Calibre Post Acute, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Las Cruces, New Mexico.
- Location
- 2029 Sagecrest Ave, Las Cruces, New Mexico 88011
- CMS Provider Number
- 325039
- Inspections on file
- 27
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Calibre Post Acute, Llc during CMS and state inspections, most recent first.
A resident with an intellectual disability received continuous care from several Developmental Disability Caregivers (DDCs) who were present at the bedside over multiple shifts. Facility records later showed the resident was found with arms tied to bed rails, and leadership informed a DDC that restraints were not allowed. The DON reported that the DDCs were expected to provide services such as feeding, redirection, and companionship, but confirmed that none of the DDCs received training on facility policies or expectations, including restraint use, and that she had only assumed their outside employer provided equivalent training.
A resident with intellectual disability, depression, and anxiety was found twice in one morning with limbs tied to the bed using sheets and blankets by a developmental disability caregiver. An LPN first discovered the resident’s feet restrained and removed the sheet, informing the caregiver that restraints were not allowed. Later, a CNA alerted the ADON and DON, who found the resident’s arms tied to the bed rails while the caregiver lay across the resident’s legs; the caregiver stated he restrained the resident due to aggressive behavior and threats to break a window. The facility’s policy allowed restraints only for medical symptoms after alternatives failed and prohibited their use for discipline, staff convenience, or fall prevention, but the resident was restrained in violation of this policy.
A resident was found twice in the same morning restrained in bed by a developmental disability caregiver, first with a sheet tied around the feet and later with blankets tying the arms to bed rails. An LPN who discovered the initial restraint removed it and informed the caregiver about the restraint-free policy but did not notify administration. Later, the ADON and DON observed the arm restraints, removed them, and documented and reported only that incident to the state agency. The earlier episode involving the resident’s feet was not reported to administration or included in the incident or follow-up reports, despite facility expectations that all abuse allegations be reported promptly.
Staff did not notify providers when two residents had repeated low blood pressure readings and antihypertensive medications were withheld, nor when another resident experienced multiple low blood sugar episodes. Required notifications and documentation were not completed according to physician orders and facility policy, as confirmed by the DON.
Two residents were prescribed psychotropic medications without evidence of ongoing need or appropriate monitoring. One resident continued to receive antidepressants and other medications despite consistently showing no depressive symptoms, and no gradual dose reduction was attempted or justified. Staff did not monitor for suicidal thoughts or behaviors as required by black box warnings for antidepressant medications, and documentation of such monitoring was absent for both residents. Nursing staff acknowledged a lack of instruction on responding to black box warnings, and the DON confirmed that monitoring and documentation for suicidal ideation were not performed.
A resident with major depressive disorder was not provided with a comprehensive care plan that included specific behaviors to monitor, non-pharmacological interventions, or detailed interventions for compulsive and sexually inappropriate behaviors. Staff confirmed that monitoring for depression symptoms and suicidal ideation was not in place, and the care plan did not reflect the resident's ongoing behavioral issues.
Staff failed to administer medications as ordered and did not notify providers when medications were held for three residents, including those with hypertension and diabetes. Medications were withheld without proper documentation, provider notification, or adherence to physician-ordered parameters and facility protocols, resulting in incomplete records and unaddressed adverse effects.
A resident with depression, dementia, and compulsive sexual behaviors did not receive timely psychiatric evaluations or recommended therapy services due to delays and breakdowns in the facility's referral and communication process. Staff lacked an effective method to track and ensure behavioral health referrals were made and followed up, resulting in missed psychiatric follow-up and absence of non-pharmacological interventions.
A physician did not document a clinical rationale for declining a consultant pharmacist's recommendation to attempt a gradual dose reduction (GDR) of an antidepressant for a resident with dementia, insomnia, and major depressive disorder. The provider noted only that the resident had a good response to the current dose, without further explanation, and this omission was confirmed through record review and staff interviews.
A resident with type 2 diabetes returned from the hospital with orders for blood glucose checks before meals and at bedtime, but staff did not enter or carry out these orders, and no blood sugar checks were documented after the resident's readmission. The provider confirmed the monitoring was intended but was unaware it had not been implemented.
A facility did not ensure that an LPN completed the required behavioral health training, as shown by missing documentation in staff training records. The Administrator confirmed that all staff were required to complete this training, but was unable to find evidence that the LPN had done so.
Care plans were not updated to reflect current interventions and care needs for three residents. One resident's care plan lacked documentation of strategies for managing care refusals and incentives used by staff, another did not include participation in a restorative program after a fall, and a third did not specify details for enteral feeding and medication administration by staff. The DON confirmed these omissions in care plan documentation.
Staff failed to maintain complete and accurate medical records for three residents, including missing documentation of care refusals, repeated care attempts, a fall and related assessments, and provider notifications for unavailable medications. These omissions were confirmed by facility leadership and involved residents with complex medical needs and care challenges.
Three staff members, including two CNAs and an ADON, did not complete required behavioral health training despite the facility having multiple residents with behavioral health needs and mental illness diagnoses. Training records and HR interview confirmed the deficiency.
Staff did not notify the provider when a resident missed doses of amiodarone and levothyroxine due to medication unavailability, despite facility expectations to do so and to document such notifications. The resident had multiple cardiac and endocrine diagnoses, and staff interviews confirmed the orders and notification requirements, but no evidence of provider notification was found in the records.
A resident experienced a fall resulting in visible injuries, including a bruise and areas of redness, but staff inaccurately documented the incident on the quarterly MDS as a fall without injury. The MDS coordinator later confirmed the assessment should have indicated a fall with injury.
A resident with multiple cardiac and endocrine conditions did not receive prescribed heart rhythm and thyroid medications as ordered, due to medication unavailability and unclear staff responsibilities. Nursing staff did not notify the provider of the missed doses, and documentation did not accurately reflect who administered care, resulting in a failure to meet professional standards of practice.
The facility failed to provide adequate ADL assistance and hygiene care for several residents due to staffing shortages. A resident was left on the toilet for an hour, causing distress, while another waited 45 minutes for help with a Hoyer lift. A third resident experienced frequent accidents due to delayed assistance. Additionally, a resident with a traumatic brain injury did not receive consistent oral care or showers, as documented in their care plan. Staff confirmed that these issues were due to insufficient staffing.
The facility failed to provide adequate staffing, resulting in residents experiencing neglect and distress. One resident with Chronic Kidney Disease was left soiled for extended periods, while another was left on the toilet for an hour due to insufficient staff. Additionally, a resident did not receive regular oral care or showers as scheduled, with staff confirming that shortages led to missed care.
The facility failed to maintain sanitary conditions in the kitchen and dining areas, affecting all residents. Observations revealed unclean floors, dark and smokey oil in the deep fryer, and unsanitary conditions such as uncovered jelly and backed-up drains. Additionally, a CNA did not perform hand hygiene before assisting a resident with their meal. These practices could likely lead to foodborne illnesses, as confirmed by staff during interviews.
A facility failed to create a baseline care plan within 48 hours of admission for a resident. The resident was admitted, but the care plan was not completed until several days later, as confirmed by the MDS Nurse. This delay could lead to inadequate care and potential risks for the resident.
A resident's blood pressure medications were not administered as ordered due to low blood pressure, without physician consultation or documented parameters. The facility failed to follow professional standards by not documenting vital signs or updating orders with specific administration guidelines.
