Albuquerque Heights Healthcare And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Albuquerque, New Mexico.
- Location
- 103 Hospital Loop Ne, Albuquerque, New Mexico 87109
- CMS Provider Number
- 325069
- Inspections on file
- 33
- Latest survey
- February 3, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Albuquerque Heights Healthcare And Rehabilitation during CMS and state inspections, most recent first.
Surveyors found multiple environmental deficiencies across three units, including a water dispenser area on a damaged, moisture-compromised countertop with broken laminate and a loose cabinet handle, as well as broken laminate floor slats near a nursing station. In one room, a resident’s dropped salad and condiment cups remained on the floor under a bedside table despite the resident’s request for assistance, and the other occupied bed in that room had a broken footboard. On another unit, strong urine odors were repeatedly noted in the hallway and common area where residents were watching TV, and a wall-mounted handrail had a cracked, jagged lower cover. The Maintenance Director, Administrator, housekeeping district manager, and DON all described expectations that such areas be kept in good repair, free of urine odors, and that staff promptly clean food spills and change soiled bedding.
A resident was admitted and subsequently diagnosed with major depression and generalized anxiety disorder, but the PASRR Level I screening documented no mental illness and was never updated to reflect the new diagnoses. Facility policy required Social Services to ensure accurate PASRR screenings and to correct any incomplete or incorrect PASRRs, yet the Social Worker acknowledged the PASRR should have been revised, and the Administrator confirmed the expectation that it be updated. This failure to revise the PASRR after the resident’s mental health diagnoses led to the cited deficiency.
A resident with severe mobility impairments was left unattended on the edge of a high bed while a CNA left the room to retrieve a mechanical lift and assistance. The resident subsequently fell to the floor, sustaining an abrasion. Staff interviews confirmed that proper procedures were not followed, as the resident should not have been left alone in this position.
Surveyors found that multiple residents with ESRD, DM2, neuropathy, and other conditions did not receive medications as ordered and missed medical appointments due to lack of transportation. One resident’s scheduled evening doses of gabapentin, atorvastatin, and Protonix were given several hours late, while another resident’s ordered gabapentin, Remeron, and Tylenol were not administered at all, despite being documented as given on the MAR. In addition, a resident with a recent eye surgery had a follow-up appointment canceled because transportation was unavailable, and a physician reported that residents, including those needing dialysis, sometimes miss appointments for the same reason.
The facility failed to ensure safe, consistent dialysis care when two residents with ESRD and dependence on renal dialysis repeatedly missed scheduled dialysis sessions because arranged transportation did not arrive. One resident, ordered for dialysis three times weekly, missed a treatment when transport failed to show and was subsequently sent to the hospital with abdominal distension, fluid overload, and severe hyperkalemia requiring urgent dialysis. Another resident missed multiple dialysis sessions due to absent transport, later developing fever, chills, swelling, confusion, and hypoxia, and required hospital admission for emergent dialysis, hyperkalemia, acute metabolic encephalopathy, and sepsis. The DON, scheduler, UM, and MD reported that insurance-based transportation had to be used before facility transport, was unreliable, frequently failed to appear, and that residents were often left waiting and missed dialysis appointments as a result.
A resident experiencing pain and requesting pain medication was found yelling for help because the call light was not accessible. The call light was observed under the bed, stuck between the bed wheels and out of the resident’s reach. The resident confirmed inability to reach the call light to summon a nurse. A CNA later verified that the call light was not within reach and acknowledged it should be accessible to the resident at all times.
A resident’s right to a clean, comfortable, and homelike environment was not honored when housekeeping failed to clean the resident’s room and floor as required. Surveyors observed a large area of dried liquid with footprints, a napkin stuck in the dried spill, and other trash and debris on the floor that appeared unclean for several days, and a subsequent observation the same morning showed the room remained in the same dirty condition. The resident reported not seeing housekeeping in the room for several days and wanting the floor cleaned, and the housekeeping leadership later confirmed that rooms are supposed to be cleaned and mopped daily and that this resident’s room had not been cleaned as it should have been.
A resident admitted with upper and lower dentures, severe protein calorie malnutrition, and a cognitively intact BIMS score was documented on admission as wearing dentures, and a provider note and physician order called for a dental referral for denture replacement. The resident reported having her dentures for only a day or two after admission before they went missing in the facility and stated she informed staff but was only told the facility was working on it. The Scheduler acknowledged seeing the denture replacement order but did not schedule a dental appointment, believing the dentures were lost at the hospital, and the DON reported she was unaware the dentures were missing despite the admission inventory and existing dental referral. Consequently, the facility failed to obtain needed dental services to replace the resident’s lost dentures.
A resident assessed as dependent for all ADLs and requiring a mechanical lift with two staff for transfers did not have these interventions documented in the care plan, despite physician orders and facility policy. The omission was confirmed by the Administrator.
Staff, residents, and family members reported frequent shortages of towels and face cloths, resulting in missed showers and the use of blankets as substitutes. The Housekeeping Director and Administrator acknowledged ongoing linen shortages despite regular orders and outsourced laundry services, with limited supplies observed in storage areas.
Staff did not document evening meal intake percentages for nine residents, with confusion among RNs and CNAs about which shift was responsible for this task. The DON confirmed that night shift staff were expected to complete the documentation, but this was not done, making it difficult for the RD to perform accurate nutrition assessments.
A resident with multiple serious health conditions had critical lab results that were not promptly communicated to the provider because facility staff did not answer repeated calls from the lab and failed to document any follow-up. The oncoming nurse was not informed of the lab draws or results during shift change and only learned of the issue from the resident's wife. The DON acknowledged ongoing problems with staff being unreachable by phone and the absence of a message system.
A resident with dementia did not receive an accurate MDS assessment, as documentation showed inconsistencies in coding for communication abilities and cognitive skills. Despite frequent behavioral incidents documented in progress notes and confirmed by staff, the MDS failed to reflect these behaviors. The MDS Coordinator acknowledged the discrepancies and incorrect coding, noting that staff did not follow up to ensure the assessment accurately represented the resident's condition.
A resident with end stage renal disease and other serious conditions was not provided a meal or snack before leaving for dialysis, despite facility policy requiring such provision. Staff interviews revealed inconsistent practices and lack of awareness regarding the need to offer food to dialysis residents, and the DON was unaware that this requirement was not being met.
Two residents who required staff assistance with ADLs and personal hygiene did not receive timely care, resulting in one being left in a soiled brief and appearing unclean, and another remaining in a soiled gown with a leaking ileostomy bag for an extended period. Staff shortages contributed to delays in providing necessary hygiene care.
Surveyors identified multiple environmental and safety deficiencies in several resident rooms and the Memory Care Unit, including broken glove holders, ripped flooring, damaged furniture, missing handrail end pieces, improper storage in showers, dirty walls, strong urine odors, dust build-up on vents, broken light covers, stained ceiling tiles, and gaps around sprinkler heads. Facility staff interviews confirmed the process for reporting maintenance issues and acknowledged the concerns.
A resident who witnessed a traumatic medical emergency involving his roommate did not receive mental health services, despite being visibly distressed and staff acknowledging the need for support. There was no documentation of assessment or referral for psychiatric care following the incident.
A resident with a history of stroke, atrial fibrillation, and hypertension received duplicate doses of carvedilol after two active orders for the medication were present in the MAR. Staff administered multiple doses over several days because the duplicate order was not discontinued, and the nurse responsible did not notice the alert for duplicate orders while multitasking. The DON confirmed the process for reviewing and resolving duplicate orders was not followed.
