Fort Bayard Medical Center

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident was treated with respect and dignity for 1 (R #13) of 1 (R #13) resident reviewed for neglect when staff failed to stay with the resident until she felt comfortable. This deficient practice could likely create a feeling of frustration, anxiety, and disappointment.

Inspectors wroteBased on record review and interview, the facility failed to submit direct care staffing information to the federal agency overseeing certification for long term care facilities for February 10, 2025, through February 22, 2025. This has the potential to affect all 117 residents in the facility, (residents were identified by the Resident Matrix provided by the Administrator on 09/15/25). This deficient practice could likely result in inaccurate direct care staffing information for residents/facility.

Inspectors wroteBased on interview, the facility failed to ensure residents were treated with respect and dignity for 3 (R #1, R #21, and R #87) of 5 (R #1, R #21, R #35, R #51 and R #87) residents sampled for dignity, when the staff failed to: 1. Refer to residents in a dignified manner to R #1 and R #87. 2. Maintain a calm and kind tone, avoid interrupting, or condescension for R #1, R #21, and R #87. These deficient practices could likely to result in residents feeling embarrassed, angry, and that their feelings and preferences are unimportant to the facility staff.

Inspectors wroteBased on interview, observation, and record review, the facility failed to keep residents free from involuntary seclusion (separation of a resident from other residents) for 1 (R #101) of 1 (R #101) resident sampled for elopement (an act or instance of leaving a safe area or safe premises, done by a person with a mental disorder or cognitive impairment) risk, when staff failed to implement and document the following: 1. The clinical criteria (rules or standards on which a decision or judgment is made to determine medical necessity) met for placement of R #101 in the secured/locked area by the R #101's physician along with information provided by members of the interdisciplinary team (IDT team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities). 2. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure the Minimum Data Set Assessment (MDS; a standardized, comprehensive assessment of an adult's functional, medical, psychosocial, and cognitive status) was accurate for 3 (R #4, R #59, and R #101) of 4 (R #4, R #21, R #59, and R #101) residents reviewed for pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure on the skin). This deficient practice could likely result in the facility not having an accurate assessment of the residents' needs.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure care plan revisions occurred for 7 (R #2, R #5, R #7, R #13, R #17, R #21, and R #59) of 21 (R #2, R #3, R #4, R #5 R #7, R #10, R #12, R #13, R #17, R #21, R #22, R #33, R #49, R #59, R #71, R #74, R #75, R #87, R #101, R #104, and R #123) 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 assist a resident in gaining access to vision services when staff failed to make appointments and arrange for transportation to the appointment for 1 (R #59) of 4 (R #2, R #9, R #59 and R #112) residents reviewed for vision and hearing. This deficient practice could likely result in residents losing some independence if they cannot see adequately or lead to an increase in the risk of missing early signs of serious eye diseases which could compromise their quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure appropriate treatment and services for Foley catheter (a thin, flexible tube inserted into the bladder to drain urine) for 1 (R #2) of 4 (R #2, R #3, R #11 and R #123) residents reviewed for catheter use when staff failed the to do the following: 1. Ensure R #2 has a clinical condition that demonstrates catheterization (the action or process of inserting a catheter into a body cavity) was necessary. 2. Ensure R #2 was assessed for the removal of the catheter as soon as possible. 3. Ensure R #2 received appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible. These deficient practices could likely result in residents getting infections and having the Foley catheter longer than needed.

Inspectors wroteBased on observation and interview, the facility failed to properly store medications in the treatment cart for all 19 residents (residents were identified by the resident matrix provided by the Administrator on 09/15/25) randomly sampled, when staff failed to secure the medication carts on the East Unit 100 hall. This deficient practice could likely result in residents obtaining medication not prescribed to them and residents having adverse side effects.

Inspectors wroteBased on record review and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections when staff failed to: 1. Ensure R #21's nasal cannula (a device that delivers extra oxygen through a tube and into your nose) was labeled with the date that it was changed. 2. Have a system of surveillance with data analysis to properly identify possible communicable diseases and infections. This failure could potentially affect all (15) residents who had infections (residents were identified by the Resident Matrix provided by the DON on 09/15/25). If the facility fails to maintain an effective infection control program, then infections could spread to residents throughout the facility, resulting in illness.

