Calibre Post Acute, LLC

Inspectors wroteBased on record review and interview, the facility failed to implement an effective training program for the Developmental Disability Caregivers (DDC, provides daily living assistance, medical support, companionship, and advocacy for individuals with intellectual or developmental disabilities) for 3 (DDC #1, DDC #2, and DDC #3) of 3 (DDC #1, DDC #2, and DDC #3) DDC's who provided care for R #89. If the DDC staff are not trained, then they could likely not have the knowledge to safely care for residents in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents remained free from physical restraints (any device used to prevent freedom of movement or action) unless staff used them to treat a specific medical condition (indication or characteristic of a medical, physical or psychological condition) as identified through an assessment for 1 (R #89) of 2 (R #3 and R #89) residents reviewed for physical restraints. This deficient practice could likely result in physical restraints being used for punishment or staff convenience; causing injury or unnecessarily restricting residents from freedom, movement, or activity.

Inspectors wroteBased on record review and interview, the facility failed to report an allegation of abuse to the State Survey Agency for 1 (R #89) of 2 (R #3 and R #89) residents reviewed for physical restraints (any device used to prevent freedom of movement or action). If the facility fails to report incidents of possible abuse to the State Agency, then the State Agency is unable to ensure residents have a safe environment.

Inspectors wroteBased on record review and interview, the facility failed to notify the provider of abnormal vital signs (blood pressure and blood sugar) and that medication was not given for 3 (R #1, R #2, and R #9) of 3 (R #1, R #2, and R #9) residents reviewed for assessment and monitoring when staff failed to notify the provider that: 1. R #1 and R #2's blood pressure was low. 2. R #9's blood sugar was low. 3. Medication was held (not given) for R #1, R #2 and R #3. These deficient practices could likely result in residents not receiving necessary care or worsening medical conditions due to lack of or changes in treatment.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents did not receive psychotropic medications (group of drugs that affect behavior, mood, thoughts, or perception. They are used to treat a variety of conditions including anxiety, depression, bipolar disorder, and schizophrenia) unless the medication was medically necessary and had adequate monitoring for 2 (R #16 and R #24) of 3 (R #16, R #24, and R #25) residents reviewed for depression (a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities) treatment, when staff failed to: 1. Ensure a gradual dose reduction (GDR; stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) was carried out for R #16. 2. [...]

Inspectors wroteBased on record review and interview, the facility failed to develop and implement accurate, person-centered comprehensive care plan for 1 (R #16) of 3 (R #16, R #24, and R #25) residents reviewed for depression when staff failed to: 1. Include what behaviors staff were expected to monitor for related to his diagnosis of depression. 2. Include non-pharmacological interventions for R #16's diagnosis of depression. These deficient practices could likely result in staff being unaware of the current and actual needs of the residents.

Inspectors wroteBased on record review, and interviews, the facility failed to meet professional standards of practice (established guidelines and expectations that ensure the delivery of high-quality care to residents) for 3 (R #1, R #2 and R #9) of 3 (R #1, R #2 and R #9) residents reviewed for assessment and monitoring when facility staff failed to: 1. Administer medications as ordered for R #1, R #2 and R #9. 2. Contact the provider to notify them when medication was held due to possible adverse effects (unintended effect that is undesirable, unpleasant, or harmful) of medication for R #1, R #2 and R #9. [...]

Inspectors wroteBased on record review, and interview, the facility failed to ensure residents received necessary behavioral health care to meet their needs for 1 (R #16) of 3 (R #16, R #24, and R #25) residents reviewed for behavioral health concerns when: 1. Staff delayed psychiatric services for R #16 after a psychiatric referral on 12/18/24 and 07/20/25. 2. Staff failed to refer R #16 for recommended therapy services on 03/14/25. 3. Staff did not have an effective process for referring residents to behavioral health services. These deficient practices could likely result in residents not receiving the behavioral or mental health care and assistance needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on record review and interview, the facility failed to ensure the physician provided documentation of a rationale (set of reasons or a logical basis for a course of action) for not following the consultant pharmacist's recommendation for 1 (R #16) of 3 (R #16, R #24, and R #25) residents reviewed for depression. This deficient practice could likely result in residents receiving medications that are no longer necessary and may cause unnecessary drug interactions (changes to medication action caused by being combined with other foods, beverages, or drugs) or adverse side effects (unwanted, undesirable effects from medication). A. Record review of R #16's admission documents, no date, revealed the following: 1. R #16 was admitted to the facility on [DATE]. 2. R #16 had the following diagnoses: a. [...]

