat anxiety, depression and insomnia) give 1 tablet 100 mg, by mouth at bedtime for insomnia.
2. An order dated 10/23/24 for Prazosin (used to treat symptoms of post-traumatic stress disorder) give 2 tablets by mouth at bedtime for nightmares.
3. An order dated 02/18/25 for Bupropion XL (Wellbutrin) (used Major Depressive Disorder) give 2 tablets by mouth every morning for major depressive disorder.
C. Record review of R #45's pharmacy recommendation summary report dated 01/14/25, revealed the following:
1. R #45 is currently receiving Doxepin 100 mg at bedtime, consider gradual dose reduction (GRD).
2. R #45's physician did not provide rationale with patient specific information as to why R #45 needed to remain on medication.
D. Record review of R #45's pharmacy recommendation summary report dated 02/29/25, revealed the following:
1. R #45 is currently receiving Prazosin 2 mg at bedtime, consider gradual dose reduction (GRD).
2. Physician documented that an outside provider prescribed the medication.
3. R #45's physician did not provide rationale with patient specific information as to why R #45 needed to remain on medication.
4. Staff did not document that the recommendation was sent to the outside provider for review and consideration.
E. Record review of R #45's pharmacy recommendation summary report dated 03/19/25, revealed the following:
1. R #45 is currently receiving Bupropion 400 mg at bedtime, consider gradual dose reduction (GRD).
2. Physician documented that an outside provider prescribed the medication.
3. R #45's physician did not provide rationale with patient specific information as to why R #45 needed to remain on medication.
4. Staff did not document that the recommendation was sent to the outside provider for review and consideration.
F. On 04/25/25 at 12:36 PM, during an interview, the DON confirmed that the provider did not provide a rationale for recommendation, follow up, or supporting information as to why the resident is still on medication Doxepin, Prazosin, and Bupropion. The DON said that the recommendations for February and March were not sent to R #45's outside provider.
R #46
G. Record review of R #46's admission Record (no date) revealed the following:
1. R #46 was admitted to the facility on [DATE].
2. R #46 was diagnosed with the following:
a. Unspecified dementia, severe (condition where confusion or cognitive impairment cannot be clearly diagnosed by a specific type of dementia characterized by significant cognitive decline and the need for constant assistance with daily activities), with anxiety (feeling of uneasiness, nervousness or fear).
b. Anxiety disorder, unspecified (diagnostic category uses when anxiety symptoms cause significant distress or impairment in daily functioning but do not meet criteria of other specific anxiety disorders).
c. Auditory hallucinations (when an individual perceives sounds without any actual auditory stimulus, can include hearing voices or noises that are not present in the environment).
H. Record review of R #46's physician's orders revealed the following:
1. An order dated 09/27/24 for hydroxyzine oral tablet (antihistamine medication which can help alleviate feelings of anxiety and promote calmness), 10 mg give 1 tablet by mouth two times a day for agitation (state of restlessness or inner tension).
2. An order dated 12/06/24 for haloperidol oral concentrate (antipsychotic medication that is commonly used to treat schizophrenia [serious mental health condition that affects how people think, feel and behave]) 2 MG/ML give 0.5 ml by mouth every four hours as needed for agitation.
I. Record review of R #46's Medication Regimen Review forms dated 02/20/25, revealed the following:
1. Gradual Dose Reduction (GDR; decreasing a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the medication can be discontinued altogether) for medication hydroxyzine 10 mg twice daily.
a. residents who use psychotropic drugs (any drug that affects brain activities associated with mental processes and behavior) must have gradual dose reduction attempts, unless clinically contraindicated, in an attempt to discontinue these drugs.
b. Do you feel a reduction could be attempted on the above medication at this time?
c. The form was marked other, and the written response was Hospice pt (patient).
2. As needed (PRN) psychotropic for medication haloperidol.
a. all PRN psychotropics, if continued past 14 days of use, must have clinical rationale and anticipated duration of use documented. There is no hospice exception to this CMS (Centers for Medicare and Medicaid Services) regulation.
b. consider discontinuing the above medication. If resident still benefits from PRN use, please document below.
c. resident requires PRN psychotropic due to area was left blank.
d. anticipated duration of use area was left blank.
e. the form was marked disagree and the written response was continues to benefit from medication due to unnecessary behaviors with dementia.
J. On 04/25/25 at 12:48 PM, during an interview, the DON confirmed that the provider did not provide rationale in R #46's medical record regarding the GDR for hydroxyzine or the continued use of PRN haloperidol and the haloperidol order did not have an end date.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
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 keep residents free from psychotropic medications (any drug that af...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to keep residents free from psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) for 2 (R #45 and R #46) of 5 (R #9, R #45, R #46, R #62 and R #90) residents reviewed for unnecessary medications when they failed to:
1. Carry out a gradual dose reduction (GDR; stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the medication can be discontinued) and failed to document clinical rationale to continue psychotropic medications for R #45 and R #46.
2. Ensure that as needed (PRN) psychotropic orders were limited to 14 days and ensure that if the prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order for R #46. If consultant pharmacist recommendations and physician's orders are not implemented in a timely manner, residents are likely to be administered medications they do not need and could likely suffer from adverse side effects. The findings are:
R #45
A. Record review of R #45's face sheet revealed R #45 was admitted to the facility on [DATE] with the following diagnosis:
1. Major Depressive Disorder (mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), recurrent, mild.
2. Schizophrenia (chronic mental disorder that affects a person's ability to think, feel, and behave clearly).
3. Bipolar Disorder (mental illness characterized by dramatic shifts in mood, energy, and activity levels, including both manic and depressive episodes)
4. Schizoaffective disorder, bipolar type (a mental health condition characterized by the combined presence of symptoms of schizophrenia and bipolar disorder).
5. Sleep disorder (a condition that disrupts normal sleep patterns, affecting the quality, timing, and duration of sleep).
6. Post Traumatic Stress Disorder (PTSD) (mental health condition that can develop after a person has experienced or witnessed a traumatic event).
7. Nightmare Disorder (sleep disorder characterized by recurrent, vivid, and frightening dreams that cause distress and impairment).
B. Record review of R #45's physician's orders revealed an order dated 10/07/24 for Doxepin (used to treat anxiety, depression and insomnia) give 1 tablet 100 mg, by mouth at bedtime for insomnia.
C. Record review of R #45's MAR dated February 2025 revealed staff documented that R #45 was given Doxepin as ordered daily.
D. Record review of R #45's pharmacy recommendation summary report dated 01/14/25 revealed the following:
1. R #45 is currently receiving Doxepin 100 mg at bedtime, consider gradual dose reduction (GRD).
2. R #45's physician did not provide rationale with patient specific information as to why R #45 needed to remain on medication.
3. R #45's physician failed to document clinical rationale to continue R #45's use of Doxepin.
E. Record review of R #45's physician's orders revealed an order dated 10/23/24 for Prazosin (used to treat symptoms of post-traumatic stress disorder) give 2 tablets by mouth at bedtime for nightmares.
F. Record review of R #45's MAR dated February 2025 revealed staff documented that R #45 was given Prazosin as ordered nightly.
G. Record review of R #45's pharmacy recommendation summary report dated 02/29/25 revealed the following:
1. R #45 is currently receiving Prazosin 2 mg at bedtime, consider gradual dose reduction (GRD).
2. R #45's physician did not provide rationale with patient specific information as to why R #45 needed to remain on medication.
3. R #45's physician failed to document clinical rationale to continue R #45's use of Prazosin.
H. Record review of R #45's physician's orders revealed an order dated 02/18/25 for Bupropion (Wellbutrin) (used Major Depressive Disorder) give 2 tablets by mouth at bedtime for nightmares.
I. Record review of R #45's pharmacy recommendation summary report dated 03/19/25 revealed the following:
1. R #45 is currently receiving Bupropion 400 mg at bedtime, consider gradual dose reduction (GRD).
2. R #45's physician did not provide rationale with patient specific information as to why R #45 needed to remain on medication.
3. R #45's physician failed to document clinical rationale to continue R #45's use of Bupropion.
J. On 04/25/25 at 12:36 PM, during an interview, the DON confirmed that there was no rationale from the physician in R #45's medical record regarding the gradual drug reduction recommendations for R #45.
R #46
K. Record review of R #46's admission Record (no date) revealed the following:
1. R #46 was admitted to the facility on [DATE].
2. R #46 was diagnosed with the following:
a. Unspecified dementia, severe (condition where confusion or cognitive impairment cannot be clearly diagnosed by a specific type of dementia characterized by significant cognitive decline and the need for constant assistance with daily activities), with anxiety (feeling of uneasiness, nervousness or fear).
b. Anxiety disorder, unspecified (diagnostic category uses when anxiety symptoms cause significant distress or impairment in daily functioning but do not meet criteria of other specific anxiety disorders).
c. Auditory hallucinations (when an individual perceives sounds without any actual auditory stimulus, can include hearing voices or noises that are not present in the environment).
L. Record review of R #46's physician's orders revealed the following:
1. An order dated 09/27/24 for hydroxyzine oral tablet (antihistamine medication which can help alleviate feelings of anxiety and promote calmness), 10 mg give 1 tablet by mouth two times a day for agitation (state of restlessness or inner tension).
2. An order dated 12/06/24 for haloperidol oral concentrate (antipsychotic medication that is commonly used to treat schizophrenia [serious mental health condition that affects how people think, feel and behave]) 2 MG/ML give 0.5 ml by mouth every 4 hours as needed for agitation.
M. Record review of R #46's Medication Regimen Review forms dated 02/20/25 revealed the following:
1. Gradual Dose Reduction (GDR; decreasing a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the medication can be discontinued altogether) for medication hydroxyzine 10 mg twice daily.
a. residents who use psychotropic drugs (any drug that affects brain activities associated with mental processes and behavior) must have gradual dose reduction attempts, unless clinically contraindicated, in an attempt to discontinue these drugs.
2. As needed (PRN) psychotropic for medication haloperidol.
a. all PRN psychotropics, if continued past 14 days of use, must have clinical rationale and anticipated duration of use documented.
N. Record review of R #46's medication administration records (MAR; a form used to document medication administration) revealed the following:
1. R #46 received hydroxyzine 10mg twice daily from 01/01/25 through 01/31/25.
2. R #46 received hydroxyzine 10mg every morning from 02/01/25 through 02/28/25.
3. R #46 received hydroxyzine 10mg at night from 02/01/25 through 02/10/25.
4. R #46 received hydroxyzine 10mg at night from 02/12/25 through 02/28/25.
5. R #46 received hydroxyzine 10mg every morning from 03/01/25 through 03/22/25.
6. R #46 received hydroxyzine 10mg every morning from 03/23/25 through 03/31/25.
7. R #46 received hydroxyzine 10mg twice daily from 04/01/25 through 04/23/25.
8. R #46 received PRN haloperidol 0.5 ML 01/29/25.
9. R #46 received PRN haloperidol 0.5 ML 04/02/25 and 04/06/25.
O. On 04/25/25 at 12:48 PM, during an interview, the DON confirmed that R #46 did not have a GDR done for her hydroxyzine and continues to receive it and PRN haloperidol order has been in place greater than 14 days with no end date (anticipated duration).
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 under sanitary conditions for all 81 residents who eat food from the kitchen (residents were identified by the resident census pro...
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Based on observation and interview, the facility failed to store food under sanitary conditions for all 81 residents who eat food from the kitchen (residents were identified by the resident census provided by the Administrator on 04/21/25), when they failed to label and date dessert items in the kitchen refrigerator. If the facility fails to store food under safe and sanitary conditions then this could likely lead to foodborne illnesses (Foodborne illness can occur if you eat foods that are contaminated with harmful pathogens such as bacteria, viruses, and fungi) in residents. The findings are:
A. On 04/21/25 at 10:24 AM, during an observation of the kitchen, revealed the walk-in refrigerator had 1 tray with 12 desserts on tray with eight (8) out of 12 desserts did not have a date to indicate when they were prepared.
B. On 04/21/25 at 10:24 AM, during an interview with the Dietary Director, she confirmed eight (8) out of 12 desserts on the 1 tray in the refrigerator did not have dates on lids. The Dietary Director stated, having a few with a date on the lids on the same tray should suffice.
C. Record review of the facilities Food Labeling and Dating policy revised date 01/25/25 revealed that any food items prepared for a meal will be labeled and dated.
