Bear Canyon Rehabilitation Center

Inspectors wroteBased on record review and interviews, the facility failed to submit the required incident summary report and five-day follow-up investigation results to the State Agency for 1 (R #2) of 1 (R #2) resident reviewed for a fall with injury. If the facility does not submit the incident summary report and the summary of the facility's investigation to the State Agency within the required timeframe, the State Agency is unable to appropriately review the allegation for further investigation.

Inspectors wroteBased on record review and interview, the facility failed to maintain complete and accurate clinical records for 1 (R #2) of 1 (R #2) resident reviewed, when the facility failed to document required neurological assessments (a physical examination to identify signs of disorders affecting your brain, spinal cord and nerves) after R #2 experienced an unwitnessed fall. This deficient practice is likely to result in staff not having the information they need to provide competent, comprehensive care and services to residents.

Inspectors wroteBased on observation and interviews, the facility failed to provide a safe and homelike environment for all residents on the 600 unit by not maintaining the hallway, including preventing a chair and table from being placed against the handrail and staff storing personal belongings on the chair and table. If the facility fails to maintain a safe and homelike environment, then residents are likely to feel uncomfortable, and existing health issues could worsen.

Inspectors wroteBased on observation and interviews, the facility failed to safeguard clinical record information by leaving Private Health Information (PHI) regarding residents of the 600-nursing unit, where unauthorized people had ability to access it. If the resident's clinical information is not sufficiently safe guarded, resident's PHI is likely to be viewed by unauthorized residents, visitors, and staff.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure residents were treated with dignity and respect for 2 (R #9 and R #17) of 2 (R #9 and R #17) residents reviewed for resident dignity, when staff failed to:Refrain from using personal cell phones while feeding R #9, who required assistance with eating. Ensure R #17's bed linens were clean and free from urine stains. This deficient practice is likely to result in residents feeling unimportant to facility staff and may increase the risk of choking and infection.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure call lights were accessible and within reach for residents at risk for falls and injury. This failure occurred for 3 (R #3, R #4, and R #5) of 3 (R #3, R #4, and R #5) reviewed and created the potential for accidents, delayed response to resident needs, and injury.

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure medications were stored securely when a medication cart remained unlocked and unattended on the 500 Hall. This failure created the potential for unauthorized access to medications, including controlled substances, for 1 of 1 medication carts observed.

Inspectors wroteBased on a record review and interviews, the facility failed to update physician's orders for 1 (R #1) of 1 (R #1) resident who received supplemental oxygen, when the resident required a greater oxygen flow rate. If staff fail to update the physician's orders, then the resident may not receive the services for optimum health.

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 showering for 1 (R #1) of 1 (R #1) residents reviewed for ADL care. This deficient practice could likely to affect the dignity and health of the residents.

Inspectors wroteBased on observation and interviews, the facility failed to maintain proper infection prevention practices, when staff did not assure: -Cats in the Memory Care Unit were not defecating (discharging feces [bodily waste discharged through the anus] from the body) in the resident's room. -Cats not having trimmed or nail covers. These deficient practices could likely result in the spread of infectious agents (viruses and bacteria) to the residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure the facility was free of accident hazards for 19 (R #1-19) of 19 (R #1-19) when the facility failed to ensure no sprinkler above the ground courtyard area could cause a trip hazard. This deficient practice could likely results in a resident falling, putting them at serious risk of adverse outcomes.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain proper infection prevention measures by having: - The oxygen cannula (a medical device that provides supplemental oxygen) on the ground. -Unbagged oxygen cannula wrapped around back wheelchair handle. Failure to adhere to an infection control program could likely spread infections and illness to all residents of the memory care unit.

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 #42) of 3 (R #31, #42 and #58) residents when they failed to monitor R #42 for signs and symptoms of stroke and to treat R #42 with blood thinning medication as ordered. This deficient practice is likely to result in residents experiencing worsened conditions or death.

