Deficiencies (last 4 years)
Deficiencies (over 4 years)
17.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
144% worse than New Mexico average
New Mexico average: 7.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
120 residents
Based on a July 2025 inspection.
Census over time
Inspection Report
Routine
Census: 120
Deficiencies: 6
Date: Jul 30, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident privacy, medication administration, respiratory care, medication security, food safety, and pest control at Uptown Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including failure to secure resident medical information on medication carts, failure to follow physician orders for diabetic and respiratory treatments, failure to secure medication carts, failure to enforce food safety practices such as wearing hairnets, and failure to maintain an effective pest control program resulting in presence of roaches, mice, and flies.
Deficiencies (6)
Failed to close or lock the computer screen on the medication cart, exposing resident medical information.
Failed to follow physician orders for diabetic medications, specifically not administering Insta-Glucose when blood sugar was below 70 mg/dL.
Failed to enter and document physician orders for nebulizer treatment, risking compromised respiratory care.
Failed to secure medications by leaving medication cart unlocked, risking unauthorized access.
Dietary staff failed to wear hairnets while preparing and serving food, risking food contamination.
Failed to maintain an effective pest control program, resulting in presence of roaches, mice, and flies in resident areas and food service areas.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 25
Residents affected: 120
Blood glucose readings below 70 mg/dL: 5
Resident census: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #9 | Observed leaving medication cart unlocked and computer screen open; involved in medication and blood sugar management | |
| Unit Manager #2 | Unit Manager | Observed locking medication cart and computer screen; provided training to Nurse #9 |
| Director of Nursing | Director of Nursing | Interviewed regarding diabetic medication administration and respiratory care expectations |
| Nurse #10 | Interviewed regarding diabetic blood sugar management and physician orders | |
| Kitchen Account Manager | Kitchen Account Manager | Interviewed regarding hairnet use and pest control in kitchen |
| Administrator | Administrator | Confirmed expectations for medication cart security, medication administration, respiratory care, food safety, and pest control |
| Market Resource Clinician | Market Resource Clinician | Interviewed regarding nebulizer treatment documentation and administration |
| Maintenance Director | Maintenance Director | Interviewed regarding pest control program and response to pest complaints |
| Unit Manager | Unit Manager | Reported resident complaints about roaches in food and mice in resident rooms |
Inspection Report
Routine
Census: 118
Deficiencies: 14
Date: May 5, 2025
Visit Reason
The inspection was a routine regulatory survey to assess compliance with healthcare facility regulations, including resident rights, environment, care planning, medication management, infection control, and safety.
Findings
The facility was found deficient in multiple areas including failure to document advance directives accurately, maintain a safe and clean environment, ensure accurate resident assessments and care plans, provide safe smoking supervision, properly label and discard medications, ensure dental care, meet nutritional needs, maintain sanitary food handling, implement infection prevention and antibiotic stewardship programs, maintain functional call light systems, and ensure a safe physical environment.
Deficiencies (14)
Failed to ensure resident's current advance directive was properly documented, causing potential confusion and delay in lifesaving procedures.
Failed to maintain a clean, safe, and comfortable environment including broken blinds, broken wall tiles, unpainted drywall, dusty ceiling fans, stained tablecloths, dirty vending machines, and standing black water in conference room sink.
Failed to ensure accurate Minimum Data Set (MDS) assessments for a resident, resulting in inaccurate documentation of cognitive status.
Failed to revise care plans to reflect current resident needs regarding use of appropriate utensils during mealtime for two residents.
Failed to ensure safe environment free of accident hazards including smoking supervision, possession of lighters, staff belongings in resident rooms, and unsecured bleach wipes in bathrooms.
Failed to date oxygen tubing and humidifiers for a resident, risking reduced oxygen flow due to dirty or outdated equipment.
Failed to ensure insulin pens were dated and discarded within 28 days of opening for five residents, risking administration of less effective or expired medication.
Failed to ensure residents obtained routine dental care, resulting in residents with ill-fitting dentures and untreated dental problems.
Failed to meet nutritional needs and preferences of residents by not serving food items listed on the menu and not providing residents opportunity to select meals in advance.