Inspectors wroteBased on record review and interview, the facility failed to ensure staff implemented a comprehensive Antibiotic Stewardship Program (ASP, a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use). This failed practice has the potential to affect the following: 1. All eight (8) residents in the facility that were taking antibiotics. Residents identified using the list of residents taking antibiotics provided by the Administrator on 09/24/25. 2. R #59 who was taking antibiotics from 9/08/25 through 09/20/25. This deficient practice could likely result in the inappropriate use of antibiotics and lead to resistance of Multi-Drug Resistant Organisms (MDRO; a germ that is resistant to many antibiotics).

Inspectors wroteNumber of residents sampled: 2Number of residents cited: 2S483.10(f) Self-DeterminationThe resident has the right to, and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to the rights specified in paragraphs (f)(1) through (11) of this section. S483.10(f)(1) The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part. S483.10(f)(2) The resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident. [...]

Inspectors wroteBased on a review of records, the facility failed to ensure residents were free from unnecessary medications and properly manage psychotropic medications for two (R #5 and R #101) of 5 (R #4, R#5, R #10, R #22, and R #101) residents reviewed for unnecessary medications when staff failed to ensure psychotropic medications for R #5 and R #101 were prescribed to treat a specific psychiatric diagnosis (mental illness, symptoms or condition that greatly disturbs your thinking, moods, and/or behavior). These deficient practices could likely result in residents receiving medications without a medical reason and being at a higher risk of adverse side effects (unwanted, harmful, or abnormal result).

Inspectors wroteBased on interview and record review the facility failed to update a resident care plan to reflect changes in the resident's treatments or interventions for 1 (R #3) of 2 (R #3 and R #101) residents reviewed for care plan accuracy. This inaccuracy has the potential of harm to a resident if the medical record does not provide correct indwelling catheter (a tube inserted into and left in the bladder to drain urine) information for staff to respond to the resident needs if the catheter had already been removed.

Inspectors wroteBased on record review, observation, 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 2 (R #4 and R #10) of 7 (R #4, R #5, R #10, R #21, R #22, R #59, and R #101) residents reviewed for medication regimen and pressure injuries when staff failed to: 1. Follow facility protocols when a new wound was identified for R #4. 2. Monitor for adverse effects of antipsychotic medication for R #10. If the facility is not identifying new wounds and following facility protocols for newly developed wounds and monitoring for adverse effects of antipsychotic medications, then residents are likely to experience adverse effects, worsening of their condition, and potential complications from not recognizing changes in the resident's condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident with limited mobility receives appropriate services and assistance to maintain or improve mobility with maximum practicable independence for 1 (R #10) of 2 (R #10 and R #112) residents reviewed for mobility and rehabilitation (specialized care provided to help residents recover from injuries, surgeries, or illnesses. These services typically include Physical therapy: Aims to restore mobility and strength. Occupational therapy: Assists residents in performing daily tasks independently. Speech therapy: Addresses communication and swallowing difficulties) and restorative (person-centered nursing care that is designed to improve or maintain the functional ability of residents, so they can achieve their highest level of well-being possible) services. [...]

Inspectors wroteBased on record review and interview, the facility failed to effectively manage pain (use of different techniques and medication to reduce and control the amount of pain a person experiences) for 1 (R #129) of 2 (R #59 and R #129) residents reviewed for pain when the facility failed to administer medications as per physician's orders and notify the provider when residents have uncontrolled pain. This deficient practice could likely result in residents experiencing unnecessary pain and could compromise their quality of life.

Inspectors wroteBased on record review and interview, the facility failed to ensure ongoing assessment of the resident's condition and monitoring for complications before and after dialysis (clinical purification of blood as a substitute for the normal function of the kidney) treatment for 1 (R #87) of 2 (R #22 and R #87) residents reviewed for dialysis care. This deficient practice could likely result in the facility being unaware of the residents' condition, potential complications and residents may not receive the appropriate monitoring and care.

