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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 5698 | 5698 | COLFAX GENERAL LTC | 3.2e+33 | 615 PROSPECT AVENUE | SPRINGER | NM | 87747 | 2010-09-10 | 441 | C | D72T11 | Based on observation and interview the facility failed to handle, store and process linens to prevent cross-contamination. This deficient practice had the potential to affect 30 resident's residing in the facility. The findings are: A. On 09/10/10 at 9:00 am, observation of the facility laundry revealed a single room divided into two sections by a partial wall, measuring three feet high by sixteen feet long. The soiled laundry was stored in four large uncovered bins at the front of the room separated by the partial wall where the clean linens were being sorted, processed and stored. Soiled linen was observed on the floor in front of the sorting bins and the table with clean linens did not have a cover on it. The sections where not separated by doors or other barriers. The room was not mechanically ventilated or under negative pressure to prevent cross-contamination. B. On 09/10/10 at 10:00 am, during an interview, the laundry Environmental Services Manager acknowledged the above and stated that the laundry room had been that way for a long time. C. On 09/10/10 at 10:05 am, during an interview, the Environmental Services Manager acknowledged they had one side for the clean linen and the other side of the room for the dirty linen separated by the three foot wall and were made aware that they needed a full wall by life safety code. | 2014-01-01 | ||
| 5697 | 5697 | COLFAX GENERAL LTC | 3.2e+33 | 615 PROSPECT AVENUE | SPRINGER | NM | 87747 | 2010-09-10 | 371 | C | D72T11 | Based on observation, interview and record review the facility failed to maintain a clean working environment in the kitchen. This deficient practice had the potential to affect 30 residents who were served meals from the kitchen. The findings are: A. On 09/07/10 at 1:20 pm, observation of the kitchen was conducted and revealed the following: 1. All gas burners on stove top were charred black with crusted burnt spills. 2. Stove knobs were covered with thick grease and grim. 3. On the counter where the microwave and juice machine were located revealed old food and dried stains. 4. The north wall in the kitchen was covered with dirt and grease. B. On 09/07/10 at 3:45 pm, observation of kitchen revealed: 1. The vent fan leading into the dry goods storage room revealed a thick layer of grease and dirt on fan. 2. All gas burners on stove top were charred black with crusted burnt spills. 3. Stove knobs were covered with thick grease and grim. 4. On the counter where the microwave and juice machine were located revealed old food and dried stains. 5. The north wall in the kitchen was covered with dirt and grease. C. On 09/08/10 at 1:17 pm, during an interview the Food Services Manager stated, "The counters are supposed to be cleaned every night, and the knobs on the stove are supposed to be wiped down every shift and the stove is supposed to be cleaned once a week." She stated, "As you can see they have not been cleaning." | 2014-01-01 | ||
| 5696 | 5696 | COLFAX GENERAL LTC | 3.2e+33 | 615 PROSPECT AVENUE | SPRINGER | NM | 87747 | 2010-09-10 | 248 | C | D72T11 | Based on record review and interview the facility failed to provide activities on Sundays and Mondays, to maintain resident's interest, mental capabilities, and psychosocial well being for all resident who participated in activities daily. This had the potential to affect all 30 residents who resided at the facility. The findings are: A. On 09/08/10 at 10:02 am, during group interview, Random Resident #1 stated, "We don't have activities on the Sundays or Mondays. I just sit in my room on the weekends." B. On 09/08/10 at 10:03 am, during group interview, Random Resident #2 stated, "On the weekends I sit or lay in bed because there's no activities." C. On 09/08/10 at 10:25 am, during an interview, the Director of Nursing stated, "We don't have an activity person on the Sundays or Mondays. Staff just try to help out when they can." D. On 09/08/10 at 11:00 am, during an interview, Resident #4 stated, "We do not have activities on the weekend. There is never any staff to do activities." E. On 09/08/10 at 11:33 am, during an interview, the Activity Director stated, "We are short handed and have nobody to work." When asked what the residents do when staff are off, she stated, "They do nothing because I don't have any staff to cover." F. On 09/09/10 at 10:32 am, review of Social Services and Activities Schedule revealed that on Sundays and Mondays no activity staff was scheduled to work. | 2014-01-01 | ||
| 5695 | 5695 | MESCALERO CARE CENTER | 325116 | 454 LIPAN AVE | MESCALERO | NM | 88340 | 2011-01-21 | 412 | E | GJSL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to assist 1 (#43) of 28 resident in obtaining dental care by not promptly scheduling a dental referral for a resident with missing teeth. Resident #43 had no upper teeth and several missing lower teeth and desired to have dentures. The findings are: A. On 01/19/11 at 9:59 am, during an interview and observation Resident #43 did not have teeth in the upper portion of her mouth and had several missing on the bottom portion of her mouth. B. Review of the Admission Record revealed Resident #43 was admitted on [DATE] with [DIAGNOSES REDACTED]. 1. Review of the Admission Nursing assessment dated [DATE] revealed, under the oral assessment portion, that "Yes" was checked next to complete oral cavity exam. Handwritten was "poor - 0 top teeth and partial bottom teeth." A line was drawn through the section for dentures. This section also indicated that the resident had her own teeth. 2. Review of Standing Physician order [REDACTED]." 3. Review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #43 required supervision and set-up help only for personal hygiene. No dental issues were identified. 4. Review of a Care Plan dated 12/16/10 revealed staff were to provide oversight with one person assisting with oral care or assist as needed. The Care Plan documented that Resident #43 had her own teeth. 5. There were no notations regarding teeth in the Social Service notes. C. On 01/20/11 at 1:57 pm, during an interview, Certified Nursing Assistant (CNA) #21, reported that Resident #43 brushed her own teeth and required set-up assistance. When asked how well the resident brushed her own teeth, she replied, "I'd say not very good." When asked if Resident #43 had dentures, CNA #21 replied, "No. She has a couple of her own teeth." D. On 01/20/11 at 3:54 pm, during an interview, the Social Services Director (SSD) was asked if the nursing staff were required to re… | 2014-01-01 | ||
| 5694 | 5694 | MESCALERO CARE CENTER | 325116 | 454 LIPAN AVE | MESCALERO | NM | 88340 | 2011-01-21 | 411 | E | GJSL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to assist one of 28 sampled residents in obtaining dental care (#32). Resident #32 had missing teeth and desired to have dentures. The findings are: A. On 01/19/11 at 2:18 pm, during an observation, Resident #32 stated, "I'm missing these down here." He pointed to his lower teeth. He stated he would like new teeth and reported he had lost a tooth eating but could not remember when. B. Record review revealed Resident #32 was admitted on [DATE]. His [DIAGNOSES REDACTED]. 1. Review of the standing physician's orders [REDACTED]." 2. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed his cognitive skills are moderately impaired, he requires limited assistance by one staff member for personal hygiene and has no oral or dental issues. 3. Review of the Care Plan dated 06/09/10 revealed under, "Grooming/Personal Hygiene" an approach, "...one staff assistance for oral care." a. "Resident has some or all natural teeth lost... does not have or does not use dentures or partial plate due to poor dental care before entering the facility and dementia," several approaches were listed. b. Approaches included: "...Resident will not have further tooth loss. Assess condition of oral cavity teeth tongue lips, provide x (times) one staff member assistance for oral hygiene..." 4. Review of the Admission Nursing assessment dated [DATE] revealed a handwritten entry under oral care, "only a few teeth." 5. Review of Social Service notes revealed no entries pertaining to teeth. C. On 01/21/11 at 10:24 am, during an interview, Registered Nurse (RN) #12 was asked if she evaluated Resident #32's teeth and mouth. She stated, "I haven't..." After reviewing the Care Plan in the chart she reported, "He does need assistance for oral care according to the plan and it says that he has his own teeth." D. On 01/21/11 at 10:55 am, during an interview, Certified Nursing Assistant (CNA) … | 2014-01-01 | ||
| 5693 | 5693 | MESCALERO CARE CENTER | 325116 | 454 LIPAN AVE | MESCALERO | NM | 88340 | 2011-01-21 | 323 | D | GJSL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that approaches were implemented to protect 1 (#13) of 28 sampled residents from falls. Resident #13 fell on two occasions and sustained an abrasion during one of the falls, while being left unattended in the restroom. The findings are: A. Review of Resident #13's Admission Record revealed she was admitted on [DATE] with [DIAGNOSES REDACTED]. 1. Review of Nurse's Notes dated 09/24/10 at 1:05 pm revealed, "Called to resident's restroom, resident lying supine on floor, incontinent of urine with depends down to her knees..." 2. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 had sustained a fall since the last assessment period. 3. Review of the Care Plan dated 11/05/09 and updated on 10/20/10 revealed the following information: a. "Problem Start Date: 11/05/2009. Resident is limited in ability to transfer self to and from toilet, bed, and wheelchair R/T (related to) decreased physical mobility and pain." b. "Goal Target Date: 10/28/2010. Resident will safely transfer self with 1 staff assist." c. "Approach Start Date: 07/28/2010. Remind resident not to transfer without assistance; Keep call light within reach; Praise resident for efforts; Monitor for presence of pain/intolerance during transfers; Teach safety measures such as locking wheels of wheelchair before transferring." d. "Problem Start Date: 11/05/2009. Resident is limited in ability to toilet self R/T decreased physical mobility and pain." e. "Goal Target Date: 10/28/2010. Resident will participate in toileting self with X 1 (1 staff) assistance." f. "Approach Start Date: 07/28/2010. Remind resident to not transfer without assistance; Provide x 1 assistance for toileting; Use grab bars for transferring to and from toilet; Establish routine for toileting-before and after meals and PRN (as needed); Assist with incontinence care, as needed..." 4. Review of Nurse's Notes dated 0… | 2014-01-01 | ||
| 5692 | 5692 | MESCALERO CARE CENTER | 325116 | 454 LIPAN AVE | MESCALERO | NM | 88340 | 2011-01-21 | 272 | F | GJSL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure that 1 (#42) of 28 sampled residents was assessed for dental care upon admission into the facility. This deficient practice had the potential to effect 39 residents currently residing in the facility and any new admissions. The findings are: A. On 01/19/11 at 9:45 am, Resident #42 was observed to have teeth that looked dirty. They were covered in black/brown material, unclean, and a smell was coming from the resident's mouth. She stated, "There is something wrong with my teeth" but had difficulty speaking. She was visibly upset with her hands shaking and her face flushed. B. Review of the Admission Record revealed Resident #42 was admitted on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. C. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was "moderately impaired in cognitive skills for decision making, expressed little interest or pleasure, she looked to be feeling or appearing down, appeared tired or as having little energy, poor appetite or overeating, being short-tempered and easily annoyed." For Activities of Daily Living (ADLs), she was assessed as "requiring no assistance with set-up help only for eating and no assistance and able to perform personal hygiene" herself. D. Review of the Care Plan dated 04/29/11 revealed a problem area for dental as follows: "Resident has some/all natural teeth lost - does not have or does not use dentures (or partial plates) R/T (related to) poor dental hygiene before entering facility." The goal for the dental area included, "Resident will not have further tooth loss." The approaches to meet that goal were "Assess condition of oral cavity, teeth, tongue, lips... Monitor adequacy of brushing... Remind resident to brush near gumline... Provide oral care daily if resident is unable to do so." E. Review of the admission nursing assessment dated on 05/27/10 revealed the "Oral" asse… | 2014-01-01 | ||
| 5691 | 5691 | MESCALERO CARE CENTER | 325116 | 454 LIPAN AVE | MESCALERO | NM | 88340 | 2011-01-21 | 282 | E | GJSL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to follow the care plan and monitor 2 (#32 and #42) of 28 sampled residents. Both residents had dental issues that had not been addressed. The findings are: A. On 01/19/11 at 2:18 pm, during an observation, Resident #32 stated, "I'm missing these down here." He pointed to his lower teeth. He stated he would like new teeth and reported he had lost a tooth eating but could not remember when. B. Record review revealed Resident #32 was admitted on [DATE]. His [DIAGNOSES REDACTED]. 1. Review of the standing physician's orders [REDACTED]." 2. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed his cognitive skills are moderately impaired, he requires limited assistance by one staff member for personal hygiene and has no oral or dental issues. 3. Review of the Care Plan dated 06/09/10 revealed under, "Grooming/Personal Hygiene" an approach, "...one staff assistance for oral care." a. "Resident has some or all natural teeth lost--does not have or does not use dentures or partial plate due to poor dental care before entering the facility and dementia," several approaches were listed. b. Approaches included: "...Resident will not have further tooth loss. Assess condition of oral cavity teeth tongue lips, provide x (times) one staff member assistance for oral hygiene..." 4. Review of the Admission Nursing assessment dated [DATE] revealed a handwritten entry under oral care, "only a few teeth." C. On 01/21/11 at 10:24 am, during an interview, Registered Nurse (RN) #12 was asked if she evaluated Resident #32's teeth and mouth. She stated, "I haven't... I would say they (the staff) would have to cue him. I think he could do it by himself." RN #12 was asked if she knew if Resident #32's care plan required anything regarding his teeth. She said, "I don't recall off-hand." After reviewing the Care Plan in the chart she reported, "He does need assistance for oral… | 2014-01-01 | ||
| 5690 | 5690 | MESCALERO CARE CENTER | 325116 | 454 LIPAN AVE | MESCALERO | NM | 88340 | 2011-01-21 | 248 | E | GJSL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to provide musical activities of interest for 1 (#44) of 28 sampled residents. The resident, who had dementia, was observed without activity stimulation on 4 of 4 observations over two days. This deficient practice had the potential to affect 1 resident, causing boredom and decreasing the quality of life. The findings are: A. Resident #44's record review revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. B. On 01/20/11 at 9:23 am, during an observation in room [ROOM NUMBER], Resident #44 was in a reclining chair in her room, no television (TV) was on except for the roommate's. There was no activities provided and no music. 1. On 01/20/11 at 1:30 pm, after lunch the resident was back to the recliner, no music or interaction noted, roommate's TV still on. On 01/20/11 at 3:30 pm the same observations were made. 2. On 01/21/11 at 09:50 am, the resident was observed in the recliner in her room after breakfast. No activities were noted. There was no music and the TV was off. The resident responded to verbal stimulation. At 11:00 am, the same was observed. 3. On 01/21/11 at 11:10 am, the resident was again observed in a reclining chair in her room, no music, no activities, roommate's TV on. C. Record review of Resident #44's Minimum Data Set assessments dated 4/26/10, 8/3/10, and 10/8/10 revealed activities were coded as provided from 1/3 - 2/3 of the time. D. Review of the care plan dated 04/26/10, revealed that Resident #44 lacked a sense of social involvement as evidenced by an inability to participate in most activities. The goal was that the resident would participate in passive activities as she was able. Review of the care plan conference notes dated 10/26/10 revealed activities to include 1-on-1 visits in the resident's room. E. Review of the Therapeutic Recreation Activity assessment dated [DATE] revealed, "Activity pursuit patterns, current interests: exerci… | 2014-01-01 | ||
| 5689 | 5689 | MESCALERO CARE CENTER | 325116 | 454 LIPAN AVE | MESCALERO | NM | 88340 | 2011-01-21 | 279 | E | GJSL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide a comprehensive care plan for 1 (#28) of 28 sampled residents for non-pressure-ulcer-related skin conditions. This had the potential to affect 39 residents in the sample who had the potential to develop non-pressure-ulcer-related skin conditions by not providing preventative measures to lessen bruises or skin tears. The findings are: A. During observation and interview on 01/18/11 at 4:35 pm, large reddish bruises were noted on both hands of Resident #28. Resident #28 was asked about the bruises at that time and stated that she bruises easily. B. Record review of Resident #28's Weekly Skin Assessment Form For Non Pressure Ulcer Skin Conditions dated 08/03/10 revealed, "...several bruises scattered to UEs et LEs (upper extremities and lower extremities)." 1. The Weekly Skin Assessment Forms dated 08/17/10 and 08/24/10 revealed, "...scattered bruises to all extremities." 2. The Weekly Skin Assessment Forms dated 09/03/10. 09/10/10, 09/17/10, 09/24/10, and 11/10/10 referenced scattered bruising to extremities. 3. The Weekly Skin Assessment Form dated 10/17/10 revealed "s/t (skin tear) to rt (right) forearm." 4. A Skin Tear Scale for Healing dated 01/04/11 revealed a 5.0 centimeter (cm) by 3.5 cm skin tear. 5. Resident #28's Nurses' Notes dated 01/16/11 at 10:30 pm revealed, "Cont (continue) ABT (antibiotic) for R (right) knee skin tear. 6. Nurses' Notes dated 01/17/11 at 2:00 pm revealed, "...Healing skin tear with scab to anterior right forearm ...Right posterior knee wound with dressing..." 7. Record review of Resident #28's 01/07/11 physician progress notes [REDACTED]. pt (patient) has multiple bruises on both forearms. 2. [MEDICAL CONDITION] area back of right knee... 1. skin tears on arms probably secondary to trauma from transfers 2. [MEDICAL CONDITION] left leg... 1. Talked to DON (Director of Nurses) re (regarding) education of CNA (Certified Nursing Assis… | 2014-01-01 | ||
| 5688 | 5688 | MESCALERO CARE CENTER | 325116 | 454 LIPAN AVE | MESCALERO | NM | 88340 | 2011-01-21 | 425 | E | GJSL11 | Based on record review, observation, and interview, the facility failed to ensure that medications were not expired in 1 of 2 medication carts (the 200-hallway medication cart). This failed practice had the potential to affect residents that received a medication that would not be as effective or for a resident to have a reaction to the expired medication from the cart. A resident roster was provided by the Administrator for 39 residents in the facility on 01/18/11. The findings are: A. On 01/18/11 at 3:30 pm, the 200 hall medication cart was inspected. 1. Observed was 1 partially used bottle of Alkums Antacid with an expiration date of November 2010. 2. Observed was one partially used bottle of Aspirin (ASA) 325 milligrams (mg) with an expiration date of "12/10." 3. Observed was one partially used bottle of ASA 81 mg with an expiration date of "12/10." 4. Observed was one partially used bottle of bisacodyl 5 mg with an expiration date of "07/10." B. During an interview on 01/18/11 at 3:35 pm, Licensed Practical Nurse #10 verified that these medications were expired. She also stated that she had some residents who currently received the ASA 81 mg. C. On 01/20/11 at 12:10 pm, the Consultant Pharmacist was asked if he checked for expired medications. He stated that he gets 15 minutes a month in his contract to check for outdated medications and does a random spot check. He stated, "Nursing staff should have caught the expired medications because they should be checking monthly." D. The Director of Nurses was interviewed on 01/21/11 at 2:00 pm about the expired medications. She stated that the nurses should be checking for expired medications once a month but it was falling through the cracks. She was asked the potential outcome if a resident received an expired medication. She stated that the medication would not be as effective or the resident could have a reaction to it. | 2014-01-01 | ||
| 5687 | 5687 | MESCALERO CARE CENTER | 325116 | 454 LIPAN AVE | MESCALERO | NM | 88340 | 2011-01-21 | 226 | D | GJSL11 | Based on observation, record review, and interview the facility failed to implement their policies and procedures for an alleged incident of abuse by not reporting an injury of unknown origin to administrative staff in a timely manner for 1 (#44) of 28 sampled residents. Administrative staff were not aware of the injury until notified by the survey team on 01/20/11. This failed practice had the potential to affect 38 residents in the census of 39 if an injury if unknown origin is not reported. The findings are: A. Observation of Resident #44 on 01/19/11 at 9:38 am revealed a purplish bruise on the right forehead with swelling. B. Record review of the Nurses' Notes revealed that the last Nurses' Notes entry was on 01/18/11 and there was no mention of a bruise, swelling to the forehead or cause for the bruise. C. An interview was conducted with the Director of Nurses (DON) on 01/20/11 at 9:30 am about an incident report for the bruise to Resident #44's forehead. She stated that she did not have one. D. An interview was conducted with Licensed Practical Nurse (LPN) #11 on 01/20/11 at 10:16 am concerning the bruise. She stated that Certified Nursing Assistant (CNA) #20 informed her of the bruise that morning (01/20/11) and that CNA #21 noticed it yesterday (01/19/11) and had not reported it to her. She was asked when bruises or injuries of unknown origin were supposed to be reported. She stated, "Right away." LPN #11 reviewed the medical record and verified there were no Nurses' Notes about the resident's bruise. E. On 01/20/11 at 10:22 am, Resident #44's bruise to the right forehead area was observed with LPN #11. She verified that the bruise was present on the right forehead, and she did not know the origin of the bruise. F. CNA #20 was interviewed on 01/20/11 at 10:55 am and asked if she saw the bruise on 01/19/11. She stated that she had worked the 100 hallway with the resident and stated that she did not notice the bruise but that CNA #21 had noticed it and texted her about it after work. G. CNA #21 was intervie… | 2014-01-01 | ||