Failed to ensure food was stored, prepared, and served under sanitary conditions including uncovered, unlabeled, undated food and beverages, dirty kitchen environment, staff not wearing hair restraints, and improper handling of drinks.
Failed to ensure garbage and refuse containers were covered or closed, risking pest infestation.
Failed to provide complete documentation and implementation of an infection prevention and control program including infection surveillance and antibiotic stewardship.
Failed to ensure call lights were functional and within reach in resident bathing areas and rooms, risking inability of residents to request assistance.
Failed to maintain a safe, easy to use, clean and comfortable environment including broken oxygen storage door, fire door not closing on alarm, damaged door frames, broken ceiling tiles, and broken electrical outlets.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 5
Residents affected: 2
Residents affected: 118
Residents affected: 118
Residents affected: 118
Residents affected: 118
Residents affected: 1
Residents affected: 118
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager #1 | Unit Manager | Interviewed regarding advance directive documentation, call light reporting, and environmental safety |
| Maintenance Director | Maintenance Director | Interviewed regarding broken blinds, call light repairs, garbage disposal, and environmental safety |
| Director of Nursing | Director of Nursing | Interviewed regarding care plan revisions, smoking supervision, insulin pen labeling, and call light accessibility |
| Administrator | Administrator | Interviewed regarding environmental deficiencies, smoking policy, dental care, call light reporting, and infection control |
| Certified Nursing Assistant #8 | Certified Nursing Assistant | Interviewed regarding oxygen tubing labeling and call light accessibility |
| Certified Nursing Assistant #12 | Certified Nursing Assistant | Interviewed regarding bleach wipes in resident bathrooms |
| Medical Director | Medical Director | Interviewed regarding infection control and antibiotic stewardship responsibilities |
| Consultant Pharmacist #1 | Consultant Pharmacist | Interviewed regarding insulin pen discard and antibiotic stewardship program |
| Dietary Manager | Dietary Manager | Interviewed regarding meal service, food storage, and sanitary practices |
| Corporate Chef | Corporate Chef | Interviewed regarding meal service and menu substitutions |
| Interim Director of Nursing | Interim Director of Nursing | Interviewed regarding infection control and call light reporting |
| Infection Control Preventionist | Infection Control Preventionist | Interviewed regarding infection surveillance documentation |
| Nurse #1 | Nurse | Interviewed regarding call light use and safety in shower room |
| Unit Manager #2 | Unit Manager | Interviewed regarding insulin pen labeling and discard |
| Nurse #2 | Nurse | Interviewed regarding insulin pen discard |
| Speech-Language Pathologist | Speech-Language Pathologist | Interviewed regarding care plan revision for resident with pureed diet |
| Social Services Director | Social Services Director | Interviewed regarding accuracy of MDS assessments |
| Housekeeping Staff | Housekeeping Staff | Interviewed regarding cleanliness of dining area and vending machines |
| Unit Manager #1 | Unit Manager | Interviewed regarding lighters in resident rooms and staff belongings in resident rooms |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Feb 27, 2025
Visit Reason
The inspection was conducted following complaints regarding staff treatment of residents, failure to report abuse allegations, and failure to follow physician orders for diabetic medications and pain management.
Complaint Details
The complaint investigation was triggered by allegations that staff yelled at a resident in pain and failed to provide timely pain medication. The facility also failed to report the abuse allegation to the State Survey Agency. The investigation included interviews with the resident, visitor, staff, and facility administrators, confirming the allegations and identifying failures in medication administration and abuse reporting.
Findings
The facility failed to ensure residents were treated with dignity and respect, failed to report an allegation of staff-to-resident abuse to the State Survey Agency, failed to follow physician orders for diabetic medication administration, and failed to provide appropriate pain management for a resident, including missed doses of prescribed oxycodone.
Deficiencies (4)
Failed to ensure staff treated residents with dignity and respect, ignoring a resident's pain calls.
Failed to timely report suspected abuse to the State Survey Agency.
Failed to follow physician orders for diabetic medications, specifically not administering Insta-Glucose gel when blood glucose was below 70 mg/dL.
Failed to provide safe, appropriate pain management, including missed doses of oxycodone and delays due to medication availability issues.