Inspectors wroteBased on record review and interview, the facility failed to administer clopidogrel (blood thinning medication used to prevent heart attacks and strokes in persons with heart disease, recent stroke, or blood circulation disease) as ordered by the physician for 1 (R #42) of 3 (R #31, #42 and #58) residents reviewed for medications. This deficient practice is likely to result in a resident failing to obtain maximum wellness or suffer prolonged illness.

Inspectors wroteBased on record review and interview, the facility failed to ensure Certified Nurse Aides (CNAs) received the required in-service training of at least 12 hours per year for 4 (CNAs #4, #5, #6, and #7) of 5 (CNAs #3, #4, #5, #6, and #7) 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 ensure residents or their guardians were aware of what medications they received and understood the reasons, risks, and benefits of the medications for 1 (R #70) of 3 (R #31, R #58 and R #70) residents reviewed for unnecessary medications. If the residents or their guardians are not informed of the risks and benefits of the medication, they are not able to make informed decisions.

Inspectors wroteBased on record review and interview, the facility failed to ensure the resident's current advance directive (a document which provides an individual's wishes for emergency and lifesaving care) was properly documented for 1 (R #16) of 1 (R #16) resident reviewed for advance directives. This deficient practice is likely to cause confusion and delay potentially lifesaving procedures.

Inspectors wroteBased on record review and interview, the facility failed to ensure accuracy of the Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) for 1(R #42) of 3 (R #31, R #42 and R #58) residents reviewed for accuracy of assessments. If the MDS assessment is inaccurate, then residents are likely to not receive the services they need.

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) for 1 (R #42) of 3 (R #31, R #42 and R #58) residents reviewed for Baseline Care Plans. This deficient practice could likely result in a decline in the residents' health due to staff not being aware of the residents' needs and residents not able to attain or maintain their highest practical level of well-being.

Inspectors wroteBased on interview and record review, the facility failed to complete staff competencies for 2 (Certified Nursing Assistants (CNA) #6, and CNA #7) of 5 (CNA #4, CNA #5, CNA #6, CNA #7, and CNA #8) CNAs sampled for annual training. This deficient practice could likely result in staff being undertrained and providing inadequate care.

Inspectors wroteBased on record review and interview, the facility failed to ensure the resident's medication regimen was free from unnecessary medications for 1 (R #104) of 1 (R #104) residents, when the attending physician: - Did not provide clinical basis when he disagreed with the facility's pharmacist consultant's recommendation on R #104's Medication Regimen Review (MMR), - Did not document in R #104's medical record the action he took to address the recommended medication dose reduction. This deficient practice is likely to cause R #104's medication regimen to not be properly evaluated resulting in a possible over medication.

Inspectors wroteBased on record review and interview, the facility failed to ensure the resident medication regimen was free from unnecessary medications for 1 (R #104) of 1 (R #104) resident, when R #104's hospice physician ordered an as needed (PRN) antipsychotic (a class of drugs that treat psychotic symptoms and disorders) medication without a 14 day stop date. This deficient practice is likely to cause R #104's medication regimen to not be properly evaluated and result in a possible over medication.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure nurses and Certified Medication Aids (CMAs) dated opened insulin glargine (a medication prescribed to help the body turn food into energy and manage blood sugar levels) pens and discarded glargine pens within 28 days of opening for 1 (R #19) of 1 (R #19) resident and to ensure medication carts were locked when unattended. These deficient practices are likely to result in R #19 receiving medications that are less effective or expired and is likely to negatively impact the health of residents on the 200 unit if they were to ingest (swallow) medications not intended for them. The findings for medication storage are: A. Record review of R #19's physician orders, dated 02/04/25, revealed R #19 received insulin glargine. B. [...]

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 1 (R #1) of 1 (R #1) residents reviewed for ADL care. This deficient practice is likely to negatively affect the dignity and health of the residents.

Inspectors wroteBased on record review and interview the facility failed to provide quality of care for 1 (R #5) of 3 (R #5, 6, and 7) residents reviewed when they failed to: 1. Identify a change in condition for seven days, 2. Notify the Physician and Power of Attorney (POA; someone to make decisions for you when you are no longer to make them) of the decline, 3. Assess for the cause of the decline and provide treatment, 4. Send the resident to the hospital and waited 15 hours after the request by the POA. This deficient practice likely resulted in further decline for R #5 and a delay in providing life saving treatment.