Jan 2025
1 deficiency
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 F0602
(Tag F0602)
Could have caused harm · This affected 1 resident
Past noncompliance
Based on record review and interview, the facility failed to prevent staff to resident exploitation when Activity Aide (AA) #1 used R #16's bank debit card to make an unauthorized (...
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Past noncompliance
Based on record review and interview, the facility failed to prevent staff to resident exploitation when Activity Aide (AA) #1 used R #16's bank debit card to make an unauthorized (without the account holders permission) money withdrawals or purchases for 1 (R #16) of 3 (R #16, R #17, and R #18) residents reviewed for abuse, neglect, and exploitation. This deficient practice could likely result in residents not having money available when they need it, psychosocial distress, and a loss of trust in staff. The findings are:
A. Record review of the facility's self report, dated 09/13/24, revealed the following:
1. The self-report was submitted to the State Agency due to allegations of misappropriation (wrongful use of another's belongings, money, etc.) of funds for R #16.
2. R #16's Power of Attorney (POA, the authority to act for another person in specified or all legal or financial matters) reported that R #16's bank account was missing nearly $3,000 and there were multiple suspicious (showing a cautious distrust) charges.
3. The police were called and started an investigation.
B. Record review of the 5 day follow-up report, dated 09/19/24, revealed the following:
1. The facility assisted R #16 with obtaining six months of bank statements.
2. R #16's POA identified charges from a phone company that did not match R #16's phone provider and other charges for vendors R #16 does not shop with.
3. The administrator went over the suspicious charges on the bank statements with the R #16.
4. R #16's POA had R #16's debit card shut off and replaced with a new card.
5. Staff were instructed that only the Activities Director would be allowed to use residents debit cards for shopping.
6. Residents who use their debit cards for shopping were encouraged to only give their debit card to the Activities Director for shopping.
7. The Activity Department used a dual signature system to verify shopping lists match receipts.
8. The police began an investigation.
9. The police were waiting for video footage from local businesses and an ATM machine to identify the individual who used R #16 debit card without authorization.
C. Record review of the follow-up to 5 day report, dated 12/10/24, revealed the following:
1. The police detective used security footage from local vendors to identify AA #1 as the individual who used R #16's debit card.
2. The investigation revealed that AA #1 had used R #16's debit card to purchase the following:
i. Gas
ii. Groceries
iii. Baby clothes
iv. Alcohol
v. Various other personal items.
3. The facility attempted to reach AA #1 to notify her that she was terminated, but her phone number was not valid.
4. A criminal complaint was filed against AA #1 for fraud.
5. An arrest warrant was served to AA #1 on 11/20/24 and she was arrested.
6. During the facility investigation, the facility identified that AA #1 had been destroying documents and receipts.
D. Record review of the Activity Director (AD) written statement, no date, revealed the following:
1. On 09/07/24, the AD was notified by an AA #2 that R #16's debit card was found on the printer in the activity office.
2. R #16 told the AD that AA #1 was supposed to go to the store and purchase some items for R #16.
3. R #16 told the AD that she had not received her debit card or her items.
4. AA #1 told the AD that R #16's debit card did not work so AA #1 was unable to purchase the items R #16 requested.
5. The AD notified R #16 that AA #1 was unable to purchase the items she requested due to her card did not work. R #16 told the AD that she should have money in her account.
6. The AD offered to go to an ATM to check R #16's account balance and R #16 agreed.
7. R #16's account balance was -$85.
8. On 09/24/24, AA #1 was placed on suspension.
E. Record review of a police report, dated 09/14/24, revealed the following:
1. R #16's debit card had various unauthorized charges between June 2024 and September 2024.
2. In June 2024, there was a $223 charge for a local cable company.
3. In July 2024, there were fraudulent charges totaling $1,878.28 for local gas stations, cell phone providers, local grocery store, Online purchases, local furniture store, ATM withdrawals, and a local automotive part store.
4. In August 2024, the fraudulent charges were in the amount of $1,014.04 for online purchases, local gas stations, and a local furniture store.
5. In September 2024, the fraudulent charges totaled $730.93 for local gas stations, online purchases, and an ATM withdrawal.
6. AA #1 was identified through surveillance footage at a local grocery store as having used R #16's debit card to purchase large bags of chicken nuggets and toddlers clothing.
7. On 11/18/24, AA #1 was arrested and admitted to using R #16's debit card to purchase items for personal use. She denied using the card for online purchases.
F. On 01/22/25 at 12:35 PM, during a joint interview with the administrator and AD, the following was revealed:
1. The facility became aware that R #16 was missing money after R #16's sister notified the facility that R #16 had suspicious charges on her account.
2. The Administrator reviewed R #16's bank statements to identify any suspicious charges.
3. The administrator began to suspect that AA #1 was responsible because she had called into work due to car troubles and there was a charge for a local automotive part store at the time of AA #1's call in.
4. AA #1 destroyed receipts and resident's shopping lists.
5. The police investigated and identified AA #1 as the person who had used R #16's debit card.
6. AA #1 was arrested.
7. AA #1 was terminated.
8. At the time of the incident, the activities department had the AD and two Activities Aides.
9. At the time, anyone in activities could go shopping for residents.
10. They found that several of the shopping lists were not filled out completely and not signed by the staff or residents.
11. The facility instituted a new process that only the AD is allowed to shop for residents.
12. The AD kept a binder with all the resident shopping lists and the shopping lists must be signed by the resident and the AD at the time the resident provides their form of payment.
13. After the purchases are complete, the AD returns the resident's card or change and reviews the receipt with the resident.
14. The resident and the AD sign the form indicating that the resident received their card or change and the receipt.
15. The AD completes an audit at the end of the month to ensure all the forms are filled out completely.
G. On 01/23/25 at 11:51 AM, during an interview with the administrator, the following was revealed:
1. All staff were retrained on abuse, neglect, and exploitation on 10/09/24.
2. All staff were educated on 10/09/24 about the facility shopping process and that the AD is the only staff member who is allowed to shop for residents.
3. All staff were educated on 10/09/24 that they are not to accept residents money or payment cards.
H. On 01/23/25 at 1:54 PM, during an interview with the AD, the following was revealed:
1. All residents who have the facility shop for them have been educated on the shopping process.
2. All residents who have the facility shop for them have been advised to only give their method of payment to the AD.
3. During Resident Council meetings, on 10/08/24, 11/12/24, 12/12/24, and 01/07/25, the facility reviewed the shopping process.
4. When resident's turn in their shopping lists, the activities staff will review the shopping process including that the resident's are to only give their method of payment to the AD.
This deficient practice was cited as past noncompliance:
Based on the facility's investigation of R #16's exploitation, the following interventions were implemented prior to survey investigation which included:
The facility shopping process was revised to include that only the Activity Director (AD) is allowed to shop for residents and use the residents financial cards for authorized purchases. Shopping list forms must be filled out completely and signed by the resident and AD at the time the residents card or change is returned. The AD conducts monthly audits to ensure that all residents cards, change, and receipts were returned to the residents.
-Record review of the facility's shopping list forms, multiple dates, revealed all of the shopping list forms were filled out completely and signed by the AD and the resident to confirm residents received their card and receipt.
-Record review of the facility's audit report forms for October 2024, November 2024, and December 2024 revealed the shopping list forms were filled out completely and included the appropriate signatures.
Staff educated residents on the revised facility shopping process. Completed 10/08/24.
-Record review of the Resident Council Meeting Minutes, dated 10/08/24, revealed the residents were educated about the revised facility shopping process and how to file a grievance.
Staff education on abuse, neglect, and exploitation and revised facility shopping process. Completed on 10/09/24.
- Record review of the Staff Meeting Minutes, dated 10/09/24, revealed staff were educated on Abuse, Neglect, and Exploitation and the revised facility shopping process.
Activity Director completed audits monthly during the months of October 2024, November 2024, and December 2024 to ensure the return of debit cards, change, and receipts to the residents. Completed on 10/28/24.
-Record review of the Resident Shopping lists, multiple dates, revealed all shopping list forms, were filled out completely and signed by the resident and AD.
-Surveyor verified the implementation of the revised facility shopping process and did not identify any further non-compliance with samples residents (R #17 and R #18).
Jul 2024
1 deficiency
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 F0655
(Tag F0655)
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 create an accurate baseline care plan (minimum healthcare informati...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to create an accurate baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) within 48 hours of admission for 1 (R #1) of 2 (R #1 and #2) residents reviewed for baseline care plans. This deficient practice could likely result in residents not receiving the appropriate care and may place residents at risk of an adverse event (undesirable experience, preventable or non-preventable, that caused harm to a resident because of medical care or lack of medical care) or worsening of current condition after admission. The findings are:
A. Record review of R #1's face sheet no date, revealed R #1 was admitted into the facility on [DATE].
B. Record review of R #1's Electronic Medical Record (EMR) revealed a fall risk evaluation (an evaluation to determine a residents risk of falls), dated 04/26/24, indicated R #1 was a high fall risk.
C. Record review of R #1's baseline care plan, dated 04/29/24, revealed staff did not develop a Baseline Care Plan that included R #1 was a high fall risk within 48 hours.
D. On 07/23/24 at 2:36 PM, during an interview with the Assistant Direct of Nursing (ADON), she confirmed R #1's baseline care plan did not include resident was a high risk for falls.
Feb 2024
16 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · 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 residents received care and treatment for pressure ulcers in...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents received care and treatment for pressure ulcers in accordance with professional standards of care (reasonable degree of care a person should provide to another person, typically in a professional or medical setting) for 1 (R #242) of 2 (R #192 and R #242) residents reviewed for pressure ulcers, when staff failed to:
1. Monitor wound progression.
2. Notify the provider about changes in wound condition.
3. Administer prescribed antibiotics in a timely manner.
This deficient practice likely resulted in unnecessary worsening of R #242's wound, pain, and suffering. The findings are:
A. Record review of R #242's medical record revealed the following:
1. R #242 was admitted to the facility on [DATE].
2. R #242 discharged to another facility on 10/25/23.
3. R #242 had a diagnosis of the following:
a. Hemiplegia (paralysis on one side of the body) and hemiparesis (weakness or the inability to move on one
side of the body) following cerebral infarction (disrupted blood flow to the brain due to problems with the
blood vessels that supply it) affecting left non-dominant side.
b. Dementia (impaired ability to remember, think, or make decisions)
c. Unspecified protein-calorie malnutrition (nutritional status in which reduced availability of nutrients leads to
changes in body composition and function).
d. Muscle wasting and atrophy (waste away) multiple sites.
e. Type 2 diabetes mellitus (a disease of inadequate control of blood levels of glucose) without complications.
B. Record review of R #242's nurse progress notes revealed the following:
1. On 06/28/23, staff identified a stage 1 pressure wound (wound caused by pressure but has no breaks or
tears) and described it as a friction/shear wound (wound that occurs when an object is dragged or rubbed
across the skin) to right buttock.
2. Wound care orders were obtained from the provider.
C. Record review of R #242's wound orders revealed the following:
1. Wound care orders for a right hip shear wound, order date 06/28/23, clean with wound cleanser, pat dry,
apply medihoney, and cover with optifoam dressing every three days.
2. No change in wound care orders between 06/29/23 and 07/20/23.
3. Wound care orders for right hip, order date 07/20/23, clean with wound cleanser, pat dry, apply
medihoney, and cover with optifoam dressing every other day.
4. Wound care every day for open wound [unstageable pressure wound] on right buttock, order date
07/28/23, for 5 days.
5. Wound care orders for Stage 4 right ischium pressure injury, order date 09/09/23, clean with normal
saline, pat dry, apply skin prep to peri wound, followed by clear drape, inert black foam to wound bed,
attach wound vac (a vacuum-assisted closure of a wound. A type of therapy to help wounds heal) to 125
mmHg continuous flow, every Tuesday, Thursday, Friday, and as needed (prn).
D. Record review of R #242's Treatment Administration Record (TAR) revealed the following:
1. June 2023 TAR revealed that staff documented that wound care was completed as ordered.
2. July 2023 TAR revealed that staff documented that wound care was completed as ordered.
3. August 2023 TAR revealed that staff documented that wound care was completed as ordered.
4. September 2023 TAR revealed that staff documented that wound care was completed as ordered.
5. October 2023 TAR revealed that staff documented that wound care was completed as ordered.
E. Record review of R #242's nursing progress notes revealed the record did not contain documentation of communication with the provider between 06/29/23 and 07/21/23 regarding changes to the pressure wound.
