Betty Dare Wellness & Rehabilitation Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Alamogordo, New Mexico.
- Location
- 3101 North Florida Avenue, Alamogordo, New Mexico 88310
- CMS Provider Number
- 325061
- Inspections on file
- 24
- Latest survey
- February 16, 2026
- Citations (last 12 mo.)
- 36
Citation history
Health deficiencies cited at Betty Dare Wellness & Rehabilitation Llc during CMS and state inspections, most recent first.
The facility failed to conduct and document effective discharge planning and to include specific discharge-related interventions in care plans for three residents. One resident with a goal to move to assisted living had no documented IDT discharge planning meetings and no care plan interventions to support that goal, as confirmed by the POA and record review. Another resident’s plan to return home with home health lacked documented, specific interventions in the care plan. A third resident was told coverage was ending and that continued stay would incur daily charges, and was discharged home without medications, DME, or information on home health, community providers, or follow-up care; there was no documentation of discharge planning, attempts to arrange home health or DME, or a post-discharge plan of care. The administrator acknowledged that discharge planning was expected to begin at admission, involve IDT meetings with residents/representatives, and be documented in the record, but confirmed this had not occurred for these residents.
Staff did not hold or document required IDT care plan meetings for two newly admitted residents after completion of their admission MDS assessments, and their POA/family reported that no meetings had occurred to discuss the residents’ care plans. In addition, another resident’s care plan was not revised to include a documented diagnosis of essential HTN, despite provider notes describing elevated BP readings and treatment with losartan. The DON and Administrator confirmed that these care plan meetings and revisions had not been completed as expected.
The facility failed to follow physician orders and accurately maintain medical records for several residents. A resident on losartan with an order to hold the medication for low SBP did not have blood pressures checked and documented on multiple mornings before administration, making it unclear if parameters were followed. Two residents who began hospice care had delays in having hospice admission orders entered into their records, leaving SNF and PT/OT/SLP orders active for days after hospice services started, and one resident’s PT order was not discontinued promptly. Another resident’s convalescent care orders for right-leg weight bearing as tolerated and left-leg partial weight bearing were not correctly entered, with the record only reflecting generalized weight bearing as tolerated and omitting the partial weight-bearing restriction.
A resident’s Medicare Part A stay ended without the required written Notice of Medicare Non-Coverage (NOMNC) being provided to the resident or the POA. Record review showed an End of Part A MDS with a documented end date for the Medicare stay, and during interview the POA reported not receiving any NOMNC indicating when coverage would end. The Administrator confirmed that staff did not issue the NOMNC, despite an expectation that such notices be given three to five days before Medicare Part A coverage ends so that informed decisions about ongoing care can be made.
A resident was transferred to the hospital for shortness of breath, and the facility failed to document the specific number of bed-hold days on the Bed Hold Notice Agreement at the time of transfer. Nursing staff reported they routinely entered a default number of days because they did not know the actual bed-hold entitlement, while the Business Office determined the true number of days later by contacting the family. In addition, Social Services did not send transfer/discharge notifications to the Ombudsman, and the Administrator had been emailing notifications to an incorrect Ombudsman address, contrary to the facility’s own transfer and discharge policy requiring written notice, appeal-rights information, and Ombudsman notification.
A resident was admitted and later discharged without a comprehensive MDS assessment ever being documented in the medical record. The MDS coordinator confirmed that the resident had been readmitted and that staff did not complete an admission MDS, despite the facility’s expectation that an admission MDS be completed for all residents within 14 days of admission. This omission was identified during review of records for residents involved in discharge planning.
A resident experienced a major decline in condition that led to hospice referral and admission, with hospice services initiated and documented by hospice staff and family signatures. Despite clear evidence that the resident’s condition had changed and hospice care had started, facility staff did not complete a Significant Change in Status Assessment (SCSA) MDS within the required 14-day timeframe. During interviews, MDS staff acknowledged the resident’s hospice status and confirmed that a change in condition MDS was expected but was not completed.
A resident’s Quarterly MDS assessment was not completed and transmitted within the required 14-day period following the ARD. Record review showed that the ARD was set, but the RN did not sign the assessment completion until several weeks later, and the MDS Coordinator confirmed during interview that the assessment was not completed and transmitted within the mandated timeframe.
A resident returned from the hospital with convalescent care orders for oxygen at 2.5 LPM, but staff did not enter this order into the medical record or provide the ordered oxygen. Observations showed no oxygen concentrator or delivery equipment in the resident’s room and no oxygen tank or nasal cannula in use while the resident was in the dining room. An LPN confirmed the oxygen order from the hospital discharge paperwork was not transcribed or implemented, and the DON confirmed staff were expected to review and enter all such orders and ensure they were carried out.
A resident admitted with a left femur fracture and a surgical incision requiring wound care did not have their wound or necessary interventions documented in the baseline care plan. Although physician orders for wound care were present and staff were providing care, the omission was confirmed by the DON, who stated that all wounds and interventions should be included in baseline care plans.
A resident with a left leg fracture and surgical wounds had physician orders and assessments indicating the need for wound care, but the care plan did not include the required interventions for wound healing. The DON confirmed that while the wounds were noted in the care plan, the specific interventions were not documented as expected.
A resident with a healing open fracture of the left leg did not have sutures and staples removed as ordered by the physician. Instead, the removal was delayed until an outside wound clinic performed the procedure, as confirmed by the DON through record review and interview.
Staff documented the removal of sutures and staples from a resident's leg in the medical record, but wound photographs and outside clinic records later confirmed that the procedure had not been performed as documented. The DON verified that the documentation was inaccurate, resulting in incomplete and misleading records.
The facility did not ensure that an RN was on duty for at least 8 consecutive hours each day, 7 days a week, for all residents. Review of PBJ staffing data for a quarterly period showed that on two days there was no documented RN coverage for the required 8 consecutive hours. In an interview, the administrator confirmed they could not provide proof of RN coverage for those days, resulting in a cited deficiency related to required RN and DON coverage.
A resident was prescribed clonazepam 0.5 mg once daily for insomnia, but the medical record contained no documented consent for this psychotropic medication. Review of records showed that the resident and/or representative had not been informed in advance about the medication’s reasons, risks, and benefits. In an interview, the DON confirmed the absence of consent and acknowledged that consents should be completed for psychotropic active medications.
Surveyors found that a resident receiving an antidepressant for depression was given the medication over several months without any documented monitoring for side effects, despite staff acknowledging that such monitoring should be recorded on the TAR. Additionally, two residents on antipsychotic medications, one with schizophrenia and one with dementia and behavioral disturbance, had repeated pharmacy recommendations for AIMS testing to monitor for tardive dyskinesia and other movement disorders, but there were no physician orders for AIMS and no AIMS assessments documented in their records; the DON confirmed these tests should have been completed and the recommendations followed.
The facility failed to provide required written transfer, bed-hold, and discharge documentation for multiple residents. One resident who fell and was transferred to the hospital had a transfer notice in the record, but a copy was not sent to the Ombudsman. Another resident sent to the ER for surgical incision concerns did not receive a written transfer notice or bed-hold notice, and her record lacked written information on appeal rights and Ombudsman contact. A third resident transferred for wound dehiscence had no written bed-hold notification documented. A resident who left AMA with family did not receive medications or discharge paperwork, and the record contained no discharge notice, discharge summary, recapitulation of stay, final status summary with individualized instructions, or medication reconciliation, and no written discharge notification was sent to the Ombudsman.
Surveyors found that the facility did not develop accurate, person-centered care plans for two residents by omitting active psychotropic and anticoagulant medications and related diagnoses from their comprehensive care plans. One resident with depression and a history of venous thrombosis and embolism was receiving antidepressants and an anticoagulant, but these medications and conditions were not reflected in the care plan. Another resident receiving memantine for cognitive decline had no documentation of this psychotropic medication or related interventions in the care plan, despite facility expectations that such medications be care planned.
Surveyors found that the facility did not complete IDT care plan meetings within 7 days of admission MDS completion for several residents and did not update care plans to reflect current conditions, orders, and preferences. One resident with COPD had a care plan that still listed PRN oxygen at 2 LPM despite a physician order for continuous oxygen at 3 LPM. A resident with a history of falls experienced another fall, after which an anti-roll back device was implemented but not added to the care plan. A resident with schizophrenia had antipsychotic-related monitoring orders, including BMP, ECG, and mood/behavior documentation, that were not incorporated into the care plan. Another resident’s documented activity interests, such as being around animals, group activities, and going outdoors, were not reflected in the care plan, and the frequency of activities was not specified. Staff interviews confirmed lack of awareness of required care conference timeframes and that these care plan updates and conferences had not been completed as required.
A resident identified as at risk for weight loss had physician orders for weekly weights and a house nutritional supplement twice daily due to poor intake, but staff documented only a single weight for the month and recorded the supplement as given only twice. The resident’s sister reported that the resident had tooth pain and had lost weight because eating was painful. A Regional Clinical Nurse confirmed that the ordered weights were not completed and that there was no documentation showing the supplement was administered as prescribed.