Inspectors wroteBased on record review and interview, the facility failed to notify the family member/Power of Attorney (POA; a power of attorney grants, in writing, a particular agent the power to make healthcare decisions on another's behalf) for 1 (R #5) of 3 (R #5, #6 and #7) residents when a resident began to decline, consistently refuse medications, and was not eating or drinking. If the facility is not notifying the resident's POA when the resident has a change of condition, then the POA is unable to make decisions related to treatment and advocate for the resident's care.

Inspectors wroteBased on record review and interview, the facility failed to: 1. Provide oversight of shower sheets to identify wounds, 2. Accurately document new skin impairments on Skin Checks, 3. Update and implement new preventative measures, treatment, and orders when new skin impairments were identified for 1 (R #1) of 3 (R #1, 2, and 3) residents reviewed for pressure wound injuries. This deficient practice could like result in new pressure injuries, pain, or significant decline in health status.

Inspectors wroteBased on observation, record review, and interview the facility failed to provide adequate supervision for 1 (R #1) of 3 (R #1-3) residents reviewed for elopement (when a resident leaves the facility without the knowledge of the staff) risk when R #1 was not adequately assessed for risk for elopement. If the facility fails to properly assess and supervise residents then serious injury is likely to occur.

Inspectors wroteBased on interview, observation, and record review, the facility failed to develop a comprehensive care plan for 2 (R #3 and R #6) of 4 (R #3, #5, #6, and #7) residents sampled for Foley catheters (a flexible tube inserted into the bladder and anchored by a balloon to allow the free flow of urine into an attached bag). This deficient practice could likely result in residents not receiving the care they need for maintaining good catheter care.

Inspectors wroteBased on record review and interview, the facility failed to meet professional standards of quality by not maintaining accurate weights for 3 (R #3, #6 and #9) of 3 (R #3, #6 and #9) residents sampled for feeding tubes (medical device used to provide nutrition) and nutrition. This deficient practice could likely result in resident nutrition or urinary retention not to be accurately assessed, causing a potential in unidentified medical issues or weight gain or weight loss.

Inspectors wroteBased on observation, record review, and interview the facility failed provide quality care for Foley Catheters (a flexible tube inserted into the bladder and anchored by a balloon to allow the free flow of urine into an attached bag) for 3 (R #3, #6, and #7) of 4 (R #3, #5, #6, and #7) residents by not: 1. Monitoring for urinary outputs for R #3 to be able to identify urinary retention. 2. Emptying the catheter bag timely for R #6. 3. Not ensuring that a Foley catheter was hung in the right position so that urine could drain freely when R #7 was placed in his wheelchair. These deficient practices could likely result in a resident's catheter backing up and causing a (UTI) urinary tract infections (an infection in any part of the urinary system), and other disease; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the required supervision for 1 (R #74) of 3 (R # 9, 74, and 78) residents reviewed when R #74 ate food from another resident's plate that was not within his ordered diet texture. This deficient practice could likely result in R #74 choking, needing to have the Heimlich maneuver (procedure for dislodging an obstruction from a person's windpipe) performed on him, be resuscitated (revived from unconsciousness), suctioned (removal of food) and could potentially cause death if this resident is not closely monitored by staff.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide sufficient nursing staff to: 1. Assist residents in getting dressed to go eat in the dining room; 2. Assist residents to shower and; 3. Provide formal/structured restorative nursing services. These deficient practices may affect all 140 residents listed on the census that was provided by the facility on 10/04/23 as it could likely result in 1. Residents feeling frustrated as they cannot honor their preference of eating in the dining room; 2. Residents feeling uncomfortable as they cannot bath on a regular basis; and 3. Residents experiencing poor quality of life due to not receiving restorative needs/services and having to wait for care while restorative services were being provided to others.

