SILVER CITY, NM- SILVER CITY CARE CENTER

The Department of Health & Human Services conducted an inspection of the facility. The following  highlighted decencies listed below were found in a public survey.

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Based on record review and interview, the facility failed to report to the State Survey Agency within five (5) days of the incident for 1 (R #21) of 1 (R #21) residents sampled for abuse. If the facility fails to report abuse to the State Agency, then corrective action may not be taken, and residents could likely continue to be abused and/or suffer serious bodily injury.

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Based on record review and interview, the facility failed to revise the care plan for 2 (R #11 and R #21) of 4 (R #11, R #12, R #13, and R #21) residents reviewed for care plans when they failed to:
1. Revise R #11’s care plan to include her regular/liberalized dysphagia advanced diet (moist foods in bite-sized pieces).
2. 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 #21.

This deficient practice could likely result in staff being unaware of changes in care provided and residents not receiving the care related to changes in their health status or healthcare decisions.

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Based on record review and interview, the facility failed to have a discharge summary that includes a summary of the resident’s stay at the facility for 1 (R #22) of 3 (R #21, R #22, and R #23) residents reviewed for discharge. Failure to provide a complete discharge summary that includes a description of the resident’s stay at the facility could likely result in the receiving facility or home health or home health agency not having the most current information to provide care to the residents.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Based on observation, and interview the facility failed to keep the residents free from accidents for all 61 residents on the 100 and 200 Units (Residents were identified by the resident Census provided by the Administrator on 05/6/24), 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.

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Based on record review and interview, the facility failed to provide metal health services for 1 (R #21) of 1 (R #21) residents reviewed for mental health concerns, when the facility failed to provide metal health services for R #21 after the provider placed an order for mental health services.

This deficient practice could likely result in worsening of behaviors and worsening of behavioral or mental health conditions causing increased depression and anxiety.

Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.

Based on record review and interview, the facility failed to ensure that staff received the appropriate behavioral health training and have the skills to provide behavioral health services for 1 (R #21) of 1 (R #21) residents reviewed for behavioral health concerns. This deficient practice is likely to result in residents not getting the care and assistance they need.

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Based on interview and record review, the facility failed to provide social services for 1 (R #21) of 1 (R #21) residents reviewed for behavioral/emotional health, when they failed to provide timely referrals for R #21 to other long term nursing facilities after R #21 requested to be transferred.

This deficient practice could likely lead to residents to feel that their wishes are not important and not attaining, or maintaining, their highest practicable mental and psychosocial well-being.

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Based on record review and interview, the facility failed to ensure residents did not receive psychotropic medications unless the medication was necessary to treat a specific psychiatric diagnosis and was documented in the medical record for 1 (R #12) of 3 (R #11, R #12 and R #13) residents reviewed for unnecessary psychotropic medications. This deficient practice could likely result in residents receiving medications without a medical reason and being at a higher risk of adverse side effects (unwanted, harmful, or abnormal result).

Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

Based on observation, record review, and interview the facility failed to provide a therapeutic diet (a die ordered by a physician or delegated registered or licensed dietitian as part of treatment for a disease or clinical condition, or to eliminate or decrease specific nutrients in the diet) as ordered by a physician for 1 (R #11) of 3 (R #11, R #12, R #13) residents reviewed for dietary services. If the facility fails to provide a diet as ordered, then residents are likely to experience weight loss due to not receiving their prescribed nutritional caloric intake and may be at risk for choking.