F. Record review of R #242's weekly skin checks revealed the following:
1. The record did not contain documentation of pressure wound between 06/25/23 and 07/23/23.
2. First documentation of pressure wound on 07/24/23, mild odor.
3. On 08/01/23 documentation revealed, moderate odor.
4. On 08/09/23 documentation revealed, purulent drainage (liquid or discharge that oozes from a wound,
usually observe has a milky look and texture), odor at 4 feet distance, maceration (a softening and breaking
down of skin resulting from prolonged exposure to moisture) present.
G. Record review of the facility's repositioning report revealed the CNAs documented they repositioned R #242 every two hours on every shift, between June 2023 and August 2023. The CNAs did not document specific times of repositioning.
H. Record review of R #242's provider progress notes revealed the following:
1. On 07/21/23, the nurse reported to the provider the wound changed and had purulent drainage, eschar
(dead tissue that sheds or falls off from the skin), and slough (the yellow/white material in the wound bed).
2. On 07/21/23, the nurse practitioner assessed the wound and described the wound as an unstageable
pressure ulcer.
3. On 07/28/23, the provider ordered Clindamycin 300 mg, four times daily, for 10 days.
I. Record review of R #242's Physicians orders revealed the following:
1. Order date 07/28/23, R #242 was referred to an out of facility wound care specialist.
2. Order date 08/01/23, [4 days after provider note ordering antibiotic] Clindamycin 300 mg four times daily
for 10 days.
J. Record review of R #242's wound care consultation documents revealed the following:
1. On 08/02/23, R #242 had first appointment with the wound care specialist.
2. On 08/07/23, the wound care specialist ordered the following:
a. Discontinue doxycycline (antibiotic used to treat and prevent infections) [R #242 had order for
Clindamycin].
b. Stop hydroxyzine (antihistamine used to treat anxiety, nausea, vomiting, allergies, skin rash, hives, and
itching) for duration of antibiotic treatment.
c. Start Levaquin (antibiotic medication that treats bacterial infections).
d. Start linezolid (antibiotic used to treat bacterial infections, including skin infections and pneumonia).
e. Hold Remeron (antidepressant used to treat depression) for duration of antibiotic treatment.
3. On 08/16/23, the wound care specialist documented the following:
a. The ADON from the facility notified the wound care specialist that the facility did not start R #242's
antibiotic until 08/15/23 and the wound had a strong odor.
b. The wound care specialist completed a wound culture on 08/02/23 which revealed R #242's wound was
positive for multiple types of bacteria.
c. The wound had a moderate amount of purulent drainage [signs of an active infection].
d. The wound had a strong odor.
e. The wound was deteriorating.
f. The wound care specialist completed a debridement (the removal of damaged tissue or foreign objects
from a wound) of the wound.
4. On 09/07/23, the wound care specialist ordered a wound vac for R #242's wound.
K. Record review of R #242's medical record revealed the record did not contain documentation of communication between the facility and the wound care specialist about the order to discontinue Doxycycline and that R #242 took Clindamycin, not Doxycycline.
L. Record review of R #242's Medication Administration Record (MAR), dated August 2023, revealed the following:
1. Clindamycin administered between 08/01/23 and 08/11/23.
2. On 08/16/23, staff administered the first dose of Levaquin in the evening.
3. On 08/16/23, staff administered the first dose of Linezolid in the evening.
M. On 02/09/24, at 11:08 AM, during an interview with the DON, she stated the following:
1. She started working at the facility in August 2023.
2. There was a change in medical providers at the facility in December 2023.
3. She could not identify any current staff who would have provided wound care for R #242.
4. There was a nine day delay in starting Levaquin and Linezolid antibiotics.
5. A delay in starting antibiotics would cause worsening of R #242's wound because the infection was not
controlled.
6. The DON was unsure why there was a delay in starting the antibiotics.
7. It was expected the nurses would notify the provider immediately when they received an order from the
wound care specialist and obtain orders from the facility providers.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation and interview the facility failed to store medications properly for all 20 residents in rooms 219 through 230 (residents were identified by the resident matrix provided by the Adm...
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Based on observation and interview the facility failed to store medications properly for all 20 residents in rooms 219 through 230 (residents were identified by the resident matrix provided by the Administrator on 02/05/24) randomly sampled residents, when they failed to dispose of one loose tablet in the medication cart on the 200 unit. This deficient practice could result in residents obtaining medication not prescribed to them resulting in adverse side effects. The findings are:
A. On 02/08/24, at 12:55 PM, during an observation, the medication cart on 200 unit revealed one loose tablet in the medication cart.
B. On 02/08/24, at 12:55 PM, during an interview, CMA #5 confirmed there was one loose tablet in the medication cart.
C. On 02/12/24, at 12:14 PM, during an interview, the DON confirmed medications should not be loose in the medication cart.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure the medical records contained documentation each resident received or staff offered the pneumococcal (a bacteria that caused pneumon...
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Based on record review and interview, the facility failed to ensure the medical records contained documentation each resident received or staff offered the pneumococcal (a bacteria that caused pneumonia infection of the respiratory tract) vaccination for 1 (R #60) of 5 (R #09, R #10, R #28, R #60, and R #86) residents reviewed for immunizations. This deficient practice could likely lead to residents contracting respiratory infections and could result in the spread of infection to other residents. The findings are:
A. Record review of R #60's medical record revealed the following:
1. Staff documented R #60 declined the pneumococcal vaccination, undated.
2. Influenza/Pneumococcal Vaccination consent form, dated 10/04/23, revealed R #60 gave consent for the pneumococcal vaccination.
3. The record did not contain any other consent forms.
C. Record review of R #60's all staff Progress Notes, from admission through review, revealed the record did not contain documentation staff administered the pneumococcal vaccination, R #60 declined the pneumococcal vaccination, or that staff provided education to R #60 on benefits and risks of the pneumococcal vaccination.
D. On 02/12/24 at 12:43 PM, during an interview, the Infection Preventionist (IP) confirmed the facility did not administer the pneumococcal vaccination to R #60. The IP stated R #60 originally consented to receive the pneumococcal vaccination, but the resident declined it on the day staff went to administer it. The IP further confirmed there was not documentation the resident declined and staff provided education to R #60 on benefits and risks of the pneumococcal vaccination.
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 and interview, the facility failed to ensure residents were treated with respect and dignity for all 19 residents in the secured unit (residents were identified by the resident ma...
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Based on observation and interview, the facility failed to ensure residents were treated with respect and dignity for all 19 residents in the secured unit (residents were identified by the resident matrix provided by the Administrator on 02/05/24), when the facility failed to refer to residents in a dignified manner. This deficient practice could likely result in residents feeling embarrassed, angry, and that their feelings are unimportant to the facility staff. The findings are:
A. On 02/05/24, at 12:11 PM, during an interview with LPN #11, she said the CNAs assist residents that need assistance with eating. LPN #11 said the secured unit had a lot of feeders. LPN #11 said they were supposed to refer to the residents as feed assists.
B. On 02/12/24, at 11:38 AM, during an interview, the DON stated staff were not supposed to refer to residents as feeders. The DON said referring to residents as feeders was a dignity issue and was not acceptable. The DON said staff were corrected right away and educated if they refer to residents as feeders.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure grievance (complaints over something believed to be wrong or unfair) were acted upon for 2 (R #1 and R #28) of 2 (R #1...
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Based on observation, interview, and record review, the facility failed to ensure grievance (complaints over something believed to be wrong or unfair) were acted upon for 2 (R #1 and R #28) of 2 (R #1 and R #28) residents reviewed for grievances.
This deficient practice could likely result in residents feeling unimportant and unsatisfied with the results of the grievance process. The findings are:
R #1
A. On 02/05/24, at 1:01 PM, during an interview, R #1 stated a blue jacket with hot pink on it went missing on 02/03/24. R #1 said she told the laundry girl the jacket was missing.
R #28
B. On 02/05/24, at 1:24 PM, during an interview, R #28 stated the following:
1. She had several pants that went missing roughly 7 months ago.
2. About two months ago one of her shirts got bleached in the laundry. She gave it to one of the laundry
workers, but did not hear anything about it.
3. She was missing a pair of jeans and told laundry staff about them.
C. On 02/08/24, at 2:27 PM, during an interview with Laundry Aide (LA) #1, she stated the following:
1. Any concerns about missing laundry should be placed in the binder for missing laundry.
2. Residents or staff should complete a concern/grievance form for missing clothing items and place them in the binder.
3. Staff frequently bring handwritten notes about residents' missing laundry.
4. There was a note on a white sheet of paper (not concern/grievance form) that indicated R #1 was missing a blue jacket.
5. There was a note on a small piece of paper that R #28 was missing a pair of jeans.
D. On 02/08/24, at 2:30 PM, during an observation of the laundry room there were several small pieces of paper posted with notes regarding residents' missing laundry on a cork board in the laundry room.
E. On 02/08/24 at 2:35 PM, during an interview with LA #1, she confirmed the following:
1. The small pieces of paper posted on a cork board were notes regarding residents' missing laundry.
2. Sometimes staff do not complete the concern/grievance forms.
3. She was unable to find a concern/grievance form for R #1's missing jacket.
4. She has not found R #1's jacket.
5. She was unable to find a concern/grievance form for R #28's missing pants.
6. She was unable to find a concern/grievance form for R #28's bleached shirt.
7. She has not found R #28's jeans.
8. She was unsure what happened if staff did not find a resident's clothing items or if clothing got ruined in the laundry.
F. On 02/08/24, at 2:46 PM, during an interview with the Social Services Director (SSD), she confirmed the following:
1. Expectation was for staff or resident to complete a concern/grievance form for each missing item and give it to laundry.
2. Staff should attempt to find the item.
3. All grievance forms should be given to the SSD after staff have looked for the item.
4. She did not have a grievance form for R #1's missing a jacket.
5. She did not have a grievance form for R #28 missing pair of jeans.
6. She did not have a grievance form for R #28's shirt that got bleached in the laundry.
G. Record review of the facility's grievance policy, revision date 08/2020, revealed that when facility staff overheard or received a complaint from a resident regarding medical care, treatment, food, clothing, or behavior of other residents, the staff member was encouraged to advise the resident/concerned party that they may file a complaint or grievance.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0603
(Tag F0603)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to keep residents free from involuntary seclusion for 5 (R #56, R #72, R #79, R #82, and R #193) of 5 (R #56, R #72, R #79, R #82, and R #193)...
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Based on interview and record review, the facility failed to keep residents free from involuntary seclusion for 5 (R #56, R #72, R #79, R #82, and R #193) of 5 (R #56, R #72, R #79, R #82, and R #193) residents sampled for elopement (an act or instance of leaving a safe area or safe premises, done by a person with a mental disorder or cognitive impairment) risk, when they failed to implement and document the following:
1. The clinical criteria (rules or standards on which a decision or judgment is made to determine medical necessity) met for placement in the secured/locked area by the resident's physician along with information provided by members of the interdisciplinary team (IDT team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities).
2. Whether placement in the secured/locked area was the least restrictive approach that was reasonable to protect the resident and assure his/her health and safety.
3. The IDT consideration of the impact and/or reaction of the resident, if any, regarding placement on the unit.
4. Ongoing review and revision of the resident's care plan as necessary, including whether he/she continues to meet the criteria for remaining in the secured/locked area, and if the interventions continue to meet the needs of the resident.
These deficient practices are likely to result in residents being placed in seclusion involuntarily causing anxiety and depression. The findings are:
R #56
A. Record review of R #56's face sheet revealed the following:
1. An admission date of 09/22/23.
2. admission diagnosis of Alzheimer's disease and dementia with unspecified severity, with other behavioral
disturbance.
B. Record review of R #56's Special Care Unit Consent form revealed R #56 was admitted to the secure unit on 01/11/24.
C. Record review of R #56's Electronic Medical Record (EMR) revealed:
1. The record did not contain clinical documentation by R #56's physician and IDT.
2. The record did not contain documentation that placement in secured unit was the least restrictive
approach.
3. The record did not contain documentation the IDT made of R #56's impact or reaction to being placed in
secured unit.
4. The record did not contain documentation of ongoing review and revision of R #56's care plan to indicate
whether R #56 continued to meet criteria to remain in the secured unit.
R #72
D. Record review of R #72's face sheet revealed the following:
1. An admission date of 04/11/23.
2. admission diagnosis of unspecified dementia, unspecified severity, with agitation.
