Taos Healthcare

Inspectors wroteBased on the interview and record review, the facility failed to ensure that grievances were consistently tracked, resolved, and communicated back to residents. If the facility is not responding to resident concerns, then residents may feel unimportant and this may impact their mental health as well as their physical health if residents are not receiving the appropriate meals and receiving regular showers.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure a safe, clean, and homelike environment when staff failed to:- Ensure residents consistently had access to hot water.- Maintain the dining room in a homelike manner.- Maintain resident rooms and restrooms in good repair. These failures had the potential to affect all residents who utilize the dining room and all residents in eight sampled resident rooms. If the facility does not ensure resident rooms and common areas are clean, free from pests, and maintained in good repair, then residents are at risk of decreased quality of life, pest infestation, injury due to unsafe environmental conditions, and infections due to hot water not being available.

Inspectors wroteBased on record review and interview, the facility failed to meet professional standards for 2 (R #'s 9 and 104) of 2 (R #'s 9 and 104) residents by: Allowing R #9 to use and store respiratory medical equipment without physician orders. Not following R #104's care plan to complete weekly skin assessments/checks. If the facility is not adhering to professional standards for quality improvement, the resident is not likely to get the highest quality of care.

Inspectors wroteBased on record review and interviews, the facility failed to complete an annual performance review of Certified Nursing Assistants (CNAs) for 3 (CNAs #4, #6, and #7) of 5 (CNAs #3, #4, #5, #6, and #7) CNAs randomly reviewed. If the facility is not completing a performance review of every CNA at least once every 12 months, then residents are likely to not receive the appropriate care and services, and the CNAs may not meet the needs of all residents.

Inspectors wroteBased on observations, record reviews, and interviews; the facility failed to ensure medication error rate did not exceed five percent for 3 (R #16, R#26, and R #61) of 3 (R #16, R#26, and R #61) residents. The medication error rate was 11.54% from staff administering 26 medications with 3 errors. This deficient practice is likely to result in medications continuing to be administered incorrectly, increasing the risk for adverse outcomes and potential harm.

Inspectors wroteBased on observation and interviews the facility failed to properly store medical supplies located in the facility medication storage room. This deficient practice is likely to result in expired medical equipment being used for resident care leading to potential infection risk, as sterility is lost over time allowing introduction of bacteria.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure residents were served meals consistent with posted menus and food preferences were followed for 5 (R #) of 5 (R #) residents reviewed for dining when: The facility did not change nor follow the posted menus. R #22 did not receive food according to her meal ticket. R #86 was not served food according to preference. This deficient practice is likely to result in residents being unable to make informed meal choices and not receiving meals consistent with their preferences.

Inspectors wroteBased on observation and interviews, the facility failed to ensure food was stored, handled, and monitored under sanitary conditions when they failed to:Ensure food items were properly stored and protected in a manner to prevent cross contamination and outdated use. Ensure required dish machine, refrigerator, and freezer temperature daily logs were up to date. Ensure staff responsible for food safety were knowledgeable of safe food temperatures. This deficient practice could likely affect all 94 residents identified on the resident census list provided by the Administrator on 01/11/26. If food was not stored, handled, and monitored under sanitary conditions then residents are at an increased risk of contracting food born illness.

Inspectors wroteBased on observation, and interviews the facility failed to maintain a safe and sanitary environment for 2 (R #'s 9 and 16) of 2 (R #'s 9 and 16) residents reviewed, when:R #9's respiratory spirometer (an instrument for measuring the air capacity of the lungs) and nebulizer (a medical device that delivers medication in the form of a fine mist directly into the lungs) was not stored appropriately to maintain cleanliness. The facility failed to administer a new medication for R #16 after a medication was removed from packaging which fell on top of medication cart and was placed back into medication cup by nurse. This deficient practice is likely to result in the transmission of infectious agents to the residents.

Inspectors wroteBased on record review and interview, the facility failed to maintain documentation related to staff COVID-19 (an acute respiratory infection caused by the SARS-CoV-2 virus) vaccinations that included staff were provided education regarding the benefits and potential risks associated with the COVID-19 vaccine, staff were offered the COVID-19 vaccine or information on obtaining a COVID-19 vaccine, and the COVID-19 vaccine status of staff and related information was available for all staff that work in the facility. This deficient practice could likely lead to residents contracting respiratory infections and could result in the spread of infection to other residents.

