rowid,facility_name,facility_id,address,city,state,zip,inspection_date,deficiency_tag,scope_severity,complaint,standard,eventid,inspection_text,filedate
1,SANTA FE CARE CENTER,325030,635 HARKLE ROAD,SANTA FE,NM,87505,2020-01-16,609,E,1,0,WQZY11,"> Based on record review and interview, the facility failed to submit a Follow-Up Report within 5 working days of the date the Incident Report was filed for 1 (R #1) of 3 (R #'s 1, 4 and 5) residents who had Incident Reports filed with the Department of Health (DOH)/Incident Management Bureau (IMB). This deficient practice has the potential for resident issues that have been reported, to not be addressed and/or rectified in a timely manner. The findings are: Findings for R #1: [NAME] Record review revealed that the facility submitted an Incident Report (self-report) to the Department of Health (DOH)/Incident Management Bureau (IMB) on 8/10/19 regarding neglect. B. Record review revealed that the 5 day follow up for the incident (on 08/09/19) was submitted on 09/09/19. C. On 01/13/20 at 3:50 pm, during an interview, the Administrator reported that she emailed the 5 Day Follow-Up Report to the DOH/IMB on 09/09/19 indicating that she found during an audit, that there was no evidence that the 5 Day Follow-Up Report was sent to the DOH/IMB. D. On 01/13/20 at 4:25 pm, during an interview, the Director of Nursing (DON) reported that she usually submits all of the Incident Reports and 5 Day Follow-Up Reports to DOH/IMB, but they were in-between DON's in (MONTH) 2019 when the Incident Report for R #1 was submitted and the 5 Day Follow-Up Report should have been submitted timely, but it was not. The DON reported that the Assistant Director of Nursing (ADON) and the Administrator serve as a back-up to her when she is unable to submit the reports. The DON reported that she officially started in the DON capacity at this facility in (MONTH) 2019.",2020-09-01
2,SANTA FE CARE CENTER,325030,635 HARKLE ROAD,SANTA FE,NM,87505,2020-01-16,660,E,1,0,WQZY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to develop post-discharge plans that focused on residents' individualized discharge goals and needs for 3 (R #'s 1, 2 and 3) of 3 (R #'s 1, 2 and 3) residents reviewed for discharge planning. This deficient practice has the potential to complicate or prevent smooth and safe transitions from the facility to the residents' post-discharge settings. The findings are: Findings for R #1: [NAME] Record review of R #1's admission record revealed that R #1 was admitted to the facility on [DATE]. B. Record review of R #1's progress notes revealed that R #1 was discharged home on[DATE]. C. Record review of the facility's Discharge Summary and Plan policy revised (MONTH) (YEAR) stipulates: 4. Every resident will be evaluated for his or her discharge needs and will have an individualized post-discharge plan. 5. The post-discharge plan will be developed by the Care Planning/Interdisciplinary Team with the assistance of the resident and his or her family and will include: a. Where the individual plans to reside; b. Arrangements that have been made for follow-up care and services; c. A description of the resident's stated discharge goals; d. The degree of caregiver/support person availability, capacity and capability to perform required care; e. How the IDT (interdisciplinary team - the group of persons who develop a individual program plan to meet the resident's needs for services.) will support the resident or representative in the transition to post-discharge care; f. What factors may make the resident vulnerable to preventable readmission; and g. How those factors will be addressed. 6. The discharge plan will be re-evaluated based on changes in the resident's condition or needs prior to discharge. 7. The resident/representative will be involved in the post-discharge planning process and informed of the final post-discharge plan. 8. Residents will be asked about their interest in returning to the community. If the resident indicates an interest in returning to the community, he or she will be referred to local agencies and support services that can assist in accommodating the resident's post-discharge preferences. 9. If it is determined that returning to the community is not feasible, it will be documented why this is the case and who made the determination. 10. Residents transferring to another skilled nursing facility or who are discharged to a home health agency, long-term care hospital or inpatient rehabilitation facility will be assisted in selecting a post-acute care provider that is relevant and applicable to the resident's goals of care and treatment preferences. Data used in helping the resident select an appropriate facility includes the receiving facility's: a. standardized patient assessment data; b. quality measure data; and c. data on resource use. 11. The resident or representative (sponsor) should provide the facility with a minimum of a seventy-two (72) hour notice of a discharge to assure that an adequate discharge evaluation and post-discharge plan can be developed. 12. A member of the IDT will review the final post-discharge plan with the resident and family at least twentyfour (24) hours before the discharge is to take place. 13. A copy of the following will be provided to the resident and receiving facility and a copy will be filed in the resident's medical records: a. An evaluation of the resident's discharge needs; b. The post-discharge plan; and c. The discharge summary. D. Record review revealed no documented Post-Discharge Plan (a plan developed by a care planning/interdisciplinary team with the assistance of the resident and/or the residents' family) was implemented for R #1. E. On 01/14/20 at 9:25 am, during an interview, the Social Services Director reported that they do not conduct Discharge Meetings unless the resident and/or family requests them, but they do discuss upcoming discharges at the weekly UR (utilization review) meetings, which occur every Tuesday; however they do not take meeting minutes (notes) or document the meetings anywhere. The SSD reported that staff members from the following departments participate in the UR meetings: therapy, business office, MDS (minimum data set), social services, medical records, nursing and sometimes the Administrator. F. On 01/14/20 at 10:50 am, during an interview, the Director of Nursing reported that they do not have a written Discharge Summary or written Post-Discharge Plan for R #1; however all discharges are discussed during the Daily Stand-Up Meeting and the resident names are documented under the Discharges Yesterday or Planned Discharges This Week sections of the Daily Stand-Up Meeting form. Findings for R #2: [NAME] Record review of R #2's admission record revealed that R #2 was admitted to the facility on [DATE]. H. Record review of R #2's progress notes revealed that R #2 was discharged home on[DATE]. I. Record review revealed no detailed Post-Discharge Plan was implemented for R #2. [NAME] On 01/14/20 at 10:50 am, during an interview, the DON reported that they do not have a written Discharge Summary or written Post-Discharge Plan for R #2. Findings for R #3: K. Record review R #3's admission record revealed that R #3 was admitted to the facility on [DATE]. L. Record review R #3's progress notes revealed that R #3 was discharged home on[DATE]. M. Record review revealed no detailed Post-Discharge Plan was implemented for R #3. N. On 01/14/20 at 10:50 am, during an interview, the DON reported that they do not have a written Discharge Summary or written Post-Discharge Plan for R #3.",2020-09-01
3,SANTA FE CARE CENTER,325030,635 HARKLE ROAD,SANTA FE,NM,87505,2020-01-16,661,E,1,0,WQZY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to develop detailed Discharge Summaries (to include overviews of resident stays at the facility and a final summary of resident statuses at the time of discharge) for 3 (R #'s 1, 2 and 3) of 3 (R #'s 1, 2 and 3) residents reviewed for discharging home. This deficient practice has the potential to prevent residents from receiving adequate care from home health agencies and primary care physicians due to being uninformed, which could result in resident goals and needs not being met as well as readmittance to a nursing facility. The findings are: Findings for R #1: [NAME] Record review of R #1's admission record revealed that R #1 was admitted to the facility on [DATE]. B. Record review of R #1's progress notes revealed that R #1 was discharged home on[DATE]. C. Record review of the facility's Discharge Summary and Plan policy revised (MONTH) (YEAR) stipulates: 1. When the facility anticipates a resident's discharge to a private residence, another nursing care facility (i.e., skilled, intermediate care, intermediate care facility for individuals with intellectual disabilities, etc.) a discharge summary and a post-discharge plan will be developed which will assist the resident to adjust to his or her new living environment. 2. The discharge summary will include a recapitulation of the resident's stay at this facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident. The discharge summary shall include a description of the resident's: a. Current diagnosis; b. Medical history (including any history of mental disorders and intellectual disabilities); c. Course of illness, treatment and/or therapy since entering the facility; d. Current laboratory, radiology, consultation, and diagnostic test results; e. Physical and mental functional status; f. Ability to perform activities of daily living including: (1) bathing, dressing and grooming, transferring and ambulating, toilet use, eating, and using speech, language, and other communication systems; (2) the need for staff assistance and assistive devices or equipment to maintain or improve functional abilities; and (3) the ability to form relationships, make decisions including health care decisions, and participate (to the extent physically able) in the day-to-day activities of the facility. g. Sensory and physical impairments (neurological, or muscular deficits; for example, a decrease in vision and hearing, paralysis, and bladder incontinence); h. Nutritional status and requirements: (1) weight and height; (2) nutritional intake; and (3) eating habits, preferences and dietary restrictions. i. Special treatments or procedures (treatments and procedures that are not part of basic services provided); j. Mental and psychosocial status (ability to deal with life, interpersonal relationships and goals, make health care decisions, and indicators of resident behavior and mood); k. Discharge potential (the expectation of discharging the resident from the facility within the next three months); l. Dental condition (the condition of the teeth, gums, and other structures of the oral cavity that may affect a resident's nutritional status, communications abilities, quality of life, and the need for and use of dentures or other dental appliances); m. Activities potential (the ability and desire to take part in activity pursuits which maintain or improve physical, mental, and psychosocial well-being); n. Rehabilitation potential (the ability to improve independence in functional status through restorative care programs); o. Cognitive status (the ability to problem solve, decide, remember, and be aware of and respond to safety hazards); and p. Medication therapy (all prescription and over-the-counter medications taken by the resident including dosage, frequency of administration, and recognition of significant side effects that would be most likely to occur in the resident). 3. As part of the discharge summary, the nurse will reconcile all pre-discharge medication with the resident's post-discharge medications. The medication reconciliation will be documented. D. On 01/14/20 at 10:50 am, during an interview, the Director of Nursing reported that they do not have a written Discharge Summary or written Post-Discharge Plan for R #1; however all discharges are discussed during the Daily Stand-Up Meeting and the resident names are documented under the Discharges Yesterday or Planned Discharges This Week sections of the Daily Stand-Up Meeting form. E. On 01/14/20 at 12:30 pm, the Social Services Director reported that the Dr./Medical Director tries to complete a Discharge Summary on all residents that discharge, but he does not always get the opportunity to do so. The SSD reported that she recently started providing the Physicians' Assistant (PA) with a list of upcoming discharges. The SSD reported that the list is titled Notification of Discharges and is provided to the PA on weekly basis. The SSD reported that they are working on tightening up (improving) their process (for discharging residents). The SSD reported that they do not have a Discharge Summary on file for R #1. F. On 01/14/20 at 1:14 pm, during a telephonic interview, R #1's wife reported we were very unhappy with the service, we received at (name of the nursing facility) for my husband. She reported we decided to bring him (R #1) home, because it didn't seem like he was getting a lot of help at (name of the nursing facility) and he appeared to be getting weaker. R #1's wife reported that he left the faciity on [DATE] and by the time they made the short drive home, R #1 was weak and so out of it mentally. She reported that when they arrived home, she had to ask her neighbor to help her get R #1 out of the car. R #1's wife reported he (R #1) spent the rest of the day in his lounge chair knocked out and when the neighbor came over to check on us, he called 911 right away. He (R #1) was hospitalized for [REDACTED]. R #1's wife reported that she does not recall receiving any discharge paperwork from the facility. [NAME] On 01/14/20 at 3:17 pm, during a telephonic interview, the office of R #1's primary care physician reported that they did not receive a Discharge Summary for R #1 from the facility upon discharge on 08/09/19. H. On 01/15/20 at 11:07 am, during an interview, the SSD reported that the following documents were provided to the home health agency for R #1 upon discharge: Dr's Discharge Orders, Admission Record, Order Summary Report, Dr's Progress Note for date of service 07/12/19, Physical Therapy Progress Reports for 07/19/19 - 07/25/19 & 07/26/19 - 08/01/19, Physical Therapy Treatment Encounter Notes for 07/22/19 - 07/24/19 & 07/30/19 - 08/01/19, Occupational Therapy Progress Reports for 07/19/19 - 07/25/19, & 07/26/19 - 08/01/19, Occupational Therapy Treatment Encounter Notes 07/19/19 - 07/25/19 & 07/26/19 - 07/31/19, Speech Therapy Progress Report for 07/23/19 - 07/29/19 and Speech Therapy Treatment Encounter Notes 07/23/19 - 07/26/19. I. On 01/15/20 at 11:17 am, during an interview, the SSD reported the only thing we provide to residents upon discharge is a Transfer/Discharge Report, but we did not provide one to (first name of R #1) upon discharge. [NAME] On 01/15/19 at 5:04 pm, during a telephonic interview, the office of the home healthcare agency reported that R #1 never started services with their agency and therefore they did not receive any discharge paperwork from the facility for R #1. Findings for R #2: K. Record review of R #2's admission record revealed that R #2 was admitted to the facility on [DATE]. L. Record review of R #2's progress notes revealed that R #2 was discharged home on[DATE]. M. Record review revealed no detailed Discharge Summary on file for R #2. N. On 01/14/20 at 10:50 am, during an interview, the DON reported that they do not have a written Discharge Summary or written Post-Discharge Plan for R #2. O. On 01/14/20 at 12:30 pm, during an interview, the SSD reported that they do not have a Discharge Summary on file for R #2. P. On 01/15/20 at 11:07 am, during an interview, the SSD reported that the following documents were provided to the home health agency for R #2 upon discharge: Dr's Discharge Orders, Admission Record, Dr's Progress Note for date of service 08/30/19, Physical Therapy Progress Report for 09/06/19 - 09/12/19, Physical Therapy Treatment Encounter Notes 09/07/19 - 09/12/19, Occupational Therapy Progress Report for 09/06/19 - 09/11/19 Occupational Therapy Treatment Encounter Notes 09/06/19 - 09/11/19 and Order Summary Report. Q. On 01/15/20 at 11:17 am, during an interview, the SSD reported that a Transfer/Discharge Report was provided to R #2 upon discharge. The Transfer/Discharge Report contained the following information: Resident Name, admitted , Resident No., Sex, Birthdate, Age, Marital Status, Religion, Primary Language, Medicare Beneficiary ID, Social Security #, Secondary Insurance ID, Medicare Advantage #, allergies [REDACTED]. The SSD reported there is nothing else provided to the residents upon discharge. R. On 01/15/20 at 3:48 pm, during a telephonic interview, the office of the home health agency reported that the facility did not provide an Order Summary Report or Discharge Summary for R #2 upon discharge. Findings for R #3: S. Record review of R #3's admission record revealed that R #3 was admitted to the facility on [DATE]. T. Record review of R #3's progress notes revealed that R #3 was discharged home on[DATE]. U. Record review revealed no detailed Discharge Summary on file for R #3. V. On 01/14/20 at 10:50 am, during an interview, the DON reported that they do not have a written Discharge Summary or written Post-Discharge Plan for R #3. W. On 01/14/20 at 12:30 pm, during an interview, the SSD reported that they do not have a Discharge Summary on file for R #3. X. On 01/14/20 at 3:36 pm, during a telephonic interview, the Receptionist at R #3's primary care physicians office reported that they did not receive a Discharge Summary for R #3 upon discharge. Y. On 01/15/20 at 11:07 am, during an interview, the SSD reported that the following documents were provided to the home health agency for R #3 upon discharge: Dr's Discharge Orders, Admission Record, Dr's Progress Notes for date of services 09/24/19 & 09/09/19, Physical Therapy Progress Reports for 09/12/19 - 09/18/19 & 09/23/19 - 09/29/19, Physical Therapy Treatment Encounter Notes 09/12/19 - 09/17/19 & 09/23/19 - 09/27/19, Occupational Therapy OT Evaluation & Plan of Treatment certification period 10/01/19 - 11/29/19 and Order Summary Report. Z. On 01/15/20 at 11:17 am, during an interview, the SSD reported that a Transfer/Discharge Report was provided to R #3 upon discharge. The Transfer/Discharge Report contained the following information: Resident Name, admitted , Resident No., Sex, Birthdate, Age, Marital Status, Religion, Primary Language, Medicare #, Medicaid #, Social Security #, Secondary Insurance ID, allergies [REDACTED]. The SSD reported there is nothing else provided to the residents upon discharge. A[NAME] On 01/15/20 at 3:48 pm, during a telephonic interview, the office of the home health agency reported that the facility did not provide an Order Summary Report or Discharge Summary for R #3 upon discharge.",2020-09-01
4,SANTA FE CARE CENTER,325030,635 HARKLE ROAD,SANTA FE,NM,87505,2020-01-16,678,J,1,0,WQZY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > On [DATE] R #9 was found unresponsive (not responding to stimuli such as calling of her name and shaking her body) in the facility dining hall. She was taken from the dining area to her room prior to initiation of CPR (techniques to manually provide for blood circulation and oxygenation in an emergency) delaying this potentially life saving measure. During interviews with multiple staff in the facility, the staff could not immediately and accurately identify residents' code status. Some staff indicated they would start CPR on any resident found unresponsive until code status could be verified by looking in the Electronic Health Record (EHR) or a binder located at the Nurses Station, and then stop CPR if resident had elected to be Do Not Resuscitate (DNR) (Do not provide CPR services). Record review for CPR Certification status of staff revealed that the two certified Nursing Assistant's (CNA's) and the nurse involved in provision of CPR during the event on [DATE] with R #9 did not have up to date certification. This resulted in an immediate jeopardy (IJ) at a scope and severity of J (isolated jeopardy to resident health and safety) being identified on [DATE] at 2:15 pm. A Plan of Removal was approved and verified on [DATE] at 1:40 pm. Based on the Plan of Removal, the interventions included: 1. Completed audit of all residents' code status. 2. All clinical staff to have a list of residents' code status provided to them each shift that is updated daily. 3. All clinical nurses and Certified Nursing Assistants (CNA) were educated to begin CPR immediately for any resident who has elected it and found requiring it at the place at which they are found according to Basic Life Support (BLS) guidelines. 4. All nursing clinical staff to have current certification in BLS/CPR as of [DATE]. Based on the Plan of Removal, the Scope and Severity was reduced from the level J to a level [NAME] Based on record review and interview, the facility failed to: 1. Initiate CPR immediately for 1 (R #9) of 1 (R #9) residents reviewed for prompt provision of CPR when required. 2. Ensure there was a system in place for all clinical staff to immediately determine the code status (level of medical interventions a patient wishes to have if their heart or breathing stops). 3. Educate all clinical staff to provide care if a resident is discovered without breathing and/or heart beat that reflected residents wishes in accordance with their Advanced Directives. 4. Ensure clinical staff with current CPR certification are available to provide CPR if needed, at all times in the facility. These deficient practices have the potential to result in a resident not receiving immediate/effective basic Life Support/CPR if they have elected that or receiving CPR if not elected for any of the 94 residents identified as living in the facility on [DATE] by the administrator in the, Patients Census And Conditions Of Residents, (CMS-672). Findings related to R #9: [NAME] Record review of census and [DIAGNOSES REDACTED].#9 revealed, she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. B. Record review of nursing progress note on [DATE] at 5:54 am, (a late entry regarding the event [DATE]) revealed, At about 8 AM Pt. (patient/resident) non-responsive heart rate (beats per minute) and respirations diminished (less than her normal) Pt. is full code CPR started. 911 EMT's(Emergency Medical Technicians) notified. CPR was stopped when told by EMT's to stop when they took over. Pt. with V/S (vital signs, generally meant to be heart rate, respirations, blood pressure) and transported by EMT's to ER (emergency room ). C. On [DATE] at 8:35 am, during interview, the Director Of Nursing (DON) revealed regarding the event on [DATE] when R #9 became non-responsive in the dining room, That was a scary one .we came up (back to the facility) and watched the video, she (R #9) is sitting at the dining room table she reaches for her hot chocolate and takes a drink - puts it back and takes another drink and then all of a sudden she drops her cocoa and has shaking (demonstrates her arms mild shaking) then she dropped her head. Then (first name of CNA #5) came and sat in front of her and kind of looked closely and called for the nurse (LPN #1) they took her back to her room (There is a camera in the dining area and hall but not resident room) (Do you have the video still?) oh no, they only last about 7 days (Do you have a record of the code event?) No, (first name of LPN #1) did not complete one .(first name of LPN #1) said they did a finger sweep and could not find anything, so started CPR (how was she when she left the building?) They were bag / masking her (putting air into her lungs with a bag and mask). Then they (staff) called us and we came, the administrator and I . I went over to the hospital, she was in the ED (Emergency Department) still they were working on her .the nurse there told me it was a poker chip (a poker chip was found in her airway), she said they found it when they tried to intubate her (put a breathing tube into the airway ) .the tube wouldn't go in and that is when they got it out .She died about 11 (pm) that night .the daughter told me. D. Record review of event timeline provided on [DATE] by the DON, which she relayed was from watching the video of the event, revealed: 1. At 8:02:56 am, resident discovered in dining room by CN[NAME] 2. At 8:03:35 am, resident was back in her room. 2. At 8:05:03 the backboard was taken to the room. E. Record review of incident report dated [DATE] at 3:03 pm, written by CNA #1, We took (first name of R #9) to her room and notified the nurse on duty as we were taking (first name of R #9) down where (first name {misspelled} of CNA #2) and i checked her throat and didn't see anything. We proceeded after with the [MEDICATION NAME]. No results. We transferred her to the bed and performed CPR until Paramedics arrived and took over. F. On [DATE] at 8:55 am, during interview, LPN #1 revealed, Worked here [AGE] years. I went and got the backboard. We did a mouth sweep and one of the boys (CNA #1 or #2) gave her a [MEDICATION NAME] .My thought was she had a [MEDICAL CONDITION] .the EMT's showed up and took over, in maybe less than 15 minutes. I was on the phone with the 911 dispatcher for a few minutes. The CNA's (CNA #1 and CNA #2) were doing most of the CPR. Every time we did a compression, in between she was flat line (heart monitor showed no activity from heart). We were bagging her color was never cyanotic (bluish discoloration that can indicate lack of adequate oxygenation). [NAME] On [DATE] at 10:10 am the DON confirmed that LPN #1, CNA #1 and CNA #2 did not have current certification in BLS/CPR. Findings related to code status: H. On [DATE] at 8:55 am, during interview, LPN #1 revealed (How do you know which of your residents want CPR ?) We mostly know who is CPR or not. We do it (assess for their wishes/advanced directives (various documents that instruct/directive medical professionals and your family to the treatments you want to receive or refuse.)) mostly when a new resident comes in. (How many residents do you have today?) About 26 I think. (rooms?) Rooms 18 through 32 (Can you tell me which residents you have today who are full code (have directed that they want to receive CPR if indicated) verses DNR (have directed they do not want to receive CPR if they have lost the ability to breathe adequately or their heart rate is not adequate to sustain their life ?) Yes, I think so . He identified R # 10 and R # 11 as full code(have directed that they desire CPR if indicated) and the rest of his assigned residents no code(DNR). I. Record review of electronic health records (EHR's), for resident in rooms 18 through 32 on [DATE], revealed the following resident's had Advanced Directives indicating they desired CPR (full codes) if needed , R #'s, 10, 12, 13, 14 and 15. (This information was confirmed by the DON on [DATE] at 11:55 am). [NAME] On [DATE] at 10:45 am, during interview CNA #4 revealed, that regarding what he would do if he found a resident was non responsive, I would call for nurse .I would yell for help .I would start the CPR . I just recently got my CPR, it was last Thursday (how would you know if the resident wanted CPR or wanted to be a no code?) that information we don't have .I guess I wouldn't .if I . started it and the nurse said they were not CPR then I probably would stop. K. On [DATE] at 10:50 am, during interview, LPN #3 revealed, that regarding how she would respond on finding a non responsive resident, We would try to help her do what we know .(how would you know the residents Advanced Directive status?) I know most of them (you just remember?) yes. We used to have the charts up here (at nurses desk) and it was about a year ago (they went to the electronic health record (EHR)) I would start it (CPR) right here I wouldn't move her. Look at the EHR or the book they are making a book .it is up front there (indicates the front hall where DON and Administration offices are) Yes, that is new. If we happen to not know (if the resident wanted CPR or not) we start it (CPR) not knowing. L. On [DATE] at 11:03 am, during interview LPN #4 revealed, (if you find a resident laying in the courtyard no pulse no respirations and you do not know the code status what do you do?), you could start it and stop it (CPR). Regarding (name of R #14, what is his code status?) It is not on here (on the banner in the residents EHR) but I admitted him so I know he is a DNR. M. Record review of R #14's EHR revealed, he had an updated Advanced Directive that indicated he wanted CPR. (is a full code, not DNR). N. On [DATE] at 11:10 am, during interview, LPN #2 revealed that regarding initiation of CPR when a resident is found unresponsive, you immediately get down and assess them . you start CPR . you get somebody to check on the computer (at the nursing station) to find out (their advanced directive). (What if they didn't want CPR?) then you stop (CPR). It is true, if they are not on your floor you may not know (their advanced directive status).",2020-09-01
5,SANTA FE CARE CENTER,325030,635 HARKLE ROAD,SANTA FE,NM,87505,2019-07-19,550,E,0,1,W7WU11,"Based on observation and interview, the facility failed to ensure that residents were treated with respect and dignity for 4 (R #37, R #57, R #61, & R #200) of 4 (R #37, R #57, R #61, & R #200) resident sampled for dignity, when they failed to 1) ensure a resident's rights to a dignified existence for R #37, R #61, and R # 200 when they were treated disrespectfully, and 2) provide privacy for R #57's urine collection bag This deficient practice could likely result in residents becoming depressed and anxious, lacking self-esteem/self-worth. The findings are: R #37 [NAME] On 07/15/19 at 2:58 PM, during an interview, R #37 stated, Some of the CNAs (Certified Nursing Assistants); I am very hesitant to ask for any help. It is because of their demeanor; they are so indifferent to me. They don't even talk to me. They are always too busy. I wanted toothpaste and I had ask 3 times until I got it and that was pretty recent. I keep asking for urinal; they took mine. There is one in a bag in the bathroom with no name on it; but it might be for my roommate. They don't respond when I ask if it is mine. I like a urinal for the AM many times when I need to go, but I can't get them to give me one. I am not a complainer. I have not complained. When R #37 was asked how that makes him feel he stated, I sleep a lot and try not to care--that is my way to handle the staff here. B. On 07/18/19 at 9:49 AM, during an interview with the DON (Director of Nurses) regarding R #37's concerns, he stated, I was not aware of his concerns. I have not heard anything about that. Last week, I moved his urinal off his bedside table just for infection control purposes. I ask how things are going with him about every week and try to listen. It is about customer service and how they feel about you and being here. That would be something to go over again with the staff. C. On 07/18/19 at 11:42 AM, during an interview with the Administrator regarding R #37's concerns and the possible outcome to the resident, she stated, It could bring the resident down. R #57 D. On 07/15/19 at 3:12 PM during random observation, it was revealed that R #57's of catheter did not have a privacy bag and the catheter bag was visible from the hallway. E. On 07/16/19 at 3:37 PM during an interview, the ADON revealed that R #57 did not have a cover on his catheter bag and she confirmed that a privacy bag should have been in place. R #61 F. On 07/16/19 at 9:36 AM, during an interview, R #61 stated that 2 CNAs, CNA #4 and CNA #5, are curt. They are disrespectful. (Name of CNA #4) is worse. It's a lack of respect. [NAME] On 07/17/19 at 10:27 AM, during an interview, R #61 stated that she had told MDS Coordinator that problems she had been having with CNA #4. H. On 07/17/19 at 11:15 AM, during an interview, the MDS Coordinator stated, On Monday, we have our angel checks. She (R #61) felt like she (CNA #4) spoke to her in a demeaning manor . The MDSC was asked if she had reported this to anyone, she stated That morning (07/15/19) at stand up, I reported it. I. On 07/17/19 at 3:12 PM, during an interview, the DON stated that he was not aware of any concerns R #61 was having with staff. I was not in that meeting, I was getting stuff ready for you all (surveyors). [NAME] On 07/17/19 at 3:20 PM, during an interview, the Administrator stated that she had heard the issues in the Monday stand up meeting, I did know (about the concerns R #61had with CNA #4) but I assumed incorrectly that the nursing would speak to nursing staff. R #200 K. On 07/15/19 at 8:38 AM, during an interview, R #200 said, I like to eat by myself. I just got here last Friday. I haven't been to the dining room and I don't want to go. This morning, the nurse (LPN #1) said 'you have to go to dining room.' The nurse said I have to go to dining to get something to eat but my roommate doesn't because she is long term (care). The CNA brought my food tray in when she was telling me that. She (the nurse) said I had to leave the curtain (privacy curtain) open and the door open so they could keep an eye on me if I ate in here. After she said that, I was not hungry. It was cruel for her to tell me that, I had to fight tears. This morning I asked the pill nurse what these medications were for and she said they are from the doctor you just have to take them. No explanation. She said she was giving me my last pain pill. I was worried and asked her to call my doctor and she said we don't call the doctor for that type of thing we will wait until he comes in. L. On 07/15/19 at 9:01 AM, during observation, R #200 was sitting in bed, the breakfast tray is sitting untouched on the bedside table. The door to the room is open and the privacy curtain is pushed back. M. On 07/15/19 at 9:52 AM, LPN #1 stated, I was told in report (Name of R #200) she is a drug seeker. I came in with all her pills and I said that for your pain pills there is only one left. She said I needed to call the doctor. The night nurse said she always wants extras. I don't know much about her. She flung the pill on the table but took the narcotic. I guess I should not have said it is your last pain pill. I showed her package and said it the last one and said we have 6 hours before next pill is due. They (R #200 and her roommate) want their door closed but she (R #200) could choke (when eating the meal) and that could be a risk. I don't want her eating with the door closed. I want her in the dining room so she can be watched. I did not let them close the door. I won't let her close the door with food in her room. I had never met her before this day. I don't know her. I have not heard anything about her being a choking risk, but I don't know her. Maybe others let her eat with door closed, but I won't let them close her door. N. On 07/18/19 at 10:10 AM, during an interview with the DON (Director of Nurses) regarding R #200's concerns, he stated, I have not heard anything about the nurse insisting the door be open, that curtains be open if the resident is eating in their room. It seems like an over abundance of caution. That was not appropriate to give the resident more hassle about it. The nurse could have said we would like to you to be up and about for recovery. I feel like the nurse did a great disservice telling her the pain medication had run out and I know that became a big concern for this resident. I teach customer service to the staff and that is not it.",2020-09-01
6,SANTA FE CARE CENTER,325030,635 HARKLE ROAD,SANTA FE,NM,87505,2019-07-19,578,E,0,1,W7WU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that the Advanced Directives were filled out completely and correctly for 9 (R #3, R #9, R #37, R #88, R #97, R #200, R #299, R #300, & R #302) of 9 (R #3, R #9, R #37, R #88, R #97, R #200, R #299, R #300, & R #302) residents reviewed for Advanced Directives/MOST form (MOST form is a doctor's order that tells emergency medical personnel and other health care providers whether or not to administer cardiopulmonary resuscitation (CPR) in the event of a medical emergency.) This deficient practice could likely result in the resident's wishes not being followed. The findings are: R #3 [NAME] Record review of the medical chart for R #3 revealed that there was no advance directive on file. B. On [DATE] at 11:18 AM, during an interview, the DON confirmed that there was no advance directive on file and he stated We will need to complete another MOST for (name of R #3) R #9 C. Record review of R #9's advanced directive dated [DATE] revealed No Heroic resuscitations efforts was marked, and Full resuscitations was marked just below that on the form. D. On [DATE] at 3:16 PM, during an interview, the DON confirmed that R #9 advanced directive was not clear in whether R #9 want to be resuscitated or not. R #37 E. Record review of the MOST for R #37, dated [DATE], revealed Sections B Medical Intervention, Section C Artificially Administered Hydration/Nutrition, and Section D Discussed With, were all blank. F. On [DATE] at 3:07 PM, during an interview, the Social Worker (SW) stated, I see those sections are blank, the nurses should have gathered that information. R #88 [NAME] Record review of the MOST for R #88 revealed it was signed by physician but not by the resident or her representative. H. On [DATE] at 3:12 PM, during an interview with the SW regarding the Most for R #88, she confirmed, I do not see a signature by the resident or her representative. R #97 I. Record review if R #97's advanced directive dated [DATE] revealed sections B. C. D. were not filled out. [NAME] On [DATE] at 3:16 PM, during an interview with the DON confirmed that the facility had not been filling out the entirety of the advanced directives. R #200 K. Record review of the MOST for R #200 revealed a signature that was not the resident's name and there is no indication on the form that this person is a legal surrogate. L. On [DATE] at 3:09 PM, during an interview, the SW stated, (Name of R #200) is her own decision maker, she should have signed the document. I do not know who the person is who signed the document. R #299 M. Record review of the MOST for R #299, dated [DATE], revealed section B Medical Interventions, Section C Artificially Administered Hydration/Nutrition, and Section D Discussed with were all blank. R #300 N. Record review of the MOST for R #300, dated [DATE], revealed section B Medical Interventions, Section C Artificially Administered Hydration/Nutrition, and Section D Discussed with were all blank. R #302 O. Record review of the MOST for R #302, dated [DATE], revealed section B Medical Interventions, Section C Artificially Administered Hydration/Nutrition, and Section D Discussed with were all blank. P. On [DATE] at 11:17 AM, during an interview, the DON confirmed that the sections were blank and stated, We are completing an audit and we are going to retrain on the completion of the MOST and re-do them all.",2020-09-01
7,SANTA FE CARE CENTER,325030,635 HARKLE ROAD,SANTA FE,NM,87505,2019-07-19,609,D,0,1,W7WU11,"Based on record review, obsevation, and interview, the facility failed to report allegations of abuse to the State Survey Agency within 24 hours for 1 (R #86) of 2 (R #48 and R #86) reviewed for allegations of abuse. This failed practice could lead to other residents being abuse and not be reported to the State Agency. The findings are: [NAME] On 07/15/19 at 9:17 AM, during an interview, R #86 revealed that on 07/10/19 she was grabbed on the arm. R #86 reported that the DON was informed of the incident. B. On 07/15/19 at 9:17 AM, during observation, it was revealed that R #86 had 5 bruises on her left arm in different healing stages. The two large bruises were the size of a quarter and 3 smaller bruises the size of a dime. C. Record review of R #86's progress notes dated 07/18/19, written by LPN #10, revealed, (Name of R #86) was walking into the dining room when she passed by (name of R # 9). (Name of R # 9) asked (Name of R #86) for a sandwich and (Name of R #86) told (Name of R #9) that in the dining room, they would give him food. (Name of R #9) told (Name of R #86) 'F___-YOU' and grabbed (Name of R #86) from the left arm. PTs (patients) were separated and (Name of R #86) has some light bruising to the inside of her left arm. D. On 07/18/19 at 9:37 AM, during an interview, the DON revealed that he did not report the incident between (Name of R #86) and (Name of R #9) to the State Survey Agency within 24 hours. He revealed that he was not made aware of the incident until the evening of or the day after the incident. E. On 07/18/19 at 2:52 PM, during an interview, the DON revealed that he did not have documented proof of sending the initial report to the State Survey Agency and was only able to provide proof of the five day follow up report",2020-09-01
8,SANTA FE CARE CENTER,325030,635 HARKLE ROAD,SANTA FE,NM,87505,2019-07-19,623,B,1,0,W7WU11,"> Based record review and interview, the facility failed to notify the ombudsman of transfers and discharges from the facility for 2 (R #99 and R #102) of 2 (R #99 and R #102) residents sampled for discharges. This deficient practice could likely result in resident not receiving assistance from the ombudsman's office for transfer or discharges. The findings are: [NAME] Record review of R #102's Medical Record revealed no documentation sent to the Ombudsman regarding R #102's discharge. B. Record review of R #99's Medical Record revealed no documentation sent to the Ombudsman regarding R #99's discharge. C. On 07/17/19 at 8:01 AM, during an interview, the Social Services Director stated that the Ombudsman said not to send any paperwork for discharge unless it was a 30 day notice. She was getting too much paperwork. We stopped in March. D. Record review of the discharge notice binder revealed no notices after (MONTH) 2019.",2020-09-01
9,SANTA FE CARE CENTER,325030,635 HARKLE ROAD,SANTA FE,NM,87505,2019-07-19,656,E,0,1,W7WU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation, the facility failed to ensure a resident who was without teeth was care planned for dental services and dietary needs for 1 (R #72) of 8 (R #21, R #30, R #37, R #48, R #55, R # 72, R #88, and R #200 ) residents reviewed for dental health and services. This deficient practice could result in the resident's needs not being met. The findings are: [NAME] On 07/15/19 at 9:16 AM, during an interview, R #72 stated, I had dentures years ago, but I had a lot of trouble with them. They kept bothering me and I kept going back (to the dentist). Finally the dentist's office said Medicaid didn't want to pay anymore for me to keep going back. I have to eat without teeth. I would like dentures that fit me. I just skip the hard foods, I can't eat the hard foods. No one has offered an appointment. B. On 07/15/19 at 9:19 AM, during observation, R #72 opened her mouth to show she had no teeth. The examination revealed the resident has no teeth. C. On 07/16/19 at 3:36 PM, during an interview, the SW (Social Worker) stated, I had not heard anything about (Name of R #72) not having teeth. I will put her on the list to see the dentist. D. On 07/16/19 at 4:15 PM, during an interview with the MDS (Minimum Data Set) Coordinator regarding R #72's oral status, she said, The SW completes that (Dental Section) and would usually follow up on dental. and ask if she (the resident) wants dentures. There should have been an inquiry. There is nothing regarding dietary and her oral status in her care plan E. Record review of the MDS dated [DATE] for R #72 revealed: Section L0200. Dental Check all that apply [NAME] Broken or loosely fitting full or partial denture(chipped, cracked, uncleanable, or loose) F. Mouth or facial pain, discomfort or difficulty with chewing Neither item was check marked",2020-09-01