A resident diagnosed with COVID-19 did not receive the prescribed antiviral medication, Molnupiravir, due to delays in obtaining approval from the DON for pharmacy billing and subsequent delivery issues. The LPN did not inform the physician about the missed doses, leading to a lapse in communication and medication management within the facility.
A resident with a Stage II pressure ulcer did not receive timely wound care due to the facility's failure to obtain and implement necessary orders. The resident was admitted with a pressure injury, but wound care orders were not in place until several days later, delaying treatment. An LPN confirmed that the nursing staff responsible for admissions should have obtained the orders.
A facility failed to ensure nursing staff competency in changing a suprapubic catheter, leading to a resident experiencing complications such as blood in the brief and bladder pain. The ADON changed the catheter without proper competency assessment, and the facility's Nurse Educator confirmed that competencies were assessed verbally without a step-by-step check-off or return demonstration. This resulted in the resident being sent to the emergency room for a displaced catheter.
The facility failed to maintain complete and accurate medical records for two residents, impacting their care. One resident's record lacked documentation of a suprapubic catheter change and related assessments, while another resident's record was missing details on breathing difficulties and treatment administration. The ADON confirmed the expectation for thorough documentation, which was not met in these cases.
The facility failed to ensure that LPNs and CNAs demonstrated necessary competencies, as five staff members lacked completed evaluations. The DON confirmed that these evaluations, crucial for assessing safe and competent performance, were not conducted upon hiring or annually, potentially affecting care for all residents.
The facility failed to provide written bed hold policy notifications to two residents and their representatives during hospital transfers. One resident's family reported no notification during three transfers, and records confirmed missing documentation of bed hold days. Staff interviews revealed inconsistencies in notifying residents and families. Another resident's transfer also lacked proper documentation. The DON acknowledged the need for clear documentation of bed hold days and notification dates.
The facility failed to ensure accurate MDS assessments for several residents, leading to potential mismanagement of care. One resident's diabetic ulcer and insulin use were not documented, another's diabetes diagnosis was omitted, and a third's constipation treatment and anticoagulant use were not recorded. Additionally, dental pain and bladder training were not documented for two other residents, despite being noted in their medical records.
The facility failed to develop accurate care plans for two residents, omitting critical medical conditions and treatments. One resident's care plan did not include a diagnosis of heart failure or the use of high-risk medication, while another's omitted urinary retention and the presence of a Foley catheter. These omissions were confirmed by the MDS Coordinator, highlighting a deficiency in documenting essential health information.
The facility failed to review and revise care plans for six residents, leading to outdated or incomplete documentation of medical conditions and treatments. One resident did not have an Interdisciplinary Team Meeting within the required timeframe, while others had care plans that did not reflect current diagnoses, medication orders, or safety interventions. These deficiencies were confirmed through staff interviews and record reviews.
A resident with diabetes did not receive a Dexcom glucose monitoring system and Trulicity injections as ordered by the physician. The Dexcom was unavailable for months, requiring frequent fingerstick checks, and Trulicity was repeatedly not administered. Despite documentation of pharmacy communication issues, there was no follow-up with the physician about the unavailability of these critical diabetes management tools.
A resident with diabetes did not receive proper care after hospice services were revoked, as the facility failed to resume blood glucose monitoring and insulin administration. The resident's blood glucose levels were not checked for several months, leading to a dangerously high level that required immediate medical attention. Facility staff confirmed the oversight in resuming diabetes management.
A resident in a long-term care facility did not receive routine medications due to unavailability, as the pharmacy had not delivered them. The resident, a new admission, missed doses of pantoprazole, iron, and atorvastatin. Staff confirmed the medications were on order, and the facility had issues with receiving timely deliveries from the contract pharmacy.
The facility failed to ensure that psychotropic medications were medically necessary for three residents. One resident continued on sertraline without a gradual dose reduction despite showing no depression symptoms. Another was prescribed olanzapine without a psychiatric diagnosis, and a third resident's duloxetine dose was not evaluated for reduction despite a recommendation. The lack of documentation and clinical rationale contributed to the deficiency.
The facility failed to provide necessary dental services to four residents, resulting in missed routine care, delayed follow-up for dental issues, and inadequate response to emergency dental needs. One resident had not seen a dentist in over a year, another awaited a follow-up for a tooth extraction, and a third experienced ongoing pain from broken teeth without timely intervention.
The facility failed to maintain proper food storage conditions in a refrigerator on the north unit, with temperatures recorded at 48 degrees Fahrenheit, above the required range. Condensation was also observed inside the refrigerator. Temperature logs were not maintained for November, and staff failed to check and record temperatures after the end of October, as confirmed by the ADON and DON.
The facility's call light system for rooms 133 to 152 on the South Unit was found to be deficient, with multiple residents reporting inconsistent functionality. Observations confirmed that unplugging a call light in certain rooms caused others to stop working, a fact verified by the Maintenance Director and ADON #1.
The facility did not ensure that five staff members, including LPNs and a CNA, completed mandatory Effective Communication training. A review of their online training transcripts confirmed the training was incomplete, and the DON acknowledged this during an interview. This deficiency could impact the staff's ability to communicate residents' health status and rights effectively.
A facility failed to provide required written transfer notifications to a resident and their representative for three hospital transfers. The notifications lacked contact information for the Ombudsman and details on appeal rights. Staff interviews confirmed that transfer notices were not given to residents or their representatives, and the facility's practice did not meet regulatory requirements.
The facility did not complete Discharge MDS assessments in a timely manner for two residents, as required by federal regulations. The assessments were completed several days after the residents' discharge dates. The MDS Coordinator confirmed the delay during an interview.
The facility failed to conduct necessary smoking evaluations for two residents, leading to potential safety risks. One resident began smoking without supervision after initially stating he would not, and another was found smoking in his room while using oxygen. Despite these changes, the facility did not reassess their smoking safety.
A LTC facility failed to provide proper urinary catheter care for two residents. One resident was not assessed for urinary retention after catheter removal, leading to hospitalization for urinary retention, constipation, and UTI. Another resident's catheter was not removed despite completing bladder training, with no documentation or physician's order for continued use. Staff interviews revealed inconsistencies in catheter care procedures and documentation.
The facility failed to include performance reviews in the 12 hours of annual training for a CNA. CNA #9, employed since early 2018, lacked performance evaluations in their records. The DON confirmed the absence of a completed evaluation and that the annual training was not based on it.
The facility failed to report injuries of unknown source to the State Agency within the required two-hour timeframe for three residents. One resident was injured by a Hoyer lift tipping over, another was found with abrasions and bruises, and a third experienced a similar lift incident. These incidents were reported late, contrary to the facility's expectations.
A facility failed to thoroughly investigate an abuse allegation involving a resident. The incident was reported by the resident's family, and CNA #11, who provided care at the time, was sent home pending investigation. The follow-up report lacked documentation of interviews with the CNA, the resident's family, or other involved CNAs, and did not explain how the allegations were deemed unsubstantiated. The DON, who was not working at the time, stated that her expectation was to remove and interview the involved staff and all parties with knowledge of the incident.
A facility failed to assess a resident for the risk of entrapment from bed rails, leading to a deficiency. The resident had a physician's order for a half bed rail, but the care plan included bed rails for mobility and safety without a risk assessment. An observation showed two bilateral half side rails instead of one. The DON confirmed the lack of a risk assessment, and the MDS specialist noted the bed rails were not documented as they were not considered a restraint.
