Albuquerque Heights Healthcare and Rehabilitation

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident had the right to communication with and access to persons and services inside the facility for 1 (R #80) of 1 (R #80) resident, when facility staff did not consistently communicate using the methods identified in R #80's care plan. If the facility does not provide residents with appropriate communicative services outlined in their plan of care, residents are likely to feel unimportant to facility staff.

Inspectors wroteBased on record review and interviews, the facility failed to notify the facility provider (Physician, Nurse Practitioner) for 1 (R #1) of 1 (R #1) resident, when staff failed to: Report R #1's follow-up blood pressure results to the Nurse Practitioner (NP) #1 as instructed. Document each time the NP #1 was notified after R #1's blood pressure was rechecked as ordered. If resident's experience a change in condition (CIC; a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains) and the facility nursing staff does not notify the provider as ordered, then residents are at an increased risk for deterioration in condition, delayed medical intervention, hospitalization, or additional complications.

Inspectors wroteBased on record review and interviews, the facility failed to ensure medications were administered as ordered for 1 (R #4) of 1 (R #4) resident, when the facility nursing staff: Failed to administer intravenous (IV; into the vein) antibiotics as ordered by a physician. If residents do not receive medications as prescribed, they may experience incomplete treatment, worsening infection, or failure to achieve the intended therapeutic effects.

Inspectors wroteBased on record review and interviews, the facility failed to implement a physician-ordered therapeutic diet for 1 (R #1) of 1 (R #1) resident, when the facility staff failed to: Provide a controlled carbohydrate (consistent or controlled; a meal plan designed to keep carbohydrate intake fairly equal at each meal and snack throughout the day and week to help stabilize blood sugar levels) diabetic diet as ordered by a physician for R #1. If physician-ordered therapeutic diets are not implemented as prescribed, then residents are likely to experience elevated blood sugars, difficulty chewing, inadequate nutritional intake, and an increased risk for further complications.

Inspectors wroteBased on observation and interview, the facility failed to ensure residents had a safe and functional environment throughout the facility, as evidenced by failure to: Ensure bed footboards were maintained in safe working condition and free from damage. Ensure food remains was promptly cleaned from resident room floors. Ensure the 100-unit water dispenser area remained in good repair. Ensure laminate wooden floor slats were intact and not broken. Ensure the handrail in the 300 unit was free from damage. Ensure the 300 unit remained free from urine odors. These deficient practices exposed residents in the 100, 300, and 400 units to an unsafe and uncomfortable environment.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR; a federal requirement to help ensure individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) was accurate for 1 (R #1) of ( R #1) resident reviewed for PASRR accuracy. This deficient practice is likely to result in the facility not providing the services needed by residents who are identified in the screening process for additional care and services.

Inspectors wroteBased on record review and interview, the facility failed to protect residents from the potential for accidents and hazards for 1 (R #20) of 4 (R #s 20, #21, #22 and #23) residents reviewed for falls by not preventing a resident from falling out of bed. This deficient practice could likely cause a resident to suffer health consequences such as a broken bone or a head injury.

Inspectors wroteBased on observation, record review, and interview, the facility failed to meet professional standards of practice for 3 (R #1, #4, and #7) of 3 (R #1, #4, and #7) residents when: R #1 and R #7 were not administered medications per physician orders. Transportation was not consistently provided to R #1, R #4, and R #7 for appointments. If the facility is not adhering to professional standards for quality improvement, then residents are unlikely to get the highest quality of care.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the residents who require dialysis (a treatment that helps remove waste products and excess fluids from the blood when the kidneys are not functioning properly) receive such services, consistent with professional standards of practice and physician orders for 2 (R #1 and R #7) of 4 (R #1, R #7 R #9 and R #10) residents reviewed for dialysis, when:The facility failed to provide adequate transportation to ensure residents attended scheduled dialysis treatments. This deficient practice led to the hospitalization of R #1 and R #7. If the facility is unable to meet the appointment needs for residents receiving dialysis treatments, then residents are likely to receive inadequate care and experience health complications.

