Village At Northrise (the) - Desert Willow I

F-F0500 interview for activity preferences:

a. How important is it to listen to music you like? Resident response: Very important.

b. How important is it to you to keep up with the news? Resident response: Very important.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 30 325111 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325111 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Village at Northrise - Desert Willow I 2884 North Road Runner Parkway Las Cruces, NM 88011

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 c. How important is it to you to go outside to get fresh air when the weather is good? Resident response: Very important. Level of Harm - Minimal harm or potential for actual harm d. How important is it to you to participate in religious services or practices? Resident response: Very important. Residents Affected - Some F. Record review of R #8's care plan dated 12/26/24 revealed staff did not document any of the activity preferences that were important to R #8.

R #184

G. Record review of R #184's admission record, no date, revealed the following:

1. R #184 was admitted to the facility on [DATE REDACTED].

2. R #184 had the following diagnoses:

a. Unspecified lack of coordination (a condition that affects the body's ability to control and execute smooth, precise movements).

b. History of Falling

H. Record review of R #184's Admission Minimum Data Set Assessment, dated 08/19/24, revealed R #184 had the following functional abilities for Activity of Daily Living (ADL, fundamental skills needed to take care of oneself):

1. Eating: Supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently).

2. Oral hygiene: Substantial/maximal assistance (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort).

3. Toileting hygiene: Substantial/maximal assistance

4. Shower/bathe self: Partial/moderate assistance (Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort).

5. Upper body dressing: Substantial/maximal assistance

6. Lower body dressing: Substantial/maximal assistance

7. Putting on/taking off footwear: Substantial/maximal assistance

8. Personal hygiene: Substantial/maximal assistance

9. Roll left and right: Substantial/maximal assistance

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 30 325111 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325111 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Village at Northrise - Desert Willow I 2884 North Road Runner Parkway Las Cruces, NM 88011

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 10. Sit to lying: Substantial/maximal assistance

Level of Harm - Minimal harm or 11. Lying to sitting on side of bed: Substantial/maximal assistance potential for actual harm 12. Sit to stand: Substantial/maximal assistance Residents Affected - Some 13. Chair/bed-to-chair transfer: Substantial/maximal assistance

14. Toilet transfer: Substantial/maximal assistance

15. Tub/shower transfer: Substantial/maximal assistance

I. Record review of R #184's care plan, dated 09/25/24, revealed staff did not document R #184's functional level and the assistance needed to complete ADL's.

J. On 01/30/25 at 10:09 AM, during an interview with the MDS Coordinator, she confirmed R #184's care plan did not include his functional abilities. She confirmed that staff should have documented R #184's functional abilities in R #184's care plan.

49313

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 30 325111 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325111 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Village at Northrise - Desert Willow I 2884 North Road Runner Parkway Las Cruces, NM 88011

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41755

Residents Affected - Some Based on record review and interview, the facility failed to ensure care plan requirements were met for 4 (R #4, R #7, R #8, and R #19) of 6 (R #2, R #4, R #7, R #8, R #18, and R #19) residents reviewed for care plans when staff failed to:

1. Have the required Interdisciplinary Team (IDT, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) members participate in the care plan meeting for R #7, R #8, and R #19.

2. Revise the care plan with the most current resident information for R #4.

These deficient practices could likely result in the care plan not being updated with the most current resident conditions and appropriate interventions due to lack of participation of the entire IDT, staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are:

IDT Team

R #7

A. Record review of the Post Admission Patient-Family Conference form dated 12/09/24, revealed R #7, nurse navigator, social services staff, rehabilitation (therapy services) staff and recreation staff, were present for the meeting.

B. Record review of R #7's care plan meeting note, dated 12/17/24, revealed R #7 and the social services worker were present for the meeting.

