Rio Rancho Center

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure residents received the necessary treatment and services to promote healing of a wound for 1 (R #1) of 1 (R #1) resident reviewed, when the facility staff failed to:Provide consistent wound care per physician orders for R #1. Implement interventions to address repeated refusals of wound care. Ensure R #1's wound care was completed by facility nursing staff and not by R #1. These deficient practices led to R #1 having maggots (a soft bodied, legless larva of a fly or other insect, found in decaying matter) present causing the wound on R #1's right foot to worsen. If wound care is not provided as ordered by a physician, then the residents are likely at risk for wound deterioration, infection, delayed healing, and other complications.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to maintain a sanitary environment to prevent the transmission risk of infectious agents for 2 (R #1, and R #4) of 2 (R #1, and R #4) residents, when:Facility staff stored wound care treatment supplies in unsanitary locations in R #1's and R #4's rooms. Enhanced Barrier Precautions (EBP; an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) guidelines were not followed when staff failed to wear Personal Protective Equipment (PPE; protective clothing, face masks, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection) while providing care to R #4, who required PPE use during care. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents were able to receive mail on Saturdays for all 110 residents residing at the facility. This deficient practice is likely to result in residents not receiving timely communication which could result in feelings of isolation.

Inspectors wroteBased on record review, observations and interviews, the facility failed to ensure beverage items used for resident meal service were labeled and dated. This deficient practice is likely to affect all 110 residents in the facility. If staff do not store food according to food handling standards, then residents could acquire foodborne illnesses.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to maintain a sanitary environment to prevent the transmission risk of infectious agents when staff failed to:- Ensure enhanced barrier precautions signage (EBP; an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) was posted outside of R #4's room.- Wear personal protective equipment (PPE) when providing direct care and administering medications through a gastric feeding tube for R #90.- Ensure nasal cannulas (flexible tube with two prongs inserted into the nostrils to deliver supplemental oxygen) and humidifiers (concentrator component; [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) accurately reflected residents' clinical status for 3 (R #7, R #79, and R #117) of 6 (R #2, R #7, R #79, R #111, R #117, and R #122) residents reviewed for assessments. If staff do not accurately assess residents, then the resident may not receive the care needed to obtain optimal health.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to create a baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) within 48 hours of admission for 4 (R #3, R #7, R #13 and R #80) of 5 (R #3, R #7, R #11, R #13 and R #80) residents reviewed for baseline care plans. This deficient practice is likely to result in residents not receiving the appropriate care needed, causing harm or worsening of their current conditions.

Inspectors wroteBased on observation, record review, and interview, the facility failed to fully and accurately develop the care plan for 2 (R #89 and R #90) of 6 (R #13, R #14, R #81, R #89, R #90, and R #117) residents reviewed for care plan, when staff failed to: Update R #89's care plan to include interventions for oxygen use that matched the physician's order. Update R #90's care plans to include interventions for oxygen use. Update R #117's care plan to reflect a change in the fluid restriction. These deficient practices are likely to result in residents' care and needs not being addressed if care plans are not updated.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide quality of care that met professional standards for 2 (R #79 and R #89) of 3 (R #2, R #79, and R #89) residents reviewed when staff failed to:- Assess R #79 prior to implementing the use of a wander guard. - Follow physician orders for pain relief cream for R #89. If staff do not follow professional standards of care, then residents may have a decreased quality of life.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to complete smoking evaluations for 2 (R #117 and R #122) of 6 (R #4, R #5, R #8, R #14, R #79, R #117 and R #122) residents reviewed. This deficient practice could likely result in residents getting injured in avoidable accidents and putting residents at risk of serious injury, serious harm, and possibly death.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure supplemental oxygen orders were complete for 2 (R #6 and R #90) of 4 (R #4, R #6, R #7, and R #90) residents reviewed for respiratory care. These deficient practices are likely to result in residents receiving too much or not enough oxygen and can lead to worsening of conditions.