| 5686 | 5686 | MESCALERO CARE CENTER | 325116 | 454 LIPAN AVE | MESCALERO | NM | 88340 | 2011-01-21 | 225 | D | GJSL11 | Based on observation, record review and interview the facility failed to report an injury of unknown origin to administrative staff in a timely manner within 24 hours for investigation for 1 (#44) of 28 sampled residents. Administrative staff were not aware of the injury until notified by the survey team on 01/20/11. This failed practice had the potential to affect 38 residents in the census of 39 if an injury if unknown origin was not reported. The findings are: A. Observation of Resident #44 on 01/19/11 at 9:38 am revealed a purplish bruise on the right forehead with swelling. B. Record review of the Nurses' Notes dated 01/18/11 did not mention that the resident had a bruise, swelling to the forehead or had a recent fall. C. An interview was conducted with the Director of Nurses (DON) on 01/20/11 at 9:30 am about an incident report for the bruise to Resident #44's forehead. She stated that she did not have one. D. An interview was conducted with Licensed Practical Nurse (LPN) #11 on 01/20/11 at 10:16 am concerning the bruise. She stated that Certified Nursing Assistant (CNA) #20 informed her of the bruise that morning (01/20/11) and that CNA #21 noticed it yesterday (01/19/11) and had not reported it to her. She was asked when bruises or injuries of unknown origin were supposed to be reported. She stated, "Right away." After looking in the medical record, LPN #11 verified there were no Nurses' Notes regarding the bruise. E. On 01/20/11 at 10:22 am, Resident #44's bruise to the right forehead area was observed with LPN #11. She verified that the bruise was present on the right forehead, and she did not know the origin of the bruise. F. CNA #20 was interviewed on 01/20/11 at 10:55 am and asked if she saw the bruise on 01/19/11. She stated that she had worked the 100 hallway with the resident and stated that she did not notice the bruise but that CNA #21 had noticed it and texted her about it after work. G. CNA #21 was interviewed on 01/20/11 at 11:00 am about Resident #44's bruised forehead. She stated that she n… | 2014-01-01 | ||
| 5685 | 5685 | MESCALERO CARE CENTER | 325116 | 454 LIPAN AVE | MESCALERO | NM | 88340 | 2011-01-21 | 166 | C | GJSL11 | Based on interview and record review, the facility failed to ensure that 1 of 28 sampled residents (#20) and the resident's family were informed of the result of a grievance investigation. The family member reported that the resident had some missing clothes and the family did not know what had been done or what the result of the facility investigation was. This failed practice had the potential to affect 39 residents and/or the persons acting on behalf of the residents who make a grievance. The findings are: A. On 01/19/11 at 11:00 am, during an interview, a family member of Resident #20 stated that some of Resident #20's clothes were missing and that they had reported it to the Director of Social Services. The family member stated there had been no discussion of the grievance since and the family did not know what had been done or the result of the facility investigation. B. On 01/20/11 at 2:45 pm, during an interview, the Director of Social Services stated that the daughter of Resident #20 did report some clothes missing. She stated she had asked the Director of Housekeeping about the clothes, and the Director of Housekeeping told her that the clothes could still be in the laundry because there were two washers broken. She then stated that she did not have any documentation and there was no follow-up. She stated that she did not know if the clothes were found or not. C. Review of the Investigating Grievance/Complaints policy, undated, revealed the following: 1. "1. The administrator has assigned the responsibility of investigating grievances and complaints to The Social Worker." 2. "4. The resident, or person acting in behalf of the resident, will be informed of the findings of the investigation, as well as any corrective actions recommended, within 10 working days of the filing of the grievance or complaint." 3. "6. Copies of all reports must be signed and will be made available to the resident or person acting in behalf of the resident." | 2014-01-01 | ||
| 5684 | 5684 | MESCALERO CARE CENTER | 325116 | 454 LIPAN AVE | MESCALERO | NM | 88340 | 2011-01-21 | 156 | C | GJSL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that 1 of 28 sampled residents (#20) and the resident's family were informed on admission of the resident's rights while living in the facility. This failed practice had the potential to affect residents who were admitted to the facility. The findings are: A. On 01/19/11 at 11:00 am, during an interview with a family member of Resident #20, the family member stated that she did not receive any statement of rights for the resident upon admission into the facility. She said no one had talked about resident rights with them. She further stated that she had no idea what the resident's rights were. B. During record review, the undated Resident Admission Record documented that Resident #20 was admitted on [DATE]. She was diagnosed with [REDACTED]. C. On 01/20/11 at 2:45 pm, during an interview, the Director of Social Services stated that she started the position in August of 2010. She stated that she had put a new packet together, but she stated that she had not gone back to verify that residents admitted before she took over had received there rights. | 2014-01-01 | ||
| 5683 | 5683 | HEARTLAND CARE OF ARTESIA | 325082 | 1402 WEST GILCHRIST | ARTESIA | NM | 88210 | 2010-09-30 | 323 | E | CWYN11 | Based on observation, record review and interview the facility failed to analyze falls to determine the cause of falls, failed to implement interventions to prevent falls, and the resident continued to have falls related to her need for assistance to the bathroom for 1 of 5 sampled residents (#26). Sensor pads were not put on the bed or wheelchair to assist staff to know when resident tried to toilet self. This deficient practice had the potential to affect the 22 residents in the facility who were identified for being at high risk for falls according to the staff development coordinator. The findings are: A. On 09/17/10 at 9:45 am, during an interview, Certified Nursing Assistant (CNA) #14 was asked about Resident #26's falls. She stated that they had placed an anti-roll back device on the wheelchair and a sensor pad on the bed. She stated, "She sometimes goes to bed during the day. She is needing more and more assist (sic) here lately and more assist (sic) getting to the bathroom." B. On 09/22/10 at 3:38 pm, during an interview, CNA #2 was asked what she would do to prevent the Resident #26 from falling. She stated, "I've noticed that she doesn't do as well. She used to walk, is more unsteady on feet and falls. We use an anti skid wheelchair. She has an alarm on the bed but not on the chair." When asked if the resident had become more incontinent of urine, she stated, "Since she first came in, it has become increasing worse. We would try to put an attend on her, and she will take them off. Occasionally takes herself to the bathroom and is unsteady on her feet. She is incontinent every day. When we put her to bed her house gown will be wet." C. On 09/24/10 at 2:50 pm, during an interview, CNA #8 was asked if Resident #26 had become more incontinent of urine. He stated, "Based on the urine odors that I have noticed in the room, I would say yes." D. On 09/22/10 at 3:38 pm, observation in room 302a revealed that there was not a sensor alarm on the bed or the chair, no fall mat was on the floor and Resident #26 was … | 2014-01-01 | ||
| 5682 | 5682 | HEARTLAND CARE OF ARTESIA | 325082 | 1402 WEST GILCHRIST | ARTESIA | NM | 88210 | 2010-09-30 | 166 | E | CWYN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to promptly resolve grievance for 1 of 5 sampled residents (#40). Resident #40's Family Member (FM) #1 requested medical records in July 2010, did not receive them, made a complaint and still did not receive them be the end of September 2010. Resident #40's FM #1 also complained that a Certified Nurse Aide (CNA) had hurt her mother's knee in July 2010, and complained of her mother not getting medication after a [MEDICAL CONDITION]. Resident #40's FM #1 did not get resolutions to the complaints. This deficient practice had the potential to affect 58 residents in the facility if complaints were not followed-up on and a resolution made. The findings are: A. On 09/16/10 at 3:30 pm, during an interview, Resident #40's FM #1 stated that she had complained that a CNA had hurt her mother's knee. She had requested medical records in July and had not received them. FM #1 had also complained that her mother did not get medication after a [MEDICAL CONDITION] when it was requested. She stated, "The medication helps my mother to relax so the [MEDICAL CONDITION] aren't as bad." She stated that she had complained to the Director of Nurses (DON) in a care plan meeting in August 2010, and that she was not getting a response to her complaints or copies of the medical records. When asked if she felt she had resolutions to the complaints, she stated, "I never had resolution to any of the 3 complaints." B. On 09/24/10 at 2:30 pm, the Medical Records Supervisor was asked if medical records had been requested by the family on Resident #40. She stated that the daughter had requested the medical records. She also stated that the daughter had spoken to the owner of the facility and the owner had told her (the Medical Record Supervisor) "to hold off on getting the medical records to the family." C. Record review of a Release of Information form dated 07/14/10 revealed, "I, (Name of Daughter) the representative /PO… | 2014-01-01 | ||
| 5681 | 5681 | HEARTLAND CARE OF ARTESIA | 325082 | 1402 WEST GILCHRIST | ARTESIA | NM | 88210 | 2010-09-30 | 153 | E | CWYN11 | Based on record review and interview the facility failed to give copies of the medical records to 1 of 5 sampled resident's (#40) family members, therefore violating resident or family members rights to have access to medical records. The family requested the records in July 2010 and had not received the medical records by the end of September 2010. This deficient practice had the potential to affect 58 residents in the facility. The findings are: A. On 09/16/10 at 3:30 pm, during an interview, Resident #40's family member (FM) #1, who was also the resident's Power of Attorney (POA), stated that she had "requested medical records for 4 months and had not received them yet." She had asked the person in medical records for copies of the records and signed a release form. She stated that she was told she could get the records within 48 hours. She did not get the records and then asked the administrator when she was going to get the medical records. She reported that he said he had to get permission from (Name of the facility owner). She stated that in August 2010 at a care plan meeting she again asked for the medical records. B. On 09/24/10 at 2:30 pm, the Medical Records Supervisor was asked if medical records had been requested by the family member of Resident #40. She stated that the daughter had requested the medical records. She also stated that the daughter had spoken to the owner of the facility and that the owner had told her (the Medical Record Supervisor) to hold off on getting the medical records to the family. C. Record review of a Release of Information form dated 07/14/10 revealed, "I, (Name of Daughter) the representative/POA (Power of Attorney) /Sponsor of (Name of Resident #40) who has been appointed to act on his/her behalf, hereby give my permission to release the following information concerning his/her: Medical Records." It was signed by the daughter on 07/14/10. D. On 09/30/10 at 10:05 am, during an interview, the Social Worker was asked if she was aware that the family member had requested cop… | 2014-01-01 | ||
| 5680 | 5680 | PALOMA BLANCA HEALTH AND REHABILITATION | 325060 | 1509 UNIVERSITY BOULEVARD NE | ALBUQUERQUE | NM | 87102 | 2011-01-26 | 329 | E | 1PCJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure that residents receiving [MEDICAL CONDITION] medications were informed of the expected effect and possible adverse reactions to the medication for 6 of 34 sampled residents (#2, 62, 120, 162, 163 and 170). This deficient practice had the potential to effect 65 residents receiving psychoactive medications (CMS-672) who may not be aware of possible adverse reactions to their medication. The findings are: A. Review of Resident #2's medical record and interview revealed the following information: 1. The physician's orders [REDACTED]. (milligrams) at bedtime, [MEDICATION NAME] 1 mg. as needed, [MEDICATION NAME] 40 mg. daily, klonopin 0.5 mg. twice a day to treat her anxiety and depression. 2. There was no documentation found in the medical record indicating the resident or resident's representative was informed of the expected effect of the medications as well as the possible side-effects prior to administering these medications. 3. On 01/20/11 at 1:45 pm, during an interview, the Assistant Director of Nursing (ADON), verified that there was no documentation to indicate the resident or residents representative had been informed of side-effects or the expected results in the medical record. B. Review of Resident #62's medical record and interview revealed the following information: 1. The physician's orders [REDACTED]. every 2 hours as needed and [MEDICATION NAME] 0.5 mg to 1 mg. every four hours as needed for anxiety. Both medications had a start date of 08/26/10. 2. No documentation was found to indicate the resident and/or resident's representative was informed of the expected outcome and possible side effects of the psychoactive medications. 3. On 01/24/11 at 9:00 am, during an interview, the Director of Nursing stated, that it would be her expectation for the nurses to document that the family and/or resident received education and an explanation of expected out comes and possi… | 2014-01-01 | ||
| 5679 | 5679 | PRINCETON PLACE | 325045 | 500 LOUISIANA BOULEVARD NE | ALBUQUERQUE | NM | 87108 | 2010-10-05 | 280 | E | EQ6511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure that Comprehensive Care Plans were being updated and revised as necessary for 3 of 32 sampled residents (#451, 452 and 448). Resident #451's care plan was not revised to reflect the resident's self-releasing seatbelt. Resident #452's care plan was not revised to reflect the resident's fall. Resident #448's care plan was not revised to reflect the resident's change of condition related to diabetes. This deficient practice had the potential to affect 329 residents who resided in the facility. (CMS 672). The findings are: A. On 09/27/10 at 3:00 pm, 09/28/10 at 10:00 am, and on 09/29/10 at 10:30 am, during observations of Resident #451, he was seated in his wheelchair with a self-releasing seat belt (SRSB) on and attached around his waist. B. On 09/29/10 at 10:45 am during interview, Licensed Practical Nurse (LPN) #7 stated, "To be honest with you, I wasn't even aware of the seat belt. I really haven't had enough time to fully assess him. I think he would be able to release it if he wanted but again I'm not sure." C. On 09/29/10 at 11:00 am, during observation the resident was observed seated in the 300 activity day room area with the self-releasing seat belt on and attached around his waist. D. On 09/29/10 at 11:00 am, during observation and interview, Certified Nursing Assistant (CNA) #6 was observed asking the resident if he could release his seat belt by asking him to remove it. The resident was observed shaking his head and only mumbling words back to the CNA. He was observed as not being able to release the SRSB by himself. The CNA was observed asking the resident if he could push the red button located in the middle of the SRSB and he was not able to comprehend what was being asked of him. At 11:05 am observation of the 300 Unit Manager/Registered Nurse (RN) #8 revealed her to be asking the resident if he could press the red button to release his SRSB. He was … | 2014-01-01 | ||
| 5678 | 5678 | PRINCETON PLACE | 325045 | 500 LOUISIANA BOULEVARD NE | ALBUQUERQUE | NM | 87108 | 2010-10-05 | 156 | E | EQ6511 | Based on record review and interview, the facility failed to ensure that the "Notice of Medicare Provider Non-Coverage" form included the reasons for non-coverage of services for 3 of 3 sample residents (#374, #389 and #436). This deficient practice had the potential to effect 48 residents who were discharged from medicare services since 04/01/10 that should have received "Liability Notices and Beneficiary Appeal Rights." (Discharge list provided by the facility) The findings are: A. A review of the facility's "Notice of Medicare Provider Non-Coverage" form revealed that there was not a specific reason given for non-Medicare coverage for Resident #374 ("Notice of Medicare Provider Non-Coverage" form dated 06/08/10), Resident #389 ("Notice of Medicare Provider Non-Coverage" form dated 07/16/10) and Resident #436 ("Notice of Medicare Provider Non-Coverage" form dated 08/14/10). B. On 09/28/10 at 1:30 pm, during interview, the Abstract Coordinator identified a Center for Medicare and Medicaid Services (CMS) - Form as the "Notice of Medicare Provider Non-Coverage" used by the facility. She confirmed that the two page document was the only document provided to the residents by the facility. She acknowledged that the facility failed to provide a specific reason for non-coverage for Residents #374, #389 and #436. | 2014-01-01 | ||
| 5677 | 5677 | PRINCETON PLACE | 325045 | 500 LOUISIANA BOULEVARD NE | ALBUQUERQUE | NM | 87108 | 2010-10-05 | 226 | E | EQ6511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to implement their written policies and procedures to ensure potential employees had not been guilty of abuse or neglect, or entered into State nurse aide registry. The facility risked the residents exposure to abuse, neglect or exploitation by not pre-screening individuals through a recognized entity prior to employment for 5 of 5 sampled Certified Nursing Assistants (CNAs) from 54 new employees since 05/24/10, as policies indicated. This deficient practice had the potential to effect all 329 residents. The findings are: A. Review of employee records, CNA #13 (date of hire 09/13/10), CNA #14 (date of hire 05/24/10), CNA #15 (date of hire 08/09/10),CNA #16 (date of hire 09/13/10) and CNA #17 (date of hire 08/09/10) revealed no record of pre-screening by a State nurse aide registry or entity recognized by the State, concerning abuse, neglect, mistreatment of [REDACTED]. B. Review of the Facilities policy and procedures "Preventing Resident Abuse" revised December 2006, (#2-l) indicated, "Conducting background investigations to avoid hiring persons or admitting new residents who have been found guilty (by a court of law) of abusing, neglecting, or mistreating individuals or those who have had a finding of such action entered into the state nurse aide registry or state sex offender registry." C. On 10/04/10 at 9:45 am, during interview, the Human Resources Director stated that she is aware of the facility's abuse policy and procedures. She further stated that the pre-screening of individuals was done prior to the interview. Background screening was done by a private contractor for immediate screening. She was unaware if the company used by the facility was a State recognized entity. D. On 10/01/10 at 10:00 am, during interview, the Caregivers Criminal History Screening Program (CCHSP) manager stated that he did not recognize the entity that the facility used for pre-screening. He further s… | 2014-01-01 | ||
| 5676 | 5676 | SUNSHINE HAVEN AT LORDSBURG | 325121 | 603 HADECO | LORDSBURG | NM | 88045 | 2010-12-03 | 425 | E | FVBE11 | Based on observation and interview, the facility failed to label medications correctly and dispose of expired medications. These improperly labeled medications and expired medications were stored with medications available for current use in the facility. The facility failed to remove expired medications from 3 of 3 medication storage locations. This deficient practice had the potential to affect 41 residents receiving medications. The findings are: A. A review of the medication room cabinets for halls 100 and 200 on 11/30/10 at 2:43 pm, revealed the following: 1. Two Purified Protein Derivative (PPD) Aplisol 10 test vials opened and not dated. B. On 11/30/10 at 2:43 pm, during interview, Licensed Practical Nurse (LPN) #2 verified the medications were not dated when opened. C. A review of medication cart 300 on 11/30/10 at 2:50 pm revealed the following: 1. Four bottles of lactulose 473 fluid ounces opened and not dated. 2. One bottle of phenytoin 8 fluid ounces opened and not dated. 3. One bottle of chlorhexidine gluconate 473 fluid ounces opened not dated. 4. One bottle of polyethylene glycol 527 ounces powder opened not dated. D. On 11/30/10 at 2:50 pm, during an interview, LPN #2 verified the medications had not been dated when opened. E. A review of the medication cart for 200 hall and 100 hall on 11/30/10 at 3:05 pm revealed the following: 1. One bottle of pink bismuth 8 fluid ounces opened but not dated. 2. One bottle of docusate sodium liquid 16 fluid ounces opened in cart with an expiration date of 10/10. 3. One bottle of Liquid tears 15 milliliters opened but not dated. 4. One bottle of Vitamin C 500 bottle of 100 tablets opened but not dated. F. On 11/30/10 at 3:05 pm, Registered Nurse (RN) #1 verified the medication was opened and not dated as well as the expired medication. G. On 12/01/10 at 12:05 pm, during review of the cart for 100 and 200 halls revealed the following: 1. One bottle of Aspirin 325 mg with 100 pill bottle opened and not dated. 2. One bottle of Aspirin 81 mg with 23 pill bottle open… | 2014-02-01 | ||
| 5675 | 5675 | SUNSHINE HAVEN AT LORDSBURG | 325121 | 603 HADECO | LORDSBURG | NM | 88045 | 2010-12-03 | 463 | E | FVBE11 | Based on observation, interview and record review, the facility failed to ensure that the call light cords in the residents' rooms were functioning for 2 of 40 sampled residents (#30 and 34). This deficient practice had the potential to impact 41 residents in the facility. The findings are: A. On 12/01/10 at 3:38 pm, the call light in the Room 101 for Resident #30 was observed to not function. B. On 12/01/10 at 4:40 pm, the call light in the Room 204 for Resident #34 was observed to not function. C. On 12/02/10 at 8:49 am, during an interview, Licensed Practical Nurse (LPN) #2 stated, "I put requests for repair in writing and give (sic) it to the Maintenance Manager. He has an office so I either hand it to him or give it to the front office and they give it to him. The Maintenance Manager will come and tell us that the call lights are repaired. The CNAs (Certified Nurses Aides) will tell me that the call lights are broken or the resident tells me. Unless a CNA or resident tells me I would not know a call light is broken." D. On 12/02/10 at 09:00 am, during an interview, the Director of Nursing (DON) stated, "I would know a call light is broken when a resident tells us that the call light is broken. Then we would put a request in to get the Maintenance Manager to fix it. Nursing does not do any routine check of the call lights to see if they are working. If there is a request, nursing puts it on the board for the Maintenance Manager." E. On 12/02/10 at 9:56 am, during an interview, the Maintenance Manager stated, "I look at the panel to see if the call lights are working. By passing by the hallway I look to see if the call light is on. There is a system in place for the Managers to see that the call lights are sufficient in length. We are to complete a Daily Department Head Rounds Form. All managers are supposed to do the check. Yes, the DON would be one of the Managers to do the check of the call lights. It is random. We turn in a sheet every morning regarding our Manager duties. There is not a system in place to… | 2014-02-01 | ||