Inspectors wroteBased on record review and interview, the facility failed to meet quality of care standards for 1 (R #9) of 3 (R #1, R #2, and R #9) residents reviewed for diabetes (chronic disease in which the body cannot use insulin properly and results in high blood sugar [BS] levels) when staff did not obtain finger stick blood glucose levels for R #9 upon return to the facility. This deficient practice could likely result in complications related to diabetes.

Inspectors wroteBased on record review and interview, the facility failed to ensure nursing staff completed mandatory behavioral health training (a form of instruction that provides knowledge and skills to identify, understand, and respond to mental health and substance use challenges, including the promotion of well-being) for 1 (LPN #26) of 4 (LPN #17, LPN #18, LPN #25, and LPN #26) staff sampled for staffing. This deficient practice could likely result in staff being unable to inform residents of their total health status and to provide notice of rights and services.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure care plan revisions occurred for 3 (R #8, R #17, and R #25) of 3 (R #8, R #17, and R #25) residents when the staff failed to revise the care plan with the most current resident information. This deficient practice could likely result in the care plan not being updated with the most current resident conditions and appropriate interventions, staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions.

Inspectors wroteBased on record review and interview, the facility failed to ensure medical records were complete and accurate for 3 (R #8, R #17, and R #25 ) of 3 (R #8, R #17, and R #25) residents reviewed for documentation accuracy when staff failed to do the following: 1. Document attempts to change R #8's brief. 2. Document attempts to shower/bathe R #8. 3. Document attempts to put sheets on R #8's mattress. 4. Document changing R #8's mattress. 5. Document R #17's fall on 04/05/25. 6. Document unavailable medication for R #25. These deficient practices have the potential to negatively impact the care staff provide to meet residents' needs due to missing or inaccurate records and resident information.

Inspectors wroteBased on record review and interview, the facility failed to provide behavioral health training (training that helps staff recognize and respond to various behavioral and mental health issues that residents may present with) for 3 (CNA #8, CNA #9 and ADON #1) of 3 (CNA #8, CNA #9 and ADON #1) staff sampled for training. This deficient practice could likely result in residents not receiving the services necessary to attain or maintain their physical, mental, and psychosocial (involving both psychological and social aspects) well-being.

Inspectors wroteBased on record review, and interview, the facility failed to notify the provider of missed medication doses for 1 (R #25) of 3 (R #18, R #25 and R #26) residents reviewed for medications not available when staff failed to: 1. Notify the provider of the missed dose of Amiodarone (medication used to treat affects the rhythm of your heartbeats. It is used to help keep the heart beating normally in people with life-threatening heart rhythm disorders of the ventricles) on 06/14/25 and 06/15/25. 2. Notify the provider of the missed dose of Levothyroxine (medication used to treat hypothyroidism underactive thyroid; a condition where the thyroid gland does not produce enough thyroid hormone) on 6/14/25 and 6/15/25. These deficient practices could likely result in residents not receiving the necessary care or worsening medical conditions due to lack of treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set Assessment (MDS; federally mandated assessment instrument completed by facility staff) was accurate for 1 (R #16) of 3 (R #16, R #17, and R #18) residents reviewed for accurate MDS assessments. This deficient practice could likely result in the facility not having an accurate assessment of the residents' needs.

Inspectors wroteBased on record review and interview, the facility failed to meet professional standards of practice for 1 (R #25) of 3 (R #18, R #25, and R #26) residents reviewed for neglect, when staff failed to administer R #25's heart rhythm and thyroid medication as ordered by the physician. This deficient practice could likely lead to the residents medical conditions worsening and having adverse (unwanted, harmful, or abnormal result) side effects or not receiving the desired therapeutic effect of the medication due to it not being administered.

Inspectors wroteBased on record review and interview, the facility failed to provide activities of daily living (ADL) assistance for 4 (R #8, R #10, R #11, and R #24) of 5 (R #8, R #10, R #11, R #24, and R #25) residents reviewed for ADL care when staff failed to: 1. Assist R #8 and R #11 with toileting. 2. Assist R #10 with ADL care. 3. Assist R #24 with brushing his teeth and showering. These deficient practices caused R #8 and R #25 psychological distress, and feeling embarrassed.

Inspectors wroteBased on record reviews, observation, and interviews, the facility failed to ensure the facility had sufficient staff to meet the needs of 5 (R #8, R #10, R #11, R #25, and R #26) of 6 (R #8, R #10, R #11, R #24, R #25, and R #26) residents reviewed for staffing when staff failed to: 1. To transfer R #8. 2. Change R #10's brief. 3. To assist R #11 to the toilet as needed. 4. Assist R #24 with oral care and showers. 5. Change R #25's brief after 30 minutes or longer. This deficient practice caused R #25 psychological distress, feeling embarrassed and crying when discussing how she was left soiled when she has to wait to be changed.

