White Sands Healthcare

Inspectors wroteBased on record review, observation, and interviews, the facility failed to obtain consent from a resident representatives prior to giving a significant haircut to a resident living on the memory care unit for 1 (R #2) of 4 (R #1, R #2, R #3 and R #4) residents reviewed. This deficient practice could likely result in residents feeling a loss of humanity and dignity.

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 #2, R #6, and R #9) of 5 (R #2, R #5, R #6, R #9, and R #31) residents reviewed for unnecessary medications, when staff failed to:1. Ensure psychotropic medications were necessary to treat a specific condition as diagnosed and documented in the clinical record for R #2.2. Ensure as needed psychotropic medications are limited to only 14 days or indicate the duration of the as needed (PRN) order for R #9. These deficient practices could likely lead to adverse drug effects and poor patient outcomes.

Inspectors wroteBased on record review and interview the facility failed to complete an accurate Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) assessment for 2 (R #9 and R #31) of 4 (R #5, R #9, R #11, and R #31) residents reviewed for assessments. This deficient practice could likely result in the residents' preferences and care needs not being met.

Inspectors wroteBased on record review and interview, the facility failed to create an accurate baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) for 2 (R #114 and R #115) of 4 (R #5, R #9, R #114 and R #115) 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 observation and interview, the facility failed to ensure food was served under sanitary conditions when staff failed to follow safe food handling practices when they:1. Touched the rims of cups while serving residents' drinks.2. Failed to sanitize their hands after touching dirty (items that may be soiled or contaminated) and serving residents' meals. These deficient practices are likely to affect all 111 residents listed on the resident census list provided by the Administrator on 03/08/26 and are likely to lead to foodborne illnesses in residents if safe food handling practices are not adhered to and stored properly.

Inspectors wroteBased on record review and interview, the facility failed to ensure the PASARR (Preadmission Screening and Resident Review) Level I Identification Screen was accurate for 2 (R #68 and R #98) of 5 (R #1, R #2, R #10, R #68, and R #98) residents reviewed for PASARR screening. If the facility does not ensure PASARR screenings are completed accurately, then residents with serious mental illness may not receive required evaluations or specialized services, placing them at risk for unmet mental health needs and a decline in psychosocial well-being.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure staff revised the care plan for 2 (R #8 and R #59) of 8 (R #1, R #2, R #4, R #6, R #7, R #8, R #10, and R #59) residents reviewed when staff failed to: -Revise R #8's care plan using his name, not another resident's name.-Revise R #59's care plan to indicate a fall mat was in use. These deficient practices are likely to result in residents' care and needs not being addressed if care plans are not updated accurately.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide respiratory care in accordance with professional standards for 1 (R #9) of 5 (R #2, R #4, R #8, R #9, and R #31) residents reviewed for respiratory care when the facility failed to ensure medical orders indicated when to administer R #9's oxygen. These deficient practices are likely to result in residents receiving too much or not enough oxygen and can lead to worsening of their conditions.

Inspectors wroteBased on observation, record review, and interview, the facility failed to obtain appropriate physician orders prior to installation of bed rails for 1 (R #5) of 3 (R #5, R #11, and R #31) residents reviewed for bedrails. This deficient practice could result in the physician, staff, and residents not knowing the needs, risks and benefits of bed rails.

Inspectors wroteBased on observation and interview, the facility failed to post nurse staffing data daily at the beginning of the shift that included the following:- Facility name.-The current date.-The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift.1. Registered nurse,2. Licensed practical nurse,3. Certified nurse aides,4. Resident census. The deficient practice has the potential to affect all 111 residents as identified by the census provided by the Administrator (ADM) on 03/08/26 and could likely result in residents and visitors not having the staffing information readily available.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all medications were not expired in the medication storage room. This deficient practice has the potential to affect any resident requiring emergency opioid overdose reversal by providing a medication with potentially reduced efficacy.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain proper infection prevention measures for 2 (R #5 and R #115) of 4 (R #4, R #5, R #10, and R #115) residents reviewed by not:1. Ensuring Personal Protective Equipment (PPE) was properly used,2. Ensuring Enhanced Barrier Protection (EBP) signage is visibly posted and PPE is available near resident's room when precautions are in place. These deficiencies place residents at risk of contracting infections, hospitalization, and death.

