Ladera Center

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents were treated with dignity and respect for 2 (R #2 and R #3) of 2 (R #2 and R #3) residents, when nursing staff and nursing students did not promote dignity and respect during a shower. This deficient practice is likely to result in residents feeling unimportant to facility staff and may negatively affect their quality of life.

Inspectors wroteBased on observations and interviews, the facility failed to maintain a safe, clean, and sanitary environment by allowing fecal matter to remain on the floor of a common resident area and by failing to ensure proper separation between soiled laundry and clean linens. These deficient practices has the potential to affect residents, staff, and visitors by increasing the risk of healthcare-associated infections.

Inspectors wroteBased on record review and interview, the facility failed to make prompt (done without delay; immediate) efforts to resolve resident's grievances for 10 (R #'s 4, 6, 8, 39, 41, 48, 56, 72, 74 and 107) of 10 (R #'s 4, 6, 8, 39, 41, 48, 56, 72, 74 and 107) residents reviewed by:1. Not responding/following-up to grievances that involved missing personal items and smoking.2. Not responding to grievances that involved allegations of neglect for several days after the grievance was reported. 3. Failing to educate all nursing staff, including the nursing staff involved, for grievances with allegations of neglect. If the facility is not ensuring that grievances are responded to and without delay, then residents are likely at risk of continued/repeat concerns and feeling as though their concerns are unimportant to the facility.

Inspectors wroteBased on record review and interview, the facility failed to provide the required transfer information to the residents' and the residents' representatives in writing for 2 (R #118, and 131) of 2 (R #118, and 131) residents sampled for hospitalizations when staff failed to: 1. Notify the residents and resident representative(s) of the resident's transfer to the hospital in writing and in a language and manner they understand. 2. Send a written copy of the Transfer Notice to the Ombudsman (is a government official who investigates and tries to resolve complaints). 3. Ensure resident or their representative received a written notice of the bed hold policy which indicated the duration the bed would be held. [...]

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 3 (R #39, #47, and #122) of 3 (R #39, #47, and #122) 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 record review and interview, the facility failed to ensure staff revised the care plan for 3 (R #41, R #47 and R #122) of 8 (R #11, R #12, R #41, R #47, R #48, #118, R#122 and R #131) residents reviewed when staff failed to: 1. Revise the care plan after R #41 developed hand contractures. 2. Revise the care plan after R #47 was diagnosed with chronic idiopathic constipation (condition with constipation symptoms but no identifiable cause). 3. Ensure the required Interdisciplinary Team (IDT, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) members participated in the care plan meeting for R #122. These deficient practices could result in residents' care and needs not being addressed.

Inspectors wroteBased on record review, observation and interview, the facility failed to provide quality care that meets professional standards for 6 (R #5, #39, #56, #90, #93, and #104) of 6 (R #5, #39, #56, #90, #93, and #104) residents reviewed when the staff failed to:-Follow physician orders.-Obtain physician ordersThese deficient practices are likely to result in residents not maintaining their optimal health as planned by their medical provider.

Inspectors wroteBased on record reviews, observations, and interviews, the facility failed to ensure that activities of daily living (ADL) are being provided to 2 (R #39, and #41) of 2 (R #39, and #41) residents reviewed, who were dependent on staff for necessary nail care. This deficient practice resulted in residents having long, jagged, and unclean fingernails, which poses a risk for the transmission of infection.

Inspectors wroteBased on observations, and interviews, the facility failed to properly store medications and medical supplies located in the facility medication carts and medication storage room when the staff failed to ensure:-Treatment carts are not left unlocked and unattended.-Medical supplies are not opened or used.-An expired insulin (a hormone that regulates the amount of glucose in the blood) pen was properly discarded. These deficient practices are likely to result in medications and medical supplies being used in resident care resulting in residents being at risk of possible infections, and medication error.

Inspectors wroteBased on observations, and interviews, the facility failed to implement and follow an ongoing infection prevention and control program (a program that is used to prevent, recognize, and control the onset and spread of infections) by ensuring: -staff follow the established hand hygiene protocols to prevent the potential spread of infection residents observed during meal assistance. -a system of surveillance is in placed to identify environmental hazards before they could spread to residents and staff. These deficient practices are places the residents and staff at risk of contracting infections.