A resident with multiple chronic conditions, including end stage renal disease and dependence on dialysis, had her lunch tray left on her bedside table while she was away for dialysis. The meal remained unrefrigerated and unheated for several hours until the resident returned and ate it, despite her request for staff to warm it up. Staff interviews confirmed the practice, while the Dietary Manager stated trays should not be left out.
Staff failed to lock an IV treatment cart containing sterile needles and catheters while it was left unattended, as confirmed by both a nurse and the DON. This lapse had the potential to impact all residents on the affected unit.
The facility failed to ensure proper communication with the dialysis center and did not monitor two residents with ESRD before and after dialysis treatment. Records showed pre-dialysis information was completed, but post-dialysis monitoring was not documented. The DON confirmed the communication sheets were not filled out as required.
A facility failed to accurately document a resident's significant weight loss in the Minimum Data Set (MDS). The resident's weight dropped from 180 pounds to 162.6 pounds, indicating a loss of more than 10% in the last 30 days. However, the discharge MDS inaccurately reported no significant weight loss. The MDS nurse later acknowledged the oversight.
A resident experienced significant weight loss due to the facility's failure to monitor and address nutritional risks. Despite being identified at risk for weight loss, the resident's weight was not consistently monitored as ordered. The resident's daughter reported that staff did not honor requests for weight checks and that the resident's food allergies and preferences were not accommodated, leading to poor appetite and weight loss. The dietician was unaware of the weight loss, and the expected weekly weigh-ins were not conducted.
A resident with schizophrenia and Alzheimer's was verbally and physically abused by a CNA during care. The resident reported being yelled at and having her hair pulled, which was corroborated by another CNA who witnessed the incident. The abusive CNA was suspended and later terminated.
The facility failed to honor residents' preferences and maintain shower facilities, leading to deficiencies in care. A resident was unable to use her room's shower due to missing knobs and stored items, forcing her to use the community shower on a schedule. Another resident preferred female staff for showers but often refused when only male staff were available. A third resident faced a lack of clean towels, requiring family assistance for showers.
The facility failed to provide a homelike environment for residents on the 300 unit due to various maintenance issues, including broken blinds, a damaged thermostat, and missing tiles in the shower room. Additional problems included unsecured outlet faceplates, a shortage of towels and sheets, and inappropriate storage of items in resident showers. Staff and residents reported these issues, but they remained unresolved, highlighting the facility's failure to ensure a safe and comfortable environment.
The facility failed to ensure call lights were accessible for six residents, with call lights found on the floor, behind desks, or wrapped around objects, making them unreachable. A CNA confirmed that call lights should be within reach.
A resident with third-degree burns and cellulitis experienced a malfunctioning wound vac upon admission to the facility. Despite the wound vac beeping and not working, staff did not notify the physician or apply an alternative dressing. The resident endured significant pain, and there was no documentation of physician notification. Interviews revealed issues with tubing compatibility and a lack of appropriate response to the malfunction.
A resident with third-degree burns and cellulitis was admitted to a facility with orders for specific wound care, including a wound vacuum set to 125 mmHg. The facility staff failed to document the administration of PRN orders and did not address the malfunctioning wound vac, which was beeping and not working properly. Interviews revealed that the staff did not follow the protocol of removing the wound vac after two hours of malfunction and did not notify the physician, leading to the resident's wound potentially going untreated.
A resident with aphasia and new onset weakness fell from his wheelchair due to an unsecured armrest, which was not properly clipped in place. The incident occurred in a common area without staff present, and interviews revealed that the resident lacked the strength to unclip the armrest himself. The Director of OT emphasized the importance of securing the armrests for safety.
A resident with dementia began showing increased phlegm, leading to a physician's order for a bedside suction machine. However, the care plan was not updated to reflect this change. The DON confirmed the care plan should have included this need.
Environmental Safety, Cleanliness, and Odor Control Deficiencies Across Multiple Units
Penalty
Summary
Surveyors identified multiple environmental deficiencies affecting the 100, 300, and 400 units, including damaged furnishings, flooring, and persistent odors. On the 100 unit, the water dispenser was placed on a countertop with visible water damage, darkened and discolored laminate consistent with prolonged moisture exposure, and broken laminate along the edges near the sink and dispenser. The cabinet door beneath had a loose, partially detached handle, and multiple broken laminate wooden floor slats were observed near the nursing station. In the 400 unit, one resident’s room contained leafy food and multiple plastic condiment cups on the floor under the bedside table next to the resident’s bed, and the other occupied bed in the same room had a broken footboard. The resident later reported she had dropped her salad during dinner the previous evening and that no staff cleaned it up despite her request for assistance, and she expressed concern that leaving food on the floor could attract cockroaches. On the 300 unit, surveyors repeatedly noted strong urine odors. A strong urine odor was observed around specific rooms and again upon entry to the unit and in the common area where residents were seated watching television on two separate days. Additionally, in the 300-unit hallway outside several rooms near the linen closet, the wall-mounted handrail’s lower protective cover was cracked and partially broken, leaving a jagged section approximately ten inches long. During interviews, the Maintenance Director acknowledged expectations that the 100-unit water dispenser area remain in good repair, that flooring be maintained to avoid tripping hazards, that the 300-unit handrail required repair, and that the bed footboard should have been properly bolted. The Administrator stated the 300 unit should not have heavy urine odors and that CNAs and housekeeping staff are expected to clean resident areas to prevent such odors. The District Manager of Housekeeping stated housekeeping cleans daily, uses rapid disinfectants, and that repeated urine odors are to be reported through the Quality Control Inspection process, while the DON stated CNAs or nursing staff are expected to clean dropped food when seen and to change residents and bedding when residents urinate in bed.
Failure to Update PASRR After New Mental Health Diagnoses
Penalty
Summary
The deficiency involves the facility’s failure to ensure an accurate Preadmission Screening and Resident Review (PASRR) for a resident with mental health diagnoses. The facility’s policy, revised 02/16/24, required the Social Worker or designated staff to assure that all patients with mental disorders or intellectual disability receive appropriate pre-admission screenings according to federal and state regulations, and that if a PASRR was not completed or was incorrect, Social Services would coordinate with the appropriate agency, review PASRR results, and incorporate recommendations into the assessment and care plan. Record review showed that the resident was admitted on a specified date and later diagnosed with Major Depression and Generalized Anxiety Disorder. Despite these diagnoses, the resident’s PASRR Level I Identification Screening, dated 12/10/25, documented that the resident did not have a diagnosis of or suspected mental illness. During interview, the Social Worker stated that the resident was diagnosed with depression and anxiety on 12/11/25 after admission and acknowledged that the PASRR should have been revised to reflect the current diagnoses. In a separate interview, the Administrator stated it was her expectation that the PASRR would have been revised with the new diagnosis. The failure to update the PASRR to reflect the resident’s mental health conditions constituted the cited deficiency.
Resident Fall Due to Inadequate Supervision During Transfer Preparation
Penalty
Summary
A deficiency occurred when a resident with significant physical impairments, including aphasia, hemiplegia, and contractures, was left unattended on the edge of a bed in a high position. The resident was dependent on staff for all activities of daily living and required a mechanical lift with two-person assistance for transfers. On the day of the incident, a CNA prepared the resident for transfer by placing the Hoyer lift sling under him but then left the room to retrieve the lift and another staff member, leaving the resident on the edge of the bed, which remained in a high position. During the CNA's absence, the resident fell from the bed and was found on the floor with an abrasion to the left lateral knee. Interviews with facility staff confirmed that the CNA did not follow proper procedures, as the resident should not have been left unattended, especially in a high bed position and near the edge. The resident's care plan specified that the bed should be in a low position and that all equipment should be ready prior to care. Staff acknowledged that the actions taken did not align with the resident's safety needs, particularly given his inability to control spastic movements.