Inspectors wroteBased on observations and interviews the facility failed to: 1. Ensure that opened and accessed (has been opened and used) insulin flex pens were dated as to when they were initially opened by nursing staff. 2. Ensure that expired medications were not stored with unexpired medications. 3. Ensure that expired supplies were not stored with unexpired supplies in the storage room. 4. Document the daily medication refrigerator internal temperatures and daily medication storage room temperatures. These deficient practices are likely to result in 144 residents that were identified on the census list provided by the Centers Executive Director (CNE) on 10/04/23, to receive expired or improperly temperature-controlled medications that have either lost their potency, or effectiveness.

Inspectors wroteBased on observation and interview, the facility failed to: 1. Discard fresh produce that was older than seven (7) days; 2. Document a date on prepared food; 3. Place a splash guard on the bottom shelf of a wire rack; 4. Measure the temperature of prepped food before serving. These deficient practices have the potential to affect all 144 residents listed on the census that was provided by the facility on 10/04/23. This deficient practice could likely lead to a forborne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) in residents if food and equipment are not being stored properly.

Inspectors wroteBased on observation, record review and interview, the facility failed to maintain proper infection prevention measures by: 1. Performing hand hygiene between residents. This deficient practice could likely result in the spread of infectious agents (viruses and bacteria) between the residents all 144 as produced on 10/04/23 by the Center Executive Director, and/or staff.

Inspectors wroteBased on interview, the facility failed to ensure staff implemented a comprehensive antibiotic stewardship program (The effort to measure and improve how antibiotics are prescribed by clinicians and used by patients. Improving antibiotic prescribing and use is critical to effectively treat infections, protect patients from harms caused by unnecessary antibiotic use, and combat antibiotic resistance). This deficient practice has the potential to affect all of the 144 residents identified on the census provided by the Executive Director (ED) on 10/04/23, and who might be placed on antibiotics, which could result in the inappropriate use of antibiotics and can lead to resistance of a multi-drug resistant organism.

Inspectors wroteBased on interview the facility failed to have a qualified, trained, or Certified Infection Preventionist. This deficient practice could likely to affect all 144 residents identified on the census provided by the Director of Nursing (DON) on 10/04/23. This deficient practice could likely result in residents being at greater risk of infectious disease.

Inspectors wroteBased on observation, record review and interview, the facility failed to have the Interdisciplinary Team (IDT consists of a team professionals of various roles within the facility who review and determine resident needs and abilities) determine if residents could self-administer medication for 3 (R #15, R #43 and R #87) of 3 (R #15, R #43 and R #87) residents reviewed. If the facility is not assessing the residents to determine if a resident is capable of self-administering medications, then this deficient practice is likely to result in residents self-administering medications inappropriately and or incorrectly, likely causing harm.

Inspectors wroteBased on observation, interview and record review, the facility failed to promote resident self determination through support of resident choice for 9 (R #s 2, 3, 20, 58, 85, 86, 94, 98, and 139) of 9 (R #s 2, 3, 20, 58, 85, 86, 94, 98, and 139) residents reviewed for preferences as indicated by: 1. Not having the dining room open for all three meals and 2. Not allowing a family member/Power of Attorney (POA) to make decisions about her husbands care. These deficient practices have the potential to affect residents who want to eat in the dining room and didn't allow the family member/POA to make decisions about her loved ones care.

Inspectors wroteBased on record review and interview, the facility failed to: 1. Update the EHR (Electronic Health Record) to match MOST forms (Medical Orders for Scope of Treatment- a type of advanced directive that indicates what type of care an individual would like to receive in the event that their heart stops beating) and; 2. Obtain an advanced directive (a written document indicating end-of-life preferences that are to be referred to if the individual becomes incapacitated (unable to make decisions on their own) for 6 (R #'s 13, 15, 27, 32, 39, and 242) of 6 (R #'s 13, 15, 27, 32, 39, and 242) residents reviewed for advanced directives. These deficient practices could likely result in a resident's wishes not being honored. Findings for R #13 A. [...]