10,SANTA FE CARE CENTER,325030,635 HARKLE ROAD,SANTA FE,NM,87505,2019-07-19,658,E,0,1,W7WU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation, the facility staff failed to ensure [MEDICATION NAME] (a [MEDICATION NAME] supplement--live microorganisms that are intended to have health benefits) was given per physician orders [REDACTED].#8) of out of 14 ( R #2, R #11, R #13, R #15, R #33, R #35, R #43, R #48, R #63, R #70, R #96, R #300, and R #303) residents reviewed during medication pass. This deficient practice could result in the resident not receiving the desired therapeutic effect of the supplement. The findings are: [NAME] Record review of the physician orders [REDACTED]. B. Record review of the MAR (Medication Administration Record) for R #8 for (MONTH) 2019 revealed: [MEDICATION NAME] Capsule 250 mg (Saccharomyses boulardii) Give 2 capsules by mouth two times a day for gut health. The MAR showed that it was noted as being administered twice a day from 07/01/19 to 07/18/19 and once on 07/19/19. C. On 7/19/19 at 08:13 AM, during observation of the medication pass, RN #1 was observed removing 2 capsules from a bottle labeled acidophilus (a type of [MEDICATION NAME]--contains the bacteria Lactobacillus acidophilus) with pectin, ( fiber found in fruit used to make medicine) and administering them to R #8. D. On 7/19/19 at 3:15 am, during an interview, RN #1 confirmed that she had given R #8 2 capsules of acidophilus with pectin. RN #1 stated, Even though the MAR says to give [MEDICATION NAME] Capsules; we have never had the. We just give the acidopilus. It doesn't mean anything if the MAR and the medicine don't match in this instance, we all know it is the same thing ([MEDICATION NAME] and Acidophilus). E. On 07/19/19 at 10:00 am, during an interview, the ADON (Assistant Director of Nurses) stated, If the [MEDICATION NAME] was not available, the nurses should have contacted the doctor instead of giving the Acidophilus. It is not what was ordered. F. Review of the National Institute of Health, [MEDICATION NAME], Fact Sheet for Professionals, (MONTH) (YEAR), revealed: [MEDICATION NAME] exert their effects usually in the gastrointestinal tract, where they may influence the intestinal microbiota. [MEDICATION NAME] can transiently colonize the human gut mucosa in highly individualized patterns, depending on the baseline microbiota, [MEDICATION NAME] strain, and gastrointestinal tract region (4). [MEDICATION NAME] also exert health effects by nonspecific, species-specific, and strain-specific mechanisms (1). The nonspecific mechanisms vary widely among strains, species, or even genera of commonly used [MEDICATION NAME] supplements. Because effects of [MEDICATION NAME] can be specific to certain [MEDICATION NAME] species and strains, recommendations for their use in the clinic or in research studies need to be species and strain specific.",2020-09-01
11,SANTA FE CARE CENTER,325030,635 HARKLE ROAD,SANTA FE,NM,87505,2019-07-19,677,D,0,1,W7WU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide ADL (activities of daily living) assistance for nail care for 1 (R #27) of 1 (R #27) residents reviewed for ADL's. This deficient practice has the potential to affect the dignity and health of the residents. The findings are: [NAME] On 07/15/19 at 12:24 pm, during observation, R #27 was observed with dirty and uncut fingernails. B. On 07/18/19 at 11:05 am, a second observation of R #27 revealed, R #27's nails had a black substance under her thumb nails and were not clean or cut. C. On 07/19/19 at 9:49 AM, the resident was observed in her room. Her nails were different lengths except her thump nails which were long and dirty with a black substance. Resident reported that she cuts her own nails and showed me a nail clipper. D. On 07/16/19 during record review of R #27's care plan dated 04/30/19 revealed: Focus: (Name of R #27) have an ADL Self Care Performance Deficit r/t: Progressed dementia and require staff assistance with all ADL's. Goal: (Name of R #27) will maintain current level of function in Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene through the review date. Interventions: C.N.[NAME] Nursing *Praise all efforts at self-care. *TOILET USE: I require (X) staff participation to use toilet. *TRANSFER: I require (1) staff participation with transfers for my safety due to risk of falls but I will usually self-transfer since I forget to call for assistance. *Encourage me to participate to the fullest extent possible with each interaction. *SKIN INSPECTION: I require SKIN inspections on my scheduled shower days 3X per week by the CNA and once weekly by my nurse. Observe for redness, open areas, scratches, cuts, bruises and report changes to the Nurse. Nurse to document ton weekly skin assessment sheets. *BATHING: I am able to participate in bathing but require staff assistance and verbal cueing. *PERSONAL HYGIENE/ORAL CARE: I require 1 staff participation with personal hygiene and oral care. *PERSONAL HYGIENE/ORAL CARE: I require limited to extensive assistance of 1 staff with my hygiene needs. Please cue and direct me so I can participate to the best of my ability. * DRESSING: Allow me sufficient time for dressing and undressing. The task is confusing for me and I require limited to extensive assist of 1 staff. E. On 07/16/19 during record review of R #27's care plan dated 04/30/19 revealed: DX (Diagnosis) UNSPECIFIED DEMENTIA WITHOUT BEHAVIORAL DISTURBANCE (F03.90), OTHER [MEDICAL CONDITION] (A condition in which there are high levels of fat particles (lipids) in the blood.) (E78.49), HISTORY OF FALLING (Z91.81), DISPLACED INTERTR[NAME]HANTERIC (fractures are considered one of the three types of [MEDICAL CONDITION]. The anatomic site of this type of [MEDICAL CONDITION] is the proximal or upper part of the femur or thigh bone) FRACTURE OF LEFT FEMUR, SEQUELA (a condition which is the consequence of a previous disease or injury.the long-term sequelae of infection) (S72.142S), DYSPHAGIA (Difficulty swallowing foods or liquids, arising from the throat or esophagus, ranging from mild difficulty to complete and painful blockage.), OROPHARYNGEAL (dysphagia encompasses problems with the oral preparatory PHASE of swallowing chewing and preparing the food), (R13.12), COGNITIVE COMMUNICATION DEFICIT (disorders are problems with communication that have an underlying cause in a cognitive deficit rather than a primary language or speech deficit.) (R41.841) E. On 07/19/19 at 9:53 AM, during record review of R #27's ADLs revealed no documentation of the resident's nails being cut. F. On 07/19/19 at 9:58 AM, during interview, CNA #5 revealed that the CNAs are responsible for cutting residents finger nails on their designated bath days. When asked if R #27 nails were cut on her last bath day, CNA #5 revealed that she had not cut R #27's nails. [NAME] On 07/19/19 at 10:20 AM, during an interview with ADON revealed that R #27's bath days are Tuesday and Fridays and confirmed that nail care should be done at that time.",2020-09-01
12,SANTA FE CARE CENTER,325030,635 HARKLE ROAD,SANTA FE,NM,87505,2019-07-19,684,E,0,1,W7WU11,"Based on record review and interview, the facility failed to provide needed care and services for hospice services for 1 (R #52) of 1 (R #52) residents sampled for hospice services, when they failed to obtain notes from hospice staff when they came to provide care for R #52. If hospice staff are not leaving notes of the care they provide to residents in the facility, then this could likely cause residents not to receive the end of life care they need. The findings are: [NAME] Record review of R #52's Medical Record revealed no notes or order for hospice services were found. B. On 07/16/19 at 8:58 AM, during an interview, LPN #6 stated that the hospice service that R #52 had does not like to leave notes for the facility. C. On 07/17/19 at 12:27 PM, during an interview, the Medical Records Director stated that No, they (the hospice services R #52 had) don't provide notes. We have a problem with them. D. On 07/19/19 at 9:23 AM, during an interview, the DON confirmed that R #52 did not have his hospice order put into the electronic medical record, and the facility should have.",2020-09-01
13,SANTA FE CARE CENTER,325030,635 HARKLE ROAD,SANTA FE,NM,87505,2019-07-19,686,D,0,1,W7WU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure ulcers (Injuries to the skin and underlying tissue resulting from prolonged pressure on the skin) from forming for 1 (R #300) of 1 (R #300) residents reviewed for pressure ulcers. This deficient practice is likely to result in wounds worsening or not healing. The findings are: [NAME] Record review of face sheet for R #300 revealed they were admitted on [DATE]. B. Record review of Admission Data collection: Section 5-Skin assessment dated [DATE] showed no pressure ulcers were present on the resident. C. Record review of BRADEN SCALE (A scale used by health professionals to assess a patient's risk of developing a pressure ulcer) FOR PREDICTING PRESSURE SORE RISK dated 07/10/19 revealed a score of 17-At risk. D. Record review of the Weekly Skin Check dated 07/10/19 showed no pressure ulcers were present on the resident. E. Record review of care plan dated 07/10/19 revealed no interventions regarding the risk and/or prevention of developing pressure ulcers. F. Record review of the Weekly Skin Check dated 07/18/19 showed resident to have a stage II (a shallow open sore) pressure ulcer. [NAME] On 07/18/19 at 3:33 PM, during an interview, the wound care nurse confirmed that there had been no interventions for pressure ulcer prevention in place prior to 07/18/19 and she also confirmed that resident had developed a stage II pressure ulcer which was noted on 07/18/19.",2020-09-01
14,SANTA FE CARE CENTER,325030,635 HARKLE ROAD,SANTA FE,NM,87505,2019-07-19,690,D,0,1,W7WU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide incontinence care for 1 (R #27) of 2 (R #27 and R #48) residents reviewed for bladder and bowel incontinence. This deficient practice has the potential to affect the self-esteem and well-being of the residents. The findings are: [NAME] On 07/16/19 at 3:13 PM, during an interview, R #27's roommate, R #86, revealed that R #27 was not changed on (MONTH) 15th and 16th from 5am to 1pm. B. On 07/17/19 at 11:50 AM, during observation, R #27 was walking down the hall towards her room with a saggy brief that appeared to be full and R #27 had the odor of urine. C. On 07/17/19 at 1:50 PM, record review of ADL (activities of daily living): The things we normally do in daily living including any daily activity we perform for self-care such as feeding ourselves, bathing, dressing, grooming, work, homemaking, and leisure.) sheets revealed that the CNAs during day-shift did not document changing resident's brief for the following days: 07/07/19, 07/12/19, and 07/16/19. D. Record review of R #27's care plan dated 04/30/19 revealed: Focus: *I, (name of R #27) have bowel and bladder (B&B) incontinence r/t: Progressed dementia Goal: *My risk for [MEDICAL CONDITION] (a serious bloodstream infection. It's also known as blood poisoning. [MEDICAL CONDITION] occurs when a bacterial infection elsewhere in the body, such as the lungs or skin, enters the bloodstream.) will be minimized/prevented via prompt recognition and treatment of [REDACTED].) through the review date. * I will decrease frequency of B&B incontinence to only once daily through the next review date by routine toileting. * I (name of R #29) will remain free from skin breakdown due to incontinence and brief use through the review date. Interventions: *ACTIVITIES: notify nursing if incontinent during activities. *BRIEF USE: I use small disposable briefs. Change every 2-3 hours and prn. Provide good peri-care (washing the genitals and anal area.) and apply skin barrier cream after each incontinent episode to protect my skin integrity. *Encourage fluids during the day to promote prompted voiding responses. *Ensure I have an unobstructed path to the bathroom. *Establish voiding patterns. *Offer prompted toileting every 2-3 hours to prevent/decrease incontinent episodes. E. On 07/18/19 at 9:13 PM during an interview, the ADON revealed that R #29 should be changed as needed and CNAs need to be checking her at least every 2 hours to ensure R #27 brief is changed.",2020-09-01
15,SANTA FE CARE CENTER,325030,635 HARKLE ROAD,SANTA FE,NM,87505,2019-07-19,692,E,0,1,W7WU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to recognize, evaluate, and addressee the nutritional needs of 1 (R #20) of 1 (R #20) residents sampled for nutrition. This deficient practice could like result residents not receiving the nutritional assistance they need. The findings are: [NAME] Record review of R #20 weight revealed the following 1. 7/1/2019 - 87.4 Lbs 2. 6/4/2019 - 95.4 Lbs an 8.42% loss in one month B. Record review of the progress notes revealed the following: 6/28/2019 Late Entry: Note Text: Monthly [MEDICAL TREATMENT]: Ht: 58 Wt: 95.4 lbs BMI: 19.9. (Name of R #20) has continued to have HD ([MEDICAL TREATMENT]) M/W/F. She is receiving a 2 gram Na (salt) diet, pureed, in her room. She does receive Magic Cups for lunch, dinner. She continues to have 25-75% intake at most meals. She is on a 1000 mL fluid restriction. [MEDICAL TREATMENT] continues to use caution when dialyzing, due to age, and tolerance of process. Her skin is currently intact. She has been 95-99 lbs x 5 months, and is currently within her IWR of 86-105 lbs. Continue with nutrition plan in place. Honor food and beverage preferences. No note regarding the weight loss was found. C. On 07/19/19 at 9:16 AM, during an interview, the DON stated It does not look like the dietician caught that one (R #20's weight loss). She came 07/03/19. The DON confirmed that no dietary changes had occurred for R #20. D. On 07/19/19 at 9:58 AM, during an interview, the Dietician stated that when she came on 06/28/19, the facility had not weighted R #20. They weighed her on 07/01/19. I am scheduled one day a week often I come second time. The dietician was asked if she had been back to the facility since 07/01/19, she stated that she had I was trying to do the residents with wounds. The dietician was asked when she was made aware of R #20's weight loss, she stated, Just now . I did not check with restorative for her weight. The dietician continued to state that the weight loss could have been due to R #20 being on [MEDICAL TREATMENT].",2020-09-01
16,SANTA FE CARE CENTER,325030,635 HARKLE ROAD,SANTA FE,NM,87505,2019-07-19,698,E,0,1,W7WU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide needed care and services for [MEDICAL TREATMENT] services for 1 (R #20) of 1 (R #20) residents sampled for [MEDICAL TREATMENT] services, when they failed to obtain notes from the [MEDICAL TREATMENT] center when R #20 came back to the facility. If facility staff are receiving notes from the [MEDICAL TREATMENT] canter, then this could likely cause residents not to receive the care they need. The findings are: [NAME] Record review of R #20's medical record revealed no notes from the [MEDICAL TREATMENT] center. B. On 07/17/19 at 8:19 AM, during an interview, LPN #6 stated We do not always get things from [MEDICAL TREATMENT]. They fax it sometimes. C. On 07/17/19 at 8:21 AM, during an interview, the Medical Records Director stated Sometimes we do. Sometimes don't (get the notes from the [MEDICAL TREATMENT] center). Last I got something was in (MONTH) (2019). D. On 07/17/19 at 8:27 AM, during an interview, the ADON stated that We just created a new communication record form that we will be sending every time they go to [MEDICAL TREATMENT]. The ADON confirmed that this was supposed to send every time residents went to [MEDICAL TREATMENT], but they had not been sending it. E. Record review of R #20 physician's orders [REDACTED]. F. On 07/17/19 at 8:34 AM, during an interview the DON confirmed that the order for R #20 should be in the electronic record, but was not.",2020-09-01
17,SANTA FE CARE CENTER,325030,635 HARKLE ROAD,SANTA FE,NM,87505,2019-07-19,726,F,0,1,W7WU11,"Based on record review and interview, the facility failed to perform nursing competencies for nursing staff. This has the potential to affect all nurses that work in the facility (Nurses were identified by the staff schedule provide by the DON on 07/15/17). If the facility does not perform nursing competencies on their nurses then this could likely result in nurses working with residents without being competent to do so, resulting injury or insufficient care to residents. The findings are: [NAME] Record review of RN #5, RN #6, RN #7, LPN #7, and LPN #8 employee records revealed no competencies. B. On 07/18/19 at 3:44 PM, during an interview the DON confirmed that the facility was only using an online education system. We don't have the competencies.",2020-09-01
18,SANTA FE CARE CENTER,325030,635 HARKLE ROAD,SANTA FE,NM,87505,2019-07-19,730,F,0,1,W7WU11,"Based on record review and interview, the facility failed to use employee evaluations for part of the 12 hours of annual education for CNA staff. This has the potential to affect all CNAs that work at the facility (CNAs were identified by the staff schedule provide by the DON on 07/15/17). If the facility is not using the employee evaluations for part of the 12 hours of annual training staff may not be learning for their mistakes and continue to do them, therefore negatively impacting on the care provided to the residents. The findings are: [NAME] Record review of CNA employee training sheets reveled the facility uses an online training format. B. On 07/18/19 at 4:21 PM, during an interview, the DON was asked if the facility uses the employee evaluations for apart of the 12 hours annual training. He stated, That is something I don't think I can provide to you, a link from evaluations to the 12 hours of training. The DON stated that because if there was something that need to be corrected the facility does not wait for the employee evaluations.",2020-09-01
19,SANTA FE CARE CENTER,325030,635 HARKLE ROAD,SANTA FE,NM,87505,2019-07-19,755,D,0,1,W7WU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation, the facility failed to provide a nicotine patch in a timely manner to 1 ( R #200) of 1 (R #200) resident reviewed randomly as a new admission. This deficient practice could likely cause unneeded suffering by an unnecessary delay in meeting the resident's needs by following the physician's orders [REDACTED]. [NAME] Review of the Medication Administration Record [REDACTED]. B. Record review of the physician order [REDACTED]. C. On 07/17/19 09:16 AM, during an interview, R #200 stated, The nurse said she would get me nicotine patches since I can't smoke here. I still don't have nicotine patches. I keep asking and asking where they are. The nurses tell me their are no patches for me yet. I am having a real hard time. D. On 07/17/19 at 9:18 AM, during an interview, LPN #1 was asked about nicotine patches for R #200. She stated, No I do not have them yet. E. On 07/17/19 at 10:13 AM, during an interview, the ADON was asked about the nicotine patches for R #200. She stated, The nicotine patches can picked up locally if needed. The order was from 07/13/19 in the afternoon and they should have started 14th (the next day). It had not come to me as a concern. On the 14th if they were not available, the nurse should have contacted nursing administration.",2020-09-01
20,SANTA FE CARE CENTER,325030,635 HARKLE ROAD,SANTA FE,NM,87505,2019-07-19,759,E,0,1,W7WU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and observation, the facility failed to ensure their medication error rate was less than 5% when they did not follow physician orders [REDACTED].#15, R #48, and R #96) out of 14 ( R #2, R #11, R #13, R #15, R #33, R #35, R #43, R #48, R #63, R #70, R #96, R #300, and R #303) residents reviewed during medication pass. This deficient practice results in the residents not receiving the medications as ordered by the physician and altering the desired therapeutic effect or exposing the resident to higher risk of experiencing side effects. The findings are: R #96 [NAME] Record review of the physician's orders [REDACTED]. B. Record review of the physician's orders [REDACTED]. Rinse mouth after administration, do no (sic) swallow. C. On 07/15/19 at 9:15 AM during observation of the medication pass, LPN #1 administered [MEDICATION NAME] Diskus 1 puff to R #96, then administered [MEDICATION NAME] HFA (a type of inhaler used to dilate the breathing tubes) one puff and almost immediately a second puff. LPN #1 did not assist the resident nor advise her to rinse her mouth with water and spit it out after using the [MEDICATION NAME] Diskus Inhaler. D. On 07/15/19 at 9:20 AM, during an interview with LPN #1 regarding the medication administration for R #96, she stated, No, it does not matter which inhaler she uses first. I did not know she needed to rinse her mouth after using a steroid inhaler. E. On 07/19/19 at 10:01 AM, during an interview with the ADON (Assistant Director of Nurses) regarding the inhaled medications for R #96, she stated, The nurse should have allowed a minute or two to pass between the [MEDICATION NAME] inhalations to get the best effect. She should have had the resident rinse her mouth and spit after the [MEDICATION NAME] inhaler. F. Review of [MEDICATION NAME] Diskus Package insert revealed: [MEDICATION NAME] can cause serious side effects, including fungal infection in your mouth or throat (thrush). Rinse your mouth with water without swallowing after using [MEDICATION NAME] to help reduce your chance of getting thrush. [NAME] Review of package insert for [MEDICATION NAME] Inhaler Glaxo[NAME]Kline (GSK) at www.[MEDICATION NAME].com. This Patient Information and Instructions for Use have been approved by the U.S. Food and Drug Administration Breathe out through your mouth and push as much air from your lungs as you can. Put the mouthpiece in your mouth and close your lips around it. Step 4. Push the top of the canister all the way down while you breathe in deeply and slowly through your mouth. Step 5. After the spray comes out, take your finger off the canister. After you have breathed in all the way, take the inhaler out of your mouth and close your mouth. Step 6. Hold your breath for about 10 seconds, or for as long as is comfortable. Breathe out slowly as long as you can. If your healthcare provider has told you to use more sprays, wait 1 minute and shake the inhaler again. Repeat R #15 H. Record review of the physician's orders [REDACTED]. I. On 07/19/19 at 7:47 AM during observation of the medication pass, RN #1 administered a pill to R #15 from a bubble pack labeled [MEDICATION NAME] (a medication used for treatment of [REDACTED]. (Each individual bubble has 1/2 pill in the bubble). [NAME] Record review of the MAR (Medication Administration Record) that RN #1 signed off as being given was labeled oxybutinin 5 mg tab po. K. On 07/29/19 at 7:50 AM, during an interview with RN #1, she stated, Yes the package is different from the MAR, but we all (all nursing staff giving medications) know she (R #15) gets just the [MEDICATION NAME] 1/2 pill. I only work 3 days a week and I expect the other nurses would let me know if there were any changes. L. On 07/19/19 at 10:01 AM, during an interview, the ADON stated, The nurse should have noticed the difference in the [MEDICATION NAME] dose and clarified the order before giving the medication. R #48 M. Record review of the physician order [REDACTED].>On 07/19/18 at 7:56 am, during observation of the medication pass, RN #1 administered a pill from a bubble pack to R #48. Record review of the pack revealed that it was labeled [MEDICATION NAME] 300 mg tablet. The Medication Administration Record [REDACTED]. N. On 7/19/19 at 8:10 am, during an interview, RN #1 stated, I see the package and the MAR indicated [REDACTED]. She affirmed she should have compared the MAR indicated [REDACTED]. O. On 07/19/19 at 10:01 AM, during an interview, the ADON stated, The nurse should have clarified the order and given the correct dosage. We have ranitadine over the counter in the medication, she could have used that and given the right dosage. P. Review of the bubble pack for R #48, labeled [MEDICATION NAME] 300 mg tablets revealed out of a 30 pill pack, 18 had been removed from the bubble pack.",2020-09-01
21,SANTA FE CARE CENTER,325030,635 HARKLE ROAD,SANTA FE,NM,87505,2019-07-19,791,E,0,1,W7WU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation, the facility failed to ensure residents who were without teeth were offered dental services for dentures for 2 (R #3 and R #72) of 2 (R #3 and R #72) residents reviewed for dental health and services. This deficient practice could result in the resident's needs not being met. The findings are: R #3 [NAME] Record review of R #3's admission record, indicated that the resident was initially admitted to the facility on [DATE]. B. On 07/15/19 at 10:14 AM, during an interview with R #3 he stated he had not seen a dentist since he has been at the facility and that he was interested in getting dentures. The residents mouth was observed, and he has one tooth on the upper right. C. On 07/17/19 at 11:20 AM, during an interview with LPN # 2, he stated he was unaware that R #3 had no teeth or that he wanted dentures. He checked the residents record and did not find any dental consultation forms. D. On 07/17/19 at 11:23 AM, during an interview, the Scheduler stated that the nurses or social workers would let her know if an appointment was needed and that R #3 had not seen a dentist. E. On 07/18/19 at 11:55 AM, during an interview with the DON and ADON, the DON said, I should speak to the Social Worker (SW) regarding dental visits for (name of R #3). F. On 07/18/19 at 4:16 PM, during an interview, the SW stated that R #3 had not been seen by the dentist. Per SW He never asked to be seen. R #72 [NAME] On 07/15/19 at 9:16 AM, during an interview, R #72 stated, I had dentures years ago, but I had a lot of trouble with them. They kept bothering me and I kept going back (to the dentist). Finally the dentist's office said Medicaid didn't want to pay anymore for me to keep going back. I have to eat without teeth. I would like dentures that fit me. I just skip the hard foods, I can't eat the hard foods. No one has offered an appointment. H. On 07/15/19 at 09:19 AM, during observation, R #72 opened her mouth to show me she had no teeth. The examination revealed the resident has no teeth. I. On 07/16/19 at 03:36 PM, during an interview with the SW (Social Worker) she stated, I had not heard anything about (Name of R #72) not having teeth. I will put her on the list to see the dentist. [NAME] On 07/16/19 at 04:15 PM, during an interview with the MDS (Minimum Data Set) Coordinator regarding R #72's oral status, she said, The SW completes that (Dental Section) and would usually follow up on dental. and ask if she (the resident) wants dentures. There should have been an inquiry. There is nothing regarding dietary and her oral status in her care plan K. Record review of the MDS dated [DATE] for R #72 revealed: Section L0200. Dental Check all that apply [NAME] Broken or loosely fitting full or partial denture(chipped, cracked, uncleanable, or loose) F. Mouth or facial pain, discomfort or difficulty with chewing Neither item was check marked",2020-09-01
22,SANTA FE CARE CENTER,325030,635 HARKLE ROAD,SANTA FE,NM,87505,2019-07-19,804,E,0,1,W7WU11,"Based on record reveiw and interview, the facility failed to ensure the food was palatable for 6 (R #11, R #37, R #55, R #57, R #86, and R #201) of 6 (R #11, R #37, R #55, R #57, R #86, and R #201) residents reviewed for food. Two residents (R #55 and R #201) said the food was cold and 4 residents said the food was not good (R #11, R #37, R #57, and R #86). This deficient practice has the potential for residents to not eat meals and could lead to weight loss. The findings are: [NAME] On 07/15/19 at 3:50 PM during an interview, R #11 revealed, The food isn't very tasty. B. On 07/15/19 at 9:37 AM during an interview, R #86 revealed that a few months ago they had chicken on a bun for four days in a roll and the chicken was dry and about two weeks ago R #86 ordered a Cesar Salad and the lettuce was brown around the edges. C. On 07/16/19 at 3:47 PM during an interview, the Dietary Manager revealed that he started a food committee to address the residents' concerns and suggestions regarding the food. D. On 07/18/19 at 3:36 PM during an interview, the Dietary Manager (DM) revealed that about two or three weeks ago R #86 brought a salad back to the kitchen because the lettuce was wilted around the edges. When asked what he observed, he reported that if he had been served that salad in a restaurant he would have complained. He reported that his staff stacked the salads on top of each other in the refrigerator and this caused the lettuce to appear wilted. E. On 07/15/19 at 2:58 PM, during an interview, R# 37 stated, The food is so bad that I lose my appetite. I am on no special diet; the food just tastes bad. I hoard salt to try and make it taste better. I have not said anything. I am reluctant to speak out. I don't want to get people mad (at me). F. On 07/15/19 at 10:15 AM, during an interview, R #55 stated, The food at best is fair, at best not great. It is not hot enough. I eat in my room. I have told staff the food is not hot, it is cold. [NAME] On 07/19/19 at 8:06 AM, during observation, R #201 said to RN #1, I cannot eat this food. The food is cold and the grease is congealed. RN #1 stated to R #201, There are no alternatives available for breakfast and left the room.",2020-09-01
23,SANTA FE CARE CENTER,325030,635 HARKLE ROAD,SANTA FE,NM,87505,2019-07-19,880,F,0,1,W7WU11,"Based on observation, interview, and record review, the facility failed to ensure 1)that nursing staff followed proper hand hygiene practices while handling linen, 2) failed to ensure staff cleaned and disinfected the glucometer (a machine used to check blood sugar) between residents for with diabetes (a disorder of metabolism), and 3) distribute ice in a sanitary manner. These deficient practices could affect all 98 residents (per matrix provided by the administrator on 07/15/19 and could likely cause cross contamination (transfer of potentially harmful organisms from one resident to another resulting in illness and death). The findings are: Hand Hygiene [NAME] On 07/19/19 at 8:52 AM during observation in the laundry room, Laundry Aid (LA) #1 did not do hand hygiene after she removed her dirty gown and gloves after loading the washer, she then proceeded into the clean dryer room and was observed taking clothing out of the dryer. When ask if she should have done hand hygiene, LA #1 gave a blank stare and looked and her supervisor, who responded for LA #1. The Supervisor stated, Yes, or at least hand sanitizer. B. On 07/19/19 at 10:08 AM during random observation, revealed that Hospitality Aid (HA) #5 was witnessed walking out of R #57's room carrying dirty linen without gloves and opened clean linen closet by her hands and then proceeded to the dirty linen closet and placed linen in dirty linen barrel then went back to the clean linen closet and took out a clean sheet without using any hand hygiene between tasks. C. On 07/19/19 at 10:16 AM during interview, HA #5 was asked if she should be using gloves. She stated, Yes, and was asked when she should she be using hand hygiene. She stated, After handling dirty linen. When asked what the outcome to not using proper hand hygiene, she reported, Cross contamination. D. On 07/19/19 at 10:48 AM during interview, the Infection Control nurse and ADON confirmed that staff should be preforming proper hand hygiene between tasks when handling dirty linen and when working residents. Glucometer Disinfection E. On 07/18/19 at 3:53 PM, during medication pass observation, RN #2 performed a fingerstick blood glucose check on R #70 with a glucometer, then wiped the glucometer with alcohol wipes before returning to the medication cart. F. On 07/19/19 at 3:58 PM, during an interview, RN #2 was asked how she disinfects the glucometer. She stated, I use the alcohol wipes. [NAME] On 07/18/19 at 4:08 PM, during medication pass observation, RN #3 performed a fingerstick blood glucose check on R #202, during the procedure she had to repeat the test and took another glucose test strip out of the vial and laid the vial on the resident's bed. After performing the test, RN #2 returned the glucometer and the vial of test strips into the basket on the medication cart containing supplies to check a blood glucose (lancets, alcohol, test strip vial, glucometer). The glucometer and vial were not cleaned nor disinfected prior to returning them to the supply basket. H. On 07/18/19 at 4:15 PM, during an interview with RN #3, she stated that she disinfects the glucometer at the beginning and end of her shift, but not in between residents. She stated that is what they do at a local hospital where she had worked. I. On 07/18/19 at 4:25 PM, during an interview, the DON was asked about the observed lack of glucometer disinfection. He stated, I teach to use the Saniwipes (a disinfectant wipe) and to disinfect after use between residents. The risk would be infection. [NAME] Record review of the facility policy Blood Sampling-Capillary (Finger Sticks), revised (MONTH) 2014, revealed: Purpose: The purpose of this procedure is to guide the safe handling of capillary-blood sampling devices to prevent transmission of bloodborne disease to residents and employees. Equipment and Supplies: 6. Approved EPA (Environmental Protection Agency) registered disinfectant for cleaning of sampling device. Steps in the Procedure: 8. Following the manufacturer's instructions, clean and disinfect reusable equipment, parts, and/or devices after each use. 11. Replace blood glucose monitoring device in storage area after cleaning. Ice Pass K. On 07/16/19 at 9:29 AM, during observation of the ice pass in Hall #1, CNA #2 was going from room to room with the ice chest on a cart remaining in the hall. CNA #2 would take each pitcher/cup and remove the lid and straw and take the cup to the ice chest. With the ice lid open, CNA #2 would use the scoop to put ice into the pitcher/cup allowing ice to overflow and go back into the ice chest. CNA #2 returned to the room to place the lid and straw back on the cup and then proceed and do the same process for the next resident. She did not perform hand hygiene between the residents although she had handled the cup and straw of the resident. L. On 07/16/19 at 3:17 PM, during observation of the ice pass in Hall #3, CNA #3 was providing ice and water to residents. CNA #3 was going from room to room providing ice from the ice chest on a cart remaining in the hallway. CNA #3 would take each pitcher/cup and remove the lid and straw then take the cup to the ice chest. With the ice lid open, CNA #3 would hold the cup over the ice chest and use the scoop to put ice into each cup allowing ice to overflow from the cup back into the ice chest. CNA then returned to the room to replace lid and straw on the cup and then proceeded with the same process for the next resident. He did not perform hand hygiene between residents although he had handled the cup, lid and straws of the residents. M. On 07/16/19 at 3:21 PM, during observation of the ice pass in Hall #3, CNA #4 was providing ice and water to residents. CNA #4 was going from room to room providing ice from the ice chest on a cart remaining in the hallway. CNA #4 would take each pitcher/cup and remove the lid and straw then take the cup to the ice chest. With the ice lid open CNA #4 would hold the cup over the ice chest and use the scoop to put ice into each cup allowing ice to overflow from the cup back into the ice chest. CNA then returned to the room to replace lid and straw on the cup and then proceeded with the same process for the next resident. She did not perform hand hygiene between residents although she had handled the cup, lid and straws of the residents. N. On 07/19/19 at 10:05 am, during an interview with the IP (Infection Preventionist) about the ice passes, she confirmed that the CNAs should be doing hand hygiene between residents and not allowing ice that touches a resident's cup fall back into the ice chest. She stated, That could cause cross contamination.",2020-09-01
24,SANTA FE CARE CENTER,325030,635 HARKLE ROAD,SANTA FE,NM,87505,2019-07-19,881,F,0,1,W7WU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure staff implemented a program of antibiotic stewardship (a set of commitments and actions designed to optimize the treatment of [REDACTED]. This deficient practice can affect any of the 98 residents in the facility (on the census list provided on 07/15/19 by the Administrator) who might be placed on antibiotics or come into contact with another resident on antibiotics. This deficient practice could result in the inappropriate use of antibiotics that can lead to unnecessary treatment, illness, adverse reactions, and contribute to the development of antibiotic-resistant organisms. The findings are: [NAME] On 07/18/19 at 2:35 pm, during an interview, the Infection Control Nurse stated that she was not familiar with the antibiotic stewardship policy. She keeps track residents and their infections and relate diagnosis. B. On 07/19/19 at 10:35 AM during an interview, the DON confirmed that the Infection Control Logs for 2019 revealed the information: admitted , onset date, site, infection related DX (diagnosis), culture, x-ray date, antibodies, Healthcare Associated Infection (HAI) and date resolved. There was no documentation for all organisms of the need for isolations. C. Record review of the Antibiotic Stewardship revised (MONTH) (YEAR) revealed: Policy Statement Antibiotics will be prescribed and administered to the residents under the guidance of the facility's Antibiotic Stewardship Program. Policy Interpretation and implementation 1. The purpose of the antibiotic Stewardship Program is to monitor the use of antibiotics in our residents. 2. Orientation, training and education of staff will emphasize the importance of antibiotic stewardship and will include how map propriate is of antibiotics affects individual residents and the overall community. 3. Training and education will include emphasis on the relationship between antibiotic use . 4. If an antibiotic is indicated, prescribers will provide complete antibiotic orders including the following elements . 5. When a resident is admitted from an emergency department, acute care facility, or other care facility, the admitting nurse will review discharge and transfer paperwork for current antibiotic/anti-anti-infective orders. 6. Discharge or transfer medical records must include all the above drugs and dosing included . 7. When a resident is discharged home, the nurse will review complete antibiotics orders with the resident including . 8. When a nurse calls physician/proscribed to communicate a suspended infection, he will have the following information available . 9. When an interacting antibiotic is to be administered concomitantly with [MEDICATION NAME], an INR will be ordered with n 3 days",2020-09-01
25,SANTA FE CARE CENTER,325030,635 HARKLE ROAD,SANTA FE,NM,87505,2019-07-19,883,E,0,1,W7WU11,"Based on interview and record review, the facility failed to provide immunizations for influenza (flu) and pneumococcal (a bacteria that can cause pneumonia) immunizations (the action of making a person or animal immune to infection, typically by inoculation) for 2 (R #39 and R #88) of 5 (R #11, R #39, R #43, R #61, R #88) residents reviewed for influenza immunizations, and 3(R #39, R #43 and R #88) of 5(R #2, R #8, R #23, R #185, R #185) reviewed for the pneumococcal vaccine. This deficient practice could likely cause the resident to become infected with influenza or pneumonia. The findings are: [NAME] Record review of R #39's Medical Record revealed R #39 did not receive her last influenza vaccination or pneumococcal in (YEAR). B. Record review of R #43 Medical Record revealed no documentation of R #39 recieving a pneumococcal vaccination. C. Record review of R #88's Medical Record revealed R #88 did not receive her last influenza vaccination. It was also revealed that there was not documentation or confirmation that R #88 had a pneumococcal vaccination. B. On 07/19/19 09:33 AM, during an interview, the Infection Control Nurse (ICN) confirmed there was no documentation of proof that R #39, R #43 and R #88 getting their immunizations in (YEAR). D. On 07/19/19 at 10:06 AM, during an interview, the DON confirmed there was no documentation of proof that R #39, R #43 and R #88 getting their immunizations in (YEAR).",2020-09-01
26,SANTA FE CARE CENTER,325030,635 HARKLE ROAD,SANTA FE,NM,87505,2017-09-21,278,D,0,1,FY1511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accurately assess 1 (R #26) of 3 (R #26, R #105, R #165) residents reviewed for Activities of Daily Living (ADL's), when they coded R #26's eating ability on her (MONTH) (YEAR) Minimum Data Set (MDS) as supervision (resident requires supervision, cueing, and reminders for safe meal completion), when she required limited assistance (resident required staff to provide non-weight-bearing assistance). This deficient practice could likely result in residents not receiving the assistance needed to accomplish everyday tasks, resulting in a decline of in function and depression from not being able to assist themselves. The finding are: [NAME] Record review of the MDS assessment dated [DATE] revealed the following: Eating: self-performance 1 (Supervision - oversight, encouragement or cueing). B. Record review of the MDS assessment dated [DATE] revealed the following: Eating: self-performance 2 (Limited assistance - resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance). C. On 09/20/17 at 9:26 am, during an interview, the MDS Coordinator (MDSC #1) stated, If we (staff) open anything (drinks food items) for them (residents) then it is coded at 2 limited assistance. MDSC also stated, She (R #26) is limited assistance because staff have to help her open containers and cut her food. D. On 09/20/17 at 10:50 am, during an interview CNA #6 stated that R #26 eats in her room and does need staff to add salt and open containers for her. Also, CNA #6 confirmed that R #26 had needed this assistance since she started to work with her. E. On 09/20/17 at 9:55 am, during an interview and record review the Human Resources Director revealed CNA #6 had been working at the facility since 11/22/16. F. Record review of the Progress Notes dated 04/06/17 revealed that .Resident has her meals in her room . [NAME] Record review of the Progress Notes dated 07/13/17 revealed that .Resident has her meals in her room .",2020-09-01
27,SANTA FE CARE CENTER,325030,635 HARKLE ROAD,SANTA FE,NM,87505,2017-09-21,279,E,0,1,FY1511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that a comprehensive care plan was fully developed for 1 (R #105) of 1 (R #105) resident sampled for unnecessary medications; and 1(R #143) of 1 (R #143) resident sampled for Hospice. They failed to 1) care plan for R #105's diuretic medication, and 2) care plan for R #143's hospice services. The care plans did not specify how the residents' needs will be met. This failed practice could lead to residents not getting the appropriate care. The findings are: R #143 [NAME] Record review of R #143's care plan, dated 08/28/17, revealed he needed extensive assistance with ADLs. The care plan does not mention that he received assistance from the Hospice Aide for this service. Care plan read, Nursing to visit and coordinate with the facility staff and Hospice aids, Social Services, and the Chaplin will assist R #143 with services. B. On 09/20/17 at 09:10 am, during an interview, CNA #1 stated that the Hospice is suppose to come every other day and bath R #143. CNA #1 reports that the resident is not always bathed by Hospice, so she continues to shower R #143 according to his previous schedule. C. On 09/20/17 at 4:27 pm, during an interview, LPN#1 reported that Hospice is supposed to document in the resident's file (medical record) under the consultants tab. D. On 09/21/17 at 11:35 am, during an interview with MDS #2, she confirmed that R #143 care plan was not specific to the resident's needs. E. Record review of R # 143's medical record, under the Consultant tab, indicated that there were no documents for Hospice located. R #105 F. Record review of R #105's physician's orders [REDACTED]. [NAME] Record review of R #105 Care Plan dated 03/20/15 determined that R #105 was not care planned for the prescribed diuretic. H. On 09/21/17 at 10:27 am, during an interview with MDS #1, she confirmed that R #105 is not care planned for diuretic medication and its side effects.",2020-09-01
