Las Cruces Village Nursing & Rehabilitation LLC

Inspectors wroteBased on observation, and interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for all 89 resident in the facility (residents were identified by the census list provided by the Administrator on 04/29/26) randomly sampled residents, when they failed to ensure a floor drain sink in the [NAME] Janitors room was in operable working condition after the drain became clogged. This deficient practice could likely result in residents living in an environment that puts them at risk of waterborne pathogens such as Legionella contamination microorganisms, bacteria and fungi, which could grow in stagnate accumulating water.

Inspectors wroteBased on observation and interview, the facility failed to secure a treatment cart for all 27 residents on the 500 and 600 unit (residents were identified by the census list provided by the Administrator on 04/29/26). This deficient practice could result in residents obtaining medication not prescribed to them resulting in adverse side effects.

Inspectors wroteBased on record review and interview, the facility failed to allow the resident the right to designate a representative and allow that representative the right to exercise the resident's rights to the extent those rights are delegated to the representative for 1 (R #1) of 3 (R #1, R #2, and R #3) residents sampled for residents rights, when the facility failed to allow R #1's POA (the legally appointed person (the agent or attorney-in-fact) to make decisions or act on their behalf regarding financial, legal, or medical matters) to obtain R #1's medical records. If resident representatives' decisions are not treated as that of a resident, then residents that do not have ability to make decisions for themselves are left with no one to advocate for their rights.

Inspectors wroteBased on interview and record review, the facility failed to provide the right to access personal and medical records pertaining to him or herself upon an oral or written request 1 (R #1) of 3 (R #1, R #2, and R #3) residents sampled for residents rights, when the facility failed to allow R #1's POA (the legally appointed person (the agent or attorney-in-fact) to make decisions or act on their behalf regarding financial, legal, or medical matters) [because R #1 did not have the capacity to on her own] to obtain R #1's medical record. If residents or their representatives acting on their behalf are not able to access their medical record, then they may not have the information needed to make healthcare decisions.

Inspectors wroteBased on record review, and interview, the facility failed to ensure care plan revisions were completed for 1 (R #24) of 3 (R #24, R #25, and R #26) residents reviewed for care plans, when the staff failed to revise the care plan with the most current resident information for R #24. This deficient practice could likely result in care plans not being updated with the most current resident conditions and appropriate interventions, 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 and interview, the facility failed to post the Ombudsman contact information in areas accessible to residents and their representatives this could affect all 89 residents in the facility (residents were identified by the census list provided by the Administrator on 04/29/26). If residents and their representatives are not aware of how to contact the Ombudsman, then they would not be aware of how contact the Ombudsman about concerns they have.

Inspectors wroteBased on observation and interview, the facility failed to retain 18 months of records for the posted nurse staff information, this could affect all 89 residents in the facility (residents were identified by the census list provided by the Administrator on 04/29/26). If the facility does not retain 18 months of posted staffing, then residents or the public would have access to review.

Inspectors wroteBased on observation, record review and interview, the facility failed to revise the care plan for 2 (R #8, and R #10) of 3 (R #8, R #9, and R #10) residents reviewed for neglect when they failed to revise the care plan for the resident's need for the following: 1. R #8 and R #10's briefs and approaches (any action, treatment, or strategy intentionally undertaken to prevent, treat, or improve an individual's health, functioning, or well-being). 2. R #8 and R #10's beds in lowest position and fall mats in place for fall risk. 3. R #8 no longer being an elopement (the unauthorized departure of a resident from the facility without the knowledge or supervision of staff) risk. 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 meet professional standards of quality care for 11 of 19 residents on the 400 Unit (residents were identified by the resident matrix provided by the Administrator on 09/08/25) when staff failed to round on residents (regularly check on residents to assess needs, safety and comfort). This deficient practice could likely lead to the residents' needs and care not being met.

Inspectors wroteBased on observation and interview, the facility failed to secure a medication cart for all 25 residents on the 500 and 600 units (residents were identified by the census list provided by the Administrator on 09/16/25). This deficient practice could result in residents obtaining medication not prescribed to them resulting in adverse side effects.

