Casa Arena Healthcare Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Alamogordo, New Mexico.
- Location
- 205 Moonglow Avenue, Alamogordo, New Mexico 88310
- CMS Provider Number
- 325043
- Inspections on file
- 26
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Casa Arena Healthcare Llc during CMS and state inspections, most recent first.
A resident with a gastrostomy tube and orders for Jevity feedings, water flushes, residual checks, and PEG-tube medications had multiple instances where bolus and continuous enteral feedings, water flushes, and residual volume checks were not documented on the MAR, even though PEG-tube medications were recorded as given. LPNs reported that they followed all enteral feeding and residual check orders, but these actions were not reflected in the medical record, and the DON confirmed that numerous feedings, flushes, and residual checks lacked documentation, resulting in incomplete and inaccurate medical records.
A resident with a cognitive communication deficit reported through the grievance process that $44 was missing from her purse, and this concern was documented in the facility’s grievance log and grievance form. The resident later reiterated in an interview that the money was missing and that she had informed a business office staff member, though she could not recall specific details. Review of the State Agency Incident Management System showed that the allegation was never reported. The Administrator acknowledged not reporting the missing money, explaining that she only reports such incidents when a resident explicitly alleges theft or reports seeing someone go through their belongings.
A resident with cognitive communication deficits reported missing $44 from her purse, which she intended to use for clothing, and a grievance was documented. Staff noted that the resident later denied missing money and suggested she might have given it to her children, and records showed she had recently withdrawn $100 and frequently purchased items from vending machines. However, the Administrator and Social Services staff did not identify which staff first received the report, did not determine how long the money had been missing, and did not interview nursing, CNA, or activities staff, review cameras, contact the resident’s family, or notify law enforcement. The resident’s daughter later confirmed she had not received any money and had not been informed by facility staff about the missing funds, indicating the allegation of misappropriation was not thoroughly investigated.
A resident with dementia and behavioral disturbances reported that a male staff member attempted to kiss her forehead, after which it was determined that only female staff should provide her care. Although this change in care preference was documented in a complaint narrative, staff did not revise the resident’s care plan to include the requirement that only female staff provide care, and the DON confirmed that this intervention was not added to the care plan.
A resident with a skin impairment on the coccyx did not have wound care assessments or treatments documented in the medical record. Although the wound care nurse assessed and treated the area, she confirmed that she did not record her findings or interventions, and the DON verified that this documentation was missing.
A resident's bathroom was found to have a strong urine odor, wet spots, and visible staining and buildup around the toilet. An LPN confirmed the unsanitary conditions, and the administrator stated that bathrooms are expected to be cleaned and staff made aware of such issues.
A resident's comprehensive MDS assessment was not completed by facility staff within the required 14-day period following admission. This delay was confirmed through record review and interviews with the administrator and director of clinical services.
A resident was admitted to hospice care, but staff did not complete and transmit the required Significant Change in Condition (SCIC) MDS assessment within 14 days of this change. This was confirmed by facility leadership during an interview.
The facility did not post complete daily nurse staffing data at the front entrance, omitting the total number of nursing staff scheduled and the actual hours worked for each shift. The Front Desk Clerk, responsible for posting this information, confirmed the omission, and the Administrator stated that the data should be posted by 10:00 AM each day.
The facility did not provide enough nursing staff to meet resident needs, resulting in delays in care such as assistance with meals, hygiene, and toileting. Multiple residents and staff reported long wait times, rushed care, and the use of non-clinical staff for direct resident services. Staffing records confirmed that only one CNA and one nurse were typically assigned per hall, which was insufficient for the level of care required.
The facility did not submit complete and accurate direct care staffing data to the federal agency for a six-month period, as contracted staff were not included in the PBJ report due to differences in timekeeping practices. This resulted in incomplete staffing information for all residents.
Staff did not ensure a homelike environment by leaving a deceased resident's belongings in large trash bags in a common area and failing to address damaged flooring and stained ceilings in a resident's room. These actions resulted in a cluttered and uncomfortable setting for residents.
Several residents received psychotropic medications without required gradual dose reductions or proper documentation for PRN orders. In multiple cases, GDRs were not attempted and physician rationales were missing from records, while PRN psychotropic medications were administered without clear documentation of duration or justification for continued use.
The facility did not update care plans for two residents to reflect changes in their medical status and physician orders. One resident's care plan continued to list wound care, antibiotic therapy, and isolation precautions after these interventions were discontinued, while another resident's care plan did not include required compression stocking use for pitting edema. The DON confirmed that the care plans should have been revised to match current orders and resident needs.
A resident with dementia, depression, and behavioral disturbances was referred for psychiatric evaluation and ongoing psychotherapy, but only received an initial assessment with no follow-up sessions. The care plan and physician orders called for regular behavioral health interventions, yet staff did not ensure continued psychiatric services, resulting in unmet behavioral health needs.
A resident with dementia did not receive person-centered care or individualized, non-pharmacological interventions, as the care plan lacked documentation of the dementia diagnosis and related care strategies. Despite staff awareness of dementia care needs and some engagement in activities like coloring, structured memory care interventions were not consistently provided, and the resident exhibited combative behaviors and refused care.
The facility did not ensure that physician responses to consultant pharmacist recommendations for medication regimen reviews were documented or implemented for three residents. In each case, the pharmacist recommended gradual dose reductions or medication changes, but the physician either did not respond or failed to provide a clinical rationale for declining the recommendations, resulting in continued administration of the medications as originally ordered.
Staff did not label or date beverages and desserts stored in the kitchen and walk-in refrigerators, as confirmed by the Dietary Manager, resulting in unsanitary food storage conditions for all residents receiving meals from the kitchen.
Two residents were not treated with dignity: one had a Foley catheter bag left uncovered without a privacy bag, and another, who had significant physical limitations, was not assisted with meal setup by a staff member who delivered the tray and left abruptly without ensuring the meal was accessible or containers were opened.
Staff did not notify the provider when two residents either refused or did not fully receive prescribed medications and treatments, including lactulose, Albuterol, and compression stockings for edema. Documentation showed the refusals and partial administration, but there was no record of provider notification or communication, as confirmed by interviews with nursing staff and the DON.
Two residents had inaccurate MDS assessments: one with documented chronic heart failure diagnoses that were omitted from the MDS, and another who was edentulous but whose MDS did not reflect the absence of natural teeth, despite supporting care plan and dental records.
A resident admitted with a foley catheter did not have the catheter or its care documented in the baseline care plan within 48 hours of admission. This was confirmed through record review and interviews, including with the resident and the Administrator, who acknowledged the omission.
Staff did not ensure that a fall mat was in place for a resident with a history of falls as required by the care plan, and another resident's care plan did not include their dementia diagnosis or interventions. The DON and other staff confirmed these omissions during interviews.
A resident with pitting edema did not receive compression stockings as ordered by the physician. The resident reported infrequent application of the stockings, and observation confirmed swelling in her legs. Review of records showed no documentation of the stockings being applied, and both an LPN and the DON confirmed the order was not followed and the resident was not wearing the stockings.