Inspectors wroteBased on observations and interviews, the facility failed to ensure that the resident call system was accessible for 2 (R #8, and #41) of 2 (R #8, and #41) residents reviewed. This deficient practice had the potential of placing the resident at risk for inability to summon health care workers as needed to receive assistance that may include urgent care to meet their medical, physical, mental, and psychosocial needs.

Inspectors wroteBased on record review and interview, the facility failed to ensure 1 (R #107) of 1 (R #107) resident was treated with respect and dignity when the facility failed to ensure that R #107 was not put to bed at night with her shoes on and fully clothed. This deficient practice is likely to result in residents feeling as if they were unimportant and that their preferences do not matter.

Inspectors wroteBased on record review, and interview, the facility failed to complete an accurate Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) assessment for 1 (R #132) of 1 (R #132) resident reviewed for assessments. This deficient practice could likely result in the residents' preferences and care needs not being met.

Inspectors wroteBased on record review and interview, the facility failed to provide an ongoing program of activities designed to meet the interests for 1 (R #11) of 6 (R #11, R #12, R #48, R #118, R #122, and R #131) residents reviewed for activities by not providing meaningful individualized activities based upon residents' interests. If residents are not provided or encouraged to attend/participate in activities that meet their interests, then they are likely to experience an increase in boredom, isolation, and depression.

Inspectors wroteBased on record review, and interview, the facility failed to meet the professional standards of practice required to prevent skin breakdown for 1 (R #132) of 1 (R #132) resident reviewed for skin assessments when the facility failed to:Ensure a Braden Scale assessment was completed upon admission-Accurately utilize standardized tools such as the Braden Scale (nursing assessment tool used to estimate a patient's risk of developing pressure injuries (pressure ulcers)).-The lack of documented off-loading (Offloading is crucial for preventing pressure ulcers, particularly in individuals with limited mobility or those confined to a bed or wheelchair. By redistributing pressure away from vulnerable areas, offloading helps mitigate the risk of pressure ulcer development) coccyx (tailbone, the last bone at the end of the spine) directly contributed to the tissue necrosis (death of body tissue). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that resident preferences were honored for 1 (R #104) of 1 (R #104) resident reviewed when:-the facility served green peas despite the resident's dietary profile indicating a preference for no peas.

Inspectors wroteBased on observation and interview, the facility failed to :Ensure stored foods are not left open to air. Ensure staff wore beard nets in the kitchen. These deficient practices are likely to affect all 107 residents listed on the census provided by the Administrator on 05/12/25 and may lead to foodborne illnesses in residents if proper food storage and safe food handling practices are not adhered to.

Inspectors wroteBased on observation and interviews, the facility failed to ensure the facility had sufficient staff to meet the needs of all 110 residents who resided in the facility when staff failed to: 1. Offer baths or showers to the residents as scheduled and per residents' preference. 2. Offer substantial/maximal eating assistance for residents that require activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) assistance. 3. Maintain fingernail length and cleanliness for residents who are dependent on the facility for ADL's. 4. Maintain dignity of residents who are dependent on the facility for ADLs. These deficient practices are likely to affect the comfort, dignity and health of the residents.

Inspectors wroteBased on observation and interview the facility failed to ensure that meals were served to residents at the posted serving times (Breakfast 7:30 am, Lunch 12:30 pm and Dinner 5:30 pm). This deficient practice is likely to result in the disruption of residents' dining experience.

Inspectors wroteBased on record review and interview, the facility failed to conduct an in-depth investigation and correct the grievance allegation for 2 (R #13 and 14) of 2 (R #13 and 14) residents reviewed for the outcomes and resolutions of their grievances. This deficient practice could likely result in the facility not considering the needs of the residents or adequately resolving their grievances and could likely lead to a decrease in resident quality of life.

Inspectors wroteBased on record review, observation, and interview, the facility failed to provide showers, eating assistance, skin assessments and grooming care for 1 (R # 5) of 1 (R #5) resident when the facility failed to assist resident with ADL (Activities of Daily Living) care in accordance with Physician approved POC (Plan of Care). This deficient practice is likely to affect the dignity, health and comfort of the residents.