Failure to Train Developmental Disability Caregivers on Facility Policies
Penalty
Summary
The facility failed to implement an effective training program for Developmental Disability Caregivers (DDCs) who provided care to a resident with unspecified intellectual disabilities. The resident was admitted with a diagnosis that limited intelligence and disrupted abilities necessary for independent living, and the facility’s records showed that DDCs were present at the bedside throughout the night and early morning. Progress notes documented that DDC staff were with the resident at multiple times, but did not specify which DDC was present at each time. Later documentation indicated that the DON and ADON observed the resident with his arms tied to the bed rails, and the ADON then informed one of the DDCs that restraints were not allowed in the facility. Interviews with the DON and ADON revealed that three DDCs rotated in providing continuous care to the resident, relieving one another over the course of the resident’s stay. The DON stated that the DDCs were expected to provide the same services they had provided in the resident’s home, such as feeding, redirection, and companionship. However, the DON confirmed that none of the three DDCs received any training from the facility regarding its policies and expectations before assisting the resident. She further stated that she assumed the DDCs’ employer required the same training as the facility required for its own staff and was unsure what training the DDCs had actually received. The facility did not provide any training to these DDCs on its policies, including those related to the use of restraints, prior to their involvement in the resident’s care.
Improper Use of Physical Restraints by Private Caregiver
Penalty
Summary
The deficiency involves the use of physical restraints on a resident without a medical indication and contrary to the facility’s restraint-free policy. The resident, who had diagnoses of unspecified intellectual disabilities, depression, and anxiety disorder, was admitted on an unspecified date. On one morning, a CNA notified the ADON and DON that the resident was restrained to the bed; when they arrived, they observed the resident’s arms tied to the bed rails with blankets while the resident’s developmental disability caregiver (DDC) was lying on the resident’s legs. The DDC stated he had restrained the resident because the resident was trying to hit and kick him and had said he was going to break the window. Further record review and interviews revealed that earlier the same morning, around 6:30–7:00 AM, an LPN had entered the resident’s room and found a sheet tied around the resident’s feet, which he then untied. The LPN reported educating the DDC at that time that the facility was restraint free and that the resident could not be restrained. Despite this, later that morning the resident was again found with arms tied to the bed rails. The DON confirmed that the facility does not allow residents to be restrained and that this resident should not have been restrained. The facility’s restraint policy stated that physical restraints shall only be used for the safety and wellbeing of residents, only after other alternatives have been tried unsuccessfully, and only to treat medical symptoms, never for discipline, staff convenience, or fall prevention.
Failure to Fully Report Allegations of Resident Restraint to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to fully and accurately report an allegation of abuse involving the use of physical restraints on a resident by the resident’s developmental disability caregiver (DDC). On one morning, a staff member notified the ADON and DON that the resident was restrained to the bed. The ADON and DON then observed the resident’s arms tied to the bed rails with blankets, and the ADON removed the restraints. The incident report submitted to the state agency documented that the resident’s arms had been restrained by the DDC at that time and that the DDC was informed the facility did not allow restraints. However, during the subsequent investigation, it was learned that earlier that same morning, between approximately 6:30 AM and 7:00 AM, an LPN had already found the resident restrained with a sheet tied around the resident’s feet by the DDC, who stated he had done so because the resident was trying to kick the window. The LPN removed the sheet and told the DDC that the facility was restraint free. The LPN did not notify administration at that time, and this earlier restraint incident was not documented in the initial incident report or in the follow-up report submitted to the state agency. The Administrator confirmed that staff were expected to notify administration immediately of any concerns of abuse and that all allegations of abuse were expected to be reported to the state agency within two hours, but the facility did not notify the state agency about the earlier restraint episode involving the resident’s feet.
Failure to Notify Provider of Abnormal Vitals and Withheld Medications
Penalty
Summary
Facility staff failed to notify providers of abnormal vital signs and the withholding of medication for three residents with significant medical conditions. For two residents with hypertensive heart disease, staff documented multiple instances of low blood pressure readings that were outside the parameters set by physician orders. Despite these abnormal readings and the decision to hold prescribed antihypertensive medications, there was no documentation that the provider was notified of the low blood pressure or the medication being withheld. Additionally, a resident with type 2 diabetes mellitus experienced several episodes of low blood sugar, as documented in the medical record. The facility's diabetic management policy and physician orders required staff to notify the provider when blood glucose levels fell below a certain threshold. However, there was no documentation that the provider was informed of these low blood sugar episodes, nor was there evidence that the required notifications were made according to policy. During an interview, the Director of Nursing confirmed that staff did not contact the provider regarding the low blood pressure readings, the withholding of blood pressure medications, or the low blood sugar levels, as required by physician orders and facility policy. The medical records lacked documentation of provider notification or any new orders resulting from these clinical findings.
Failure to Ensure Gradual Dose Reduction and Monitoring for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents did not receive unnecessary psychotropic medications and that adequate monitoring was in place for those receiving such medications. For one resident with diagnoses including dementia, insomnia, and major depressive disorder, there was no evidence of depressive symptoms since admission, as indicated by repeated PHQ-9 scores of zero. Despite this, the resident continued to receive escitalopram, oxcarbazepine, and trazodone at the same dosages without any documented attempt at gradual dose reduction (GDR) or clinical rationale for not attempting a GDR, even after a pharmacist recommended a dose reduction. The provider declined the recommendation without providing a clinical justification, and the medical record lacked documentation supporting the continued use of these medications at their current dosages. Additionally, the facility did not adequately monitor for adverse side effects or follow black box warning requirements for residents on antidepressant medications. Staff interviews revealed that nurses were not monitoring for suicidal thoughts, behaviors, or worsening depression symptoms, despite black box warnings attached to the orders for escitalopram and trazodone. Staff acknowledged these warnings in the electronic medical record but were not instructed on appropriate actions to take, and there was no documentation that providers were notified of the warnings or that residents were being monitored as required. A second resident with multiple psychiatric and neurocognitive diagnoses was prescribed duloxetine, which also carries a black box warning for monitoring suicidal thoughts and behaviors. However, there was no documentation in the medical record that this resident was being monitored for these symptoms. Nursing staff confirmed that unless the medication administration record (MAR) specifically instructed them to monitor for suicidal ideation, such monitoring and documentation did not occur. The DON confirmed the absence of monitoring and documentation for suicidal ideations, despite the presence of black box warnings and the expectation that staff would assess and communicate with providers as needed.
Failure to Develop and Implement Comprehensive Care Plan for Depression
Penalty
Summary
The facility failed to develop and implement an accurate, person-centered comprehensive care plan for a resident diagnosed with major depressive disorder. The care plan did not specify which behaviors staff should monitor related to the resident's depression diagnosis or antidepressant medication, despite a black box warning requiring close monitoring for clinical worsening and emergence of suicidal thoughts and behaviors. Additionally, the care plan lacked documentation of non-pharmacological interventions for depression, did not detail the compulsive or sexually inappropriate behaviors the resident exhibited, and omitted interventions for these behaviors. Multiple progress notes documented ongoing sexually inappropriate and agitated behaviors, but these were not reflected in the care plan. Interviews with staff confirmed that the resident was not being monitored for symptoms of depression or suicidal ideation, and that no non-pharmacological interventions were in place for depression. The care plan also failed to include specific behaviors to monitor or interventions to address the resident's compulsive and sexually inappropriate behaviors. The Director of Nursing acknowledged these omissions, confirming that the care plan did not include necessary monitoring or interventions for the resident's depression or related behaviors.
Failure to Administer Medications as Ordered and Notify Providers of Held Doses
Penalty
Summary
Facility staff failed to meet professional standards of practice for three residents by not administering medications as ordered and not notifying providers when medications were held due to possible adverse effects. For one resident with hypertensive heart disease and heart failure, staff held blood pressure medications multiple times without provider notification, despite the absence of physician-ordered parameters for holding these medications. Documentation was inconsistent, with missing blood pressure readings and unclear reasons for withholding medications. Another resident with hypertensive heart disease without heart failure had a blood pressure medication order with specific parameters for holding the medication. However, staff frequently held the medication outside of these parameters, failed to document required blood pressure and heart rate readings, and did not consistently notify the provider when the medication was withheld. There were also instances where the medication was not administered even though the documented vital signs were within the parameters to give the medication, and staff did not document communication with the provider regarding missed doses due to appointments or low readings. A third resident with type 2 diabetes mellitus and hyperglycemia experienced multiple instances where insulin was not administered as ordered, including when the medication was not available or when blood sugar was low, despite the absence of hold parameters in the physician's order. Staff did not follow the facility's diabetic management policy for hypoglycemia, as there was no documentation of providing fast-acting sugar, rechecking blood glucose, or notifying the provider after low blood sugar episodes. The DON confirmed that staff did not notify providers about held medications and did not follow established protocols for medication administration and documentation.
Failure to Provide Timely Behavioral Health Services and Referrals
Penalty
Summary
The facility failed to ensure that a resident with multiple behavioral health diagnoses received necessary behavioral health care and services. The resident, who had Parkinson's Disease, dementia without behavioral disturbance, insomnia, and major depressive disorder, exhibited ongoing sexually inappropriate and compulsive behaviors, as well as an episode of self-harm. Despite physician orders for psychiatric referrals and behavior monitoring, there were significant delays in the resident being seen by psychiatric providers after referrals were made, and recommended therapy services were not initiated. Documentation showed that staff made psychiatric referrals on two occasions, but the resident was not seen by the psychiatric provider until several months later. Additionally, after a psychiatric evaluation recommended therapy services, there was no evidence that the resident was ever referred for or received therapy. Staff interviews revealed a lack of clarity and an ineffective process for tracking and ensuring that referrals were communicated and acted upon. The Social Services Director (SSD) and Director of Nursing (DON) both confirmed there was no tracking method to ensure referrals were sent and followed up, and the psychiatric provider was not always notified of new or urgent behavioral concerns. The resident's medical record and staff interviews further confirmed that non-pharmacological interventions for depression were not in place, and the resident was not receiving counseling or therapy services as recommended. The psychiatric nurse practitioner also confirmed gaps in communication regarding referrals and behavioral incidents, resulting in missed opportunities for timely psychiatric follow-up and intervention.
Lack of Physician Rationale for Not Following Pharmacist's Antidepressant Dose Reduction Recommendation
Penalty
Summary
The facility failed to ensure that a physician provided documentation of a clinical rationale for not following a consultant pharmacist's recommendation regarding a resident's antidepressant medication regimen. Specifically, a resident with diagnoses including dementia without behavioral disturbance, insomnia, and major depressive disorder had been prescribed escitalopram 20 mg daily since admission. The consultant pharmacist recommended a gradual dose reduction (GDR) of escitalopram, but the provider declined this recommendation, stating only that the resident had a good response and to maintain the current dose, without providing a clinical rationale for not attempting the GDR. Review of the resident's medical record confirmed that no clinical rationale was documented for declining the pharmacist's recommendation. Interviews with the DON and Medical Director further confirmed that the provider did not document a reason for not conducting a GDR, despite facility expectations that such rationale should be provided when a GDR is not attempted for antidepressant medications. This lack of documentation was identified during record review and staff interviews.
Failure to Implement Blood Glucose Monitoring Orders for Diabetic Resident
Penalty
Summary
A resident with a diagnosis of type 2 diabetes mellitus and hyperglycemia was admitted to the facility and later sent to the hospital following a fall. Upon discharge from the hospital and return to the facility, the resident's convalescent care orders included instructions for blood glucose checks (accuchecks) before meals and at bedtime. The facility provider also documented the need to continue these blood sugar checks in the resident's progress notes. Despite these clear orders, a review of the resident's physician's orders revealed that no order for accuchecks or blood sugar checks was entered upon the resident's return from the hospital. Additionally, documentation showed that no blood glucose checks were completed by staff after a specific date prior to the resident's readmission. During an interview, the provider confirmed the intent for blood glucose monitoring and was unaware that the order had not been implemented.
Failure to Ensure Completion of Mandatory Behavioral Health Training
Penalty
Summary
The facility failed to ensure that all nursing staff completed mandatory behavioral health training as required by facility policy and assessment. Record review showed that one LPN did not complete the required behavioral health training, which is designed to provide staff with the knowledge and skills to identify, understand, and respond to mental health and substance use challenges. During an interview, the Administrator was unable to locate documentation of this LPN's behavioral health training and confirmed that all staff were required to complete it.
Failure to Revise Care Plans with Current Resident Information and Interventions
Penalty
Summary
The facility failed to ensure that care plans were revised to reflect the most current information and interventions for three residents. For one resident, staff observed a strong odor of urine and noted the resident was only wearing a soiled brief with no sheets on the bed. Interviews with the ADON and DON revealed that the resident frequently refused care, including changing briefs, showering, and having sheets on the bed, and that staff sometimes used Diet Dr. Pepper and chips as incentives for compliance. However, the care plan did not document these interventions, nor did it include strategies for managing refusals of care, changing sheets, or the frequency of mattress changes. The DON confirmed that the care plan had not been updated to reflect these interventions or the resident's current care needs. Another resident experienced a fall due to weakness and imbalance and was subsequently enrolled in a restorative program to address these issues. Despite this, the care plan was not updated to include participation in the restorative program as an intervention to prevent further falls. For a third resident, physician orders indicated a change from a regular diet to enteral feeding via G-tube, along with specific medication administration instructions. The care plan, however, lacked details on whether male staff could provide feeding or medication administration and did not specify how to ensure the resident received nutrition and medications as ordered. The DON confirmed these omissions in the care plan documentation.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, resulting in missing documentation of care and significant events. For one resident with a history of refusing care, staff did not document repeated attempts to change briefs, provide showers, put sheets on the bed, or change the mattress, despite the resident's noncompliance and the presence of strong urine odor in the room. Interviews with the ADON confirmed that these care attempts and refusals were not consistently recorded in the medical record. Another resident experienced a fall due to weakness and imbalance, but staff did not document the fall, any post-fall assessment, or notifications to the provider or family. The DON confirmed that the expected documentation for such incidents, including assessment and notifications, was missing from the resident's medical record. A third resident did not receive prescribed medications on two occasions because the medications were unavailable. Although staff noted the unavailability in the medication administration record, there was no documentation in the progress notes that the physician was notified about the missed doses. The DON confirmed that staff are expected to notify the provider when medications are not available, but this was not documented.
Failure to Provide Behavioral Health Training to Staff
Penalty
Summary
The facility failed to provide behavioral health training to three staff members, specifically two certified nursing assistants and one assistant director of nursing, as required by the facility's assessment. Record review showed that the facility had 20 residents with behavioral health needs and 30 residents with mental illness diagnoses. Training records confirmed that these staff members did not complete the required behavioral health training. This was further corroborated during an interview with Human Resources, who verified the lack of completed training for the identified staff.
Failure to Notify Provider of Missed Medication Doses
Penalty
Summary
Facility staff failed to notify the provider when a resident missed doses of two critical medications, amiodarone and levothyroxine, on two consecutive days. Documentation in the Medication Administration Record (MAR) indicated that both medications were not available and were not administered on those dates. However, there was no evidence in the resident's progress notes that the provider was informed of these missed doses, as required by facility policy. The resident involved had multiple significant diagnoses, including hypertensive heart disease with heart failure, paroxysmal atrial fibrillation, atherosclerotic heart disease, chronic systolic heart failure, cardiomegaly, and hypothyroidism. Staff interviews confirmed the medication orders and the expectation to notify the provider if medications are not available or refused, as well as to document all provider contact. Despite these expectations, the required notifications and documentation were not completed for the missed medication doses.
Inaccurate MDS Assessment Following Resident Fall
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one resident. The resident was admitted to the facility and subsequently experienced a fall, resulting in a bruise to the side of the left eye and redness to the forehead, left shoulder, left hip, and both knees, as documented in the progress notes. However, the quarterly MDS assessment completed by staff inaccurately recorded that the resident had one fall without injury and zero falls with injury, despite clear documentation of injuries following the fall. During an interview, the MDS coordinator confirmed that the assessment was inaccurate and should have reflected a fall with injury.
Failure to Administer Prescribed Medications and Notify Provider
Penalty
Summary
Staff failed to administer a resident's heart rhythm and thyroid medications as ordered by the physician. The resident, who had multiple complex diagnoses including hypertensive heart disease with heart failure, paroxysmal atrial fibrillation, chronic systolic heart failure, and hypothyroidism, was admitted with orders for specific medications to be given via gastrostomy tube. On two consecutive days, documentation in the Medication Administration Record (MAR) indicated that the amiodarone and levothyroxine doses were not administered, with staff citing medication unavailability and other reasons. Despite these missed doses, there was no evidence in the progress notes that the physician was notified about the unavailability or omission of the medications. Interviews with nursing staff revealed confusion regarding responsibility for medication administration, particularly due to the resident's preference for female caregivers. One nurse stated he did not administer the medications or feedings and was unsure if another nurse had done so, while another nurse confirmed administering a feeding and medication but was uncertain about the earlier scheduled feeding. The Director of Nursing confirmed that staff are expected to notify the provider if medications are not available or not administered, and to document all provider contact in the medical record. However, documentation and communication protocols were not followed, as the provider was not notified of the missed doses and staff documentation did not accurately reflect who provided care. This failure to follow professional standards of practice resulted in the resident not receiving prescribed medications as ordered.
Inadequate ADL Assistance and Hygiene Care Due to Staffing Shortages
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for several residents, leading to significant distress and unmet care needs. Resident #8 was left on the toilet for approximately an hour due to insufficient staffing, causing her psychological distress and feelings of neglect. Interviews with staff and the resident revealed that the South Unit was understaffed, with only two CNAs available to care for 58 residents, many of whom required two-person assistance. This staffing shortage resulted in delayed responses to call lights and unmet toileting needs. Resident #10 also experienced delays in receiving assistance, often waiting 45 minutes for help due to the need for a Hoyer lift and the lack of available staff. The resident's care plan indicated a dependency on staff for multiple ADLs, including toileting and personal hygiene. Similarly, Resident #11 reported frequent accidents due to long wait times for assistance, as staff were unable to respond promptly to call lights. Interviews with CNAs confirmed the ongoing issue of inadequate staffing, leading to residents being left in soiled conditions. Resident #24, who has a traumatic brain injury, did not receive consistent oral care or showers as documented in their care plan. The resident's family member reported that oral hygiene was not performed after meals, and the shower schedule was not adhered to, resulting in a noticeable odor. Staff interviews corroborated these findings, with CNAs acknowledging that showers and oral care were often missed due to staffing shortages. The facility's failure to provide necessary ADL assistance and maintain hygiene standards for these residents highlights significant deficiencies in care delivery.
Staffing Shortages Lead to Resident Neglect
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of its residents, resulting in several instances of neglect and distress. One resident, who was dependent on staff for all activities, experienced psychological distress due to prolonged periods of being left soiled. This resident, diagnosed with Chronic Kidney Disease, reported that call lights often went unanswered for 30 minutes or longer, particularly during the day shift, leading to feelings of embarrassment and neglect. Another resident was left on the toilet for approximately an hour due to insufficient staffing. This resident required assistance from two staff members to use the bathroom, but due to a shortage of CNAs, the call light went unanswered for an extended period. The resident expressed feelings of being uncared for and reported that call lights typically took 15 minutes to an hour to be answered. The lack of staff was further confirmed by a CNA who noted that many residents required two-person assistance, which left the unit understaffed and unable to meet all residents' needs. Additional deficiencies were noted in the care of another resident who did not receive regular oral care or showers as scheduled. The resident's sister reported that the facility was short-staffed, leading to missed showers and inadequate oral hygiene. Documentation revealed numerous instances where oral care and showers were not provided, corroborating the claims of insufficient staffing. Interviews with CNAs confirmed that when the facility was short-staffed, scheduled showers and oral care were often not completed, further highlighting the impact of inadequate staffing on resident care.
Sanitation Deficiencies in Kitchen and Dining Areas
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen and dining areas, affecting all 98 residents who consume food prepared in the facility. Observations revealed that the deep freezer and kitchen floors were unclean, with food particles, spilled liquids, and sticky surfaces. The oil in the deep fryer was dark, smokey, and contained food particles, while the surrounding areas, including the floor and appliances, were covered in oil. Additional unsanitary conditions included uncovered jelly in the refrigerator, coffee spilled on the floor, and a wet, dirty blanket under a sink used to clean up a leak. The drain on the floor was backed up with food particles and paper trash, and there were straws and cup lids on the floor around the trash cans by the dishwasher. In the Assisted Dining Room, a CNA failed to perform hand hygiene before assisting a resident with their meal after adjusting the resident's feet on the footrest and the brake on the wheelchair. The CNA confirmed during an interview that she did not perform hand hygiene as required before resuming assistance. These practices could likely lead to foodborne illnesses, as confirmed by the Kitchen Manager and the CNA during interviews.
Failure to Create Timely Baseline Care Plan
Penalty
Summary
The facility failed to create an accurate baseline care plan within 48 hours of admission for a resident, identified as R #3. Upon review of R #3's admission records, it was found that the resident was admitted to the facility on an unspecified date, but the baseline care plan was not created until 01/27/25, which was beyond the required 48-hour timeframe. During an interview on 02/20/25, the MDS Nurse confirmed that the baseline care plan should have been created by the admitting nurse upon admission, but acknowledged that R #3's care plan was not completed within the mandated period. This oversight could potentially result in residents not receiving appropriate care and may place them at risk of adverse events or worsening conditions after admission.
Failure to Administer Blood Pressure Medications as Ordered
Penalty
Summary
The facility failed to meet professional standards of practice by not administering blood pressure medications as ordered by the physician for one resident. The resident had physician orders for carvedilol, hydralazine, and guanfacine to be administered via PEG tube for hypertension. However, on multiple occasions, these medications were not given as prescribed. Specifically, on two consecutive days, the medications were withheld due to low blood pressure, but there were no parameters in place to guide the decision to hold the medications. The Medication Administration Record (MAR) and nurse progress notes revealed that the staff documented low blood pressure as the reason for not administering the medications, but they failed to document the resident's vital signs or consult the physician for guidance. The Director of Nursing confirmed that the staff did not follow the physician's orders and did not contact the physician to determine whether the medications should be held or if the orders needed updating with specific parameters for administration.
Failure to Administer Prescribed Antiviral Medication
Penalty
Summary
The facility failed to provide necessary medication for a resident diagnosed with COVID-19, as per the physician's orders. The resident, who was admitted to the facility and later tested positive for COVID-19, was prescribed Molnupiravir, an antiviral medication, to be administered twice daily. However, the Medication Administration Record indicated that the medication was not given for several days, with staff notes citing reasons such as the medication not being available and pending delivery from the pharmacy. Additionally, it was noted that the pharmacy required approval from the Director of Nursing (DON) to bill the facility for the medication, which was not obtained in a timely manner. The lack of communication and follow-through resulted in the resident not receiving the prescribed antiviral treatment. The Licensed Practical Nurse (LPN) involved did not inform the physician that the medication had not been administered, contrary to the physician's expectations. This oversight could have led to the staff and physician being unaware of changes in the resident's condition, potentially worsening the resident's health. The deficiency highlights a breakdown in the facility's medication management and communication processes, impacting the quality of care provided to the resident.
Failure to Obtain and Implement Wound Care Orders
Penalty
Summary
The facility failed to ensure that wound care orders were obtained and implemented for a resident with pressure ulcers. Upon admission, the resident was noted to have a Stage II pressure injury to the sacrum. However, there were no wound care orders in place from January 24 to January 26, 2025. It was not until January 27, 2025, that the facility obtained and implemented wound care orders, which included cleansing the site with normal saline, applying calcium alginate and MediHoney, and covering with a foam dressing. The delay in obtaining wound care orders was due to the nursing staff not consulting with the facility provider until January 27, 2025. An interview with an LPN revealed that the nursing staff responsible for the admission should have obtained the necessary orders if none were present. Consequently, wound care for the resident was not initiated until January 27, 2025, despite the presence of a pressure ulcer noted upon admission.
Inadequate Competency in Suprapubic Catheter Change
Penalty
Summary
The facility failed to ensure that nursing staff demonstrated competency in changing a suprapubic catheter, which led to a deficiency in care for a resident. The Assistant Director of Nursing (ADON) was involved in changing the suprapubic catheter of a resident who had been admitted with diagnoses including acute cystitis with hematuria and obstructive and reflux uropathy. After the catheter change, the resident experienced complications such as blood in the brief, no urine drainage, and bladder pain, which necessitated a visit to the emergency room. A CT scan revealed that the catheter balloon was inflated in the resident's prostate, leading to a diagnosis of a displaced suprapubic catheter. The ADON admitted to not remembering if she had completed a competency regarding suprapubic catheter changes, and the facility's Nurse Educator confirmed that competencies were assessed verbally without a step-by-step check-off or return demonstration. This lack of proper competency assessment and training contributed to the improper catheter change and subsequent resident complications. The deficiency highlights the facility's failure to ensure that nursing staff had the necessary skills and techniques to safely perform catheter changes, potentially resulting in inappropriate care and injury to residents.
Incomplete Medical Records for Two Residents
Penalty
Summary
The facility failed to ensure complete and accurate medical records for two residents, leading to potential negative impacts on their care. For the first resident, the medical record lacked documentation of a suprapubic catheter change, urine output, and the resident's tolerance of the procedure. The Assistant Director of Nursing (ADON) confirmed the absence of this documentation and acknowledged that staff are expected to document any procedures performed, concerns identified, and provider notifications. For the second resident, the facility's records did not document when the resident began experiencing breathing difficulties, assessments of the resident's breathing status, oxygen saturations, lung sounds, or the administration of DuoNeb treatments. The ADON confirmed that staff are expected to document all resident assessments, provider contacts, orders received, and treatments administered. The lack of documentation could hinder the ability of staff to provide appropriate care and respond to the resident's needs effectively. The report highlights the facility's failure to maintain accurate and complete medical records, which is essential for ensuring residents receive appropriate care. The absence of critical documentation regarding medical procedures and resident assessments could lead to inadequate care and response to residents' health conditions. The facility's policies require thorough documentation, but the staff did not adhere to these standards in the cases of the two residents reviewed.
Lack of Competency Evaluations for Nursing Staff
Penalty
Summary
The facility failed to ensure that licensed nurses and certified nursing assistants (CNAs) demonstrated the necessary competencies to care for residents effectively. This deficiency was identified for five staff members, including three LPNs and two CNAs, whose personnel files lacked completed competency evaluations. These evaluations are crucial for assessing an individual's knowledge and skills related to safe and competent performance. The absence of these evaluations suggests that these staff members may not have the required competencies to provide appropriate care to the residents. The Director of Nursing (DON) confirmed during an interview that the competency evaluations for the identified staff members were not completed. The DON acknowledged that these evaluations should be conducted upon hiring, before the staff begin working on the floor, and annually thereafter. The lack of completed competency evaluations for these staff members could potentially affect the care provided to all 94 residents in the facility, as identified by the Resident Matrix provided by the DON.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of the bed hold policy to residents and their representatives during hospital transfers, affecting two residents. For one resident, the family member reported that the resident was transferred to the hospital three times, but neither the resident nor the representative received a bed hold policy notification on any occasion. Record reviews confirmed that the bed hold notices lacked documentation of the number of days the bed would be held, and there was no evidence that the notifications were provided to the resident or their representative. Interviews with staff, including an LPN and the Social Services Director, revealed inconsistencies in the process of notifying residents and their families about the bed hold policy, with some staff confirming that notifications were not completed as required. For the second resident, the discharge summary indicated a hospital transfer due to hardware exposure, but the bed hold notice also lacked documentation of the number of days the bed would be held and the date the notice was provided. The Director of Nursing acknowledged that the bed hold notice should include the number of days and be documented when provided to the resident or their representative. This deficiency in communication and documentation could lead to residents and their families being unaware of the bed hold policy upon hospital transfers.
Inaccurate MDS Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for several residents, leading to potential mismanagement of their care needs. For one resident, the MDS assessment did not document the presence of a diabetic ulcer on the right heel and a wound on the right great toe, despite these conditions being noted in the resident's medical records and confirmed by the MDS Coordinator. Additionally, the resident's use of insulin, a high-risk medication, was not accurately recorded in the MDS assessment. Another resident, who was confirmed to be diabetic and receiving insulin, did not have this diagnosis or dietary needs documented in their MDS assessment. This oversight was acknowledged by both the LPN and the Director of Nursing, who confirmed that the resident's current diagnosis should have been included to ensure appropriate care. Similarly, a third resident's MDS assessment failed to reflect their ongoing treatment for constipation and the use of an anticoagulant, both of which are critical to their care management. Further deficiencies were noted in the documentation of dental pain for a resident who had been receiving pain medication for broken teeth, yet this was not recorded in their MDS assessment. Additionally, another resident undergoing bladder training with a Foley catheter had no documentation of this trial in their MDS assessment, despite staff records indicating the procedure was carried out. These inaccuracies in the MDS assessments could lead to inadequate care and treatment for the residents involved.
Deficient Care Plans for Residents
Penalty
Summary
The facility failed to develop accurate, person-centered comprehensive care plans for two residents, which could result in staff being unaware of the residents' current and actual needs. For one resident, the care plan did not document the diagnosis of hypertensive heart disease with heart failure, nor did it include the use of the high-risk medication furosemide, despite these being noted in the resident's medical records and confirmed by the MDS Coordinator. This oversight was identified during a review of the resident's admission record, physician's orders, and the Quarterly Minimum Data Set. For another resident, the care plan failed to document the diagnosis of urinary retention and the presence of a Foley catheter, which were noted in the resident's admission record, progress notes, and physician orders. The MDS Coordinator confirmed that the care plan should have included these details. The lack of documentation in the care plans for both residents indicates a deficiency in ensuring that all relevant medical conditions and treatments are accurately reflected, potentially impacting the quality of care provided.
Deficiencies in Care Plan Reviews and Revisions
Penalty
Summary
The facility failed to ensure timely and accurate care plan reviews and revisions for six residents. For one resident, the facility did not conduct an Interdisciplinary Team Meeting within seven days after completing the Admission Minimum Data Set assessment. This oversight was confirmed through interviews and record reviews, indicating a lack of adherence to required timelines for care plan development. Additionally, the care plans for five other residents were not updated to reflect current medical conditions and treatments. One resident's care plan did not include their diagnosis of depression or the prescribed antidepressant and antipsychotic medications. Another resident's care plan failed to document their refusal of enteral feeding, which was confirmed by the Director of Nursing. Similarly, a resident who smoked was not documented as such in their care plan, nor were any safety interventions noted, despite the resident smoking unsupervised. Further deficiencies were noted in the care plans of residents with specific needs. One resident's care plan inaccurately stated they were continent, despite evidence of occasional incontinence. Another resident's care plan was not revised after an incident of smoking in their room while using oxygen, and it did not reflect the facility's new smoking policies and safety measures. These omissions were confirmed through interviews with staff, including the MDS Coordinator and the Director of Nursing, highlighting a systemic issue in maintaining up-to-date care plans.
Failure to Administer Diabetes Management Orders
Penalty
Summary
The facility failed to provide services that meet professional standards of practice for a resident with diabetes, as evidenced by the failure to obtain and administer a Dexcom continuous glucose monitoring system and Trulicity injections as ordered by the physician. The resident reported not having the Dexcom device for two months, resulting in the need for fingerstick glucose checks four times a day. The physician's orders for the Dexcom sensor and weekly Trulicity injections were not followed, with multiple instances of non-administration documented in the medication administration records (MAR) from July to October 2024. The progress notes indicated that the Dexcom was consistently unavailable, with documentation of communication with the pharmacy regarding insurance approval and supply issues, but no further follow-up or communication with the physician was recorded after early August. Similarly, Trulicity was repeatedly marked as unavailable, with no documentation of attempts to notify the physician about the missed doses. The Director of Nursing confirmed that staff did not document any attempts to notify the physician about the unavailability of the Dexcom and missed Trulicity doses, which was against the facility's expectations.
Failure to Resume Diabetes Management Post-Hospice
Penalty
Summary
The facility failed to provide quality care for a resident with diabetes by not checking blood glucose levels and administering diabetic medications. The resident was initially referred to hospice, and during this period, their insulin and Metformin prescriptions were discontinued. However, after the resident's hospice services were revoked, the facility did not resume the necessary diabetes management, including blood glucose monitoring and insulin administration, from the time hospice was revoked until several months later. The resident's medical records showed no documentation of blood glucose levels being checked from the time they were discharged from hospice until a significant change in condition was noted, with a dangerously high blood glucose level of 480. Despite the physician's recommendation for insulin administration, the facility did not have a clear process to reinstate diabetes management after the resident's hospice care was revoked. Interviews with facility staff confirmed the oversight in resuming diabetes treatment and monitoring.
Failure to Provide Routine Medications for New Admission
Penalty
Summary
The facility failed to ensure pharmaceutical services were adequately provided for a resident, identified as R #251, who was a new admission. The resident did not receive routine medications as prescribed, including pantoprazole, iron, and atorvastatin, due to the medications not being available. Observations during a medication pass revealed that the LPN did not administer medications to the resident because they were on order from the pharmacy. The resident's medication administration record (MAR) showed multiple instances where medications were marked as not administered, with notes indicating they were on order. Interviews with staff, including a CMA and the Director of Nursing (DON), confirmed that the resident's medications were still on order from the pharmacy, which often delivered partial fills. The progress notes for October and November 2024 documented that the medications were on order, but there were instances where the reason for non-administration was not documented. The DON acknowledged that the facility had issues with receiving medications from the contract pharmacy, leading to missed doses for the new admission.
Failure to Ensure Medically Necessary Use of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents did not receive psychotropic medications unless medically necessary, affecting three out of five residents reviewed. For one resident, the facility did not carry out a gradual dose reduction (GDR) for sertraline, an antidepressant, despite the resident showing no signs of depression and consistently participating in activities with a positive demeanor. The medical record lacked documentation of the clinical rationale for continuing the medication at the current dose. Another resident was prescribed olanzapine, an antipsychotic, for major depressive disorder without an appropriate psychiatric diagnosis to justify its use. The MDS Coordinator and the Director of Nursing confirmed that the resident did not have a psychiatric diagnosis warranting the use of an antipsychotic, indicating a failure to ensure the medication was prescribed for a specific psychiatric condition. A third resident was taking duloxetine for depression, but the facility did not document a clinical rationale for maintaining the current dose despite a recommendation for GDR. The resident's progress notes indicated an absence of depressive symptoms for a significant period, with only mild depression reported later. The lack of documentation and evaluation of the necessity of the medication contributed to the deficiency.
Failure to Provide Necessary Dental Services
Penalty
Summary
The facility failed to ensure that residents received necessary dental services, affecting four residents. One resident had been at the facility for over a year without any dental visits, despite the power of attorney's request for regular appointments and teeth cleaning. Another resident had not been to the dentist since a checkup over a year ago, despite having a dental infection treated with antibiotics and a referral for dental follow-up. A third resident was waiting for a follow-up appointment for a tooth extraction after being referred to an oral surgeon for a fractured tooth with an abscess. The health information specialist confirmed that these residents had not received the necessary dental care. Additionally, a fourth resident reported broken teeth and ongoing tooth pain, receiving acetaminophen for pain relief on multiple occasions. Although an appointment was scheduled, it was canceled due to a conflict with a family visit, and the resident was not informed of a rescheduled appointment. The Director of Nursing confirmed that the process to address the resident's dental pain was not followed, and it was unclear if the provider had referred the resident to a dentist or notified anyone to schedule an appointment.
Improper Food Storage Conditions in Facility Refrigerator
Penalty
Summary
The facility failed to store and serve food under sanitary conditions according to professional standards of food service safety, potentially affecting all 40 residents on the north unit. During an observation of the nourishment room refrigerator by the nurses' station, it was found that the refrigerator thermometer read 48 degrees Fahrenheit, which is above the required range of 36-46 degrees Fahrenheit. Additionally, there was condensation on the back wall inside the refrigerator, indicating improper storage conditions. A review of the refrigerator temperature log revealed that the temperatures were not recorded for November 2024, and the last recorded temperature was on 10/31/24. Interviews with the ADON and DON confirmed that the night shift nurses are expected to check and record the refrigerator temperature every evening, but this was not done after 10/31/24. The DON also confirmed that staff are expected to address any temperature discrepancies immediately, which did not occur in this instance.
Deficient Call Light System Functionality
Penalty
Summary
The facility failed to ensure that the call light system was functioning properly for rooms 133 to 152 on the South Unit. Multiple residents reported that their call lights did not work consistently, with some stating that the issue occurred frequently and had been reported to staff. One resident mentioned that if a call light was unplugged, it affected the functionality of other call lights on the unit, particularly at night, making it difficult for residents to call for help. Observations confirmed that when a call light was unplugged in certain rooms, it caused the call lights in other rooms to stop working. The Maintenance Director and ADON #1 verified these findings during interviews, acknowledging that the call lights for rooms 133 to 145 and 146 to 152 did not function when specific call lights were unplugged. This deficiency in the call light system could potentially prevent residents from notifying staff when they need assistance.
Failure to Complete Effective Communication Training
Penalty
Summary
The facility failed to ensure that the nursing staff completed the mandatory Effective Communication training. This deficiency was identified for five staff members, including four LPNs and one CNA, who were randomly sampled for staffing. A review of their online training transcripts revealed that none of these staff members had completed the required training. During an interview, the Director of Nursing (DON) confirmed that the Effective Communication Training had not been completed by these staff members. This oversight could likely result in staff being unable to effectively inform residents of their total health status and provide notice of rights and services.
Failure to Provide Required Transfer Notifications
Penalty
Summary
The facility failed to provide timely written notification to a resident and their representative regarding hospital transfers, as required by regulations. Specifically, the facility did not provide written transfer notices to the resident or their representative for three hospital transfers, including one on 10/27/24. The transfer notices lacked essential information such as the contact details for the Office of the State Long-Term Care Ombudsman and a statement of the resident's appeal rights. Additionally, there was no documentation that a copy of the transfer notice was sent to the Ombudsman. Interviews with staff, including an LPN, the Social Services Director, and the DON, revealed that the facility's practice did not align with regulatory requirements. Staff confirmed that transfer notices were not given to residents or their representatives and did not include necessary information for contacting the Ombudsman or appealing a transfer. The Social Services Director also confirmed that while a weekly report of transfers was sent to the Ombudsman, individual transfer notices were not. This lack of compliance with notification requirements was consistent across multiple instances of resident transfers.
Delayed Completion of Discharge MDS Assessments
Penalty
Summary
The facility failed to ensure the timely completion of comprehensive Minimum Data Set (MDS) assessments for two residents, which is a federally mandated requirement. For one resident, the medical record indicated a discharge date, but the Discharge MDS assessment was not completed until several days later. Similarly, another resident's Discharge MDS assessment was also delayed, being completed after the discharge date. During an interview, the MDS Coordinator confirmed that the Discharge MDS assessments for both residents were not completed upon their discharge, as required.
Failure to Conduct Smoking Evaluations for Resident Safety
Penalty
Summary
The facility failed to ensure the safety of residents who smoke by not completing necessary smoking evaluations. Resident #46 was admitted to the facility and initially stated he would not smoke during his stay. However, after his family brought him smoking supplies, he began smoking without supervision. Despite the change in his smoking status, the nursing staff did not conduct a new smoking evaluation to assess his ability to smoke safely, as confirmed by the Activities Director, MDS Coordinator, and the Director of Nursing (DON). Resident #64 was found smoking in his room while using oxygen, which posed a significant safety risk. Although his initial smoking evaluation indicated he could smoke independently, the facility did not conduct a new evaluation after this incident. The DON considered the incident a behavior and reeducated the resident on smoking safety, but did not require a reevaluation of his smoking safety, contradicting the expectation that staff should have completed another evaluation after the incident.
Deficient Urinary Catheter Care in LTC Facility
Penalty
Summary
The facility failed to provide appropriate care for two residents with indwelling Foley catheters, leading to deficiencies in urinary catheter care. One resident, who had completed bladder training, had her Foley catheter removed but was not assessed for urinary retention for 11 hours post-removal. This lack of monitoring resulted in the resident experiencing pain and being sent to the hospital, where she was diagnosed with urinary retention, constipation, and a urinary tract infection. The facility's records did not document any assessment for urinary retention during the critical period after the catheter removal. Another resident had a Foley catheter in place for about three months, despite having completed bladder training and having an order for the catheter's removal. The resident expressed a desire to have the catheter removed, but it remained in place without a documented physician's order. The facility's records lacked documentation of the catheter's removal or any assessment for urinary retention, contradicting the staff's statements about the procedure being completed. Interviews with staff, including an LPN and the DON, revealed inconsistencies in the documentation and execution of catheter care procedures. The facility's policy required documentation of catheter removal and assessment data, which was not adhered to in these cases. The failure to follow proper procedures and documentation protocols for catheter care exposed the residents to potential health risks, including infections and urinary retention.
Deficiency in CNA Annual Training and Performance Evaluation
Penalty
Summary
The facility failed to include performance reviews as part of the required 12 hours of annual training for one of the two certified nurse aides (CNAs) sampled. Specifically, CNA #9, who was hired on January 16, 2018, did not have any performance evaluations included in their training records. This omission was confirmed by the Director of Nursing (DON) on November 6, 2024, who acknowledged that CNA #9 had been employed at the facility for over a year without a completed performance evaluation, and the annual training was not conducted based on this evaluation.
Failure to Timely Report Injuries of Unknown Source
Penalty
Summary
The facility failed to report injuries of unknown source to the State Agency within the required two-hour timeframe for three residents. Resident #8 experienced an incident on 06/07/24 where a Hoyer lift tipped over during a transfer, resulting in head injuries. The incident was documented in a progress note, and the resident was sent to the emergency room for evaluation. However, the incident was not reported to the State Agency until the following day, 06/08/24. Resident #9 was found with abrasions and bruises on 06/08/24 by a family member, who informed the nursing staff. Despite this, the incident was not reported to the State Agency until 06/10/24. Similarly, Resident #11 experienced a Hoyer lift tipping incident on 06/17/24, but it was not reported until 06/21/24. The facility's administrator acknowledged that these incidents should have been reported within two hours, as per the facility's expectations.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of abuse involving a resident, identified as R #9, out of three residents reviewed for abuse and neglect. The incident was reported by the resident's daughter and son-in-law. The facility's 5-day follow-up report indicated that CNA #11, who provided care to the resident at the time of the alleged incident, was sent home pending investigation. However, the report lacked documentation of interviews with CNA #11, the resident's family, or other CNAs involved in the incident. Additionally, the report did not explain how the facility determined that the allegations were unsubstantiated. During an interview, the Director of Nursing (DON) stated that she was not working at the time of the incident but expected that the involved staff member would be removed, interviewed, and suspended pending investigation, and that all parties with knowledge of the incident would be interviewed.
Failure to Assess Bed Rail Entrapment Risk
Penalty
Summary
The facility failed to assess a resident for the risk of entrapment from bed rails, which is a deficiency that could lead to serious injury. The resident was admitted to the facility and had a physician's order for a half bed rail on the left side based on a physical therapist's recommendation. However, the care plan indicated the use of bed rails for mobility, positioning, and safety without a completed risk assessment. An observation revealed that the resident's bed had two bilateral half side rails instead of one. The Director of Nursing confirmed that the bed rails were added to the care plan without a risk assessment. Additionally, the MDS specialist stated that the bed rails were not documented on the MDS assessment as they were not considered a restraint.
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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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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