Inspectors wroteBased on observation and interviews, the facility failed to provide reasonable accommodation of needs for 1 (R #4) of 1 (R #4) resident reviewed by ensuring a call light was within reach. This deficient practice is likely to result in the residents not being able to call for help when needed.

Inspectors wroteBased on observation and interview, the facility failed to maintain an environment that was clean and sanitary for 1 (R #4) of 1 (R #4) resident reviewed for a homelike environment by not maintaining and regularly cleaning a resident's room. If the facility fails to maintain a homelike environment, then residents are likely to feel uncomfortable and could exacerbate (make worse) health issues.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure dental services were obtained to replace dentures (removable plate or frame holding one or more artificial teeth) for 1 (R #5) of 1 (R #5) resident reviewed for dental care and services. This deficient practice could likely result in the residents not receiving dental care and services to meet their needs.

Inspectors wroteBased on record review and interview, the facility failed to develop a comprehensive care plan that included interventions for transfer assistance consistent with the resident's assessed needs and physician orders for 1 (R #4) of 1 (R #4) resident reviewed. If the facility fails to develop and implement a comprehensive care plan regarding a resident's transfer requirements, then staff may attempt unsafe transfer methods that increase the risk of falls, fractures, and other serious injuries.

Inspectors wroteBased on observation and interview, the facility failed to maintain a homelike environment when the facility did not have enough bath towels and face cloths for the residents. This deficient practice could cause residents to miss a shower if there are not enough towels available.

Inspectors wroteBased on record review and interview, the facility failed to ensure resident records were complete when staff did not document the evening meal percentages for 9 (R #1, #2, #3, #4, #5, #6, #7, #8 and #9) of 9 (R #1, #2, #3, #4, #5, #6, #7, #8 and #9) residents reviewed for meal intakes. This deficient practice could likely cause the Registered Dietician (RD) to not implement nutrition interventions if the meals were not documented for the RD's consideration during resident record reviews.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Minimum Data Set (MDS; a federally mandated comprehensive assessment of a resident's functional, medical, psychosocial and cognitive assessment completed by facility staff) was accurate for 1 (R #61) of 1 (R #61) resident reviewed for MDS assessments. This deficient practice could result in failure to provide adequate care and treatment of the resident's needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a light meal or a snack for 1 (R #177) of 1 (R #177) before the resident left the facility to go to dialysis (a medical treatment which filters waste and excess fluid from the blood.) This deficient practice could potentially cause prolonged recovery time for the resident after dialysis.

Inspectors wroteBased on record review and interview, the facility failed to provide activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) assistance for baths and showers for 2 (R #6 and #38) of 2 (R #6 and #38) residents sampled for ADLs when staff failed to: 1) Change R #6's soiled brief prior to assisting him to bed. 2) Clean and change R #38's ileostomy (a surgically made opening that connects your small intestine to your abdominal wall) bag. These deficient practices could likely result in residents being at a higher risk for infection and to feel unimportant, embarrassed and undignified.

Inspectors wroteBased on observation and interview, the facility failed to ensure residents had a safe and functional environment for resident rooms 205, 206, 207, 208, 211, and 213 when staff failed to: 1) Replace a broken plastic disposable glove holder in room [ROOM NUMBER] and 208. 2) Repair ripped flooring near a resident bed in room [ROOM NUMBER]. 3) Repair the hand rail end piece outside of room [ROOM NUMBER]. 4) Repair or replace a broken closet, a broken dresser, missing dresser drawer, broken blinds, and ripped flooring near the resident's bed in room [ROOM NUMBER]. 5) Maintain the shower in room [ROOM NUMBER] free of the storage of random items. 6) Replace broken blinds, cleaning a wall, and ensuring the room was free from a pungent (strong) urine odor in room [ROOM NUMBER]. [...]

Inspectors wroteBased on record review and interview, the facility failed to provide mental health services for 1 (R #57) of 1 (R #57) resident after the resident witnessed his roommate unconscious and unresponsive as staff performed life saving procedures on the roommate. If residents are not provided with mental health services, then residents are likely to experience a decline in their psychosocial well-being.