Inspectors wroteBased on record review and interview, the facility failed to offer COVID-19 (an acute respiratory disease in humans characterized mainly by fever and cough, capable of progressing to severe symptoms and in some cases death) vaccinations to 3 (R #89, R #117, and R #122) of 5 (R #4, R #11, R #89, R #117, and R #122) residents reviewed for COVID-19 vaccinations. This deficient practice could likely result in residents having a higher likelihood of contracting COVID-19 and spreading the infection to other residents in the facility.

Inspectors wroteBased on observation, record reviews, and interviews, the facility failed to completed a Preadmission Screening and Resident Review (PASARR; a Federal requirement to help ensure individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long-term care) prior to admission for 1 (R #59) of 3 (R #3, R #8, and R #59) residents reviewed for PASARR accuracy. This deficient practice is likely to result in the facility not providing the specialized services and support needed by residents.

Inspectors wroteBased on record review and interview, the facility failed complete performance reviews every 12 months for Certified Nursing Assistants (CNAs) for 1 (CNAs #4) of 5 (CNAs #4, #5, #6, #7, and #8) CNAs reviewed. If the facility is not completing a performance review of every CNA at least once every 12 months, then residents may not receive the appropriate care and services from the CNAs.

Inspectors wroteBased on observations and interviews, the facility failed to ensure staff properly stored and secured medications for all residents residing on the North Hall when staff left a medication storage cart unlocked and unattended. If the facility is not storing medications securely, then residents could experience injury or illness.

Inspectors wroteBased on interviews and record reviews, the facility failed to properly complete consent forms for 4 (R #'s 1, 2, 5, and 6) of 6 (R #'s 1, 2, 3, 4, 5, and 6) residents, when:Psychotropic medication (medication used to treat mental health conditions) consent forms were not signed by residents or resident representatives. This deficient practice is likely to result in residents and/or their representatives not being consulted and informed of the risks and benefits of medications and treatments being provided to them.

Inspectors wroteBased on observation and interviews, the facility failed to safeguard clinical record information by leaving Private Health Information (PHI) regarding residents of the 100-nursing unit, where unauthorized people had ability to access it. If the resident's clinical information is not sufficiently safe guarded, resident's PHI is likely to be viewed by unauthorized residents, visitors, and staff.

Inspectors wroteBased on observations and interviews, the facility failed to ensure the environment was free of accident hazards for residents residing on the 100-unit, when:An unattended computer cart with a cup of coffee, a chair, and a backpack was stationed in the doorway of room [ROOM NUMBER], blocking the entrance and without facility staff nearby. An unattended computer cart with a chair was blocking the hallway and handrails between rooms #138 and #140, without facility staff nearby. This deficient practice is likely to result in residents getting injured in avoidable accidents and putting residents at risk of serious injury and harm.

Inspectors wroteBased on record review and interview, the facility failed to ensure a comprehensive Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) assessment was completed for 2 (R #1 and R #2) of 4 (R #1, #2, #5 and #6) residents, when:The facility did not change R #1 and R #2's discharge MDS status from return anticipated (returning to the facility) to return not anticipated (not returning to the facility). This deficient practice is likely to result in residents' needs not being met.

Inspectors wroteBased on observations and interviews, the facility failed to store and serve food under sanitary condition when staff. Failed to ensure food and beverage items in the North and South nutrition room refrigerators were labeled and dated. Failed to ensure expired foods were not stored in the North and South nutrition room refrigerators. This deficient practice is likely to affect all 112 residents listed on the resident census list provided by the Administrator on 03/09/26, and is likely lead to foodborne illnesses in residents if food is not being stored properly.

Inspectors wroteBased on observation and interview, the facility failed to provide reasonable accommodations of needs and preferences for 3 (R #25, #26 and #27) of 3 (R #25, #26 and #27) residents observed for call light access, when:The call light was outreach and for R #'s 25, 26, and 27. This deficient practice is likely to result in residents not being able to notify staff when they are in need of assistance.

