Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at El Paso Rehabilitation And Health Care Center during CMS and state inspections, most recent first.
Failure to notify the State Guardian of a cognitively impaired resident’s elopement. Staff found that a resident had exited the building without signing out or being directly observed leaving through a secured exit, and the chart did not document notification to the guardian. The guardian later stated she was not told the resident had left unsupervised, and the Administrator said notification did not occur until later.
Failure to identify elopement risk for a cognitively impaired resident. A resident with Alzheimer’s disease, psychosis, delusions, hallucinations, and exit-seeking behaviors was documented as independently mobile and with a history of elopement, but the care plan and MDS did not address the behavior. The elopement assessment indicated the resident was at risk and should have had elopement interventions and a care plan, but staff verified these were not in place.
A resident with cognitive impairment had a long history of exit-seeking and sitting by the front door waiting for family to pick him up, but the care plan did not include goals or interventions for elopement risk. Staff observed the resident repeatedly stating he was waiting for his mom, dad, brother, or family to take him to the farm, and an LPN/Care Plan Coordinator said these behaviors should have been care planned.
Failure to supervise a cognitively impaired resident with known exit-seeking behavior led to an unsupervised elopement from the facility. The resident had Alzheimer’s disease, schizophrenia, psychotic disorder, and a guardian, and his elopement risk assessment identified history of elopement, wandering, and a desire to leave. Although staff knew he frequently sat by the front door and talked about family picking him up to go to a farm, his care plan did not address elopement risk. Staff later learned from a neighbor that the resident was outside on her porch and walking back toward the facility, but the event was not documented in the chart and the guardian was not notified.
Multiple alert and oriented residents were subjected to physical abuse by peers with known behavioral issues, including one resident whose hand was punched in the dining room, resulting in a mildly displaced metacarpal fracture, and others who were struck in the face or body with a thrown plate, fists, or other blows during meal service and common‑area interactions. Staff and witnesses consistently described verbal altercations and escalating behaviors that culminated in residents throwing punches or objects, with some aggressors having documented schizoaffective disorder, dementia, or impaired impulse control and existing care plans noting physical aggression toward peers and vulnerability to peer conflict. These repeated resident‑to‑resident altercations, occurring in dining and common areas and causing bruising, facial redness, and other injuries, show that residents were not effectively protected from physical abuse despite the facility’s abuse prevention policy.
A resident was subjected to nonconsensual sexual contact by another resident in a common area, as witnessed by staff and confirmed by both residents involved. The incident was reported and documented, with the affected resident stating the contact was unwanted and made her uncomfortable. Facility policy prohibits such abuse, but the event occurred despite these guidelines.
A resident with mental health concerns was transferred to the hospital due to behavioral issues and later returned to the facility in an agitated state. The facility did not notify the resident's guardian of the return, despite policy requiring such notification, and the guardian only became aware after reaching out to the facility.
A resident identified as an elopement risk made multiple attempts to leave the facility unattended, including one incident where the resident exited into the parking lot and became combative. Despite these events, the care plan was not updated or revised to include new interventions, as confirmed by the Care Plan Coordinator.
Menus were not consistently prepared in advance, followed, updated, or reviewed by a dietician, resulting in failure to meet the nutritional needs of residents according to their care plans.
A resident with multiple medical and psychiatric diagnoses was transferred to the hospital without completion of the required SBAR assessment or documentation of a provider order, as mandated by facility policy. Staff interviews confirmed the absence of necessary documentation and uncertainty about policy requirements for hospital transfers.
A resident with severe cognitive impairment and a history of aggression struck another cognitively intact resident on the head during a verbal altercation in a common area. The incident was witnessed by another resident and confirmed by an LPN, and occurred despite facility policies requiring close supervision for residents identified as moderate risk for behavioral issues.
Two residents with histories of behavioral issues were involved in a physical altercation in the dining room, resulting in one resident being struck in the mouth and bleeding. Despite one-to-one monitoring and multiple staff present, the aggressive resident was able to hit both another resident and staff members. The incident was witnessed by several staff, and the facility's investigation lacked comprehensive witness details.
The facility did not complete thorough abuse investigations for three residents, failing to identify and interview all potential witnesses and relying on generic interview forms that did not address the specific details of the alleged incidents. In one case, a physical altercation between two residents was not fully investigated, and in another, an allegation of verbal abuse by a consultant was not explored in detail. Staff confirmed that original statements were not retained and that the process lacked targeted questioning.
A resident with a history of physical aggression and multiple psychiatric diagnoses was left unsupervised in his room with the door closed, despite being on 1:1 supervision status. The CNA assigned to supervise him was assisting another resident at the time, leaving the resident out of sight, contrary to facility in-service requirements that mandate continuous observation.
A resident with an indwelling urinary catheter was found with the catheter tubing unsecured and hanging out of an incontinent brief, contrary to facility policy requiring the use of a leg strap. The resident expressed concern about the tubing not being strapped, and both a CNA and the ADON confirmed that a stabilizer should have been in place.
A facility failed to protect residents' health information when a group text message containing dietary information cards with residents' names, room numbers, and diet details was shared among CNAs. Despite the facility's policy on PHI protection, this incident violated HIPAA regulations. The Administrator was aware of the issue but could not initially find proof, while the DON confirmed the breach as a HIPAA violation. Residents expressed concerns about their privacy.
Two residents experienced physical abuse from fellow residents in separate incidents. One resident was pushed against a wall after asking another to stay out of her room, while another was pushed in the dining room following a disagreement over meal tickets. Both residents were cognitively intact, and the incidents were reported to the state agency.
The facility failed to maintain a homelike environment, with issues such as chipped paint, holes in walls, and loose cable cords observed in several resident rooms. The maintenance supervisor was unaware of many issues until the survey, and work orders were not adequately documented or addressed. Residents expressed dissatisfaction with their living conditions, which were not promptly addressed by the facility.
The facility failed to process medication orders timely, resulting in six residents not receiving prescribed medications. The Psychiatric Nurse Practitioner entered orders into the EMR, but they remained pending until confirmed by an LPN, who was unavailable to do so promptly. This led to missed doses of medications for residents with conditions such as schizophrenia, depression, and anxiety.
The facility failed to maintain privacy and dignity for two residents. One resident's room door would not latch, preventing privacy, and the issue was known but unresolved. Another resident's urinary catheter bag was exposed in the dining room, contrary to her care plan, and the facility lacked a policy for covering catheter bags.
The facility failed to accommodate the needs of two residents by placing activity calendars too high and in small print, making them inaccessible. One resident, blind in one eye, missed activities due to this oversight. The DON confirmed the calendars were not appropriately placed or legible.
A facility failed to include a resident's Hepatitis C and blindness in the right eye in their care plan. The resident, observed in a wheelchair with a cloudy right eye, confirmed blindness. The face sheet documented these diagnoses, but the care plan did not address them. The care plan coordinator acknowledged the oversight.
A facility failed to implement nonpharmacological interventions for a resident with depression and anxiety, despite documented verbal and physical behaviors. The facility's policy requires such interventions, but the resident's care plan lacked them, and the DON confirmed their absence, stating the resident was only on antidepressants.
A facility failed to have a signed hospice contract for a resident receiving hospice services. The resident, with a terminal diagnosis related to dementia, had an order for hospice evaluation and treatment. Communication with the resident's POA and the local hospice was documented, and the resident was approved for hospice services. However, during a survey, the facility could not provide a signed hospice contract, as confirmed by the Administrator.
The facility's survey book was not up-to-date, missing the most recent survey and several complaint investigations from 2024. This was confirmed by the administrator and could potentially affect all 88 residents.
The facility failed to maintain the required minimum of three years of resident grievance records, only having records for 2023 and 2024. The Director of Nursing and Administrator confirmed the absence of 2022 records, which could affect all 88 residents.
