Bolivia Rehabilitation and Healthcare Center

Inspectors wroteBased on record review and staff interviews, the facility failed to implement a facility-wide system to monitor the use of antibiotics. This was evident for 8 of 9 months (July 2025, August 2025, September 2025, October 2025, November 2025, December 2025, February 2026, March 2026) that surveillance data was reviewed. This practice had the potential to affect all residents in the facility.

Inspectors wroteBased on record review, and interviews with facility staff, the Nurse Practitioner, Pharmacy Consultant and the Pharmacy Director, the facility failed to 1) have effective safeguards and systems in place to prevent drug diversion of discontinued Oxycodone (narcotic pain medication), Hydrocodone/Acetaminophen (narcotic pain medicine with Tylenol) and Lorazepam (an antianxiety medication); and 2) failed to have an effective tracking system to monitor declining count sheets and remove discontinued controlled substances from the medication cart for 5 of 6 residents reviewed for drug diversion (Residents #9, #41, #69, #94, and #95). These failures resulted in inaccurate narcotic counts and had the potential for residents being administered incorrect medications, and receiving narcotics that were not physician ordered.

Inspectors wroteBased on observations, record review and staff interviews the facility failed to treat a resident in a respectful and dignified manner when Resident #19 was seated in his geriatric wheelchair (a special medical recliner with a wheeled base designed for older adults and individuals with mobility issues) and Nurse Aide #1 pulled the wheelchair down the hall with the resident positioned behind her resulting in the resident being unable to see where he was going. A reasonable person would have had the expectation of being treated with dignity and would have wanted to be wheeled facing forward. In addition, the facility failed to promote dignity during meals when Nurse Aide #1 and Nurse Aide #4 were observed standing over the bedside feeding Resident #19 and Resident #33 who required total dependent care with eating. [...]

Inspectors wroteBased on record review, and staff and Nurse Practitioner interviews, the facility failed to follow a physician's order when nursing staff administered the wrong dose of a prescription opioid pain medication 5 times for 1 of 6 residents reviewed for medications (Resident #69).

Inspectors wroteBased on observations, record review, and resident and staff interviews, the facility failed to assist a resident who was dependent on staff for feeding assistance with a meal. This resulted in Resident #2, who was cognitively impaired, waiting for assistance with eating after the meal tray was placed within view at the bedside. This occurred for 1 of 3 residents reviewed for assistance with activities of daily living (Resident #2).

Inspectors wroteBased on record review and staff and Nurse Practitioner interviews, the facility failed to obtain weights as ordered by the physician and failed to verify the accuracy of weights after significant weight changes for 1 of 3 residents reviewed for weight monitoring (Resident #32).

Inspectors wroteBased on record review, resident and staff, and the Nurse Practitioner's interviews the facility failed to administer an as needed antihypertensive medication (Clonidine 0.2 milligrams) according to the physician's order and withhold the medication Isosorbide Mononitrate (a vasodilator that relaxes and dilates blood vessels and can lower blood pressure) according to the physicians order when blood pressure parameters were met. This occurred for 1 of 6 residents reviewed for medication administration (Resident #60).

Inspectors wroteBased on record review and interviews with the Nurse Practitioner and staff, the facility failed to accurately document the administration of controlled substances for 4 of 6 residents reviewed for accurate medical records (Residents #41, #69, #94 and #95).

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to implement their infection control policy and procedures for Contact Precautions when cleaning a resident's room (Resident #37) who was on Contact Precautions for suspicion of Norovirus (a highly contagious group of viruses that cause inflammation of the stomach and intestines and can survive on surfaces for weeks) and Rotavirus (a highly contagious virus that causes gastrointestinal symptoms). This occurred with 2 of 5 staff members who were observed for infection control practices (Housekeeping Aide #1 and Housekeeping Aide #2).