28,SANTA FE CARE CENTER,325030,635 HARKLE ROAD,SANTA FE,NM,87505,2017-09-21,281,D,0,1,FY1511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation the facility failed to meet professional standards of quality when the staff failed to clarify conflicting MEDICATION ORDERS FOR [REDACTED]#140, R #180, R #194 and R #196) surveyed for medication reconciliation with the medication pass. This deficient practice could result the resident not receiving the right medication. The findings are: [NAME] On 09/21/17 at 8:19 am, during medication pass observation, LPN #4 administered a medication from a bubble pack labeled metoproplol [MEDICATION NAME] (an immediate release antihypertenisve medication) 25 mg tab (tablet) to R #54. The Medication Administration Record [REDACTED]. B. On 09/21/17 at 8:30 am, during an interview with LPN #4, when asked about the difference between the bubble pack ([MEDICATION NAME]) and the MAR ([MEDICATION NAME] ER) she said, Well, they are both [MEDICATION NAME]. No problem. C. Record review of the local hospital's Transfer Orders dated 03/21/17 revealed an order for [REDACTED].>D. Record review an actual prescription dated 03/21/17 revealed an order for [REDACTED]. E. Record review of the facility Physician Orders, dated (MONTH) (YEAR), revealed an order for [REDACTED].>F. On 09/21/17 at 10:46 am, during an interview with the Director of Nurses, when asked about the discrepancy between the medication LPN #4 gave, the medication on the MAR, the Physician order [REDACTED].#54, he stated, The nurse should have stopped, noticed the difference in the orders and called (the physician) for clarification. [NAME] Review of the facility procedure Medical Administration Orals, Section 7.5, dated 12/12 (sic) revealed: Procedures: 5. Review and confirm MEDICATION ORDERS FOR [REDACTED] H. Review of 2014 Lippincott Manual of Nursing Practice - 10th Ed. Philadelphia, P[NAME] Lippincott[NAME] & Wilkins. ISBN-10: 1-4511-7354-7, ISBN-13: 978-1-4511-7354-3. STAT!Ref Online Electronic Medical Library. http://online.statref.com/Document.aspx?fxId=485&docId=7. 12/13/2016 4:31:58 PM CST (UTC -06:00). Common Departures from the Standards of Nursing Care: Legal claims most commonly made against professional nurses include the following departures from appropriate care: failure to assess the patient properly or in a timely fashion, follow physician orders, follow appropriate nursing measures, communicate information about the patient, adhere to facility policy or procedure, document appropriate information in the medical record, administer medications as ordered, and follow physician's orders [REDACTED].",2020-09-01
29,SANTA FE CARE CENTER,325030,635 HARKLE ROAD,SANTA FE,NM,87505,2017-09-21,309,D,0,1,FY1511,"483.25 Quality of care. Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices, including but not limited to the following: This REQUIREMENT is Not Met as evidenced by: Based on record review and staff interview, the facility failed to ensure that a comprehensive care plan for Hospice was fully developed and further failed to ensure that the Hospice provider provided progress notes for 1 (R #143) of 1 (R #143) resident sampled for Hospice. The care plan did not specify how the resident's needs will be met and could impact the residents quality of care and quality of life. This failed practice could lead to residents not getting the appropriate care. The findings are: R #143 [NAME] Record review of R #143's care plan, dated 08/28/17, revealed he needs extensive assistance with ADLs. The care plan does not mention that the resident received assistance from the Hospice Aide for this service. Care plan read, Nursing to visit and coordinate with the facility staff and Hospice aids, Social Services, and the Chaplin will assist (name of R #143) with services. B. On 09/20/17 at 09:10 am, during an interview, CNA #1 stated that the Hospice is suppose to come every other day and bath R #143. CNA #1 reports that the resident is not always bathed by Hospice so she continues to shower R #143 according to his previous schedule. C. On 09/20/17 at 4:27 pm during an interview, LPN#1 reports that Hospice is supposed to document in the resident's file (medical record) under the consultants tab. D. On 09/21/17 at 11:35 am during an interview with MDS #2 she confirmed that R #143's care plan was not specific to the resident's needs. E. Record review of R # 143's medical record, under the Consultant tab, indictated that there were no documents for Hospice located.",2020-09-01
30,SANTA FE CARE CENTER,325030,635 HARKLE ROAD,SANTA FE,NM,87505,2017-09-21,332,D,0,1,FY1511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation, the facility failed to ensure medication error rate did not exceed 5% when the medication error rate was 8.57% (3 errors out of 35 opportunities) when 3 medications were left in the resident's room and not administered by the nurse to 1 ( R # 54) of 9 (R #9, R #31, R #43, R #66, R #68, R #140, R #180, R #194 and R #196) residents reviewed during medication pass. This deficient practice could likely result in the resident not receiving the intended therapeutic relief from the medications to help with his breathing. The findings are: [NAME] On 09/21/17 at 8:20 am, during observation of LPN (Licensed Practical Nurse) #5 during a medication pass, it was observed that LPN #5 left 3 ampoules (small, sealed containers) of medications that are meant to be nebulized (aerosolized for inhalation via a nebulizer machine) on the resident's table and then LPN #5 left the room. The medications left were: 1) [MEDICATION NAME] (a medication to reduce inflammation in the airways), 0.5/mg ( milligram, a metric measurement) /2 ml (milliliter a metric measurement) 2) [MEDICATION NAME] (a medication to treat [MEDICATION NAME]--a spasm and narrowing of the breathing tubes), 2.5 mg/3 ml solution 3) [MEDICATION NAME]/[MEDICATION NAME] sulfate (combined medications to treat [MEDICATION NAME] and to reduce inflammation in the airways) 0.5 -3(2.5) mg/3 ml B. On 09/21/17 at 8:30 am, during an interview with LPN #5, she stated, I leave them (the medications) with him. (Name R #54) prefers to give them himself. Occasionally, he lets me set one up (prepare the treatment), but he usually doesn't allow it. When asked if R #54 was care planned for self-administration of the medication, LPN #5 replied, Yes he is. C. On 09/21/17 at 10:46 am, during an interview with the DON (Director of Nurses), he stated, The nurse should have not left the medications with him (R #54). She should have stayed and helped him. He (#54) has not been evaluated for self -administration of medication. D. Record review of the medical record for R #54 did not include an assessment for self-administration of medication. E. Review of the facility policy for Medication Administration Self-Administration by Resident, Section 7.3, dated 10/07 revealed: Policy: Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe.",2020-09-01
31,SANTA FE CARE CENTER,325030,635 HARKLE ROAD,SANTA FE,NM,87505,2017-09-21,371,F,0,1,FY1511,"Based on record review, observation, and interview, the facility failed to ensure that freezer/refrigerator temperatures were not recorded daily to monitor food safety. This deficient practice could lead to food borne illnesses that could affect 102 out of 103 residents who eat food prepared in the kitchen (residents were identified by the census list provided by the Administrator on 09/18/17). The findings are: [NAME] Record review of refrigerator/freezer temerature logs dated (MONTH) (YEAR) indicated: 1. Temperature logs for the kitchen refrigerator and freezers were missing documentation on the following days: 09/08/17, 09/09/17, 09/16/17, and 09/17/17 B. On 09/18/17 at 0845 am, during an interview, the Dietary Manager (DM) confirmed that the documentation was not done on the days listed indicating that the temperatures were not recorded. C. Record Review of facility's policy under Refrigerator Thermometers: Cold Facts about Food Safety, No date. 1. Chilling foods to proper temperatures is the best way to slow the growth of bacteria 2. To ensure .your refrigerator is doing its job, its important to keep temperature at 40 degrees or below; the freezer should be at 0 degrees",2020-09-01
32,SANTA FE CARE CENTER,325030,635 HARKLE ROAD,SANTA FE,NM,87505,2017-09-21,431,E,0,1,FY1511,"Based on record review, interview, and observation, the facility failed to ensure drugs were stored under proper temperature controls, when the temperature log for (MONTH) (YEAR) on medication refrigerator in the Medication Room showed blank entries for 3 out of 19 days, and there were no temperature logs available for (MONTH) or (MONTH) of (YEAR). This deficient practice likely results in the inability of the facility to substantiate data that reflects that the medication refrigerator temperatures were within acceptable parameters on a daily basis to help assure the potency of the refrigerated medications, and has the potential to affect all 103 residents residing in the facility (residents were identified by the census list provided by the administrator on 09/18/17). The findings are: [NAME] On 09/20/17 at 9:55 am, during medication storage observation in the Med Room, it was revealed that the Daily Temperature Log on the medication refrigerator was missing temperatures on 09/02/17, 09/07/17, and 09/08/17. The refrigerator contained insulin for specific residents, tuberculin solution for skin testing and other medications. B. On 09/20/17 at 10:16 am, during an interview with ADON (Assistant Director of Nurses) #2, he said the night shift is responsible to complete the logs and he acknowledged that some dates were missing indicating the temperatures were not done on those dates. C. On 09/20/17 at 11:49 am, the DON (Director of Nurses) said he was unable to provide temperature logs for the medication refrigerator for (MONTH) and (MONTH) of (YEAR). The DON said he believes the refrigerator logs were misplaced or lost during the recent renovations. The DON affirmed his expectation is that the medication refrigerators should have the temperature checked daily to assure it is in the proper range for medication storage. D. Review of the facility procedures Storage of Medication, Section 4.1, dated 05/16 revealed: 11. Medications requiring 'refrigeration' or 'temperatures between 2 degrees C (Centigrade) (36 degrees Fahrenheit) and 8 degrees centigrade (46 degrees F) are kept in the refrigerator with a thermometer to allow temperature monitoring. 16. Medication storage conditions are monitored on a regular basis as a random quality assurance (QA) check.",2020-09-01
33,SANTA FE CARE CENTER,325030,635 HARKLE ROAD,SANTA FE,NM,87505,2017-09-21,441,E,0,1,FY1511,"Based on record review and interview, the facility failed to ensure 1) the staff did proper hand hygiene between residents while performing medication pass in Wing 3, which has the potential to affect all 18 residents residing in the wing (residents were identified by the census list provided by administrator on 09/18/17), and 2) 1 (R #2) of 1 (R #2) (random resident seen going though items on the lunch tables and the trash) resident cleaned her hands after touching used items on dining tables after every meal and after rummaging through garbage bins attached to medication carts, which has the potential to affect all These deficient practices could lead to cross contamination (the process of transferring bacteria or other harmful agents from one surface to another) that could result in illness, debility and death. The findings are: [NAME] On 09/19/17 at 12:13 pm, during observation of the medication pass done by LPN #1, it was observed that LPN #1 administered an insulin injection to R #194, then removed her gloves and wiped her hands with a Prima Guard Adult Cleansing Washcloth (label stated alcohol free). When asked about using the patient care wipes, LPN #1 stated, I am using these today because my little bottle of the waterless hand cleaner has been missing off my cart. I think it is fine (to use the Adult Cleansing Washcloths) and doesn't make my hands so dry. B. On 09/21/17 at 10:49 am, during an interview with the DON (Director of Nurses), he stated, We supply alcohol hand cleanser for the medication carts. Using that (alcohol hand clenser) or washing with soap and water would be appropriate. The adult wipes would not be appropriate. I would say it is possible that there could cross contamination between residents. C. Review of the facility competency form on Handwashing revealed: Washing hands with soap and water is the best way to reduce germs on them. If soap and water are not available, use an alcohol based hand sanitizer that contains at least 60% alcohol. R #2 D. On 09/18/17 at 12:40 pm, during dining observation, R #2 was observed going to tables where all the residents were gone, but the lunch dishes were still on the table. R #2 picked through the plates, rearranged the plates and the meal tickets, and picked up empty baggies and other small items and placed them in her lap. LPN #2, CNA #1 and CNA #2 were present in the dining room; no one attempted tempted to stop her. R #2 moved to another empty table and does the same action; but now had a handful of used paper napkins that she placed in her lap. CNA #1 looks briefly at R #2 and stated That's dirty, (Name of R #2). CNA #1 turned back and talked to another resident. R #2 picks up another empty baggie and puts on her lap. These behaviors were observed again on 09/19/17, 09/20/17, and 09/21/17. The staff did not redirect her not to touch the items on the tables, nor did they attempt to direct her to wash her hands after she had touched the items. E. On 09/21/17 at 9:36 am, R #2 was observed in Wing 1. R #2 had self propelled her wheel chair to the medication cart and opened the attached garbage bin. R #2 rummaged through the contents for few (approximately 3) minutes. The resident then returned to her room. No staff was present in the hall at that time. F. On 09/21/17 at 10:30 am, during an interview, the WCN (Wound Care Nurse) was asked about R #2's behaviors. The nurse explained that this was her normal behavior and that if she was asked not to do this, R #2 gets very upset and become verbally and physically aggressive. She is care planned not to redirect her. When asked about cleaning her hands after this behavior, the WCN stated that they tried to put alcohol based hand sanitizer in her hands and she just made a face at them. When asked about having her wash her hands, the WCN stated that they had not tried this. [NAME] On 09/21/17 at 12:30 pm, during an interview, the DON explained that this was R #2's normal behavior and that if she was asked not to do this, R #2 gets very upset and become verbally and physically aggressive. She is care planned not to redirect her. When asked about cleaning her hands after this behavior, the DON stated that they tried to put alcohol based hand sanitizer in her hands and she just made a face at them. When asked about having her wash her hands, the DON stated that they had not tried this.",2020-09-01
34,SANTA FE CARE CENTER,325030,635 HARKLE ROAD,SANTA FE,NM,87505,2018-10-28,609,D,0,1,GNFO11,"Based on record review and interview the facility failed to report to the State Survey Agency allegations of abuse/neglect within 24 hours of notification, for 1 (R #42) of 2 (R #42 and R #18) residents sampled for abuse/neglect. This deficient practice likely resulted in the claim of abuse not being met with a timely investigation. If the facility fails to report allegations of abuse/neglect to the State Survey Agency, corrective measures may not be acted on, and the facility is unable to assure residents are free from abuse/neglect. The findings are: [NAME] On 10/22/18 at 4:35 pm, during an interview R #42 stated, A Certified Nursing Assistant (CNA #7) about four or five months ago called me dirty names. B. On 10/26/18 the facility was unable to produce evidence that the incident regarding abuse/neglect for R #42 was reported within the required twenty four hours. C. Record review of a (five day review) report dated 08/21/18 revealed that CNA #7 was accused of making abusive statements towards R #42 on or about 08/04/18. D. Record review of Transmission Verification Report (fax) sent to State Survey Agency dated 08/22/18 revealed that the (five day review) follow-up report for R #42 was sent on 08/22/18 at 11:58 am. E. On 10/26/18 at 3:10 pm, the Administrator (ADM) stated, The incident occurred on or about 08/14/18 while they were at an event out of town, however we do not have a copy of the incident report to show we reported the alleged abuse. F. On 10/26/18 at 3:00 pm, during an interview with the Director of Nursing (DON) and ADM they stated that they could not find a copy of the initial report that was sent to the State Survey Agency for the incident between R #42 and CNA #7.",2020-09-01
35,SANTA FE CARE CENTER,325030,635 HARKLE ROAD,SANTA FE,NM,87505,2018-10-28,656,D,0,1,GNFO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to develop a comprehensive person-centered care plan for 2 (R #29 and R #69) of 2 (R #29 and R #69 ) residents reviewed for 1) oxygen use and care, and 2) dental care. Failure to develop and implement a resident centered care plan may result in staff's failure to understand and implement the needs and treatments of residents possibly resulting in decline in abilities and a failure to thrive. The findings are: Resident #29 [NAME] On 10/22/18 at 9:10 am an observation of R #29 revealed that the resident was using oxygen while sitting in assigned room. B. Record review of baseline care plan dated 05/02/18 revealed that R #29 was admitted with oxygen at 2 liters per minute. C. Record review of Care Plan dated 05/30/18 revealed that R #29 had not been care planned for the use of oxygen. D. On 10/26/18 at 11:00 am, during an interview, the MDS coordinator stated, I was looking for orders for the O2 (oxygen), if he didn't have orders for the O2 he wouldn't be care planned. E. On 10/26/18 at 2:34 pm, during an interview Assistant Director of Nursing (ADON) stated, (resident name) does not have an O2 order, the only place I see is on the admission where they started to mark it yes and then marked it no. I am writing an order for [REDACTED]. Resident #69 F. Record review of the facility facesheet for R #69 dated 08/15/17 revealed, an admitted d 08/15/17. Admission [DIAGNOSES REDACTED]. [NAME] On 10/22/18 at 4:21 pm, observation of R #69's teeth revealed, they were brown, worn down and chipped. H. Record review of R #69's Minimum Data Set (MDS) assessment (Center for Medicare/Medicaid assessment tool) dated 07/05/18 revealed no triggers for dental issues. 1. MDS dated [DATE] revealed, Triggers: Oral/Dental status: Pain, discomfort, difficulty chewing. Teeth very poor condition, probable caries broken/missing teeth and refuses dental care. Requires good oral hygiene at least 2 times a day. Will continue to care plan. 2. MDS dated [DATE] revealed, Triggers: Oral/Dental status: Cavity or broken natural teeth, pain discomfort, difficulty chewing. Poor oral dentition related to (r/t) weakness, decreased trunk control and cognitive deficit. Will care plan. I. Record review of the care plan dated 09/19/17 for R #69 revealed, no care plan for dental issues. [NAME] On 10/26/18 at 9:07 am, during an interview, the Director of Nursing stated I don't see it on his (R #69) care plan but I am going to get help. K. On 10/26/18 at 9:40 am, during an interview, the MDS Registered Nurse (RN)stated that the issues with his (R #69) teeth are not care plan. L. On 10/26/18 at 10:05 am, the MDS Licensed Practical Nurse stated that dental issues for R #69 should be on the care plan.",2020-09-01
36,SANTA FE CARE CENTER,325030,635 HARKLE ROAD,SANTA FE,NM,87505,2018-10-28,677,D,0,1,GNFO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide ADL (activities of daily living) assistance for nail care for 1 (R #30) of 1 (R #30) residents reviewed for ADL's. This deficient practices has the potential to affect the dignity and health of the residents. The findings are: [NAME] On 10/23/18 at 2:24 pm, during observation, R #30 was observed with dirty and uncut fingernails. R #30 has a slight contracture (abnormal shortening of muscle tissue, making it difficult to open hand) of the right hand and the nails were long enough to dig into his hand. B. On 10/27/18 at 10:05 am, a second observation of R #30 revealed, R #30's nails had a black substance under the nails and were not clean or cut. C. Record review of the care plan for R #30 dated 09/21/17 revealed, Self care deficit: requires 1 person assist for all transfers related to (r/t) [DIAGNOSES REDACTED]. (Name of Resident) also has generalized weakness and loss of function in right arm and limited function in right leg. Requires set up for all meals and eats in dining room. Staff times 1 to assist with showers as scheduled. Set up and assist with all grooming/hygiene needs. 05/14/18 Requires extensive assist with most ADL's such as bed mobility, transfers, dressing toileting, hygiene and showers. D. On 10/27/18 at 10:10 am, during an interview, the Director of Nursing (DON) stated I think that was a pretty poor job of hygiene, the nurse should be cutting his nails. E. On 10/27/18 at 10:30 am, during an interview, Certified Nurse Aide (CNA) #6, stated that nails should be cleaned at every shower and as needed. F. On 10/27/18 at 10:39 am, during an interview, Licensed Practical Nurse (LPN) stated that R #30 nails should be cut and cleaned.",2020-09-01
37,SANTA FE CARE CENTER,325030,635 HARKLE ROAD,SANTA FE,NM,87505,2018-10-28,726,F,0,1,GNFO11,"Based on staff interview, the facility failed to ensure that the certified nursing assistants (CNAs) had documented, demonstrated competencies (ability of an individual to do a job properly), before they worked with the residents, and annually. All 52 CNAs could be impacted by this (based on a list of nurse aides provided by the Director of Nursing (DON) on 10/23/18). This could lead to the residents not receiving the care and services as described on the care plan. The findings are: [NAME] Record review of Facility CNA Training Records revealed, 1. CNA #1 - no competencies in the training record 2. CNA #2 - no competencies in the training record 3. CNA #3 - no competencies in the training record 4. CNA #4 - no competencies in the training record 5. CNA #5 - no competencies in the training record B. On 10/28/18 at 8:30 am during an interview the Director of Nursing (DON) stated, I realized a few weeks ago I didn't have any competencies for the staff. I'm starting a program that will be done in their anniversary month but now I do not have any competencies for staff.",2020-09-01
38,SANTA FE CARE CENTER,325030,635 HARKLE ROAD,SANTA FE,NM,87505,2018-10-28,730,F,0,1,GNFO11,"Based on staff interview, the facility failed to ensure the annual performance review for the certified nursing assistants (CNAs) had been completed . This could lead to CNA's not receiving further education in areas identified during their evaluation and residents not receiving the care and services as described on the care plan. The findings are: [NAME] Record review of CNA Personnel records revealed no evidence of a Annual Performance Evaluation. B. On 10/27/18 at 2:55 pm during an interview the Director of Nursing (DON) stated, I don't have Annual Performance Evaluations for the CNA's. I'd start doing them people wouldn't show up for the evaluation so I quit doing them.",2020-09-01
39,SANTA FE CARE CENTER,325030,635 HARKLE ROAD,SANTA FE,NM,87505,2018-10-28,732,F,0,1,GNFO11,"Based on observation and interview the facility failed to 1) accurately post the actual number of nursing staff (Registered Nurses (RN), Licensed Practical Nurses (LPN) and Certified Nursing Assistants (CNA)) on shift and 2) update the list within 2 hours of the beginning of each shift, and 3) posting multiple dates 10/26/18 to 10/30/18 with all shifts pre-populated. This deficient practice likely prevented the 99 residents identified on the facility census list provided by the Administrator on 10/21/18 to have access to accurate staffing information. The findings are: [NAME] On 10/27/10 at 2:30 pm during an observation the Daily Staff Posting, on the Wing 3 Hallway on the left wall approximately 5 feet above the floor, was noted to be for the dates of 10/26/18 to 10/30/18. The numbers of RN's, LPN's and CNA's had been pre-populated for this 5 day time period with no modification made as to actual numbers of staff on shift. B. On 10/27/18 at 3:10 pm during an interview the Assistant Director of Nursing (ADON) stated that the Daily Staff Postings are completed ahead of the shifts for all shifts. The Director of Nursing (DON) confirmed that the Daily Staff Posting were not done within 2 hours of the beginning of a shift but sometimes as much as 2-3 days ahead. The DON and ADON also confirmed that the location of the Daily Staff Posting was not readily accessible to all residents, family members or visitors.",2020-09-01
40,SANTA FE CARE CENTER,325030,635 HARKLE ROAD,SANTA FE,NM,87505,2018-10-28,761,E,0,1,GNFO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure that medications on Wing 1 medication storage cart, Wing 3 medication storage cart, and the main medication storage room were not expired. This deficient practice is likely to affect 7 (R #12, 38, 55, 61, 89, 306, and 307) of 99 residents on the facility matrix as provided by the Administrator on 10/21/18. The use of expired medication is likely to cause residents to receive medications which are less effective due to a breakdown in chemical makeup leading to less than optimal benefit from medications. The findings are: [NAME] On 10/23/18 at 2:15 pm, an observation of the medication storage cart on Wing #1 revealed that the cart contained four expired drugs: [MEDICATION NAME] INJ (injectable) USP (United States Pharmacopia) (helps to treat [MEDICAL CONDITION]) 5 milligrams/milliliter (mg/ml) for R #55, expired on 06/18; [MEDICATION NAME] (helps to treat [MEDICAL CONDITION]) 1 mg tablet for R #306, expired on 12/17; [MEDICATION NAME] (is used to treat depression) 7.5 mg tablet for R #306, expired on 08/18; and Donepezil HCL (used to treat mild to moderate dementia caused by [MEDICAL CONDITION]) 5 mg tablet for R #61, expired on 08/18. B. On 10/23/18 at 2:45 pm, an observation of the medication storage cart on Wing #3 revealed that the cart contained two expired drugs, the findings are as follows: [MEDICATION NAME] HCL (used to prevent or treat nausea and vomiting) 8 mg tablet for R #38, expired on 04/18; and [MEDICATION NAME]-[MEDICATION NAME] (used to treat moderate to severe pain) 5-325 mg tablet for R #12, expired on 05/18. C. On 10/28/18 at 9:45 am, an observation of the main medication storage room revealed that the room contained three expired medications, the findings are as follows: Latanoprost (used in the eye to treat open angle [MEDICAL CONDITION] and high pressure in the eye) 0.005% OPH (ophthalmic) eye drops for R #307, expired on 09/28/18; Latanoprost 0.005% OPH eye drops for R #89, expired on 08/23/18, and three (3) bottles of Acid Gone (antacid) 100 chewable tablets, expired on 08/18. D. On 10/25/18 at 10:35 am, during an interview Licensed Practical Nurse (LPN) #2 stated, Some of those medications we haven't used in forever, must have given us an old box, the [MEDICATION NAME] injection we haven't even given to R #55 in a long time, it doesn't work anyway. We must have missed them while we were cleaning it out. E. On 10/25/18 at 10:36 am, during an interview LPN #2 stated, The expired meds are put in the storage room in a box labeled for disposal. F. On 10/28/18 at 10:33 am, during an interview Director of Nursing (DON) stated, No that is not normal practice, we've been expecting this (survey process) for the last few months, so I've had them (nurses) checking the carts for the past few months. As far as a medication from (YEAR) being in there .that is a little baffling.",2020-09-01
41,SANTA FE CARE CENTER,325030,635 HARKLE ROAD,SANTA FE,NM,87505,2018-10-28,791,D,0,1,GNFO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to ensure that residents obtain routine dental care for 1 (R #69) of 1 (R #69) resident reviewed for dental services. This failure has the potential to cause the resident pain, embarrassment over condition of teeth, and potential weight loss. The findings are: [NAME] Record review of the facility facesheet for R #69 dated 08/15/17 revealed, an admitted d 08/15/17. Admission [DIAGNOSES REDACTED]. B. On 10/22/18 at 4:21 pm, observation of R #69's teeth revealed, they were brown, worn down and chipped. C. Record review of R #69's Minimum Data Set (MDS) assessment (Center for Medicare/Medicaid assessment tool) dated 07/05/18 revealed no triggers for dental issues. 1. MDS dated [DATE] revealed, Triggers: Oral/Dental status: Pain, discomfort, difficulty chewing. Teeth very poor condition, probable caries broken/missing teeth and refuses dental care. Requires good oral hygiene at least 2 times a day. Will continue to care plan. 2. MDS dated [DATE] revealed, Triggers: Oral/Dental status: Cavity or broken natural teeth, pain discomfort, difficulty chewing. Poor oral dentition related to (r/t) weakness, decreased trunk control and cognitive deficit. Will care plan. D. On 10/15/18 at 9:43 am during an interview, the Social Services Assistant (SSA) stated I do not have any documentation to show (Name of Resident) has seen a dentist for dental needs. The SSA also stated that when he (R #69) came he had behaviors and it was very difficult to get him to do anything, he stayed in his room and did not interact with anyone. E. Record review of the care plan dated 09/19/17 revealed, no interventions for dental issues. F. On 10/26/18 at 8:49 am, during an interview, R #69 stated that he would like to see a dentist.",2020-09-01
42,SANTA FE CARE CENTER,325030,635 HARKLE ROAD,SANTA FE,NM,87505,2018-10-28,804,F,0,1,GNFO11,"Based on interview, observation, and record review the facility failed to provide meals that taste good, looked appetizing, and were served at the correct temperature. This failed practice had the potential to affect all 99 residents identified on the resident census list provided by the administrator on 10/21/18. This deficient practice has the potential for residents to not eat meals and could lead to weight loss. The findings are: [NAME] On 10/22/18 at 9:12 am during an interview, R #78 stated that the food is terrible. I eat what I can. B. On 10/22/18 at 4:41 pm during an interview, R #42 stated, The food is horrible, sometimes its cold when its supposed to be hot. Sometimes it takes a long time to get the trays to the rooms. C. On 10/22/18 at 3:34 pm, during an interview, R #77 stated, The meals could be warmer, by the time it gets to you they are sometimes cold, sometimes staffing is short, they try the best they can .but. D. On 10/22/18 at 4:00 pm during an interview, R #150 stated food is horrible. if my family didn't bring me things, I would starve to death. E. On 10/23/18 at 10:05 am during the resident council meeting, residents stated the food served at the facility was always the same, it was undercooked, not at a good temperature, had no flavor, and no spice. F. On 10/23/18 at 2:20 pm, during an interview, R #30 stated that the food was a 3 on a scale from 1 to 10, (1 bad and 10 good). [NAME] On 10/23/18 at 4:55 pm during observation and test tray validation of the dinner meal the following was indicated: 1. oven baked chicken was 130 degrees Fahrenheit (temperture should be 140 degrees) and the inside was pink in color, 2. mixed vegetable blend were mushy to taste and not warm. 3. The appearance of food on the plate was unappetizing. H. On 10/24/18 at 12:00 pm, an observation of test tray from the kitchen revealed that the meal (chicken fried steak, mashed potatoes, and spinach) was not appetizing/appealing. The meat appeared still pink on the inside, and the breading was soggy, The entire meal was bland to the taste. I. On 10/24/18 at 12:15 pm during an interview, the Dietary Manager stated he was aware of resident complaints about the food served at the facility. [NAME] On 10/25/18 at 10:50 am during an Interview, the facility administrator stated, the food is not going to get better until we can get out from under the current contracted company.",2020-09-01
43,SANTA FE CARE CENTER,325030,635 HARKLE ROAD,SANTA FE,NM,87505,2018-10-28,810,D,0,1,GNFO11,"Based on record review, observation and interview the facility failed to ensure that residents are provided with special eating equipment when needed to consume meals and snacks for 1 (R #52) of 1( R #52) resident reviewed during random observation. If residents are not provided special eating equipment as needed, then residents are likely to not be able to consume their meals and snacks which could likely result in weight loss and malnutrition. The findings are: [NAME] On 10/24/18 at 12:22 pm, during a random meal observation, R #52's meal ticket revealed, Nosey cup as needed or requested. Observation revealed, R #52 was having difficulty drinking from a regular cup and did not have a nosey cup (cup with a cut out for the nose when drinking), for his liquids. B. On 10/24/18 at 12:30 pm, during observation of a document hanging in the kitchen, revealed E-Z Sip Lids - Attention: The following resident's need to have a lid placed on cup with all liquids: (Name of Resident #52) Nosey cup. Updated 10/17/18. C. On 10/25/18 at 7:35 am, during meal observation, R #52 did not have a nosey cup to drink his liquids. D. On 10/25/18 at 7:40 am, during an interview, Certified Nurse Aide (CNA) #4 stated He (R #53) was to have a nosey cup, CNA #4 went to check and stated I will go get him one. E. On 10/27/18 at 3:21 pm, during an interview, the Assistant Director of Nursing stated that a clarification order had been written for the use of the nosey cup.",2020-09-01
44,SANTA FE CARE CENTER,325030,635 HARKLE ROAD,SANTA FE,NM,87505,2018-10-28,880,F,0,1,GNFO11,"Based on interview and record review, the facility failed to maintain an infection prevention and control program for all residents by not maintaining surveillance of infections prior to (MONTH) (YEAR). This deficient practice could likely effect all 99 residents in the facility as identified on the Facility Matrix provided by the Administrator on 10/21/18. Failure to implement an infection control program likely causes the spread of infections and illness to residents and staff within the facility. The findings are: A: On 10/28/18 record review of the facility Infection Control Tracking log revealed that the log only contained documentation starting in (MONTH) for the current year (08/18). B: On 10/28/18 at 12:40 pm, during an interview Director of Nursing (DON) stated, It looks like it starts in (MONTH) (08/18), I don't have any information prior to that. I don't know where the previous Infection Control Nurse would have put the information prior to that.",2020-09-01
45,SANDIA RIDGE CENTER,325032,2216 LESTER DRIVE NE,ALBUQUERQUE,NM,87112,2018-03-14,557,E,0,1,YN7D11,"Based on interview and observation the facility failed to treat 1 (R #39) of 1 (R #39) resident with respect and dignity when staff removed R #39's personal possessions from a dresser, placing them in a box while R #39 was out of the facility. This deficient practice created a feeling of frustration for not being asked about the removing the dresser and coming back to the facility and finding her belongings in a box. The findings are: [NAME] On 03/07/18 at 10:32 am, during an interview with R #39, she stated that around 2 or 3 months ago she was out at the hospital and while she was gone they took her dresser. She stated that when she returned from the hospital the dresser wasn't there and her personal items were in a box. She never received a explanation and was never offered another dresser. B. On 03/13/18 at 9:21 am, during an interview with CNA #3, she stated that she and another CNA did take the dresser from R #39's room. She stated that R #39 was out at the hospital when the dresser was taken and they placed some items in a box. She stated that they also threw out a lot of it because it was a bunch of papers and sugar packets. She also stated that R #39 was not notified because she was out at the hospital. C. On 03/13/18 at 10:32 am, an observation was made of R #39's room. It was observed that R #39 had a three drawer dresser and across from that there was box where R #39 stated the smaller dresser used to be. D. On 03/14/18 at 11:29 am, during an interview with RN #2 she stated that if a new resident coming into the facility needs a dresser or another piece of furniture than they (staff) would let maintenance know and they would get whatever was needed out of storage. RN #2 also stated that no you would never take it from another resident who was using it. If a resident is using it, it becomes their property. E. On 03/14/18 at 11:32 am, during an interview with the Maintenance Director, he stated that they do have furniture in storage that they will pull from if they need too. He stated that, he tries to have one dresser to one resident. He stated that staff will pull furniture from another resident if needed but there would be a conversation with that resident first. F. On 03/14/18 at 11:57 am, during an interview with the Administrator, she stated that they don't have a particular policy on the amount of furniture a resident can have just as long as it is not a fire hazard. They do have furniture in storage and if a resident requests a second dresser they would typically provide that. She stated that it would not be appropriate to pull furniture from a resident without them knowing and agreeing to it.",2020-09-01
46,SANDIA RIDGE CENTER,325032,2216 LESTER DRIVE NE,ALBUQUERQUE,NM,87112,2018-03-14,600,H,0,1,YN7D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that residents residing on the Dementia (a decline in mental ability severe enough to interfere with daily life) Unit were free from physical abuse for 8 (R #s 4, 33, 62, 71, 79, 87, 93, and 108) of 8 (R #s 4, 33, 62, 71, 79, 87, 93, and 108) residents reviewed for abuse by failing to prevent R #97 from pushing, slapping, grabbing, and pulling a resident out of bed onto the floor. This deficient practice subjected vulnerable residents to assaults, which are likely to cause serious injury, feelings of fear, distress and humiliation. The findings are: [NAME] Record review of R # 97's Admission record, revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. B. Record review of R # 97's Resident Management System Summary Reports revealed the following resident to resident altercations with/alleged abuse: 1. On 04/06/17, This resident (R #97) had a physical altercation with another resident, (who was not identifed in report), unknown what triggered resident to hit another resident. He sustained a skin tear on in (sic) right bridge nose area. The (unidentified) resident would not allow nurse to administer first (aid), he was combative and attempted to hit nurse. 2. On 05/11/17, During breakfast this resident (R #97) became annoyed with female resident (who was not identifed in report), who attempted taking (sic) his drinks, was persistently bothering him with conversation and calling him daddy .female resident was directed to another table but came back to stand next to him. (R #97) then got up and slapped female resident several times in face. 3. On 07/22/17, This resident (R #97) was walking into dining room when (R #71) stood up and told him not to sit in the chair. This resident then pushed (R #71) with both hands into the wall. Nurse and Certified Nurses Aide (CNA) unable to intervene before contact was made between residents. 4. On 09/30/17, This resident (R #97) struck/pushed another resident (R #87) to the floor, and attempted to continue attack on his victim (victim) was lying on the floor. 5. On 10/28/17, Resident (R #33) stood up from his wheelchair and grabbed onto the back of this residents (R #97) chair he was sitting in. This resident then stood up and pushed (R #33) causing him to fall on the floor. This resident then reached down grabbing (R #33's) shirt trying to pull him up off floor. 6. On 01/12/18, Resident (R #97) hit (R #108) while he was eating his dinner. (R #108) then hit him back with his cane causing a laceration on this resident's (R #97) forehead. 7. On 01/14/18, Resident (R #97) was sitting at dining room table with a male resident (who was not identifed in report), (un readable) heard calling out. Upon entering room, both residents (R #97 and the unidentified male resident), (unreadable), was pulling on a female resident's (not identifed in report) hand. Resident's (R #97 and unidentifed male resident) hands were separated and (unidentifed) female resident was asked if she would like to move to another seat. Unidentifed female resident replied yes and was assisted to another table in a different section of the dining room. Each resident (all three) was examined for injury. Upon visual inspection of hands, a skin tear upon the back of (unidentifed) male resident's hand was located between thumb and index finger. 8. On 01/22/18, Resident (R #97) was found by CNA in a neighboring room. Resident was witnessed pulling on the arm of another male resident (R #93) who was on the floor. 9. On 01/31/18, Resident (R #62) was found on the floor on his back in room [ROOM NUMBER] (R #97's room). (R #97) had his hand on resident's wrist. 10. On 02/09/18, I heard (R #93) yell out in fear. I ran down to room and found (R #97) standing above (R #93), holding his left leg, jerking it, pulling him off the bed onto the floor, onto the mat next to the bed. (R #93) yelling out in fear. No physical injury noted, but Pt (patient # 93) is very upset. 11. On 02/13/18, Per nurse report, nurse heard yelling from nurses station and when (sic) to check noted this resident (R #79) being pushed by another resident (R #97) into the hall from his room causing her to fall on floor in hallway, nurse noted the other resident, R #97 then attempting to pull her to standing position. C. Record review of R # 97's Psychiatry Note dated 02/05/18, revealed Patient has shown improvement in behaviors with [MEDICATION NAME] (used to treat high blood pressure). Continues to have some agitation with certain residents. He is more easily redirected. D. Record review of R #97's Minimum (MDS) data set [DATE], revealed that he has Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) occurring 4 to 6 days, in the 7 day look back period. R #97 has wandered 4 to 6 days in the 7 day look back. He requires limited assistance with walking and locomotion (how resident moves between locations). He has no physical impairments to his upper and lower extremities (arms and legs) and he does not use any mobility devices (wheelchair, walker, cane). E. Record review of R # 97's Physician order [REDACTED]. Every shift for resident to resident abuse. The orders indicate the following medications are in the process of being gradually reduced or were discontinued: [MEDICATION NAME] (an anticonvulsant) for Dementia and behaviors, [MEDICATION NAME] for agitated behavior related to Dementia, [MEDICATION NAME] for Dementia, agitation, and behaviors, [MEDICATION NAME] (antipsyhotic) for violent psychiatric behavior, severe agitation, restlessness, and [MEDICATION NAME] (antipsychotic) for agitation. F. Record review of the Progress Notes dated 03/19/17 through 03/08/18, revealed the following incidents with R #97: was physically aggressive and/or attempting to hit, choke, push, grab, slap both residents and staff members; 1. On 03/03/18 at 2:18 am, Pt (R #97) was awoken by another Pt. (resident unidentifed) going in his room yelling and looking for her husband. He (R #97) came out with a jolt to his room door. Following the other Pt. (resident unidentifed) into the dining room. 2. On 2/25/18, Resident tried grabbing another resident's (resident unidentifed) arm who sat down at the same table. 3. On 02/21/18, Resident got up to go to the bathroom, CNA assisted him to the bathroom. (R #97) pushed CNA up against the wall when returning to bed. 4. On 02/13/18, during a meeting with (R #97) family, states (R #97) was sent to (name of hospital) to try and have the eval (evaluation ) done, but they were unable to do a med (medication) eval due to his severe dementia. (R #97) has been aggressive with all the family members at one time or another. They understand that he can hurt someone and they don't want him to hurt anyone. His meds will be adjusted so that he is unable to hurt anyone. 5. On 02/06/18, While attempting to redirect resident to his room, he attempted to strike and choke the CN[NAME] Once assisted to his room, resident again attempted to strike and push both nurse and CNA inside resident room. 6. On 02/01/18, Resident with aggressive behaviors throughout afternoon. Not hard to divert but persistent in his attempts to threaten other residents with body language or reaching out with both hands. 