Report Facts
Blood glucose readings below 70 mg/dL: 3
Missed oxycodone doses: 5
Pain rating: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant #1 | CNA | Named in the finding related to yelling at resident R #1 and being suspended during abuse investigation. |
| Unit Manager #1 | Unit Manager | Interviewed regarding diabetic medication administration and oxycodone medication issues. |
| Director of Nursing | DON | Interviewed regarding medication refill authorization and pain management. |
| Nurse #3 | Nurse | Interviewed regarding diabetic blood sugar management and following physician orders. |
| Nurse #4 | Nurse | Interviewed regarding diabetic blood sugar management and following physician orders. |
| Social Services Director | SSD | Conducted abuse investigation and failed to report incident to State Survey Agency. |
| Administrator | Administrator and Abuse Coordinator | Interviewed about awareness of abuse incident and reporting. |
Inspection Report
Routine
Deficiencies: 2
Date: Nov 14, 2024
Visit Reason
The inspection was conducted to assess compliance with foot care and medical record documentation requirements for residents, focusing on podiatry consults and care.
Findings
The facility failed to provide appropriate podiatry consult and care for one resident, resulting in untreated foot conditions. Additionally, the facility did not maintain accurate and updated medical records for two residents regarding podiatry visits and refusals.
Deficiencies (2)
Failed to provide a podiatry consult and care for one resident, resulting in untreated foot problems.
Failed to ensure medical records were updated and accurate for two residents regarding podiatry care and refusals.
Report Facts
Residents reviewed for foot care: 3
Residents affected by foot care deficiency: 1
Residents affected by medical record deficiency: 2
Date of podiatry consult order: May 14, 2024
Date of most recent podiatry note for Resident #2: Dec 22, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #1 | Interviewed regarding Resident #1's foot care and podiatry visits | |
| Unit Manager | Interviewed regarding Resident #1's toenail condition and podiatry care | |
| CNA #2 | Interviewed regarding Resident #1's hygiene and toenail condition | |
| Administrator | Administrator | Interviewed regarding podiatry care documentation and facility practices |
Inspection Report
Annual Inspection
Census: 116
Deficiencies: 7
Date: Aug 16, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home care, including resident safety, quality of care, and facility conditions.
Findings
The facility was found deficient in multiple areas including maintaining a safe and clean environment, safeguarding resident belongings, providing timely and adequate care and assessments, ensuring proper medication administration and documentation, providing sufficient nursing staff to meet resident needs, and implementing proper infection control practices.
Deficiencies (7)
Failed to maintain a clean, safe, and homelike environment on the 400 Unit with clutter such as mattresses and equipment left in hallways.
Failed to protect a resident's belongings from theft and did not offer a safe place for belongings until after the theft occurred.
Failed to meet professional standards of quality by not providing care or assessments timely upon admission and not obtaining physician orders or providing care for a resident's PICC line.
Failed to provide adequate activities of daily living (ADL) assistance, specifically bed baths and showers, to multiple residents as scheduled.
Failed to provide enough nursing staff to meet the needs of all residents, resulting in missed baths and showers.
Failed to maintain accurate and complete medical records, including documenting medication administration when medications were not available or were refused.
Failed to implement proper infection prevention and control practices during wound care, including changing gloves appropriately and disposing of soiled bandages in biohazard receptacles.
Report Facts
Residents: 116
Missing check amount: 800
Medication doses left: 122
Days for insurance claim investigation: 30
Days for insurance claim investigation: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #3 | Registered Nurse | Confirmed mattresses and oxygen concentrator should not have been left in hallway |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Confirmed bedside commode should not have been in hallway |
| Administrator | Administrator | Acknowledged mattresses, oxygen concentrator, and commode should not have been in hallway |
| Business Office Manager | Business Office Manager | Investigated stolen check and filed police report |
| Registered Nurse #1 | Registered Nurse | Admitting nurse who did not provide timely care and hydration to resident #7 |
| Unit Manager #1 | Unit Manager | Stated residents should not wait several hours to be assessed and hydrated |
| Director of Nursing | Director of Nursing | Stated expectations for resident admission care and PICC line monitoring |
| Registered Nurse #2 | Registered Nurse | Confirmed PICC line dressing was changed only once and no physician orders were present |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Stated residents should be offered at least two bed baths or showers weekly |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Observed improper wound care practices |
| Wound Care Nurse | Wound Care Nurse | Observed improper wound care practices |
| Registered Nurse #4 | Registered Nurse | Observed medication pass and confirmed inhaler was unused |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 18, 2024
Visit Reason
The inspection was conducted due to concerns about the facility's failure to notify a resident's Power of Attorney (POA) prior to transferring the resident to another facility.