The facility failed to maintain a proper bookkeeping system for resident accounts, affecting all 93 residents. The electronic ledger system was hacked, and manual ledgers were not adequately maintained. The Administrator could not provide current balances, and the last balance report was from September 2023. V4 struggled to keep up with manual processes, and required documentation was not submitted to the corporate office since September 2023.
A resident was physically abused by another resident who pulled her hair and pushed her head down after being asked to stop tampering with diet cards. The facility's investigation confirmed the abuse, but the motive remained unclear as both residents refused to discuss the incident further.
A resident with severe mental health issues, including Bipolar disorder and Generalized Anxiety, was involuntarily discharged without a signed physician order, despite a history of aggressive behaviors and elopement attempts. The facility failed to ensure proper documentation and compliance with discharge procedures, leading to a deficiency in handling the resident's discharge.
A resident with mental health disorders did not receive required social services, including one-on-one visits and group therapies, during their stay. The facility's social services department was newly established and lacked in-house psychiatric services, contributing to the deficiency.
The facility failed to employ a Certified Dietary Manager, affecting all 95 residents. The current Dietary Manager is not certified and has not been enrolled in a certification program. They do not perform clinical nutrition tasks, such as reviewing weight records or completing the MDS section, as they are often filling in for absent staff. This deficiency was noted in the facility's application for Medicare and Medicaid.
The facility failed to provide adequate staffing in the Dietary Department, resulting in delayed meal services for all 95 residents. The Facility Assessment indicated a need for 900 to 945 hours of staffing per two-week period, but only 301.25 hours were worked. On one occasion, the Dietary Manager had to cook due to a call-off, and residents reported frequent meal delays of up to an hour, attributed to short staffing.
The facility failed to maintain a clean and sanitary kitchen environment, with appliances covered in food debris and grease, improper food storage, and inadequate sanitation practices. The Dietary Manager cited staffing challenges as a reason for these deficiencies, which could affect the safety and quality of food for the 95 residents.
The facility failed to properly dispose of garbage, as observed with an open dumpster and surrounding debris. Dietary Aides noted the dumpster is often overflowing, especially on weekends. This deficiency could impact all 95 residents.
The facility failed to maintain the walk-in refrigerator at the correct temperature, with issues such as a loose gasket, improper shelf repair, and condensation collection. The Dietary Manager reported these issues, but no repairs were made. The Maintenance Supervisor was unaware of the problems due to a backlog of work orders. The facility's Administrator in Training confirmed the absence of work order copies, except for one. These deficiencies potentially affected all 95 residents.
The facility failed to maintain an effective pest control program, resulting in flies and gnats in the kitchen, dining room, and resident rooms. Flies were observed landing on food and clean items in the kitchen, and residents reported issues with flies in their rooms. An appliance meant to control flies was found unplugged in the dining room.
A resident with a history of inappropriate behavior, including spitting and making unwanted physical contact, continued to abuse other residents despite being on 1:1 supervision and having interventions in place. The facility's incident logs document multiple occurrences of this resident's abusive behavior towards others, highlighting a failure to protect residents from abuse.
The facility did not accommodate a resident's shaving preferences because mirrors were removed from shower rooms during remodeling. A resident reported being unable to shave, and a CNA confirmed that residents had to request staff assistance to shave in their rooms where mirrors were available.
A facility failed to honor a resident's request to empty their urinal at night, resulting in the resident enduring the smell of urine throughout the night. A CNA confirmed that the urinal was often full when they arrived for their shift, despite the facility's policy to treat residents with dignity and maintain a clean environment.
A facility failed to provide a bed hold notification to a resident transferred to the hospital, as required by their policy. The resident was hospitalized and returned with new orders for an antibiotic due to a urinary tract infection. The facility administrator confirmed that no bed hold notification was recorded for this hospital stay.
A facility failed to update a resident's care plan and conduct quarterly elopement risk assessments, despite the resident's high risk for wandering and exit-seeking behavior. The resident, with a history of paranoid schizophrenia and anxiety disorder, attempted to leave the facility multiple times. Staff confirmed the lack of personal safety devices or alarms and the absence of required assessments.
A facility failed to provide appropriate dialysis care for a resident by not ensuring proper communication and collaboration with the dialysis unit. The resident's care plan lacked specific details about dialysis schedules and access site care, and communication forms were inconsistently completed. Additionally, there were no instructions in the resident's room regarding the care of the fistula, potentially compromising the resident's dialysis care.
A resident with moderate cognitive impairment physically assaulted another resident during a meal, leading to a deficiency in preventing resident-to-resident abuse. The incident, witnessed by an RN, involved a misunderstanding over seating and food, resulting in the aggressor striking the other resident. The assaulted resident, with multiple psychiatric diagnoses, expressed confusion and fear during the event.
The facility did not follow its abuse policy by failing to investigate a resident-to-resident altercation involving two residents with behavioral issues. Despite the policy requiring thorough investigations, including staff interviews, the administrator chose not to investigate further after speaking with the residents involved, who reported being fine. This incident was not reported to the State Department of Public Health, highlighting a deficiency in the facility's adherence to its abuse prevention procedures.
The facility failed to report a physical altercation between two residents to the State Agency, as required by its Abuse Prevention and Prohibition Policy. The incident, which occurred in the dining room, involved a verbal altercation escalating into a physical one. Despite the policy mandating reports for all physical altercations, the Administrator did not report the incident, highlighting a lapse in following established procedures.
The facility did not conduct a thorough investigation into a resident-to-resident altercation, as required by its Abuse Prevention and Prohibition Policy. The incident involved two residents in the dining room, where one reportedly initiated a physical altercation. Although the residents were separated and assessed, the facility failed to interview staff or obtain witness statements, leading to a noted deficiency.
A facility failed to document the justification for not readmitting a resident after a hospital stay. The resident, with a history of mental health issues, was sent to the hospital for evaluation. Despite the hospital's notes indicating stability, the facility did not document the reason for refusal to readmit, nor did they communicate with the hospital about the resident's condition. The administration cited the lack of a private room as the reason, but this was not documented, and the facility's physician was not involved in the decision.
A resident was not readmitted to the facility after a psychiatric hospitalization due to the facility's inability to meet the resident's needs for a private room. Despite the hospital's communication of the resident's stability and readiness for discharge, the facility lacked a Transfer/Discharge policy and did not facilitate the resident's return, resulting in an extended hospital stay.
Failure to Notify State Guardian of Resident Elopement
Penalty
Summary
The facility failed to notify the State Guardian of an elopement involving a cognitively impaired resident, R1, after staff became aware that R1 had exited the building without signing out or being directly observed leaving through a secured exit. The facility’s Significant Condition Change and Notification policy states that the resident’s family or representative and medical practitioner are to be notified of resident changes, including an accident or incident with or without injury that has the potential for needed medical practitioner interventions and a significant change in physical, mental, or psychosocial status, and the form documents an incident of wandering or elopement. The facility’s Past Noncompliance Statement dated 5/10/26 states staff were unsure how R1 exited because the doors were magnetically locked and required a code to disengage the system. R1’s progress notes did not document that V18, the State Guardian, was notified of the elopement, and V18 stated on 5/18/26 that she was not notified of R1 leaving the facility unsupervised. The Administrator later stated on 5/20/26 that V18 was not notified until that date.
Failure to Identify Elopement Risk
Penalty
Summary
The facility failed to accurately assess a cognitively impaired resident with known exit-seeking behaviors as an elopement risk. The facility’s Elopement Policy states that all residents will be assessed for behaviors or conditions that place them at risk for elopement and that identified issues will be addressed in individual care plans, and the Care Planning policy states that residents will be assessed using the MDS according to RAI guidelines. R1’s current care plan and MDS did not address R1’s exit-seeking behaviors. R1’s Elopement Risk Assessment documented that R1 was cognitively impaired and independently mobile, had a history of elopement, a desire to leave the building, exit-seeking with a purpose, and wandering activity, and indicated that if any of those items were checked, the resident was at risk for elopement and should have elopement interventions and an elopement risk care plan. During interview, the Social Service Aide stated that R1 had Alzheimer’s disease and psychosis, with a history of delusions and hallucinations and fixation on the family farm, and that R1 stated his family was coming to pick him up to take him to the farm. The Social Service Aide and the LPN/Care Plan Coordinator both verified that R1 should have been triggered as an elopement risk and that interventions should have been put into place, but were not.