Inspectors wroteBased on record review and interviews, the facility failed to ensure resident property was protected from misappropriation (the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent) for 1 (R #2) of 1 (R #2) resident reviewed for misappropriation of resident funds. If the facility fails to ensure resident property is protected from misappropriation, then residents are at risk for unauthorized use of personal funds, financial exploitation, and potential financial loss.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide quality care that meets professional standards for 1 (R #1) of 1 (R #1) residents reviewed, when staff: Administered oxygen (O2) to R #1 without a physician's order. This deficient practice is likely to result in residents not maintaining their optimal health as planned by their medical provider, and potential respiratory complications.

Inspectors wroteBased on record reviews and interviews, the facility failed to prevent a significant medication error for 1(R #1) of 1(R #1) resident reviewed, when: The facility did not have R #1's medications readily available, which prevented administration per physician orders. If the facility does not have resident's medications readily available, then residents are likely to receive incorrect or missed medication doses, which could potentially result in serious harm.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure staff utilized enhanced barrier precautions (EBP; an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) for 1 (R #2) of 1 (R #2) resident who required additional infection prevention measures due to open wounds. This deficient practice had the potential to increase the risk for the transmission of infectious organisms to staff and other residents.

Inspectors wroteBased on record review and staff interviews, the facility failed to develop and implement a complete baseline care plan within 48 hours of admission for 1 (R #3) of 1 (R #3) resident. If the facility fails to implement a complete baseline care plan within 48 hours of admission for residents with complex needs and high fall risk, then staff may lack necessary guidance to prevent injury, resulting in avoidable harm such as serious falls, hospital transfers, and worsening of clinical status.

Inspectors wroteBased on record review and interview, the facility failed to promote resident choices for 4 (R #14, 49, 59 and 71) of 4 (R #14, 49, 59 and 71) residents reviewed for choices when staff failed to: 1. Offer R #14, R #49 and R #59 showers per their preference 2. Offer R #71 to have his bed at his preferred height These deficient practices are likely to result in the resident's personal choices not being honored.

Inspectors wroteBased on record review and interviews, the facility failed to ensure staff revised the care plans for 6 (R #'s 4, 14, 31, 61, 104, and 108) of 6 (R #'s 4, 14, 31, 61, 104, and 108) residents reviewed when staff failed to: 1. Update R #4's plan of care to include Hospice Care. 2. Conduct a quarterly care plan meeting as required for R #14 in accordance with his admission date and Minimum Data Set (MDS)assessment. 3. Update R #31's plan of care to include dialysis (artificial way to eliminate waste and excess fluid from the body). 4. Ensure care plan was updated to reflect R #61's current diet. 5. Update R #104's plan of care to include diabetic management and insulin use, pain management and narcotic use, and oxygen (O2) use. 6. Update R #108's plan of care to include O2 use. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure drug regimen review were completed for 3 (R #7, R #27, and R #67) of 5 (R #7, R #13, R #27, R #67, and R #89) residents reviewed. The failure to review and consider resident medication regimens each month could result in residents receiving unnecessary or ineffective medications.

Inspectors wroteBased on observation, record review and interview the facility failed to administer medications for 2 (R #49 and R #67) of 4 (R #49, R #67, R #85 and R #105) residents with an error rate less than 5%. The facility administered 15 of 33 observed medications late for an error rate of 45.45%. Failure to administer medications without error could result in residents not receiving maximum benefit of their prescribed medications.

Inspectors wroteBased on record review and interview, the facility failed to ensure Certified Nurse Aides (CNAs) received the required in-service training of at least 12 hours per year for 3 (CNAs #1, #3, and #4) of 5 (CNAs #1, #2, #3, #4, and #5) CNAs randomly reviewed for required in-service training. This deficient practice is likely to result in the nurses aides not receiving the necessary training to meet the care needs of the residents.

Inspectors wroteBased on observation and interview the facility failed to safeguard clinical record information by leaving Private Health Information (PHI) where unauthorized persons had access to the PHI for 1 (R #49) of 1 (R #49) residents reviewed during random observation. If resident's clinical information is not sufficiently safe guarded, resident's PHI is likely to be viewed by unauthorized residents, visitors and staff.