Two residents who required assistance with activities of daily living did not receive appropriate nail care. One resident with diabetes and neuropathy had long, painful toenails without a podiatry referral, while another resident needing substantial ADL support had long, unkempt fingernails. Staff interviews confirmed that nail care was not provided as expected.
A treatment cart containing medications was found unlocked in a central hallway, as confirmed by an LPN and the DON. This unsecured cart affected all residents outside the secure unit, as identified by the facility census.
Two residents had incomplete or inaccurate medical records, including a mismatch between a physician's order and medication packaging for an antipsychotic, and missing heart failure diagnoses in the medical record despite documentation elsewhere. These discrepancies were confirmed by staff interviews and record reviews.
Staff did not consistently implement enhanced barrier precautions (EBP) for two residents requiring them: one with a feeding tube did not have proper gown use by an LPN during medication administration, and another with multiple wounds lacked EBP signage and room-based PPE, with staff only using PPE during wound care. Facility leadership confirmed that EBP protocols were not fully followed for these residents.
The facility failed to report abuse incidents to the State Agency within the required two-hour timeframe. In one case, a resident used a wheelchair to push another onto his bed, and in another, a resident hit another while passing by. Additionally, a resident grabbed another's breast. These incidents were reported late, contrary to the facility's expectations for timely reporting.
The facility failed to meet professional standards by not obtaining medication orders for a resident returning from the ER and not entering several medication orders for another resident upon admission. This resulted in missed administration of prescribed medications, including antibiotics and other essential treatments, as confirmed by staff interviews and record reviews.
A facility failed to finalize a baseline care plan within 48 hours for a resident with chronic pain and intervertebral disc disorder. The plan lacked specific approaches for pain management, and the DON confirmed the oversight, which could lead to inadequate care.
A resident did not receive prescribed pregabalin for nerve pain on multiple occasions due to unavailability in the Pyxis system, and there was no documentation of attempts to contact the pharmacy or physician. An LPN could not recall the reason for non-administration, and the DON confirmed the oversight.
The facility failed to develop accurate care plans for two residents. One resident's care plan inaccurately included a schizophrenia diagnosis not supported by their records, while another resident's care plan omitted their need for substantial assistance in daily activities. These deficiencies could lead to staff being unaware of the residents' actual needs.
A resident at high risk for falls experienced a fall in the bathroom, but the care plan was not updated to include this incident or any interventions to prevent future falls. The MDS Coordinator confirmed the oversight, noting that the care plan should have been revised by the DON or MDS Coordinator.
A resident with chronic kidney disease and elevated potassium levels was not properly monitored or treated due to the facility's failure to notify the provider about abnormal lab results and drug interactions. The resident experienced nausea and vomiting, symptoms of hyperkalemia, but the staff did not notify the provider. The resident was found unresponsive and pronounced deceased.
The facility failed to safeguard resident medical record information for all 101 residents. A computer on the medication cart was observed to be open and unlocked, making resident information visible. An LPN and the DON confirmed that the computer should have been locked to prevent unauthorized access.
The facility failed to maintain a grievance policy that retained records of grievance results for up to three years. The Social Services Director admitted to discarding grievances at the end of each calendar year, confirming that no grievances from the previous year were available. This failure has the potential to affect all 101 residents in the facility.
The facility failed to maintain a clean kitchen environment and did not hold puree cold foods at the required temperature of 41 degrees Fahrenheit or lower. Observations revealed a dirty ice machine, food crumbs and oil stains on the fryer, and brownish sticky substances on the floor. A resident was served puree foods at temperatures significantly above the required 41 degrees Fahrenheit.
The facility failed to ensure that nursing staff completed mandatory QAPI training. Five staff members, including two ADONs, two CNAs, and one LPN, did not have documentation of completed training. The Administrator confirmed the lack of formal training despite staff awareness of the policy.
The facility failed to provide reasonable accommodations for two residents. One resident's call light was not within reach, confirmed by both the resident and a CNA. Another resident's bedside table with a pitcher was across the room and not within reach, confirmed by the ADON.
The facility failed to notify the provider about a resident's nausea and vomiting, which were symptoms of a potential drug interaction between Bactrim and spironolactone. The Medical Director was not informed, which could have led to a delay in necessary treatment.
The facility failed to provide a home-like environment for all 16 residents in the secure unit by leaving meals and drinks on plastic serving trays during the lunch meal. CNA #21 and the Activities Assistant placed the serving trays with meals in front of each resident in the dining room and in the resident rooms. The DON confirmed that plates should be removed from the serving trays and placed in front of residents to eat, but staff have been leaving the serving trays with the meals on them.
The facility failed to report an allegation of abuse within the required two-hour timeframe to the SA. A resident reported being assaulted by another resident over a water mug, resulting in scratch marks on the face. The incident occurred at 1:00 pm, but the report was not sent to the SA until the following morning, outside the mandated reporting window. The Administrator confirmed the delay in reporting.
The facility failed to provide written transfer notices to a resident and their representative during three hospital transfers. The Social Services Director and Director of Nursing confirmed that the required notices, including appeal information and State Ombudsman contact details, were not given as per protocol.
The facility failed to provide written bed hold notices to residents and their representatives during hospital transfers. This deficiency was identified for three residents who were transferred multiple times without receiving the required notices, as confirmed by the BOM and DON.
A facility failed to complete and transmit a Significant Change MDS assessment within 14 days after a resident was admitted to hospice. The assessment, opened on 02/26/24, was not signed off by the RN until 04/03/24, as confirmed by the MDS and Regional MDS Coordinators.
The facility failed to complete quarterly MDS assessments on time for three residents, with assessments finalized 14 days after the ARD. The Regional MDS Coordinator confirmed the delay.
The facility failed to develop timely and accurate baseline care plans for two residents, with one plan initiated four days after admission and another missing critical psychotropic medication information. This could result in inadequate care and services.
The facility failed to develop comprehensive care plans for two residents, omitting critical information about one resident's dentures and glaucoma treatment, and another resident's acute kidney failure diagnosis. These omissions were confirmed by the MDS Coordinator and MDS Nurse.
The facility failed to update care plans for four residents, including changes in unit placement, seizure diagnosis, medication orders, wound care, and UTI diagnosis. This was confirmed through record reviews, observations, and staff interviews.
Failure to Accurately Document Enteral Feedings and Tube Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records for a resident receiving enteral nutrition via a gastrostomy tube. The resident had diagnoses including dysphagia in the oropharyngeal phase and a gastrostomy, and had physician orders for bolus and continuous Jevity tube feedings, scheduled water flushes, residual volume checks, and multiple medications to be given via PEG-tube. Record review of the December MAR showed that staff did not document administration of multiple ordered bolus feedings on numerous specified dates and times. In January, the MAR showed that staff did not document administration of ordered continuous Jevity feedings and scheduled water every six hours on two mornings, despite documenting administration of PEG-tube medications during those same shifts. Further record review showed that staff also failed to document required enteral tube flushes and residual volume checks on the same dates when medications were recorded as given via the PEG-tube. Specifically, there was no documentation that the tube was flushed with 30 mL of water before and after medication administration and 5–10 mL between medications, and no documentation that residual volumes were checked or what the residual amounts were. During interviews, two LPNs stated they administered the resident’s enteral feedings as ordered, followed all physician orders, and checked residual volumes as required, but these actions were not reflected in the medical record. The DON confirmed that staff did not document multiple bolus feedings in December, did not document continuous feedings, residual checks, or water flushes on the identified January mornings, and stated that staff were expected to follow all orders and document in the medical record.
