Aztec Healthcare

Inspectors wroteBased on record review and interview, the facility failed to ensure advanced directives (code status; documents providing an individual's wishes for emergency and lifesaving care) were accurate within the Electronic Health Record (EHR) for 1 (R #21) of 2 (R #16 and #21) residents reviewed for advance directives, when: The facility failed to ensure R #21's advance directive forms and EHR contained matching and consistent information regarding the residents' end-of-life wishes. The facility staff did not update the resident's advanced directives in the EHR after the resident completed their Medical Orders for Scope of Treatment (MOST; a legal document which outlines the care the resident wants when they become incapacitated and unable to speak for themselves) form. The facility staff failed to honor R #21's do not resuscitate (DNR; [...]

Inspectors wroteBased on record reviews, observations, and interviews, the facility failed to meet professional standards of practice for 2 (R #1 and R #2) of 2 (R #1 and R #2) residents, when: R #1 was administered oxygen (O2) without a physician's order. R #2 used a foley catheter (a thin, sterile tube inserted into the bladder to drain urine) without a physician's order. These deficient practices are likely to result in residents not maintaining their optimal health as planned by their medical provider.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment (to prevent the development and transmission of communicable diseases and infections) for 1 (R #4) of 1(R #4) residents, when: The facility failed to follow the required Enhanced Barrier Precautions (EBP; an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) by not wearing appropriate personal protective equipment (PPE; protective clothing, face masks, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection) when providing direct care to the resident. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure residents received the necessary treatment and services to prevent the development and worsening of pressure ulcers (PU; an injury to skin and underlying tissue resulting from prolonged pressure on the skin) for 1 (R #1) of 1 (R #1) resident when staff failed to: Begin wound care after identification of a coccyx (tailbone area; base of spine) wound. Administer wound care for R #1's coccyx pressure ulcer as ordered. Notify the facility Wound Care Nurse (WCN) and administrative nursing staff of R #1's worsening pressure ulcer and of the development of a new pressure wound on R #1's left ischial (hip bone) in a timely manner. These deficient practices likely resulted in R #1's pressure ulcer worsening with necrotic tissue (dead tissue) which required hospitalization for advanced wound care treatment.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Minimum Data Set Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) was accurate for 1 (R #2) of 1 (R #2) resident reviewed for MDS accuracy. This deficient practice could result in failure to provide adequate care and treatment of the resident's needs.

Inspectors wrotePAST NOT COMPLIANCE Based on record review and interview, the facility failed to notify the physician, for 1 (R #7) of 1 (R #7) resident reviewed, of the results of the resident's ordered chest X-ray, complete blood count (CBC; a blood test that measures the number and type of cells in the blood), and comprehensive metabolic panel (CMP; a group of tests to measure various substances in the blood) following a change in condition. This deficient practice likely resulted in delayed treatment for pneumonia (a lung infection that makes it difficult for a person to breathe) and likely contributed to R #7's death.

Inspectors wrotePAST NON-COMPLIANCE Based on record review and interview, the facility failed to notify the physician, for 1 (R #7) of 1 (R #7) resident reviewed, of the results of the resident's ordered chest X-ray, complete blood count (CBC; a blood test that measures the number and type of cells in the blood), and comprehensive metabolic panel (CMP; a group of tests to measure various substances in the blood) following a change in condition. This deficient practice likely resulted in delayed treatment for pneumonia (a lung infection that makes it difficult for a person to breathe) and likely contributed to R #7's death.

Inspectors wroteBased on record review and interview, the facility failed to assist 1 (R #3) out of 3 (R #1, 2 and 3) residents reviewed for activities of daily living (ADLs; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating). This deficient practice could likely cause a resident to feel like they are a burden and embarrassed.

Inspectors wroteBased on interview and record review the facility failed to keep residents free from abuse for 4 (R #27, R #28, R #56 and R #134) of 5 (R #20, R #27, R # 28, R #54 and R #134) residents reviewed for abuse when staff failed to: 1. Prevent emotional trauma as a result of not immediately removing the deceased body of R #27's roommate or moving R #27 from the room while waiting for the funeral home. 2. Physical abuse by the same Certified Nurse Aide (CNA) for R #27, 38, 56, and 134.

Inspectors wroteBased on record review and interview, the facility staff failed to report incidents to the State Agency (SA) in which the management received an allegation of employee-to-resident abuse/neglect and submit a five day follow-up report (a report detailing the facility's investigation, conclusion, and corrections for incidents reported to the SA) for 5 residents (R #28, #45, #56, #133, and #134) of 7 (R #20, #27, #28, #45, #56, #133 and #134) residents reviewed for abuse. If the facility fails to report incidents and follow-ups to the SA, then it could likely impact the safety and well-being of the residents.

Inspectors wroteBased on record review and interview, the facility failed to meet professional standards of quality for any of the residents who resided on 100, 200 hallways. This deficient practice could cause any of the residents on those two hallways to not have their needs met, which could cause issues like skin breakdown, infections, falls, and dehydration.

Inspectors wroteBased on observation, interview and record review, the facility failed to keep residents free from accidents for 2 (R #14 and R #58 ) of 2 (R #14 and R #58) residents reviewed when staff failed to: 1. Ensure R #14's fall mat (a safety feature placed along the side of the bed to prevent injury) was picked up when the resident was not in bed. 2. Ensure staff checked placement of the wanderguard for R #58. These deficient practices could likely result injury or death to residents due to tripping on the floor mats and eloping from the facility.

Inspectors wroteBased observation, record review, and interview the facility failed to have the Interdisciplinary Team (IDT; a facility team composed of various professionals who review and determine resident needs and abilities) determine if residents could self-administer medication for 1 (R #73) of 1 (R #73) residents randomly sampled. This deficient practice is likely to result in residents self-administering medication inappropriately or incorrectly which could cause harm.

Inspectors wroteBased on record review and interview, the facility failed to develop a comprehensive, person-centered plan which included information about fall interventions used for 1 (R #14) of 1 (R #14) residents reviewed for care plans. This deficient practice could likely result in residents not receiving the care needed to reach their highest practicable level of wellbeing.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide proper infection control practices when staff failed to ensure collection bags are kept off the floor for 2 (R #1 and R #2) of 3 (R #1, R #2, and R #3) residents. If the facility is not using proper infection control practices the residents are likely to acquire infections.

Inspectors wroteBased on record review and interview, the facility failed to create an accurate Baseline Care Plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) within 48 hours of admission for 1 (R #1) of 3 (R #1, R #2, and R #3) residents reviewed for baseline care plans. This deficient practice could likely result in a decline in the resident's condition due to staff not being aware of the care residents need and residents not being able to attain or maintain their highest practical level of wellbeing.

Inspectors wroteBased on record review and interview, the facility failed to ensure that residents received necessary treatment and service to prevent development and promote healing of pressure wounds (damaged skin caused by pressure, shear or friction) for 1 (R #19) of 3 ( R #11, 19, and 125) residents reviewed for pressure ulcers. This deficient practice likely resulted in a facility acquired pressure wound becoming necrotic (death of living tissue) before treatment was initiated.

Inspectors wroteBased on observation and interview, the facility failed to distribute food under sanitary conditions by not transporting resident meals, covered, when serving meals to residents in their rooms. This deficient practice could likely affect any of the 76 residents served meals in their rooms, identified on the resident census list provided by the Administrator (ADM) on 02/06/23. [...]

Inspectors wroteBased on record review and interview, the facility failed to create an accurate Baseline Care Plan within 48 hours of admission for 1 (R #60) of 8 (R #'s 4, 41, 47, 51, 60, 63, 67 and 176) residents reviewed for Baseline Care Plans. This deficient practice could likely result in a decline in the residents condition due to staff not being aware of needed care and/or residents not being able to attain or maintain their highest practicable level of well-being.

Inspectors wroteBased on record review and interview, the facility failed to ensure that the care plan had been developed and implemented for 2 (R #35 and R #60) residents of 3 (R #35, R#60, and R #16) residents reviewed for comprehensive care plans by: 1. Not developing a comprehensive care plan for R #60 within 7 days of completion of the comprehensive assessment [Minimum Data Set - MDS - clinical assessment that describes a person's overall condition] or within 21 days of admission for R #60. 2. Not including a resident or resident representative in care plan meetings for R #35. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the proper dose of medication was administered for 1 (R #23) of 10 (R #23,11, 62, 40,31,60,45,24,15,54) residents reviewed during random observation by: Administering the wrong medication dose for R #23. This deficient practice can likely result in adverse health consequences for any residents who experience this type of error. Excessive doses or being administered medications for longer than the time frame they are ordered for can lead to residents experiencing a delay in or failing to achieve their highest level of wellbeing.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure that safe serving temperatures were maintained by not: 1. Recording food temperatures prior to meal service,. 2. Having potatoes placed on the steam table in the kitchen at an unsafe temperature awaiting to be distributed to residents, and for a cranberry dessert left out of the refrigerator for an extended period of time before being served. This deficient practice could likely affect all 76 residents identified on the facility census provided by the Director of Nursing (DON) on 01/04/22 with possible food-borne illnesses, if food or beverages are not served at the proper temperatures.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the nutritional needs and preferences were met for all 76 residents listed on the facility census provided by the Director of Nursing (DON) on 01/04/22 by: 1. Not following the menu for all residents. 2. Not providing an alternative meal to residents that request an alternate meal. 3. Not ensuring residents were given food choices and that resident food preferences were honored resulting in the staff having to go to a local fast food restaurant to provide additional food for residents. If the facility is not following the menu, honoring resident's meal choices/preferences, and not providing an alternative meal, then residents are likely to have experience weight loss, frustration, and depression.

Inspectors wroteBased on observation and interview, the facility failed to store and serve food under sanitary conditions by not: 1. Ensuring boxes of food were properly stored off of the refrigerator, freezer, and dry storage floors. 2. Ensuring food items in the refrigerator, freezer, and dry storage were properly labeled, dated, and stored appropriately. 3. Ensuring large chunks of ice were cleaned off of the freezer floor. 4. Ensuring foods stored in the dry storage was not expired. 5. Ensuring the kitchen walls and floors were clean. 6. Ensuring the food in the unit nourishment refrigerators was labeled and dated. 7. Ensuring cleaning solutions placed in cleaning buckets was properly utilized. 8. Ensuring dishes were properly cleaned after each use. 9. Ensuring the refrigerator and freezer temperature logs were maintained and completed. 10. Ensuring staff wears hair nets in the kitchen. [...]

Inspectors wroteBased on observation and interview the facility failed to maintain proper infection prevention measures by: 1. Staff failing to wear surgical face masks (a loose-fitting, disposable device that creates a physical barrier between the mouth and nose of the wearer), when in residents rooms or around residents. 2. Staff failing to wear N95 face masks (a filtering face piece respirator) properly. Failure to adhere to an infection control program is likely to cause the spread of infections and illness to all 76 residents listed on the census as provided by the Director of Nursing (DON) on 01/04/22.

Inspectors wroteBased on record review and interview, the facility failed to promote resident self determination through support of resident choice for 2 (R #17 and 53) of 2 (R #17 and 53) residents reviewed for choices, by not accommodating residents desire to visit with each other. If the facility is not honoring resident's choices, then residents are likely to experience frustration and depression.

Inspectors wroteBased on record review and interview the facility failed: 1. Ensure that the New Mexico Medical Orders For Scope of Treatment (NM MOST) form and the Physicians order revealed the same resident wishes for 3 (R #12, 19 and 178) of 5 (R# 7, 12,19, 57 and 178) residents. 2. Ensure that the Physicians signatures were on the MOST form in a timely manner for 4 (R #12,19, 57 and 178) residents 3. Ensure that the current MOST form is included in the residents medical record These deficient practices are likely to cause residents to receive unwanted or unplanned treatment during a medical emergency.

Inspectors wroteBased on observation, record review, and interview the facility failed to develop and implement a comprehensive person-centered care plan for 2 (R #43 and 57) of 3 (R #43, 51, and 57) residents by: 1) Not developing a care plan to address oxygen (O2) use for R #43. 2) Not developing a completed care plan to address a skin rash for R #57. Failure to develop and implement person-centered care plans for residents is likely to result in staff not being made aware of the needs and treatments of residents and is likely to result in decline in their abilities and failure to thrive.

Inspectors wroteBased on observation, record review and interview, the facility failed to meet professional standards of care for 3 (R #39, 43, and 178 ) of 3 (R #39, 43, and 178) residents reviewed by: 1. Not administering oxygen (O2) in accordance with the physician's orders for R #39 2. Administering O2 without physician orders and not labeling and dating O2 tubing for R #43. 3. Not having a physicians order for a Foley catheter for R #178 4. Not having a physicians order for a Foley catheter If the facility is not administering medications and treatments as prescribed, the residents are likely to not get the therapeutic results of medication/treatment needed and/or resident should.

Inspectors wroteBased on record review and interview, the facility failed to provide ADL (activities of daily living) assistance for baths/showers for 6 (R #'s 15, 19, 35, 48, 56, and 57) of 6 (R #'s 15, 19, 35, 48, 56, and 57) residents reviewed for ADL care. 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 assure that 5 (R #12, 15, 24, 57 and 58) of 5 (R #12, 15, 24, 57 and 58) resident's medical chart and medication regimen was reviewed each month by a licensed pharmacist. If a licensed pharmacist fails to review all resident's medical record and medication regimen on a monthly basis residents are likely to be administered medications contrary to their medical needs, receive medications that are unnecessary, experience unnecessary drug interactions or adverse side effects.

Inspectors wroteBased on observation and interview the facility failed to 1. Ensure that medications in the medication cart were not expired 2. Ensure that all medication is properly labeled and stored. 3. Refrigerator in the 400 hall medication room temperature log had not been completed from 01/02/22 to 01/06/22. These deficient practices are likely to result in resident injury, through dosing with expired medications and dosing with medications that have been improperly stored.

Inspectors wroteBased on observation and interview, the facility failed to promote care with dignity and respect for 7 (R #19, 22 ,23 ,25, 31, 33, and 55 ) of 7 (R #19, 22, 23, 25, 31, 33, and 55 ) residents reviewed during random observation by not knocking before entering room # 's 201, 302, 304, and room [ROOM NUMBER]. This deficient practice is likely to result in residents feeling disrespected and unimportant to the facility staff.

Inspectors wroteBased observation, record review, and interview the facility failed to have the Interdisciplinary Team (IDT) (a facility team composed of various professionals who review and determine resident needs and abilities) determine if residents could self-administer medication for one (R #73) of one (R #73) random residents sampled. This deficient practice is likely to result in residents self-administering medication inappropriately or incorrectly causing harm.

Inspectors wroteBased on record review and interview, the facility failed to ensure that the MDS (Minimum Data Set) assessment accurately reflects the current status of the residents for 1 (R #78) of 3 (R #76, 77, and 78) reviewed for accuracy of MDS in relation to resident discharges. This deficient practice is likely to result in a lack of identification of risks and failure to implement interventions necessary for appropriate resident care and/or discharge.

Inspectors wroteBased on record review and interview, the facility failed to ensure that 1 (R #48) of 3 (R # 35, 48, and 56) residents reviewed for vision and hearing assisted devices, received proper assistive devices to maintain their vision and/or hearing. If the facility is not assisting residents in accessing treatment and devices to maintain their vision and/or hearing, then residents are likely to lose their ability to see and hear, which will compromise their quality of life.

Inspectors wroteBased on observation, record review and interview the facility failed to provide a mechanically altered diet as ordered by a Physician for 1 (R #43) residents of 1 (R #43) residents reviewed during random dining observations. If the facility fails to provide a diet as ordered, then residents are likely to experience weight loss due to not receiving their prescribed nutritional caloric intake, and are at risk for choking.