cms_NM
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| Link | rowid ▼ | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 1 | SANTA FE CARE CENTER | 325030 | 635 HARKLE ROAD | SANTA FE | NM | 87505 | 2020-01-16 | 609 | E | 1 | 0 | WQZY11 | > Based on record review and interview, the facility failed to submit a Follow-Up Report within 5 working days of the date the Incident Report was filed for 1 (R #1) of 3 (R #'s 1, 4 and 5) residents who had Incident Reports filed with the Department of Health (DOH)/Incident Management Bureau (IMB). This deficient practice has the potential for resident issues that have been reported, to not be addressed and/or rectified in a timely manner. The findings are: Findings for R #1: [NAME] Record review revealed that the facility submitted an Incident Report (self-report) to the Department of Health (DOH)/Incident Management Bureau (IMB) on 8/10/19 regarding neglect. B. Record review revealed that the 5 day follow up for the incident (on 08/09/19) was submitted on 09/09/19. C. On 01/13/20 at 3:50 pm, during an interview, the Administrator reported that she emailed the 5 Day Follow-Up Report to the DOH/IMB on 09/09/19 indicating that she found during an audit, that there was no evidence that the 5 Day Follow-Up Report was sent to the DOH/IMB. D. On 01/13/20 at 4:25 pm, during an interview, the Director of Nursing (DON) reported that she usually submits all of the Incident Reports and 5 Day Follow-Up Reports to DOH/IMB, but they were in-between DON's in (MONTH) 2019 when the Incident Report for R #1 was submitted and the 5 Day Follow-Up Report should have been submitted timely, but it was not. The DON reported that the Assistant Director of Nursing (ADON) and the Administrator serve as a back-up to her when she is unable to submit the reports. The DON reported that she officially started in the DON capacity at this facility in (MONTH) 2019. | 2020-09-01 |
| 2 | 2 | SANTA FE CARE CENTER | 325030 | 635 HARKLE ROAD | SANTA FE | NM | 87505 | 2020-01-16 | 660 | E | 1 | 0 | WQZY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to develop post-discharge plans that focused on residents' individualized discharge goals and needs for 3 (R #'s 1, 2 and 3) of 3 (R #'s 1, 2 and 3) residents reviewed for discharge planning. This deficient practice has the potential to complicate or prevent smooth and safe transitions from the facility to the residents' post-discharge settings. The findings are: Findings for R #1: [NAME] Record review of R #1's admission record revealed that R #1 was admitted to the facility on [DATE]. B. Record review of R #1's progress notes revealed that R #1 was discharged home on[DATE]. C. Record review of the facility's Discharge Summary and Plan policy revised (MONTH) (YEAR) stipulates: 4. Every resident will be evaluated for his or her discharge needs and will have an individualized post-discharge plan. 5. The post-discharge plan will be developed by the Care Planning/Interdisciplinary Team with the assistance of the resident and his or her family and will include: a. Where the individual plans to reside; b. Arrangements that have been made for follow-up care and services; c. A description of the resident's stated discharge goals; d. The degree of caregiver/support person availability, capacity and capability to perform required care; e. How the IDT (interdisciplinary team - the group of persons who develop a individual program plan to meet the resident's needs for services.) will support the resident or representative in the transition to post-discharge care; f. What factors may make the resident vulnerable to preventable readmission; and g. How those factors will be addressed. 6. The discharge plan will be re-evaluated based on changes in the resident's condition or needs prior to discharge. 7. The resident/representative will be involved in the post-discharge planning process and informed of the final post-discharge plan. 8. Residents will be asked about their interest in returning to the… | 2020-09-01 |
| 3 | 3 | SANTA FE CARE CENTER | 325030 | 635 HARKLE ROAD | SANTA FE | NM | 87505 | 2020-01-16 | 661 | E | 1 | 0 | WQZY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to develop detailed Discharge Summaries (to include overviews of resident stays at the facility and a final summary of resident statuses at the time of discharge) for 3 (R #'s 1, 2 and 3) of 3 (R #'s 1, 2 and 3) residents reviewed for discharging home. This deficient practice has the potential to prevent residents from receiving adequate care from home health agencies and primary care physicians due to being uninformed, which could result in resident goals and needs not being met as well as readmittance to a nursing facility. The findings are: Findings for R #1: [NAME] Record review of R #1's admission record revealed that R #1 was admitted to the facility on [DATE]. B. Record review of R #1's progress notes revealed that R #1 was discharged home on[DATE]. C. Record review of the facility's Discharge Summary and Plan policy revised (MONTH) (YEAR) stipulates: 1. When the facility anticipates a resident's discharge to a private residence, another nursing care facility (i.e., skilled, intermediate care, intermediate care facility for individuals with intellectual disabilities, etc.) a discharge summary and a post-discharge plan will be developed which will assist the resident to adjust to his or her new living environment. 2. The discharge summary will include a recapitulation of the resident's stay at this facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident. The discharge summary shall include a description of the resident's: a. Current diagnosis; b. Medical history (including any history of mental disorders and intellectual disabilities); c. Course of illness, treatment and/or therapy since entering the facility; d. Current laboratory, radiology, consultation, and diagnostic test results; e. Physical and mental functional status; f. Abili… | 2020-09-01 |
| 4 | 4 | SANTA FE CARE CENTER | 325030 | 635 HARKLE ROAD | SANTA FE | NM | 87505 | 2020-01-16 | 678 | J | 1 | 0 | WQZY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > On [DATE] R #9 was found unresponsive (not responding to stimuli such as calling of her name and shaking her body) in the facility dining hall. She was taken from the dining area to her room prior to initiation of CPR (techniques to manually provide for blood circulation and oxygenation in an emergency) delaying this potentially life saving measure. During interviews with multiple staff in the facility, the staff could not immediately and accurately identify residents' code status. Some staff indicated they would start CPR on any resident found unresponsive until code status could be verified by looking in the Electronic Health Record (EHR) or a binder located at the Nurses Station, and then stop CPR if resident had elected to be Do Not Resuscitate (DNR) (Do not provide CPR services). Record review for CPR Certification status of staff revealed that the two certified Nursing Assistant's (CNA's) and the nurse involved in provision of CPR during the event on [DATE] with R #9 did not have up to date certification. This resulted in an immediate jeopardy (IJ) at a scope and severity of J (isolated jeopardy to resident health and safety) being identified on [DATE] at 2:15 pm. A Plan of Removal was approved and verified on [DATE] at 1:40 pm. Based on the Plan of Removal, the interventions included: 1. Completed audit of all residents' code status. 2. All clinical staff to have a list of residents' code status provided to them each shift that is updated daily. 3. All clinical nurses and Certified Nursing Assistants (CNA) were educated to begin CPR immediately for any resident who has elected it and found requiring it at the place at which they are found according to Basic Life Support (BLS) guidelines. 4. All nursing clinical staff to have current certification in BLS/CPR as of [DATE]. Based on the Plan of Removal, the Scope and Severity was reduced from the level J to a level [NAME] Based on record review and interview, the facility failed to: 1. … | 2020-09-01 |
| 5 | 5 | SANTA FE CARE CENTER | 325030 | 635 HARKLE ROAD | SANTA FE | NM | 87505 | 2019-07-19 | 550 | E | 0 | 1 | W7WU11 | Based on observation and interview, the facility failed to ensure that residents were treated with respect and dignity for 4 (R #37, R #57, R #61, & R #200) of 4 (R #37, R #57, R #61, & R #200) resident sampled for dignity, when they failed to 1) ensure a resident's rights to a dignified existence for R #37, R #61, and R # 200 when they were treated disrespectfully, and 2) provide privacy for R #57's urine collection bag This deficient practice could likely result in residents becoming depressed and anxious, lacking self-esteem/self-worth. The findings are: R #37 [NAME] On 07/15/19 at 2:58 PM, during an interview, R #37 stated, Some of the CNAs (Certified Nursing Assistants); I am very hesitant to ask for any help. It is because of their demeanor; they are so indifferent to me. They don't even talk to me. They are always too busy. I wanted toothpaste and I had ask 3 times until I got it and that was pretty recent. I keep asking for urinal; they took mine. There is one in a bag in the bathroom with no name on it; but it might be for my roommate. They don't respond when I ask if it is mine. I like a urinal for the AM many times when I need to go, but I can't get them to give me one. I am not a complainer. I have not complained. When R #37 was asked how that makes him feel he stated, I sleep a lot and try not to care--that is my way to handle the staff here. B. On 07/18/19 at 9:49 AM, during an interview with the DON (Director of Nurses) regarding R #37's concerns, he stated, I was not aware of his concerns. I have not heard anything about that. Last week, I moved his urinal off his bedside table just for infection control purposes. I ask how things are going with him about every week and try to listen. It is about customer service and how they feel about you and being here. That would be something to go over again with the staff. C. On 07/18/19 at 11:42 AM, during an interview with the Administrator regarding R #37's concerns and the possible outcome to the resident, she stated, It could bring the resident down. R … | 2020-09-01 |
| 6 | 6 | SANTA FE CARE CENTER | 325030 | 635 HARKLE ROAD | SANTA FE | NM | 87505 | 2019-07-19 | 578 | E | 0 | 1 | W7WU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that the Advanced Directives were filled out completely and correctly for 9 (R #3, R #9, R #37, R #88, R #97, R #200, R #299, R #300, & R #302) of 9 (R #3, R #9, R #37, R #88, R #97, R #200, R #299, R #300, & R #302) residents reviewed for Advanced Directives/MOST form (MOST form is a doctor's order that tells emergency medical personnel and other health care providers whether or not to administer cardiopulmonary resuscitation (CPR) in the event of a medical emergency.) This deficient practice could likely result in the resident's wishes not being followed. The findings are: R #3 [NAME] Record review of the medical chart for R #3 revealed that there was no advance directive on file. B. On [DATE] at 11:18 AM, during an interview, the DON confirmed that there was no advance directive on file and he stated We will need to complete another MOST for (name of R #3) R #9 C. Record review of R #9's advanced directive dated [DATE] revealed No Heroic resuscitations efforts was marked, and Full resuscitations was marked just below that on the form. D. On [DATE] at 3:16 PM, during an interview, the DON confirmed that R #9 advanced directive was not clear in whether R #9 want to be resuscitated or not. R #37 E. Record review of the MOST for R #37, dated [DATE], revealed Sections B Medical Intervention, Section C Artificially Administered Hydration/Nutrition, and Section D Discussed With, were all blank. F. On [DATE] at 3:07 PM, during an interview, the Social Worker (SW) stated, I see those sections are blank, the nurses should have gathered that information. R #88 [NAME] Record review of the MOST for R #88 revealed it was signed by physician but not by the resident or her representative. H. On [DATE] at 3:12 PM, during an interview with the SW regarding the Most for R #88, she confirmed, I do not see a signature by the resident or her representative. R #97 I. Record review if R #97's adv… | 2020-09-01 |
| 7 | 7 | SANTA FE CARE CENTER | 325030 | 635 HARKLE ROAD | SANTA FE | NM | 87505 | 2019-07-19 | 609 | D | 0 | 1 | W7WU11 | Based on record review, obsevation, and interview, the facility failed to report allegations of abuse to the State Survey Agency within 24 hours for 1 (R #86) of 2 (R #48 and R #86) reviewed for allegations of abuse. This failed practice could lead to other residents being abuse and not be reported to the State Agency. The findings are: [NAME] On 07/15/19 at 9:17 AM, during an interview, R #86 revealed that on 07/10/19 she was grabbed on the arm. R #86 reported that the DON was informed of the incident. B. On 07/15/19 at 9:17 AM, during observation, it was revealed that R #86 had 5 bruises on her left arm in different healing stages. The two large bruises were the size of a quarter and 3 smaller bruises the size of a dime. C. Record review of R #86's progress notes dated 07/18/19, written by LPN #10, revealed, (Name of R #86) was walking into the dining room when she passed by (name of R # 9). (Name of R # 9) asked (Name of R #86) for a sandwich and (Name of R #86) told (Name of R #9) that in the dining room, they would give him food. (Name of R #9) told (Name of R #86) 'F___-YOU' and grabbed (Name of R #86) from the left arm. PTs (patients) were separated and (Name of R #86) has some light bruising to the inside of her left arm. D. On 07/18/19 at 9:37 AM, during an interview, the DON revealed that he did not report the incident between (Name of R #86) and (Name of R #9) to the State Survey Agency within 24 hours. He revealed that he was not made aware of the incident until the evening of or the day after the incident. E. On 07/18/19 at 2:52 PM, during an interview, the DON revealed that he did not have documented proof of sending the initial report to the State Survey Agency and was only able to provide proof of the five day follow up report | 2020-09-01 |
| 8 | 8 | SANTA FE CARE CENTER | 325030 | 635 HARKLE ROAD | SANTA FE | NM | 87505 | 2019-07-19 | 623 | B | 1 | 0 | W7WU11 | > Based record review and interview, the facility failed to notify the ombudsman of transfers and discharges from the facility for 2 (R #99 and R #102) of 2 (R #99 and R #102) residents sampled for discharges. This deficient practice could likely result in resident not receiving assistance from the ombudsman's office for transfer or discharges. The findings are: [NAME] Record review of R #102's Medical Record revealed no documentation sent to the Ombudsman regarding R #102's discharge. B. Record review of R #99's Medical Record revealed no documentation sent to the Ombudsman regarding R #99's discharge. C. On 07/17/19 at 8:01 AM, during an interview, the Social Services Director stated that the Ombudsman said not to send any paperwork for discharge unless it was a 30 day notice. She was getting too much paperwork. We stopped in March. D. Record review of the discharge notice binder revealed no notices after (MONTH) 2019. | 2020-09-01 |
| 9 | 9 | SANTA FE CARE CENTER | 325030 | 635 HARKLE ROAD | SANTA FE | NM | 87505 | 2019-07-19 | 656 | E | 0 | 1 | W7WU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation, the facility failed to ensure a resident who was without teeth was care planned for dental services and dietary needs for 1 (R #72) of 8 (R #21, R #30, R #37, R #48, R #55, R # 72, R #88, and R #200 ) residents reviewed for dental health and services. This deficient practice could result in the resident's needs not being met. The findings are: [NAME] On 07/15/19 at 9:16 AM, during an interview, R #72 stated, I had dentures years ago, but I had a lot of trouble with them. They kept bothering me and I kept going back (to the dentist). Finally the dentist's office said Medicaid didn't want to pay anymore for me to keep going back. I have to eat without teeth. I would like dentures that fit me. I just skip the hard foods, I can't eat the hard foods. No one has offered an appointment. B. On 07/15/19 at 9:19 AM, during observation, R #72 opened her mouth to show she had no teeth. The examination revealed the resident has no teeth. C. On 07/16/19 at 3:36 PM, during an interview, the SW (Social Worker) stated, I had not heard anything about (Name of R #72) not having teeth. I will put her on the list to see the dentist. D. On 07/16/19 at 4:15 PM, during an interview with the MDS (Minimum Data Set) Coordinator regarding R #72's oral status, she said, The SW completes that (Dental Section) and would usually follow up on dental. and ask if she (the resident) wants dentures. There should have been an inquiry. There is nothing regarding dietary and her oral status in her care plan E. Record review of the MDS dated [DATE] for R #72 revealed: Section L0200. Dental Check all that apply [NAME] Broken or loosely fitting full or partial denture(chipped, cracked, uncleanable, or loose) F. Mouth or facial pain, discomfort or difficulty with chewing Neither item was check marked | 2020-09-01 |
| 10 | 10 | SANTA FE CARE CENTER | 325030 | 635 HARKLE ROAD | SANTA FE | NM | 87505 | 2019-07-19 | 658 | E | 0 | 1 | W7WU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation, the facility staff failed to ensure [MEDICATION NAME] (a [MEDICATION NAME] supplement--live microorganisms that are intended to have health benefits) was given per physician orders [REDACTED].#8) of out of 14 ( R #2, R #11, R #13, R #15, R #33, R #35, R #43, R #48, R #63, R #70, R #96, R #300, and R #303) residents reviewed during medication pass. This deficient practice could result in the resident not receiving the desired therapeutic effect of the supplement. The findings are: [NAME] Record review of the physician orders [REDACTED]. B. Record review of the MAR (Medication Administration Record) for R #8 for (MONTH) 2019 revealed: [MEDICATION NAME] Capsule 250 mg (Saccharomyses boulardii) Give 2 capsules by mouth two times a day for gut health. The MAR showed that it was noted as being administered twice a day from 07/01/19 to 07/18/19 and once on 07/19/19. C. On 7/19/19 at 08:13 AM, during observation of the medication pass, RN #1 was observed removing 2 capsules from a bottle labeled acidophilus (a type of [MEDICATION NAME]--contains the bacteria Lactobacillus acidophilus) with pectin, ( fiber found in fruit used to make medicine) and administering them to R #8. D. On 7/19/19 at 3:15 am, during an interview, RN #1 confirmed that she had given R #8 2 capsules of acidophilus with pectin. RN #1 stated, Even though the MAR says to give [MEDICATION NAME] Capsules; we have never had the. We just give the acidopilus. It doesn't mean anything if the MAR and the medicine don't match in this instance, we all know it is the same thing ([MEDICATION NAME] and Acidophilus). E. On 07/19/19 at 10:00 am, during an interview, the ADON (Assistant Director of Nurses) stated, If the [MEDICATION NAME] was not available, the nurses should have contacted the doctor instead of giving the Acidophilus. It is not what was ordered. F. Review of the National Institute of Health, [MEDICATION NAME], Fact Sheet for Prof… | 2020-09-01 |
| 11 | 11 | SANTA FE CARE CENTER | 325030 | 635 HARKLE ROAD | SANTA FE | NM | 87505 | 2019-07-19 | 677 | D | 0 | 1 | W7WU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide ADL (activities of daily living) assistance for nail care for 1 (R #27) of 1 (R #27) residents reviewed for ADL's. This deficient practice has the potential to affect the dignity and health of the residents. The findings are: [NAME] On 07/15/19 at 12:24 pm, during observation, R #27 was observed with dirty and uncut fingernails. B. On 07/18/19 at 11:05 am, a second observation of R #27 revealed, R #27's nails had a black substance under her thumb nails and were not clean or cut. C. On 07/19/19 at 9:49 AM, the resident was observed in her room. Her nails were different lengths except her thump nails which were long and dirty with a black substance. Resident reported that she cuts her own nails and showed me a nail clipper. D. On 07/16/19 during record review of R #27's care plan dated 04/30/19 revealed: Focus: (Name of R #27) have an ADL Self Care Performance Deficit r/t: Progressed dementia and require staff assistance with all ADL's. Goal: (Name of R #27) will maintain current level of function in Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene through the review date. Interventions: C.N.[NAME] Nursing *Praise all efforts at self-care. *TOILET USE: I require (X) staff participation to use toilet. *TRANSFER: I require (1) staff participation with transfers for my safety due to risk of falls but I will usually self-transfer since I forget to call for assistance. *Encourage me to participate to the fullest extent possible with each interaction. *SKIN INSPECTION: I require SKIN inspections on my scheduled shower days 3X per week by the CNA and once weekly by my nurse. Observe for redness, open areas, scratches, cuts, bruises and report changes to the Nurse. Nurse to document ton weekly skin assessment sheets. *BATHING: I am able to participate in bathing but require staff assistance and verbal cueing. *PERSONAL HYGIENE/ORAL CARE: I requi… | 2020-09-01 |
| 12 | 12 | SANTA FE CARE CENTER | 325030 | 635 HARKLE ROAD | SANTA FE | NM | 87505 | 2019-07-19 | 684 | E | 0 | 1 | W7WU11 | Based on record review and interview, the facility failed to provide needed care and services for hospice services for 1 (R #52) of 1 (R #52) residents sampled for hospice services, when they failed to obtain notes from hospice staff when they came to provide care for R #52. If hospice staff are not leaving notes of the care they provide to residents in the facility, then this could likely cause residents not to receive the end of life care they need. The findings are: [NAME] Record review of R #52's Medical Record revealed no notes or order for hospice services were found. B. On 07/16/19 at 8:58 AM, during an interview, LPN #6 stated that the hospice service that R #52 had does not like to leave notes for the facility. C. On 07/17/19 at 12:27 PM, during an interview, the Medical Records Director stated that No, they (the hospice services R #52 had) don't provide notes. We have a problem with them. D. On 07/19/19 at 9:23 AM, during an interview, the DON confirmed that R #52 did not have his hospice order put into the electronic medical record, and the facility should have. | 2020-09-01 |
| 13 | 13 | SANTA FE CARE CENTER | 325030 | 635 HARKLE ROAD | SANTA FE | NM | 87505 | 2019-07-19 | 686 | D | 0 | 1 | W7WU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure ulcers (Injuries to the skin and underlying tissue resulting from prolonged pressure on the skin) from forming for 1 (R #300) of 1 (R #300) residents reviewed for pressure ulcers. This deficient practice is likely to result in wounds worsening or not healing. The findings are: [NAME] Record review of face sheet for R #300 revealed they were admitted on [DATE]. B. Record review of Admission Data collection: Section 5-Skin assessment dated [DATE] showed no pressure ulcers were present on the resident. C. Record review of BRADEN SCALE (A scale used by health professionals to assess a patient's risk of developing a pressure ulcer) FOR PREDICTING PRESSURE SORE RISK dated 07/10/19 revealed a score of 17-At risk. D. Record review of the Weekly Skin Check dated 07/10/19 showed no pressure ulcers were present on the resident. E. Record review of care plan dated 07/10/19 revealed no interventions regarding the risk and/or prevention of developing pressure ulcers. F. Record review of the Weekly Skin Check dated 07/18/19 showed resident to have a stage II (a shallow open sore) pressure ulcer. [NAME] On 07/18/19 at 3:33 PM, during an interview, the wound care nurse confirmed that there had been no interventions for pressure ulcer prevention in place prior to 07/18/19 and she also confirmed that resident had developed a stage II pressure ulcer which was noted on 07/18/19. | 2020-09-01 |