E. Record review of R #72's Special Care Unit Consent form revealed R #72 was admitted to the secure unit on 01/11/24.
F. Record review of R #72's EMR revealed:
1. The record did not contain clinical documentation by R #72's physician and IDT.
2. The record did not contain documentation that placement in secured unit is least restrictive approach.
3. The record did not contain documentation the IDT made of R #72's impact or reaction to being placed in
secured unit.
4. The record did not contain documentation of ongoing review and revision of R #72's care plan to indicate
whether R #72 continued to meet criteria to remain in the secured unit.
R #79
G. Record review of R #79's face sheet revealed the following:
1. An admission date of 08/16/23.
2. admission diagnosis of unspecified dementia, mild, with agitation.
H. Record review of R #79's Special Care Unit Consent form revealed R #79 was admitted to the secure unit on 08/17/23.
I. Record review of R #79's EMR revealed:
1. The record did not contain clinical documentation by R #79's physician and IDT.
2. The record did not contain documentation that placement in secured unit is least restrictive approach.
3. The record did not contain documentation the IDT made of R #79's impact or reaction to being placed in
secured unit.
4. The record did not contain documentation of ongoing review and revision of R #79's care plan to indicate
whether R #79 continued to meet criteria to remain in the secured unit.
R #82
J. Record review of R #82's face sheet revealed the following:
1. An admission date of 10/19/23.
2. admission diagnosis of Alzheimer's disease, unspecified, unspecified dementia, unspecified severity, with
agitation.
K. Record review of R #82's Special Care Unit Consent form revealed R #82 was admitted to the secure unit on 10/26/23.
L. Record review of R #82's EMR revealed:
1. The record did not contain clinical documentation by R #82's physician and IDT.
2. The record did not contain documentation that placement in secured unit is least restrictive approach.
3. The record did not contain documentation the IDT made of R #82's impact or reaction to being placed in
secured unit.
4. The record did not contain documentation of ongoing review and revision of R #82's care plan to indicate
whether R #82 continued to meet criteria to remain in the secured unit.
R #193
M. Record review of R #193's face sheet revealed an admission date of 01/20/24.
N. Record review of R #193's Special Care Unit Consent form revealed R #193 was admitted to the secure unit on 01/20/24.
O. Record review of R #193's EMR revealed:
1. The record did not contain clinical documentation by R #193's physician and IDT.
2. The record did not contain documentation that placement in secured unit is least restrictive approach.
3. The record did not contain documentation the IDT made of R #193's impact or reaction to being placed in
secured unit.
4. The record did not contain documentation of ongoing review and revision of R #193's care plan to indicate
whether R #193 continued to meet criteria to remain in the secured unit
P. On 02/08/24, at 9:52 AM, during an interview with the DON and Administrator, they confirmed the following:
1. The facility determines which residents need to be in the secured unit with a qualifying diagnosis of
dementia and an elopement assessment.
2. The physician did not document in R #56, R #72, R #79, R #82, and R #193 medical record for the
clinical criteria for placement in the secure unit, or any information provided by members of the IDT.
3. There was not any documentation that placement in the secured/locked area is the least restrictive
approach that is reasonable to protect the resident and assure his/her health and safety.
4. There was not any documentation of the impact and/or reaction of the resident, if any, regarding placement
on the unit.
5. The facility has not reviewed and revised the resident's care plan as necessary, including whether he/she
continues to meet the criteria for remaining in the secured/locked area, and if the interventions continue to
meet the needs of the resident.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
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 residents, their representatives, and the Ombudsman received ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure residents, their representatives, and the Ombudsman received a written notice of transfer as soon as practicable for 3 (R #1, R #16, and R #28 ) of 3 (R #1, R #16, and R #28) residents reviewed for hospitalization. This deficient practice could likely result in the resident and/or their representative not knowing the reason or location the resident was discharged . The findings are:
R #1
A. On 02/05/24, at 1:11 PM, during an interview, R #1 stated she went to the hospital about three weeks ago.
B. Record review of R #1's transfer documents revealed the following:
1. The facility transferred R #1 to the hospital on [DATE].
2. The transfer notice was an electronic form in the resident's electronic medical record
(EMR), and the EMR did not contain evidence to show the resident received the
transfer notice in writing.
3. Transfer notice did not have information regarding:
a. How the resident or the resident representative can appeal the
transfer/discharge.
b. How the resident or resident representative can contact the Ombudsman.
4. The facility transferred R #1 to the hospital again on 01/27/24.
5. The transfer notice was an electronic form in the resident's EMR, and the EMR did
not contain evidence to show the resident received the transfer notice in writing.
6. Transfer documentation did not have information regarding:
a. How the resident or the resident representative can appeal the
transfer/discharge.
b. How the resident or resident representative can contact the Ombudsman.
R #16
C. On 02/05/24, at 2:45 PM, during an interview with R #16, he revealed the following:
1. He was sent to the hospital about 6-8 weeks ago.
2. He not receive any transfer paperwork.
D. Record review of R #16's transfer documents revealed the following:
1. The facility transferred R #16 to the hospital on [DATE].
2. The transfer notice was an electronic form in the resident's EMR, and the EMR did
not contain evidence to show the resident received the transfer notice in writing.
3. Transfer documentation did not have information regarding:
a. How the resident or the resident representative can appeal the
transfer/discharge.
b. How the resident or resident representative can contact the Ombudsman.
R #28
E. On 02/05/24, at 1:34 PM, during an interview with R #28, she revealed:
1. She went to hospital for back and side pain.
2. She did not receive any documents when she left.
F. Record review of R #28's transfer documents revealed the following:
1. The facility transferred R #28 to the hospital on [DATE].
2. The transfer notice was an electronic form in the resident's EMR, and the EMR did
not contain evidence to show the resident received the transfer notice in writing.
3. Transfer documentation did not have information regarding:
a. How the resident or the resident representative can appeal the
transfer/discharge.
b. How the resident or resident representative can contact the Ombudsman.
G. On 02/12/24 at 10:25 AM, during an interview with the Social Services Director, she confirmed the following:
1. She completed the transfer notices when the resident discharged from the facility.
2. The nurses completed the transfer notices when the resident went to the hospital.
3. She notified the Ombudsman monthly about transfers via email, over the phone, or if
the Ombudsman was in the facility she went over them with her (not a copy of the
written notice of transfer) .
4. She emailed an admit/discharge list (not a copy of the written notice of transfer) to
the Ombudsman monthly or printed out an admit/discharge report for the month and
gave it to her when she was here.
5. She did not send a copy of the transfer notice to the Ombudsman.
H. On 02/12/24, at 10:36 AM, during an interview with RN #21, she confirmed the following:
1. Nurses completed an eInteract change of condition form and an eInteract Transfer
Form when sending a resident to the hospital.
2. Nurses print out the transfer document, admission form, medications, treatment
orders, and diagnosis and gave it to Emergency Medical Services for the transfer.
3. Nurses did not give the resident a copy unless they asked for it.
4. The eInteract Transfer form did not have information for how the resident can appeal
a transfer or discharge or how to contact the Ombudsman.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
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 written information to the resident or resident representat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide written information to the resident or resident representative that specified the bed hold policy and the number of days the facility will hold a bed for the resident at the time of the transfer for 3 (R #1, R #16, and R #28) of 3 (R #1, R #16, and R #28) residents sampled for hospitalizations, when they failed to:
1) Use a written Bed Hold Notice that included the number of days the facility will hold a bed for the resident at the time of the transfer for R #1 and R #28.
2) Provide written information to the resident or resident representative that specified the bed hold policy and the number of days the facility will hold a bed for the resident at the time of the transfer for R #16.
This deficient practice could likely result in the resident and/or their representative being unaware of the resident ability to return to their previous room or the next available room upon return from the hospital. The findings are:
R #1
A. On 02/05/24, at 1:11 PM, during an interview, R #1 stated went to the hospital about three weeks ago.
B. Record review of R #1's medical record revealed the following:
1. R #1 was transferred to the hospital on [DATE].
2. The Bed Hold Agreement form did not have the number of days the facility would hold a bed for the
resident.
C. Record review of R #1's medical record revealed the following:
1. R #1 was transferred to the hospital on [DATE].
2. The Bed Hold Agreement form did not have the number of days the facility would hold a bed for the
resident.
R #16
D. On 02/05/24, at 2:45 PM, during an interview with R #16, he revealed the following:
1. He was sent to the hospital about 6-8 weeks ago.
2. He did not receive any transfer paperwork.
3. The administrator told him he would hold R #16's bed for him.
E. Record review of R #16's medical record revealed the following:
1. R #16 was transferred to the hospital on [DATE].
2. The Bed Authorization form had R #16's wife's name with a phone number and was dated 12/18/23
(indicating only verbal notice).
3. The resident's medical record did not contain evidence to show the resident or legal representative
received a written notice of the bed hold policy and authorization.
R #28
F. On 02/05/24, at 1:34 PM, during an interview with R #28, she revealed:
1. She went to hospital for back and side pain.
2. She did not receive a bed hold notification.
G. Record review of R #28's medical record revealed the following:
1. R #28 was transferred to the hospital on [DATE].
2. The resident's medical record did not contain evidence to show the resident or legal representative
received notice of the bed hold policy in writing at the time of transfer.
H. Record review of R #28's medical record revealed the following:
1. R #28 was transferred to the hospital on [DATE].
2. The resident's medical record did not contain evidence to show the resident or legal representative
received notice of the bed hold policy in writing at the time of transfer.
I. On 02/12/24, at 10:02 AM, during an interview with the Business Office Manager (BOM), she confirmed the following:
1. She completed bed holds within 24 hours of the resident transfer from the facility.
2. If a resident transferred on a weekend, she completed the form on Monday.
3. The nurses did a verbal bed hold notification over the phone to residents or representatives but not a
written notice.
4. The facility recently changed forms from the Bed Hold Authorization form to the Bed Hold Agreement
form.
5. The Bed Hold Agreement form that R #1 received on 01/05/24 and 01/27/24 did not indicate how many
days the bed will be held for the resident.
6. R #1 or her representative would not be aware of how many days a bed would be held for the resident if
they received the Bed Hold Agreement form.
7. She called R #16's wife on 12/18/24 and the BOM documented the wife's name and phone number on
the Bed Hold Authorization form.
8. R #16 or his representative did not receive a written copy of the Bed Hold Authorization form.
9. R #28 or her representative did not receive a written bed hold notice for her transfers on 01/27/24 or
01/31/24.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to ensure staff completed a comprehensive Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff, which...
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Based on record review and interview, the facility failed to ensure staff completed a comprehensive Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff, which included the traditional care of the resident, the prevention and early detection of disease, and rehabilitation) assessment within 14 calendar days after admission for 1 (R #56) of 5 (R #56, R #72, R #79, R #82, and R #193) residents reviewed for completion of a comprehensive MDS assessment. This deficient practice could likely result in residents' preferences and needs not being met. The findings are:
A. Record review of R #56's medical record revealed an admission date of 01/20/24.
B. Record review of R #16's medical record revealed staff did not complete an admission MDS assessment as of 02/12/24.
C. On 02/12/24, at 11:30 AM, during an interview, the MDS Coordinator confirmed R #56's admission MDS was not completed within 14 days of R #56's admission to the facility. The MDS Coordinator said that the admission MDS's should be completed within 14 days.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
Based on observation, record review, and interview, the facility failed to develop and implement a comprehensive person-centered care plan for 6 (R #16, R #50, R #56, R #79, R #82, and R #193) of 6 (R...
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Based on observation, record review, and interview, the facility failed to develop and implement a comprehensive person-centered care plan for 6 (R #16, R #50, R #56, R #79, R #82, and R #193) of 6 (R #16, R #50, R #56, R #79, R #82, and R #193) residents reviewed for comprehensive care plans. Failure to develop a person-centered care plan could likely result in staff's failure to understand the needs, preferences, and treatments for residents to achieve their highest level of well-being. The findings are:
A. On 02/12/24 at 11:00 AM, during an interview with the DON, she confirmed resident care plans should be person centered and should include correct information about resident care so the nurses are aware of how to care for the residents.
R #16
B. On 02/05/24 at 2:47 PM, during an observation of R #16's room, it was observed that that R #16 had a dialysis catheter to the left chest.