A resident with dementia and schizophrenia was receiving donepezil with an indication documented as schizophrenia. During a monthly drug regimen review, the consultant pharmacist recommended changing the indication from schizophrenia to dementia, but the physician did not update the order to reflect dementia until well after the recommendation, and there was no documented rationale for the delay. The DON later confirmed that the diagnosis was not updated within the same month as the pharmacist’s recommendation, as it should have been.
A resident with a history of venous thrombosis and embolism was receiving rivaroxaban for anticoagulation, and a pharmacist had recommended monitoring for bleeding and thromboembolism as potential side effects. Review of the medical record showed no documentation that staff monitored for these anticoagulant side effects. An LPN and a Regional Clinical Nurse both confirmed that nurses were expected to monitor and document anticoagulant side effects in the MAR, yet acknowledged that no such documentation existed for this resident.
A resident experienced ongoing tooth pain after a dentist visit where a tooth extraction was attempted and decay under the gum was noted, leaving part of the tooth broken and requiring an oral surgeon. Although a referral to an oral surgeon was documented, there was no record that an appointment was made or that the resident was ever seen by the specialist. The resident and the POA both reported that the resident continued to have tooth pain and had not yet seen an oral surgeon, and facility staff, including Medical Records and the DON, confirmed that the referral had not been followed through.
A resident did not receive needed dental services after a scheduled routine dental exam was canceled by the dental office because the resident’s insurance was inactive. The resident’s family reported the resident had not seen a dentist since admission, and facility staff, including Medical Records and a Regional Clinical Nurse, confirmed that the canceled dental appointment was never rescheduled, resulting in a failure to provide or obtain dental care as required.
Surveyors found that the facility failed to maintain complete and accurate records for several residents. A resident with type 2 DM had physician orders for twice-monthly blood glucose checks, but no blood sugar values were documented on the TAR for multiple consecutive months, which the Regional Clinical Nurse confirmed were not recorded at the time of testing. Another resident’s MDS showed that certain activities, such as being around animals, going outside, and religious services, were very important, yet progress notes reflected almost no documentation of group or 1:1 activity participation. A third resident with dementia had documented preferences for animals, news, group and outdoor activities, and morning/afternoon programs, but these were not incorporated into the care plan approaches, and there was no activity participation documentation for several months despite the Activities Director stating the resident participated daily and acknowledging that activity records and care plan updates were not being completed.
A resident with legal blindness, hearing impairment, and diabetes did not receive needed ADL assistance, including nail care and help returning to his room after a meal. The resident's fingernails were observed to be long and jagged, and he was left alone in the dining room for an extended period, unable to get staff attention. Staff and DON interviews confirmed the resident's need for assistance and that required protocols were not followed.
A deficiency was identified when a resident with dementia, muscle weakness, and a history of falls was observed lying in bed with her drinking water placed on a bedside table positioned about two feet away and at a height she could not reach. A CNA confirmed the table and water were out of the resident’s reach, preventing her from accessing fluids independently. The ADON and a regional clinical nurse acknowledged that staff were expected to position bedside tables so residents could reach their water and personal items.
A resident admitted with muscle weakness and a history of an unspecified fall experienced another fall that required transfer to a hospital for evaluation. Despite this event, the admission MDS completed afterward documented that the resident had no falls since admission. During interview, the MDS Coordinator confirmed that the fall had occurred prior to completion of the MDS and should have been included but was not, resulting in an inaccurate federally mandated assessment.
A resident admitted for orthopedic aftercare following a surgical amputation and with PVD had detailed MD orders for left BKA wound care, including cleansing, skin prep, Bacitracin, Xeroform, ABD pad, Kerlix, and Ace wrap. However, the baseline care plan initiated after admission did not include any interventions or plan for the surgical site wound care, and this omission was confirmed by the RCN during interview.
The facility failed to ensure accurate and readily accessible code status information for two residents. One resident’s MOST form indicated full code, but no code status order was entered in the EMR and the nurse rounding tool incorrectly listed DNR. Another resident had both a MOST form and a physician order for full code, yet the nurse rounding tool also showed DNR. An LPN confirmed the expectation to enter code status orders on admission and to rely on the EMR or nurse rounding tool in emergencies, while the DON and a regional clinical nurse acknowledged that MOST forms were not consistently available at the skilled unit nurses’ station and that the rounding tools did not reflect the correct code status.
A resident with reported left-ear hearing loss repeatedly requested a hearing evaluation but was never scheduled for one. EMR care plan notes documented that a hearing appointment was supposedly already scheduled at one point and later that an appointment was still needed, yet no evaluation occurred. The Regional Clinical Nurse confirmed that, despite the documented requests and care plan notes, the resident had not been seen or scheduled for a hearing evaluation, resulting in a failure to provide proper treatment to maintain hearing.
A resident with mobility needs had a physician order and PT discharge recommendation for a restorative nursing ambulation program, but the program was not implemented for an extended period and lacked clear frequency directions in the order. The resident reported she was only walked after surveyors arrived, and the MDS showed no restorative days in the review period. Staff interviews revealed the restorative program had been inactive due to staffing issues, that the restorative program only recently restarted, and that the RNA was frequently pulled to work as a CNA, resulting in the resident not being ambulated as intended and not being properly care planned for restorative services.
A resident with a history of UTIs and urinary retention reported fatigue and progressively cloudy urine in her catheter. A provider documented a complicated UTI with multidrug-resistant Pseudomonas and planned IV cefepime therapy once IV access was established. However, there was no documentation that IV or PICC access was obtained, no corresponding cefepime order in the physician’s orders, and the MAR showed the resident never received IV cefepime, only ongoing oral cephalexin for UTI suppression. The Regional Clinical Nurse confirmed the absence of documentation for IV access and that no IV cefepime doses were administered.
A resident with COPD and asthma, ordered to receive 3 LPM of oxygen continuously, was observed with a nasal cannula positioned on the cheek instead of in the nostrils, and later not wearing the cannula at all. Signage at the bedside indicated a 3 LPM order, but the oxygen concentrator was found set at 3.5 LPM without any provider order or documentation for the change. LPNs confirmed the cannula was improperly positioned, that the resident was supposed to be on continuous oxygen, and that staff were not to adjust oxygen settings without a provider’s order, which was not present.
The facility did not complete a required annual performance evaluation for one CNA. Personnel records showed that a CNA hired more than a year earlier did not have an annual performance review completed within 12 months, and the administrator confirmed the omission during interview.
Medication and treatment carts containing various drugs and biologicals were found unlocked and unattended in multiple areas of the facility. Staff and the Administrator confirmed that these carts should be locked when not in use, but observations revealed that this protocol was not followed, impacting all residents in the facility.
A resident repeatedly refused showers over several months, but the care plan was not updated to reflect these refusals or to include interventions for staff to encourage bathing. The omission was confirmed by the Regional Nurse Consultant, who acknowledged that the care plan did not address the resident's refusals or provide guidance for staff.
Staff did not notify the physician when a resident's blood pressure medication was unavailable for several days and failed to report multiple instances of blood glucose readings above 400 mg/dL, despite physician orders requiring notification. The DON and regional nurse confirmed that no provider contact was documented for these events.
A resident's room was found to have four pieces of velcro on the wall, a scraped and unpainted wall behind the bed, and an electrical outlet without a cover while in use. The resident reported these issues had been present since moving in, and the administrator confirmed the findings during the survey.
A resident with multiple mobility and care needs was admitted and assessed for specific levels of assistance with ADLs, but staff failed to document these functional abilities and required assistance in the care plan. The DON was unaware that this information should be included, and the corporate nurse confirmed its necessity.
Staff failed to follow physician orders and document care for two residents, including not entering or acting on orders for urinalysis and urine culture for a resident with urinary symptoms, and not administering prescribed blood pressure medication and insulin or notifying the physician about missed doses and high blood sugar for another resident. Interviews and record reviews confirmed these deficiencies and lack of required notifications.
A resident with mobility issues and a need for personal care assistance received only two showers during their stay, despite requiring partial to moderate help and the facility's policy of providing showers three times weekly. Documentation confirmed that showers were not given as scheduled, and the DON verified the shortfall, resulting in a deficiency in ADL care.
A resident experiencing burning during urination had a physician order for a urinalysis and urine culture, but staff failed to document provider notification, enter the orders into the EMR, or collect the required specimens. Interviews confirmed that expected documentation and follow-through were not completed.
The facility did not provide the required RN coverage for eight hours a day, seven days a week, as confirmed by the Infection Preventionist and Business Office Manager. The absence of RN coverage on specific dates was noted, with a resident census of 48. The Director of Nurses cited challenges in hiring nurses as a contributing factor.
The facility failed to maintain a clean environment, with staff using disinfectant sprays like Lysol to mask odors instead of following proper cleaning protocols. A strong urine smell was noted near the 100 unit, and inappropriate spraying was observed by housekeeping staff, a van driver, and an RN. A resident and a family member reported the sprays were overpowering. The Maintenance Director confirmed the odor issue was due to old water in the carpet shampooer, contrary to the facility's policy against using deodorizers.
