Gallup Nursing & Rehabilitation LLC

Inspectors wroteBased on record reviews and interviews, the facility failed to follow physician orders for 2 (R #50 and R #51) of 2 (R #50 and R #51) residents reviewed when: Facility staff failed to administer or withhold blood pressure medications as directed by blood pressure parameters (boundary or limit defining scope of particular activity or process) per R #50 and R #51's physician's order. If the facility does not follow physician orders for the management of a resident's blood pressure, then it is likely to result in the resident not maintaining optimal health outcomes as established by the medical provider.

Inspectors wroteBased on observation and interview, the facility failed to maintain a safe environment and protect the residents from the potential for accidents and hazards by: Failing to ensure adhesive tape (is a strip of material with a sticky surface on one side that is used to hold, fasten, or secure items in place) applied to resident room floors remained secured and flat to the surface in Room (RM) #41, Failing to ensure a water hose connected to the ice machine remained secured within its protective case, allowing water to drip onto the floor in a hall that is accessible to all residents. This deficient practice is likely to affect all 57 residents listed on the facility census by creating a tripping and slipping hazards, which can put the residents at risk for falls and potential injury.

Inspectors wroteBased on observation and interview, the facility failed to ensure residents had a safe and functional environment for 7 (Rooms: RM's #15, 31, 33, 34, 36, 37, 43, 44 ) of 13 (RM's #15, 16, 17, 21, 25, 31, 33, 34, 36, 37, 43, 44, 45 and 49) rooms observed when the facility failed to: Repair walls with intact, smooth, and cleanable surfaces (scuff marks, chipped paint, uneven paint, visible putty). Repair windowsills and surrounding tiles. Repair fixtures and building components (heating vent and electrical outlet). These deficient practices are likely to expose residents to an unsafe and uncomfortable environment.

Inspectors wroteBased on record review and interview, the facility failed to create a 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 #67) of 1 (R #67) resident reviewed for baseline care plans. This deficient practice could likely result in the residents' preferences and care needs not being met.

Inspectors wroteBased on a record review and interviews, the facility failed to ensure medical records were complete for 1 (R #51) of 1 (R #51) resident reviewed when staff failed to: Document accurately and completely when R #51 was not administered medication per physician's orders. This deficient practice is likely to result in staff not having the information they need to provide competent, comprehensive care and services to residents.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for 1 (R #34) of 1 (R #34) resident reviewed for infection control when: The facility did not ensure R #34's urinary catheter (a thin, sterile tube inserted into the bladder to drain urine) drainage bag had a privacy bag (bag that covers urination drainage bag) present. The facility did not ensure R #34's urinary catheter tubing (is the flexible tube that carries urine from the catheter (inside the bladder) to the drainage bag outside the body) remained off the floor to prevent contamination. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (R #1) of 3 (R #'s 1, 2 and 3) residents when they failed to properly assess a resident following an unwitnessed fall that resulted in injury. If the facility fails to properly assess residents who have an unwitnessed fall with an injury, then the residents may experience unidentified life-threatening conditions such as a brain bleed. This deficient practice likely contributed to the hospitalization and passing of R #1.

Inspectors wroteBased on record review and interview, the facility failed to provide facility Initiated Reports (mandatory self-initiated facility report of an incident) to the State Survey Agency (SSA) for 1 (R #1) of 3 (R #'s 1, 2 and 3) residents reviewed for incidents when staff failed to report an unwitnessed fall with an injury for R #1.

Inspectors wroteBased on interview and record review, the facility failed to ensure their binding arbitration agreement included a provision for convenient venue (a location in which to carry out arbitration proceedings which should be agreed upon and suitable for both parties) selection. Failure to include this provision in the agreement could likely result in residents who choose to seek arbitration experiencing frustration and difficulty deterring them from exercising their rights. This deficient practice has the potential to affect 56 of the 57 facility residents who signed the binding arbitration agreement.

Inspectors wroteBased on observation, record review, and interview, the facility failed to promote care with dignity and respect for 1 (R #35) of 1 (R #35) residents reviewed for residents' rights when staff closed the resident's room door against his wishes and without communicating why to the resident. This deficient practice is likely to result in residents feeling disrespected and as if they were kept in their room against their will.

