SILVER CITY, NM- SILVER CITY CARE CENTER

Based on observation, record review and interview, the facility failed to ensure that residents were treated with respect and dignity for 2 (R #30 & R #70) of 2 (R #30 & R #70) residents sampled for dignity, when the facility failed to shave R #30 and left R #70 in a soiled brief (a kind of underwear that allows one to urinate in a discreet manner) This deficient practice could likely result in residents becoming depressed, anxious, and lacking self-esteem/self-worth.

Based on record review and interview, the facility failed to ensure that the MDS (Minimum Data Set) assessment accurately reflected the status of the resident when it did not include the resident’s falls for 1 (R#59) of 9 ( R #20, R #37, R #49, R #56, R #59, R #69, R #74, R #174 and R #175) reviewed for accuracy of MDS . This deficient practice has the potential for lack of identification of risks and interventions related to medical issues and/or safety concerns.

Based on observation, record review, and interview, the facility failed to implement a Comprehensive Care Plan for a resident with [CONDITION(S)] (condition where ankles and/or feet are swollen) who required TED ([CONDITION(S)]-Embolic Deterrent)[blood clot preventing] Hose (stockings that help prevent blood clots and swelling in your legs) for 1 (R #49) of 6 (R #8, R #40, R #49, R #56, R #64, and R #70) reviewed for Care Plans. This deficient practice could likely lead to worsening [CONDITION(S)] and staff may be unaware of resident care needs.

Based on record review and interview the facility failed to ensure that Care Plans were revised, current, and accurate for 1 (R #59) of 7 (R #8, R #40, R #49, R #56, R #59, R #64, and R #70) residents reviewed for Care Plan Timing and Revision. This deficient practice has the potential for staff to fail to review, identify, update, and modify the Care Plan to meet the resident’s needs.

Based on observation, record review, and interview, the facility failed to ensure a resident with decreased range of motion (the full movement potential of a joint) received appropriate treatment and services to prevent further decrease in range of motion and/or help increase range of motion for 1 (R #42) of 2 (R #20 and R #42) reviewed for positioning (deliberate placement of the patient or a body part to promote physiological [consistent with an organism’s normal functioning] and/or psychological [relating to, or arising from the mind or emotions] well-being) and mobility. This deficient practice could likely lead to pain, increased stiffness, difficulty positioning the resident and/or loss of function of affected limb(s) (arm(s) and/or leg(s).

Based on interview and record review, the facility failed to ensure that residents were free from accidents for 1 (R #70) of 10 (R #11, R #15, R #20, R #33, R #37, R #49, R #56, R #59, R #70 and R #176) residents sampled for accidents, by not providing smoking supervision as indicated.

Based on observation, interview, and record review, the facility failed to have adequate staffing for all 72 residents in the facility (residents were identified by the resident matrix provided by the DON on 06/07/21), on several occasions when only 2 CNA’s and 1 nurse were working at night. 

Based on record review and interview, the facility failed to ensure the completion of the Nurse Aide
Performance Review and the 12 hours of in-service training (required of all CNAs) for 1(CNA #14) of 3(CNA #14, CNA #15 & CNA #16). This failed practice could lead to residents not receiving the appropriate care to meet their individual needs

Based on record review and interview, the facility failed to ensure there was a clinical diagnosis for the use of [CONDITION(S)] (any medication capable of affecting the mind, emotions, and behavior) medications for 1 (R #49) of 5 (R #11, R #20, R #33, R #49 and R #67) residents reviewed for unnecessary medications. This deficient practice could likely result in residents receiving medications without a clinical indication (reason) and put the resident in an unnecessary risk for side effects of the medication.

Based on record review and interview, the facility failed to ensure documents in resident records were complete and accurate for 2 (R #40 and R #70) of 2 (R #40 and R #70) residents reviewed for advanced directives ( MOST form- Medical Orders for Scope of Treatment ) legal document also known as a living will which specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity). This deficient practice could likely result in staff not knowing the medical intervention wishes of residents during an emergency.