Inspectors wroteBased on observation and interview, the facility failed to store and serve food under sanitary conditions in accordance with professional standards of food service safety for all 98 residents in the facility (residents were identified on the resident matrix provided by the DON on 02/13/25) who eat food prepared in the kitchen when staff failed to: 1. Keep the deep freezer and kitchen floors clean. 2. Keep the stoves and surrounding areas clean from oil. 3. Maintain the quality of the oil (fresh) in the deep fryer. 4. Perform hand hygiene prior to assisting R #24 with meal. These deficient practices could likely lead to foodborne illnesses.

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 #3) of 1 (R #3) resident reviewed for baseline care plans. This deficient practice could likely result in residents not receiving the appropriate care and may place residents at risk of an adverse event (undesirable experience, preventable or non-preventable, that caused harm to a resident because of medical care or lack of medical care) or worsening of current condition after admission.

Inspectors wroteTHIS IS A REPEAT DEFICIENCY FROM 11/06/24 Based on record review and interview, the facility failed to meet professional standards of practice for 1 (R #3) of 4 (R #1, R #2, R #3, and R #4) residents reviewed for physician's orders, when staff did not administer R #3's blood pressure medication as ordered by the physician. This deficient practice could likely lead to the resident having adverse (unwanted, harmful, or abnormal result) side effects or not receiving the desired therapeutic effect of the medication due to it not being administered.

Inspectors wroteBased on record review and interviews, the facility failed to receive medication needed for treatment of an illness for 1 (R #4) of 4 (R #1, R #2, R #3, and R #4) residents reviewed for quality of care. Failure to follow physician orders could likely lead to facility staff and physician being unaware of changes in resident's condition and could likely lead to worsening of resident's condition.

Inspectors wroteBased on record review and interview, the facility failed to ensure wound care orders were obtained and implemented for 1 (R #3) of 1 (R #3) residents reviewed for pressure ulcers (damage to an area of the skin caused by constant pressure on the area for a long time). This deficient practice could likely result in the provider being unaware of the resident's current condition, leading to inconsistent interventions and worsening of pressure ulcers.

Inspectors wroteBased on record review and interview, the facility failed to ensure nursing staff demonstrated competency in the skills and techniques necessary to safely change a suprapubic catheter (a thin flexible tube inserted directly into the bladder through a small incision in the lower abdomen, just above the pubic bone. It is used to drain urine from the bladder when a person is unable to urinate normally) for residents for 1 (ADON) of 1 (ADON) employees sampled for training and competency. This deficient practice could likely result in nurses working with residents without adequate knowledge and skills to do so; likely resulting in injury or inappropriate care being provided to the residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure medical records were complete and accurate for 2 (R #17 and R #18) of 2 (R #17 and R #18) residents reviewed for documentation accuracy. This deficient practice has the potential to negatively impact the care staff provide to meet residents' needs due to missing or inaccurate records and resident information.

Inspectors wroteBased on interview and record review, the facility failed to ensure the licensed nurses (RN's and LPN's) and CNA's are able to demonstrate competency in skills and techniques necessary to care for residents' needs for 5 (CNA #8, CNA #9, LPN #8, LPN #9, and LPN #10) of 5 (CNA #8, CNA #9, LPN #8, LPN #9, and LPN #10) reviewed for competent nursing staff. This could affect all 94 residents in the facility (residents were identified by Resident Matrix provided by the DON on 10/28/24). This deficient practice could likely result in nurses and CNA's working with residents without adequate knowledge to do so; likely resulting in injury or inappropriate care being provided to the residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents and their representatives received a written notice of the bed hold policy which indicated the duration the bed would be held for 2 (R #77 and R #94) of 2 (R #77 and R #94) residents reviewed for hospitalization. This deficient practice could likely result in the resident and/or their representative being unaware of the bed hold policy upon return from the hospital.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the Minimum Data Set Assessment (MDS, part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid-certified nursing homes. It is a core set of screening, clinical and functional status elements, including common definitions and coding categories, which forms the foundation of a comprehensive assessment) was accurate for 5 (R #33, R #36, R #48, R #84, and R #85) of 6 (R #5, R #33, R #36, R #48, R #84, and R #85) residents review for MDS assessment accuracy. This deficient practice could likely result in the facility not having an accurate assessment of the residents' needs.

