Deficiencies (last 4 years)
Deficiencies (over 4 years)
22.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
217% worse than New Mexico average
New Mexico average: 7.1 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
92 residents
Based on a April 2023 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Routine
Deficiencies: 2
Date: Aug 21, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights and safety, including accurate documentation of code status and maintaining a safe environment free from accident hazards.
Findings
The facility failed to ensure consistent documentation of a resident's code status, posing a risk of life-threatening medical errors. Additionally, the facility did not maintain a safe environment, leaving electrical junction boxes unsecured, cords across hallways, an open fire alarm control panel, and hazardous items in a resident's room, all presenting potential risks to residents.
Deficiencies (2)
Failed to ensure medical records consistently reflected the correct code status for a resident, leading to conflicting documentation between DNR and Full Code status.
Failed to maintain the resident environment free from accident hazards, including unsecured electrical junction box, electrical cords across the hallway floor, an open fire alarm control panel, and hazardous items in a resident's room.
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Verified conflicting code status information and stated facility expectations |
| Assistant Director of Nursing | Assistant Director of Nursing | Stated fire alarm control panel should be secured and commented on hazards related to resident's possession of a kitchen knife and WD-40 |
| Maintenance Director | Maintenance Director | Stated electrical boxes and fire alarm panel should be secured and noted fall hazard from unsecured cords |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jul 17, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to timely report a significant medication-related event, failure to provide required discharge documentation, and failure to maintain a hazard-free environment in the facility.
Complaint Details
The complaint investigation found substantiated deficiencies related to failure to report a medication-related overdose event, failure to provide required discharge documentation, and failure to maintain a hazard-free environment.
Findings
The facility failed to report a suspected opioid overdose incident to the State Survey Agency, failed to provide a written discharge notice to a resident discharged after a suspected overdose, and failed to maintain a hazard-free environment by leaving an electrical cord protector improperly placed, an unsecured electrical outlet casing with exposed wires, and an unattended unlocked medication treatment cart.
Deficiencies (3)
Failed to timely report a significant medication-related event involving a suspected opioid overdose requiring Narcan administration and Code Blue activation.
Failed to provide a written discharge notice including reason, effective date, appeal rights, and contact information to a resident discharged after a suspected overdose.
Failed to ensure the physical environment was free from hazards including unsecured electrical cord protector posing trip hazard, unsecured electrical outlet casing with exposed wires, and an unattended unlocked medication treatment cart.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 3
Medication dose: 10
Cord protector diameter: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding medication event, discharge decision, and environmental hazards |
| Administrator | Administrator | Interviewed regarding reporting of medication event, discharge decision, and environmental hazards |
| Licensed Practical Nurse #1 | Licensed Practical Nurse (LPN) | Interviewed regarding unlocked medication treatment cart |
| RN #1 | Registered Nurse | Interviewed regarding exposed electrical wiring in resident rooms |
| Social Worker Assistant | Social Worker Assistant | Interviewed regarding discharge planning and notification |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Apr 25, 2025
Visit Reason
The inspection was conducted following complaints and allegations of abuse involving resident #1, including incidents where staff physically restrained and swatted the resident's hands, and concerns about the accuracy of the facility's investigation and assessments related to these allegations.
Complaint Details
The complaint investigation involved resident #1 who reported abuse when a nurse swatted his hands and pushed him back inside the facility as he tried to exit. The facility substantiated the abuse incident and terminated the nurse involved. The investigation was found to be inaccurate and incomplete, with errors in reporting and documentation. Resident #1 also exhibited suicidal ideation and behavioral issues.
Findings
The facility failed to protect residents from abuse when staff swatted resident #1's hands and pushed him back inside the building. The facility also failed to conduct an accurate investigation of the abuse allegations and did not ensure the accuracy of resident assessments. Additionally, the facility failed to secure a treatment cart, potentially exposing residents to harm.
Deficiencies (4)
Failed to protect resident #1 from abuse when staff swatted his hands and pushed him back inside the facility.
Failed to complete an accurate investigation regarding allegations of abuse for resident #1.
Failed to ensure the Minimum Data Set assessment was accurate for resident #1.
Failed to protect a treatment cart from unauthorized access by leaving it unlocked and unattended.