Inspectors wroteBased on interview, and record review the facility failed to keep the resident free from neglect for 1 (R #8) of 3 (R #8, R #9, and R #10) residents reviewed for neglect when staff failed to conduct rounds (check on) on a resident and was left on the floor after a fall for 3 hours and 10 mins. This deficient practice could likely result in the resident suffering from lack of care, having anger, fear, and anxiety as a result of their neglect, and not getting the help she needs in a timely manner.

Inspectors wroteBased on record review and interview, the facility failed to provide evidence for the alleged violations of neglect and exploitation were thoroughly investigated for 2 (R #8 and R #16) of 6 (R #8, R #9, R #10, R #16, R #17, and R #18) residents reviewed for allegations of neglect and misappropriation of property (the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent). If the facility does not keep evidence of investigations, then the state agency is unable to determine if a thorough investigation was completed and determine if the facility implemented appropriate actions to protect residents.

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 #24) of 3 (R #24, R #26 and R #27) 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 provide treatment and services specialized in managing and healing wounds that do not heal properly for pressure ulcers (damage to an area of the skin caused by constant pressure on the area for a long time) for 1 (R #24) of 3 (R #8, R #24 and R #25) residents reviewed for pressure ulcers, when staff failed to: Obtain wound care orders for R #24's pressure ulcer until three days after admission, Perform wound care for one day of the six days R #24 was in the facility. These deficient practices 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 the record review and interview, the facility failed to ensure RN coverage was provided for 8 consecutive hours a day and for 7 days a week. This failure could potentially affect all 79 residents who lived in the facility (residents were identified by the Resident Matrix provided by the Administrator on 06/23/25. This deficient practice is likely to result in residents not receiving the services they require.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and serve food under sanitary conditions by professional standards of food service safety, this could affect all 78 residents living in the facility (residents were identified by the Resident Matrix provided by the Administrator on 06/22/25). When they failed to ensure staff maintain refrigerator temperatures in the dietary west wing kitchen. This deficient practice could expose residents to foodborne illnesses, which includes failing to maintain safe food temperatures. This can lead to a range of health risks, such as foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins), affecting residents and requiring immediate attention to ensure their safety.

Inspectors wroteBased on record review and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary 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 wroteA. On 06/26/25 at 10:41 AM, during an interview, ADON #2 confirmed that she is the current IP and confirmed that she has started but has not completed the required IP training and does not have the training certificate yet. B. On 06/27/25 at 10:12 AM, during an interview, the Director of Clinical Services confirmed that ADON #2 had not completed the required IP training to receive her certification.

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide a safe, comfortable, and homelike environment for 2 (R #47 and R #61) of 4 (R #27, R #30, R #47 and R #61) residents reviewed for missing property, when staff failed to ensure that that resident property was free from loss or theft. This deficient practice could likely cause residents to feel like they are not living in a safe, comfortable, and home-like environment and like they are not valued.

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) unless the medication was medically necessary for 3 (R #12, R #17, R #44,) of 6 (R #1, R #7, R #12, R #17, R #44, and R #75) residents reviewed for unnecessary medications, when staff failed to ensure: 1. Psychotropic medications for R #12 were prescribed to treat a specific psychiatric diagnosis (mental illness, symptoms or condition that greatly disturbs your thinking, moods, and/or behavior). 2. 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 #44. 3. [...]

Inspectors wroteBased on record review and interview, the facility failed to provide the required discharge or transfer information to the resident and the resident's representative(s) in writing for 4 (R #12, R #47, R #78 and R #179) of 5 (R #12, R #47, R #75, R #78 and R #179) residents sampled for hospitalizations or discharge when staff failed to: 1. Notify the resident and the resident's representative of the plan to discharge the resident from the facility in writing and in a language and manner they understand for R #78. 2. Complete a discharge summary for R #78 that included the following: a. A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. b. [...]