Inspectors wroteBased on record review and interview, the facility failed to develop an accurate, person-centered comprehensive care plan for 2 (R #48 and R #77) of 6 (R #5, R #41, R #48, R #60, R #77 and R #81) residents reviewed for care plans. This deficient practice could likely result in staff being unaware of the current and actual needs of the residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure care plans were reviewed and revised for 6 (R #26, R #28, R #46, R #59, R #64, and R #85) of 6 (R #26, R #28, R #46, R #59, R #64, and R #85) residents reviewed for care plans when they failed to: 1. Have an Interdisciplinary Team Meeting (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of their clients) within seven days after the completion of the admission Minimum Data Set assessment (MDS, part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid-certified nursing homes. It is a core set of screening, clinical and functional status elements, including common definitions and coding categories, which forms the foundation of a comprehensive assessment) for R #85. 2. [...]

Inspectors wroteBased on record review and interview, the facility failed to provide services that meet professional standards of practice for 1 (R #81) of 5 (R #52, R #59, R #60, R #81 and R #251) residents reviewed for physician's orders when staff failed to: 1. Obtain a Dexcom (continuous glucose monitoring system that tracks glucose levels in the body, without requiring fingersticks [use of lancet to draw blood from the finger]) as ordered by the physician. 2. Ensure R #81 received weekly Trulicity (injectable medication used to treat diabetes by assisting the body to use the insulin it is already making) injections. These deficient practices could likely result in worsening of medical conditions.

Inspectors wroteBased on record review and interview, the facility failed to provide quality of care for 1 (R #36) of 1 (R #36) resident reviewed for diabetes (chronic condition that happens from persistently high blood sugar levels) when staff did not check blood glucose levels (the process of checking your blood sugar level to ensure they are within a healthy range) and administer diabetic medications. This deficient practice could likely result in R #36 having a higher risk of developing long-term health problems and a higher risk of diabetic ketoacidosis (DKA; a serious complication of diabetes that can be life-threatening. Occurs when blood sugar is very high, and ketones [acids your body makes when it's using fat instead of sugar for energy] build up in the body, causing symptoms of increased thirst, frequent urination, weakness and fatigue).

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure pharmaceutical services (the direct, responsible provision of medication-related care) were met for 1 (R #251) of 5 (R #52, R #59, R #60, R #81 and R #251) residents reviewed for medications when they failed to provide routine medication for a resident. This deficient practice could likely lead to unresolved or worsening of medical issues.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents did not receive psychotropic medications (antidepressants, anti-anxiety medications, stimulants, antipsychotics, and mood stabilizers) unless the medication was medically necessary for 3 (R #5, R #26 and R #48) of 5 (R #5, R #26, R #31, R #33 and R #48) residents reviewed for unnecessary medications. This deficient practice could likely result in residents receiving medications without a medical reason or when no longer necessary, placing these residents at a higher risk of adverse side effects (unwanted, harmful, or abnormal result) when the facility failed to: 1. Carry out a gradual dose reduction (GDR; [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents obtained dental services for 4 (R #41, R #50, R #81, and R #84) of 4 (R #41, R #50, R #81, and R #84) residents sampled for dental services, when: 1. Receive routine dental care to include an annual inspection of the mouth for signs of disease, dental cleaning, fillings, or minor partial or full denture adjustments for R #41 and R #50. 2. Schedule required dental follow-up for R #50 and R # 81. 3. Emergency dental services for R#84. These deficient practices are likely to cause the resident unnecessary pain, embarrassment over the condition and/or appearance of teeth, and potential dental or oral complications.

Inspectors wroteBased on observation and interview, the facility failed to store and serve food under sanitary conditions by professional standards of food service safety. This failure could potentially affect all 40 residents on the north unit (residents were identified by the Resident Matrix provided by the Administrator on 10/28/24). When they failed to ensure staff maintain refrigerator temperatures in the nutrition refrigerators. If the facility fails to adhere to safe food storage, residents could likely be exposed to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins).

Inspectors wroteBased on observation and interview, the facility failed to ensure call lights worked at all times as intended for Rooms 133 to 152 on the South Unit reviewed for call system functioning. This deficient practice could likely result in residents being unable to notify staff when they are in need of assistance.

Inspectors wroteBased on record review and interview, the facility failed to ensure the nursing staff have completed the mandatory Effective Communication training for 5 (LPN #8, LPN #9, LPN #10, LPN #11, and CNA #8) of 5 (LPN #8, LPN #9, LPN #10, LPN #11, and CNA #8) staff randomly sampled for staffing. This deficient practice could likely result in staff being unable to inform residents of their total health status and to provide notice of rights and services.