| 14 | 14 | SANTA FE CARE CENTER | 325030 | 635 HARKLE ROAD | SANTA FE | NM | 87505 | 2019-07-19 | 690 | D | 0 | 1 | W7WU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide incontinence care for 1 (R #27) of 2 (R #27 and R #48) residents reviewed for bladder and bowel incontinence. This deficient practice has the potential to affect the self-esteem and well-being of the residents. The findings are: [NAME] On 07/16/19 at 3:13 PM, during an interview, R #27's roommate, R #86, revealed that R #27 was not changed on (MONTH) 15th and 16th from 5am to 1pm. B. On 07/17/19 at 11:50 AM, during observation, R #27 was walking down the hall towards her room with a saggy brief that appeared to be full and R #27 had the odor of urine. C. On 07/17/19 at 1:50 PM, record review of ADL (activities of daily living): The things we normally do in daily living including any daily activity we perform for self-care such as feeding ourselves, bathing, dressing, grooming, work, homemaking, and leisure.) sheets revealed that the CNAs during day-shift did not document changing resident's brief for the following days: 07/07/19, 07/12/19, and 07/16/19. D. Record review of R #27's care plan dated 04/30/19 revealed: Focus: *I, (name of R #27) have bowel and bladder (B&B) incontinence r/t: Progressed dementia Goal: *My risk for [MEDICAL CONDITION] (a serious bloodstream infection. It's also known as blood poisoning. [MEDICAL CONDITION] occurs when a bacterial infection elsewhere in the body, such as the lungs or skin, enters the bloodstream.) will be minimized/prevented via prompt recognition and treatment of [REDACTED].) through the review date. * I will decrease frequency of B&B incontinence to only once daily through the next review date by routine toileting. * I (name of R #29) will remain free from skin breakdown due to incontinence and brief use through the review date. Interventions: *ACTIVITIES: notify nursing if incontinent during activities. *BRIEF USE: I use small disposable briefs. Change every 2-3 hours and prn. Provide good peri-care (washing the ge… | 2020-09-01 |
| 15 | 15 | SANTA FE CARE CENTER | 325030 | 635 HARKLE ROAD | SANTA FE | NM | 87505 | 2019-07-19 | 692 | E | 0 | 1 | W7WU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to recognize, evaluate, and addressee the nutritional needs of 1 (R #20) of 1 (R #20) residents sampled for nutrition. This deficient practice could like result residents not receiving the nutritional assistance they need. The findings are: [NAME] Record review of R #20 weight revealed the following 1. 7/1/2019 - 87.4 Lbs 2. 6/4/2019 - 95.4 Lbs an 8.42% loss in one month B. Record review of the progress notes revealed the following: 6/28/2019 Late Entry: Note Text: Monthly [MEDICAL TREATMENT]: Ht: 58 Wt: 95.4 lbs BMI: 19.9. (Name of R #20) has continued to have HD ([MEDICAL TREATMENT]) M/W/F. She is receiving a 2 gram Na (salt) diet, pureed, in her room. She does receive Magic Cups for lunch, dinner. She continues to have 25-75% intake at most meals. She is on a 1000 mL fluid restriction. [MEDICAL TREATMENT] continues to use caution when dialyzing, due to age, and tolerance of process. Her skin is currently intact. She has been 95-99 lbs x 5 months, and is currently within her IWR of 86-105 lbs. Continue with nutrition plan in place. Honor food and beverage preferences. No note regarding the weight loss was found. C. On 07/19/19 at 9:16 AM, during an interview, the DON stated It does not look like the dietician caught that one (R #20's weight loss). She came 07/03/19. The DON confirmed that no dietary changes had occurred for R #20. D. On 07/19/19 at 9:58 AM, during an interview, the Dietician stated that when she came on 06/28/19, the facility had not weighted R #20. They weighed her on 07/01/19. I am scheduled one day a week often I come second time. The dietician was asked if she had been back to the facility since 07/01/19, she stated that she had I was trying to do the residents with wounds. The dietician was asked when she was made aware of R #20's weight loss, she stated, Just now . I did not check with restorative for her weight. The dietician continued to state that the weight… | 2020-09-01 |
| 16 | 16 | SANTA FE CARE CENTER | 325030 | 635 HARKLE ROAD | SANTA FE | NM | 87505 | 2019-07-19 | 698 | E | 0 | 1 | W7WU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide needed care and services for [MEDICAL TREATMENT] services for 1 (R #20) of 1 (R #20) residents sampled for [MEDICAL TREATMENT] services, when they failed to obtain notes from the [MEDICAL TREATMENT] center when R #20 came back to the facility. If facility staff are receiving notes from the [MEDICAL TREATMENT] canter, then this could likely cause residents not to receive the care they need. The findings are: [NAME] Record review of R #20's medical record revealed no notes from the [MEDICAL TREATMENT] center. B. On 07/17/19 at 8:19 AM, during an interview, LPN #6 stated We do not always get things from [MEDICAL TREATMENT]. They fax it sometimes. C. On 07/17/19 at 8:21 AM, during an interview, the Medical Records Director stated Sometimes we do. Sometimes don't (get the notes from the [MEDICAL TREATMENT] center). Last I got something was in (MONTH) (2019). D. On 07/17/19 at 8:27 AM, during an interview, the ADON stated that We just created a new communication record form that we will be sending every time they go to [MEDICAL TREATMENT]. The ADON confirmed that this was supposed to send every time residents went to [MEDICAL TREATMENT], but they had not been sending it. E. Record review of R #20 physician's orders [REDACTED]. F. On 07/17/19 at 8:34 AM, during an interview the DON confirmed that the order for R #20 should be in the electronic record, but was not. | 2020-09-01 |
| 17 | 17 | SANTA FE CARE CENTER | 325030 | 635 HARKLE ROAD | SANTA FE | NM | 87505 | 2019-07-19 | 726 | F | 0 | 1 | W7WU11 | Based on record review and interview, the facility failed to perform nursing competencies for nursing staff. This has the potential to affect all nurses that work in the facility (Nurses were identified by the staff schedule provide by the DON on 07/15/17). If the facility does not perform nursing competencies on their nurses then this could likely result in nurses working with residents without being competent to do so, resulting injury or insufficient care to residents. The findings are: [NAME] Record review of RN #5, RN #6, RN #7, LPN #7, and LPN #8 employee records revealed no competencies. B. On 07/18/19 at 3:44 PM, during an interview the DON confirmed that the facility was only using an online education system. We don't have the competencies. | 2020-09-01 |
| 18 | 18 | SANTA FE CARE CENTER | 325030 | 635 HARKLE ROAD | SANTA FE | NM | 87505 | 2019-07-19 | 730 | F | 0 | 1 | W7WU11 | Based on record review and interview, the facility failed to use employee evaluations for part of the 12 hours of annual education for CNA staff. This has the potential to affect all CNAs that work at the facility (CNAs were identified by the staff schedule provide by the DON on 07/15/17). If the facility is not using the employee evaluations for part of the 12 hours of annual training staff may not be learning for their mistakes and continue to do them, therefore negatively impacting on the care provided to the residents. The findings are: [NAME] Record review of CNA employee training sheets reveled the facility uses an online training format. B. On 07/18/19 at 4:21 PM, during an interview, the DON was asked if the facility uses the employee evaluations for apart of the 12 hours annual training. He stated, That is something I don't think I can provide to you, a link from evaluations to the 12 hours of training. The DON stated that because if there was something that need to be corrected the facility does not wait for the employee evaluations. | 2020-09-01 |
| 19 | 19 | SANTA FE CARE CENTER | 325030 | 635 HARKLE ROAD | SANTA FE | NM | 87505 | 2019-07-19 | 755 | D | 0 | 1 | W7WU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation, the facility failed to provide a nicotine patch in a timely manner to 1 ( R #200) of 1 (R #200) resident reviewed randomly as a new admission. This deficient practice could likely cause unneeded suffering by an unnecessary delay in meeting the resident's needs by following the physician's orders [REDACTED]. [NAME] Review of the Medication Administration Record [REDACTED]. B. Record review of the physician order [REDACTED]. C. On 07/17/19 09:16 AM, during an interview, R #200 stated, The nurse said she would get me nicotine patches since I can't smoke here. I still don't have nicotine patches. I keep asking and asking where they are. The nurses tell me their are no patches for me yet. I am having a real hard time. D. On 07/17/19 at 9:18 AM, during an interview, LPN #1 was asked about nicotine patches for R #200. She stated, No I do not have them yet. E. On 07/17/19 at 10:13 AM, during an interview, the ADON was asked about the nicotine patches for R #200. She stated, The nicotine patches can picked up locally if needed. The order was from 07/13/19 in the afternoon and they should have started 14th (the next day). It had not come to me as a concern. On the 14th if they were not available, the nurse should have contacted nursing administration. | 2020-09-01 |
| 20 | 20 | SANTA FE CARE CENTER | 325030 | 635 HARKLE ROAD | SANTA FE | NM | 87505 | 2019-07-19 | 759 | E | 0 | 1 | W7WU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and observation, the facility failed to ensure their medication error rate was less than 5% when they did not follow physician orders [REDACTED].#15, R #48, and R #96) out of 14 ( R #2, R #11, R #13, R #15, R #33, R #35, R #43, R #48, R #63, R #70, R #96, R #300, and R #303) residents reviewed during medication pass. This deficient practice results in the residents not receiving the medications as ordered by the physician and altering the desired therapeutic effect or exposing the resident to higher risk of experiencing side effects. The findings are: R #96 [NAME] Record review of the physician's orders [REDACTED]. B. Record review of the physician's orders [REDACTED]. Rinse mouth after administration, do no (sic) swallow. C. On 07/15/19 at 9:15 AM during observation of the medication pass, LPN #1 administered [MEDICATION NAME] Diskus 1 puff to R #96, then administered [MEDICATION NAME] HFA (a type of inhaler used to dilate the breathing tubes) one puff and almost immediately a second puff. LPN #1 did not assist the resident nor advise her to rinse her mouth with water and spit it out after using the [MEDICATION NAME] Diskus Inhaler. D. On 07/15/19 at 9:20 AM, during an interview with LPN #1 regarding the medication administration for R #96, she stated, No, it does not matter which inhaler she uses first. I did not know she needed to rinse her mouth after using a steroid inhaler. E. On 07/19/19 at 10:01 AM, during an interview with the ADON (Assistant Director of Nurses) regarding the inhaled medications for R #96, she stated, The nurse should have allowed a minute or two to pass between the [MEDICATION NAME] inhalations to get the best effect. She should have had the resident rinse her mouth and spit after the [MEDICATION NAME] inhaler. F. Review of [MEDICATION NAME] Diskus Package insert revealed: [MEDICATION NAME] can cause serious side effects, including fungal infection in your mouth or throat (thrush). … | 2020-09-01 |
| 21 | 21 | SANTA FE CARE CENTER | 325030 | 635 HARKLE ROAD | SANTA FE | NM | 87505 | 2019-07-19 | 791 | E | 0 | 1 | W7WU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation, the facility failed to ensure residents who were without teeth were offered dental services for dentures for 2 (R #3 and R #72) of 2 (R #3 and R #72) residents reviewed for dental health and services. This deficient practice could result in the resident's needs not being met. The findings are: R #3 [NAME] Record review of R #3's admission record, indicated that the resident was initially admitted to the facility on [DATE]. B. On 07/15/19 at 10:14 AM, during an interview with R #3 he stated he had not seen a dentist since he has been at the facility and that he was interested in getting dentures. The residents mouth was observed, and he has one tooth on the upper right. C. On 07/17/19 at 11:20 AM, during an interview with LPN # 2, he stated he was unaware that R #3 had no teeth or that he wanted dentures. He checked the residents record and did not find any dental consultation forms. D. On 07/17/19 at 11:23 AM, during an interview, the Scheduler stated that the nurses or social workers would let her know if an appointment was needed and that R #3 had not seen a dentist. E. On 07/18/19 at 11:55 AM, during an interview with the DON and ADON, the DON said, I should speak to the Social Worker (SW) regarding dental visits for (name of R #3). F. On 07/18/19 at 4:16 PM, during an interview, the SW stated that R #3 had not been seen by the dentist. Per SW He never asked to be seen. R #72 [NAME] On 07/15/19 at 9:16 AM, during an interview, R #72 stated, I had dentures years ago, but I had a lot of trouble with them. They kept bothering me and I kept going back (to the dentist). Finally the dentist's office said Medicaid didn't want to pay anymore for me to keep going back. I have to eat without teeth. I would like dentures that fit me. I just skip the hard foods, I can't eat the hard foods. No one has offered an appointment. H. On 07/15/19 at 09:19 AM, during observation, R #72 opened her mouth to sho… | 2020-09-01 |
| 22 | 22 | SANTA FE CARE CENTER | 325030 | 635 HARKLE ROAD | SANTA FE | NM | 87505 | 2019-07-19 | 804 | E | 0 | 1 | W7WU11 | Based on record reveiw and interview, the facility failed to ensure the food was palatable for 6 (R #11, R #37, R #55, R #57, R #86, and R #201) of 6 (R #11, R #37, R #55, R #57, R #86, and R #201) residents reviewed for food. Two residents (R #55 and R #201) said the food was cold and 4 residents said the food was not good (R #11, R #37, R #57, and R #86). This deficient practice has the potential for residents to not eat meals and could lead to weight loss. The findings are: [NAME] On 07/15/19 at 3:50 PM during an interview, R #11 revealed, The food isn't very tasty. B. On 07/15/19 at 9:37 AM during an interview, R #86 revealed that a few months ago they had chicken on a bun for four days in a roll and the chicken was dry and about two weeks ago R #86 ordered a Cesar Salad and the lettuce was brown around the edges. C. On 07/16/19 at 3:47 PM during an interview, the Dietary Manager revealed that he started a food committee to address the residents' concerns and suggestions regarding the food. D. On 07/18/19 at 3:36 PM during an interview, the Dietary Manager (DM) revealed that about two or three weeks ago R #86 brought a salad back to the kitchen because the lettuce was wilted around the edges. When asked what he observed, he reported that if he had been served that salad in a restaurant he would have complained. He reported that his staff stacked the salads on top of each other in the refrigerator and this caused the lettuce to appear wilted. E. On 07/15/19 at 2:58 PM, during an interview, R# 37 stated, The food is so bad that I lose my appetite. I am on no special diet; the food just tastes bad. I hoard salt to try and make it taste better. I have not said anything. I am reluctant to speak out. I don't want to get people mad (at me). F. On 07/15/19 at 10:15 AM, during an interview, R #55 stated, The food at best is fair, at best not great. It is not hot enough. I eat in my room. I have told staff the food is not hot, it is cold. [NAME] On 07/19/19 at 8:06 AM, during observation, R #201 said to RN #1, I cannot… | 2020-09-01 |
| 23 | 23 | SANTA FE CARE CENTER | 325030 | 635 HARKLE ROAD | SANTA FE | NM | 87505 | 2019-07-19 | 880 | F | 0 | 1 | W7WU11 | Based on observation, interview, and record review, the facility failed to ensure 1)that nursing staff followed proper hand hygiene practices while handling linen, 2) failed to ensure staff cleaned and disinfected the glucometer (a machine used to check blood sugar) between residents for with diabetes (a disorder of metabolism), and 3) distribute ice in a sanitary manner. These deficient practices could affect all 98 residents (per matrix provided by the administrator on 07/15/19 and could likely cause cross contamination (transfer of potentially harmful organisms from one resident to another resulting in illness and death). The findings are: Hand Hygiene [NAME] On 07/19/19 at 8:52 AM during observation in the laundry room, Laundry Aid (LA) #1 did not do hand hygiene after she removed her dirty gown and gloves after loading the washer, she then proceeded into the clean dryer room and was observed taking clothing out of the dryer. When ask if she should have done hand hygiene, LA #1 gave a blank stare and looked and her supervisor, who responded for LA #1. The Supervisor stated, Yes, or at least hand sanitizer. B. On 07/19/19 at 10:08 AM during random observation, revealed that Hospitality Aid (HA) #5 was witnessed walking out of R #57's room carrying dirty linen without gloves and opened clean linen closet by her hands and then proceeded to the dirty linen closet and placed linen in dirty linen barrel then went back to the clean linen closet and took out a clean sheet without using any hand hygiene between tasks. C. On 07/19/19 at 10:16 AM during interview, HA #5 was asked if she should be using gloves. She stated, Yes, and was asked when she should she be using hand hygiene. She stated, After handling dirty linen. When asked what the outcome to not using proper hand hygiene, she reported, Cross contamination. D. On 07/19/19 at 10:48 AM during interview, the Infection Control nurse and ADON confirmed that staff should be preforming proper hand hygiene between tasks when handling dirty linen and when working resid… | 2020-09-01 |
| 24 | 24 | SANTA FE CARE CENTER | 325030 | 635 HARKLE ROAD | SANTA FE | NM | 87505 | 2019-07-19 | 881 | F | 0 | 1 | W7WU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure staff implemented a program of antibiotic stewardship (a set of commitments and actions designed to optimize the treatment of [REDACTED]. This deficient practice can affect any of the 98 residents in the facility (on the census list provided on 07/15/19 by the Administrator) who might be placed on antibiotics or come into contact with another resident on antibiotics. This deficient practice could result in the inappropriate use of antibiotics that can lead to unnecessary treatment, illness, adverse reactions, and contribute to the development of antibiotic-resistant organisms. The findings are: [NAME] On 07/18/19 at 2:35 pm, during an interview, the Infection Control Nurse stated that she was not familiar with the antibiotic stewardship policy. She keeps track residents and their infections and relate diagnosis. B. On 07/19/19 at 10:35 AM during an interview, the DON confirmed that the Infection Control Logs for 2019 revealed the information: admitted , onset date, site, infection related DX (diagnosis), culture, x-ray date, antibodies, Healthcare Associated Infection (HAI) and date resolved. There was no documentation for all organisms of the need for isolations. C. Record review of the Antibiotic Stewardship revised (MONTH) (YEAR) revealed: Policy Statement Antibiotics will be prescribed and administered to the residents under the guidance of the facility's Antibiotic Stewardship Program. Policy Interpretation and implementation 1. The purpose of the antibiotic Stewardship Program is to monitor the use of antibiotics in our residents. 2. Orientation, training and education of staff will emphasize the importance of antibiotic stewardship and will include how map propriate is of antibiotics affects individual residents and the overall community. 3. Training and education will include emphasis on the relationship between antibiotic use . 4. If an antibiotic is indicated, presc… | 2020-09-01 |
| 25 | 25 | SANTA FE CARE CENTER | 325030 | 635 HARKLE ROAD | SANTA FE | NM | 87505 | 2019-07-19 | 883 | E | 0 | 1 | W7WU11 | Based on interview and record review, the facility failed to provide immunizations for influenza (flu) and pneumococcal (a bacteria that can cause pneumonia) immunizations (the action of making a person or animal immune to infection, typically by inoculation) for 2 (R #39 and R #88) of 5 (R #11, R #39, R #43, R #61, R #88) residents reviewed for influenza immunizations, and 3(R #39, R #43 and R #88) of 5(R #2, R #8, R #23, R #185, R #185) reviewed for the pneumococcal vaccine. This deficient practice could likely cause the resident to become infected with influenza or pneumonia. The findings are: [NAME] Record review of R #39's Medical Record revealed R #39 did not receive her last influenza vaccination or pneumococcal in (YEAR). B. Record review of R #43 Medical Record revealed no documentation of R #39 recieving a pneumococcal vaccination. C. Record review of R #88's Medical Record revealed R #88 did not receive her last influenza vaccination. It was also revealed that there was not documentation or confirmation that R #88 had a pneumococcal vaccination. B. On 07/19/19 09:33 AM, during an interview, the Infection Control Nurse (ICN) confirmed there was no documentation of proof that R #39, R #43 and R #88 getting their immunizations in (YEAR). D. On 07/19/19 at 10:06 AM, during an interview, the DON confirmed there was no documentation of proof that R #39, R #43 and R #88 getting their immunizations in (YEAR). | 2020-09-01 |
| 26 | 26 | SANTA FE CARE CENTER | 325030 | 635 HARKLE ROAD | SANTA FE | NM | 87505 | 2017-09-21 | 278 | D | 0 | 1 | FY1511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accurately assess 1 (R #26) of 3 (R #26, R #105, R #165) residents reviewed for Activities of Daily Living (ADL's), when they coded R #26's eating ability on her (MONTH) (YEAR) Minimum Data Set (MDS) as supervision (resident requires supervision, cueing, and reminders for safe meal completion), when she required limited assistance (resident required staff to provide non-weight-bearing assistance). This deficient practice could likely result in residents not receiving the assistance needed to accomplish everyday tasks, resulting in a decline of in function and depression from not being able to assist themselves. The finding are: [NAME] Record review of the MDS assessment dated [DATE] revealed the following: Eating: self-performance 1 (Supervision - oversight, encouragement or cueing). B. Record review of the MDS assessment dated [DATE] revealed the following: Eating: self-performance 2 (Limited assistance - resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance). C. On 09/20/17 at 9:26 am, during an interview, the MDS Coordinator (MDSC #1) stated, If we (staff) open anything (drinks food items) for them (residents) then it is coded at 2 limited assistance. MDSC also stated, She (R #26) is limited assistance because staff have to help her open containers and cut her food. D. On 09/20/17 at 10:50 am, during an interview CNA #6 stated that R #26 eats in her room and does need staff to add salt and open containers for her. Also, CNA #6 confirmed that R #26 had needed this assistance since she started to work with her. E. On 09/20/17 at 9:55 am, during an interview and record review the Human Resources Director revealed CNA #6 had been working at the facility since 11/22/16. F. Record review of the Progress Notes dated 04/06/17 revealed that .Resident has her meals in her room . [NAME] Record review of the Progr… | 2020-09-01 |