Inspectors wroteBased on record review and interviews, the facility failed to ensure psychotropic medication (medication used to treat mental health conditions) consent forms were signed by the resident or resident representative prior to medication administration for 3 (R #'s 3, 6, and 8) of 3 (R #'s 3, 6, and 8) residents reviewed for unnecessary psychotropic drugs. This deficient practice is likely to put residents at an increased risk for undesirable side effects (including but not limited to; increased thoughts of suicide, insomnia, fatigue, sexual dysfunction) associated with the use of these medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from abuse for 1 (R #25) of 1 (R #25) resident reviewed, when:Facility nursing staff used threatening language via text messages to R #25 while on approved facility leave. A facility nurse inappropriately touched R #25's foot when he returned to the facility after approved facility leave. If the facility performs inappropriate use of text messaging and touching, then residents are at risk for physical injury and psychological harm, including fear or distress related to staff interactions.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR; 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) Level 1 screening was completed accurately for 1 (R#6) of 1(R #6) resident reviewed, when the PASRR level 1 indicated no mental health diagnosis despite admission documentation identifying a diagnosis of bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). This deficient practice could result in the facility failing to identify and address residents' mental health needs and ensure appropriate screening and services at admission.

Inspectors wroteBased on record review and interview, the facility failed to revise the care plan for 1 (R #11) of 1 (R #11) resident reviewed for oxygen (O2) use. If the facility is not updating the care plan to reflect the residents' current care areas and treatment, then the facility may not be providing the appropriate care and treatment to meet the residents' needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure pain management was provided in accordance with professional standards for 1 (R #25) of 3 (R #21, 25 and 60) when staff administered pain medication to a resident when the resident reported pain levels of 2 - 7, which did not meet the physician's ordered parameters of 8 or higher. If staff are not following physicians' orders then residents are at risk of being over medicated and may have inadequate pain control.

Inspectors wroteBased on observation, record review, and interviews; the facility failed to acquire medications for 1 (R #61) of 9 (R 35, R #16, R #26, R #58, R #61, R #65, R #67, R #89, and R #103) residents. This deficient practice is likely to result in missed doses of medication continuing, and potentially lead to serious harm, exacerbation of disease process, or other adverse outcomes for residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure the results of all investigations of allegations of abuse, neglect, and injuries of unknown source were submitted to the State Agency within 5 working days for 1(R #1) of 1(R #1) resident. If the facility is not submitting the five-day follow-up, residents are likely to be at risk of further abuse/neglect.

Inspectors wroteBased on record review and interview, the facility failed to thoroughly investigate allegation of abuse for 1 (R #1) of 1 (R #1) resident reviewed for abuse. If staff do not thoroughly investigate allegations of abuse, then the other residents are at risk of abuse which may cause physical, emotional, and psychological harm.

Inspectors wroteBased on record review, observation, and interview, the facility failed to store and serve food under sanitary conditions when staff failed to: 1. Ensure opened food items in the refrigerator, freezer, and dry storage room were dated and labeled. 2. Ensure staff utilized a sanitizing solution when cleaning various food related surfaces. 3. Ensure eggs and cheese were stored in a manner to prevent food borne pathogen growth when not in the refrigerator. 4. Ensure all storage areas are kept clean and free of debris. 5. Ensure kitchen staff wore their face mask appropriately. These deficient practices are likely to affect all 85 residents listed on the resident census list and are likely lead to foodborne illnesses if food is not being stored properly and safe food handling practices are not adhered to.

Inspectors wroteBased on record review and interview, the facility failed to give written notice for a room change, including the reason for the change, before the residents were moved for 2 (R #1 and R #3) of 2 (R #1 and R #3) residents. This deficient practice is likely to result in frustration and confusion for residents.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure 3 (R #5, #6 and #7) of 3 (R #5, #6 and #7) residents reviewed had a working portable concentrator. This deficient practice is likely to have a resident become hypoxic (having too little oxygen in the blood).

Inspectors wroteBased on record review and interview, the facility failed to notify the Providers (Physicians and Nurse Practitioners) of a change in condition in which a resident began to have behaviors for 1 (R #1) of 1 (R #1) residents reviewed for change of condition. If the physician is not notified of changes in residents status then residents are likely to not get the care needed.