Inspectors wroteBased on record review and interview, the facility failed to notify the resident and the resident's representative of a transfer in writing for 1 (R #77) of 2 (R #77 and R #94) residents sampled for hospitalizations when they failed to: 1. Notify the resident or the resident's representative of the transfers to the hospital in writing and in a language and manner they understand. 2. Contents of the notice include the following: -The name, phone number, and address (mailing and email) of the Office of the State Long-Term Care Ombudsman on the transfer notification form. -Statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request. 3. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure a comprehensive Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff that reflects a resident's functional capabilities) was completed for 2 (R #82 and R #88) of 3 (R #5, R #82, and R #88) residents reviewed for resident assessments. This deficient practice could likely result in in the facility receiving monies they are not entitled to and possible delays in transitions to a new setting.

Inspectors wroteBased on interview, and record review, the facility failed to keep residents free from accidents for 2 (R #46 and R #64) of 2 (R #46 and R#64) residents reviewed for smoking, when staff failed to complete smoking evaluations to determine resident safety while smoking. This deficient practice could likely result in residents being at risk of serious harm or injury.

Inspectors wroteBased on interviews, observation, and record review, the facility failed to ensure a resident who entered the facility with an indwelling Foley catheter [a tube inserted through the urethra (the tube through which urine leaves the body) and into the bladder to drain urine] received appropriate treatment for 2 (R #77 and R #85) of 2 (R #77 and R #85) residents reviewed for urinary catheter care, when they failed to: 1. Assess R #77 for urinary retention (a condition that occurs when a person is unable to empty their bladder, either partially or completely) after the removal of her foley catheter. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed include performance reviews as part of their 12 hours of annual training for 1 (CNA #9) of 2 (CNA #8 and CNA #9) CNAs sampled for 12 hours of annual training. This deficient practice could likely result in staff being under trained and providing inadequate care.

Inspectors wroteBased on record review and interview the facility failed to report injuries of unknown source within two hours to the State Agency (SA) for 3 (R #8, R #9, and R #11) of 3 (R #8, R #9, and R #11) residents sampled for abuse and neglect. If the facility fails to report allegations of injuries of unknown source to the SA within two hours, then residents could likely continue to be abused or suffer serious bodily injury.

Inspectors wroteBased on record review and interview, the facility failed to complete a thorough investigation regarding allegations of abuse for 1 (R #9) of 3 (R #8, R #9, and R #10) residents reviewed for abuse and neglect. This failure could likely lead to residents' claims of abuse, neglect, or exploitation not being thoroughly investigated and determining the cause.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure resident was assessed for risk of entrapment (state of being stuck or caught on bed rail) from bed rails for 1 (R #25) of 1 (R #25) resident reviewed for accidents. This deficient practice has the potential to cause serious injury by becoming trapped between the mattress and bed rail.

Inspectors wroteBased on record review and interview, the facility failed to ensure a safe, orderly discharge occurred for 1 (R #22) of 1 (R #22) residents reviewed for discharge. This deficient practice could likely cause the resident not to have their needs met outside of the facility, and the resident could decline and be re-hospitalized .

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store medications, when they failed to: 1) Secure medications in a insulin cart on South Unit, 2) Dispose of a loose tablet stored in the medication cart on North Unit, and 3) Keep temperature logs for a medication refrigerator. This could affect all 95 residents in the facility (Residents were identified by the resident matrix provided by the Administrator on 07/27/23). This deficient practice could result in residents obtaining medications that have no longer effective or that are not prescribed to them resulting in adverse side effects.

Inspectors wroteBased on observation and interview, the facility failed to store and serve food under sanitary conditions in accordance with professional standards of food service safety for all 95 residents in the facility (residents were identified on the resident matrix provided by the Administrator on 07/27/23) who eat food prepared in the kitchen when they failed to: 1. Keep the deep freezer and kitchen floors clean, 2. Wear hairnets in the kitchen 3. Failed to keep the stoves and surrounding areas clean from grease, 4. Maintain the quality of the oil (fresh) in the deep fryer, and 5. Ensure that spices in the kitchen are labeled and dated. These deficient practices could likely lead to foodborne illnesses.

Inspectors wroteBased on observation, record review, and interview, the facility failed to have reasonable accommodations for 1 (R #72) of 2 (R #8 and R #72) residents sampled for environment, when they failed to provide R #72 with a mattress to fit her bed. This deficient practice could likely result in the resident being at risk for accidents.

Inspectors wroteBased on record review and interview, the facility failed to ensure that resident's New Mexico Medical Orders For Scope of Treatment (MOST Advance Directives) were completed accurately for 2 (R #3 and R #53) of 5 (R #3, R #8, R #28, R #53 and R #69) reviewed for Advance Directives. When they failed to: 1) Ensure that the resident's wishes were accurately reflected 2) Ensure that the MOST form was signed by the resident or their designated healthcare decision maker. These deficient practices could likely result in the residents' end-of-life choices not being known.