Report Facts
Residents affected: 1
Residents affected: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding ongoing issues with resident #1, substantiated complaint, and reported nurse termination | |
| Director of Nursing (DON) | Interviewed regarding resident #1's behaviors and treatment cart security | |
| Registered Nurse (RN) #1 | Interviewed about responsibility for treatment cart security | |
| Certified Medication Technician (CMT) #1 | Interviewed about treatment cart being unlocked |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 12, 2025
Visit Reason
The inspection was conducted due to complaints alleging possible neglect, abuse, and medication errors involving three residents (R #1, R #2, and R #3). The facility was reviewed for its reporting and investigation of these incidents.
Complaint Details
The complaint investigation involved three residents: R #1 had a medication error resulting in choking; R #2 had allegations of sexual misconduct by a staff member; R #3 reported a medication error. The facility did not report these incidents to the state agency and did not document or investigate the sexual misconduct allegation thoroughly. The facility disputes the citation.
Findings
The facility failed to timely report allegations of possible neglect and abuse for three residents and did not complete thorough investigations or report findings within five working days. Medication errors and a possible sexual abuse incident were investigated internally but not reported to the state agency as required.
Deficiencies (2)
Failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Failed to complete a thorough investigation and report the investigation findings within five working days for allegations of abuse and mistreatment.
Report Facts
Residents reviewed for incidents: 3
Residents reviewed for investigations: 5
Date of complaint: Jan 2, 2025
Date of complaint: Jan 16, 2025
Date of grievance: Jan 3, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing #2 | Assistant Director of Nursing | Provided written statement and described reprimands of CNA #1 regarding R #2 incident |
| Administrator | Administrator | Interviewed regarding awareness and reporting of incidents involving residents #1, #2, and #3 |
| ADON #1 | Assistant Director of Nursing | Investigated medication error grievance submitted by R #3 and took corrective actions |
Inspection Report
Routine
Deficiencies: 16
Date: Nov 15, 2024
Visit Reason
Routine inspection of The Suites Rio Vista nursing home to assess compliance with regulatory standards including resident care, medication administration, infection control, and facility safety.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident needs such as call light accessibility, safeguarding resident health information, maintaining a clean environment, accurate PASRR screening, comprehensive care planning, medication administration errors, infection prevention, and proper storage and use of medical equipment. Several residents did not receive timely or appropriate care, and medication carts were left unlocked. Food safety and dental care services were also inadequate.
Deficiencies (16)
Failed to provide reasonable accommodations for resident needs and preferences by not ensuring call light was within reach.
Failed to safeguard clinical record information by leaving private health information accessible to unauthorized persons.
Failed to maintain a clean, comfortable, and homelike environment by leaving used meal trays in residents' rooms.
Failed to ensure PASRR screening was accurate and complete for a resident requiring referral.
Failed to develop and implement a complete care plan meeting all resident needs including activity preferences and hospice services.
Failed to revise care plans timely to include staff assistance levels and hospice services.
Failed to ensure professional standards of quality in medication administration and resident self-administration assessments and orders.
Failed to assist resident in gaining access to vision services in a timely manner.
Failed to ensure resident was free from accident hazards by not securing an electric cord in the walking path.
Failed to provide safe and appropriate respiratory care including proper orders and monitoring for C-PAP/Bi-PAP use.
Failed to ensure physicians responded to pharmacist recommendations or provided rationale for disagreement.
Medication error rate exceeded 5% during observed medication administration.
Failed to ensure medication carts were locked when unattended.
Failed to provide or obtain dental services as ordered for a resident.
Failed to provide and implement an infection prevention and control program including proper storage of nebulizer mask and safe medication handling.
Failed to procure food from approved sources and maintain proper labeling, dating, and storage of food items in kitchen and nourishment refrigerators/freezers.