R #8

C. Record review of the Post Admission Patient-Family Conference form, dated 12/30/24, revealed R #8, dietary manager, R #8's family member (FM), nurse navigator, social services staff, rehabilitation staff and recreation staff were present for the meeting (no other care plan meetings were held for R #8).

R #19

D. Record review of R #19's care plan meeting note, dated 10/14/24, revealed R #19 and the social services worker were present for the meeting.

E. Record review of the Post Admission Patient-Family Conference form, dated 11/12/24, revealed the following:

1. The Patient/Family conference serves as the baseline care plan review and care plan meeting note.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 30 325111 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325111 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Village at Northrise - Desert Willow I 2884 North Road Runner Parkway Las Cruces, NM 88011

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 2. R #19, social services worker, and recreation worker were present for the meeting.

Level of Harm - Minimal harm or F. Record review of R #19's Post Admission Patient-Family Conference Form, dated 12/19/24, revealed R potential for actual harm #19, family, nurse navigator, rehabilitation staff, and recreation worker were all present for the meeting.

Residents Affected - Some G. On 01/30/25 at 3:04 PM, the social services worker revealed the following:

1. She is responsible for inviting people to the care plan meetings.

2. She invites the resident, their family, therapy director, the ADON (for nursing), activities, and dietary to the meetings.

3. She does not invite the CNA's and the providers to the meetings.

Care Plan Revision

R #4

H. Record review of R #4's admission record (no date) revealed R #4 was admitted to the facility on [DATE REDACTED].

I. Record review of R #4's nursing progress notes, revealed the following:

1. Skilled evaluation note dated 01/10/25 staff documented:

a. New skin issue, right heel stage I (intact skin with non-blanchable [skin does not turn white when pressed] redness of a localized area usually over a bony prominence) pressure ulcer injury.

b. Wound acquired in house.

J. Record review of R #4's care plan initiated 12/30/24 revealed staff did not update R #4's care plan to document R #4's new pressure ulcer.

49313

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 30 325111 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325111 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Village at Northrise - Desert Willow I 2884 North Road Runner Parkway Las Cruces, NM 88011

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49313 potential for actual harm Based on record review and interview, the facility failed to ensure residents received treatment and care in Residents Affected - Few accordance with professional standards of practice for 2 (R #11 and R #184) of 2 (R #11 and R #184) residents when staff failed to:

1. Implement convalescent care orders (physician's orders that admit a patient to a nursing facility after a hospital stay) for R #11 wounds.

2. Assess R #11's wounds upon admission.

3. Notify the provider when R #184 developed Moisture Associated Skin Damage (MASD, a condition where prolonged exposure to moisture, such as urine, sweat, wound exudate, or saliva, leads to skin damage).

Failure to implement convalescent care orders and notify the provider about changes in resident conditions could likely lead to facility staff and the physician being unaware of changes in resident condition and could likely lead to worsening of resident's condition. The findings are:

R #11

A. Record review of R #11's admission record revealed the following:

1. admitted [DATE REDACTED].

2. Diagnoses included the following:

a. Cellulitis (a common bacterial infection of the skin and underlying tissues) of Left Lower Limb

b. Cellulitis of Right Lower Limb

c. Sepsis (a life-threatening condition that occurs when the body's immune system overreacts to an infection), unspecified organism.

d. Methicillin Resistant Staphylococcus Aureus Infection (MRSA, infection is caused by a type of staph bacteria that's become resistant to many of the antibiotics used to treat ordinary staph infections) as the cause of Diseases Classified Elsewhere

e. Ileostomy (a surgical procedure that creates an opening (stoma) in the abdominal wall through which the ileum, the last part of the small intestine, is brought out onto the skin) Status

B. Record review of R #11's convalescent care orders, dated 12/27/24, revealed the following:

1. Continue with wound treatment orders.

2. R #11 had the following wounds and wound treatment orders:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 30 325111 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325111 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Village at Northrise - Desert Willow I 2884 North Road Runner Parkway Las Cruces, NM 88011

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 a. Wound #1- Ulceration (an open sore or break in the skin that exposes underlying tissues) on left upper arm. Level of Harm - Minimal harm or potential for actual harm - Wound Care Orders- Apply Xeroform (non-adherent gauze dressing used to treat wounds, burns, and skin abrasions) and mepilex (a soft, absorbent foam dressing used to treat wounds) border. Residents Affected - Few b. Wound #2- Multiple scattered ulcerations on left leg.