Inspectors wroteBased on observation and interview the facility failed to provide a comfortable and homelike environment for 1 (R #8) of 2 (R #8 and R #72) residents sampled for environment, when they failed to match the existing paint from previous repairs. This deficient practice could likely cause residents to feel like they are not living in a comfortable home-like environment and like they are not valued.

Inspectors wroteBased on record review, observation, and interview the facility failed to report to the State Survey Agency timely for 4 (R #28, R #43, R #53, and R #74) of 5 (R #3, R #28, R #43, R #53, and R #74) residents sampled for abuse and accidents when they failed to report allegations of abuse or serious bodily injury within two hours to the State Agency. If the facility fails to report allegations of abuse or serious bodily injury to the State Agency within two (2) hours, then residents could likely continue to be abused or suffer serious bodily injury.

Inspectors wroteBased on record review and interview the facility failed to ensure residents, their representatives, and the Ombudsman received a written notice of transfer as soon as practicable for 3 (R #3, R #55, and R #89) of 3 (R #3, R #55, and R # 89) residents reviewed for hospitalization. This deficient practice could likely result in the resident and/or their representative not knowing the reason or location that the resident was discharged .

Inspectors wroteBased on record review and interview, the facility failed to provide written information to the resident or resident representative that specifies the bed hold policy at the time of the transfer for 3 (R #3, R #55, and R #89) of 3 (R #3, R #55, and R #89) residents sampled for hospitalizations. This deficient practice could likely result in the resident and/or their representative being unaware of the resident ability to return to their previous room or the next available room upon return from the hospital.

Inspectors wroteBased on record review and interview the facility failed to ensure that the Minimum Data Set (MDS) Assessments were accurate for 1 (R #55) of 2 (R #55 and R #74) residents sampled for MDS accuracy. This deficient practice could likely result in residents not receiving the care and treatment they need.

Inspectors wroteBased on record review and interview, the facility failed to develop a comprehensive person-centered care plan for 3 (R #34, R #53, and R #74) of 7 (R #8, R #28, R #29, R #34, R #53, R #55, and R #74) 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 revise the Care Plan for 2 (R #55) of 3 (R #3, R #55 and R #74) residents reviewed for care plan revisions. This deficient practice could likely result in staff being unaware of changes in care being provided and residents not receiving the care related to changes in their health status or healthcare decisions.

Inspectors wroteBased on record review and interview, the facility failed to care plan hospice/facility care responsibilities for 1 (R #29) of 1 (R #29) residents sampled for hospice. This deficient practice could likely result in residents not receiving the care they need from hospice.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure that a resident who enters the facility without an indwelling foley catheter (tube that is inserted through the urethra and into the bladder to drain urine) is not catheterized (procedure that involves placing a foley catheter) unless clinical condition demonstrates that catheterization was necessary and was treated appropriately for Urinary Tract Infection (UTI) for 1 (R #55) of 2 (R #55 and R #241) residents reviewed for Urinary Tract Infections and Foley Catheters when they: 1) Failed to document the need for foley catheter insertion. 2) Failed to ensure an appropriate diagnosis for long term use of a foley catheter. [...]

Inspectors wroteBased on record review, and interview the facility failed to provide trauma informed care (care to help prevent furtherance of trauma and promote safety and well-being) to 1 (R #72) of 1 (R #72) resident diagnosed with a trauma incident. Failing to provide care and seek out knowledge of triggers is likely to cause the resident to become secluded (withdrawn), exhibit behaviors, or cause self harm.

Inspectors wroteBased on interview and record review, the facility failed to have competent staff when the failed to have competencies for 4 (CNA #23, CNA #24, CNA #25, and LPN #5) of 4 (CNA #23, CNA #24, CNA #25, and LPN #5) nursing staff sampled for competency. This deficient practice could likely result in staff working who are not competent to give care to residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure that 1 (R #55) of 6 (R #53, R #55, R #69, R #72, R #73, and R #74) residents reviewed for behavioral-emotional health were receiving necessary behavioral health care to meet their needs. This deficient practice could likely result in residents having a decline in their physical, mental, and psychosocial well-being.

Inspectors wroteBased on record review and interview, the facility failed to ensure pharmaceutical services (the direct, responsible provision of medication-related care) were met for 2 (R #55 and R #241) of 3 (R #55, R #74, and R #241) residents reviewed for pharmacy services when they failed to provide routine and emergency medications to residents. These deficient practices could likely lead to unresolved infections, worsening of infection or uncontrolled pain.

Inspectors wroteBased on record review and interview, the facility failed to ensure that each resident received or was offered Pneumococcal (a bacteria that causes pneumonia infection of the respiratory tract) immunization for 1 (R #28) of 5 (R #8, R #16, R #28, R #69 and R #72) residents reviewed for immunizations. This deficient practice could likely lead to residents contracting respiratory infections and could result in the spread of infection to other residents.