Inspectors wroteBased on record review and interview, the facility failed to develop an accurate and implement a comprehensive person-centered care plan for 4 (R #15, R #74, R #114, R #242) of 4 (R #15, R #74, R #114, R #242) residents reviewed for Comprehensive Care Plans. Failure to develop a person-centered care plan could likely result in staff's failure to understand the needs, preferences, and treatments for residents to achieve their highest level of well-being.

Inspectors wroteBased on record review and interview, the facility failed to provide care plan meetings on a quarterly basis for 2 (R #39 and R #85) of 2 (R #39 and R #85) residents reviewed for care plan meetings. This deficient practice could likely result in the lack of input from a resident regarding their care interventions and preferences.

Inspectors wroteBased on observation, record review, and interview, the facility failed to meet professional standards of care for 2 (R #15 and R #118) of 3 (R #15 and R #118) residents reviewed for respiratory care by: 1. Not properly dating the oxygen tubing and not dating the humidifier bottle (bottle of water that provides water to the oxygen to prevent the air from being too dry) for residents; These deficient practices could likely lead to respiratory infections by the oxygen tubing becoming clogged due to condensation (process where water vapor becomes liquid) or becoming dirty leading to the reduced flow of oxygen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to inquire about daily meal preferences for 6 (R #'s 2, 18, 26, 32, 68, and 85) of 6 (R #'s 2, 18, 26, 32, 68, and 85) residents reviewed for meal satisfaction. This deficient practice could likely result in residents feeling frustrated as they cannot make their own choice about their meal preference for the day.

Inspectors wroteBased on observation and interview the facility failed to ensure for 1 (R #104) of 1 (R #104) resident reviewed for dignity was not shaved as frequently as R #104 would like. This deficient practice could likely have caused the resident to not maintain her shaving preference.

Inspectors wroteBased on record review and interview the facility failed to notify facility management (Center Executive Director (CED) and Director of Nursing (DON)), the facility physician, and the representative/Power of Attorney (POA) of a resident not returning to the facility after not returning from an offsite visit for 1 (R #141) of 1 (R #141) resident looked at for discharge. This deficient practice resulted in R #141 being discharged Aganist Medical Advice (AMA) with no information or follow up from the facility.

Inspectors wroteBased on observation and interview, the facility failed to provide a safe, functional, and comfortable environment for 1 (R #118) of 1 (R #118) resident, as identified by the facility census provided by the Administrator on 10/04/23, by failing to maintain and repair a curtain railing system (a metal rail that is attached to the ceiling and allows a curtain give a patient privacy). This deficient practice is likely to affect their safety and psychosocial well being.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide an ongoing activity program to meet the resident's interests and support residents' psychosocial well-being for 1 (R #68) of 1 (R #68) resident reviewed for activities and during random observation. If the facility is not providing engaging activities to residents, then residents are at risk of boredom, depression, and decrease in actitivies that are important.

Inspectors wroteBased on record review and interview, the facility failed to provide quality care for 1 (R #6) of 1 (R #6) resident due to the facility not fixing or replacing the resident's wheelchair. This deficient practice could likely result in the resident not getting out of bed per her preference.

Inspectors wroteBased on record review and interview, the facility failed to effectively manage pain for 1 (R #87) of 1 (R #87) residents reviewed for pain by not assessing for pain and providing pain treatment. This deficient practice could likely result in R #87 experiencing a significant (long) period of pain without sufficient relief for pain.

Inspectors wroteBased on record review and interview, the facility failed to ensure that residents have the right to make treatment decisions based on their individuals needs and understanding for 2 (R #35 and R # 87) of 2 (R #35 and R #87) residents reviewed. This deficient practice could likely result in residents feeling anxious and unsupported and not receiving the treatment and services they need to attain or maintain their highest practicable physical, mental, and psychosocial (the minds ability to adjust and relate the body to its social environment) well-being.