A facility failed to ensure proper PPE use and infection control practices. An LPN did not wear gowns for residents requiring Enhanced Barrier Precautions, and patient equipment was not consistently cleaned after use. Additionally, hand hygiene was not performed during medication administration, contrary to facility policy.
A resident in a long-term care facility did not receive a requested shower before a doctor's appointment, leading to feelings of indignity. Despite being scheduled for showers and requiring assistance, the resident's request was not communicated between shifts, resulting in the resident attending the appointment without a shower. Facility records showed inadequate documentation of bathing, and staff interviews revealed a lack of awareness and communication regarding the resident's needs.
A facility failed to assess a resident for self-administration of medication, as observed during a survey. The resident, who was cognitively intact, had Tums left at her bedside without a physician's order or care plan. The LPN confirmed the resident's request to leave the medication at the bedside, but acknowledged the lack of proper authorization. Facility policy requires a physician's order and care plan for self-administration, which was not followed.
The facility failed to accurately code the MDS for two residents receiving hospice services and one resident receiving oxygen therapy, potentially risking unmet care needs. Errors were identified through observations and interviews, with the MDSC acknowledging mistakes in coding hospice status and oxygen therapy, despite available documentation.
A facility failed to create a comprehensive, person-centered care plan with measurable goals for a resident receiving hospice services. The care plan only included basic information under 'Advanced Directives' without specific details or objectives. Interviews with the MDSC and DON confirmed the lack of specifics in the care plan, potentially impacting the resident's well-being.
Failure to Conduct and Document Effective Discharge Planning and Care Plan Interventions
Penalty
Summary
The deficiency involves the facility’s failure to implement an effective discharge planning process and to ensure care plans reflected specific discharge interventions for three residents. For one resident admitted in early February, the care plan documented a goal to discharge to an assisted living facility, but there were no specific interventions listed to help achieve this goal. The resident’s POA reported that no meetings had been held with her to discuss what interventions were being implemented to support the planned discharge. The medical record contained no documentation of discharge planning meetings with the IDT, the resident, or the resident’s representative. A second resident was admitted and later discharged home with home health services identified as the discharge plan. However, the care plan did not include specific interventions to assist the resident in meeting this discharge goal. There was no indication in the cited documentation that the comprehensive care plan or discharge plan had been updated with treatment preferences and needs related to the discharge. A third resident was admitted and later discharged home after Medicare Part A coverage ended. The resident’s family member reported being informed by a social services clerk that Medicare coverage would end on a specific date and that continued stay would cost a daily rate, and another staff member told her the resident had to leave by noon on the last covered day to avoid charges. The family member stated there had been no meetings with her or the resident to discuss the discharge or interventions needed for a safe discharge, and that the resident was discharged without medications, DME, home health information, community provider information, or follow-up appointment information. The care plan listed a goal to discharge home with home health services but lacked specific interventions, and the medical record did not contain documentation of discharge planning, attempts to obtain home health or DME, or a post-discharge plan of care. The administrator confirmed the absence of documented discharge planning meetings and care plan updates for all three residents and was unable to determine whether discharge plans had been discussed with the third resident or his family member.
Failure to Hold Timely IDT Care Plan Meetings and Update Care Plan Diagnoses
Penalty
Summary
The facility failed to ensure required IDT care plan meetings were held within 7 days of completion of the admission MDS assessments and on a quarterly basis for two residents, and failed to revise a care plan to reflect an updated diagnosis for another resident. For one resident admitted on an unspecified date, the admission MDS was completed on 12/15/25, but there was no documentation in the medical record of an IDT care plan meeting, and the resident’s POA reported that staff had not met with her to discuss the resident’s care plan. For a second resident admitted on an unspecified date, the admission MDS was completed on 11/18/25, but the medical record likewise contained no documentation of an IDT care plan meeting, and a family member stated that staff had not met with the resident or family to discuss the care plan. The Administrator confirmed that IDT care plan meetings had not been held for these two residents since admission, despite an expectation that such meetings occur quarterly based on MDS assessments. The facility also failed to revise the care plan for a third resident to include a diagnosis of essential hypertension. This resident, admitted on an unspecified date, had diagnoses including hypokalemia and dementia. A provider progress note dated 11/10/25 documented a plan addressing essential hypertension, noting blood pressure readings ranging from 121/71 to 162/79 while on losartan 50 mg daily and consideration of titration for persistent elevated blood pressures. However, review of the resident’s care plan dated 11/06/25 showed that it was not updated to include the essential hypertension diagnosis. The DON confirmed that the resident’s care plan had not been revised to reflect this diagnosis.
Failure to Follow Medication Parameters and Accurately Enter Hospice and Weight-Bearing Orders
Penalty
Summary
The deficiency involves multiple failures to provide treatment and care according to physician orders and residents’ needs. One resident with diagnoses including hypokalemia, dementia, and essential hypertension had a physician’s order for losartan 50 mg daily, later increased to 75 mg daily, with instructions to hold the medication if the systolic blood pressure (SBP) was less than 110. Review of the MARs and blood pressure logs for December and January showed that staff did not document checking this resident’s blood pressure on numerous mornings before administering losartan, and the DON confirmed that the blood pressure was not checked every morning during that period. As a result, it was unclear whether the ordered parameters to hold the medication for low SBP were followed. The deficiency also includes failures related to hospice admission orders and therapy orders for two residents. One resident was readmitted with an order to admit to SNF and had active orders for PT, OT, and SLP. A hospice nurse visit note documented that hospice services started on a specific date, but the hospice admission order was not entered into the medical record until a week later, leaving the SNF and therapy orders active. Another resident was admitted and later discharged, with documentation showing a hospice admission agreement signed by family and a hospice nurse visit note indicating the start of hospice services on a certain date. However, the hospice admission order was not entered into the medical record until several days later, and the PT order remained active and was not discontinued until days after hospice services began. The therapists and the DON confirmed that residents on hospice should not be receiving PT, OT, or SLP and that hospice and SNF/therapy orders were not updated timely in the medical record. Additionally, the facility failed to correctly enter weight-bearing orders for another resident at admission. Convalescent care orders specified weight bearing as tolerated for the right leg and partial weight bearing for the left leg. When these orders were entered into the medical record, staff documented only “weight bearing as tolerated” without specifying the right leg and did not enter any order for partial weight bearing on the left leg. An LPN and the DON confirmed that the convalescent care orders included both right-leg weight bearing as tolerated and left-leg partial weight bearing, that these were not fully or correctly entered into the medical record, and that staff were expected to review and enter all such orders correctly at the time of admission.
Failure to Provide Required Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide a required written Notice of Medicare Non-Coverage (NOMNC) to one resident receiving Medicare Part A services. Record review showed the resident was admitted on an unspecified date and had an End of Part A MDS assessment indicating the end date of the most recent Medicare Part A stay was 01/09/26. During an interview, the resident’s Power of Attorney stated she did not receive a NOMNC informing her of the last day of the resident’s Medicare Part A coverage. In a subsequent interview, the Administrator confirmed that staff did not give the resident or her POA a NOMNC, despite the facility’s expectation that residents or their representatives receive a copy of the NOMNC at least three to five days prior to the end of Medicare Part A coverage so they can make informed decisions regarding the resident’s care. The deficiency was identified through record review and interviews with the resident’s POA and the Administrator, and it involved one of three residents reviewed for beneficiary notices. The report notes that if residents or their representatives are not provided with the beneficiary notices, they may not make an informed decision about the services provided to them and this could likely result in a decline in health and function.
Failure to Provide Complete Bed-Hold Information and Ombudsman Notification for Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to provide required written transfer and bed-hold information for a hospitalized resident. Record review showed that one resident was admitted on an identified date and later sent to the hospital due to shortness of breath. The resident’s Bed Hold Notice Agreement, completed on the date of transfer, did not include documentation of the number of days the bed would be held. Interviews revealed that an RN routinely entered a default of three days for bed holds because nursing staff did not know the actual number of days available, and the Business Office Manager stated that nursing initiates the discharge/transfer while the Business Office determines the actual bed-hold days by contacting the family, typically the next day. This process resulted in the bed-hold notice lacking the required specific duration at the time of transfer. The facility also failed to send required written transfer/discharge notices to the Ombudsman. The Social Service Clerk stated that she did not send notifications to the Ombudsman when the resident was discharged from the facility. The Administrator reported that Social Services was responsible for sending Ombudsman notifications and that she believed monthly notifications by email were acceptable, citing an email she sent covering a range of dates. However, record review of an email from the Ombudsman showed that the Administrator had been sending notifications to an incorrect email address. The facility’s Transfer and Discharge policy required complete documentation, written notice to residents and/or representatives, informing residents of their right to appeal, and notification of the Ombudsman, but these requirements were not met for the resident who was transferred to the hospital.