Inspectors wroteBased on record review and interview, the facility failed to discontinue a duplicate order of carvedilol (a blood pressure medication used to prevent high blood pressure and strokes in persons with heart disease or hypertension) for 1 (R #61) of 1 (R #61) resident reviewed for unnecessary medications. This deficient practice is likely to result in a resident failing to obtain maximum wellness or suffering prolonged illness.

Inspectors wroteBased on observation and interview, the facility failed to protect a treatment cart (a movable piece of equipment used in healthcare facilities to store, transport, and dispense treatment supplies and tools) from unauthorized access when staff failed to lock the treatment carts while staff were away from the cart. This failure had the potential to affect all 48 residents on the 300 Unit, as identified by the Resident Census provided by the Administrator on 04/07/25. If staff fail to lock an unsupervised treatment cart, then residents could obtain medial equipment which could result in injury or death.

Inspectors wroteBased on observation and interview, the facility failed to serve a meal that had been at a palatable temperature for 1 (R #177) of 1 (R #177) resident when staff left the resident's lunch tray on the bedside table while the resident was at dialysis. This deficient practice could cause a resident to not eat her lunch and could cause weight loss.

Inspectors wroteBased on interview and record review, the facility failed to promptly notify the ordering provider of critical laboratory results for 1 (R #180) of 1 (R #180) resident reviewed for change in condition. This deficient practice could cause a delay in treatment, creating a potential for harm or death to the resident.

Inspectors wroteBased on record review and interview, the facility failed to ensure ongoing communication and collaboration with the dialysis (clinical purification of blood as a substitute for the normal function of the kidney) facility regarding dialysis care and failed to monitor the resident before and after dialysis treatment for 2 (R #1 and R #2) of 2 (R #1 and R #2) residents reviewed for dialysis care. These deficient practices could likely result in the facility being unaware of the resident's condition, possible complications that arise during dialysis treatment, and residents may not receive the appropriate monitoring and care.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) was accurate for 1 (R #10) of 1 (R #10) resident when the MDS Nurse did not document the decline in R #10's weight to reflect R #10's status at the time of the assessment. This deficient practice is likely to result in R #10 not receiving the appropriate care and treatment she needs.

Inspectors wroteBased on interviews and record review, the facility failed to identify a resident at nutritional risk or address the risk factors for impaired nutritional status for 1(R #10) of 1(R #10) resident. When the facility's staff failed to weigh R #10 weekly or when ordered by the facility's provider. This deficient practice could likely lead to the resident to suffer from unplanned weight loss.

Inspectors wroteBased on interview and record review, the facility failed to keep a resident free from abuse for 1 (R #2) of 3 (R #2) residents reviewed for abuse when Certified Nurse Aide (CNA) was verbally and physically abusive to R #2 when providing care. This deficient practice likely resulted in emotional distress and trauma for R #2.

Inspectors wroteBased on record review and interview, the facility failed to honor residents' choices for 3 (R #8, R #16 and R #17) of 3 (R #8, R #16 and R #17) residents reviewed for choices when staff failed to: 1. Ensure showers in resident rooms were in working order (including missing faucet knobs and having random items stored in them), which caused R #8 to utilize the community shower only on scheduled days/times rather than choosing the days and times she preferred to shower. 2. Ensure a female staff was available to provide showers per R #16 preference for female staff only for showers. 3. Ensure there were clean towels available for resident showers. These deficient practices are likely to cause frustration and diminish quality of life.

Inspectors wroteBased on observation and interview, the facility failed to provide a homelike environment for all residents on the 300 units (residents were identified by the resident census provided by the Administrator on 08/19/24) when they failed to: 1. Repair damaged and broken blinds in rooms 302, 307, 308, 314, 322, and 325. 2. Repair a damaged thermostat that controlled the 300 unit. 3. Repair 11 broken floor tieles and broken toilets in the shower room. 4. Ensure handrails were secured to the wall. 5. Repair four outlet faceplates on the 300 unit which were loose and not secured. 6. Ensure bed frames were not stored in the 300 Hallway. 7. Ensure there were enough towels available for the residents during showers. 8. Repair areas in 12 resident rooms with unpainted patchwork. 9. [...]