Inspectors wroteBased on record review, and staff, Nurse Practitioner, and Physician interviews, the facility failed to notify the Physician, or the Nurse Practitioner of a resident's blood pressure medication Carvedilol 3.125 milligrams prescribed for hypertension and scheduled for administration twice a day was held 34 times during a period of 77 days or that Midodrine (prescribed to increase blood pressure) was being administered outside of the prescribed parameters. This occurred for 2 of 5 residents (Resident #54) reviewed for medication administration and notification to the physician.

Inspectors wroteBased on record review, observations, Administrator, and Maintenance Director interviews, the facility failed to remove the black greenish substance from the commode base caulking in resident rooms (200, 201, 205, 207, 208, 209, 305, and 411), failed to repair resident's overhead lights that were non-functioning in resident rooms (202 and 411). These failures occurred on 3 of 5 hallways (200, 300, and 400 Halls) observed for a safe, clean, homelike environment and failed to maintain hot water temperatures in 2 of the 2 shower rooms on the 300-hall (Spa #1 and Spa #2) reviewed for hot water.

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to provide bathing and showers (Resident #39, Resident #53, and Resident #60) and incontinence care (Resident #7) to residents who were dependent on staff assistance with activities of daily living (ADL). This occurred for 4 of 5 residents reviewed for ADL care.

Inspectors wroteBased on record review, and staff, Registered Dietician and Physician interviews, the facility failed to provide a nutritional supplement ordered twice a day for 30 days for wound healing to a resident who was at risk for malnutrition and had a facility acquired unstageable deep tissue injury of the right heel and a deep tissue injury to the left heel that developed into a Stage IV pressure wound. This occurred to 1 of 10 residents (Resident #60) reviewed for nutrition.

Inspectors wroteBased on record review and staff interviews, the facility failed to provide 8 hours of Registered Nurse (RN) coverage for 13 of 275 days reviewed for staffing (04/6/24, 04/20/24, 04/21/24, 07/13/24, 07/27/24, 08/17/24, 09/07/24, 09/08/24, 09/28/24, 09/29/24, 10/05/24, 10/28/24, and 12/03/24).

Inspectors wroteBased on record review, and Physician and Consultant Pharmacist's interviews, the Pharmacist failed to identify and address during the monthly medication regimen review that a residents Carvedilol 3.125 milligrams prescribed for hypertension was held 17 out of 31 days during December 2024. This occurred for 1 of 5 residents (Resident #54) reviewed for medication administration.

Inspectors wroteBased on record review, and staff, Physician, Nurse Practitioner, and the Consultant Pharmacist interviews the facility failed to 1.)administer the antihypertensive medication Carvedilol 3.125 milligrams prescribed twice a day for hypertension. Resident #54 experienced no significant outcome by not receiving the medication. 2.) hold the blood pressure medication Midodrine (prescribed to increase blood pressure) when the systolic blood pressure was greater than 130 millimeters of mercury (mmHg). Resident #43 experienced no significant outcome from receiving the additional doses. This occurred for 2 of 5 residents (Resident #54 and Resident #43) reviewed for medication administration.

Inspectors wroteBased on observations and staff interviews the facility failed to ensure that food items that were stored for use in 1 of 1 walk-in refrigerator, 1 of 1 reach-in refrigerator and the dry goods storage pantry were labeled, dated, or discarded when expired. This deficient practice had the potential to affect food served to residents.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) program established and implemented effective systems to monitor and evaluate action plans previously developed to correct identified deficiencies. This failure resulted in the facility being unable to sustain compliance at F584, F677, F727, F732, and F812. During a complaint investigation and follow up survey of 02/04/23, the facility failed to maintain hot water temperatures in a shower room used by residents (F584). During a complaint investigation survey of 01/25/24, the facility failed to provide incontinent care to dependent residents (F677). [...]