Failure to Complete Timely Comprehensive MDS Assessment After Admission
Penalty
Summary
The deficiency involves the facility’s failure to complete a comprehensive Minimum Data Set (MDS) assessment within 14 calendar days of admission for one resident who was reviewed for discharge planning. Record review showed that this resident was admitted to the facility and later discharged, but there was no documented comprehensive MDS assessment in the medical record during the resident’s stay. During an interview, the MDS coordinator confirmed that the resident had been readmitted, that staff did not complete or document an admission MDS for this resident, and that facility expectations were for an admission MDS to be completed for all residents within 14 days of admission. The coordinator further confirmed that the admission MDS for this resident should have been completed by a specific date, but it was not done. This failure to complete and document the required comprehensive MDS assessment within the regulatory timeframe constituted the identified deficiency for this resident among those reviewed for discharge planning.
Failure to Complete Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) MDS within 14 days after determining a resident had a major decline in condition and required hospice services. The resident was admitted on 11/07/25 and subsequently had a physician order on 01/16/26 for a hospice referral, followed by an order on 01/22/26 to admit the resident to hospice. A hospice admission agreement was signed by the resident’s family member on 01/17/26, and a hospice nurse documented a start-of-care visit on the same date. Despite these documented indicators that the resident’s condition had declined and hospice services had begun, record review showed no significant change MDS assessment was completed within the required 14-day timeframe. During interview, the MDS Coordinator and Regional MDS Coordinator confirmed the resident was placed on hospice services on 01/17/26, that no change in condition MDS assessment was completed, and that staff were expected to complete such an assessment within 14 days after identifying a change in condition.
Failure to Complete and Transmit MDS Assessment Within Required Timeframe
Penalty
Summary
The facility failed to complete and transmit a Minimum Data Set (MDS) assessment within 14 days of the Assessment Reference Date (ARD) for one of three residents reviewed. Record review showed that this resident’s Quarterly MDS had an ARD of 01/14/26, but the RN did not sign the assessment completion date until 02/10/26. During an interview on 02/16/26 at 4:50 PM, the MDS Coordinator confirmed that this MDS assessment was not completed and transmitted within the required 14-day timeframe. This failure involved only the timeliness of the MDS completion and transmission; no additional clinical details, medical history, or resident condition at the time of the deficiency were documented in the report.
Failure to Implement and Document Physician-Ordered Oxygen Therapy
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory care in accordance with professional standards by not implementing and documenting a physician’s order for oxygen therapy for one resident. The resident was readmitted to the facility from the hospital with convalescent care orders dated 02/13/26 that included an order for oxygen at 2.5 liters per minute. Review of the resident’s medical record showed that this oxygen order was not entered into the resident’s active orders. Subsequent observations of the resident’s room revealed there was no oxygen concentrator or oxygen delivery equipment present, and observation of the resident in the dining room showed the resident did not have an oxygen tank or nasal cannula in use. During interviews, an LPN confirmed that the resident did not have an oxygen order in the medical record despite the convalescent care orders specifying oxygen at 2.5 LPM, and acknowledged that the resident had not been placed on oxygen after returning from the hospital. The LPN also stated that staff were expected to enter all convalescent care orders into the medical record upon a resident’s return from the hospital. The DON similarly confirmed that staff were expected to review all convalescent care orders, enter them into the resident’s medical record, and ensure all orders were implemented, which did not occur in this case.
Failure to Document Surgical Wound and Interventions in Baseline Care Plan
Penalty
Summary
The facility failed to create a baseline care plan that included all necessary information for providing care to a newly admitted resident with a surgical wound. Specifically, a resident admitted with a diagnosis of a left femur fracture and a surgical incision with staples did not have this wound or the required wound care interventions documented in their baseline care plan. Physician orders were in place for wound care, including cleaning the incision and ensuring a dressing was in place each shift until staple removal, but these interventions were not reflected in the baseline care plan. Interviews confirmed that staff were performing wound care and that the resident was scheduled for staple removal, yet the baseline care plan omitted any mention of the surgical wound or related interventions. The Director of Nursing acknowledged that staff were expected to document all wounds and interventions in baseline care plans, but this was not done for the resident in question.
Failure to Document Wound Care Interventions in Care Plan
Penalty
Summary
The facility failed to develop an accurate, person-centered comprehensive care plan for a resident admitted with a left fibula fracture and surgical wounds on the left knee and ankle. Record review showed that while physician orders and the MDS assessment documented the presence of surgical wounds and required wound care, the resident's care plan did not include the specific interventions ordered to treat these wounds. During an interview, the DON confirmed that although the care plan noted the existence of wounds, it lacked documentation of the interventions in place to promote healing, despite staff expectations to include all such interventions in the care plan.
Failure to Follow Physician's Orders for Wound Care
Penalty
Summary
The facility failed to meet professional standards of practice by not following a physician's order for wound care for one resident. The resident was admitted with a diagnosis of a left fibula fracture, specifically an open fracture type 1 or 2, and was progressing with routine healing. A physician's order dated 12/03/25 directed staff to remove the resident's sutures and staples from the left leg. However, staff did not carry out this order as required. Instead, the removal of the sutures and staples was delayed until the resident attended an outside wound care clinic, where the procedure was performed on 12/23/25. The Director of Nursing confirmed during an interview that staff were expected to follow physician's orders and acknowledged that the removal had not been completed by facility staff as ordered. This lapse was identified through record review and staff interview.
Incomplete and Inaccurate Medical Record Documentation for Wound Care
Penalty
Summary
Staff failed to ensure that medical records were complete and accurate for a resident who was admitted with a left fibula fracture and had an order for suture and staple removal from the left leg. The physician's order specified that the sutures and staples should be removed, and staff documented in the Treatment Administration Record that this procedure was completed as ordered. However, subsequent wound photographs taken several days later showed that both sutures and staples remained in place on the resident's leg. Further review of wound clinic documentation revealed that the sutures and staples were not actually removed until a later visit to an outside wound care clinic. During an interview, the Director of Nursing confirmed that staff had documented the removal of sutures and staples even though the procedure had not been performed. This inaccurate documentation resulted in incomplete and misleading medical records for the resident.
Failure to Provide Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure required RN coverage of at least 8 consecutive hours per day, 7 days a week, for all 72 residents identified on the resident matrix. Review of the Payroll Based Journal (PBJ) Staffing Data Report for Quarter #1 (covering October 1 through December 31, 2025) showed there was no RN coverage for at least 8 consecutive hours on two specific dates, 10/06/24 and 12/31/24. During an interview, the administrator confirmed they were unable to provide proof that an RN was on duty for the required hours on those dates. This deficient practice was cited under the requirement to have a registered nurse on duty 8 hours a day and to have a registered nurse serving as the full-time director of nursing, and was determined to potentially affect all residents in the facility by likely resulting in residents not receiving the services they require.
Lack of Informed Consent for Psychotropic Medication
Penalty
Summary
Surveyors found that the facility failed to ensure a resident and/or representative was informed in advance about a prescribed medication and understood the reasons, risks, and benefits. Record review showed that the resident had a physician’s order dated 10/28/25 for clonazepam 0.5 mg once daily for insomnia. Further review of the medical record revealed there was no documented consent for the clonazepam. During an interview on 11/21/25 at 10:19 AM, the DON confirmed that there was no consent for the resident’s clonazepam and stated that consents should be completed for psychotropic active medications. This deficiency was identified for 1 of 5 residents reviewed for unnecessary medications, indicating that the required process of obtaining and documenting informed consent for a psychotropic medication was not followed for this resident.
Failure to Monitor Psychotropic Medication Side Effects and Complete AIMS Assessments
Penalty
Summary
Surveyors identified a deficiency in the facility’s monitoring of psychotropic medications for multiple residents. One resident with a diagnosis of depression was admitted on an unspecified date and had a physician’s order for citalopram hydrobromide 20 mg for depression. Medication administration records showed the antidepressant was administered consistently over several months. However, review of the resident’s entire medical record revealed no documentation that staff assessed for side effects of the antidepressant. In an interview, an LPN confirmed the resident had an order for citalopram, that staff were not monitoring for antidepressant side effects, and that such monitoring should have been documented on the Treatment Administration Record. The Regional Clinical Nurse also confirmed that staff were expected to monitor for antidepressant side effects. Surveyors also found that two residents receiving antipsychotic medications were not assessed using the Abnormal Involuntary Movement Scale (AIMS) despite pharmacy recommendations. One resident with schizophrenia had an order for thioridazine 10 mg twice daily, and pharmacy recommendations on three separate dates stated that the antipsychotic could cause tardive dyskinesia and other movement disorders and recommended a movement test within 30 days and then every six months. Another resident with unspecified dementia with behavioral disturbance had orders for mirtazapine for agitation and risperidone for psychosis, and pharmacy recommendations similarly advised a movement test within 30 days and then every six months. For both residents, record review showed no AIMS orders and no documented AIMS tests. In an interview, the DON confirmed there were pharmacy recommendations for movement tests for both residents and that an AIMS test should have been done initially upon admission and that the recommendations should have been followed.