Failure to Care Plan for Elopement Risk
Penalty
Summary
The facility failed to implement elopement interventions for one cognitively impaired resident whose care plan, dated 5/15/26, did not contain goals or interventions for exit-seeking or elopement risk behaviors. The facility’s Care Planning policy, approved 12/2024, states that residents are to be assessed using the MDS and that the assessment data is to be used to develop a comprehensive plan of care to address each resident’s strengths, weaknesses, and care needs. In this case, the resident had a long history of sitting by the front doors waiting for family to pick him up to take him to the farm, and the LPN/Care Plan Coordinator stated that these behaviors of sitting at the door on a daily basis and talking about visiting friends in the neighborhood should have been care planned. During observations, the resident repeatedly sat by the front door and made statements consistent with exit-seeking, including waiting for his mom, dad, and brother to pick him up, waiting for tractors to go by, and waiting for family to come get him to go to the farm. The resident was unable to give any specific information concerning leaving the day he left the building. The record and staff interview showed that these behaviors were ongoing and known to the facility, yet they were not included in the resident’s care plan.
Failure to Supervise Resident With Known Exit-Seeking Behavior
Penalty
Summary
The facility failed to ensure adequate supervision and effective interventions to prevent the elopement of a cognitively impaired resident with known exit-seeking behaviors. The resident had diagnoses including Alzheimer's disease, schizophrenia, psychotic disorder, and other medical conditions, and had an order appointing the Office of State Guardian as guardian for his person. His elopement risk assessment identified him as cognitively impaired and independently mobile, with a history of elopement, a desire to leave the building, exit-seeking with a purpose, and wandering activity, which indicated he was at risk for elopement. The resident's care plan documented impaired cognitive function, altered mood, impaired judgment, confusion, and a need for 15-minute safety checks, but it did not include interventions to address exit-seeking or elopement risk. Facility records and staff interviews showed that the resident had a long history of sitting by the front door and stating that his family was coming to pick him up to go to the farm. Staff also reported that he repeatedly expressed delusional beliefs about his family, a farm, and leaving with relatives, and that these behaviors were known to multiple staff members. On 5/10/26, staff became aware that the resident had exited the building without signing out or being directly observed leaving through a secured exit. A neighbor reported that the resident was on her porch, and staff found him walking back across the street toward the facility parking lot. Staff stated they did not know how he got outside, and one staff member believed he may have followed a flower delivery person or that someone may have given him the door code. The resident's progress notes did not document the unsupervised exit or a physical assessment after his return, and staff stated that the incident was not documented in the electronic record and the resident's State Guardian was not notified.
Failure to Prevent Multiple Resident-to-Resident Physical Abuse Incidents
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from physical abuse and resident-to-resident altercations, despite having an Abuse, Prevention and Prohibition Policy stating that residents must be free from abuse, corporal punishment, and involuntary seclusion. One alert and oriented resident (R1, BIMS 11) reported that while her hand was resting on a dining room table, another resident (R2) came by and punched the top of her hand without provocation. Staff heard R1 yell “Ouch” and state that R2 hit her, and R1 subsequently complained of left hand pain. Swelling and slight discoloration of the middle finger and knuckles were observed, and an X‑ray showed a mildly displaced fracture of the base of the first metacarpal bone, with reduced bone density and degenerative osteoarthritis changes. R2’s care plan documented behavioral symptoms related to schizoaffective disorder, generalized anxiety disorder, and dementia, including verbal or physical aggression when overstimulated. Another alert and oriented resident (R7, BIMS 11) was struck in the face with a plate thrown by a peer (R5) during a mid‑day meal. R7 stated that she moved away after R5 was talking loudly about sexual ideals, and that R5 then picked up a plate with food and threw it, hitting her on the right side of her face from eyebrow to cheek and causing a bruise. Progress notes documented that R7 was hit in the face with a plate by another resident in the dining room. Multiple staff witnesses, including the Social Service Director, a CNA, and an activity aide, described a verbal altercation between R5 and R7 that escalated when R5 “chucked” or threw a plate full of food at R7, striking her face and leaving a red line. Staff also reported that it took several staff members to calm R5 and that R5 attempted to lunge at R7 again while being escorted from the dining room. R5’s care plan documented physical aggression toward peers related to difficulty managing emotions and recent incidents of aggressive behavior toward other residents. A third alert and oriented resident (R3, BIMS 12) with diagnoses including disorganized schizophrenia, obsessive‑compulsive personality disorder, and borderline personality was also subjected to physical aggression by R5. Progress notes documented that R3 was standing too close to another resident’s boyfriend when R5 hit R3 in the back area and told her not to touch him. The facility’s investigation concluded that a resident‑to‑resident physical altercation occurred, initiated by R5 striking R3, and that R3 was the recipient of the behavior with no contributing actions identified. A staff statement documented that R3 had patted another resident on the back when R5 hit her and said, “Don’t touch my boyfriend or me,” and an LPN reported that R5 told R3 to get away and then hit R3 in the lower stomach. R3 was otherwise observed walking in the halls, speaking, and laughing with staff and residents, and did not display adverse behaviors. Another alert and oriented resident (R4, BIMS 15) was involved in a physical altercation with resident R6. Progress notes documented that R4 was hit on the right cheek by R6, and the facility’s investigation confirmed that R6 struck R4. A CNA’s signed statement indicated that she heard a scuffle in the dining room and turned to see R4 and R6 throwing punches at each other. R4 later stated that he had been sitting in the dining room when another resident came up and hit him in the head for no reason. R6’s care plan documented vulnerability to peer conflict due to cognitive impairment and environmental triggers, with a history of resistance to resident altercations involving physical contact, and identified R6 as being at risk for resident‑to‑resident altercations related to behavioral triggers and environmental factors. A further incident involved resident R9, who was physically struck by R6. The facility’s report documented that R6 made unwanted contact with R9 in a dining/living room area, and progress notes recorded that R6 had a physical altercation with a female peer (R9), after which 911 was called and R6 was sent to the emergency room for evaluation. A staff member from medical records stated that both R6 and R9 were in line for a vending event when R9 began yelling at R6 to hurry up, and R6 turned around and hit R9 in the face. The administrator stated that R6 had previously been placed on one‑on‑one supervision for 72 hours after the first incident with R4, and that due to the client population it was impossible to stop every resident‑to‑resident incident. Across these events, multiple residents with known behavioral issues and documented risks for aggression engaged in physical abuse of other residents, resulting in injuries such as fractures, bruising, and facial redness, demonstrating the facility’s failure to ensure residents were free from physical abuse as required by its own abuse prevention policy.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse, as evidenced by an incident in which one resident was observed to have nonconsensual physical contact with another resident in a common area. According to the facility's records and staff interviews, one resident approached another and touched her chest without her permission or consent. The incident was witnessed by a staff member, who intervened and reported the event. The resident who was touched confirmed that the contact was unwanted and made her feel uncomfortable. The resident who initiated the contact admitted to the action and stated he did not know it was wrong because the other resident did not tell him to stop. Facility documentation, including the Abuse Prevention and Prohibition Policy, clearly states that residents have the right to be free from all forms of abuse, including sexual abuse, and that such abuse is defined as non-consensual sexual contact of any type. Despite these policies, the incident occurred in a supervised area, and multiple staff members, including the administrator, were made aware of the event through direct observation and resident reports. The records indicate that the facility did not prevent the occurrence of nonconsensual sexual contact between residents.