-Wound Care Orders- Apply xeroform with medihoney (a topical wound dressing made from medical-grade active Leptospermum honey). Apply kerlix (a brand of gauze bandage rolls that are used to cover wounds and absorb drainage) and ace wrap (a self-adhering medical device used to provide compression and support to injured or swollen areas).

c. Wound #3- Ulceration on left foot.

-Wound Care Orders- Apply xeroform with medihoney. Apply kerlix and acewrap.

d. Wound #4- Pressure wound (a localized area of skin damage that develops when prolonged pressure is applied to a specific area of the body) on left heel.

- Wound Care Orders- Apply mepilex foam and offload (a treatment for pressure ulcers that involves reducing pressure on the affected area).

e. Wound #5- Ulceration on right leg.

- Wound Care Orders- Apply xeroform with medihoney. Apply kerlix and acewrap.

f. Wound #6- Surgical wound (an incision or cut made in the skin or underlying tissues during a surgical procedure) on midline (center) abdomen with staples present.

- Wound Care Orders- Clean with normal saline and cover with mepilex.

g. Wound #7- Stoma (a surgically created opening in the abdomen that allows waste to exit the body) to right lower abdomen.

- Wound Care Orders- Ostomy Care (cleaning the skin around the stoma and changing the ostomy pouch).

C. Record review of R #11's admission assessment, dated 12/27/24, revealed staff did not assess R #11's skin.

D. Record review of R #11's skin assessment, dated 12/28/24, revealed staff documented R #11 had a surgical incision to his midline abdomen with staples, a colostomy, and scattered scabbing to bilateral lower extremities.

E. Record review of R #11's physician's orders, dated 01/03/24, revealed the following:

1. Wound care for both lower legs every other day.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 30 325111 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325111 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Village at Northrise - Desert Willow I 2884 North Road Runner Parkway Las Cruces, NM 88011

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 2. Wound care for both lower legs as needed.

Level of Harm - Minimal harm or 3. Wound care and off load left heel every other day and as needed. potential for actual harm 4. The medical record did not contain any wound care orders between R #11's admission on 12/27/24 and Residents Affected - Few 01/02/25.

F. Record review of R #11's entire medical record, no date, revealed staff did not document that the provider was contacted for wound care orders regarding R #11's prior to 01/03/25.

G. Record review of R #11's entire medical record, no date, revealed staff did not document that wound care was completed for R #11 between 12/27/24 and 01/02/25.

H. On 01/17/25 at 11:23 AM, during an interview with the ADON, the following was confirmed:

1. R #11's convalescent care orders stated R #11 had seven (7) wounds.

2. Staff did not document any wound care orders for R #11 until 01/03/25.

3. Staff did not document that R #11 received any wound care prior to 01/03/25.

4. The admission nurse should have entered the convalescent care orders into R #11's medical record at

the time of admission.

5. The admission nurse should have completed a skin assessment during admission.

6. He was unable to determine if R #11 received any wound care between 12/27/24 and 01/02/25.

R #184

I. Record review of R #184's admission record revealed an admitted [DATE REDACTED].

J. Record review of R #184's progress notes, multiple dates, revealed the following:

1. On 09/25/24 staff documented R #184 had a 6 centimeter (cm) long and 6 cm wide MASD due to incontinence (involuntary loss of urine or stool), on his buttocks.

2. On 09/27/24, staff documented R #184 had a 6 centimeter (cm) long and 6 cm wide MASD on his buttocks due to incontinence.