Inspectors wroteBasedonobservations recordreview andstaffinterviews thefacilityfailedtoimplementthefacilitysinfectioncontrolpolicyandproceduresforEnhancedBarrierPrecautions(EBP when1.) Nurse#5 provideddirect careforResident#60'sStageIVandunstageablechronicfootwoundswithoutapplyingthenecessary personalprotectiveequipment(PPE and 2.) whentwonurseaides(NurseAide#1 andNurseAide#2) providedcare to Resident #7 withoutapplyingthenecessary PPE whohadastageIVpressureulcerandtubefeedingport Thisoccurredfor3 of3 staff(Nurse#5, Nurse Aide #1 andNurse Aide #2) observedforinfectioncontrolpractices

Inspectors wroteBased on observation, record review, and resident and staff interviews, the facility failed to provide a resident with their preferred number of showers a week for 1 of 1 residents reviewed for choices (Resident #38).

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to protect a residents' right to be free from neglect when a nurse (Nurse#5) failed to perform the daily wound care to an infected Stage IV left heel pressure wound and an unstageable right heel pressure wound both of which were facility acquired. This failure occurred for 1 of 3 residents reviewed for neglect.

Inspectors wroteBased on observations, record review, and staff, the Medical Director and the Wound Physician interviews, the facility failed to provide wound care according to the physician's order for a Stage IV pressure ulcer on the left heel and an unstageable deep tissue injury on the right heel. This occurred for 1 of 3 residents (Resident #60) reviewed for wound care.

Inspectors wroteBased on observations, record review, staff, and resident interviews the facility failed to provide sufficient nursing staff to provide incontinence care to a dependent resident (Resident #7). Nurse Aide #2 reported she changed Resident #7's brief at approximately at 7:30 AM and had not checked the resident for incontinence needs again until 1:15 PM. This occurred for 1 of 24 residents reviewed for sufficient staffing.

Inspectors wroteBased on observations, record review and staff interviews the facility failed to maintain a medication error rate of less than 5%. There were 3 medication errors observed out of 25 opportunities which resulted in a medication error rate of 12%. This occurred for 2 of 4 residents reviewed during a medication pass observation (Resident #79 and #66).

Inspectors wroteBased on observations, record review, and staff, Nurse Practitioner, Rehabilitation Director, and Registered Dietician interviews, the facility failed to implement a written order for occupational therapy evaluation for 1 of 10 residents (Resident #7) reviewed for nutrition.

Inspectors wroteBased on record review and staff interviews, the facility failed to accurately document the Daily Nursing Hours' postings on 4 of 324 days reviewed (6/8/24, 6/9/24, 8/17/24 and 12/3/24).

Inspectors wroteBased on record review and staff interviews, the facility failed to provide 8 hours of Registered Nurse (RN) coverage on 28 of 45 days reviewed.

Inspectors wroteBased on record review, staff and Nurse Practitioner interviews, the facility failed to follow the physician order and provide sliding scale insulin to 2 residents (Resident #60 and Resident #2) when the blood glucose reading was greater than 200 mg/dl (milligrams per deciliter). This resulted in Resident #60 not receiving a total of 21 doses of sliding scale insulin from 03/08/24 through 03/17/24 and Resident #2 not receiving a total of 6 doses of sliding scale insulin from 03/01/24-03/17/24. This was for 2 of 2 residents reviewed for insulin administration. There was no significant outcome to either resident.

Inspectors wroteBased on observations and staff interviews the facility failed to ensure refrigerated meat items stored for use in the walk-in refrigerator for resident sandwiches were dated and sealed. This practice had the potential to affect food quality.

Inspectors wroteBased on record review, Nurse Practitioner interview and staff interviews, the facility's Quality Assessment and Assurance (QAA) program failed to maintain implemented procedures and monitor interventions the committee put in place following the recertification survey completed on 10/26/21 and an on-site revisit survey and complaint investigation survey completed on 02/04/23. This was for three repeat deficiencies originally cited in the areas of Posted Nurse Staffing Information (F732), Residents Are Free of Significant Med Errors (F760) and Resident Records - Identifiable Information (F842). The continued failure during two or more federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program.