| 5674 | 5674 | SUNSHINE HAVEN AT LORDSBURG | 325121 | 603 HADECO | LORDSBURG | NM | 88045 | 2010-12-03 | 221 | B | FVBE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, the facility failed to ensure the resident's medical symptom was identified on the physician's order and the restraint consent form for one of one sampled resident with restraints (#6). This deficient practice had the potential to affect one residents in the facility placed in physical restraints. The findings are: A. Review of the monthly Physician's Orders recapitulation for November 2010 had a treatment that read, "Apply T-belt (a pelvic belt restraint) while up in wheelchair (sic), per POA (Power of Attorney) request for safety concerns." B. Review of the resident's Monthly Nursing Summary between May 2010 and November 2010 revealed the following reasons for the restraint: 1. "family request" 2. "res (resident) safety" 3. "fall risk/ family request" 4. "family request. resident gets up and fall (sic)" C. Review of the Physical Restraint Consent dated 01/02/08 and signed by the POA read as the reason for the restraint as, "Safety." D. On 12/02/10 at 11:00 am, during an interview, the Director of Nurses stated that she did not know that facility needed the medical symptom related to medical [DIAGNOSES REDACTED]. She confirmed that these were not currently on the order or the consent for the restraint. | 2014-02-01 | ||
| 5673 | 5673 | VILLAGE AT NORTHRISE (THE) - DESERT WILLOW I | 325111 | 2884 NORTH ROAD RUNNER PARKWAY | LAS CRUCES | NM | 88011 | 2010-10-21 | 225 | D | 49QP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report to the central intake for Health Facility and Licensing and Certification Bureau (HFLC) an allegation that a Certified Nursing Assistant (CNA) struck a resident in the back of the head with a hair brush for 1 of 6 sampled residents (#2). The facility failed to provide proof that a thorough investigation of this allegation was conducted and that findings of the investigation were reported within five days of the occurrence. This deficient practice had the potential to affect twenty residents and/or their representatives who seek to have a thorough investigation conducted by the facility on the allegation of abuse. The findings are: A. Review of the Admission Minimum (MDS) data set [DATE], revealed in Section B4, "Cognitive Skills," a "1," which indicated modified independence. B. Review of the Nursing Assessment Re-admitted d 08/12/10, revealed under Section 5, Cognition, the finding "Memory Ok," and for Decision Making, the finding "Independent - consistent/reasonable." C. Review of a Interdisciplinary Progress Note dated 10/09/10, revealed the resident was discharged home on that date. D. On 10/19/10 at 9:25 am, during an interview, Resident #2's daughter stated that on 10/03/10, her mother called her on the telephone and said a CNA smacked her on the back of the head with a hair brush, when they were showering her. E. Review of the facility's Grievance QA (Quality Assurance) Log from August 2010 through October 2010 revealed no documentation of an alleged report of abuse for Resident #2. F. Review of the facility's Risk Management System Event Tracking Log from August 2010 through October 2010 revealed no incident related to Resident #2's allegation of abuse. G. Review of Interdisciplinary Progress Notes dated on 10/04/10 at 2:30 pm revealed, "Late entry. Patient yelled out on Sunday (indecipherable) in the morning while waiting at the scales to get weighed. Said someone ha… | 2014-02-01 | ||
| 5672 | 5672 | CASA DEL SOL CENTER | 325108 | 2905 EAST MISSOURI | LAS CRUCES | NM | 88011 | 2010-11-12 | 226 | E | KZUG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to seek a caregiver criminal history screening within 20 days of hire for 2 of 5 sampled employees (#20 and #21). This deficient practice had the potential to affect 55 residents by failing to prevent the hire of caregivers legally barred from employment in a nursing facility. The findings are: A. Review of the personnel file of Certified Nursing Assistant (CNA) #20 revealed a Personnel Action Form dated 09/21/10 documenting the employee as a hire as of that date. Review further revealed a check request form for payment of the caregiver criminal history screening fee, signed by the facility administrator on 11/5/10. This was 45 days after the date CNA #20 was hired. B. Review of the personnel file of CNA #21 revealed a Personnel Action Form dated 09/22/10 documenting the employee as a hire as of that date. Review further revealed a check request form for payment of the background screening fee, signed by the facility administrator on 10/27/10. This was 35 days after CNA #21 was hired. C. On 11/12/10 at 11:20 am, during an interview, the facility Human Resources director described their process by stating, "We have to get a check from corporate. We have to submit a check request to have them send a check for CCHSP (Caregiver Criminal History Screening Program). It costs $65 to get fingerprints cleared." D. On 11/12/10 at 12:05 pm, during an interview, when asked about the deadline for submitting a fingerprint request after hire, the facility Administrator stated, "It has to be done within 20 days." When asked to describe the process, the Administrator stated, "Somebody comes in and applies for work. We interview them to see if they're a good candidate for the job. ...After they're hired, we do their fingerprints and submit them into the state within 20 days. ...We have to submit a request to pay ... because you have to attach a check to pay for the fingerprint process. (Name of the Busi… | 2014-02-01 | ||
| 5671 | 5671 | TAOS LIVING CENTER | 325105 | 1340 MAESTAS ROAD | TAOS | NM | 87571 | 2010-10-27 | 248 | D | QZEW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to develop and implement an activity program to meet the needs for two of eight sampled residents (#1 and 4). This deficient practice had the potential to affect 94 residents in the facility. The findings are: A. Review of the information face sheet dated 06/22/10 for Resident #1 revealed a [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE], Section I. diseases: indicated Resident #1 also had a [MEDICAL CONDITION] disorder, history of [MEDICAL CONDITION] with [MEDICAL CONDITION]/[MEDICAL CONDITION]. B. Record review of the care plan dated 09/22/10 revealed the Social Isolation section, the goals included for the resident to "participate in at least two activities per week for the next 90 days." Approaches included "post activity calendar in room, assist resident with selecting appropriate activities, provide resident with verbal reminders of upcoming activities, offer verbal praise to reinforce positive social behavior in group activities settings, if resident unable to tolerate group activities setting, provide one-to-one visits and individualized activities program, until resident can resume participation in group activities settings and document resident response to interventions." C. During observation, throughout the survey, from 09/20/10 through 09/24/10 between the hours of 8:00 am and 5:00 pm, Resident #1 was observed sitting in his room, in his wheelchair facing the wall. D. On 09/22/10 at 3:05 pm, during an interview, the Activities Director stated they do one-on-one activities with the resident because he often refuses to participate. An Activity Participation Record was produced with a date of 08/01/10 and September (no date). The 08/01/10 documentation revealed that from 08/02/10 through 08/21/10 no one-on-one activities were offered or documented. For the month of September, only September 9 was check marked for one-on-on… | 2014-02-01 | ||
| 5670 | 5670 | TAOS LIVING CENTER | 325105 | 1340 MAESTAS ROAD | TAOS | NM | 87571 | 2010-10-27 | 502 | D | QZEW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to obtain a urinalysis and results for two of eight sampled residents (#2 and 4). The facility also failed to obtain a [MEDICATION NAME] level (for [MEDICAL CONDITION]) for one of eights sampled residents (#1). These deficient practices had the potential to affect all 94 residents who may require laboratory tests and subsequent results for treatment. The findings are: A. Review of the face sheet dated 06/22/10 for Resident #1 revealed a [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE], section I. diseases: indicated Resident #1 also had a [MEDICAL CONDITION] disorder, history of [MEDICAL CONDITION] with [MEDICAL CONDITION]/[MEDICAL CONDITION]. B. Review of the Physician orders [REDACTED].#1 was ordered to have a [MEDICATION NAME] level taken (to ensure levels were therapeutic in the prevention of [MEDICAL CONDITION]) every December and June. No lab results were found in the chart for June 2010. C. On 10/27/10 at 2:40 pm, during an interview, Nurse #5 confirmed she could not find the results. She then called the hospital to get the results. After calling, she indicated that the [MEDICATION NAME] level had not been completed as ordered. D. On 10/27/10 at 2:55 pm, during an interview, the Pharmacist stated that he ensured that the labs were put of the Medication Administration Record. He indicated this process began in "either in August or September 2010." He then reported that other labs were drawn but confirmed that the [MEDICATION NAME] level was missed. E. Review of the face sheet dated 09/15/10 for Resident #2 revealed a [DIAGNOSES REDACTED]. 1. Review of Resident #2's chart revealed a "Dr. Visit/Consultant Visit" dated 09/15/10 at 8:15 am, with an order to obtain a urinalysis (U/A) and urine culture. 2. Review of the chart revealed no results for the urinalysis and there was no documentation in the nurses notes indicating if it had been compl… | 2014-02-01 | ||
| 5669 | 5669 | TAOS LIVING CENTER | 325105 | 1340 MAESTAS ROAD | TAOS | NM | 87571 | 2010-10-27 | 225 | G | QZEW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to report and investigate all allegations of abuse, neglect, exploitation, and injuries of unknown origin to the state survey agency for two of eight sampled residents (#2 and 5). This deficient practice had the potential to affect 94 residents receiving care and services at the facility. The findings are: A. Review of the face sheet dated 09/15/10 for Resident #2 revealed a [DIAGNOSES REDACTED]. 1. Review of the Quarterly Minimum Dated Set (MDS) assessment dated [DATE] indicated in section B. Cognitive Decision Making was intact (no long term or short term memory loss and able to make decisions independently). Section G1b. Indicated the resident required limited assistance of one for transfers. 2. Review of the Nurses notes dated 07/17/10 at 9:10 pm read, "(Name of Resident's son) stated that his mother had told him that she had been assisted by male CNA (Certified Nursing Assistant) #8 to restroom and that he had been rude to resident and hurried her along, therefore causing her back to hurt." 3. Review of the History & Physical (H&P) dated 07/18/10 revealed Resident #2 went to the emergency room (ER) after complaining of back pain. On the H&P, revealed that Resident #2 stated the following, "The aide #8 that assisted her was extremely rough and was hurting her." Patient stated she requested him to stop and he did not, so she cried out at which point he just left her. Patient had to get in her wheelchair and go to the desk for help. After she was assisted she called her son who came to the (Name of facility) and requested to speak to the aide and was declined so he called police." B. Review of the facility's Incident Log from July 2010 through September 2010 revealed no incident report for Resident #2. Review of the medical record for Resident #2 revealed an H&P dated 07/18/10 that indicated the resident had complained of rough treatment by a male CNA #8 at the nursing home where she… | 2014-02-01 | ||
| 5668 | 5668 | TAOS LIVING CENTER | 325105 | 1340 MAESTAS ROAD | TAOS | NM | 87571 | 2010-10-27 | 325 | D | QZEW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure an avoidable weight loss was prevented for one of eight sampled residents (#8). The facility also failed to implement corrective action when the Resident #8 began losing weight. This deficient practice had the potential to affect 56 residents who required nutritional assistance from the facility. The findings are: A. Review of the facility weight log for 2010 indicated the following weights for Resident #8: 1. March 2010 weight log - 122 pounds 2. May 2010 weight log - 121 pounds 3. June 2010 weight log - 120 pounds 4. July 2010 weight log - 116 pounds 5. August 2010 weight log - 112.8 pounds 6. September 2010 weight log - 109 pounds This weight log indicated Resident #8 had a significant, 13 pound weight loss in a six month period. This was 10 percent of the Resident's weight. B. Review of the care plan conference summary dated 08/04/10 indicated the following [DIAGNOSES REDACTED]. 1. Review of Resident #8's admission sheet dated 10/04/07 indicated the same diagnoses. There was no documentation in the medical record indicating a condition, disease, or [DIAGNOSES REDACTED]. 2. Review of the nutritional progress notes for Resident #8 indicated the last documented entry was dated 02/24/10 by the registered dietician. There was no documentation indicating Resident #8 was losing weight or suggestions to improve his nutritional status. C. Review of Resident #8's last quarterly minimum data set (MDS) assessment dated [DATE] indicated the resident had not lost weight when the weight log indicated the resident had lost five pounds from the May 2010 assessment time frame. D. Review of the care plan conference summary dated 08/04/10 indicated Resident #8 was not a "weight loss" when the weight log indicated the resident had lost nine pounds from March 2010 to August 2010. E. On 10/26/10 at 3:30 pm, during an interview, the Director of Dietary Services stated she had begun working at th… | 2014-02-01 | ||
| 5667 | 5667 | TAOS LIVING CENTER | 325105 | 1340 MAESTAS ROAD | TAOS | NM | 87571 | 2010-10-27 | 323 | K | QZEW11 | The facility failed to provide adequate supervision for 1 of 8 sampled resident's (Resident #5) who resided at the facility by leaving harmful chemicals unlocked and unsecured in resident areas with access. Resident #5 swallowed a toxic lemon cleaner left in the room unsecured on 07/02/10 which resulted in her having to be transported to the emergency room . During Administrative Review at the Health Facility Licensing and Certification Bureau and in conjunction with consultation with the Centers for Medicare and Medicaid Services, it was determined that an Immediate Jeopardy situation had occurred. The Administrator was notified of the Immediate Jeopardy on 09/21/10 at 7:50 pm. The facility took corrective action by providing an acceptable plan of removal on 09/21/10 at 10:30 pm. This resulted in the scope and severity of the deficiency being lowered to Level 3, Scope H. The plan of removal included the following items: 1. The Director of Maintenance and the Director of Nursing (DON) will ensure that each housekeeping cart is locked into their respective janitorial closets with bottles or containers of harmful products are locked. The Director of Maintenance along with available nursing staff will also perform rounds of the entire facility this evening to ensure that no extraneous bottles or containers of harmful products are located in any other accessible areas. 2. The Director of Maintenance and the DON will re-train current and future staff on the procedures for handling and storing harmful products to ensure that residents remain free from accidental ingestion. 3. The Director of maintenance will install self-locking door locks that lock when staff leave the storage areas. The director of maintenance will also ensure that the locking mechanisms of the housekeeping carts will be repaired. 4. Maintenance/life safety rounds will closely monitor all storage areas to ensure that they are consistently locked, the housekeeping carts when they are in use throughout the facility, the common areas listed including th… | 2014-02-01 | ||
| 5666 | 5666 | TAOS LIVING CENTER | 325105 | 1340 MAESTAS ROAD | TAOS | NM | 87571 | 2010-10-27 | 280 | E | QZEW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to follow the resident's comprehensive plan of care to maintain the resident's highest practicable physical, mental and psychosocial well-being for one of eight sampled resident's (Resident #1). This deficient practice had the potential to affect 94 residents residing in the facility. The findings are: A. Review of the face sheet dated 06/22/10 revealed a [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] under section I. for diseases, indicated Resident #1 also had a [MEDICAL CONDITION] disorder, history of [MEDICAL CONDITION] with [MEDICAL CONDITION]/[MEDICAL CONDITION]. B. Review of the Care Plan last updated on 06/23/10 indicated the following information: 1. For alteration in the resident's cognitive status, the approaches included: "16. Introduce self when communicating or caring for res (resident). 18. Call light in reach. 19. Answer call light promptly." The handwritten approaches included: "20. Tell (Name of resident) what you are going to do before you do it. 21. Talk in front of (Name of resident) not behind him." 2. For alteration in the resident's vision, the handwritten approaches included: "Tell (Name of resident) where things are located so that he may maintain as much as independence as possible." 3. For alteration in Activities of Daily Living, the approaches included: "15. Keep res (resident) clean & dry. 19. Dress in clean clothes daily." 4. For alteration in elimination, the goals included: "Res will be kept clean, dry & odor free this quarter. The approaches included: 3. Assure good personal hygiene." The handwritten approaches included: "Make sure call light, water pitcher, etc is to (Name of resident's) right." 5. For alteration in nutrition, the handwritten approaches included: "12. Tell (Name of resident) what is on his plate and where it is located using the clock system. 14. Maintain dignity while (Name of r… | 2014-02-01 | ||
| 5665 | 5665 | TAOS LIVING CENTER | 325105 | 1340 MAESTAS ROAD | TAOS | NM | 87571 | 2010-10-27 | 252 | E | QZEW11 | Based on observation and interview the facility failed to provide a clean and comfortable homelike environment for 4 of 8 sampled residents (#1, 2, 6 and 7) and one Random Resident (#1). This deficient practice had the potential to affect 94 resident's residing at the facility. The findings are: A. On 09/20/10 at 2:10 pm, during the initial tour of the facility a strong urine smell was noted on the 300, 400 and 600 hallways. Resident #1, 2, 6 and 7 rooms were noted to have a very strong urine smell during observation, throughout the survey week, from 09/20/10 to 09/24/10, between the hours of 8:00 am and 5:00 pm. B. On 09/21/10 at 5:00 pm, during an interview, Certified Nursing Assistant (CNA) #4 stated, "The smell just doesn't go away, there's another room on the 100 hall that is always like that as well." C. On 09/22/10 at 11:30 am, during an interview, CNA #6 stated, "It smells liked urine all the time. Maybe it's because (Name of Random Resident #1) has a catheter and (Name of Resident #7) is incontinent." D. On 09/20/10 at 2:30 pm, during the initial tour of the facility, Resident #1's room was noted to have bare walls and had no personal effects in his room.. E. On 09/22/10 at 12:05 pm, during an interview, the Director of Nursing stated, "I'm in total agreement that the resident's room needs to be more homelike. Activities could do something." F. On 09/24/10 at 1:30 pm, during an interview, the social worker stated the resident was blind and did not want anything in his room. She also acknowledged she had not documented the resident's preferences. G. On 09/24/10 at 2:00 pm, during an interview, Resident #1 stated he did not mind having pictures put up in his room. | 2014-02-01 | ||
| 5664 | 5664 | TAOS LIVING CENTER | 325105 | 1340 MAESTAS ROAD | TAOS | NM | 87571 | 2010-10-27 | 241 | D | QZEW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to provide appropriate care and services for 1 of 8 sampled residents (#1) to maintain the resident's dignity. This deficient practice had the potential to affect 94 residents who resided at the facility. The findings are: A. Review of the face sheet dated 06/22/10 revealed a [DIAGNOSES REDACTED]. B. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE], Section B. Cognitive Pattern indicated that the resident did not have long term or short term memory problems and had modified independence in daily decision making. Section G. Physical Functioning and Structural Problems indicated the resident required total assist of one person with dressing and personal hygiene. The resident also required limited assist of one for eating. C. Review of the Care Plan last updated on 06/23/10 indicated the following information: 1. For alteration in the resident's cognitive status, the approaches included: "16. Introduce self when communicating or caring for res (resident). 18. Call light in reach. 19. Answer call light promptly." The handwritten approaches included: "20. Tell (Name of resident) what you are going to do before you do it. 21. Talk in front of (Name of resident) not behind him." 2. For alteration in the resident's vision, the handwritten approaches included: "Tell (Name of resident) where things are located so that he may maintain as much as independence as possible." 3. For alteration in Activities of Daily Living (ADLs), the approaches included: "15. Keep res (resident) clean & dry. 19. Dress in clean clothes daily." 4. For alteration in elimination, the goals included: "Res will be kept clean, dry & odor free this quarter. The approaches included: 3. Assure good personal hygiene." The handwritten approaches included: "Make sure call light, water pitcher, etc is to (Name of resident's) right." 4. For alteration in nutrition, the handwritten approaches included… | 2014-02-01 | ||
| 5663 | 5663 | CARLSBAD MEDICAL CENTER - TCU | 325101 | 2430 WEST PIERCE STREET | CARLSBAD | NM | 88220 | 2010-12-16 | 279 | D | KU6411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to have individualized Comprehensive Care Plans for 2 of 7 sampled patients (#89 and 90) by not care planning for indwelling Foley catheters to drain urine from the bladder. This deficient practice had the potential to affect 2 patients who had Foley catheters by not providing interventions needed for the care of the catheters which had the potential to lead to urinary tract infections. The findings are: A. On 12/13/10 at 3:15 pm, observation of Resident #90 revealed she had an indwelling urinary Foley catheter (a catheter in the bladder) and it remained in place throughout the survey. B. On 12/14/10 at 9:08 am, observation of Resident #89 revealed she had a Foley catheter and it remained in place throughout the survey. C. Record review for Resident #89 with an admission date of [DATE] revealed there were no interventions documented on the Initial Care Plan dated 12/11/10 for the care of the indwelling Foley catheter to include when to clean the catheter, how to position the catheter, or other interventions used for catheter care. The section for "Problem 2" revealed, "(Name of facility) standards of care; Outcome: Optimize and maintain previous bladder continence. Maintain integrity and comfort if incontinent. Intervention: Provide bladder training." D. Record review for Resident #90 with an admission date of [DATE] revealed on the Initial Care Plan dated 11/30/10 there were no problems, interventions, or goals listed about the care for the indwelling Foley catheter for a [DIAGNOSES REDACTED]. Maintain integrity and comfort if incontinent. Intervention: Provide bladder training." E. On 12/16/10 at 10:40 am, an interview was conducted with the Administrator. When asked if the Initial Care Plan should address the Foley catheters for Resident #89 and 90, she stated, "It should be on the Care Plan. The nurses generate the care plan and the computer just prints out a generic o… | 2014-02-01 | ||