Report Facts
Medication error rate: 14.71
Medication administration observed: 34
Residents affected: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | CNA | Confirmed call light pad was not within reach for resident R #47 |
| Director of Nursing | DON | Confirmed call light pad should be within reach, care plans incomplete, medication orders missing, and infection control deficiencies |
| Registered Nurse #2 | RN | Observed leaving medication cart unlocked |
| Certified Medication Aide #1 | CMA | Observed medication administration with errors and using bare fingers to handle medication |
| Licensed Practical Nurse #1 | LPN | Verified unsecured electrical cord was a tripping hazard |
| Social Services Director | SSD | Confirmed delays in scheduling vision and dental appointments |
| Administrator | ADM | Provided facility medication administration policy |
| Activities Director | AD | Reported not updating resident care plans after activities assessments |
| Nurse Practitioner #1 | NP | Confirmed need for physician order and assessment for resident self-administering insulin |
| Assistant Director of Nursing | ADON | Confirmed pharmacist recommendations not reviewed by physicians with rationale |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 10, 2024
Visit Reason
The inspection was conducted following complaints regarding incomplete and inaccurate medical records for a resident requiring skilled care, and unsafe patient care equipment that led to a resident fall.
Complaint Details
The complaint investigation found substantiated deficiencies related to incomplete medical records for resident #1 and unsafe equipment leading to a fall for resident #2.
Findings
The facility failed to maintain complete and accurate medical records for one resident receiving skilled care, resulting in inadequate documentation of daily care and condition changes. Additionally, the facility failed to ensure safe operating condition of patient care equipment, leading to the collapse of a shower gurney and a resident fall without injury.
Deficiencies (2)
Failed to ensure medical records were complete and accurate for a resident receiving skilled care, lacking daily skilled care notes and clear documentation of condition changes.
Failed to ensure patient care equipment was in safe operating condition, resulting in the collapse of a shower gurney and a resident fall.
Report Facts
Residents affected: 1
Residents affected: 1
Blood sugar measurement: 68
Date of survey completed: Jul 10, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding resident #2 fall and equipment failure |
| Certified Nurses Aide #1 | Certified Nurses Aide | Interviewed and demonstrated equipment failure leading to resident #2 fall |
| Director of Nursing | Director of Nursing | Interviewed regarding medical record deficiencies for resident #1 |
| Assistant Director of Nursing | Assistant Director of Nursing | Acknowledged equipment failure and staff education following resident #2 fall |
| Administrator | Administrator | Confirmed equipment failure and corrective actions after resident #2 fall |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Jan 19, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to provide proper hydration and medication administration via a gastrostomy tube (G-Tube) for resident #1 upon admission.
Complaint Details
The complaint investigation found substantiated issues with medication and hydration administration delays for resident #1 due to equipment incompatibility and staff unfamiliarity with supplies. Interviews with nursing staff and the resident's daughter confirmed the delays and lack of documentation.
Findings
The facility failed to meet professional standards of quality for resident #1 by not knowing the location of G-Tube equipment, not providing hydration for 22 hours, not administering medications for 17 hours via G-Tube, and failing to document blood glucose levels. Staff reported equipment incompatibility and lack of proper supplies, resulting in delayed care.
Deficiencies (4)
Did not know where the gastrostomy tube (G-Tube) equipment for resident #1 was located.
Did not provide resident #1 with proper hydration for 22 hours via G-Tube.
Did not provide resident #1 medications upon admission for 17 hours via G-Tube.
Did not document resident #1's blood glucose (sugar) levels checks.
Report Facts
Hours without hydration via G-Tube: 22
Hours without medication via G-Tube: 17
Medication dosages: 4
Residual volume threshold: 60
Water flush volume: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Administered medications on 12/16/23; reported delays in medication and hydration administration; did not document blood sugar levels. |
| RN #2 | Registered Nurse | Connected and programmed G-Tube pump; notified ADON of equipment issues on 12/15/23. |
| Assistant Director of Nursing (ADON) | Notified of equipment incompatibility; arrived 12/16/23 and assisted with medication administration; confirmed staff unfamiliarity with supplies. | |
| Director of Nursing (DON) | Confirmed expectations for staff communication and timely medication administration; confirmed documentation deficiencies. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Dec 11, 2023
Visit Reason
The inspection was conducted due to complaints and grievances filed by residents and their families regarding neglect, abuse, and failure to provide adequate care, including leaving a resident in a wheelchair overnight, failure to report abuse allegations, incomplete investigations of abuse/neglect allegations, and failure to provide adequate assistance with activities of daily living such as bathing and showering.