Inspectors wroteBased on observation and interview the facility failed to ensure call lights in the residents' rooms were within reach of the resident while in bed or were accessible to them if they were in their wheelchair in the room for 6 residents (R #4, #5, #6, #7, #9 and #10) out of 7 (R #4, #5, #6, #7, #9, #10 and #11) reviewed for call lights. If the call lights are not accessible to the residents then their needs could likely go unidentified.

Inspectors wroteBased on record review and interview, the facility failed to notify the physician or on call physician when facility staff had problems with a wound vacuum (wound vac; a type of therapy to help wounds heal, the device decreases air pressure on the wound and helps it heal more quickly.) functioning properly for 1 (R #3) of 2 (R #3 and R #18) residents reviewed for wound vac care. This deficient practice of not notifying the physician and receiving further orders on how to continue with wound care could cause the wound to worsen or become infected.

Inspectors wroteBased on record review and interview, the facility failed to follow physician orders when facility staff were having problems with a wound vacuum (wound vac; a type of therapy to help wounds heal, the device decreases air pressure on the wound and helps it heal more quickly) functioning properly for 1 (R #3) of 2 (R #3 and R #18) residents reviewed for wound vacuum care. This deficient practice of not following physician orders could likely cause the wound to go untreated, worsen, or become infected.

Inspectors wroteBased on observation and interview, the facility failed to keep the residents free from accidents failing to safely secure the arm of his wheelchair for 1 (R #12) of 1 (R #12) residents observed for falls. This deficient practice likely resulted in R #12 falling from R #12's wheelchair that could of resulted in injury.

Inspectors wroteBased on record review and interview, the facility failed to update a resident's care plan for 1 (R #2) of 2 ( R #2 and R #3) residents reviewed for a change in condition. This deficient practice could likely result in residents not receiving the care or treatment needed to ensure their overall safety or ability to maintain their highest practicable well being.

Inspectors wroteBased on observation and interview, the facility failed to ensure food was stored, prepared, distributed, and served to residents in accordance with professional standards of food service safety when staff failed to: 1. Ensure all food items in the kitchen refrigerator and freezer were stored properly. 2. Ensure the kitchen pots, pans, and cooking utensils were cleaned properly. 3. Ensure the sanitizer sink water had the appropriate amount of sanitizer. 4. Ensure all food items are served at the appropriate temperature. These deficient practices are likely to affect all 127 residents identified on the resident census list provided by the Administrator on 1/22/24. These deficient practices are likely to expose residents to food borne illnesses.

Inspectors wroteBased on observation, record review, and interview, the facility failed to promote care with dignity and respect for 5 (R #'s 18, 23, 47, 53, and 65) of 5 (R #'s 18, 23, 47, 53, and 65) residents reviewed during random observation when staff failed to : 1. Serve all residents who were sitting at the same table in the 300 unit a meal at the same time. 2. Ensure Spanish speaking resident had proper intervention for their language barrier in place. These deficient practices are likely to result in residents feeling as if their feelings and preferences are unimportant to the facility staff.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide reasonable accommodation of needs for 7 (R #'s 11, 20, 23, 39, 55, 68 and 89) of 7 (R #'s 11, 20, 23, 39, 55, 68, and 89) residents when staff failed to: 1. Ensure call light were within residents' reach for R #'s 11, 20, 39 and 68. 2. Ensure residents attended medical appointments for R #'s 23, 55, and 89. These deficient practices are likely to result in the residents not being able to call for help when needed, and residents not receiving the appropriate medical care as desired resulting in an exacerbation (to make worse) of current medical conditions.

Inspectors wroteBased on record review and interview, the facility failed to notify residents of the findings of their grievances. This deficient practice could likely result in the facility not considering the needs of the residents and lead to a decrease in resident quality of life.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain an environment that was clean, in good condition, and free from wall debris for 8 (R #'s 5, 22, 24, 45, 67, 80, 81, and 87) of 8 (R #'s 5, 22, 24, 45, 67, 80, 81, and 87) residents sampled for a homelike environment. Failure to maintain the building in a clean and comfortable manner, is likely to result in unsafe conditions and prevent residents from enjoying everyday activities.