Failure to Report Allegation of Misappropriation of Resident Money to State Agency
Penalty
Summary
The facility failed to timely report an allegation of misappropriation of resident property to the State Agency within 24 hours as required. A resident with a diagnosis of cognitive communication deficit was admitted on an unspecified date and later reported missing money. The facility’s grievance log for March 2026 showed that on 03/03/26 the resident reported $44 missing. A grievance form dated the same day documented the resident’s report of missing $44, and an entry on 03/05/26 indicated staff documented that the resident later stated she was not missing any money. Review of the State Agency Incident Management System showed that staff did not report this allegation of missing money to the State Agency. During an interview on 03/11/26, the resident stated she was missing $44 from her purse, that the money went missing about one to two weeks before the interview, and that she had informed a staff member in the business office, though she was unsure of the staff member’s name, title, or the date she reported it. In a subsequent interview on 03/12/26, the Administrator confirmed that the grievance about the missing $44 was not reported to the State Agency. The Administrator stated she only reports missing money or property if the resident alleges theft or reports seeing someone going through their belongings, and in this case the resident had not stated that she thought someone stole the money. As a result, the allegation of misappropriation of resident property was not reported to the State Agency within 24 hours of the allegation.
Failure to Thoroughly Investigate Allegation of Missing Resident Funds
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of misappropriation of a resident’s money. The resident had a diagnosis of cognitive communication deficit and reported missing $44, which she stated had been in a pink bag in her purse and which she intended to use to buy pants. The grievance log documented that the resident reported missing money, and a grievance form was completed. The Social Services Clerk assisted the resident in searching her drawers and documented that the resident later stated she was not missing money and might have given it to her children. The Administrator’s investigation note reflected that the resident told her she was not missing money, that she gives money to her children, and that she buys items from vending machines. The Business Office Manager confirmed the resident had withdrawn $100 several days earlier and that the resident frequently buys snacks from vending machines and had planned for her daughter to buy clothes with the withdrawn funds. Despite these reports, the facility did not conduct a comprehensive investigation into the allegation of missing money. The Social Services Clerk did not contact the resident’s children or notify law enforcement. The Administrator did not determine which staff member initially received the report of missing money, did not clarify how long the money had been missing, and did not interview nursing staff, CNAs, or activities staff to determine whether anyone had information about the missing funds or whether the resident had given money to staff to purchase items. The Administrator also did not review camera footage. The resident’s daughter later reported that the resident had called her about missing $44, that she had not received any money from the resident, and that facility staff had not notified her of the missing money or asked if the resident had given her money. After the resident told the Administrator and Social Services Clerk that she was not missing money, no further investigative steps were taken, resulting in an incomplete investigation of the misappropriation allegation.
Failure to Update Care Plan With Resident’s Gender-Specific Care Preference
Penalty
Summary
The facility failed to revise a resident’s care plan to reflect updated care preferences after a reported incident involving staff-resident interaction. The resident, admitted with unspecified dementia of unspecified severity with behavioral disturbances, reported that a male staff member attempted to kiss her forehead. Following this report, the facility documented in a 5‑day complaint narrative that only female staff were to provide care to this resident. However, review of the resident’s care plan revision dated 03/03/26 showed that this intervention—limiting care provision to female staff—was not added to the care plan. During interview, the DON confirmed that the resident’s care plan had not been revised to include this intervention, despite the change in the resident’s care preferences.
Failure to Document Wound Care Assessments and Treatments
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for one resident with a skin impairment. Record review showed that the resident had an open area on the coccyx, and the medical provider was notified. The wound care nurse (WCN) was assigned to treat the area, and the plan was to follow up with daily assessments and treatment. However, there was no documentation by the WCN in the resident's medical record regarding her assessments or treatments of the wound. Interviews with staff confirmed the lack of documentation. The LPN stated that the WCN was treating the area, and the WCN herself acknowledged that she had not documented her assessments or treatments, despite assessing the wound and planning interventions. The Director of Nursing (DON) also confirmed that the WCN should have documented these observations, assessments, and treatments in the resident's medical record, but this was not done.
Failure to Maintain Clean and Homelike Resident Bathroom
Penalty
Summary
Staff failed to maintain a clean and comfortable environment for one resident when the bathroom used by the resident was observed to have a strong urine odor, a wet spot on the floor around the toilet, and visible staining and dark buildup around the toilet seal. During observation, these unsanitary conditions were confirmed by an LPN, who acknowledged the presence of urine and odor but did not believe the toilet was leaking. The administrator later stated that the expectation is for bathrooms to be cleaned and for staff to be made aware of such issues. These findings indicate that the facility did not ensure the resident's right to a safe, clean, and homelike environment, as required.
Delayed Completion of Admission MDS Assessment
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set (MDS) assessment within 14 calendar days of admission for one resident. Record review showed that the resident was admitted on 04/09/25, but the admission MDS assessment was not completed by the registered nurse until 04/26/25, exceeding the required timeframe. During an interview, both the administrator and the director of clinical services confirmed that the assessment was not completed within the mandated period. This deficiency was identified through record review and staff interviews.
Failure to Complete Timely SCIC MDS Assessment After Hospice Admission
Penalty
Summary
The facility failed to complete and transmit a Significant Change in Condition (SCIC) Minimum Data Set (MDS) assessment within 14 days after determining a significant change in a resident's physical or mental condition. Specifically, a review of the medical record showed that a resident was admitted to hospice care as indicated by physician's orders. However, the required SCIC MDS assessment was not completed upon this admission to hospice. During an interview, the administrator and director of clinical services confirmed that staff did not complete the SCIC MDS assessment within the required timeframe.
Failure to Post Complete Daily Nurse Staffing Data
Penalty
Summary
The facility failed to post daily nurse staffing data in a manner accessible to the public and all 102 residents, as required. Observation on 07/10/25 revealed that the nurse staffing data posted at the front entrance did not include the total number of actual nursing staff scheduled or the actual hours worked by staff for the day. During an interview, the Front Desk Clerk, who is responsible for posting this information, confirmed that the required data was not posted on 07/10/25 and acknowledged that the posting should include the total number of staff scheduled for each shift and the number of hours each nursing staff member is scheduled to work. The Administrator also stated that her expectation is for the nurse staffing data to be posted at the front entrance by 10:00 AM daily.
