Manzano Del Sol by Purehealth

Inspectors wroteBased on record review and interview, the facility failed to complete and submit a Five-Day Report (a report sent to the State Survey Agency which includes the results of the facility's investigation into alleged violations) to the State Agency regarding allegations of abuse for 1 (R #5) of 1 (R #5) residents. If the facility does not submit follow-up reports, then the State Agency cannot ensure the residents are safe and free of abuse.

Inspectors wroteCross reference to F756. Based on record reviews and interviews, the facility failed to keep a resident free from significant medication errors for 1 (R #25) of 1 (R #25) resident, when staff entered a duplicate medication order of clopidogrel (an antiplatelet; medication that prevents blood clots by preventing platelets in the blood from sticking together) and administered the clopidogrel for a period of 19 consecutive days. This deficient practice had the potential to cause severe complications including but not limited to severe bleeding and death.

Inspectors wroteCross reference to F756, F868 and F880. Based on record review and interviews, the facility failed to ensure the Medical Director (MD) participated in the Quality Assurance and Performance Improvement (QAPI; a structured framework used in healthcare to enhance the quality of care provided to patients), the Infection Prevention and Control Program (IPCP, a set of strategies and practices designed to prevent and control the spread of infections in healthcare settings), and the Medication Regimen Review (MRR) program. This failure had the potential to affect all residents at the facility. If the MD does not participate in QAPI, Infection Control, and MRR to assist in identifying, prioritizing, and correcting quality deficiencies, then the facility cannot ensure quality of care and services are consistently monitored and improved.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure the Medical Director participated in the Quality Assurance and Performance Improvement/Quality Assurance and Assessment (QAPIQAA) Committee meetings, as required by regulation. This failure had the potential to affect all residents. If the facility does not ensure required members, including the Medical Director (MD), participate in the QAPI/QAA Committee, then the committee may not fully meet regulatory requirements for oversight of quality issues.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure an effective Infection Prevention and Control program (IPCP, a set of strategies and practices designed to prevent and control the spread of infections in healthcare settings) when the facility's Medical Director (MD) failed to attend the scheduled infection control monthly meetings or be part of the program. This failure had the potential to affect all residents. If the MD does not participate in the facility's infection control program, then residents may be at an increased risk of infections due to a delay in identification and response of outbreaks.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure hazardous chemicals were stored securely and remained inaccessible to 4 (R #13, R #41, R #46 and R #55) out of 4 (R #13, R #41, R #46 and R #55) residents. If hazardous chemicals are left unattended and accessible to residents with significant cognitive impairments, then residents are at risk for accidental ingestion, misuse, or chemical contact injuries, which can result in serious harm.

Inspectors wroteBased on record reviews and interviews, the facility failed to provide routine and emergency dental services for 2 (R #4 and R #48) of 2 (R #4 and R #48) residents. If the facility does not ensure residents with identified dental pain are referred for prompt evaluation and treatment, then residents are at risk for unresolved oral pain, infection, poor nutrition, and overall decline in health and quality of life.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure residents maintained a dignified existence when staff failed to assist a resident with arranging grooming services for 1 (R #50) of 1 (R #50) resident reviewed for resident rights. This deficient practice limits the residents' ability to maintain dignity, personal appearance, and quality of life and had the potential to affect all residents who relied on facility staff to arrange grooming services. If the facility fails to assist residents in arranging grooming services, this could impact the resident's dignity, potentially leading to or worsening depression.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's current advanced directive (a document which provides an individual's wishes for emergency and lifesaving care) was properly documented for 1 (R #7) of 1 (R #7) resident. This deficient practice is likely to cause confusion and delay potentially lifesaving procedures.

Inspectors wroteBased on record reviews and interviews, 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 1 (R #66) of 1 (R #66) resident, when staff failed to ensure the resident's as needed (PRN) alprazolam (anti-anxiety medication) was prescribed for a limit of 14 days, unless there was documentation in the resident's medical record of the rationale to extend beyond 14 days. This deficient practice could likely result in residents receiving medications without a medical reason and being at a higher risk of adverse side effects (unwanted, harmful, or abnormal result).