| 27 | 27 | SANTA FE CARE CENTER | 325030 | 635 HARKLE ROAD | SANTA FE | NM | 87505 | 2017-09-21 | 279 | E | 0 | 1 | FY1511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that a comprehensive care plan was fully developed for 1 (R #105) of 1 (R #105) resident sampled for unnecessary medications; and 1(R #143) of 1 (R #143) resident sampled for Hospice. They failed to 1) care plan for R #105's diuretic medication, and 2) care plan for R #143's hospice services. The care plans did not specify how the residents' needs will be met. This failed practice could lead to residents not getting the appropriate care. The findings are: R #143 [NAME] Record review of R #143's care plan, dated 08/28/17, revealed he needed extensive assistance with ADLs. The care plan does not mention that he received assistance from the Hospice Aide for this service. Care plan read, Nursing to visit and coordinate with the facility staff and Hospice aids, Social Services, and the Chaplin will assist R #143 with services. B. On 09/20/17 at 09:10 am, during an interview, CNA #1 stated that the Hospice is suppose to come every other day and bath R #143. CNA #1 reports that the resident is not always bathed by Hospice, so she continues to shower R #143 according to his previous schedule. C. On 09/20/17 at 4:27 pm, during an interview, LPN#1 reported that Hospice is supposed to document in the resident's file (medical record) under the consultants tab. D. On 09/21/17 at 11:35 am, during an interview with MDS #2, she confirmed that R #143 care plan was not specific to the resident's needs. E. Record review of R # 143's medical record, under the Consultant tab, indicated that there were no documents for Hospice located. R #105 F. Record review of R #105's physician's orders [REDACTED]. [NAME] Record review of R #105 Care Plan dated 03/20/15 determined that R #105 was not care planned for the prescribed diuretic. H. On 09/21/17 at 10:27 am, during an interview with MDS #1, she confirmed that R #105 is not care planned for diuretic medication and its side effects. | 2020-09-01 |
| 28 | 28 | SANTA FE CARE CENTER | 325030 | 635 HARKLE ROAD | SANTA FE | NM | 87505 | 2017-09-21 | 281 | D | 0 | 1 | FY1511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation the facility failed to meet professional standards of quality when the staff failed to clarify conflicting MEDICATION ORDERS FOR [REDACTED]#140, R #180, R #194 and R #196) surveyed for medication reconciliation with the medication pass. This deficient practice could result the resident not receiving the right medication. The findings are: [NAME] On 09/21/17 at 8:19 am, during medication pass observation, LPN #4 administered a medication from a bubble pack labeled metoproplol [MEDICATION NAME] (an immediate release antihypertenisve medication) 25 mg tab (tablet) to R #54. The Medication Administration Record [REDACTED]. B. On 09/21/17 at 8:30 am, during an interview with LPN #4, when asked about the difference between the bubble pack ([MEDICATION NAME]) and the MAR ([MEDICATION NAME] ER) she said, Well, they are both [MEDICATION NAME]. No problem. C. Record review of the local hospital's Transfer Orders dated 03/21/17 revealed an order for [REDACTED].>D. Record review an actual prescription dated 03/21/17 revealed an order for [REDACTED]. E. Record review of the facility Physician Orders, dated (MONTH) (YEAR), revealed an order for [REDACTED].>F. On 09/21/17 at 10:46 am, during an interview with the Director of Nurses, when asked about the discrepancy between the medication LPN #4 gave, the medication on the MAR, the Physician order [REDACTED].#54, he stated, The nurse should have stopped, noticed the difference in the orders and called (the physician) for clarification. [NAME] Review of the facility procedure Medical Administration Orals, Section 7.5, dated 12/12 (sic) revealed: Procedures: 5. Review and confirm MEDICATION ORDERS FOR [REDACTED] H. Review of 2014 Lippincott Manual of Nursing Practice - 10th Ed. Philadelphia, P[NAME] Lippincott[NAME] & Wilkins. ISBN-10: 1-4511-7354-7, ISBN-13: 978-1-4511-7354-3. STAT!Ref Online Electronic Medical Library. http://online.statref.com/Document.aspx… | 2020-09-01 |
| 29 | 29 | SANTA FE CARE CENTER | 325030 | 635 HARKLE ROAD | SANTA FE | NM | 87505 | 2017-09-21 | 309 | D | 0 | 1 | FY1511 | 483.25 Quality of care. Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices, including but not limited to the following: This REQUIREMENT is Not Met as evidenced by: Based on record review and staff interview, the facility failed to ensure that a comprehensive care plan for Hospice was fully developed and further failed to ensure that the Hospice provider provided progress notes for 1 (R #143) of 1 (R #143) resident sampled for Hospice. The care plan did not specify how the resident's needs will be met and could impact the residents quality of care and quality of life. This failed practice could lead to residents not getting the appropriate care. The findings are: R #143 [NAME] Record review of R #143's care plan, dated 08/28/17, revealed he needs extensive assistance with ADLs. The care plan does not mention that the resident received assistance from the Hospice Aide for this service. Care plan read, Nursing to visit and coordinate with the facility staff and Hospice aids, Social Services, and the Chaplin will assist (name of R #143) with services. B. On 09/20/17 at 09:10 am, during an interview, CNA #1 stated that the Hospice is suppose to come every other day and bath R #143. CNA #1 reports that the resident is not always bathed by Hospice so she continues to shower R #143 according to his previous schedule. C. On 09/20/17 at 4:27 pm during an interview, LPN#1 reports that Hospice is supposed to document in the resident's file (medical record) under the consultants tab. D. On 09/21/17 at 11:35 am during an interview with MDS #2 she confirmed that R #143's care plan was not specific to the resident's needs. E. Record review of R # 143's medical record, under the Consultant tab, indictated that there were no … | 2020-09-01 |
| 30 | 30 | SANTA FE CARE CENTER | 325030 | 635 HARKLE ROAD | SANTA FE | NM | 87505 | 2017-09-21 | 332 | D | 0 | 1 | FY1511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation, the facility failed to ensure medication error rate did not exceed 5% when the medication error rate was 8.57% (3 errors out of 35 opportunities) when 3 medications were left in the resident's room and not administered by the nurse to 1 ( R # 54) of 9 (R #9, R #31, R #43, R #66, R #68, R #140, R #180, R #194 and R #196) residents reviewed during medication pass. This deficient practice could likely result in the resident not receiving the intended therapeutic relief from the medications to help with his breathing. The findings are: [NAME] On 09/21/17 at 8:20 am, during observation of LPN (Licensed Practical Nurse) #5 during a medication pass, it was observed that LPN #5 left 3 ampoules (small, sealed containers) of medications that are meant to be nebulized (aerosolized for inhalation via a nebulizer machine) on the resident's table and then LPN #5 left the room. The medications left were: 1) [MEDICATION NAME] (a medication to reduce inflammation in the airways), 0.5/mg ( milligram, a metric measurement) /2 ml (milliliter a metric measurement) 2) [MEDICATION NAME] (a medication to treat [MEDICATION NAME]--a spasm and narrowing of the breathing tubes), 2.5 mg/3 ml solution 3) [MEDICATION NAME]/[MEDICATION NAME] sulfate (combined medications to treat [MEDICATION NAME] and to reduce inflammation in the airways) 0.5 -3(2.5) mg/3 ml B. On 09/21/17 at 8:30 am, during an interview with LPN #5, she stated, I leave them (the medications) with him. (Name R #54) prefers to give them himself. Occasionally, he lets me set one up (prepare the treatment), but he usually doesn't allow it. When asked if R #54 was care planned for self-administration of the medication, LPN #5 replied, Yes he is. C. On 09/21/17 at 10:46 am, during an interview with the DON (Director of Nurses), he stated, The nurse should have not left the medications with him (R #54). She should have stayed and helped him. He (#54) has not be… | 2020-09-01 |
| 31 | 31 | SANTA FE CARE CENTER | 325030 | 635 HARKLE ROAD | SANTA FE | NM | 87505 | 2017-09-21 | 371 | F | 0 | 1 | FY1511 | Based on record review, observation, and interview, the facility failed to ensure that freezer/refrigerator temperatures were not recorded daily to monitor food safety. This deficient practice could lead to food borne illnesses that could affect 102 out of 103 residents who eat food prepared in the kitchen (residents were identified by the census list provided by the Administrator on 09/18/17). The findings are: [NAME] Record review of refrigerator/freezer temerature logs dated (MONTH) (YEAR) indicated: 1. Temperature logs for the kitchen refrigerator and freezers were missing documentation on the following days: 09/08/17, 09/09/17, 09/16/17, and 09/17/17 B. On 09/18/17 at 0845 am, during an interview, the Dietary Manager (DM) confirmed that the documentation was not done on the days listed indicating that the temperatures were not recorded. C. Record Review of facility's policy under Refrigerator Thermometers: Cold Facts about Food Safety, No date. 1. Chilling foods to proper temperatures is the best way to slow the growth of bacteria 2. To ensure .your refrigerator is doing its job, its important to keep temperature at 40 degrees or below; the freezer should be at 0 degrees | 2020-09-01 |
| 32 | 32 | SANTA FE CARE CENTER | 325030 | 635 HARKLE ROAD | SANTA FE | NM | 87505 | 2017-09-21 | 431 | E | 0 | 1 | FY1511 | Based on record review, interview, and observation, the facility failed to ensure drugs were stored under proper temperature controls, when the temperature log for (MONTH) (YEAR) on medication refrigerator in the Medication Room showed blank entries for 3 out of 19 days, and there were no temperature logs available for (MONTH) or (MONTH) of (YEAR). This deficient practice likely results in the inability of the facility to substantiate data that reflects that the medication refrigerator temperatures were within acceptable parameters on a daily basis to help assure the potency of the refrigerated medications, and has the potential to affect all 103 residents residing in the facility (residents were identified by the census list provided by the administrator on 09/18/17). The findings are: [NAME] On 09/20/17 at 9:55 am, during medication storage observation in the Med Room, it was revealed that the Daily Temperature Log on the medication refrigerator was missing temperatures on 09/02/17, 09/07/17, and 09/08/17. The refrigerator contained insulin for specific residents, tuberculin solution for skin testing and other medications. B. On 09/20/17 at 10:16 am, during an interview with ADON (Assistant Director of Nurses) #2, he said the night shift is responsible to complete the logs and he acknowledged that some dates were missing indicating the temperatures were not done on those dates. C. On 09/20/17 at 11:49 am, the DON (Director of Nurses) said he was unable to provide temperature logs for the medication refrigerator for (MONTH) and (MONTH) of (YEAR). The DON said he believes the refrigerator logs were misplaced or lost during the recent renovations. The DON affirmed his expectation is that the medication refrigerators should have the temperature checked daily to assure it is in the proper range for medication storage. D. Review of the facility procedures Storage of Medication, Section 4.1, dated 05/16 revealed: 11. Medications requiring 'refrigeration' or 'temperatures between 2 degrees C (Centigrade) (36 degrees Fa… | 2020-09-01 |
| 33 | 33 | SANTA FE CARE CENTER | 325030 | 635 HARKLE ROAD | SANTA FE | NM | 87505 | 2017-09-21 | 441 | E | 0 | 1 | FY1511 | Based on record review and interview, the facility failed to ensure 1) the staff did proper hand hygiene between residents while performing medication pass in Wing 3, which has the potential to affect all 18 residents residing in the wing (residents were identified by the census list provided by administrator on 09/18/17), and 2) 1 (R #2) of 1 (R #2) (random resident seen going though items on the lunch tables and the trash) resident cleaned her hands after touching used items on dining tables after every meal and after rummaging through garbage bins attached to medication carts, which has the potential to affect all These deficient practices could lead to cross contamination (the process of transferring bacteria or other harmful agents from one surface to another) that could result in illness, debility and death. The findings are: [NAME] On 09/19/17 at 12:13 pm, during observation of the medication pass done by LPN #1, it was observed that LPN #1 administered an insulin injection to R #194, then removed her gloves and wiped her hands with a Prima Guard Adult Cleansing Washcloth (label stated alcohol free). When asked about using the patient care wipes, LPN #1 stated, I am using these today because my little bottle of the waterless hand cleaner has been missing off my cart. I think it is fine (to use the Adult Cleansing Washcloths) and doesn't make my hands so dry. B. On 09/21/17 at 10:49 am, during an interview with the DON (Director of Nurses), he stated, We supply alcohol hand cleanser for the medication carts. Using that (alcohol hand clenser) or washing with soap and water would be appropriate. The adult wipes would not be appropriate. I would say it is possible that there could cross contamination between residents. C. Review of the facility competency form on Handwashing revealed: Washing hands with soap and water is the best way to reduce germs on them. If soap and water are not available, use an alcohol based hand sanitizer that contains at least 60% alcohol. R #2 D. On 09/18/17 at 12:40 pm, during dinin… | 2020-09-01 |
| 34 | 34 | SANTA FE CARE CENTER | 325030 | 635 HARKLE ROAD | SANTA FE | NM | 87505 | 2018-10-28 | 609 | D | 0 | 1 | GNFO11 | Based on record review and interview the facility failed to report to the State Survey Agency allegations of abuse/neglect within 24 hours of notification, for 1 (R #42) of 2 (R #42 and R #18) residents sampled for abuse/neglect. This deficient practice likely resulted in the claim of abuse not being met with a timely investigation. If the facility fails to report allegations of abuse/neglect to the State Survey Agency, corrective measures may not be acted on, and the facility is unable to assure residents are free from abuse/neglect. The findings are: [NAME] On 10/22/18 at 4:35 pm, during an interview R #42 stated, A Certified Nursing Assistant (CNA #7) about four or five months ago called me dirty names. B. On 10/26/18 the facility was unable to produce evidence that the incident regarding abuse/neglect for R #42 was reported within the required twenty four hours. C. Record review of a (five day review) report dated 08/21/18 revealed that CNA #7 was accused of making abusive statements towards R #42 on or about 08/04/18. D. Record review of Transmission Verification Report (fax) sent to State Survey Agency dated 08/22/18 revealed that the (five day review) follow-up report for R #42 was sent on 08/22/18 at 11:58 am. E. On 10/26/18 at 3:10 pm, the Administrator (ADM) stated, The incident occurred on or about 08/14/18 while they were at an event out of town, however we do not have a copy of the incident report to show we reported the alleged abuse. F. On 10/26/18 at 3:00 pm, during an interview with the Director of Nursing (DON) and ADM they stated that they could not find a copy of the initial report that was sent to the State Survey Agency for the incident between R #42 and CNA #7. | 2020-09-01 |
| 35 | 35 | SANTA FE CARE CENTER | 325030 | 635 HARKLE ROAD | SANTA FE | NM | 87505 | 2018-10-28 | 656 | D | 0 | 1 | GNFO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to develop a comprehensive person-centered care plan for 2 (R #29 and R #69) of 2 (R #29 and R #69 ) residents reviewed for 1) oxygen use and care, and 2) dental care. Failure to develop and implement a resident centered care plan may result in staff's failure to understand and implement the needs and treatments of residents possibly resulting in decline in abilities and a failure to thrive. The findings are: Resident #29 [NAME] On 10/22/18 at 9:10 am an observation of R #29 revealed that the resident was using oxygen while sitting in assigned room. B. Record review of baseline care plan dated 05/02/18 revealed that R #29 was admitted with oxygen at 2 liters per minute. C. Record review of Care Plan dated 05/30/18 revealed that R #29 had not been care planned for the use of oxygen. D. On 10/26/18 at 11:00 am, during an interview, the MDS coordinator stated, I was looking for orders for the O2 (oxygen), if he didn't have orders for the O2 he wouldn't be care planned. E. On 10/26/18 at 2:34 pm, during an interview Assistant Director of Nursing (ADON) stated, (resident name) does not have an O2 order, the only place I see is on the admission where they started to mark it yes and then marked it no. I am writing an order for [REDACTED]. Resident #69 F. Record review of the facility facesheet for R #69 dated 08/15/17 revealed, an admitted d 08/15/17. Admission [DIAGNOSES REDACTED]. [NAME] On 10/22/18 at 4:21 pm, observation of R #69's teeth revealed, they were brown, worn down and chipped. H. Record review of R #69's Minimum Data Set (MDS) assessment (Center for Medicare/Medicaid assessment tool) dated 07/05/18 revealed no triggers for dental issues. 1. MDS dated [DATE] revealed, Triggers: Oral/Dental status: Pain, discomfort, difficulty chewing. Teeth very poor condition, probable caries broken/missing teeth and refuses dental care. Requires good oral hygiene at least 2 times a … | 2020-09-01 |
| 36 | 36 | SANTA FE CARE CENTER | 325030 | 635 HARKLE ROAD | SANTA FE | NM | 87505 | 2018-10-28 | 677 | D | 0 | 1 | GNFO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide ADL (activities of daily living) assistance for nail care for 1 (R #30) of 1 (R #30) residents reviewed for ADL's. This deficient practices has the potential to affect the dignity and health of the residents. The findings are: [NAME] On 10/23/18 at 2:24 pm, during observation, R #30 was observed with dirty and uncut fingernails. R #30 has a slight contracture (abnormal shortening of muscle tissue, making it difficult to open hand) of the right hand and the nails were long enough to dig into his hand. B. On 10/27/18 at 10:05 am, a second observation of R #30 revealed, R #30's nails had a black substance under the nails and were not clean or cut. C. Record review of the care plan for R #30 dated 09/21/17 revealed, Self care deficit: requires 1 person assist for all transfers related to (r/t) [DIAGNOSES REDACTED]. (Name of Resident) also has generalized weakness and loss of function in right arm and limited function in right leg. Requires set up for all meals and eats in dining room. Staff times 1 to assist with showers as scheduled. Set up and assist with all grooming/hygiene needs. 05/14/18 Requires extensive assist with most ADL's such as bed mobility, transfers, dressing toileting, hygiene and showers. D. On 10/27/18 at 10:10 am, during an interview, the Director of Nursing (DON) stated I think that was a pretty poor job of hygiene, the nurse should be cutting his nails. E. On 10/27/18 at 10:30 am, during an interview, Certified Nurse Aide (CNA) #6, stated that nails should be cleaned at every shower and as needed. F. On 10/27/18 at 10:39 am, during an interview, Licensed Practical Nurse (LPN) stated that R #30 nails should be cut and cleaned. | 2020-09-01 |
| 37 | 37 | SANTA FE CARE CENTER | 325030 | 635 HARKLE ROAD | SANTA FE | NM | 87505 | 2018-10-28 | 726 | F | 0 | 1 | GNFO11 | Based on staff interview, the facility failed to ensure that the certified nursing assistants (CNAs) had documented, demonstrated competencies (ability of an individual to do a job properly), before they worked with the residents, and annually. All 52 CNAs could be impacted by this (based on a list of nurse aides provided by the Director of Nursing (DON) on 10/23/18). This could lead to the residents not receiving the care and services as described on the care plan. The findings are: [NAME] Record review of Facility CNA Training Records revealed, 1. CNA #1 - no competencies in the training record 2. CNA #2 - no competencies in the training record 3. CNA #3 - no competencies in the training record 4. CNA #4 - no competencies in the training record 5. CNA #5 - no competencies in the training record B. On 10/28/18 at 8:30 am during an interview the Director of Nursing (DON) stated, I realized a few weeks ago I didn't have any competencies for the staff. I'm starting a program that will be done in their anniversary month but now I do not have any competencies for staff. | 2020-09-01 |
| 38 | 38 | SANTA FE CARE CENTER | 325030 | 635 HARKLE ROAD | SANTA FE | NM | 87505 | 2018-10-28 | 730 | F | 0 | 1 | GNFO11 | Based on staff interview, the facility failed to ensure the annual performance review for the certified nursing assistants (CNAs) had been completed . This could lead to CNA's not receiving further education in areas identified during their evaluation and residents not receiving the care and services as described on the care plan. The findings are: [NAME] Record review of CNA Personnel records revealed no evidence of a Annual Performance Evaluation. B. On 10/27/18 at 2:55 pm during an interview the Director of Nursing (DON) stated, I don't have Annual Performance Evaluations for the CNA's. I'd start doing them people wouldn't show up for the evaluation so I quit doing them. | 2020-09-01 |
| 39 | 39 | SANTA FE CARE CENTER | 325030 | 635 HARKLE ROAD | SANTA FE | NM | 87505 | 2018-10-28 | 732 | F | 0 | 1 | GNFO11 | Based on observation and interview the facility failed to 1) accurately post the actual number of nursing staff (Registered Nurses (RN), Licensed Practical Nurses (LPN) and Certified Nursing Assistants (CNA)) on shift and 2) update the list within 2 hours of the beginning of each shift, and 3) posting multiple dates 10/26/18 to 10/30/18 with all shifts pre-populated. This deficient practice likely prevented the 99 residents identified on the facility census list provided by the Administrator on 10/21/18 to have access to accurate staffing information. The findings are: [NAME] On 10/27/10 at 2:30 pm during an observation the Daily Staff Posting, on the Wing 3 Hallway on the left wall approximately 5 feet above the floor, was noted to be for the dates of 10/26/18 to 10/30/18. The numbers of RN's, LPN's and CNA's had been pre-populated for this 5 day time period with no modification made as to actual numbers of staff on shift. B. On 10/27/18 at 3:10 pm during an interview the Assistant Director of Nursing (ADON) stated that the Daily Staff Postings are completed ahead of the shifts for all shifts. The Director of Nursing (DON) confirmed that the Daily Staff Posting were not done within 2 hours of the beginning of a shift but sometimes as much as 2-3 days ahead. The DON and ADON also confirmed that the location of the Daily Staff Posting was not readily accessible to all residents, family members or visitors. | 2020-09-01 |