C. On 02/06/24 at 2:22 PM, during an interview with R #16, he confirmed the following:
1. He received dialysis on Mondays, Wednesdays, and Fridays through the dialysis catheter in his left chest.
2. He received dialysis through a dialysis catheter for two to three years.
3. He did not want an arteriovenous fistula/shunt (AV; an AV fistula is a connection that is made between an artery and a vein for dialysis access. A surgical procedure, done in the operating room, is required to stitch together two vessels to create an AV fistula).
D. Record review of R #16's dialysis care plan, initiated 04/10/23, revealed the following:
1. The resident had an AV Shunt.
2. The plan instructed the nurses to feel for thrill-vibration (A thrill is a vibration felt upon palpation of a blood vessel), bruits-pulsation (rushing sounds heard over large and medium-sized arteries as a result of vibration in the vessel wall caused by turbulent blood flow.), blood flowing through the AV shunt.
E. On 02/12/24 at 11:00 AM, during an interview, the DON confirmed the following:
1. R #16's medical record indicated R #16 had a dialysis catheter to the left chest.
2. R #16's care plan indicated R #16 had an AV shunt.
3. R #16's care plan instructed the nurses to feel for thrill-vibration, bruits-pulsation, blood flowing through the AV shunt.
4. R #16's dialysis care plan was not resident specific as it did not indicate the resident had a dialysis catheter.
5. R #16's care plan did not include information about how to care for R #16's dialysis catheter.
R #50
F. On 02/05/24 at 11:52 AM, during an observation of the secured unit, R #50 was in the unit.
G. Record review of R #50's medical record revealed R #50 was admitted to hospice on 03/02/23.
H. Record review of R #50's care plan revealed the following:
1. Staff did not document the placement of R #50 in the secured unit.
2. Staff did not document the coordination of care between hospice and the facility.
3. Staff did not document the contact information for hospice.
I. On 02/08/24 at 11:03 AM, during an interview, LPN #11 confirmed R #50's care plan did not document the resident was in the secured unit. LPN #11 said staff should update the care plan to show R #50 was in the secured unit. LPN # 11 also confirmed hospice care coordination and the contact information was not in R #50's care plan.
J. On 02/12/24 at 11:34 AM, during an interview, the DON said they needed to make sure they coordinated care with hospice. She confirmed staff did not document a detailed plan for hospice for R #50. The DON also confirmed R #50's placement in the secured unit was not on her care plan.
R #56
K. On 02/05/24 at 11:52 AM, during an observation of the secured unit, R #56 was in the unit.
L. Record review of R #56's Special Care Unit Consent revealed R #56 was admitted to the secured unit on 01/11/24.
M. Record review of R #56's care plan revealed the staff did not document the placement of R #56 in the secured unit.
N. On 02/12/24 at 11:17 AM, during an interview, the DON confirmed R #56's care plan did not document that R #50 was in the secured unit. The DON said staff should care plan the resident was in the secured unit.
R #79
O. On 02/05/24 at 11:52 AM, during an observation of the secured unit, R #79 was in the unit.
P. Record review of R #79's Special Care Unit Consent revealed R #79 was admitted to the secured unit on 08/17/23.
Q. Record review of R #79's care plan revealed the staff did not document the placement of R #79 in the secured unit.
R. On 02/12/24 at 11:25 AM, during an interview, the DON confirmed R #79's care plan did not document that R #79 was in the secured unit. The DON said staff should care plan the resident was in the secured unit.
R #193
O. On 02/05/24 at 11:52 AM, during an observation of the secured unit, it was observed that R #193 was in the unit.
P. Record review of R #193's Special Care Unit Consent revealed R #193 was admitted to the secured unit on 02/02/24.
Q. Record review of R #193's care plan revealed the staff did not document the placement of R #193 in the secured unit.
R. On 02/12/24 at 11:17 AM, during an interview, the DON confirmed R #193's care plan did not document that R #193 was in the secured unit. The DON said staff should care plan the resident was in the secured unit.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to revise the care plan for 1 (R #1) of 1 (R #1) resident reviewed for care plans. This deficient practice could likely result in staff being ...
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Based on record review and interview, the facility failed to revise the care plan for 1 (R #1) of 1 (R #1) resident reviewed for care plans. This deficient practice could likely result in staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are:
A. On 02/05/24, at 1:09 PM, during an interview, R #1 stated she lost weight due to irritable bowel syndrome (an intestinal disorder causing pain in the belly, gas, diarrhea, and constipation).
B. On 02/05/24, at 1:09 PM, during an observation, R #1 appeared very thin.
C. Record review of weights log revealed the following:
1. On 07/04/23 - 101.2 lbs.
2. On 08/02/23 - 98.4 lbs.
3. On 09/05/23 - 92.8 lbs.
4. On 10/06/23 - 88.8 lbs.
5. On 11/06/23 - 90.4 lbs.
6. On 12/11/23 - 79.0 lbs.
7. On 12/25/23 - 82.4 lbs.
8. On 01/08/24 - 80.8 lbs.
9. On 01/08/24 - 80.8 lbs.
10. On 01/15/24 - 84.4 lbs.
11. On 01/22/24 - 82.6 lbs.
12. On 01/26/24 - 93.8 lbs.
13. On 01/29/24 - 81.4 lbs.
14. On 02/12/24 - 78.2 lbs.
15. On 02/15/24 - 81.8 lbs.
E. Record review of R #1's care plan, revised on 10/25/23, revealed:
1. R #1 had a potential for nutritional problems related to a diagnosis of dementia (impaired ability to
remember, think, or make decisions that interferes with doing everyday activities.), anorexia (an eating
disorder characterized by restriction of food intake leading to low body weigh), and malnutrition (lack of
proper nutrition).
2. The interventions directed staff to monitor the resident for signs of malnutrition, to include weight loss.
3. The care plan revision, dated 10/25/23, did not indicate R #1 had actual weight loss.
F. On 02/09/24, at 12:18 PM, during an interview with the DON, she confirmed the following:
1. R # 1 had weight loss.
2. R #1's care plan was not revised to include R #1's actual weight loss.
3. Resident care plans should be revised to include the most up-to-date information so the nurses are aware
of changes in the resident's status and can provide appropriate care to the residents.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected multiple residents
Based on interview, observation, and record review, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight for 1 (R #1) of 1 (R #1) residents sampled fo...
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Based on interview, observation, and record review, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight for 1 (R #1) of 1 (R #1) residents sampled for nutrition, when they failed to:
a. Update the care plan to reflect actual weight loss.
b. Follow dietitian's recommendations.
These deficient practices could likely result in residents losing weight without the facility being aware causing physical and mental health issues. The findings are:
A. On 02/05/24, at 1:09 PM, during an interview and observation with R #1, she stated she lost weight due to irritable bowel syndrome (an intestinal disorder causing pain in the belly, gas, diarrhea, and constipation). R #1 appeared very thin.
B. Record review of R #1's Medical Record revealed R #1's medical diagnoses:
1. Anorexia nervosa (an eating disorder that causes a severe and strong fear of gaining weight), onset date 0
9/03/21.
2. Unspecified protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads
to changes in body composition and function), onset date 08/20/21.
D. Record review of R #1's weight log revealed staff documented the following weights:
1. On 07/04/23 - 101.2 lbs.
2. On 08/02/23 - 98.4 lbs.
3. On 09/05/23 - 92.8 lbs.
4. On 10/06/23 - 88.8 lbs.
5. On 11/06/23 - 90.4 lbs.
6. On 12/11/23 - 79.0 lbs.
7. On 12/25/23 - 82.4 lbs.
8. On 01/08/24 - 80.8 lbs.
9. On 01/15/24 - 84.4 lbs.
10. On 01/22/24 - 82.6 lbs.
11. On 01/26/24 - 93.8 lbs.
12. On 01/29/24 - 81.4 lbs.
13. On 02/12/24 - 78.2 lbs.
14. On 02/15/24 - 81.8 lbs.
E. Record review of the Monthly Weight Loss Report revealed the following:
1. In September 2023, R #1 had a 5.7% weight loss in 30 days.
2. In October 2023, R #1 had a 9.8% weight loss in 90 days.
3. In December 2023, R #1 had a 12.6% weight loss in 30 days.
F. Record review of R #1's Progress Notes revealed staff documented the following:
1. On 10/13/23, the dietitian recommended staff give R #1 a lactose free supplement (supplement that did
not contain a sugar found in milk and milk products) three times a day.
2. R #1 refused nutritional supplements on the following dates:
a. 01/15/24.
b. 01/16/24.
c. 01/22/24.
d. 01/23/24.
e. 01/28/24.
f. 01/29/24.
g. 01/31/24.
3. On 12/14/23, the dietitian recommended the facility consider adding Remeron (medication used to treat
depression. It can raise blood cholesterol levels, raise appetite, and cause weight gain) to R #1's orders for
appetite stimulation.
G. Record review of R #1's physician's orders revealed the record did not contain an order for Remeron.
H. Record review of R #1's medical record revealed the staff failed to document the following:
1. Staff notified the Interdisciplinary team (team members from different disciplines working collaboratively,
with a common purpose, to set goals, make decisions and share resources and responsibilities) or the
provider about the dietitian's recommendation for Remeron to be added to R #1's medications for appetite
stimulation.
2. The Interdisciplinary team or provider considered the dietitian's recommendation for Remeron to be added
to R #1's medications for appetite stimulation and their rationale for not ordering Remeron.
I. Record review of R #1's care plan, revised on 10/25/23, revealed:
1. R #1 had a potential for nutritional problems related to a diagnosis of dementia, anorexia, and malnutrition.
2. The interventions indicated staff should provide and serve supplements as ordered by the Registered
Dietitian.
3. Staff did not include R #1's actual weight loss in the care plan revision.
J. On 02/09/24, at 12:18 PM, during an interview with the DON, she stated the following:
1. R #1 had significant weight loss.
2. Staff did not revise R #1's care plan to include actual weight loss.
3. On 12/14/23, the dietitian recommended the facility consider adding Remeron to R #1's medications for
appetite stimulation.
4. Staff did not order Remeron.
5. Staff failed to document if they notified the provider about the dietitian recommendation to start Remeron.
6. The expectation was for the nurses to notify the provider about any recommendations from the dietitian.
7. The expectation was for conversations with the provider to be documented in the medical record.
K. On 02/15/24, at 2:39 PM, during an interview with the DON she confirmed the following:
1. In December 2023, the facility initiated a protocol to perform weekly weights on residents who had
significant weight loss.
2. R #1 did not get weekly weights until 12/25/23.
L. Record review of the facility's Weight System Policy, dated 05/2017, revealed the following:
1. Any resident with significant weight loss will be reweighed within 24 hours.
2. Weight variances will be reviewed weekly.
3. Residents with a significant weight change are to be weighed weekly for a minimum of four weeks or until
weight is stabilized.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
Could have caused harm · This affected multiple residents
Based on interview and record review the facility failed to ensure residents obtained dental services for 2 (R #13 and R #16) of 3 (R #13, R #16, and R # 193) residents sampled for dental services, wh...
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Based on interview and record review the facility failed to ensure residents obtained dental services for 2 (R #13 and R #16) of 3 (R #13, R #16, and R # 193) residents sampled for dental services, when they failed to:
a. Ensure residents received routine dental care to include an annual inspection of the mouth for signs of
disease, dental cleaning, fillings, or minor partial or full denture adjustments.
b. Ensure residents received emergent dental services when indicated.
These deficient practices are likely to cause the resident unnecessary pain, embarrassment over the condition/appearance of teeth, and potential dental or oral complications. The findings are:
R #13
A. Record review of R #13's medical record revealed an admission date of 08/11/23.
B. On 02/06/24, at 10:01 AM, during an interview with R #13, he said his front teeth were missing, and he would like to have them replaced. R #13 said he talked to staff and his guardian, but they did not make him an appointment. R #13 said he had not been to the dentist since he has been at the facility.
C. B. On 02/07/24, at 1:16 PM, during an interview with Social Services (SS), she said she did know R #13 was missing teeth. SS said R #13 had not been to the dentist since he has been at the facility.
D. On 02/07/24, at 11:36 AM, during an interview, the Administrator said residents typically get dental care when they need it and not for routine dental care. The Administrator said there was not a schedule for routine dental care. The Administrator said routine dental visits would catch things that needed to be caught.