Inspectors wroteBased on record review and interview, the facility failed to develop and implement accurate, person-centered comprehensive care plan for 4 (R #1, R #7, R #77, and R #179) of 4 (R #1, R #7, R #77, and R #179) residents reviewed for care plans when staff failed to:1. Include personal preferences for activities for R #1 and R #7.2. Include a care plan for R #77's primary diagnosis. 3. Include a care plan for R #179's diagnosis and level assistance needed for showering. These deficient practice could likely result in staff being unaware of the current and actual needs of the residents.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure care plan revisions and care plan meeting requirements occurred for 8 (R #12, R #18, R #25, R #27, R #34, R #44, R #47, and R #61) of 8 (R #12, R #18, R #25, R #27, R #34, R #44, R #47, and R #61) residents reviewed for care plans, when the staff failed to: 1. Ensure the care plan meeting was held within 7 days from the completion of the MDS (MDS; a standardized, comprehensive assessment of an adult's functional, medical, psychosocial, and cognitive status) assessment when creating or revising the care plan for R #44, R #47 and R #61. 2. Revise the care plan with the most current resident information for R #12, R #18, R #25, R #27, and R #34. [...]

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 or showers for 1 (R #55) of 3 (R #55, R #61, and R #179) residents reviewed for ADL care. 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 provide an ongoing program of activities designed to meet the interests for 3 (R #1, R #7, and R #75) of 5 (R #1, R #7, R #18, R #27 and R #75) 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 meets their interests, then they are likely to experience an increase in boredom, isolation, and depression.

Inspectors wroteBased on interviews the facility failed to have a qualified activities professional to direct an ongoing program of activities designed to meet the interests for resident, for all 13 residents residing in the secure unit of the facility (resident were identified by the Resident Matrix provided by the Administrator on 06/22/25) sampled for activities when staff failed to do the following: 1. Have the Activities Director (AD) licensed or registered as a Activities Director. 2. Have 2 years experience in a social or recreational program within the last 5 years. If the facility is not providing an ongoing activity program this can lead to a less engaging and beneficial program for residents and can negatively impact residents' well-being and quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the nursing staff were able to demonstrate competency in skills and techniques necessary to care for residents' needs for 3 (RN #16, LPN #16, and CNA #16) of 3 (RN #16, LPN #16, and CNA #16) staff reviewed for competent nursing staff, when they failed to have a competency evaluation (the facility's way to measure an individual's knowledge and skills as related to safe, competent performance through demonstration of those skills) for RN #16, LPN #16, CNA #16, and CNA #17at the time of hire before they start to work with residents. These deficient practices could likely result in nursing staff 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 obtained dental services for 4 (R #25, R #34, R #44, and R #61) of 7 (R #7, R #25, R #34, R #44, R #58, R #61, and R #75) residents sampled for dental services, when staff failed to ensure residents 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 is likely to 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 2 (R #27 and R #34) of 4 (R #27, R #30, R #34, and R #78) residents reviewed for documentation accuracy when they failed to do the following: 1. Document R #27's fall. 2. Document applying R #34's elbow splint and palm guard. 3. Document R #34's refusal to wear elbow splint and palm guard. 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 record review and interview, the facility failed to ensure nursing staff completed the mandatory training for Effective Communication for 6 (RN #16, LPN #16, CNA #16, Nursing Assistant (NA) #16, Dietary Aide (DA) #16, and Activity Aide (AA) #16) of 6 (RN #16, LPN #16, CNA #16, NA #16, DA #16, and AA #16) staff sampled for training completion. 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 ensure nursing staff completed the mandatory Quality Assurance and Performance Improvement (QAPI, a systematic approach used in healthcare, particularly in nursing homes and other long-term care facilities, to enhance the quality of care and resident experience) training for 6 (RN #16, LPN #16, CNA #16, Nursing Assistance (NA) #17, Dietary Aide (DA) #16, and Activity Aide (AA) #16) of 6 (RN #16, LPN #16, CNA #16, NA #16, DA #16, and AA #16) staff sampled for staffing. This deficient practice could likely result in staff being unable to identify opportunities for improvement, address gaps in systems or processes, develop and implement an improvement or corrective plan, and continuously monitor the effectiveness of interventions.