Medication Administration Errors and Missed Medical Appointments Due to Lack of Transportation
Penalty
Summary
The deficiency involves the facility’s failure to meet professional standards of practice for medication administration and transportation to medical appointments for three residents. One resident with ESRD, dependence on renal dialysis, and type 2 DM with neuropathy had physician orders for gabapentin three times daily for anxiety, crying, and insomnia; atorvastatin 40 mg at bedtime; and Protonix 40 mg at bedtime. The MAR for this resident showed these medications, scheduled for 8:00 pm, were not administered until midnight. The resident reported to the day shift nurse that the night nurse did not give the 8:00 pm medications until midnight, and the UM and DON confirmed the medications were not administered as ordered on that date. Another resident with ESRD, dependence on renal dialysis, type 2 DM with neuropathy, and polyneuropathy had physician orders for gabapentin 100 mg at bedtime for neuropathy, Remeron 30 mg once daily for depression and appetite, and Tylenol 325 mg three times per day for pain. The MAR indicated these medications, scheduled for 9:00 pm, were documented as administered at midnight. The resident informed the day shift nurse that the night nurse did not give the 9:00 pm medications, and reiterated during a care plan meeting that no medications were administered during that night. The UM confirmed the resident did not receive the night medications as ordered, and the Administrator stated the night shift nurse admitted the medications were not administered despite being marked as given on the MAR. The DON confirmed that, on the night in question, one resident received medications late and the other did not receive ordered medications at all, although they were documented as administered. The facility also failed to consistently provide transportation for scheduled medical appointments. One resident, who had a follow-up appointment related to recent eye surgery, was observed waiting at the front door with a CNA and the UM for transportation to an 8:30 am appointment. The UM later confirmed that this follow-up appointment was canceled because no transportation was available. The report also references additional missed appointments for two other residents, including dialysis appointments, due to lack of transportation. A physician stated his expectation that residents should not miss appointments, including dialysis, due to transportation issues and confirmed that such missed appointments had occurred at the facility.
Missed Dialysis Treatments Due to Unreliable Transportation
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents requiring dialysis received services consistent with physician orders and professional standards of practice, specifically due to inadequate and unreliable transportation to scheduled dialysis treatments. One resident with ESRD, dependence on renal dialysis, and type 2 DM with neuropathy was ordered to receive dialysis on Monday, Wednesday, and Friday. Nursing documentation showed this resident did not attend dialysis on a scheduled Monday because the transportation company failed to arrive, with the last completed dialysis session occurring the prior Friday. The following day, a change in condition note documented abdominal distension and fluid overload attributed to the missed dialysis appointment due to lack of transportation, with a recommendation to send the resident to the hospital. Hospital records indicated the resident presented with missed dialysis due to arranged transport missing the scheduled pick-up, reporting abdominal fullness and shortness of breath from volume overload. The exam and labs showed abdominal distension and significantly elevated potassium, BUN, and creatinine, and the assessment identified hyperkalemia due to missed dialysis, requiring urgent dialysis. Another resident with ESRD, dependence on renal dialysis, type 2 DM with neuropathy, and polyneuropathy had multiple documented missed dialysis sessions because transportation failed to arrive. Nursing notes showed missed dialysis on several occasions, with one missed session followed by hospital transfer after the resident developed fever, chills, shaking, no urine output for two days, and body swelling. Provider notes linked the acute deterioration, including fever, hypertension, hypoxia, and worsening confusion, to a missed dialysis session. Hospital records documented emergent dialysis in the ED for hyperkalemia from a missed dialysis appointment due to transportation issues and admission for acute metabolic encephalopathy likely due to missed dialysis and sepsis, most likely from pneumonia. Interviews with the DON, scheduler, UM, and MD confirmed that insurance-based transportation was required to be used first, was unreliable, frequently failed to show, and that residents, including these two, missed dialysis appointments and were hospitalized after missed treatments.
Failure to Ensure Resident Call Light Was Within Reach
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate a resident’s needs and preferences by ensuring the call light was within reach. During an observation and interview on 12/11/25 at 7:55 a.m., the resident was heard yelling from her room asking staff for help, stating she wanted a nurse because she was in pain and needed pain medication. At that time, the resident’s call light was observed under the bed, stuck between the bed wheels and out of the resident’s reach. The resident confirmed she could not reach the call light and needed a nurse to administer pain medication. In a subsequent interview at 8:00 a.m. on the same day, a CNA confirmed that the resident’s call light was not within reach and stated that the call light should be within reach at all times. Based on these observations and interviews, the facility failed to provide reasonable accommodation of the resident’s needs by not ensuring access to the call light.
Failure to Maintain Clean and Sanitary Resident Room
Penalty
Summary
The facility failed to maintain a clean and sanitary, homelike environment for one resident when staff did not regularly clean the resident’s room and floor. On 12/11/25 at 7:55 am, observation of the resident’s room revealed a large area of dried liquid on the floor with dried footprints indicating someone had walked through it, along with a napkin stuck in the dried liquid and additional tissues and unidentified debris scattered on the floor, giving the appearance that the floor had not been cleaned for several days. At 7:58 am, the resident reported not having seen housekeeping in her room for several days and stated she wanted her floor cleaned. A follow-up observation at 8:15 am the same day showed the room remained dirty, with the same dried liquid area and trash and debris still present on the floor. On 12/12/25 at 10:05 am, the Housekeeping District Manager (HDM) stated that resident rooms should be cleaned and mopped daily and that the Housekeeping Manager is responsible for checking that rooms are cleaned properly and thoroughly. The HDM confirmed that the resident’s room was dirty and that the floor should have been cleaned sooner. Later that day at 1:30 pm, the HDM reported that the housekeeper assigned to that room acknowledged the room had not been cleaned on 12/11/25, despite it being scheduled for cleaning, confirming the lapse in maintaining the resident’s environment.
Failure to Arrange Denture Replacement After Loss in Facility
Penalty
Summary
The deficiency involves the facility’s failure to obtain dental services to replace dentures for a cognitively intact resident who was admitted with documented upper and lower dentures. The facility’s dental service policy states it is responsible for loss or damage of dentures when caused by staff misplacement, inadvertent disposal, or destruction. On admission, the resident’s personal effects inventory and admission progress note documented that she wore upper and lower dentures. The resident had a diagnosis of severe protein calorie malnutrition, and a Brief Interview of Mental Status (BIMS) score of 13 indicated she was cognitively intact. Shortly after admission, a provider encounter note and physician orders documented that the resident required a dental referral for denture replacements. Despite the physician order and policy, the Scheduler acknowledged that no denture replacement appointment was made, even though she was aware of the order and believed the dentures had been lost at the hospital. During observation and interview, the resident was edentulous and reported she had her dentures for one or two days after admission before they went missing in the facility, and that she had informed staff but only heard that the facility was “working on it.” The DON stated she had not seen the resident with dentures and was unaware until the survey date that the dentures were missing, despite the admission inventory documenting their presence and the existing dental referral order. As a result of these inactions, the facility did not provide the required dental services to replace the resident’s dentures in accordance with its own policy and the physician’s order.
Failure to Include Transfer Assistance in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed a resident's need for transfer assistance as identified in her assessments and physician orders. The facility's policy required that residents needing extensive or total assistance with transfers be moved using a mechanical lift with two trained staff members. The resident in question was admitted with a diagnosis of muscle weakness and was assessed as dependent for all activities of daily living, including transfers, requiring a mechanical lift and two staff for assistance. Physician orders specified bed rest with turns every hour and no independent transfers. Despite these documented needs and orders, the resident's care plan did not include interventions specifying the requirement for two staff members or the use of a mechanical lift for transfers. This omission was confirmed during an interview with the Administrator, who acknowledged that the care plan should have addressed these specific transfer needs.