Inspectors wroteBased on interview and record review the facility failed complete 12 hours of annual training that included the performance reviews and the facility assessment for 3 (CNA #26, CNA #27, and CNA #28) of 3 (CNA #26, CNA #27, and CNA #28) CNAs sampled for 12 hours of annual training. This deficient practice could likely result in staff being under trained and providing inadequate care.

Inspectors wroteBased on interview and record review, the facility failed to obtain laboratory testing for 1 (R #72) of 1 (R #72) residents reviewed for laboratory services. If the facility fails to obtain labs that have been ordered, this could likely cause a delay in chemotherapy (the treatment of disease by the use of chemical substances, especially the treatment of cancer), causing unnecessary harm to the resident.

Inspectors wroteBased on interview, and observation, the facility failed to ensure residents knew where the most recent survey was located and accessible to all residents. This could affect all 57 residents in the facility (residents were identified by the facility census provided by the Administrator on 08/31/22). If residents are unable to locate the latest survey conducted by State Surveyors, then residents, representatives, and visitors are unable to know how the facility is doing and make decisions accordingly.

Inspectors wroteRecite from 06/24/2021 Based on record review, and interview, the facility failed to provide the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, seven days a week. This could affect all 57 residents in the facility (residents were identified by census list provided by the Administrator on 08/31/22). This deficient practice could likely result in resident's not receiving the services that they require to provide the optimal quality of care.

Inspectors wroteBased on record review, and interview, the facility failed to follow pharmacy recommendations for all 58 residents in the facility (residents were identified by the Resident matrix provided by the Administrator on 08/31/22), when they failed to: 1) Receive the pharmacy recommendation for June 2022 for all 58 residents, 2) Follow the pharmacy recommendation to provide rationale (reason why) for R #25's PRN (as needed) Lorazepam (antianxiety) longer than 14 days. 3) Follow Pharmacy recommendation for R #21, to update the directions on the MAR (Medication administration Record) to monitor and report any signs and symptoms of bleeding. 4) Follow Pharmacy recommendation for R #40, to add a standing order for PRN (as needed) Naloxone (generic name for Narcan a medication used for the emergency treatment of known or suspected opioid overdose) to the MAR. [...]

Inspectors wroteRecite from 06/24/2021 Based on observation, and interview, the facility failed to ensure that food items in the kitchen were labeled and dated. These deficient practices could likely lead to foodborne illnesses that could affect all 57 residents in the facility (residents were identified by the resident matrix provided by the Administrator on 08/31/22).

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the facility assessment was accurate and current. This could affect all 57 residents in the facility (residents were identified by census list provided by the Administrator on 08/31/22). This deficient practice could lead to the residents not receiving the care they need to reach their highest well-being.

Inspectors wroteBased on record review and interview, the facility failed to ensure that all staff were tested two times a week for Covid-19 (virus that causes a variety of respiratory, gastrointestinal, and neurological diseases] which is characterized mainly by fever and cough). At the time of the recertification survey the facility should have been testing staff twice weekly due to facility having a Covid-19 outbreak (when 1 covid-19 positive staff or resident is identified) . This deficient practice could affect all 57 residents in the facility (residents were identified by census list provided by the Administrator on 08/31/22) and could likely lead to lack of identifying Covid-19 positive staff or residents and continue the spread of the infection within the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents were treated with respect and dignity for 2 (R #29 and R #41) of 2 (R #29 and R #41) residents randomly sampled, when the facility failed to provide a dignity cover for their Foley catheter bag (soft plastic or rubber tube that is inserted to the bladder to drain the urine and is connected in a collecting bag). This deficient practice could likely result in residents becoming depressed, anxious, and lacking self-worth.

Inspectors wroteBased on interview, and record review, the facility failed to provide written notice for room/roommate change for 2 (R #33, and R #45) of 2 (R #33, and R #45) resident sampled for notification of change. This deficient practice could likely cause residents to become anxious and depressed if they are not given written room/roommate change notices.

Inspectors wroteBased on interview and record review, the facility staff did not demonstrate their response and rationale to grievances/concerns for 6 (R #3, R #4, R #13, R #19, R #28, and R #43) out of 6 (R #3, R #4, R #13, R #19, R #28, and R #43) residents in Resident Council. This deficient practice could result in the issues continuing and resident's rights not being honored.