Failure to Maintain Adequate Staffing Levels
Penalty
Summary
The facility failed to maintain adequate staffing levels to meet the needs of all residents, as evidenced by multiple resident and staff interviews, observations, and review of staffing records. Several residents and their family members reported delays in receiving care, such as assistance with meals, hygiene, and toileting. One resident's daughter stated she had to come in the mornings to help her mother because staff were unable to provide timely care, including giving dentures and washing hair. Other residents reported long wait times for call light responses, delayed delivery of pain medication, and cold or late meals due to insufficient staff. Observations revealed that non-clinical staff, such as the medical records coordinator, were assigned to pass meal trays, and did not provide necessary assistance with meal setup or communication. Staff interviews confirmed that there was typically only one CNA per hall, which was not sufficient to meet resident needs, especially when residents required two-person assistance for transfers or toileting. Staff reported having to rush through care, leaving residents waiting for assistance, and not having enough time to spend with each resident. Some staff also indicated that additional help was only provided when surveyors were present. Review of staffing assignments and time sheets for multiple days confirmed that the facility routinely operated with minimal staffing, often with only one CNA and one nurse per hall, and sometimes with nurses splitting coverage between halls. The DON stated that she believed staffing was adequate, but staff and residents consistently reported otherwise. The lack of sufficient staff led to delays in care, unmet resident needs, and the use of non-clinical staff for direct resident services.
Failure to Submit Complete Direct Care Staffing Data
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to the federal agency responsible for certification of long-term care facilities for the period of July 2024 through December 2024. Record review of the Payroll Based Journal (PBJ) Staffing Data Report for the third and fourth quarters of 2024 showed low weekend staffing. During an interview, the Administrator acknowledged that contracted staff were not being included in the PBJ report because they do not clock in and out at the facility, and their time is tracked by their agency instead. The Administrator indicated that this issue was being addressed with the corporate office.
Failure to Maintain Homelike Environment and Proper Storage of Resident Belongings
Penalty
Summary
Staff failed to maintain a comfortable and homelike environment for all residents outside the secure unit. Observations revealed that a deceased resident's belongings were stored in large black trash bags in the main hall, a common area shared by residents. These bags were visible upon entering the facility and contributed to a cluttered appearance. The Administrator confirmed that the bags contained the deceased resident's belongings and were left in the main hall for family pickup, without specifying how long they had been there. Additionally, in one resident's room, there was a deep indention in the floor in front of the restroom door and two large brown stains on the ceiling above the bed. The Maintenance director confirmed these issues during an interview and stated he was not previously aware of them, and there were no work orders addressing these problems. These conditions were directly observed and reported by both facility staff and the state ombudsman.
Failure to Ensure Proper Use and Documentation of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents did not receive psychotropic medications unless medically necessary, as evidenced by the lack of gradual dose reductions (GDR) and improper management of PRN (as needed) psychotropic medication orders. For two residents with diagnoses including depressive disorders and dementia, the facility did not attempt GDRs for medications such as fluoxetine, divalproex, buspirone, and sertraline, despite pharmacist recommendations. In both cases, the medical records lacked documentation from the physician providing a rationale for not attempting GDRs, and the relevant forms were either unsigned or incomplete. Additionally, two other residents received PRN psychotropic medications, such as lorazepam and Ativan, without proper documentation of the rationale for continued use beyond 14 days or an indication of the duration of the PRN order. In one case, the medication regimen review form for lorazepam was incomplete, with the anticipated duration of use left blank, even though the physician agreed with the recommendation. In another case, the medical record for Ativan did not include a documented rationale or duration for the PRN order. These deficiencies were confirmed through record reviews and interviews with the DON and Regional Nurse Consultant, who acknowledged the lack of GDR attempts, missing physician rationales, and incomplete documentation for PRN psychotropic medications. The findings indicate that the facility did not follow required protocols for the use and documentation of psychotropic medications for several residents.
Failure to Revise Care Plans with Current Resident Information
Penalty
Summary
The facility failed to ensure that care plans were revised to reflect the most current information for two residents. For one resident, physician's orders indicated changes in wound care, antibiotic therapy, and isolation precautions over several months. However, the care plan was not updated to show that the wound had healed, antibiotic therapy had ended, and isolation precautions were discontinued. Both the wound care nurse and the DON confirmed that the care plan still included outdated interventions and should have been revised when the resident's condition and treatment changed. For another resident, physician's orders required the use of compression stockings for pitting edema, specifying when they should be applied and removed. Despite these orders, the care plan did not document the use of compression stockings or related interventions. The DON acknowledged that these interventions should have been included in the care plan to ensure care was provided as ordered.
Failure to Provide Consistent Behavioral Health Services
Penalty
Summary
The facility failed to ensure that a resident with significant behavioral health concerns received necessary and consistent behavioral health care services. The resident was admitted with diagnoses including unspecified dementia with psychotic disturbance, recurrent depressive disorders, and behavioral disturbances. Physician orders indicated a referral to a psychiatric provider for evaluation and treatment, and an initial psychotherapy assessment was completed, recommending ongoing psychotherapy one to four times per month to address symptoms such as agitation, anger, anxiety, psychosis, and aggressive or sexually inappropriate behavior. The resident's care plan also identified the need for psychiatric and psychological support, with approaches including psychiatric consultation and monitoring for behavioral issues. Despite these documented needs and recommendations, the resident received only one psychotherapy visit, with no further sessions documented after the initial assessment. During an interview, the administrator confirmed that the resident was not seen for additional psychotherapy visits and was unsure why services were discontinued. This lack of follow-up and ongoing behavioral health care represents a failure to provide the necessary services as outlined in the resident's care plan and physician orders.
Failure to Provide Person-Centered Dementia Care and Services
Penalty
Summary
The facility failed to provide appropriate, person-centered treatment and services for a resident diagnosed with dementia. The resident's care plan did not include the dementia diagnosis or any related interventions, despite the resident having documented orders for dementia medications and exhibiting behaviors consistent with dementia, such as agitation, combativeness, and refusal of care. Progress notes indicated multiple incidents where the resident was physically combative, attempted to leave the facility, and refused assistance with activities and care. Staff were unable to provide medications or feed the resident due to his combative behavior, and the care plan lacked individualized, non-pharmacological approaches to address these issues. Interviews with staff revealed that while some dementia-appropriate activities, such as coloring and visiting the fish, were offered, more structured memory care activities were not consistently implemented. The Activities Director acknowledged knowledge of memory care interventions but had not regularly used them with the resident. The Director of Nursing confirmed the resident's dementia diagnosis and the need for care to support memory and health, but the documentation and care planning did not reflect this need, resulting in a lack of person-centered, dignity-maximizing care for the resident.