Failure to Notify Family of Resident's Return from Hospital
Penalty
Summary
The facility failed to notify a resident's family member of the resident's return from the hospital, as required by facility policy. The policy directs staff to inform the resident's family or representative and medical practitioner of significant changes, including transfers, and to document each attempt to contact them. In this case, a resident with a history of mental health issues was transferred to the emergency room after exhibiting increased behaviors and delusions. The resident returned to the facility later that morning, displaying agitation and refusing vital signs. Despite being the resident's guardian, the family member was not informed of the resident's return and only learned of it after contacting the facility the following day. The administrator confirmed that the family member had not been notified of the resident's return.
Failure to Update Care Plan After Repeated Elopement Attempts
Penalty
Summary
The facility failed to update and revise the care plan for a resident who made repeated attempts to elope from the facility on two separate occasions. According to the facility's own care planning policy, staff are required to use assessment data to develop and update a comprehensive plan of care that addresses each resident's needs. Despite documentation in the nursing progress notes that the resident left the building through the front door and, on a later date, exited into the parking lot and down the street while becoming combative, no new interventions were added to the resident's care plan after these incidents. The resident's care plan, last revised prior to the elopement attempts, already identified the individual as an elopement risk and included interventions such as distraction, monitoring for fatigue and weight loss, and redirection. However, after the documented elopement events, the care plan was not reviewed or updated to include additional measures. This was confirmed by the Care Plan Coordinator, who acknowledged that the management team did not revise the plan following the resident's recent attempts to leave the facility unattended.
Deficiency in Menu Planning and Nutritional Oversight
Penalty
Summary
Menus did not consistently meet the nutritional needs of residents as required. The menus were not always prepared in advance, were not consistently followed, and were not regularly updated to reflect residents' current needs. Additionally, menus were not always reviewed by a dietician, and there were instances where the dietary needs of residents were not met according to their care plans. These deficiencies were identified through review of facility records and observations, which showed lapses in menu planning, preparation, and oversight by qualified dietary staff.
Failure to Follow Discharge/Transfer Policy During Resident Hospitalization
Penalty
Summary
The facility failed to follow its own Discharge/Transfer policy for a resident who was hospitalized. According to the facility's policy, an SBAR (Situation Background Assessment Recommendation) assessment should be completed prior to contacting the provider, and a provider order should be obtained and entered into the electronic health record before transferring a resident to the emergency room or hospital. In this case, the resident, who had diagnoses including Paranoid Schizophrenia, Major Depression Disorder, and Hypertension, complained of multiple episodes of loose stool, nausea, and abdominal pain, and requested to be sent to the hospital. The DON was informed, and the resident was sent to the hospital via ambulance for further evaluation. Upon review, it was found that the required SBAR form was not completed prior to the transfer, and there was no documentation of a provider order authorizing the transfer. Interviews with facility staff confirmed that the SBAR was not completed and that there was uncertainty regarding the policy requirement for obtaining a physician's order before sending a resident to the emergency room. The facility was unable to provide any documentation regarding the transfer, indicating a failure to adhere to established procedures for resident transfers.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of behavioral problems, including aggression and a moderate risk designation, physically struck another cognitively intact resident on the head following a verbal altercation. The incident took place in a common area near the nurse's station, where the aggressor, who has diagnoses including Schizoaffective Disorder, Bipolar Disorder, Major Depressive Disorder, and Dementia with Moderate Agitation, was involved in an argument over towels. Witnesses, including another resident and an LPN, confirmed that the aggressor became upset and hit the other resident after being confronted about his behavior. The facility's own policies require close supervision and more frequent observation for residents identified as moderate risk, particularly those with a history of aggression and behavioral issues. Documentation shows that the aggressor required attentive monitoring and periodic assessment to determine if the level of supervision was adequate. Despite these requirements, the physical altercation occurred, resulting in the cognitively intact resident being struck and calling for help, with staff responding after the incident had already taken place.
Failure to Prevent Resident-to-Resident Physical Abuse in Dining Room
Penalty
Summary
The facility failed to prevent resident-to-resident physical abuse involving two residents with known behavioral histories. One resident, who had diagnoses including schizoaffective disorder, alcohol-induced dementia, and severe cognitive impairment, was on one-to-one monitoring due to a history of verbal and physical aggression. Despite this, while in the dining room, this resident was approached by another resident who touched his shoulder and began shouting. The first resident became startled, stood up, and began swinging his arms, striking the other resident in the mouth and causing bleeding. Multiple staff members were present and attempted to intervene, but the incident still resulted in physical harm. The investigation revealed that the resident who initiated the physical contact had a history of behavioral problems, including yelling, cursing, and physical aggression. Staff interviews confirmed that the aggressive resident struck both the other resident and several staff members during the incident. The event was witnessed by several CNAs and a social service assistant, who described the escalation and the immediate efforts to separate the residents and evacuate the dining room. Documentation showed that the resident responsible for the physical aggression was under one-to-one supervision at the time, yet was able to physically harm another resident and staff. The facility's abuse investigation did not include comprehensive witness identification or detailed accounts from all present, limiting the ability to fully reconstruct the incident. The event was reported to the administrator, physician, and local law enforcement, and the aggressive resident was temporarily sent to a hospital for evaluation before returning to the facility.
Failure to Conduct Thorough Abuse Investigations
Penalty
Summary
The facility failed to conduct thorough abuse investigations for three residents out of thirteen reviewed for abuse. According to the facility's Abuse, Prevention, and Prohibition Policy, the Administrator is responsible for ensuring a comprehensive investigation of all alleged violations, including interviewing all potential witnesses and documenting appropriate actions. However, in the case of a physical altercation between two residents in the dining room, the investigation did not include interviews with all possible witnesses, such as tablemates or other residents present during the incident. The staff and resident interview forms used were generic and did not capture specific details about the event, and there was no documentation identifying who witnessed the altercation. Additionally, in a separate incident involving an allegation of verbal and mental abuse by a consultant towards a resident, the investigation was similarly lacking in detail. The Administrator was unaware of the allegation until informed by the State Agency and initiated an investigation only after being notified. The investigation consisted of generic questions to staff and residents, with no specific questions related to the alleged verbal abuse. The resident involved denied knowing the accused staff member and reported feeling safe, but also mentioned that other staff and residents had made derogatory comments, which was not further explored in the investigation. Interviews with facility staff confirmed that the Administrator did not maintain a list of witnesses for the incidents and did not retain original handwritten statements after typing them up. The Administrator acknowledged that the investigations did not include detailed or specific interviews regarding the incidents and confirmed that the process relied on non-specific forms rather than targeted questioning of those directly involved or present during the alleged events.
Failure to Maintain Continuous 1:1 Supervision for Aggressive Resident
Penalty
Summary
The facility failed to provide continuous one-to-one supervision for a resident with a history of physical aggression and impulsive behaviors, as required by the facility's in-service documentation. The documentation specified that residents on one-to-one supervision should never be out of sight and must always be accompanied by staff. The resident in question had multiple diagnoses, including schizoaffective disorder, alcohol-induced dementia with behavioral disturbances, and severe manic episodes with psychotic symptoms. The resident was placed on one-to-one supervision due to these behaviors and the inability to consent to medication. On the morning of 3/11/25, the resident was observed alone in his room with the door closed, making him not visible from the hallway. The CNA assigned to supervise the resident was found assisting another resident in a different room at the same time, leaving the aggressive resident unattended. Both the DON and the Administrator confirmed that the expectation for one-to-one supervision is that the resident must always be within staff eyesight, and the in-service training reiterated this requirement. There was no formal policy on one-to-one supervision, but staff were in-serviced on the procedure.