3. On 09/28/24, staff documented R #184 had a 6 centimeter (cm) long and 6 cm wide MASD on his buttocks due to incontinence.

4. On 09/29/24, staff documented R #184 had a 6 centimeter (cm) long and 6 cm wide MASD on his buttocks due to incontinence.

5. On 10/01/24, staff documented R #184 had a 6 centimeter (cm) long and 6 cm wide MASD on his buttocks due to incontinence.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 30 325111 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325111 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Village at Northrise - Desert Willow I 2884 North Road Runner Parkway Las Cruces, NM 88011

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 6. On 10/02/24, staff documented R #184 had a 6 centimeter (cm) long and 6 cm wide MASD on his buttocks due to incontinence. Level of Harm - Minimal harm or potential for actual harm 7. On 10/03/24, staff documented R #184 had a 6 centimeter (cm) long and 6 cm wide MASD on his buttocks due to incontinence. Residents Affected - Few 8. On 10/09/24, staff documented R #184 had a 6 centimeter (cm) long and 6 cm wide MASD on his buttocks due to incontinence.

9. On 10/10/24, staff documented R #184 had a 6 centimeter (cm) long and 6 cm wide MASD on his buttocks due to incontinence.

10. On 10/11/24, staff documented R #184 had a 6 centimeter (cm) long and 6 cm wide MASD on his buttocks due to incontinence.

11. On 10/12/24, staff documented R #184 had a 6 centimeter (cm) long and 6 cm wide MASD on his buttocks due to incontinence.

12. On 10/13/24, staff documented R #184 had a 6 centimeter (cm) long and 6 cm wide MASD on his buttocks due to incontinence.

13. Staff did not document that the provider was notified about R #184 having MASD.

14. Staff did not document that any treatment for R #184's MASD was provided.

K. Record review of R # 184's physician's orders, no date, revealed the medical record did not contain any orders to treat R #184's MASD.

L. On 01/29/25 at 3:16 PM, during an interview, CNA #16 stated if a resident develops redness to the skin or any changes to the skin, the CNA is expected to notify the nurse so the nurse can assess the resident and tell the CNA if they are supposed to apply barrier cream (to create a protective barrier on the skin's surface) to the area.

M. On 01/29/25 at 3:19 PM, during an interview with RN #16, the following was revealed:

1. If the nurse is notified by the CNA that a resident developed redness or skin changes, the nurse is expected to assess the resident's skin to determine what kind of skin issue the resident has.

2. The nurse is expected to contact the provider to get orders.

3. She confirmed that staff did not document in R #184's medical record that the provider was notified about his MASD.

4. She confirmed that R #184's medical record did not have any orders to treat his MASD.

N. 01/30/25 at 2:58 PM, during an interview with the DON, the following was confirmed:

1. R #184 had MASD.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 30 325111 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325111 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Village at Northrise - Desert Willow I 2884 North Road Runner Parkway Las Cruces, NM 88011

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 2. R #184's medical record did not contain any documentation that the provider was notified about his MASD. Level of Harm - Minimal harm or potential for actual harm 3. Staff should have notified the physician and the resident's family about his skin changes.

Residents Affected - Few 4. Staff should have documented any communication with the provider and family about his skin changes.

5. Any orders received from the provider should be documented and followed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 30 325111 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325111 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Village at Northrise - Desert Willow I 2884 North Road Runner Parkway Las Cruces, NM 88011

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41755 potential for actual harm Based on record review and interview, the facility failed to ensure wound care orders were obtained and Residents Affected - Few implemented and wound care was completed for 1 (R #4) of 3 (R #4, R #11, and R #28) residents reviewed for pressure ulcers (damage to an area of the skin caused by constant pressure on the area for a long time).