Failure to Provide Required Written Transfer, Bed-Hold, and Discharge Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide required written discharge and transfer information, including notices to residents, their representatives, and the Ombudsman, as well as required bed-hold notifications and discharge summaries. For one resident who fell and was transferred to the hospital, the record contained a transfer notice indicating the transfer was due to an unwitnessed fall, but the social services worker stated he did not send a copy of this transfer notice to the Ombudsman. Another resident reported being sent to the ER due to concerns about surgical incisions and stated she did not receive a written transfer notice or a written bed-hold notice. Review of her medical record confirmed there was no written transfer notification that included appeal information or Ombudsman contact information, and no written bed-hold notification for her hospital transfer. A third resident’s EMR showed a transfer to the hospital due to changes in wound appearance and dehiscence, but the record did not contain a written bed-hold notification for that transfer. The corporate nurse confirmed that staff did not complete a written bed-hold notification for this resident and that staff were expected to send copies of transfer notices to the Ombudsman. The social services worker also confirmed he did not send the Ombudsman copies of written notices of transfers. The administrator confirmed that for the resident transferred for surgical incision concerns, staff did not complete a written transfer notification or a written bed-hold notification, despite an expectation that staff complete these notices, provide copies to the resident or representative at the time of transfer, and send a copy of the transfer notice to the Ombudsman. For another resident who was admitted and later left the facility AMA with family, the progress note documented that the resident was not given medications or discharge paperwork at the time of departure. Review of this resident’s medical record showed there was no discharge notice, no discharge summary, no recapitulation of the stay, no final summary of the resident’s status with individualized care instructions, and no medication reconciliation between pre-discharge and post-discharge medications. The Social Service Coordinator confirmed that the resident’s record did not contain documentation of a discharge summary, discharge notification, recapitulation of stay, or medication reconciliation, that a written discharge notification was not sent to the Ombudsman, and that there was no documentation in the record of a report made to APS for this discharge, although the coordinator stated it had been reported.
Failure to Include Psychotropic and Anticoagulant Medications in Comprehensive Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop accurate, person-centered comprehensive care plans that reflected current physician orders and diagnoses for two residents. For one resident with documented diagnoses of depression, history of venous thrombosis, and embolism, the admission MDS showed the resident was receiving antidepressant and anticoagulant medications, including bupropion, citalopram, and rivaroxaban for depression and DVT prevention. However, the resident’s care plan, revised in late October, did not include the resident’s antidepressant medication orders or the diagnoses of venous thrombosis and embolism, nor the associated anticoagulant orders. During interview, the Regional Clinical Nurse confirmed the presence of these orders and acknowledged that the care plan did not document the antidepressant and anticoagulant medications, despite the expectation that such medications be care planned. For another resident admitted in early November with an order for memantine to treat cognitive decline, the physician orders documented memantine 5 mg twice daily. The resident’s care plan, dated shortly after admission, did not include the psychotropic medication memantine or any interventions related to its use. In interview, the Regional Clinical Nurse confirmed that the care plan lacked documentation of memantine and its interventions and stated that all psychotropic medications and their interventions were expected to be included in residents’ care plans.
Failure to Complete Timely IDT Care Conferences and Update Care Plans With Current Orders and Preferences
Penalty
Summary
The deficiency involves the facility’s failure to complete timely IDT care plan meetings within 7 days of the completion of admission MDS assessments and to revise care plans to reflect current orders, conditions, and preferences for multiple residents. For one resident with COPD, the admission MDS was completed on 09/04/25, but the IDT care conference was not held until 10/06/25. Another resident’s admission MDS was completed on 11/13/25, and as of 11/21/25 there was no record of an IDT care plan meeting. A third resident’s admission MDS was completed on 09/19/25, but the IDT care conference did not occur until 10/08/25. The social services worker stated he was unaware of the required timeframe for IDT care conferences and confirmed that these care conferences were not held within 7 days of the MDS completion. The facility also failed to revise care plans to reflect changes in residents’ conditions and physician orders. One resident, readmitted with a diagnosis including a fall subsequent encounter, sustained a fall on 11/04/25; although an anti-roll back device was implemented for the resident’s wheelchair after the fall, the existing care plan, which already identified the resident as at risk for falls, was not revised to include this new intervention. For the resident with COPD, physician orders dated 09/25/25 specified oxygen at 3 LPM continuously, but the care plan, dated 09/03/25, continued to state oxygen at 2 LPM PRN for hypoxia, and staff did not revise the care plan when the oxygen order changed. The Regional Clinical Nurse confirmed that the care plan did not match the current oxygen order and that staff were expected to revise care plans when orders changed. Additional failures to update care plans were identified for residents with psychiatric and activity needs. One resident with schizophrenia had multiple physician orders related to antipsychotic medication management, including thioridazine dosing, BMP every three months, mood and behavior monitoring with documentation in progress notes, and ECG every six months, but these interventions were not documented in the resident’s care plan dated 10/14/25. Another resident’s activities initial assessment documented that being around animals, keeping up with the news, participating in groups, going outdoors, and morning and afternoon activities were very important, yet the care plan dated 09/16/25 did not include these personal preferences or specify the frequency of activity participation. The Activities Director confirmed that the resident’s care plan did not reflect the interests and frequency identified in the initial assessment.
Failure to Follow Weight Monitoring and Nutritional Supplement Orders
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for one resident when staff did not follow physician orders for weight monitoring and nutritional supplementation. The resident had an order dated 10/16/25 to be weighed weekly for four weeks and then monthly, and a subsequent order dated 10/27/25 for a house nutritional supplement (house shake) 4 oz twice daily for poor intake. Record review showed that for October 2025 the resident’s weight was documented only once, on 10/16/25, instead of weekly as ordered, and the house shake supplement was documented as given only twice on 10/31/25, rather than twice daily as ordered. During an interview, the resident’s sister reported that the resident was experiencing tooth pain and had lost weight because eating caused pain. In a later interview, the Regional Clinical Nurse confirmed that the resident was not weighed per the physician’s order and that there was no documentation that the ordered house supplement was provided as directed, acknowledging that physician orders should be followed and that supplement administration should be documented in the record. These findings were based on record review and interviews and involved one of three residents reviewed for nutrition and maintenance of acceptable parameters of nutritional status.
Failure to Timely Implement Pharmacist Recommendation for Medication Indication
Penalty
Summary
Surveyors identified a deficiency in the facility’s process for ensuring that consultant pharmacist recommendations are reviewed and acted upon by the physician. A resident with diagnoses of unspecified dementia without behavioral, psychotic, mood disturbance, or anxiety, and unspecified schizophrenia was admitted on an unspecified date. The physician’s order dated 08/11/25 for donepezil 10 mg at bedtime listed the indication as schizophrenia, unspecified. During the monthly Medication Regimen Review dated 09/05/25, the consultant pharmacist recommended clarification of the donepezil indication, specifying that it should be changed from schizophrenia to dementia. Record review showed that the physician’s order for donepezil was not updated to reflect dementia as the indication until 10/28/25, indicating that the pharmacist’s recommendation was not implemented in a timely manner and no documented rationale for not following the recommendation was provided. During an interview on 11/21/25 at 10:19 AM, the DON confirmed that the diagnosis for donepezil was not updated until 10/28/25 and stated that the diagnosis should have been updated within the month of the recommendation. This sequence of events demonstrated the facility’s failure to ensure that the consultant pharmacist’s recommendation regarding the medication indication was reviewed and implemented by the physician or that a rationale was documented for not following it.
Failure to Monitor and Document Anticoagulant Side Effects
Penalty
Summary
The deficiency involves the facility’s failure to monitor and document monitoring for side effects of an anticoagulant medication for one resident. The resident was admitted with a history of venous thrombosis and embolism and had physician orders for rivaroxaban, initially 20 mg for DVT prevention and later changed to 10 mg once daily for anticoagulation. A pharmacist’s recommendation dated 09/05/25 directed staff to monitor the resident for bleeding or thromboembolism as potential side effects of the anticoagulant therapy. Record review of the resident’s entire medical record showed no documentation that staff monitored for side effects of the anticoagulant medication. During an interview, an LPN stated that the resident had an order for rivaroxaban, that nurses were supposed to monitor residents for anticoagulant side effects, and that such monitoring was expected to be documented in the MAR, but confirmed there was no such documentation for this resident. In a separate interview, the Regional Clinical Nurse confirmed that staff were expected to monitor for anticoagulant side effects, acknowledged the pharmacist’s recommendation to monitor for bleeding and thromboembolism, and confirmed that the resident’s record lacked documentation of this monitoring.