Failure to Secure Indwelling Urinary Catheter Tubing
Penalty
Summary
A deficiency was identified when a resident with an indwelling urinary catheter was observed without the catheter tubing secured to her leg as required by facility policy. The catheter tubing was seen hanging out of the resident's incontinent brief with a clasp dangling, and not attached to a leg strap. The resident confirmed that the tubing was not strapped to her leg and expressed concern about the risk of it being yanked. A CNA verified that there was no leg strap in place, and the Assistant Director of Nursing acknowledged that a stabilizer should have been used for the catheter tubing. The resident's physician order sheet documented the presence of an indwelling urinary catheter, and facility policy specified that the catheter should be secured with a leg strap to minimize friction and movement at the insertion site.
Breach of Resident Privacy Through Group Text Message
Penalty
Summary
The facility failed to maintain the privacy of residents' health information for six residents, as evidenced by a group text message that included snapshots of dietary information cards displaying residents' full names, room numbers, and diet information. This breach of confidentiality involved a group text message shared among 16 people, all CNAs, some of whom no longer work at the facility. The facility's policy, as outlined in the Employee Handbook, emphasizes the importance of protecting Protected Health Information (PHI) in accordance with HIPAA regulations, yet this incident demonstrates a clear violation of these guidelines. The incident was brought to light through interviews and record reviews, revealing that the Administrator was aware of the group text message but could not initially find proof of its existence. The CNA involved, V22, confirmed being part of the group text but was unable to identify who initially shared the dietary cards. Despite the Administrator's in-service training on HIPAA conducted prior to the incident, the breach occurred, and the Director of Nursing confirmed that sharing such information in a group chat constitutes a HIPAA violation. Residents expressed their concerns about privacy, emphasizing the importance of keeping their personal and health information confidential.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from resident-to-resident physical abuse, as evidenced by two separate incidents involving unwanted physical contact. In the first incident, a resident with a BIMS score of 14, indicating cognitive intactness, was pushed by another resident, resulting in a fall against a wall. The incident occurred after the resident who was pushed asked the other resident to stay out of her room. The facility's investigation revealed that the push was deliberate, although the instigating factors were unclear to the resident who was pushed. In the second incident, another resident with a BIMS score of 15, also indicating cognitive intactness, was pushed by a fellow resident in the dining room. This occurred after a disagreement over picking up meal tickets for dietary staff. The resident who was pushed did not fall but reported being pushed hard. Both incidents were reported to the state agency, and immediate actions were taken to separate the involved residents and notify relevant parties.
Facility Fails to Maintain Homelike Environment Due to Maintenance Issues
Penalty
Summary
The facility failed to maintain a homelike environment for its residents, as evidenced by various maintenance issues observed in multiple resident rooms. These issues included chipped paint, holes in walls, missing trim, loose cable cords, and unpainted walls. The maintenance supervisor, who has been in the position since August 2024, was unaware of several of these issues until they were pointed out during the survey. The facility's maintenance work orders were not adequately documented or addressed, with no dates for repair entered for several reported issues. In one instance, a maintenance work order dated August 25, 2024, reported holes in the wall of a shared room, but there was no documentation confirming the repair. Residents expressed dissatisfaction with the condition of their rooms, noting that the appearance of the walls bothered them and made them feel less comfortable. The maintenance supervisor confirmed the presence of these issues during the survey but had not noticed them prior to the inspection. The facility's failure to address these maintenance issues in a timely manner resulted in an environment that did not meet the residents' right to a safe, clean, and comfortable living space. The lack of a documented maintenance policy and the absence of a systematic approach to addressing work orders contributed to the ongoing deficiencies in the facility's environment.
Failure to Timely Process Medication Orders
Penalty
Summary
The facility failed to process medication orders in a timely manner, resulting in medications not being administered as per physician orders for six residents. The Medication Administration Policy requires that all medication orders be prescribed by a licensed healthcare professional and documented accurately in the resident's medical records. However, the facility did not adhere to this policy, as evidenced by the Medication Administration Records (MARs) of the affected residents. For instance, a resident with paranoid schizophrenia did not receive their prescribed Aripiprazole on two consecutive days, and another resident with major depressive disorder missed doses of Nortriptyline. Similar issues were noted for residents with bipolar disorder, depression, anxiety disorder, and generalized anxiety disorder, where medications such as Quetiapine, Escitalopram, Trazadone, and Lorazepam were not administered as ordered. The deficiency was primarily due to the process involving the Psychiatric Nurse Practitioner (V6) and the Licensed Practical Nurse (V7). V6 entered medication orders into the Electronic Medical Record (EMR), but these orders remained in a pending status until V7 confirmed them. V7 was responsible for verifying and completing the pending orders, but due to an appointment, V7 did not confirm the orders in a timely manner, leading to a delay in medication administration. The Registered Nurse (V9) and another Registered Nurse (V5) confirmed that the nurses relied on V7 to activate the orders, and without V7's confirmation, the medications were not administered. This lapse in the medication administration process resulted in the residents not receiving their prescribed medications on the specified dates.
Privacy and Dignity Deficiencies for Two Residents
Penalty
Summary
The facility failed to maintain the privacy and dignity of two residents, R59 and R52, as observed during a survey. R59's room door would not latch shut, preventing her from having a private space to dress and reducing noise from the hallway. This issue was known to the facility, as a maintenance work order had been pending since June 29, 2024, but had not been resolved due to the unavailability of a replacement part. The Maintenance Supervisor confirmed the door's malfunction and acknowledged the delay in addressing the issue. Additionally, R52, who has an indwelling urinary catheter, was observed in the dining room with her catheter bag exposed, contrary to her care plan which required the bag to be covered for dignity. Initially, the bag was not covered, and it was only after staff intervention that a blue absorbent pad was used to wrap the bag. The Director of Nursing confirmed that the facility lacked a policy regarding the covering of catheter bags, indicating a gap in the facility's procedures to ensure resident privacy and dignity.
Inaccessible Activity Calendars for Residents
Penalty
Summary
The facility failed to accommodate the needs and preferences of two residents, R46 and R60, by not ensuring that the activity calendar was accessible and legible for them. R60, who is blind in her right eye, had her activity calendar taped on her bathroom door approximately five feet high, making it difficult for her to see. R60 expressed that she could not see the calendar and required larger print to read it. As a result, R60 missed activities, including nail care, which she found important. R60's Minimum Data Set (MDS) assessment indicated that participating in her favorite activities was very important to her. Similarly, R46's activity calendar was also placed too high on the bathroom door, making it inaccessible for her to see. R46 confirmed that the calendar's placement was too high for her to view. The Director of Nursing (DON) acknowledged that both R46 and R60's calendars were posted too high and printed in a faint and small font size, confirming the residents' inability to see the activities scheduled. Both residents' MDS assessments highlighted the importance of engaging in their favorite activities, which the facility failed to accommodate.
Care Plan Deficiency for Hepatitis C and Blindness
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident diagnosed with Hepatitis C and blindness in the right eye. During an observation, the resident was seen sitting in a wheelchair with a cloudy and distorted right eye, and the resident confirmed blindness in that eye. The resident's face sheet documented diagnoses of unspecified viral Hepatitis C without hepatic coma and blindness in the right eye. However, the current care plan did not address these conditions. The care plan coordinator confirmed the omission, acknowledging that both conditions were significant enough to warrant inclusion in the care plan.
Failure to Implement Nonpharmacological Interventions for Resident's Behavioral Needs
Penalty
Summary
The facility failed to implement nonpharmacological interventions for a resident with mood behavior monitoring needs. The facility's policy requires staff to evaluate residents' mood and behavior patterns and incorporate findings into the care plan, utilizing nonpharmacological approaches to manage behavioral symptoms. However, the medical record of a resident diagnosed with depression and anxiety showed no nonpharmacological interventions for behavior monitoring, despite documentation of verbal and physical behaviors. The Director of Nursing confirmed the absence of such interventions, stating that the resident was only on antidepressants.