| 40 | 40 | SANTA FE CARE CENTER | 325030 | 635 HARKLE ROAD | SANTA FE | NM | 87505 | 2018-10-28 | 761 | E | 0 | 1 | GNFO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure that medications on Wing 1 medication storage cart, Wing 3 medication storage cart, and the main medication storage room were not expired. This deficient practice is likely to affect 7 (R #12, 38, 55, 61, 89, 306, and 307) of 99 residents on the facility matrix as provided by the Administrator on 10/21/18. 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. The findings are: [NAME] On 10/23/18 at 2:15 pm, an observation of the medication storage cart on Wing #1 revealed that the cart contained four expired drugs: [MEDICATION NAME] INJ (injectable) USP (United States Pharmacopia) (helps to treat [MEDICAL CONDITION]) 5 milligrams/milliliter (mg/ml) for R #55, expired on 06/18; [MEDICATION NAME] (helps to treat [MEDICAL CONDITION]) 1 mg tablet for R #306, expired on 12/17; [MEDICATION NAME] (is used to treat depression) 7.5 mg tablet for R #306, expired on 08/18; and Donepezil HCL (used to treat mild to moderate dementia caused by [MEDICAL CONDITION]) 5 mg tablet for R #61, expired on 08/18. B. On 10/23/18 at 2:45 pm, an observation of the medication storage cart on Wing #3 revealed that the cart contained two expired drugs, the findings are as follows: [MEDICATION NAME] HCL (used to prevent or treat nausea and vomiting) 8 mg tablet for R #38, expired on 04/18; and [MEDICATION NAME]-[MEDICATION NAME] (used to treat moderate to severe pain) 5-325 mg tablet for R #12, expired on 05/18. C. On 10/28/18 at 9:45 am, an observation of the main medication storage room revealed that the room contained three expired medications, the findings are as follows: Latanoprost (used in the eye to treat open angle [MEDICAL CONDITION] and high pressure in the eye) 0.005% OPH (ophthalmic) eye drops for R #307, expired on 09/28/18; Latanoprost 0.005% OPH … | 2020-09-01 |
| 41 | 41 | SANTA FE CARE CENTER | 325030 | 635 HARKLE ROAD | SANTA FE | NM | 87505 | 2018-10-28 | 791 | D | 0 | 1 | GNFO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to ensure that residents obtain routine dental care for 1 (R #69) of 1 (R #69) resident reviewed for dental services. This failure has the potential to cause the resident pain, embarrassment over condition of teeth, and potential weight loss. The findings are: [NAME] Record review of the facility facesheet for R #69 dated 08/15/17 revealed, an admitted d 08/15/17. Admission [DIAGNOSES REDACTED]. B. On 10/22/18 at 4:21 pm, observation of R #69's teeth revealed, they were brown, worn down and chipped. C. Record review of R #69's Minimum Data Set (MDS) assessment (Center for Medicare/Medicaid assessment tool) dated 07/05/18 revealed no triggers for dental issues. 1. MDS dated [DATE] revealed, Triggers: Oral/Dental status: Pain, discomfort, difficulty chewing. Teeth very poor condition, probable caries broken/missing teeth and refuses dental care. Requires good oral hygiene at least 2 times a day. Will continue to care plan. 2. MDS dated [DATE] revealed, Triggers: Oral/Dental status: Cavity or broken natural teeth, pain discomfort, difficulty chewing. Poor oral dentition related to (r/t) weakness, decreased trunk control and cognitive deficit. Will care plan. D. On 10/15/18 at 9:43 am during an interview, the Social Services Assistant (SSA) stated I do not have any documentation to show (Name of Resident) has seen a dentist for dental needs. The SSA also stated that when he (R #69) came he had behaviors and it was very difficult to get him to do anything, he stayed in his room and did not interact with anyone. E. Record review of the care plan dated 09/19/17 revealed, no interventions for dental issues. F. On 10/26/18 at 8:49 am, during an interview, R #69 stated that he would like to see a dentist. | 2020-09-01 |
| 42 | 42 | SANTA FE CARE CENTER | 325030 | 635 HARKLE ROAD | SANTA FE | NM | 87505 | 2018-10-28 | 804 | F | 0 | 1 | GNFO11 | Based on interview, observation, and record review the facility failed to provide meals that taste good, looked appetizing, and were served at the correct temperature. This failed practice had the potential to affect all 99 residents identified on the resident census list provided by the administrator on 10/21/18. This deficient practice has the potential for residents to not eat meals and could lead to weight loss. The findings are: [NAME] On 10/22/18 at 9:12 am during an interview, R #78 stated that the food is terrible. I eat what I can. B. On 10/22/18 at 4:41 pm during an interview, R #42 stated, The food is horrible, sometimes its cold when its supposed to be hot. Sometimes it takes a long time to get the trays to the rooms. C. On 10/22/18 at 3:34 pm, during an interview, R #77 stated, The meals could be warmer, by the time it gets to you they are sometimes cold, sometimes staffing is short, they try the best they can .but. D. On 10/22/18 at 4:00 pm during an interview, R #150 stated food is horrible. if my family didn't bring me things, I would starve to death. E. On 10/23/18 at 10:05 am during the resident council meeting, residents stated the food served at the facility was always the same, it was undercooked, not at a good temperature, had no flavor, and no spice. F. On 10/23/18 at 2:20 pm, during an interview, R #30 stated that the food was a 3 on a scale from 1 to 10, (1 bad and 10 good). [NAME] On 10/23/18 at 4:55 pm during observation and test tray validation of the dinner meal the following was indicated: 1. oven baked chicken was 130 degrees Fahrenheit (temperture should be 140 degrees) and the inside was pink in color, 2. mixed vegetable blend were mushy to taste and not warm. 3. The appearance of food on the plate was unappetizing. H. On 10/24/18 at 12:00 pm, an observation of test tray from the kitchen revealed that the meal (chicken fried steak, mashed potatoes, and spinach) was not appetizing/appealing. The meat appeared still pink on the inside, and the breading was soggy, The entire meal was… | 2020-09-01 |
| 43 | 43 | SANTA FE CARE CENTER | 325030 | 635 HARKLE ROAD | SANTA FE | NM | 87505 | 2018-10-28 | 810 | D | 0 | 1 | GNFO11 | Based on record review, observation and interview the facility failed to ensure that residents are provided with special eating equipment when needed to consume meals and snacks for 1 (R #52) of 1( R #52) resident reviewed during random observation. If residents are not provided special eating equipment as needed, then residents are likely to not be able to consume their meals and snacks which could likely result in weight loss and malnutrition. The findings are: [NAME] On 10/24/18 at 12:22 pm, during a random meal observation, R #52's meal ticket revealed, Nosey cup as needed or requested. Observation revealed, R #52 was having difficulty drinking from a regular cup and did not have a nosey cup (cup with a cut out for the nose when drinking), for his liquids. B. On 10/24/18 at 12:30 pm, during observation of a document hanging in the kitchen, revealed E-Z Sip Lids - Attention: The following resident's need to have a lid placed on cup with all liquids: (Name of Resident #52) Nosey cup. Updated 10/17/18. C. On 10/25/18 at 7:35 am, during meal observation, R #52 did not have a nosey cup to drink his liquids. D. On 10/25/18 at 7:40 am, during an interview, Certified Nurse Aide (CNA) #4 stated He (R #53) was to have a nosey cup, CNA #4 went to check and stated I will go get him one. E. On 10/27/18 at 3:21 pm, during an interview, the Assistant Director of Nursing stated that a clarification order had been written for the use of the nosey cup. | 2020-09-01 |
| 44 | 44 | SANTA FE CARE CENTER | 325030 | 635 HARKLE ROAD | SANTA FE | NM | 87505 | 2018-10-28 | 880 | F | 0 | 1 | GNFO11 | Based on interview and record review, the facility failed to maintain an infection prevention and control program for all residents by not maintaining surveillance of infections prior to (MONTH) (YEAR). This deficient practice could likely effect all 99 residents in the facility as identified on the Facility Matrix provided by the Administrator on 10/21/18. Failure to implement an infection control program likely causes the spread of infections and illness to residents and staff within the facility. The findings are: A: On 10/28/18 record review of the facility Infection Control Tracking log revealed that the log only contained documentation starting in (MONTH) for the current year (08/18). B: On 10/28/18 at 12:40 pm, during an interview Director of Nursing (DON) stated, It looks like it starts in (MONTH) (08/18), I don't have any information prior to that. I don't know where the previous Infection Control Nurse would have put the information prior to that. | 2020-09-01 |
| 45 | 45 | SANDIA RIDGE CENTER | 325032 | 2216 LESTER DRIVE NE | ALBUQUERQUE | NM | 87112 | 2018-03-14 | 557 | E | 0 | 1 | YN7D11 | Based on interview and observation the facility failed to treat 1 (R #39) of 1 (R #39) resident with respect and dignity when staff removed R #39's personal possessions from a dresser, placing them in a box while R #39 was out of the facility. This deficient practice created a feeling of frustration for not being asked about the removing the dresser and coming back to the facility and finding her belongings in a box. The findings are: [NAME] On 03/07/18 at 10:32 am, during an interview with R #39, she stated that around 2 or 3 months ago she was out at the hospital and while she was gone they took her dresser. She stated that when she returned from the hospital the dresser wasn't there and her personal items were in a box. She never received a explanation and was never offered another dresser. B. On 03/13/18 at 9:21 am, during an interview with CNA #3, she stated that she and another CNA did take the dresser from R #39's room. She stated that R #39 was out at the hospital when the dresser was taken and they placed some items in a box. She stated that they also threw out a lot of it because it was a bunch of papers and sugar packets. She also stated that R #39 was not notified because she was out at the hospital. C. On 03/13/18 at 10:32 am, an observation was made of R #39's room. It was observed that R #39 had a three drawer dresser and across from that there was box where R #39 stated the smaller dresser used to be. D. On 03/14/18 at 11:29 am, during an interview with RN #2 she stated that if a new resident coming into the facility needs a dresser or another piece of furniture than they (staff) would let maintenance know and they would get whatever was needed out of storage. RN #2 also stated that no you would never take it from another resident who was using it. If a resident is using it, it becomes their property. E. On 03/14/18 at 11:32 am, during an interview with the Maintenance Director, he stated that they do have furniture in storage that they will pull from if they need too. He stated that, he tries to … | 2020-09-01 |
| 46 | 46 | SANDIA RIDGE CENTER | 325032 | 2216 LESTER DRIVE NE | ALBUQUERQUE | NM | 87112 | 2018-03-14 | 600 | H | 0 | 1 | YN7D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that residents residing on the Dementia (a decline in mental ability severe enough to interfere with daily life) Unit were free from physical abuse for 8 (R #s 4, 33, 62, 71, 79, 87, 93, and 108) of 8 (R #s 4, 33, 62, 71, 79, 87, 93, and 108) residents reviewed for abuse by failing to prevent R #97 from pushing, slapping, grabbing, and pulling a resident out of bed onto the floor. This deficient practice subjected vulnerable residents to assaults, which are likely to cause serious injury, feelings of fear, distress and humiliation. The findings are: [NAME] Record review of R # 97's Admission record, revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. B. Record review of R # 97's Resident Management System Summary Reports revealed the following resident to resident altercations with/alleged abuse: 1. On 04/06/17, This resident (R #97) had a physical altercation with another resident, (who was not identifed in report), unknown what triggered resident to hit another resident. He sustained a skin tear on in (sic) right bridge nose area. The (unidentified) resident would not allow nurse to administer first (aid), he was combative and attempted to hit nurse. 2. On 05/11/17, During breakfast this resident (R #97) became annoyed with female resident (who was not identifed in report), who attempted taking (sic) his drinks, was persistently bothering him with conversation and calling him daddy .female resident was directed to another table but came back to stand next to him. (R #97) then got up and slapped female resident several times in face. 3. On 07/22/17, This resident (R #97) was walking into dining room when (R #71) stood up and told him not to sit in the chair. This resident then pushed (R #71) with both hands into the wall. Nurse and Certified Nurses Aide (CNA) unable to intervene before contact was made between residents. 4. On 09/30/17, This resident (R #97) struck… | 2020-09-01 |
| 47 | 47 | SANDIA RIDGE CENTER | 325032 | 2216 LESTER DRIVE NE | ALBUQUERQUE | NM | 87112 | 2018-03-14 | 607 | E | 0 | 1 | YN7D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to implement their policy regarding reporting incidents of resident to resident abuse and failed to ensure the results of an investigation was reported to the State Survey Agency within 5 days for 7 (R #s 33, 62, 71, 87, 93, 97 and 108) of 7 (R #s 33, 62, 71, 87, 93, 97 and 108) residents reviewed for abuse. If the facility is not reporting and investigating resident to resident abuse according to policies, then the facility is likely to be unable to determine the cause and identify strategies for preventing further abuse. The findings are: [NAME] Record review of the Resident Management System (RMS) Summary Reports revealed the following resident to resident altercations with alleged abuse: 1. On 04/06/17, This resident (R #97) had a physical altercation with another resident, (who was not identifed in report), unknown what triggered resident to hit another resident. He sustained a skin tear on in (sic) right bridge nose area. The unidentified resident would not allow nurse to administer first (aid), he was combative and attempted to hit nurse. 2. On 05/11/17, During breakfast this resident (R #97) became annoyed with female resident (who was not identifed in report), Please identify who attempted taking (sic) his drinks, was persistently bothering him with conversation and calling him daddy .female resident was directed to another table but came back to stand next to him. (R #97) then got up and slapped female resident several times in face. 3. On 07/22/17, This resident (R #97) was walking into dining room when (R #71) stood up and told him not to sit in the chair. This resident then pushed (R #71) with both hands into the wall. Nurse and CNA (certified nursing assistant) unable to intervene before contact was made between residents. 4. On 09/30/17, This resident (R #97) struck/pushed another resident (R #87) to the floor, and attempted to continue attack on his victim was (sic) lyi… | 2020-09-01 |
| 48 | 48 | SANDIA RIDGE CENTER | 325032 | 2216 LESTER DRIVE NE | ALBUQUERQUE | NM | 87112 | 2018-03-14 | 609 | E | 0 | 1 | YN7D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure incidents of resident to resident abuse were reported to the State Survey Agency within 2 hours for 7 (R #s 33, 62, 71, 87, 93, 97, and 108) of 7 (R #s 33, 62, 71, 87, 93, 97, and 108) residents reviewed for abuse. If the facility fails to report allegations of abuse to the State Survey Agency, corrective measures may not be acted on, and the facility is unable to assure residents are free from abuse. The finding are: [NAME] Record review of the Resident Management System (RMS) Summary Reports revealed the following resident to resident altercations with alleged abuse: 1. On 04/06/17, This resident (R #97) had a physical altercation with another resident (unidentifed resident), unknown what triggered resident to hit another resident (unidentifed). Resident (unidentifed resident) sustained a skin tear on in (sic) right bridge nose area. He would not allow nurse to administer first (aid), he was combative and attempted to hit nurse. 2. On 05/11/17, During breakfast this resident (R #97) became annoyed with female resident (unidentifed) who attempted taking (sic) his drinks, was persistently bothering him with conversation and calling him daddy .female resident was directed to another table but came back to stand next to him. (R #97) then got up and slapped female resident several times in face. 3. On 07/22/17, This resident (R #97) was walking into dining room when (R #71) stood up and told him not to sit in the chair. This resident then pushed (R #71) with both hands into the wall. Nurse and CNA (certified nursing assistant) unable to intervene before contact was made between residents. 4. On 09/30/17, This resident (R #97) struck/pushed another resident (R #87) to the floor, and attempted to continue attack on his victim was (sic) lying on the floor. 5. On 10/28/17, Resident (R #33) stood up from his wheelchair and grabbed onto the back of this residents (R #97) chair he was … | 2020-09-01 |
| 49 | 49 | SANDIA RIDGE CENTER | 325032 | 2216 LESTER DRIVE NE | ALBUQUERQUE | NM | 87112 | 2018-03-14 | 610 | E | 0 | 1 | YN7D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to thoroughly investigate incidents of resident to resident abuse and report the results of those investigations to the Licensing Authority within 5 days for 7 (R #s 33, 62, 79, 87, 93, 97, and 108) of 7 (R #s 33, 62, 79, 87, 93, 97, and 108) residents reviewed for abuse. This deficient practice has the potential to prevent staff from determining the cause of the incident, identifying the need for staff training and implementing needed changes to prevent resident to resident abuse. The findings are: [NAME] Record review of the Resident Management System (RMS) Summary Reports revealed the following resident to resident altercation with alleged abuse: 1. On 09/30/17, This resident (R #97) struck/pushed another resident (R #87) to the floor, and attempted to continue attack on his victim was lying on the floor. 2. On 10/28/17, Resident (R #33) stood up from his wheelchair and grabbed onto the back of this residents (R #97) chair he was sitting in. This resident then stood up and pushed (R #33) causing him to fall on the floor. This resident then reached down grabbing (R #33's) shirt trying to pull him up off floor. 3. On 01/12/18, Resident hit (R #108) while he was eating his dinner. (R #108) then hit him back with his cane causing a laceration on this resident's (R #97) forehead. 4. On 01/14/18, Resident (R #97) was sitting at dining room table with a male resident (who was not identifed in report), (un readable) heard calling out. Upon entering room, both residents (R #97 and the unidentified) male resident, (unreadable), was pulling on a female resident's (not identifed in report) hand. Resident's (R #97 and unidentifed male resident) hands were separated and (unidentifed) female resident was asked if she would like to move to another seat. Resident (unidentifed female resident) replied yes and was assisted to another table in a different section of the dining room. Each resident (all … | 2020-09-01 |
| 50 | 50 | SANDIA RIDGE CENTER | 325032 | 2216 LESTER DRIVE NE | ALBUQUERQUE | NM | 87112 | 2018-03-14 | 656 | E | 0 | 1 | YN7D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure that comprehensive person-centered care plans were developed for 2 (R #s 38 and 81) of 2 (R #s 38 and 81) residents reviewed for nutritional issues. Focus areas, goals and individualized interventions were missing for a resident on dysphagia (means it takes more time and effort to move food or liquid from your mouth to your stomach) pureed diet (R #81) and malnutrition (R# 38). These deficient practice were likely to result in inconsistent delivery of interventions to residents in need of specialized care. The findings are: Findings for R #81: [NAME] Record review of R #81's Care Plan, revealed updates to the care plan to include R #81 exhibits impaired swallowing related to dementia (a group of symptoms caused by disorders that affect the brain. It is not a specific disease) . The care plan was updated on 03/06/18. B. On 03/07/18 at 8:26 am, during interview the MDS Coordinator confirmed that she updated R #81's care plan on 03/06/18, because she felt that everyone should be aware of her dysphagia. At 8:32 am, she confirmed that R #81's impaired swallowing was not care planned prior to 03/06/18. Findings for R #38: C. Record review of the Admission Record indicated that R #38 was admitted on [DATE]. D. Record review of the Nutrition assessment dated [DATE] indicated that R #38 had a nutrition problem. R #38 was malnourished with a low (BMI) Body Mass Index (the body mass index is a value derived from the mass and height of an individual). E. Record review of the initial care plan dated 12/25/17 with a revision on 01/17/18 indicated that there was no care plan intervention for R #38's nutrition problem /malnutrition related to: self inflicted by not eating, concerns of allergies [REDACTED]. [MEDICAL CONDITION] from [MEDICAL CONDITION] also contributing to diarrhea, low BMI of 13.38 with a weight of 80.4 pounds and a lack of drinking fluids regularly. F. On 03/09/18 at 10:32 am… | 2020-09-01 |
| 51 | 51 | SANDIA RIDGE CENTER | 325032 | 2216 LESTER DRIVE NE | ALBUQUERQUE | NM | 87112 | 2018-03-14 | 684 | E | 0 | 1 | YN7D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to follow physician orders [REDACTED].#62) of 1 (R #62) residents reviewed for quality of care. If the facility is not following physician orders, then residents could likely not receive the treatment necessary to improve and/or maintain their health. The findings are: [NAME] Record review of R #62's Physician's Telephone Order dated 10/11/17, revealed [MEDICATION NAME] (an anticonvulsant) 200 mg (milligram) one-tab (tablet) PO (by mouth) BID (twice a day) x 4 d (times four days), then increase to TID (three times a day). Dx: (diagnosis): Impulsive behavior. B. Record review of R #62's Medication Administration Records (MARs) for (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR), revealed [MEDICATION NAME] was administered twice a day, at 8:00 am and 4:00 pm. C. On 03/06/18 at 9:22 am, during an interview Registered Nurse (RN) #1 stated, that R #62 gets 200 mg of [MEDICATION NAME] twice a day. RN #1 verified that the order to increase the medication to three times a day was ordered in (MONTH) (2017) and stated that she didn't know why it was not changed in the computer system. D. On 03/06/18 at 9:23 am, during an interview the Director of Nursing (DON) confirmed that R #62's order to increase [MEDICATION NAME] was not changed to three times a day. The DON stated that the order was written by the psychiatrist in (MONTH) of last year and that they should have written two orders, one for routine for four days and the new order to increase to three times a day. The DON stated that the order was not followed for about five months. | 2020-09-01 |