Complaint Details
The complaint investigation involved grievances filed by residents and family members alleging neglect and abuse, including a resident left in a wheelchair overnight, inappropriate behavior by therapy staff, failure to report abuse allegations to the State Agency, incomplete investigations of abuse/neglect allegations, and inadequate assistance with bathing and hygiene. The facility confirmed some of the allegations and acknowledged failures in reporting and investigation processes.
Findings
The facility was found deficient in multiple areas including failure to honor residents' rights to dignity and respect, failure to timely report suspected abuse and neglect to the State Survey Agency, failure to conduct thorough investigations and document findings related to abuse and neglect allegations, and failure to provide adequate assistance with activities of daily living such as bathing and showering for several residents. These deficiencies were associated with minimal harm or potential for actual harm to residents.
Deficiencies (4)
Failed to promote care with dignity and respect for a resident left sitting in a wheelchair in the hallway overnight.
Failed to timely report suspected abuse, neglect, or theft and report investigation results to proper authorities within 5 working days for two residents.
Failed to complete and document thorough investigations and implement corrective actions regarding allegations of physical and verbal abuse and neglect for two residents.
Failed to provide activities of daily living assistance for baths and showers for two residents, resulting in inadequate hygiene care.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 2
Bed baths/showers provided: 3
Bed baths/showers provided: 1
Bed baths/showers missed: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| OT #1 | Occupational Therapist | Named in grievance for inappropriate behavior and failure to properly investigate allegations |
| Administrator | Administrator (ADM) | Confirmed failures in reporting and investigation of abuse/neglect allegations |
| Human Resources | Human Resources (HR) | Spoke to rehab staff and confirmed abuse allegations should have been reported |
| Assistant Director of Nursing | ADON #1 | Partially completed investigation and confirmed documentation failures |
| Director of Nursing | DON | Confirmed failures in documentation and investigation of abuse/neglect and inadequate ADL care |
| Director of Rehab | DOR | Interviewed resident's daughter and participated in grievance process |
| Certified Nurse Aide #5 | CNA | Acknowledged inability to provide bed bath due to staffing and assistance needs |
Inspection Report
Complaint Investigation
Deficiencies: 17
Date: Dec 11, 2023
Visit Reason
The inspection was conducted due to complaints and grievances filed by residents and family members regarding neglect, abuse, failure to report incidents, inadequate investigations, and failure to provide appropriate care and services.
Complaint Details
The visit was complaint-related based on grievances filed by residents and family members regarding neglect, abuse, failure to report incidents, inadequate investigations, and failure to provide appropriate care and services. The complaints were substantiated as the facility failed in multiple regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to promote dignified care, failure to timely report abuse and neglect, incomplete investigations of abuse allegations, inaccurate PASRR assessments, failure to revise care plans, inadequate assistance with activities of daily living, failure to provide meaningful activities, lack of proper assistive devices for vision, expired CNA performance review, medication administration errors, improper medication storage, failure to employ a certified dietary manager, serving food at improper temperatures, failure to accommodate dietary restrictions and preferences, inadequate hydration, unsanitary kitchen conditions, and failure to maintain infection prevention measures.
Deficiencies (17)
Failed to promote care with dignity and respect for a resident left sitting in a wheelchair overnight.
Failed to timely report suspected abuse and neglect incidents to the State Survey Agency.
Failed to complete and document thorough investigations and corrective actions regarding allegations of abuse and neglect.
Failed to ensure PASRR assessment was accurate for a resident with schizophrenia.
Failed to revise and update care plan to remove discontinued use of CPAP/Bi-PAP machine.
Failed to provide adequate assistance with activities of daily living, including baths and showers.
Failed to provide meaningful individualized activities and one-to-one activities for residents confined to rooms.
Failed to assist a resident in gaining access to vision services and proper assistive devices.
Failed to complete annual performance review for a Certified Nurses Aide.
Failed to administer intravenous antibiotic medication in a timely manner as per physician's order.
Failed to ensure medications were stored properly and not left on bedside tables in residents' rooms.
Failed to employ a Certified Dietary Manager meeting required qualifications by the deadline.
Failed to serve meals at preferred temperatures; hot foods served below 135°F and cold foods above 41°F.
Failed to provide food that accommodated resident allergies, intolerances, and preferences.
Failed to provide drinks consistent with resident needs and preferences and sufficient to maintain hydration.