| 5662 | 5662 | RATON NURSING AND REHAB CENTER | 325084 | 1660 HOSPITAL DRIVE | RATON | NM | 87740 | 2010-11-09 | 431 | D | Y77F11 | Based on observation, record review and interview the facility failed to ensure safe storage and accurate reconciliation of controlled substances in one of two medication rooms. The findings are: A. On 11/03/10 at 2:45 pm, during observation, two vials of Lorazepam injectable syringes were located in the refrigerator of the north wing medication room. The syringes were in a clear plastic container with a lock tag attached which had the seal broken. B. Record review of the narcotic reconciliation binder located on the north wing nursing station revealed no reconciliation for the Lorazepam injectable syringes. C. On 11/03/10 at 2:45 pm, during an interview, the Director of Nursing Services (DNS) confirmed that the seal on the lock tag was broken for the Lorazepam injectable syringes. The DNS also confirmed that the facility was not accountable for the Lorazepam injectable syringes due to their lack of reconciliation. | 2014-02-01 | ||
| 5661 | 5661 | RATON NURSING AND REHAB CENTER | 325084 | 1660 HOSPITAL DRIVE | RATON | NM | 87740 | 2010-11-09 | 315 | D | Y77F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide medical justification for a urinary catheter for one of two sampled residents (#9). This deficient practice had the potential to affect three residents (CMS-672) with an indwelling or external catheter. The findings are: A. Record review of Resident #9's medical record revealed the following information: 1. History and Physical dated 02/09/08 revealed a past history of "Suprapubic (SP) catheter for unknown reason." 2. Physician admission orders Suprapubic catheter - change every month." No [DIAGNOSES REDACTED]. 3. Physician admission orders [REDACTED]. 4. Minimum Data Set (MDS) assessment dated [DATE] revealed, "Indwelling catheter, SP." 5. MDS assessment dated [DATE] revealed under section AC1.n that the resident, "Has had catheter for a long time." 6. The medical record did not contain documentation when the catheter was initially inserted or the reason for the catheter. B. On 11/04/10 at 5:00 PM, during an interview, Registered Nurse (RN) #1 stated, "I do not know what [DIAGNOSES REDACTED]. I looked in her chart and couldn't find a [DIAGNOSES REDACTED]." | 2014-02-01 | ||
| 5660 | 5660 | RATON NURSING AND REHAB CENTER | 325084 | 1660 HOSPITAL DRIVE | RATON | NM | 87740 | 2010-11-09 | 225 | D | Y77F11 | Based on record review and interview, the facility failed to report a possible injury of unknown source for 1 of 3 sampled residents (#27). This deficient practice had the potential to affect 55 (CMS-672) residents that could present with a possible injury of unknown source. The findings are: A. Record review of the "Investigative Finding and Summary" dated 05/10/10 revealed "Resident in Dementia unit and unable to tell us what happened. Resident had not been reported to anyone as having fallen. Spoke with CNA (Certified Nursing Assistant #1) who stated that his hand had started swelling the day before and she reported it to the nurse. The nurse (Registered Nurse # 4) did state it was reported to her and she filled out an incident report because she did not know how it happened. Today his hand is swollen red and tender to the touch." B. On 11/09/10 at 9:22 am, during an interview, the State Health Facility Licensing and Certification Complaints Intake Staff verified that this incident should have been reported to the State Agency. C. On 11/09/10 at 3:00 pm, during an interview, the Director of Nursing Services stated, "I did not think I needed to report this incident." | 2014-02-01 | ||
| 5659 | 5659 | RATON NURSING AND REHAB CENTER | 325084 | 1660 HOSPITAL DRIVE | RATON | NM | 87740 | 2010-10-07 | 221 | D | CCIN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to ensure justification for the use of physical restraints (2 full side rails) for 1 of 9 sampled residents (#5). The facility failed to provide adequate assessments and reassessments of medical necessity for restraints as evidenced by incomplete or lack of physician's orders [REDACTED]. These deficient practices had the potential to impact 6 residents identified as having restraints. The findings are: A. On 10/05/10, review of the face sheet dated 01/06/10 for Resident #5 indicated the resident had a [DIAGNOSES REDACTED]. Review of the Nurses Notes dated 09/22/10 read, "Review falls committee, no falls since 06/15/10. Discharge from fall committee..." The Minimum Data Set (MDS) assessment dated [DATE], under section B2 revealed the resident had short term memory problem and B4 indicated the resident had modified independence for daily decision making. Section C4 and C5 revealed the resident was able to make herself understood and understood others. Review of the medical record revealed no order, no consent form, no assessment and no care plan for the use of side rails. B. On 10/04/10 at 2:30 pm, 10/05/10 at 1:50 pm and 10/06/10 at 10:20 am, during observations, the resident was noted to be in bed with 2 full side rails up. C. On 10/6/10 at 10:20 am, during an interview, Resident #5 stated she "did not like the side rails, but she was not given a choice." She indicated she would like 1/2 side rails. She also indicated she knew how to use her call bell for help to the bathroom and did not get up unassisted. D. On 10/06/10 at 1:50 pm, during an interview, Nurse #1 stated Resident #5 "has side rails because she gets up and she's a fall risk. The resident had a fall when she first came in." The nurse looked through the chart and confirmed the last time Resident #5 fell was in June 2010 and she did not see an order for [REDACTED]. E. On 10/06/10 at 1:52 pm, during an interview… | 2014-02-01 | ||
| 5658 | 5658 | RATON NURSING AND REHAB CENTER | 325084 | 1660 HOSPITAL DRIVE | RATON | NM | 87740 | 2010-10-07 | 279 | D | CCIN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews the facility failed to follow the care plan for 1 of 9 sampled residents (#6) who had two full side rails and required padding on the side rails to prevent injury. This deficient practice had the potential to affect 54 residents in the facility who had a care plan that needed to be followed. The findings are: A. On 10/05/10, review of the physician's orders [REDACTED]. B. On 10/05/10, review of the care plan updated on 09/23/10 revealed Resident #6 had 2 side rails due to [MEDICAL CONDITION] and the approaches included "6) padded SR (side rails)" which was hand written. C. Throughout the survey, from 10/04/10 until 10/07/10 between the hours of 8:00 am and 5:30 pm, during observation Resident #6's side rails were noted not to be padded. D. On 10/06/10 at 2:20 pm, during an interview with the Minimum Data Set coordinator confirmed that the resident did not have padded side rails, although he was care planned for them. | 2014-02-01 | ||
| 5657 | 5657 | RATON NURSING AND REHAB CENTER | 325084 | 1660 HOSPITAL DRIVE | RATON | NM | 87740 | 2010-10-07 | 278 | D | CCIN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to accurately assess the conditions of 2 of 9 sampled residents (#7 and #8) in their Minimum Data Set (MDS) Assessments. This deficient practice had the potential to affect 54 residents in the facility who received Minimum Data Set evaluations. The findings are: A. On 10/06/10, review of Resident #7's Nursing Notes indicated the resident had a fall on 07/25/10 and was "found on the floor next to bed." B. On 10/06/10, review of Resident #7's Nursing Notes dated 07/29/10 indicated the resident's Foley catheter (a tube inserted into the urethra for urine drainage) was patent (in the right place). The Nursing Notes dated 08/08/10 indicated the "Foley cath (catheter) noted on floor (the Foley catheter was no longer in place)." C. On 10/06/10, review of the Annual MDS assessment dated [DATE] with a reference date of 08/08/10 (look back period from 08/02/10 through 08/08/10) revealed section J4 (accidents) a. (fall in last 30 days) was not marked. Section H3 (appliances and programs) d. (indwelling catheter) was not marked. D. On 10/06/10 at 3:00 pm, during an interview, the MDS Coordinator confirmed that the fall and Foley catheter had not been marked on the Annual MDS. E. On 10/04/10, review of Resident #8's Nursing Notes dated 07/01/10 "reviewed by wound committee stage II left gluteal, measures 0.6 cm x 0.6 cm." The Nursing Notes dated 07/08/10 "reviewed by wound committee stage II decub to left gluteal measures 0.6 x 0.5 cm." The Nursing Notes dated 07/14/10 "reviewed by wound committee stage II decub to left gluteal measures 0.6 x 0.5 cm." The Nursing Notes dated 07/23/10 "reviewed by wound committee stage II decub to left gluteal measures 0.6 x 0.2 cm." F. On 10/06/10, review of the Annual MDS assessment dated [DATE] with an assessment reference date of 08/08/10 (look back period from 08/02/10 through 08/08/10) revealed that under section M1. (Ulcers (due to any cause) and… | 2014-02-01 | ||
| 5656 | 5656 | RATON NURSING AND REHAB CENTER | 325084 | 1660 HOSPITAL DRIVE | RATON | NM | 87740 | 2010-10-07 | 202 | D | CCIN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to complete a discharge summary for 2 of 9 sampled residents (#1 and #3). This deficient practice had the ability to affect 54 resident's who may be discharged or transferred to another facility. The findings are: A. On [DATE] at 2:00 pm, review of the medical record for Resident #1 indicated the resident deceased on [DATE]. Review of the discharge summary was blank. 1. On [DATE] at 2:35 pm, during an interview with the Director of Nursing, she stated she could not locate the discharge summary. 2. On [DATE] at 4:30 pm, during interview with the Administrator and the Minimum Data Set (MDS) coordinator confirmed that the discharge summary could not be located. B. On [DATE] at 2:00 pm, review of the medical record for Resident #3 indicated the resident was discharged to the hospital on [DATE]. Review of the discharge summary revealed it was incomplete. C. On [DATE] at 4:30 pm, during an interview, the Administrator stated that Social Services usually initiated the form but he did not know why it was not completed. He confirmed the discharge summary was not complete. | 2014-02-01 | ||
| 5655 | 5655 | SOUTH VALLEY CARE CENTER, LLC | 325083 | 1629 BOWE LANE SW | ALBUQUERQUE | NM | 87105 | 2010-10-21 | 309 | G | 2WC611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility neglected to protect 1 of 6 sampled residents (#1) from being inappropriately fondled and touched sexually by another resident (#2) with a known history of exhibiting sexual behaviors towards female residents. This deficient practice had the potential to directly affect 26 female residents in the facility. The findings are: A. On Monday 10/18/10, State Central Intake received a allegation that a resident identified as Resident #2 was witnessed at 5:30 am on 10/17/10 pulling down the pants of a female resident, Resident #1 and touching her private parts. According to an Incident Report, dated 10/18/10, it indicated a witness (identified as Resident #3) saw Resident #2 pull down Resident #1's pants and was touching her private parts. Resident #2 was taken into police custody and Resident #1 was taken for a sexual assault examination. B. On 10/20/10 at 4:00 am, during observation Resident #1 was wandering around the facility by herself and crying. At this time, the resident was identified as not being interviewable when spoken to. She was the only female resident to be up and wandering around the facility at this time. Three male residents were also up and wandering the facility at this time. C. On 10/20/10 at 6:00 am, 6:20 am, 6:40 am, 7:35 am, 8:00 am, 10:00 am, 12:00 pm, 2:00 pm, Resident #1 was observed wandering around the facility by herself. D. On 10/20/10 at 4:25 am, during an interview, Certified Nursing Assistant (CNA) #3 stated that when this incident occurred on the early morning of 10/17/10, Resident #1 "was already up walking around the building beginning around 3:30 am." CNA #3 also stated, "We were aware of other incidents involving (name of Resident #1) in the past." E. On 10/20/10 at 4:30 am, during an interview, Licensed Practical Nurse (LPN) #2 stated that on the early morning of 10/17/10 she was passing medications and heard Resident #3 yelling down the North hal… | 2014-02-01 | ||
| 5654 | 5654 | SOUTH VALLEY CARE CENTER, LLC | 325083 | 1629 BOWE LANE SW | ALBUQUERQUE | NM | 87105 | 2010-10-21 | 226 | D | 2WC611 | Based on record review and interview, the facility failed to implement and develop a policy outlining the seven components of abuse and neglect to include procedures for protecting residents against sexual abuse and neglect. This failure resulted in 1 of 6 sampled residents (#1) being inappropriately fondled and touched sexually by another resident (#2) with a known history of exhibiting sexual behaviors towards female residents. The findings are: A. Review of the facilities Abuse Prevention Program, dated 2001, and revised August 2006, revealed "Residents have the right to be free from abuse, neglect..." The Policy further indicated, "Comprehensive policies and procedures have been developed to aid the facility in preventing abuse and neglect." Upon request, the Director of Nursing (DON) was not able to provide a more comprehensive policy and procedure outlining the seven components of abuse and neglect. B. On 10/20/10 at 11:45 am, during interview, the DON stated, "All we have is a generic policy we use." | 2014-02-01 | ||
| 5653 | 5653 | SOUTH VALLEY CARE CENTER, LLC | 325083 | 1629 BOWE LANE SW | ALBUQUERQUE | NM | 87105 | 2010-10-21 | 224 | G | 2WC611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility neglected to protect 1 of 6 sampled residents (#1) from being inappropriately fondled and touched sexually by another resident (identified as Resident #2) with a known history of exhibiting sexual behaviors towards female residents. This deficient practice had the potential to affect 26 female residents in the facility. The findings are: A. On Monday 10/18/10, State Central Intake received a allegation that a resident identified as Resident #2 was witnessed at 5:30 am on 10/17/10 pulling down the pants of a female resident, Resident #1 and touching her private parts. According to an Incident Report, dated 10/18/10, it indicated a witness (identified as Resident #3) saw Resident #2 pull down Resident #1's pants and was touching her private parts. Resident #2 was taken into police custody and Resident #1 was taken for a sexual assault examination. B. On 10/20/10 at 4:00 am, during observation Resident #1 was wandering around the facility by herself and crying. At this time, the resident was identified as not being interviewable when spoken to. She was the only female resident to be up and wandering around the facility at this time. Three male residents were also up and wandering the facility at this time. C. On 10/20/10 at 6:00 am, 6:20 am, 6:40 am, 7:35 am, 8:00 am, 10:00 am, 12:00 pm, 2:00 pm, Resident #1 was observed wandering around the facility by herself. D. On 10/20/10 at 4:25 am, during an interview, Certified Nursing Assistant (CNA) #3 stated that when this incident occurred on the early morning of 10/17/10, Resident #1 "was already up walking around the building beginning around 3:30 am." CNA #3 also stated, "We (staff) were aware of other incidents involving (name of Resident #1) in the past." E. On 10/20/10 at 4:30 am, during an interview, Licensed Practical Nurse (LPN) #2 stated that on the early morning of 10/17/10 she was passing medications and heard Resident #3 yell… | 2014-02-01 | ||
| 5652 | 5652 | HOBBS HEALTH CARE CENTER | 325040 | 5715 NORTH LOVINGTON HIGHWAY | HOBBS | NM | 88240 | 2011-01-28 | 226 | E | 9D4X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to implement their abuse investigation policy by not investigating an injury of unknown origin immediately when the injury was reported to administrative staff for 1 (#20) of 24 residents. The facility also failed to implement their abuse reporting policy by not reporting to the State Agency for 8 days an injury of unknown source for Resident #20. The findings are: A. Observation of Resident #20 on 01/25/11 at 9:25 am, revealed the resident sitting on the floor in the hallway outside her room, picking at the floor. When she looked up, there were yellow/green discolorations under both eyes. B. Record review of the Interdisciplinary Progress Notes (IPN) dated 01/16/11 at 1:00 pm revealed, "CNA (Certified Nurse Aide) noticed resident had Rt (right) eyebrow and eye lid bruise with eyebrow swollen." 1. IPN dated 01/16/11 at 7:45 pm revealed, "hematoma noted to R (right) eye, [MEDICAL CONDITION] noted." 2. IPN dated 01/17/11 at 10:15 am revealed, "Bruising to R eye lid dark purple bruising to L (left) eye lid and below lower lid. Yellow/green bruise noted to upper R eyebrow." 3. IPN dated 01/18/11 at 6:00 pm revealed, "Both eye lids are purple..." 4. IPN dated 01/23/11 at 7:20 pm revealed, "Bruises to bil (bilateral) eyes noted, light yellow in color bruises noted to forehead." C. Review of the physician progress notes [REDACTED]." D. Review of the Incident Report dated 01/24/11 revealed, "Nurse notified by CNA this resident was on the floor which she is often and she had a bruise on her right eye brow and it was swollen. Unknown origin, nobody witnessed any falls or incidents." The report identified the incident occurred on 01/16/11 at 12:40 pm, and was reported to the State Agency on 01/24/11 at 5:31 pm, 8 days after the bruising occurred. E. The policy provided by the facility, revision date 10/2010, titled "What You Need To Know" Abuse Prohibition, revealed on page 2. under t… | 2014-02-01 | ||
| 5651 | 5651 | HOBBS HEALTH CARE CENTER | 325040 | 5715 NORTH LOVINGTON HIGHWAY | HOBBS | NM | 88240 | 2011-01-28 | 225 | E | 9D4X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to self-report an injury of unknown origin to the State Agency Hotline for 8 days for 1 (#20) of 24 residents. The facility also failed to investigate an injury of unknown origin to identify the source of an injury for Resident #20. The initial investigation began 8 days after the incident occurred. The findings are: A. Observation of Resident #20 on 01/25/11 at 9:25 am, revealed the resident was sitting on the floor in the hallway outside her room, picking at the floor. When she looked up, there were yellow/green discolorations under both eyes. B. Record review of the Interdisciplinary Progress Notes (IPN) dated 01/16/11 at 1:00 pm revealed, "CNA (Certified Nurse Aide) noticed resident had Rt (right) eyebrow and eye lid bruise with eyebrow swollen." 1. IPN dated 01/16/11 at 7:45 pm revealed, "hematoma noted to R (right) eye, [MEDICAL CONDITION] noted." 2. IPN dated 01/17/11 at 10:15 am revealed, "Bruising to R eye lid dark purple bruising to L (left) eye lid and below lower lid. Yellow/green bruise noted to upper R eyebrow." 3. IPN dated 01/18/11 at 6:00 pm revealed, "Both eye lids are purple ..." 4. IPN dated 01/23/11 at 7:20 pm revealed, "Bruises to bil (bilateral) eyes noted, light yellow in color bruises noted to forehead." C. Review of the physician progress notes [REDACTED]." D. Review of the Incident Report dated 01/24/11 revealed, "Nurse notified by CNA this resident was on the floor which she is often and she had a bruise on her right eye brow and it was swollen. Unknown origin, nobody witnessed any falls or incidents." The report identified the incident occurred on 01/16/11 at 12:40 pm and was reported to the State Agency on 01/24/11 at 5:31 pm, 8 days after the bruising had occurred. E. The policy provided by the facility, revision date 10/2010, titled "What You Need To Know" Abuse Prohibition, revealed on page 2. under the policy section, "3. The facility's Le… | 2014-02-01 | ||
| 5650 | 5650 | LANDSUN HOMES, INC. | 325080 | 1900 WESTRIDGE ROAD | CARLSBAD | NM | 88220 | 2010-11-12 | 309 | D | S2O311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to adequately monitor 1 of 1 sampled residents (#77) on [MEDICAL TREATMENT], after returning from [MEDICAL TREATMENT]. This had the potential for a severe drop in blood pressure or bleeding from the access site which could result in adverse consequences for the patient. This deficient practice had the potential to affect future [MEDICAL TREATMENT] patients who may reside in the facility. The findings are: A. Record review of the facility policy titled [MEDICAL TREATMENT] Policy & Procedure dated 09/2009 revealed, "Upon return from [MEDICAL TREATMENT] center (name of facility) staff will: Monitor for s/sx (signs and symptoms) of orthostatic hypertension. Nurse to monitor and ensure pressure dressing to shut site is intact. Monitor for pain and treat per physician's orders. Monitor for any changes in resident's LOC (level of consciousness). Communicate any problems/concerns to [MEDICAL TREATMENT] center &/or physician. Document in nurses' notes." B. Record review for Resident #77, revealed that he was receiving [MEDICAL TREATMENT] treatments at the local [MEDICAL TREATMENT] center on Monday, Wednesday and Friday. Nurses Notes dated 11/08/10 and 11/10/10 revealed no documentation that his blood pressure or access site were monitored after he returned from [MEDICAL TREATMENT]. 1. Nurses Note dated 11/08/10 at 9:30 am, revealed, "Res. (resident) consumed 100% of am meal. Res. out of facility for routine [MEDICAL TREATMENT] appt (appointment). Res. offered no complaints prior to appt." 2. Nurses Note dated 11/10/10 at 9:30 am, revealed, "Res left facility via city transit for scheduled [MEDICAL TREATMENT] treatment. Snack provided for res. Res ate approx (approximately) 100% of breakfast." 3. On 11/11/10 at 3:30 pm, Licensed Practical Nurse #2 provided a document titled, Daily Vital Signs, dated 11/10/10 for Resident #77. The document revealed vital signs as "BP (blood pressure) 130/62, P (pu… | 2014-03-01 | ||
| 5649 | 5649 | LANDSUN HOMES, INC. | 325080 | 1900 WESTRIDGE ROAD | CARLSBAD | NM | 88220 | 2010-11-12 | 282 | D | S2O311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to implement the Care Plan by not monitoring 1 of 1 [MEDICAL TREATMENT] patients (#77) after the return from [MEDICAL TREATMENT]. This deficient practice had the potential to adversely affect the patient if there was: 1. a severe drop in blood pressure; or 2. bleeding from the access site, both which could result in adverse consequences for the patient. The findings are: A. Record review of Resident #77's Care Plan dated 01/05/10 and revised on 10/05/10 revealed, "10. Problem; Altered circulatory system R/T (related to) [MEDICAL CONDITION] (end stage [MEDICAL CONDITION]) and need for [MEDICAL TREATMENT] tx (treatment) 3 x (times) wk (week), [MEDICAL TREATMENT] shunt in left forearm, DX (diagnosis): [MEDICAL CONDITION] [MEDICAL CONDITION], DM (diabetes mellitus) type 2. Goals: [MEDICAL TREATMENT] shunt will be without complications by next review. Approaches; Monitor for bleeding and/or s/s (signs and symptoms) infection at needle insertion sight after [MEDICAL TREATMENT]: Redness, pain, [MEDICAL CONDITION]." 1. Record review for Resident #77, with an admission date of [DATE], revealed that he was receiving [MEDICAL TREATMENT] treatments at the local [MEDICAL TREATMENT] center on Monday, Wednesday and Friday. Nurses Notes dated 11/08/10 and 11/10/10 revealed no documentation that his blood pressure or access site were monitored after he returned from [MEDICAL TREATMENT]. 2. Nurses Note dated 11/08/10 at 9:30 am, revealed, "Res. (resident) consumed 100% of am meal. Res. out of facility for routine [MEDICAL TREATMENT] appt (appointment). Res. offered no complaints prior to appt." 3. Nurses Note dated 11/10/10 at 9:30 am, revealed, "Res left facility via city transit for scheduled [MEDICAL TREATMENT] treatment. Snack provided for res. Res ate approx (approximately) 100% of breakfast." 4. On 11/11/10 at 3:30 pm, Licensed Practical Nurse #2 provided a document titled, "Daily Vital Signs, date… | 2014-03-01 | ||