Inspectors wroteBased on observation, record review, and interview, the facility failed to complete a thorough investigation for an allegation of abuse for 1 (R #46) of 1 (R #46) residents reviewed for incidents. If the facility is not adequately investigating allegations of abuse, then corrective action is not implemented to prevent other residents from similar abuse which puts residents at risk of adverse serious outcomes.

Inspectors wroteBased on record review and interview, the facility failed to provide sufficient preparation for discharge for 2 (R #104 and #122) of 2 (R #104 and #122) residents reviewed by: 1. Not ensuring the referral for services had been received, accepted and was scheduled to provide care for the resident upon discharge home for R #104. 2. R #122 discharged without and not accepted back to the facility without notice or without other interventions for their behaviors. These deficient practices could likely result in resident not receiving needed services and having to navigate referral process for services unassisted.

Inspectors wroteBased on record review and interview, the facility failed to meet professional standards of quality for 1 (R #46) of 1 (R #46) residents when hospice services (a type of compassionate care provided to individuals who are in the final stages of a terminal illness) were provided without physician orders. If the facility is not obtaining physician orders prior to initiating hospice services, then residents are likely to not receive the therapeutic benefits and care needed.

Inspectors wroteBased on observations, record review and interview, the facility failed to ensure that 1 (R #114) of 1 (R #114) resident was provided treatment and care to maintain her overall well-being. The facility failed to ensure that resident's brief was changed and she was repositioned to prevent the development of a wound.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure that 1 (R#58) of 1 (R #58) resident was provided with a device to reduce injury from falling. The facility failed to provide a fall mat (a soft cushion placed on the floor next to the bed to help absorb the impact of a fall and reduce injury) at the side of R #58's bed is likely to result in a resident incurring greater injury should he fall.

Inspectors wroteBased on record review and interview, the facility failed to ensure a portable oxygen tank was filled with oxygen for 1 (R #61) of 1 (R #61) residents reviewed for respiratory care (use of oxygen). This deficient practice is likely to affect residents with COPD (chronic obstructive pulmonary disease), shortness of breath and dependence on supplemental oxygen by not supplying enough oxygen in order to prevent hypoxia (decreased oxygen to the body).

Inspectors wroteBased on observation and interview, the facility failed to ensure medications were: 1. Stored properly 2. Narcotics given when signed out on the narcotic book. These deficient practices are likely to result in inaccurate medication counts and residents not getting the desired therapeutic results if medications are not administered as ordered.

Inspectors wroteBased on observation and interview, the facility failed to ensure meals were served at an appetizing temperature for 1 (R #97) of 1 (R #97) residents reviewed for meal quality. This deficient practice may decrease the resident's quality of life and have the potential to cause weight loss due to the food not being the proper temperature.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure food preference was followed for 1 (R#97) of 1 (R #97) observed for dining observation., This deficient practice could result in the resident not eating and losing weight. A. On 02/18/25 at 1:24 pm, during interview, R #97 stated I don't like eggs and they keep giving me eggs that are cold for breakfast. B. On 02/19/25 at 8:45 am, during an observation of R #97's breakfast, there were eggs on his breakfast plate which he had not eaten. C. Record review of R #97's meal ticket revealed the meal tick did not have any indication of R #97 disliking eggs. D. On 02/24/25 at 1:52 pm during an interview, Dietary Manager (DM) stated she interviews residents upon admission and she reviews their preferences every quarterly, or as needed. She confirmed that she did not know R #97 did not like eggs.

Inspectors wroteBased on a record review and interview, the facility failed to ensure medical records were complete for 1 (R #89) of 1 (R #89) residents reviewed. This deficient practice is likely to result in staff not having the information they need to provide competent, comprehensive care and services to residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure there was collaboration between the facility and hospice services for 1 (R #4) of 1 (R #4) residents reviewed for hospice services by not developing a coordinated plan of care for the resident. This deficient practice is likely to result in the residents not receiving the services needed.