Failed to ensure staff wore hair restraints in the kitchen and maintain kitchen cleanliness.
Failed to maintain proper infection prevention measures including timely PICC line dressing changes, labeling oxygen tubing, and preventing catheter tubing from dragging on floor.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 1
Certified Nurses Aides reviewed: 5
Medication administration errors: 1
Residents affected: 100
Residents affected: 100
Residents affected: 6
Residents affected: 3
Residents affected: 4
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| OT #1 | Occupational Therapist | Named in abuse allegation and grievance investigation |
| Administrator | Administrator | Confirmed failure to report abuse and incomplete investigations |
| Human Resources | Human Resources Staff | Spoke to rehab staff and confirmed abuse grievance |
| Director of Nursing | Director of Nursing | Confirmed failures in investigations, care plan revisions, and medication administration |
| Assistant Director of Nursing #1 | Assistant Director of Nursing | Interviewed regarding grievance investigations |
| Certified Nurse Practitioner | Certified Nurse Practitioner | Interviewed about importance of timely IV antibiotic administration |
| Dietary Manager | Dietary Manager | Interviewed about food temperatures, dietary requirements, kitchen cleanliness, and certification |
| Certified Nurse Aide #5 | Certified Nurse Aide | Interviewed about ADL assistance and documentation |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Interviewed about medication storage and milk provision |
| Certified Nurse Aide #4 | Certified Nurse Aide | Reported medication cup left on bedside table |
| Certified Nurse Aide #3 | Certified Nurse Aide | Confirmed catheter tubing on floor |
| Registered Nurse #1 | Registered Nurse | Observed medication administration and PICC line dressing |
| Social Services Director | Social Services Director | Interviewed about eye exam scheduling |
Inspection Report
Complaint Investigation
Deficiencies: 11
Date: May 5, 2023
Visit Reason
The inspection was conducted based on complaints regarding failure to honor residents' rights, abuse allegations, inadequate wound care, ileostomy care issues, and infection control concerns.
Complaint Details
The complaint involved failure to honor residents' rights, abuse allegations between residents, inadequate wound and ileostomy care, failure to report abuse timely, and infection control deficiencies. The abuse allegations were not substantiated due to lack of evidence, but the facility failed to adequately investigate and protect residents.
Findings
The facility failed to honor residents' choices regarding funeral home and medical appointments, did not prevent or properly investigate resident-to-resident abuse, failed to document and monitor bruising and wound care properly, allowed family to provide ileostomy care without adequate monitoring, did not measure ostomy pouches correctly, failed to provide food accommodating resident preferences, and did not maintain proper infection control practices.
Deficiencies (11)
Failed to honor residents' choices for funeral home and medical appointments.
Failed to protect residents from verbal abuse and threats by another resident and did not implement adequate corrective measures.
Failed to timely report suspected abuse and provide follow-up reports to the State Survey Agency.
Failed to complete thorough investigation and implement corrective actions regarding allegations of verbal abuse.
Failed to document unknown bruising on a resident taking blood thinners.
Failed to ensure proper pressure ulcer care by using a gloved finger instead of an applicator to apply wound dressing.
Allowed resident's family to provide ileostomy care without adequate monitoring and failed to measure and fit ileostomy pouch properly.
Failed to provide food that accommodates resident preferences, resulting in obstructed ileostomy and resident dissatisfaction.
Failed to provide proper infection control practices including overflowing trash bins and unclean scissors used during ostomy care.
Failed to investigate and resolve a grievance filed by a resident and failed to document and communicate during investigations involving resident abuse.
Failed to ensure staff possessed necessary skills to provide ileostomy care, risking infection and skin breakdown.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding funeral home choice, abuse reporting, and wound care documentation | |
| Assistant Director of Nursing | Interviewed regarding abuse investigation and ostomy care | |
| Social Services Director | Interviewed regarding abuse investigation and resident grievances | |
| Registered Nurse #1 | Interviewed regarding abuse reporting and bruising documentation | |
| Licensed Practical Nurse #1 | Observed and interviewed regarding ostomy care practices | |
| Certified Nursing Assistant #1 | Interviewed regarding resident abuse reporting | |
| Certified Nursing Assistant #2 | Interviewed regarding resident abuse reporting | |
| Psychologist #1 | Provided psychotherapy encounters for residents involved in abuse allegations | |
| Administrator | Interviewed regarding grievance investigation and administrative communication | |
| Dietary Supervisor | Interviewed regarding resident dietary preferences | |
| Activities Director | Interviewed regarding resident abuse awareness and activity attendance |
Inspection Report
Routine
Census: 92
Deficiencies: 6
Date: Apr 4, 2023
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory standards related to resident rights, physical environment, dietary services, food safety, and infection control at The Suites Rio Vista nursing home.