Inspectors wroteBased on record review and interview, the facility failed to provide activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) assistance for baths and showers by the facility staff for 2 (R #5 and R #12) of 2 (R #5 and R #12) residents reviewed for ADLs (activities of daily living). This deficient practice is likely to affect the dignity and health of the residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents had a written, signed, and dated progress note from their physician after each visit for 3 (R #'s 4, 7 and 8) of 3 ( R #'s 4, 7 and 8) residents reviewed for current physician progress notes and documentation. This deficient practice is likely to result in resident's records being incomplete and resident care not being documented and reviewed.

Inspectors wroteBased on record review and interview, the facility failed to provide quality of care for 1 (R #4) of 3 (R #'s 4, 7, and 8) residents reviewed for change in condition when care was not provided in a timely manner. This deficient practices likely resulted in worsening condition and unnecessary discomfort for the residents.

Inspectors wroteBased on record review and interview, the facility failed to effectively manage pain for 1 (R #1) of 1 (R #1) resident reviewed for pain when staff did not provide pain treatment. This deficient practice likely resulted in R #1 experiencing long periods of pain without sufficient relief.

Inspectors wroteBased on record review and interview, the facility failed to notify the medical provider (Physicians and Nurse Practitioners) of a change in condition in which a resident with a history of myocardial infarction (MI; heart attack) reported chest pain for 1 (R #112) of 1 (R #112) residents reviewed for provider notification. If the facility fails to notify the provider of intermittent (not continuous) chest pain for a resident with prior history of MI (a major risk factor for having another MI), then it could likely delay the resident receiving necessary testing to determine if the resident requires life-saving medical intervention. This deficient practice likely contributed to the passing of R #1.

Inspectors wroteBased on record review and interview, the facility failed to provide quality care to 1 (R #112) of 1 (R #112) residents when they failed to properly assess a resident with history of myocardial infarction (MI; heart attack) ) after the resident reported chest pains. If the facility fails to properly assess a resident who reports chest pains, then the resident may experience unidentified life-threatening conditions such as a heart attack. This deficient practice likely contributed to the passing of R #1 within the hour of reporting chest pain.

Inspectors wroteBased on observation and interview, the facility failed to serve food under sanitary conditions when staff did not use proper handling techniques of glasses, bowls, and drinks while distributing meals to residents in the dining room. This deficient practice is likely to affect all 117 residents listed on the resident census list provided by the administrator on 10/21/24; and could likely lead to foodborne illnesses in residents if safe food handling practices are not adhered to.

Inspectors wroteBased on interview and observation the facility failed to ensure staff served meals that were attractive and palatable (pleasant to taste) for 3 (R #'s 10 , 52, and 54) of 5 (R #'s 10, 52, 54, 97 and 107) residents reviewed for meal quality. This deficient practice reduces residents' ability to eat and enjoy meals, may decrease their quality of life, and could likely lose weight.

Inspectors wroteBased on record review and interview, the facility failed to ensure care plans included comprehensive medical history information for 1 (R #112) of 1 (R #112) residents reviewed for comprehensive care plans. This deficient practice could likely result in staff not understanding and implementing the needs and treatments of residents.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) were maintained for 1 (R #10) of 3 (R #'s 10, 97, and 107) residents sampled for ADLs when staff failed to provide assistance with toileting needs for R #10 when staff told him to use the restroom in his brief instead of assisting him up to the toilet. This deficient practice could likely result in residents' experiencing a decline in their ability to perform activities of daily living (ADLs) and to feel embarrassed and undignified.

Inspectors wroteBased on interviews and record review, the facility failed to follow dietary orders regarding food allergies for 1 (R # 77) of 1 (R #77) resident reviewed with food allergies. This failure had the potential to affect residents with food allergies. This deficient practice could likely cause a resident to have a medical emergency due to food allergies.

Inspectors wroteBased on record review and interview, the facility failed to ensure there was enough staff available to operate a Hoyer lift (mechanical device used to transfer patients from one surface to another) for 2 (R #1 and R #3) of 3 ( R #1, R #3, and R #4) residents reviewed for Hoyer lift usage. This deficient practice could likely result in residents experiencing issues while being transferred, including being bumped into walls, developing bruises, and feelings of frustration.