E. On 2/07/24, at 11:54, during an interview, the DON said staff provide oral care (practice of keeping one's oral cavity clean and free of disease and other problems by regular brushing of the teeth and adopting good hygiene habits) in the mornings. The DON said if staff identify the residents had cavities then they notified the DON. The DON said if residents had cavities and then the staff make a dental appointment for the resident.
R #16
F. Record review of R #16's face sheet revealed R #16 an admission date of 06/11/22.
G. On 02/05/24, at 2:38 PM, during an interview with R #16, he stated the following:
1. He did not go to see the dentist in over 10 years.
2. His gums hurt a little and he had a tooth that gave him problems for a couple of months.
3. He told a staff member a couple of months ago that his tooth hurt.
4. He could not remember name of the staff member that he told.
5. The staff member said they would set up an appointment.
H. Record review of R #16's medical record revealed the following:
1. The record did not contain documentation of a dental assessment for R #16.
2. A Long Term Care Evaluation, date 09/22/23, indicated staff did not assess R #16's dental status.
I. Record review of R #16's current all staff progress notes revealed the record did not contain any documentation regarding R #16's dental concerns or a plan to make a dental appointment for R #16.
J. On 02/07/24 at 9:24 AM, during an interview with the DON, she stated the following:
1. During the IDT (team members from different disciplines working collaboratively, with a common purpose,
to set goals, make decisions and share resources and responsibilities), the resident or family can ask for the
resident to go to the dentist.
2. Staff will get an order for the appointment.
3. Social services will communicate with transportation schedulers to notify them to schedule the appointment
for the resident.
4. Transportation schedulers will schedule the appointment with the dentist office.
5. She was unsure if routine appointments were scheduled annually or every six months.
6. The facility scheduled the resident follow-up appointments based on dentist recommendations.
K. On 02/07/24, at 12:37 PM, during an interview with the Administrator, he said resident dental needs were discussed during the 48-hour meeting at admission.
L. On 02/08/24 at 2:41 PM, during an interview with the SSD, she confirmed the following:
1. She was not aware if R #16 had any dental needs.
2. R #16 did not have a dental appointment scheduled.
3. The facility did not have any records to show R #16 attended any dental appointments.
M. On 02/09/24, at 1:08 PM, during an interview with the Administrator and DON, they confirmed R #16 had not received routine or emergent dental care since he arrived at the facility.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to accurately document in the resident record for 1 (R #60) of 5 (R #1, R #49, R #60, R #78, and R #82) residents sampled for unnecessary medi...
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Based on record review and interview, the facility failed to accurately document in the resident record for 1 (R #60) of 5 (R #1, R #49, R #60, R #78, and R #82) residents sampled for unnecessary medications. This deficient practice could likely cause staff to be unaware of residents' current conditions if they are not documenting accurately in the medical chart. The findings are:
A. Record review of R #60's Physician's Orders revealed the following:
1) Soliqua (a fixed-dose combination medication that combines insulin glargine and lixisenatide and is used to treat diabetes.) pen-injector. (Insulin Glargine-Lixisenatide) Inject 15 units, in the morning related to Type 2 diabetes. Hold if blood sugar is less then 150.
B. Record review of R #60's TAR, for January 2024, revealed staff documented they gave R #60 Soliqua on the following dates:
1) On 01/01/24 with a blood sugar reading of 139.
2) On 01/02/24 with a blood sugar reading 145.
3) On 01/07/24 with a blood sugar reading 142.
4) On 01/31/24 with a blood sugar reading 120.
C. Record review of R #60's TAR, for February 2024, revealed staff documented they gave R #60 Soliqua on the following dates:
1) On 01/05/24 but staff did not document R #60's blood sugar reading.
D. On 02/07/24 at 1:36 PM, during an interview, LPN #15 stated staff gave R #60 the insulin outside of the ordered parameters, because the resident asked for it. LPN #15 stated R #60 stated he did not feel good unless he took his insulin. LPN #15 confirmed she notified the provider, and the provider stated it was okay to administer the insulin outside of the parameters. LPN #15 confirmed she did not document the notification of the provider in R #60's medical record.
E. On 02/07/24 at 1:39 PM, during an interview the DON confirmed nurses should document their notification to the providers in the medical record.
F. On 02/07/24 at 1:45 pm, during an interview, Nurse Practitioner #3 confirmed staff notified him and he gave permission to administer the insulin to R #60 even though it was outside of the ordered parameters.
G. On 02/07/24 at 2:05 PM, during an interview, LPN #16 stated staff gave R #60 the insulin outside of the ordered parameters because the resident asked for it. LPN #16 stated that R #60 stated that he did not feel good unless he took his insulin. LPN #16 confirmed she notified the provider, and the provider stated it was okay to administer the insulin outside of parameters. LPN #16 confirmed she did not document the notification of the provider in R #60's medical record.
H. On 02/08/24 at 11:49 AM, during an interview LPN #17 stated staff gave R #60 the insulin outside of the ordered parameters because the resident asked for it. LPN #17 stated R #60 stated that he did not feel good unless he took his insulin. LPN #17 confirmed she notified the provider, and the provider stated it was ok to administer the insulin outside of parameters. LPN #17 confirmed she did not document the notification of the provider in R #60's medical record.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected most or all residents
Based on record review and interview, the facility failed to ensure staff acted upon pharmacy recommendations for all 85 residents in the facility (residents were identified on the resident matrix pro...
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Based on record review and interview, the facility failed to ensure staff acted upon pharmacy recommendations for all 85 residents in the facility (residents were identified on the resident matrix provided by the Administrator on 02/05/24), when they failed to get the pharmacy recommendations back from the provider with instructions to accept or decline recommendations, within 30 days of the facility receiving the pharmacy recommendations. This deficient practice could likely result in residents being at a higher risk of adverse (undesired harmful effect resulting from medication) side effects. The findings are:
A. Record review of the Pharmacy Recommendations, for November 2023, revealed the following:
1. The pharmacist conducted a facility wide Medication Regimen Review on 11/11/23.
2. The provider signed off on the recommendations from the pharmacist Medication Regimen Review on
12/15/23.
B. Record review of the Pharmacy Recommendations, for December 2023, revealed the following:
1. The pharmacist conducted a facility wide Medication Regimen Review on 12/19/23.
2. The provider signed off on the recommendations from the pharmacist Medication Regimen Review on
01/29/24.
C. Record review of facility's Drug Regimen Review Policy, dated 06/2020, revealed the following:
1. The attending physician must review and respond to Pharmacist's report.
2. Documentation by the attending physician must occur within 30 days of issuance of the pharmacist's
report, unless the irregularity is emergent.
D. On 02/12/24 at 11:10 AM, during an interview with the Administrator, he stated the following:
1. The pharmacist sent the Medication Regimen Review within a couple of days of the review.
2. The facility policy stated the physician must review the recommendations within 30 days of the review
unless emergent.
3. November 2023 pharmacist Medication Regimen Review was completed on 11/11/23 and was not
reviewed by the provider until 12/15/2023.
4. The provider reviewed the November pharmacist Medication Regimen Review greater than 30 days after
the pharmacist review.
5. The December 2023 pharmacist Medication Regimen Review was completed on 12/19/23 and was not
reviewed by the provider until 01/29/2024.
6. The provider reviewed of the December pharmacist Medication Regimen Review greater than 30 days
after the pharmacist review.
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 follow procedures in accordance with professional standards of food service safety, when they failed to:
1. Ensure the chemical sanitation so...
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Based on observation and interview, the facility failed to follow procedures in accordance with professional standards of food service safety, when they failed to:
1. Ensure the chemical sanitation solution was maintained at the correct concentration.
2. Properly label opened food items in the walk-in refrigerator and walk-in freezer.
This failure had the potential to affect all 81 residents in the facility who eat food prepared in the kitchen. Residents were identified by the Resident Matrix provided by the Administrator on 02/05/24. If the facility fails to adhere safe food storage then residents are likely to be exposed to foodborne illnesses. The findings are:
Sanitizer Solution
A. On 02/05/24 at 10:05 AM, during an observation, the kitchen revealed the following:
1. The chemical sanitation solution, used during the rinse cycle of dishwashing, leaked from the container onto the counter.
2. The Dietary Director (DD) ran a sanitizer strip test, during the rinse cycle of dishwashing, but the sanitizer solution did not register on the test strip.
B. On 02/05/24 at 10:05 AM, during an interview the DD confirmed the sanitizer strip test did not register. The DD stated the sanitizer strip test should be 150-200 ppm (parts per million).
Labeled Opened Food Items
C. On 02/05/24 at 10:15 AM, an observation of the kitchen revealed the following:
1. Three trays of food in the walk-in refrigerator with the following:
a. Clear cups with thick tan substance, covered with saran wrap, with no date.
b. [NAME] bowls with clear lids with food in them, with no date.
c. Small brown bowls with saran wrap and an unknown substance in bowls, with no date.
D. On 02/05/24 at 10:20 AM, during an interview with the Dietary Manager (DM), she confirmed the following:
1. The items in the clear cups were pureed fruit crumble being served for lunch that day.
2. The items in the brown bowls with the clear lids were fruit crumble being served for lunch that day.
3. The items in the smaller brown bowls with saran wrap were fruit crumble that had been cut into smaller pieces for residents with specific dietary needs.
4. These items did not have a prepared date on them.
5. These items should have a prepared date on them.
E. On 02/05/24 at 10:23 AM, an observation of the kitchen revealed the following:
1. One large, open container of vanilla ice cream, with no open date.
2. Two bags of open pepperoni, with no open date.
F. On 02/05/24 at 10:23 AM, during an interview with the DM, she confirmed the following:
1. The large container of vanilla ice cream was opened.
2. The vanilla ice cream did not have an open date.
3. The two bags of open pepperoni did not have an open date.
4. Staff should date all open items in the refrigerator and freezer with the open date.
Jun 2023
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
Deficiency F0655
(Tag F0655)
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 create a Baseline Care Plan (Plan that includes the instructions ne...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to create a Baseline Care Plan (Plan that includes the instructions needed to provide effective and person-centered care upon admission) with interventions (actions required by staff to assist resident) within 48 hours of admission for 1 (R #21) of 2 (R #1 and R #21) residents sampled for Baseline Care Plans. This deficient practice could likely result in the resident not receiving the appropriate care and services and may place the resident at risk of an adverse event (An event, preventable or nonpreventable, that caused harm to a patient as a result of medical care or lack of medical care) that could occur after admission. The findings are:
A. Record review of R #21's Electronic Medical Record revealed that R #21 was admitted on [DATE].
B. Record Review of R #21's Baseline Care Plan dated 05/01/23 was blank and not completed.
C. On 06/22/23 at 3:16 PM, during an interview, the DON confirmed that R #21's baseline care plan should have been done within forty-eight hours of admission and that it was not done.
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
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and observation, the facility failed to provide housekeeping necessary to maintain a sanitary, orderly, and c...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and observation, the facility failed to provide housekeeping necessary to maintain a sanitary, orderly, and comfortable homelike environment for 9 (R #11, R #12, R #13, R #15, R #16, R #17, R #18, R #19 and R #20) of 12 (R #1, R #3, R #11, R #12, R #13, R #15, R #16, R #17, R #18, R #19, R #20, and R #21) residents reviewed for safe, clean, comfortable and home like environment. This deficient practice could likely cause the spread of disease-causing organisms and for the residents to be uncomfortable and feel like they are not valued. The findings are:
A. On 06/20/23 at 2:30 PM, during an observation of residents rooms, the following was revealed:
1. room [ROOM NUMBER] the baseboards were dirty with papers, dirt and had dead bugs. The floors were sticky.
2. room [ROOM NUMBER] had trash, hair, spilled liquid, and crumbs on the floor. There were cobwebs and dead bugs on the floor in the corners of the room. The beds had trash and probe covers (physical barrier designed to prevent cross-contamination) under the beds.
3. room [ROOM NUMBER] had dirty, dusty and sticky floors. There were papers and trash on the floors.
4. room [ROOM NUMBER] had trash and papers on the floor around the resident's feet. The bed had trash and dirty napkins under it. Floors by the window had cobwebs and dirt.
5. room [ROOM NUMBER] floors were sticky and dirty looking with streaks and dust.
6. room [ROOM NUMBER] floors were dirty, there was trash and band aid peels under the beds.
B. On 06/20/23 at 2:36 PM, during an interview with CNA #11, she confirmed that there was trash, liquid, crumbs, dead bugs, and cobwebs on the floors. She confirmed that there was trash under the beds. CNA #11 confirmed that Rooms # 124, #202, #221, # 227, and #230 were dirty.