Findings
The facility was found deficient in honoring a resident's medication administration preferences, maintaining sanitary conditions in resident rooms, meeting dietary preferences, ensuring food safety by serving cold food cold, and implementing proper infection prevention measures related to oxygen nasal cannula use.
Deficiencies (6)
Failed to honor a resident's request to crush medications and place them in applesauce to ease swallowing.
Failed to ensure sanitary conditions in resident rooms, including missing air conditioner covers, broken glass on floors, trash, and inadequate cleaning.
Failed to maintain adequate linens and towels, resulting in residents not receiving bed baths or showers as needed.
Failed to meet dietary preferences of a resident by not consistently providing soup as requested.
Failed to ensure cold food was served cold and discarded when warm, risking foodborne illness.
Failed to maintain proper infection control by allowing a resident's oxygen nasal cannula to be left on the floor.
Report Facts
Residents affected: 1
Residents affected: 71
Residents affected: 1
Residents affected: 92
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Aide #1 | Certified Medication Aide | Named in medication administration deficiency related to failure to crush medication as requested |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed regarding linen and towel shortages |
| Certified Nursing Assistant #8 | Certified Nursing Assistant | Reported no bed baths due to lack of towels |
| Certified Nursing Assistant #9 | Certified Nursing Assistant | Observed food safety issue with yogurt and oxygen nasal cannula on floor |
| Environmental Maintenance Director | Environmental Maintenance Director | Interviewed about room damage and cleaning challenges |
| Environmental Services Director | Environmental Services Director | Interviewed about cleaning practices and resident behavior |
| Environmental Services Supervisor | Environmental Services Supervisor | Interviewed about resident behavior and cleaning frequency |
| Laundry Staff #1 | Laundry Staff | Interviewed about linen availability and usage |
| Dietary Supervisor | Dietary Supervisor | Interviewed about dietary services and resident meal preferences |
| Director of Nursing | Director of Nursing | Interviewed about infection control practices related to nasal cannula replacement |
Inspection Report
Routine
Census: 76
Deficiencies: 19
Date: Aug 31, 2022
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident rights, care, safety, activities, medication management, dietary services, and facility environment.
Findings
The facility was found deficient in multiple areas including failure to honor resident rights and dignity, inadequate care and assistance with activities of daily living, failure to provide timely and appropriate medication and treatment, inadequate infection control and respiratory care, failure to prevent falls, improper food handling and storage, and unsanitary conditions in resident rooms and bathrooms.
Deficiencies (19)
Failed to treat residents with respect and dignity by not serving meals at the same time as tablemates, using inappropriate language such as 'Heavy Wetters', 'Burdens', and 'Feeders', and not ensuring call lights were within reach.
Failed to provide reasonable accommodations for resident shower preferences, resulting in showers given late in the afternoon instead of the requested morning times.
Failed to ensure residents could meet privately in Resident Council meetings, which were held in open dining areas without privacy.
Failed to make the most recent survey results readily accessible to residents and visitors, as the survey book was kept behind other items and not easily accessible.
Failed to respond promptly to grievances for three residents, resulting in delayed or incomplete grievance resolution.
Failed to timely report an incident of neglect to the State Survey Agency within 5 days.
Failed to complete Minimum Data Set (MDS) assessments quarterly for a resident, resulting in outdated assessments.
Failed to ensure accurate MDS assessments reflecting resident status, including extent of physical assistance needed.
Failed to revise care plan to reflect resident's inability to maintain Transmission Based Precautions (TBP), resulting in resident not following infection control protocols.
Failed to provide assistance with activities of daily living (ADL) including baths/showers for multiple residents, resulting in residents not receiving expected hygiene care.
Failed to provide an ongoing program of activities meeting residents' interests and needs, including lack of individualized activity assessments and one-to-one activities.