Inspectors wroteBased on record review and interview, the facility failed to ensure the care plan was revised for 2 (R #22 and #27) out of 2 (R #22 and #27) residents reviewed when staff failed to: 1. Update a care plan to reflect CPAP (continuous positive airway pressure; a machine that keeps your airways open while you sleep so you can receive oxygen) use for R #22. 2. Conduct quarterly care plan meetings as required for R #27. These deficient practices are likely to result in staff not being aware of residents' care needs and preferences, and residents not receiving the needed care.

Inspectors wroteBased on observation, record review, and interview, the facility failed to meet professional standards of quality for 2 (R #4 and #62) of 2 (R #4 and #62) residents when staff failed to: 1. Change R # 4's empty oxygen (O2) humidifier. 2. Change O2 tubing per physician orders for R #62. If the facility is not changing and labeling oxygen tubing then residents are likely to not receive the therapeutic benefits and care needed.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide an ongoing program of activities designed to meet the interests and well-being for 3 (R #78, #128 and #143) of 3 (R #78, #128, #143) residents reviewed for activities when staff failed to: 1. Provide meaningful individualized activities based upon residents' interests as identified on their individual care plans. 2. Encourage activities in a convenient community setting. If residents are not provided or encouraged to attend and participate in activities that meet their interests, are enjoyable, and enhance their social and emotional well-being, then they are likely to experience an increase in boredom, isolation, and depression.

Inspectors wroteBased on record review and interview, the facility failed to complete an annual performance review of Certified Nurses Aides (CNAs) for 5 (CNAs) #1, #3, #4, #5, and #6) of 5 (CNAs #1, #3, #4, #5, and #6) randomly reviewed. If the facility is not maintaining the annual performance reviews then residents are likely to not receive the appropriate care and services, and the CNA's may not meet the needs of all residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure 2 (R #'s 27 and 53) of 2 (R #'s 27 and 53) residents reviewed for behavioral health concerns received necessary behavioral health care to meet their needs when staff failed to: 1. Ensure R #27 was seen soon by a psychiatric provider after experiencing suicidal ideations while in the facility. 2. Ensure effective communication between the facility and psychiatric (psych) providers and consistent psychiatric services regarding R #53's psych service needs. These deficient practices are likely to result in the residents not receiving the behavioral or mental health care and assistance needed to improve mood and reduce depression and anxiety.

Inspectors wroteBased on record review and interview, the facility failed to ensure Certified Nurse Aides (CNAs) received the required in-service training of no less than 12 hours per year for 3 (CNA #4, #5, and #6) of 5 (CNA #1, #3, #4, #5, and #6) CNAs randomly reviewed for required in-service training. This deficient practice is likely to result in the nurses aides not receiving the necessary training to meet the care needs of the residents.

Inspectors wroteBased on record review and interview, the facility failed to promote resident choices when staff did not assist residents with a new medication per their request and preference or communicate the status of the medication request for 1 (R #21) of 1 (R #21) residents reviewed for choices. This deficient practice is likely to result in the resident's personal choices, needs, and preferences not being honored.

Inspectors wroteBased on record review and interview, the facility did not ensure 1 (R #83) of 3 (R #s 80, 83, and 328) residents reviewed for timely Beneficiary Protection Notification received the correct notifications. This deficient practice can result in confusion for the resident or their representative as to what services they have or do not have financial coverage for under Medicare A.

Inspectors wroteBased on record review and interview, the facility failed to develop an effective discharge plan that included a facility provider (Nurse Practitioner (NP), Physician's Assistant (PA), and Physician) for 1 (R #149) of 1 (R #149) residents reviewed for discharge planning (the process of transitioning a resident from one level of care to the next). This deficient practice is likely to result in complicated or unsafe transitions from the facility to the residents' post-discharge settings.