Complaint Details
The complaint investigation found that the facility did not notify the resident's POA prior to transferring the resident despite the resident's elopement behaviors. The POA was only notified after the transfer had occurred.
Findings
The facility failed to notify the POA of resident #5 before transferring him to a different facility with a secured locked unit. The resident exhibited elopement behaviors, and staff did not inform the POA until after the transfer had occurred.
Deficiencies (1)
Failure to provide timely notification to the resident's Power of Attorney before transfer to another facility.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Social Services Director | Realized she forgot to call the Guardian and called the Guardian immediately after the resident was transferred. |
| facility administrator | facility administrator | Interviewed regarding the resident's elopement behaviors and the transfer decision. |
Inspection Report
Deficiencies: 1
Date: Feb 16, 2024
Visit Reason
The inspection was conducted to evaluate compliance with dietary orders and nutritional needs of residents, specifically to ensure menus meet nutritional requirements and are properly followed and updated.
Findings
The facility failed to follow dietary orders for double entrees and did not include all items on the resident's meal ticket for one resident (R #105). Observations and interviews confirmed the resident received single entrees instead of double and was missing items such as green beans, milk, and margarine.
Deficiencies (1)
Failed to follow dietary orders for double entrees and include all items on the resident's meal ticket for resident #105.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Interviewed regarding failure to serve double entrees and missing meal items for resident #105. |
Inspection Report
Routine
Census: 122
Deficiencies: 10
Date: Feb 16, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, nutrition, infection control, medication management, and facility environment.
Findings
The facility was found deficient in maintaining a safe and homelike environment, revising care plans after significant weight loss, ensuring accurate resident weights, following physician orders for care and meals, maintaining oxygen safety signage, conducting annual staff performance reviews, managing medication and supply storage properly, following dietary orders, discarding expired food, and enforcing infection prevention measures including PPE use.
Deficiencies (10)
Failed to maintain an environment that was homelike, free of clutter and broken items in dining and living areas.
Failed to revise care plan after documented significant weight loss for resident #84.
Failed to maintain accurate weights for residents #26, #84, and #165; failed to float heels per physician orders for resident #102; failed to ensure dialysis resident #55 received meal per physician orders.
Failed to ensure quality care and treatment for residents #84, #87, and #262 including appointment scheduling, ADL care, and weekly weights.
Failed to maintain oxygen equipment safety by not posting oxygen in use signs on resident #4's room door.
Failed to conduct annual performance reviews for 2 CNAs.
Medication carts contained loose medications; expired supplies stored with unexpired supplies in medication room.
Failed to follow dietary orders for double entrees and include all items on resident #105's meal ticket.
Failed to discard expired or undated food items in kitchen, including moldy fruit, expired milk, and undated desserts.
Failed to maintain proper infection prevention measures; staff did not wear appropriate PPE before entering COVID-positive resident rooms.