Inspectors wroteBased on record review and interview, the facility failed to complete and document a thorough investigation had been done for 1 (R #1) of 2 (R #1 and #8) residents reviewed for an allegation of abuse. If the facility fails to complete thorough investigations residents are likely to feel frustrated and unsafe.

Inspectors wroteBased on record review and interview, the facility failed to include required information in the residents medical record for transfer or discharge for 1 (R #1) of 1 (R #1) residents reviewed for discharges. This deficient practice is likely to result in resident and residents family being unable to locate an appropriate placement putting the residents at risk of an unsafe discharge.

Inspectors wroteBased on interview, record review, and an observation of the [NAME] Unit, the facility failed to ensure a medication cart remained locked when not in use. This deficient practice is likely to result in residents having access to the medications in the unlocked medication cart.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure the facility had sufficient staff to meet the needs of all 77 residents who resided in the facility when staff failed to: 1. Offer baths or showers to residents as scheduled and per resident preference. 2. Effectively communicate with residents to meet their needs. These deficient practices are likely to negatively impact resident comfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the kitchen in a sanitary manner when staff failed to: - Store food in a manner that prevented cross contamination when staff did not label and date open food items. - Utilize hair restraints and beard guards in a manner which restrained all hair while in the kitchen. - Test the sanitizer level in a sanitizing bucket. - Failure to store ice scoop appropriately. These failures have the potential to result in cross contamination, the growth of foodborne pathogens, and foodborne illness. This failure had the potential to affect all residents who ate food from the kitchen.

Inspectors wroteBased on record review and interview, the facility failed to promote resident choices for 2 (R #72 and #175) of 2 (R #72 and #175) residents reviewed for choices when staff failed to: 1. Accommodate R #72's choice to have his pacemaker (a device that stimulates the heart rate when it is beating too slowly) monitor present in the facility. 2. Offer R #175 showers per his preference. These deficient practices are likely to result in the resident's personal choices not being honored.

Inspectors wroteBased on interview, the facility failed to ensure residents received mail on Saturdays for all 77 residents who resided 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 observation, record review, and interview, the facility failed to ensure staff revised the care plan for 4 (R #19, #39, #71, and #72) of 4 (R #19, #39, #71, and #72) residents reviewed when staff failed to: 1. Update the care plan to include a wander guard (wearable technology used to keep residents from wandering or eloping from the facility unattended) use for R #19 and #39. 2. Update the care plan to include family assistance with activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) care for R #71. 3. Update the care plan to include the use of a fall mat for R #72. These deficient practices are likely to result in residents' care and needs not being addressed if care plans are not updated.

Inspectors wroteBased on record review and interview, the facility failed to provide activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) assistance for baths and showers by the facility staff for 1 (R #58) of 1 (R #58) residents reviewed for ADL care. This deficient practice is likely to affect the dignity and health of the residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide restorative physical therapy service devices as recommended by the therapy department for 1 (R #37) of 1 (R #37) residents. This deficient practice is likely to result in residents having pain and a decrease in mobility, causing psychosocial harm and despair.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure 2 (R #12 and #62) of 2 (R #12 and #62) residents reviewed for behavioral health concerns received necessary behavioral health care to meet their needs when staff failed to ensure effective communication between the facility and psychiatric providers and provide consistent psychiatric services to meet R #12 and #62 psychiatric service needs. These deficient practices are likely to result in the residents not receiving the behavioral or mental health care and assistance needed to improve mood and reduce depression and anxiety.

Inspectors wroteBased on record review and interview, the facility failed to ensure 4 (R #13, #21, #48, and #6) out of 5 residents (R #13, #21, #48, #6 and #14) reviewed for immunizations had completed and signed consent/refusal forms on file to show they consented to or declined the pneumococcal (for pneumonia, an infection in one or both lungs) and influenza (flu) vaccines. If residents are not vaccinated as appropriate against pneumonia and influenza they have a higher likelihood of contracting that illness and spreading it to other residents and staff in the facility.

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 2 (CNAs #3 and #4) of 5 (CNAs #3,#4, #5, #6, and #7) 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, record review, and interview, the facility failed to promote care with dignity and respect for 1 (R #19) of 1 (R #19) residents reviewed for residents' rights by placing a WanderGuard (a bracelet that sets off an alarm when the person wearing it attempts to exit the building) on a resident who did not attempt to leave the facility grounds. This deficient practice is likely to result in residents feeling as if they were kept in the facility against their will.