Inspectors wroteBased on record review, and interview, the facility failed to ensure the resident's ability to perform activities of daily living (ADLs) was maintained for 1 (R # 25) of 1 (R # 25) resident when staff failed to ensure R #25 received restorative therapy (therapy in which a patient trains on abilities they already have to perfect them and helps maintain physical abilities to perform ADLs.) If the facility does not ensure that residents receive restorative services, then the residents are likely to experience a decrease in their ability to walk, transfer, and do other activities of daily living.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide activities of daily living (ADL) assistance for facial hair shaving for 1 (R #27) of 1 (R #27) residents reviewed for ADL care when staff failed to: 1. Offer to shave R #27's facial hair. 2. Provide the correct facial hair shaving equipment for R #27. This deficient practice is likely to affect the dignity and health of the residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure ongoing communication and collaboration with the dialysis (mechanical purification of blood in place of normal kidney function) facility regarding dialyses care and services for 1 (R #23) of 2 (R #23 and #45 ) residents reviewed for dialysis. If the facility is unaware of the status, condition, or complications that arise during dialysis treatment then residents are likely to not receive the appropriate monitoring and care they need.

Inspectors wroteBased on record review and interview, the facility failed to schedule an appointment for dental services for 1 (R #19) of 1 (R #19) residents sampled for dental services. This deficient practice could likely result in continued dental pain or infection for the resident.

Inspectors wroteBased on record review and interview, the facility failed to ensure the medical record was accurate for 1 (R #228) of 1 (R #228) resident reviewed. This deficient practice is likely to result in staff confusion as to the services and treatment provided.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (R #1) of 3 (R #1-3) residents reviewed for hypoglycemia [a condition in which your blood sugar levels drop below the specified limits (less than 70)] by not ensuring meals are served timely. This deficient practice is likely to result in residents experiencing a change in condition.

Inspectors wroteBased on record review, observation and interview, the facility failed to deliver meals consistently and timely to all 127 residents that receive room trays or eat in the dining room. This deficient practice is likely to cause frustration, hunger, and hypoglycemic episodes [a condition in which your blood sugar levels drop below the specified limits (less then 70)] for residents with diabetes [a chronic medical condition where your blood sugar (glucose) levels are consistently high].

Inspectors wroteBased on record review, interview, and observation, the facility failed to provide sufficient support staff to carry out the functions of food and nutrition services at the facility. This deficient practice is likely to result in the residents' dietary needs not being met and longer waits for meal service for all 127 residents residing at the facility.

Inspectors wroteBased on observation and interviews, the facility failed to provide hydration between meals by not: 1. Ensuring there was process or a responsible department to pass out clean water pitchers/water during the day/night. 2. Ensuring there were water pitchers available for residents use. These deficient practices are likely to affect all 127 residents residing in the facility resulting in residents becoming at increased risk for dehydration.

Inspectors wroteBased on observation and interview, the facility failed to store and serve food under sanitary conditions. This deficient practice is likely to affect all 127 residents listed on the resident census list provided by the Administrator on 10/26/23 and is likely to lead to foodborne illnesses, if food is not being stored properly and safe food handling practices are adhered to.

Inspectors wroteBased on observation, record review, and interview, the facility failed to meet professional standards of quality for 1 (R #1) of 1 (R #1) resident reviewed by not obtaining physicians orders to treat, monitor, and document an injury of unknown origin on R #1's right arm. If the facility is not documenting or monitoring an injury of unknown origin then the resident is likely to not receive the necessary treatment needed to heal the wound.

Inspectors wroteBased on interview the facility failed to consistently offer snacks to all 125 residents residing in the facility. This deficient practice is likely to cause frustration and unnecessary hunger with the residents.