Failure to Review and Document Physician Response to Pharmacist Medication Recommendations
Penalty
Summary
The facility failed to ensure that consultant pharmacist recommendations regarding drug regimen reviews were reviewed and implemented by the attending physician, or that the physician provided documentation of a rationale for not following the pharmacist's recommendations. This deficiency was identified for three out of seven residents reviewed for unnecessary medications. In each case, the pharmacist had made specific recommendations, such as considering gradual dose reductions (GDR) for psychotropic medications, but there was no evidence in the medical records that the physician responded to or documented a clinical rationale for declining these recommendations. For one resident with a diagnosis of recurrent depressive disorders, the pharmacist recommended a GDR for fluoxetine (Prozac), but the physician did not implement the recommendation or document a reason for not doing so. The medication administration record showed that the resident continued to receive the medication as originally ordered, and the physician response section on the pharmacist's form was left blank. Another resident with depression, seizures, and traumatic brain injury had a recent fall, and the pharmacist noted that the resident's medications could increase fall risk, asking if the physician would like to make any changes and to provide a clinical rationale. The physician only documented that the resident was stable on the medications, without specifically addressing the pharmacist's recommendations or providing a detailed rationale. A third resident with dementia and depressive disorders had multiple psychotropic medications for which GDRs were recommended and declined, but the physician did not document any rationale in the medical record for not following the pharmacist's recommendations.
Failure to Label and Date Food Items in Kitchen Refrigerators
Penalty
Summary
Staff failed to label and date all items in the kitchen refrigerator, resulting in food not being stored under sanitary conditions for all 94 residents who consume food from the kitchen. During an observation, two trays with 10 lid-covered beverages in the refrigerator were found without dates on the lids, and three trays with covered desserts in the walk-in refrigerator also lacked dates indicating when they were prepared. The Dietary Manager confirmed in an interview that all drinks and desserts should have been labeled with the date they were prepared.
Failure to Maintain Resident Dignity During Care and Meal Service
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity in two separate instances. For one resident with a Foley catheter, staff did not use a privacy bag to conceal the urine drainage bag, as observed during a unit round. This was confirmed by both a CNA and the Director of Nursing, who stated that catheter bags should have privacy covers. In another case, a resident with muscle weakness, hemiplegia, and upper arm contracture did not receive appropriate assistance during lunch service. The medical records coordinator delivered the meal tray, did not set up the meal or assist with opening containers, and left the room abruptly after a brief exchange with the resident, who was unable to move the tray within reach. The LPN later acknowledged that the coordinator should not have treated the resident in that manner, and the administrator confirmed that staff are expected to treat residents with dignity and respect.
Failure to Notify Provider of Missed Medications and Treatment Refusals
Penalty
Summary
Facility staff failed to notify the provider when two residents either refused or did not receive their prescribed medications and treatments. For one resident with orders for lactulose and Albuterol, staff documented that the resident refused lactulose and only took one puff of Albuterol instead of the ordered two. However, there was no documentation that the provider was notified of these refusals or partial administration, as confirmed by both the LPN and RN involved, as well as the Director of Nursing. The medical record only reflected the refusal and partial dose, not the required provider notification or documentation of such communication. For another resident with a diagnosis of edema and an order for compression stockings, staff did not consistently apply the stockings as ordered and failed to document their application in the treatment administration record. Interviews revealed that the resident often refused to wear the stockings, but there was no documentation of these refusals or any notification to the provider regarding the resident's non-compliance with the order. The DON confirmed that provider notification was expected in such cases, but it was not done or documented.
Inaccurate MDS Assessments for Diagnoses and Oral Status
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two of nine residents reviewed. For one resident, documentation in the admission records, history and physical, and care plan all indicated diagnoses of chronic systolic and diastolic heart failure, as well as congestive heart failure. However, the resident's quarterly MDS assessment did not include any documentation of heart failure, despite confirmation from the DON and administrator that these diagnoses were present and should have been recorded in the MDS. For another resident, interviews and dental records confirmed the individual was edentulous, with no natural teeth, and this was also reflected in the care plan. Despite this, the annual MDS assessment did not document the absence of natural teeth or tooth fragments in Section L (Oral/Dental status). The administrator and Regional Nurse Consultant confirmed the resident's edentulous status and acknowledged the inaccuracy in the MDS documentation.
Failure to Develop Baseline Care Plan for Foley Catheter
Penalty
Summary
The facility failed to create an accurate baseline care plan within 48 hours of admission for one of three residents reviewed. Specifically, a resident who was admitted with a foley catheter for medical necessity did not have any documentation of the catheter, related interventions, or care included in their care plan dated the day of admission. This omission was confirmed through record review and interviews, including with the resident, who stated he had a catheter, and with the Administrator, who acknowledged that the catheter should have been care planned to ensure proper care.
Failure to Implement and Document Person-Centered Care Plans
Penalty
Summary
Staff failed to follow the care plan for a resident with a history of falls, muscle weakness, cognitive communication deficit, traumatic brain injury, and metabolic encephalopathy. The resident's care plan required a fall mat to be placed next to the bed due to previous falls with injury. However, during two separate observations, the resident was found in bed without a fall mat present. Interviews with a CNA and an LPN confirmed the absence of the fall mat, and the LPN acknowledged that the care plan did require it. The DON also confirmed that the fall mat should have been in place according to the care plan and that staff are expected to ensure this intervention is implemented. Another resident with a diagnosis of dementia was admitted to the facility, but the care plan did not document the dementia diagnosis or any interventions to address it. The care plan lacked information on maintaining the resident's highest practicable well-being related to dementia. The DON confirmed that the resident's dementia diagnosis and related interventions were not included in the care plan and stated that this information should be documented to provide appropriate care for memory and health maintenance.
Failure to Follow Physician Order for Compression Stockings
Penalty
Summary
Staff failed to follow a physician's order for a resident requiring compression stockings to address pitting edema. The resident reported that the stockings had only been applied a few times since admission, and observation confirmed that her legs were swollen and puffy without the stockings in place. Review of the treatment administration record for the month showed no documentation that the compression stockings were applied as ordered. During interviews, both an LPN and the Director of Nursing confirmed the lack of documentation and that the resident was not wearing the prescribed compression stockings, despite the presence of edema.
Failure to Provide Nail Care for Dependent Residents
Penalty
Summary
Staff failed to provide necessary activities of daily living (ADL) assistance for two residents in the facility. One resident, diagnosed with Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, was observed to have long toenails, with the great toe on the right foot curving and causing discomfort. The resident could not recall when her toenails were last trimmed. Interviews with staff revealed that nurses are responsible for trimming the nails of diabetic residents, and the Director of Nursing confirmed that diabetic residents should be referred to a podiatrist. However, there was no podiatry referral found in the resident's chart. Another resident, who required substantial to maximal assistance for ADL care, was observed to have long and unkempt fingernails. Staff confirmed that the resident's fingernails needed to be cut and stated that nail checks are typically performed on shower days. The Director of Nursing acknowledged that ADL care, including nail care, should be provided. These findings indicate that the facility did not ensure proper ADL assistance related to nail care for both residents.
Unlocked Treatment Cart Found in Central Hallway
Penalty
Summary
A treatment cart containing drugs and biologicals was observed to be unlocked in a central location near hall 600. At the time of observation, the cart was not secured, and this was confirmed by an LPN present at the scene. The Director of Nursing also confirmed during an interview that treatment carts and medication carts are required to be secured when staff are not present. This deficiency affected all 69 residents who do not reside in the secure unit, as identified by the facility's census list.