D. On 06/20/23 at 2:42 PM, during an interview with R #13, she said that the floors are always dirty, and they never get cleaned.
E. On 06/20/23 at 2:46 PM, during an interview, CNA #11 confirmed that room [ROOM NUMBER] was not clean.
F. On 06/20/23 at 3:08 PM, during an interview, R #11 said that there are a lot of dead roaches and that the floors are dirty.
G. On 06/22/23 at 11:56 AM, during an interview with the Administrator, he said that the rooms should be clean and comfortable for the residents.
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
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to develop a comprehensive person-centered care plan for 2 (R #2 and R #13) of 3 (R #1, R #2, and R #13) residents reviewed for Comprehensive ...
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Based on record review and interview, the facility failed to develop a comprehensive person-centered care plan for 2 (R #2 and R #13) of 3 (R #1, R #2, and R #13) residents reviewed for Comprehensive Care Plans. Failure to develop a person-centered care plan could likely result in staff's failure to understand the needs, preferences, and treatments for residents to achieve their highest level of well-being.
The findings are:
Resident #2:
A. Record review of R #2's admission Record revealed an admission date of 06/02/23.
B. Record review of R #2's Care Plan initiated 06/02/23 revealed no discharge plan in place.
Resident #13:
C. Record review of R #13's admission Record revealed an admission date of 07/05/22.
D. Record review of R #13's Care Plan initiated 03/08/23 revealed no discharge plan in place.
E. On 06/22/23 at 2:40 PM, during a joint interview with the ADON and DON, they confirmed that there were no discharge plans in place for R #2 and R #13. The ADON stated, the discharge plan should be started on admission.
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
Based on record review and interview, the facility failed to ensure call-lights were answered timely when a resident needed assistance for 2 (R #11 and R #12) of 3 (R #1, R #11, R #12) residents revie...
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Based on record review and interview, the facility failed to ensure call-lights were answered timely when a resident needed assistance for 2 (R #11 and R #12) of 3 (R #1, R #11, R #12) residents reviewed for call-lights. This deficient practice could result in the residents' needs not being met, leaving them at risk for incontinence (lack of voluntary control over urination or defecation) and falls.
The findings are:
Resident #11:
A. On 06/20/23 at 3:08 PM, during an interview, R #11 stated that it takes about 20 minutes for staff to respond to her call light.
B. Record review of R #11's admission record revealed an original admission date of 06/29/21.
C. Record review of R #11's Care plan revision date of 05/03/23, revealed the following:
1. R #11 is at risk for falls.
2. The call light needs to be in reach of R #11.
3. Requests for assistance need prompt response.
D. Record review of R #11's Call Light log from 05/21/23 to 06/20/23 revealed the following:
1. 05/22/23 at 8:04 AM wait time 19 minutes
2. 05/23/23 at 5:41 PM wait time 20 minutes
3. 05/24/23 at 8:34 AM wait time 29 minutes
4. 05/28/23 at 8:12 AM wait time 18 minutes
5. 05/29/23 at 5:34 PM wait time 26 minutes
6. 05/29/23 at 11:43 PM wait time 16 minutes
7. 05/30/23 at 8:28 AM wait time 56 minutes
8. 05/31/23 at 7:04 PM wait time 17 minutes
9. 06/01/23 at 11:51 AM wait time 17 minutes
10. 06/05/23 at 9:21 AM wait time 36 minutes
11. 06/15/23 at 7:14 PM wait time 29 minutes
12. 06/18/23 at 6:36 AM wait time 16 minutes
13. 06/19/23 at 8:34 AM wait time 17 minutes
14. 06/19/23 at 10:08 AM wait time 21 minutes
Resident #12:
E. On 06/20/23 at 3:34 PM, during an interview, R #12 was unable to answer questions regarding the call light times.
F. Record review of R 12's admission record revealed the following:
1. An admission date of 06/07/23.
2. A diagnosis of Aphasia (loss of ability to produce or understand language) following Cerebral Infarction (stroke).
G. Record review of R #12's MDS Section C0200 dated 06/09/23 revealed a BIMS (Brief Interview for Mental Status- A score of 13 to 15 suggests the patient is cognitively intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment) score of 12.
H. Record review of R #12's care plan dated 06/08/23, revealed that she is encouraged to call for assistance.
I. Record review of R #12's call light log from 06/07/23 to 06/20/23 revealed the following:
1. 06/08/23 at 6:32 PM wait time 19 minutes
2. 06/11/23 at 9:50 AM wait time 24 minutes
3. 06/13/23 at 4:27 PM wait time 37 minutes
4. 06/14/23 at 6:52 AM wait time 16 minutes
5. 06/14/23 at 8:34 AM wait time 16 minutes
6. 06/16/23 at 5:49 PM wait time 46 minutes
7. 06/18/23 at 07:33 AM wait time 32 minutes
8. 06/18/23 at 9:45 AM wait time 18 minutes
9. 06/18/23 at 6:00 PM wait time 16 minutes
10. 06/19/23 at 8:10 AM wait time 27 minutes
11. 06/19/23 at 9:56 AM wait time 24 minutes
12. 06/19/23 at 2:18 PM wait time 54 minutes
13. 06/19/23 at 5:51 PM wait time 21 minutes
14. 06/20/23 at 6:57 AM wait time 1 hour, 9 minutes
J. On 06/21/23 at 11:56 AM during an interview with the Administrator, he said the expectation for the call light response is under 10 minutes.
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 F0760
(Tag F0760)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to ensure that residents are free of any significant medication errors for 1 (R #1) of 3 (R #1, R #3, and R #11) residents reviewed for medica...
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Based on record review and interview, the facility failed to ensure that residents are free of any significant medication errors for 1 (R #1) of 3 (R #1, R #3, and R #11) residents reviewed for medication administration when they failed to administer medication per prescriber's orders. This deficient practice could likely lead to the residents having adverse (unwanted, harmful, or abnormal result) side effects, or not receiving the desired therapeutic effect of the medication.
The findings are:
A. Record review of R #1's Physician's orders revealed: Order Date 04/06/23; Oxycodone-Acetaminophen (combination medication is used to relieve moderate to severe pain) 5-325 mg (dosage of medication) Give 1 tablet by mouth every 6 hours as needed for pain .
B. Record review of R #1's April 2023 Medication Administration Record (MAR) and Controlled Drug Record for Oxycodone-Acetaminophen 5-325 mg for pain revealed:
1. Medication was signed out and documented as administered on 04/08/23 at 9:00 PM and was administered again 5 hours later on 04/09/23 at 2:00 AM.
2. Medication was signed out and documented as administered on 04/12/23 at 10:06 AM and was administered again 5 hours and 36 minutes later on 04/12/23 at 3:36 PM.
3. Medication was signed out and documented as administered on 04/12/23 at 3:36 PM and was administered again 3 hours and 24 minutes later on 04/12/23 at 7:00 PM.
C. On 06/22/23 at 2:45 PM, during an interview, the DON confirmed that R #1's Oxycodone-Acetaminophen was not given as prescribed due to being given too soon and not waiting 6 hours in between doses. The DON confirmed that the medication should be given every 6 hours as ordered.
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
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to accurately document resident's records for 1 (R #1) of 3 (R #1, R #3, and R #11) residents reviewed for medication administration when they...
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Based on record review and interview, the facility failed to accurately document resident's records for 1 (R #1) of 3 (R #1, R #3, and R #11) residents reviewed for medication administration when they failed to document the administration of medication on R #1's Medication Administration Record (MAR). This deficient practice could likely result in staff being unaware of the resident's current medication status and could likely result in injury or uncontrolled symptoms due to being under or overmedicated.
The findings are:
A. Record review of R#1's Controlled Drug Record for Oxycodone-Acetaminophen (combination medication is used to relieve moderate to severe pain) 5-325 mg (dosage of medication) revealed:
1. Medication was signed out on Controlled Drug Record on 04/07/23 at 9:00 AM.
2. Medication was signed out on Controlled Drug Record on 04/07/23 at 3:00 PM.
3. Medication was signed out on Controlled Drug Record on 04/08/23 at 9:00 AM.
4. Medication was signed out on Controlled Drug Record on 04/08/23 at 3:00 PM.
5. Medication was signed out on Controlled Drug Record on 04/09/23 at 2:00 AM.
6. Medication was signed out on Controlled Drug Record on 04/10/23 at 9:30 AM.
7. Medication was signed out on Controlled Drug Record on 04/12/23 at 10:06 AM.
8. Medication was signed out on Controlled Drug Record on 04/12/23 at 3:36 PM.
B. Record review of R #1's MAR dated April 2023 revealed the following: Oxycodone-Acetaminophen Tablet 5-325 mg give 1 tablet by mouth every 6 hours as needed for pain.
1. Medication was not documented as given on 04/07/23 at 9:00 AM.
2. Medication was not documented as given on 04/07/23 at 3:00 PM.
3. Medication was not documented as given on 04/08/23 at 9:00 AM.
4. Medication was not documented as given on 04/08/23 at 3:00 PM.
5. Medication was not documented as given on 04/09/23 at 2:00 AM.
6. Medication was not documented as given on 04/10/23 at 9:30 AM.
7. Medication was not documented as given on 04/12/23 at 10:06 AM.
8. Medication was not documented as given on 04/12/23 at 3:36 PM.
C. On 6/22/23 at 2:45 PM, during an interview, the DON confirmed that the Controlled Drug Record and MAR did not have the matching documentation. It is her expectation that the sign out on the Controlled Substance Log would match the time and date the medication is administered on the MAR.
Nov 2022
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure that residents were treated with respect and dignity for 1 (R #52) of 1 (R #52) residents randomly sampled, when the f...
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Based on observation, interview, and record review, the facility failed to ensure that residents were treated with respect and dignity for 1 (R #52) of 1 (R #52) residents randomly sampled, when the facility did not have any pants or bottom covering for R #52 who's lower body was uncovered exposing her brief. This deficient practice could likely result in residents becoming depressed, anxious, and lacking self-worth. The findings are:
A. On 10/26/22 at 10:52 AM, during observation of the Memory Care Unit, R #52 was observed laying in the bed closest to the door, the curtain and the door were open. R #52 had a shirt but was not covered with a blanket. R #52 did not have pants on and her brief was completely exposed.
B. On 10/26/22 at 10:55 AM, during an interview CNA #21 confirmed the resident was not covered and she covered her.
C. On 10/31/22 at 3:50 PM, during observation of R #52's room and interview with the Maintenance Director (MD), R #52 was observed uncovered and her brief was exposed. The MD confirmed that R #52 had a shirt on but was uncovered from the waist down exposing her brief. The MD covered R #52. When asked, the MD confirmed that R #52 should have some sort of covering so her brief would not be exposed.
D. Record review of [name of facility] Dignity policy, revised date February 2021, revealed:
1) Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.
2) Policy Interpretation and Implementation: a) Residents are treated with dignity and respect at all times. b) Staff are expected to treat cognitively impaired residents with dignity and sensitivity .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
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 the facility Bed-hold notice upon transfer for 1 (R #45) of...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide the facility Bed-hold notice upon transfer for 1 (R #45) of 1 (R #45) residents sampled for bed hold. This deficient practice could likely cause resident frustration and anxiety about not knowing if the facility will hold their bed while away. The findings are:
A. Record review of R #45's Medical Record revealed the following:
1) R #45 went to the hospital on [DATE].
2) No documentation of a bed hold notice was found.
B. On 11/01/22 at 5:05 PM, during an interview with the Business Office Manager (BOM) and the Administrator, the BOM stated that R #45 was not given a bed hold policy. The BOM and Administrator stated that the facility tried to contact R #45 family and R #45 but could not get a hold of them. The Administrator did confirm that there was documentation of the facilities attempts to contact R #45 or his family.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0577
(Tag F0577)
Could have caused harm · This affected multiple residents
Based on interview and observation, the facility failed to:
1. Ensure residents participating in Resident Council knew where the most recent survey was located,
2. Update the binder with the most rece...
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Based on interview and observation, the facility failed to:
1. Ensure residents participating in Resident Council knew where the most recent survey was located,
2. Update the binder with the most recent survey for residents/family's access.
This could affect the 9 (R#7, R#8, R#16, R#33, R#36, R#47, R#57, R#59 and R #68) of 9 (R#7, R#8, R#16, R#33, R#36, R#47, R#57, R#59 and R #68 ) residents sampled in Resident Council. If residents are unable to locate the latest survey conducted by State Surveyors, then residents, representatives, and visitors are unable to know how the facility is doing and make decisions accordingly. The findings are:
A. On 10/28/22 at 2:00 PM, during the resident council interview, R#7, R#8, R#16, R#33, R#36, R#47, R#57, R#59 and R #68 revealed:
1. Residents were not aware that they have access to the most recent Survey.
2. The residents did not know where the latest survey is located.
B. On 10/28/22 at 10:15 am, during an observation of the front lobby revealed a displayed Survey binder.
C. Record review of the Survey Binder revealed the last survey on display was from 2020 (surveys from 2021 and 2022 were not found).