Lack of Signed Hospice Contract for Resident
Penalty
Summary
The facility failed to have a signed hospice contract for a resident who was reviewed for hospice services. The resident's medical record included an order dated December 5, 2024, indicating approval for hospice evaluation and treatment. The nurses' notes from the same date documented communication with the resident's Power of Attorney, who agreed to hospice services, and the Medical Doctor was notified. The local hospice was informed, and documentation was faxed as requested. By December 9, 2024, the facility was notified that the resident had been approved for hospice, and a hospice nurse was scheduled to complete the admission. The resident's care plan, initiated on December 11, 2024, confirmed the receipt of hospice services due to a terminal diagnosis related to dementia. Despite these actions, during the survey conducted from January 7 to January 10, 2025, the facility was unable to produce a signed hospice contract, as verified by the Administrator on January 10, 2025.
Survey Book Not Up-to-Date
Penalty
Summary
The facility failed to maintain an up-to-date survey book, which is required to be accessible to residents and their advocates. On January 10, 2025, it was observed that the survey book located in the front foyer area did not contain the most recent survey results. The last survey included in the book was dated April 10, 2024. Additionally, the facility had several complaints filed with the State Agency on October 5, November 8, November 22, and December 18, 2024, which were investigated but not included in the survey book. This oversight was confirmed by the facility's administrator, who acknowledged that the survey book was not current, potentially affecting all 88 residents residing in the facility.
Failure to Maintain Three Years of Resident Grievance Records
Penalty
Summary
The facility failed to maintain the required minimum of three years of resident grievance records, which has the potential to affect all 88 residents residing in the facility. The facility's Resident Grievance Process Policy, reviewed in August 2023, mandates that copies of all grievances be maintained according to the community record retention policy. However, upon review, it was found that the facility's Grievance Binder only contained records for the years 2023 and 2024, lacking documentation for the year 2022, which is necessary to meet the three-year requirement. Interviews with facility staff confirmed the deficiency. The Director of Nursing (DON) acknowledged that the 2022 grievance reports were not available and that the facility only had records for 2023, 2024, and any for 2025. The Administrator also confirmed the absence of grievance records prior to 2023, stating that they could not be located and were unavailable for review. This oversight in maintaining grievance records as per policy could potentially impact all residents in the facility.
Failure to Maintain Resident Account Bookkeeping
Penalty
Summary
The facility failed to maintain a proper bookkeeping system for managing individual resident accounts, affecting all 93 residents. The deficiency was identified when the Administrator, V1, could not provide current balances for any resident accounts due to discrepancies found in the account balances not being carried over. The last available balance report was from September 30, 2023. The facility had been using an electronic account ledger system that was hacked, necessitating a switch to manual ledgers, which was not completed. V5, the Regional Revenue Cycle Manager, was in the process of creating manual account ledgers from the last balance report using various financial documents, estimating a four-week completion time. V4, responsible for Payroll and Human Resources, admitted to difficulties in maintaining the manual ledgers, stating that the process was too much for one person to handle. The manual process had been ongoing for approximately a year, and V4 was unable to keep up with the required documentation. The Administrator, V1, acknowledged that no adequate system had been in place since his employment began in May 2024, and V4 had not been submitting the necessary documents to the corporate office monthly since September 30, 2023. The facility's Resident Trust Fund Policy, last revised in 2012, required a full and complete separate accounting ledger for each resident, with monthly reconciliations and submissions to the corporate office, which were not being followed.
Failure to Prevent Resident-on-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent the physical abuse of a resident, identified as R3, by another resident, R7. According to the facility's Abuse, Prevention and Prohibition Policy, each resident has the right to be free from abuse, including physical abuse. The incident occurred when R3 observed R7 tampering with the diet cards of residents, which could potentially lead to incorrect meals being served. R3 asked R7 to stop, and as R3 bent down to pick up some cards that had fallen on the floor, R7 pulled R3's hair and pushed her head down. The facility's investigation into the incident confirmed that R7's actions constituted physical abuse. Despite attempts to interview both residents about the incident, neither R3 nor R7 was willing to discuss it further. The facility administrator acknowledged the incident as founded physical abuse, although the motive behind R7's actions could not be determined due to R7's refusal to communicate about the event.
Inadequate Management of Involuntary Discharge for Resident with Severe Mental Health Issues
Penalty
Summary
The facility failed to appropriately manage the involuntary discharge of a resident, identified as R1, who had a history of severe mental health issues, including Bipolar disorder, Generalized Anxiety, and Conversion Disorder with Seizures. R1 required continuous supervision and had a documented history of aggressive behaviors, including verbal and physical aggression towards staff and peers, as well as attempts to elope from the facility. Despite these challenges, the facility did not ensure that a signed physician discharge order was in place when serving a notice of involuntary discharge. The report details several incidents involving R1 that led to her being sent to a local hospital for psychiatric evaluation. These incidents included physical altercations with other residents, attempts to leave the facility, and aggressive behavior towards staff. On one occasion, R1 was involved in a physical altercation with another resident, and on another, she attempted to break windows and spat on staff. Despite these behaviors, the facility's documentation did not include a signed physician order for R1's discharge, which is a requirement for involuntary discharge. Interviews with facility staff, including the Director of Nursing and a Certified Nursing Assistant, revealed that R1's aggressive behaviors were consistent and not new. However, on the day of the involuntary discharge, R1's behavior was described as being at a new level of severity. The facility's failure to obtain a signed physician order for the discharge, despite the documented need for such an order, constitutes a deficiency in the facility's handling of the situation.
Failure to Provide Medically Related Social Services
Penalty
Summary
The facility failed to provide medically related social services for a resident who was reviewed for involuntary discharge. The resident had a history of Bipolar Disorder, Generalized Anxiety Disorder, and Conversion Disorder with Attacks or Seizures, and required continuous assistance with activities of daily living, safety, and mental health management. The resident's care plan included interventions for managing agitation and aggression, as well as addressing risks for elopement and ineffective coping due to PTSD. Despite these documented needs, the facility did not offer the resident any one-on-one social service visits, group therapies, or behavioral management interventions during their stay. The facility's assessment indicated that it was equipped to manage mental health and behavioral needs, including providing psycho/social/spiritual support and opportunities for social activities. However, the social services notes for the resident only documented multiple referrals for placement in other facilities, with no evidence of the required psychosocial therapies being provided. Interviews with facility staff revealed that the social services department was newly established and lacked in-house psychiatric services or group therapies at the time of the resident's stay. The Director of Nursing confirmed that psychiatric visits were conducted through telehealth, and the facility administrator acknowledged the absence of psychosocial therapies during the resident's stay. The social services department was in transition, with a new team and a recently appointed Social Services Director, which contributed to the lack of services provided to the resident. This deficiency highlights the facility's failure to meet the resident's documented needs for social and behavioral support, as outlined in their care plan and preadmission screening.
Lack of Certified Dietary Manager in Facility
Penalty
Summary
The facility failed to employ a Certified Dietary Manager in the kitchen, which has the potential to affect all 95 residents living in the facility. The job description for the Dietary Supervisor outlines responsibilities such as participating in the nutrition assessment process, providing progress notes in residents' medical records, and participating in care conferences. However, the current Dietary Manager, identified as V15, is not certified and has not been enrolled in a certification program despite being informed by management that certification was necessary. During an interview, V15 admitted to not performing clinical nutrition tasks for residents, such as reviewing weight records or completing the Minimum Data Set (MDS) section. V15 stated that they are often occupied with filling in for absent staff in the dietary department, indicating a lack of focus on the essential duties outlined in the job description. This deficiency was documented in the facility's Long-Term Care Facility Application for Medicare and Medicaid, which recorded 95 residents residing in the facility at the time of the survey.
Insufficient Dietary Staffing Leads to Delayed Meal Service
Penalty
Summary
The facility failed to provide sufficient staff to effectively carry out the functions of the food and nutrition service, potentially affecting all 95 residents. The Facility Assessment indicated that staffing should ensure sufficient personnel to meet residents' needs, with budgeted hours ranging from 900 to 945 hours per two-week payroll period. However, the Time Detail Report for the period from 7/07/24 to 7/20/24 showed only 301.25 hours worked in the Dietary Department. On 7/21/24, only three dietary employees were present, with the Dietary Manager having to cook due to the absence of the scheduled morning cook. The Dietary Manager noted frequent call-offs and staffing shortages. During a Resident Council Meeting, several residents reported that meals were often served 30 to 60 minutes late, with staff citing short staffing in the kitchen as the reason.
Facility Fails to Maintain Clean and Sanitary Kitchen Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, as observed during a surveyor's visit. The kitchen was found to be unkempt and dirty, with various appliances such as the convection oven, range, grill, and dishwasher area covered in dried food splashes, grease, and debris. The walls and drawers in the kitchen also had visible food debris and dust. Additionally, storage containers were improperly placed on the floor, and food items were not labeled or dated as required. Eggs were stored incorrectly, posing a risk of contamination to other food items. The facility also failed to maintain proper sanitation practices. The chlorine level in the low-temperature dish machine was not consistently tested, and there was no log of the dishwasher chlorine tests. The sanitation bucket, which contained quaternary ammonia, was not tested with the appropriate test strips, and staff were unaware of the correct procedures for testing and logging the sanitation solution. This lack of proper sanitation practices could potentially affect the safety and quality of food served to the 95 residents in the facility. The Dietary Manager, V15, acknowledged the issues and attributed them to staffing challenges, stating that staff frequently called off, leaving her to handle cooking and food preparation duties. This situation made it difficult to maintain cleanliness and sanitation standards, and the manager admitted that it was a challenge to get meals out on time. The facility's failure to adhere to professional standards for food storage, preparation, and sanitation was evident, as documented in the surveyor's findings.
Improper Garbage Disposal and Maintenance
Penalty
Summary
The facility failed to maintain proper disposal of garbage and refuse, as evidenced by the observation of an open large outside garbage dumpster and debris surrounding the area. This deficiency was noted during an observation on 7/21/24 at 11:30 AM when two Dietary Aides, V20 and V21, were seen taking trash containers to the dumpster. The dumpster lid was open, and several items had fallen onto the ground, with weeds surrounding the dumpster. V20, a Dietary Aide, mentioned that the dumpster is often full to overflowing, particularly on weekends. The facility's document on Garbage Disposal, which lacks a date, specifies that storage areas should be kept clean to deter pests and that outdoor trash receptacles should be covered with the surrounding area free of litter. This deficiency has the potential to affect all 95 residents residing in the facility.
Refrigerator Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the walk-in refrigerator at the correct temperature, with the thermometer inside the unit registering 50 to 52 degrees Fahrenheit, above the required 41 degrees Fahrenheit or below. The door to the refrigerator had a gap due to a loose gasket, which the Dietary Manager unsuccessfully attempted to reattach. Additionally, a yellow bucket, typically used for scrubbing floors, was found half full of black dirty water, collecting condensation from a hose coming down from the fan box area. The top shelf in the refrigerator was improperly repaired with a zip-tie, which had broken, causing the shelf to be at a 45-degree angle. The Dietary Manager reported that work orders had been submitted for these issues since December, but no repairs had been made. The Maintenance Supervisor was unaware of the problems with the walk-in refrigerator and had not reviewed the work orders due to being the only maintenance person for the past four months. The facility's Administrator in Training confirmed that the Dietary Manager had resigned and that the work orders she claimed to have copied could not be found, except for one dated 7/12/24. The facility's documentation indicated that 95 residents resided within the facility, all potentially affected by these deficiencies.
Pest Control Deficiency in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of flies and gnats in the kitchen, dining room, and resident rooms. During a kitchen tour, flies were observed landing on food items being prepared, on food items in the steam table, and on clean dishes, glasses, plates, and silverware. Flies were also seen landing on the Dietary Manager and Dietary Aides, indicating a persistent issue. The Dietary Manager acknowledged the constant presence of flies, stating that they are also present in the dining room. During the Resident Council Meeting, several residents reported the presence of flies in the dining room and their bedrooms, with one resident mentioning that flies and gnats become particularly problematic in their room. An appliance intended to eliminate flies was found in the dining room but was not plugged in or functioning. The facility's documentation confirmed that 95 residents currently reside within the facility, all potentially affected by this issue.
Failure to Protect Residents from Abuse by Another Resident
Penalty
Summary
The facility failed to protect residents from physical abuse by another resident, identified as R32, who has a history of inappropriate behavior, including spitting on others. R32 was admitted with diagnoses of Bipolar Disorder and Generalized Anxiety Disorder. Despite being on 1:1 supervision and having interventions in place, such as encouraging R32 to wear a surgical mask and providing a cup for spitting, R32 continued to engage in abusive behavior towards other residents. The incidents included spitting on multiple residents during meals and in common areas, making unwanted physical contact, and throwing ice on a resident. The facility's incident logs and reports document multiple occurrences of R32's abusive behavior towards other residents over a period of time. These incidents involved R32 spitting on residents during meals, in the dining room, and in the smoking area, as well as pushing a resident to sit in a chair and throwing ice on another resident. The facility's administrator acknowledged the difficulty in meeting R32's needs and the ongoing attempts to implement new interventions to prevent further abuse. However, the repeated incidents indicate a failure to effectively protect residents from abuse by R32.
Failure to Accommodate Shaving Preferences Due to Lack of Mirrors
Penalty
Summary
The facility failed to accommodate the shaving preferences of a resident due to the absence of mirrors in the shower rooms. During an observation, it was noted that all four resident shower rooms lacked mirrors, which are essential for residents to shave. A resident expressed that he was unable to shave because of this deficiency. A Certified Nurse Aide confirmed that the mirrors were removed during a recent remodeling of the facility. As a result, residents who wished to shave had to request assistance from staff, who would then provide a razor and supervise the shaving in the resident's room where mirrors were available. However, the usual practice was for residents to shave in the shower rooms, which was no longer feasible due to the lack of mirrors.
Failure to Honor Resident's Request for Urinal Disposal
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not complying with a request to discard odorous urine at the bedside. The resident, identified as R60, reported that staff did not empty their urinal at night, resulting in the resident having to endure the smell of urine throughout the night. This was corroborated by a Certified Nursing Assistant (CNA), who noted that the urinal was often full when they arrived for their shift, and acknowledged that the resident might refuse to be changed at night, but emphasized that the urinal should still be emptied. The facility's Residents' Rights policy, revised in November 2018, mandates that residents be treated with dignity and respect, and that the facility should promote a safe, clean, and homelike environment, which was not upheld in this instance.
Failure to Provide Bed Hold Notification
Penalty
Summary
The facility failed to provide a bed hold notification to a resident who was transferred to the hospital, which is a requirement according to their Bed Hold Policy and Agreement. This policy, dated February 2024, mandates that the facility must notify the resident or their representative about the bed hold policy whenever a resident is transferred to a hospital or takes therapeutic leave. In this case, a resident was sent to the hospital on March 13, 2024, and returned to the facility on March 15, 2024, with new orders for an antibiotic due to a urinary tract infection. However, the facility administrator admitted that there was no record of a bed hold notification being given to the resident or their representative for this hospital stay.
Failure to Update Elopement Risk Care Plan and Conduct Quarterly Assessments
Penalty
Summary
The facility failed to adhere to its elopement policy by not updating a resident's care plan to reflect their high risk for elopement and by not conducting the required quarterly assessments. The resident, who has diagnoses of paranoid schizophrenia, anxiety disorder, and other psychological conditions, was identified as having a high risk to wander or exit seek based on an evaluation conducted in November 2023. Despite this, the resident's care plan did not include necessary interventions such as ensuring the resident wore a personal safety device or that facility doors were alarmed, as stipulated by the facility's policy. The resident's medical records revealed multiple instances where the resident attempted to exit the facility unsupervised, indicating a pattern of elopement behavior. Progress notes documented several attempts by the resident to leave the facility through various doors, with the resident expressing intentions to leave for specific reasons, such as waiting for a car or going on a dinner date. Interviews with facility staff confirmed that the required elopement risk assessments were not conducted quarterly, and the facility did not utilize personal safety devices or alarms to prevent such incidents.