These deficient could likely result in the provider being unaware of the resident's current condition, leading to inconsistent interventions and worsening of pressure ulcers. The findings are:

A. Record review of R #4's admission record (no date) revealed R #4 was admitted to the facility on [DATE REDACTED].

B. Record review of the wound care consultation (outside wound care provider) note dated 12/25/24 revealed the following:

1. Stage II (shallow, open ulcer with a red-pink wound bed, without slough [non-viable tissue composed of dead cells accumulating on the wound surface. Can appear as a moist, yellow, tan, or white layer and is often fibrous or stringy in texture]) coccyx (tailbone, is a small triangle-shaped bone at the end of the spinal column) pressure ulcer

a. Coccyx (tailbone, is a small triangle-shaped bone at the end of the spinal column) wound present on arrival: Continue wound care. Turn every two hours to offload pressure points.

C. Record review of R #4's facility's provider progress notes revealed the following:

1. History and Physical (H and P; most formal and complete assessment of the patient and the problem is a formal document that providers produce through the interview with the patient, the physical exam, and the summary of the testing either obtained or pending) dated 12/31/24

a. Coccyx wound present on arrival: Continue wound care.

D. Record review of R #4's Dietitian assessment note dated 01/06/25 revealed the following:

1. R #4 was admitted with a wound to coccyx.

2. R #4 is at nutritional risk due to skin breakdown.

E. Record review of R #4's physician's orders revealed an order date 01/11/25, Wound care - Sacrum (area of spinal column just above the coccyx) apply Allevyn sacrum dressing (name brand, highly absorbent adhesive sacral shaped foam dressing with waterproof and bacteria proof outer film layer) for pressure relief

on bony prominence. Maintain dressing clean dry and intact. Change every other day and as needed one time a day every other day.

F. Record review of R #4's Treatment Administration Record (TAR, electronic document where facility staff document wound care was completed) for December 2024 revealed facility staff did not have orders in place for treatment of R #4's pressure ulcer for 12/30/24 and 12/31/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 30 325111 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325111 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Village at Northrise - Desert Willow I 2884 North Road Runner Parkway Las Cruces, NM 88011

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 G. Record review of R #4's TAR for January 2025 revealed facility staff did not have orders in place for treatment of R #4's pressure ulcer until 01/11/25. Level of Harm - Minimal harm or potential for actual harm H. Record review of R #4's Nursing Progress Notes dated 12/30/24 through 01/11/24 revealed staff did not consult with the facility provider to obtain wound care orders. Residents Affected - Few I. On 01/30/25 at 4:12 PM, during an interview, the DON stated the following:

1. Nursing staff are not identifying wounds for residents upon admission.

2. Nursing staff did not obtain orders for R #4's pressure ulcer which was present on admission.

3. It is her expectation that orders be obtained on admission if residents are admitted with pressure ulcers.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 30 325111 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325111 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Village at Northrise - Desert Willow I 2884 North Road Runner Parkway Las Cruces, NM 88011

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm 47510

Residents Affected - Some Based on observation, and interview the facility failed to keep the residents free from accidents for all 14 residents on the East Unit (Residents were identified by the resident Census provided by the Administrator

on 01/14/25), when they failed to keep treatment carts (a movable piece of equipment used in healthcare facilities to store, transport, and dispense treatment supplies and tools) locked when not supervised by staff.

This deficient practice could likely result in injury to residents obtaining medical equipment which can cause injury/death:. The findings are:

A. On 01/15/25 at 9:12 AM, during an observation of the East Unit, the IV (intravenous, within vein) treatment cart was unlocked and opened, the cart had sterile needles, and intravenous catheters (a thin, flexible tube inserted into a vein to deliver fluids). Staff were not present.

B. On 01/15/25 at 9:14 AM, during an interview, RN #8 confirmed the IV treatment cart was unlocked and opened. She said the treatment cart should be locked when not in their sight or control.