Inspectors wroteBased on observation, record review, and interview, the facility failed to prevent an accident for 1 (R #75) of 1 (R #75) residents reviewed for falls: 1. When the facility failed to routinely assess R #75 to check for injuries following the first fall. 2. When the facility failed to follow post-fall protocols after R #75's first and second falls. These deficient practices likely resulted in R #75 having falls with injuries that required treatment at the hospital.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that ileostomy [a surgical procedure in which the last part of the small intestine (ileum) is connected to the abdominal wall and an opening (stoma) is created in the abdominal wall to allow waste to leave the body] care was consistent with professional standards of practice for 1 (R #13) of 1 (R #13) resident when the ostomy bag and the abdominal binder (wide compression belt that encircles the abdomen) was not consistently offered/applied per physician order. This deficient practice could likely result in skin breakdown/infection around the ostomy opening.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Elopement Risk Evaluation was accurate for 1 (R #19) of 1 ( R #19) residents reviewed when staff did not accurately complete R #19's evaluation to reflect the resident's elopement risk. This deficient practice is likely to result in resident not receiving the appropriate care and treatment he may need.

Inspectors wroteBased on observation and interview, the facility failed to ensure the bedroom for 1 of (R#3) of 1 (R #3) residents was clean, without food debris and used medical equipment on the floor. This deficient practice is likely to make the resident feel as if he was not important and he did not matter to the facility.

Inspectors wroteBased on record review and interview, the facility failed to promote residents' choices for 2 (R #4 and #5) of 2 (R #4 and #5) residents reviewed for choices when staff placed a bladder control pad (products made for incontinence control to pull moisture away from your skin) in the briefs of residents. These deficient practices are likely to result in the resident's personal choices, needs, and preferences not being honored.

Inspectors wroteBased on record review and interview, the facility failed to revise the care plan for 1 (R #1) of 3 (R #1, 2, 3) residents reviewed for falls. If the facility is not updating the care plan to reflect the resident's current care needs and treatments, then the facility may not be providing the appropriate care to meet the resident's needs.

Inspectors wroteBased on interview, the facility failed to ensure that residents and resident representatives have a right to voice grievances to the facility without fear of discrimination or retaliation (the act of hurting someone or doing something harmful to someone, because they have done or said something harmful to you) for 7 (Anonymous residents/representatives) identified during random review. This deficient practice could likely result in residents not getting the care and assistance needed or feel like they must discharge from the facility to get the care needed/desired which may be further away from family support.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure staff updated the care plan to reflect the current conditions for 2 (R #5 ad 14) of 2 (R #5 and 14) residents reviewed during random observation. If the care plan is not updated to reflect the residents current conditions, then residents may not get the care and assistance needed.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide an ongoing activity program to meet the residents' interests and support residents' psychosocial well-being for 5 (R #1, 4, 11, 12 and 13) of 5 (R #1, 4, 11, 12 and 13) residents reviewed for activities and during random observation. If the facility is not providing engaging activities to residents then residents are at risk of boredom, depression, and decrease in quality of life.

Inspectors wroteBased on record review and interview, the facility failed to ensure that staff monitor anxiety symptoms and the effectiveness of anxiety medications being administered for 1(R #4) of 1(R #4) resident identified during random observation. If the facility is not monitoring for the use of psychotropic medications then resident may not be getting adequate relief and treatment from symptoms.

Inspectors wroteBased on record review, observation, and interview the facility failed to ensure the medical record accurately reflected resident's level of assistance and advanced directives for 6 (R #2, 7, 9, 14, 15 and 16) of 16 (R #1-16) residents reviewed for feeding assistance and during random observation. If resident medical records are not accurate, then there is not an accurate history of residents care.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the call light functioned for 2 (R #4 and R #8) of 4 (R #2, #4, #8 and #13) resident reviewed for call lights within reach and during random observation. If residents are unable to request staff assistance when needed then residents are likely not able to get their needs met.

Inspectors wroteBased on record review, observation, and interview, the facility failed to provide accommodation of residents needs for 1(R #4) of 4 (R #2, 4, 8 and 13) residents reviewed for call lights within reach and during random observation, when the call light/pressure pad call light was not within resident's reach. This deficient practice is likely to result in residents being unable to request assistance, such as needing help with transferring, after falling, or other acute distress.