Inspectors wroteBased on record review and interview, the facility failed to keep a resident free from abuse for 1(R #4) of 8(R #1-8) residents reviewed for abuse when Nurse Aide in Training (NAIT) #2 was verbally and physically abusive to R #4 when providing care. This deficient practice likely resulted (based upon the reasonable person standard) in R #4 experiencing emotional distress and trauma.

Inspectors wroteBased on record review and interview, the facility failed to report an allegation of abuse for 1(R #4) of 8(R #1-8) residents reviewed for abuse, when staff waited 7 days to report witnessed staff to resident abuse. If the staff fail to report allegations of abuse to the facility administration, then corrective measured may not be acted on and the facility would be unable to assure residents are free from abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Nurse Aide in Training (NAIT) completed a Nurse Aide Training and Competency Evaluation Program (NATCEP) or a Competency Evaluation Program (CEP) within four months of being employed at the facility. This deficient practice is likely to affect all 108 residents residing at the facility by allowing untrained staff to provide direct care to residents.

Inspectors wroteBased on record review and interview, the facility failed to prevent an accident for 1 (R #1) of 1 (R #1) resident reviewed for falls, when the facility failed to ensure staff used a mechanical lift as required. This deficient practice resulted in R #1 falling and sustaining a Subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain) was identified on (Computed Tomography; a medical imaging procedure that uses x-rays to create detailed cross-sectional images of the body) CT that required treatment at a hospital for higher level of care. A. Record review of R #1's face sheet revealed R #1 was admitted into the facility on [DATE] and currently has the following diagnoses:1. Type 2 Diabetes.2. Alzheimer's (brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out the simplest tasks).3. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were free of any significant medication errors for 1 (R #1) of 1 (R #1) resident reviewed for medication administration when staff failed to administer medication per physician's orders. This deficient practice could likely lead to the residents having adverse (unwanted, harmful, or abnormal result) side effects, or not receiving the desired therapeutic effect of the medication.

Inspectors wroteBased on observation and interview, the facility failed to ensure all treatment carts were locked while unattended. This deficient practice had the potential to affect all 27 people residing in rooms on the 200 hall by allowing unauthorized people access to their medical supplies and personal health information.

Inspectors wroteBased on observation and interview, the facility failed to safeguard resident's personal health information by leaving a list of residents with their associated wound care orders in plain view. This deficient practice had the potential to affect all 27 people residing in the rooms on the 200 hall by allowing unauthorized people access to their personal health information.

Inspectors wroteBased on interview, record review, and observation the facility failed to ensure residents received information on how to contact the State Survey Agency to file a complaint. This deficient practice could likely affect all 110 residents residing in the facility as identified on the census provided by the Administrator (ADM) on 01/05/25.

Inspectors wroteBased on observation and interview, the facility failed to provide a clean and homelike environment when staff did not clean vomit off the floor in the dining area of the memory care unit. This deficient practice could likely affect all 21 residents residing in the memory care unit as identified by the census provided by the Administrator on 01/05/25. Failure to provide a clean and homelike environment is likely to result in unsafe conditions and prevent residents from enjoying everyday activities.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR; a screening to help ensure that individuals are not inappropriately placed in nursing homes for long term care) assessment was accurate for 5 (R #23, R #25, R #95, R #98, R #104) of 6 (R #17, R #23, R #25, R # 95, R #98, R #104) residents reviewed for PASRR accuracy. This deficient practice is likely to result in the residents not receiving the services they need.

Inspectors wroteBased on observation, record review, and interview, the facility failed to develop and implement an accurate, person-centered comprehensive care plan for 2 (R#1 and #26) of 8 (R #1, R #23, R #25, R #26, R #55, R #65, R #95, and R #98) residents reviewed for care plans. This deficient practice could likely result in staff being unaware of the current and actual needs of the residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide respiratory care in accordance with professional standards for 2 (R #17 and R #104) of 3 (R #17, R #70, and R #104) residents reviewed for respiratory care when staff failed to change the oxygen concentrator (a medical device that provides extra oxygen) tubing. If the facility fails to provide new, clean tubing for oxygen concentrators then residents are at risk of becoming ill.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents were assessed for risk of entrapment (state of being stuck or caught on bed rail) in bed rails for 6 (R #23, R #25, R #55, R #65, R # 95, and R # 98) of 8 (R #21, R #23, R #25, R #55, R #65, R #77, R #95, and R #98) resident reviewed for accidents. This deficient practice has the potential to cause serious injury by becoming trapped between the mattress and bed rail.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that the medication error rate was 5% or less when staff administered medications without wearing gloves or using a medication cup for 1 (R# 30) of 1 (R# 30) residents reviewed during medication administration. This resulted in a medication error rate of 15.63%. If the staff members do not wear gloves or use a medication cup when administering medications, then residents are likely to become ill due to cross-contamination.