C. On 01/15/25 at 9:16 AM, during an observation of the East Unit, the treatment cart was unlocked and opened, the cart had diclofenac (anti-inflammatory), bacitracin (antibiotic cream), nystati (antibiotic cream), mupirocin (antibiotic cream), silvasorb (antimicrobial wound dressing) lotions, and scissors. Staff were not present.

D. On 01/15/25 at 9:19 AM, during an interview, LPN #8 confirmed the treatment cart was unlocked and opened, even though the treatment cart is supposed to be locked.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 30 325111 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325111 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Village at Northrise - Desert Willow I 2884 North Road Runner Parkway Las Cruces, NM 88011

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Minimal harm or potential for actual harm 47510

Residents Affected - Few Based on observation, record review and interview, the facility failed to ensure a resident with a condom catheter (an external urinary device that collects urine from men with urinary incontinence or difficulty urinating) had an order and clinical condition that demonstrated that a condom catheter was necessary for 1 (R #191) of 1 (R #191) residents reviewed for catheter use. This deficient practice could likely result in an increased and unnecessary risk of a urinary tract infection (bacteria in the urinary tract).

A. On 01/15/25 at 1:53 PM, during an interview, R #191 said he had a catheter to streamline the process of elimination. R #191 said that he is continent of bowel and bladder.

B. On 01/15/25 at 1:54 PM, during an observation of R #191, revealed R #191 had a catheter.

C. Record review of R #191's physicians orders revealed R #191 did not have an order for a condom catheter.

D. Record review of R #191's medical record revealed the record did not contain any documentation of a clinical condition for the need of a condom catheter.

E. On 01/17/25 at 2:30 PM, during an interview, the DON confirmed she did not see an order, or a clinical condition documented for R #191's catheter. The DON said that the expectation is that all residents have orders for catheters and that there should be a clinical reason for the resident to have a catheter.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 30 325111 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325111 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Village at Northrise - Desert Willow I 2884 North Road Runner Parkway Las Cruces, NM 88011

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or 47510 potential for actual harm Based on observation, interview, and record review, the facility failed to provide respiratory care (health care Residents Affected - Few discipline specializing in the promotion of optimum cardiopulmonary function, health and wellness) that was consistent with professional standards of practice for 1 (R #2) of 1 (R #2) resident sampled for respiratory care when staff failed to change R #2's nasal cannula (medical device to provide supplemental oxygen therapy to through the nose) within 7 days of the previous change. This deficient practice could likely cause

the nasal cannula to become obstructed, non-functional, and unsanitary and not provide the resident with the oxygen needed. The findings are:

A. On 01/15/25 at 11:03 AM, during an observation of R #2 revealed R #2 had a portable oxygen tank and nasal cannulas. The nasal cannulas were not dated with a date indicating the date they had been changed.

B. Record review of R #2's Physicians Orders dated 12/18/24 revealed Oxygen at 2 Liters to be administer via nasal cannula continuously.

C. On 01/16/25 at 1:51 PM, during an interview, the DON stated the oxygen cannula's are changed once a week, usually on Sundays. The DON said that there should be a piece of tape on the tubing with a date to document when the tubing was changed. The DON stated that the tape on the tubing is how they document when it was changed.

D. On 01/16/23 at 1:55 PM, during an interview CNA #8 confirmed R #2's cannula does not have a date indicating when the cannula was changed. CNA #8 said that the cannulas are usually changed on Sundays and she could not confirm if R #2's cannula had been changed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 30 325111 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325111 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Village at Northrise - Desert Willow I 2884 North Road Runner Parkway Las Cruces, NM 88011

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0732 Post nurse staffing information every day.

Level of Harm - Potential for 41755 minimal harm Based on observation and interview, the facility failed to post nurse staffing data on a daily basis that Residents Affected - Many included the following:

1. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift to include:

a. Registered nurses.

b. Licensed practical nurses.

c. Certified nurse aides.