D. On 10/28/22 at 10:20 am, during an interview, the Activity Director confirmed that the last survey displayed was from 2020. He also confirmed that during Resident Council, they have not informed residents about the Survey binders.
E. Record review of [name of facility] Survey Results, Examination policy revised April 2007 revealed:
1) Policy Statement: Copies of survey results are maintained in the administrative office. (Note: Survey results mean the Statement of Deficiencies .)
2) Policy Interpretation and Implementation: A copy of the most recent standard survey, including any subsequent extended surveys, follow-up revisits reports, etc., along with state approved plans of correction of noted deficiencies, is maintained in a 3-ring binder located in an area frequented by most residents, such as the main lobby or resident activity room.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
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 provide written notice of transfer as soon as practicable to reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide written notice of transfer as soon as practicable to residents and the ombudsman when residents were transferred to the hospital for emergency services for 3 (R #4, R #45, and R #56) of 5 (R #4, R #42, R #45, R#56 and R #66) residents. This deficient practice could likely result in residents or their representatives and the ombudsman being unaware of the reason for the transfer and the right to appeal. The findings are:
R #4
A. Record review of R #4's Medical Record revealed the following:
1) R #4 went to the hospital on [DATE].
B. Record review of R #4 Transfer Notice dated 10/04/22 revealed R #4 did not sign until he returned to the facility on [DATE].
C. On 11/02/22 at 1:13 pm, during an interview the SSD (Social Service Director) confirmed that R #4 did not get a Transfer Notice until R #4 came back to the facility on [DATE].
R #45
D. Record review of R #45's Medical Record revealed the following:
1) R #45 went to the hospital on [DATE].
E. Record review of R #45 Transfer Notice dated 08/13/22 revealed R #45 did not sign until he returned to the facility on [DATE].
F. On 11/02/22 at 1:13 pm, during an interview, the SSD confirmed that R #45 did not get a Transfer Notice until R #45 came back to the facility on [DATE].
R #56
G. Record review of R #56's Progress Notes revealed that he was transferred to the hospital on [DATE].
H. Record review of R #56's Medical Record revealed no written notice of transfer to the hospital.
I. Record review of the Notice of Transfer or Discharge dated 08/11/22 revealed the following:
The form was signed by R #56's spouse on 11/02/22 and had a fax cover sheet confirming that it was sent to the Ombudsman on 11/02/22.
J. On 11/02/22 at 1:12 PM, during an interview the SSD confirmed that she had found R #56's form when reviewing documents. The SSD confirmed that R #56's spouse signed the form 11/02/22 and confirmed the ombudsman was notified of the transfer via fax on 11/02/22.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to ensure that pharmacist recommendations were reviewed by a physician and implemented after repeated monthly recommendations for 2 (R #56 and...
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Based on record review and interview, the facility failed to ensure that pharmacist recommendations were reviewed by a physician and implemented after repeated monthly recommendations for 2 (R #56 and R #66) of 5 (R #4, R #23, R #32, R #52, R #56 and R #66) residents reviewed for unnecessary medications. This deficient practice could likely result in residents receiving medications that are no longer necessary and may cause unnecessary drug interactions or adverse side effects. The findings are:
R #56
A. Record review of Pharmacy Recommendation for R #56 dated 06/12/22 revealed:
1. The resident has an order for Fentanyl (powerful opioid drug used in the treatment of severe pain), Tramadol (opioid analgesic used to help relieve moderate to moderately severe pain), Codeine-Guaifenesin liquid (combination of an opioid cough suppressant and an expectorant cough syrup used to reduce cough and loosen mucus), and Acetaminophen-Codeine (opioid combination medication used to help relieve mild to moderate pain). Please add the standing order for PRN (as needed) Naloxone (Narcan; medicine that rapidly reverses an opioid overdose) to EMAR (Electronic Medication Administration record, document with medication orders where staff document that medication was given)
2. The resident has orders for insulin (hormone which helps regulates the amount of glucose (sugar) in the blood and is used to treat diabetes by lowering the blood sugar). Please verify if orders for PRN Glucagon injectable (natural substance given by injection when patient is unable to swallow that raises blood sugar rapidly by causing the body to release sugar stored in the liver and is used to treat very low blood sugar) and/or PRN Glucose gel (sugar in gel form used to treat low blood sugar when a patient is still able to swallow) can be added to the EMAR for hypoglycemic (symptom when blood sugar level is too low and if left untreated can cause seizures, loss of consciousness and in severe cases can even be fatal) protocol.
B. Record review of Pharmacy Recommendation for R #56 dated 07/12/22 revealed:
1. The resident has an order for Tramadol. Please add the standing order for PRN Naloxone (Narcan) to the EMAR since Tramadol is considered an opioid analgesic (known as narcotic analgesics are pain relievers that act on the central nervous system [part of the nervous system that consists of the brain and spinal cord]).
2. The resident has orders for insulin (hormone which helps regulates the amount of glucose (sugar) in the blood and is used to treat diabetes by lowering the blood sugar). Please verify if orders for PRN Glucagon injectable (natural substance given by injection when patient is unable to swallow that raises blood sugar rapidly by causing the body to release sugar stored in the liver and is used to treat very low blood sugar) and/or PRN Glucose gel (sugar in gel form used to treat low blood sugar when a patient is still able to swallow) can be added to the EMAR for hypoglycemic (symptom when blood sugar level is too low and if left untreated can cause seizures, loss of consciousness and in severe cases can even be fatal) protocol.
C. Record review of pharmacy recommendation for R #56 dated 10/17/22 revealed:
Please add the diagnosis to the EMAR for Lorazepam (mild tranquilizer in the class of drugs known as benzodiazepines (medications that act on the central nervous system and are used for a variety of medical conditions, such as anxiety, seizures, alcohol or can be used before surgery to cause drowsiness).
D. Record review of R #56's Physician's Orders revealed the following:
1) R #56's Orders were not updated to include Naloxone until 08/31/22,
2) Glucagon and glucose gel were not added until 10/24/22.
E. Record review of R #56's EMAR (Electronic Medication Administration Record) for November 2022 revealed:
R #56's diagnosis for Lorazepam had not been updated as of 11/01/22.
R #66
F. Record review of Pharmacy Recommendation for R #66 dated 07/12/22 revealed Please update the PRN (as needed) for Acetaminophen (drug used to relieve mild or chronic pain and to reduce fever) to include the wording not to exceed 3,000 mg (dosage of medication) of Acetaminophen in a 24-hour period (total amount of Acetaminophen a person should take to avoid potentially harming the liver).
G. Record review of pharmacy recommendation for R #66 dated 09/15/22 revealed repeat recommendation Please update the PRN for Acetaminophen to include the wording not to exceed 3,000 mg (dosage of medication) of Acetaminophen in a 24-hour period (total amount of Acetaminophen a person should take to avoid potentially harming the liver).
H. Record review of R #66's Physician's Orders for October 2022 revealed that the order for Acetaminophen was not updated to include the maximum dosage of Acetaminophen until 10/20/22.
I. On 11/01/22 at 1:52 PM, during an interview, the interim ADON, confirmed that the pharmacy recommendation for R #56 and R #66 were not carried out after repeated monthly recommendations.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
Based on record review and interview the facility failed to have complete and accurate documentation in the medical record for 1 (R #50) of 1 (R #50) resident when they failed to:
1) Document the plan...
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Based on record review and interview the facility failed to have complete and accurate documentation in the medical record for 1 (R #50) of 1 (R #50) resident when they failed to:
1) Document the plan for treatment from the NP (Nurse Practitioner) for R #50 after her labs came back with a recommendation to repeat sample and labs,
2) Document the cancellation of R #50's eye surgery appointment.
This deficient practice could likely result in residents being unaware of their plan of care or upcoming appointments cause anxiety and depression. The findings are:
Labs
A. Record review of R #50's Physicians Orders revealed the following:
1) 09/28/2022 Culture, Urine.
2) 09/29/2022 Culture, Urine (a separate order).
B. Record review of the lab results revealed the following:
1) The sample could have been contaminated and asks the facility to resubmit a new sample.
2) Handwritten at the bottom revealed NP notified on 10/03/22 at 16:48. (4:48 pm)
C. Record review of R #50's Medical Record revealed the following:
1) No documentation of what the NP wanted to do about the lab request for a new sample were found.
2) No order for lab were found.
3) No other results for labs were found.
D. On 11/01/22 at 11:28 AM, during an interview the ADON and the Medical Records Director revealed that R #50 had been seen by a Urologist (doctor for the urinary system). R #50's Urologist had been treating R #50 for chronic UTI's (Urinary Tract Infections). The NP had consulted the Urologist and they did not want to conduct another lab for R #50. The MRD stated that the facility did not document this in R #50's chart.
E. On 11/02/22 at 9:58 am, during an interview the NP confirmed that the facility did contact her for R #50's lab results. The NP confirmed that R #50 had been treated for chronic UTI by the Urologist and they did not want to redo the UA.
Eye Appointment
F. On 10/27/22 at 11:09 AM, during an interview with R #50 revealed R #50 had and Eye surgery appointment that was canceled and she did not know why.
G. Record review of R #50's medical record revealed no documentation of R #50's eye appointment cancellation.
H. On 11/01/22 1:55 PM, during an interview with the Scheduler and the MRD revealed the following:
1) R #50 had appointment on 03/15/22 for surgery.
2) She was in the hospital just before and probably was not well enough for the surgery. A short time after the hospitalization R #50 was put on Hospice.
3) The Scheduler and MRD confirmed that there was no documentation that the facility told R #50 why the appointment was canceled.
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
- "What safeguards are in place to prevent abuse and neglect?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 44% turnover. Below New Mexico's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 1 harm violation(s). Review inspection reports carefully.
- • 43 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • $19,971 in fines. Above average for New Mexico. Some compliance problems on record.
- • Grade F (28/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is Paloma Springs Healthcare Llc's CMS Rating?
CMS assigns Paloma Springs Healthcare LLC an overall rating of 2 out of 5 stars, which is considered below average nationally. Within New Mexico, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Paloma Springs Healthcare Llc Staffed?
CMS rates Paloma Springs Healthcare LLC's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 44%, compared to the New Mexico average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Paloma Springs Healthcare Llc?
State health inspectors documented 43 deficiencies at Paloma Springs Healthcare LLC during 2022 to 2025. These included: 1 that caused actual resident harm and 42 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Paloma Springs Healthcare Llc?
Paloma Springs Healthcare LLC is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by OPCO SKILLED MANAGEMENT, a chain that manages multiple nursing homes. With 94 certified beds and approximately 84 residents (about 89% occupancy), it is a smaller facility located in T OR C, New Mexico.
How Does Paloma Springs Healthcare Llc Compare to Other New Mexico Nursing Homes?
Compared to the 100 nursing homes in New Mexico, Paloma Springs Healthcare LLC's overall rating (2 stars) is below the state average of 2.9, staff turnover (44%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Paloma Springs Healthcare Llc?
Based on this facility's data, families visiting should ask: "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "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 substantiated abuse finding on record.
Is Paloma Springs Healthcare Llc Safe?
Based on CMS inspection data, Paloma Springs Healthcare LLC has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in New Mexico. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Paloma Springs Healthcare Llc Stick Around?
Paloma Springs Healthcare LLC has a staff turnover rate of 44%, which is about average for New Mexico nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Paloma Springs Healthcare Llc Ever Fined?
Paloma Springs Healthcare LLC has been fined $19,971 across 1 penalty action. This is below the New Mexico average of $33,279. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Paloma Springs Healthcare Llc on Any Federal Watch List?
Paloma Springs Healthcare LLC 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.