Inspectors wroteBased on interview and record review the facility failed to ensure residents obtained dental services for 1 (R #2) of 2 (R #2 and R #59) residents sampled for dental services, when staff failed to ensure R #2 received 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. This deficient practice could likely cause the resident unnecessary pain, embarrassment over the condition/appearance of teeth, and potential dental or oral complications.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure medical records were complete and accurate for 1 (R #101) of 4 (R #4, R #21, R #59, and R #101) residents reviewed for pressure injury and involuntary seclusion when staff failed to do the following: 1. Accurately document R #101's skin assessments. 2. Ensure R #101's medical record contained the results of preadmission screening. 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 ensure the medical records contained documentation each resident received or was offered pneumococcal (a bacteria that causes pneumonia infection of the respiratory tract) and influenza (an acute respiratory infection caused by influenza viruses) immunizations for 2 (R #59 and R #101) of 5 (R #4, R #11, R #59, R #87, and R #101) 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 record review and interview, the facility failed to ensure the residents' medical record contained documentation each resident received or was offered covid-19 (an acute respiratory infection caused by the SARS-CoV-2 virus) immunization for 1 (R #59) of 5 (R #4, R #11, R #59, R #87, and R #101) 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 record review and interview, the facility failed to report all injuries of unknown origin and the results of all investigations to the State Survey Agency for 1 (R #21) of 3 (R #19, R #20, and R #21) residents reviewed for falls. If the facility fails to report injuries of unknown origin and the results of investigations within five (5) business days 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 ensure residents and/or their representatives were informed in advance of what medications they received and understood the reasons, risks, and benefits of the medications for 1 (R #17) of 3 (R #16, R #17, and R #18) residents reviewed for unnecessary medications. If the residents or their representatives are not informed of the risks and benefits of the medication or treatment alternatives, they are not able to make informed decisions regarding residents' care.

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. Are used to treat a variety of conditions including anxiety, depression, bipolar disorder, and schizophrenia) unless the medication was medically necessary for 2 (R #17 and R #18) of 3 (R #16, R #17, and R #18) residents reviewed for unnecessary medications, when staff failed to ensure: 1. Psychotropic medications for R #17 were prescribed to treat a specific psychiatric diagnosis (mental illness, symptoms or condition that greatly disturbs your thinking, moods, and/or behavior). 2. Psychotropic medications ordered to be given as needed (PRN) for R #18 were not prescribed for longer than 14 days without a rationale from the provider for why the medication was needed for longer than 14 days. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure medical records were complete and accurate for 1 (R #18) of 3 (R #16, R #17, and R #18) residents reviewed for unnecessary medications. This deficient practice has the potential to negatively impact on the care staff provided to meet residents' needs due to missing or inaccurate records and resident information.

Inspectors wroteTHIS IS A REPEAT DEFICIENCY FROM 08/09/24 Based on observation, record review and interview, the facility failed to ensure residents were free from physical restraints unless being used to treat a specific medical condition (indication or characteristic of a medical, physical or psychological condition) as identified through an assessment for 3 (R #1, R #2, and R #8) of 3 (R #1, R #2, and R #8) reviewed for physical restraints. This deficient practice could likely result in physical restraints being used for staff convenience; unnecessarily preventing residents from freedom, movement, and/or activity.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure care plans were reviewed and revised for 1 (R #1) of 3 (R #1, R #2, and R #8) residents reviewed for care plans when they 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 observation and interview, the facility failed to post nurse staffing data on a daily basis for all 105 residents in the facility (residents were identified by the census list provided by the Administrator on 08/05/24), when staff failed to: 1) Post Staffing Information that included the following: a. Facility name. b. The current date. c. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: i. Registered nurses. ii. Licensed practical nurses. iii. Certified nurse aides. iv. Resident census. 2) Retain 18 months of staff posting records. These deficient practices could cause residents anxiety not knowing what staff are working.