Inspectors wrotePast Noncompliance Based on record review and interview, the facility failed to ensure that bathing/showering assistance was provided for 1 (R #1) of 1 (R #1) resident reviewed for ADLs (activities of daily living). This deficient practice could likely result in residents in need of this specialized care experiencing a decline in their ability to perform hygiene tasks and maintain good personal hygiene.

Inspectors wroteBased on record review and interview, the facility failed to ensure accuracy of the Minimum Data Set (MDS - a standardized assessment tool that measures health status in nursing home residents ) for 1(R #3) of 3 (R #'s 2, 3 and 4 ) resident reviewed. If the MDS assessment is inaccurate, then residents are likely to not receive the services they need or have an accurate record of the services needed and received.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that residents receive their meals in accordance with the menu schedule for 2 (R #'s 2, and 5) of 3 (R #'s 2, 4 and 5) residents reviewed during meal observations. If the facility is not ensuring that meals are served timely as scheduled, then residents are likely to be at risk of malnutrition and frustration.

Inspectors wroteBased on interview and record review the facility failed to have a Registered Nurse (RN) at least 8 hours during each 24 hour period. This deficient practice is likely to affect all 114 residents on the census list provided by the Administrator on 08/13/24. This deficient practice is likely to result in residents not receiving the services they required.

Inspectors wroteBased on record review and interview, the facility failed to meet professional standards of quality by not maintaining accurate weights for 1 (R #14) of 3 (R #13, 14 and #15) residents sampled for nutrition. This deficient practice could likely result in resident nutrition to not be accurately assessed, causing a potential for unidentified medical issues or weight gain or loss.

Inspectors wroteBased on observations and interviews the facility failed to ensure they had sufficient staff to meet the needs of all 113 residents residing in the facility when staff failed to. 1. Offer baths or showers to residents as scheduled; 2. Answer call lights timely to meet the needs of the residents. These deficient practices are likely to negatively impact resident safety, comfort, and to impede processes such as timely incontinence care (assisting residents to the bathroom or changing adult briefs), regular turning schedules (moving or turning residents that need assistance and are unable to move on their own), showers, and appropriate assistance with meals.

Inspectors wroteBased on observation, record review, and interview, the facility failed to promote residents choices for 5 (R #'s 16, 76, 94, 95, and 96) of 5 (R #'s 16, 76, 94, 95, and 96) residents reviewed for choices when staff failed to: 1. Offer R #16 showers per his preference. 2. Ensure medical appointments were not missed due to lack of transportation for R #'s 76, 95, and 96. 3. Ensure R #94 was provided clothing that fit and ensure she had clothing available. These deficient practices are likely to result in the resident's personal choices, poor hygiene, needs, and preferences not being honored.

Inspectors wroteBased on record review and interview, the facility failed to notify residents of the findings of their grievances. This deficient practice is likely to result in the facility not considering the needs of the residents.

Inspectors wroteBased on record review and interview, the facility did not ensure 2 (R #'s 92 and 107) of 3 (R #s 39, 92, and 107) residents reviewed for timely Beneficiary Protection Notification received the correct notifications form 10055: Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) . This deficient practice can result in confusion for the resident or their representative as to what services they have or do not have financial coverage for.

Inspectors wroteBased on record review and interview, the facility failed to conduct quarterly care plan meetings as required for 3 (R #'s 19, 25, and 73) of 3 (R #'s 19, 25, and 73) residents reviewed. This deficient practice is likely to result in staff not being aware of residents' care needs and preferences, and residents not receiving the needed care.

Inspectors wroteBased on observation, record review, and interview, the facility failed to meet professional standards of quality for 5 (R #'s 8, 11, 14, 21, and 73) of 5 (R #'s 8, 11, 14, 21, and 73) residents when staff failed to: 1. Label, date, and change oxygen (O2; labeling and date as to when the O2 was replaced with new tubing) for R #'s 11, 14, and 73. 2. Ensure humidifier bottles (bottles with distilled water used to provide humidity) on O2 were full for R #8 and #21 If the facility is not changing and labeling oxygen tubingand not ensuring humidifier bottles were full then residents are likely to not receive the therapeutic benefits and care needed.