Inspectors wroteBased on record review and interview, the facility failed to ensure nursing staff completed the mandatory behavioral health training for 6 (RN #16, LPN #16, CNA #16, Nursing Assistant (NA) #16, Dietary Aide (DA) #16, and Activity Aide (AA) #16) of 6 (RN #16, LPN #16, CNA #16, NA #16, DA #16, and AA #16) staff sampled for staffing. 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 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 #75) of 6 (R #1, R #7, R #12, R #17, R #44, and R #75) 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 report an allegation of abuse to the State Survey Agency within two (2) hours of the allegation for 1 (R #12) of 2 (R #12 and R #179) residents reviewed for abuse. 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 interview and record review, the facility failed to meet regulatory requirements for discharge for 1 (R #78) of 1 (R #78) resident when staff failed to:1. Conduct discharge planning.2. Ensure proper notification was given to the resident.3. Confirm resident receipt of the discharge notice.4. Notify Ombudsman of R #78's discharge. These failures have the potential for an incomplete, unsafe discharge and increase risk of resident harm.

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 1 (R #61) of 6 (R #10, R #17, R #25, R #61, R #77 and R #179) 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 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 #75) of 3 (R #18, R #27 and R #75) 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 interview and record review, the facility failed to ensure a resident received restorative rehabilitation (focuses on maximizing an optimal level of functioning, enabling clients to regain/retain their independence following the debilitating effects of illness or injury) services as recommended by physical therapy and occupational therapy for 1 (R #34) of 1 (R #34) residents reviewed for rehabilitation services. This deficient practice is likely to result in a decrease in residents functional mobility.

Inspectors wroteBased on record review and interview, the facility failed to ensure wound care orders were implemented, wound care was completed, and staff documented that the wound care was performed for 1 (R #58) of 1 (R #58) residents reviewed for pressure ulcers (damage to an area of the skin caused by constant pressure on the area for a long time). These deficient 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 observation, interview, and record review, the facility failed to keep residents free from accidents for 1 (R #44) of 2 (R #27 and R #44) resident reviewed for accidents, when staff failed to ensure that ordered fall mats were in place when R #44 was in bed. This deficient practice could likely result in residents getting injured if they fall from their bed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep residents free from accidents for 1 (R #44) of 2 (R #27 and R #44) resident reviewed for accidents, when staff failed to ensure that ordered fall mats were in place when R #44 was in bed. This deficient practice could likely result in residents getting injured if they fall from their bed.

Inspectors wroteBased on record review and interview, the facility failed to ensure the consultant pharmacist's recommendations were reviewed and implemented by the physician and/or 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 #44) of 5 (R #1, R #7, R #12, R #44, and R #75) 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 there was a coordinated plan of care for 1 (R #17) of 1 (R #17) resident reviewed for hospice services. This deficient practice is likely to result in residents not receiving necessary services.

Inspectors wroteBased on observation, and interview, the facility failed to ensure that staff were properly trained for feeding 1 (R #53) of 1 (R #53) residents reviewed for dining. This deficient practice could likely result in the increased risk of choking and aspiration pneumonia, brain damage (brain damage refers to the destruction or deterioration of brain cells, which can result from various conditions such as trauma, stroke, or infections), or even death from improper feeding techniques.

Inspectors wroteBased on record review and interview, the facility failed to notify the provider of abnormal vital signs (blood pressure and heart rate outside of set parameters) for 1 (R #2) of 3 (R #1, R #2, and R #3) residents reviewed for provider notification, when staff failed to notify the provider that R #2's blood pressure (bp) was high and R #2's pulse was low. This deficient practice 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 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 1 (R #1) of 3 (R #1, R #2 and R #3) residents reviewed for medication regimen when staff failed to: 1. Contact the physician/provider when medication is held. 2. Contact the physician/provider to notify them of medication refusals. If the facility is not providing care per physician's orders, notifying the provider of changes and providing care that meets professional standards of practice, then residents are likely to experience adverse effects, worsening of their condition, and potential complications from not receiving the care ordered by the physician.

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 #16) of 1 (R #16) resident when staff failed to adequately assess the cause and adequately treat R #16's prolonged diarrhea. Failure to adequately assess the cause of diarrhea and provide appropriate treatment could likely lead to worsening of resident's condition.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure the facility had sufficient staff to meet the needs of 4 (R #1, R #3, R #4, and R #5) of 5 (R #1, R #2, R #3, R #4, and R #5) residents reviewed for staffing when staff failed to: 1. Assist R #1 to the toilet as ordered by the physician. 2. Assist R #3 and R #5 with transfers in and out of bed when requested. 3. Get R #4 up and ready to eat meals in the dining room. These deficient practices are likely to cause residents psychological distress, make them feel as if they are not valued, and negatively impact resident comfort.