| 52 | 52 | SANDIA RIDGE CENTER | 325032 | 2216 LESTER DRIVE NE | ALBUQUERQUE | NM | 87112 | 2018-03-14 | 686 | G | 0 | 1 | YN7D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to adequately monitor (through skin assessments) and prevent skin breakdown that led to pressure sores for 1 (R #38) of 1 (R #38) residents looked at for pressure injury/sores and skin breakdown. This deficient practice contributed to R #38 having multiple pressure sores (areas of damaged skin caused by staying in one position for too long) which commonly form where your bones are close to your skin, such as your ankles, back, elbows, heels and hips due to (MASD) Moisture Associated Skin Damage (which is the general term for inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva, or mucus), creating more issues with nutrition and requiring wound treatment that creates pain. The findings are: [NAME] Record review of the Shower sheets indicated that during a shower dated 01/29/18 that R #38 had redness/rash and there was an open area. B. Record review of the Weekly Skin Check Assessments for R #38 indicated that a skin check was done on 12/22/17 and 12/29/17 and there was not another Skin Assessment completed until 02/28/18. C. Record review of the Skin Integrity Report that the DON fills out, indicated that on 01/28/18 and 02/06/18 that R #38 had Moisture Associated Skin Damage (MASD). D. Record review of the Nursing Progress Notes dated 02/04/18, indicated that Resd (resident) appeared very weak and dehydrated. Fluids encouraged and 3 cups taken during shift . [MEDICATION NAME] (a foam dressing suitable for a wide range of wounds like venous leg ulcers, pressure ulcers or diabetic ulcers) intact on coccyx area for protection. Very red open areas on groin areas with clear fluid drainage. Cleansed with warm soapy water and barrier cream applied. E. Record review of the Nursing Progress Notes dated 02/08/18, indicated that . Open area/redended (sic) area noted to coccyx. Dressing applied. Barrier cream applied t… | 2020-09-01 |
| 53 | 53 | SANDIA RIDGE CENTER | 325032 | 2216 LESTER DRIVE NE | ALBUQUERQUE | NM | 87112 | 2018-03-14 | 689 | J | 0 | 1 | YN7D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure that accident hazards were minimized on the locked Dementia (a general term for loss of memory and other mental abilities severe enough to interfere with daily life) unit, by failing to provide residents with the correct consistency snack. This deficient practice resulted in an Immediate Jeopardy (IJ) at a scope and severity of J being identified on 03/06/18. The facility was notified on 03/06/18 at 4:21 pm. The facility took corrective action by providing an acceptable Plan of Removal on 03/06/18 at 4:23 pm. Based on the Plan of Removal, interventions included: 1. Snack lists have been reviewed for correct diet by CNE (Center Nurse Executive) and Dietician on 03/06/18. 2. Diet orders have been provided to the nursing stations for quick review for staff on 03/06/18. 3. Staff currently working were educated on the diet order notebooks on 03/06/18, other staff will be re-educated prior to working their next shift. 4. Daily checks will be conducted for residents on snacks for correct diet by the unit manager or designee for 1 week, and then weekly for 4 weeks, and then monthly thereafter. 5. The daily checks will be brought to QAPI (Quality Assurance Performance Improvement) monthly for three months. Based on the Plan of Removal, the IJ was lifted on 03/06/18 at 4:25 pm. This resulted in the scope and severity being reduced from level J to level D. Based on observation, record review, and interview, the facility failed to ensure that residents received the correct consistency of snacks and that the resident environment was free of tripping hazards for 3 (R #s 35, 81, 97) of 3 (R #s 35, 81, 97) residents reviewed for accident hazards. This deficient practice increases the risk for falls, choking, aspiration, and/or death. The findings are: Findings for R #81 [NAME] Record review of R #81's Diet Order and Communication Form dated 11/06/17, revealed R #81's diet was changed to dysphasia puree (diet where all food has b… | 2020-09-01 |
| 54 | 54 | SANDIA RIDGE CENTER | 325032 | 2216 LESTER DRIVE NE | ALBUQUERQUE | NM | 87112 | 2018-03-14 | 725 | F | 0 | 1 | YN7D11 | Based on record review and interview the facility failed to ensure sufficient nursing staff to answer call lights in a timely manner, on a consistent basis, across all shifts, for the needs of all 126 residents identified on the alphabetical resident census provided by the Administrator on 03/05/18. This deficient practice has the potential to negatively impact resident safety and comfort, and to impede processes such as timely incontinence care and regular turning schedules. The findings are: [NAME] On 03/05/18 at 9:31 am, during an interview with resident (R) #114, she stated that they (staff) don't have enough help. R #114 stated that I will go to the bathroom in my pants before they get to me. R #114 stated that more than five times she has gone in her pants because she couldn't hold it any longer. R #114 stated that it is worse on the weekends. B. On 03/05/18 at 9:40 am, during an interview with R #66, she stated I want to get up the morning but they are short handed. R #66 also stated that last night (03/04/18) they were short handed, she waited about an hour to be put to bed. C. On 03/05/18 at 9:09 am, during an interview with R #9, he stated that sometimes there are 4 people assigned to the unit but other times there are only 2. When there are only 2 workers, I have to wait between 30 and 45 minutes. D. On 03/05/18 at 2:19 pm, during an interview with R #2, she stated that sometimes they are short handed. She stated that there are times you're laying there and you may need the restroom but you have to wait 30 minutes before you get help. E. On 03/05/18 at 9:49 am, during an interview with R #89's family member, the family stated that sometimes they are a little short staffed. My mom is here and she's pretty high maintenance, but she has to wait quite a bit. F. On 03/05/18 at 9:53 am, during an interview with R #273, she stated that nights had been a problem. There is one person working the night shift. R #273 stated that it felt like they need more staff. She went to the bathroom three times before they g… | 2020-09-01 |
| 55 | 55 | SANDIA RIDGE CENTER | 325032 | 2216 LESTER DRIVE NE | ALBUQUERQUE | NM | 87112 | 2018-03-14 | 756 | D | 0 | 1 | YN7D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to have the pharmacist conduct a Medication Regimen Review for 1 (R #38) of 6 (R#s 38, 9, 18, 38, 104, 119) residents reviewed for unnecessary medications. This deficient practice likely contributed to R #38 receiving medication that she did not need for a [DIAGNOSES REDACTED]. The findings are: [NAME] Record review of the Medication Regimen Review for (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) indicated that R #38 did not have any of her medications reviewed by the Pharmacist. B. On 03/09/18 at 10:15 am, during an interview with the Director Of Nursing (DON), she stated that no, the pharmacist had not reviewed R #38 in (MONTH) or (MONTH) (YEAR). The pharmacist had also not been out for the month of (MONTH) (YEAR) yet and she would make sure that R #38 was reviewed. | 2020-09-01 |
| 56 | 56 | SANDIA RIDGE CENTER | 325032 | 2216 LESTER DRIVE NE | ALBUQUERQUE | NM | 87112 | 2018-03-14 | 757 | G | 0 | 1 | YN7D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide a drug regimen that was free from unnecessary medication, duplicate medication, or medication that had an appropriate [DIAGNOSES REDACTED].#38) of 6 (R#s 38, 9, 18, 38, 104, 119) residents reviewed for unnecessary medication. This deficient practice likely contributed to R #38's dehydration and malnourishment and caused R #38 to have moisture associated skin breakdown, eventually returning to the hospital and prolonging and complicating her recovery. The findings are: [NAME] Record review of the Admission Record indicated that R #38 had a [DIAGNOSES REDACTED]. B. Record review of the R #38's physician's orders [REDACTED]. C. Record review of R #38's physician's orders [REDACTED]. D. Record review of the Medication Administration Record [REDACTED]. E. Record review of the MAR for the month of the (MONTH) (YEAR) indicated that R #38 received 16 out of 18 doses of the [MEDICATION NAME] medication and 15 out of 18 of the Sennosides medication. R #38 refused one dose of [MEDICATION NAME] on 02/03/18 and refused again on 02/09/18. On 02/03/18 R #38 refused both doses of the Sennosides medication and refused one dose on 02/09/18. F. Record review of the Activities of Daily Living (ADL) flowsheet dated 01/29/18 indicated that R #38 had several days of loose stools, some entries are noted as soft formed and some are watery. Entries from the ADL flowsheet from 02/01/18 to 02/09/18 indicated that R #38 had watery stools daily. [NAME] Record review of the Minimum Data Set ((MDS) dated [DATE], section I, indicated that R #38 had a [DIAGNOSES REDACTED]. H. Record review of the care plan dated 12/25/17 and revised on 01/17/18 indicated that there was not a care plan focus or intervention for R #38's diarrhea and malnutrition. I. Record review of the (Name of Healthcare Facility), History and Physical Report indicated that R #38 was admitted to the emergency room (ER) on 02/09/18 for softba… | 2020-09-01 |
| 57 | 57 | SANDIA RIDGE CENTER | 325032 | 2216 LESTER DRIVE NE | ALBUQUERQUE | NM | 87112 | 2018-03-14 | 842 | D | 0 | 1 | YN7D11 | Based on interview and record review the facility failed to consistently document on the Activities of Daily Living (ADL) flowsheets for 1 (R #38) of 2 (R #38 and #66) residents looked at for ADLs. This deficient practice has the potential for residents to not be identified as having poor meal and fluid intakes, how frequently a resident is experiencing diarrhea and if they are declining. The findings are: [NAME] Record review of R #38's ADL flowsheet for (MONTH) (YEAR), indicated that for the meal and fluid percentages that 17 out of 31 days nothing was documented for the whole day. On 12 different days for the month there was no documentation for breakfast and lunch, dinner was the only meal documented for the day. B. Record review of R #38's ADL flowsheet for (MONTH) (YEAR), indicated that for the bowel section, on 18 occasions there was no documentation indicating the number of times the resident had a bowel movement or what the consistency and size was. C. On 03/14/18 at 1:11 pm, during an interview with Registerd Nurse (RN) #3, he stated that the documentation on the ADL sheet for R #38 in (MONTH) (YEAR) was incomplete. RN #3 also agreed that it would be difficult to get an accurate picture of a resident when the there is inconsistent documentation. RN #3 also stated that the CNAs are responsible for documenting the ADLs in the chart before the end of shift. D. On 03/14/18 at 11:25 am, during an interview with CNA #14, she stated that yes the documentation on the ADL flowsheet for R #38 was incomplete. She stated that it looks like the CNA did not fill it in, not that that the activity didn't happen. They are supposed to be filling in all of the ADLs for all their residents before the end of their shift every time they work. E. On 03/09/18 at 10:37 am, during an interview with the Registered Dietician (RD), he stated that when he is making his assessments for residents he will pull information from different sources. The RD also stated that yes the ADL record at a minimum he will look at. He will look at th… | 2020-09-01 |
| 58 | 58 | SANDIA RIDGE CENTER | 325032 | 2216 LESTER DRIVE NE | ALBUQUERQUE | NM | 87112 | 2018-03-14 | 947 | E | 0 | 1 | YN7D11 | Based on record review and interview, the facility failed to ensure that all employees working with Dementia (a disorder of the brain affecting a persons ability to think and remember and can also affect a person's daily functioning) residents received training at least once per year. This deficient practice has the potential to effect all 126 residents identified on the alphabetical resident census provided by the Administrator on 03/05/18 by not preparing employees for the challenges of working with demented residents, causing higher staff burnout and residents not having their needs met. The findings are: [NAME] During record review of the employee training's it revealed that five employees (CNA #s 8, 15, 16, 17 and 18) did not receive dementia training. B. On 03/12/18 at 3:45 pm, during an interview with the Administrator, she stated that only 75% of the staff that work with residents at the facility have had dementia training. | 2020-09-01 |
| 59 | 59 | SANDIA RIDGE CENTER | 325032 | 2216 LESTER DRIVE NE | ALBUQUERQUE | NM | 87112 | 2017-03-20 | 166 | D | 0 | 1 | 30NH11 | Based on observation, interview, and record review, the facility failed to ensure that a grievance for a missing purse was initiated for 1 (R #130) of 2 (R #130 and 58) residents reviewed for missing personal items. This deficient practice has the potential to result in feelings of anger and frustration due to the facility not looking into the missing purse. The findings are: [NAME] On 03/14/17 at 9:11 am, during an interview with R #130, she stated that her purse was missing and it had her identification and social security card in it. She stated that she did tell a staff member about the missing purse. B. On 03/16/17 at 8:30 am, during an interview with SSD (Social Services Director) and SSA (Social Services Assistant) the assistant stated that she had been told by R #130 about her missing purse. She stated that R #130 came to her and told her about a missing gray purse with a zipper on top. Then about an hour later she came back and told her that the missing purse was peach in color. The SSA stated that because of the variance in color and that she wasn't aware that R #130 had a purse, she didn't write up a grievance and/or investigate the missing purse. C. On 03/16/17 at 8:40 am, during an interview with the Business Office Manager, she stated that R #130 came to her and asked if anyone had turned in a missing purse and she told R #130, No, no one has turned in a missing purse. She stated that the business office is the lost and found for the building and that is why R #130 came to her. She stated that she didn't feel like it was worth writing a grievance over because she felt like it was more of a question about the purse than that someone had stolen her purse. D. On 03/16/17 at 9:15 am, during an interview with CNA (Certified Nurse Aide) #16, she stated that R #130 had not told her about a missing pure. CNA #16 stated that if R #130 had told her about a missing purse, she would have notified the nurse and that Social Services (SS) would have gotten involved and that SS would write up a grievance and investi… | 2020-09-01 |
| 60 | 60 | SANDIA RIDGE CENTER | 325032 | 2216 LESTER DRIVE NE | ALBUQUERQUE | NM | 87112 | 2017-03-20 | 224 | H | 0 | 1 | 30NH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure that residents were free from neglect for 1 (R #13) of 1 (R #13) residents reviewed for wounds by not notifying the HCP (healthcare provider) of the development of R #13's bilateral (both) heel ulcers. This deficient practice resulted in inconsistent and inaccurate monitoring of bilateral heel ulcers and lack of physician orders for treatment which allowed for R # 13's bilateral heel ulcers to worsen. The findings are: [NAME] Record review of the Nursing Assessment-Initial (Admission) dated 12/15/16 revealed Integumentary (skin) assessment describing skin as occasionally moist, normal for ethnicity skin color, warm, and without skin impairment present. B. Record review of the Progress Notes revealed the following: 1. On 12/23/16 resident had a new onset/change in skin integrity as evidenced by ulcer-pressure. The location is identified as skin breakdown to bilateral heels noted. 2. On 12/28/16 the resident had a skin injury/wound that was previously identified and described the area as pressure area location bilateral wounds to heels. 3. On 01/04/17 the resident had previously identified injury/wound and described the wounds as located on bilateral heels. 4. On 01/26/17 a skin injury was present that had previously been identified and was evaluated and the location was pressure area. 5. On 03/02/17 a previously identified skin injury/wound was present and located on bilateral heels. 6. On 03/13/17, bilateral heel wounds were found by the CNP (certified nurse practitioner). C. Record review of the Skin Check documentation revealed: 1. Skin check documentation dated 12/28/16, 01/04/17, 01/26/17, and 03/02/17 revealed a skin injury/wound was identified, the wound was not new, was a pressure type wound, and was located on bilateral heels. 2. Skin check documentation dated 01/11/17, 01/18/17, 02/02/17, 02/09/17, 02/16/17, 02/23/17, and 03/09/17 revealed no skin injury identified. 3… | 2020-09-01 |
| 61 | 61 | SANDIA RIDGE CENTER | 325032 | 2216 LESTER DRIVE NE | ALBUQUERQUE | NM | 87112 | 2017-03-20 | 241 | E | 0 | 1 | 30NH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure that residents had the right to a dignified existence for 6 (R #s 5, 9, 13, 103, 161 and 165) of 6 (R #s 5, 9, 13, 103, 161 and 165) residents reviewed for dignity. This deficient practice may result in feelings of frustration, embarrassment and may lower self-esteem. The findings are: [NAME] On 03/14/17 at 9:34 am, Certified Nurse Aide (CNA) #1 entered R #103's room without knocking or asking for permission to enter. B. On 03/14/17 at 10:20 am, CNA #1 entered R #161's room without waiting for permission to enter after knocking once. C. On 03/14/17 at 3:12 pm, CNA #2 entered R #165's room without waiting for permission to enter after knocking. D. On 03/16/17 at 8:38 am, Transportation Aide #1 entered R #165's room without waiting for permission to enter after knocking. E. On 03/14/16 at 4:05 pm, during interview with Unit Manager (UM) #1, he stated that staff should be knocking on the room door, announcing themselves and waiting for the resident to give permission prior to entering the room. UM #1 stated that staff entering the residents' room without requesting permission was unacceptable. F. Record review of the Dignity Policy dated 09/01/13 indicated, (Name of Center) will promote care for patients in a manner and in an environment that maintains or enhances each patient's dignity and respect in full recognition of his or her individuality .knock on doors and request permission to enter . [NAME] On 03/14/17 at 2:19 pm, CNA #3 entered R #13's room without knocking or asking permission to enter. He walked around the resident's bed without acknowleding the resident. H. On 03/14/17 at 2:21 pm, CNA #3 entered R #9's room without knocking or asking permission to enter. He opened the resident's bedside table drawers without acknowledging the resident. I. On 03/17/17 at 9:52 am, during interview with R #5, she stated that CNAs on the 500-unit are sarcastic, nasty and … | 2020-09-01 |
| 62 | 62 | SANDIA RIDGE CENTER | 325032 | 2216 LESTER DRIVE NE | ALBUQUERQUE | NM | 87112 | 2017-03-20 | 246 | E | 0 | 1 | 30NH11 | Based on observation, interview and record review the facility failed to ensure that residents had access to their call lights for 3 (R #s 86, 97 and 119) of 8 (R #s 86, 97, 119, 58, 15, 19, 127, 118) residents reviewed during random observation of call lights. This deficient practice has the potential to result in delays for residents receiving treatment; and staff being unaware of an emergency situation if a resident had a fall while attempting to get of bed. The findings are: [NAME] On 03/13/17 at 11:53 am, an observation was made of R #86's call light. The call light was on the floor and resident did not have access to it.the B. On 03/17/17 at 8:49 am, an observation was made of R #97's call light. The call light was on the floor at the end of the bed under R #97's oxygen machine. R #97 was currently in bed and would have been unable to access his call light. C. On 03/17/17 at 8:55 am, an observation was made of R #119's call light. The call light was on the floor under the bed. R #119 was currently in bed and would have been unable to access his call light. D. On 03/17/17 at 9:02 am, an observation was made of R #86's call light. The call light was behind the bed on the floor. E. On 03/17/17 at 9:09 am, during an interview with Certified Nurse Aide (CNA) #17, she stated that the CNAs are supposed to check the call lights frequently for all residents. For those residents that don't get out of bed often, staff will clip call lights on their sheets, to the bed, or to the residents gown to make sure that the call light is always within reach. F. On 03/17/17 at 9:25 am, during an interview with Licensed Practical Nurse (LPN) #5, he stated that the CNAs do rounds on their assigned halls, but because he (LPN #5) is in and out of the rooms all day, he will frequently take care of call lights. He stated that if there is a bed bound resident, he will place the call light on their chest. LPN #5 agreed that a call light should not be on the floor at anytime. | 2020-09-01 |
| 63 | 63 | SANDIA RIDGE CENTER | 325032 | 2216 LESTER DRIVE NE | ALBUQUERQUE | NM | 87112 | 2017-03-20 | 248 | E | 0 | 1 | 30NH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide an ongoing activity program for 1 (R #13) of 3 (R #s 3, 13 and 70) residents reviewed for activities by not providing activities that the resident indicated are very important to him. This deficient practice has the potential to cause a decline in the residents psychosocial well being. The findings are: [NAME] Record review of the MDS (Minimum Data Set) assessment dated [DATE] revealed that it is very important for the R #13 to listen to music, be around animals such as pets, keep up with the news, and go outside to get fresh air when the weather is good. B. Record review of the Care Plan dated 01/13/17 revealed: 1. Resident exhibits or is at risk for limited meaningful engagement related to social isolation, speaks very little English. Spanish speaking only. 2. The documented goal was resident will accept invitations to activities. Resident will participate in meaningful activities 1 to 2 times per week for 90 days. 3. The interventions listed were: inform resident of facility happenings, encourage resident to participate in meaningful activities of interest such as music socials, exercise class, coloring art, outdoors for fresh air, and catholic mass. C. Record review of the Recreation Activity Logs revealed: 1. (MONTH) (YEAR); Resident documented to be actively involved on 01/18/17 and 01/25/17 for Church/Clergy and on 01/22/17 for Gospel Music. There is 1 entry of a refusal on 01/07/17 for a pet visit. No other offered opportunities for pet visits are documented. 2. (MONTH) (YEAR); Resident was not documented as being actively involved in any activity. 3. (MONTH) (YEAR); resident documented as actively involved in Church/Clergy on 03/01/17 and 03/15/17, and Stress Mgmt (management)/relaxation 03/01/17, 03/13/17 and 03/15/17. The log indicated one refusal for Music. The log did not indicate the resident was offered to go outside to get fresh air, have a pet visit, or keep … | 2020-09-01 |
| 64 | 64 | SANDIA RIDGE CENTER | 325032 | 2216 LESTER DRIVE NE | ALBUQUERQUE | NM | 87112 | 2017-03-20 | 279 | G | 0 | 1 | 30NH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to develop and revise comprehensive care plans with individualized goals and interventions for 2 (R #s 57 and 128) of 2 (R #s 57 and 128) residents reviewed for care plan issues. After R #128 sustained a fall which resulted in a [MEDICAL CONDITION], the facility failed to update his care plan and did not create any new interventions to prevent future falls, which resulted in the resident falling 2 more times acquiring multiple skin tears and another [MEDICAL CONDITION]. This deficient practice resulted in staff failing to identify and create new interventions that were necessary to prevent avoidable falls which resulted in serious injury to R #128. The findings are: Findings related to R #57: [NAME] Record review of R #57's electronic record revealed he was admitted to the facility on [DATE]. B. Record review of R #57's current care plan dated [DATE] revealed only 2 entries: one related to pain inititated on [DATE] and one related to [MEDICAL CONDITION] drugs (drugs that change brain function and results in alterations in perception, mood, or consciousness) initiated on [DATE]. C. On [DATE] at 2:36 pm, during an interview with the MDS (Minimum Data Set) Coordinator, she stated that back on [DATE] an MDS (Minimum Data Set) Asssessment was accidentally submitted that indicated the resident had died . She stated the mistake was corrected the same day however the error caused R #57's care plan to be deleted from his eletronic record. The MDS Coordinator stated she would have to contact the IT (Information Technology) department to see if they can recover his full care plan. D. On [DATE] at 11:51 am, during an interview with the Administrator, she verified that R #57's care plan was accidentally deleted and that none of the staff had access to it from [DATE] up until today ([DATE]). Findings related to R #128: E. Record review of R #128's Nurse's Note dated [DATE] stated, This day an Agency … | 2020-09-01 |