Failure to Provide Adequate Linens for Resident Care
Penalty
Summary
The facility failed to maintain a homelike environment by not providing an adequate supply of bath towels and face cloths for residents. Multiple Certified Nursing Assistants (CNAs) reported that linens, including towels and sheets, were frequently unavailable in the linen storage closets, requiring them to search other units for supplies, which were also insufficient. Family members and residents confirmed that clean towels and face cloths were often not available, resulting in missed showers and the use of blankets as substitutes. The Housekeeping Director acknowledged the ongoing shortage, noting that although new linens were ordered monthly, the supply remained inadequate. The facility outsourced its laundry services, and there was uncertainty about whether the same quantity of linens sent out was returned clean. Observations confirmed that only a limited number of new towels and washcloths were available for resident use. The Administrator was aware of the persistent linen shortage and ongoing complaints from staff and residents, despite regular orders for new supplies. Several residents and CNAs described instances where showers were postponed or not given at all due to the lack of towels, further illustrating the impact of the deficiency on daily care routines.
Failure to Document Evening Meal Intake Percentages
Penalty
Summary
Staff failed to document evening meal intake percentages for nine residents over a period of nearly one month. Record review showed that the evening meal intake was not recorded for any of these residents, and multiple staff interviews revealed confusion regarding which shift was responsible for this documentation. Registered nurses and a CNA indicated that the dinner meal was typically served during the shift change, leading to uncertainty about whether the evening or night shift should complete the documentation. The Director of Nursing confirmed that the night shift was expected to document the dinner meal percentages, but this was not consistently done. The Registered Dietician stated that she relies on meal intake documentation to complete quarterly nutrition assessments and determine if interventions are needed. She noted that missing dinner meal intake information made it more challenging to assess residents' nutritional needs. The lack of documentation affected all nine residents reviewed for meal intakes, and the issue had been previously addressed with staff, but the deficiency persisted.
Failure to Notify Provider of Critical Lab Results Due to Missed Communication
Penalty
Summary
The facility failed to promptly notify the ordering provider of critical laboratory results for a resident with multiple serious medical conditions, including severe chronic kidney disease, diabetes, and a history of heart surgery. On two separate occasions, critical lab results were reported by the laboratory, which attempted multiple times to contact the facility during early morning hours. Facility staff did not answer the phone during these attempts, and there was no documentation that staff returned the lab's calls or communicated the critical results to the provider. Additionally, the nurse coming on shift was not informed about the lab draws or the critical results during shift change, and only became aware of the situation when the resident's wife brought it to her attention. The Director of Nursing confirmed that the facility had ongoing issues with staff being unreachable by phone and lacked a message system for callers. The expectation was for staff to communicate critical lab results to the provider as soon as possible, but this did not occur in these instances.
Inaccurate MDS Assessment for Cognition and Behaviors
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for a resident with dementia and cognitive impairment. Record reviews showed inconsistencies in the MDS documentation regarding the resident's ability to understand and be understood, as well as their cognitive skills for daily decision making. For example, different MDS assessments alternately indicated the resident was rarely understood, usually understood, or had a BIMS score indicating moderate impairment, while progress notes and interviews described the resident as unable to provide meaningful history or answer questions. The MDS Coordinator acknowledged that the MDS was coded incorrectly for communication abilities and that discrepancies existed between the MDS and the resident's record. Additionally, the MDS failed to accurately reflect the resident's behavioral symptoms. While the annual MDS indicated no behaviors, progress notes documented frequent episodes of yelling, cursing, and disruptive behavior over several dates. The Dementia Program Director confirmed that the resident exhibited behaviors weekly, and the MDS Coordinator stated that the MDS should have indicated the presence of behaviors, as staff had recorded such incidents almost every other day. The MDS Coordinator also noted that staff responsible for completing the MDS did not follow up on discrepancies, resulting in an inaccurate representation of the resident's condition.
Failure to Provide Pre-Dialysis Meal or Snack to Resident
Penalty
Summary
The facility failed to provide a light meal or snack to a resident prior to the resident leaving for dialysis, as required by the facility's Dialysis Policy. The policy specified that nutritional and fluid management for dialysis residents should include meals before, during, and after hemodialysis, with monitoring of intake and output as ordered. The resident, who had multiple diagnoses including end stage renal disease, dependence on dialysis, congestive heart failure, and diabetes, reported that staff did not offer her anything to eat before dialysis and that she typically had to wait until after returning from dialysis to eat her lunch, which was left on her table during her absence. Interviews with staff revealed a lack of consistent practice regarding the provision of snacks or meals to residents going to dialysis. One CNA stated she did not offer snacks or lunch because the resident left right after breakfast, while another CNA also confirmed not offering snacks to dialysis residents. The nurse interviewed stated that all staff were responsible for ensuring dialysis residents received a snack or lunch before leaving, and the Dietary Manager indicated that sack lunches or snacks were prepared depending on the dialysis schedule. However, the Director of Nursing was unaware that staff were not offering snacks or lunch to residents going to dialysis, indicating a breakdown in communication and adherence to policy.
Failure to Provide Timely ADL and Hygiene Assistance
Penalty
Summary
Staff failed to provide adequate assistance with activities of daily living (ADLs) for two residents who required support with personal hygiene. One resident, who needed substantial staff assistance for toileting hygiene due to limited mobility and weakness, was observed lying in bed in a hospital gown, appearing unclean and disheveled, with greasy hair and food crumbs in his beard. The resident reported frequently going to bed with a soiled brief and was unsure how often this occurred, but stated it happened often. His care plan indicated a need for staff assistance with bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting. Another resident, with a diagnosis of colostomy and requiring partial staff assistance for toileting hygiene and ostomy management, was observed dressed in a soiled hospital gown with feces present and a leaking ileostomy bag at the base. The resident stated his gown had been soiled since the previous night and that staff would promise to return to change him but did not follow through. He also reported waiting a long time for staff to answer the call light and to be changed since early in the morning. A Certified Nursing Aide confirmed that there were often not enough CNAs working, which delayed hygiene care for residents who needed assistance.
Environmental Safety and Maintenance Deficiencies in Resident Rooms and Memory Care Unit
Penalty
Summary
Multiple resident rooms, including rooms 205, 206, 207, 208, 211, and 213, were found to have environmental deficiencies that compromised safety and functionality. Observations revealed broken plastic glove holders, ripped flooring near resident beds, broken or missing dresser drawers, broken blinds, and malfunctioning thermostats. In some rooms, handrails outside entry doors were missing end pieces, exposing sharp edges, and showers were used for storage of unrelated items such as foam pads and cushions. Additionally, walls were found to be dirty with substances present, and strong urine odors were detected in certain rooms. Further inspection of the Memory Care Unit identified additional concerns, including filthy dust build-up on ceiling vents, broken light coverings, stained ceiling tiles, and gaps around sprinkler heads. Interviews with facility staff confirmed that maintenance issues were to be reported by CNAs and nurses through an electronic system, and that only one maintenance person was currently available. The Director of the Memory Unit acknowledged the environmental and safety concerns during the survey.