Failed to provide timely medications and appropriate respiratory treatments, including delayed pain medication administration, failure to provide oxygen during shower, and refusal to provide nebulizer treatments.
Failed to properly document administration of narcotic medication, resulting in inaccurate narcotic counts.
Failed to ensure pressure ulcer care and prevention interventions were followed, including missing pressure relieving devices and improper use of wheelchair by resident with pressure injury.
Failed to prevent falls by not implementing appropriate fall prevention interventions, resulting in multiple falls with injuries for a resident.
Failed to ensure medications and medical supplies were not expired and stored securely, including expired influenza vaccines and Narcan, and unattended medications on medication carts.
Failed to ensure resident bathroom was kept clean and free of odors, with feces observed on bathroom walls and unflushed commode.
Failed to ensure food items were properly labeled, dated, stored, and free from signs of expiration in kitchen, nourishment refrigerators, freezers, and dry storage.
Failed to honor resident dietary preferences, resulting in serving food with gravy despite resident's dislike and request for green chile.
Report Facts
Residents affected: 8
Residents affected: 1
Residents affected: 76
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 6
Residents affected: 1
Residents affected: 4
Residents affected: 3
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 76
Residents affected: 1
Residents affected: 88
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #2 | Confirmed resident R #77 was served before other residents at the table | |
| Dietary Manager | Confirmed residents should be served at the same time while sitting at the same table | |
| Certified Nursing Assistant #3 | Confirmed use of inappropriate language 'Heavy Wetters' and reported resident embarrassment | |
| Director of Nursing | DON | Confirmed inappropriate language use and expectation for respectful phrasing |
| Certified Nurse Assistant #7 | Confirmed showers are given late in the afternoon and not in the morning as preferred by resident R #61 | |
| Assistant Director of Nursing #2 | ADON | Confirmed call light was not within reach of resident R #49 and repositioned it |
| Social Services Director | SSD | Confirmed grievances for residents R #234, R #235, and R #236 were not completed timely |
| Licensed Practical Nurse #1 | LPN | Confirmed resident R #233 was not in her room or on Transmission Based Precautions |
| Assistant Director of Nursing | ADON | Confirmed resident R #233's inability to follow TBP should have been care planned |
| Certified Nursing Assistant #4 | Confirmed resident R #229 was not offered bed bath/shower | |
| Certified Nursing Assistant #5 | Reported low oxygen saturation for resident R #238 after shower and notified nurse | |
| Licensed Practical Nurse #1 | LPN | Confirmed resident R #238 was not on oxygen during shower and was not reported to nurse |
| Nurse Practitioner #1 | NP | Confirmed nebulizer treatments are not allowed in facility due to COVID-19 policies |
| Director of Nursing | DON | Confirmed nebulizer treatments can be administered if needed and providers should review charts |
| Medication Aide #1 | MA | Confirmed narcotic count for resident R #240 was inaccurate |
| Registered Nurse Manager #1 | RNM | Unaware that pressure relieving boots for resident R #48 were missing |
| Certified Nursing Assistant #11 | CNA | Confirmed pressure relieving cushion for resident R #48 was not in bed as ordered |
| Hospice Nurse | Reported fall prevention measures not implemented for resident R #77 including scoop mattress | |
| Medical Tech/CNA #6 | MT/CNA | Reported resident R #77 falls mostly at night and use of Lorazepam to calm resident |
| Director of Nursing | DON | Confirmed scoop mattress was ordered but not used for resident R #77 |
| Medication Technician #2 | MT | Confirmed medication should never be left unattended on medication carts |
| Certified Nursing Assistant #1 | CNA | Confirmed resident R #232 went extended time without pain medication and was in pain |
| Licensed Practical Nurse #2 | LPN | Reported night shift agency nurse did not give medications and was rude |
| Registered Nurse #1 | RN | Confirmed resident R #232 ran out of pain medication and was not administered acetaminophen |
| Medication Technician #1 | MT | Confirmed medications expired and should have been disposed |
| Assistant Director of Nursing #2 | ADON | Confirmed ointment left open in resident R #49's room and zinc oxide medication |
| Dietary Manager | DM | Confirmed food and beverage items were not labeled, dated, or stored properly |
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