Inspectors wroteBased on record review and interview, the facility failed to notify the resident representative of resident change in conditions which required hospital transfer for 2 (R #1 and 8) of 2 (R #1 and 8) residents reviewed for wound care and during random observations. This deficient practice could likely result in the resident representative unable to provide advocacy and make medical decision when needed.

Inspectors wroteBased upon record review, observation, and interview the facility failed to ensure that 1 (R #4) of 1 (R #4) resident observed during random observation was free from neglect when facility staff failed to respond to R #4's cries/yelling out. This deficient practice could likely result in residents going without the assistance, care, or treatment needed and/or experiencing feelings of helplessness and not being cared for, resulting in mental anguish (a degree of mental pain and suffering that arises from another person's negligence - failure to exercise the care that a reasonably sensible person would exercise in like circumstances).

Inspectors wroteBased on record review and interview, the facility failed to transport residents to physician appointments for 1 (R #8) of 1 (R #8) resident reviewed for follow up appointments. This deficient practice could likely cause delays in needed care and/or treatment prolonging the healing process.

Inspectors wroteBased on interviews the facility failed to ensure that they had sufficient staff to guarantee the needs of all 88 residents residing in the facility. 1. Offering baths/showers to residents; 2. Changing residents briefs timely; 3. Having enough facility staff 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), timely showers and appropriate assistance with meals.

Inspectors wroteBased on record review and interview, the facility failed to ensure the nutritional needs and preferences were met for all 88 residents, listed on the resident census provided on 08/07/23. If staff do not follow the menu and do not have the specified menu items on hand to meet this requirement then residents are not likely to not receive the appropriate nutrition.

Inspectors wroteBased on interviews, the facility failed to: 1. Provide hydration between meals; 2. Provide coffee during breakfast meal. These deficient practices are likely affect all 88 residents listed on the census as provided by the Director of Nursing (DON) on 08/07/23 and likely result in residents becoming at increased risk for dehydration.

Inspectors wroteBased on observation, interview, and record review the facility failed to deliver meals consistently and timely for all 88 residents in the facility. This deficient practice could potentially lead to frustration and hunger.

Inspectors wroteBased on record review and interview, the facility failed to ensure staff implemented a comprehensive antibiotic stewardship program (a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use). This deficient practice has the potential to affect any of the 88 residents identified on the census provided by the Director of Nursing (DON) on 08/07/23, and who might be placed on antibiotics, which could result in the inappropriate use of antibiotics and that can lead to resistance of multi-drug resistant organisms.

Inspectors wroteBased on interview and observation, the facility failed to respond to resident grievances, regarding another resident yelling and cussing, for 1 (R #61) of 1 (R #61) resident reviewed. If the facility fails to respond to residents' grievances then residents are likely to feel uncomfortable and could exacerbate (make worse) health issues.

Inspectors wroteBased on record review and interview, the facility failed to ensure the care plan was revised for 4 (R #'s 14, 37, 59 and 91) out of 5 (R #'s 1, 14, 37, 59, and 91) residents reviewed by: 1. Not conducting quarterly care plan meetings as required for R #'s 14, 37, and 59; 2. Not updating a care plan to reflect oxygen (O2) use for R #59 and hospice (health care that focuses on the palliation of a terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) services for R #91. These deficient practices are 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 2 (R #'s 57 and 59) of 2 (R #'s 57 and 59) residents by not 1. Changing R #57's oxygen (O2) weekly as ordered; 2. Labeling, dating, and changing O2 for R #59. If the facility is not changing and labeling oxygen tubing then residents are likely to not receive the therapeutic benefits and care needed.

Inspectors wroteBased on record review and interview, the facility failed to provide ADL (Activities of Daily Living) assistance for 2 (R #'s 1 and 32) of 2 (R #'s 1 and 32) residents reviewed for ADL care by not: 1. Changing R #1's wet brief; 2. Providing baths/showers for R #32. These deficient practices are likely to affect the dignity and health of the residents if they are left in wet briefs or are not offered a bath or shower on a regular basis.

Inspectors wroteBased on record review and interview, the facility failed to assure physicians responded to the pharmacist's recommendations submitted during the pharmacist's monthly medication review and obtain physician rational, specific to the resident, which agreed or disagreed with the pharmacist's recommendations for 1 (R #2) of 6 (R #'s 1, 2, 6, 14, 35, and 79) residents reviewed for unnecessary medications. This deficient practice is likely to cause resident medication regimen to not be properly evaluated resulting in possible over medication.