Failure to Provide Mental Health Services After Traumatic Event
Penalty
Summary
A deficiency occurred when a resident who witnessed a traumatic medical emergency involving his roommate did not receive appropriate mental health services. The resident, who had a history of heart failure and bilateral hearing loss, was present in the room when his roommate was found unconscious from a suspected drug overdose and subsequently received CPR from staff. Both the registered nurse and physician assistant confirmed that the resident was visibly distressed, crying, and scared during the incident. Despite this, there was no documentation in the resident's medical record indicating that he was seen by a medical professional on the day of the incident or afterwards, nor was there any record of a referral for psychiatric evaluation or talk therapy. Interviews with facility staff, including the RN, PA, social services, and the administrator, revealed that although staff recognized the traumatic nature of the event and the need for mental health support, no action was taken to provide such services. The social services staff admitted to not speaking with the resident or making a referral, and the administrator confirmed that no psychiatric services were ordered or documented for the resident following the incident.
Duplicate Carvedilol Orders Result in Significant Medication Error
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral infarction, paroxysmal atrial fibrillation, and essential hypertension was administered duplicate doses of carvedilol due to the presence of two active orders for the medication in the Medication Administration Record (MAR). The MAR showed that both a 3.125 mg and a 6.25 mg carvedilol order were active, and staff administered multiple doses of 6.25 mg carvedilol on several consecutive days. The duplicate order was not discontinued when the new order was added, resulting in the resident receiving more medication than intended. Interviews with facility staff revealed that the Practitioner Assistant acknowledged there should have only been one active order for carvedilol and that the second order should have been discontinued. The Director of Nursing confirmed that staff administered duplicate doses over several days and explained that an alert system was in place to notify staff of duplicate orders, with the expectation that the nurse entering the order would verify and resolve any duplicates with the provider. The nurse responsible for entering the duplicate order stated she was multitasking and did not recall seeing the duplicate order alert.
Meal Left Unattended for Dialysis-Dependent Resident
Penalty
Summary
A deficiency occurred when staff failed to ensure that a meal was served at a palatable temperature for a resident who was dependent on renal dialysis and had multiple medical conditions, including congestive heart failure, ischemic cardiomyopathy, type II diabetes, and end stage renal disease. The resident's lunch tray was delivered and left on her bedside table while she was away at dialysis. Observations confirmed that the tray remained on the bedside table for several hours, from the time it was delivered until the resident returned from dialysis and ate the meal. The resident reported that she was hungry upon her return and asked staff to heat up her meal, but staff did not do so. Interviews with staff revealed that it was common practice to leave the meal tray in the resident's room so she could eat upon her return, although the Dietary Manager stated that trays should not be left out and should instead be returned to the kitchen for proper storage. The tray, which included a tamale and black beans, was ultimately consumed by the resident after it had been sitting out for more than two hours, as confirmed by a CNA who removed the tray afterward.
Unattended and Unlocked IV Treatment Cart
Penalty
Summary
Staff failed to secure an intravenous (IV) treatment cart on the 300 Unit, leaving it unlocked and unattended. During an observation, the cart was found open and contained sterile needles and IV catheters, with no staff present in the area. A registered nurse confirmed that the cart was unlocked and acknowledged that it should be locked when not in use. The Director of Nursing also stated that IV treatment carts should never be left unlocked while unattended. This deficiency had the potential to affect all 48 residents on the 300 Unit, as identified by the facility's resident census.
Failure to Monitor and Document Dialysis Care
Penalty
Summary
The facility failed to ensure proper communication and collaboration with the dialysis center and did not monitor residents before and after dialysis treatment. Two residents with end-stage renal disease (ESRD) were affected by this deficiency. The facility's records showed that pre-dialysis information was completed, but there was no documentation of post-dialysis monitoring or assessments on multiple occasions. This lack of documentation was confirmed by the Director of Nursing, who acknowledged that the dialysis communication sheets were not filled out as required. The absence of post-dialysis information in the residents' records indicates a failure to monitor their condition after treatment. This deficiency could lead to the facility being unaware of any complications that might arise during dialysis, potentially affecting the residents' care. The Director of Nursing confirmed that the nurses were expected to complete the dialysis communication sheets daily, but this was not done on the specified dates.
Inaccurate MDS Documentation of Resident's Weight Loss
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) for a resident, identified as R #10, which is a federally mandated assessment instrument. The MDS nurse did not document a significant decline in the resident's weight, which was crucial for reflecting the resident's status at the time of the assessment. Specifically, the resident's weight was recorded as 180 pounds on the comprehensive admission MDS, but later assessments showed a weight of 162.6 pounds, indicating a loss of more than 10% in the last 30 days prior to the discharge MDS assessment. Despite this, the discharge MDS inaccurately stated that the resident did not experience a weight loss of 5% or more in the last month or 10% or more in the last six months. During an interview, the MDS nurse acknowledged the oversight, admitting that the resident's weight loss should have been documented on the discharge MDS.
Failure to Monitor Nutritional Risk Leads to Resident's Weight Loss
Penalty
Summary
The facility failed to identify and address the nutritional risk for a resident, leading to unplanned weight loss. The resident was admitted on 09/07/24 and discharged to an assisted living facility on 10/03/24. The care plan noted the resident was at nutritional risk for weight loss, and the provider's progress notes indicated a poor appetite and concerns for weight loss. Despite an order to reweigh the resident upon the daughter's request on 09/16/24, the facility staff did not document a weight for that week. The resident's weight dropped from 180.2 pounds on 09/07/24 to 162.6 pounds on 10/01/24, with no additional weight assessments recorded. Interviews revealed that the resident's daughter repeatedly requested weight checks, but staff claimed they were too busy and provided outdated weight information. The daughter reported that her mother complained of not eating well due to food allergies and preferences not being honored. The facility's dietician confirmed the resident's poor appetite and added snacks to the meal plan but was not informed of the weight loss. The 100 Hall Nurse Manager expected staff to weigh the resident weekly and per the provider's order, which was not done, contributing to the resident's significant weight loss.
Resident Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from abuse when a Certified Nurse Aide (CNA) was verbally and physically abusive during care. The resident, who has a complex medical history including schizophrenia, Alzheimer's disease, and other cognitive and mood disorders, reported that the CNA yelled at her and pulled her hair, causing her to feel scared. The care plan for the resident indicated a potential for verbal behaviors due to her cognitive conditions, but the CNA's actions exacerbated the situation. During the incident, another CNA witnessed the abusive behavior, including the CNA yelling obscenities and physically restraining the resident by pulling her hair and pushing her down on the bed. The witness reported the incident to a nurse, who then informed the Unit Manager. The abusive CNA was subsequently suspended and later terminated. The facility's administrator confirmed the incident and took immediate action based on the witness's account, although the abusive CNA had no prior allegations of abuse.
Failure to Honor Resident Preferences and Maintain Shower Facilities
Penalty
Summary
The facility failed to honor the residents' choices and preferences, leading to deficiencies in the quality of care provided. For one resident, the shower in her room was not in working order due to missing faucet knobs and random items stored in it, forcing her to use the community shower only on scheduled days and times. This limited her ability to choose when to shower, as the community shower was often occupied by residents requiring assistance. The Director of Nursing acknowledged that the situation was unacceptable, and the Administrator was unaware of the issue. Another resident preferred to have showers done by female staff, but there were instances when female staff were unavailable, leading to the resident refusing showers. The Daily Shower Tracking Sheets indicated multiple refusals without documented reasons, often signed by male staff. Additionally, a third resident experienced a lack of clean towels, resulting in her family bringing towels from home to assist with her shower. This resident also preferred female staff for showers and felt demeaned and embarrassed when her preferences were not honored.