Report Facts
Residents affected: 122
Weight loss percentage: 20.9
Weight loss percentage: 27.6
Residents reviewed for care plan revisions: 3
Residents reviewed for nutrition and skin issues: 5
Residents reviewed for respiratory care: 3
Residents affected by infection prevention deficiency: 28
Residents affected by expired food: 122
Residents affected by CNA performance review deficiency: 3
Residents affected by medication and supply storage deficiency: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Verified weight changes and care plan deficiencies for resident #84; confirmed oxygen signage and PPE use deficiencies; stated lack of annual CNA performance reviews |
| Maintenance Director | Maintenance Director | Interviewed regarding storage of unusable items in van and patio area |
| RN #1 | Registered Nurse | Interviewed about inaccurate resident weights and failure to reweigh residents |
| Unit Manager #1 | Unit Manager | Interviewed about weight measurement inconsistencies and referral for pulmonary specialist |
| Registered Dietician | Registered Dietician | Interviewed about weighing system and challenges with weight assessments |
| Dietary Manager | Dietary Manager | Interviewed about meal preparation and dietary order compliance |
| Certified Nurse Assistant #1 | Certified Nurse Assistant | Identified as overdue for annual performance review |
| Certified Nurse Assistant #2 | Certified Nurse Assistant | Identified as overdue for annual performance review |
| Physical Therapy Aide | Physical Therapy Aide | Observed entering COVID-positive room without PPE |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed about loose medications in medication cart |
| Registered Nurse #1 | Registered Nurse | Interviewed about expired supplies in medication room |
| Corporate District Manager | Corporate District Manager | Interviewed about food safety walk-throughs |
Inspection Report
Complaint Investigation
Census: 119
Deficiencies: 3
Date: Jan 4, 2024
Visit Reason
The inspection was conducted based on complaints regarding medication administration, timely pericare, and food service issues at the facility.
Complaint Details
The visit was complaint-related, triggered by concerns about medication administration practices, delayed pericare, and food service issues including late meal delivery and improper food temperatures.
Findings
The facility failed to ensure medications were not left unattended in resident rooms, did not provide timely pericare for residents, and failed to serve food in a timely manner while maintaining proper food temperatures. These deficiencies posed risks of resident discomfort, potential injury, and foodborne illness.
Deficiencies (3)
Medications were left on a bedside table in a resident's room contrary to orders prohibiting self-administration.
Failure to provide timely pericare for 3 of 4 residents reviewed, causing discomfort and prolonged soiling.
Food was not served according to established meal times and cooked food was not maintained at proper holding temperatures.
Report Facts
Residents affected: 1
Residents affected: 3
Residents reviewed for brief maintenance: 4
Residents affected: 119
Census: 119
Food temperature: 102.2
Meal serving time: 11.4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director Of Nursing | Director Of Nursing (DON) | Interviewed regarding medication administration and pericare deficiencies |
| Dietary Manager | Dietary Manager (DM) | Interviewed regarding food service and temperature deficiencies |
Inspection Report
Deficiencies: 5
Date: Oct 24, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident environment, pain management, elopement risk, medication monitoring, and meal quality at Uptown Rehabilitation Center.
Findings
The facility was found deficient in maintaining a fly-free environment, providing adequate pain management for a hospice resident, ensuring supervision to prevent elopement, monitoring narcotic medications properly, and serving meals at appropriate temperature and quality. These deficiencies posed risks of discomfort, inadequate pain control, resident elopement, medication misappropriation, and decreased resident quality of life.
Deficiencies (5)
Failed to maintain an environment free of flies affecting 3 residents.
Failed to provide quality pain management for 1 resident on hospice.
Failed to ensure supervision to prevent elopement for 1 resident at risk.
Failed to ensure proper monitoring and documentation of narcotic medications for 30 residents.
Failed to ensure meals were served at an appetizing temperature and were palatable for 5 residents.
Report Facts
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 30
Residents affected: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) #1 | Stated flies have been an issue in the building | |
| Maintenance Director (MD) | Discussed fly control measures and issues | |
| Certified Medication Assistant (CMA) #4 | Commented on flies aggravating staff and residents and medication refill process | |
| Licensed Practical Nurse (LPN) #2 | Discussed fly problem and medication refill issues | |
| Director of Nursing (DON) | Explained elopement incident and narcotic monitoring requirements | |
| Unit Manager (UM) #1 | Explained wander guard alarm response and resident grievances about food | |
| Dietary Manager | Discussed resident complaints about cold food and meal tray delivery issues | |
| Registered Nurse (RN) #2 | Explained narcotic count and documentation process |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 14, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to administer medications as ordered for a resident, specifically the unavailability of prescribed medication.
Complaint Details
The complaint was substantiated as the facility failed to administer the prescribed medication Tizanidine to resident R #1 due to medication unavailability. The medication had been reordered but had not arrived, and the physician was not notified of the shortage.
Findings
The facility failed to administer the prescribed medication Tizanidine to one resident (R #1) from 06/11/23 to 06/12/23 due to medication unavailability, resulting in the resident experiencing uncontrolled muscle spasms. The medication reorder had not arrived, and the physician was not notified of the medication shortage.