Incomplete and Inaccurate Medical Records for Two Residents
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for two of four residents reviewed. For one resident with a diagnosis of unspecified psychosis, the physician's order specified Abilify 15 mg, with instructions to administer 10 mg by mouth at bedtime. However, the medication blister pack was labeled for aripiprazole 10 mg, and the label did not match the physician's order. This discrepancy was confirmed by an LPN during an interview, indicating a lack of consistency between the physician's order and the medication packaging. For another resident, the medical record did not include diagnoses of chronic systolic and diastolic heart failure, despite these being documented in the resident's history and physical and care plan. The Director of Nursing confirmed that the resident's diagnoses in the medical record were not updated to reflect these conditions, even though they were present in other documentation. These omissions and inconsistencies in documentation could impact the care provided to residents due to missing or inaccurate information.
Failure to Implement Enhanced Barrier Precautions for Residents with Medical Devices and Wounds
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program by not implementing and following enhanced barrier precautions (EBP) for two residents who required such measures. For one resident with a peripherally inserted gastrostomy tube (PEG) and an active order for enteral feeding, an LPN administered medications through the PEG tube without donning a gown, despite an EBP sign on the door instructing staff to wear gown and gloves for all high-contact care activities. The LPN stated she was trained on EBP but was unaware that gown use was mandatory in this situation. For another resident with multiple wounds requiring ongoing wound care, there was no EBP sign on the door, and the wound care nurse reported that the resident was not on any transmission-based precautions. The infection preventionist and DON confirmed that residents with wounds should be on EBP, with appropriate signage and PPE available in the resident's room. However, the facility practice was to only use PPE during wound care and not to post EBP signage or maintain PPE in the room, contrary to established protocols.
Failure to Timely Report Abuse Incidents
Penalty
Summary
The facility failed to report allegations of abuse to the State Agency (SA) within the required two-hour timeframe for five residents involved in separate incidents. The first incident involved two residents, where one used a wheelchair to push the other onto his bed. This incident occurred on August 3, 2024, at 4:30 PM, but was not reported to the SA until August 5, 2024, at 12:41 PM. The second incident involved two other residents, where one hit the other while passing by. This occurred on July 25, 2024, at 11:30 AM, and was reported to the SA at 4:36 PM the same day, still outside the two-hour window. Another incident involved a resident grabbing another's breast as she walked past him. This occurred on August 24, 2024, but was not reported until August 26, 2024. During an interview, the Administrator confirmed that staff are expected to report all allegations of abuse to the SA within two hours of becoming aware of the incident. However, the incidents were reported late, indicating a failure to adhere to the reporting requirements, which could potentially allow for continued abuse or distress among residents.
Failure to Obtain and Enter Medication Orders
Penalty
Summary
The facility failed to provide services that meet professional standards of practice for two residents, resulting in deficiencies related to medication orders. For one resident, the facility did not obtain the necessary medication orders upon the resident's return from the emergency room. The resident was discharged from the hospital with a diagnosis of a urinary tract infection and a prescription for cephalexin, an antibiotic. However, the facility did not document any attempts to contact the doctor to confirm the antibiotic order, and the resident did not receive the prescribed medication. For another resident, the facility failed to enter several medication orders upon admission from the hospital. The resident had multiple diagnoses, including dementia and delirium, and was prescribed several medications, including cephalexin, cyanocobalamin, olanzapine, ursodiol, Centrum Silver, hydroxyzine, latanoprost, Tylenol, Miralax, and a probiotic. However, the facility did not enter orders for Centrum Silver, latanoprost, Tylenol, Miralax, or the probiotic, despite receiving these orders from the hospital and confirming them with the provider. Interviews with facility staff, including an LPN and the DON, revealed that the admitting nurse was expected to assess the resident, enter the hospital discharge orders, and confirm them with the provider. Despite this expectation, the orders for the second resident were not fully entered into the medical record, indicating a lapse in the facility's process for managing medication orders upon admission and return from the hospital.
Failure to Finalize Baseline Care Plan for Pain Management
Penalty
Summary
The facility failed to create an accurate baseline care plan within 48 hours of admission for a resident, identified as R #3. The resident was admitted with diagnoses including cramp, spasm, chronic pain, and intervertebral disc disorder with radiculopathy. Despite these conditions, the baseline care plan was not finalized by all required staff until a later date, and it lacked specific approaches for pain management, leaving critical areas blank. During an interview, the Director of Nursing (DON) confirmed that the baseline care plan for R #3 was not completed within the required timeframe and did not include necessary instructions for staff on how to manage the resident's pain. This oversight in the care planning process could potentially lead to inadequate care for the resident's pain management needs.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to ensure pharmaceutical services were adequately provided for a resident, identified as R #3, who was admitted on an unspecified date. The resident had physician orders for pregabalin, a medication used to treat nerve pain, with two different dosages: 75mg at bedtime and 50mg once daily. However, the Medication Administration Record (MAR) indicated that the 50mg dose was not administered on several occasions, specifically on 10/05/24, 10/06/24, 10/07/24, and 10/09/24. Similarly, the 75mg dose was not given on 10/04/24, 10/06/24, and 10/07/24, with no documentation for 10/05/24. There was no record of communication with the pharmacy or the physician regarding the missed doses. Interviews with staff revealed that the medication was unavailable in the Pyxis system, and the facility had to wait for the pharmacy to deliver it. An LPN could not recall why the medication was not administered, and the Director of Nursing (DON) confirmed the lack of administration and documentation of any attempts to resolve the issue. This deficiency in pharmaceutical services could likely lead to unnecessary pain for the resident due to the failure to provide routine medication as prescribed.
Inaccurate and Incomplete 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 inaccurately included a diagnosis of schizophrenia, which was not supported by the resident's admission record or history and physical assessment. The Director of Nursing confirmed that the resident did not have a diagnosis of schizophrenia and was not on medication for it, indicating a discrepancy in the care plan. For another resident, the care plan did not address the resident's functional abilities, despite the admission Minimum Data Set Assessment indicating the need for substantial or maximal assistance in several areas, including eating, toileting hygiene, and transfers. The MDS Coordinator confirmed that the care plan should have included these functional abilities after the completion of the admission MDS, highlighting a failure to incorporate critical assessment information into the care plan.
Failure to Revise Care Plan After Resident Fall
Penalty
Summary
The facility failed to revise the care plan for a resident who was at high risk for falls after the resident experienced a fall in the bathroom. The resident's care plan, dated prior to the fall, did not include any updates or interventions to prevent future falls following the incident. The MDS Coordinator confirmed that the care plan was not revised to reflect the fall or to include preventive measures, which should have been done by either the DON or the MDS Coordinator after the fall occurred.