Facility Fails to Maintain Homelike Environment Due to Maintenance Issues
Penalty
Summary
The facility failed to maintain a homelike environment for residents on the 300 unit, as evidenced by multiple maintenance issues. Observations revealed broken blinds in several rooms, a damaged thermostat hanging by wires, and missing tiles in the shower room. Additionally, the toilet in the shower room was found with dried feces and no water, and handrails in the hallway were insecurely attached. The Maintenance Director acknowledged awareness of some issues but cited a lack of work orders as a reason for delays in repairs. Further deficiencies included unsecured outlet faceplates, an unoccupied bed frame stored in the hallway, and a shortage of towels and sheets across the facility. The Assistant Administrator confirmed awareness of the linen shortage. Observations also noted unpainted patchwork in twelve resident rooms, and various maintenance issues in individual rooms, such as missing faucet knobs, leaking sinks, and inappropriate storage of items in showers. Interviews with staff and residents highlighted ongoing problems, such as leaking sinks and random items stored in showers, which were not addressed despite being reported multiple times. The Director of Nursing acknowledged these issues, stating they were unacceptable. Residents expressed confusion and frustration over the presence of unrelated items in their living spaces, further emphasizing the facility's failure to provide a safe and comfortable environment.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that call lights in residents' rooms were within reach for six out of seven residents reviewed. Observations on the 300 unit revealed that several residents, whether in bed or in their wheelchairs, could not access their call lights. Specifically, one resident in a wheelchair had their call light on the floor by the wall, another resident asleep in bed had their call light on the floor, and a third resident in bed had their call light on a desk behind them. Additionally, a resident in a wheelchair had their call light on the floor by the curtain, another resident in bed had their call light wrapped around the bed rail, and yet another resident in bed had their call light wrapped around a feeding tube stand. During an interview, a CNA confirmed that call lights should be within reach and not on the floor or wrapped around objects.
Failure to Notify Physician of Wound Vac Malfunction
Penalty
Summary
The facility failed to notify the physician or on-call physician when staff encountered issues with a wound vacuum (wound vac) for a resident with third-degree burns and cellulitis on her right lower limb. The resident was discharged from the hospital with specific orders for wound care, including the use of a wound vac set to 125 mmHg continuously. Upon admission to the facility, the staff was unable to get the wound vac to function properly, and the machine was left beeping and not working for an extended period. The resident's daughter reported that the facility staff attempted to fix the wound vac for hours without success, leaving the dressing unchanged despite the malfunction. Progress notes indicated that the wound vac was not working and leaking, causing the resident significant pain. Despite the malfunction, there was no documentation that the staff notified the resident's doctor about the issue. Interviews with nurses revealed that the tubing from the hospital did not fit the facility's wound vac, and the staff did not take appropriate steps to address the malfunction, such as applying a different dressing or notifying the physician. The unit manager confirmed the absence of documentation regarding communication with the on-call physician about the wound vac issues. The failure to notify the physician and obtain further orders for wound care could potentially lead to worsening of the wound or infection. The report highlights the deficiency in communication and adherence to wound care protocols, which directly impacted the resident's care and comfort.
Failure to Follow Physician Orders for Wound Vacuum Care
Penalty
Summary
The facility failed to adhere to physician orders regarding the management of a wound vacuum for a resident with third-degree burns and cellulitis on her right lower limb. Upon discharge from the hospital, the resident was to receive specific wound care, including the use of a wound vacuum set to 125 mmHg continuously. However, the facility staff did not document the administration of the PRN wound vac orders or the PRN NPWT order from 06/01/24 through 06/07/24. The resident's daughter reported that the wound vac was not functioning properly upon her mother's arrival at the facility, and the staff struggled for hours to get it to work, leaving the dressing unchanged despite the machine's malfunction. Interviews with staff revealed that the wound vac machine was beeping, indicating it was not working properly, and the issue persisted without appropriate intervention. Nurse #6 confirmed that the wound vac should not remain on for more than two hours if malfunctioning and that a different dressing should have been applied. The Unit Manager acknowledged the lack of documentation indicating that the night nurse contacted the on-call physician about the malfunctioning wound vac. This oversight in following physician orders and addressing the malfunctioning equipment could have led to the resident's wound going untreated.
Failure to Secure Wheelchair Armrest Leads to Resident Fall
Penalty
Summary
The facility failed to ensure the safety of a resident, identified as R #12, by not properly securing the arm of his wheelchair, which likely resulted in a fall. R #12, who suffered from aphasia following a stroke affecting his right side, was observed to have new onset weakness. During an interview, a family member expressed concerns about the resident's wheelchair arm being broken and not clipping in correctly, noting that the resident had not yet received his custom wheelchair. This concern was validated when R #12 was observed falling out of the left side of his wheelchair due to the left armrest being flipped backward and not securely clipped in place. At the time of the incident, no staff members were present in the common area to assist. Further interviews revealed that the wheelchair was not properly secured when the resident fell. A registered nurse confirmed that the armrest was not clicked into place, and the resident did not have the strength or range of motion to unclip it himself. The Director of Occupational Therapy was unaware of any issues with the wheelchair and stated that the armrests should click into place to ensure safety. The director also confirmed that the wheelchair fit the resident well and emphasized the importance of staff ensuring the armrests are properly secured.
Failure to Update Care Plan for Resident's Change in Condition
Penalty
Summary
The facility failed to update a resident's care plan following a change in condition, which was identified during a survey. The resident, who was admitted with unspecified dementia and other behavioral disturbances, began to exhibit a new symptom of increased phlegm. This change was documented in the physician's notes, and a physician's order was made for a suction machine to be placed at the resident's bedside. However, the care plan, last reviewed over a month prior, did not reflect this new requirement. During an interview, the Director of Nursing acknowledged that the care plan should have included the need for a suction machine at the bedside.
Latest citations in New Mexico
Surveyors found that the facility did not provide required written transfer and bed-hold notices when several residents were sent to the hospital for events such as falls with injury, unresponsiveness, and episodes of nausea, vomiting, and bleeding. Medical records lacked written transfer notices and bed-hold notifications, and the transfer information that should have been given to residents or their representatives did not include mandated details about appeal rights, how to request an appeal, or how to contact the State LTC Ombudsman. The Social Services Director reported that she does not notify the Ombudsman of hospital transfers and only sends a monthly email list of discharged residents, without written copies of transfer or discharge notices.
Two cognitively impaired residents with dementia and significant behavioral and continence needs were sent to a local ER after falls and were discharged back to the facility’s care, but the facility failed to provide timely transportation for their return. In both cases, hospital discharge times were documented, yet ER staff reported making multiple unsuccessful calls to the facility, reaching the Administrator only after repeated attempts. One resident, described as very disoriented, remained in the ER for several hours after discharge without 1:1 supervision, while the other waited approximately 11 hours, during which ER staff observed increasing confusion and attempts to get out of bed. The Administrator acknowledged awareness of the discharges, the lack of 24-hour transportation, and that the residents were not picked up until many hours after they had been discharged from the ER.
Two residents who required staff assistance for ADLs and transfers reported neglectful and rude behavior by a CNA and delayed nursing response to care needs. One resident with a history of cerebral infarction and schizophrenia stated that a CNA mocked him and that his requested wound dressing change was not performed for several hours, which was later corroborated by video showing a long gap between the CNA’s visit and the nurse’s entry to the room. Another resident with a right femur fracture, type II DM, and repeated falls, who needed one-person assistance for mobility and self-care, reported that a CNA refused to help and told her she could do some care herself, making her feel she was not trying in her recovery. Documentation and interviews confirmed that staff did not provide timely wound care or required assistance, and that these interactions caused residents to feel uncomfortable and negatively about their care.