Inspectors wroteBased on observation and interview, the facility failed to store and serve food under sanitary conditions by not: 1. Ensuring food and beverage items in the refrigerator, freezer, and kitchen were properly labeled and dated. 2. Ensuring food items in the refrigerator and freezer were properly stored. 3. Ensuring food and beverage items are labeled, dated, and stored appropriately in the 300 unit nourishment refrigerators and freezers. 4. Ensuring food items were not expired in the kitchen refrigerator. 5. Ensuring food items were not stored on the floor. 6. Ensuring the kitchen floor was clean and free from trash and debris. These deficient practices are likely to affect all 125 residents listed on the resident census list provided by the Administrator (ADM) on 01/09/23. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to promote care with dignity and respect for 12 (R #'s 8, 10, 15, 30, 32 ,34, 37, 40, 45, 88, 91, and 175) of 12 (R#'s 8, 10, 15, 30, 32, 34, 37, 40, 45, 88, 91, and 175) residents reviewed during random observation by: 1. Referring to residents that require dining assistance as feeders. 2. Not removing meals from serving trays during meal times for any residents eating in the main facility dining room making it a non homelike environment. These deficient practices are likely to result in residents feeling as if their feelings and preferences are unimportant to the facility staff.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide reasonable accommodations of resident needs and preferences for 2 (R #'s 12 and 15) of 3 (R #'s 12, 15, and 41) residents reviewed by not: 1. Ensuring R #12 had access to his call light. 2. Ensuring R #15 was dressed in his own clothing and not in a hospital gown. These deficient practices are likely to result in residents feeling embarrassed and that their preferences are not important to the facility; and residents being unable to request assistance, such as needing help with transferring, after falling or other acute distress.

Inspectors wroteBased on record review and interview the facility failed to ensure that 4 (R #12, 98, 103, and 182) of 4 (R #12, 98, 103 and 182) resident's records reviewed for advanced directives (legal documents that allow you to spell out your decisions about end-of-life care ahead of time) were complete. This deficient practice could likely affect residents' fulfillment of their end of life medical care choices and could likely result in unnecessary suffering for the resident.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain an environment that is safe and at a comfortable temperature by not ensuring a functioning thermostat for 1 (R #12) of 2 (R #12 and #28) residents reviewed for room temperatures. This deficient practice is likely to result in residents feeling unsafe or uncomfortable if the facility fails to maintain the building in a safe and homelike environment.

Inspectors wroteBased on record review and interview, the facility failed to ensure that grievances by residents are responded to timely for 2 (R #3 and #12) of 2 (R #3 and #12) residents reviewed. If the facility is not ensuring that grievances are responded to timely, then residents are likely at risk of continued/repeat concerns and feeling as though their concerns are unimportant to the facility.

Inspectors wroteBased on record review and interview, the facility failed to revise the care plan for 1 (R #9) of 1 (R #9) residents reviewed. If the facility is not updating the care plan to reflect the resident's current care areas and treatment, then the facility may not be providing the appropriate care and treatment to meet the residents' needs.

Inspectors wroteBased on observation, record review and interview, the facility failed to meet professional standards of quality for 2 (R #'s 8, 59) of 2 (R #'s 8, 59) residents by: 1. Providing oxygen (O2) to R #8 without physician orders. 2. Not labeling, dating, and changing O2 tubing in accordance with physician orders for R #59 If the facility is providing O2 without physician orders, or not changing and labeling oxygen tubing per physician orders, then residents are likely to not receive the therapeutic benefits and care needed.

Inspectors wroteBased on record review and interview, the facility failed to provide ADL (Activities of Daily Living) assistance with showering for 1 (R #66) of 2 (R #'s 66 and 78) resident reviewed for showers. This deficient practice is likely to affect the dignity and health of the residents.

Inspectors wroteBased on record review, observation, and interview the facility failed to ensure that 2 (R #'s 9 and 51) of 2 (R #'s 9 and 51) residents reviewed received care and treatment that met the resident's needs by not updating hospice binders to include hospice notes/records and documenting hospice communication. If the facility fails to communicate with other entities that are providing care it is likely residents physical, mental, and psychosocial well being may decline.

Inspectors wroteBased on record review and interview, the facility failed to complete an annual performance review of 2 Certified Nurses Aide (CNA #5 and #6) of 5 (Certified Nurses Aide #5, #6, #7, #8, #9) randomly reviewed. If the facility is not maintaining the annual performance reviews then residents are likely to not receive the appropriate care, services and may not meet the needs of all residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that 1 (R #'s 41) of 2 (R #'s 37 and 41) residents reviewed for behavioral health concerns were receiving necessary behavioral health care to meet their needs by not: 1. Ensuring R #41 was seen by Psychiatry on a regular basis. 2. Ensuring medications recommended by Psychiatry were reviewed and documented as to why R #41 was not provided or administered the medication. This deficient practice is likely to result in the residents not receiving the behavioral or mental health care and assistance they require that has the potential to improve mood and reduce depression and anxiety.