Inspectors wroteBased on record review of the facilities Legionella Water Management Program policy and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections when they failed to have a water management program to minimize the risk of Legionella [a bacteria that can grow in parts of building water systems that are continually wet (e.g., pipes, faucets, water storage tanks, decorative fountains) and cause a serious type of pneumonia], and other opportunistic pathogens (bacteria that do not usually cause diseases in healthy people but may become extremely injurious to unhealthy individuals) in the building's water system. [...]

Inspectors wroteBased on record reviews, observations and interviews, the facility failed to treat resident with dignity when staff failed to: 1. Provide nondisposable cutlery and dishware to all 75 residents, who did not use adaptive equipment were not on enteral feeding tube (a medical device used to provide nutrition to people who cannot obtain nutrition by mouth) (residents were identified by the adaptive equipment list provided by the Administrator on 08/13/24 and the resident matrix provided by the Administrator on 08/05/24), and 2. Let R #98 self-determine (choice) her use of a belt alarm (an alarm for a wheelchair). These deficient practices could likely cause residents to feel anxious or depressed and like they are not valued.

Inspectors wroteBased on observations and interviews, the facility failed to provide a homelike environment with comfortable sound levels for 3 (R #73, R #86, and R #99) of 3 (R #73, R #86, and R #99) residents reviewed for homelike environment. This deficient practice could likely cause residents to feel anxious or depressed and feel that they are not valued.

Inspectors wroteBased on observations, record reviews and interviews the facility failed to keep residents free from physical restraints for 5 (R #30, R #34, R #45, R #82 and R #98) of 5 (R #30, R #34, R #45, R #82 and R #98) residents reviewed for physical restraints, when staff used the following: 1. Wheelchair alarms on R #30, R #82, and R #98 2. Bed alarms on R #30, R #34, R #82, and R #98 3. Bathroom alarms on R #30, R #45, and R #98 These deficient practices could likely result in physical restraints being used for discipline or staff convenience; unnecessarily preventing residents from freedom, movement, or activity.

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 #35) of 1 (R #35) 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 reviews and interviews, the facility failed to ensure the consultant pharmacist's recommendations were reviewed and implemented by the physician or that the physician provided a rationale for not following the consultant pharmacist's recommendation for 2 (R #31 and R #50) of 5 (R #31, R #44, R #50, R #51, and R #82) residents reviewed for unnecessary medications. 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).

Inspectors wroteBased on record review and interview, the facility failed to ensure: 1) Residents did not receive psychotropic medications (antidepressants, anti-anxiety medications, stimulants, antipsychotics, and mood stabilizers) unless the medication was necessary to treat a specific psychiatric diagnosis and was documented in the medical record, and 2) Have the consent of resident/representative for psychotropic medications for 2 (R #31 and R # 44) of 5 (R #31, R #44, R #50, R #51, and R #82) residents reviewed for unnecessary psychotropic medications. These deficient practices could likely result in residents receiving medications without a medical reason and being at a higher risk of adverse side effects (unwanted, harmful, or abnormal result).

Inspectors wroteBased on record review of the CMS-10055 Form and interview, the facility failed to inform residents when changes in coverage were made to items and services covered by Medicare and/or by Medicaid for 1 (R #9) of 3 (R #9, R #31, and R #256) residents reviewed for beneficiary notices when staff failed to provide R #9 with Form CMS-10055- Skilled Nursing Facility (SNF) Advanced Beneficiary Notice (ABN) of Non-Coverage [form used to inform the beneficiary (resident) about potential non-coverage and the option to continue services with the beneficiary accepting financial liability for those services.] This deficient practice can likely confuse the resident or their representative as to what services they receive or do not have financial coverage for under Medicare and/or Medicaid.

