ALBUQUERQUE, NM- LADERA CENTER

Based on interview and record review the facility failed to recognize and respond timely to a change in
condition involving muscle weakness, numbness and slurred speech for 1 (R #7) of 3 (R #2, 5 and 7)
residents reviewed for delay in treatment. This deficient practice likely resulted in R #7 to have newly
developed persistent left sided arm and leg weakness that resulted in her inability to stand and walk as she had previously done.

Record review of nursing progress notes dated 08/29/21 at 8:48 am revealed, late entry from 8/27/2021
Ms. [last name of R #7]was not able to work with therapy do to weakness on lower extremities [part of the
body from the hips to the toes], this was report by therapy staff before lunch around 11:30 am. Daughters
was here and report that Ms. [last name of R #7] was having weakness and numbness on left upper
extremities [body parts including shoulder, arm, forearm, wrist, and hand] and lower extremities [leg, foot].
This was reported around 3:40 pm. Physician was at the facility at this time and was informed of Ms. [last
name of R #7] complain of L [left] side weakness and numbness, Physician assess her and inform daughter
about the citation [situation] and recommend daughter to have Ms. [last name of R #7] [be] check [ed] out at
the hospital to rule out any cardiac [heart] issues, daughter agree and transportation was arrange
immediately. Patient was send to [name of local hospital] with all necessary paper work. She was transfer on
stretcher via ambulance around 5:15 pm.

On 12/07/21 at 11:10 am during interview with the R #7’s daughter she revealed, the first time she visited
her mother on 08/27/21 was in the morning about 10:30 am and her mom had been seen by the nurse
because she had not felt good enough to go for a walk and she [the daughter] was told she was okay by the
nurse. The next time she saw her mom was in the late afternoon of 08/27/21 at about 4:00 pm and her mom
had slurred speech [mumbling, unable to speak clearly] and left sided weakness and that she was the
person who alerted the staff to this change. She revealed, The hospital said she had a stroke. Since then
she has more difficulty with the left side of her body.

Record review of, ADL [Activities of Daily Living, such as bathing turing in bed, walking] Record for August
of 2021 prior to R #7’s hospitalization , she was documented as walking in her room and as able to do this
with supervision [watching but not physically assisting] of one person. When she returned from the hospital,
her October 2021 the ADL record documented, that the activity did not occur [she was no longer able to
perform this activity].