Inspectors wroteBased on record review and interview, the facility failed to ensure monitoring for efficacy (effectiveness) /proper dosing of medication for 1 (R #51) of 1 (R #51) resident reviewed for pain. This deficient practice is likely to result in residents receiving unwarranted medications, with an increased likelihood of negative side effects or drug interactions.

Inspectors wroteBased on observation and interview, the facility failed to: 1. Ensure that medications and supplies are stored securely (locked) and out of reach of residents and visitors on the 100, 300 and 400 units medication and treatment carts. 2. Ensure that expired medications were not being stored with unexpired medications on the 200 units medication cart. 3. Ensure that medications were stored properly and not found out of package and laying in bottom of drawer inside of medication cart on the 200 unit. 4. Ensure that expired medications were not being stored with unexpired medications in the 100 and 300 units medication storage rooms. 5. Failed to label and lock alcoholic beverages for residents found stored inside the medication storage room on the 300 unit. 6. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide assist devices (3 compartment plate) for 2 (R #11 and 91) of 2 (R #11 and 91) residents reviewed. This deficient practice is likely to result in residents consuming less food resulting in weight loss. Findings for R#11: A. Record review of R #11's Nutritional assessment dated [DATE] and completed by the Registered Dietitian, revealed a recommendation for a 3-compartment plate. (a plate with 3 different eating divided areas) B. On 01/09/23 at 12:22 pm during random lunch meal observation and an interview with the Dietary Manager he confirmed that R #11 should have her meals served on a 3-compartment plate as noted on her meal ticket and she was not. Findings for R #91: C. Record review of R #91's care plan dated 12/12/22 revealed, Focus: [name of R #91] is at nutritional risk r/t [related to]: [...]

Inspectors wroteBased on record review and interview, the facility failed to promote resident choices for 1 (R #3) of 2 (R #'s 3 and 78) residents reviewed for choices by not assisting residents showers per their requested schedule and preference. This deficient practice is likely to result in the resident's personal choices, poor hygiene and needs and preference not being met.

Inspectors wroteBased on record review and interview, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR) screening tool had been fully completed for 1 (R #38) of 1 residents (R #38) reviewed for PASRR clearance, prior to admission. This deficient practice is likely to result in residents with physical or intellectual disabilities not receiving needed services.

Inspectors wroteBased on record review and interview, the facility failed to develop and implement a comprehensive person-centered care plan that reflects a dementia diagnosis for 1 (R #37) of 1 (R #37) residents. 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.

Inspectors wroteBased on record review and interview, the facility failed to ensure that 1 (R #56) of 1 (R #56) resident reviewed for hearing assisted devices, received proper interventions and/or appointments to maintain their hearing. If the facility is not assisting residents in accessing treatment and devices to maintain their hearing, then residents are likely to lose their ability to hear compromising their quality of life.

Inspectors wroteBased on observation, record review, and interview, the facility failed to: 1. Provide dining assistance for R #91 who is triggered for significant weight loss 2. Document/track meal intake percentages for every meal for R #91 for 1 (R #91) of 1 (R#91) resident reviewed for weight loss This deficient practice is likely to result in malnutrition, dehydration, weight loss and decline in resident's well-being.

Inspectors wroteBased 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 has the potential to affect all 125 residents identified on the resident census list provided by the Administrator on 01/09/23. This deficient practice is likely to cause residents to not eat meals which could lead to weight loss.

Inspectors wroteBased on observation and interview the facility failed to maintain proper infection prevention practices by not ensuring that aseptic technique (using practices and procedures to prevent contamination from a bacteria, virus, or other microorganism that can cause disease) were followed when administering wound care. This deficient practices are likely to result in contamination, infection and worsening of the wound.