Inspectors wroteBased on record reviews and interview, the facility failed to complete and submit a Five Day Report (a report sent to the State Survey Agency which includes the results of the facility's investigation into alleged violations) to the State Agency regarding allegations of neglect (the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress) for 1 (R #77) of 1 (R #77) resident. If the facility does not submit follow-up reports, then the State Agency cannot assure the residents are safe and free of neglect.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure the Minimum Data Set (MDS; a federally mandated comprehensive assessment of a resident's functional, medical, psychosocial and cognitive assessment completed by facility staff) was accurate for 2 (R #6 and R #23) of 2 (R #6 and R #23) residents. If staff do not complete an accurate assessment of residents, then staff may not provide adequate care and treatment of the resident's needs.

Inspectors wroteBased on record reviews and staff interviews, the facility failed to develop and implement a complete baseline care plan within 48 hours of admission for 1 (R #73) of 1 (R #73) resident. If the facility fails to implement a complete baseline care plan within 48 hours of admission for residents, then the resident may be at risk of serious falls, hospital transfers, and worsening of clinical status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement resident focused, comprehensive care plans to address the oral hygiene needs for 1 (R #6) of 1 (R #6) resident. This deficient practice is likely to place the residents at risk for inadequate routine dental care, pain, infection, and complications to underlying conditions and prescribed medications.

Inspectors wroteCross reference to F760 and F605. Based on record reviews and interviews, the facility failed to ensure pharmaceutical services (the direct, responsible provision of medication-related care) were met for 1 (R #66) of 1 (R #66) residents reviewed for unnecessary medications when the Attending Physician (AP) and the Medical Director (MD) failed to review, respond to, and act on the Consultant Pharmacist (CP)'s identified irregularities (the use of medication that is inconsistent with accepted standards of practice for providing pharmaceutical services, not supported by medical evidence, and that impedes or interferes with achieving the intended outcomes of pharmaceutical services) sent monthly via Medication Regimen Reviews (MRRs, pharmacy review of the medication a resident receives). [...]

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to: - Ensure resident refrigerators were maintained in a clean and sanitary condition. - Label and date food items in the refrigerators. This failure had the potential to affect 1 (200-unit ) out of 1 (200-unit) unit refrigerators. If the facility does not maintain refrigerators in a safe and sanitary manner, then residents are at risk of consuming spoiled or contaminated food, which could result in foodborne illness or decline in health.

Inspectors wroteBased on record review and interview, the facility failed to ensure a comprehensive Minimum Data Set Assessment (MDS; a federally mandated assessment instrument completed by facility staff) was accurate for 1 (R #1) of 1 (R #1) residents reviewed for accurate MDS Assessments. If resident assessments are not complete and accurate, the facility could misidentify clinical complications and fail to provide adequate care to treat the resident's medical condition.

Inspectors wroteBased on record review and interview, the facility failed to provide quality of care for 1 (R #1) of 1 (R #1) resident reviewed for dehydration and nutrition when: 1. Staff failed to identify the decrease in nutritional intake and weight loss for R #1 as a change in condition. 2. Staff delayed to send R #1 to the hospital for two days after significant change in vitals. These deficient practices likely resulted in R #1's admission to the hospital with dehydration, urinary tract infection and sepsis (severe infection).

Inspectors wroteBased on record review and interview, the facility failed to prevent an accident and to provide a safe transfer when the facility failed to: 1. Ensure beds were locked. 2. Ensure staff used equipment correctly 3. Ensure staff supervised residents needing help during transfers. 4. Ensure staff used the lift properly and with the appropriate equipment. These failures had the potential to affect 4 (R #5, R #21, #34, and R #58) out of 4 (R #5, R #21, R #34, R #58) residents reviewed for falls. These deficient practices could likely result in the residents falling and injuring themselves.

Inspectors wroteBased on observation and interviews, the facility failed to: 1. Ensure expired supplies were not kept with unexpired supplies. 2. Ensure staff documented the medication refrigerator temperatures. These deficient practices are likely to result in all 11 residents who resided on the 100 hall, as identified on the census list provided by the Executive Director (ED) on [DATE], to have expired supplies that have lost either their potency or effectiveness used on them, or to receive medication that has lost either their potency or effectiveness.

Inspectors wroteBased on record review, and interview, and observation the facility failed to ensure residents received appropriate treatment and services to prevent decrease in range of motion and mobility to the extent possible, for 1 (R #26) of 4 (R #2, R #26, R #36 and R #13) residents reviewed for range of motion and mobility, when they failed to provide a restorative nursing program [a nursing service with the goal to maximize function and prevent functional decline in residents who require assistance from staff for mobility and activities of daily living (ADLs)] for residents with limited range of motion and/or mobility. This deficient practice could likely result in residents' decreased ability to participate in ADLs and thus failing to reach their highest practicable level of wellbeing.