Inspectors wroteBased on record review and interview, the facility failed to: 1. Administer medications as ordered by a physician and; 2. Notify the physician when a medication was not administered. This deficient practice was found to affect 1 (R #85) of 1 (R #85) resident reviewed for medication administration. This deficient practice could likely result in residents not feeling well due to the absence of a regularly administered medication. A. Record review of New Mexico complaint #69179, dated 09/07/23, revealed . they keep running out of her [R #85] meds [medications]. She goes two (2) or three (3) days without because they don't order. One is a blood thinner and the other is for cholesterol B. [...]

Inspectors wroteBased on observation and interview, the facility failed to store and serve food under sanitary conditions by not ensuring: 1. Food items stored in facilities refrigerators were labeled and dated, 2. Expired foods were disposed of, 3. Personal items and Personal Protective Equipment (PPE) were kept separate from food preparation, utensil and dining ware storage areas, and 4. Steeping tea was covered, labeled, and dated. These deficient practices are likely to affect all 118 residents, identified on Resident Census provided by the Center Executive Director on 07/27/22, residing at the home and could likely cause foodborne illnesses in residents if food is not being stored properly and safe food handling practices are not adhered to.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that a resident was getting in and out of bed according to his preferences for 1 (R #113) of 1 (R #113) resident reviewed for choices. This deficient practice has the potential to prevent residents from attending social and religious activities, maintaining personal hygiene and skin health per their personal preference and could likely result in residents to suffer a decline in their social interactions, enjoying activities, decline in self-esteem and an increase of feelings of helplessness and depression.

Inspectors wroteBased on record review and interview, the facility failed to revise the care plans for 2 (R #33 and 39) of 4 (R #33, 39, 66, and 105 ) residents reviewed for complete care plans. This deficient practice could likely result in the care plan not reflecting the resident's current goals and care needs and the facility not providing the appropriate care and treatment to ensure the resident gains or maintains their highest practicable level of well-being.

Inspectors wroteBased on interview, observation, and record review the facility failed to provide for all the needed hygiene and grooming for 3 (R #'s 33, 86, and 113) of 3 ( R #'s 33, 86, and 113) residents noted to have unclean hair, skin, teeth or overly long finger/toe nails. This deficient practice may likely lead to residents affected feeling uncomfortable as well as put them at increased risk for failing to maintain their optimal levels of well being.

Inspectors wroteBased on record review, observation, and interview the facility failed to ensure treatment or services that met that resident's needs in accordance with accepted professional standards for 4 (R #'s 39, 97, 105 and 118) of 4 (R #'s 39, 97, 105 and 118) residents by: 1. The Hospice company lack of communication and documentation to the facility for R #97 2. Not administering timely and documenting accurately medications and nutritional feedings prescribed for R #118. 3. Providing oxygen therapy for residents with no order for the oxygen supplementation as well as failing to change the oxygen tubing and humidifier bottles timely for R #'s 39 and 105. These deficient practices may likely result in residents affected failing to achieve their highest practicable level of well-being.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain a process that would allow residents to receive outside appointments timely for 2 (R #'s 8 and 61) of 2 (R #'s 8 and 61) residents who revealed they needed vision services. This deficient practices may likely result in residents not receiving the specialized medical attention needed to address deficits in visual abilities and in failure to maintain or achieve their highest practicable level of well being.

Inspectors wroteBased on record review and interview, the facility failed to monitor and treat pressure ulcers (areas of damaged skin caused by pressure, shear or friction) for 1 (R #121) of 4 (R #s 61, 65, 66, and 121) residents reviewed for pressure ulcers. This deficient practice caused a delay in wound care treatment and could likely have contributed to resident being discharged to the hospital with a possible infection.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that resident's received restorative [a nursing service that often follows rehabilitation services in nursing homes with the goal to maximize function and prevent functional decline in residents dependent on others for certain actions] treatment and services to optimize their well-being for 3 (R #'s 33, 61 and 86) of 5 (R #'s 33, 39, 61, 86 and 118) residents reviewed for restorative services by failing to provide: 1. Assistance to ambulate [walk] for R #61 2. Range of motion for dependent residents for R #'s 33 and 86. This deficient practice may likely result in decreased mobility or a decrease in the function in joints that can cause a loss of independence and sometimes pain for any resident affected.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain a hazard free environment for 3 (R #'s 26, 72, and 89) of 3 (R #'s 26, 72 and 89) residents reviewed for: 1. Placement of fall mat when R #'s 26 and 72 are out of bed, and 2. Resident positioning in bed and bed height for R #89. These deficient practices could likely result in an increased risk for an avoidable fall