Deficiencies (1)
Failure to administer medications as ordered due to medication unavailability for resident R #1.
Report Facts
Medication doses not administered: 4
Medication dosage: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) #1 | Confirmed resident had not received medication since 06/11/23 and that medication reorder had not arrived | |
| Director of Nursing (DON) | Confirmed medication unavailability, reorder status, and lack of physician notification |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 14, 2023
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction report for Uptown Rehabilitation Center following a survey completed on 06/14/2023.
Findings
No health deficiencies were found during the survey.
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: May 30, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to timely report suspected abuse, failure to ensure residents were transported to provider appointments as ordered, and failure to maintain accurate medical records.
Complaint Details
The complaint investigation revealed that the facility failed to submit a timely follow-up report for an incident involving a resident alleging abuse by staff. Additionally, the facility failed to ensure two residents were transported to their medical appointments as ordered, resulting in multiple missed appointments. The facility also failed to maintain accurate medical records for one resident regarding the correct side of a fracture.
Findings
The facility failed to submit a timely 5-day follow-up report for an incident involving suspected abuse, failed to ensure two residents were transported to provider appointments as ordered resulting in missed appointments, and failed to maintain accurate medical records for one resident regarding the side of a fracture.
Deficiencies (3)
Failed to timely report suspected abuse by submitting the 5-day follow-up report late for one resident.
Failed to provide appropriate treatment and care by not scheduling and transporting two residents to provider appointments as required and requested.
Failed to safeguard resident-identifiable information and maintain accurate medical records for one resident.
Report Facts
Residents reviewed for provider care and treatment: 8
Residents affected by failure to transport to appointments: 2
Residents reviewed for incident follow-up: 1
Days late for follow-up report submission: 6
Missed appointments by Resident #3: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | Unit Manager | Responsible for scheduling appointments for residents in units 100, 200, and 300; acknowledged issues with appointment scheduling and transportation system. |
| Unit Manager | Acknowledged missed orthopedic appointment for Resident #4 and failure to reschedule until 05/23/23. | |
| Director of Nursing | Director of Nursing (DON) | Confirmed Resident #4 should have had orthopedic consult and acknowledged failure to ensure this occurred. |
| Licensed Practical Nurse #1 | Licensed Practical Nurse (LPN) | Reported Resident #2's fracture was on the right lower extremity. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 30, 2023
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to ensure residents were transported to and attended their scheduled provider appointments as required and requested.
Complaint Details
The complaint stated that the facility could not get the patient (R #3) to her appointments and that calls to the facility were not returned. The complainant reported multiple missed appointments for R #3 and inability to speak to the resident when calling. The complaint was substantiated by interviews and record reviews.
Findings
The facility failed to provide appropriate treatment and care by not scheduling and transporting two residents (R #3 and R #4) to their medical appointments, resulting in missed appointments and delayed medical follow-up. Interviews and record reviews confirmed missed orthopedic and oncology appointments due to scheduling and transportation issues.
Deficiencies (1)
Failure to ensure residents were transported to provider appointments when required and requested.
Report Facts
Residents reviewed for provider care and treatment: 8
Residents with unmet needs for scheduling and transportation: 2
Missed appointments for Resident #3: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager | Responsible for setting appointments for residents; acknowledged missed and unrescheduled appointments for R #4 | |
| Director of Nursing | Confirmed that R #4 should have had orthopedic consults and follow-up which did not occur | |
| Licensed Practical Nurse (LPN) #2, Unit Manager | Described issues with appointment scheduling and transportation system; stated R #3 does not refuse appointments |
Inspection Report
Complaint Investigation
Deficiencies: 11
Date: Nov 17, 2022
Visit Reason
The inspection was conducted due to a complaint investigation regarding physical abuse of one resident by another, allegations of misappropriation of property, inadequate pain assessment, failure to develop comprehensive care plans, failure to provide restorative nursing services, inadequate assistance with activities of daily living, improper resident transfers causing injury, improper supervision of smoking residents, failure to follow menus and provide palatable food, unsanitary kitchen conditions, and failure to follow infection prevention and control protocols during a COVID-19 outbreak.