This deficient practice could likely result in residents not knowing which staff is working. The findings are:

A. On 01/30/25 at 3:29 PM, during an observation of the facility, revealed the nurse staffing data posted at

the front entrance of the facility did not include the total number of actual nursing staff scheduled and actual hours worked by nursing staff for the day.

B. On 01/30/25 at 4:15 PM, during an interview, the DON confirmed the night shift nurse is responsible for posting the nurse staffing data and it should include the total number of staff scheduled for each shift and the number of hours that each nursing staff is scheduled to work.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 30 325111 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325111 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Village at Northrise - Desert Willow I 2884 North Road Runner Parkway Las Cruces, NM 88011

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 49313 Residents Affected - Some Based on observation and interview, the facility failed to properly store medications, when staff failed to ensure medications were not expired in medication cart for all 14 residents on the East Unit (Residents were identified by the resident matrix provided by the Administrator on 01/15/25).

This deficient practice could likely result in residents obtaining medications that are no longer effective, resulting in adverse side effects. The findings are:

A. On 01/21/25 at 3:25 PM, an observation of the medication cart on the East Unit revealed fish oil supplement (a supplement used to help reduce pain, improve morning stiffness and relieve joint tenderness

in people with rheumatoid arthritis), 1000 mg, expired on 12/2024.

B. On 01/21/25 at 3:27 PM, during an interview with RN #16, she confirmed the bottle of Fish Oil 1000 mg was expired and should not have been in the medication cart.

C. On 01/21/25 at 3:35 PM, during an interview with the DON, she confirmed expired medications should not be in the medication carts. Nurses should check for expired medications in the medication carts each shift.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 30 325111 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325111 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Village at Northrise - Desert Willow I 2884 North Road Runner Parkway Las Cruces, NM 88011

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 49313 potential for actual harm Based on record review and interview, the facility failed to maintain an infection prevention and control Residents Affected - Many program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections when they failed to have a water management program to minimize the risk of Legionella [a bacteria that can grow in parts of building water systems that are continually wet (e.g., pipes, faucets, water storage tanks, decorative fountains) and cause a serious type of pneumonia], and other opportunistic pathogens (bacteria that do not usually cause diseases in healthy people but may become extremely injurious to unhealthy individuals) in the building's water system. This failure could potentially affect all (27) residents who live in the facility (residents were identified by the Resident Matrix provided by the Administrator on 01/15/25).

If the facility fails to maintain an effective infection control program, then infections could spread to residents throughout the facility, resulting in illness. The findings are:

A. Record review of the facility's Water Management Policy, revised 09/13/24, revealed the following:

1. The facility will develop a Water Management Plan that is overseen by the water management plan team.

2. Water management team consists of Center leadership, infection preventionist, maintenance employees, safety officers, risk and quality management staff, and the Director of Nursing.

3. To minimize exposure to Legionella and other water-borne pathogens to our patients, family members, staff, and visitors.

4. The Maintenance Director maintains documentation in the TELS (is a building management platform designed for Senior Living with integrated Asset Management, Life Safety, and Maintenance solutions) Water Management Plan that describes the Center's water system.

5. A risk assessment will be conducted by the water management team annually to identify where Legionella and other opportunistic waterborne pathogens could grown and spread in the facilities water systems.

6. Data to be used for completing the risk assessment may include, but are not limited to:

a. Water system schematic/description;

b. Legionella environment assessment;

c. Patient infection control surveillance data;

d. Environment culture results;

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 30 325111 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325111 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Village at Northrise - Desert Willow I 2884 North Road Runner Parkway Las Cruces, NM 88011

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 e. Rounding observation data;

Level of Harm - Minimal harm or f. Water temperature logs; potential for actual harm g. Water quality reports from drinking water provider; Residents Affected - Many h. Community infection surveillance data.

B. On 01/29/25 at 3:46 PM, during an interview with the Director of Maintenance, stated the following:

1. He has been the Director of Maintenance since 10/2023.

2. He was not aware of anything that was supposed to be done to prevent the growth of Legionella or other waterborne pathogen.