| 5648 | 5648 | LANDSUN HOMES, INC. | 325080 | 1900 WESTRIDGE ROAD | CARLSBAD | NM | 88220 | 2010-11-12 | 167 | C | S2O311 | Based on observation and interview the facility failed to post a notice for the availability and location of the most recent survey results. This had the potential to affect 93 current residents. The findings are: A. On 11/08/10 at 8:30 am, during observation, there was no posting of the survey results in the Manor section or the Main area of the facility. B. On 11/09/10 at 11:44 pm, an interview with the Resident Council President was conducted. When asked if he was aware of the survey results and where they were located, he stated that he did not know anything about the survey results. The Resident Council President resided in the Manor section of the facility. C. On 11/11/10 at 10: 55 pm, an interview was conducted with the Director of the facility. When asked where the notice of the survey results was located, she stated, "I don't have a sign." | 2014-03-01 | ||
| 5647 | 5647 | LANDSUN HOMES, INC. | 325080 | 1900 WESTRIDGE ROAD | CARLSBAD | NM | 88220 | 2010-11-12 | 166 | E | S2O311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to resolve complaints for 2 of 34 sampled residents (#46, 87 ). Resident #46 complained about a missing item. Resident # 87's Power of Attorney (POA) complained of the resident having abnormal movements. This deficient practice had the potential to affect all 93 residents in the facility if a complaint was not resolved. The findings are: A. On 11/08/10 at 2:20 pm, during an interview, Resident #46 and her husband Resident #39 both stated that a new white sweater with gold buttons and 2 pair of scissors were missing. Resident #46 stated that the nurse aids and nurses had been told, and staff had not found the missing items. 1. On 11/09/10 at 8:37 am, during an interview, Certified Nurse Assistant (CNA) #2 was asked about the missing sweater. She stated that it had been missing for a couple of weeks and they had checked individual's closets and the laundry, and had not found the sweater. She stated that the daughter took the scissors away because the resident had cut her hair. She stated that the nurse had the scissors, and the resident could use them anytime she wanted to. 2. On 11/10/10 at 11:45 am, during an interview, Registered Nurse (RN) #1 was asked about the missing white sweater. She stated that she did not know anything about the white sweater. 3. On 11/10/10 at 11:48 am, during an interview, Social Worker (SW) #1 was asked about the missing items. She stated that she did not know about a missing white sweater or the scissors. B. On 11/10/10 at 2:00 pm, during an interview, SW #1 provided Concern/Communication Forms dated 11/10/10. The forms revealed that the family had taken the sweater home thrown it away and had taken the scissors home. The forms were signed by Family Member (FM) #1. SW #1 stated that the family had taken the items. C. Review of the facility's policy undated titled, 'Policy and Procedure Regarding Complaints' revealed, "Definition of a complaint: a problem pr… | 2014-03-01 | ||
| 5646 | 5646 | LANDSUN HOMES, INC. | 325080 | 1900 WESTRIDGE ROAD | CARLSBAD | NM | 88220 | 2010-11-12 | 159 | B | S2O311 | Based on record review and interview, the facility failed to ensure 1 of 34 sampled residents (#5) that have personal funds managed by the facility have ready and reasonable access to those funds during non business office hours. This deficient practice had the potential to affect 44 residents, identified by the facility as having personal funds accounts. The findings are: A. On 11/09/10 at 9:16 am, Resident #5 was interviewed concerning a personal funds account with the facility. When Resident #5 was asked if they had a personal funds account with the facility, Resident #5 stated, "Yes." When asked if they had access to their money when needed, which included weekends, Resident #5 stated, "I don't know." B. On 11/11/10 at 9:45 am, an interview was conducted with the Director of Social Services (DSS) and the Director of Accounting Services (DAS). When asked if the residents can acquire their personal funds on off hours, such as the weekends, the DAS stated, "The residents can request to draw funds from the Business Office and are able to draw from the Business Office through Friday. When asked if there are provisions to get funds on the weekends the DAS stated, "No, we don't have any arrangements like that." C. Record review of the facility's policy titled, "Management of Residents' Personal Funds" (revised/reviewed 08/09) revealed, "...d. The resident may have the facility hold, safeguard, and manage his/her personal funds... 4. The resident may withdraw his/her request for the facility to manage his/her personal funds at any time by submitting a written notice to the Administrator." | 2014-03-01 | ||
| 5645 | 5645 | GOOD SAMARITAN SOCIETY - FOUR CORNERS VILLAGE | 325071 | 500 CARE LANE | AZTEC | NM | 87410 | 2010-12-08 | 431 | E | XCQ311 | Based on observation and interview, the facility failed to ensure that medications and supplies in stock past the manufacturer's recommended expiration date were not available for resident use by not removing 82 expired drugs and biologicals from 1 of 3 medication rooms. This deficient practice had the potential to affect all residents receiving medications. The findings are: A. On 12/03/10 at 10:53 am, observation of refrigerated medications for residents, located at Station B's medication room revealed 6 acetaminophen suppositories with a manufacturer expiration date of 10/10. B. On 12/06/10 at 3:30 pm, observation of Station B's medication/supply room revealed the following items: 1. 2 boxes of Glucerna 8, dietary supplement, with manufacturer expiration dates of 08/10 and 10/10. 2. 2 vials of dry concentrate Fortaz with an expiration date of 09/10. 3. 2 vials of potassium chloride with a manufacturer expiration date of 11/10. 4. 29 individual packaged angiocatheter's with an expiration date of 10/09. 5. 4 vials of sodium chloride with a manufacturer expiration date of 10/10. 6. 4 1000 milliliter bags of intravenous solution dextrose normal saline with a manufacturer expiration date of 10/10. 7. 1 1000 milliliter bags of intravenous solution dextrose with a manufacturer expiration date of 09/10. 8. 3 packages of toothette suction swabs with an expiration date of 07/10. 9. 29 Cepti- Seal IV start kits including gloves with an expiration date of 02/10. C. On 12/06/10 at 4:30 pm, during interview, the Minimum Data Set (MDS) Coordinator verified the manufacturer expiration dates on the medications and medical supplies as expired. She stated that the supplies should have been properly disposed of prior to expiration. | 2014-03-01 | ||
| 5644 | 5644 | VIDA ENCANTADA NURSING & REHAB | 325065 | 2301 COLLINS DRIVE | LAS VEGAS | NM | 87701 | 2010-11-19 | 241 | E | OEUD11 | Based on observation and interview the facility failed to provide privacy when providing pericare (incontinence care) to 3 of 6 sampled residents (#3, 5 and 6). This deficient practice had the ability to affect 75 residents who reside in the facility and may require care and privacy. The findings are: A. On 11/18/10 at 10:20 am, during observation, Resident #3 was having a treatment done to a stage II pressure ulcer on the buttocks by Licensed Practical Nurse (LPN) #1. LPN #1 left the room to get measuring items without covering the resident, leaving her buttocks exposed to the hallway where visitors, staff, and other residents may be present. B. On 11/18/10 at 4:10 pm, during observation, Resident #6 was receiving pericare and Foley Catheter care by Certified Nursing Assistant (CNA) #1 and 2. Both CNA #1 and 2 were observed giving care. CNA #1 and 2 failed to cover the resident or pull the privacy curtain while performing these duties. CNA #2 left the room to get more wipes and the resident was left exposed to the hallway, where visitors, staff and other residents may be present. C. On 11/18/10 at 4:30 pm, during observation, Resident #5 was receiving pericare by CNA #1 and 2. The privacy curtain was not drawn, which exposed the resident to the hallway where visitors, staff and other residents could possibly see. Resident #5 complained to the CNAs to hurry because she was afraid a man would come in. D. On 11/19/10 at 11:00 am, during interview, the Administrator and Director of Nursing stated the facility had received in-service training on privacy and dignity numerous times with the staff, "but they don't get it." | 2014-03-01 | ||
| 5643 | 5643 | MONTEBELLO ON ACADEMY (THE) | 325048 | 10500 ACADEMY ROAD NE | ALBUQUERQUE | NM | 87111 | 2010-11-10 | 279 | E | Y06J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure that care plans were completed with specific goals and objectives for discharge from the facility for 3 of 29 sampled residents (#101, 108 and 119). This deficient practice had the potential to effect 59 residents who could possibly be discharged . The findings are: A. During review of Resident #108's care plan dated 08/10 there was no care plan related to discharge potential. There was no problem or concern, no goal or approach indicating that the resident would be discharged from the facility within 30-90 days. 1. A form titled Discharge Plan/Discharge Plan Review dated 08/04/10 indicated an anticipated length of stay 30-90 days. The resident and resident representative reaction to discharge plan was to "D/C (discharge) to ALU (Assisted Living Unit) or LTC (Long Term Care)." 2. A physician telephone order dated 08/17/10 indicated, "Transfer pt (patient) to (facility) with meds (medications)." 3. Discharge Summary dated 08/20/10 indicated that the patient was discharged on [DATE] at 11:00 am to (Name of facility). Social Service Summary dated 08/17/10 indicated, "Rsd (Resident) was scheduled to D/C to SNF (Skilled Nursing Facility) on 08/19/10; however, (Name of facility) had a bed available 08/17/10. SS (Social Services set up transport & D/C order. Rsd A & O x 1-2 & has family support. Rsd needed medicaid cert (certified) facility." B. During review of Resident #101's care plan dated 08/10 there was no care plan related to discharge potential. There was no problem or concern, no goal or approach indicating that the resident would be discharged from the facility within 30-90 days. Review of the Plan of Care Conference Summary dated 8/10/10 indicated "D/C home if possible." C. Review of the 11/03/10 Social Services quarterly note revealed, "rsd will d/c on 11/11/10 from facility to an assisted living in Indiana to be closer to her niece, nephew, and elderly sister. Rsd's POA … | 2014-03-01 | ||
| 5642 | 5642 | SAGECREST NURSING AND REHABILITATION | 325039 | 2029 SAGECREST COURT | LAS CRUCES | NM | 88011 | 2010-11-19 | 463 | E | Y6RN11 | Based on observation and interview, the facility failed to maintain the nursing station call system in functioning order or instruct staff on alternate procedures when the audible element of the call system failed at both the North and South stations, with the result that 4 of 7 calls to the nursing stations went unnoticed by nursing staff at the nursing station. This deficient practice had the potential to affect 80 residents in the facility. The findings are: A. On 11/18/10 at 12:20 pm, during observation on the South hall, the call light over the door of room #158 illuminated. The call light indicator on the Nursing station panel illuminated; however, there was no audible alarm. Certified Medication Aide (CMA) #13 was at the nursing station but was unaware of the alarm. Her attention was on her nursing cart. Although CMA #13 was present, the light went unnoticed until 12:25 pm. B. On 11/18/10 at 12:25 pm, during an interview, when asked about the lack of an audible alarm, CMA #13 stated, "There must be something wrong with it. We've had problems with it before, and maintenance has had to order a part. It's an old building." C. On 11/18/10 at 12:40 pm, during an interview, when asked about the lack of an audible alarm, Certified Nursing Assistant (CNA) #20 stated, "We came back from our day off and we noticed it didn't ring anymore. That was Thursday - yesterday (11/17/10). It rang Monday." D. On 11/18/10 at 7:10 pm, observation on the North (skilled) hall revealed a call light on over the door of room #130, at the far end of the hall. Examination of the call light panel revealed that it was on with the room's light illuminated, but it emitted no sound. No staff were visible at the nursing station. No staff were in the room or in the hallway. Licensed Practical Nurse (LPN) #11 was the only staff visible at the far end of the opposite hall, in front of room #101. His attention was on his medication cart, and he appeared unaware of the call light. At 7:20 pm, the call light over the door of room #119 illuminated.… | 2014-03-01 | ||
| 5641 | 5641 | CASA REAL | 325038 | 1650 GALISTEO STREET | SANTA FE | NM | 87505 | 2010-11-16 | 225 | G | 8PRQ11 | Based on record review and interviews, the facility failed to investigate, immediately report and do a follow-up investigation for 1 of 6 sampled residents (#1) who sustained a dislocated hip (injury of unknown origin). This injury resulted in Resident #1 having to go to the emergency room (ER) for treatment. This deficient practice had the potential to affect 117 residents who resided at the facility. The findings are: A. On 11/16/10 at 9:45 am, during an interview, Resident #1's granddaughter stated that when she visited the resident on 07/10/10, she could hear her grandfather yelling as she walked down the hallway. When she entered his room she stated, "He was in bed and his left foot was turned out." She asked the staff if he had fallen and they told her no. She asked for her grandfather to be transported to the emergency room (ER) to be evaluated. She stated at the ER, hospital staff told her that Resident #1 had a dislocated hip and "it had to be popped back into place." B. On 11/16/10, review of Resident #1's chart revealed a nurse's note dated 07/10/10 at 2:30 pm. The note indicated, "Resident's son and granddaughter into visit with him. Per son 'he's C/O (complaining of) pain to his hip & it looks twisted.' Went to assess resident's L (left) leg/hip appears out of place. Touched leg/foot, resident states 'it hurts too much don't move it.'" The signature on the note belonged to Licensed Practical Nurse #1, who no longer works at the facility. C. On 11/16/10 at 1:10 pm, during an interview, the Director of Nursing (DON) stated, "I don't remember being told anything about this incident." D. On 11/16/10 at 2:05 pm, during an interview, the Administrator stated, "I'm the abuse coordinator for the building and this is a reportable incident but it was not reported to me." The Administrator confirmed that they failed to investigate, report, and do a follow-up investigation. E. On 11/16/10 at 3:05 pm, during an interview, Certified Nursing Assistant #1 stated, "The resident was on a low bed, had a tabs alarm with… | 2014-03-01 | ||
| 5640 | 5640 | RIO RANCHO CENTER | 325033 | 4210 SABANA GRANDE SE | RIO RANCHO | NM | 87124 | 2010-12-14 | 332 | E | ODHQ11 | **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 with less than a 5% error rate for 3 of 10 sampled residents (#83, 88 and 126). The error rate was 10.52% with 6 errors in 57 opportunities. Drugs or supplements that were administered 60 minutes earlier or later than the scheduled time of administration were counted as wrong time errors. Supplements that were not given in the amount ordered by the physician were counted as wrong dose errors. The findings are: A. On 12/09/10 at 6:47 pm, during evening medication pass observation, Registered Nurse (RN) #1 was observed administering the following medications to Resident #83: 1. Duo neb 0.5 percent [MEDICATION NAME] inhalation. 2. [MEDICATION NAME] 10 milligrams (mg) by mouth, 3. [MEDICATION NAME] 12.5 mg by mouth. 4. Mirtazepine 7.5 mg by mouth. B. During the medication reconciliation, review of the Physicians Recapitulation Order for Resident #83, dated December 2010, revealed the following information: 1. [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME] 0.5 inhalation four times a day everyday at 8:00 am, 12:00 pm, 4:00 pm and 8:00 pm. 2. [MEDICATION NAME] 10 mg by mouth everyday at 8:00 pm. 3. Mirtazepine 7.5 mg by mouth at 8:00 pm. 4. [MEDICATION NAME] 12.5 mg by mouth twice a day at 8:00 am and 4:00 pm. C. Review of the December 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. D. On 12/09/10 at 6:47 pm, during an interview, RN #1 stated, "The family likes us to give the medication to this resident (Resident #83) when they are still here." E. On 12/09/10 at 1:34 pm, during afternoon medication pass observation, RN #2 was observed administering medication to Resident #88. RN #2 administered an unspecified amount in blue cup by mouth of Medpass 2.0. The Medpass was not observed being measured. F. During medication reconciliation, review of the Physicians Telephone Order, dated 12/… | 2014-03-01 | ||
| 5639 | 5639 | TAOS RETIREMENT VILLAGE | 325122 | 414 CAMINO DE LA PLACITA #24 | TAOS | NM | 87571 | 2011-03-23 | 497 | E | EFEP11 | Based on record review and interview the facility failed to ensure that Certified Nursing Assistants (CNAs) were provided 12 hours of in-service training per year to include working with the cognitively impaired for 4 (#1, #2, #3 and #4) of 4 employees (#1, #2, #3 and #4). This deficient practice was likely to present a risk for harm to 14 residents listed on the CMS-802 provided by the administrator on 03/21/11 receiving direct care from these employees. The finding are: A. Review of employee files containing in-service training hours did not specify the hours for each in-service training. 1. CNA #1 with a hire date of 01/07/04 attended eight in-service trainings, which did not include working with the cognitively impaired. 2. CNA #2 with a hire date of 12/14/98 attended eight in-service trainings, which did not include working with the cognitively impaired. 3. CNA #3 with a hire date of 04/26/06 attended eight in-service trainings, which did not include working with the cognitively impaired. 4. CNA #4 with a hire date of 06/11/06 attended eight in-service trainings, which did not include working with the cognitively impaired. B. On 03/23/11 at 10:35 am, during an interview, the Administrator stated that there was no other record of in-service trainings. C. On 03/23/11 at 10:43 am, during an interview the Director of Nursing verified that the records reviewed were all the in-service trainings. She stated that she was unaware of the need to specify the hours completed and further stated that there was no previous record of in-service trainings and CNAs had no record themselves when asked. | 2014-04-01 | ||
| 5638 | 5638 | TAOS RETIREMENT VILLAGE | 325122 | 414 CAMINO DE LA PLACITA #24 | TAOS | NM | 87571 | 2011-03-23 | 441 | F | EFEP11 | Based on observation and interview, the facility failed to ensure that laundry was handled in a manner that prevented spread of infection. Laundry personnel transport soiled laundry through a clean linen room to get to the washing room. This deficient practice was likely to cause the of contamination to all 14 residents listed on the CMS-802 provided by the administrator on 03/21/11. The findings are: A. On 03/22/11 at 2:20 pm, observation of the facility's laundry room revealed that the door intended to provide proper airflow and separation of soiled and clean linens was not being used. In addition, there was another room that contained two standard washers and two standard dryers side by side with only one entrance/exit to the room. B. On 03/22/11 at 2:25 pm, during an interview with the Housekeeping Supervisor she explained the process she follows for laundry. The Housekeeping Supervisor stated and demonstrated that the soiled linens were in barrels and were brought in to the wash area through the room where clean clothes were handled. There the soiled laundry was sorted and facility linens were washed. The soiled personal clothing were carried to the room containing washers and dryers. There the personal laundry was sorted, washed, dried, folded and bagged all in the same area. She further stated that she had never used the door where the washers were located. She stated that she was unaware of the cross contamination of soiled and clean linen and the need for airflow. | 2014-04-01 | ||
| 5637 | 5637 | HEARTLAND CONTINUING CARE CENTER | 325114 | 1604 WEST 18TH STREET | PORTALES | NM | 88130 | 2011-01-05 | 282 | G | 2TVE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to implement the Resident's Care Plan for falls by not using a two-person transfer to help prevent falls for 1 of 6 sampled residents (#5). This failure to follow the care plan resulted in the resident having a fall with a fracture. This deficient practice had the to potential to affect the 13 other residents identified on the Roster/Sample Matrix provided by the facility on 01/03/11 who have had falls and/or fractures. The findings are: A. Record review of Resident #5's Care Plan dated 06/03/10 and revised 09/01/10 revealed, "Problems: Potential for falls related to history of falls at home, weakness, hx (history) [MEDICAL CONDITION] with right sided [MEDICAL CONDITION]. Goals: Resident will have no injury from falls over the next 90 days. Interventions: Transfers x 2 ( two-person) assist using gait belt. ...unable to ambulate as she did before d/t (due to) heaviness/weakness to (R) leg - dragging leg when walking." B. On 01/04/11 at 2:45 pm, Registered Nurse (RN) #1 was interviewed. When asked to describe what happened on 12/18/10 with Resident #5, she stated, "The CNA (Certified Nursing Assistant) came to get me and tell me she was in the bathroom with (Name of Resident #5) and when she was getting her from the toilet to the wheelchair, her legs got twisted as they often do. When I tried to turn her onto her back, she screamed with pain." When asked if Resident #5 needed assistance for transfers, RN #1 stated, "Yes, she needed a lot of help because of her bad leg and she would get one leg stuck behind the other one." When asked how many aides were supposed to transfer Resident #5, and was a gait belt used, RN #1 stated, "She was a two-person transfer and (Name of CNA #1) was the only one in with her. There was not a gait belt on her when I got in the bathroom." C. On 01/05/11 at 10:50 am, a phone interview was done with CNA #1. When asked to describe the fall incident with Resident … | 2014-04-01 | ||