Inspectors wroteBased on observation and interview, the facility failed to provide a comfortable, homelike environment for 2 (R #5 and R #7) of 3 (R #5, R #6, and R #7) residents reviewed for resident rights by failing to ensure the hallway remained free of a persistent urine smell. This deficient practice could lead to residents feeling disrespected, uncomfortable, and embarrassed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an activities program designed to meet the interest and preferences of each resident for 3 (R #4, R #5, and R #6) of 3 (R #4, R #5, and R #6) residents reviewed for activities. This deficient practice could result in residents feeling less connected to their peers, having lower self-esteem, and experiencing a decline in psychosocial well-being.

Inspectors wroteBased on record review and interview, the facility failed to: 1. Monitor blood sugar levels, and; 2. Notify the physician when a resident's blood sugar dropped below 70 milligrams (mg) / decilitre (dL; A blood sugar reading below 70 mg/dL is considered low and dangerous. A a normal level is 90 to 130 mg/dL.) This deficient practice affected 2 ( R #6 and R #11) of 3 (R #6, R #8, and R #11) residents reviewed for diabetic management. This deficient practice could likely result in residents feeling physically ill and unsatisfied with the care received.

Inspectors wroteBased on record review and interview, the facility failed to ensure medications were administered as ordered by the physician for 1 (R #11) of 3 (R # 11, 12, 13) resident reviewed for medications. This deficient practice resulted in R#11's pulmonary embolism [blood clots in the lungs (PE)] getting worse since the last CT scan (medical imaging technique used to obtain detailed internal images of the body) on 09/08/23 putting resident at increased risk for stroke and blockage of blood flow to the heart which could result in death.

Inspectors wroteBased on record review and interview, the facility failed to prevent resident-to-resident physical abuse and to protect multiple residents from physical altercations for 2 (R #3 and 4) of 3 (R #3, 4 and 6) residents reviewed for abuse. This deficient practice could likely result in residents feeling unsafe in their home.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide quality care for 5 (R #29, 38, 61, 65 and 81) of 5 (R #s 29, 38, 61, 65 and 81) residents reviewed by not monitoring and treatment of wounds. This deficient practices could likely cause a decline in residents' health and well-being if physician orders are not followed, wounds could likely become infected causing sepsis (blood infection), osteomyelitis (bone infection) and/or other medical conditions could likely worsen.

Inspectors wroteBased on record review, observation, and interview, the facility failed to prevent resident to resident sexual abuse and to protect multiple residents from observing ongoing sexual behaviors and verbal abuse for 6 (R #3, 29, 31, 45, 87 and 109) of 6 (R #3, 29, 31, 45, 87 and 109) residents reviewed for abuse. This deficient practice likely resulted in psychosocial distress (unpleasant emotions associated with a highly stressful environment) for the residents who observed the behavior; and for R #3 being uncomfortable around R #104.

Inspectors wroteBased on interview, observation, and record review, the facility failed to: 1. Serve food according to the presented menu; 2. Communicate menu changes with residents; 3. Follow Dietary Orders regarding food allergies. These deficient practices have the potential to affect all residents listed on the census presented by the Center Executive Director on 08/27/23 and could likely result in resident frustration and/or dissatisfaction with meal options and having a medical emergency due to food allergies.

Inspectors wroteBased on observation and interview, the facility failed to serve food under sanitary conditions by: 1. Not dating food packages in reach-in refrigerator and walk-in refrigerator and freezer; 2. Not using proper handling techniques of glasses, bowls and drinks while distributing meals to residents in the dining room; and 3. Not storing or not disposing individual salsa and individual butter servings, after meal service. These deficient practices are likely to affect all 117 residents listed on the resident census list provided by the Administrator on 08/27/23; and could likely lead to foodborne illnesses in residents if safe food handling practices are not adhered to.

Inspectors wroteBased on record review and interview, the facility failed to ensure that residents or the guardians were aware of and understood the risks and benefits of medication and the reason they were receiving the medications for 2 (R #63 and R #67) of 3 (R #2, R #63, R #67) residents reviewed for unnecessary medications. If the residents or their guardians are not informed of the risks of benefits of the medication, they are not able to make informed decisions.

Inspectors wroteBased on observation and interview the facility failed to safeguard (secure or protect) clinical record information by leaving Protected Health Information (PHI) unattended. This deficient practice has the potential to affect all 25 residents residing on the south middle hall (residents were identified by the Resident Census List provided by the Administrator on 08/27/23). If resident's clinical information is not adequately safeguarded, resident's PHI is likely to be accessed (obtained or examined) by unauthorized (not having permission or approval) residents, visitors, and/or staff.

Inspectors wroteBased on record review, observation, and interview, the facility failed to accurately complete the Minimum Data Set (MDS - assessment tool used to facilitate resident care in nursing homes) of 3 (R #22, R #94 and R #225) of 4 (R #22, R #94, R #224 and R #225) residents reviewed for current and up-to-date comprehensive assessments of residents. The facility failed to comply with the requirement to thoroughly assess and plan care for the residents by not completing the MDS in a timely manner. This deficient practice is likely to result in residents not receiving the optimal care needed to live and thrive within their environment.

Inspectors wroteThis is a repeat deficiency. Based on observation, record review, and interview, the facility failed to revise the care plan for 2 (R #55 and R #94) of 2 (R #55 and R #94) residents reviewed for care plan revisions. This deficient practice could likely result in staff being unaware of residents' healthcare care needs, durable medical equipment (a medically necessary device that helps improve residents' quality of life) needs, and may present safety hazards (objects or situations that could cause harm, injury or illness).

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide activities to promote the mental and psychosocial well-being for 2 (R #23 and R #43) of 9 (R #23, R #29, R #34, R #40, R #43, R #46, R #50, R #52, and R #62) residents reviewed for activities. This deficient practice has the potential to result in residents becoming depressed and feel like they have no quality of life.

Inspectors wroteBased on record review, observation, and interview, the facility failed to offer sufficient fluid for hydration (the replacement of body fluids lost through sweating, exhaling, and eliminating waste) for 1 (R #23) of 1 (R #23) resident sampled for hydration. This deficient practice could likely result in the resident feeling dehydrated (occurs when a person uses or loses more fluid than taken in, and the body doesn't have enough water and other fluids to carry out its normal functions), the body lacking adequate hydration for highest practicable well-being, and low blood pressure.

Inspectors wroteBased on observation, record review, and interview, the facility failed to meet professional standards of care for 6 (R #9, R #17, R #75, R #88, R #111, and R #279) out of 6 (R #9, R #17, R #75, R #88, R #111, and R #279) residents reviewed for respiratory care by: 1. Not properly dating and monitoring the oxygen delivery tubing for residents and not dating the humidifier bottle (bottle of water that provides water to the oxygen to prevent the air from being too dry) for residents; 2. Not ensuring that R #9 had his oxygen (O2) machine turned on and the tubing was placed in his nostrils and that R #75 had his O2 tubing in his nostrils and; 3. Not providing written physician orders for the administration of oxygen therapy for R #279. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure ongoing communication and collaboration with the dialysis (clinical purification of blood as substitute for normal kidney functioning) facility regarding dialysis care and services for 1 (R #55) of 1 (R #55) resident reviewed for dialysis. If the facility is unaware of residents status, current condition, or any barriers or complications, then residents are likely to not receive the appropriate monitoring and care they need.

Inspectors wroteBased on record review and interview, the facility failed to provide a drug regimen (prescribed systematic form of treatment) that was free from unnecessary psychotropic medication (psychotropic medication is a type of medication that affects the mind, emotions) by not responding to the pharmacy recommendations for 2 (R #9 and R #63) of 6 ( R #9, 11, 31, 35, 63 and 224) residents reviewed for unnecessary medication. This deficient practice could likely have lead to residents receiving antipsychotic medication that they may not need which could cause increased risk of adverse drug effects, including falls and cognitive impairment and harmful drug interactions.

Inspectors wroteBased on observation and interview the facility failed to: 1. Properly store medications in a medication cart; 2. Document the daily medication refrigerator internal temperatures and daily medication storage room temperatures; 3. Lock medications carts when they were unattended. These deficient practices have the likelihood to result in the residents in the south back and north back hall, that were identified on the census list provided by the Centers Executive Director (CNE) on 08/27/23, to receive improperly temperature-controlled medications that have either lost their potency (strength of a drug) or effectiveness; allow residents medications to be accessed by unauthorized (not having permission or approval) staff or residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident received dental services for 1 (R #30) of 1 (R #30) resident reviewed for dental services. This deficient practice can result in the resident not receiving dental care and services to meet the resident's needs.