Failure to Notify Provider and Monitor Resident Leads to Death
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. Specifically, the facility did not notify the provider about the resident's abnormal lab values, including high potassium levels, and potential drug-to-drug interactions. The resident, who had chronic kidney disease and was on medications that could cause hyperkalemia, was not properly monitored for potassium levels. Additionally, the facility did not notify the provider about the resident's symptoms of nausea and vomiting, which are indicative of hyperkalemia. The resident's medical records revealed that the resident had elevated potassium, high blood urea nitrogen (BUN), high creatinine, and low glomerular filtration rate (GFR). Despite these abnormal lab results, the staff did not contact the provider to notify them. The resident was also prescribed Bactrim, which has a known interaction with Spironolactone, a medication the resident was already taking. The electronic medical record system triggered alerts for these drug interactions, but the staff did not notify the provider or document any communication regarding these alerts. The resident experienced nausea and vomiting, symptoms that could be related to elevated potassium levels, but the staff did not notify the provider. The resident was given Zofran for nausea, which also had potential drug interactions with other medications the resident was taking. The staff failed to document vital signs and did not notify the provider about the resident's condition. Ultimately, the resident was found unresponsive and was pronounced deceased. The facility's failure to notify the provider about abnormal lab results, drug interactions, and the resident's symptoms likely contributed to the resident's death.
Removal Plan
- Facility will review the last 30 days of labs for all current residents. If abnormal lab is discovered, facility will check to see if MD/provider was notified. If not, we will notify MD/Provider and follow any orders given. An identification audit will be completed by the DON/designee. The identification audit will be reported to MD/provider for further interventions based on findings. The DON/designee will communicate orders given by MD/provider for implementation.
- Facility will look at current resident charts for current drug to drug interactions on spironolactone and residents with chronic kidney disease. The DON/designee will check to see if MD/provider was notified. If not, MD/provider will be notified and follow any orders given. An identification audit will be completed by the DON/designee. The identification audit will be reported to MD/provider for further interventions based on findings. The DON/designee will communicate orders given by MD/provider for implementation.
- Facility will educate current nursing staff regarding the process for reviewing labs which is: When new lab results are returned to the center, the nurse will review the lab results to determine if any abnormal lab results are present. The nurse will then notify the MD/provider of the abnormal lab result, follow orders given and document the notification in the medical record.
- Education also to include what to do for drug-to-drug interaction notification in PCC. When the nurse is entering new resident orders into PCC and a notification comes up for a drug-to-drug interaction the nurse is to notify the MD/provider of the interaction, follow orders given and document the notification in PCC.
- DON/designee will complete the education for staff on shift today. Staff not present will receive education before start of their shift.
Failure to Safeguard Resident Medical Record Information
Penalty
Summary
The facility failed to safeguard resident medical record information for all 101 residents. During an observation of the medication cart, it was revealed that the computer on the cart was open and the screen was not locked, making all resident information visible. An LPN confirmed that the computer was left open with resident information visible. The Director of Nursing (DON) also confirmed that the computer screen should be locked when not in the direct control of staff to prevent unauthorized access to resident information.
Failure to Maintain Grievance Records for Required Period
Penalty
Summary
The facility failed to maintain a grievance policy that retained records of grievance results for up to three years. During an interview, the Social Services Director (SSD) admitted to discarding grievances at the end of each calendar year, confirming that no grievances from the year 2023 were available. A review of the facility's Grievances/Complaint Filing Policy, revised in April 2017, revealed that the results of all grievances filed and investigated were supposed to be maintained on file for a minimum of three years from the issuance of the grievance decision. This failure has the potential to affect all 101 residents in the facility, as identified by the resident matrix provided by the Administrator.
Failure to Maintain Kitchen Cleanliness and Proper Food Temperatures
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment and did not hold puree cold foods at the required temperature of 41 degrees Fahrenheit or lower. During an observation, the ice machine was found to be dirty with yellowish stains, and there were no cleaning logs available to show that it had been cleaned. Additionally, the fryer had food crumbs and oil stains, and there were brownish sticky substances on the floor and underneath the racks in the stock room. The kitchen supervisor confirmed these findings and stated that an outside agency cleans the ice machine once a month, while the kitchen staff performs daily wipe-downs. However, the cleaning logs were not posted as required. During a dinner service, a resident was served puree egg salad, puree diced tomato salad, and puree crackers, all of which were found to be at temperatures significantly above the required 41 degrees Fahrenheit. The Dietary Manager incorrectly stated that cold foods should be held at 45 degrees Fahrenheit and that the puree crackers should be at room temperature. The temperatures of the puree foods were measured at 88.5 F, 84.7 F, and 93.3 F, respectively. This failure to maintain proper food storage and preparation standards could likely lead to foodborne illnesses among the residents.
Failure to Complete Mandatory QAPI Training
Penalty
Summary
The facility failed to ensure that nursing staff completed the mandatory Quality Assurance and Performance Improvement (QAPI) training. Specifically, five staff members, including two Assistant Directors of Nursing (ADONs), two Certified Nursing Assistants (CNAs), and one Licensed Practical Nurse (LPN), did not complete the required QAPI training. Record reviews of the employee training files revealed that none of these staff members had documentation of completed QAPI training. During an interview, the Administrator confirmed the lack of documentation and admitted that while staff were aware of the policy, no formal training had been provided.
Failure to Provide Reasonable Accommodations for Residents
Penalty
Summary
The facility failed to provide reasonable accommodations for the needs of two residents. For one resident, the call light was observed hanging on the back of the bed and not within reach, which the resident confirmed during an interview. A CNA also confirmed that the call light was not within the resident's reach. For another resident, the bedside table with a pitcher was observed to be across the room and not within reach, which was confirmed by the ADON during an interview.
Failure to Notify Provider of Change in Condition
Penalty
Summary
The facility failed to notify the provider of a change in condition for a resident with chronic kidney disease who was experiencing nausea and vomiting. The resident was on Bactrim for a UTI, which triggered a drug protocol alert for a potential interaction with spironolactone, a potassium-sparing diuretic. Despite the alert indicating a risk of hyperkalemia, the staff did not notify the provider about the resident's nausea and vomiting, which are symptoms of elevated potassium levels. The Medical Director confirmed that she was not informed about the resident's nausea or the potential drug interaction. She stated that if she had been notified, she would have either discontinued spironolactone or prescribed a different antibiotic. The failure to notify the provider about the resident's condition and the potential drug interaction could have led to a delay in necessary treatment and worsening of the resident's kidney disease.