Inspectors wroteBased on record review and staff interviews, the facility failed to accurately document the time and date in the electronic Medication Administration Record (eMAR) 5 out of 28 times when prescribed as needed narcotic pain medications were removed from the narcotic dispensing cards for 2 of 2 residents reviewed (Residents #46 and #177).

Inspectors wroteBased on record review and staff interviews the facility failed to accurately document the Daily Nursing Hours postings for 2 of 45 Daily Nursing Hours reports reviewed.

Inspectors wroteBased on observations, record review, and staff interviews the facility failed to provide incontinence care to 4 of 4 residents (Resident #5, #10, #11, and #12) who were unable to carry out activities of daily living (ADL's) without staff assistance and were reviewed for needing assistance with ADLs.

Inspectors wroteBased on observations, record review and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) program failed to maintain implemented procedures and monitor interventions the committee put in place following the complaint investigation survey of 3/8/21, the recertification survey of 10/26/21, and the recertification and complaint investigation survey of 12/16/22. This was for two deficiencies in the areas of Activities of Daily Living (ADL) Care Provided to Dependent Residents (F677) and Nutrition and Hydration Status Maintenance (F692). These areas were subsequently recited during the current revisit and complaint investigation survey of 01/25/24. The continued failure during three federal surveys of record shows a pattern of the facility's inability to sustain an effective QAPI program.

Inspectors wroteBased on observations, record review and staff, Registered Dietician and Physician interviews, the facility failed to: a) follow the physician orders to administer a nutritional supplement twice daily with lunch and dinner for weight loss; and b) obtain weekly weights as ordered for a resident (Resident #2) who had a weight loss. This was for 1 of 1 residents reviewed for weight loss.

Inspectors wroteBased on observations, record review, staff and Nurse Practitioner interviews, the facility failed to protect residents' right to be free from sexual abuse (Resident #2) and intentional inappropriate touching (Resident #6) perpetrated by Resident #1. In the evening of 11/26/23 the facility was made aware Resident #1 entered another resident's room (Resident #6) uninvited and Resident #6 reported to Nurse #1 that a strange man (identified as Resident #1) woke her up and was holding her hand, telling her he was going to care for her and kissed her on the cheek. Resident #6 was upset and scared and was not sure what Resident #1 was doing in the room and told him he did not belong in her room. Resident #6 required Ativan (a medication to treat anxiety) 4 days later because she was still upset. [...]

Inspectors wroteBased on record review, and staff interviews, the facility failed to protect Resident #2 from sexual abuse when the Administrator was made aware of Resident #1 entering Resident #6's room uninvited on 11/26/23. Resident #6 reported to Nurse #1 that Resident #1 woke her up and was holding her hand, telling her he was going to care for her and kissed her on the cheek. Resident #6 was upset and scared and was not sure what he was doing in the room and told him he did not belong in her room. The following day 11/27/23, Resident #1 was found by Nurse Aide #1 in Resident #2's room sitting at his bedside while Resident #2 lay in bed. Resident #1 had his hand down Resident #2's brief and was manually stimulating (moving hand in an up and down motion) his penis. [...]

Inspectors wroteBased on observations, record review and staff interviews, the facility's Quality Assurance and Performance Improvement Program (QAPI) failed to maintain implemented procedures and monitor interventions that the committee put into place following the complaint survey of 05/10/21 for one deficiency that was originally cited in area of abuse (F600), and during a recertification survey of 10/26/21 for two deficiencies that were originally cited in the areas of abuse (F600) and not following abuse policy (F607). These deficiencies were subsequently recited on the current complaint survey on 12/11/23. The continued failure during 2 or more surveys of record shows a pattern of the facility's inability to sustain an effective Quality Assurance Program.