Inspectors wroteBased on record review and interview, the facility failed to create a 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 #108) of 3 (R #15, #25 and #108) residents reviewed for Baseline Care Plans. This deficient practice could likely result in a decline in the residents' condition due to staff not being aware of the care residents' need and residents not being able to attain or maintain their highest practical level of well-being.

Inspectors wroteBased on record review and interview, the facility failed to meet professional standards of practice for 1 (R #208) of 1 (R #208) residents reviewed for medication administration, when staff did not administer R #208's lactulose [a medication used to prevent and treat complications of hepatic encephalopathy (liver disease) by decreasing the amount of ammonia in the blood] as ordered by the medical provider. 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 observations and interviews, the facility failed to: 1. Ensure that opened and accessed (has been opened or accessed) for a flex pen weren't dated as to when they were initially opened/accessed, by nursing staff. 2. Ensure that undated medications (not dated when opened) were not stored with dated medications that are available for use 3. Ensure that expired supplies are not stored with unexpired supplies in the storage rooms 4. To properly store medications in medications carts. 5. Ensure treatment/medication carts were kept locked when not in use. These deficient practices have the likelihood to result in 57 (fifty-seven) residents that were identified on the census list provided by Center Executive Director (CED) on 06/12/23, to receive medications that had either lost their potency or effectiveness.

Inspectors wroteBased on observation and interview, the facility failed to store and serve food under sanitary conditions by not ensuring: 1. Freezer units' temperatures were taken daily, 2. Proper handling techniques were used when handling cups and glasses when drinks were distributed to residents served in the dining room 3. Hands were not sanitized prior to handling residents' meals after handling resident's adaptive equipment during a meal. These deficient practices are likely to affect all 57 residents listed on the resident census list provided by the Administrator on 06/16/23; and could likely lead to foodborne illnesses in residents if safe food handling practices are not adhered to.

Inspectors wroteBased on record reviews, interviews and observations, the facility failed to provide proper infection control practices by: 1. Not performing hand hygiene between residents, and 2. Providing resident care, not removing used gloves before entering the hallway. These deficient practices could likely affect all 57 residents in the facility on the census provided by the Center Executive Director (CED) on 06/12/23. Failure to practice infection control standards could likely cause the spread of infection and illnesses to residents and staff within the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure that the resident's responsible party, Power of Attorney (POA) and/or family was notified of a resident's change in condition for 1 (R #49) of 1 (R #49) resident reviewed for weight decline. This deficient practice could likely result in the resident's responsible party, POA, and/or family not participating in important decisions regarding the resident's health and well-being.

Inspectors wroteBased on record review and interview, the facility failed to report an Injury of Unknown Origin to the State Survey Agency, for 1 (R #11) of 3 (R #s 11, 28, and 35) residents reviewed for Injury of Unknown Origin. This deficient practice is likely to result in the State Survey Agency not being aware of facility incidents, and unable to assure residents a safe and hazard free environment.

Inspectors wroteBased on observation, record review, and interview, the facility failed to implement an ongoing one-to-one, resident-centered activities program for 1 (R #52) of 3 (R #s 14, 20 and 52) residents looked at for activities. This deficient practice does not encourage stimulation for residents who have a physical condition; as it does not allow them to attend the regularly scheduled activities programs. This could potentially cause depression and an overall decline of the resident's well-being.

Inspectors wroteBased on record review, interview, and observation, the facility failed to ensure that restorative services (person-centered and designed to improve or maintain the functional ability of residents, so they can achieve their highest level of well-being possible) were being provided for 1 (R #15) of 1 (R #15) resident reviewed for mobility capabilities (ability to move purposely as you go throughout your day). This deficient practice could likely result in resident joints feeling contracted (when muscles, tendons, joints, or other tissues tighten or shorten causing a deformity) or weakened.

Inspectors wroteBased on record review and interview, the facility failed to ensure that 1 (R #110) of 1 (R #110) resident reviewed for behavioral health concerns, was receiving necessary behavioral health care to meet the resident's needs. This deficient practice could likely cause the resident to not receive the mental health care and assistance that they may need.