Inspectors wroteBased on record review and interview, the facility failed to ensure psychotropic medication (medication used to treat mental health conditions) consent forms were signed by the resident or resident representative prior to medication administration for 5 (R #'s 6, 9, 45, 52, and 56) of 5 (R #'s 6, 9, 45, 52, and 56) residents reviewed for unnecessary psychotropic drugs. This deficient practice is likely to put residents at an increased risk for undesirable side effects (increased thoughts of suicide, insomnia, fatigue, sexual dysfunction) associated with the use of these medications.

Inspectors wroteBased on observation and interview, the facility failed to: 1. Ensure expired medications are discarded and not stored in the cart; 2. Ensure expired medications were not stored with unexpired medications; 3. Ensure medications, stored on medication cart for 200 and 300 halls, were kept in their original labeled packaging and in a manner that maintains the sterility of the product. These deficient practices are likely to negatively impact the health of residents if they received expired, potentially ineffective/compromised, or contaminated medications and medical supplies due to inappropriate storage.

Inspectors wroteBased on record review and interview, the facility failed to ensure Certified Nurse Aides (CNA's) received the required in-service training of not less than 12 hours per year for 7 (CNA #13, CNA #14, CNA #15, CNA, #16, CNA #17, CNA #18, and CNA #19) of 7 (CNA #13, CNA #14, CNA #15, CNA, #16, CNA #17, CNA #18, and CNA #19) CNA's 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 interview and record review, the facility failed to provide reasonable accommodations of resident needs and preferences for 2 (R #7 and 66) of 2 (R #7 and 66) residents reviewed by: 1. Not accommodating R #7's preference for what time she gets up in the morning; 2. Not accommodating R #66's preference of using pull-up's (disposable underwear) for incontinence (loss of bladder control). If facility is not honoring resident preferences then residents are not able to make choices about aspects of their lives which are important to them. This deficient practice is likely to result in the resident's life style, personal choices, needs, and preference not being met.

Inspectors wroteBased on record review and interview, the facility failed to notify the resident's Power of Attorney (POA) when an accident occurred for 1 (R #1) of 1 (R #1) residents reviewed for falls. If the facility does not notify the POA when the resident has a fall then the POA is unable to make decisions related to treatment and advocate for the resident's care.

Inspectors wroteBased on interview, observation, and record review, the facility failed to develop a discharge plan that focused on the resident's individualized discharge goals and needs for 3 (R #'s 35, #88 and #89) of 3 (R #'s 35, #88 and #89) residents reviewed for discharge planning. This deficient practice is likely to prevent a safe transition from the facility to the resident's post-discharge setting.

Inspectors wroteBased on record review and interview, the facility failed to ensure that 1 (R #50) of 1 (R #50) resident, reviewed during random observation, received the appropriate supervision to prevent or minimize the risk of elopement (an unauthorized departure of a patient from an around-the-clock care setting) when the facility failed to notify facility leadership of an elopement attempt and revise the elopement risk assessment and the plan of care. This deficient practice could likely put residents at risk of unsafe situations.

Inspectors wroteBased on record review and interview, the facility failed to maintain oxygen (O2) equipment according to professional standards for 2 (R #'s 59 and 76) of 2 (R #'s 59 and 76) residents reviewed for respiratory care by applying R #59's O2 saline and concentrator on R #76 in error. This deficient practice could likely result in oxygen tubing not being changed according to the date of install or the previous replacement and using humidifier bottles without physician instruction.

Inspectors wroteBased on observation and interview, the facility failed to: 1. Ensure safe serving temperatures (cold foods: equal to or less than 40 degrees Fahrenheit and hot foods: equal to or greater than 135 degrees Fahrenheit) were maintained for room trays awaiting to be distributed to the residents; 2. Ensure cups of milk were maintained temperature below 40 degrees. These deficient practices are likely to cause resident to suffer from food borne illnesses if food is not served at the proper temperature.

Inspectors wroteBased on observation, record review, and interview the facility failed to maintain proper infection prevention measures for 1(R #59) of 1(R #59) resident reviewed during random observation by: 1. Facility staff storing R #59's Oxygen (O2) tubing non-covered and on a chair and R #59's O2 tubing being on the floor.