| 5636 | 5636 | HEARTLAND CONTINUING CARE CENTER | 325114 | 1604 WEST 18TH STREET | PORTALES | NM | 88130 | 2011-01-05 | 323 | E | 2TVE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to prevent an avoidable fall for a resident by not providing a two-person assist for 1 of 6 sampled residents (#5). This failure resulted in Resident #5 falling and sustaining a fracture of the right femur. This deficient practice had the potential to affect 13 residents identified on the Roster/Sample Matrix provided by the facility on 01/03/11 who have had falls and/or fractures. The findings are: A. Record review of Resident #5's Care Plan dated 06/03/10 and revised 09/01/10 revealed, "Problems: Potential for falls related to history of falls at home, weakness, hx (history)of CVA (Cerebral Vascular Accident) with right sided [DIAGNOSES REDACTED]. Goals: Resident will have no injury from falls over the next 90 days. Interventions: Transfers x 2 (two-person) assist using gait belt." 1. Review of Resident #5's Nurse's Notes dated 12/18/10 at 8:30 am revealed, "(Name of Certified Nurse Aide (CNA) #1) came to tell me that res (resident) had fallen in bathroom. Res was on R (right) side with head under sink and feet towards toilet. (Name of Registered Nurse (RN) #1 and CNA #1) eased her on to back. She (Resident #5) screamed and stated her knee was hurting..." 2. Review of Resident #5's X-ray report from the hospital dated 12/18/10 revealed, "Indications: Fall. Findings: Bones: Is a comminuted fracture of the distal femur near the junction middle and distal thirds. There is overriding of the comminuted fracture fragments." 3. Review of the facility "Incident Report" dated 12/20/10, revealed, "During the Incident... CNA lowered her to the floor. Res immediately complained of pain to R (right) knee. After the Incident: CNA did not follow plan of care. ...Res (resident) is a two person transfer." B. On 01/04/11 at 2:45 pm, Registered Nurse (RN) #1 was interviewed. When asked to describe what happened on 12/18/10 with Resident #5's fall, she stated, "The CNA came to get me and tell me she wa… | 2014-04-01 | ||
| 5635 | 5635 | HEARTLAND CONTINUING CARE CENTER | 325114 | 1604 WEST 18TH STREET | PORTALES | NM | 88130 | 2011-01-05 | 272 | D | 2TVE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to assess the resident after a fall prior to moving the resident. Staff moved the patient from the floor to a wheelchair without stabilizing the fracture to the right leg which had the potential to worsen the fracture. These deficient practices had the potential to affect 13 residents who have had falls as identified on the Roster/Sample Matrix form CMS 802 provided by the facility on 01/03/01. The findings are: A. Record review of the Policy and Procedure (not dated) for falls, provided by the facility revealed, "Falls, Observed and Unobserved. Policy: 2. If a resent (sic) is found on the floor, the nurse will assess them immediately before the resident is moved. 6. If the resident is acutely injured, the nurse will determine if the resident can be moved for treatment of [REDACTED]. 1. Record review of Resident #5's Nurse's Notes dated 12/18/10 at 8:30 am revealed, "(Name of Certified Nurse Aide (CNA) #1) came to tell me that res (resident) had fallen in bathroom. Res (Resident) was on R (right) side with head under sink and feet towards toilet. ...She (Resident #5) screamed and stated her knee was hurting... (Name of Registered Nurse (RN) #1 and CNA #1) eased her on to back. She screamed and stated her knee was hurting. ...After a couple of minutes, (Name of Licensed Practical Nurse (LPN) #1) came from south. The 3 of us assisted res to w/c (wheelchair) as best as we could. We brought res to nurse's station. ...I took residents vitals and checked res knee. ...I called the on-call physician... at around 0850 (8:50 am) or so. ...Ten minutes or so (Name of Physician) called back. Gave me an order to transfer. I called 911 for transfer the time was 9 am... EMT (Emergency Medical Technician) arrived about 0913 (9:13 am): ...they started IV (intravenous) and put res leg in brace." 2. Review of the "Prehospital Care Report" from the EMT dated 12/18/10 revealed, "Summary of Events: A: Upon a… | 2014-04-01 | ||
| 5634 | 5634 | COUNTRY COTTAGE CARE AND REHAB | 325112 | 2101 BENSING ROAD | HOBBS | NM | 88240 | 2010-12-01 | 226 | E | 525311 | Based on record review and interview the facility failed to follow their policies on abuse reporting. There was an allegation of verbal abuse for 3 of 5 sampled residents (#1, 2 and 3) on October 25, 2010. The facility failed to report the incident allegation and investigation results to the State Agency until November 23, 1010. This deficient practice had the potential to expose 30 additional residents to verbal abuse. The findings are: A. Record review of a hand written note by Licensed Practical Nurse (LPN) #1 dated 10/25/10 addressed to the Administrator and Director of Nurses (DON) revealed, "I was informed by 3 residents after this that she (Certified Nursing Assistant (CNA) #1) has been verbally abusive to them. They are (Name of Residents #1, #2 and #3). What if any action will be taken... 3 residents told me she was verbally abusive to them and (Name of Resident #3) said she was also rough with her when giving care..." B. Record review of a document titled 'Abuse allegation investigation' dated 11/05/10 sent to the corporate office revealed, "On 10/26/10 (Name of DON) interviewed (Names of Resident #1 and #3) regarding allegations made against (Name of CNA#1) by (Name of LPN #1). Both residents denied telling (Name of LPN #1) any allegations. (Name of DON) also spoke with (Name of CNA #1) who also denied the allegations. After speaking with you, I spoke with (Name of Resident #1) and asked him if there was any problems with any CNAs - he denied any problems except for sometimes they are slow when the call lights are used. When asked specifically about verbal abuse i.e. yelling he denied that anyone had done that." C. Record review of the Facility's policy 'Abuse Prevention Program (RM-20) Policy and Procedure' dated 5/2004 revealed, "It is the policy of (Name of Corporation) to affirm the right of our resident to be free from abuse, neglect... The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect, or abuse of our … | 2014-04-01 | ||
| 5633 | 5633 | COUNTRY COTTAGE CARE AND REHAB | 325112 | 2101 BENSING ROAD | HOBBS | NM | 88240 | 2010-12-01 | 225 | E | 525311 | Based on record review, and interview the facility failed to report to the State Agency an allegation of verbal abuse. The facility also failed to report the investigation results for 3 of 5 sampled residents (#1, 2 and 3) within the time frame required. This deficient practice had the potential to expose 30 additional residents to verbal abuse. The findings are: A. Record review of a hand written note by Licensed Practical Nurse (LPN) #1 dated 10/25/10 addressed to the Administrator and Director of Nurses (DON) revealed, "I was informed by 3 residents after this that she (Certified Nursing Assistant (CNA) #1) has been verbally abusive to them. They are (Name of Residents #1, #2, #3). What if any action will be taken... 3 residents told me she was verbally abusive to them and (Name of Resident #3) said she was also rough with her when giving care..." B. Record review of a document titled 'Abuse allegation investigation' dated 11/05/10 sent to the corporate office revealed, "On 10/26/10 (Name of DON) interviewed (Names of Resident #1 and #3) regarding allegations made against (Name of CNA #1) by (Name of LPN #1). Both residents denied telling (Name of LPN #1) any allegations. (Name of DON) also spoke with (Name of CNA #1) who also denied the allegations. After speaking with you, I spoke with (Name of Resident #1) and asked him if there was any problems with any CNAs - he denied any problems except for sometimes they are slow when the call lights are used. When asked specifically about verbal abuse i.e. yelling he denied that anyone had done that." C. On 11/30/10 at 10:00 am, the DON was asked about the allegations of abuse by LPN #1. She stated that LPN #1 had left a note under the Administrator's door that alleged the verbal abuse. She also stated that she interviewed the residents and they denied telling the nurse or saying that they had been abused. 1. On 12/01/10 at 2:00 pm, the Administrator was interviewed and asked when she had received the abuse allegations. She stated that there was a hand written note un… | 2014-04-01 | ||
| 5632 | 5632 | TAOS LIVING CENTER | 325105 | 1340 MAESTAS ROAD | TAOS | NM | 87571 | 2011-04-07 | 309 | J | DLHX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure that Resident #10 received the correct consistency of thickened liquids as ordered by the physician. This resulted in an Immediate Jeopardy (IJ) being identified on 03/28/11 at 1:00 pm. The Administrator was notified of the findings for the IJ on 03/28/11 at 6:50 pm. The facility took corrective action by providing an acceptable Plan of Removal on 03/28/11 at 7:35 pm. This resulted in the scope and severity of the deficiency being lowered to a Level 2, Scope D. The Plan of Removal included that for the remainder of the evening, all residents with physician orders [REDACTED]. The Plan of Removal also indicated that the Director of Nursing (DON), the Dietary Manager (DM) and the Director of Rehabilitation (DOR) along with the Speech Therapist (ST) will do the following: "Confirm that the current list of residents on thickened liquids is updated and accurate based on the current physicians orders. Begin re-training staff tonight (03/28/11) to include Registered Nurses (RNs), Licensed Practical Nurses (LPNs), Certified Nursing Assistant (CNAs), Restorative Nurse Aides and Activities staff on providing the appropriate liquid textures to those residents covering the 7:00 pm to 7:00 am licensed nursing shifts as well as the 2:00 pm to 10:00 pm and the 10:00 pm to 6:00 am CNA shifts. Ensure that thickened liquids are available to those residents who need them throughout the evening by providing pre-thickened liquids. All staff to be re-trained by 04/01/11 and prior to their next shift." Based on observation, interview and record review the facility failed to provide the correct consistency of thickened liquids necessary to maintain the highest practicable physical well-being for one (#10) of six (#1, #10, #25, #33, #49 and #101) residents who were at risk for aspiration. The findings are: A. On 03/28/11 at 12:45 pm, during observation, CNA #2 gave Resident #10 a large cup of water and added one and one half scoop of thic… | 2014-04-01 | ||
| 5631 | 5631 | TAOS LIVING CENTER | 325105 | 1340 MAESTAS ROAD | TAOS | NM | 87571 | 2011-04-07 | 425 | F | DLHX11 | Based on observation and interview the facility failed to ensure that expired medications and expired blood sample containers stored in both medication storage rooms were removed and disposed. This deficient practice presented a risk to all 97 residents residing in the facility, listed on the resident census list provided by the administrator on 03/28/11. The findings are: A. On 03/30/11 at 1:45 pm, observations of the medication storage room located on the Rose unit revealed the following items: 1. Four Vacutainers (container for blood samples) with an expiration date of 02/10. 2. One Vacutainers with an expiration date of 01/11. 3. 19 Vacutainers with an expiration date of 05/10. 4. Two (32 ounce) bottles of Buffered Eye-Lert (emergency eye and skin flush) with an expiration date of 02/11. B. On 03/30/11 at 2:00 pm observations of the medication storage room located on the Iris unit revealed the following: 1. Two Vacutainers with an expiration date of 02/10. 2. One Vacutainer with an expiration date of 01/11. 3. Seven Vacutainers with expiration date of 09/10. 4. Two (32 ounce) bottles of Buffered Eye-Lert with an expiration date of 02/11. C. On 03/30/11 at 2:15 pm, during interview, the Director of Nursing confirmed that the medications and blood sample containers were expired. | 2014-04-01 | ||
| 5630 | 5630 | TAOS LIVING CENTER | 325105 | 1340 MAESTAS ROAD | TAOS | NM | 87571 | 2011-04-07 | 497 | F | DLHX11 | Based on record review and interview the facility failed to ensure that Certified Nursing Assistants (CNAs) received a performance review at least once every 12 months for six (#4, 5, 6, 7, 8 and 9) of six (#4, 5, 6, 7, 8 and 9) CNAs. The finding are: A. Record review of the employee files for CNAs #4, 5, 6, 7, 8 and 9 revealed no performance reviews. B. On 04/07/11 at 11:23 am, during interview, the Director of Nursing stated she had not conducted performance evaluations for any of the CNAs. | 2014-04-01 | ||
| 5629 | 5629 | TAOS LIVING CENTER | 325105 | 1340 MAESTAS ROAD | TAOS | NM | 87571 | 2011-04-07 | 441 | F | DLHX11 | Based on observation, interview and record review the facility staff failed to follow proper hand hygiene during medication administration. This deficient practice presented a risk for the spread of infection to all 97 residents residing in the facility, listed on the resident census list provided by the administrator on 03/28/11. The findings are: A. On 03/30/11 at 4:00 pm, during observation and interview, Licensed Practical Nurse (LPN) #1 administered medications to Resident #123, Resident #128 and Resident #31. LPN #1 did not wash her hands or apply hand sanitizer before, after or between contact with residents. When asked why she did not use hand sanitizer, she stated "Sorry." B. On 03/31/11 at 8:45 am, during observation Registered Nurse (RN) #2 administered medications to Resident #106 and Resident #129. RN #2 did not wash his hands or apply hand sanitizer before or between contact with residents. RN #2 broke a pill in half with his bare hands, placed the pill back into the cup with the remaining pills and administered them to the resident. RN #2 then administered eye drops to Resident #106 touching the resident's face and eye lids with his bare hands and he did not wash or sanitize his hands prior to administering the eye drops. C. On 04/01/11 at 9:22 am, during observation LPN #2 administered medications to Resident #33 and Resident #41. LPN #2 did not wash or sanitize her hands before, during or after contact between the two residents. When asked why she did not use any sanitizer, she stated "I usually do." D. On 04/04/11 at 9:22 am, Certified Medication Assistant (CMA) administered medications to Resident #42, Resident #56 and Resident #112. CMA #1 did not wash her hands before, after or between residents. When asked why she did not sanitize her hands, she stated "Oh, I usually do." E. Record review of the facility's policy and procedure for handwashing/hand hygiene revised June 2010 noted, "When to use alcohol-based hand rub: a) before and after direct contact with residents, d) before preparing or ha… | 2014-04-01 | ||
| 5628 | 5628 | TAOS LIVING CENTER | 325105 | 1340 MAESTAS ROAD | TAOS | NM | 87571 | 2011-04-07 | 323 | J | DLHX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure that Resident #10 received the correct consistency of thickened liquids as ordered by the physician. This resulted in an Immediate Jeopardy (IJ) being identified on 03/28/11 at 1:00 pm. The Administrator was notified of the findings for the IJ on 03/28/11 at 6:50 pm. The facility took corrective action by providing an acceptable Plan of Removal on 03/28/11 at 7:35 pm. This resulted in the scope and severity of the deficiency being lowered to a Level 2, Scope D. The Plan of Removal included that for the remainder of the evening, all residents with physician orders [REDACTED]. The Plan of Removal also indicated that the Director of Nursing (DON), the Dietary Manager (DM) and the Director of Rehabilitation (DOR) along with the Speech Therapist (ST) will do the following: "Confirm that the current list of residents on thickened liquids is updated and accurate based on the current physicians orders. Begin re-training staff tonight to include Registered Nurses (RNs), Licensed Practical Nurses (LPNs), Certified Nursing Assistant (CNAs), Restorative Nurse Aides and Activities staff on providing the appropriate liquid textures to those residents covering the 7:00 pm to 7:00 am licensed nursing shifts as well as the 2:00 pm to 10:00 pm and the 10:00 pm to 6:00 am CNA shifts. Ensure that thickened liquids are available to those residents who need them throughout the evening by providing pre-thickened liquids. All staff to be re-trained by 04/01/11 and prior to their next shift." Based on observation, interview and record review the facility failed to provide supervision to ensure that the correct consistency of thickened liquids was given for one (#10) of six (#1, #10, #25, #33, #49 and #101) residents who were at risk for aspiration. This deficient practice is likely to cause a resident to choke. The findings are: A. On 03/28/11 at 12:45 pm, during observation, CNA #2 gave Resident #10 a large cup of water and added one an… | 2014-04-01 | ||
| 5627 | 5627 | TAOS LIVING CENTER | 325105 | 1340 MAESTAS ROAD | TAOS | NM | 87571 | 2011-04-07 | 166 | D | DLHX11 | Based on interview and record review, the facility failed to resolve a grievance related to a missing personal item for one (#111) of three (#4, #84 and #111) residents that reported an item missing. The findings are: A. On 03/30/11 at 10:18 am, during interview, Resident #111 stated that he reported $30.00 dollars and a money clip missing to Certified Nursing Assistant (CNA) #1. B. On 04/04/11 at 4:24 pm, during interview, the Social Services Director stated that they have not received missing property reports from staff or from Resident #111. C. On 04/06/11 at 10:00 am, during interview, CNA #1 stated that he did not recall Resident #111 reporting that his money or a money clip were missing. D. On 04/07/11 at 9:26 am, during interview, Resident #111 stated that he talked to CNA #1 several times about the missing money and money clip. Resident #111 also stated that he told one of the Social Workers (resident could not identify which one). E. On 04/07/11 at 10:00 am, during interview, Director of Nursing stated that she heard about Resident #111's "missing property issue but never followed-up on it." She also said that the Social Worker would be the one to handle that particular situation. F. Record review of the facility's policy and procedure "Investigating Incidents of Theft and/or Misappropriation of Resident Property" dated 12/05 noted "All reports of theft or misappropriation of resident property shall be promptly and thoroughly investigated." | 2014-04-01 | ||
| 5626 | 5626 | HEARTLAND CARE OF ARTESIA | 325082 | 1402 WEST GILCHRIST | ARTESIA | NM | 88210 | 2012-07-31 | 224 | K | 63B411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility neglected to provide the supervision, assessment, and interventions to protect 2 (#56, 59) of 2 (#56, 59) residents from neglect by not preventing elopement. This was evidenced by 1) Two elopements by Resident #56 with minor injuries without assessment prior to or after the elopement and 2) Multiple elopements of Resident #59. These failures could likely cause serious injury or death to residents with elopement behaviors. This was evidenced by: 1. Resident #59 (R #59) eloped from the facility on [DATE]. R #59 was found, by an activity worker, and walked back into the facility. R #59's face was flushed and sweating. On [DATE], R #59 was found in the parking lot of the business next door to the facility and returned to the facility. On [DATE], R #59 walked across the street and down the block, almost to a stop sign on a 4 lane street. Another resident told the staff they saw him there, and the staff brought him back to the facility. On [DATE] at 8:15 pm, staff was not able to locate R #59. Another resident's family member brought R #59 to the facility at 8:30 pm, face was flushed. On [DATE] at 4:15 pm, the charge nurse was unable to locate R #59. R #59 was found walking down a 4 lane busy street almost 1 mile from the facility. 2. Resident #56 (R #56) eloped from the facility on [DATE]. R #56 was found outside the facility, across 13th street (a 4 lane street) by a staff member. On [DATE], R #56 was seen walking out of the facility parking lot. When staff attempted to call her back, she began running faster. Staff called other staff for assistance and R #56 continued to run. The facility called 911 for the police, but facility staff were able to return her to the facility. Resident was taken by ambulance to the hospital with an abrasion noted to the bridge of the nose and a skin tear to the left hand. 3. The facility failed to assess the residents for elopement, failed to implement supervision … | 2014-04-01 | ||
| 5625 | 5625 | ST ANTHONY HEALTHCARE AND REHAB CENTER, L | 325076 | 1400 WEST 21ST STREET | CLOVIS | NM | 88101 | 2011-06-03 | 282 | D | ZR4X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to follow the physician's order for the correct dose of medication for 1 (#18) of 10 (#3, 10, 13, 15, 18, 27, 28, 36, 49 and 69) residents reviewed during medication pass observation. This deficient practice had the potential for the resident to receive too much calcium which could lead to the formation of hard deposits or calcifications in soft tissues of the body, blood vessels which can block the flow of blood. Calcifications can also lead to [MEDICAL CONDITION], lung disease and painful joints. The findings are: A. On 06/01/11 at 8:15 am, during medication pass observation, Resident #18 received Tums chewable 1000 milligrams (mg) from Licensed Practical Nurse #1. B. The Physician order dated 10/06/09 revealed, "Tums 500 mg 1 qid (4 times a day)." C. The Director of Nurses (DON) was interviewed on 06/02/11 at 2:35 pm. After reviewing the 10/06/09 physicians orders, she agreed that the physician order had not been followed. The medication cart was checked and the only bottles of Tums in the cart was 1000 mg. D. On 06/02/11 at 3:30 pm, an interview with the DON revealed that the only dose of Tums in the facility stock medications and medication carts were 1000 mg and 750 mg. The DON stated that she had sent the facility driver to the local pharmacy to get 500 mg of Tums. | 2014-04-01 | ||
| 5624 | 5624 | VIDA ENCANTADA NURSING & REHAB | 325065 | 2301 COLLINS DRIVE | LAS VEGAS | NM | 87701 | 2010-10-08 | 514 | D | NIV811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to document on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. This deficient practice had the potential to affect 20 residents (CMS-672) in the facility that were receiving respiratory treatment. The findings are: A. Record review of Resident #2's medical record revealed that the MARs for August, September and October 2010 did not have a medication listed to be given through the nebulizer. B. On 10/06/10 at 3:55 pm, during interview, LPN #1 stated, "The order was for [MEDICATION NAME] treatments." She confirmed that the order for the routine nebulizer twice a day (BID) was an incomplete order since it did not contain the name of the medication. She stated "I hand wrote [MEDICATION NAME] on the MAR indicated [REDACTED]." C. On 10/08/10 at 10:30 am, during interview, the Director of Nursing (DON) confirmed that the nurse did not transcribe the order properly on the MAR for October 2010. The DON stated, "She (nurse) should have yellowed out the entire order and written a new one with the name of the medication, dose, route, times and initialed it and dated it." Based on record review, observation and interview, the facility failed to document the effectiveness of pain medication for one of two sampled Hospice residents (#9). By failing to do this, the facility was unable to monitor that the resident was achieving his care plan goal of pain minimization. This deficient practice had the potential to affect two residents (CMS-672) receiving hospice. The findings are: A. Record review of the care plan dated 04/02/10 for Resident #9 revealed the goal of "Pain will be minimized." Staff were to administer pain medications as ordered and if not effective to notify the physician. B. On 10/07/10 at 9:45 am, during observation and interview, Resident #9 was observed with a grimace on face. Resident #9 was asked if he was having pain in his right arm. He sta… | 2014-04-01 | ||