Complaint Details
The complaint investigation involved allegations of physical abuse of Resident 51 by Resident 111, misappropriation of property for Resident 68, inadequate pain assessment for Resident 68, failure to develop care plans for oxygen use for Resident 100, failure to provide restorative nursing services for Residents 68 and 99, failure to assist Resident 9 with ADLs, improper transfer causing injury to Resident 21, improper supervision of smoking residents (Residents 11, 37, 54, 262), failure to follow menus and provide palatable food for multiple residents, unsanitary kitchen conditions, and failure to follow infection prevention and control protocols during a COVID-19 outbreak affecting residents including Residents 25 and 33.
Findings
The facility failed to protect a resident from physical abuse resulting in injury, failed to thoroughly investigate a missing wheelchair, did not assess pain adequately, lacked comprehensive care plans for oxygen use, failed to provide restorative nursing services, did not assist a resident with personal hygiene, improperly transferred a resident causing a fracture, failed to supervise smoking residents properly, did not follow menus or provide palatable food, maintained unsanitary kitchen conditions, and failed to ensure proper infection control measures during a COVID-19 outbreak.
Deficiencies (11)
Failed to protect a resident from physical abuse by another resident resulting in injury.
Failed to ensure thorough investigation of alleged misappropriation of property (missing wheelchair).
Failed to ensure comprehensive pain assessment was completed for a resident.
Failed to develop and implement a comprehensive care plan related to oxygen use.
Failed to provide restorative nursing services as ordered to maintain or improve functional ability.
Failed to provide assistance with activities of daily living including personal hygiene and bathing.
Failed to properly transfer a resident with two-person assist resulting in a fractured tibia.
Failed to properly supervise smoking residents and prevent possession of lighters in undesignated areas.
Failed to ensure menus were followed, food was palatable, and portions were adequate for residents.
Failed to maintain kitchen and food service areas in a sanitary manner, including glove use, dish machine area, refrigerator temperatures, and food storage.
Failed to provide and implement an infection prevention and control program, including proper use of PPE and hand hygiene during COVID-19 outbreak.
Report Facts
Residents affected by abuse: 1
Residents affected by misappropriation investigation failure: 1
Residents affected by inadequate pain assessment: 1
Residents affected by lack of oxygen care plan: 1
Residents affected by lack of restorative nursing services: 2
Residents affected by lack of ADL assistance: 1
Residents affected by improper transfer causing injury: 1
Residents affected by improper smoking supervision: 4
Residents affected by menu and food issues: 11
Residents affected by unsanitary kitchen conditions: 114
Residents affected by infection control failures: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Named in abuse investigation and interview regarding Resident 51 abuse incident |
| CNA4 | Certified Nurse Aide | Witness to abuse incident and interview regarding Resident 51 abuse |
| CNA3 | Certified Nurse Aide | Transferred Resident 21 alone causing injury; had prior disciplinary action for unsafe transfer |
| LPN4 | Licensed Practical Nurse | Observed failing to perform hand hygiene during wound dressing change |
| CNA1 | Certified Nurse Aide | Failed to wear eye protection entering COVID-19 positive resident room |
| CNA2 | Certified Nurse Aide | Failed to wear eye protection entering COVID-19 positive resident room |
| CNA10 | Certified Nurse Aide | Failed to wear gloves and hand sanitize when entering/exiting COVID-19 positive resident room |
| CNA11 | Certified Nurse Aide | Failed to wear gloves and hand sanitize when entering/exiting COVID-19 positive resident room |
| CNA8 | Certified Nurse Aide | Failed to wear eye protection entering COVID-19 positive resident room |
| Dietary Manager | Dietary Manager | Interviewed regarding food service issues and kitchen sanitation |
| Registered Dietitian | Registered Dietitian | Interviewed regarding food service and kitchen sanitation issues |
| Maintenance Director | Maintenance Director | Interviewed regarding kitchen and dumpster area maintenance |
| Administrator | Facility Administrator | Interviewed regarding abuse incident, food service, infection control, and facility operations |
| Director of Nursing | Director of Nursing | Interviewed regarding abuse incident, infection control, and facility operations |
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