A resident with a history of opioid dependence and polysubstance abuse was on a secure unit with a care plan that included safety risk evaluations and monitoring for signs of substance abuse. Staff later observed the resident discarding an empty Suboxone packet, even though the resident was not prescribed this medication, and the incident was reported to the on-call provider with subsequent monitoring and a room search. However, the care plan was not revised to reflect this new substance-related event, and both the DON and Administrator acknowledged that the care plan should have been updated when this new risk and behavior were identified.
Surveyors identified that a medication cart on the north hall was left unlocked and unattended outside a resident room. An LPN acknowledged that the cart was hers and that she had not locked it before leaving to answer a call light, despite facility expectations. The DON confirmed that all medication and treatment carts are required to remain locked when not in use or when staff are away from them.
Surveyors found that a document containing multiple residents’ PHI, including full names, room numbers, and code status, was left unattended and visible on a south nurse’s station counter. An RN confirmed the document was a resident list with PHI and acknowledged it had been left exposed and that such information should not be left unattended.
Surveyors found that a lunch tray return cart containing uncovered, soiled food trays and dishes was left unattended in a main hallway outside an activity room. The housekeeping/laundry manager acknowledged seeing the unattended cart, and the Dietary Manager confirmed that such carts are supposed to remain only in designated areas, such as near the nurse’s station or in the kitchen, and should be returned to the kitchen for cleaning as soon as all trays are collected. This failure was cited as likely to expose all residents to potential pathogens associated with food waste.
Two residents with scheduled showers reported that they were offered or received showers in very cold water during a prolonged period when hot water was not reliably available in care areas. One resident stated he refused cold showers and was only offered sponge baths once or twice, despite his preference to stay clean. Another resident reported receiving cold showers, including being rinsed with cold water while still soaped, and subsequently began refusing showers and bed baths due to the cold water. A CNA confirmed that water in the shower rooms was “ice cold” for several months, leading to resident complaints and refusals, while the Maintenance Director reported that a needed part to correct the hot water problem was on back order, delaying resolution and resulting in the facility not honoring residents’ bathing preferences.
Surveyors observed that unused medications were improperly discarded in a trash bin attached to a medication cart on the north hallway, rather than being disposed of in a designated drug disposal container. Two pills, a round blue tablet stamped "61" and an oblong orange tablet stamped "20," were found together in an unlabeled medication cup in the trash. An RN confirmed the medications were discarded there and acknowledged that unused medications should be placed in the drug buster container in the cart drawer. The Unit Manager also confirmed that facility practice requires all unused medications to be disposed of using the drug buster and that controlled substances must be destroyed by two licensed staff and documented on the narcotic count sheet.
The facility failed to follow documented allergy information, diet orders, and meal tickets for three residents. A resident with a documented chocolate allergy was served chocolate ice cream after requesting it, and the Nutrition Director admitted not reading the allergy notation on the meal ticket. Another resident on a pureed diet received whole mandarin oranges instead of pureed fruit, which a CNA confirmed. A third resident whose meal ticket called for a grilled Swiss sandwich received a sandwich that was not grilled, as confirmed by a CNA and a dietary manager.
Failure to Provide Required Written Transfer, Appeal, Ombudsman, and Bed-Hold Notices During Hospitalizations
Penalty
Summary
Surveyors identified that the facility failed to provide required written transfer and bed-hold information for multiple residents who were hospitalized. For three residents who experienced transfers to the hospital after events such as falls with injury, unresponsiveness, and episodes of nausea, vomiting, and bleeding, record review showed there were no written transfer notices or written bed-hold notices in their medical records. Specifically, one resident transferred after a fall on 01/31/26 had no documented written transfer notice or bed-hold notice. Another resident transferred on 02/27/26 for nausea, vomiting, and bleeding, and later readmitted on 03/05/26, had no written transfer notification that included information on appeal rights or Ombudsman contact, and no written bed-hold notification. A third resident transferred on 01/29/26 after a fall with a forehead laceration and again on 03/17/26 for unresponsiveness, also had no documented written transfer or bed-hold notices for either hospitalization. The deficiency also included the facility’s failure to provide required content in transfer notices and to notify the State Long-Term Care Ombudsman in writing. For the residents reviewed, there was no evidence that written transfer notices were provided to the residents or their representatives in a language and manner they could understand, and the notices were missing required elements such as a statement of appeal rights, the name, mailing and email address, and phone number of the entity receiving appeals, and information on how to obtain and complete an appeal form. The notices also lacked the name, phone number, and mailing and email address of the State Long-Term Care Ombudsman, and written copies of the transfer notices were not sent to the Ombudsman. During interview, the Social Services Director confirmed that transfer and bed-hold notices were not documented for at least one resident’s hospitalization, that she does not notify the Ombudsman about transfers to the hospital, and that she only emails a monthly list of residents discharged from the facility without sending written copies of transfer or discharge notices.
Failure to Timely Retrieve Residents From ER After Discharge
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from neglect by not arranging timely transportation back to the facility after emergency room (ER) discharge. A consumer complaint alleged that residents sent to the local ER were being left there for extended periods after discharge. For one resident with an admission date of 10/13/25, records showed multiple cognitive and behavioral diagnoses, including Alzheimer’s disease, vascular dementia with agitation and other behavioral disturbances, mild cognitive impairment, cognitive communication deficit, and restlessness and agitation. A change of condition MDS documented a Brief Interview for Mental Status (BIMS) score of 1 and frequent incontinence of urine and bowel. Nursing progress notes for this resident showed that 911 was called at 3:00 AM and the resident was transferred to the ER after a fall. Hospital discharge instructions indicated the resident was discharged from the ER at approximately 5:21 AM, while the ER nurse reported discharge at about 5:30 AM. The ER nurse stated she made numerous calls to the facility but was unable to reach anyone. She reported that the resident was very disoriented and that the ER did not have enough staff to provide 1:1 supervision. The ER nurse eventually reached the Administrator, who stated staff would come to pick up the resident as soon as possible. Facility records showed the resident was not discharged from the facility on that date, and the ER nurse reported that facility staff did not pick the resident up until approximately 8:30 AM, several hours after discharge. A second resident, admitted on 11/25/25, had diagnoses including Alzheimer’s disease, dementia with behavioral disturbance, bipolar disorder with severe depression and psychotic features, depression, and anxiety disorder. The admission MDS documented a BIMS score of 2, frequent urinary incontinence, constant bowel incontinence, and a need for substantial/maximal assistance with toileting hygiene. Nursing notes showed this resident was sent to the ER for evaluation after a fall and did not return until the following morning. Hospital discharge instructions documented discharge from the ER at 10:16 PM, and the Administrator confirmed being notified of the discharge at about 10:30 PM and that the facility did not have 24-hour transportation. The Administrator acknowledged the resident was not picked up until approximately 9:00 AM the next day. The ER nurse reported making several calls to the facility that went to voicemail, eventually reaching the Administrator, who initially stated staff were on the way, then stopped answering calls. During the approximately 11-hour wait, the ER nurse stated the resident was confused, attempted to get out of bed, and became more confused as the night progressed.