| 65 | 65 | SANDIA RIDGE CENTER | 325032 | 2216 LESTER DRIVE NE | ALBUQUERQUE | NM | 87112 | 2017-03-20 | 282 | D | 0 | 1 | 30NH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to implement the plan of care for 1 (R #160) of 4 (R #s 79, 128, 156 and 160) residents reviewed for accidents and [MEDICAL TREATMENT] by not palpating (examining by touch) for thrill (a vibration of blood going through the access site) and auscultating (listen to the internal sound) for bruit (audible sound associated with obstructed blood flow) the resident's A/V (arteriovenous) graft (an artificial vein that can be used repeatedly for needle placement and blood access during [MEDICAL TREATMENT]-a machine that filters wastes, salts and fluid from the body when the kidneys are no longer healthy enough to do this work). This deficient practice has the potential to prevent identification of complications with the A/V graft site and may prevent the completion of [MEDICAL TREATMENT]. The findings are: [NAME] Record review of the Care Plan dated 02/08/17 indicated the following: (Name of R #160) is at risk for impaired renal function and is at risk for complications related to [MEDICAL TREATMENT] .Monitor [MEDICAL TREATMENT] access for bruit and thrill q (every) shift and prn (as needed). B. Record review of R #160's medical record revealed no documentation to indicate that the [MEDICAL TREATMENT] site was assessed. C. On 03/17/17 at 4:14 pm, during interview with the Director of Nursing (DON), he stated that the [MEDICAL TREATMENT] should be assessed daily and documented on the TAR (Treatment Administration Record). When informed that this was not the case, he verified this with the documentation and stated that the [MEDICAL TREATMENT] should have been assessed per the resident's care plan (q shift) and that without ongoing assessments of the site, staff would have no way of knowing if there were problems with the area that would prevent successful [MEDICAL TREATMENT]. D. Record review of the [MEDICAL TREATMENT] Policy and Procedure dated 11/28/16 indicated the following: Evaluate [MEDICA… | 2020-09-01 |
| 66 | 66 | SANDIA RIDGE CENTER | 325032 | 2216 LESTER DRIVE NE | ALBUQUERQUE | NM | 87112 | 2017-03-20 | 312 | E | 0 | 1 | 30NH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents were provided the assistance they need in performing hygiene care and showers for 2 (R #s 3 and 70) of 2 (R #s 3 and 70) residents reviewed for ADLs (activities of daily living). This deficient practice has the potential to result in poor hygiene, lower self-esteem and could result in further decline in residents' ability to participate in their ADLs. The findings are: [NAME] On 03/15/17 at 2:10 pm, during an interview with LPN (licensed practical nurse) #6, she stated that sometimes, it depends on R #70's mood on whether R #70 will get a shower. She stated that she does not know him to refuse showers that much because the CNAs (certified nursing assistant) should be coming to her to let her know when he does refuse. She stated that when this happens she will go talk to him and come back later if she needs to, to talk to him about taking a shower. She stated that yes it should be documented if he is refusing showers or even if he is getting his showers. B. On 03/15/17 at 3:45 pm, during an interview with the DON (Director of Nursing) he stated that he thinks part of the problem is that agency staff don't document the showers. He stated that they either don't know how or they just don't do it. When asked about the difficulty of the actual shower sheet needing a minimum of a date, time and signature to document the showers, he had no response. The DON also stated that it was the facility's responsibility to train agency staff. C. On 03/16/17 at 11:25 am, during an interview with the DON he stated that by looking at the shower sheets R #70 does not appear to be receiving showers. D. On 03/20/17 at 10:33 am, during an interview with CNA #18 she stated that the process for showers would be if a resident refuses a shower they tell the nurse. They will try to ask again later. She stated that CNAs are responsible for documenting showers on the ADL sheet and also on the… | 2020-09-01 |
| 67 | 67 | SANDIA RIDGE CENTER | 325032 | 2216 LESTER DRIVE NE | ALBUQUERQUE | NM | 87112 | 2017-03-20 | 314 | H | 0 | 1 | 30NH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide necessary treatment and services to heal pressure ulcers for 1 (R #13) of 1 (R #13) residents reviewed for wounds when they failed to notify the healthcare provider of the development of bilateral heel ulcers. This deficient practice likely resulted in the resident not receiving the care and services necessary to promote healing which resulted in worsening of the bilateral pressure ulcers. The findings are: [NAME] Record review of the Nursing Assessment-Initial (Admission) dated 12/15/16 revealed Integumentary (skin) assessment describing skin as occasionally moist, normal for ethnicity skin color, warm, and without skin impairment present. B. Record review of the Progress Notes revealed: 1. Entry dated 12/23/16 revealed resident had a new onset/change in skin integrity as evidenced by ulcer-pressure. The location is identified as skin breakdown to bilateral heels noted. 2. Entry dated 12/28/16 revealed the resident had a skin injury/wound that was previously identified and described the area as pressure area location bilateral wounds to heels. 3. Entry dated 01/04/17 revealed the resident had previously identified injury/wound and described the wounds as located on bilateral heels. 4. Entry dated 01/23/17 revealed Res (resident) heels improved. Scab is beginning to peel away with pink healing. Dressing applied to protect scab from ripping away. 5. Entry dated 01/26/17 revealed a skin injury was present that had previously been identified and was evaluated and the location was pressure area. 6. Entry dated 03/02/17 revealed a previously identified skin injury/wound was present located on bilateral heels. 7. Entry dated 03/13/17 stated This nurse called to resident's room by CNP (certified nurse practitioner) to assess diabetic ulcers on bilateral heels .100 % eschar (dead tissue) bilateral heels, heels are boggy (abnormal texture of tissue) and surrounding area is calloused … | 2020-09-01 |
| 68 | 68 | SANDIA RIDGE CENTER | 325032 | 2216 LESTER DRIVE NE | ALBUQUERQUE | NM | 87112 | 2017-03-20 | 323 | G | 0 | 1 | 30NH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that each resident received adequate supervision and assistive devices to avoid falls and elopement (unsupervised exit from the facility) for 2 (R #s 4 and 128) of 6 (R #s 4, 73, 79, 128, 156 and 160) residents reviewed for accident hazards. R #4 was not fitted with a Wanderguard device (an electronic monitoring bracelet), allowing her to exit the facility without detection. After R #128 sustained a fall which resulted in a fractured hip, the facility failed to provide adequate supervision, which resulted in the resident falling 2 mores times resulting in skin tears and another fractured hip. These deficient practices likely caused R #128's injuries, and could jeopardize residents at risk for elopement through exposure to street traffic, temperature extremes, or other environmental hazards. The findings are: Findings related to R #4: [NAME] Record review of a Risk Management System document dated 3/19/17 found that it pertained to an elopement event of R #4 on 03/17/17. The document indicated The resident exited the center with another resident at 7:12 pm. The staff was informed of the resident outside at 7:21 pm. The resident was brought back into the center and was assessed for injury and none was noted. B. Record review of R #4's care plan dated 08/02/16 found a focus area stating Resident/Patient is at risk for elopement related to: Cognitive Loss (thinking impairment) / Dementia. Among the listed interventions was Utilize and monitor security bracelet per protocol. All later versions of R #4's care plan were found to have continued this focus area and intervention. C. Record review of R #4's Minimum Data Set Assessment (a tool for reporting on resident characteristics) found a section stating Wandering - Presence & Frequency. To the question Has the resident wandered?, a response of Behavior of this type occurred daily was documented and signed by the Social Services Dir… | 2020-09-01 |
| 69 | 69 | SANDIA RIDGE CENTER | 325032 | 2216 LESTER DRIVE NE | ALBUQUERQUE | NM | 87112 | 2017-03-20 | 329 | E | 0 | 1 | 30NH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that residents were free from unnecessary medications for 2 (R #s 3 and 70) of 5 (R #s 3, 58, 70, 99, and 110) residents reviewed for unnecessary medications by not completing behavior monitoring and pain assessments. This deficient practice has the potential to result in residents receiving unnecessary [MEDICAL CONDITION] (chemical substance that changes brain function and results in alterations in perception, mood, or consciousness) and pain medications, not receiving the right dose of a medication, and staff not knowing whether a medication is effective due to the lack of monitoring of pain and behaviors. The findings are: Findings for R #70: [NAME] Record review of the physcian's orders and admission face sheet indicated that R #70 had a [DIAGNOSES REDACTED]. R #70 is taking [MEDICATION NAME] (a medication for depression) 20 mg (milligrams) per day and [MEDICATION NAME] (antipsychotic medication) 50 mg every 8 hours for behaviors. B. Record review of a progress note dated 01/4/17 indicated that R #70 had a history of [REDACTED]. The note also stated that: 1. Resident exhibits behavior: Physical aggression as evidenced by: hitting, striking out, kicking, and pushing; 2. resists care or treatment, verbal aggression as evidenced by: yelling, cursing, insults to others; easily startled; 3. doesn't like when others talk to him; 4. combative/physically abusive with ADLS (activities of daily living); 5. He can be noncompliant/resistant to care. Hx (history) of suicidal ideation. Resident is very independent due to his military background and does not like getting help from staff. C. Record review of progress note dated 01/11/17, R #70 hit another resident while they were in the dining room near the coffee pot. Staff intervened and stopped R #70 of his aggression and both residents were separated. R #70 punched the other resident on his face and stomach. D. Record review of a pro… | 2020-09-01 |
| 70 | 70 | SANDIA RIDGE CENTER | 325032 | 2216 LESTER DRIVE NE | ALBUQUERQUE | NM | 87112 | 2017-03-20 | 371 | F | 0 | 1 | 30NH11 | Based on observation, interview and record review the facility failed to ensure that all kitchen equipment used in the cooking, storing and preparing of food was properly working and in sanitary condition for all 116 residents on the census list provided by the Administrator on 03/13/17 by: 1. Not having calibrated and properly working thermometers that are used when checking to ensure that foods being served are at the proper temperature. 2. That the stove and grill were properly cleaned after each meal and staff were unaware of the last time that the stove had been deep cleaned. These deficient practices have the potential to make residents sick if the food is not served at the proper temperature and the stove and grill are dirty and are not being properly cleaned. The findings are: [NAME] On 03/13/17 at 12:35 pm, an observation was made of a dietary aide not being sure how to calibrate a thermometer when asked to check the temperature of the food that was getting ready to be served to the residents for lunch. The head chef told the dietary aide how to calibrate a thermometer and it was observed that the dietary aide #1 did what the head cook instructed her to do. After roughly 5 minutes the thermometer that had been sitting in ice, was checked and it was at 40 degrees. They got out a second thermometer and placed that in the ice water. This thermometer worked and it was registering at 32 degrees. B. On 03/14/17 at 7:40 am, an observation was made of a very strong smoke smell and smoke in the air throughout the facility. The smoke was coming from the grill in the kitchen. C. On 03/14/17 at 7:50 am, during an interview with the Head Chef, he stated that the stove top was turned up too high and that was the reason it was smoking so bad. An observation was then made of the back door being open trying to allow the smoke out. D. On 03/15/17 at 2:47 am, during an interview with the Dietary Director, he stated that most of the staff are new and they are trying to get them trained. He stated that they have a training p… | 2020-09-01 |
| 71 | 71 | SANDIA RIDGE CENTER | 325032 | 2216 LESTER DRIVE NE | ALBUQUERQUE | NM | 87112 | 2017-03-20 | 464 | F | 0 | 1 | 30NH11 | Based on observation and interview, the facility failed to provide a well ventilated dining/activity room for 4 (R #s 21, 50, 133 and 144) of 4 (R #s 21, 50, 133 and 144) residents who enter the dining/activity area for social time and activities. This deficient practice has the potential to affect residents comfort and may result in respiratory distress. The findings are: [NAME] Record review revealed resident smoking times listed at 9:00 am, 11:30 am, 1:30 pm, 4:00 pm, and 8:00 pm. The designated smoking area was listed as out on the patio by the dining/activity room. B. On 03/13/17 at 9:11 am, during an observation, 10 smokers were observed to be smoking outside the dining/activity room area close to the doorway. The dining/activity room was observed to smell like cigarette smoke. Non-smoking residents were observed to be sitting in the dining/activity area. C. On 03/14/17 at 9:00 am, during an observation, an automatic door leading out to the designated smoking area was located in the dining/activity area. Breakfast had ended and several residents were sitting in the dining/activity area. D. On 03/14/17 at 9:05 am, during an interview, R #50, R #133, and R #144 were sitting in the dining/activity room stating whenever the door opens the smell of cigarette smoke comes into the dining/activity room area. They stated they did not like the smoke smell. E. On 03/14/17 at 9:05 am, during an observation in the dining/activity room, each time the door opened, the smell of cigarette smoke entered the facility. Outside, it was noted several residents sitting close to the doorway smoking cigarettes. F. On 03/16/17 at 8:29 am, R # 21 stated smoke from the cigarette smokers bothered her but what can I do. She stated it also bothers us during activities. [NAME] On 03/16/17 at 9:06 am, during an observation, the smell of cigarette smoke entered the dining/activity room each time the automatic door opened to the designated smoking area. H. On 03/16/17 at 9:14 am, during interview, Dietary Aide #1 was observed to be clearing … | 2020-09-01 |
| 72 | 72 | SANDIA RIDGE CENTER | 325032 | 2216 LESTER DRIVE NE | ALBUQUERQUE | NM | 87112 | 2017-03-20 | 498 | F | 0 | 1 | 30NH11 | Based on record review and interview, the facility failed to ensure that Certified Nursing Aides (CNAs) demonstrated competency in skills and techniques necessary to meet resident's needs including performing range of motion activities, providing transfer assistance and carrying out the appropriate infection control and safety procedures. This deficient practice has the potential to negatively affect all 116 residents in the facility as identified on the Resident Census provided by the administrator on 03/13/17 and may result in care that is inconsistent with residents' needs. The findings are: [NAME] Record review of employee personnel files revealed the following: 1. CNA #10's most recent skills assessment was from 2014, 2. CNA #11's most recent skills assessment was from (YEAR), 3. CNA #12's most recent skills assessment was from 2007, 4. CNA #13's most recent skills assessment was from 2014, 5. CNA #14's most recent skills assessment was from (YEAR) B. On 03/20/17 at 11:20 am, during interview with the administrator, she stated that the Nurse Practice Educator who was responsible for tracking staff training was no longer working at the facility and that there was not currently a staff member assigned to tracking staff training. The administrator stated that one on one in-service education was provided to staff on an as needed basis but she was unable to indicate how the facility ensured that staff had the necessary education and training to provide care that was consistent with resident needs since training and skills assessments were not being completed. | 2020-09-01 |
| 73 | 73 | SANDIA RIDGE CENTER | 325032 | 2216 LESTER DRIVE NE | ALBUQUERQUE | NM | 87112 | 2019-03-22 | 689 | E | 0 | 1 | 8F5T11 | This is a repeat deficiency from the survey dated 03/14/18. Based on record review, interview and observation, the facility failed to have a door to a utility closet closed and locked. The closet contained an open, unlabeled container of bleach. This deficient practice has the potential to result in harm for all 121 residents who were identified on the resident census provided by the Executive Center Director at the start of survey on 03/18/19 if a resident were to accidentally open and use without appropriate personal protective equipment or for any demented residents on that hall who could mistakenly drink the bleach. The findings are: [NAME] On 03/20/19 at 9:42 am, during a tour of the facility storage and laundry areas, it was observed that a utility closet door was slightly open. Upon entering the utility closet a gallon size bottle was noted on the floor. The bottle did not have a label on it but there was writing on the bottle that stated Clorox. B. On 03/20/19 at 10:30 am, during an interview with the Housekeeping Director (HD), he stated that any of the utility closets should be fully shut and locked, and it did not matter what hall it was on. The HD also indicated that there should not be any unlabeled containers. That would apply to storage rooms and housekeeping carts. C. On 03/20/19 at 9:56 am, an observation was made of the HD taking the unlabeled container and putting it in his office. D. Record review of the Storage 1.1 Environmental Services Policies and Procedures last revised on 11/01/07, indicated the following Process: 4. Storage areas are locked when not in operation to prevent unauthorized access. 5. Chemical Storage: 5.4: Chemicals are stored in their original containers. Chemicals in spray bottles are labeled with contents and hazard warning. | 2020-09-01 |
| 74 | 74 | SANDIA RIDGE CENTER | 325032 | 2216 LESTER DRIVE NE | ALBUQUERQUE | NM | 87112 | 2019-03-22 | 756 | E | 0 | 1 | 8F5T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This is a repeat deficiency from the survey dated 03/14/18. Based on record review and interview, the facility failed to ensure that pharmacy recommendations were reviewed, responded to, and/or any changes or reasons to decline a change were documented in the medical chart for 8 residents (R #'s 301, 45, 82, 84, 11, 302, 8 and 89) of 10 (R #'s 301, 45, 82, 84, 11, 302, 8, 89, 27 and 19) residents reviewed for unnecessary medications. This deficient practice has the potential to cause harm to residents by: 1. not receiving the proper dose of a medication, 2. not having medications adjusted according to labwork, The findings are: Findings for R #301: [NAME] Record review of R #301's pharmacy consultation report dated (MONTH) (YEAR) indicated that there were three recommendations: 1. Adjust the dose of [MEDICATION NAME] (used for mood as an anticonvulsant, and nerve pain) to 700 milligrams (mg) once daily: for CrCl (Creatinine Clearance)15-29 milliliter/minimum ( to check kidney function) total daily dose range 200 mg to 700 mg given in one daily dose. The Rational for Recommendation is that dosing should be adjusted according to renal (kidney) function. 2. Consider changing [MEDICATION NAME] (is used to treat high blood pressure) to an alternate antihypertensive. The Rational for Recommendation is that Thiazide diuretics are considered less effective when Creatinine clearance drops below 30 ml/min. 3. Consider discontinuing Duloxetine (anti-depressant medication) and starting a new antidepressant. R #301 has [MEDICAL CONDITION] stage 3 and an estimated Creatinine Clearance of 26. Recommendation is for any person who has CrCL less than 30 to switch to something else. The response from the physician was (name of company) declined the recommendation without providing a rationale as to why. B. Record review of R #301's pharmacy consultation report dated (MONTH) (YEAR) indicated that there were three recommendations: 1. R #301 was on [MEDICATION NAM… | 2020-09-01 |
| 75 | 75 | SANDIA RIDGE CENTER | 325032 | 2216 LESTER DRIVE NE | ALBUQUERQUE | NM | 87112 | 2019-03-22 | 758 | E | 0 | 1 | 8F5T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review observation and interview the facility failed to ensure that [MEDICAL CONDITION] medication orders met regulatory requirements for 2 (R #'s 8 and 27) of 2 (R #'s 8 and 27) residents reviewed for unnecessary [MEDICAL CONDITION] drugs. This deficient practice puts affected residents at increased risk for undesirable side effects associated with the use of these medications. The findings are: For R #8: [NAME] Record review of, (Name of facility) .Medication Review Report, for active [MEDICAL CONDITION] medications orders revealed: 1. On 03/16/19, [MEDICATION NAME] (sedative medication) Tablet 0.5 MG (milligrams). Give 0.25 mg by mouth every 8 hours as needed for severe anxiety Give half a tablet (0.25 mg) by oral route 3-times per day as needed (PRN) for severe anxiety. Hold for sedation. This PRN order for a psychoactive drug had no stop date. 2. On 08/10/18, QUEtiapine [MEDICATION NAME] (is an antipsychotic medication) Tablet 25 MG Give 50 mg by mouth at bedtime for dementia related physical outbursts, depression, anxiety, and [MEDICAL CONDITION] .QUEtiapine [MEDICATION NAME] Tablet 25 MG Give 25 mg by mouth in the morning for dementia. B. Record review of R #8's medication orders on paper chart from the, (Name of program) revealed an order dated 11/28/18, 25 mg. oral tablet .Quetiapine Give 1-tab by mouth twice daily (breakfast and 2-pm. Give 2-tabs at bedtime. The resident was not receiving her 2:00 pm dose. C. On 03/21/19 at 11:35 am, during interview with the nurse manager on the unit where the resident resides she revealed, when (name of outpatient program resident attends) sends the orders we reconcile them, so we are giving her what they ordered . (regarding the 2 pm dose of Quetiapine) we missed that. D. 03/21/19 at 03:08 pm during interview with the CNE she revealed, I have gotten that order changed (re: Quetiapine; side effect drowsiness) we will have it reduced .I don't want her any sleepier than she is. For R… | 2020-09-01 |