Inspectors wroteBased on record reviews and interview, the facility failed to create an accurate baseline care plan (minimum healthcare information necessary to provide effective and person-centered care immediately upon their admission to the facility) within 48 hours of admission for 1 (R #103) of 2 (R #103 and R #104) residents 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 wroteBased on observation, record review, and interview, the facility failed to ensure care plan revision occurred for 6 (R #30, R #34, R #35, R #45, R #82, and R #98) of 6 (R #30, R #34, R #35, R #45, R #82, and R #98) residents reviewed for care plans, when they failed to: 1. Update R #30, R #34, R #45, R #82, and R #98's care plans for intervention for the wheelchair, bed, and bathroom alarms. 2. Update R #35's care plan for removal of bed alarm. These deficient practices 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 interview and record review, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight for 1 (R #14) of 2 (R #25 and R #62) residents sampled for nutrition, when staff failed to follow protocols for identifying weight loss when R #14 had severe weight loss. This deficient practice could likely result in residents losing weight without the facility being aware causing physical and mental health issues.

Inspectors wroteBased on record review and interview, the facility failed to provide quality of care for 1 (R #4) of 3 (R #3, R #4, and R #5) residents reviewed for diabetes (chronic condition that happens from persistently high blood sugar levels) when staff did not administer diabetic medications to R #4 upon admission to the facility and did not monitor the resident's blood glucose when exhibiting symptoms of high blood sugar. This deficient practice likely resulted in R #4 being admitted to the hospital for diabetic ketoacidosis (DKA; a serious complication of diabetes that can be life-threatening. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep residents free from accidents for 1 (R #21) of 3 (R #21, R #22, & R #23) residents reviewed for falls, when staff failed to: 1. Identify the cause of R #21's onset of fatigue and weakness. 2. Evaluate R #21's ability to safely use a wheelchair independently. This deficient practice likely resulted in R #21 falling multiple times and sustaining an intracranial hemorrhage (bleeding in the skull or brain tissue).

Inspectors wroteBased on record review and interview, the facility failed to ensure staff completed a discharge summary that included a recapitulation (a summary describing the resident's course of treatment while residing in the facility) and a reconciliation of all medication at the time of discharge for 3 (R #1, R #2 and R #3) of 3 (R #1, R #2 and R #3) residents sampled for discharge from the facility. This deficient practice could likely lead to the receiving facility, community agency, or family member not knowing what the current care needs and/or current medications are for the resident.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents have a written, signed, and dated progress note from the provider (physician or nurse practitioner) at each visit for 3 (R #2, R #4 and R #5) of 3 (R #2, R #4 and R #5) residents reviewed for physician's visits. This deficient practice could likely result in the resident's needs not being met due to facility staff being unaware of resident's status related to lack of written, signed, and dated progress notes at the time of the visit. A. Record review of R #2's progress notes revealed: 1. Nurse Practitioner (NP) note: New patient encounter, effective date 01/26/24. The NP did not sign the note until 01/28/24. B. Record review of R #4's progress notes revealed: 1. Medical Doctor (MD) note: Progress note, effective date 03/03/24. The MD did not sign the note until 03/06/24. C. [...]

Inspectors wroteBased on record review and interview, the facility failed to develop an effective discharge plan for 1 (R #1) of 3 (R #1, R #2, and R #3) residents reviewed for discharge planning (the process of transitioning a resident from one level of care to the next), when staff failed to: 1) Involve R #1's Insurance Case Manager (ICM) in obtaining services through Mi Via (a self-directed waiver program for individuals with diagnosed intellectual and developmental disabilities), 2) Obtain services through Mi Via for R #1 (that he had prior to admission) and was brought up by family during a meeting on 11/09/23 prior to discharge on [DATE]. This deficient practice is likely to result in complicated or unsafe transitions from the facility to the residents' post-discharge settings.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the nutritional needs and preferences were met for all 99 residents in the facility, based on the resident census provided by the Administrator on 05/22/23; by not following the menu. These deficient practices are likely to result in resident weight loss, frustration, and not meeting their nutritional needs.

Inspectors wroteBased on record review and interview the facility failed to provide a qualified, trained or certified Infection Preventionist (IP) affecting all 98 residents in the facility (residents were identified by the facility census provided by the Director of Nursing (DON) on 05/22/23). This deficient practice could likely result in residents being at greater risk of infectious disease.

Inspectors wroteBased on record review and interview, the facility failed to notify the resident/resident's representative(s) of the transfer in writing for 1 (R #82) of 1 (R #82) resident sampled for hospitalizations when they failed to: 1. Notify the resident and the resident's representative(s) of the transfer or discharge in writing and in a language and manner they understand. 2. A 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. The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; [...]