Inspectors wroteBased on record review and interview, the facility failed to ensure the resident's ability to perform activities of daily living (ADLs) was maintained for 2 (R #'s 14 and 42) of 2 (R #'s 14 and 42) residents reviewed for restorative therapy (therapy in which a patient trains on abilities they already have to perfect them and helps maintain physical abilities to perform ADLs.) If the facility does not ensure that residents receive restorative services, then the residents are likely to experience a decrease in their ability to walk, transfer (move from one place to another), and do other activities of daily living.

Inspectors wroteBased on record review and interview, the facility failed to: 1. Ensure an elopement risk assessment was completed for a resident with elopement risks. 3. Ensure the elopement book was updated to include R #34 These deficient practices are likely to put residents at risk of unsafe situations.

Inspectors wroteBased on observation, interview, and record review the facility failed to meet professional standards of quality for 2 (R #62, and R #118) of 2 (R #62 and R #118) residents when staff failed to: 1. Ensure oxygen was not administered without a physician's order. 2. Ensure oxygen was administered in accordance with the physician's orders 3. Ensure BIPAP (machine that can help push air into lungs) was administered in accordance with physician's orders. If the facility is not administering oxygen as prescribed and without an order then the residents are likely to not get the therapeutic results as needed or administered if not needed.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff communicated and collaborated with the dialysis (clinical purification of blood as substitute for normal kidney functioning) facility regarding dialysis care and services for 1 (R #94) of 1 (R #94) residents reviewed for dialysis. If the facility is unaware of the status, condition, or complications that arise during dialysis treatment then residents are likely not to receive the appropriate monitoring and care they need.

Inspectors wroteBased on record review and interview, the facility failed to ensure 1 (R #109) of 1 (R #109) resident's reconciliation (the process of ensuring the number on the medication log and the number of pills in the container are the same) of medication log was accurate. Failure to accurately document when medications are dispensed and administered are likely to cause medication errors resulting in over-dosing or under-dosing residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure 4 (R #34, 51, 65, 76) of 5 (R #9, 34, 51, 65, 76) resident's medications were reviewed by the pharmacist and physician and acted on. These deficient practices are likely to cause residents to receive unnecessary medications, experience potential unnecessary drug interactions or adverse side effects.

Inspectors wroteBased on record review and interview, the facility failed to ensure medications were administered as ordered by the Physician for 1 (R #110) of 2 (R #110 and 156) residents reviewed for medication administration. This deficient practice is likely to result in a resident failing to obtain maximum wellness and/or suffering prolonged illness.

Inspectors wroteBased on observation and interview the facility failed to: 1. Ensure medications and other medical supplies were properly stored and not expired. 2. Ensure temperatures for medication room and refrigerators were monitored daily as per facility procedure. 3. Ensure medication carts were locked when not in use. This deficient practice is likely to result in medications losing their potency and affect the quality of specimens needed for lab tests.

Inspectors wroteBased on observation, interview, and record review the facility failed to deliver meals consistently and timely for all 113 residents in the facility. This deficient practice could potentially lead to frustration and hunger.

Inspectors wroteBased on observation and interview, the facility failed to provide food according to U.S. Food and Drug Administration (FDA) Food Code, 2022 edition, for 2 (R #8 and #9) of 2 (R #8 and #9) residents observed for hot food temperature. This deficient practice is likely to result in residents getting a foodborne illness or having weight loss.

Inspectors wroteBased on record review and interview, the facility failed to ensure staff offered COVID -19 (a highly infectious viral disease) vaccinations to 2 (R #'s 63 and 76) of 4 (R #37, #40, #63, #76, and #110) residents reviewed for COVID-19 vaccines. This deficient practice could likely result in residents at risk of exposure to COVID-19 related infections.

Inspectors wroteBased on record review, observation and interview the facility failed to properly inform 1 (R #93) of 1 (R #93) resident of treatment decisions by failing to utilize interpreter line (service used for communication) to communicate with resident in a language the resident could understand. If the facility is not able to communicate with residents then residents are likely not to get their needs met.