Inspectors wroteBased on record review and interview, the facility failed to accurately document in resident's records the Administration Disclosures (also referred to as a consent form - consent explaining risks and benefits of psychotropic medication) when they failed to document antidepressant medications, and anti-anxiety medication on the consent form for 1 (R # 67) of 1 (R #67) resident reviewed for psychotropic medication (a type of medication that affects the mind, emotions and behavior). This deficient practice could likely result in residents and/or resident healthcare decision makers not being informed about the risks and benefits of using Psychotropic Medications.

Inspectors wroteBased on observation and interview, the facility failed to ensure a resident was treated with dignity and respect when staff did not provide privacy for 1 (R #75) of 1 (R #75) resident. This deficient practice could likely cause the resident to feel embarrassed and disrespected.

Inspectors wroteThis is a repeat deficiency. Based on interview and record review, the facility failed to ensure a current copy of a resident's advance directive [a document, also known as the New Mexico Medical Orders For Scope of Treatment (MOST) form indicating a person's wish whether or not to receive CPR (cardiopulmonary resuscitation: an emergency lifesaving procedure performed when the heart stops beating) when they have no pulse or are not breathing] was present in the resident's medical record for 1 (R #81) of 1 (R #81) resident reviewed for advance directives. This deficient practice could likely result in a resident's wishes not being honored.

Inspectors wroteBased on interview and record review, the facility failed to ensure written grievance (complaints over something believed to be wrong or unfair) decisions included whether or not the grievance was confirmed and the date the grievance was resolved for 1 (R #31) of 1 (R #31) resident reviewed for grievances. This deficient practice could likely result in residents feeling unimportant and/or unsatisfied with the results of the grievance process.

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep residents free from physical restraints for 1 (R #23) of 1 (R #23) resident, when staff used the resident's geriatric chair as a side rail to keep resident from getting out of bed for R #23. This deficient practice could likely result in physical restraints being used for discipline or staff convenience; therefore, unnecessarily preventing residents from freedom, movement, or activity.

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 #224) of 3 (R #'s 94, 224 and 225) 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, observation, and interview, the facility failed to develop and implement a comprehensive person-centered care plan for 2 (R #38 and R #94 ) of 3 (R #s 38, 94, 224 and 225) residents reviewed for comprehensive person-centered care plans. This deficient practice could likely result in staff's failure to understand the needs and implement the appropriate treatments for residents, possibly resulting in decline in abilities and a failure to thrive.

Inspectors wroteBased on record review, interveiws and observations, the facility failed to provide services that meet professional standards for 1 (R #38) of 1 (R #38) residents by: 1. Staff did not follow physician's orders for R #38. 2. Staff did not document compression stockings being placed on the resident. These deficit practices may cause edema (swelling) in bilateral extremities if staff do not follow physician's orders. This can cause build up of fluid, pain, and swelling due to lack of care. Findings for #38 A. On 08/27/23 at 8:23 pm, during an observation, R #38 sat up in his wheelchair. He (resident) had red socks on his (resident) feet. R #38's legs and feet were swollen, and the socks left an indention in his ankle. R #38 did not have compression stockings on. B. On 08/28/23 at 2:30 pm, during an observation, R #38 sat up in his wheelchair. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide podiatry (the medical care and treatment of the human foot) services for 1 (R #40) of 1 ( R #40) resident reviewed for toenail care. This deficient practice could likely result in functional decline, pain, and infections. A. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure urine collection bags did not touch the floor for 1 (R #279) of 1 (R #279) residents with indwelling urinary catheters (plastic tubing that allows urine to come from the body and into a collection bag). This deficient practice could lead to urinary tract infections (UTIs-an infection in any part of the urinary system, the kidneys, bladder, or urethra) and possibly sepsis (an infection of the blood stream that can be life-threatening).

Inspectors wroteBased on record review and interview, the facility failed to provide a drug regimen that was free from unnecessary medication by not responding to the pharmacy recommendations for 1 (R #9) of 5 (R #9, 11, 31, 35 and 224) residents reviewed for unnecessary medication. This deficient practice could have likely led to R #9 receiving medication he no longer needed.

Inspectors wroteBased on observation and interview, the facility failed to maintain a clean and sanitary dining area for the 116 residents listed on the facility census, as provided by facility administrator on 08/27/23. This deficient practice could likely make residents feel uncomfortable due to the unsanitary (dirty area with the likelihood of growing bacteria) floor.