Failure to Arrange Oral Surgeon Follow-Up After Dental Referral
Penalty
Summary
The facility failed to ensure that a resident received necessary dental services, including follow-up with an oral surgeon after a dental referral. The resident’s POA reported that the resident’s teeth were hurting and was unsure if the resident had seen a dentist. Progress notes dated 07/30/25 documented that the resident had been seen by a dentist for a tooth extraction, that decay was present under the gum, the tooth broke, and that the resident needed to see an oral surgeon to extract the remaining portion of the tooth. Review of the medical record showed no documentation that the resident had been seen by an oral surgeon. Medical Records staff confirmed that the resident had been to the dentist on 07/30/25, that there was a referral to an oral surgeon, and that the resident had not been seen by the oral surgeon. The resident reported ongoing tooth pain, including pain when eating or drinking anything cold and when chewing on the side of the broken tooth, and stated that she was supposed to see an oral surgeon but the facility had not yet made an appointment. The DON confirmed that the resident had not seen an oral surgeon and stated that referrals should be followed up and appointments made.
Failure to Reschedule Canceled Dental Appointment Due to Insurance Issue
Penalty
Summary
The facility failed to ensure that a resident received necessary dental services when a scheduled dental appointment was canceled due to insurance issues and not rescheduled. The resident was admitted on an unspecified date and, according to an interview with the resident’s son on 11/18/25, had not seen a dentist since admission. A progress note dated 01/28/25 documented that the resident had been scheduled for a routine dental exam, but the dental office canceled the appointment because the resident’s insurance was inactive. In an interview on 11/19/25, Medical Records confirmed that the dental office canceled the 01/28/25 appointment due to inactive insurance and acknowledged that the appointment had not been rescheduled. On 11/20/25, the Regional Clinical Nurse further confirmed that a dental appointment had not been rescheduled for this resident. This deficient practice was identified for one of two residents reviewed for dental care and was cited as a failure to provide or obtain dental services for each resident, which could likely result in tooth decay, tooth pain, and difficulty chewing.
Incomplete Documentation of Blood Glucose Monitoring and Activity Participation
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records for multiple residents. For one resident with type 2 diabetes mellitus without complications, a physician’s order dated 03/11/25 directed blood glucose monitoring twice monthly on the first and fifteenth. Review of this resident’s Treatment Administration Record (TAR) showed that blood sugar levels were not documented for the months of September, October, or November 2025. In an interview, the Regional Clinical Nurse confirmed that the blood glucose checks were not being documented in the medical record and acknowledged that blood glucose levels should be recorded at the time they are checked. The deficiency also includes failures in documenting and care planning for activity participation. One resident’s MDS indicated that being around animals, going outside in good weather, and participating in religious services were very important, and the care plan noted a preference for staying in her room watching TV and engaging in 1:1 activities. However, progress notes from late August through mid-November 2025 showed no documentation of group activity participation and only one entry of 1:1 activity. Another resident with unspecified dementia and behavioral disturbance had an activities assessment indicating that being around animals, keeping up with the news, group activities, going outdoors, and morning/afternoon activities were very important, but these preferences were not reflected in the care plan approaches/tasks. Additionally, this resident’s Activity Participation Record contained no documentation for September or October 2025, and the Activities Director confirmed that the resident was involved in daily activities and 1:1 programs but that daily participation and progress notes were not documented, and the care plan had not been updated for a year.
Failure to Provide ADL Assistance for Visually Impaired Resident
Penalty
Summary
Staff failed to provide necessary assistance with activities of daily living (ADLs) for a resident who was legally blind, hard of hearing, and required help with personal care. The resident, who also had Type 2 Diabetes Mellitus, reported that his fingernails were too long and getting caught on things, and he expressed a desire for staff to cut them. Observation confirmed that his fingernails were long, jagged, and broken. An LPN confirmed that the resident could not cut his own fingernails and required staff assistance, which had not been provided. Additionally, the resident was left alone in the dining room after a meal and was unable to return to his room independently due to his blindness and mobility limitations. He had been in the dining room for an extended period, attempting to get staff attention without success. Staff interviews confirmed that the resident required assistance to return to his room and that staff were supposed to remain in the dining area until all residents had left. The DON also confirmed that a nurse should have been present and that the resident should not have been left alone.
Failure to Ensure Bedside Water Was Within Resident’s Reach
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate a resident’s needs and preferences by not ensuring drinking water was within reach. The resident had been admitted with diagnoses including dementia, muscle weakness, and an unspecified fall, and was observed lying in bed with the bed in the lowest position. During the observation, the resident’s drinking water was placed on a bedside table positioned approximately two feet from the bed and raised to a height the resident could not reach. A nursing aide confirmed that the bedside table was out of the resident’s reach and that the resident could not access her water. In a joint interview, the ADON and Regional Clinical Nurse confirmed that staff were expected to ensure bedside tables were within residents’ reach so they could access water and personal items.
Inaccurate MDS Assessment Related to Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure an accurate Minimum Data Set (MDS) assessment for a resident reviewed for falls. The resident was admitted with diagnoses including muscle weakness and an unspecified fall. Progress notes show that the resident experienced a fall and was transferred to the hospital for evaluation on 10/13/25. However, the admission MDS dated 10/14/25 documented that the resident had no falls since admission, omitting the fall that occurred on 10/13/25. In an interview, the MDS Coordinator confirmed that the resident had fallen on 10/13/25 and that this fall should have been documented on the admission MDS but was not. This failure to document the fall accurately on the federally mandated MDS assessment resulted in the resident’s assessment not reflecting the actual occurrence of a fall since admission.
Failure to Develop Baseline Care Plan for Post-Amputation Wound Care
Penalty
Summary
The facility failed to create a baseline care plan within 48 hours of admission for one of three residents reviewed for baseline care plans. The resident was admitted with diagnoses including encounter for orthopedic aftercare following surgical amputation and peripheral vascular disease. Physician orders dated 08/30/25 directed specific wound care for the resident’s left below-knee amputation, including cleansing with normal saline or wound cleanser, patting dry with gauze, applying skin prep around wound edges, applying Bacitracin to the wound bed, applying Xeroform, covering with an ABD pad, and wrapping with Kerlix and an Ace bandage. Record review of the resident’s care plan, initiated on 08/30/25, showed that it did not contain any plan addressing the resident’s below-knee amputation surgical site wound care, despite the existing physician orders. During an interview on 11/21/25, the Regional Clinical Nurse confirmed that the resident’s care plan did not include a plan for the surgical site wound care. This omission constituted the failure to develop the minimum healthcare information necessary to properly care for the resident immediately upon admission.
Failure to Maintain Accurate and Accessible Code Status Information
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and readily accessible system for determining residents’ code status, specifically regarding whether cardiopulmonary resuscitation (CPR) should be initiated in an emergency. For one resident, admission documents showed a Medical Orders for Scope of Treatment (MOST) form indicating the resident was a full code and wanted CPR performed in an emergency, but there was no corresponding physician order for code status in the electronic medical record (EMR). The nurse rounding tool, which staff were expected to use when they did not have computer access, incorrectly listed this resident as Do Not Resuscitate (DNR). An LPN confirmed that staff were expected to enter a code status order upon admission, that MOST forms should be scanned into the EMR, that there was no code status order for this resident, and that the nurse rounding tool’s DNR designation did not match the resident’s MOST form indicating full code. For another resident, the MOST form and a physician’s order both documented that the resident was a full code and should receive CPR in an emergency, but the nurse rounding tool incorrectly listed this resident as DNR as well. The DON stated that staff were expected to look at residents’ MOST forms to determine code status and that there was a binder with MOST forms at another nurses’ station, but this binder was not readily available to staff on the skilled unit and did not contain the first resident’s MOST form. The DON also confirmed that the social services worker kept another binder with MOST forms in his office, which did include the first resident’s MOST form, and that for both residents the nurse rounding tool listed DNR despite their MOST forms indicating full code. The regional clinical nurse confirmed that MOST forms should be readily available at the nurses’ station and that nurse rounding tools should contain the correct code status for each resident.
Failure to Arrange Needed Hearing Evaluation
Penalty
Summary
The facility failed to ensure a resident received proper treatment to maintain hearing by not arranging a needed hearing evaluation. During an interview on 11/18/25, Resident #1 reported experiencing hearing loss in her left ear and stated she had requested a hearing evaluation but had not been scheduled. Record review showed the resident had been readmitted to the facility on an unspecified date, and care plan conference notes in the EMR documented on 07/18/25 that a hearing appointment was already scheduled and on 10/18/25 that the resident needed an appointment. In a subsequent interview on 11/21/25, the Regional Clinical Nurse confirmed that the care plan notes reflected the resident’s request for a hearing evaluation and acknowledged that the resident had not yet been seen or scheduled for this evaluation. This deficient practice was identified for 1 of 1 residents reviewed for vision and hearing and was noted as likely to result in residents losing some independence if they cannot hear, which would compromise their quality of life.