| 5623 | 5623 | VIDA ENCANTADA NURSING & REHAB | 325065 | 2301 COLLINS DRIVE | LAS VEGAS | NM | 87701 | 2010-10-08 | 328 | D | NIV811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide the correct respiratory treatment for one of 10 sampled residents (#8). This deficient practice had the potential to affect 20 residents (CMS-672) receiving respiratory treatment. The findings are: A. Record review of Resident #2's medical record revealed a [DIAGNOSES REDACTED]. Review of the physician order dated 06/10/10 contained an order for [REDACTED]. Licensed Practical Nurse (LPN) #1 hand wrote "[MEDICATION NAME]" on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. B. On 10/06/10 at 3:55 pm, during an interview, Licensed Practical Nurse (LPN) #1 stated, "The order was for [MEDICATION NAME] treatments." She confirmed that the order for the routine nebulizer BID was an incomplete order since it did not contain the name of the medication. She stated "I hand wrote [MEDICATION NAME] on the MAR indicated [REDACTED]." LPN #1 confirmed that the medication cart did not contain any [MEDICATION NAME] solution and that the resident was being administered the wrong medication. C. On 10/06/10 at 4:00 pm, during an interview, Certified Medication Assistant (CMA) #1 stated that Resident #2 was being administered [MEDICATION NAME] 2.5mg/3cc solution through the nebulizer for his routine nebulizer BID. CMA #1 confirmed that the medication cart did not contain any [MEDICATION NAME] solution and that the resident was receiving the wrong medication. D. On 10/08/10 at 10:30 am, during an interview, the Director of Nursing (DON) confirmed that the nurse did not transcribe the order properly on the MAR for October 2010. The DON stated, "She (nurse) should have yellowed out the entire order and written a new one with the name of the medication, dose, route, times and initialed it and dated it." | 2014-04-01 | ||
| 5622 | 5622 | VIDA ENCANTADA NURSING & REHAB | 325065 | 2301 COLLINS DRIVE | LAS VEGAS | NM | 87701 | 2010-10-08 | 309 | G | NIV811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility failed to provide pain relief and assistive devices for comfort for one of two sampled residents (#9) on hospice services. This deficient practice had the potential to affect two residents (CMS-672) receiving hospice care. The findings are: A. Record review of May 2010 physicians orders for Resident #9 revealed the resident was admitted to hospice services on 05/13/10 with [DIAGNOSES REDACTED]. Review of the physician order [REDACTED]. B. Record review of the care plan dated 04/02/10 for Resident #9 revealed that staff were supposed to monitor Resident #9 for signs and symptoms of pain such as "facial grimacing, crying, etc." The care plan also instructed the staff to administer pain medications and if not effective to notify the physician. 1. On 09/30/10, the care plan was updated with instructions that Resident #9 was now on scheduled pain medication due to recent issues of pain. 2. The resident needed to wear a right hand splint while sitting in his wheelchair for comfort and to prevent further decline in status. The resident also needed to wear a right elbow protector to prevent skin breakdown. C. On 10/06/10 at 12:20 pm, during observation and interview, Resident #9 was observed sitting in his wheelchair with a grimace on his face. His right hand was contracted and laying on his lapboard. There was no splint to his right hand and no elbow protector to his right elbow. Resident #9 was asked if he was in pain. He nodded his head "yes" and pointed to his right arm. D. Record review of the October 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. E. On 10/07/10 at 9:45 am, during observation and interview, Resident #9 was observed in bed positioned on his right side. He had a grimace on face. Resident #9 was asked if he was having pain in his right arm. He stated "Yes" and began to cry. F. On 10/07/10 at 9:45 am, during interview, Register… | 2014-04-01 | ||
| 5621 | 5621 | VIDA ENCANTADA NURSING & REHAB | 325065 | 2301 COLLINS DRIVE | LAS VEGAS | NM | 87701 | 2010-10-08 | 156 | E | NIV811 | Based on interview and record review, the facility failed to provide 3 of 3 sampled residents (#2, #30 and #48) who were discharged from skilled nursing services within the last six months a notice of Medicare non-coverage and the reasons for the termination of specific Medicare services. Additionally, the facility failed to provide these residents with a notice of potential liability for payment for the non-covered services and an opportunity to request a demand bill. This deficient practice had the potential to affect 10 residents (CMS-672) who were receiving Skilled Nursing services. The findings are: A. On 10/06/10 at 10:52 am, during interview, the Social Services Director stated that she had never issued this type of notice. B. Record review of Residents #2, #30 and #48 revealed that the correct liability notice and beneficiary appeal rights were not issued to these residents. | 2014-04-01 | ||
| 5620 | 5620 | VIDA ENCANTADA NURSING & REHAB | 325065 | 2301 COLLINS DRIVE | LAS VEGAS | NM | 87701 | 2010-10-08 | 371 | F | NIV811 | Based on observation, interview and record review, the facility failed to ensure that nourishments for residents were labeled, dated and held below the "Danger Zone" (above 41 degrees Farenheit) temperature. This deficient practice had the potential to affect all 70 residents (CMS-672) in the facility that may be offered a snack from the nourishment refrigerator. The findings are: A. On 10/06/10 at 10:35 am, during observation, the "Resident Use Only" refrigerator on Wing A contained an open can of soda, half a candy bar and a bottle of Gatorade. The nourishments were not dated and were not labeled with a residents name. B. On 10/06/10 at 10:40 am, during an interview, the Dietary Manager confirmed that the nourishments were not dated or labeled. She stated "The resident snacks should be dated and labeled." C. On 10/07/10 at 9:22 am, during an interview, Certified Medication Assistant (CMA) #1 stated, "The refrigerators on Wing A and Wing B are for resident use only and all snacks for residents should be labeled and dated." D. On 10/07/10 at 9:00 am, during observation, the temperature of the refrigerator on Wing A was 42 degrees F. E. Record review of the temperature log for the refrigerator on Wing A revealed that the refrigerator temperatures ranged from 34 degrees to 38 degrees F. The log also indicated that temperatures that were not in these ranges were to be reported the supervisor. Between the dates of 08/20/10 and 10/07/10, there were 36 days where the temperature was in the Danger Zone. The temperatures ranged from 42 degrees F to 50 degrees F. F. On 10/07/10 at 9:22 am, during observation, the temperature of the refrigerator on Wing B was 51 degrees F. G. On 10/07/10 at 11:00 am, during observation, the temperature of the refrigerator on Wing B was 48 degrees F. H. Record review of the temperature log for the refrigerator on Wing B revealed that between the dates of 06/11/10 and 10/06/10, there were 16 days where the temperature was in the Danger Zone. The temperatures ranged from 42 degrees F to 48 de… | 2014-04-01 | ||
| 5619 | 5619 | PALOMA BLANCA HEALTH AND REHABILITATION | 325060 | 1509 UNIVERSITY BOULEVARD NE | ALBUQUERQUE | NM | 87102 | 2011-01-26 | 157 | E | 1PCJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure that the physician was informed of the inability to obtain a lab sample and the resident's refusal of medications for 1 of 34 sampled residents (#27). This deficient practice had the potential to effect the care of 99 residents (CMS 671) if the physician was not notified of significant changes in the resident's health status. The findings are: A. Review of Resident #27's medical record and interviews, revealed the following information in regards to the lab sample: 1. A Physicians Telephone Order, dated 12/10/10, directed the staff to monitor for signs and symptoms of a possible urinary tract infection. Staff were directed to obtain a urine sample for a urinalysis and to follow-up with culture and sensitivity if indicated. 2. There were no urinalysis lab results found in the medical record. 3. There was no documentation that the staff were unable to obtain a sample or that the physician was informed. 4. On 01/20/11 at 4:30 pm, during an Interview, the Corporate Nurse Consultant/ Regional Quality Specialist stated, "I can see here we may have a not been following physician orders. I don't see any lab results in here." 5. On 01/20/11 at 5:25 pm, during an interview, the Medical Records Director stated that she called the lab, they verified that there was never a urinalysis done and therefore they have no results. B. Review of Resident #27's medical record and interviews, revealed the following information in regards to the refused medication: 1. A Physicians Telephone Order, dated 10/03/10, indicated that the resident was to receive an increase of [MEDICATION NAME] 150 milliliters (ml) 3 times a day for hepatic [MEDICAL CONDITION]. 2. The November and December 2010, Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. 3. On 01/21/10 at 11:18 am, during an interview, the Director of Nursing, stated that in reviewing the MAR indicated [REDACTED]. T… | 2014-04-01 | ||
| 5618 | 5618 | GOOD SAMARITAN SOCIETY - GRANTS | 325058 | 840 LOBO CANYON ROAD | GRANTS | NM | 87020 | 2011-02-10 | 156 | E | O2M911 | Based on record review and interview the facility failed to ensure that residents were provided with the necessary information in order to make an informed decision about the end of their skilled services for 2 (#82 and #87) of 3 residents (#82, #87 and #96). The findings are: A. A review of Resident #82's "Notice of Medicare Provider Non-Coverage" dated 02/04/11 indicated that the effective date her coverage of current skilled nursing services would end was 02/06/11. There was no documentation indicating why the services were going to end. B. A review of Resident #87's "Notice of Medicare Provider Non-Coverage" dated 11/29/10 indicated that the effective date his coverage of current skilled nursing services would end was 12/02/10. There was no documentation indicating why the services were going to end. C. On 02/07/11 at 2:00 pm, during an interview, the Social Services Director verified the notices given to Residents #82 and #87. He then stated that he received the information with the reason why the resident was being discharged from physical therapy or whatever source that applies. He then gave the information to the resident or family and filled out the form. He further stated that he did not include why the residents were no longer receiving medicare services on the letter. | 2014-04-01 | ||
| 5617 | 5617 | CASA DE ORO CENTER | 325047 | 1005 LUJAN HILL ROAD | LAS CRUCES | NM | 88005 | 2011-01-13 | 371 | D | CNPK11 | Based on observation and interview, the facility failed to properly store, label and dispose of food items in a "snack" refrigerator located behind the Nurse's station at the end of the 300 Hall. This deficient practice had the potential to affect residents served from the refrigerator for the 300 and 400 Halls. The findings are: A. During observations on 01/17/11 at 9:30 am, the following items were found: 1. A bag of baby carrots opened and undated. 2. A sandwich undated. 3. A sandwich dated 01/11 (2011). 4. A pitcher with an orange kool-aid substance less than 1/2 full dated 01/11. 5. A half empty 32 fluid ounce container of Med Pass 2.0 dated 12/27 (2010). Instructions on the back of the carton read, "Use within 48 hours after opening." B. During an interview on 01/17/11 at 9:45 am, Registered Nurse #10 reported that the refrigerator should be examined every day and that food items should be cleaned out the following day, liquids every evening and she was unsure about the storage time for the Med Pass 2.0. When asked about the carrots, she stated, "I don't even know whose those are." C. During an interview at 9:50 am, Certified Medication Aid #53 (CMA #53) reported that the Med Pass 2.0 should be disposed of at the end of every shift." | 2014-04-01 | ||
| 5616 | 5616 | CASA DE ORO CENTER | 325047 | 1005 LUJAN HILL ROAD | LAS CRUCES | NM | 88005 | 2011-01-13 | 318 | E | CNPK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to prevent 1 (#120) of 39 residents sampled from having a decline in Activities of Daily Living (ADLs). Resident #120 was referred for restorative therapy services but did not receive those services and had declined. This deficient practice had the potential to affect 67 residents who require some assistance with ADLs and have the potential to decline without appropriate services and interventions. The findings are: A. On 01/11/11 at 12:16 pm, Resident #120 was observed in her room sitting in her wheelchair. She had a contracture of the left hand and her left leg was on a foot rest attached to the wheelchair. She stated that she had therapy, "A long time ago..." She reported she wanted to walk again and was emotional and crying when she stated, "They just don't seem to understand that." B. Review of the Admission Record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. 1. Review of an Annual History and Physical (H&P) dated 06/26/10 revealed, "stroke with left side paralysis." 2. Review of physician's orders [REDACTED]." Further review revealed a discharge order on 09/18/10, "D/C (discharge) skilled PT/OT serves due to: Maximum therapeutic benefit achieved at this time. Patient centered goals met. May participate in restorative nursing program as written per (name of the Registered Occupational Therapist (OTR))..." 3. Review of physician progress notes [REDACTED]." A subsequent entry on 12/30/10 revealed, "Bed and chair bound." 4. Review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #120 had modified independence for decision making and required extensive assistance with a one person physical assist for transfers and toilet use. Resident #120 had partial loss of voluntary movement on one side for the arm, hand, leg and foot. 5. Review of Interdisciplinary Progress Notes revealed the following information: a. On… | 2014-04-01 | ||
| 5615 | 5615 | CASA DE ORO CENTER | 325047 | 1005 LUJAN HILL ROAD | LAS CRUCES | NM | 88005 | 2011-01-13 | 282 | B | CNPK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to provide written proof room visits were being conducted for 1 (#3) of 3 sampled residents. Resident #3 was care planned to receive 3 to 4 room visits per week. This deficient practice had the potential to affect 16 other residents care planned for room visits. The findings are: A. Review of the Face sheet dated 09/27/10 revealed Resident #3 was admitted on [DATE], with [DIAGNOSES REDACTED]. 1. Review of the History and physical dated 05/2008, revealed [DIAGNOSES REDACTED]. 2. Review of a Physician Standing Order dated 12/23/10, revealed, "May participate in activity and general conditioning program as desired." 3. Review of the Care plan dated 03/24/10 with revision on 03/25/10, revealed, "(Resident #3's name) has chronic and progressive decline characterized by; deficit in memory, judgment, decision making and thought process related to mental illness; brain deterioration secondary to TBI ([MEDICAL CONDITION])... has room visit three to four times a week from activity." 4. Review of an Activity Progress Note dated 12/08/10, indicated, "Doesn't participate in activity we go and do 3 - 4 room visit per week. Activity will continue and put music to (sic) him to listen (sic) hard rock. We continue to provide a monthly calendar." 5. Review of a Recreation Quarterly Progress note dated 09/03/10, read, "Continue to stay in his room and listen to rock and roll music. He gets 3 - 4 room visits per week. Activity and staff will continue to monitor any change. We will continue to provide a monthly calendar." B. During observation on 01/06/11 at 10:15 am, the resident was asleep in his room with the door shut. 1. During observation on 01/06/11 at 1:15 pm, the resident was awake, alone, and lying in bed. 2. During observation on 01/06/11 at 3:02 pm, the resident was awake, alone, and in bed with the door shut. C. On 01/06/11 at 3:40 pm, during an interview, Licensed Practical Nurse (… | 2014-04-01 | ||
| 5614 | 5614 | CASA DE ORO CENTER | 325047 | 1005 LUJAN HILL ROAD | LAS CRUCES | NM | 88005 | 2011-01-13 | 279 | B | CNPK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a comprehensive plan of care addressing the need for support in activities for 1 (#159) of 3 cognitively impaired residents requiring assistance with activities. This failed practice had the potential to affect 69 residents identified by the facility with dementia or other cognitive impairment disorders. The findings are: A. Review of the 04/21/10 Admission Record for Resident #159 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. B. Review of the 03/31/10 Admission Nursing Assessment, for cognition, revealed that the resident suffered short-term and long-term memory problems and was oriented to person only. C. Review of the 04/13/10 initial Minimum Data Set assessment (version 2.0) for Resident #159 revealed that the resident was active morning, afternoon and evening, and active more than 2/3 of the time. D. Review of the 04/13/10 Resident Assessment Protocol (RAP) revealed that the resident had been assessed for a possible need for care planning. However, for, "proceed to care plan," the RAP documented, "no" and "r/t (related to) see above notes (activity notes identified in the previous question)." E. An Activities progress note dated 04/14/10 documented, "Will do 3-4 room visits and we will encourage to participate in activity." F. On 01/07/11 at 3:30 pm, during an interview, the facility Activity Director identified herself as the person who had completed the activity assessment. She stated that she had decided not to care plan the resident because the resident was participating in activities. When asked if the resident was confused, she stated, "Yes." When asked if the resident was capable of reviewing the activity calendar and choose his own activities, she stated, "That's why we'd go and get him. He doesn't read it. He is not able to say 'no, I don't want to go,' or 'yes I want to go.' We had to watch him because he would stand up and then he wo… | 2014-04-01 | ||
| 5613 | 5613 | CASA DE ORO CENTER | 325047 | 1005 LUJAN HILL ROAD | LAS CRUCES | NM | 88005 | 2011-01-13 | 252 | C | CNPK11 | Based on observation and interview, the facility failed to maintain a safe and homelike environment for six areas throughout the facility. This deficient practice had the potential to affect 142 residents live in the facility. Residents were identified on a resident census roster provided by the facility on 01/03/11. The findings are: A. An observations on 01/17/11 between 10:00 am and 2:30 pm revealed the following: 1. Room 406 had chipped and missing paint on the bathroom walls and holes in the bathroom walls from a former toilet paper dispenser and towel rack. 2. Room 407 and 409 shared a bathroom. Room 407's door was scratched with pieces of wood coming off the door at the handle level and was damaged on the inside of the door as well. 3. Room 411 and 413 shared a bathroom. There was a broken screen to the bathroom window. Dead bug carcasses were trapped between the bathroom window and the screen. 4. Room 412 and 414 shared a bathroom. The wall had water damage next to the sink and the paint was bubbled, stained, and coming off the wall in places. There was hair hanging off the overhead sprinkler. 5. Room 504 revealed a cork bulletin board mounted on the wall over the B-bed. The frame of the bulletin board was broken, with the bottom part of the frame dangling downward by one corner and the cork board fallen partially out of the frame. 6. Room 521 revealed a square cut hole in the drywall, 2" x 2", at eye level beside the door to the restroom. B. During an interview on 01/17/11 at 11:30 am, the Maintenance Director reported he did facility-wide checks every week. He reported he checked some resident rooms on a monthly basis but not all. When asked why there were so many rooms in need of repairs, he reported that he was only allotted an $800 budget per month and that there was not enough money and he can, "...only do so much." When asked how problems were brought to his attention, he stated there was a log at each Nurse's station that should be completed daily and submitted to him. The log was reviewed and dat… | 2014-04-01 | ||
| 5612 | 5612 | CASA DE ORO CENTER | 325047 | 1005 LUJAN HILL ROAD | LAS CRUCES | NM | 88005 | 2011-01-13 | 156 | C | CNPK11 | Based on observation and interview, the facility failed to maintain, in a public area, a posting of contact information for the State survey and certification agency. This failed practice had the potential to affect 142 of 142 facility residents by denying them the opportunity to present concerns to the State survey and certification agency. Residents were identified on a resident census roster provided by the facility on 01/03/11. The findings are: A. On 01/13/11 at 10:00 am, observation in the facility public areas revealed no posting of contact information for the State survey and certification agency. B. On 01/13/11 at 10:10 am, during interview, the facility Assistant Director of Social Services was asked to point out the facility's posting of contact information for the State survey and certification agency. C. On 01/13/11 at 11:30 am, during interview, the facility Assistant Director of Social Services reported that she could not find a posting of contact information for the State survey and certification agency. | 2014-04-01 | ||
| 5611 | 5611 | CASA DE ORO CENTER | 325047 | 1005 LUJAN HILL ROAD | LAS CRUCES | NM | 88005 | 2011-01-13 | 425 | D | CNPK11 | Based on observation and interview, the facility failed to ensure that medications available for resident use were not past the manufacturer's recommended expiration date. This deficient practice had the potential to affect 68 residents in the facility receiving medications from the West and East Medication rooms. The residents were identified on a census list provided by the facility on 01/03/11. This deficient practice presented a risk for residents to not receive the accurate potency of the medication dose ordered by the physician. The findings are: A. On 01/06/11 at 4:00 pm, during an observation of the facility's West Medication Room, 12 medication vials were found in a storage box in a refrigerator with dates that were past the manufacturer's recommended expiration dates. The observed items were: 1. Cefepime 1 Gm, 2 vials with the expiration date of May 2010. 2. Ampicillin 3 Gm, 3 vials with the expiration date of 02/2010. 3. Nafcillin 2 Gm, one vial with the expiration date of 11/2010. 4. Tobramycin 80 milligrams (mg)/(per) 2 ml, 6 vials with the expiration date of April 2010. B. On 01/06/11 at 4:30 pm, during an interview with the Director of Nursing (DON), the DON verified that all 12 vials given to her from the West Medication Room had dates which had expired. C. On 01/06/11 at 4:40 pm, during an observation on the facility's East Medication Room, 11 medication vials were found in a plastic storage box with dates on them past the manufacturer's recommended expiration dates. The observed items were: 1. 50% Dextrose 50 ml, 1 vial with an expiration date of September 2010, 2 vials with an expiration date of January 2010, and 4 vials with an expiration date of April 2010. 2. Bacteriostatic Sodium Chloride 30 ml, one vial with an expiration date of January 2009 and one vial with an expiration date of August 2010. 3. Geodon 20 mg/ml, 2 vials with an expiration date of 04/2010. D. On 01/06/11 at 4:50 pm, during an interview with the DON, she verified that all 11 vials given to her from the East Medication Room… | 2014-04-01 | ||