3. The previous administrator handled water management.

4. The previous administrator left in May or June 2024.

C. On 01/29/25 at 3:44 PM, during an interview with the DON, stated the following:

1. She has not been involved in any meetings regarding preventing the growth of Legionella or other waterborne pathogens.

2. She has not done anything for the management of Legionella or other waterborne pathogens.

D. On 01/30/25 at 8:26 AM, during an interview with the Administrator, the following was confirmed:

1. The Director of Maintenance should have a diagram of the water system and any areas where Legionella or other waterborne pathogens could grow.

2. He was not aware of who was on the Water Management Plan team.

3. He has not been involved in any meetings about water management.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 30 325111 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325111 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Village at Northrise - Desert Willow I 2884 North Road Runner Parkway Las Cruces, NM 88011

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0882 Designate a qualified infection preventionist to be responsible for the infection prevent and control program in

the nursing home. Level of Harm - Minimal harm or potential for actual harm 49313

Residents Affected - Many Based on interview and record review, the facility failed to designate a qualified, trained, or certified Infection Preventionist (IP) who was responsible for the facility's Infection Prevention and Control Program (IPCP.)

This failure could affect all 27 residents in the facility (residents were identified by the resident matrix provided by the Administrator on 01/08/24). This deficient practice could likely result in residents being at greater risk of infectious disease. The findings are:

A. On 01/29/24 at 3:33 PM, during an interview, the DON stated the following:

1. The IP had some issues with her nursing license.

2. The IP has been on leave due to the issues with her nursing license since 01/10/25.

3. She is now performing IP duties.

4. She is working to obtain her IP certification.

B. Record review of the former IP's time sheet, no date, confirmed she last worked at the facility on 01/10/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 30 325111 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 325111 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Village at Northrise - Desert Willow I 2884 North Road Runner Parkway Las Cruces, NM 88011

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area.

Level of Harm - Minimal harm or 47510 potential for actual harm Based on observation and interview, the facility failed to ensure the call light pull cords in resident's rooms Residents Affected - Some were adequately equipped to allow residents to call for help using the call light system for 3 (R #4, R #8, and R #15) of 3 (R #4, R #8, and R #15) when the facility failed to have proper pull cords on the call light system

in the resident's rooms when they could not be reached if the resident was not in bed. This deficient practice could likely result in residents being unable to call for assistance. The findings are:

R #4

A. 01/15/25 3:48 PM, during an interview, R #4's wife said that R #4 was not cognizant (not having knowledge or being aware of) enough to pull the cord on the call light. R #4 had no other option for the calling for help.

R #8

B. On 01/15/25 at 11:01 AM, during an interview and observation of R #8's room revealed a trash bag was tied to the end of the call light. R #8 said that the cord on his call light is too short and he can't reach the call light. R #8 said he didn't know why the trash bag was tied to the cord except to maybe make it longer.

R #15

C. On 01/30/25 at 11:43 AM during an observation of resident's rooms, revealed R #15 can not reach the call light from his bed. During an interview, the Maintenance Director (MD) #1 confirmed R #15 can't reach his call light while he is out of bed.

D. On 01/30/25 at 10:59 AM, during an interview, MD #1 confirmed the pull cords for the call lights for R #4 and R #8 can only be reached if the residents are laying in their beds. MD #1 confirmed that if R #4 and R #8 could not use their call lights to call for help while not in bed. MD #1 confirmed that none of the pull cords in

the resident's rooms in the facility could be reached if residents were not in their beds. MD #1 said the cord used to be longer but would get tangled up so they made them shorter. MD #1 said that the cord attached to

the call light on the wall was the only option for call lights. MD #1 said that they did not have any way to modify the pull cord for residents that were not cognizant enough to pull the cord. MD #1 said that some of

the cords had bags tied to them because it made it easier for the resident's to grip.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 30 325111