| 76 | 76 | SANDIA RIDGE CENTER | 325032 | 2216 LESTER DRIVE NE | ALBUQUERQUE | NM | 87112 | 2019-03-22 | 760 | D | 0 | 1 | 8F5T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure that medications were administered correctly for 1 (R #46) of 8 (R #s 12, 26, 46, 69, 95, 102, 109 and 110) residents during the observation of the medication administration. If medications are administered in ways that can affect how other medications work, or in a manner that alters the way they are absorbed by the resident, given in doses that are in excess of the resident's need or given in ways that can cause serious adverse events to a resident, the residents affected are exposed to potentially significant and unnecessary harm. The findings are: [NAME] On 03/21/19 at 11:19 am, during a medication administration observation, Licensed Practical Nurse (LPN) #1 administered Humalog (a fast-acting insulin that controls the blood sugar spikes that occur while eating) 10 units subcutaneously (applied under the skin) in the right deltoid (upper arm muscle) to R #46. B. Record review of R #46's physician's orders [REDACTED]. Do not administer if not eating a meal. Please discontinue sliding scale. C. On 03/22/19 at 10:00 am, during an interview, LPN #1 stated when asked how much Humalog insulin did she administer to R #46 the day before? She stated, 10 units. When LPN #1, looked into R #46's Medication Administration Record [REDACTED]. She said, I don't know where I came up with the 10 units of Humalog. D. Record review of the facility's policy and procedure titled Medication Administration: General, last revised on 07/24/18, revealed the following: A licensed nurse, Med Tech, or medication aide, per state regulations, will administer medications to patients .To provide a safe, effective medication administration process . | 2020-09-01 |
| 77 | 77 | SANDIA RIDGE CENTER | 325032 | 2216 LESTER DRIVE NE | ALBUQUERQUE | NM | 87112 | 2019-03-22 | 812 | F | 0 | 1 | 8F5T11 | Based on observation, interview, and record review, the facility failed to ensure that: 1. Staff were wearing beard nets while preparing food, 2. The vents that were directly above where food was being prepared, were clean and free of debris, These deficient practices could effect all 121 residents, identified on the alphabetical census list provided by the Administrator on 3/18/19, who eat food prepared in the kitchen. This could lead to foodborne illnesses causing residents to become sick and possibly decline. The findings are: [NAME] On 3/19/19 at 11:54 am, during an initial tour of the facility kitchen, dietary assistant #1 who had a beard was preparing food without a beard net. B. On 3/19/19 at 11:57 am, during an interview with the Registered Dietician (RD), he confirmed with the kitchen manager that staff should be wearing a beard net or beard mask while preparing food. C. Record review of the Food and Nutrition Services Policies and Procedures indicate: 1. POLICY TITLE: 2:2 Personal Hygiene last REVISION DATE: 07/24/18 2. PURPOSE: To maintain a professional appearance at all times. 3. PR[NAME]ESS: #7 Hair restraints such as hats, hair coverings, or nets are worn to effectively keep hair from contacting exposed food. Facial hair coverings are used to cover all facial hair. D. On 03/19/19 at 12:12 pm, during the initial tour of the facility kitchen, there were dust bunnies (a ball of dust and fluff) in the vent over the area where food was being prepared. E. On 03/19/19 at 9:51 am, during an interview with the RD and Kitchen Manager, the RD stated he did not know who was responsible for cleaning the vents. The Kitchen Manager stated the kitchen staff and himself are responsible for cleaning the vents in the kitchen. The Kitchen Manager stated the vents are cleaned daily or as needed. He stated he would clean the vent immediately due to confirming the dust bunnies in the vent over the area where food was being prepared. F. Record review of the Genesis kitchen cleaning policy 4.0 Cleaning Standards; MANUAL TI… | 2020-09-01 |
| 78 | 78 | SANDIA RIDGE CENTER | 325032 | 2216 LESTER DRIVE NE | ALBUQUERQUE | NM | 87112 | 2019-03-22 | 880 | F | 0 | 1 | 8F5T11 | Based on observation, interview, and record review, the facility failed to demonstrate proper infection control practices as evidence by: 1. contamination of clean linens and resident supplies, from dust and debris on floor surfaces, 2. not placing a solid barrier (liner) on the bottom shelf of wire storage racks, 3. having items stored directly on the floor, 4. using cardboard boxes to store resident supplies These deficient practices have the potential to effect all 122 residents per the facility census provided by the Administrator on 03/18/19 resulting in; 1. Exposure of bugs and rodent droppings to residential supplies. 2. Contamination of resident supplies due to dirt, dust and debris being kicked up from floor surfaces. The findings are: [NAME] On 03/20/19 at 10:16 am, during a tour of Central Supply, observations were made of the following: 1. Supplies being stored on the floor in card board boxes. 2. Items being stored on the bottom shelf of the shelving unit, with no solid barrier that was too low to the floor. B. On 03/22/19 at 10:14 am, during an interview with the Director of Nursing (DON), she stated that she was not aware of the issues in Central Supply. She confirmed that their supplies are being stored on the floor and in cardboard boxes. She also acknowledged that the wire shelving units did not have solid bottoms and one of those shelving units was almost sitting on the ground (recommended 6-8 inches off the floor). C. Record review of the Storage 1.1 Environmental Services Policies and Procedures, revised on 11/01/07, indicated all shelves, storage racks, and platforms are not to be placed directly on the floor, stored items should be 18 below sprinkler head/ceiling, unless waiver is obtained from the licensing authority and cardboard boxes are emptied and removed from storage as they are received. | 2020-09-01 |
| 79 | 79 | SANDIA RIDGE CENTER | 325032 | 2216 LESTER DRIVE NE | ALBUQUERQUE | NM | 87112 | 2017-11-07 | 285 | D | 1 | 0 | C0CW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to refer a resident with qualifying [DIAGNOSES REDACTED].#1) of 4 (R #s 1, 2, 3, and 4) residents reviewed during a complaint investigation. If residents with a qualifying [DIAGNOSES REDACTED]. The findings are: [NAME] Record review of R #1's Admission Record, revealed she was admitted to the facility on [DATE] and discharged on [DATE]. R #1 had the following medical [DIAGNOSES REDACTED]. B. On 11/06/17 at 2:38 pm, during interview with the PASRR Supervisor, she stated that R #1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. C. On 11/06/17 at 3:49 pm, during interview the Admission Director stated that the Social Service Director at the time reviewed R #1's PASRR and stated that the [DIAGNOSES REDACTED]. The Admission Director confirmed that the PASRR was not completed prior to R #1's admission. D. On 11/06/17 at 4:09 pm, during interview with the previous Social Service Director, she stated that she was reviewing R #1's medical record and saw a medical [DIAGNOSES REDACTED]. She stated that she made the corrections and resubmitted, but R #1 was already admitted . | 2020-09-01 |
| 80 | 80 | RIO RANCHO CENTER | 325033 | 4210 SABANA GRANDE SE | RIO RANCHO | NM | 87124 | 2018-02-12 | 561 | E | 0 | 1 | M2BO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide reasonable accommodations of resident needs and preferences for 2 (R #s 5 and 307) of 2 (R #s 5 and 307) residents reviewed for choices. The facility failed to shower R #5 per her schedule and did not respect R #307's food preferences. This deficient practice has the potential to prevent residents from maintaining personal hygiene per their personal preference and feelings of frustration about the lack of autonomy regarding things that are important in their life. The findings are: Findings for R #5: [NAME] On 02/06/18 at 2:18 pm, during interview R #5 stated she hasn't had a shower in three weeks. She stated that the shower aide has not been here. B. Record review of R #5's Weekly Bath and Skin Report dated 12/20/17, indicated the last documented shower for R #5 was on 01/09/18. C. Record review of R #5's Weekly Bath and Skin Report dated 01/10/18, revealed on 01/12/18, she refused shower due to pain. No other showers are documented on the form. D. Record review of R #5's Activities of Daily Living (ADL) Record for (MONTH) (YEAR), showed R #5 refused showers on 1/2/18, 1/5/18, 1/12/18. No other showers were documented. E. Record review of the ADL Record for (MONTH) (YEAR), showed R #5 has not received a shower with no documented refusals for the month. F. Record review of the Minimum (MDS) data set [DATE], revealed a BIMs (brief interview for mental status) score of 11 (Range is 00-15 with 15 being cognitively in tact) and requires extensive assistance with a two person physical assist for all ADLs. R #5 is total dependence for bathing. [NAME] On 02/07/18 at 2:22 pm, during interview the Director of Nursing (DON) stated that the resident is very particular about who she will let shower her. She stated that if the shower aid that she likes is not working, then she will refuse showers. She also stated that if showers are offered and she refuses, it would be documented in the … | 2020-09-01 |
| 81 | 81 | RIO RANCHO CENTER | 325033 | 4210 SABANA GRANDE SE | RIO RANCHO | NM | 87124 | 2018-02-12 | 578 | D | 0 | 1 | M2BO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to update the medical chart for 1 (R #5) of 1 (R #5) residents reviewed for advanced directives, when they failed to update her code status as DNR (Do Not Resuscitate) and inform direct care staff of R #5's wishes. This deficient practice could likely result in residents not having their wishes honored if a life threatening event occurred. The findings are: [NAME] Record review of R #5's Electronic Medical Record, indicated resident is Full Code. B. On [DATE] at 3:18 pm, during interview with RN (Registered Nurse) #2, she stated that R #5 is a full code. RN #2 stated that if R #5 coded, she would start CPR (Cardiopulmonary Resuscitation). C. On [DATE] at 3:19 pm, during interview with RN #1, he stated R #5 was a full code and he would call out for somebody, get a crash cart and start CPR. D. Record review of R #5's MOST (Medical Orders for Scope of Treatment) form dated [DATE], indicated R #5 selected Do Not Attempt Resuscitation/DNR. Options were discussed with R #5 and she signed on [DATE]. E. On [DATE] at 3:36 pm, during interview the Director of Nursing (DON) stated that she was looking into the issue, because she identified a discrepancy yesterday. The DON verified that if R #5 did request to be DNR, the nurse should have immediately went to the physician and got a new order for DNR and it should have been updated in the electronic chart. | 2020-09-01 |
| 82 | 82 | RIO RANCHO CENTER | 325033 | 4210 SABANA GRANDE SE | RIO RANCHO | NM | 87124 | 2018-02-12 | 645 | D | 1 | 0 | M2BO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure that clearance from the Pre-Admission Screening and Resident Review (PASRR) program had been obtained prior to admission for 1 (R #256) of 4 residents (R #s 256, 19, 56 and 162) reviewed for PASRR clearance. The PASRR Level 1 screening tool had been completed incorrectly for R #256, which the facility failed to identify within 24 hours. This deficient practice has the potential to result in residents with physical or intellectual disabilities not receiving needed services after admission to the facility. The findings are: [NAME] Record review of a letter of complaint dated 11/28/17 sent to the State Central Intake by the PASRR Supervisor, indicated that R #256 had been admitted to the facility without the required clearance from the PASRR program. It indicated that the resident required PASRR level II screening and review due to his [MEDICAL CONDITION] (TBI). B. On 02/08/18 at 2:15 pm, during an interview with the PASRR supervisor, she stated that the facility admitted R #256 on 08/14/17. R #256 arrived with a level I PASRR screening but it was not filled out accurately. If the facility had looked at the hospital records closer they would have seen that R #256 had a TBI before the age of 16. This [DIAGNOSES REDACTED]. She also stated that it was on the receiving facility to make sure that the PASRR was done correctly before admitting a resident to their facility. The level II PASRR also must be done before a resident was admitted or they must have a clearance letter stating that this resident will not require services past 30 days. She stated that if these things aren't done properly than it will fall on the facility. C. On 02/09/18 at 2:06 pm, during an interview with Admissions, she stated that they have a 24 hour window when a resident is admitted to the facility and they identify whether or not the PASRR is accurate. She stated that she had looked at the records and rea… | 2020-09-01 |
| 83 | 83 | RIO RANCHO CENTER | 325033 | 4210 SABANA GRANDE SE | RIO RANCHO | NM | 87124 | 2018-02-12 | 655 | D | 0 | 1 | M2BO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to develop a baseline care plan for a resident with a moderate to high nutritional risk for 1 (R #307) of 1 (R #307) resident reviewed for nutrition. The care plan failed to address R #307's therapeutic diets and did not include nutritional services that were to be furnished to attain the resident's highest level of well-being. This deficient practice has the potential to result in inconsistent care of residents, through misinterpretation of residents' needs. The findings are: [NAME] Record review of R #307's medical record revealed she was originally admitted to the facility on [DATE], discharged on [DATE] and then was readmitted on [DATE]. B. Record review of R #307's physician diet orders revealed the following: 1. An order dated 01/06/18 for a Heart Healthy (no added salt) diet. This diet order was discontinued on 01/23/18. 2. An order dated 01/23/18 for a Regular/Liberalized diet. This diet order was discontinued on 01/29/18. 3. An order dated 01/29/18 for a Dysphagia Advance texture (mechanical soft). C. Record review of R #307's Nutritional Assessment completed by the dietician dated 01/11/18 stated, Resident at moderate to high nutritional risk 2/to (secondary to) hx (history) of R (right) lung mass which is presumably Ca (cancer), [MEDICAL CONDITION] ([MEDICAL CONDITIONS] is a disease that causes obstructed airflow from the lungs), pAF([MEDICAL CONDITION]), DM (Diabetes Mellitus), ETOH (alcohol) abuse . D. Record review of R #307's Nutritional Assessment completed by the dietician dated 01/29/18 stated, Resident at moderate to high nutritional risk 2/to hx of R lung mass which is presumably Ca, [MEDICAL CONDITION], pAF, DM, ETOH abuse . E. Record review of R #307's baseline care plan originally dated 01/06/18 revealed it did not address her Heart Healthy (no added salt) diet or her Dysphagia Advance texture (mechanical soft) diet. The care plan did not address her nutritional r… | 2020-09-01 |
| 84 | 84 | RIO RANCHO CENTER | 325033 | 4210 SABANA GRANDE SE | RIO RANCHO | NM | 87124 | 2018-02-12 | 656 | D | 0 | 1 | M2BO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that a comprehensive care plan was developed for one resident (R #76) of 32 residents (R #s 2, 5, 8, 14, 15, 18, 19, 26, 31, 36, 37, 45, 47, 51, 55, 56, 61, 62, 68, 75, 76, 89, 91, 94, 95, 96, 101, 156, 164, 167, 209 & 307) reviewed for care plan accuracy. No items in R #76's care plan addressed his care in the facility related to his [DIAGNOSES REDACTED].) This deficient practice had the potential to result in inconsistent care of the resident, through inappropriate food offerings, and the failure to assess for [MEDICAL TREATMENT]-related complications, such as bleeding. The findings are: [NAME] On 02/05/18 at 2:25 pm, during interview with R #76, he stated, I'm a diabetic and damned near everything here is sweet. I don't take any meds (medications) - I control it through diet. I don't know how you can control your sugar when everything is sweet. B. Record review of R #76's electronic medical record found: 1. that he was admitted to the facility on [DATE], and discharged on [DATE]. 2. that his listed medical diagnoses included [MEDICAL CONDITION], dependence on renal (related to the kidneys) [MEDICAL TREATMENT], [MEDICAL CONDITION] (a liver disease), and gastrointestinal hemorrhage (bleeding in the digestive system.) No [DIAGNOSES REDACTED]. 3. a care plan dated 1/22/18 that did not have focus sections related to diabetes management or [MEDICAL TREATMENT] procedures. 4. a physician's orders [REDACTED].> a. that the resident had [MEDICAL TREATMENT] scheduled for each Tuesday, Thursday and Saturday. b. that interventions to assess the [MEDICAL TREATMENT] were ordered. c. that the resident was ordered for a regular/liberalized diet. d. that no fluid restrictions were ordered. e. no checks of the resident's glucose levels were ordered. 5. that a nutritional assessment dated [DATE] did not acknowledge the resident's diabetes. It stated that the resident had declined a renal diet,… | 2020-09-01 |
| 85 | 85 | RIO RANCHO CENTER | 325033 | 4210 SABANA GRANDE SE | RIO RANCHO | NM | 87124 | 2018-02-12 | 684 | D | 0 | 1 | M2BO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide good quality of care in a timely manor for 1 (R #31) of 1 (R #31) resident looked at during dining observation. This deficient practice caused R #31 neck pain and stiffness due to facility employees not being observant and identifying that the neck support on R #31's wheelchair was not raised to support her neck and head. The findings are: [NAME] On 02/07/18 at 7:48 am, while watching dining, it was observed that R #31 was in her wheelchair at a dining table and her head was leaned very far back with no support. It was observed that R #31 was not able to support her head on her own. B. On 02/07/18 at 8:01 am, during an interview with R #31 she stated that she was uncomfortable and would like to be moved. R #31 was not sure how long she had been like that. C. On 02/07/18 at 8:04 am, during an interview with the Administrator he stated that he took care of the situation with R #31. He stated that the headrest on the wheelchair was pushed all the way down and that it just needed to be raised up. He stated that he was not clear why the Certified Nurses Aide did not catch that her head rest was not up in the proper position when she brought R #31 into the dining room. The Administrator did not have an answer for why no one else observed R #31 in that position and identified that R #31 was uncomfortable. D. Record review of the Minimum Date Set (MDS) dated (MONTH) (YEAR), indicated that R #31 is extensive assist. She requires a Hoyer lift (used for transfers when a person requires 90-100% assistance to get into and out of bed) with two people and is dependent on staff for all of her activities of daily living. E. Record review of R #31's electronic medical record indicated that she has [DIAGNOSES REDACTED]. | 2020-09-01 |
| 86 | 86 | RIO RANCHO CENTER | 325033 | 4210 SABANA GRANDE SE | RIO RANCHO | NM | 87124 | 2018-02-12 | 692 | D | 0 | 1 | M2BO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that a resident with a [DIAGNOSES REDACTED].#76) of 8 (R #s 2, 19, 31, 36, 68, 76, 89 and 307) residents reviewed for nutrition. There was no indication that facility staff, other than the admitting physician, was aware that the resident was diabetic, and no supportive interventions were in place. This deficient practice has the potential to result in dangerously high or low blood glucose levels in a diabetic resident. The findings are: [NAME] On 02/05/18 at 2:25 pm, during interview with R #76, he stated, I'm a diabetic and damned near everything here is sweet. I don't take any meds (diabetes medications)- I control it through diet. I don't know how you can control your sugar when everything is sweet. B. Record review of R #76's electronic medical record found: 1. that he was admitted to the facility on [DATE], and discharged on [DATE]. 2. that his listed medical diagnoses included [MEDICAL CONDITION], dependence on [MEDICAL TREATMENT] (filtering of the blood to compensate for impaired kidney function), [MEDICAL CONDITION] (a liver disease), and gastrointestinal hemorrhage (bleeding in the digestive system.) No [DIAGNOSES REDACTED]. 3. a care plan dated 1/22/18 that did not have focus sections related to diabetes management. 4. a physician's orders [REDACTED]. 5. that a nutritional assessment dated [DATE] did not acknowledge the resident's diabetes. It stated that the resident had declined a renal diet, in favor of a regular diet. 6. that an Admission MDS (Minimum Data Set, a data collection tool) assessment, dated 01/22/18, stated, Diabetes mellitus: No. 7. that the Treatment Administration Records for (MONTH) and (MONTH) (YEAR) showed no tasks related to diabetes management. C. Record review of a physician's History and Physical document for R #76, dated 01/18/18, indicated that DM 2 (Type II Diabetes Mellitus) was among his diagnoses in the History of Present Illness sect… | 2020-09-01 |
| 87 | 87 | RIO RANCHO CENTER | 325033 | 4210 SABANA GRANDE SE | RIO RANCHO | NM | 87124 | 2018-02-12 | 725 | F | 0 | 1 | M2BO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure sufficient nursing staff numbers to answer call lights in a timely manner, ensure all residents received restorative therapy as ordered and attend to residents' needs for all 113 residents identified on the alphabetical resident census provided by the Administrator on 02/05/18. This deficient practice has the potential to negatively impact resident safety and comfort, and to impede processes such as restorative therapy, timely incontinence care, regular turning schedules, timely showers and appropriate assistance with meals. The findings are: [NAME] On 02/05/18 at 2:38 pm, during an interview with R #26, he stated the staff is always complaining among themselves that they are short staffed. He stated that during the week it takes 20 minutes for them to answer his call light and about 30 minutes on the weekends. B. On 02/05/18 at 2:44 pm, during an interview with R #8, she stated that she needs help to transfer herself from her wheelchair to the toilet. She stated that on three separate occasions, she soiled her brief because staff did not answer call light in time. She stated that after she soiled herself she could not find any staff in her hallway so she had to propel herself to the nurse's station and asked someone to help her. R #8 stated this was very embarrassing and that even after she requested help, she had to wait another 30 minutes before she received help changing her brief. C. On 02/06/18 at 8:42 am, during an interview with R #15, she stated there is not enough staff. She stated that at night she will push her call light and no one will come. She stated that she has soiled her brief because the staff take too long to respond to her call light. D. On 02/06/18 at 8:35 am, during an interview with R #14, she stated the night shift will take a long time to answer her call light. She stated she waited for almost two hours for pain medications. E. On 02/06/18 at 9:59 am… | 2020-09-01 |