Inspectors wroteBased on observation and interview the facility failed to provide all care needed to prevent complications with use of Gastrostomy tubes [G-tube, tube through the abdomen wall and into the stomach used for people who cannot swallow safely] for 2 (R #'s 86 and 118) of 3 (R #'s 39, 86 and 118) residents by: 1. Not flushing the G-tube with water to clear contents when nutritional supplement discontinued for multiple hours for 2 (R #'s 86 and 118) 2. Flushing the G-tube with more water than ordered for 1 (R #86) which may likely result in an overfilled stomach and regurgitation [stomach contents being brought back up to the mouth]. These failed practices may likely result in clogged/obstructed gastrostomy tube or resident inhalation [breathing in] of stomach contents into the lungs which can cause Pneumonia [an infection in the lung] .

Inspectors wroteBased on interview and record review, the facility failed to maintain a process that would allow each resident the opportunity to have a physician visit for 3 (R #'s 2, 15, and 57) of 3 (R #'s 2, 15, and 57) residents reviewed for frequency of physician visits. This deficient practice could likely result in an undiagnosed illness or an unaddress concerns.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the medication error rate did not exceed 5% by failing to: 1. Give correct medication to R #118 2. Give a short acting muscle relaxant timely to R #118 for 1 (R #118) of 8 (R #'s 36, 39, 86, 103, 110, 118, 220, and 221] residents reviewed for medication administration. This resulted in two errors out of 27 opportunities for error and an error rate of 7.41%. If medications are not administered as ordered, residents are likely to experience an exacerbation [sudden worsening] of symptoms that the medication was ordered for to prevent, relieve, or decrease symptoms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to adhere to a process that would allow residents the ability to communicate for 1 [R #8] of 3 [R #'s 2, 8, and 80] residents reviewed for call light accessibility. This deficient practice could likely result in residents not receiving the help they need or developing feelings of frustration.

Inspectors wroteBased on record review, observation, and interview the facility failed to ensure a resident was treated with respect and dignity for 1 (R #118) of 1 (R #118) resident reviewed for dignity by not dressing a resident daily. This deficient practice could likely result in the resident becoming depressed, anxious, feeling of hopelessness and lacking self-worth.

Inspectors wroteBased on interview and record review the facility failed to document in the resident record for 1 (R #120) of 1 (R #120) residents reviewed for available pertinent information about their discharge. This deficient practice could likely cause an unsafe discharge to the resident due to a lack of information or documentation on where the resident discharged to.

Inspectors wroteBased on record review and interview, the facility failed to develop a baseline care plan within 48 hours that would provide information about the residents care and needs upon admission for 1 (R #121) of 2 (R #'s 112 and 121) residents reviewed for baseline care plans. This deficient practice could likely result in needed care not being delivered and any resident affected failing to achieve or maintain their highest level of well-being.

Inspectors wroteBased on interview and record review, the facility failed to change the urine collection bag as required for 1 (R #37) of 1 (R #37) resident reviewed for incontinence care was noted to be incontinent of urine [the involuntary loss of urine] and required the use of a urine catheter (a thin, sterile tube inserted into the bladder to drain urine-the urine drains through the catheter tube into a bag, which is emptied when full). This deficient practice may likely result in a resident being at increased risk for Urinary Tract Infection (UTI), avoiding social situations, having feelings of embarrassment, shame, and frustration.

Inspectors wroteBased on interview and record review the facility failed to follow through with a needed dental appointment for 1 (R #13) of 1 ( R #13) resident reviewed for dental care. This deficient practice could cause residents to avoid eating causing weight loss and could also cause untreated dental issues to become infected causing further complications with the residents health.