Inadequate Dialysis Care and Communication for Resident
Penalty
Summary
The facility failed to provide appropriate dialysis care and services for a resident requiring renal hemodialysis, as evidenced by a lack of documented collaboration and communication with the dialysis unit. The Dialysis Services Coordination Agreement and facility policies require documented evidence of collaboration and communication between the long-term care facility and the dialysis unit, including the use of a dialysis communication form. However, the resident's progress notes lacked evidence of such collaboration, and the dialysis communication forms were inconsistently completed, with only twenty-six out of sixty-one forms filled out between March and July 2024. Additionally, some forms lacked signatures or post-dialysis assessments, making it unclear if the resident received dialysis on those occasions. The resident's care plan and physician's orders were also found to be inadequate. The care plan did not specify the days or times of scheduled dialysis treatments, nor did it include instructions for blood pressure monitoring or details about the dialysis access site. The physician's orders did not specify the type or location of the dialysis access site, nor which arm to avoid for blood pressure measurements. Furthermore, there were no signs or instructions in the resident's room regarding the care of the fistula, such as avoiding blood pressure measurements or blood draws from the left arm. This lack of detailed documentation and communication could potentially compromise the resident's dialysis care.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to prevent resident-to-resident physical abuse involving two residents. An incident occurred where one resident, diagnosed with mild neurocognitive disorder and a history of aggressive behavior, physically assaulted another resident during a meal. The aggressor, who has a BIMS score indicating moderate cognitive impairment, struck the other resident in the abdomen and back after a misunderstanding over seating and food. The assaulted resident, who has a BIMS score indicating cognitive intactness, was shocked by the incident and was still processing the event. The incident was witnessed by a registered nurse who reported that the aggressor attempted to sit in the other resident's chair, leading to a verbal exchange and subsequent physical altercation. The assaulted resident, who has multiple psychiatric diagnoses including PTSD and bipolar disorder, expressed confusion and fear during the incident. The facility's failure to prevent this altercation highlights a deficiency in protecting residents from abuse, as outlined in their Abuse Prevention and Prohibition Policy.
Failure to Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to adhere to its Abuse Prevention and Prohibition Policy by not conducting a thorough investigation into an incident of resident-to-resident abuse involving two residents, R6 and R9. According to the policy, the facility is required to ensure a comprehensive investigation of any alleged violations of individual rights, which includes interviewing all employees working on the specific hall or wing where the incident occurred. However, the facility's administrator decided not to pursue further investigation after speaking with the involved residents, R6 and R9, who reported being fine post-incident. This decision was made despite the policy's requirement for interviews and witness statements from staff or residents who might have knowledge of the incident. The incident in question involved R6 and R9, who were involved in a physical altercation in the dining room. R6, who has a history of aggressive behavior and a BIMS score indicating moderate cognitive impairment, reported that R9 initiated the altercation by throwing a tea cup at him. R9, who has a BIMS score indicating cognitive intactness, is noted to have a history of inappropriate behaviors. The facility's failure to report the incident to the State Department of Public Health and to conduct a thorough investigation as per their policy constitutes a deficiency in following established procedures to prevent abuse and ensure resident safety.
Failure to Report Resident Altercation
Penalty
Summary
The facility failed to report allegations of abuse to the State Agency for two residents involved in a physical altercation. According to the facility's Abuse Prevention and Prohibition Policy, the Administrator is responsible for ensuring a thorough investigation of alleged violations and reporting them to the mandated state agency. However, the altercation between the two residents, which occurred in the dining room, was not reported to the state authorities as required. The incident involved a verbal altercation that escalated into a physical one, with the residents being separated immediately and assessed by the staff. The Administrator acknowledged that reports should be sent to the State Department whenever there is a physical altercation, regardless of whether an injury occurs. Despite this policy, the altercation between the two residents was not reported, indicating a failure to adhere to the facility's established procedures for handling and reporting such incidents. This oversight was identified during interviews and record reviews conducted by the surveyors.
Failure to Investigate Resident-to-Resident Altercation
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of resident-to-resident abuse involving two residents. According to the facility's Abuse Prevention and Prohibition Policy, a comprehensive investigation should include interviews with witnesses, staff, residents, or visitors who might have knowledge of the incident. However, in the case of the altercation between the two residents, the facility did not conduct interviews with the staff or obtain witness statements. The incident occurred in the dining room, where one resident reportedly initiated a physical altercation with another. Although the residents were separated and assessed immediately, the lack of a thorough investigation was noted as a deficiency.
Failure to Document Justification for Resident's Non-Readmission
Penalty
Summary
The facility failed to provide adequate documentation and justification for the refusal to readmit a resident, identified as R2, after a hospital stay. The facility's policy requires that involuntary discharges be documented by a physician, detailing why the resident's needs cannot be met at the facility. However, in this case, there was no documentation from a physician regarding the basis for R2's involuntary discharge or the specific needs that could not be met. R2 had a history of mental health issues, including Bipolar Disorder, Auditory Hallucinations, and Schizoaffective Disorder, and was sent to the hospital for a psychiatric evaluation due to increased confusion, hallucinations, and aggressive behavior. Despite the hospital's progress notes indicating R2 was coherent and without psychotic thought content, the facility did not document the reason for not readmitting R2, nor did they document any communication with the hospital regarding R2's condition upon the hospital's request for return. The facility's administration and social service director admitted to not documenting the decision-making process or the resident's status at the time of the hospital's request for return. The facility's administrator in training stated that R2 was not accepted back due to the lack of a private room, which was deemed necessary for R2's needs due to her behaviors. However, this decision was not documented, and the facility's physician was not involved in the decision-making process, highlighting a lack of communication and documentation regarding the resident's discharge and readmission process.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to permit a resident, identified as R2, to return to the nursing home after a psychiatric hospitalization, which exceeded the bed-hold policy. R2, who was covered by Medicaid, was hospitalized for psychiatric evaluation and treatment due to delusions, suicidal and homicidal ideations, and self-harm. Despite the hospital's attempts to communicate R2's readiness for discharge and the facility's initial indication that R2 could return once stable, the facility did not accept R2 back, citing an inability to meet R2's needs for a private room due to behavioral issues. The facility's lack of a Transfer/Discharge policy contributed to the deficiency, as there was no documented procedure to address the return of residents after hospitalization. The facility's Administrator in Training (AIT) and Social Service Director (SSD) both indicated that R2 was not accepted back due to the need for a private room, which the facility could not provide. The hospital's Licensed Clinical Social Worker (LCSW) reported multiple attempts to contact the facility for updates and to arrange R2's return, but these efforts were met with no response. R2 remained in the hospital for over 30 days, awaiting nursing home placement, as the facility did not facilitate R2's return. The hospital's medical staff confirmed R2's stability and readiness for nursing home placement, but the facility did not have a policy to guide the process of readmitting residents after hospitalization. This lack of policy and communication resulted in R2's prolonged hospital stay, as the facility did not take the necessary steps to readmit R2 or provide a clear plan for discharge and transfer.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 113 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near El Paso
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arc At El Paso | 0.5 mi | ★★★★★ | 5 | 0 |
| Flanagan Rehabilitation And Health Care Center | 9.8 mi | ★★★★★ | 3 | 0 |
| Apostolic Christian Home | 11.4 mi | ★★★★★ | 8 | 0 |
| Loft Rehabilitation & Nursing | 14.1 mi | ★★★★★ | 2 | 1 |
| Mclean County Nursing Home | 15.1 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.