| 88 | 88 | RIO RANCHO CENTER | 325033 | 4210 SABANA GRANDE SE | RIO RANCHO | NM | 87124 | 2018-02-12 | 756 | F | 0 | 1 | M2BO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop a policy/procedure for the monthly drug regimen review that included time frames for the different steps in the process and failed to ensure that consultant pharmacist recommendations were forwarded to the physician for review. These deficient practices have the potential to affect all 113 residents identified on the alphabetical census list provided by the Administrator on 02/05/18. If consultant pharmacist recommendations are not being reviewed by the physician, residents are likely to experience a potential for unnecessary drug interactions and adverse side effects. The findings are: [NAME] Record review of R #101's pharmacist recommendation dated 03/31/17 stated, (R #101) receives [MEDICATION NAME] (Medication that treats [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder) 125 mg (milligrams) TID (three times a day) for dementia with associated behaviors. Please consider a gradual dose reduction, perhaps decreasing to [MEDICATION NAME] 125 mg BID (twice a day) . The recommendation was signed by the Director of Nursing (DON) on 04/15/17. There was no response from the physician noted. B. Record review of R #101's pharmacist recommendation dated 04/26/17 stated (R #101) receives [MEDICATION NAME] (an antipsychotic medication) 50 mg BID (twice a day) . Please consider a gradual dosage reduction to [MEDICATION NAME] 25 mg QAM (every morning) and 50 mg at HS (at bedtime), with the end goal of discontinuations of therapy. The recommendation was signed by the DON on 05/15/17. There was no response from the physician noted. C. On 02/08/18 at 11:41 am, during an interview with the DON, she stated that when she signs the recommendation it indicates that she has received it from the pharmacist and reviewed it herself. She stated she usually reviews the recommendations with the physician in person. She stated that after looking for R #101's recommendation dated 03/31/17 and 04/26/… | 2020-09-01 |
| 89 | 89 | RIO RANCHO CENTER | 325033 | 4210 SABANA GRANDE SE | RIO RANCHO | NM | 87124 | 2018-02-12 | 758 | E | 0 | 1 | M2BO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Surveyor: Puccetti, Ulysses Based on record review and interview, the facility failed to ensure that consultant pharmacist recommendations regarding gradual dose reductions of [MEDICAL CONDITION] medication were forwarded to the physician for 1 (R #101) of 5 (R #s 26, 31, 55, 90 and 101) residents reviewed for unnecessary medications. If consultant pharmacist recommendations are not reviewed by the physician and implemented in a timely manner, residents are likely to be administered medications they do not need, experience potential unnecessary drug interactions and adverse side effects. The findings are: [NAME] Record review of R #101's pharmacist recommendation dated 03/31/17 stated, (R #101) receives [MEDICATION NAME] (Medication that treats [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder) 125 mg (milligrams) TID (three times a day) for dementia with associated behaviors. Please consider a gradual dose reduction, perhaps decreasing to [MEDICATION NAME] 125 mg BID (twice a day) . The recommendation was signed by the Director of Nursing (DON) on 04/15/17. There was no response from the physician noted. B. Record review of R #101's pharmacist recommendation dated 09/30/17 stated REPEATED RECOMMENDATION from 3/31/17. Please respond promptly to assure facility compliance with Federal regulations. (R #101) receives [MEDICATION NAME] 125 mg TID for dementia with associate behaviors. Please consider a gradual dose reduction, perhaps decreasing to [MEDICATION NAME] 125 mg BID . The recommendation was signed by the DON on 04/15/17. The physician response was I accept the recommendation above with the following modifications: D/c (discontinue) [MEDICATION NAME]. Did this turn into a physician order? C. Record review of R #101's Medication Administration Record [REDACTED]. D. Record review of R #101's pharmacist recommendation dated 04/26/17 stated (R #101) receives [MEDICATION NAME] (an antipsychotic medication) 50 mg BID . Please consider a gra… | 2020-09-01 |
| 90 | 90 | RIO RANCHO CENTER | 325033 | 4210 SABANA GRANDE SE | RIO RANCHO | NM | 87124 | 2018-02-12 | 761 | F | 0 | 1 | M2BO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that medications were stored safely, which had the potential to affect any of the facility's 113 residents listed on the facility census provided by the Administrator on 02/05/18. Expired medications were stored with current medications, a lock box for controlled medications was not secured, food was present in a medication storage room, and medications were left unsecured at an unattended medication cart. These deficient practices have the potential to result in resident injury, through dosing with expired medications, absence of needed controlled medications, contamination of medications, or overdose by a confused resident. The findings are: [NAME] On 02/07/18 at 3:37 pm, during observation in the north unit's medication room, two medication refrigerators were inspected. Observed inside were: 1. An open bottle of a medicinal yeast product with a marked expiration date of (MONTH) (YEAR). 2. 2 bags of injectable [MEDICATION NAME] Sodium (an antibiotic) for use by former resident #308 showing an expiration date of 01/19/18. 3. A opened vial of influenza vaccine, in a water-damaged box, dated 12/04/17. 4. A locked clear medication storage box, containing 5 cards of controlled medications, which was not permanently affixed to the refrigerator and was able to be easily removed. B. On 02/07/18 at 3:49 pm, during interview with Licensed Practical Nurse (LPN) #1, he confirmed that the medications were expired. He indicated that the date on the influenza vaccine was the date that it had been opened, but stated that it's only good for 30 days after opening. He advised that the expired medications would be destroyed. C. On 02/07/18 at 3:53 pm, during interview with LPN #2, she was asked to open the south unit medication room for inspection. She responded Don't eat my chicken! Upon observation of the medication room, a plate containing LPN #2's dinner was noted on the count… | 2020-09-01 |
| 91 | 91 | RIO RANCHO CENTER | 325033 | 4210 SABANA GRANDE SE | RIO RANCHO | NM | 87124 | 2017-02-14 | 160 | B | 0 | 1 | R9L211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to convey the funds of deceased residents to the appropriate party within thirty days after the death of the resident for 3 (R #s 232, 233 and 234) of 3 (R #s 232, 233 and 235) residents reviewed for personal funds. This deficient practice hinders the closing of resident trust accounts and the distribution of the residents' estate. The findings are: [NAME] Record review of an Action Summary report dated [DATE] revealed the following: 1. R #232 deceased on [DATE]. 2. R #233 deceased on [DATE]. 3. R #234 deceased on [DATE]. B. Record review of R #232's Resident Statement dated [DATE] indicated her remaining funds were paid out on [DATE] and her resident fund account was closed on [DATE]. C. Record review of R #233's Resident Statement dated [DATE] indicated her remaining funds were paid out on [DATE] and her resident fund account was closed on [DATE]. D. Record review of R #234's Resident Statement dated [DATE] indicated his remaining funds were paid out on [DATE] and his resident fund account was closed on [DATE]. E. On [DATE] at 3:04 pm, during an interview with the Business Office Manager (BOM), she stated the facility's policy is to close resident accounts within 30 days after they pass away and disperse the remaining funds to the appropriate party. The BOM verified that the accounts for R #232, R #233 and and R #234 were not closed within the 30 day window as they should have been. | 2020-09-01 |
| 92 | 92 | RIO RANCHO CENTER | 325033 | 4210 SABANA GRANDE SE | RIO RANCHO | NM | 87124 | 2017-02-14 | 285 | E | 0 | 1 | R9L211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the accuracy of PASRR (preadmission screening and resident review) screening for 2 (R #125 and 230) of 5 (R's #1, 25, 56, 125 and 230) residents reviewed for PASRR screening. This deficient practice had the potential to prevent residents from receiving the necessary outside services to attain/maintain the highest level of psychosocial well-being. The findings are: [NAME] On 02/14/17 at 8:21 am, during an interview the Admissions Director she stated the following: 1. If a resident meets the level II PASRR the agency will give an okay over the phone and if requested then a letter will be sent to the facility. The PASRR paperwork is usually completed at the hospital or if not a hospital then from the community. 2. The facility has liaisons that are in the community who will go and make sure the forms are completed and correct before the resident leaves the hospital. 3. Once all the information is gathered it is sent to the Developmental Disabilities Supports Division (PASRR) for review. 4. If the resident does qualify for services through the PASRR department the facility will receive a letter stating so. 5. R #125 was not a level II PASRR per the documentation received from the hospital and the interview done at the facility. She received a letter stating that R #125 was not a level II. 6. R #230's medical record indicated that the resident came from the hospital with the PASRR paperwork but it didn't reflect a qualifying diagnosis. 7. She had to do a correction for R #230 and submit it to the PASRR Department and then an evaluation would be done by a doctor from the department. 8. All staff covering for admissions is trained on completing the proper paperwork and submitting it, there is someone on duty that can handle the situation when PASRR is in question. B. On 02/14/17 at 9:17 am, during an interview with PASRR worker, she stated that R #230 was admitted to the facility wi… | 2020-09-01 |
| 93 | 93 | RIO RANCHO CENTER | 325033 | 4210 SABANA GRANDE SE | RIO RANCHO | NM | 87124 | 2017-02-14 | 431 | E | 0 | 1 | R9L211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure: 1. That access to non-controlled discontinued drugs that were stored in open containers in the two medication rooms, without being double-locked, were not readily and easily available for staff members' personal use 2. that insulin vials were labeled when opened and that insulin vials were not being used greater than 28 days from date they were opened. These deficient practices have the potential to negatively impact all 112 residents, identified on the alphabetical list provided by the Administrator on [DATE], through semi-restricted access to discontinued medications by staff and for residents to receive medications that have lost their potency and effectiveness. The findings are: [NAME] On [DATE] at 12:15 pm, the medication storage observation of the North and South Hall medication rooms revealed opened boxes indicated for discontinued medications all easily accessible to staff members' personal use. The opened boxes contained the following medications: [REDACTED] 1. latanoprost (used to reduce intraocular pressure in the eye) 2. Spiriva (an inhaler used to help expand lung passages) 3. Nicotine Transdermal patches 21 mg (6) (used to reduce the urge to smoke) 4. albuterol nebs (used to help expand lung passages) 5. Alphagan (used to reduce intraocular pressure in the eye) 6. Flovent (a steroid inhaler that expands lung passages) B. On [DATE] at 1:40 pm, during interview, the Unit Manager for the North hall stated that the discontinued medications or medications of discharged residents are stored in the opened box. During the night shift, the nurse catalogs the medications, the medications are then placed in a box that is sealed and ready for the pharmacist or pharmacy courier (a messenger who transports goods or documents) to pick up from the facility once a week. C. Record review of the facility's policy titled Delivery and Receipt of Medication and Pharmac… | 2020-09-01 |
| 94 | 94 | RIO RANCHO CENTER | 325033 | 4210 SABANA GRANDE SE | RIO RANCHO | NM | 87124 | 2017-02-14 | 514 | D | 0 | 1 | R9L211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This is a repeat deficiency from the survey conducted on 01/08/16. Based on record review and interview, the facility failed to ensure that clinical records were complete and accurate for 2 (R #s 110 and 145) of 2 (R #s 110 and 145) residents reviewed for accurate and complete records by failing to ensure that residents' Medication Administration Record [REDACTED]. This deficient practice is likely to result in staff not knowing whether the physician was notified and is aware of the resident's condition. The findings are: Findings for R #110: [NAME] Record review of R #110's physician order [REDACTED]. Notify physician for absence of bruit/thrill every shift. B. Record review of R #110's MAR indicated [REDACTED].where documentation was not complete for checking the thrill/bruit of the residents fistula. C. On 02/10/2017 at 11:59 am, during an interview with the Director of Nursing (DON), she stated it should be documented on all orders on the MAR. She confirmed that nursing staff are not signing off on checking the thrill on the fistula. Findings for R #145 D. Record review of R #145's physician's orders [REDACTED]. The order indicated that if the resident's blood glucose level is over 401 gm/dl (grams/deciliter) to give 10 units and to notify the physician on call. E. Record review of R #145's MAR indicated [REDACTED]. F. On 02/10/17 at 11:45 am, during an interview with the DON, she stated that nurses are expected to document when the physician is contacted due to residents' high blood glucose levels. The DON stated they document this either on the back of the MAR indicated [REDACTED] R #145's high blood glucose levels on 4 separate days during (MONTH) (YEAR). | 2020-09-01 |
| 95 | 95 | RIO RANCHO CENTER | 325033 | 4210 SABANA GRANDE SE | RIO RANCHO | NM | 87124 | 2019-03-07 | 558 | E | 0 | 1 | IVL411 | Based on interview, the facility failed to accommodate for 2 (R #s 6 and 11) of 2 (R #s 6 and 11) residents reviewed for accommodations provided to meet transfer needs requiring assistance with the use of a Hoyer lift (a mechanical device designed to lift residents safely). This deficient practice has the potential to affect residents physical health and comfort levels, by decreasing resident mobility. The findings are: [NAME] On 03/04/19 at 10:31 am, during an interview, R #6 revealed, They have to go all around to find the lift (Hoyer lift) They only have one or two I think .(so) they change my briefs on their schedule. B. On 03/04/19 at 11:37 am, during interview, Certified Nurse Aide (CNA) #2 revealed, We have two of them (Hoyer lifts) we could use more. C. On 03/07/19 at 1:06 pm, during interview, Licensed Practical Nurse (LPN) #5 revealed, regarding Hoyer lifts, We don't have enough .it impacts the residents getting up (out of bed). D. On 03/07/19 at 2:25 pm, during interview, the CNE (Center Nurse Executive) revealed, we have about 12 residents on each side that need the Hoyer lifts (~ (approximately)12 residents on the north hall and ~12 residents on the south hall). E. On 03/07/19 at 4:20 pm, during interview, R #11 revealed, I wait all the time, because the Hoyer isn't available .they need another one especially on this hall (South Hall). | 2020-09-01 |
| 96 | 96 | RIO RANCHO CENTER | 325033 | 4210 SABANA GRANDE SE | RIO RANCHO | NM | 87124 | 2019-03-07 | 656 | E | 0 | 1 | IVL411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop and implement a comprehensive person-centered care plan for 2 (R #s 28 and 92) of 4 (R #s 22, 28, 75 and 92) residents reviewed for care plans. Failure to develop and implement a resident centered care plan may result in staff's failure to understand and implement the needs and treatments of residents possibly resulting in a decline in their abilities and a failure to thrive. The findings are: Findings for R #28: [NAME] Record review of R #28's face sheet (undated} reveals dependence on supplemental oxygen. B. Record review of R #28's Physicians orders dated 03/06/18, revealed, Oxygen at 2 l/min (liters per minute) via nasal cannula (a device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help) continuously. Attempt to wean (to make someone gradually stop depending on something that they have become used to) to room air as appropriate every shift. Oxygen tubing change weekly. Label each component with date and initials. C. Record review of R #28's care plan (undated) did not reveal a care plan for the use of oxygen. Findings for R #92: D. Record review of R #92's face sheet (undated) reveals [MEDICAL CONDITION] (A group of lung diseases that block airflow and make it difficult to breathe). E. Record review of R #92's physician's orders [REDACTED].> (greater than) 90% (percent). Check Q (every) shift. F. Record review of R #92's care plan does not reveal a care plan for O2 treatment. [NAME] On 03/06/19 at 3:25 pm, during an interview with Licensed Practical Nurse (LPN) #10 she stated, The use of oxygen should be care planned. | 2020-09-01 |
| 97 | 97 | RIO RANCHO CENTER | 325033 | 4210 SABANA GRANDE SE | RIO RANCHO | NM | 87124 | 2019-03-07 | 657 | D | 0 | 1 | IVL411 | Based on record review and interview, the facility failed to ensure that the care plan had been revised for 1 (R #10) of 1 (R #10) resident reviewed for accuracy of care plans by not identifying what assistive device should be used to properly transfer the resident. This deficient practice is likely to result in the resident not getting the care and assistance he needs. The findings are: [NAME] Record review of R #10's care plan dated 11/22/16 reveals: Provide resident/patient with total assist with Hoyer lift (a device used to assist with transfers) of 2 for transfers. B. Record review of R #10's care plan dated 11/29/16 reveals: Sara lift (patient sit to stand assistive device) with 2-person for transfers. C. On 03/07/19 at 2:26 pm, during an interview with Licensed Practical Nurse (LPN) #2, stated, We (staff) use a Hoyer lift for all transfers, the care plan does state use a Sara lift. I know we have to use a Hoyer lift for all transfers. D. On 03/07/19 at 4:53 pm, during an interview with LPN #4, stated, I am not sure if he (R #10) uses a Sara lift. It (care plan) should have been revised to reflect what they (staff) are using to transfer him (R #10). When a care plan is revised it is done by the nursing staff. I did confirm a Hoyer lift is the only thing used to transfer the resident. | 2020-09-01 |
| 98 | 98 | RIO RANCHO CENTER | 325033 | 4210 SABANA GRANDE SE | RIO RANCHO | NM | 87124 | 2019-03-07 | 684 | D | 0 | 1 | IVL411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide services for 2 (R #s 12 and 25) of 2 (R #s 12 and 25) residents reviewed for treatment and care in accordance with professional standards of practice. For (R #12) Hospice (end of life care management) Care, the facility staff failed to assure a resident receiving hospice care was being monitored by hospice staff. For R #25, the resident was not repositioned in bed for many hours and in accordance with the guidance on her kardex (document where the tasks a Certified Nurses Aide (CNA) should provide to a resident is delineated). This deficient practice was likely to result in a resident receiving inadequate and/or untimely care and treatment during daily and end of life care. The findings are: Findings for R #12: [NAME] Record review of R #12's face sheet dated 03/06/19 revealed he was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. [MEDICAL CONDITION]-Stage 3 (Moderate) (long term decline of kidney function) 2. Acute Kidney Failure (immediate failure of kidney function) 3. [MEDICAL CONDITION] in [MEDICAL CONDITION] (blood red cell abnormalities due to kidney disease) B. Record review of R #12's physician order [REDACTED].#12 was admitted to (name of selected hospice service) under routine level of care. Primary Diagnosis: [REDACTED]. C. Record review of R #12's written progress notes of care provided to R #12 by the selected Hospice service reveals that he was seen by a Registered Nurse, Licensed Practical Nurse or Social Worker from the hospice service on 12/14/18, 12/31/18, 01/18/19, 01/21/19, 01/29/19, 02/01/19, 02/05/19, 02/08/19, 02/12/19 and 02/15/19. There were no other written progress notes available after this date. D. On 03/06/19 at 9:15 am, during interview with the Social Services Director (SSD), stated that hospice nurses were suppose to come weekly. She stated that when the Hospice nurses come they document their visit … | 2020-09-01 |
| 99 | 99 | RIO RANCHO CENTER | 325033 | 4210 SABANA GRANDE SE | RIO RANCHO | NM | 87124 | 2019-03-07 | 695 | E | 0 | 1 | IVL411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, record review and interview, the facility failed to meet professional standards of care by failing to date the oxygen and nebulizer (respiration device that delivers medication) tubing for 4 (R #s 22, 28, 75 and 92) of 4 (R #s 22, 28, 75 and 92) residents reviewed for oxygen care. This deficient practice is likely to result in staff being unaware as to when the tubing should be changed and could cause tubing to become clogged or dirty leading to reduced flow of oxygen or upper respiratory infections. The findings are: Findings for R #22: [NAME] On 03/05/19 at 9:34 am, during an observation R #22's oxygen tubing, nebulizer tubing and humidifier bottle were not dated. B. On 03/07/19 at 10:49 am, during an observation R #22's oxygen tubing, nebulizer tubing and humidifier bottle were not dated. C. Record review of R #22's Physicians orders dated 02/23/19, revealed, O2 (oxygen) at 2L (liters) via nasal cannula (a device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help) as needed to maintain O2 sat (saturation) > (greater than) 90% (percent) (Normal range 90-100%). Oxygen tubing change weekly label each component with date and initials. Every day shift every Saturday label each component with date and initials. D. Record review of R #22's Care Plan dated 05/31/18, revealed, (name of R #22) exhibits or is at risk for respiratory complications related to [MEDICAL CONDITION] (A group of lung diseases that block airflow and make it difficult to breathe) exacerbation (the worsening of a disease or an increase in its symptoms) and [MEDICAL CONDITION] (Longstanding disease of the kidneys leading to [MEDICAL CONDITION]). Interventions: O2 as ordered via nasal cannula (a device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help). Findings for R #28: E. On 03/06/19 at 11:08 am during an observation, R #28's oxygen tubin… | 2020-09-01 |
| 100 | 100 | RIO RANCHO CENTER | 325033 | 4210 SABANA GRANDE SE | RIO RANCHO | NM | 87124 | 2019-03-07 | 726 | E | 0 | 1 | IVL411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that licensed nursing staff were properly trained to provide emergency intervention and Cardio-Pulmonary Resuscitation (CPR) (life saving technique used during a medical emergency when the heart has stopped and/or the victim is not breathing) during a life threatening event. This deficient practice is likely to affect all residents who are full code and may require CPR. This deficient practice are likely to result in nursing staff providing inadequate and unsafe response during an emergency situation. The findings are: [NAME] On [DATE] at 1:33 pm, during an interview, the Center Nurse Executive (CNE) stated that all nursing staff are to have a current valid CPR certification. She was uncertain if each nurse had CPR certification which had been obtained through a qualified hands-on certification program. B. Record review of facility staffing dated [DATE] to [DATE], revealed there were 7 Registered Nurses (RN) and 13 Licensed Practical Nurses (LPN) assigned to work. C. Record review of facility provided CPR certifications revealed the facility provided current CPR certifications for LPN #3, LPN #6, RN #2, and LPN #8, which were each obtained through online computer-based certification programs that did not require any hands-on training to receive CPR certification. D. Record review of facility provided CPR certifications revealed the facility did not provide CPR certifications for LPN #1, LPN #9, RN #3, RN #4, RN #5 or RN #6 and therefore, their competency could not be confirmed. | 2020-09-01 |
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CREATE TABLE [cms_NM] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );