Bloomfield Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Bloomfield, New Mexico.
- Location
- 803 Hacienda Lane, Bloomfield, New Mexico 87413
- CMS Provider Number
- 325066
- Inspections on file
- 24
- Latest survey
- January 9, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Bloomfield Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that the facility failed to ensure the DON was not used as a floor/charge nurse when the census was above 60 residents. Census records showed multiple days with 72–82 residents, and staffing logs documented that on several of those days the DON worked full or partial shifts as a nurse/charge nurse due to insufficient nurse coverage. In interview, the DON confirmed working these shifts, explained that recent loss of agency nurses contributed to the coverage gaps, and stated that working the floor made it difficult to complete DON responsibilities, potentially affecting all 72 residents in the facility at the time of the survey.
The facility failed to complete required annual performance reviews for several CNAs, as shown by missing evaluations in their personnel records despite documented hire dates. Review of training transcripts revealed that multiple CNAs had no annual performance reviews on file, and the DON confirmed in interviews that only training logs were available and that the annual performance reviews for these CNAs had not been completed as required.
Staff removed a cognitively intact resident’s personal belongings from his room due to concerns about clutter and "hoarding" and placed them in a locked conference room, limiting his access to his own items. The resident, who had epilepsy, TBI, intellectual disabilities, and alcoholic cirrhosis, had a documented tendency to collect items, and his care plan called for education about what could safely be kept at bedside. Nursing notes described his belongings piling up under the bed and his agitation when told he could not keep them there. A behavioral agreement referencing hoarding and other behaviors was implemented without corresponding monitoring orders in the EHR. The Administrator and Social Services Director went through his belongings and removed containers, bags, and a box with snacks, drinks, pens, and personal items, storing them in a staff-locked conference room, and the resident did not have consistent access to these possessions.
A resident with documented expressive language disorder, bilateral sensorineural hearing loss, dysphagia, and cognitive communication deficit was consistently described in care plans, therapy evaluations, psychiatric notes, and staff interviews as nonverbal, using a notebook or communication board to communicate, and having profound hearing impairment. Despite this, multiple MDS Section B (Hearing, Speech, Vision) assessments were coded by the MDSC as showing adequate hearing and clear speech, which the MDSC later acknowledged was inaccurate.
Surveyors found a portable electric space heater plugged in and operating on the floor of a common hallway near a vending machine, in an area accessible to residents. The heater’s placement and operation in this location created an accident hazard, particularly for residents with dementia or limited safety awareness, as acknowledged by the substitute Administrator and the Maintenance Director during interviews.
Surveyors found an unattended, unlocked medication cart on one hall, with an LPN later acknowledging he had stepped away without securing it, contrary to stated expectations from the DON and Administrator that carts be locked when not in use. In a separate observation of the medication storage room, a sealed bottle of 325 mg Aspirin with an expiration date already passed remained on the shelf; an LPN confirmed it was expired and should have been removed, and the DON stated this did not meet her expectations for proper medication disposal.
Surveyors identified multiple infection control failures, including a resident with significant respiratory conditions whose portable O2 concentrator was repeatedly stored uncovered on the floor of the room, contrary to staff and DON expectations for proper storage. In addition, an LPN administered medications to a resident without performing hand hygiene before or after, and another LPN prepared and administered medications without sanitizing hands and applied eye drops to a resident while using an ungloved hand to hold the eyelid open, again without hand hygiene. Staff later acknowledged they should have sanitized their hands, and the DON stated her expectation that hand hygiene be performed before and after medication administration and resident or environmental contact.
A resident with Huntington’s disease did not have an advance directive or MOST form available in the EHR or in physical form for staff. Record review showed no such documents were completed or accessible, and the DON confirmed she was unable to locate any advance directive or MOST form for the resident, despite acknowledging that one should have been readily available.
A resident with Parkinson’s disease, dementia, and epilepsy was observed on multiple occasions receiving O2 at 2 L/min via nasal cannula from an oxygen concentrator, with documentation showing an SpO2 of 98% on O2 but no corresponding physician order. An LPN reported initiating O2 after noting desaturation into the low 80% range and increasing weakness, without obtaining a physician order and without consistent documentation of O2 use, SpO2 levels, or desaturation episodes. The ADON was unaware O2 had been started and could not find evidence of physician notification, orders, or supervisory review, while the DON and medical director both confirmed they had not been notified despite expectations for notification and appropriate orders when O2 is initiated after a change in condition.
A resident admitted with Parkinson's disease, dementia, and epilepsy did not have a Baseline Care Plan developed and implemented within 48 hours of admission as required. Record review showed that the care plan initiation date occurred after the 48-hour window, and an interview with the DON confirmed that nursing staff are responsible for initiating baseline care plans and that the expected timeframe was not met in this case.
Nursing staff initiated and continued O2 therapy at 2 L/min via nasal cannula for a resident with Parkinson’s disease, dementia, and epilepsy after observing O2 saturation levels in the low 80% range, but did so without obtaining a physician order. The resident was repeatedly observed on O2, yet staff did not consistently document O2 use, O2 saturation levels, or desaturation episodes, and there was no evidence of ongoing monitoring, physician notification, or clinical follow-up. The ADON reported she was not informed that O2 had been started and could not locate any documentation of physician notification, an O2 order, or supervisory review related to the resident’s O2 therapy.
A resident with expressive language disorder, profound bilateral hearing loss, and documented nonverbal status was consistently described by therapy, nursing, activities, and social services staff as nonverbal and reliant on a notebook or communication board to communicate. The care plan and progress notes reflected impaired communication and the need for alternative communication methods, while a speech therapy evaluation documented absence of useful hearing and no speech. However, provider documentation within the EHR repeatedly recorded that the resident had clear speech and could speak without limitations, creating inaccurate and incomplete documentation of the resident’s communication and hearing impairments.
A resident with multiple chronic conditions did not receive daily wound care to the left lower extremity as ordered by the physician. Review of the Treatment Administration Record and interviews with the DON, LPN, and wound care nurse revealed that wound care was missed on several days and documentation was inaccurate, with discrepancies between recorded and actual care provided.
A resident with multiple chronic conditions did not receive daily wound care as ordered, and the facility's documentation inaccurately indicated that wound care was completed on days when it was not. The DON and an LPN confirmed discrepancies between the actual care provided and what was recorded on the TAR, resulting in inaccurate medical records.
The facility did not ensure that PASARR screenings were accurately reviewed and completed for three residents, resulting in at least one resident's depression diagnosis being omitted from the screening. Both the Marketing Director and Social Services Director, who were responsible for verifying PASARR accuracy, did not review the documentation prior to admission, leading to incomplete and inaccurate records.
A resident with epilepsy did not receive prescribed Lacosamide due to failures in medication reconciliation and procurement after admission. The medication was not available, and staff did not secure it from the pharmacy or alternative sources, nor did they notify the provider. This omission led to the resident experiencing multiple seizures and requiring hospitalization, with staff only becoming aware of the missed doses after the hospital transfer.
The facility failed to maintain a certified infection preventionist onsite at least part-time, as required by their policy. The previous IP nurse was terminated after working remotely on an as-needed basis, and the newly hired RN was not certified and only worked for four days. The infection control data for July and August was incomplete, and the DON was unaware of the requirement for an onsite IP.
A facility failed to provide a written bed hold notice to a resident transferred to the hospital, as required by their policy. The resident, with a history of chronic obstructive pulmonary disease, dementia, and hypothyroidism, was discharged due to altered mental status. Staff interviews revealed that nurses were responsible for initiating bed holds, but this was not done, despite recent in-service training. The BOM confirmed the deficiency and noted no written bed hold notices had been received since February.
The facility failed to follow professional standards in blood glucose monitoring for three residents with type two diabetes. An LPN did not discard the first drop of blood during testing, which is a recognized standard practice. The residents had varying cognitive impairments and specific care plans for diabetes management. The DON confirmed the standard practice but was unsure if it was in the facility's policy.
A resident's referral for a barium swallow study was delayed, placing them at risk of not having pleasurable items. Despite the family's request for a swallowing evaluation, the Rehabilitation Director and receptionist failed to follow up and schedule the referral in a timely manner, contrary to the facility's 24 to 48-hour scheduling expectation.
The facility failed to maintain clean respiratory equipment for three residents, leading to potential exposure to contaminated equipment. Despite orders to clean oxygen concentrators weekly, observations revealed dusty equipment over several days. Staff confirmed the cleaning schedule but acknowledged the oversight.
A resident with severe cognitive impairment was prescribed Mirtazapine for depression without proper diagnosis clarification. The facility's consultant pharmacist recommended a Gradual Dose Reduction and requested diagnosis clarification, but the Medical Director did not respond. The DON admitted the pharmacy recommendations were not submitted to the doctor, and recent changes in staff and pharmacy services led to lapses in consultant pharmacy reviews.
The facility failed to implement a 14-day stop date for PRN anti-anxiety medication and did not provide a rationale for its continued use for a resident with major depressive disorder and anxiety. Additionally, the facility did not implement a gradual dose reduction (GDR) for a resident with dementia receiving antipsychotic medication. Interviews revealed a breakdown in communication and processes related to medication regimen reviews and GDRs, exacerbated by a recent pharmacy switch.
A resident with cognitive alertness and multiple diagnoses, including bipolar disorder and dysphagia, did not receive scheduled dental services for a loose tooth. The facility's process for scheduling appointments failed, as confirmed by interviews with staff, leading to a lack of follow-up on the dental consult. The DON acknowledged scheduling issues despite hiring a unit clerk to improve the process.
Two residents in an LTC facility did not have their food preferences honored, leading to dissatisfaction with meals. One resident, with cerebral palsy, repeatedly received peas and spinach despite expressing his dislike. The Dietary Manager confirmed that food preferences were not documented upon admission, and meal tickets did not reflect these dislikes. Another resident consistently did not receive cottage cheese listed on his meal tickets, as the facility had not stocked it for over a month. These issues highlight a failure in documenting and communicating residents' dietary preferences.
The facility failed to follow proper infection control practices during blood glucose monitoring and medication administration. Staff did not use protective barriers for supplies at the bedside for four residents and did not wear appropriate PPE while administering medications through a gastrostomy tube for one resident. Supplies for multiple residents were carried into each room, increasing the risk of cross-contamination. Interviews confirmed these practices were not in line with best practices.
An LPN in a LTC facility pre-poured medications and handed them to the wrong resident, causing hypotension and hospitalization. The LPN did not report the error immediately, and the resident was found dizzy and on the floor. The facility's investigation revealed previous issues with the LPN's medication administration practices.
A resident with dementia received the wrong medication due to an LPN's distraction and failure to report the error, resulting in hypotension and hospitalization for observation. The facility had previously conducted training on proper medication administration procedures.
DON Used as Floor Nurse When Census Exceeded 60 Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure the DON was not used as a floor/charge nurse when the facility census exceeded 60 residents, as required. Census records from early November through early January showed multiple days when the resident census ranged from 72 to 82. Staffing logs for the same period documented that on several of those days with a census above 60, the DON was scheduled and worked on the floor as a nurse/charge nurse, including full and partial shifts on multiple dates. During an interview, the DON confirmed she had worked the floor on the identified dates because there was not enough nurse coverage and stated that when she works as a floor or charge nurse, it is difficult for her to complete her other DON responsibilities. She also reported having recently lost three agency nurses and that the facility was in the process of obtaining new agency contracts. The facility census at the time of the survey was 72 residents, and the surveyors concluded that this practice was likely to affect all 72 residents in the facility.
Failure to Complete Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to complete required annual performance reviews for multiple CNAs, resulting in a deficiency related to staff evaluation and training. Record review of training transcripts showed that CNA #6, hired on 10/01/18, had no annual performance review on file; CNA #7, also hired on 10/01/18, had no annual performance review on file; and CNA #8, hired on 09/15/22, likewise had no annual performance review documented. During an interview on 01/09/26 at 11:24 a.m., the DON stated she only had training logs for the requested staff and confirmed that CNAs #6, #7, and #8 did not have annual performance reviews completed. In a subsequent interview on 01/14/26 at 2:30 p.m., the DON reiterated that she did not have performance reviews available for these CNAs and acknowledged that CNA annual performance reviews should have been completed as required, but were not. The report notes that if the facility is not completing a performance review of every CNA at least once every 12 months, then residents are likely to not receive the appropriate care and services, and the CNAs may not meet the needs of all residents.
Resident’s Personal Belongings Removed and Locked Away Without Consistent Access
Penalty
Summary
Facility staff removed a cognitively intact resident’s personal belongings from his room and restricted his access to them, infringing on his right to retain and use personal possessions. The resident, who had epilepsy, traumatic brain injury, intellectual disabilities, and alcoholic cirrhosis, had a BIMS score of 15, indicating intact cognition. His care plan documented a tendency to collect and store items such as perishable goods, cleaning supplies, facility linens, silverware, toilet paper, towels, and wash rags, with interventions focused on educating him, his family, and staff about safety-related limits on certain items and the need to report concerns. Nursing documentation noted that the resident had been “hoarding” belongings under his bed, that items had begun to pile up, and that he became upset and agitated when told he could not keep all of his things packed under the bed. A behavioral agreement was created and signed, listing expectations related to uncooperative behavior with care, inappropriate touching of staff, and hoarding, and referenced potential consequences such as police involvement, transfer, or discharge. However, the electronic health record did not contain orders for monitoring the behaviors identified in the behavioral agreement. The Administrator and Social Services Director reported that the resident’s room was frequently cluttered, with items on top of the wardrobe and under the bed, and that he became very upset when asked to sort through his belongings. The Administrator and Social Services Director went through his belongings while he was present, and the Administrator removed two totes, a duffle bag, shopping bags, and a box from behind the headboard, stating the items took up too much space. These belongings, which included snacks, beverages, pens, an anime drawing book, a comic, and socks, were placed in a locked conference room that only staff could access, and the resident did not have consistent access to them. The Administrator later confirmed that the resident should have been able to access his belongings stored in the conference room whenever he wanted, but that this was not occurring.
Inaccurate MDS Coding for Resident With Nonverbal Status and Hearing Loss
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate completion of the Minimum Data Set (MDS) for one resident in the area of hearing and speech. The resident was admitted with diagnoses including expressive language disorder, bilateral sensorineural hearing loss, dysphagia, other drug-induced secondary parkinsonism, and cognitive communication deficit. Physician orders included a referral for speech therapy evaluation and treatment with a recommended non-verbal communication board. Multiple psychiatric notes documented that the resident was nonverbal and that assessments were completed via chart review and staff input because the resident used paper and pencil to answer questions. The resident’s care plan and progress notes consistently identified significant communication and hearing impairments. The care plan documented potential for impaired communication related to impaired hearing, with goals and interventions for the resident to express needs through non-verbal communication, use alternative methods such as writing, and ensure availability and functioning of adaptive equipment. Progress notes described the resident as primarily nonverbal, using a communication board, pen, and paper, and needing special adaptive equipment, including a communication board and written instructions/gestures for hearing loss, while also stating there were no cognitive limitations. A speech therapy evaluation further documented that the resident was nonverbal, had no speech clarity, used a notepad to communicate, had profound hearing loss with highly impaired ability to hear, and required skilled therapeutic interventions due to these physical impairments. Despite this documentation, multiple MDS assessments for the resident’s Section B (Hearing, Speech, Vision) were coded as having adequate hearing and clear speech on several quarterly and annual assessments. During interviews, the resident was observed to be nonverbal and communicating via notebook, and multiple staff members, including CNAs, a CMA, the Activities Director, the Director of Rehab, and the Social Services Director, all stated that the resident did not speak and used a notebook or communication board to communicate, and that the resident had hearing impairment. The MDS Coordinator, who was responsible for completing the resident’s MDS assessments, stated that these MDS Section B assessments were coded as reflecting adequate hearing and speech and acknowledged that the MDS Section B should have been accurate but was not.
Portable Space Heater Left Operating in Accessible Hallway
Penalty
Summary
Surveyors identified a deficiency related to accident hazards when a portable electric space heater was found plugged in and operating in a common hallway accessible to residents. On 01/05/26 at 12:27 pm, the heater was observed positioned directly on the hallway floor next to a vending machine at the front entrance, placed against the wall and immediately adjacent to the vending machine, with a digital display reading 72°F. This location was a common hallway area accessible to residents, including those who walk by the front entrance. During a 01/08/26 interview, the substitute Administrator stated the space heater should not be plugged in and left in the hallway unattended and acknowledged that residents could burn themselves on the heater. In a 01/13/26 interview, the Maintenance Director similarly stated the space heater should not be plugged in, noting that a resident with dementia, characterized by impairment of at least two brain functions such as memory loss and judgment, could get burned on the heater. The facility’s failure to maintain an environment free of accident hazards was based on the presence and operation of this portable electric space heater in an area accessible to residents, including those with impaired cognition or limited safety awareness.
Unlocked Medication Cart and Expired Aspirin in Medication Storage Room
Penalty
Summary
The deficiency involves failure to ensure medications were securely stored and properly monitored for expiration. On the 100 Hall, a medication cart was observed unlocked and unattended. An LPN acknowledged stepping away from the cart and leaving it unlocked, despite stating it was his expectation to lock the cart when unattended and not in use. The DON stated that staff should never leave a medication cart open and unattended and that her expectation was that all medication carts are locked when not in use. The Administrator also stated his expectation that all medication carts be locked when not in use. In the medication storage room, surveyors observed one sealed bottle of Aspirin 325 mg with an expiration date of 06/25 that remained in stock. An LPN confirmed the Aspirin had expired and should have been removed. The DON stated that finding expired medications in the medication room did not meet her expectations and that the medication should have been disposed of properly and immediately. These observations show that expired medication remained available in the storage area and that medication security practices were not consistently followed.
Improper Oxygen Equipment Storage and Hand Hygiene Failures During Medication Administration
Penalty
Summary
The deficiency involves failures in infection prevention and control related to oxygen equipment storage and hand hygiene during medication administration. One resident with acute and chronic respiratory failure with hypoxia, pulmonary hypertension, chronic pulmonary embolism, and dependence on supplemental oxygen had a physician’s order for BiPAP with oxygen and oxygen via nasal cannula, and a care plan addressing risk of respiratory complications and the need for oxygen as ordered. Surveyors observed this resident’s portable oxygen concentrator lying directly on the floor of the room on multiple occasions, including after a CNA removed it to be filled and then returned it to the floor uncovered. Another CNA stated that portable oxygen equipment and tubing should not be placed on the floor and should be stored behind the wheelchair or in the oxygen storage room, and the DON stated her expectation that oxygen delivery devices not be stored on the floor because this could be an accident hazard or lead to respiratory infection. Additional deficiencies were identified in hand hygiene and technique during medication administration, including topical eye medication. One LPN was observed leaving a resident’s room without sanitizing her hands before or after administering medications and confirmed she should have sanitized between residents. Another LPN prepared and administered medications to a resident without sanitizing his hands before or after administration, and later applied eye drops to a different resident using an ungloved hand to hold the eyelid open, again without performing hand hygiene afterward. This LPN acknowledged he should have sanitized his hands after touching each resident and administering medications. The DON stated her expectation that staff sanitize or wash their hands before and after medication administration, after touching a resident, or after touching environmental surfaces.
Advance Directive Not Available in Resident’s Record
Penalty
Summary
The facility failed to ensure a resident’s current advance directive or MOST form was available in the Electronic Health Record (EHR) or in physical form for staff use. The resident, admitted on 10/14/25, had a diagnosis of Huntington’s disease. Record review of the resident’s face sheet confirmed the admission date and diagnosis, and further review of the EHR showed there was no advance directive or MOST form completed or available for this resident. During an interview on 01/07/26 at 1:16 pm, the DON reported that she searched for the resident’s advance directive but could not locate it and confirmed that the resident did not have an advance directive or MOST form readily available, despite the expectation that one should have been accessible. This deficient practice was identified by surveyors as likely to cause confusion and delay potentially lifesaving procedures.
Failure to Obtain Physician Order and Notify Physician for Initiation of Oxygen Therapy
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician and obtain a medical order when a resident experienced a significant change in condition requiring oxygen (O2) therapy. The resident was admitted with Parkinson’s disease, dementia, and epilepsy. On multiple observations over several days, the resident was seen in a wheelchair and in bed with a nasal cannula in place, receiving O2 at 2 liters per minute via a portable oxygen concentrator and then an oxygen concentrator. Record review showed an oxygen saturation of 98% on O2, but there was no corresponding physician order for oxygen use in the resident’s medical record as of the date reviewed. During interviews, an LPN reported that O2 therapy had been initiated after staff noted the resident desaturating into the low 80% range and appearing increasingly weak, but acknowledged there was no physician order authorizing O2. The LPN also stated that staff were not consistently documenting the resident’s O2 use, O2 saturation levels, or desaturation episodes, and could not identify documentation of ongoing monitoring, physician notification, or clinical follow-up related to the resident’s O2 needs. The ADON stated she was unaware the resident had been receiving O2 until informed shortly before her interview and confirmed there was no documentation of physician notification, an order, or supervisory review. The DON stated the physician or medical director should have been notified on the first day O2 was initiated, and the medical director stated there should have been a standing order for O2 and that he expected to be notified of any decrease in O2 saturation, but he was not notified in this case.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
Surveyors identified that the facility failed to create and implement a Baseline Care Plan within 48 hours of admission for one resident. Record review showed that this resident was admitted with diagnoses including Parkinson's disease, dementia, and epilepsy. The resident’s face sheet confirmed the admission date, but review of the care plan revealed that no baseline care plan was developed within the required 48-hour timeframe; instead, the care plan initiation date was documented as 12/22/2025, which was after the 48-hour window. In an interview, the DON stated that nursing staff are responsible for initiating the baseline care plan and acknowledged that her expectation was for the baseline care plan to be completed within 48 hours of admission, which did not occur for this resident. This deficiency was based on record review of the resident’s admission documentation and care plan dates, as well as the DON’s interview confirming both the facility’s process and the failure to meet the 48-hour requirement for baseline care plan completion.
Unauthorized and Undocumented Oxygen Therapy Without Physician Notification
Penalty
Summary
Nursing staff initiated and continued oxygen (O2) therapy for Resident #25 without a physician’s order, failed to document the resident’s O2 use, and did not notify the physician when the resident experienced O2 desaturation. Resident #25, admitted with Parkinson’s disease, dementia, and epilepsy, was repeatedly observed over several days seated in a wheelchair and lying in bed with a nasal cannula in place and connected to an oxygen concentrator delivering 2 liters per minute. Record review of the resident’s physician orders on 01/07/26 showed no order for O2 use. Licensed Practical Nurse (LPN) #1 reported that O2 therapy was started after staff noted the resident’s O2 saturation readings in the low 80% range and increasing weakness, but acknowledged that he did not see a physician’s order authorizing O2. LPN #1 further stated that staff were not consistently documenting the resident’s O2 use, O2 saturation levels, or episodes of desaturation, and he was unable to identify documentation of ongoing monitoring, physician notification, or clinical follow-up related to the resident’s O2 needs. The Assistant Director of Nursing (ADON) stated she was unaware the resident had been receiving O2 prior to being informed by LPN #1 shortly before the interview and confirmed she should have been notified when O2 was initiated. The ADON was unable to identify documentation of physician notification, a physician’s order, or supervisory review related to the resident’s O2 use prior to 01/07/26.
Inaccurate EHR Documentation of Communication and Hearing Status
Penalty
Summary
The deficiency involves the facility’s failure to ensure the accuracy and completeness of the electronic health record (EHR) for one resident with significant communication and hearing impairments. The resident’s face sheet documented diagnoses including expressive language disorder, bilateral sensorineural hearing loss, dysphagia, other drug-induced secondary Parkinsonism, and a cognitive communication deficit. Multiple clinical records, including psychiatric notes, care plans, progress notes, speech therapy evaluations, physician orders, and staff interviews, consistently described the resident as nonverbal, using a notebook, whiteboard, or communication board to communicate, and having profound hearing loss or highly impaired hearing. Despite this consistent documentation and staff reports, the provider documentation within the EHR repeatedly indicated that the resident had “clear speech” and could speak without limitations on several dates. Psychiatric notes on multiple occasions stated that the resident was nonverbal and that assessments were completed via chart review and staff support. The speech therapy evaluation documented that the resident was nonverbal, had no useful hearing, and relied on a notepad to communicate, with auditory comprehension not indicated due to profound hearing loss. The care plan and progress notes also identified the resident as primarily nonverbal, using alternative communication methods, and at risk for adjustment issues related to communication challenges. Interviews with facility staff, including CNAs, an RN, a CMA, the Activities Director, the Director of Rehab, the Social Services Director, and the DON, uniformly confirmed that the resident did not speak and used written communication methods, and that the resident had significant hearing impairment or profound hearing loss. The DON acknowledged that the EHR should reflect the resident as nonverbal with hearing loss but did not, due to the conflicting provider documentation indicating clear speech. This inconsistency between provider documentation and all other clinical records and staff observations resulted in an inaccurate and incomplete EHR for the resident’s communication and hearing status.
Failure to Provide Physician-Ordered Wound Care and Accurate Documentation
Penalty
Summary
The facility failed to provide wound care as ordered by the physician for one resident with a history of atrial fibrillation, type II diabetes, chronic venous hypertension with ulcer and inflammation of the left lower extremity, and pulmonary hypertension. Physician orders specified daily wound care to the resident's left lower extremity, including cleansing, application of a silver collagen sheet, hydrogel dressing, and securing with kerlix and tape, with documentation required on the Treatment Administration Record (TAR). However, review of the TAR and direct observation revealed that wound care was not performed or documented on several days as required. The wound dressing was observed to be dated several days prior, and the resident reported that her dressing had not been changed recently, despite believing daily care was required. Interviews with the DON, LPN, and wound care nurse confirmed inconsistencies between the documented wound care and actual care provided. The DON acknowledged that the TAR indicated wound care was completed on certain days when it was not, and the wound care nurse stated he was unaware of any issues with wound care completion, as no staff had requested assistance. The LPN could not explain discrepancies between her initials on the TAR and the actual dates wound care was performed. Record review and staff interviews confirmed that the physician's order for daily wound care was not followed, and documentation was inaccurate.
Inaccurate Documentation and Missed Wound Care for Resident with Venous Ulcers
Penalty
Summary
The facility failed to accurately document and perform wound care for a resident with multiple medical conditions, including atrial fibrillation, type II diabetes, chronic venous hypertension with ulceration, and pulmonary hypertension. Physician orders specified daily wound care to the resident's left lower extremity, including cleansing, application of a silver collagen sheet, hydrogel dressing, and securing with kerlix and tape, with documentation required on the Treatment Administration Record (TAR). However, during an interview and observation, the resident reported that her wound dressing had not been changed recently, and the dressing was found to be dated several days prior, despite TAR entries indicating daily wound care had been completed. Further review and interviews with the DON and an LPN confirmed discrepancies between the documented wound care and the actual care provided. The DON acknowledged that the TAR inaccurately reflected wound care as completed on days when it was not performed, and the LPN could not explain the inconsistencies between her initials on the TAR and the actual dates wound care was provided. This inaccurate documentation and failure to provide wound care as ordered resulted in a deficiency related to maintaining accurate medical records and safeguarding resident-identifiable information.
Failure to Accurately Review PASARR Screenings for Mental Disorders
Penalty
Summary
The facility failed to ensure that Level 1 Preadmission Screening and Resident Review (PASARR) screenings were reviewed for accuracy and completion for three residents. Specifically, for one resident with diagnoses of dementia and depression, the PASARR Level 1 Identification Screen completed by a previous facility did not include the resident's diagnosis of depression, despite depression being listed as a mental illness example on the screening form. The resident's Minimum Data Set (MDS) confirmed a diagnosis of depression and the use of antidepressant medication, indicating a discrepancy between the PASARR and the resident's actual medical condition. Interviews with facility staff revealed that both the Marketing Director and the Director of Social Services were responsible for verifying the accuracy of PASARR screenings prior to admission. However, both staff members were new to their positions and did not review the resident's Level 1 PASARR for accuracy. The Marketing Director acknowledged that the PASARR was incorrect due to the missing depression diagnosis and stated that it was expected for all PASARRs to be screened before admission. The Social Services Director also confirmed the expectation for accurate PASARRs and noted that improper screening could result in residents not receiving necessary care or services.
Failure to Administer Anti-Seizure Medication Results in Hospitalization
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of epilepsy was admitted to the facility and did not receive their prescribed anti-seizure medication, Lacosamide, as ordered. The resident's medication orders included Lacosamide 200 mg to be administered orally every 12 hours, but review of the medication administration record showed that the medication was not given from the time of admission through several days following. The care plan for the resident specifically identified the risk for seizure activity and included interventions to medicate as ordered and assess for effectiveness and adverse effects. The failure to administer the anti-seizure medication was due to a breakdown in the medication reconciliation and procurement process. Upon admission, the resident's seizure medication was not available at the facility, and staff did not ensure its timely delivery or obtain it from alternative sources. The pharmacy was unable to fill the prescription because it had already been filled by the previous facility, and attempts to obtain the medication from the prior facility were unsuccessful. Staff did not notify the provider or take further steps to secure the medication, and the lack of communication and follow-up resulted in the resident not receiving the necessary treatment. As a result of not receiving the prescribed anti-seizure medication, the resident experienced multiple seizures and required transfer to the hospital. Hospital records confirmed that the resident had not received Lacosamide for several days prior to the seizure event, and that the resident's seizures had previously been stable for the past year. Interviews with facility staff confirmed that the omission of the medication was not identified until after the resident was hospitalized for seizure activity.
Failure to Maintain Certified Infection Preventionist Onsite
Penalty
Summary
The facility failed to ensure they had a certified infection prevention nurse hired at least part-time onsite, which could potentially increase infection rates due to the lack of active surveillance and staff education. The facility's policy required an Infection Preventionist (IP) to work at least part-time, but the previous IP nurse, who had been working remotely on an as-needed basis since April 2024, was terminated on September 13, 2024. This nurse had only been onsite four or five times since April to deliver completed work and provide verbal education to staff. The Director of Nursing (DON) informed the previous IP nurse of her termination because a new RN was hired for the IP role, although the new RN was not certified as an IP and had only worked at the facility for four days. The Medical Director stated that he reviewed infections monthly and identified the new IP nurse as RN5. However, the Administrator was unaware that the previous IP nurse was told to stop working on any IP work and acknowledged that the infection control data for July and August was incomplete. The DON confirmed that the new IP nurse was only going to be a floor nurse and did not want to be in a management role. The DON also admitted to not being aware of the requirement to have a part-time or full-time IP onsite until September 17, 2024.
Failure to Provide Bed Hold Notice During Hospital Transfer
Penalty
Summary
The facility failed to provide a written bed hold notice to a resident, identified as R79, when they were transferred to the hospital. According to the facility's policy, when a resident is transferred to a hospital or on therapeutic leave, the designated staff member must provide the resident and their representative with a written Bed Hold Policy and Authorization form. However, a review of R79's electronic medical records revealed no evidence that this policy was followed when R79 was discharged to the hospital due to altered mental status. The resident's medical history included chronic obstructive pulmonary disease, dementia, and hypothyroidism. Interviews with facility staff confirmed the deficiency. The Business Office Manager (BOM) acknowledged that the facility failed to provide the bed hold policy to R79 upon transfer and noted that nurses were responsible for initiating bed holds, which had not been done. Despite holding an in-service training for nursing staff regarding bed holds, the BOM reported not receiving any written bed hold notices since their employment began in February 2024. Additionally, a Licensed Practical Nurse (LPN) admitted to knowing about the bed hold form but not using it, while a Registered Nurse (RN) stated they documented hospital transfers but left bed hold information to the BOM.
Failure to Follow Professional Standards in Blood Glucose Monitoring
Penalty
Summary
The facility failed to adhere to professional standards of practice in conducting fingerstick blood glucose monitoring for three residents diagnosed with type two diabetes mellitus. The facility's policy on fingerstick blood glucose monitoring did not include the step of discarding the first drop of blood before obtaining a sample, which is a recognized standard practice. During observations, an LPN was seen checking the blood glucose levels of three residents without discarding the first drop of blood, which could potentially affect the accuracy of the glucose readings. The LPN admitted to not routinely discarding the first drop of blood and was unsure if it was part of the facility's policy. The residents involved included one with severe cognitive impairment, one who was cognitively intact, and another with mild cognitive impairment. Each resident had specific care plans and active orders related to their diabetes management, including monitoring blood glucose levels and notifying a physician if levels were outside specified ranges. The Director of Nursing confirmed that the professional standard involves discarding the first drop of blood, although he was uncertain if this was explicitly stated in the facility's policy.
Delayed Referral for Barium Swallow Study
Penalty
Summary
The facility failed to send a referral for a barium swallow study in a timely manner for a resident, identified as R76, which placed the resident at risk of not having pleasurable items. R76 was admitted with diagnoses including aftercare following surgery on the nervous system, post-traumatic hydrocephalus, and encephalitis and encephalomyelitis. The resident's family requested a swallowing evaluation as R76 wanted to drink fluids, juice, and ice-chips. Despite the family's request and the resident's needs, the referral for the barium swallow study was delayed. The delay was due to a lack of follow-up on the referral by the Rehabilitation Director and the receptionist, who was responsible for scheduling the appointment. The Rehabilitation Director acknowledged notifying the receptionist about the need for a referral but did not follow up. The receptionist confirmed that she had not scheduled the referral yet, despite the facility's expectation to schedule appointments within 24 to 48 hours. This inaction resulted in the resident's family being unable to provide the resident with different items due to the pending swallow study.
Failure to Maintain Clean Respiratory Equipment
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards for three residents, leading to the potential for exposure to contaminated respiratory equipment and improper airflow. Resident 16, who was admitted with a diagnosis of unspecified chronic bronchitis and had severe cognitive impairment, was observed to have a dusty oxygen concentrator over multiple days. The facility's policy did not specify the frequency of cleaning for the oxygen concentrator, and staff confirmed that the concentrator should be cleaned weekly on Saturdays. Resident 18, diagnosed with chronic respiratory failure with hypoxia and pulmonary hypertension, was cognitively intact and had an order to clean the oxygen concentrator's external filter every Saturday night. However, observations revealed the concentrator and filter were dusty over consecutive days. Similarly, Resident 31, with diagnoses of unspecified asthma and chronic obstructive pulmonary disease, had a dusty oxygen concentrator and filter despite an order to clean it weekly. Staff interviews confirmed the cleaning schedule and acknowledged the failure to adhere to it.
Failure to Clarify Antidepressant Diagnosis and Address Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure an appropriate diagnosis for the use of an anti-depressant was clarified by the Medical Director for one of the residents reviewed for unnecessary medications. This deficiency was identified during a review of the facility's policies and procedures, which require a licensed pharmacist to perform a monthly drug regimen review and ensure that medications are clinically indicated. The consultant pharmacist had recommended a Gradual Dose Reduction (GDR) for psychotropic medications and requested clarification of the diagnosis for the anti-depressant Mirtazapine prescribed to the resident. However, there was no response or rationale documented from the physician regarding these recommendations. The resident in question, who was admitted with a diagnosis of depression, was observed to have severe cognitive impairment and was receiving Mirtazapine. The Director of Nursing (DON) acknowledged that the pharmacy recommendations were not submitted back to the doctor, and the process for handling these recommendations was flawed. The Medical Director confirmed that due to recent changes in pharmacy services, DON, and administrators, the consultant pharmacy reviews had not been conducted as required. This oversight led to the failure in addressing the consultant pharmacist's recommendations and ensuring the medication's appropriateness.
Failure to Implement PRN Stop Date and GDR for Psychotropic Medications
Penalty
Summary
The facility failed to implement a 14-day stop date for the PRN use of an anti-anxiety medication and did not provide a rationale for the continued use of the medication for a resident with major depressive disorder and anxiety. The resident, who was cognitively intact, had an order for Lorazepam to be administered as needed for anxiety or end-of-life care. However, there was no documentation by the resident's physician of the clinical rationale for the continued use of PRN Lorazepam, which is against the facility's policy that requires such documentation if the PRN order is to be extended beyond 14 days. Additionally, the facility failed to implement a gradual dose reduction (GDR) for a resident with unspecified dementia and psychotic disturbance who was receiving antipsychotic medication. The resident had been on Seroquel since late the previous year, but there was no evidence of a GDR in the electronic medical record. The facility's system for obtaining GDRs from the pharmacist and providing that information to the physician was not functioning properly, as indicated by the lack of available pharmacist consultant records and the absence of physician action on drug regimen reviews. Interviews with the facility's Administrator, Director of Nursing (DON), and Medical Director revealed a breakdown in communication and processes related to medication regimen reviews and GDRs. The facility had switched pharmacies, and the monthly meetings to discuss antipsychotic medications had not been occurring. The Medical Director acknowledged that the facility staff, including himself, the DON, and the pharmacist, had failed to maintain the necessary systems to ensure residents were on the lowest possible doses of antipsychotic medications.
Failure to Schedule Dental Services for Resident
Penalty
Summary
The facility failed to assist a resident, identified as R54, in obtaining routine dental services, as required by their policy. R54 was admitted with diagnoses including bipolar disorder, anxiety disorder, and dysphagia, and was assessed to be cognitively alert with a BIMS score of 15 out of 15. Despite this, attempts to interview R54 were unsuccessful. The resident's Power of Attorney (POA) reported that R54 was supposed to have a dental consult for a loose tooth, but there was no follow-up on the appointment. The facility's process for scheduling appointments involves nurses printing orders and giving them to the receptionist, who is responsible for setting up appointments. However, interviews with the RN and the receptionist revealed that no dental appointment was scheduled for R54. The Director of Nursing (DON) acknowledged issues with scheduling and mentioned that a unit clerk was hired to streamline the process. Despite these measures, the facility did not meet its policy requirement to provide or obtain dental services for R54.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of two residents, R29 and R44, which could potentially lead to adverse effects such as weight loss and dissatisfaction with meals. R29, who has cerebral palsy and no cognitive impairment, reported that despite informing staff of his dislike for peas and spinach, these items were still being served to him. The Dietary Manager (DM) confirmed that a food preferences interview was not conducted upon R29's admission, and the previous dietary manager did not document his dislikes. Although the DM updated the Meal Tracker system with R29's preferences in July, the meal tickets did not reflect these dislikes, leading to continued errors in meal preparation. R44, who is cognitively alert, expressed frustration that his meal tickets consistently listed cottage cheese, which he never received. Observations confirmed that cottage cheese was missing from his meal trays on multiple occasions. The DM admitted that the facility had not stocked cottage cheese for over a month and had not placed any orders for it during that time. This oversight resulted in R44 not receiving a food item that was supposed to be part of his meals, as indicated on his meal tickets. The facility's policy requires that food preferences be identified within 72 hours of admission, but this was not adhered to for R29. The DM acknowledged that there was no documentation of R29's preferences prior to her arrival and that the meal tickets did not have enough space to list dislikes, relying instead on staff to remember residents' preferences. This lack of proper documentation and communication led to repeated failures in meeting the dietary needs and preferences of the residents, as evidenced by the experiences of R29 and R44.
Infection Control Deficiencies in Blood Glucose Monitoring and Medication Administration
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed by staff during blood glucose monitoring and medication administration. Specifically, staff did not use a protective barrier for blood glucose supplies at the bedside for four residents and did not wear appropriate personal protective equipment (PPE) while administering medications through a gastrostomy tube for one resident. These actions were observed during a survey, indicating a lack of adherence to the facility's policies on enhanced barrier precautions and fingerstick glucose monitoring. For Resident 38, who was readmitted with a gastrostomy tube, the facility's care plan did not address enhanced barrier precautions, and active orders did not specify the use of PPE. During an observation, a registered nurse administered medication via the gastrostomy tube wearing only gloves, contrary to the facility's policy requiring a gown and gloves. Interviews with staff revealed that enhanced barrier supplies were not readily available, and staff were not consistently using gowns prior to the survey. For Residents 14, 37, 49, and 52, staff failed to use a protective barrier when placing blood glucose monitoring supplies on bedside tables. Supplies for multiple residents were carried into each room in a shared container, increasing the risk of cross-contamination. Interviews with nursing staff and the Director of Nursing confirmed that the practice of carrying all supplies into each room was not in line with best practices, and only the necessary supplies for each resident should be taken into their rooms.
Medication Administration Error Due to LPN's Incompetency
Penalty
Summary
The facility failed to ensure that nursing staff demonstrated competency in safely administering medications, which led to a significant medication error. An LPN pre-poured medications and, due to distraction, handed them to the wrong resident. This error resulted in the resident receiving another resident's medications, including Prilosec and lisinopril, which caused hypotension and required hospitalization for observation and treatment. The LPN did not immediately report the error to the physician or the Director of Nursing (DON), further compounding the issue. The resident who received the wrong medications experienced a significant drop in blood pressure and was found dizzy and on the floor by a housekeeper. The resident was subsequently sent to the emergency room, where he was evaluated and admitted for observation. The hospital records indicated that the resident was hypotensive due to the medication error but remained stable without any overnight events and was discharged back to the nursing home the following day. The facility's investigation revealed that the LPN had previously been written up for pre-pouring medications and had completed initial and re-education competency assessments. Despite this, the LPN failed to follow the five rights of medication administration, leading to the error. Observations of other nursing staff showed that they followed proper procedures for medication administration, including verifying resident identity and medication details. The DON confirmed that new staff shadow senior nurses and complete competency assessments annually, but this incident highlighted a lapse in adherence to these protocols.
Removal Plan
- LPN #1 was immediately suspended pending investigation for delayed notification of medication error.
- All residents on LPN #1's assignment were evaluated for changes in status and screened for concerns related to their medication to rule out the potential of other medication errors. All resident audits were completed by nursing staff. The residents did not have changes from their baseline.
- All nurses and CMAs to be educated on the five rights of medication administration related to resident identification. In-service and ongoing.
- Random medication administration observations to be completed by DON or Designee three times per shift. Evaluate and bring results to Quality Assurance Performance Improvement (QAPI) monthly until determination of stop. Start date and ongoing.
- LPN #1 was terminated from the facility and turned into the New Mexico Board of Nursing.
Medication Error Leads to Resident Hospitalization
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors, resulting in a resident receiving the wrong medication. An LPN pre-poured medications and, due to distraction, handed them to the wrong resident. The LPN realized the mistake immediately but did not report the error to the physician or the Director of Nursing (DON). The resident who received the wrong medication experienced adverse side effects, including a drop in vital signs, and was subsequently hospitalized for observation. The resident who received the wrong medication had a history of unspecified dementia with behavioral disturbances and vascular dementia. The resident was given medications intended for another resident, including Prilosec and lisinopril, which led to hypotension and dizziness. The resident was found on the floor by a housekeeper and was later sent to the emergency room for evaluation and observation. The DON confirmed that the LPN had previously been written up for pre-pouring medications and that the facility had conducted an in-service on the seven rights of medication administration. Observations of other staff members during medication passes showed that they followed proper procedures, including verifying resident identity and medication details. However, the initial error and failure to report it promptly led to the resident's hospitalization.
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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