7. On 01/28/18, Resident sitting in dining room when he stood up from his chair and attempted to slap another male resident (resident unidentifed) walking by. 8. On 01/16/18, Resident observed standing up to strike another male resident (resident unidentifed) in the face. 9. On 01/15/18, (Name of a behavioral health hospital) called and said that (R #97's) dementia is too severe and he wouldn't be able to participate in their program. 10. On 01/14/18, Female resident (resident unidentifed) had entered resident's room at 5:15 am. Female was overheard stating that she was looking for the restroom. Upon entering the room to direct female resident, the patient charged at her with hands out as if preparing to push her. 11. On 01/11/18, Female resident (resident unidentifed) was standing near sink in dining room when this resident (R #97) walked in and up to her raising his hands towards her. 12. On 01/11/18, Resident attempted to become physically aggressive with (R #4) twice today. Both times (R #4) was just passing by in hallway and (R #97) went after him attempting to grab him while staring him in face. Both times resident (R #97) was intercepted from hitting resident (R #4). (R #4) did nothing to bring on (R #97's) anger. 13. On 01/10/18, Resident in hall at approximately 3:30 am. As I (RN #2) went to investigate the resident had reentered his room and was sitting on the edge of the bed. I entered the room to check on his needs when the resident stood from the edge of the bed and charged at this nurse. Using my hands to fend him off the resident grabbed both my hands in a crushing grip, and started to push wildly at me, and backed me out of the room and into the hall. Where he momentarily stopped his attack. The resident walked back into his room turned around, spotted me in the doorway, and charged at me again. Further review of the progress notes revealed between (MONTH) (YEAR) and (MONTH) (YEAR), R #97 has had 24 attempted incidents of physical aggression such as hitting, choking, pushing, grabbing, and slapping both residents and staff members and 10 incidents of actual physical contact between R #97, other residents, or staff. [NAME] Record review of the care plan updated on 02/09/18, indicated that interventions were being added to the care plan. Some of the new interventions were: 1. Add 1:1 2. Guide resident through the task at hand 3. Make eye contact prior to starting care 4. Provide outdoor activities 5. Monitor medications, especially new/changed/discontinued 6. Observe for non-verbal signs of physical aggression, e.g.,rigid body position, clenched fists H. On 03/08/18 at 9:36 am, during interview the Director of Nursing (DON) stated R #97 Has spatial issues, if you get too close he gets angered more. At night he was roaming more, so we put the 1:1 (one on one/staff to resident) at night. The DON stated that staff should be arms length away at all times a night. I. On 03/08/18 at 9:48 am, during interview the Corporate Compliance Nurse (CCN) stated that R #97 is territorial and reacts when residents get too close. She stated that R #97 used to be able to communicate, but he has declined. She stated that his behaviors are communicating his needs and that R #97 was reacting to situations were he was provoked by other residents. She stated that R #97 was not intending to hurt other residents, but from the reports it seemed like he was concerned for the other person and was trying to help them up. The CCN confirmed that R #97 would push residents away if they got to close to him, went in his room, or sat at the same table. She stated that they increased his behavior management and feels like it has been successful in reducing his behaviors. [NAME] On 03/08/18 at 11:49 am, during an interview the Administrator stated that R #97 reacts because he is usually provoked by residents getting in his space. She stated that if somebody is at his table trying to do something with him, he'll push them. The Administrator stated that his Dementia was increasing, he was no longer verbal. She stated that the interventions they have in place are: to give him space in the dining room, they put a stop sign across his door and another residents door, medication adjustments, put him on extra monitoring, one on one, and stated that she has seen a decrease in his behaviors. The Administrator stated that R #97 has no place else to go and that the residents on the unit are as safe as they can be. The Administrator stated that R #97 does not posses the cognition to have the intention to cause harm to other residents, but that he is reacting to situations were he feels like his space is being invaded. The Administrator verified that R #97 has made physical contact with residents, but that it is not intentional when he pushes them, it is him reacting to the situation. K. On 03/08/18 at 2:09 pm, during an interview the DON stated that she made the decision after discussing with the doctor to put R #97 on one to one monitoring at night because his behaviors were worse. She stated that during the day, she has enough staff working on the unit to monitor him during the day. The DON stated that R #97 hasn't always been aggressive, but that his Dementia is worse and his speech and understanding has declined over the last few months. She stated that she sent him out for an evaluation and has a referral to see a psychiatrist off site and is working to reduce his medications. L. On 03/08/18 at 2:27 pm, during an interview Certified Nursing Assistant (CNA) #10 stated that R #97 will usually get upset when it's meal time and he gets his food. CNA #10 stated that if somebody touches his food, he reacts and pushes people. She stated that he has behaviors at every meal, so they try to pay attention to make sure no one goes around him. She stated that R #97 is tall and strong and states that when he pushes or hits residents, that it's deliberate. M. On 03/09/18 at 10:04 am, during an interview Licensed Practical Nurse (LPN) #1 stated that R #97 has behaviors if people intrude on his space. LPN #1 stated that about a month ago he got confused and pulled another resident out of bed. LPN #1 also stated that it was reported to her that a female resident went into his room and R #97 pushed her out of his room into the hall. She stated there are a lot of other incidents where other residents will approach him, try to hover over him, or take his drinks and that is when he gets defensive. N. On 03/09/18 at 10:56 am, during an interview Registered Nurse (RN) #3 stated, that he thinks R #97 only responds to things in his field of vision. RN #3 stated that he does not see a purpose with any of R #97's behaviors, it's more of a reflex, not intent. RN #3 stated that R #97 Can no longer form the intent. Other than him pushing residents from his bubble, there is no intent involved. He does not have spasms, he does not jerk. When asked if R #97 pushes residents accidentally, RN #3 stated No, it's not that he brushed them accidentally, it's deliberate but not intentional. When asked if R #97 is a danger to other residents, RN #3 stated that was a hard question to answer, but stated He is still very strong. He physically ejected me from his room. RN #3 stated the potential for R #97 to hurt someone is there. O. On 03/12/18 at 4:07 am, during observation and interview CNA #11, was observed in R #97's room doing 1:1 care. CNA #11 stated that she is a little scared because R #97 tries to grab her when he gets up. She stated that when he goes after her, she gets scared but she tries not to show fear because she doesn't want him to become more aggressive. P. On 03/12/18 at 6:05 am, during an interview CNA #12 stated that R #97 was going into other resident rooms and that before the 1:1 he would go straight to R #93's room and pull him off the bed. She stated that R #97 was pulling R #93 off the bed or going into his room often enough that one on one was started. Nobody is safe. We don't know what triggers him. If you happen to be passing by, you're the one that's gonna get it. If you are in his face, it will be faster. She was asked if R #97 was appropriate on the unit, she stated No. She was asked if R #97 is dangerous, she stated To staff and residents. (Name of R #97) is pretty strong. A lot of female staff are afraid of him. He mostly attacks the girly women. Some people (staff doing 1:1) sit in his room, I don't. If it's dark and you startle him, he's going to attack you. He tends to go for strangers. I stay in the hallway because I know he is going to two places, he goes to R #93's room or the dining room. Q. On 03/12/18 6:18 am, during a second interview CNA #11 stated He was really aggressive, so when he comes at you, if you don't run away he will assault you. Since he doesn't speak you don't know what's going on. He stares and he frightens you. When they decided to put him on 1:1 that was when he was always going to one room and pulling the resident out of bed. That was scary, we didn't know what happened. More than two times he was going to the room of a particular resident. I witness (sic) it twice, he (R #93) was yelling and crying and R #97 was standing over him. I was in a room, I just find (sic) the resident on the floor with the bed sheets on the floor. The second time, (R #97) was pulling on his foot. It was scary because you don't know what can happen. CNA #11 was asked if R #97 is dangerous, she stated Yes, because in the dining room, if you leave him alone, he will go and slap all the people. I saw four times (sic) this week already with one woman (R #79). R. Record review of the Abuse Prohibition Policy dated 09/01/16, stated Centers will prohibit abuse, mistreatment, neglect, involuntary seclusion, and misappropriation of property for all patients through the following; prevention of occurrences, identification of possible incidents or allegations which need investigation. Purpose: to ensure that center staff are doing all that is within their control to prevent occurrences of abuse and mistreatment for [REDACTED].",2020-09-01
47,SANDIA RIDGE CENTER,325032,2216 LESTER DRIVE NE,ALBUQUERQUE,NM,87112,2018-03-14,607,E,0,1,YN7D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to implement their policy regarding reporting incidents of resident to resident abuse and failed to ensure the results of an investigation was reported to the State Survey Agency within 5 days for 7 (R #s 33, 62, 71, 87, 93, 97 and 108) of 7 (R #s 33, 62, 71, 87, 93, 97 and 108) residents reviewed for abuse. If the facility is not reporting and investigating resident to resident abuse according to policies, then the facility is likely to be unable to determine the cause and identify strategies for preventing further abuse. The findings are: [NAME] Record review of the Resident Management System (RMS) Summary Reports revealed the following resident to resident altercations with alleged abuse: 1. On 04/06/17, This resident (R #97) had a physical altercation with another resident, (who was not identifed in report), unknown what triggered resident to hit another resident. He sustained a skin tear on in (sic) right bridge nose area. The unidentified resident would not allow nurse to administer first (aid), he was combative and attempted to hit nurse. 2. On 05/11/17, During breakfast this resident (R #97) became annoyed with female resident (who was not identifed in report), Please identify who attempted taking (sic) his drinks, was persistently bothering him with conversation and calling him daddy .female resident was directed to another table but came back to stand next to him. (R #97) then got up and slapped female resident several times in face. 3. On 07/22/17, This resident (R #97) was walking into dining room when (R #71) stood up and told him not to sit in the chair. This resident then pushed (R #71) with both hands into the wall. Nurse and CNA (certified nursing assistant) unable to intervene before contact was made between residents. 4. On 09/30/17, This resident (R #97) struck/pushed another resident (R #87) to the floor, and attempted to continue attack on his victim was (sic) lying on the floor. 5. On 10/28/17, Resident (R #33) stood up from his wheelchair and grabbed onto the back of this residents (R #97) chair he was sitting in. This resident then stood up and pushed (R #33) causing him to fall on the floor. This resident then reached down grabbing (R #33's) shirt trying to pull him up off floor. 6. On 01/12/18, Resident hit (R #108) while he was eating his dinner. (R #108) then hit him back with his cane causing a laceration on this resident's (R #97) forehead. 7. On 01/14/18, Resident (R #97) was sitting at dining room table with a male resident (who was not identifed in report), (un readable) heard calling out. Upon entering room, both residents (R #97 and the unidentified male resident), (unreadable), was pulling on a female resident's (not identifed in report) hand. Resident's (R #97 and unidentifed male resident) hands were separated and (unidentifed) female resident was asked if she would like to move to another seat. Resident (Unidentifed female resident) replied yes and was assisted to another table in a different section of the dining room. Each resident (all three) was examined for injury. Upon visual inspection of hands, a skin tear upon the back of (unidentifed) male resident's hand was located between thumb and index finger. 8. On 01/22/18, Resident (R #97) was found by CNA in a neighboring room. Resident was witnessed pulling on the arm of another male resident (R #93) who was on the floor. 9. On 01/31/18, Resident (R #62) was found on the floor on his back in room [ROOM NUMBER] (R #97's room). (R #97) had his hand on resident's wrist. B. On 03/08/18 at 9:36 am, during an interview with the Director of Nursing (DON) regarding R #97's incidents of resident to resident abuse, she stated that she would not report as abuse, due to No intent and no major injuries. C. On 03/08/18 at 9:48 am, during an interview the Corporate Compliance Nurse (CCN), verified that the incidents involving R #97 and resident to resident abuse, were not reported to the State Agency because they felt that it was a behavior and not intended to injure other residents. She stated that most of the cases were provoked incidents and they didn't feel he was intending to hurt somebody. The CCN stated that they (staff) didn't feel like the incidents needed to be reported. D. On 03/08/18 at 10:50 am, during an interview the DON confirmed that all nine incidents mentioned in Finding 'A' (Incidents dated 04/06/17, 05/11/17, 07/22/17, 09/30/17, 10/28/17, 01/12/18, 01/14/18, 01/22/18 and 01/31/18) were not reported to the State Agency. E. On 03/08/18 at 11:49 am, during an interview the Administrator stated that resident to resident abuse, Would be somebody attempting to hurt somebody. When asked about Dementia (decline in mental ability severe enough to interfere with daily life) residents, she stated that residents Are not willfully doing it. They are not going after somebody. The Administrator verified that the incidents were not reported to the State Agency, stating We didn't feel like the intent was there. It was a response to the situation. F. On 03/08/18 at 11:05 am, the Administrator was asked to provide the internal investigations for the suspected incidents of resident to resident abuse for: 02/13/18, 02/09/18, 09/30/18, 01/12/18, 10/28/17, 01/14/18, 01/22/18, and 01/31/18. [NAME] On 03/08/18 at 11:49 am, during an interview the Administrator provided 3 documents for the internal investigations: 1. RN (registered nurse) #3 stated, In reference to incident on unit 100 from a few days ago, Sep 30, (YEAR), after reflection, I have come to the conclusion that the resident in question was responding behaviorally, and was not acting with malice toward the other resident. 2. Handwritten statement (not dated) states, To whom it may concern, this nurse went into room [ROOM NUMBER] and found (Name of R #62) on the floor. (Name of R #97) had his hand on his wrist. (Name of R #97) was not agitated or angry. He was easily redirected. Both residents were separated and redirected. 3. A skin integrity report for R #79 (not dated), stated No skin impairment. The Administrator did not provide any other documentation showing that investigations were completed on any of the incidents in question. The Administrator verified that she does not document interviews or the findings of investigations. H. Record review of the two reported incidents on 02/09/18 and 02/13/18, revealed no documentation showing that interviews were conducted with staff to determine what happened before the incident, resident behaviors before, during and after the incident, residents expressions or signs of aggression or fear or if there were witnesses. I. Record review of the Abuse Prohibition Policy dated 09/01/16, revealed The person witnessing or suspecting the alleged abuse (reporter) will- with assistance from his/her supervisor, CED (Center Executive Director), or designee - report within 24 hours the allegation of abuse, neglect, or misappropriation of property to the (Name of State Licensing Authority). The CED or designee will report findings of all completed investigations to officials within five working days of the incident or in accordance with state law, and take all necessary, corrective actions depending on the results of the investigation.",2020-09-01
48,SANDIA RIDGE CENTER,325032,2216 LESTER DRIVE NE,ALBUQUERQUE,NM,87112,2018-03-14,609,E,0,1,YN7D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure incidents of resident to resident abuse were reported to the State Survey Agency within 2 hours for 7 (R #s 33, 62, 71, 87, 93, 97, and 108) of 7 (R #s 33, 62, 71, 87, 93, 97, and 108) residents reviewed for abuse. If the facility fails to report allegations of abuse to the State Survey Agency, corrective measures may not be acted on, and the facility is unable to assure residents are free from abuse. The finding are: [NAME] Record review of the Resident Management System (RMS) Summary Reports revealed the following resident to resident altercations with alleged abuse: 1. On 04/06/17, This resident (R #97) had a physical altercation with another resident (unidentifed resident), unknown what triggered resident to hit another resident (unidentifed). Resident (unidentifed resident) sustained a skin tear on in (sic) right bridge nose area. He would not allow nurse to administer first (aid), he was combative and attempted to hit nurse. 2. On 05/11/17, During breakfast this resident (R #97) became annoyed with female resident (unidentifed) who attempted taking (sic) his drinks, was persistently bothering him with conversation and calling him daddy .female resident was directed to another table but came back to stand next to him. (R #97) then got up and slapped female resident several times in face. 3. On 07/22/17, This resident (R #97) was walking into dining room when (R #71) stood up and told him not to sit in the chair. This resident then pushed (R #71) with both hands into the wall. Nurse and CNA (certified nursing assistant) unable to intervene before contact was made between residents. 4. On 09/30/17, This resident (R #97) struck/pushed another resident (R #87) to the floor, and attempted to continue attack on his victim was (sic) lying on the floor. 5. On 10/28/17, Resident (R #33) stood up from his wheelchair and grabbed onto the back of this residents (R #97) chair he was sitting in. This resident then stood up and pushed (R #33) causing him to fall on the floor. This resident then reached down grabbing (R #33's) shirt trying to pull him up off floor. 6. On 01/12/18, Resident hit (R #108) while he was eating his dinner. (R #108) then hit him back with his cane causing a laceration on this resident's (R #97) forehead. 7. On 01/14/18, Resident (R #97) was sitting at dining room table with a male resident (who was not identifed in report), (un readable) heard calling out. Upon entering room, both residents (R #97 and the unidentified) male resident, (unreadable), was pulling on a female resident's (not identifed in report) hand. Resident's (R #97 and unidentifed male resident) hands were separated and (unidentifed) female resident was asked if she would like to move to another seat. Resident (unidentifed female resident) replied yes and was assisted to another table in a different section of the dining room. Each resident (all three) was examined for injury. Upon visual inspection of hands, a skin tear upon the back of (unidentifed) male resident's hand was located between thumb and index finger. 8. On 01/22/18, Resident (R #97) was found by CNA in a neighboring room. Resident was witnessed pulling on the arm of another male resident (R #93) who was on the floor. 9. On 01/31/18, Resident (R #62) was found on the floor on his back in room [ROOM NUMBER] (R #97's room). (R #97) had his hand on resident's wrist. B. On 03/08/18 at 9:36 am, during interview with the Director of Nursing (DON) regarding R #97's incidents of resident to resident abuse, she stated that she would not report as abuse, due to No intent and no major injuries. C. On 03/08/18 at 9:48 am, during interview the Corporate Compliance Nurse (CCN), was asked about incidents of abuse with Dementia residents, she stated If they don't have a BIMs (Brief interview for mental status), they are not cognitive. If they are both not cognitive, the interpretation is, how do you state intent. The CCN verified that the incidents involving R #97 and resident to resident abuse, were not reported to the State Agency because they felt that it was a behavior and not intended to injure other residents. She stated that most of the cases were provoked incidents and they didn't feel he was intending to hurt somebody. The CCN stated that they (staff) didn't feel like they (incidents) needed to be reported. D. On 03/08/18 at 10:50 am, during interview the DON confirmed that all nine incidents mentioned in Finding 'A' (Incidents dated 04/06/17, 05/11/17, 07/22/17, 09/30/17, 10/28/17, 01/12/18, 01/14/18, 01/22/18 and 01/31/18) were not reported to the State Agency. E. On 03/08/18 at 11:49 am, during interview the Administrator stated that resident to resident abuse, Would be somebody attempting to hurt somebody. When asked about Dementia (decline in mental ability severe enough to interfere with daily life) residents, she stated that residents Are not willfully doing it. They are not going after somebody. The Administrator verified that the incidents were not reported to the State Agency, stating We didn't feel like the intent was there. It was a response to the situation. F. Record review of the Abuse Prohibition Policy dated 09/01/16, revealed The person witnessing or suspecting the alleged abuse (reporter) will- with assistance from his/her supervisor, CED (Center Executive Director), or designee - report within 24 hours the allegation of abuse, neglect, or misappropriation of property to the (Name of State Licensing Authority).",2020-09-01
49,SANDIA RIDGE CENTER,325032,2216 LESTER DRIVE NE,ALBUQUERQUE,NM,87112,2018-03-14,610,E,0,1,YN7D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to thoroughly investigate incidents of resident to resident abuse and report the results of those investigations to the Licensing Authority within 5 days for 7 (R #s 33, 62, 79, 87, 93, 97, and 108) of 7 (R #s 33, 62, 79, 87, 93, 97, and 108) residents reviewed for abuse. This deficient practice has the potential to prevent staff from determining the cause of the incident, identifying the need for staff training and implementing needed changes to prevent resident to resident abuse. The findings are: [NAME] Record review of the Resident Management System (RMS) Summary Reports revealed the following resident to resident altercation with alleged abuse: 1. On 09/30/17, This resident (R #97) struck/pushed another resident (R #87) to the floor, and attempted to continue attack on his victim was lying on the floor. 2. On 10/28/17, Resident (R #33) stood up from his wheelchair and grabbed onto the back of this residents (R #97) chair he was sitting in. This resident then stood up and pushed (R #33) causing him to fall on the floor. This resident then reached down grabbing (R #33's) shirt trying to pull him up off floor. 3. On 01/12/18, Resident hit (R #108) while he was eating his dinner. (R #108) then hit him back with his cane causing a laceration on this resident's (R #97) forehead. 4. On 01/14/18, Resident (R #97) was sitting at dining room table with a male resident (who was not identifed in report), (un readable) heard calling out. Upon entering room, both residents (R #97 and the unidentified) male resident, (unreadable), was pulling on a female resident's (not identifed in report) hand. Resident's (R #97 and unidentifed male resident) hands were separated and (unidentifed) female resident was asked if she would like to move to another seat. Resident (unidentifed female resident) replied yes and was assisted to another table in a different section of the dining room. Each resident (all three) was examined for injury. Upon visual inspection of hands, a skin tear upon the back of (unidentifed) male resident's hand was located between thumb and index finger. 5. On 01/22/18, Resident (R #97) was found by CNA in a neighboring room. Resident was witnessed pulling on the arm of another male resident (R #93) who was on the floor. 6. On 01/31/18, Resident (R #62) was found on the floor on his back in room [ROOM NUMBER] (R #97's room). (R #97) had his hand on residents wrist. 7. On 02/09/18, I heard (R #93) yell out in fear. I ran down to room and found (R #97) standing above (R #93), holding his left leg, jerking it, pulling him off the bed onto the floor, onto the mat next to the bed. (R #93) yelling out in fear. No physical injury noted, but Pt (patient # 93) is very upset. 8. On 02/13/18, Per nurse report, nurse heard yelling from nurses station and when (sic) to check noted this resident (R #79) being pushed by another resident (R #97) into the hall from his room causing her to fall on floor in hallway, nurse noted the other resident then attempting to pull her to standing position. B. On 03/08/18 at 11:05 am, the Administrator was asked to provide the internal investigations for the suspected incidents of resident to resident abuse for: 09/30/18, 10/28/17, 02/13/18, 02/09/18, 01/12/18, 01/14/18, 01/22/18, and 01/31/18. C. On 03/08/18 at 11:49 am, during interview the Administrator provided 3 documents for the internal investigations: 1. RN (registered nurse) #3 stated, In reference to incident on unit 100 from a few days ago, Sep 30, (YEAR), after reflection, I have come to the conclusion that the resident in question was responding behaviorally, and was not acting with malice toward the other resident. 2. Handwritten statement not dated states, To whom it may concern, this nurse went into room [ROOM NUMBER] and found (Name of R #62) on the floor. (Name of R #97) had his hand on his wrist. (Name of R #97) was not agitated or angry. He was easily redirected. Both residents were separated and redirected. 3. A skin integrity report for R #79 not dated, stated No skin impairment. 4. The Administrator did not provide any other documentation showing that investigations were completed on any of the incidents in question. The Administrator verified that she does not document interviews or the findings of investigations. D. Record review of the two reported incidents on 02/09/18 and 02/13/18, revealed no documentation showing that interviews were conducted with staff to determine what happened before the incident, resident behaviors before, during and after the incident, residents expressions or signs of aggression or fear or if there were witnesses.",2020-09-01
50,SANDIA RIDGE CENTER,325032,2216 LESTER DRIVE NE,ALBUQUERQUE,NM,87112,2018-03-14,656,E,0,1,YN7D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure that comprehensive person-centered care plans were developed for 2 (R #s 38 and 81) of 2 (R #s 38 and 81) residents reviewed for nutritional issues. Focus areas, goals and individualized interventions were missing for a resident on dysphagia (means it takes more time and effort to move food or liquid from your mouth to your stomach) pureed diet (R #81) and malnutrition (R# 38). These deficient practice were likely to result in inconsistent delivery of interventions to residents in need of specialized care. The findings are: Findings for R #81: [NAME] Record review of R #81's Care Plan, revealed updates to the care plan to include R #81 exhibits impaired swallowing related to dementia (a group of symptoms caused by disorders that affect the brain. It is not a specific disease) . The care plan was updated on 03/06/18. B. On 03/07/18 at 8:26 am, during interview the MDS Coordinator confirmed that she updated R #81's care plan on 03/06/18, because she felt that everyone should be aware of her dysphagia. At 8:32 am, she confirmed that R #81's impaired swallowing was not care planned prior to 03/06/18. Findings for R #38: C. Record review of the Admission Record indicated that R #38 was admitted on [DATE]. D. Record review of the Nutrition assessment dated [DATE] indicated that R #38 had a nutrition problem. R #38 was malnourished with a low (BMI) Body Mass Index (the body mass index is a value derived from the mass and height of an individual). E. Record review of the initial care plan dated 12/25/17 with a revision on 01/17/18 indicated that there was no care plan intervention for R #38's nutrition problem /malnutrition related to: self inflicted by not eating, concerns of allergies [REDACTED]. [MEDICAL CONDITION] from [MEDICAL CONDITION] also contributing to diarrhea, low BMI of 13.38 with a weight of 80.4 pounds and a lack of drinking fluids regularly. F. On 03/09/18 at 10:32 am, during an interview with the Registered Dietitian (RD), he stated that R #38 was very picky, and underweight, poor intake at the time she was admitted . He stated that R #38 was so underweight, anything she ate was a promise for her to gain weight. He stated that he did his nutritional assessment right away and started her on supplements.",2020-09-01
51,SANDIA RIDGE CENTER,325032,2216 LESTER DRIVE NE,ALBUQUERQUE,NM,87112,2018-03-14,684,E,0,1,YN7D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to follow physician orders [REDACTED].#62) of 1 (R #62) residents reviewed for quality of care. If the facility is not following physician orders, then residents could likely not receive the treatment necessary to improve and/or maintain their health. The findings are: [NAME] Record review of R #62's Physician's Telephone Order dated 10/11/17, revealed [MEDICATION NAME] (an anticonvulsant) 200 mg (milligram) one-tab (tablet) PO (by mouth) BID (twice a day) x 4 d (times four days), then increase to TID (three times a day). Dx: (diagnosis): Impulsive behavior. B. Record review of R #62's Medication Administration Records (MARs) for (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR), revealed [MEDICATION NAME] was administered twice a day, at 8:00 am and 4:00 pm. C. On 03/06/18 at 9:22 am, during an interview Registered Nurse (RN) #1 stated, that R #62 gets 200 mg of [MEDICATION NAME] twice a day. RN #1 verified that the order to increase the medication to three times a day was ordered in (MONTH) (2017) and stated that she didn't know why it was not changed in the computer system. D. On 03/06/18 at 9:23 am, during an interview the Director of Nursing (DON) confirmed that R #62's order to increase [MEDICATION NAME] was not changed to three times a day. The DON stated that the order was written by the psychiatrist in (MONTH) of last year and that they should have written two orders, one for routine for four days and the new order to increase to three times a day. The DON stated that the order was not followed for about five months.",2020-09-01
52,SANDIA RIDGE CENTER,325032,2216 LESTER DRIVE NE,ALBUQUERQUE,NM,87112,2018-03-14,686,G,0,1,YN7D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to adequately monitor (through skin assessments) and prevent skin breakdown that led to pressure sores for 1 (R #38) of 1 (R #38) residents looked at for pressure injury/sores and skin breakdown. This deficient practice contributed to R #38 having multiple pressure sores (areas of damaged skin caused by staying in one position for too long) which commonly form where your bones are close to your skin, such as your ankles, back, elbows, heels and hips due to (MASD) Moisture Associated Skin Damage (which is the general term for inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva, or mucus), creating more issues with nutrition and requiring wound treatment that creates pain. The findings are: [NAME] Record review of the Shower sheets indicated that during a shower dated 01/29/18 that R #38 had redness/rash and there was an open area. B. Record review of the Weekly Skin Check Assessments for R #38 indicated that a skin check was done on 12/22/17 and 12/29/17 and there was not another Skin Assessment completed until 02/28/18. C. Record review of the Skin Integrity Report that the DON fills out, indicated that on 01/28/18 and 02/06/18 that R #38 had Moisture Associated Skin Damage (MASD). D. Record review of the Nursing Progress Notes dated 02/04/18, indicated that Resd (resident) appeared very weak and dehydrated. Fluids encouraged and 3 cups taken during shift . [MEDICATION NAME] (a foam dressing suitable for a wide range of wounds like venous leg ulcers, pressure ulcers or diabetic ulcers) intact on coccyx area for protection. Very red open areas on groin areas with clear fluid drainage. Cleansed with warm soapy water and barrier cream applied. E. Record review of the Nursing Progress Notes dated 02/08/18, indicated that . Open area/redended (sic) area noted to coccyx. Dressing applied. Barrier cream applied to groin (sic) and buttocks area. Repositioned on side. F. Record review of the (name of the hospital) History and Physical Addendum by (name of person) for R #38 dated 02/10/18, indicated that Nursing notes severe skin breakdown in groin and pressure ulcer at heel. Will have wound care evaluate. [NAME] Record review of the (name of hospital) Wound Care/Ostomy Forms, Plan of Care: indicated that on 02/11/18 the head to toe skin assessment determined that R #38 had Noted R (right) lateral heel unstageable pressure injury. Wound over heel with tan slough (a layer or mass of dead tissue separated from surrounding living tissue, as in a wound, a sore, or an inflammation) throughout. Foam dressing in place, peeled back to assess . Positioned patient off wound using pillow. Bilateral (affecting both sides) inner thigh, labia majora, Please define perineum (the area between the anus and the scrotum or vulva) and inner buttocks denuded (Denuded means skin gone via chemical means (urine, feces, sweat)). MASD likely from urine leakage .L (left) inferior and superior coccyx (tail bone) with unstageable pressure injuries. Circular wounds over bony prominence. Tan slough throughout both. Non blanching (to cause to become pale, by using digital pressure). No s/s of infection. Blancable redness over entire sacrococcoygeal (pertaining to both the sacrum and coccyx (the tailbone)) area . H. Record review of the care plan dated 12/25/17 indicated that one of the interventions for skin breakdown was to do Weekly Skin Assessments by the licensed nurse. I. On 03/08/18 at 2:32 pm, during an interview with Director of Nursing (DON), she stated that R#38 was originally admitted for a right non surgical leg fracture. She stopped eating for three days so she was sent out to psych (psychiatric) services. Psych services sent her to (name of hospital) and they performed surgery on her right leg fracture and sent her back to this facility. After the surgery she thought that R #38 was in a cast and that it was not removable, but it was a removable cast. When asked if the right heel was being checked, the DON stated that she was not looking at it and that there was a failure on the part of the facility. [NAME] On 03/08/18 at 4:42 pm, during an interview with Licensed Practical Nurse (LPN) #4, she stated that R #38 wouldn't drink enough. She stated that she knew R #38 was dehydrated because of the dry skin, poor skin turgor and cracked lips. She also stated that her pulse was often times high. She stated that R #38 was incontinent and had diarrhea. LPN #4 also stated that if R #38 was having diarrhea she would not give R #38 her stool softeners. LPN #4 also stated that R #38 did have an open area on her Coccyx (referred to as the tailbone), and they were putting cream and a foam dressing on it. When LPN #4 was asked about R #38's heel she stated that she did not have an open area on her heel. K. On 03/12/18 at 9:12 am, during an interview with the Director of Nursing (DON), she confirmed that on the Activities of Daily Living (ADL) flowsheet R #38 was having constant watery stools for (MONTH) (YEAR). She also stated that if a resident was having constant watery stools they should not be getting stool softeners. This could cause skin breakdown and diarrhea depending on fluid intake. The reason that stool softeners are usually prescribed is for residents on opiod (drugs that act on the nervous system to relieve pain) pain medications. L. On 03/12/18 at 9:47 am, during a second interview with the DON, she stated that R #38 had a removable boot but she thought it was a cast. It was removable but she wasn't looking at it. She stated that R #38 did have Moisture Associated Damage and because of this R #38 could have been raw, maybe bloody, because of the wiping when she was incontinent. The DON also stated that the dehydration can contribute to Urinary Tract Infection (UTI's). [MEDICAL CONDITION] (potentially life-threatening complication of an infection) could have been caused by the [MEDICAL CONDITION] but I can't say the UTI is what caused it. The Uropethay (occurs when urine cannot drain through a ureter) could have caused [MEDICAL CONDITION]. It's hard to know and the hospital didn't know either. M. On 03/14/18 at 9:10 am, during an interview with Certified Nursing Assistant (CNA) #14, she stated that R #38 had a red bottom with severe diarrhea 3 or 4 times per shift. She also stated that R #38 was not drinking enough fluids and not eating. CNA #14 stated that they apply cream and put on a foam dressing over that area. She stated that they (the CNAs) were telling the nurses about the poor food and fluid intake, the redness and the diarrhea. N. On 03/14/18 at 9:10 am, during an interview with RN #3, he stated that the incontinence could have contributed to R #38 having an open area. He also stated that the day that R #38 went out to the emergency room (ER), she had lost a lot of weight in a short period of time. Like 14 pounds in ten days or two weeks. He stated that R #38 wasn't eating or drinking on and off since admission. O. On 03/14/18 at 10:27 am, during an interview with the DON, she stated that she had a conversation with the Power of Attorney (POA) sometime after 02/09/18. The POA reported to her that R #38 had an unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed) pressure ulcer to the right heel. The DON stated that R #38 did not get any of the pressure ulcers at the facility, that R #38 got the pressure ulcers while at the hospital. The DON stated that she was aware of the Moisture Associated Damage on her Coccyx and she was actively looking at this area. When asked about the lack of assessments for R #38, the DON indicated that the nurses are supposed to be doing skin assessments and that probably when R #38 returned from the hospital the first time (early (MONTH) (YEAR)) she is not sure that she triggered for skin assessments and that this is probably why they weren't done.",2020-09-01
53,SANDIA RIDGE CENTER,325032,2216 LESTER DRIVE NE,ALBUQUERQUE,NM,87112,2018-03-14,689,J,0,1,YN7D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure that accident hazards were minimized on the locked Dementia (a general term for loss of memory and other mental abilities severe enough to interfere with daily life) unit, by failing to provide residents with the correct consistency snack. This deficient practice resulted in an Immediate Jeopardy (IJ) at a scope and severity of J being identified on 03/06/18. The facility was notified on 03/06/18 at 4:21 pm. The facility took corrective action by providing an acceptable Plan of Removal on 03/06/18 at 4:23 pm. Based on the Plan of Removal, interventions included: 1. Snack lists have been reviewed for correct diet by CNE (Center Nurse Executive) and Dietician on 03/06/18. 2. Diet orders have been provided to the nursing stations for quick review for staff on 03/06/18. 3. Staff currently working were educated on the diet order notebooks on 03/06/18, other staff will be re-educated prior to working their next shift. 4. Daily checks will be conducted for residents on snacks for correct diet by the unit manager or designee for 1 week, and then weekly for 4 weeks, and then monthly thereafter. 5. The daily checks will be brought to QAPI (Quality Assurance Performance Improvement) monthly for three months. Based on the Plan of Removal, the IJ was lifted on 03/06/18 at 4:25 pm. This resulted in the scope and severity being reduced from level J to level D. Based on observation, record review, and interview, the facility failed to ensure that residents received the correct consistency of snacks and that the resident environment was free of tripping hazards for 3 (R #s 35, 81, 97) of 3 (R #s 35, 81, 97) residents reviewed for accident hazards. This deficient practice increases the risk for falls, choking, aspiration, and/or death. The findings are: Findings for R #81 [NAME] Record review of R #81's Diet Order and Communication Form dated 11/06/17, revealed R #81's diet was changed to dysphasia puree (diet where all food has been ground, pressed, and/or strained to a consistency of a soft smooth paste) by the Speech Therapist. B. On 03/06/18 at 11:06 am, during observation in the locked Dementia Unit, R #81 was given a whole banana as a snack. C. On 03/06/18 at 2:07 pm, during observation in the locked Dementia Unit, R #81 was given half of a peanut butter and jelly sandwich as a snack. D. On 03/06/18 at 2:16 pm, during interview CNA (Certified Nursing Assistant) #1 stated that he believed R #81 was on a mechanical soft diet (foods that are chopped or soft). After checking, CNA #1 verified that R #81 is dysphasia pureed and confirmed that he did give her a peanut butter and jelly sandwich. CNA #1 also stated that residents' diet orders are communicated three ways: 1. on the diet sheets kept in the medical charts, 2. the nurses tell CNAs, 3. On the diet order slips. E. On 03/06/18 at 2:19 pm, during interview RN (Registered Nurse) #1 stated that a peanut butter and jelly sandwich is not appropriate on a pureed diet. RN #1 confirmed that CNAs should know which residents are on a pureed diet, stating that most of the CNAs are regulars, so they are well aware. F. On 03/06/18 at 2:30 pm, during interview the Dietary Director confirmed that a peanut butter and jelly sandwich is not acceptable on a pureed diet. The Dietary Director stated that the snacks will have a nutrition label put on it from the kitchen and then staff take them down to the Dementia unit. He stated that diet orders are inputted into the labeling system by either himself, the dietician or via a request from physical therapy. [NAME] On 03/06/18 at 2:40 pm, observations in the refrigerator on the Dementia Unit, showed that the information on the peanut butter and jelly sandwiches included the name of the resident, the date, and what the snack is. During interview with the Dietary Director and Dietitian on the unit, they both verified that the nutrition label does not state the diet type, stating that if staff are not familiar with the residents, they could pass the wrong snacks. H. On 03/06/19 at 2:52 pm, during interview the Dietary Director stated that R #81's diet change to a puree diet was not updated in the Resident Diet System (RDS) which prints out the nutrition labels for the snacks. He stated R #81 has been getting non-pureed snacks for about a year and a half. He stated that he did not know who put the order in for her pureed diet. I. On 03/06/18 at 3:27 pm, during interview the Speech Therapist stated that in (MONTH) (2017) she put R #81 on a pureed diet because of excessive chewing and pocketing of her food, not because of choking. She stated that excessive chewing could cause her to pocket her food, which could lead to aspiration. The Speech Therapist was asked if a banana was appropriate, she stated No, I don't trust her with a banana. I wouldn't clear it until I cleared it. I consider it (a banana) more regular diet. Unless it's mashed up, I wouldn't feel comfortable with her eating a whole banana. [NAME] On 03/06/18 at 3:37 pm, during interview CNA #2 stated that she believes R #81 gets a peanut butter and jelly sandwich as a snack. When asked which residents were on a pureed diet, CNA #2 did not indicate R #81 was on a pureed diet. CNA #2 stated that the snacks come from the kitchen with nutrition labels and she just hands them out to residents. CNA #2 stated that she would give R #81 a banana because she is on a regular diet. She also stated that when she passes out meals, she looks at the meal ticket and the food to make sure they match, but could not remember if R #81 was on a pureed diet. CNA #2 also stated that the bananas come from the kitchen with no nutrition labels. During the interview, CNA #2 looked at R #81's Kardex (a summary of all the resident's care needs which includes diet consistency) which showed her diet as regular/liberalized and mechanical. K. On 03/06/18 at 4:07 pm, during interview the Unit Manager stated that she just looked up R #81's diet and stated it was dysphasia pureed. She stated that on the meal tickets and CNA Kardex, it says what diet residents are on. The Unit Manager stated that as far as she knew, the snacks come from the kitchen labeled, so CNAs know who to give the snacks to. When asked if a peanut butter and jelly sandwich was appropriate, she stated, I had to clarify that too. No, it's not, unless they have been evaluated by speech therapy. The Unit Manager stated that she did not recall seeing R #81 eating a sandwich or a banana. She verified that if CNAs are passing meals with pureed food, they should see that the snacks are not appropriate. L. Record review of the Nutritional Snack Label provided by the Dietary Director dated 03/06/18, showed R #81's name, room number, and 1/2 peanut butter and jelly sandwich. M. Record review of R #81's Care Plan, revealed it was updated on 03/06/18 with the focus, goal, and interventions related to impaired swallowing. R #81 was not care planned for swallowing issues or a pureed diet prior to 03/06/18. N. Record review of the Nutritional assessment dated [DATE], revealed diet is Dysphagia puree. O. On 03/06/18 at 5:20 pm, during interview the Administrator stated that she talked to the CNA working day shift on 03/06/18 and confirmed that at around 11:00 am, she gave R #81 a whole banana and she did not mash it. Findings for R #97 P. Record review of the Physician order [REDACTED]. Q. On 03/06/18 at 3:37, during observations of the fridge on the Dementia Unit, revealed a small sealed cup of fruit chunks with R #97's name written on the top. R. On 03/06/18 at 2:19 pm, during interview with RN #1 she stated that R #97 was on a pureed diet. S. On 03/06/18 at 3:37 pm, during interview with CNA #2 she stated that R #97 was on a pureed diet. She stated that R #97 gets yogurt, soft foods or the health shake for snacks. CNA #2 did not know why the fruit cup with his name on it was in the fridge. She also stated that she has not seen him eat a sandwich or a banana. T. Record review of the 1:1 (one on one) Monitoring sheets for R #97, dated 2/16/18 to 03/06/18, revealed the following: 1. On 02/16/18 at 10:20 pm, states had a snack (banana and milk shake). 2. On 02/21/18 at 4:35 am, states he woke up and ate snack (cracker) then went back to bed asleep. 3. On 02/23/18 at 11:30 am, states still watching. Health shake, juice, sandwich. 4. On 02/23/18 at 1:12 am, states I gave him some snacks i.e. sandwich, yogurt, and shake. He went back to bed after snacking. At 5:19 am, states the resident came out of his room to the dining room, offered him some snacks, shake, sandwich and yoplait (yogurt). 5. On 02/25/18 at 7:00 am, states he's in DR (dining room) got his coffee and a cookie while waiting calmly for breakfast. 6. At 1:00 am (not dated), states resident got up, used restroom, ate a cookie went back to bed. 7. On 03/05/18 at 1:15 am, states rsd (resident) gets a cookie and milk. U. On 03/09/18 at 10:22 am, during interview the Speech Therapist stated that she was not aware that R #97 was getting non-pureed snacks. She stated I was not aware, because I would have intervened. The Speech Therapist stated that at the request of the family she evaluated R #97, and is now being monitored for a dysphagia advanced diet (mechanical soft). She confirmed that a whole banana is not appropriate on a pureed diet, stating that if the banana was mashed up it would be acceptable. The Speech Therapist stated It makes me nervous, when she said that she would expect staff to notify her if residents receive inappropriate snacks. She stated that it never occurred to her that staff who work with residents every day, that if they pass their meals why they would given them snacks that are not appropriate. She stated It's common sense to not give a resident a cookie, if they don't get one at meals, if every one else gets one with regular diets. She stated that she is going to be spending more time on the locked unit, because she didn't know staff were giving residents non-pureed snacks. Findings related to R #35: V. On 03/07/18 at 9:20 am, observation of R #35's room revealed an area on the floor between the resident's bed and the bathroom approximately 3 feet by 3 feet where several of the rectangular floor pieces were warped. The floor was slightly raised at the places where the ends of two floor pieces met creating small humps approximately half an inch in height. There were several humps across this area which made the floor an uneven surface. W. On 03/08/18 at 10:46 am, during an interview with the Maintenance Director, he stated that R #35 tends to flush items down the toilet such as wipes, towels and underwear. He stated that his toilet got clogged about 3 weeks ago and the water overflowed from the toilet and flooded part of the resident's room. He stated the wooden floor pieces were warped by the water damage which then created the uneven surface in his room. He stated he ordered new vinyl flooring and is waiting for them to arrive. X. Record review of the facility's purchase order dated 03/02/18 revealed that new vinyl flooring was ordered on [DATE]. Y. Record review of the facility's list of incidents that occurred from (MONTH) (YEAR) to (MONTH) (YEAR) revealed that R #35 had the following falls/incidents: 1. On 06/22/17 resident stated he hit his head on the bathroom door when he tried to open it. 2. On 07/03/17 resident was found sitting on the floor with no injuries. 3. On 12/24/17 resident fell trying to get into his bed while it was in the high position. 4. On 01/09/18 resident was found on the floor in his room with a bruise on his forehead. Z. Record review of R #35's most recent MDS assessment dated [DATE] revealed that his vision is moderately impaired and does not wear corrective lenses. A[NAME] On 03/08/18 at 10:45 am, during an interview with the Director of Nursing, she verified that R #35 has a history of falling but that all his previous falls occurred in his previous room. She stated that he was moved into his current room in (MONTH) (YEAR) and has not had a fall since. She stated they are planning on replacing the floor once the new floor pieces arrive. She stated she does not know the exact day as to when the flooding occurred but thinks it was a few weeks ago. The DON verified that R #35 has poor vision and that the uneven floor is a potential tripping hazard for him.",2020-09-01
54,SANDIA RIDGE CENTER,325032,2216 LESTER DRIVE NE,ALBUQUERQUE,NM,87112,2018-03-14,725,F,0,1,YN7D11,"Based on record review and interview the facility failed to ensure sufficient nursing staff to answer call lights in a timely manner, on a consistent basis, across all shifts, for the needs of all 126 residents identified on the alphabetical resident census provided by the Administrator on 03/05/18. This deficient practice has the potential to negatively impact resident safety and comfort, and to impede processes such as timely incontinence care and regular turning schedules. The findings are: [NAME] On 03/05/18 at 9:31 am, during an interview with resident (R) #114, she stated that they (staff) don't have enough help. R #114 stated that I will go to the bathroom in my pants before they get to me. R #114 stated that more than five times she has gone in her pants because she couldn't hold it any longer. R #114 stated that it is worse on the weekends. B. On 03/05/18 at 9:40 am, during an interview with R #66, she stated I want to get up the morning but they are short handed. R #66 also stated that last night (03/04/18) they were short handed, she waited about an hour to be put to bed. C. On 03/05/18 at 9:09 am, during an interview with R #9, he stated that sometimes there are 4 people assigned to the unit but other times there are only 2. When there are only 2 workers, I have to wait between 30 and 45 minutes. D. On 03/05/18 at 2:19 pm, during an interview with R #2, she stated that sometimes they are short handed. She stated that there are times you're laying there and you may need the restroom but you have to wait 30 minutes before you get help. E. On 03/05/18 at 9:49 am, during an interview with R #89's family member, the family stated that sometimes they are a little short staffed. My mom is here and she's pretty high maintenance, but she has to wait quite a bit. F. On 03/05/18 at 9:53 am, during an interview with R #273, she stated that nights had been a problem. There is one person working the night shift. R #273 stated that it felt like they need more staff. She went to the bathroom three times before they got to her. R #273 also stated that she is leaving the facility because they are not attending to her enough. [NAME] On 03/06/18 at 11:29 am, during an interview with R #58, she felt like they could use more staff at the busy times, after breakfast and early in the morning when residents are getting up. It feels like a long time when you are waiting and it takes even longer on the weekends - not as many people working on the weekend. Pain medications are sometimes given 1.5 hours after they are supposed to be given. H. On 03/06/18 at 10:01 am, during an interview with R #93, she stated they are extremely short staffed for the population. Meal times are the worst, total chaos. One or two night time aides and one night nurse. I. On 03/07/18 at 10:34 am, during an interview with R #39, she stated that they have two or three Certified Nursing Assistants (CNAs) right now, because we're (surveyors) here. R #39 stated that you will see the nurse one time in the morning and one time in the evening and that's it. She stated that there will be one CNA and one nurse on the night shift, and for help you might have to wait a half hour to 40 minutes. [NAME] On 03/06/18 at 10:05 am, during an interview with R#44, she stated that she only has to wait when no one shows up to work. That doesn't happen very often. She also stated that you do have to wait longer on the weekends. There is no one here from the other departments so if you need anything you have to wait until Monday. K. On 03/12/18 at 10:30 am, during an interview with R #6, she stated that on her floor/hall there are only two girls (staff) and it is just not enough staff on the floor. She has sat there on the pot, she may sit there and sit there and sit. Banging on the door to get someone down there to help her. She will wait 30 minutes to one hour. The call light is fixed in the bathroom now, but she still waits. L. On 03/12/18 at 4:25 am, during an interview with Licensed Practical Nurse #2, she stated that there is only one nurse for two halls and 2 CNAs, one for each hall. She did not feel that there was enough staff at night. Primarily with the CNAs. She stated that tonight they have a CNA who floats and that this can make all the difference in resident care. LPN #2 indicated that when there are only two CNAs for two halls it will create longer call light response times. Not always, on every occasion, but it happens. LPN #2 also stated that the residents' will complain to them about how long it takes to get assistance. M. On 03/12/18 at 4:25 am, during an interview with CNA #4, CNA #4 stated that there is not enough staff on nights typically. When they have a floater, like tonight, then it makes a big difference. Residents don't have to wait as long. N. On 03/12/18 at 5:10 am, during an interview with CNA #5, CNA #5 stated that when they have two people on this hall at night it is much better. CNA #5 stated that there had been lots of complaints to the scheduler and the DON about needing more staff at night. CNA #5 also stated that they have to take time away from resident care to go out to storage to get the items they need when they run out. O. On 03/12/18 at 5:25 am, during an interview with CNA #6, CNA #6 stated that someone always calls in. Sometimes people will call in if they don't want to work a particular hall. CNA #6 also indicated that complaints had been made about not having enough staff. CNA #6 stated that you can't really meet all of the resident needs timely if there isn't enough staff. P. On 03/12/18 at 5:40 am, during an interview with CNA #8, CNA #8 stated that she works all over but works mainly at night. CNA #8 stated that when the facility fully staffs the building with enough staff it makes a huge difference for both the staff and residents. CNA #8 also stated that when there is a floater in the building that assists the other CNAs it makes all the difference but they don't typically have one. Q. On 03/13/18 at 1:14 pm, during an interview with the Staffing Coordinator (SC), she stated that the higher the census the more staff they have. It is based off of all of the residents, on every hall in the building. The SC stated that the (name of the hall) has the highest turnover of residents. She indicated that even though the resident census may fluctuate more on the (name of the hall) it doesn't affect the residents on the other halls. The SC also stated that if there is a higher need on 200 hall than she might place the floater there and take it from 300 and 400 hall which leaves the 300 and 400 hall with one CNA a piece. When asked, the SC did not feel that 1 CNA for 29 residents for (name of the hall) would be too much, stating that depending on who is working will depend on whether or not they can manage the work load. R. On 03/12/18 at 3:35 pm, during an interview with the Administrator she stated that there are 15 employees dedicated to the night shift. Depending on the acuity and the needs. If the needs are greater on one hall over another than they may pull a person from that hall. She indicated that on (name of halls) they may need to pull more employees too, which means moving the staff around. When asked whether another staff member is ever added instead of pulling them from some where else, she stated that yes that has happened. An extra person was added to (name of hall). When asked about what the need was that required an extra staff person, the Administrator answered that they added an extra person for a one on one situation. S. Record review of the Facility Assessment: Staffing section, indicated that for (name of hall) the ideal staff for the night shift would be 1.5 employees to 21 residents. For the (name of hall) the ideal staffing on the night shift would be 1.5 employees to 29 resident.",2020-09-01
55,SANDIA RIDGE CENTER,325032,2216 LESTER DRIVE NE,ALBUQUERQUE,NM,87112,2018-03-14,756,D,0,1,YN7D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to have the pharmacist conduct a Medication Regimen Review for 1 (R #38) of 6 (R#s 38, 9, 18, 38, 104, 119) residents reviewed for unnecessary medications. This deficient practice likely contributed to R #38 receiving medication that she did not need for a [DIAGNOSES REDACTED]. The findings are: [NAME] Record review of the Medication Regimen Review for (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) indicated that R #38 did not have any of her medications reviewed by the Pharmacist. B. On 03/09/18 at 10:15 am, during an interview with the Director Of Nursing (DON), she stated that no, the pharmacist had not reviewed R #38 in (MONTH) or (MONTH) (YEAR). The pharmacist had also not been out for the month of (MONTH) (YEAR) yet and she would make sure that R #38 was reviewed.",2020-09-01
56,SANDIA RIDGE CENTER,325032,2216 LESTER DRIVE NE,ALBUQUERQUE,NM,87112,2018-03-14,757,G,0,1,YN7D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide a drug regimen that was free from unnecessary medication, duplicate medication, or medication that had an appropriate [DIAGNOSES REDACTED].#38) of 6 (R#s 38, 9, 18, 38, 104, 119) residents reviewed for unnecessary medication. This deficient practice likely contributed to R #38's dehydration and malnourishment and caused R #38 to have moisture associated skin breakdown, eventually returning to the hospital and prolonging and complicating her recovery. The findings are: [NAME] Record review of the Admission Record indicated that R #38 had a [DIAGNOSES REDACTED]. B. Record review of the R #38's physician's orders [REDACTED]. C. Record review of R #38's physician's orders [REDACTED]. D. Record review of the Medication Administration Record [REDACTED]. E. Record review of the MAR for the month of the (MONTH) (YEAR) indicated that R #38 received 16 out of 18 doses of the [MEDICATION NAME] medication and 15 out of 18 of the Sennosides medication. R #38 refused one dose of [MEDICATION NAME] on 02/03/18 and refused again on 02/09/18. On 02/03/18 R #38 refused both doses of the Sennosides medication and refused one dose on 02/09/18. F. Record review of the Activities of Daily Living (ADL) flowsheet dated 01/29/18 indicated that R #38 had several days of loose stools, some entries are noted as soft formed and some are watery. Entries from the ADL flowsheet from 02/01/18 to 02/09/18 indicated that R #38 had watery stools daily. [NAME] Record review of the Minimum Data Set ((MDS) dated [DATE], section I, indicated that R #38 had a [DIAGNOSES REDACTED]. H. Record review of the care plan dated 12/25/17 and revised on 01/17/18 indicated that there was not a care plan focus or intervention for R #38's diarrhea and malnutrition. I. Record review of the (Name of Healthcare Facility), History and Physical Report indicated that R #38 was admitted to the emergency room (ER) on 02/09/18 for softball sized abdominal mass, a 14 pound weight loss, altered mental status. While in the ER, R #38 was noted to have an Acute Kidney Injury (AKI) [MEDICAL CONDITION] (an infection) from a Urinary Tract Infection [MEDICAL CONDITION]. The History and Physical also indicated that R #38 had a past medical history to include Chronic Diarrhea. [NAME] On 03/08/18 at 4:42 pm, during an interview with Licensed Practical Nurse (LPN) #4, she stated that R #38 wasn't eating or drinking fluids. Or at least not enough fluids. LPN #4 stated that she did appear dehydrated due to dry skin, lips were cracked, poor skin turgor. She was incontinent and had diarrhea. She stated that when R #38 was incontinent she would hold her [MEDICATION NAME]. She also stated that R #38 had an open wound on her coccyx (tailbone) because of the incontinence. A foam dressing was being placed along with barrier cream. K. On 03/09/18 at 8:26 am, during an interview with CNA #13, he stated that R #38 never ate or drank much. He stated that her stools weren't loose all the time but that she did have loose stools. They would offer her drink supplements and she would drink a little of that. L. On 03/09/18 at 10:15 am, during an interview with Director of Nurses (DON), she stated that the pharmacist had not reviewed R #38 since she arrived on 12/22/17. She stated that the pharmacist had not been in for this month (March (YEAR)) but he would be conducting a Medication Regimen Review for R #38. M. On 03/12/18 at 9:12 am, during an interview with the DON, she confirmed that on the ADL flowsheet R #38 was having constant watery stools for (MONTH) (YEAR). She also stated that if a resident was having constant watery stools they should not be getting stool softeners. This could cause skin breakdown and diarrhea depending on fluid intake. The reason that stool softeners are usually prescribed is for those residents on opiod (are primarily used for pain relief) medications. N. On 03/14/18 at 9:10 am, during an interview with CNA #14, she stated that R #38 had a red bottom with severe diarrhea 3 or 4 times per shift. She also stated that R #38 was not drinking any fluids and not eating. She stated that they (the CNAs) were telling the nurses about the poor intake, the redness and the diarrhea.",2020-09-01
57,SANDIA RIDGE CENTER,325032,2216 LESTER DRIVE NE,ALBUQUERQUE,NM,87112,2018-03-14,842,D,0,1,YN7D11,"Based on interview and record review the facility failed to consistently document on the Activities of Daily Living (ADL) flowsheets for 1 (R #38) of 2 (R #38 and #66) residents looked at for ADLs. This deficient practice has the potential for residents to not be identified as having poor meal and fluid intakes, how frequently a resident is experiencing diarrhea and if they are declining. The findings are: [NAME] Record review of R #38's ADL flowsheet for (MONTH) (YEAR), indicated that for the meal and fluid percentages that 17 out of 31 days nothing was documented for the whole day. On 12 different days for the month there was no documentation for breakfast and lunch, dinner was the only meal documented for the day. B. Record review of R #38's ADL flowsheet for (MONTH) (YEAR), indicated that for the bowel section, on 18 occasions there was no documentation indicating the number of times the resident had a bowel movement or what the consistency and size was. C. On 03/14/18 at 1:11 pm, during an interview with Registerd Nurse (RN) #3, he stated that the documentation on the ADL sheet for R #38 in (MONTH) (YEAR) was incomplete. RN #3 also agreed that it would be difficult to get an accurate picture of a resident when the there is inconsistent documentation. RN #3 also stated that the CNAs are responsible for documenting the ADLs in the chart before the end of shift. D. On 03/14/18 at 11:25 am, during an interview with CNA #14, she stated that yes the documentation on the ADL flowsheet for R #38 was incomplete. She stated that it looks like the CNA did not fill it in, not that that the activity didn't happen. They are supposed to be filling in all of the ADLs for all their residents before the end of their shift every time they work. E. On 03/09/18 at 10:37 am, during an interview with the Registered Dietician (RD), he stated that when he is making his assessments for residents he will pull information from different sources. The RD also stated that yes the ADL record at a minimum he will look at. He will look at the meal and fluid percentages when he is assessing a resident. The RD also stated that he does see some limitations with the documentation and that the CNAs do get training on how to document the percentages but it is a crude tool.",2020-09-01
58,SANDIA RIDGE CENTER,325032,2216 LESTER DRIVE NE,ALBUQUERQUE,NM,87112,2018-03-14,947,E,0,1,YN7D11,"Based on record review and interview, the facility failed to ensure that all employees working with Dementia (a disorder of the brain affecting a persons ability to think and remember and can also affect a person's daily functioning) residents received training at least once per year. This deficient practice has the potential to effect all 126 residents identified on the alphabetical resident census provided by the Administrator on 03/05/18 by not preparing employees for the challenges of working with demented residents, causing higher staff burnout and residents not having their needs met. The findings are: [NAME] During record review of the employee training's it revealed that five employees (CNA #s 8, 15, 16, 17 and 18) did not receive dementia training. B. On 03/12/18 at 3:45 pm, during an interview with the Administrator, she stated that only 75% of the staff that work with residents at the facility have had dementia training.",2020-09-01
59,SANDIA RIDGE CENTER,325032,2216 LESTER DRIVE NE,ALBUQUERQUE,NM,87112,2017-03-20,166,D,0,1,30NH11,"Based on observation, interview, and record review, the facility failed to ensure that a grievance for a missing purse was initiated for 1 (R #130) of 2 (R #130 and 58) residents reviewed for missing personal items. This deficient practice has the potential to result in feelings of anger and frustration due to the facility not looking into the missing purse. The findings are: [NAME] On 03/14/17 at 9:11 am, during an interview with R #130, she stated that her purse was missing and it had her identification and social security card in it. She stated that she did tell a staff member about the missing purse. B. On 03/16/17 at 8:30 am, during an interview with SSD (Social Services Director) and SSA (Social Services Assistant) the assistant stated that she had been told by R #130 about her missing purse. She stated that R #130 came to her and told her about a missing gray purse with a zipper on top. Then about an hour later she came back and told her that the missing purse was peach in color. The SSA stated that because of the variance in color and that she wasn't aware that R #130 had a purse, she didn't write up a grievance and/or investigate the missing purse. C. On 03/16/17 at 8:40 am, during an interview with the Business Office Manager, she stated that R #130 came to her and asked if anyone had turned in a missing purse and she told R #130, No, no one has turned in a missing purse. She stated that the business office is the lost and found for the building and that is why R #130 came to her. She stated that she didn't feel like it was worth writing a grievance over because she felt like it was more of a question about the purse than that someone had stolen her purse. D. On 03/16/17 at 9:15 am, during an interview with CNA (Certified Nurse Aide) #16, she stated that R #130 had not told her about a missing pure. CNA #16 stated that if R #130 had told her about a missing purse, she would have notified the nurse and that Social Services (SS) would have gotten involved and that SS would write up a grievance and investigate the missing item. She stated that it doesn't matter what the item might be, glasses, dentures or a book, SS would look into the missing item. CNA #16 stated that a missing purse would have been at the top of the list of things to investigate, if someone had a purse go missing. E. Record review of the Personal Property: Patient's policy and procedure dated 11/28/16, indicated in section 6.1: Any loss or breakage of a patient's personal item will be properly documented on the property loss form (Obtain from Claims Department) by the person receiving the report, and then referred to the Center Executive Director (CED). 6.2: The CED or designee will investigate the lost item.",2020-09-01
60,SANDIA RIDGE CENTER,325032,2216 LESTER DRIVE NE,ALBUQUERQUE,NM,87112,2017-03-20,224,H,0,1,30NH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure that residents were free from neglect for 1 (R #13) of 1 (R #13) residents reviewed for wounds by not notifying the HCP (healthcare provider) of the development of R #13's bilateral (both) heel ulcers. This deficient practice resulted in inconsistent and inaccurate monitoring of bilateral heel ulcers and lack of physician orders for treatment which allowed for R # 13's bilateral heel ulcers to worsen. The findings are: [NAME] Record review of the Nursing Assessment-Initial (Admission) dated 12/15/16 revealed Integumentary (skin) assessment describing skin as occasionally moist, normal for ethnicity skin color, warm, and without skin impairment present. B. Record review of the Progress Notes revealed the following: 1. On 12/23/16 resident had a new onset/change in skin integrity as evidenced by ulcer-pressure. The location is identified as skin breakdown to bilateral heels noted. 2. On 12/28/16 the resident had a skin injury/wound that was previously identified and described the area as pressure area location bilateral wounds to heels. 3. On 01/04/17 the resident had previously identified injury/wound and described the wounds as located on bilateral heels. 4. On 01/26/17 a skin injury was present that had previously been identified and was evaluated and the location was pressure area. 5. On 03/02/17 a previously identified skin injury/wound was present and located on bilateral heels. 6. On 03/13/17, bilateral heel wounds were found by the CNP (certified nurse practitioner). C. Record review of the Skin Check documentation revealed: 1. Skin check documentation dated 12/28/16, 01/04/17, 01/26/17, and 03/02/17 revealed a skin injury/wound was identified, the wound was not new, was a pressure type wound, and was located on bilateral heels. 2. Skin check documentation dated 01/11/17, 01/18/17, 02/02/17, 02/09/17, 02/16/17, 02/23/17, and 03/09/17 revealed no skin injury identified. 3. Skin check documentation dated 03/13/17 revealed a skin injury/wound was identified, the wound was not new, and described the wound as diabetic ulcers bilateral heels. D. Record review of the Skin Integrity Report revealed 1 entry dated 03/13/17 regarding bilateral heel ulcers indicated the following: 1. Left Heel described wound as diabetic, 100 % necrotic eschar (dead tissue), measuring 3.2 cm (centimeters) length, 4.0 cm width, 2. Right Heel described wound as diabetic, 100 % necrotic eschar (dead tissue), measuring 3.5 cm length, 3.7 cm width, E. Record review of the physician orders, Medication Administration Record, [REDACTED]. F. Record review of the Care Plan dated 05/08/16 revealed no care plan focus, goals, or interventions related to R #13 actual bilateral heel ulcers. [NAME] Record review of the physician progress notes [REDACTED].> 1. On 01/23/17 physical exam Skin: Inspection: No rashes or ulcers on exposed skin. 2 .On 02/16/17 physical exam Skin: Inspection: No rashes or ulcers on exposed skin. 3. On 03/13/17 physical exam Skin: Bilateral wounds on heels, L (left) heel with drainage and foul smelling. H. On 03/16/17 at 8:35 am, during interview with the Unit Manager (UM) #3, she confirmed she was not notified of R # 13's initial documentation of bilateral heel ulcers by facility nursing staff. She stated she was notified of the bilateral heel ulcers by the CNP on 03/13/17. The UM #3 verified there were no physician orders related to wound care until the CNP notified her of the wounds on 03/13/17 nor were there care plans in place related to the actual wounds prior to that. I. On 03/20/17 at 8:36 am, during interview with the CNP, she confirmed she is R # 13 primary medical provider. She stated staff did not notify her of R #13 bilateral heel ulcers and she found them herself on 03/13/17. She described the left heel wound as moist and smelled bad. She described the right heel wound as mostly dry and about the same size. When asked if she would call his wounds pressure ulcers, she replied yes. She stated she observed the resident without a heels up cushion (a cushion used to lift heels up off the bed to alleviate pressure) and went to the UM #3 to notify her that the staff needed education regarding wounds. [NAME] Record review of emergency room Discharge report dated 03/19/17 revealed R # 13 sent to emergency room regarding bilateral heel ulcers. K. Record review of the facility policy and procedure Skin Integrity Management revealed: 1. Identify patient's skin integrity status and need for prevention, intervention or treatment modalities through review of all appropriate assessment information. 2. Include all patients who have newly identified skin impairments on the Center's 24 hours summary report. 3. Perform skin inspection on admission/re-admission and weekly. Document on treatment administration record (TAR) or in Point click care (PCC). 4. Perform wound observations and measurements and complete Skin Integrity Report upon initial identification of altered skin integrity, weekly, and with anticipated decline of wound. 5. Perform daily monitoring of wounds or dressings for presence of complications or declines and document. 6. Develop comprehensive, interdisciplinary plan of care including prevention and wound treatments as indicated. 7. Document daily monitoring of ulcer site, with or without dressing.",2020-09-01
61,SANDIA RIDGE CENTER,325032,2216 LESTER DRIVE NE,ALBUQUERQUE,NM,87112,2017-03-20,241,E,0,1,30NH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure that residents had the right to a dignified existence for 6 (R #s 5, 9, 13, 103, 161 and 165) of 6 (R #s 5, 9, 13, 103, 161 and 165) residents reviewed for dignity. This deficient practice may result in feelings of frustration, embarrassment and may lower self-esteem. The findings are: [NAME] On 03/14/17 at 9:34 am, Certified Nurse Aide (CNA) #1 entered R #103's room without knocking or asking for permission to enter. B. On 03/14/17 at 10:20 am, CNA #1 entered R #161's room without waiting for permission to enter after knocking once. C. On 03/14/17 at 3:12 pm, CNA #2 entered R #165's room without waiting for permission to enter after knocking. D. On 03/16/17 at 8:38 am, Transportation Aide #1 entered R #165's room without waiting for permission to enter after knocking. E. On 03/14/16 at 4:05 pm, during interview with Unit Manager (UM) #1, he stated that staff should be knocking on the room door, announcing themselves and waiting for the resident to give permission prior to entering the room. UM #1 stated that staff entering the residents' room without requesting permission was unacceptable. F. Record review of the Dignity Policy dated 09/01/13 indicated, (Name of Center) will promote care for patients in a manner and in an environment that maintains or enhances each patient's dignity and respect in full recognition of his or her individuality .knock on doors and request permission to enter . [NAME] On 03/14/17 at 2:19 pm, CNA #3 entered R #13's room without knocking or asking permission to enter. He walked around the resident's bed without acknowleding the resident. H. On 03/14/17 at 2:21 pm, CNA #3 entered R #9's room without knocking or asking permission to enter. He opened the resident's bedside table drawers without acknowledging the resident. I. On 03/17/17 at 9:52 am, during interview with R #5, she stated that CNAs on the 500-unit are sarcastic, nasty and disrespectful They're kids, and they open their big nasty mouth to me and it's just devastating. I was taught to have more respect for older people when I was their age. When I say anything to the higher-ups (about staff attitude), nothing gets accomplished. [NAME] On 03/17/17 at 10:21 am, during interview with the Administrator, she indicated that one way that management monitors staff treatment of [REDACTED]. K. On 03/17/17 at 11:02 am, during interview with R #5, she stated that no one from management checks in with her on any regular basis. L. Record review of the Guardian Angel Assignments document provided by the Administrator on 03/17/17 found that patient rooms were divided into 17 groups, with a manager assigned to each group. Among the facility's managers with room assignments were the Payroll & Scheduling, Medical Records, and Business Office Managers, as well as the Assistant Business Office Manager and the Director of Recreation. A statement on the form stated All Guardian Angel rounds must be made every morning. Fill out Guardian Angel forms and bring to morning meeting. M. On 03/20/17 at 8:30 am, during interview with the Payroll & Scheduling Manager, he stated that he was a new employee. He indicated that he was unaware of the Guardian Angel program, was unaware that there were resident rooms assigned to him for rounds, and was unaware of who, if anyone, might be visiting those rooms until he was fully up-to-speed in his role. N. On 03/20/17 at 8:31 am, during interview with the Medical Records Dept. Manager, she stated that she visited her assigned rooms daily. When asked for the completed forms documenting the visits, she indicated that she had no documentation. She stated We're supposed to be filling out forms, but we haven't been doing it. O. On 03/20/17 at 8:37 am, during interview with the Director of Recreation, she was unable to state which rooms were assigned to her, until she found a copy of the Guardian Angel Assignments document. She stated that she tries to visit her assigned residents once or twice a week, but that it's really hard to squeeze it in. P. On 03/20/17 at 8:42 am, during interview with the Business Office Manager, she was unable to state which were her assigned rooms, until she located a copy of the Guardian Angel Assignments document. She indicated that she has not been doing these visits at all, stating I just found out about this. Q. On 03/20/17 at 8:43 am, during interview with the Assistant Business Office Manager, she denied knowledge of the program of Guardian Angel rounds, stating No, I haven't been doing them. I didn't even know about them. R. On 03/20/17 at 8:49 am, during interview with the Administrator, she conceded that the Guardian Angel program was not the best, and that some of the listed managers weren't doing the rounds. She stated that she hoped to revamp the program, using a different model, but had not yet done so. Reminded of her earlier statement indicating that Guardian Angel rounds were a primary means of ensuring that residents were being treated by nursing staff with dignity and respect, she indicated that, instead, she and her staff informally check with residents when they see them around the facility.",2020-09-01
62,SANDIA RIDGE CENTER,325032,2216 LESTER DRIVE NE,ALBUQUERQUE,NM,87112,2017-03-20,246,E,0,1,30NH11,"Based on observation, interview and record review the facility failed to ensure that residents had access to their call lights for 3 (R #s 86, 97 and 119) of 8 (R #s 86, 97, 119, 58, 15, 19, 127, 118) residents reviewed during random observation of call lights. This deficient practice has the potential to result in delays for residents receiving treatment; and staff being unaware of an emergency situation if a resident had a fall while attempting to get of bed. The findings are: [NAME] On 03/13/17 at 11:53 am, an observation was made of R #86's call light. The call light was on the floor and resident did not have access to it.the B. On 03/17/17 at 8:49 am, an observation was made of R #97's call light. The call light was on the floor at the end of the bed under R #97's oxygen machine. R #97 was currently in bed and would have been unable to access his call light. C. On 03/17/17 at 8:55 am, an observation was made of R #119's call light. The call light was on the floor under the bed. R #119 was currently in bed and would have been unable to access his call light. D. On 03/17/17 at 9:02 am, an observation was made of R #86's call light. The call light was behind the bed on the floor. E. On 03/17/17 at 9:09 am, during an interview with Certified Nurse Aide (CNA) #17, she stated that the CNAs are supposed to check the call lights frequently for all residents. For those residents that don't get out of bed often, staff will clip call lights on their sheets, to the bed, or to the residents gown to make sure that the call light is always within reach. F. On 03/17/17 at 9:25 am, during an interview with Licensed Practical Nurse (LPN) #5, he stated that the CNAs do rounds on their assigned halls, but because he (LPN #5) is in and out of the rooms all day, he will frequently take care of call lights. He stated that if there is a bed bound resident, he will place the call light on their chest. LPN #5 agreed that a call light should not be on the floor at anytime.",2020-09-01
63,SANDIA RIDGE CENTER,325032,2216 LESTER DRIVE NE,ALBUQUERQUE,NM,87112,2017-03-20,248,E,0,1,30NH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide an ongoing activity program for 1 (R #13) of 3 (R #s 3, 13 and 70) residents reviewed for activities by not providing activities that the resident indicated are very important to him. This deficient practice has the potential to cause a decline in the residents psychosocial well being. The findings are: [NAME] Record review of the MDS (Minimum Data Set) assessment dated [DATE] revealed that it is very important for the R #13 to listen to music, be around animals such as pets, keep up with the news, and go outside to get fresh air when the weather is good. B. Record review of the Care Plan dated 01/13/17 revealed: 1. Resident exhibits or is at risk for limited meaningful engagement related to social isolation, speaks very little English. Spanish speaking only. 2. The documented goal was resident will accept invitations to activities. Resident will participate in meaningful activities 1 to 2 times per week for 90 days. 3. The interventions listed were: inform resident of facility happenings, encourage resident to participate in meaningful activities of interest such as music socials, exercise class, coloring art, outdoors for fresh air, and catholic mass. C. Record review of the Recreation Activity Logs revealed: 1. (MONTH) (YEAR); Resident documented to be actively involved on 01/18/17 and 01/25/17 for Church/Clergy and on 01/22/17 for Gospel Music. There is 1 entry of a refusal on 01/07/17 for a pet visit. No other offered opportunities for pet visits are documented. 2. (MONTH) (YEAR); Resident was not documented as being actively involved in any activity. 3. (MONTH) (YEAR); resident documented as actively involved in Church/Clergy on 03/01/17 and 03/15/17, and Stress Mgmt (management)/relaxation 03/01/17, 03/13/17 and 03/15/17. The log indicated one refusal for Music. The log did not indicate the resident was offered to go outside to get fresh air, have a pet visit, or keep up with the news. D. On 03/16/17 at 1:52 pm, during interview with the Activities Assistant., she stated that she documented that R # 13 participated in the (MONTH) (YEAR) activities of Stress Mgmt/Relaxation because she observed him resting in his room on those occasions. E. On 03/16/17 at 1:52 pm, during interview with the Director of Recreation, she stated activity assessments are done quarterly and confirmed R # 13 had only had two assessments done since he was admitted on [DATE]. She stated I can see we are not doing enough with him. She confirmed the Activities Assistant documented the resident participated in a stress management/relaxation activity from 03/01/17 to 03/13/17 and on 03/15/17 incorrectly. She stated that a resident resting in his room should not be documented as an activity. She stated it's our fault for not taking R #13 outside for fresh air as written in his care plan. F. Record review of Residents/Patient's Choice recreation policy and procedure dated 07/01/14 revealed: 1. Residents/Patients have the right to participate in activities of their choosing . 2. The purpose is to provide opportunities for recreation and social involvement. 3. Residents/Patients who prefer not to participate in structured programs will be offered alternatives and necessary support/resources for meaningful individual pursuit of leisure interests.",2020-09-01
64,SANDIA RIDGE CENTER,325032,2216 LESTER DRIVE NE,ALBUQUERQUE,NM,87112,2017-03-20,279,G,0,1,30NH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to develop and revise comprehensive care plans with individualized goals and interventions for 2 (R #s 57 and 128) of 2 (R #s 57 and 128) residents reviewed for care plan issues. After R #128 sustained a fall which resulted in a [MEDICAL CONDITION], the facility failed to update his care plan and did not create any new interventions to prevent future falls, which resulted in the resident falling 2 more times acquiring multiple skin tears and another [MEDICAL CONDITION]. This deficient practice resulted in staff failing to identify and create new interventions that were necessary to prevent avoidable falls which resulted in serious injury to R #128. The findings are: Findings related to R #57: [NAME] Record review of R #57's electronic record revealed he was admitted to the facility on [DATE]. B. Record review of R #57's current care plan dated [DATE] revealed only 2 entries: one related to pain inititated on [DATE] and one related to [MEDICAL CONDITION] drugs (drugs that change brain function and results in alterations in perception, mood, or consciousness) initiated on [DATE]. C. On [DATE] at 2:36 pm, during an interview with the MDS (Minimum Data Set) Coordinator, she stated that back on [DATE] an MDS (Minimum Data Set) Asssessment was accidentally submitted that indicated the resident had died . She stated the mistake was corrected the same day however the error caused R #57's care plan to be deleted from his eletronic record. The MDS Coordinator stated she would have to contact the IT (Information Technology) department to see if they can recover his full care plan. D. On [DATE] at 11:51 am, during an interview with the Administrator, she verified that R #57's care plan was accidentally deleted and that none of the staff had access to it from [DATE] up until today ([DATE]). Findings related to R #128: E. Record review of R #128's Nurse's Note dated [DATE] stated, This day an Agency nurse worked on hall 500. Reported that resident was found on the floor at 7am during breakfast, lying down and a pillow on the back of his head. Nurse stated that assessed resident and was in pain. (Name of Nurse Practitioner) was informed and assessed Resident and gave new orders to transport resident to the ER (emergency room ) for evaluation. Efforts to reach the nurse for pertinent details fruitless. F. Record review of R #128's Nurse's Note dated [DATE] stated, Resident was re-admitted [DATE] from the hospital due to a hip fx (fracture). [NAME] Record review of the facility's investigative report regarding R #128's incident on [DATE] concluded by saying, His care plan has been updated with new fall interventions. H. Record review of the Fall Risk Assessment portion of R #128's Nursing assessment dated [DATE] indicated he scored of 19.0 which was considered High Risk for falls. I. Record review of R #128's Nurse's Note dated [DATE] stated, Resident self-reported to me @ around 1500, that he had tripped in his room; time unknown. He sustained 2 skin tears; one to his left outer elbow and one to his left knee. [NAME] Record review of the facility's RMS (Risk Management System) Event Summary Report regarding R #128's fall on [DATE] stated Preventative measures in place prior to fall: n/a. The report also stated Interventions added immediately after fall and care plan updated: VS (vital signs) taken; woundcare. K. Record review of R #128's Nurse's Note dated [DATE] stated, Received call back from on call (Name of on call physician) for Radiology Report on (Name of R #128). Results is right intertrochanteric fracture ([MEDICAL CONDITION]) with minimal displacement. keep patient comfortable and let (Name of R #128's physician) know in the morning. message was left for family member during day shift. No call back. L. Record review of the facility Follow-up Summary of R #128's incident on [DATE] revealed The resident did have a surgical repair of his hip and has returned back to the center. Although the center could not conclude the causation of the fracture, it is possible the resident fell in his room and got himself back up. Per the hospital records, the ortho (orthopedic, the branch of medicine dealing with the correction of deformities of bones or muscles) notes stated his fracture was acute and was probably due to a fall as they found a laceration (a deep cut or tear in skin or flesh) to his scalp. M. Record review of R #128's History and Physical completed by his physician on [DATE] indicated his past medical history of [REDACTED]. It also indicated his subsequent surgeries related to those fractures: Left Hip ORIF (An Open Reduction Internal Fixation surgery which involves realigning the bone or joint and then using steel rods, screws and/or plates to keep the fracture stable.) (MONTH) (YEAR), Right Hip ORIF (MONTH) 16, (YEAR). N. Record review of R #128's care plan revealed he did not have a focus related to fall prevention or any fall related interventions prior to [DATE]. O. On [DATE] at 2:53 pm, during an interview with Licensed Practical Nurse (LPN) #4, she stated R #128 did not have a fall when he was on the 100 unit in (MONTH) (YEAR). She stated he complained of pain and was eventually sent out for an x-ray which confirmed a [MEDICAL CONDITION] however since nobody saw him fall she stated she did not consider that he fell . LPN #4 stated R #128 was unsteady on his feet but did not consider him to be a fall risk. She also stated she was not sure whether R #128 had any interventions in place related to fall prevention. P. On [DATE] at 3:33 pm, during an interview with the Director of Nurses (DON), he stated that a resident is considered a fall risk after they have their first fall. The DON verified that R #128's first fall at the facility occurred on [DATE] which resulted in his left hip being fractured. The DON stated that after a fall, the resident's care plan should be updated with new interventions added to prevent future falls. The DON failed to provide an updated care plan for R #128 after his fall on [DATE] and after his fall on [DATE] which resulted in 2 skin tears. Q. On [DATE] at 8:47 am, during an interview with the Administrator, she verified that R #128 did not have his care plan updated after his fall on [DATE] or after his fall on [DATE]. She verified that his care plan was not updated until [DATE] after his fall on [DATE]. The Administrator was unable to provide an answer as to what interventions were in place to prevent R #128's second and third falls.",2020-09-01
65,SANDIA RIDGE CENTER,325032,2216 LESTER DRIVE NE,ALBUQUERQUE,NM,87112,2017-03-20,282,D,0,1,30NH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to implement the plan of care for 1 (R #160) of 4 (R #s 79, 128, 156 and 160) residents reviewed for accidents and [MEDICAL TREATMENT] by not palpating (examining by touch) for thrill (a vibration of blood going through the access site) and auscultating (listen to the internal sound) for bruit (audible sound associated with obstructed blood flow) the resident's A/V (arteriovenous) graft (an artificial vein that can be used repeatedly for needle placement and blood access during [MEDICAL TREATMENT]-a machine that filters wastes, salts and fluid from the body when the kidneys are no longer healthy enough to do this work). This deficient practice has the potential to prevent identification of complications with the A/V graft site and may prevent the completion of [MEDICAL TREATMENT]. The findings are: [NAME] Record review of the Care Plan dated 02/08/17 indicated the following: (Name of R #160) is at risk for impaired renal function and is at risk for complications related to [MEDICAL TREATMENT] .Monitor [MEDICAL TREATMENT] access for bruit and thrill q (every) shift and prn (as needed). B. Record review of R #160's medical record revealed no documentation to indicate that the [MEDICAL TREATMENT] site was assessed. C. On 03/17/17 at 4:14 pm, during interview with the Director of Nursing (DON), he stated that the [MEDICAL TREATMENT] should be assessed daily and documented on the TAR (Treatment Administration Record). When informed that this was not the case, he verified this with the documentation and stated that the [MEDICAL TREATMENT] should have been assessed per the resident's care plan (q shift) and that without ongoing assessments of the site, staff would have no way of knowing if there were problems with the area that would prevent successful [MEDICAL TREATMENT]. D. Record review of the [MEDICAL TREATMENT] Policy and Procedure dated 11/28/16 indicated the following: Evaluate [MEDICAL TREATMENT] site upon return from [MEDICAL TREATMENT] center, every shift and more frequently if complications suspected .",2020-09-01
66,SANDIA RIDGE CENTER,325032,2216 LESTER DRIVE NE,ALBUQUERQUE,NM,87112,2017-03-20,312,E,0,1,30NH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents were provided the assistance they need in performing hygiene care and showers for 2 (R #s 3 and 70) of 2 (R #s 3 and 70) residents reviewed for ADLs (activities of daily living). This deficient practice has the potential to result in poor hygiene, lower self-esteem and could result in further decline in residents' ability to participate in their ADLs. The findings are: [NAME] On 03/15/17 at 2:10 pm, during an interview with LPN (licensed practical nurse) #6, she stated that sometimes, it depends on R #70's mood on whether R #70 will get a shower. She stated that she does not know him to refuse showers that much because the CNAs (certified nursing assistant) should be coming to her to let her know when he does refuse. She stated that when this happens she will go talk to him and come back later if she needs to, to talk to him about taking a shower. She stated that yes it should be documented if he is refusing showers or even if he is getting his showers. B. On 03/15/17 at 3:45 pm, during an interview with the DON (Director of Nursing) he stated that he thinks part of the problem is that agency staff don't document the showers. He stated that they either don't know how or they just don't do it. When asked about the difficulty of the actual shower sheet needing a minimum of a date, time and signature to document the showers, he had no response. The DON also stated that it was the facility's responsibility to train agency staff. C. On 03/16/17 at 11:25 am, during an interview with the DON he stated that by looking at the shower sheets R #70 does not appear to be receiving showers. D. On 03/20/17 at 10:33 am, during an interview with CNA #18 she stated that the process for showers would be if a resident refuses a shower they tell the nurse. They will try to ask again later. She stated that CNAs are responsible for documenting showers on the ADL sheet and also on the shower sheets. She stated that R #70 refuses showers all the time and that R #70 would prefer a male to shower him. She stated that they do try to accommodate that request. E. Record review indicated that R #70's shower days are Wednesday and Saturday. F. Record review of the Weekly Bath and Skin Report dated from 09/01/16 to 02/28/17 indicated that R #70 did not receive 42 out of 52 showers with four documented refusals. [NAME] Record review of the ADL log sheets for bathing from 09/01/16 to 02/28/17 indicated that R #70 did not receive 41 of 52 showers with four documented refusals. Findings for R #3 I. On 03/13/17 at 01:17 pm, R #3 was observed to have a contracture (a permanent shortening of muscle, tendon, or scar tissue producing deformity or distortion) of the left hand and held it in a fist. He was observed to have untrimmed nails on both hands with brown/black material underneath them. [NAME] 03/15/2017 at 1:44 pm, during interview and observation with the DON, he shook R #3 hand and observed both hands. He stated the nails were too long on both hands and needed to be trimmed. He stated the nails on his left hand could break the integrity of the skin if not trimmed due to the resident having a contracture on that hand. K. Record review of the Care Plan revised on 05/08/15 revealed R #3 requires assistance with ADL care in bathing, grooming, dressing, bed mobility, transfer, locomotion, toileting due to cognitive loss. [DIAGNOSES REDACTED]. L. Record review of the policy and procedure Activities of Daily Living dated 11/28/16 revealed: 1. Based on the comprehensive assessment of a patient and consistent with the patient's needs and choices, the Center must provide the necessary care and services to ensure that a patient's abilities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. 2. The Center must ensure that a patient is given the appropriate treatment and services to maintain or improve his/her ability to carry out ADL's. 3. A patient who is unable to carry out ADL's receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.",2020-09-01
67,SANDIA RIDGE CENTER,325032,2216 LESTER DRIVE NE,ALBUQUERQUE,NM,87112,2017-03-20,314,H,0,1,30NH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide necessary treatment and services to heal pressure ulcers for 1 (R #13) of 1 (R #13) residents reviewed for wounds when they failed to notify the healthcare provider of the development of bilateral heel ulcers. This deficient practice likely resulted in the resident not receiving the care and services necessary to promote healing which resulted in worsening of the bilateral pressure ulcers. The findings are: [NAME] Record review of the Nursing Assessment-Initial (Admission) dated 12/15/16 revealed Integumentary (skin) assessment describing skin as occasionally moist, normal for ethnicity skin color, warm, and without skin impairment present. B. Record review of the Progress Notes revealed: 1. Entry dated 12/23/16 revealed resident had a new onset/change in skin integrity as evidenced by ulcer-pressure. The location is identified as skin breakdown to bilateral heels noted. 2. Entry dated 12/28/16 revealed the resident had a skin injury/wound that was previously identified and described the area as pressure area location bilateral wounds to heels. 3. Entry dated 01/04/17 revealed the resident had previously identified injury/wound and described the wounds as located on bilateral heels. 4. Entry dated 01/23/17 revealed Res (resident) heels improved. Scab is beginning to peel away with pink healing. Dressing applied to protect scab from ripping away. 5. Entry dated 01/26/17 revealed a skin injury was present that had previously been identified and was evaluated and the location was pressure area. 6. Entry dated 03/02/17 revealed a previously identified skin injury/wound was present located on bilateral heels. 7. Entry dated 03/13/17 stated This nurse called to resident's room by CNP (certified nurse practitioner) to assess diabetic ulcers on bilateral heels .100 % eschar (dead tissue) bilateral heels, heels are boggy (abnormal texture of tissue) and surrounding area is calloused (hardened). C. Record review of the Skin Check documentation revealed: 1. Skin check documentation dated 12/28/17, 01/04/17, 01/26/17, and 03/02/17 revealed a skin injury/wound was identified, the wound was not new, was a pressure type wound, and was located on bilateral heels. 2. Skin check documentation dated 01/11/17, 01/18/17, 02/02/17, 02/09/17, 02/16/17, 02/23/17, and 03/09/17 revealed no skin injury identified. 3. Skin check documentation dated 3/13/17 revealed a skin injury/wound was identified, the wound was not new, and described the wound as diabetic ulcers bilateral heels. D. Record review of the Skin Integrity Report revealed one entry dated 03/13/17 regarding bilateral heel ulcers. 1. Left Heel described wound as diabetic, 100 % (percent) necrotic eschar (dead tissue), measuring 3.2 cm (centimeters) length, 4.0 cm width, 2. Right Heel described wound as diabetic, 100 % necrotic eschar (dead tissue), measuring 3.5 cm length, 3.7 cm width, E. Record review of the physician orders, Medication Administration Record, [REDACTED]. F. Record review of the Care Plan dated 05/08/16 revealed no care plan focus, goals, or interventions related to R #13's actual bilateral heel ulcers. [NAME] Record review of the physician progress notes [REDACTED].> 1. On 01/23/17 physical exam Skin: Inspection: No rashes or ulcers on exposed skin. 2 .On 02/16/17 physical exam Skin: Inspection: No rashes or ulcers on exposed skin. 3. On 03/13/17 physical exam Skin: Bilateral wounds on heels, L (left) heel with drainage and foul smelling. H. On 03/16/17 at 4:14 pm, during interview with UM #3 (unit manager) she verified she was the facility wound care nurse. She stated R #13's bilateral heel ulcers are considered in house acquired. I. On 03/16/17 at 8:35 am, during interview with the UM #3, she confirmed she was not notified of R # 13's initial documentation of bilateral heel ulcers by facility nursing staff. She stated she was notified of the bilateral heel ulcers by the CNP on 03/13/17. The wound care nurse verified there were no physician orders related to wound care until the CNP notified her of the wounds on 03/13/17 nor were there care plans in place related to the actual wounds prior to that. [NAME] On 3/20/17 at 08:36 am, during interview with the CNP, she confirmed she is R # 13's primary medical provider. She stated staff did not notify her of R #13's bilateral heel ulcers and she found them herself on 03/13/17. She described the left heel wound as moist and smelled bad. She described the right heel wound as mostly dry and about the same size. When asked if she would call his wounds pressure ulcers, she replied yes. She stated she observed the resident without a heels up cushion (a cushion that lifts the heels up off the bed to alleviate pressure) and went to the UM #3 to notify her the staff needed education. K. Record review of emergency room Discharge report revealed R #13 sent to emergency room regarding bilateral heel ulcers on 03/19/17. The discharge [DIAGNOSES REDACTED]. L. Record review of the facility policy and procedure Skin Integrity Management revealed: 1. Identify patient's skin integrity status and need for prevention intervention or treatment modalities through review of all appropriate assessment information. 2. Include all patients who have newly identified skin impairments on the Center's 24 hours summary report. 3. Perform skin inspection on admission/re-admission and weekly. Document on treatment administration record (TAR) or in Point click care (PCC). 4. Perform wound observations and measurements and complete Skin Integrity Report upon initial identification of altered skin integrity, weekly, and with anticipated decline of wound. 5. Perform daily monitoring of wounds or dressings for presence of complications or declines and document. 6. Develop comprehensive, interdisciplinary plan of care including prevention and wound treatments as indicated. 7. Document daily monitoring of ulcer site, with or without dressing.",2020-09-01
68,SANDIA RIDGE CENTER,325032,2216 LESTER DRIVE NE,ALBUQUERQUE,NM,87112,2017-03-20,323,G,0,1,30NH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that each resident received adequate supervision and assistive devices to avoid falls and elopement (unsupervised exit from the facility) for 2 (R #s 4 and 128) of 6 (R #s 4, 73, 79, 128, 156 and 160) residents reviewed for accident hazards. R #4 was not fitted with a Wanderguard device (an electronic monitoring bracelet), allowing her to exit the facility without detection. After R #128 sustained a fall which resulted in a fractured hip, the facility failed to provide adequate supervision, which resulted in the resident falling 2 mores times resulting in skin tears and another fractured hip. These deficient practices likely caused R #128's injuries, and could jeopardize residents at risk for elopement through exposure to street traffic, temperature extremes, or other environmental hazards. The findings are: Findings related to R #4: [NAME] Record review of a Risk Management System document dated 3/19/17 found that it pertained to an elopement event of R #4 on 03/17/17. The document indicated The resident exited the center with another resident at 7:12 pm. The staff was informed of the resident outside at 7:21 pm. The resident was brought back into the center and was assessed for injury and none was noted. B. Record review of R #4's care plan dated 08/02/16 found a focus area stating Resident/Patient is at risk for elopement related to: Cognitive Loss (thinking impairment) / Dementia. Among the listed interventions was Utilize and monitor security bracelet per protocol. All later versions of R #4's care plan were found to have continued this focus area and intervention. C. Record review of R #4's Minimum Data Set Assessment (a tool for reporting on resident characteristics) found a section stating Wandering - Presence & Frequency. To the question Has the resident wandered?, a response of Behavior of this type occurred daily was documented and signed by the Social Services Director on 01/27/17. D. Record review of R #4's progress notes found: 1. A nurse's note dated 07/25/16 stating Res (resident) up through much of shift wandering Tries doors and attempts to enter residents' rooms. Redirected multiple times. 2. A Social Services Dept. (SSD) note dated 07/26/16 stating She is exit seeking and has tried to get out the doors on hall 500. She is wearing a wanderguard bracelet as she does wander around the facility. 3. A Social Services Dept. note dated 08/03/16 stating SSD also spoke to (resident's family member/power-of-attorney) about how (R #4) is wandering around the facility and that she has been exit seeking. Again they refused to have her in the secured unit. The family believes she will adjust and that it will just take her time. SSD explained that we are worried for her safety as she tries to go out the side doors that do not have the wanderguard alarm system. Family wants to keep her in the general area. 4. An Administrator's note dated 08/10/16 stating . She continues to wander and is exit seeking. Family denies her needing a locked unit. Will continue to educate family that she would be safer in a locked unit. Resident has a wander guard . 5. A Social Services Dept. note dated 11/01/16 stating She does have a wanderguard. 6. A nurse's note dated 03/18/17, related to the elopement incident on 03/17/17, stating Resident left facility with another resident this evening at shift change. Residents both found at sign attempting to return. Resident no longer has a wanderguard. Requesting orders for renewal of wanderguard order. Spoke with family, and family wants resumption of wanderguard order. E. On 03/20/17 at 12:35 pm, during interview with the Administrator, she stated that R #4 was on a trial of not having a Wanderguard. She stated that she would look for documents supporting her assertion that a planned, intentional trial was taking place. She did not provide any such documentation by survey's end. F. On 03/20/17 at 12:52 pm, during interview with Unit Manager #3, she stated that R #4 was discharged to a hospital on [DATE], and returned on 03/14/17. She stated that EMTs (Emergency Medical Technicians) routinely cut off Wanderguards when transporting patients, and confirmed that R #4's Wanderguard was not replaced upon her return to the facility. She confirmed that the resident was not wearing a Wanderguard when she eloped through the facility's front door on 03/17/17. [NAME] On 03/20/17 at 12:55 pm, during interview with R #4's family member/power-of-attorney, she stated that R #4 is supposed to have a Wanderguard. She stated that R #4 had had a Wanderguard prior to being discharged to the hospital on [DATE], but that when she returned from the hospital on [DATE], she no longer had it on. She indicated that facility staff had advised her that a new physician's orders [REDACTED].#4 eloped. Findings Related to R #128: H. Record review of R #128's Nurse's Note dated 07/01/16 stated, This day an Agency nurse worked on hall 500. Reported that resident was found on the floor at 7am during breakfast, lying down and a pillow on the back of his head. Nurse stated assessed resident and was in pain. (Name of Nurse Practitioner) was informed and assessed Resident and gave new orders to transport resident to the ER (emergency room ) for evaluation. Efforts to reach the nurse for pertinent details fruitless. I. Record review of R #128's Nurse's Note dated 07/06/16 stated, Resident was re-admitted [DATE] from the hospital due to a hip fx (fracture). [NAME] Record review of the facility's investigative report regarding R #128's incident on 07/01/16 concluded by saying, His care plan has been updated with new fall interventions. K. Record review of the Fall Risk Assessment portion of R #128's Nursing assessment dated [DATE] indicated he scored 19.0 which was considered High Risk for falls. L. Record review of R #128's Nurse's Note dated 10/26/16 stated, Resident self-reported to me @ (at) around 1500 (3:00 pm), that he had tripped in his room; time unknown. He sustained 2 skin tears; one to his left outer elbow and one to his left knee. M. Record review of the facility's RMS (Risk Management System) Event Summary Report regarding R #128's fall on 10/21/16 stated Preventative measures in place prior to fall: n/a. The report also stated Interventions added immediately after fall and care plan updated: VS (vital signs) taken; woundcare. N. Record review of R #128's Nurse's Note dated 02/15/17 stated, Received call back from on call (Name of on call physician) for Radiology Report on (Name of R #128). Results are right intertrochanteric fracture (hip fracture) with minimal displacement. Keep patient comfortable and let (Name of R #128's physician) know in the morning. Message was left for family member during day shift. No call back. O. Record review of the facility Follow-up Summary of R #128's incident on 02/15/17 revealed The resident did have a surgical repair of his hip and has returned back to the center. Although the center could not conclude the causation of the fracture, it is possible the resident fell in his room and got himself back up. Per the hospital records, the ortho (orthopedic, the branch of medicine dealing with the correction of deformities of bones or muscles) notes stated his fracture was acute and was probably due to a fall as they found a laceration (a deep cut or tear in skin or flesh) to his scalp. P. Record review of R #128's History and Physical completed by his physician on 03/02/17 indicated his past medical history of [REDACTED]. It also indicated his subsequent surgeries related to those fractures: Left Hip ORIF (An Open Reduction Internal Fixation surgery which involves realigning the bone or joint and then using steel rods, screws and/or plates to keep the fracture stable) (MONTH) (YEAR), Right Hip ORIF (MONTH) 16, (YEAR). Q. Record review of R #128's care plan revealed he did not have a focus related to fall prevention or any fall related interventions prior to 02/16/17. R. On 03/15/17 at 2:53 pm, during an interview with LPN #4, she stated R #128 did not have a fall when he was on the 100 unit in (MONTH) (YEAR). She stated he complained of pain and was eventually sent out for an x-ray which confirmed a hip fracture however since nobody saw him fall she stated she did not consider that he fell . LPN #4 stated R #128 was unsteady on his feet, but did not consider him to be a fall risk. She also stated she was not sure whether R #128 had any interventions in place related to fall prevention. S. On 03/15/17 at 3:33 pm, during an interview with the DON, he stated that a resident is considered a fall risk after they have their first fall. The DON verified that R #128's first fall at the facility occurred on 07/01/16 which resulted in his left hip being fractured. The DON stated that after a fall, the resident's care plan should be updated with new interventions added to prevent future falls. The DON failed to provide an updated care plan for R #128 after his fall on 07/01/16 and after his fall on 10/21/16 which resulted in 2 skin tears. T. On 03/16/17 at 8:47 am, during an interview with the Administrator, she verified that R #128 did not have his care plan updated after his fall on 07/01/16 or after his fall on 10/21/16. She verified that his care plan was not updated until 02/16/17 after his fall on 02/15/17. The Administrator was unable to provide an answer as to what interventions were in place to prevent R #128's second and third falls.",2020-09-01
69,SANDIA RIDGE CENTER,325032,2216 LESTER DRIVE NE,ALBUQUERQUE,NM,87112,2017-03-20,329,E,0,1,30NH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that residents were free from unnecessary medications for 2 (R #s 3 and 70) of 5 (R #s 3, 58, 70, 99, and 110) residents reviewed for unnecessary medications by not completing behavior monitoring and pain assessments. This deficient practice has the potential to result in residents receiving unnecessary [MEDICAL CONDITION] (chemical substance that changes brain function and results in alterations in perception, mood, or consciousness) and pain medications, not receiving the right dose of a medication, and staff not knowing whether a medication is effective due to the lack of monitoring of pain and behaviors. The findings are: Findings for R #70: [NAME] Record review of the physcian's orders and admission face sheet indicated that R #70 had a [DIAGNOSES REDACTED]. R #70 is taking [MEDICATION NAME] (a medication for depression) 20 mg (milligrams) per day and [MEDICATION NAME] (antipsychotic medication) 50 mg every 8 hours for behaviors. B. Record review of a progress note dated 01/4/17 indicated that R #70 had a history of [REDACTED]. The note also stated that: 1. Resident exhibits behavior: Physical aggression as evidenced by: hitting, striking out, kicking, and pushing; 2. resists care or treatment, verbal aggression as evidenced by: yelling, cursing, insults to others; easily startled; 3. doesn't like when others talk to him; 4. combative/physically abusive with ADLS (activities of daily living); 5. He can be noncompliant/resistant to care. Hx (history) of suicidal ideation. Resident is very independent due to his military background and does not like getting help from staff. C. Record review of progress note dated 01/11/17, R #70 hit another resident while they were in the dining room near the coffee pot. Staff intervened and stopped R #70 of his aggression and both residents were separated. R #70 punched the other resident on his face and stomach. D. Record review of a progress note dated 03/01/17, indicated that R #70 was sitting in the dinning room at 1700 (5:00 pm) with another resd (resident) on (sic) his table drinking coffee. They got mad at each other for something and tried to hit. They were in physical contact but did not hit. They were separated from each other and were moved out of the dining room. E. Record review of the Behavior Monitoring Flowsheet for (MONTH) (YEAR) R #70 indicated that for the month of (MONTH) (YEAR), R #70 had a behavior monitoring sheet that was inaccurately filled by not having all of R #70's behaviors noted on the behavior sheet that they were monitoring. For the months of (MONTH) (YEAR) through (MONTH) 17, (YEAR) all of the behavior monitoring sheets were filled out inaccurately with no behaviors documented. There was no behavior monitoring sheet at all for R #70 for the month of (MONTH) (YEAR). F. Record review of the care plan dated 03/14/17 indicated that as an intervention for the use of [MEDICAL CONDITION] drugs, R #70 will have: 1. A behavior monitoring flowsheet completed and that monitoring for continued need of medication as related to behavior and mood. 2. Monitor for continued need of medication as related to behavior and mood. [NAME] On 03/15/17 at 3:22 pm, during an interview with Unit Manager #3, she stated that her expectation in documenting behaviors would be to document a behavior that was not the resident's baseline. They document behaviors by exception, so if someone was always cranky, then when they were cranky they wouldn't document that as a behavior. If they are on [MEDICAL CONDITION] medications all behaviors need to be documented on the behavior monitoring sheet. Otherwise a behavior from a resident would be documented in the progress notes. The behavior tracking sheet should be in the TAR (treatment administration record). H. On 03/16/17 at 11:25 am, during an interview with the DON (Director of Nursing), he stated that the behavior monitoring sheets from 09/01/16 to 02/28/17 for R #70 were incomplete. He also stated that it is agency staff that are not documenting the behaviors. I. On 03/15/17 at 2:10 pm, during an interview with LPN #6, she stated that R #70 easily get's angry with other residents, especially if they get in his way. He will sometimes become upset on his shower days. She stated that behaviors are documented by nursing staff and that CNAs or anyone else who might see behaviors should report them to the nurse. She stated that behaviors are being documented in the resident's medical chart but made no mention of the behavior monitoring sheets. Findings for R #3 Behavior Monitoring [NAME] Record review of the (MONTH) (YEAR) physician orders [REDACTED].> 1. [MEDICATION NAME] HCL ([MEDICATION NAME]) (narcotic pain reliever used to treat moderate to severe pain) tablet 5 mg (milligrams). Give 5 mg by mouth three times a day for pain. Order date of 01/06/17. 2. [MEDICATION NAME] HCL (antidepressant used to treat depression) tablet 25 mg. Give 1 tablet by mouth one time a day for depression. Order date of 02/23/16. 3. [MEDICATION NAME] (antidepressant used to treat depression) tablet 15 mg. Give 1 tablet by mouth one time a day related to [MEDICAL CONDITION]. Order date of 01/06/17. 4. [MEDICATION NAME] (An antidepressent used to treat depression) tablet 20 mg. Give 20 mg by mouth in the evening related to dementia in other diseases classified elsewhere with behavioral disturbance. Order date of 04/27/16. K. Record review of R #3's Care Plan revised on 01/13/17 revealed: 1. Is at risk for complications related to the use of [MEDICAL CONDITION] drugs; Medication: [MEDICATION NAME], and [MEDICATION NAME]. 2. The goal is to have him have the smallest most effective dose without side effects for 90 days. 3. The interventions include monitor for continued need of medictation as related to behavior and mood, monitor for changes in mental status and functional level and report to MD (medical doctor) as indicated, monitor for side effects and consult physician and/or pharmacist as needed, and obtain psych (mental) evaluation as ordered. L. Record review of the Monthly Behavior Monitoring Flowsheets for (MONTH) (YEAR) and (MONTH) (YEAR) revealed that flowsheets were blank without any documentation. Facility unable to provide flowsheet for (MONTH) (YEAR). M. Record review of the Progress notes dated 01/13/17 revealed resident can be verbally and physically agressive. He will also refuse care, especially showers. N. On 03/16/17 at 9:57 am, during interview the the DON, he stated the facility has new Behavior Monitoring and Intervention forms and they are to be charted by exception (charting only when a behavior occurs). He stated the forms for the months of (MONTH) (YEAR) and (MONTH) (YEAR) are incomplete because staff are not documenting refusals of care. He stated they have had agency staff working that have not filled out the forms correctly. He stated staff need training on filling out these Behavior Monitoring and Intervention forms correctly. Findings for R #3 Pain Assessment Documentation O. Record review of the Pain Assessment Medication sheet revealed: 1. Incomplete pain assessment for (MONTH) (YEAR) with 52 out of 78 missed opportunities where pain level is not documented. 2. Incomplete pain assessment for (MONTH) (YEAR) with 58 out of 84 missed opportunities where pain level is not documented. 3. Incomplete pain assessment for (MONTH) (YEAR) with 30 out of 44 missed opportunities where pain level is not documented. P. Review of the MAR (Medication Administration Record) for [MEDICATION NAME] HCL prescribed three times a day revealed incomplete pain assessments where pain level is not documented: 1. Pain assessment for (MONTH) (YEAR) with 53 out of 78 missed opportunities. 2. Pain assessment for (MONTH) (YEAR) with 83 out of 84 missed opportunities. 3. Pain assessment for (MONTH) (YEAR) with 41 out of 44 missed opportunities. Q. On 03/15/17 at 2:43 pm, during an interview with the DON, he stated pain assessments for R #3 should be done before each dose of [MEDICATION NAME] is given for pain, even if the dose is scheduled three times a day. He stated it should be documented in the MAR and he also stated it can be documented on the Pain Assessment Medication Sheet. He confirmed both the MAR and Pain Assessment Medication Sheet were incomplete without pain levels being documented.",2020-09-01
70,SANDIA RIDGE CENTER,325032,2216 LESTER DRIVE NE,ALBUQUERQUE,NM,87112,2017-03-20,371,F,0,1,30NH11,"Based on observation, interview and record review the facility failed to ensure that all kitchen equipment used in the cooking, storing and preparing of food was properly working and in sanitary condition for all 116 residents on the census list provided by the Administrator on 03/13/17 by: 1. Not having calibrated and properly working thermometers that are used when checking to ensure that foods being served are at the proper temperature. 2. That the stove and grill were properly cleaned after each meal and staff were unaware of the last time that the stove had been deep cleaned. These deficient practices have the potential to make residents sick if the food is not served at the proper temperature and the stove and grill are dirty and are not being properly cleaned. The findings are: [NAME] On 03/13/17 at 12:35 pm, an observation was made of a dietary aide not being sure how to calibrate a thermometer when asked to check the temperature of the food that was getting ready to be served to the residents for lunch. The head chef told the dietary aide how to calibrate a thermometer and it was observed that the dietary aide #1 did what the head cook instructed her to do. After roughly 5 minutes the thermometer that had been sitting in ice, was checked and it was at 40 degrees. They got out a second thermometer and placed that in the ice water. This thermometer worked and it was registering at 32 degrees. B. On 03/14/17 at 7:40 am, an observation was made of a very strong smoke smell and smoke in the air throughout the facility. The smoke was coming from the grill in the kitchen. C. On 03/14/17 at 7:50 am, during an interview with the Head Chef, he stated that the stove top was turned up too high and that was the reason it was smoking so bad. An observation was then made of the back door being open trying to allow the smoke out. D. On 03/15/17 at 2:47 am, during an interview with the Dietary Director, he stated that most of the staff are new and they are trying to get them trained. He stated that they have a training program that covers serving, taking the temperature of food and calibrating a thermometer. They put the staff through this training the first month that they are employed with the facility. He agreed that it was concerning that not all staff are aware of how to calibrate a thermometer and that the thermometer wasn't properly working. E. On 03/17/17 at 11:00 am, during an interview with the Dietary Director, he stated that yes, all staff should know how to calibrate a thermometer. He also stated that the grill that currently had not been cleaned from breakfast and still had grease and pancake residue on it, should have been cleaned already and will be cleaned before they serve lunch. He also stated that if the grill hadn't been cleaned and it had a lot of grease on it, it would smoke if it was turned on and became very hot. He stated that this could have contributed to the smoke issue from the other morning.",2020-09-01
71,SANDIA RIDGE CENTER,325032,2216 LESTER DRIVE NE,ALBUQUERQUE,NM,87112,2017-03-20,464,F,0,1,30NH11,"Based on observation and interview, the facility failed to provide a well ventilated dining/activity room for 4 (R #s 21, 50, 133 and 144) of 4 (R #s 21, 50, 133 and 144) residents who enter the dining/activity area for social time and activities. This deficient practice has the potential to affect residents comfort and may result in respiratory distress. The findings are: [NAME] Record review revealed resident smoking times listed at 9:00 am, 11:30 am, 1:30 pm, 4:00 pm, and 8:00 pm. The designated smoking area was listed as out on the patio by the dining/activity room. B. On 03/13/17 at 9:11 am, during an observation, 10 smokers were observed to be smoking outside the dining/activity room area close to the doorway. The dining/activity room was observed to smell like cigarette smoke. Non-smoking residents were observed to be sitting in the dining/activity area. C. On 03/14/17 at 9:00 am, during an observation, an automatic door leading out to the designated smoking area was located in the dining/activity area. Breakfast had ended and several residents were sitting in the dining/activity area. D. On 03/14/17 at 9:05 am, during an interview, R #50, R #133, and R #144 were sitting in the dining/activity room stating whenever the door opens the smell of cigarette smoke comes into the dining/activity room area. They stated they did not like the smoke smell. E. On 03/14/17 at 9:05 am, during an observation in the dining/activity room, each time the door opened, the smell of cigarette smoke entered the facility. Outside, it was noted several residents sitting close to the doorway smoking cigarettes. F. On 03/16/17 at 8:29 am, R # 21 stated smoke from the cigarette smokers bothered her but what can I do. She stated it also bothers us during activities. [NAME] On 03/16/17 at 9:06 am, during an observation, the smell of cigarette smoke entered the dining/activity room each time the automatic door opened to the designated smoking area. H. On 03/16/17 at 9:14 am, during interview, Dietary Aide #1 was observed to be clearing off dishes from the dining room. She stated she smells cigarette smoke every day in the dining room around 9:00 am. I. On 03/16/17 at 9:15 am, during an interview, Housekeeper #1 observed to be cleaning the dining room area stated residents who sit in the dining room complained they smell cigarette smoke. [NAME] On 03/20/17 at 11:23 am, during an interview, the Maintenance Supervisor stated residents have complained about cigarette smoke in the dining room and stated the smoking area is right by the dining room. He stated they try to synchronize smoke breaks that way they don't mix with meal times but it's just that the area is so close to the dining room and people come in the building smelling like smoke. K. Record review of the facility policy and procedure Smoking dated 04/01/15 revealed: 1. The purpose is to ensure that patients who choose not to smoke are not exposed to smoke. 2. Smoking (including electronic cigarettes) will only be allowed in designated areas. An area designated as a smoking area will be environmentally separate from all patient care areas, will be well ventilated,",2020-09-01
72,SANDIA RIDGE CENTER,325032,2216 LESTER DRIVE NE,ALBUQUERQUE,NM,87112,2017-03-20,498,F,0,1,30NH11,"Based on record review and interview, the facility failed to ensure that Certified Nursing Aides (CNAs) demonstrated competency in skills and techniques necessary to meet resident's needs including performing range of motion activities, providing transfer assistance and carrying out the appropriate infection control and safety procedures. This deficient practice has the potential to negatively affect all 116 residents in the facility as identified on the Resident Census provided by the administrator on 03/13/17 and may result in care that is inconsistent with residents' needs. The findings are: [NAME] Record review of employee personnel files revealed the following: 1. CNA #10's most recent skills assessment was from 2014, 2. CNA #11's most recent skills assessment was from (YEAR), 3. CNA #12's most recent skills assessment was from 2007, 4. CNA #13's most recent skills assessment was from 2014, 5. CNA #14's most recent skills assessment was from (YEAR) B. On 03/20/17 at 11:20 am, during interview with the administrator, she stated that the Nurse Practice Educator who was responsible for tracking staff training was no longer working at the facility and that there was not currently a staff member assigned to tracking staff training. The administrator stated that one on one in-service education was provided to staff on an as needed basis but she was unable to indicate how the facility ensured that staff had the necessary education and training to provide care that was consistent with resident needs since training and skills assessments were not being completed.",2020-09-01