Failure to Provide Ordered Restorative Ambulation Services
Penalty
Summary
The deficiency involves the facility’s failure to provide restorative rehabilitation services as ordered for a resident with mobility needs. The resident was admitted on 08/22/25 and had a physician’s order dated 09/16/25 stating she may participate in a Restorative Nursing Program, but the order did not specify the frequency of services. A physical therapy discharge note dated 09/24/25 recommended discharge to long-term care with a restorative nursing program for ambulation two times per day for at least five days a week with a front wheel walker and staff setup and supervision. However, the resident’s quarterly MDS assessment showed zero days of participation in a restorative nursing program in the seven days reviewed. During an interview, the resident reported she was supposed to be walking daily with restorative nursing and stated she was walked the previous day for the first time in four months because state surveyors were in the building. Staff interviews confirmed that the restorative program was not implemented as ordered. The RNA reported that 11/17/25 was the first day the restorative program was “back in session” and that she ambulated the resident that day, stating it was the first time in a while because there had been no restorative program. She also stated the resident should be ambulated daily but was not ambulated on 11/18/25 and 11/19/25 because the RNA was pulled to work as a CNA on the floor for her entire shift. The Restorative Nurse confirmed that the resident was ordered to start the restorative program on 09/16/25 but did not begin until 11/17/25 due to staffing issues, and that the expectation was for the program to be followed as ordered and completed by the RNA. The Regional Nursing Consultant confirmed there was no active restorative program in September 2025, that the resident should have been care planned with a correctly written order specifying frequency, and that while CNAs on the unit were assisting with ambulation and documenting refusals, the resident and others in the program did not have appropriate restorative care planning in place.
Failure to Implement Ordered IV Antibiotic Therapy for UTI
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with a diagnosed urinary tract infection (UTI) received the ordered antibiotic treatment. The resident, who had diagnoses including a UTI of unspecified site and unspecified urinary retention, had a history of UTIs as reported by her son, who stated she had experienced two UTIs since admission. A provider encounter note documented that the resident complained of fatigue, generally not feeling well, and that her urine in the catheter had become progressively more cloudy. The provider assessed her as having a complicated UTI with multidrug-resistant Pseudomonas, previously shown to be sensitive to cefepime and Zosyn, and planned to start cefepime 1 gram IV every 12 hours once IV access (PICC or peripheral) could be established and maintained for seven days. Record review showed no documentation in the progress notes regarding whether IV access was ever obtained, and the physician’s orders contained no order for cefepime corresponding to the provider’s plan. Instead, the only antibiotic order identified was for cephalexin 250 mg orally once daily for UTI suppression, which the resident received from mid-August through early October. The medication administration records confirmed that the resident did not receive any doses of IV cefepime. During interview, the Regional Clinical Nurse confirmed there was no documentation of the resident going out for PICC or IV access and that the resident did not receive any IV cefepime as indicated in the provider encounter note.
Failure to Ensure Proper Oxygen Administration and Use of Nasal Cannula
Penalty
Summary
Surveyors identified a deficiency in the provision of respiratory care for one resident with COPD and asthma who was ordered to receive 3 LPM of oxygen continuously. Record review showed a physician’s order dated 09/25/25 for continuous oxygen at 3 LPM. During an observation and interview on 11/17/25 at 2:00 PM, the resident was in bed with a nasal cannula in place but with the nasal prongs resting on the left cheek instead of inside the nostrils. The resident stated he needed oxygen because of COPD and reported that the nasal cannula would not stay in place and kept slipping to his left cheek; when he repositioned it, it again moved back to his cheek. A sign above the bed indicated the resident was to be on 3 LPM of oxygen continuously, but the oxygen concentrator was observed to be set at 3.5 LPM. At 2:06 PM the same day, an LPN confirmed that the nasal cannula was incorrectly positioned on the resident’s cheek and should have been in his nose, and also confirmed that the physician’s order was for 3 LPM while the concentrator was set at 3.5 LPM. The LPN stated that staff were not supposed to adjust residents’ oxygen without notifying the provider and obtaining an order. On a subsequent observation on 11/19/25 at 11:18 AM, the resident was not wearing the nasal cannula at all, while the concentrator remained set at 3 LPM; another LPN confirmed the resident was supposed to be wearing oxygen continuously. The Regional Clinical Nurse later confirmed that staff should contact the provider for oxygen adjustments, that the order remained for 3 LPM continuously, and that there was no documentation explaining why the oxygen had been set at 3.5 LPM.
Failure to Complete Annual Performance Evaluation for CNA
Penalty
Summary
The facility failed to complete an annual performance review for one of three sampled CNAs. Record review showed that CNA #1 was hired on 10/01/24 and did not have a performance evaluation completed in October 2025, as required for an annual review. During an interview on 11/21/25 at 2:38 PM, the administrator confirmed that CNA #1’s annual performance evaluation had not been completed. The report states that this deficient practice could likely result in staff being undertrained and providing inadequate care.
Failure to Secure Medication and Treatment Carts
Penalty
Summary
Surveyors observed that medication and treatment carts containing drugs and biologicals were left unlocked and unattended in the facility. Specifically, a medication cart in the 100 hallway was found unlocked during an observation, and this was confirmed by an LPN who acknowledged that carts should be locked when unattended. Additionally, a treatment cart located across from the nurse’s station, accessible to all floors, was also found unlocked and not under staff control. This cart contained various medications, including Aspercreme, coloplast, triamcinolone acetonide, and gentamicin sulfate cream. Interviews with staff and the Administrator confirmed that the expectation is for all medication and treatment carts to be locked when not in use or when unattended. The Administrator reiterated that carts containing medications should not be left unlocked. The observations and staff confirmations indicate that the facility failed to secure medications as required, affecting all 61 residents as identified by the census list.
Failure to Update Care Plan After Repeated Refusals of Showers
Penalty
Summary
The facility failed to revise the care plan for one resident after repeated refusals of showers were documented. Record review showed that the resident was offered showers twelve times and refused six of those offers over a three-month period. Despite this pattern, the resident's care plan, which indicated a need for partial/moderate assistance with bathing, was not updated to reflect the refusals or to include interventions staff could use to encourage showering. This deficiency was confirmed by the Regional Nurse Consultant during an interview, who acknowledged that the care plan did not address the resident's refusals or outline staff actions to address the issue.
Failure to Notify Physician of Missed Medication and Critical Blood Sugar Levels
Penalty
Summary
Facility staff failed to notify the physician when a resident's prescribed blood pressure medication, diltiazem, was not available for administration on multiple consecutive days. Documentation in the Medication Administration Record (MAR) indicated that the medication was not given on several occasions, but there was no evidence in the progress notes that the physician was informed about the unavailability of the medication as required. Additionally, staff did not notify the physician when the same resident experienced multiple episodes of significantly elevated blood sugar levels, with readings consistently above 400 mg/dL. The resident's physician orders specifically required staff to call the physician when blood sugar exceeded 400, but there was no documentation of such notifications in the progress notes. During interviews, the DON and regional nurse confirmed that staff did not contact the provider regarding either the missed medication or the high blood sugar levels.
Failure to Maintain Safe and Homelike Resident Room Environment
Penalty
Summary
A deficiency was identified when a resident reported and surveyors observed that the wall near her window had four pieces of velcro attached, the wall behind her bed was scraped with missing paint, and the electrical outlet behind her bed lacked a cover while in use for charging a cell phone. The resident stated that the velcro had been present since she moved into the room approximately two months prior, and she also noted the condition of the wall and the uncovered outlet. During an interview, the facility administrator confirmed the presence of the velcro, the scraped and unpainted wall, and the missing outlet cover, stating that the velcro was previously used to hang an activities calendar, but no calendar was currently present. The administrator was unaware of the wall damage and the missing outlet cover prior to the surveyor's observation.
Failure to Document Resident Functional Abilities in Care Plan
Penalty
Summary
Facility staff failed to develop an accurate, person-centered comprehensive care plan for one resident. The resident was admitted with multiple diagnoses, including unsteadiness on feet, a healing femur fracture, a history of falls, abnormal gait and mobility, and a need for assistance with personal care. The resident's Minimum Data Set (MDS) assessment documented specific levels of assistance required for various activities of daily living (ADLs), such as eating, oral hygiene, toileting, bathing, dressing, transfers, and mobility. However, review of the resident's care plan revealed that staff did not document the resident's functional level or the assistance needed to complete ADLs. During interviews, the DON confirmed that the care plan did not include the resident's functional abilities and expressed uncertainty about whether this information should be included. The corporate nurse subsequently confirmed that care plans should include residents' functional abilities. The lack of documentation in the care plan could result in staff being unaware of the resident's current and actual needs.
Failure to Follow Physician Orders and Document Care for Two Residents
Penalty
Summary
Staff failed to meet professional standards of practice for two residents by not following physician orders and not documenting required care. For one resident, who was admitted and later discharged from the facility, staff documented symptoms of burning during urination. The on-call physician ordered a urinalysis and urine culture due to these symptoms, but staff did not enter these orders into the electronic medical record (EMR), nor did they collect or document the collection of a urine sample. Interviews with staff and nursing leadership confirmed that the physician's order was present in a scanned document, but staff did not check scanned documents for orders and did not follow the expected process of entering and acting on such orders in the EMR. For another resident with diagnoses of hypertension and type 2 diabetes, staff failed to administer prescribed blood pressure medication (diltiazem) and insulin as ordered. Medication administration records showed multiple instances where the medication was not given, and staff used a code indicating 'other/see nurse note,' but there was no documentation that the physician was notified about the missed doses. Additionally, the resident experienced several episodes of elevated blood sugar levels above 400, but there was no documentation that the physician was notified as required by the order. Interviews with staff and nursing leadership confirmed that the provider was not notified about the unavailability of medication or the high blood sugar readings. The deficiencies were identified through record review and staff interviews, which revealed a lack of documentation, failure to follow up on physician orders, and failure to notify the provider as required. These actions and inactions resulted in the facility not meeting professional standards of quality for the care of these residents.