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 1 (R #82) of 1 (R #82) resident sampled for hospitalizations when they failed to provide documentation of written Bed Hold Policy notice R #82. 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 or the next available room upon return from the hospital.

Inspectors wroteBased on record review and interview, the facility failed to develop an accurate, effective, person-centered Baseline Care Plan within 48 hours of admission for 2 (R #95 and R #98) of 2 (R #95, R #98) residents sampled for baseline care plans. If resident's Baseline Care Plans are not accurate, residents are not likely to get the care and services needed.

Inspectors wroteBased on record review, observation, and interview, the facility failed to develop and/or implement a comprehensive person-centered care plan for 4 (R #3, R #39, R #74 and R #79) of 6 (R #3, R #39, R #40, R #43, R #74 and R #79) residents reviewed for care plans: 1. Failing to include the primary diagnosis in the care plan for R #3 2. Not implementing the notification to the provider of R #39's severe bruising, or tiny red or purple spots on skin. 3. Not developing a care plan for R #74 and R #79's code status (the type of emergent treatment a person would or would not receive if their heart or breathing were to stop). Failure to develop a comprehensive person-centered care plan is likely to result in staff's failure to understand and implement the needs 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 #58 and R #99) of 3 (R #27, R #58 and R #99) residents reviewed for care plans when they failed to: 1. Update R #58's care plan for Lorazepam 2. Update R #99's care plan to show that he was placed on palliative care (comfort care for the terminally ill and their families). These deficient practices 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 observation, record review, and interview, the facility failed to provide respiratory care (breathing support) consistent with professional standards for 1 (R #27) of 3 (R #27, R #34 and R #43) residents reviewed for respiratory care when the facility failed to monitor R #27's oxygen levels. If the facility fails to monitor the residents oxygen levels they may fail to provide the resident with supplemental oxygen (administered of oxygen to maintain oxygen levels above 90%) as needed.

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 by not ensuring food/food products are discarded by their expiration dates, and ensuring food items in the refrigerator were sealed after opening. These deficient practices are likely to affect all 99 residents in the facility, as identified by the resident census provided by the Administrator on 05/22/23, who eat food prepared in the kitchen. If the facility fails to adhere to safe food handling practices, residents are likely to be exposed to foodborne illnesses and become sick.

Inspectors wroteBased on record review and interview, the facility failed to ensure documents in resident records were complete and accurate for 4 (R #6, R #9, R #40 and R #43) of 8 (R #3, R #6, R #9, R #27, R #34, R #40, R #43 and R #57) residents reviewed for advanced directives (legal document in which a person specifies what actions should be taken for their health when they are no longer able to make decisions for themselves due to illness or incapacity). This deficient practice could likely result in staff not knowing a resident's medical intervention wishes and could result in delay of care, or going against a resident's wishes.

Inspectors wroteBased on record review and interview, the facility failed to ensure that 8 staff (CNA #1, CNA #2, CNA #3, CMA #1, RN #1, RN #2, RN #3 and RN #4) of 10 staff (CNA #1, CNA #2 CNA #3, NA (Nurse Assistant) #1, CMA #1, LPN #1, RN #1, RN #2, RN #3 and RN #4) had annual training on abuse, neglect, and exploitation and dementia (group of symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function) management. This has the potential to affect all 99 residents in the facility, as identified by the resident census provided by the Administrator on 05/22/23. This deficient practice could likely result in residents not receiving the services that they require to provide the optimal quality of care and quality of life.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident was given the right to maintain and improve their self-esteem and self-worth by not being given a choice to remain at an activity being held by the facility; and not respecting a resident's choices for 1 (R #65) of 1 (R #65) resident reviewed for Resident Rights. This deficient practice is likely to negatively impact resident's self-esteem and self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that 1 (R #65) of 1 (R #65) resident reviewed for food and drink were provided food prepared in a form designed to meet the resident's needs. This deficient practice is likely to negatively impact a resident's nutritional intake and result in weight loss.