73,SANDIA RIDGE CENTER,325032,2216 LESTER DRIVE NE,ALBUQUERQUE,NM,87112,2019-03-22,689,E,0,1,8F5T11,"This is a repeat deficiency from the survey dated 03/14/18. Based on record review, interview and observation, the facility failed to have a door to a utility closet closed and locked. The closet contained an open, unlabeled container of bleach. This deficient practice has the potential to result in harm for all 121 residents who were identified on the resident census provided by the Executive Center Director at the start of survey on 03/18/19 if a resident were to accidentally open and use without appropriate personal protective equipment or for any demented residents on that hall who could mistakenly drink the bleach. The findings are: [NAME] On 03/20/19 at 9:42 am, during a tour of the facility storage and laundry areas, it was observed that a utility closet door was slightly open. Upon entering the utility closet a gallon size bottle was noted on the floor. The bottle did not have a label on it but there was writing on the bottle that stated Clorox. B. On 03/20/19 at 10:30 am, during an interview with the Housekeeping Director (HD), he stated that any of the utility closets should be fully shut and locked, and it did not matter what hall it was on. The HD also indicated that there should not be any unlabeled containers. That would apply to storage rooms and housekeeping carts. C. On 03/20/19 at 9:56 am, an observation was made of the HD taking the unlabeled container and putting it in his office. D. Record review of the Storage 1.1 Environmental Services Policies and Procedures last revised on 11/01/07, indicated the following Process: 4. Storage areas are locked when not in operation to prevent unauthorized access. 5. Chemical Storage: 5.4: Chemicals are stored in their original containers. Chemicals in spray bottles are labeled with contents and hazard warning.",2020-09-01
74,SANDIA RIDGE CENTER,325032,2216 LESTER DRIVE NE,ALBUQUERQUE,NM,87112,2019-03-22,756,E,0,1,8F5T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This is a repeat deficiency from the survey dated 03/14/18. Based on record review and interview, the facility failed to ensure that pharmacy recommendations were reviewed, responded to, and/or any changes or reasons to decline a change were documented in the medical chart for 8 residents (R #'s 301, 45, 82, 84, 11, 302, 8 and 89) of 10 (R #'s 301, 45, 82, 84, 11, 302, 8, 89, 27 and 19) residents reviewed for unnecessary medications. This deficient practice has the potential to cause harm to residents by: 1. not receiving the proper dose of a medication, 2. not having medications adjusted according to labwork, The findings are: Findings for R #301: [NAME] Record review of R #301's pharmacy consultation report dated (MONTH) (YEAR) indicated that there were three recommendations: 1. Adjust the dose of [MEDICATION NAME] (used for mood as an anticonvulsant, and nerve pain) to 700 milligrams (mg) once daily: for CrCl (Creatinine Clearance)15-29 milliliter/minimum ( to check kidney function) total daily dose range 200 mg to 700 mg given in one daily dose. The Rational for Recommendation is that dosing should be adjusted according to renal (kidney) function. 2. Consider changing [MEDICATION NAME] (is used to treat high blood pressure) to an alternate antihypertensive. The Rational for Recommendation is that Thiazide diuretics are considered less effective when Creatinine clearance drops below 30 ml/min. 3. Consider discontinuing Duloxetine (anti-depressant medication) and starting a new antidepressant. R #301 has [MEDICAL CONDITION] stage 3 and an estimated Creatinine Clearance of 26. Recommendation is for any person who has CrCL less than 30 to switch to something else. The response from the physician was (name of company) declined the recommendation without providing a rationale as to why. B. Record review of R #301's pharmacy consultation report dated (MONTH) (YEAR) indicated that there were three recommendations: 1. R #301 was on [MEDICATION NAME] (a diuretic which helps to not retain fluid) and has not had an electrolyte evaluation (an electrolyte panel help investigate conditions that cause electrolyte imbalances such as dehydration, kidney disease, lung diseases, or heart conditions) in the previous 6 months. Consider doing a Basic Metabolic Panel (BMP, a panel of 8 tests that gives a health practitioner important information about a residents current status) on the next lab day. 2. Attempt a gradual dose reduction (GDR) of [MEDICATION NAME] (an anti-psychotic) PO (by mouth) from 5 mg to 2.5 mg. R #301 has been on the 5mg dose since 11/2017. 3. R #301 has diabetes and needs her A1C (test of glucose in the blood over a period spanning around 3 months) completed. It has not been done in the previous six months. Please consider monitoring A1C on the next lab day. 4. The response from the physician was (name of company) refused the recommendation without providing a rationale as to why. Findings for R #45: C. Record review of R #45's pharmacy consultation report dated (MONTH) (YEAR) indicated that there was one recommendation that was a repeat recommendation from (MONTH) (YEAR). 1. As needed (PRN) [MEDICATION NAME] (antianxiety) did not have a stop date. PRN antipsychotic [MEDICAL CONDITION] drugs are limited to 14 days unless the prescriber documents a specific concern or condition that is being treated, rationale for the extended time period and duration for the PRN order. There was also a recommendation to have a lab done to monitor R #45's TSH ([MEDICAL CONDITION]-stimulating hormone is a pituitary hormone that stimulates the [MEDICAL CONDITION] to produce [MEDICATION NAME] .) Written at the bottom of both consultation reports (name of company) no response multiple attempts. Findings for R #82: D. Record review of R #82's pharmacy consultation report dated (MONTH) (YEAR) indicated that there were two recommendations: 1. R #82 receives [MEDICATION NAME] 20 mg for management of major [MEDICAL CONDITION] since 02/2017. Please consider a GDR unless it is clinically contraindicated at this time. 2. Please consider monitoring BMP on the next lab day due to R #82 receiving Lorsartan (used to treat high blood pressure and heart failure. It is also used to improve the chance of living longer after a [MEDICAL CONDITION]) but does not have a Creatinine/electrolyte evaluation within the past 6 months. Written at the bottom of both consultation reports (name of company) no response multiple attempts. Findings for R #84, R #11 and R #302: E. Record review of the pharmacy consultation report dated (MONTH) (YEAR) indicated the following three recommendations for R #s 84, 11 and 302: 1. R #84 had a PRN (as needed) order for the antipsychotic [MEDICATION NAME] for more than 14 days without a stop date. The recommendations for R #84 is that PRN orders should be limited to 14 days unless the prescriber documents the condition being treated or the rationale for using the drug for an extended time. The response was not checked and at the bottom of the page is written no response from (name of company) multiple attempts. 2. R #302 had a PRN order [MEDICATION NAME] (antianxiety) without a stop date. The recommendations for R #302 is that PRN orders should be limited to 14 days unless the prescriber documents the condition being treated or the rationale for using the drug for an extended time. The response was not checked and at the bottom of the page is written no response from (name of company) multiple attempts. 3. R #11 had a PRN order for [MEDICATION NAME] longer than 14 days without a stop date. The recommendations for R #11 are that PRN orders should be limited to 14 days unless the prescriber documents the condition being treated or the rationale for using the drug for an extended time; and the prescriber should directly examine the resident and assess the residents condition to determine if the PRN mediation is still needed. The response was not checked and at the bottom of the page is written no response from (name of company) multiple attempts. Findings for R #8: F. Record review of R #8's pharmacy consultation report dated (MONTH) (YEAR) indicated that there was one recommendation that was a repeat recommendation from (MONTH) (YEAR). 1. R #8 has a PRN order for [MEDICATION NAME] (antianxiety) with no stop date. The recommendations for R #8 are that PRN orders should be limited to 14 days unless the prescriber documents the condition being treated or there is a rationale for using the drug for an extended time; and the prescriber should directly examine the resident and assess the residents condition to determine if the PRN medication is still needed. Hand written at the bottom of the page indicated: (name of company) multiple attempts. 2. R #8 receives Duloxetine 60 mg QD (every day). [MEDICATION NAME] Clearance of 29 mL/min on 08/28/18 with no recent labs in the medical chart. Consider a GDR of the Duloxetine to 40 mg QD with end goal of discontinuation. If therapy is to continue at current dose it is recommended that the prescriber to assessment of risk vs. benefit that it continues to be a valid therapeutic intervention for this individual. The physician's response was to decline the recommendation stating that (name of company) would do the lab. It was not clear at end of survey whether this lab work was completed. Findings for R #89 [NAME] Record review of the pharmacy consultation report dated (MONTH) 1, (YEAR) to (MONTH) 31st, (YEAR) indicated that there was one recommendation for R #89 that was a repeat recommendation from (MONTH) (YEAR). 1. R #89 received [MEDICATION NAME] (anti-epileptic drug, also called an anticonvulsant. It affects chemicals and nerves in the body that are involved in the cause of [MEDICAL CONDITION] and some types of pain) and it was written in a (name of company) note that she (R #89) was experiencing hallucinations. The recommendation was to reevaluate the continued use of [MEDICATION NAME]. 2. A recommendation to attempt a GDR of quetiapine (an antipsychotic medication) that R #89 had been on since 01/2018 from 75 mg QD (every day) and 25 mg Q (every) 4 hours as needed, to 50 mg QD (every day) with end goal of discontinuation. For both recommendations, at the bottom of the page is written no response from (name of company) multiple attempts. H. Record review of the pharmacy consultation report dated (MONTH) 1, (YEAR) to (MONTH) 31st, (YEAR) indicated that there was three recommendations for R #89, with one being a repeat recommendation. 1. A repeat recommendation from 07/02/18 and 08/11/18 indicated that there was no stop date for the PRN medication [MEDICATION NAME] (an antipsychotic medication). There is a response that indicated a verbal decline from (name of company) on 10/11/18. 2. There was a recommendation to consider a GDR for [MEDICATION NAME] 200 mg TID (three times per day) to [MEDICATION NAME] 200 mg BID (twice per day). At the bottom in writing it indicated that (name of company) declined. There was no rationale or explanation as to why it was declined. R #89 has remained on this same dose and frequency with no changes, since this recommendation was made. 3. A recommendation to monitor R #89's serum Creatinine because she was on [MEDICATION NAME] on next lab day and every six months thereafter. This was declined, indicating the (name of company) does their own labs. Record review of the labwork in the medical chart did not show that this was completed. For all three of these recommendations, it is unclear if the recommendations were done, were declined after consideration, completed with new orders, or completed with no new orders. I. On 03/21/19 at 11:18 am, during an interview with Licensed Practical Nurse #1, she stated that the pharmacy that is reviewing the medications for the residents residing at the facility should not be reviewing the residents that are apart of the (name of company) residents. Since (name of company) has their own physician's and they use a different pharmacy they should have a pharmacist that reviews the medications for these residents. She also stated that she had not ever seen any pharmacy reviews from the pharmacy that had been prescribing medications to these residents. LPN #1 also stated that when labs are ordered, the (name of company) will usually call the facility and have the facility utilize the lab that they use. Residents don't get sent out to a different lab or go to the (name of company) clinic to have labs drawn. LPN #1 stated that because they usually use their lab for labwork, then all of lab results should be in the electronic medical record or the paper chart. [NAME] On 03/21/19 at 11:28 am, during an interview with with Center Executive Director, she stated that there is a communication problem between the facility and (name of company). They don't always respond to the pharmacy reviews and the Administrator has requested to receive the pharmacy reviews back but they have not or can not produce any to them. K. On 03/21/19 at 2:58 pm, during an interview with Unit Manger #1, she stated that there are constant issues with (name of company). She stated that she is supposed to call the nurse line but stopped doing that and started calling the emergency line because that was the only way to get a response. She also stated that they can't make any changes with any of the medications because it has to come from (name of company) physician's. Unit Manager #1 stated that an example of an issue would be: R #38 was prescribed an antidepressant, (unable to remember the name) when she got the order from (name of company) it was already (MONTH) 2019. The order had been written in (MONTH) 2019. UM #1 called the power of attorney to ask if she had been notified of the medication. The POA stated that she was unclear of why a depression medication was prescribed and did not see any issues that would suggest her mother was depressed. UM #1 agreed and stated that she had not seen any signs of depression either. UM #1 and the POA had been trying to call (name of company) but had not actually spoken to anyone about it. The POA asked that the antidepressant not be given to her mother. L. On 03/22/19 at 7:46 am, during an interview with the Center Nurse Executive (CNE), She stated that she would send a fax to (name of company). Then (name of company) faxes them to the pharmacist and that pharmacist reviews them. The CNE stated that it seems like (name of company) maybe making some changes and doing some labs for their residents but that they (the facility) would not know that because they never send any responses back to the facility. There are times that (name of company) may fax over new orders to the facility based on a recommendation or lab but they don't ever give us that information. The CNE also stated that she is now has the pharmacist phone number and will be dealing directly with her. She stated that this is the first time (03/22/19) she had ever gotten the pharmacy consults back from (name of company). The CNE stated that the facility has no idea what had been acted on, changed, or declined, from (name of company). M. Record review of the facility Healthcare Center Supplemental Monthly Medication Regimen Review, revised 12/12/18, 9.1 Timeframe's for Pharmacy Consultant Recommendation Process, third bullet down Physician/PA (Physician Assistant)/ANP (Adult Nurse Practionier) will return completed MMR (Monthly Medication Review) Consultant Reports within 10 days. N. Record review of a collaboration meeting on 03/21/19 between the facility and (name of company) indicated that the facility was addressing the lack of physician oversight of patients with their program. (Name of company) responded that they had not been able to meet these requirements with the current provider staff at this time but new providers are coming on board and they will be able to comply moving forward.",2020-09-01
75,SANDIA RIDGE CENTER,325032,2216 LESTER DRIVE NE,ALBUQUERQUE,NM,87112,2019-03-22,758,E,0,1,8F5T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review observation and interview the facility failed to ensure that [MEDICAL CONDITION] medication orders met regulatory requirements for 2 (R #'s 8 and 27) of 2 (R #'s 8 and 27) residents reviewed for unnecessary [MEDICAL CONDITION] drugs. This deficient practice puts affected residents at increased risk for undesirable side effects associated with the use of these medications. The findings are: For R #8: [NAME] Record review of, (Name of facility) .Medication Review Report, for active [MEDICAL CONDITION] medications orders revealed: 1. On 03/16/19, [MEDICATION NAME] (sedative medication) Tablet 0.5 MG (milligrams). Give 0.25 mg by mouth every 8 hours as needed for severe anxiety Give half a tablet (0.25 mg) by oral route 3-times per day as needed (PRN) for severe anxiety. Hold for sedation. This PRN order for a psychoactive drug had no stop date. 2. On 08/10/18, QUEtiapine [MEDICATION NAME] (is an antipsychotic medication) Tablet 25 MG Give 50 mg by mouth at bedtime for dementia related physical outbursts, depression, anxiety, and [MEDICAL CONDITION] .QUEtiapine [MEDICATION NAME] Tablet 25 MG Give 25 mg by mouth in the morning for dementia. B. Record review of R #8's medication orders on paper chart from the, (Name of program) revealed an order dated 11/28/18, 25 mg. oral tablet .Quetiapine Give 1-tab by mouth twice daily (breakfast and 2-pm. Give 2-tabs at bedtime. The resident was not receiving her 2:00 pm dose. C. On 03/21/19 at 11:35 am, during interview with the nurse manager on the unit where the resident resides she revealed, when (name of outpatient program resident attends) sends the orders we reconcile them, so we are giving her what they ordered . (regarding the 2 pm dose of Quetiapine) we missed that. D. 03/21/19 at 03:08 pm during interview with the CNE she revealed, I have gotten that order changed (re: Quetiapine; side effect drowsiness) we will have it reduced .I don't want her any sleepier than she is. For R #27: E. Record review of, (name of facility) .Medication Review Report .Active orders as of 03/22/2019 for [MEDICAL CONDITION] medications orders revealed: 1. On 01/09/19, [MEDICATION NAME] Tablet 0.5 MG Give 0.5 mg by mouth every 4 hours as needed for Anxiety/Agitation. This PRN order for a psychoactive drug had no stop date. F. On 03/21/19 at 1:20 pm, during interview with the Chief Nursing Executive she revealed, That is wrong (No stop date) it will be fixed right away.",2020-09-01
76,SANDIA RIDGE CENTER,325032,2216 LESTER DRIVE NE,ALBUQUERQUE,NM,87112,2019-03-22,760,D,0,1,8F5T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure that medications were administered correctly for 1 (R #46) of 8 (R #s 12, 26, 46, 69, 95, 102, 109 and 110) residents during the observation of the medication administration. If medications are administered in ways that can affect how other medications work, or in a manner that alters the way they are absorbed by the resident, given in doses that are in excess of the resident's need or given in ways that can cause serious adverse events to a resident, the residents affected are exposed to potentially significant and unnecessary harm. The findings are: [NAME] On 03/21/19 at 11:19 am, during a medication administration observation, Licensed Practical Nurse (LPN) #1 administered Humalog (a fast-acting insulin that controls the blood sugar spikes that occur while eating) 10 units subcutaneously (applied under the skin) in the right deltoid (upper arm muscle) to R #46. B. Record review of R #46's physician's orders [REDACTED]. Do not administer if not eating a meal. Please discontinue sliding scale. C. On 03/22/19 at 10:00 am, during an interview, LPN #1 stated when asked how much Humalog insulin did she administer to R #46 the day before? She stated, 10 units. When LPN #1, looked into R #46's Medication Administration Record [REDACTED]. She said, I don't know where I came up with the 10 units of Humalog. D. Record review of the facility's policy and procedure titled Medication Administration: General, last revised on 07/24/18, revealed the following: A licensed nurse, Med Tech, or medication aide, per state regulations, will administer medications to patients .To provide a safe, effective medication administration process .",2020-09-01
77,SANDIA RIDGE CENTER,325032,2216 LESTER DRIVE NE,ALBUQUERQUE,NM,87112,2019-03-22,812,F,0,1,8F5T11,"Based on observation, interview, and record review, the facility failed to ensure that: 1. Staff were wearing beard nets while preparing food, 2. The vents that were directly above where food was being prepared, were clean and free of debris, These deficient practices could effect all 121 residents, identified on the alphabetical census list provided by the Administrator on 3/18/19, who eat food prepared in the kitchen. This could lead to foodborne illnesses causing residents to become sick and possibly decline. The findings are: [NAME] On 3/19/19 at 11:54 am, during an initial tour of the facility kitchen, dietary assistant #1 who had a beard was preparing food without a beard net. B. On 3/19/19 at 11:57 am, during an interview with the Registered Dietician (RD), he confirmed with the kitchen manager that staff should be wearing a beard net or beard mask while preparing food. C. Record review of the Food and Nutrition Services Policies and Procedures indicate: 1. POLICY TITLE: 2:2 Personal Hygiene last REVISION DATE: 07/24/18 2. PURPOSE: To maintain a professional appearance at all times. 3. PR[NAME]ESS: #7 Hair restraints such as hats, hair coverings, or nets are worn to effectively keep hair from contacting exposed food. Facial hair coverings are used to cover all facial hair. D. On 03/19/19 at 12:12 pm, during the initial tour of the facility kitchen, there were dust bunnies (a ball of dust and fluff) in the vent over the area where food was being prepared. E. On 03/19/19 at 9:51 am, during an interview with the RD and Kitchen Manager, the RD stated he did not know who was responsible for cleaning the vents. The Kitchen Manager stated the kitchen staff and himself are responsible for cleaning the vents in the kitchen. The Kitchen Manager stated the vents are cleaned daily or as needed. He stated he would clean the vent immediately due to confirming the dust bunnies in the vent over the area where food was being prepared. F. Record review of the Genesis kitchen cleaning policy 4.0 Cleaning Standards; MANUAL TITLE: Food and Nutrition Services Policies indicates the following: 1. Procedures last REVISION DATE: 06/15/18 2. PURPOSE: To ensure all food service equipment and areas are clean and sanitary. 3. PR[NAME]ESS: a. Cleaning procedures are available to Food and Nutrition Services employees. b. Employees utilize the cleaning procedures when completing assigned cleaning duties. c. Cleaning and sanitizing agents are available for use during all hours of operation.",2020-09-01
78,SANDIA RIDGE CENTER,325032,2216 LESTER DRIVE NE,ALBUQUERQUE,NM,87112,2019-03-22,880,F,0,1,8F5T11,"Based on observation, interview, and record review, the facility failed to demonstrate proper infection control practices as evidence by: 1. contamination of clean linens and resident supplies, from dust and debris on floor surfaces, 2. not placing a solid barrier (liner) on the bottom shelf of wire storage racks, 3. having items stored directly on the floor, 4. using cardboard boxes to store resident supplies These deficient practices have the potential to effect all 122 residents per the facility census provided by the Administrator on 03/18/19 resulting in; 1. Exposure of bugs and rodent droppings to residential supplies. 2. Contamination of resident supplies due to dirt, dust and debris being kicked up from floor surfaces. The findings are: [NAME] On 03/20/19 at 10:16 am, during a tour of Central Supply, observations were made of the following: 1. Supplies being stored on the floor in card board boxes. 2. Items being stored on the bottom shelf of the shelving unit, with no solid barrier that was too low to the floor. B. On 03/22/19 at 10:14 am, during an interview with the Director of Nursing (DON), she stated that she was not aware of the issues in Central Supply. She confirmed that their supplies are being stored on the floor and in cardboard boxes. She also acknowledged that the wire shelving units did not have solid bottoms and one of those shelving units was almost sitting on the ground (recommended 6-8 inches off the floor). C. Record review of the Storage 1.1 Environmental Services Policies and Procedures, revised on 11/01/07, indicated all shelves, storage racks, and platforms are not to be placed directly on the floor, stored items should be 18 below sprinkler head/ceiling, unless waiver is obtained from the licensing authority and cardboard boxes are emptied and removed from storage as they are received.",2020-09-01
79,SANDIA RIDGE CENTER,325032,2216 LESTER DRIVE NE,ALBUQUERQUE,NM,87112,2017-11-07,285,D,1,0,C0CW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to refer a resident with qualifying [DIAGNOSES REDACTED].#1) of 4 (R #s 1, 2, 3, and 4) residents reviewed during a complaint investigation. If residents with a qualifying [DIAGNOSES REDACTED]. The findings are: [NAME] Record review of R #1's Admission Record, revealed she was admitted to the facility on [DATE] and discharged on [DATE]. R #1 had the following medical [DIAGNOSES REDACTED]. B. On 11/06/17 at 2:38 pm, during interview with the PASRR Supervisor, she stated that R #1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. C. On 11/06/17 at 3:49 pm, during interview the Admission Director stated that the Social Service Director at the time reviewed R #1's PASRR and stated that the [DIAGNOSES REDACTED]. The Admission Director confirmed that the PASRR was not completed prior to R #1's admission. D. On 11/06/17 at 4:09 pm, during interview with the previous Social Service Director, she stated that she was reviewing R #1's medical record and saw a medical [DIAGNOSES REDACTED]. She stated that she made the corrections and resubmitted, but R #1 was already admitted .",2020-09-01
80,RIO RANCHO CENTER,325033,4210 SABANA GRANDE SE,RIO RANCHO,NM,87124,2018-02-12,561,E,0,1,M2BO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide reasonable accommodations of resident needs and preferences for 2 (R #s 5 and 307) of 2 (R #s 5 and 307) residents reviewed for choices. The facility failed to shower R #5 per her schedule and did not respect R #307's food preferences. This deficient practice has the potential to prevent residents from maintaining personal hygiene per their personal preference and feelings of frustration about the lack of autonomy regarding things that are important in their life. The findings are: Findings for R #5: [NAME] On 02/06/18 at 2:18 pm, during interview R #5 stated she hasn't had a shower in three weeks. She stated that the shower aide has not been here. B. Record review of R #5's Weekly Bath and Skin Report dated 12/20/17, indicated the last documented shower for R #5 was on 01/09/18. C. Record review of R #5's Weekly Bath and Skin Report dated 01/10/18, revealed on 01/12/18, she refused shower due to pain. No other showers are documented on the form. D. Record review of R #5's Activities of Daily Living (ADL) Record for (MONTH) (YEAR), showed R #5 refused showers on 1/2/18, 1/5/18, 1/12/18. No other showers were documented. E. Record review of the ADL Record for (MONTH) (YEAR), showed R #5 has not received a shower with no documented refusals for the month. F. Record review of the Minimum (MDS) data set [DATE], revealed a BIMs (brief interview for mental status) score of 11 (Range is 00-15 with 15 being cognitively in tact) and requires extensive assistance with a two person physical assist for all ADLs. R #5 is total dependence for bathing. [NAME] On 02/07/18 at 2:22 pm, during interview the Director of Nursing (DON) stated that the resident is very particular about who she will let shower her. She stated that if the shower aid that she likes is not working, then she will refuse showers. She also stated that if showers are offered and she refuses, it would be documented in the ADL record and on the shower sheets. The DON also stated that according to the documentation, R #5 probably has not had a shower since 01/12/18, when she refused, stating she probably hasn't had one other than a bed bath. Findings for R #307: H. On 02/06/18 at 1:47 pm, during an interview with R #307, she stated staff completely messed up her meal ticket. She stated there are items listed as likes which she does not necessarily like such as chocolate pudding. She stated there are many items listed as dislikes which she does not dislike such as fruit punch, bell pepper, cooked onions, mushrooms, squash and sweet potatoes. She stated that she has explained to staff that she has diverticulitis (a condition where small pouches form in the lining of your digestive system) so she cannot have any nuts or seeds but she is occasionally served meals with seeds or nuts included. She also explained to staff a few days ago she does not like chile and at the next meal they brought her a bowl of chile. I. Record review of R #307's meal ticket dated 02/01/18 revealed the following: LIKES: Chocolate pudding, Italian dressing, vanilla pudding. DISLIKES: Fruit punch, bell pepper, chile, cooked onions, mushrooms, poppy seeds, spicy food, squash, sweet potatoes. The ticket did not have nuts or any other type of seed besides poppy listed in the dislike section. [NAME] On 02/08/18 at 11:37 am, during an interview with the Dietician, she stated that after speaking with R #307 today, she verified that many of the items listed in the dislike section are incorrect which include fruit punch, bell pepper, cooked onions, mushrooms, squash and sweet potatoes. The Dietician stated she updated the resident's meal ticket to reflect her preferences. The Dietician also verified that R #307 has diverticulitis and cannot have nuts or seeds. K. On 02/08/18 10:45 am, during an interview with the Interim Dietary Manager, he stated that he is not sure how the incorrect likes and dislikes got onto the meal ticket. He stated that the only 3 people that have the ability to edit meal tickets: himself, the dietician and the executive chef. He verified that none of those people made the change for R #309 so it must have been the previous Dietary Manager who was terminated about 2 weeks ago. He stated he found an old meal ticket dated 01/10/18 where the resident wrote down some of her likes and dislikes. L. Record review of R #307's meal ticket dated 01/10/18 stated LIKES: N/[NAME] DISKLIKES: N/[NAME] R #309 wrote a hand-written message on the meal ticket which stated .No sausage! Nothing with seeds or nuts. I have diverticulitis. No Mexican spices re: salsa and chile .Thanks. -(Name of R #307).",2020-09-01
81,RIO RANCHO CENTER,325033,4210 SABANA GRANDE SE,RIO RANCHO,NM,87124,2018-02-12,578,D,0,1,M2BO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to update the medical chart for 1 (R #5) of 1 (R #5) residents reviewed for advanced directives, when they failed to update her code status as DNR (Do Not Resuscitate) and inform direct care staff of R #5's wishes. This deficient practice could likely result in residents not having their wishes honored if a life threatening event occurred. The findings are: [NAME] Record review of R #5's Electronic Medical Record, indicated resident is Full Code. B. On [DATE] at 3:18 pm, during interview with RN (Registered Nurse) #2, she stated that R #5 is a full code. RN #2 stated that if R #5 coded, she would start CPR (Cardiopulmonary Resuscitation). C. On [DATE] at 3:19 pm, during interview with RN #1, he stated R #5 was a full code and he would call out for somebody, get a crash cart and start CPR. D. Record review of R #5's MOST (Medical Orders for Scope of Treatment) form dated [DATE], indicated R #5 selected Do Not Attempt Resuscitation/DNR. Options were discussed with R #5 and she signed on [DATE]. E. On [DATE] at 3:36 pm, during interview the Director of Nursing (DON) stated that she was looking into the issue, because she identified a discrepancy yesterday. The DON verified that if R #5 did request to be DNR, the nurse should have immediately went to the physician and got a new order for DNR and it should have been updated in the electronic chart.",2020-09-01
82,RIO RANCHO CENTER,325033,4210 SABANA GRANDE SE,RIO RANCHO,NM,87124,2018-02-12,645,D,1,0,M2BO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure that clearance from the Pre-Admission Screening and Resident Review (PASRR) program had been obtained prior to admission for 1 (R #256) of 4 residents (R #s 256, 19, 56 and 162) reviewed for PASRR clearance. The PASRR Level 1 screening tool had been completed incorrectly for R #256, which the facility failed to identify within 24 hours. This deficient practice has the potential to result in residents with physical or intellectual disabilities not receiving needed services after admission to the facility. The findings are: [NAME] Record review of a letter of complaint dated 11/28/17 sent to the State Central Intake by the PASRR Supervisor, indicated that R #256 had been admitted to the facility without the required clearance from the PASRR program. It indicated that the resident required PASRR level II screening and review due to his [MEDICAL CONDITION] (TBI). B. On 02/08/18 at 2:15 pm, during an interview with the PASRR supervisor, she stated that the facility admitted R #256 on 08/14/17. R #256 arrived with a level I PASRR screening but it was not filled out accurately. If the facility had looked at the hospital records closer they would have seen that R #256 had a TBI before the age of 16. This [DIAGNOSES REDACTED]. She also stated that it was on the receiving facility to make sure that the PASRR was done correctly before admitting a resident to their facility. The level II PASRR also must be done before a resident was admitted or they must have a clearance letter stating that this resident will not require services past 30 days. She stated that if these things aren't done properly than it will fall on the facility. C. On 02/09/18 at 2:06 pm, during an interview with Admissions, she stated that they have a 24 hour window when a resident is admitted to the facility and they identify whether or not the PASRR is accurate. She stated that she had looked at the records and realized that the PASRR was wrong and she called the PASRR Supervisor to notify her. It was too late though, she had already missed her window. She stated that the 24 hour time frame isn't long enough. She stated that they caught it, but they caught it too late. She stated that since this incident the facility had put more things in place to help ensure that they are identifying residents who may require specialized services. She also stated that the nurses are more involved now so they can help identify if a resident's PASRR is incorrect, and get it taken care of faster.",2020-09-01
83,RIO RANCHO CENTER,325033,4210 SABANA GRANDE SE,RIO RANCHO,NM,87124,2018-02-12,655,D,0,1,M2BO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to develop a baseline care plan for a resident with a moderate to high nutritional risk for 1 (R #307) of 1 (R #307) resident reviewed for nutrition. The care plan failed to address R #307's therapeutic diets and did not include nutritional services that were to be furnished to attain the resident's highest level of well-being. This deficient practice has the potential to result in inconsistent care of residents, through misinterpretation of residents' needs. The findings are: [NAME] Record review of R #307's medical record revealed she was originally admitted to the facility on [DATE], discharged on [DATE] and then was readmitted on [DATE]. B. Record review of R #307's physician diet orders revealed the following: 1. An order dated 01/06/18 for a Heart Healthy (no added salt) diet. This diet order was discontinued on 01/23/18. 2. An order dated 01/23/18 for a Regular/Liberalized diet. This diet order was discontinued on 01/29/18. 3. An order dated 01/29/18 for a Dysphagia Advance texture (mechanical soft). C. Record review of R #307's Nutritional Assessment completed by the dietician dated 01/11/18 stated, Resident at moderate to high nutritional risk 2/to (secondary to) hx (history) of R (right) lung mass which is presumably Ca (cancer), [MEDICAL CONDITION] ([MEDICAL CONDITIONS] is a disease that causes obstructed airflow from the lungs), pAF([MEDICAL CONDITION]), DM (Diabetes Mellitus), ETOH (alcohol) abuse . D. Record review of R #307's Nutritional Assessment completed by the dietician dated 01/29/18 stated, Resident at moderate to high nutritional risk 2/to hx of R lung mass which is presumably Ca, [MEDICAL CONDITION], pAF, DM, ETOH abuse . E. Record review of R #307's baseline care plan originally dated 01/06/18 revealed it did not address her Heart Healthy (no added salt) diet or her Dysphagia Advance texture (mechanical soft) diet. The care plan did not address her nutritional risk related to her diagnoses. F. On 02/08/18 at 2:37 pm, during an interview with the Registered Dietician, she stated that she does not complete nutritional care plans for residents unless they have significant weight loss/gain or have nutritional [DIAGNOSES REDACTED]. She stated that she does not do a care plan for residents solely because of a mechanical soft diet or a no added salt diet. She stated that she writes moderate to high nutritional risk in every nutritional assessment she does.",2020-09-01
84,RIO RANCHO CENTER,325033,4210 SABANA GRANDE SE,RIO RANCHO,NM,87124,2018-02-12,656,D,0,1,M2BO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that a comprehensive care plan was developed for one resident (R #76) of 32 residents (R #s 2, 5, 8, 14, 15, 18, 19, 26, 31, 36, 37, 45, 47, 51, 55, 56, 61, 62, 68, 75, 76, 89, 91, 94, 95, 96, 101, 156, 164, 167, 209 & 307) reviewed for care plan accuracy. No items in R #76's care plan addressed his care in the facility related to his [DIAGNOSES REDACTED].) This deficient practice had the potential to result in inconsistent care of the resident, through inappropriate food offerings, and the failure to assess for [MEDICAL TREATMENT]-related complications, such as bleeding. The findings are: [NAME] On 02/05/18 at 2:25 pm, during interview with R #76, he stated, I'm a diabetic and damned near everything here is sweet. I don't take any meds (medications) - I control it through diet. I don't know how you can control your sugar when everything is sweet. B. Record review of R #76's electronic medical record found: 1. that he was admitted to the facility on [DATE], and discharged on [DATE]. 2. that his listed medical diagnoses included [MEDICAL CONDITION], dependence on renal (related to the kidneys) [MEDICAL TREATMENT], [MEDICAL CONDITION] (a liver disease), and gastrointestinal hemorrhage (bleeding in the digestive system.) No [DIAGNOSES REDACTED]. 3. a care plan dated 1/22/18 that did not have focus sections related to diabetes management or [MEDICAL TREATMENT] procedures. 4. a physician's orders [REDACTED].> a. that the resident had [MEDICAL TREATMENT] scheduled for each Tuesday, Thursday and Saturday. b. that interventions to assess the [MEDICAL TREATMENT] were ordered. c. that the resident was ordered for a regular/liberalized diet. d. that no fluid restrictions were ordered. e. no checks of the resident's glucose levels were ordered. 5. that a nutritional assessment dated [DATE] did not acknowledge the resident's diabetes. It stated that the resident had declined a renal diet, in favor of a regular diet. 6. that an Admission MDS (Minimum Data Set, a data collection tool) assessment, dated 01/22/18, stated, Diabetes mellitus: No. 7. that the Treatment Administration Records for (MONTH) (YEAR) and (MONTH) (YEAR) showed no tasks related to diabetes management. C. Record review of a physician's History and Physical document for R #76, dated 01/18/18, indicated that DM 2 (Type II Diabetes Mellitus) was among his diagnoses in the History of Present Illness section. [MEDICAL CONDITION] and a history [MEDICAL CONDITION](stroke) were additional diagnoses listed on the document. The resident's diabetes was not mentioned in the Plan section of the document, though there was a statement indicating his chronic medical conditions are stable. D. On 02/09/18 at 1:24 pm, during interview with the Director of Nursing (DON), she confirmed that diabetes and [MEDICAL TREATMENT] were not addressed in R #76's care plan. She acknowledged that a complete care plan, including all information necessary to care for the resident, should have been completed within 21 days of his admission. E. On 02/08/18 at 10:07 am, during interview with the facility's Dietician, she stated I probably didn't know that he was diabetic (when I did his nutritional assessment.) If I had known he was diabetic, I definitely would have put it in my assessment. Sometimes I do my assessment before they're seen by the doctor, so the History & Physical wouldn't be available. F. On 02/08/18 at 3:13 pm, during interview with Nurse Practitioner #1, she stated that liberalized diets for diabetics are intended to reduce sweets, not eliminate them entirely. She indicated that it would have made sense, given the liberalized diet, that his blood sugar should have been checked, maybe every morning.",2020-09-01
85,RIO RANCHO CENTER,325033,4210 SABANA GRANDE SE,RIO RANCHO,NM,87124,2018-02-12,684,D,0,1,M2BO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide good quality of care in a timely manor for 1 (R #31) of 1 (R #31) resident looked at during dining observation. This deficient practice caused R #31 neck pain and stiffness due to facility employees not being observant and identifying that the neck support on R #31's wheelchair was not raised to support her neck and head. The findings are: [NAME] On 02/07/18 at 7:48 am, while watching dining, it was observed that R #31 was in her wheelchair at a dining table and her head was leaned very far back with no support. It was observed that R #31 was not able to support her head on her own. B. On 02/07/18 at 8:01 am, during an interview with R #31 she stated that she was uncomfortable and would like to be moved. R #31 was not sure how long she had been like that. C. On 02/07/18 at 8:04 am, during an interview with the Administrator he stated that he took care of the situation with R #31. He stated that the headrest on the wheelchair was pushed all the way down and that it just needed to be raised up. He stated that he was not clear why the Certified Nurses Aide did not catch that her head rest was not up in the proper position when she brought R #31 into the dining room. The Administrator did not have an answer for why no one else observed R #31 in that position and identified that R #31 was uncomfortable. D. Record review of the Minimum Date Set (MDS) dated (MONTH) (YEAR), indicated that R #31 is extensive assist. She requires a Hoyer lift (used for transfers when a person requires 90-100% assistance to get into and out of bed) with two people and is dependent on staff for all of her activities of daily living. E. Record review of R #31's electronic medical record indicated that she has [DIAGNOSES REDACTED].",2020-09-01
86,RIO RANCHO CENTER,325033,4210 SABANA GRANDE SE,RIO RANCHO,NM,87124,2018-02-12,692,D,0,1,M2BO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that a resident with a [DIAGNOSES REDACTED].#76) of 8 (R #s 2, 19, 31, 36, 68, 76, 89 and 307) residents reviewed for nutrition. There was no indication that facility staff, other than the admitting physician, was aware that the resident was diabetic, and no supportive interventions were in place. This deficient practice has the potential to result in dangerously high or low blood glucose levels in a diabetic resident. The findings are: [NAME] On 02/05/18 at 2:25 pm, during interview with R #76, he stated, I'm a diabetic and damned near everything here is sweet. I don't take any meds (diabetes medications)- I control it through diet. I don't know how you can control your sugar when everything is sweet. B. Record review of R #76's electronic medical record found: 1. that he was admitted to the facility on [DATE], and discharged on [DATE]. 2. that his listed medical diagnoses included [MEDICAL CONDITION], dependence on [MEDICAL TREATMENT] (filtering of the blood to compensate for impaired kidney function), [MEDICAL CONDITION] (a liver disease), and gastrointestinal hemorrhage (bleeding in the digestive system.) No [DIAGNOSES REDACTED]. 3. a care plan dated 1/22/18 that did not have focus sections related to diabetes management. 4. a physician's orders [REDACTED]. 5. that a nutritional assessment dated [DATE] did not acknowledge the resident's diabetes. It stated that the resident had declined a renal diet, in favor of a regular diet. 6. that an Admission MDS (Minimum Data Set, a data collection tool) assessment, dated 01/22/18, stated, Diabetes mellitus: No. 7. that the Treatment Administration Records for (MONTH) and (MONTH) (YEAR) showed no tasks related to diabetes management. C. Record review of a physician's History and Physical document for R #76, dated 01/18/18, indicated that DM 2 (Type II Diabetes Mellitus) was among his diagnoses in the History of Present Illness section. The resident's diabetes was not mentioned in the Plan section of the document, though there was a statement indicating his chronic medical conditions are stable. D. On 02/09/18 at 1:24 pm, during interview with the Director of Nursing (DON), she confirmed that diabetes was not addressed in R #76's care plan. She acknowledged that a complete care plan, including all information necessary to care for the resident, should have been completed within 21 days of his admission. E. On 02/08/18 at 10:07 am, during interview with the facility's Dietician, she stated I probably didn't know that he was diabetic (when I did his nutritional assessment.) If I had known he was diabetic, I definitely would have put it in my assessment. Sometimes I do my assessment before they're seen by the doctor, so the History & Physical wouldn't be available. F. On 02/08/18 at 3:13 pm, during interview with Nurse Practitioner #1, she stated that liberalized diets for diabetics are intended to reduce sweets, not eliminate them entirely. She indicated that it would have made sense, given the liberalized diet, that his blood sugar should have been checked, maybe every morning.",2020-09-01