Failure to Provide Scheduled Showers for Resident Requiring ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs), specifically showers or baths, for a resident who required partial to moderate help. The resident, who had diagnoses including unsteadiness on feet, a healing femur fracture, abnormal gait, and a need for personal care assistance, was admitted and later discharged within a specified period. According to the admission MDS assessment, the resident required staff support for bathing. Documentation showed that the resident received only two showers during her stay, with one documented refusal. The facility's shower schedule required showers three times a week for residents, and refusals were to be documented in the electronic medical record and progress notes. Review of the resident's records, including the documentation summary report, shower sheets, and progress notes, confirmed that showers were not provided according to the established schedule. The DON verified that only two showers were given between admission and discharge, and that CNAs were responsible for both providing and documenting showers, as well as reporting refusals. The lack of adherence to the shower schedule and incomplete documentation led to the deficiency in providing necessary ADL care for the resident.
Incomplete Medical Record Documentation for Resident with Urinary Symptoms
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for one resident reviewed for neglect. Specifically, the resident was admitted with a documented complaint of burning during urination, and a progress note indicated this symptom. An on-call physician's note showed that a urinalysis and urine culture were ordered due to dysuria. However, staff did not document that the provider was notified about the resident's symptoms, nor did they enter the orders for the urinalysis and urine culture into the electronic medical record (EMR). Interviews with staff, including an LPN, the DON, and a corporate nurse, confirmed that there was no documentation in the EMR regarding provider notification or the entry of the physician's orders. The on-call physician's note was only available as a scanned document, which staff would not routinely see, and there was no evidence that the required urine tests were ordered or collected as directed. Staff acknowledged that it was their responsibility to document provider contact, enter orders, and complete ordered tasks in the EMR, but these actions were not completed for this resident.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that Registered Nurse (RN) coverage was provided for eight hours a day, seven days a week, as required. This deficiency was identified through a review of the Fiscal Year Quarter 2 Payroll Based Journal (PBJ) of the Certification and Survey Provider Enhanced Reports (CASPER), which showed no RN coverage on specific dates. The Infection Preventionist (IP) and the Business Office Manager (BOM) confirmed the absence of RN coverage on two of these dates, with a resident census of 48 at the time. The Director of Nurses (DON) acknowledged the staffing issue, citing difficulties in hiring nurses within the community. The facility's policy on Nursing Services Staff emphasized the need for sufficient nursing staff to ensure resident safety and well-being, including the requirement for RN services for at least eight consecutive hours daily.
Improper Use of Disinfectant Sprays and Odor Management
Penalty
Summary
The facility failed to maintain a clean and homelike environment, as evidenced by the strong smell of urine near the entrance to the 100 unit and the inappropriate use of disinfectant sprays by staff. During an initial tour, a strong odor of urine was detected, and it was observed that the facility had carpet in several areas, including the day area, nurses' station, and 100/200 units. Housekeeper 2 was seen spraying Lysol in the hallway and into the entrance of residents' rooms, creating a strong and pungent smell. Interviews with housekeeping staff revealed that carpets were cleaned twice a week, but the use of Lysol was not a standard practice, indicating a deviation from the facility's cleaning protocol. Further observations revealed that a facility van driver and a registered nurse also engaged in spraying Lysol and cologne in the hallways and near the nurse's station to mask odors. A family member and a resident reported that the sprays used in the rooms were overpowering and caused discomfort. The Maintenance Director confirmed that staff were not supposed to mask odors with sprays and identified that the odor was due to old water in the carpet shampooer. The facility's policy on managing odors emphasized systematic cleaning rather than using deodorizers, which contributed to indoor air contamination.
Inadequate PPE Use and Infection Control Practices
Penalty
Summary
The facility failed to ensure that staff wore appropriate Personal Protective Equipment (PPE) for residents requiring Enhanced Barrier Precautions (EBP). Observations revealed that an LPN did not wear a gown while providing care to three residents with conditions necessitating EBP, such as indwelling catheters and feeding tubes. Despite the presence of STOP EBP signs and isolation carts, the LPN did not adhere to the required PPE protocols, potentially facilitating the spread of multi-drug resistant organisms (MDROs). Additionally, the facility did not consistently clean and disinfect patient equipment after use. An LPN was observed using a blood pressure cuff on a resident and returning it to the equipment basket without cleaning it. This oversight occurred despite the facility's policy requiring equipment to be cleaned before and after each use. The LPN acknowledged forgetting to clean the equipment, which could contribute to cross-contamination between residents. The facility also failed to follow proper hand hygiene practices during medication administration. An LPN did not perform hand hygiene after assisting a resident with a medication inhaler and swish-and-spit procedure. This lapse in hand hygiene was contrary to the facility's policy, which mandates hand hygiene before and after resident care and between residents. The Infection Preventionist and Director of Nursing confirmed the expectations for hand hygiene, highlighting the discrepancy between policy and practice.
Failure to Provide Requested Shower Before Appointment
Penalty
Summary
The facility failed to honor a resident's request for a shower before a doctor's appointment, leaving the resident feeling undignified and upset. The resident, who was alert and oriented, required extensive assistance with bathing and was scheduled for showers on specific days. Despite requesting a shower the night before and the morning of the appointment, the resident did not receive one. The resident expressed distress over not being clean for the appointment, and the CNA on duty was unaware of the request due to a lack of communication from the previous shift. The facility's records showed only two notations of shower refusals, with no evidence of showers or bed baths being offered since the resident's admission. Interviews with staff revealed a breakdown in communication between shifts, with assumptions made about the resident's refusal and no follow-up to ensure the shower was provided. The Director of Nurses was unaware of the missed shower, and the resident and family members confirmed the lack of showers and bed baths, highlighting a failure to maintain the resident's dignity as per the facility's policy.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to assess a resident for self-administration of medication, which was observed during a survey. The resident, who was cognitively intact with a BIMS score of 15 out of 15, had two white tablets identified as Tums on her bedside table. The resident stated that she was supposed to take them after her morning medication, sometimes chewing them throughout the morning. The LPN confirmed that the resident requested the Tums be left at her bedside, as she preferred to take them after eating, but acknowledged there was no physician's order or care plan allowing for this practice. The facility's policy requires a physician's order and a care plan for residents to self-administer medications, which was not in place for this resident. The MDS Coordinator and the DON both stated that medications should not be left at the bedside without proper orders. The DON was unaware of the situation until informed of the incident, and mentioned that the resident's daughter sometimes brought in medications. The facility's policy outlines the need for an interdisciplinary team assessment and a physician's order for self-administration, which was not followed in this case.
Inaccurate MDS Coding for Hospice and Oxygen Therapy
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for residents receiving hospice services and oxygen therapy, which could potentially place residents at risk for unmet care needs. Specifically, two residents receiving hospice services and one resident receiving oxygen therapy were inaccurately coded in their MDS assessments. This discrepancy was identified through observations, record reviews, and interviews with facility staff. For one resident receiving hospice services, the MDS Coordinator (MDSC) incorrectly coded the resident's prognosis and hospice status, despite the resident having been on hospice since early May. The MDSC acknowledged the error, attributing it to a typographical mistake. Similarly, another resident receiving hospice services was not coded correctly in the MDS, which was confirmed by the MDSC and the Director of Nursing (DON), who stated that the error was missed during the corporate review process. Additionally, a resident receiving oxygen therapy was inaccurately coded as not receiving such therapy in the MDS, despite having a continuous order for oxygen since March. The MDSC admitted to missing this information during the assessment process. These coding inaccuracies highlight a failure in ensuring the accuracy of resident assessments, which is crucial for addressing their care needs.
Failure to Develop Comprehensive Care Plan for Hospice Resident
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan with measurable goals, specific objectives, and interventions for a resident receiving hospice services. The facility's policy requires a comprehensive care plan to be developed using an interdisciplinary team approach, which includes measurable objectives and timeframes to meet a resident's needs. However, the care plan for the resident in question only included basic information under 'Advanced Directives' and did not provide specific details or measurable goals related to the hospice services being provided. Interviews with facility staff, including the Minimum Data Set Coordinator (MDSC) and the Director of Nursing (DON), revealed that the care plan lacked specifics beyond the name and address of the hospice company. The MDSC acknowledged that the care plan for hospice was under 'Advanced Directives' and lacked further specifics, while the DON confirmed that the facility's care plan did not include additional details. This lack of a comprehensive, person-centered care plan may result in the resident not receiving appropriate interventions to achieve the highest practicable well-being.
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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