Inspectors wroteBased on record review, and interview, the facility failed to ensure residents, or their representatives received a written notice of transfer as soon as practicable for 3 (R #22, R #25, and R #34) of 3 (R #22, R #25 and R #34) residents reviewed for hospitalizations. This deficient practice could likely result in the resident and/or their representative not knowing the reason that the resident was sent to the hospital.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents, or their representatives received a written notice of their bed hold policy indicating the duration that the bed would be held for 3 (R #22, R #25, and R #34) of 3 (R #22, R #25, and R #34) residents reviewed for transfers to hospital. This deficient practice could likely result in the resident and/or their representative being unaware of the resident being able to return to their previous room upon return from the hospital.

Inspectors wroteBased on record review and interview, the facility failed to develop and implement an accurate, comprehensive person-centered care plan for 4 (R #21, R #23, R #33, and R #42) of 4 (R #21, R #23, R #33, and R #42) residents reviewed for care plans, when they failed to: [...]

Inspectors wroteBased on interview, and record review, the facility failed to provide quality of care for 1 (R #33) of 1 (R #33) residents review for food, when the facility changed R #33's dietary order from mechanical soft diet chopped constancy (chopped up foods) to regular consistency (regular whole foods) on 07/26/22 without the Medical Providers approval. This deficient practice could likely result in the resident having the wrong consistency diet and not being able to consume her food.

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 services for 1 (R #42) of 1 (R #42) residents sampled for dialysis. This deficient practice could likely result in residents not receiving the care and monitoring they need after dialysis treatment.

Inspectors wroteBased on record review, and interview, the facility failed to provide 12 hours of annual training that included the staff performance review and the facility assessment for 3 (CNA #12, CNA #13, and CNA #14) of 3 (CNA #12, CNA #13, and CNA #14) CNAs reviewed for 12 hours of annual training. This deficient practice could likely result in staff not receiving the proper training's for areas needing improvement or for special needs populations they care for.

Inspectors wroteBased on record review, and interview, the facility failed keep residents free from unnecessary Psychotropic medications for 1 (R #25) of 5 (R #9, R #21, R #22, R #25, R #34) sampled for unnecessary medications, when they failed to: 1) Provide rationale (reason for) for R #25's PRN (as needed) Lorazepam (antianxiety) longer than 14 days, and 2) Provide a correct diagnosis for R #25's antipsychotic (used to treat psychotic symptoms such as hallucinations, and delusions) medication QUEtiapine Fumarate ordered to treat dementia. This deficient practice could likely result in residents receiving psychotropic medications longer than needed.

Inspectors wroteBased on observation, and interview, the facility failed to properly label medication for all 5 residents on North unit (residents were identified by the resident matrix provided by the Administrator on 08/31/22), when they failed to label 9 open over-the-counter medications with an open date in the medication cart. This deficient practice could likely result in resident receiving expired medications.

Inspectors wroteBased on record review, and interview, the facility failed to ensure there was relevant communication in the resident's record indicating the delivery of hospice services (services provided for a person experiencing an advanced, life-limiting illness) for 1 (R #2) of 1 (R #2) residents reviewed for Hospice Services. This deficient practice could likely lead to the resident not receiving the services needed due to lack of collaboration and communication between the facility and hospice provider.

Inspectors wroteBased on record review, and interview, the facility failed to provide abuse, neglect, and exploitation training to 3 (LPN #7, LPN #8, and LPN #9) of 3 (LPN #7, LPN #8, and LPN #9) staff members sampled for abuse, neglect, and exploitation training. This deficient practice could likely result in staff not knowing who, what, and when to report things like abuse, neglect and exploitation.

Inspectors wroteBased on record review, and interview, the facility failed to develop and implement an accurate, effective, person-centered baseline care plan within 48 hours of admission to include Physician's Orders for 1 (R #159) of 1 (R #159) resident reviewed for baseline care plans. This deficient practice could likely lead to residents not receiving the appropriate care, services, and monitoring needed upon admission to the facility.

Inspectors wroteBased on observation, and interview, the facility failed to maintain repairs on the facility's van that is used to transport residents to and from appointments. This deficient practice could likely affect all 57 residents (resident were identified on the census provided by the Administrator on 08/31/22.) This could lead to resident's being in danger of harm or death if the Facility Van is not operating in a safe manner during a transport.

Inspectors wroteBased on observation, and interview, the facility failed to follow proper infection control practices for 13 residents (R #5, R #10, R #12, R #14, R #15, R #16, R #24, R #29, R #32, R #33, R #43, R #52, and R #53) of 13 residents (R #5, R #10, R #12, R #14, R #15, R #16, R #24, R #29, R #32, R #33, R #43, R #52, and R #53) randomly sampled, when 4 staff members failed to wear their masks in resident care areas. This deficient practice could likely result in the spread of infection and could cause residents to become sick from the staff.