Inspectors wroteBased on record review and interview, the facility failed to ensure medical records were complete and accurate for 2 (R #16 and R #19) of 4 (R #16, R #17, R #18, and R #19) 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 observation and interview, the facility failed to maintain proper infection prevention measures when they failed to ensure facility staff follow transmission-based precautions (actions to prevent the spread of infectious agents from individuals who are suspected to be infected, such as gloves, facemasks, and gowns) for residents diagnosed with COVID-19 (an acute respiratory disease in humans characterized mainly by fever and cough and capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions). Failure to adhere to an infection control program could likely cause the spread of infections and illness to all 67 residents in the facility (residents were identified by the resident matrix provided by the administrator on 12/11/24).

Inspectors wroteBased on interview and record review, the facility failed to keep residents free from involuntary seclusion (separation of a resident from other residents, from her/his room or confinement to her/his room [with or without roommates] against the resident's will, or the will of the resident representative) for 1 (R #1) of 3 (R #1, R #2, and R #5) residents sampled for involuntary seclusion when the staff failed to allow a resident to move freely throughout the unit. This deficient practice is likely to result in residents experiencing anxiety and/or depression related to being isolated from staff and other residents.

Inspectors wroteBased on record review and interview, the facility failed to prevent misappropriation (the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent) of residents medication for 3 (R #8, R #9, and R #10) of 3 (R #8, R #9, and R #10) residents when they failed to ensure that as needed (PRN) controlled narcotics (drug or chemical that is regulated by the government) prescribed to residents were given when it was documented as given. This deficient practice could likely result in residents not having medication available when they need them.

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 57 residents in the facility who eat food prepared in the kitchen (residents were identified by the Resident Matrix provided by the Administrator on 03/04/24). When they failed to: 1. Keep the kitchen floors clean. 2. Keep the stoves and surrounding areas clean from grease. 3. Ensure food in the dry pantry and freezer was labeled and dated. 4. Ensure staff maintain refrigerator temperatures. 5. Have staff perform hand hygiene when assisting residents in the dining room. [...]

Inspectors wroteBased on observation and interview the facility failed to provide a homelike environment for all 35 residents on the 300 and 400 units (residents were identified by the resident matrix provided by the Administrator on 03/04/24), when they failed to repair: 1) Damaged/broken ceiling tiles in the hallways of the 300 and 400 units. 2) A hole in R #31's bathroom wall caused by maintenance staff removing a hand rail. If residents do not have a homelike environment, they may become depressed and anxious that things are in disrepair.

Inspectors wroteBased on record review and interview, the facility failed to: 1) Notify the resident and resident's representatives of a transfer in writing, and 2) Have all the required information on the written notice of transfer for 4 (R #8, R #33, R #37, and R #51) of 4 (R #8, R #33, R #37, and R #51) resident sampled for hospitalizations. These deficient practices could likely result in the resident and/or their representative not knowing the reason for a transfer, their rights to advocate and make informed decision regarding their healthcare.

Inspectors wroteBased on record review and interview, the facility failed to: 1) Ensure residents or their representatives received a written notice of the bed hold policy within 24 hours of a transfer, and 2) Indicated the duration the bed would be held on the notice for 4 (R #8, R #33, R #37, and R #51) of 4 (R #8, R #33, R #37, and R #51) residents reviewed for hospitalization. These deficient practices 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 interview, observation, and record review, the facility failed to ensure the MDS assessment accurately reflected the resident's status at the time of the assessment for 2 (R #15 and R #43) of 4 (R #8, R #15, R #33, and R #43) 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 ensure care plans were reviewed and revised for 12 (R #8, R #12, R #15, R #19, R #33, R #37, R #40, R #41, R #43, R #44, R #50, and R #51) of 12 (R #8, R #12, R #15, R #19, R #33, R #37, R # 40, R #41, R #43, R #44, R #50, and R #51) residents reviewed for care plans when they failed to: 1. Have 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 participate in the care plan meeting for R #8, R #15, R #33, R #44, and R #51. 2. Have the care plan meeting within seven days after the completion of the quarterly assessment for R #8, R #15, R #33, R #44, and R #51. 3. [...]