Inspectors wroteBased on observation and interview, the facility failed to store food under sanitary conditions by not ensuring food stored in refrigerators were covered, labeled, dated, and not expired. This deficient practice is likely to affect all 59 residents listed on the facility census provided by the administrator on 01/23/23. If the facility fails to adhere to safe food handling practices, then residents are likely to be exposed to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins).

Inspectors wroteBased on record review and interview, the facility failed to ensure that residents had accurate and complete advanced directives (a written statement of a person's wishes regarding medical treatment) on file for 2 (R #22 and R #52) of 4 ( R #22, R #40, R #52, and R #210) residents reviewed. This deficient practice could likely result in residents receiving a response and/or treatment that is not to their preference during a medical emergency.

Inspectors wroteBased on record review and interview, the facility failed to create an accurate Baseline Care Plan within 48 hours of admission for 1 (R #11) of 4 (R #'s 8, 11, 17 and 42) residents reviewed for Baseline Care Plans. If the facility fails to include care, treatment, services, and goals the residents may not receive the appropriate care. This deficient practice could likely result in a decline in the residents condition due to staff not being aware of needed care and/or residents not being able to attain or maintain their highest practicable level of well-being.

Inspectors wroteBased on record review and interview, the facility failed to develop and implement (put into place) a comprehensive person-centered care plan for 2 (R #s 11 and 49) of 4 (R #s 8, 11, 40 and 49) residents reviewed for care plans. This deficient practice could likely result in staff's failure to understand and implement the needs and treatments of the residents.

Inspectors wroteBased on observation and interview, the facility failed to: 1. Ensure that expired medications were not being stored with unexpired medications on the second floor inside of the medication storage room. 2. Ensure that products used to clean and disinfect surfaces were not expired. This deficient practice is likely to negatively impact the health of all the residents on the second floor by receiving expired medications could likely result in residents receiving medications that have lost their potency and effectiveness leaving them vulnerable to acquiring infections. Using expired products to clean and disinfect patient care areas can leave residents vulnerable to acquiring infections due to ineffective of the expired products. The findings for the second-floor medication room are: A. [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent misappropriation of resident money, when money wasn't deposited onto R #14's debit card and money was taken by staff for one resident (R #14) of 3 (R #14, 26 and 49) residents looked at for misappropriation/missing of property. This deficient practice could likely cause residents to feel unsafe, not trust the staff at the facility, and to experience anger and frustration.

Inspectors wroteBased on record review and interview the facility failed to complete a revised care plan to include interventions for 1 (R #48) of 1 (R #48) resident who was receiving renal dialysis (process of removing waste products and excess fluid from the body). This deficient practice could likely result in residents not receiving the care and services needed for renal dialysis.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the facility was free from accident hazards for 1 (R #19) of 1 ( R# 19) resident by having a bed side table placed on top of a fall mat (thick padded floor mat for the prevention of injuries due to falls from beds ext .). This deficient practice could most likely result in harm from injuries if resident was to fall from his/her bed.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that oxygen tubing was changed and dated for 2 (R #35 and R #210) of 2 (R #35 and R #210) residents reviewed for oxygen care. This deficient practice could likely result in residents using old or contaminated oxygen tubing.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure that medications were administered as ordered for 1 (R # 28) of 10 (R #'s 3, 6, 13, 18, 28, 33, 36, 42, 44, and 51) residents reviewed for medication administration, as ordered by the physician. This deficient practice can result in a resident failing to obtain maximum wellness and/or suffering prolonged illness.

Inspectors wroteBased on record review and interview, the facility failed to notify the Therapy Department of a referral for 1 (R #40) of 3 (R #14, R #40, and R #48) residents reviewed for PT, OT, and ST (PT- physical therapy is the treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise. OT- occupational therapy is a form of therapy that encourages rehabilitation through the performance of activities required in daily life. ST- speech therapy is a form of therapy to improve speaking and swallowing). This deficient practice could likely result in residents not receiving therapy services as requested to improve or maintain their physical functional ability.

Inspectors wroteBased on interview and record review the facility failed to consistently document tube feedings (is a medical device used to feed a person who is unable to eat or drink) on the Medication Administration Record for 1 (R #2) of 1 (R #2) resident looked at for tube feedings. This deficient practice could likely cause confusion on who is caring for the resident and if that staff member is aware of where to find and document the care they are giving.