| 5610 | 5610 | CASA DE ORO CENTER | 325047 | 1005 LUJAN HILL ROAD | LAS CRUCES | NM | 88005 | 2011-01-13 | 332 | E | CNPK11 | **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 administered with an error rate of less than 5%. The medication administration error rate was 6% with 3 errors in 50 opportunities for Medication Pass Residents 3 (#164, 110 and 39) of 11 (#12, 24, 39,110,123, 135, 136, 137,144, 164, and 209) residents who received the wrong dose of medications during the medication pass observation. This deficient practice had the potential to affect all 142 residents in the facility who may receive the wrong medication dose. A wrong medication dose could lead to adverse reactions that could impact residents' health and safety. The residents were identified on a census list provided by the facility Administrator on 01/03/11. The findings are: A. On 01/06/11 at 7:00 am, during a medication pass observation, Certified Medication Assistant (CMA) #52 was observed to give Resident #164 [MEDICATION NAME] 10 GM/15 ML (10 grams/15 milliliters), 15 ML by mouth. 1. Record review of the 01/2011 Physician order [REDACTED]. 2. Record review of the 01/2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. B. On 01/05/11 at 7:10 am, during a medication pass observation, CMA #52 was observed to give Resident #110 [MEDICATION NAME] (10 GM/15 ML), 15 ML by mouth. 1. Record review of the 01/2011 Physician order [REDACTED]. 2. Record review of the 01/2011 MAR for Resident #110 revealed an order for [REDACTED]. C. On 01/05/11 at 07:15 am, during a medication pass observation, CMA #52 was observed to give Resident #39 [MEDICATION NAME] (10 Gm/15 ml) 15 ml by mouth. 1. Record review of the 01/2011 Physician order [REDACTED]. 2. Record review of the 01/2011 MAR for Resident #39 revealed an order for [REDACTED]. D. On 01/05/11 at 09:45 am, during an interview with CMA #52, she stated that she had given Residents #164, #110 and #39 the wrong dose of [MEDICATION NAME] 10 GM/15 ML during her morning… | 2014-04-01 | ||
| 5609 | 5609 | CASA REAL | 325038 | 1650 GALISTEO STREET | SANTA FE | NM | 87505 | 2010-12-21 | 279 | D | TWMK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to develop a Care Plan for the use of an antianxiety medication with potential side effects for 1 of 31 sampled residents (#108). This had the potential to affect 21 residents receiving antianxiety medications which could cause side-effects. The findings are: A. On 12/21/10 at 3:00 pm, review of the face sheet dated 11/23/10 revealed Resident #108 was re-admitted on [DATE]. Review of the physician's orders [REDACTED]. Review of the care plan dated 11/23/10 did not reveal documentation for the use of the antianxiety medication or what side-effects to watch for. B. On 12/20/10 at 2:55 pm, during an interview, Registered Nurse #1 stated that the admitting nurse usually added the medication to the care plan. C. On 12/23/10 at 4:30 pm, during an interview, Licensed Practical Nurse/Care Plan Coordinator #1 stated she usually did not add antianxiety medications to the care plan. D. On 12/23/10 at 4:45 pm, during an interview, the Director of Nursing confirmed that the antianxiety medication along with the potential side-effects should have been listed on the care plan. | 2014-04-01 | ||
| 5608 | 5608 | CEDAR RIDGE INN | 325113 | 800 SAGUARO TRAIL | FARMINGTON | NM | 87401 | 2011-02-24 | 225 | D | 1 | 0 | AHN111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to investigate, immediately report and submit a follow-up investigation for 2 (#1 and #2) of 5 residents (#1 - #5) regarding an allegation of abuse. The allegation identified that residents were afraid to call for help, felt helpless and had Bengay applied to the entire body and inserted into the rectum. The findings are: A. On 02/21/11 at 7:45 am, State Central Intake received a complaint indicating that Resident #1 and Resident #2 reported that the nursing aides were being rough with them during transfers and being told they "better not tell anyone." The complaint further indicated both residents reported being afraid to call for help due to fear of repercussion, reports of feeling helpless, and having Bengay applied to the entire body and inserted into their rectum. B. Record review of the closed medical record for Resident #1 revealed the following information: 1. The Face Sheet, dated 01/13/11 indicated [DIAGNOSES REDACTED]. 2. The Admission Resident Data Sheet, dated 01/10/11 indicated that Resident #1's decision making was moderately to severely impaired and that the resident required extensive assistance for transfers, bed mobility, and toileting needs. B. Record review of Nurses Notes revealed the following information: 1. On 01/13/11 at 1:30 pm, "Resident complained of not getting enough help and waiting to do any care for self then complained to staff when receiving help... Tells staff she gets thrown around... Social Services (SS) notified of false allegations." 2. On 01/23/11 at 10:28 am, "Resident continued making false statements. Said there were men in her room during the night doing care she didn't like." 3. On 02/02/11 at 1:17 pm, "Family complains of roughness with care." 4. On 02/03/11 at 1:32 pm, note from Social Services Director, "Resident... since day after admit they have been reporting to the nurses in charge the following concerns: 1) Staff have been treating… | 2014-06-01 |
| 5607 | 5607 | COUNTRY COTTAGE CARE AND REHAB | 325112 | 2101 BENSING ROAD | HOBBS | NM | 88240 | 2011-11-08 | 283 | D | 0 | 1 | XF4111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to have a discharge summary that included a recapitulation of the resident's stay and a final summary of the resident's status for 1 (#36) of 7 (#25, 32, 33, 35, 36, 37, 39) residents sampled for admission and discharge records. This failed practice presents a risk that residents may be discharged inappropriately and a risk of the lack of communication of necessary information to the continuing care provider. The findings are: A. Record review of Resident #36's closed medical record revealed an admission date of [DATE] and a discharge date of [DATE]. The record did not include a Discharge Plan and Summary. B. On 11/01/11 at 2:30 pm, an interview was conducted with the Medical Records Coordinator concerning the incomplete record. When asked where the clinical record information for Resident #36's chart was located she stated, "I don't know. Let me go look and see if it has been misfiled." C. Record review of the Facility's policy dated 10/2005, titled, "Chart Order and Thinning (MR-001) Policy and Procedure" revealed, "Policy-It is the policy of (Name of the Corporate Organization) to maintain organization in the resident's medical records." D. On 11/08/11 at 1:00 pm, an interview was conducted with the Medical Records Coordinator concerning the missing items in Resident #36's medical record. When asked if she had any progress in finding the additional information for the record, she stated, "No, and I don't understand why this medical record is not complete. I make dividers to make sure what is supposed to be in the medical record." | 2014-06-01 |
| 5606 | 5606 | COUNTRY COTTAGE CARE AND REHAB | 325112 | 2101 BENSING ROAD | HOBBS | NM | 88240 | 2011-11-08 | 514 | D | 0 | 1 | XF4111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to maintain accurate and accessible medical records for 1 (#36) of 7 (#25, 32, 33, 35, 36, 37, 39) residents sampled for admission records. This failed practice presents a risk that resident's medical records are not readily accessible for resident care. The findings are: A. Record review of Resident #36's closed medical record revealed missing documentation. The missing documentation included: 1. Initial Physician admission orders [REDACTED]. 3. Admission Nursing Assessment 4. Pain Assessment 5. Bowel and Bladder Assessment 6. Fall Risk Assessment 7. Laboratory reports 8. physician progress notes [REDACTED]. Therapy Progress Notes 11. Nurses Progress Notes and Quarterly Summaries 12. Social Services Assessment and Notes 13. Dietary Nutritional Assessment and Progress notes 14. Activity Assessment and Progress notes. 15. Discharge Plan and Summary. B. On 11/01/11 at 2:30 pm, an interview was conducted with Medical Records Coordinator concerning the incomplete record. When asked where the clinical record information for Resident #36's chart was located she stated, "I don't know. Let me go look and see if it has been misfiled." C. Record review of the Facility's policy dated 10/2005, titled, "Chart Order and Thinning (MR-001) Policy and Procedure" revealed, "Policy-It is the policy of (Name of the Corporate Organization) to maintain organization in the resident's medical records." In the section titled, "Procedure-...4. All chart tabs are to be in the order listed below-Order-Admission Tab; Advance Directive Tab; History and Physical Tab; Physician order [REDACTED]. D. On 11/08/11 at 1:00 pm, an interview was conducted with the Medical Records Coordinator concerning the missing items in Resident #36's medical record. When asked if she had any progress in finding the additional information for the record, she stated, "No, and I don't understand why this medical record is not complete. I m… | 2014-06-01 |
| 5605 | 5605 | COUNTRY COTTAGE CARE AND REHAB | 325112 | 2101 BENSING ROAD | HOBBS | NM | 88240 | 2011-11-08 | 325 | E | 0 | 1 | XF4111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review observation and interview the facility failed to provide a therapeutic diet that was recommended by the Registered Dietitian for 1 (#23) of 3 (#23, 11, 28) residents reviewed for nutritional concerns. The Dietitian recommended Med Pass 2.0, a protein supplement. The Med Pass was not given from 05/23/11 when the resident was readmitted from a hospitalization , and the resident continued to have weight loss. The resident lost weight from 114 pounds to 108 pounds and was 71 inches tall. The findings are: A. Record review of Resident #23's monthly weights revealed a weight (wt) of 111 pounds (lbs) in May 2011, 114 lbs in June, 109 lbs in July, 112 lbs in August, 110 lbs in September, and 108 lbs in October 2011. The resident was 71 inches tall. 1. Record review of the Registered Dietitian (RD)'s Nutrition Services Progress note dated 05/12/11 revealed, "...continue wt loss Diet Regular high pro (protein) double portions with high protein snacks, resident continues to lose weight. Recommend Med Pass 2.0 90 ml (milliliters) tid (three times a day.)" 2. Record review revealed the resident went to the hospital from 05/19-23/11. 3. Record review of the RD's 09/07/11 Nutrition Services Progress note revealed, "...has had wt loss ...diet regular high pro with double portions, hi pro snacks, Med Pass 2.0 90 ml tid with low fat per physician...several interventions in place for weight gain and healing, will continue to encourage high pro intake..." 4. Record review of the RD's 10/01/11 Nutritional Services Progress Note revealed, "... and BMI (body mass index) 15 with decreasing weight. Regular hi pro low fat with Med pass 2.0 90 ml tid double portions. Recommend 1 scoop pro powder tid for wound healing." 5. Record review of Resident #23's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. 6. Record review of Resident #23's 10/11 Physician orders [REDACTED]. B. On 10/31/11 at 2:28 pm, Licensed Prac… | 2014-06-01 |
| 5604 | 5604 | COUNTRY COTTAGE CARE AND REHAB | 325112 | 2101 BENSING ROAD | HOBBS | NM | 88240 | 2011-11-08 | 280 | E | 0 | 1 | XF4111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to revise the plan of care to include therapeutic diet changes that were recommended by the Registered Dietitian for 1 (#23) of 3 (#23, 11, 28) residents reviewed for nutritional concerns. The resident continued to have weight loss. The resident lost weight from 114 pounds in June 2011 to 108 pounds in October 2011 and was 71 inches tall. The findings are: A. Record review of Resident #23's monthly weights (wt) revealed a weight of 111 pounds (lbs) in May 2011, 114 lbs in June, 109 lbs in July, 112 lbs in August, 110 lbs in September, and 108 lbs in October 2011. The resident was 71 inches tall. 1. Record review of the Registered Dietitian (RD)'s Nutrition Services Progress note dated 05/12/11 revealed, "...continue wt loss Diet Regular high pro (protein) double portions with high protein snacks, resident continues to lose weight. Recommend Med Pass 2.0 90 ml (milliliters) tid (three times a day.)" 2. Record review of the RD's 09/07/11 Nutrition Services Progress note revealed, "...has had wt loss ...diet regular high pro with double portions, hi pro snacks, Med Pass 2.0 90 ml tid with low fat per physician...several interventions in place for weight gain and healing, will continue to encourage high pro intake..." 3. Record review of the RD's 10/01/11 Nutritional Services Progress Note revealed, "... and BMI (body mass index) 15 with decreasing weight. Regular hi pro low fat with Med Pass 2.0 90 ml tid double portions. Recommend 1 scoop pro powder tid for wound healing." 4. Record review of Resident #23's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. 5. Record review of Resident #23's 10/11 Physician orders [REDACTED]. 6. Review of Resident #23's Plan of Care dated 03/08/11, reviewed 06/08/11 and 09/07/11, revealed, "High Risk for Weight loss. Goal: Resident will be served appropriate diet related to dental and health needs. Interve… | 2014-06-01 |
| 5603 | 5603 | COUNTRY COTTAGE CARE AND REHAB | 325112 | 2101 BENSING ROAD | HOBBS | NM | 88240 | 2011-11-08 | 253 | D | 0 | 1 | XF4111 | Based on observation and interview the facility failed to provide repairs needed in 1 Resident room (#205) of 27 rooms observed ( room numbers 102, 103, 104, 105, 106, 107, 109, 108, 110, 204, 205, 206, 207, 208, 210, 301, 303, 304, 305, 306, 307, 308, 309, 310,312, 314, 316) and in the laundry room. Resident #18's room 205 had jagged wooden edges which had the potential for Resident #18 to obtain splinters, and the linoleum was cracked. There was the potential for insects and vermin to get into residents clothes in the laundry room due to a large hole in the door or the clothes to be stolen due to the broken lock on the laundry door. The findings are: A. On 11/01/11 at 10:15 am, observation in Resident #18's room # 205 revealed that the lower third quadrant of the wooden door edge contained jagged edges. A splinter was obtained by the surveyor when running a hand over the area. The linoleum had a long crack in the middle of the room's flooring. B. On 11/04/11 at 9:30 am, the Maintenance Supervisor (MS) verified the jagged edges on the door. The MS agreed that Resident #18, who lived in room 205, had the potential to obtain splinters from the jagged edge. The MS verified the cracked linoleum and stated that it needed to be puttied. C. On 11/04/11 at 10:30 am, observation was made of the laundry room. A hole approximately 8 inches X 5 inches was observed in the bottom of the north door in the laundry room. The north laundry door opened onto a field. The hole was verified by Housekeeping Worker (HKW) #1. When asked if mice could get through the hole and get in residents clothing, HKW #1 stated, "Yes that has happened before, but not for awhile." The laundry door also did not lock. When asked, HKW #1 agreed there was the potential for residents' laundry to get stolen when the laundry was not staffed since the door would not lock. | 2014-06-01 |
| 5602 | 5602 | COUNTRY COTTAGE CARE AND REHAB | 325112 | 2101 BENSING ROAD | HOBBS | NM | 88240 | 2011-11-08 | 250 | E | 0 | 1 | XF4111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility's Social Services failed to monitor 1 (#23) of 3 (23, 30, 34) residents who was depressed. This deficient practice presents a risk for the resident to continue to be depressed and not obtain needed mental health services. The findings are: A. Record review of Resident #23's History and Physical dated 05/19/11 revealed, "...The patient was quite depressed at the time and was still experiencing unresolved grief about the death of his wife ... I spoke with (name of Licensed Practical Nurse #2) at the nursing home, ... indicated the patient was quite depressed, ...avoiding activities ...low motivation...sleeping a lot...functioning very poorly,... During evaluation, having suicidal ideation, and I recommended that be directly admitted to the mental health unit ..." 1. Resident #23 was admitted to the psychiatric unit of the hospital on [DATE] and readmitted back to the nursing facility on 05/23/11. 2. Review of the physician progress notes [REDACTED]. 3. Review of the Social Services notes revealed no entries related to the Resident #23's depression, past suicide ideation, or psychiatric unit admission. B. During an interview on 11/04/11 at 10:00 am, the Social Worker (SW) admitted that she did not know the resident had depression problems, did not know that the resident was having psychiatric services, and did not know that there were previous suicide ideas. The SW stated, "I had no idea that he had a history." The SW agreed that she did not know how Resident #23 was doing, that she had not read Resident #23's psychiatric progress notes. When asked would it be important for you to know how the resident is doing since there was past suicide thoughts, the SW stated, "Definitely." | 2014-06-01 |
| 5601 | 5601 | KASEMAN SUBACUTE AND REHABILITATION | 325095 | 8300 CONSTITUTION AVENUE NE | ALBUQUERQUE | NM | 87110 | 2010-11-10 | 441 | E | 0 | 1 | NWNH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure that the infection control policy and practices were followed to avoid cross contamination for 5 of 12 sampled residents (#14, 55, 76, 204 and 210) in contact isolation. This deficient practice had the potential to affect all 33 residents residing in the skilled unit. The findings are: A. Record review revealed that Resident #14 had [DIAGNOSES REDACTED]. B. On 11/08/10 at 9:56 am, during observation, Registered Nurse (RN) #5 obtained a bagged [MEDICATION NAME] medication device (A hand inhaler used once a day, inhaled maintenance prescription treatment for [REDACTED]. RN #5 then entered the resident's room, removed the medication [MEDICATION NAME] device from a plastic bag and placed the bag on a shelf near the doorway in the resident's room. RN #5 used a personal digital assistant (PDA) device to scan the resident's identification wrist bracelet. RN #5 then placed the PDA device on the medication cart. RN #5 then handed the [MEDICATION NAME] container to Resident #14. The resident grasped the [MEDICATION NAME] and placed the medication device in her mouth and then handed the medication back to the nurse. RN #5, with her gloved hand, then placed the [MEDICATION NAME] medication device in the plastic bag with the same gloved hand. The PDA device was not cleaned by by RN #5 after being used on Resident #14. C. On 11/08/10 at 10:05 am, during interview, RN #5 stated, "Yes, I was supposed to clean the PDA device." D. On 11/09/10 at 9:00 am, Resident #55 was observed wheeling himself past his room doorway into the hall to retrieve an isolation gown and gloves from the isolation cart which was located in the hall next to the door of his room. He wheeled himself back into his room and put on the gown and gloves. He then wheeled himself out of his room and down the hallway wearing the gloves and isolation gown. Resident #55 had [DIAGNOSES REDACTED]. 1. On 11/09/10 at 2:4… | 2014-06-01 |
| 5600 | 5600 | CASA MARIA HEALTHCARE CENTER AND PECOS VALLEY REHA | 325086 | 1601 SOUTH MAIN STREET | ROSWELL | NM | 88203 | 2011-02-11 | 508 | E | 1 | 1 | ZTSZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensuring a chest x-ray for possible aspiration (inhalation of foreign material into the lungs) was completed for 10 days after the physician order [REDACTED]. The findings are: A. Nurse's Notes dated 03/06/10 through 03/09/10 revealed Resident #220 had a non-productive cough and vital signs including temperatures were within normal range. Resident was on currently on an antibiotic. B. Record review for Resident #220 revealed a physician's orders [REDACTED]." Additional record review include the following information: 1. Nurse's Notes dated 03/15/10 at 1:10 pm revealed "...Wife want to know when chest x-ray is. Put communication to (Name of transportation person)." 2. Nurse's Notes dated 03/16/10 at 3:00 pm revealed, "Resp (respirations) even and unlabored, ...Asked (Name of transportation person) when appt (appointment) for x-ray is. She is going to get back with me ASAP (As Soon As Possible). Wife wants to know when appt is..." 3. Nurse's Notes dated 03/17/10 at 1:10 pm, "...Resp (respiration) even and unlabored. ... X-ray appt. for Friday. Wife notified." 4. Nurse's Notes dated 03/19/10 at 6:00 pm revealed, "Out for CXR at 1230 (12:30 pm)." 5. "Radiologist Report" dated 03/19/10, revealed "Examination: PA and lateral: Indication: Pneumonia. Impression: Moderate linear atelectasis and probable superimposed pneumonia seen in the right lower lobe. Lungs are moderately underventilated." 6. Nurse's Notes dated 03/24/10 at 2:00 pm revealed, "X-ray results came in. Called (Name of Nurse Practitioner) with results. Started resident on ABT (antibiotic therapy)." 7. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. (milligrams) 1 tab PO (by mouth) QD (once a day) x (for) 7 days DX pneumonia," was started on 03/24/10. 8. Nurse's Notes dated 03/24/10 through 03/26/10, when resident was discharged to another facility, revealed no temperature elevation or… | 2014-06-01 |
| 5599 | 5599 | CASA MARIA HEALTHCARE CENTER AND PECOS VALLEY REHA | 325086 | 1601 SOUTH MAIN STREET | ROSWELL | NM | 88203 | 2011-02-11 | 312 | D | 1 | 1 | ZTSZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide showers as scheduled, for 1 (#79) of 34 sampled residents on the 300 unit who was dependent on staff for bathing. The findings are: A. Record Review was conducted for Resident #79. Review of the Minimum Data Set ((MDS) dated [DATE], revealed "Section G 0120 bathing Self Performance is 4, total dependence and Support provided is 2, One person physical assist." 1. The Care Plan dated 01/04/11 revealed Problem Bathing: "Extensive assist with one person. Approach Start Date 01/04/11. Set-up, assist, give shower, shave, oral, hair, nail care per schedule and prn (as needed)." 2. The CNA (Certified Nursing Assistant) - Activities of Daily Living (ADL) Tracking Form dated 01/01/11 revealed on the 6:00 am to 2:00 pm shift, Resident #79 was given a partial bath on 01/06, 01/12, 01/15, 01/18, 01/21, 01/23, and 01/24. On the 2:00 pm to 10:00 pm shift, Resident #79 was given a bed bath on 01/21/11 and no showers that month. 3. The CNA - ADL Tracking Form dated 02/01/11 revealed on the 6:00 am to 2:00 pm shift, partial baths were given 02/01, 02/03, and 02/06 through 02/09/11. On the 2:00 pm to 10:00 pm shift, Resident #79 was given a shower on 02/04/11. 4. The Shower schedule for the 300 unit revealed showers were scheduled on Monday and Wednesday nights for Resident #79. B. On 02/09/11 at 11:20 am, an interview was conducted with Resident #79. When Resident #79 was asked about not getting showers, she stated, "I have only gotten I think maybe 2 since I came back here. They give me these little 'wash-ups' that are just not good enough at all." When asked if she had ever refused to take a shower, she stated, "Not that I can remember. I just don't know why they don't even offer to give me one." 1. On 02/09/11 at 4:40 pm, CNA #2 was interviewed. When asked when Resident #79 gets her showers, CNA #2 stated, "Her shower schedule is two times a week on the evening shift because the residents … | 2014-06-01 |
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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 );