Inspectors wroteBased on record review and interview the facility failed to have a discharge summary that includes a compilation of the resident's stay at the facility for 1 (R #57) of 1 (R #57) residents reviewed for discharge. If residents do not have a discharge summary that includes a compilation of the resident's stay at the facility, then the receiving facility or home health will not have the information to provide care.

Inspectors wroteBased on record review, observation, and interview, the facility failed to provide an ongoing activity program to support residents in their choice of activities designed to support their physical, mental, and psychosocial well-being for 2 (R #33 and R #51) of 2 (R #33 and R #51) residents reviewed for activities. If the facility does not ensure that all residents are receiving an ongoing activity program, documenting resident refusals, and making in-room activity accommodations, then residents are likely to demonstrate an increase in isolation and depression and could likely experience a decline in independence.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 3 (R #8, R #15, and R #51) of 4 (R #8, R #15, R #17 and R #51) residents when they failed to: 1. Monitor R #8 after an episode of altered mental status (a change in mental function) on 02/18/24. 2. Obtain information from wound care appointments (outside of the facility) for R #15 and R #51. 3. Obtain wound care information from contracted wound care staff caring for R #15 and R #51 in the facility. These deficient practices could likely lead to residents needs not being met and/or a worsening of their condition.

Inspectors wroteBased on interviews, 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 (The tube through which urine leaves the body) 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 for 1 (R #15) of 1 (R #15) residents reviewed for Foley Catheters when they failed to ensure an appropriate diagnosis for long term use of a Foley catheter. This deficient practice could likely result in residents being susceptible (likely or liable to be influenced) to infection due to insertion of Foley catheter, worsening of infection, or becoming septic (potentially life-threatening when the body responds to infection by damaging it's own tissues).

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 5 (R #33, R # 40, R #48, R #50 and R #51) of 5 (R #33, R #40, R #48, R #50 and R #51) 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 observation and interview, the facility failed to store medications properly and medication carts were locked for all 25 residents in the 200 and 400 Units (residents were identified by the resident matrix provided by the Administrator on 03/04/24) . Randomly sampled residents when they failed to dispose of one loose tablet in the medication cart on the 400 unit. This deficient practice could result in residents obtaining medication not prescribed to them resulting in adverse side effects.

Inspectors wroteBased on record review and interview, the facility failed to complete a physical therapy (therapy that is used to preserve, enhance, or restore movement and physical function) screening for 1 (R #19) of 1 (R #19) resident reviewed for activities of daily living (ADL's; daily self-care activities such as eating, dressing and using the toilet). This deficient practice could likely result in residents not receiving services as needed or ordered to improve or maintain their physical functional ability.

Inspectors wroteBased on record review and interview, the facility failed to provide abuse, neglect, and exploitation (ANE) training to 2 staff (CNA #1 and RN #1) of 6 (CNA #1, CNA #2, CNA #3, LPN #1, RN #1, and RN #2) staff sampled for training. This deficient practice could likely result in staff not knowing who, what, and when to report abuse, neglect, and exploitation.

Inspectors wroteBased on record review and interview, the facility failed to notify the physician or resident representative of a change in medical status for 1 (R #8) of 1 (R #8) residents reviewed for hospitalization, when they failed to immediately notify R #8's representative and the physician of R #8's low oxygen saturation (amount of oxygen in the blood) and altered mental status (a change in mental function that stems from illnesses, disorders and injuries affecting your brain). This deficient practice could likely result in the resident's representative and the physician being unaware of resident's current condition resulting in delay in treatment.

Inspectors wroteBased 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 deficient practice is likely to affect all 55 residents (residents were identified by the Census List provided by facility administrator on 01/19/23). This deficient practice could likely result in resident's not receiving the services required for care.

Inspectors wroteBased on record review and interview, the facility failed to ensure that residents representatives or medical provider (physician or nurse practitioner) were notified following a change in condition or treatment for 3 (R #8, R #53, and R #107) of 3 (R #8, R #53, and R #107) residents reviewed for notification of change. If the facility does not notify resident's representatives or medical provider of the change in treatments or condition, then they will not have an opportunity to make decisions and/or advocate for treatment or care on behalf of the resident.