Inspectors wroteBased on observation, record review, and interview, the facility failed to promote care with dignity and respect for 2 (R #52 and R #9) of 2 (R #52 and R #9) residents reviewed for rights when they: 1. Provided a medical assessment in the dining area during mealtime. 2. Interrupted a resident during mealtime to prepare her to take medications. This deficient practice could result in residents feeling as if they were unimportant and not having privacy.

Inspectors wroteBased on observation, record review, and interview, the facility failed to store and serve food under sanitary conditions when they failed to remove an unlabeled and undated pitcher of white liquid from the television area of the memory care unit. This deficient practice could likely affect all 21 residents residing in the memory care unit as identified on the census provided by the Administrator (ADM) on 01/05/25.

Inspectors wroteBased on observation and interview, the facility failed to: 1. Ensure medications and other medical supplies were not expired. 2. Ensure medications for 1 (R #88) of 1 (R #88) residents were destroyed after completion of therapy. This deficient practice has the potential to affect all 110 residents identified on the facility census list provided by the Administrator on [DATE]. The use of expired medication is likely to cause residents to receive medications which are less effective due to a breakdown in chemical makeup, leading to less-than-optimal benefit from medications. Continuing to leave discharged /completed medications in the medication storage room is likely to cause residents to receive a medication that is not theirs.

Inspectors wroteBased on record review, observation, and interview, the facility failed to properly inform 1 (R #92) of 1 (R #92) resident of treatment decisions by failing to utilize interpreter line (service used for communication) or a communication board to communicate with resident in a language the resident could understand. If the facility is not able to communicate with residents then residents are not likely to get their needs met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards of care and failed to monitor oxygen (O2) equipment for 3 (R #'s 24, 41, and 69) of 3 (R #'s 24, 41, and 69) residents reviewed for O2 administration 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 24 and 41. 2. Administer O2 per physician's orders and have O2 equipment available in the room for R #69. If the facility is not changing and labeling oxygen tubing or providing O2 per physician orders, then residents are likely to not receive the therapeutic benefits and care needed.

Inspectors wroteBased on record review and interview, the facility failed to update the medical chart for 1 (R #32) of 1 (R #32) residents reviewed for advanced directives when they failed to update the resident's code status. This deficient practice is likely to result in residents not having their wishes honored if a life threatening event occurred.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure staff revised the care plan for 2 (R #41 and #32) of 2 (R #41 and #32) residents reviewed when staff failed to: 1. Update the care plan to include oxygen (O2) use. 2. Update the care plan to match the physician's orders. 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 food that accommodated resident preferences for 1 (R #41) of 1 (R #41) residents observed for food preferences. This deficient practice is likely to result in weight loss due to the resident not eating or an allergic reaction to the food being served to the resident. A. Record review of R #41's physician order dated 02/26/24 revealed an order for regular diet, pureed with ground meat texture and mildly thick consistency. B. Record review of R #41's dinner meal ticket, dated 02/06/24, revealed staff to serve the resident one cup of pureed pork posole, pureed soft cooked vegetable, pureed broccoli, pureed frosted gelatin poke cake, and pureed tortilla. C. [...]

Inspectors wroteBased on observation, record review, and interview the facility failed to provide a therapeutic diet as ordered by a Physician for 1 (R #41) of 1 (R #41) residents reviewed during random dining observations. If the facility fails to provide a diet as ordered, then residents are likely to experience weight loss due to not receiving their prescribed nutritional caloric intake and may be at risk for choking.

Inspectors wroteBased on observation and interview, the facility failed to have the most recent survey results in a place that was readily accessible (a place, such as a lobby or other area frequented by most residents, visitors, or other individuals where individuals wishing to examine survey results do not have to ask to see them) for all 105 residents residing in the facility. If residents are unable to locate the latest survey results conducted by State Surveyors, residents, representatives, and visitors are unable to know how the facility is doing and make decisions accordingly.