87,RIO RANCHO CENTER,325033,4210 SABANA GRANDE SE,RIO RANCHO,NM,87124,2018-02-12,725,F,0,1,M2BO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure sufficient nursing staff numbers to answer call lights in a timely manner, ensure all residents received restorative therapy as ordered and attend to residents' needs for all 113 residents identified on the alphabetical resident census provided by the Administrator on 02/05/18. This deficient practice has the potential to negatively impact resident safety and comfort, and to impede processes such as restorative therapy, timely incontinence care, regular turning schedules, timely showers and appropriate assistance with meals. The findings are: [NAME] On 02/05/18 at 2:38 pm, during an interview with R #26, he stated the staff is always complaining among themselves that they are short staffed. He stated that during the week it takes 20 minutes for them to answer his call light and about 30 minutes on the weekends. B. On 02/05/18 at 2:44 pm, during an interview with R #8, she stated that she needs help to transfer herself from her wheelchair to the toilet. She stated that on three separate occasions, she soiled her brief because staff did not answer call light in time. She stated that after she soiled herself she could not find any staff in her hallway so she had to propel herself to the nurse's station and asked someone to help her. R #8 stated this was very embarrassing and that even after she requested help, she had to wait another 30 minutes before she received help changing her brief. C. On 02/06/18 at 8:42 am, during an interview with R #15, she stated there is not enough staff. She stated that at night she will push her call light and no one will come. She stated that she has soiled her brief because the staff take too long to respond to her call light. D. On 02/06/18 at 8:35 am, during an interview with R #14, she stated the night shift will take a long time to answer her call light. She stated she waited for almost two hours for pain medications. E. On 02/06/18 at 9:59 am, during an interview with R #61, she stated they could use more staff since she has to wait over an hour and a half during meal times for staff to answer her call light. She stated that after 10:00 pm she sometimes has to wait up to 2 hours for pain medication. F. On 02/06/18 at 10:19 am, during an interview with R #2, she stated the staff takes a while to assist her to the bathroom. She stated that she does not want to go to the bathroom in her pants so she will hold it and becomes very constipated. [NAME] On 02/06/18 at 10:39 am, during an interview with #55, he stated there are less staff on the weekend and he has to wait up to an hour for assistance. H. On 02/06/18 at 2:41 pm, during an interview R #5, stated that showers are too short due to staff shortage. She also stated that she has occasional diarrhea and sometimes waits for an hour to get cleaned up. She stated that it feels like acid is on her. I. On 02/07/18 at 9:39 am, during an interview with R #47, he stated he has to wait over 30 minutes for staff to respond to his call light to help him change or with transfers. He stated that the staff sometimes tie the call light so it is out of his reach and then he has the yell to get the staff's attention. [NAME] On 02/09/18 at 1:46 pm, during an interview with Restorative Aide (RA) #1, she stated there are 2 restorative aides, herself and RA #2. She stated that they alternate their work schedule so that one of them is working each day of the week. RA #1 stated that sometimes her workload gets to be too much for her. She stated that sometimes they have up to 23 residents on the restorative program that she works with in addition to the assistance she provides during meals as well as weighing residents. She stated when they have around 22 or 23 residents on the restorative program, she sometimes does not have enough time to get to all of them and some residents miss their restorative therapy. RA #1 stated that she has worked at the facility for a long time and remembers when they used to have 7 restorative aides and that it slowly dwindled down to 1 restorative aide. She stated that she is glad there are currently 2 restorative aides but that when the number of residents needing restorative therapy goes up there is not always enough time to get to everyone. RA #1 also stated that she is told to work the floor as a CNA about 2 times a week which also takes time away from the restorative therapy program. She stated that she does get complaints from residents about having to wait a long time for their call light to be answered. K. On 02/09/18 at 2:57 pm, during an interview with RA #2, she verified that when the number of residents on the restorative program gets to be around 22 or 23 residents they do not always get everyone's therapy completed as ordered. L. On 02/09/18 at 2:17 pm, during an interview with the Staffing Coordinator, she stated that the number of staff they have depends on the resident census and the acuity of the residents. She stated that she considers fully staffed to be a PPD (Per Patient Day - a calculation used to determine how many direct care staff hours, on average, are devoted to a single resident each day) between 3.0 and 3.17 hours. She stated they have met those numbers for the most part. She stated the only time they had problems with staffing on the weekend was back in (MONTH) (YEAR) during the balloon fiesta when a lot of people called in. M. Record review of the facility staffing calculation worksheet for PPD hours from 11/01/17 to 01/31/18 revealed a range of 2.66 to 3.79 with many of the lower numbers occurring on the weekends: 1. On 11/11/17 (a Saturday) the PPD was 2.94. 2. On 12/02/17 (a Saturday) the PPD was 2.91. 3. On 12/09/17 (a Saturday) the PPD was 2.90. 4. On 12/10/17 (a Sunday) the PPD was 2.94. 6. On 01/06/18 (a Saturday) the PPD was 2.78. 7. On 01/13/18 (a Saturday) the PPD was 2.88. 8. On 01/20/18 (a Saturday) the PPD was 2.66. 9. On 01/27/18 (a Saturday) the PPD was 2.86. 10. On 01/28/18 (a Sunday) the PPD was 2.86. N. On 02/12/18 at 10:15 am, during an interview with Licensed Practical Nurse (LPN) #3, she stated that she usually has anywhere from 27 to 30 residents to care for on her shift. When asked whether they have enough staff to meet the needs of all the residents, she responded sometimes. She stated that she usually works on the hall that has residents that are high acuity. She stated that at one point she had 5 residents on IV (intravenous) therapy, 8 residents that needed CBG (capillary blood glucose) checks and 3 residents that had [DEVICE]s (tube inserted through the abdomen that delivers nutrition directly to the stomach). She stated that when she has such high acuity residents it takes her longer to care for their needs and sometimes has to work overtime. LPN #3 stated that they frequently have new admitted residents on her hall which require a lot of paperwork and assessments to be completed which takes time away from other residents. She stated that she thinks they need at least 5 CNAs (Certified Nursing Aides) for the north side of building however they usually only get 4 CNAs. O. Record review of a grievance dated 10/11/17 submitted by the resident council stated. Resident Council reported that call lights are taking a long time to answer up to 30-45 minutes. It is generally happening on evening and night shift and facility wide. P. On 02/12/18 at 10:57 am, during an interview with the Administrator, he stated that when they have complaints about long call light response time, they do a call light audit which involves measuring how long staff take to answer call lights. He stated that in response to the resident council grievance in (MONTH) (YEAR) they educated CNAs to respond to call lights in a timely manner. He stated they did not do a call light audit because the problem was not widespread. He stated that the north side of the building is staffed with 2 nurses who split the residents based on hallway and whether the room number is odd or even. He stated they do not split the workload based on the acuity of the residents.",2020-09-01
88,RIO RANCHO CENTER,325033,4210 SABANA GRANDE SE,RIO RANCHO,NM,87124,2018-02-12,756,F,0,1,M2BO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop a policy/procedure for the monthly drug regimen review that included time frames for the different steps in the process and failed to ensure that consultant pharmacist recommendations were forwarded to the physician for review. These deficient practices have the potential to affect all 113 residents identified on the alphabetical census list provided by the Administrator on 02/05/18. If consultant pharmacist recommendations are not being reviewed by the physician, residents are likely to experience a potential for unnecessary drug interactions and adverse side effects. The findings are: [NAME] Record review of R #101's pharmacist recommendation dated 03/31/17 stated, (R #101) receives [MEDICATION NAME] (Medication that treats [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder) 125 mg (milligrams) TID (three times a day) for dementia with associated behaviors. Please consider a gradual dose reduction, perhaps decreasing to [MEDICATION NAME] 125 mg BID (twice a day) . The recommendation was signed by the Director of Nursing (DON) on 04/15/17. There was no response from the physician noted. B. Record review of R #101's pharmacist recommendation dated 04/26/17 stated (R #101) receives [MEDICATION NAME] (an antipsychotic medication) 50 mg BID (twice a day) . Please consider a gradual dosage reduction to [MEDICATION NAME] 25 mg QAM (every morning) and 50 mg at HS (at bedtime), with the end goal of discontinuations of therapy. The recommendation was signed by the DON on 05/15/17. There was no response from the physician noted. C. On 02/08/18 at 11:41 am, during an interview with the DON, she stated that when she signs the recommendation it indicates that she has received it from the pharmacist and reviewed it herself. She stated she usually reviews the recommendations with the physician in person. She stated that after looking for R #101's recommendation dated 03/31/17 and 04/26/17, she could not find anything that showed the physician was aware of them. She stated she does not know if the physician was made aware of the recommendation in another way. D. Record review of the facility's current policy on Medication Regimen Review dated 11/28/16 revealed there are no time frames given for the different steps of the medication regimen review. E. On 02/08/18 at 9:46 am, during an interview with the Administrator, he verified their policy does not specify specific timeframe's given for the different steps of the medication regimen review process. He stated they are working on formulating a new policy to include timeframe's.",2020-09-01
89,RIO RANCHO CENTER,325033,4210 SABANA GRANDE SE,RIO RANCHO,NM,87124,2018-02-12,758,E,0,1,M2BO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Surveyor: Puccetti, Ulysses Based on record review and interview, the facility failed to ensure that consultant pharmacist recommendations regarding gradual dose reductions of [MEDICAL CONDITION] medication were forwarded to the physician for 1 (R #101) of 5 (R #s 26, 31, 55, 90 and 101) residents reviewed for unnecessary medications. If consultant pharmacist recommendations are not reviewed by the physician and implemented in a timely manner, residents are likely to be administered medications they do not need, experience potential unnecessary drug interactions and adverse side effects. The findings are: [NAME] Record review of R #101's pharmacist recommendation dated 03/31/17 stated, (R #101) receives [MEDICATION NAME] (Medication that treats [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder) 125 mg (milligrams) TID (three times a day) for dementia with associated behaviors. Please consider a gradual dose reduction, perhaps decreasing to [MEDICATION NAME] 125 mg BID (twice a day) . The recommendation was signed by the Director of Nursing (DON) on 04/15/17. There was no response from the physician noted. B. Record review of R #101's pharmacist recommendation dated 09/30/17 stated REPEATED RECOMMENDATION from 3/31/17. Please respond promptly to assure facility compliance with Federal regulations. (R #101) receives [MEDICATION NAME] 125 mg TID for dementia with associate behaviors. Please consider a gradual dose reduction, perhaps decreasing to [MEDICATION NAME] 125 mg BID . The recommendation was signed by the DON on 04/15/17. The physician response was I accept the recommendation above with the following modifications: D/c (discontinue) [MEDICATION NAME]. Did this turn into a physician order? C. Record review of R #101's Medication Administration Record [REDACTED]. D. Record review of R #101's pharmacist recommendation dated 04/26/17 stated (R #101) receives [MEDICATION NAME] (an antipsychotic medication) 50 mg BID . Please consider a gradual dosage reduction to [MEDICATION NAME] 25 mg QAM (every morning) and 50 mg at HS (at bedtime), with the end goal of discontinuations of therapy. The recommendation was signed by the DON on 05/15/17. There was no response from the physician noted. E. Record review of R #101's pharmacist recommendation dated 08/28/17 stated (R #101) receives [MEDICATION NAME] 50 mg BID .Please consider a gradual dosage reduction to [MEDICATION NAME] 25 mg QAM and 50 mg at HS, with the end goal of discontinuations of therapy. The recommendation was signed by the DON on 10/09/17. The physician response was, I accept the recommendation above, please implement as written. F. Record review of R #101's MAR indicated [REDACTED]. On 9/14/17 a new order for [MEDICATION NAME] was entered and R #101 was administered the lower dose of [MEDICATION NAME] (25 mg in the morning and 50 mg at bedtime). [NAME] On 02/08/18 at 11:41 am, during an interview with the DON, she stated that when she signs the recommendation it indicates that she has received it from the pharmacist and reviewed it herself. She stated she usually reviews the recommendations with the physician in person. She stated that after looking for R #101's recommendation dated 03/31/17 and 04/26/17, she could not find anything that showed the physician was aware of them. She stated she does not know if the physician was made aware of the recommendation in another way. The DON verified the recommendations dated 09/30/17 and 08/28/17 were both repeat recommendations that were first suggested months prior. The DON stated she could not speak as to whether the physician would have discontinued R #101's [MEDICATION NAME] or agreed to the [MEDICATION NAME] dose reduction months prior since she cannot verify whether the physician received those recommendations.",2020-09-01
90,RIO RANCHO CENTER,325033,4210 SABANA GRANDE SE,RIO RANCHO,NM,87124,2018-02-12,761,F,0,1,M2BO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that medications were stored safely, which had the potential to affect any of the facility's 113 residents listed on the facility census provided by the Administrator on 02/05/18. Expired medications were stored with current medications, a lock box for controlled medications was not secured, food was present in a medication storage room, and medications were left unsecured at an unattended medication cart. These deficient practices have the potential to result in resident injury, through dosing with expired medications, absence of needed controlled medications, contamination of medications, or overdose by a confused resident. The findings are: [NAME] On 02/07/18 at 3:37 pm, during observation in the north unit's medication room, two medication refrigerators were inspected. Observed inside were: 1. An open bottle of a medicinal yeast product with a marked expiration date of (MONTH) (YEAR). 2. 2 bags of injectable [MEDICATION NAME] Sodium (an antibiotic) for use by former resident #308 showing an expiration date of 01/19/18. 3. A opened vial of influenza vaccine, in a water-damaged box, dated 12/04/17. 4. A locked clear medication storage box, containing 5 cards of controlled medications, which was not permanently affixed to the refrigerator and was able to be easily removed. B. On 02/07/18 at 3:49 pm, during interview with Licensed Practical Nurse (LPN) #1, he confirmed that the medications were expired. He indicated that the date on the influenza vaccine was the date that it had been opened, but stated that it's only good for 30 days after opening. He advised that the expired medications would be destroyed. C. On 02/07/18 at 3:53 pm, during interview with LPN #2, she was asked to open the south unit medication room for inspection. She responded Don't eat my chicken! Upon observation of the medication room, a plate containing LPN #2's dinner was noted on the counter. She stated You don't see that, and I have to put it in here, or they'll eat it. If you'll just turn your back for a minute, it'll be gone. Upon inspection of the medication refrigerator, a banana was found inside. LPN #1 stated That's for a patient. D. On 02/08/18 at 9:00 am, during observations in the north unit hallway, an unattended medication cart was present. On top of the medication cart was a bottle of [MEDICATION NAME] (a steroid medication) solution 5 mg/5 mL (5 milligrams per 5 milliliters) labeled for use by resident #164. Over the next 5 minutes, multiple residents and staff walked or wheeled past the cart. The staff (including the Administrator and LPN #1) did not take any action to secure the medication. After 5 minutes, RN #1 returned to the cart and stated that he had left the [MEDICATION NAME] on top of the cart because he had had to go to the medication storage room to retrieve another of R #164's medications. He acknowledged that it was not appropriate to leave the medication unattended on top of the cart. E. On 02/08/18 at 10:26 am, during interview with the Director of Nursing (DON) she confirmed: 1. that expired medications should be identified, collected and logged, and that pharmacy should be called right away for pickup. 2. that the influenza vaccine vial was expired 30 days after opening. 3. that the other medications found, which she had inspected, were also expired. 4. that there should never be any food in the medication rooms. 5. that the controlled medication lock box should be permanently affixed to the refrigerator. 6. that medications should be consistently secured to prevent unauthorized access. F. On 02/08/18 at 12:34 pm, during observations in the north unit hallway, RN #1's medication cart was noted to be unlocked and unattended, with the drawers opening easily when pulled. After 2 minutes, RN #1 returned to the cart, and stated that he had left the cart unlocked because he had been called away during medication preparation. [NAME] Record review of a document titled Storage and Expiration Dating of Drugs, Biological's, Syringes, and Needles, dated 08/01/02 and last revised 05/16/11, found statements indicating: 1. Policy: Drugs, biological's, syringes, and needles are stored under proper conditions with regard to sanitization, temperature, light, moisture, ventilation, segregation, security, and expiration date as directed by state and federal regulations and manufacturer/supplier guidelines. 2. All drugs and biological's, including treatment items, are securely stored in a locked cabinet/cart or locked medication room, inaccessible by patients and visitors. 3. Food is not stored in the refrigerator, freezer, or general storage areas where drugs and biological's are stored. 4. Drugs and biological's that have an expired date on the label or are after manufacturer/supplier guidelines/recommendations, or if contaminated or deteriorated, are stored separately, away from use, until destroyed or returned to the provider. 5. All discontinued drugs and biological's for expired or discharged patients are stored separately, away from use, until destroyed or returned to the provider. 6. The Center destroys or returns all discontinued, outdated/expired, or deteriorated drugs or biological's, per pharmacy return/destruction guidelines.",2020-09-01
91,RIO RANCHO CENTER,325033,4210 SABANA GRANDE SE,RIO RANCHO,NM,87124,2017-02-14,160,B,0,1,R9L211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to convey the funds of deceased residents to the appropriate party within thirty days after the death of the resident for 3 (R #s 232, 233 and 234) of 3 (R #s 232, 233 and 235) residents reviewed for personal funds. This deficient practice hinders the closing of resident trust accounts and the distribution of the residents' estate. The findings are: [NAME] Record review of an Action Summary report dated [DATE] revealed the following: 1. R #232 deceased on [DATE]. 2. R #233 deceased on [DATE]. 3. R #234 deceased on [DATE]. B. Record review of R #232's Resident Statement dated [DATE] indicated her remaining funds were paid out on [DATE] and her resident fund account was closed on [DATE]. C. Record review of R #233's Resident Statement dated [DATE] indicated her remaining funds were paid out on [DATE] and her resident fund account was closed on [DATE]. D. Record review of R #234's Resident Statement dated [DATE] indicated his remaining funds were paid out on [DATE] and his resident fund account was closed on [DATE]. E. On [DATE] at 3:04 pm, during an interview with the Business Office Manager (BOM), she stated the facility's policy is to close resident accounts within 30 days after they pass away and disperse the remaining funds to the appropriate party. The BOM verified that the accounts for R #232, R #233 and and R #234 were not closed within the 30 day window as they should have been.",2020-09-01
92,RIO RANCHO CENTER,325033,4210 SABANA GRANDE SE,RIO RANCHO,NM,87124,2017-02-14,285,E,0,1,R9L211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the accuracy of PASRR (preadmission screening and resident review) screening for 2 (R #125 and 230) of 5 (R's #1, 25, 56, 125 and 230) residents reviewed for PASRR screening. This deficient practice had the potential to prevent residents from receiving the necessary outside services to attain/maintain the highest level of psychosocial well-being. The findings are: [NAME] On 02/14/17 at 8:21 am, during an interview the Admissions Director she stated the following: 1. If a resident meets the level II PASRR the agency will give an okay over the phone and if requested then a letter will be sent to the facility. The PASRR paperwork is usually completed at the hospital or if not a hospital then from the community. 2. The facility has liaisons that are in the community who will go and make sure the forms are completed and correct before the resident leaves the hospital. 3. Once all the information is gathered it is sent to the Developmental Disabilities Supports Division (PASRR) for review. 4. If the resident does qualify for services through the PASRR department the facility will receive a letter stating so. 5. R #125 was not a level II PASRR per the documentation received from the hospital and the interview done at the facility. She received a letter stating that R #125 was not a level II. 6. R #230's medical record indicated that the resident came from the hospital with the PASRR paperwork but it didn't reflect a qualifying diagnosis. 7. She had to do a correction for R #230 and submit it to the PASRR Department and then an evaluation would be done by a doctor from the department. 8. All staff covering for admissions is trained on completing the proper paperwork and submitting it, there is someone on duty that can handle the situation when PASRR is in question. B. On 02/14/17 at 9:17 am, during an interview with PASRR worker, she stated that R #230 was admitted to the facility without prior approval from PASRR. Her office discovered that he had a [MEDICAL CONDITION] disorder before the age of 22. The PASRR worker stated she had a conversation with R# 230's mother and she informed them (PASSR) that he has had [MEDICAL CONDITION] since age 13. C. On 02/14/17 at 9:21 am, during an interview with PASRR worker, she stated that according to R #230's paperwork, [MEDICAL CONDITION] are listed on the form and this should have been a flag to the facility. As for R #125 the office received level I. R #125 was admitted on [DATE] with the [DIAGNOSES REDACTED]. The facility failed to notify PASRR that R #125 was admitted and a Level I PASRR call was not received.",2020-09-01
93,RIO RANCHO CENTER,325033,4210 SABANA GRANDE SE,RIO RANCHO,NM,87124,2017-02-14,431,E,0,1,R9L211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure: 1. That access to non-controlled discontinued drugs that were stored in open containers in the two medication rooms, without being double-locked, were not readily and easily available for staff members' personal use 2. that insulin vials were labeled when opened and that insulin vials were not being used greater than 28 days from date they were opened. These deficient practices have the potential to negatively impact all 112 residents, identified on the alphabetical list provided by the Administrator on [DATE], through semi-restricted access to discontinued medications by staff and for residents to receive medications that have lost their potency and effectiveness. The findings are: [NAME] On [DATE] at 12:15 pm, the medication storage observation of the North and South Hall medication rooms revealed opened boxes indicated for discontinued medications all easily accessible to staff members' personal use. The opened boxes contained the following medications: [REDACTED] 1. latanoprost (used to reduce intraocular pressure in the eye) 2. Spiriva (an inhaler used to help expand lung passages) 3. Nicotine Transdermal patches 21 mg (6) (used to reduce the urge to smoke) 4. albuterol nebs (used to help expand lung passages) 5. Alphagan (used to reduce intraocular pressure in the eye) 6. Flovent (a steroid inhaler that expands lung passages) B. On [DATE] at 1:40 pm, during interview, the Unit Manager for the North hall stated that the discontinued medications or medications of discharged residents are stored in the opened box. During the night shift, the nurse catalogs the medications, the medications are then placed in a box that is sealed and ready for the pharmacist or pharmacy courier (a messenger who transports goods or documents) to pick up from the facility once a week. C. Record review of the facility's policy titled Delivery and Receipt of Medication and Pharmacy Documents from the Facility to the Pharmacy, last revised on [DATE], revealed the following: .Facility should securely store the medications that Facility intends to return or sent to Pharmacy for repackaging until the medications are picked up by Pharmacy courier . D. On [DATE] at 11:26 am, during observation of the medication cart, revealed one (1) opened undated multi-dose vial of insulin indicated for resident use, no date was indicated on the vial. E. On [DATE] at 11:35 am, observation of the medication cart, revealed two (2) opened and dated multi-dose vials of insulin indicated for resident use, that had been opened beyond the 28 days that manufacturer's recommend. Also found during this observation was one (1) Lantus (a long-acting insulin) Insulin pen with no resident identification or when it was opened any where on the insulin pen. F. On [DATE] at 11:37 am, during interview, Licensed Practical Nurse (LPN) #1 stated, that all insulins are expired after being opened for 28 days, including insulin flex pens. [NAME] On [DATE] at 1:38 pm, during interview, the Unit Manager for the North hall confirmed that the one opened undated injectable vial of insulin should have been dated and that the two opened dated injectable vials of insulin were beyond the 28 days that are recommended by the manufacturer. H. Record review of the facility's policy titled Storage and Expiration Dating of Drugs, Biologicals, Syringes and Needles, last revised on [DATE] revealed the following: .safety and security, and expiration date as directed by state and federal regulations and manufacturer/supplier guidelines .Once any drug or biological package is opened, follow manufacturer/supplier guidelines for in use expiration dating. Drugs and biologicals with soiled, illegible, worn, makeshift, incomplete, damaged, or missing labels are destroyed by the Center .",2020-09-01
94,RIO RANCHO CENTER,325033,4210 SABANA GRANDE SE,RIO RANCHO,NM,87124,2017-02-14,514,D,0,1,R9L211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This is a repeat deficiency from the survey conducted on 01/08/16. Based on record review and interview, the facility failed to ensure that clinical records were complete and accurate for 2 (R #s 110 and 145) of 2 (R #s 110 and 145) residents reviewed for accurate and complete records by failing to ensure that residents' Medication Administration Record [REDACTED]. This deficient practice is likely to result in staff not knowing whether the physician was notified and is aware of the resident's condition. The findings are: Findings for R #110: [NAME] Record review of R #110's physician order [REDACTED]. Notify physician for absence of bruit/thrill every shift. B. Record review of R #110's MAR indicated [REDACTED].where documentation was not complete for checking the thrill/bruit of the residents fistula. C. On 02/10/2017 at 11:59 am, during an interview with the Director of Nursing (DON), she stated it should be documented on all orders on the MAR. She confirmed that nursing staff are not signing off on checking the thrill on the fistula. Findings for R #145 D. Record review of R #145's physician's orders [REDACTED]. The order indicated that if the resident's blood glucose level is over 401 gm/dl (grams/deciliter) to give 10 units and to notify the physician on call. E. Record review of R #145's MAR indicated [REDACTED]. F. On 02/10/17 at 11:45 am, during an interview with the DON, she stated that nurses are expected to document when the physician is contacted due to residents' high blood glucose levels. The DON stated they document this either on the back of the MAR indicated [REDACTED] R #145's high blood glucose levels on 4 separate days during (MONTH) (YEAR).",2020-09-01
95,RIO RANCHO CENTER,325033,4210 SABANA GRANDE SE,RIO RANCHO,NM,87124,2019-03-07,558,E,0,1,IVL411,"Based on interview, the facility failed to accommodate for 2 (R #s 6 and 11) of 2 (R #s 6 and 11) residents reviewed for accommodations provided to meet transfer needs requiring assistance with the use of a Hoyer lift (a mechanical device designed to lift residents safely). This deficient practice has the potential to affect residents physical health and comfort levels, by decreasing resident mobility. The findings are: [NAME] On 03/04/19 at 10:31 am, during an interview, R #6 revealed, They have to go all around to find the lift (Hoyer lift) They only have one or two I think .(so) they change my briefs on their schedule. B. On 03/04/19 at 11:37 am, during interview, Certified Nurse Aide (CNA) #2 revealed, We have two of them (Hoyer lifts) we could use more. C. On 03/07/19 at 1:06 pm, during interview, Licensed Practical Nurse (LPN) #5 revealed, regarding Hoyer lifts, We don't have enough .it impacts the residents getting up (out of bed). D. On 03/07/19 at 2:25 pm, during interview, the CNE (Center Nurse Executive) revealed, we have about 12 residents on each side that need the Hoyer lifts (~ (approximately)12 residents on the north hall and ~12 residents on the south hall). E. On 03/07/19 at 4:20 pm, during interview, R #11 revealed, I wait all the time, because the Hoyer isn't available .they need another one especially on this hall (South Hall).",2020-09-01
96,RIO RANCHO CENTER,325033,4210 SABANA GRANDE SE,RIO RANCHO,NM,87124,2019-03-07,656,E,0,1,IVL411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop and implement a comprehensive person-centered care plan for 2 (R #s 28 and 92) of 4 (R #s 22, 28, 75 and 92) residents reviewed for care plans. Failure to develop and implement a resident centered care plan may result in staff's failure to understand and implement the needs and treatments of residents possibly resulting in a decline in their abilities and a failure to thrive. The findings are: Findings for R #28: [NAME] Record review of R #28's face sheet (undated} reveals dependence on supplemental oxygen. B. Record review of R #28's Physicians orders dated 03/06/18, revealed, Oxygen at 2 l/min (liters per minute) via nasal cannula (a device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help) continuously. Attempt to wean (to make someone gradually stop depending on something that they have become used to) to room air as appropriate every shift. Oxygen tubing change weekly. Label each component with date and initials. C. Record review of R #28's care plan (undated) did not reveal a care plan for the use of oxygen. Findings for R #92: D. Record review of R #92's face sheet (undated) reveals [MEDICAL CONDITION] (A group of lung diseases that block airflow and make it difficult to breathe). E. Record review of R #92's physician's orders [REDACTED].> (greater than) 90% (percent). Check Q (every) shift. F. Record review of R #92's care plan does not reveal a care plan for O2 treatment. [NAME] On 03/06/19 at 3:25 pm, during an interview with Licensed Practical Nurse (LPN) #10 she stated, The use of oxygen should be care planned.",2020-09-01
97,RIO RANCHO CENTER,325033,4210 SABANA GRANDE SE,RIO RANCHO,NM,87124,2019-03-07,657,D,0,1,IVL411,"Based on record review and interview, the facility failed to ensure that the care plan had been revised for 1 (R #10) of 1 (R #10) resident reviewed for accuracy of care plans by not identifying what assistive device should be used to properly transfer the resident. This deficient practice is likely to result in the resident not getting the care and assistance he needs. The findings are: [NAME] Record review of R #10's care plan dated 11/22/16 reveals: Provide resident/patient with total assist with Hoyer lift (a device used to assist with transfers) of 2 for transfers. B. Record review of R #10's care plan dated 11/29/16 reveals: Sara lift (patient sit to stand assistive device) with 2-person for transfers. C. On 03/07/19 at 2:26 pm, during an interview with Licensed Practical Nurse (LPN) #2, stated, We (staff) use a Hoyer lift for all transfers, the care plan does state use a Sara lift. I know we have to use a Hoyer lift for all transfers. D. On 03/07/19 at 4:53 pm, during an interview with LPN #4, stated, I am not sure if he (R #10) uses a Sara lift. It (care plan) should have been revised to reflect what they (staff) are using to transfer him (R #10). When a care plan is revised it is done by the nursing staff. I did confirm a Hoyer lift is the only thing used to transfer the resident.",2020-09-01
98,RIO RANCHO CENTER,325033,4210 SABANA GRANDE SE,RIO RANCHO,NM,87124,2019-03-07,684,D,0,1,IVL411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide services for 2 (R #s 12 and 25) of 2 (R #s 12 and 25) residents reviewed for treatment and care in accordance with professional standards of practice. For (R #12) Hospice (end of life care management) Care, the facility staff failed to assure a resident receiving hospice care was being monitored by hospice staff. For R #25, the resident was not repositioned in bed for many hours and in accordance with the guidance on her kardex (document where the tasks a Certified Nurses Aide (CNA) should provide to a resident is delineated). This deficient practice was likely to result in a resident receiving inadequate and/or untimely care and treatment during daily and end of life care. The findings are: Findings for R #12: [NAME] Record review of R #12's face sheet dated 03/06/19 revealed he was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. [MEDICAL CONDITION]-Stage 3 (Moderate) (long term decline of kidney function) 2. Acute Kidney Failure (immediate failure of kidney function) 3. [MEDICAL CONDITION] in [MEDICAL CONDITION] (blood red cell abnormalities due to kidney disease) B. Record review of R #12's physician order [REDACTED].#12 was admitted to (name of selected hospice service) under routine level of care. Primary Diagnosis: [REDACTED]. C. Record review of R #12's written progress notes of care provided to R #12 by the selected Hospice service reveals that he was seen by a Registered Nurse, Licensed Practical Nurse or Social Worker from the hospice service on 12/14/18, 12/31/18, 01/18/19, 01/21/19, 01/29/19, 02/01/19, 02/05/19, 02/08/19, 02/12/19 and 02/15/19. There were no other written progress notes available after this date. D. On 03/06/19 at 9:15 am, during interview with the Social Services Director (SSD), stated that hospice nurses were suppose to come weekly. She stated that when the Hospice nurses come they document their visit in the paper chart. The SSD confirmed that the chart had not been updated since 02/15/19 and stated she believed this was an error and that they just forgot to chart for him on his last visit. Findings for R #25: E. On 03/04/19 at 8:40 am, during an observation, R #25 was lying in bed with the head of the bed (HOB) elevated approximately (~) 30 degrees and positioned on her back tilted slightly to her right side. F. On 03/04/19 at 11:15 am, during an observation, the resident was in bed positioned slightly, to the right, with HOB up ~ 30 degrees. [NAME] On 03/04/19 at 12:20 pm, during observation, the resident was slightly on her right side but has slid down in bed about a foot. H. On 03/04/19 at 2:48 pm, during observation, R #25 has slid down a little further in her bed and still slightly to her right side. I. On 03/05/19 at 8:41 am, during an observation, R #25 was positioned with her HOB up ~30 degrees on her back. [NAME] On 03/05/19 at 12:13 pm, during an observation, R #25 remains in bed with the HOB up ~ 30 degrees on her back. K. On 03/05/19 at 12:20 pm, during an interview, CNA #1 who was caring for the resident, was asked if (name of resident R #25) been turned this morning? we will do that at about 1 (pm) when her feeding tube (a medical device used to provide nutrition to people who cannot obtain nutrition by mouth) is turned off .I've been told not to turn her when her tube feed was turned on. L. Record review of the Kardex for R #25 revealed, Assist resident in turning and reposition every 2 hrs. (hours).",2020-09-01
99,RIO RANCHO CENTER,325033,4210 SABANA GRANDE SE,RIO RANCHO,NM,87124,2019-03-07,695,E,0,1,IVL411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, record review and interview, the facility failed to meet professional standards of care by failing to date the oxygen and nebulizer (respiration device that delivers medication) tubing for 4 (R #s 22, 28, 75 and 92) of 4 (R #s 22, 28, 75 and 92) residents reviewed for oxygen care. This deficient practice is likely to result in staff being unaware as to when the tubing should be changed and could cause tubing to become clogged or dirty leading to reduced flow of oxygen or upper respiratory infections. The findings are: Findings for R #22: [NAME] On 03/05/19 at 9:34 am, during an observation R #22's oxygen tubing, nebulizer tubing and humidifier bottle were not dated. B. On 03/07/19 at 10:49 am, during an observation R #22's oxygen tubing, nebulizer tubing and humidifier bottle were not dated. C. Record review of R #22's Physicians orders dated 02/23/19, revealed, O2 (oxygen) at 2L (liters) via nasal cannula (a device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help) as needed to maintain O2 sat (saturation) > (greater than) 90% (percent) (Normal range 90-100%). Oxygen tubing change weekly label each component with date and initials. Every day shift every Saturday label each component with date and initials. D. Record review of R #22's Care Plan dated 05/31/18, revealed, (name of R #22) exhibits or is at risk for respiratory complications related to [MEDICAL CONDITION] (A group of lung diseases that block airflow and make it difficult to breathe) exacerbation (the worsening of a disease or an increase in its symptoms) and [MEDICAL CONDITION] (Longstanding disease of the kidneys leading to [MEDICAL CONDITION]). Interventions: O2 as ordered via nasal cannula (a device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help). Findings for R #28: E. On 03/06/19 at 11:08 am during an observation, R #28's oxygen tubing was not dated. F. On 03/07/19 at 11:28 am during an observation, R #28's oxygen tubing was not dated. [NAME] Record review of R #28's Physicians orders dated 07/09/18 revealed, Oxygen tubing change weekly. Label each component with date and initials. Findings for R #75: H. On 03/06/19 at 12:20 pm, during an observation, R #75's oxygen tubing was not dated. I. Record review of R #75's physician's orders [REDACTED]. Label each component with date and initial. Every day shift every Monday label each component with date and initials. [NAME] Record review of R #75's care plan revised on 01/31/19, revealed, Resident has a [DIAGNOSES REDACTED]. Interventions: O2 as ordered. Findings for R #92: K. On 03/04/19 at 11:48 am, during an observation R #92's oxygen tubing, humidifier bottle or nebulizer tubing were not dated. L. On 03/07/19 at 10:50 am, during an observation R #92's oxygen tubing, humidifier bottle or nebulizer tubing were not dated. M. Record review of R #92's physician's orders [REDACTED].> 90%. Check Q (every) shift. N. On 03/07/19 at 10:55 am, during an interview Licensed Practical Nurse (LPN) #6, stated, O2 tubing should be changed once a week or more often if we see it is dirty, and it is changed by the Certified Nurse Aides (CNAs). When it is changed we put a tape on the tubing and we will write the date on the humidifier bottle. The nebulizer masks should be kept in a plastic bag when they are not in use. All of these (O2 tubing, nebulizer tubing and humidifier bottle) should have been dated.",2020-09-01
100,RIO RANCHO CENTER,325033,4210 SABANA GRANDE SE,RIO RANCHO,NM,87124,2019-03-07,726,E,0,1,IVL411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that licensed nursing staff were properly trained to provide emergency intervention and Cardio-Pulmonary Resuscitation (CPR) (life saving technique used during a medical emergency when the heart has stopped and/or the victim is not breathing) during a life threatening event. This deficient practice is likely to affect all residents who are full code and may require CPR. This deficient practice are likely to result in nursing staff providing inadequate and unsafe response during an emergency situation. The findings are: [NAME] On [DATE] at 1:33 pm, during an interview, the Center Nurse Executive (CNE) stated that all nursing staff are to have a current valid CPR certification. She was uncertain if each nurse had CPR certification which had been obtained through a qualified hands-on certification program. B. Record review of facility staffing dated [DATE] to [DATE], revealed there were 7 Registered Nurses (RN) and 13 Licensed Practical Nurses (LPN) assigned to work. C. Record review of facility provided CPR certifications revealed the facility provided current CPR certifications for LPN #3, LPN #6, RN #2, and LPN #8, which were each obtained through online computer-based certification programs that did not require any hands-on training to receive CPR certification. D. Record review of facility provided CPR certifications revealed the facility did not provide CPR certifications for LPN #1, LPN #9, RN #3, RN #4, RN #5 or RN #6 and therefore, their competency could not be confirmed.",2020-09-01