Inspectors wroteBased on observation and interview the facility failed to provide a comfortable and homelike environment for 3 (R #19, R #21, and R #43) of 3 (R #19, R #21, and R #43) residents sampled for environment, when they failed to maintain a temperature range of 71° to 81°F when the heating system went out in the 300 unit in January 2023. This deficient practice could likely result in residents being cold and uncomfortable due to loss of body heat.

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 6 (R #6, R #8, R #11, R #36, R #42, and R #50 ) of 6 (R #6, R #8, R #11, R #36, R#42, and R #50) residents reviewed for discharge. 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 ensure residents, or their representatives received a written notice of their bed hold policy indicating the duration that the bed would be held for 6 (R #6, R #8, R #11, R #36 R #42, R #50 ) of 6 (R #6, R #8, R #11, R #36, R #42, ,and , R #50 ) residents reviewed for transfers to hospital. 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 record review and interview, the facility failed to develop and implement an accurate, effective, person-centered Baseline Care Plan within 48 hours of admission for 2 (R #50 and R #52) of 3 (R #50, R #52 and R #105) residents sampled for baseline care plans. If resident's Baseline Care Plans are not accurate, then 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 #6, R #36, R #43, and R #107) of 10 (R #5, R #6, R #15, R #16, R #25, R #28, R #36, R #43, R #44, and R #107) residents reviewed for Comprehensive Care Plans by: 1. Not developing a care plan for psychotropic medications for R #6, 2. Not implementing washing of feet daily for R #36, 3. Not developing a care plan for Irritability and anger diagnosis for R #43, and 4. Not implementing Occupational and Physical therapy for R #107. Failure to develop a resident 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 3 (R #8, R #27, and R #154) of 3 (R #8, R #27, and R #154) residents sampled for Care Plan documentation. 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.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents receiving dialysis (process of removing excess water and toxins from the blood in people whose kidneys can no longer perform these functions naturally) receive services consistent with professional standards of practice and the comprehensive person-centered care plan facility regarding dialysis care and services for 1 (R #16) of 1 (R #16) 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 observation, record review, and interview the facility failed to maintain appropriate staffing levels to meet the needs of the residents. This failure has the potential to affect all 14 residents in the secure unit (residents were identified by the resident census list provided by the Administrator on 01/12/23). This deficient practice could likely result in residents not receiving the care and service needed while in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs for 3 (CNA #4, CNA #5, and CNA #6) of 3 (CNA #4, CNA #5, and CNA #6) CNAs randomly sampled for competency. This deficient practice could likely result in staff working who are not competent to give care to residents.

Inspectors wroteBased on interview and record review, the facility failed to complete performance reviews at least every 12 months for 3 (CNA #4, CNA #5, and CNA #6) of 3 (CNA #4, CNA #5, and CNA #6) 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 ensure that 1 (CNA #5 ) of 3 (CNA #4, CNA #5, and CNA #6) CNA's reviewed for behavioral health training had the appropriate training to provide care for residents with behavioral health issues/needs. This deficient practice could likely result in residents not receiving the appropriate care to meet their needs.

Inspectors wroteBased on record review and interview, the facility failed to ensure documents in resident records were complete and accurate for 9 (R #9, R #11, R #12, R #24, R #42, R #43, R #43, R #45 and R #105) of 9 (R #9, R #11, R #12, R #24, R #39, R #42, R #43, R #45 and R #105) residents reviewed for advanced directives (MOST form- Medical Orders for Scope of Treatment legal document also known as a living will which specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity). This deficient practice could likely result in staff not knowing the medical intervention wishes of residents during an emergency.

Inspectors wroteBased on record review and interview, the facility failed to ensure the MDS ((Minimum Data Set) accurately reflected all the falls for 1 (R #8) of 1 (R #8) resident randomly sampled when they failed to document R #8's falls on the MDS. If the resident's MDS is not accurate it is likely that residents will not get the care and assistance needed.

Inspectors wroteBased on observation, and interview, the facility failed to keep residents free from accidents for all 15 residents on the 400 hallway (Residents were identified by the resident matrix provided by the Administrator on 01/26/23) when they failed to secure a treatment cart. This deficient practice could result in residents obtaining medical equipment that could be harmful to them resulting in injury.