Inspectors wroteBased on observation and interview, the facility failed to maintain an environment that was clean, in good condition, and had basic toiletries (paper towels, etc) for 2 (R #'s 61 and 109) of 2 (R #'s 61 and 109) residents sampled for a homelike environment. Failure to maintain the building in a clean and comfortable manner is likely to result in unsafe conditions and prevent residents from enjoying everyday activities.

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 1 (R # 40) of 1 (R #40) residents reviewed for pressure ulcers (localized damage to skin/tissue occurs as a result of pressure) and pain. This deficient practice is likely to result in residents experiencing pain or a worsened condition.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents received foot treatment and care in accordance with professional standards of practice for 1 ( R #62) of 1 (R #62) residents reviewed for foot care and dressing changes. This deficient practice is likely to result in residents experiencing worsened wound conditions.

Inspectors wroteBased on observation and interview, the facility failed to provide food according to the residents meal tickets for 4 (R #25, R # 32 , R #64, and R #93) of 4 (R #25, R # 32 , R #64, and R #93) residents observed during lunch. This deficient practice is likely to result in weight loss due to residents not meeting caloric intake goals.

Inspectors wroteBased on observation and interview, the facility failed to ensure a garbage can was covered and not placed in a food storage area. This practice had the potential to affect all 113 residents, as listed on the facility census provided by the Administrator on 02/12/24, by attracting insects and rodents into the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide proper infection control practices when staff failed to: 1. Wash hands before and change gloves after performing peri-care (cleaning the private areas of a resident) and prior to cleaning wound. 2. Change gloves after administering wound care. 3. Ensure clean bandages did not touch a non-clean surface (bed). 4. Dispose of soiled bandages in proper receptacle for items that contain biohazards waste and not disposing in resident rooms If the facility is not using proper infection control practices the residents are likely to acquire infections.

Inspectors wroteBased on observation and interview, the facility failed to have the most recent survey results in a place readily accessible (such as a lobby or other area frequented by most residents, visitors, or other individuals) to all 113 residents that resided in the facility. If residents are unable to locate the latest survey results conducted by State Surveyors, then residents, representatives, and visitors are unable to know how the facility is doing and make decisions accordingly.

Inspectors wroteBased on record review and interview, the facility failed to ensure a discharge was properly documented in the resident's medical record and provide a completed discharge plan for 2 (R #'s 2 and 3) of 2 (R #'s 2 and 3) residents reviewed for discharge. This deficient practice is likely to result in residents not having what they need for a safe discharge.

Inspectors wroteBased on record review and interview, the facility failed to provide ADL (Activities of Daily Living) assistance for baths/showers for 1 (R #1) of 2 (R #'s 1 and 3) 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 promote resident choices by not assisting residents with showers per their requested schedule and preference for 1 (R #4) of 1 (R #4) residents reviewed for choices . This deficient practice is likely to result in the resident's personal choices, poor hygiene, needs, and preferences not being honored.

Inspectors wroteBased on record review and interview, the facility failed to honor residents' rights by discharging a resident to hospital without providing proper notice and planning to one (R #1) of one (R #1) residents reviewed for discharge and planning. This deficient practice is likely to result in the resident experiencing feelings of frustration, fear and anxiety about where they will be residing after discharge from facility. A. Record review of facesheet revealed R #1 was admitted to facility on 01/17/22 with the following diagnosis: 1. Schizophrenia, unspecified (Mental condition that involving breakdown between thoughts, emotion and behavior, leading to faulty perception) 2. Anxiety disorder, unspecified (Mental illness that causes distressing and disruptive thoughts) 3. Major depressive disorder (Tendency of an individual to suffer recurrent episodes of depressed B. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure medications were administered as ordered by the Physician, for 1 (R #5) of 1 (R #5) resident reviewed for medication administration. This deficient practice is likely to result in a resident failing to obtain maximum wellness and/or suffering prolonged illness.