Failure to Timely Provide Wound Care and Required Assistance, Resulting in Resident Neglect
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from neglect when staff did not respond appropriately to requests for care and assistance. One resident with a history of cerebral infarction due to embolism and schizophrenia, admitted on 01/30/26 and requiring staff assistance for ADLs and mechanical lift transfers, reported that a CNA was rude and mocking and that his wound dressing was not changed for several hours after he requested it. The Kardex showed he needed staff help for toileting, bathing, hygiene, bed mobility, dressing, and transfers. Nursing progress notes documented a change in condition on 03/02/26 after the resident stated the CNA was rude and would not assist as requested. The Administrator later confirmed, via video review, that the CNA entered the resident’s room at 2:30 am, the resident requested a dressing change, and no nurse entered the room until 5:00 am, despite the nurse’s statement that she went in “right away.” The DON also confirmed that the resident’s grievance described the wound dressing not being changed until hours after the request. Another resident, admitted with a right femur fracture, type II diabetes, and repeated falls, required one-person assistance for dressing, hygiene, bathing, bed mobility, and transfers, and could toilet herself with assistance for transfers. Nursing progress notes documented an alleged abuse incident on 03/02/26 in which this resident stated a CNA was rude, refused to help her, and told her she could perform some care tasks herself without staff assistance. An abuse questionnaire completed the same day showed the resident answered “Yes” to having interactions that made her feel uncomfortable or negative, and she reported that the CNA made her feel as though she was not trying with her own recovery. The Administrator and DON acknowledged that staff are expected to help residents as required and that staff interactions must be encouraging rather than making residents feel bad about needing assistance.
Failure to Revise Care Plan After Substance-Related Incident
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s care plan after a significant substance-related incident. The resident was originally admitted with a diagnosis of opioid dependence and resided on a secure unit related to polysubstance abuse disorder. The existing care plan, dated 01/21/26, identified the resident as residing on a secure unit due to polysubstance abuse disorder with interventions to perform safety risk evaluations on admission, as needed, and upon changes in condition. The care plan also identified the resident as at risk for substance use disorder with interventions to monitor for signs or symptoms of substance abuse. On 02/01/26, nursing notes documented that staff observed the resident discarding an empty Suboxone packet in the trash, even though the resident was not prescribed Suboxone and denied taking any. Staff notified the on-call provider, who ordered monitoring for adverse reactions, and nursing staff and security conducted a room search that revealed no additional contraband. Despite this incident, the resident’s care plan was not updated to address the new substance-related event. During interviews, the DON acknowledged awareness of the incident and confirmed the care plan was not revised, and the Administrator stated her expectation that nursing would update the care plan when a new risk or behavior was identified and confirmed she would have expected the care plan to be updated for this resident.
Unattended, Unlocked Medication Cart on North Hall
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were properly stored and secured in accordance with professional standards and facility expectations. On 03/24/26 at 9:06 a.m., surveyors observed a medication cart on the north hall left unlocked and unattended outside a resident room. At 9:08 a.m., the LPN responsible for the cart confirmed during interview that the cart was hers, that it was unlocked and unattended, and acknowledged she should have locked it before responding to a call light. Later that day at 3:37 p.m., the DON stated in an interview that medication and treatment carts are expected to be locked at all times when nurses are away from them, confirming that the observed practice did not meet facility expectations. This deficient practice was cited as likely to allow unauthorized personnel access to medications, which could result in injury or overdosing.
Unattended PHI Document Left Exposed at Nurse’s Station
Penalty
Summary
Surveyors identified a deficiency in the facility’s protection of residents’ personal health information (PHI) when a document containing multiple residents’ full names, assigned room numbers, and code status was left unattended and exposed on the south nurse’s station counter. On 03/16/26 at 9:04 a.m., an observation revealed a piece of paper on a clipboard with complete resident information placed on top of the south nurse’s counter in public view. At 9:06 a.m., during an interview, RN #2 confirmed that the list contained residents’ names, room numbers, and code status, acknowledged that it had been left exposed and unattended, and stated that PHI should not be left unattended. No additional clinical details or medical histories of the residents listed on the document were provided in the report.
Unattended Soiled Lunch Cart Left Uncovered in Hallway
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the handling of soiled food service equipment. On 03/24/26 at 12:58 pm, a lunch tray return cart containing soiled food trays and dishes that were uncovered was observed sitting unattended in the main hallway outside the activity room. At 1:06 pm, the housekeeping/laundry manager confirmed she saw the return cart left unattended in that location. At 1:08 pm, the Dietary Manager stated that lunch return carts should only be left in designated areas such as by the nurse’s station or inside the kitchen, and that the cart should be returned to the kitchen for cleaning as soon as all trays have been picked up, which did not occur in this instance. This deficient practice was noted as likely to expose all residents to potential pathogens associated with food waste.
Failure to Honor Resident Bathing Preferences During Prolonged Hot Water Issues
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ bathing preferences when hot water was not reliably available in resident care areas. Record review showed that one resident was scheduled to receive three showers per week on specific days, and another resident was scheduled for two showers per week. One resident reported that staff attempted to have him shower in cold water, which he refused, and that sponge baths were only offered once or twice during the period when the hot water was not working. He stated that he liked to be clean and did not feel like himself when he was dirty. A CNA reported that there was no hot water in resident care areas from the middle of December until early March, and that large barrels of warm water were brought to shower rooms to offer sponge baths, which this resident refused. Another resident, also on a scheduled twice-weekly shower regimen, stated that she received cold showers and began refusing showers because of how cold the water was. She described the water running cold unpredictably, including an instance when the water was initially warm but turned cold while she was still soaped, requiring rinsing with cold water, which she described as horrible. A social services note documented that this resident’s daughter reported the resident had been declining showers and bed baths offered because the water was too cold. A CNA corroborated that the water was “ice cold” and that residents began complaining and refusing showers around mid-December. The Maintenance Director stated that it took a while for hot water to reach the shower room and that a needed part to fix the cold-water problem was on back order, contributing to the prolonged period of inadequate hot water and resulting in residents not having their bathing preferences honored.
Improper Disposal of Unused Medications on Medication Cart
Penalty
Summary
Surveyors identified a deficiency related to accident hazards and inadequate supervision when unused medications were improperly discarded on the north hallway. During observation of the north hall nurses’ station, two medications were found in the trash bin attached to the medication cart, placed together inside an unlabeled medication cup. The pills were described as a round blue pill stamped with “61” and an oblong orange pill stamped with “20.” In an interview immediately following the observation, an RN confirmed that these medications were in the trash bin and stated that unused medications should instead be disposed of in the drug buster, a sealed container for drug disposal located in the bottom drawer of the cart. In a subsequent interview, the Unit Manager confirmed that all unused medications are to be disposed of using the drug buster and acknowledged that this did not occur, further stating that if the medications are controlled substances such as narcotics, two licensed personnel are required to dispose of them together and document the disposal on the narcotic count sheet. This deficient practice was noted as likely to affect any resident who might acquire and ingest the discarded medications, potentially causing medication side effects.
Failure to Follow Allergy, Diet, and Meal Ticket Requirements
Penalty
Summary
The facility failed to provide meals consistent with residents’ documented allergies, diet orders, and meal tickets for three residents. One resident, admitted with a documented allergy to chocolate, had a face sheet and lunch ticket indicating they were not to receive chocolate. During a lunch observation, this resident was served and was eating chocolate ice cream. An LPN confirmed the resident’s chocolate allergy and that the resident should not be eating chocolate. The Nutrition Director acknowledged that the meal ticket stated the resident should not have chocolate but reported serving chocolate ice cream after the resident requested it, stating he had not read that the resident was allergic to chocolate. Another resident, admitted with hypokalemia and ordered a regular/liberalized pureed diet per the MDS, had a lunch ticket indicating a pureed diet but was observed receiving whole mandarin oranges instead of pureed fruit. A CNA confirmed that the dessert was not pureed. A third resident’s meal ticket specified a grilled Swiss sandwich, but observation of the tray showed the sandwich was not grilled. During interviews, a CNA and a dietary manager confirmed that the sandwich was not grilled as ordered on the meal ticket.
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