Failure to Provide a Home-Like Environment in Secure Unit
Penalty
Summary
The facility failed to provide a home-like environment for all 16 residents in the secure unit by leaving meals and drinks on plastic serving trays during the lunch meal. This practice was observed on 04/15/24 at 11:59 AM, where CNA #21 and the Activities Assistant placed the serving trays with meals in front of each resident in the dining room and in the resident rooms. The Activities Assistant confirmed that meals are usually removed from the serving trays in the main dining room, but in the secure unit, they typically leave the meals on the serving trays for easier cleanup. During an interview on 04/24/24 at 2:32 PM, the DON confirmed that plates should be removed from the serving trays and placed in front of residents to eat. However, staff have been leaving the serving trays with the meals on them when serving meals in the secure unit and when residents eat in their rooms. This practice could likely cause residents to feel depressed and anxious, as it does not provide a comfortable home-like environment.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse within the required two-hour timeframe to the State Agency (SA). A resident reported being assaulted by another resident over a water mug, resulting in scratch marks on the face. The incident occurred at 1:00 pm on 02/28/24, but the report was not sent to the SA until 8:50 am on 02/29/24, which is outside the mandated reporting window. The Administrator confirmed that the allegation was reported to him on 02/28/24, but he did not report it to the SA until the following day.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to ensure that residents and their representatives received a written notice of transfer as soon as practicable. Specifically, Resident #89 was transferred to the hospital on three separate occasions (02/03/24, 04/06/24, and 04/09/24) without receiving a written transfer notice. The nursing progress notes confirmed these transfers, but the medical record lacked any documentation of written transfer notices being provided to the resident or their representative. During interviews, the Social Services Director (SSD) and the Director of Nursing (DON) confirmed that the facility's protocol was not followed. The SSD acknowledged that neither the resident nor their representative received the required written transfer notices, which should have included appeal information and contact details for the State Ombudsman. The DON confirmed that the transferring nurse is responsible for providing the transfer notice to the resident and notifying the resident's representative at the time of transfer. However, this procedure was not adhered to in the case of Resident #89.
Failure to Provide Written Bed Hold Notices
Penalty
Summary
The facility failed to ensure that residents and their representatives received a written notice of the bed hold policy, indicating the duration the bed would be held in cases of transfer to a hospital. This deficiency was identified for three residents. Resident #82 was transferred to the hospital for behavioral changes, but neither the resident nor their representative received a written bed hold notice. The Administrator and Business Office Manager (BOM) confirmed that no notice was provided because the resident returned the same day. Resident #86 was transferred to the hospital twice, once after a seizure and once after a seizure and fall. The bed hold notice for the first transfer did not specify the number of bed hold days, and no notice was provided for the second transfer. The BOM confirmed these omissions during an interview. Resident #89 was transferred to the hospital three times for various reasons, including a fall, bruising, and extreme agitation. In all three instances, neither the resident nor their representative received a written bed hold notice. The BOM and Director of Nursing (DON) confirmed that the facility did not provide the required notices. The BOM also noted that the facility's bed hold notice forms do not include a section to document the number of bed hold days available and that the facility does not send these forms to the resident's representative.
Failure to Timely Complete Significant Change MDS Assessment
Penalty
Summary
The facility failed to complete and transmit a Significant Change Minimum Data Set (MDS) assessment within 14 days after determining a significant change in a resident's condition. Specifically, a resident was admitted to hospice on 02/24/24, but the MDS assessment was not completed and signed off by the Registered Nurse until 04/03/24. This delay was confirmed during an interview with the MDS Coordinator and the Regional MDS Coordinator, who acknowledged that the assessment was opened on 02/26/24 but not completed within the required timeframe.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were completed every three months for three residents. Specifically, the quarterly MDS assessments for three residents were not completed on time, being finalized 14 days after the assessment reference date (ARD). Record reviews revealed that the ARD dates for the three residents were in early March, but the completion dates were in early April. During an interview, the Regional MDS Coordinator confirmed the delay in completing the MDS assessments for these residents.
Failure to Develop Timely and Accurate Baseline Care Plans
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for two residents, which could likely result in residents not receiving the appropriate care and services. For one resident, the baseline care plan was initiated four days after admission, and the MDS Nurse confirmed that it was not completed within the required 48-hour timeframe. The Director of Nursing also confirmed that the baseline care plan should be completed between 48-72 hours after admission, but this was not done for the resident in question. For another resident, the baseline care plan was initiated one day after admission, but it did not include the resident's psychotropic medications. The MDS Coordinator confirmed that the resident's psychotropic medications were not listed on the baseline care plan. This oversight could potentially lead to inadequate care for the resident's bipolar disorder, as the necessary medications were not documented in the care plan.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop a comprehensive care plan for two residents, leading to potential unawareness of their needs by the staff. Resident #9 reported wearing dentures that felt uncomfortable and loose, which she stored in her drawer instead of wearing. Additionally, she had glaucoma and was prescribed Xalatan Ophthalmic Solution for her condition. However, a review of her care plan revealed that it did not document her denture use or her pre-glaucoma condition and the prescribed eye drops. The MDS Coordinator confirmed these omissions during an interview. Resident #108 was admitted with a diagnosis of acute kidney failure, as indicated in her medical records and admission MDS assessment. Despite this, her care plan did not include her acute kidney failure diagnosis or any interventions to prevent the worsening of her condition. The MDS Nurse confirmed that the care plan should have included this diagnosis and relevant interventions, highlighting a significant oversight in the resident's care planning.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to ensure that the care plans for four residents were revised to reflect their current health status and care needs. Specifically, one resident's care plan was not updated to show that she was no longer in the secured unit. Another resident's care plan did not include his diagnosis of seizures, despite this being documented in his medical records. A third resident's care plan failed to address the medications and orders for wounds, including antidepressants, anticoagulants, and anticonvulsants, as well as the interventions for his wounds. Lastly, a fourth resident's care plan did not include her diagnosis of a urinary tract infection (UTI) and the prescribed treatment for it. These deficiencies were confirmed through record reviews, observations, and interviews with staff members, including the Social Services staff, MDS Nurse, MDS Coordinator, and Wound Care Nurse. The failure to update the care plans could result in staff being unaware of changes in care provided, potentially leading to residents not receiving the necessary care related to their health status or healthcare decisions.
Latest citations in New Mexico
Surveyors found that the facility did not provide required written transfer and bed-hold notices when several residents were sent to the hospital for events such as falls with injury, unresponsiveness, and episodes of nausea, vomiting, and bleeding. Medical records lacked written transfer notices and bed-hold notifications, and the transfer information that should have been given to residents or their representatives did not include mandated details about appeal rights, how to request an appeal, or how to contact the State LTC Ombudsman. The Social Services Director reported that she does not notify the Ombudsman of hospital transfers and only sends a monthly email list of discharged residents, without written copies of transfer or discharge notices.
Two cognitively impaired residents with dementia and significant behavioral and continence needs were sent to a local ER after falls and were discharged back to the facility’s care, but the facility failed to provide timely transportation for their return. In both cases, hospital discharge times were documented, yet ER staff reported making multiple unsuccessful calls to the facility, reaching the Administrator only after repeated attempts. One resident, described as very disoriented, remained in the ER for several hours after discharge without 1:1 supervision, while the other waited approximately 11 hours, during which ER staff observed increasing confusion and attempts to get out of bed. The Administrator acknowledged awareness of the discharges, the lack of 24-hour transportation, and that the residents were not picked up until many hours after they had been discharged from the ER.
Two residents who required staff assistance for ADLs and transfers reported neglectful and rude behavior by a CNA and delayed nursing response to care needs. One resident with a history of cerebral infarction and schizophrenia stated that a CNA mocked him and that his requested wound dressing change was not performed for several hours, which was later corroborated by video showing a long gap between the CNA’s visit and the nurse’s entry to the room. Another resident with a right femur fracture, type II DM, and repeated falls, who needed one-person assistance for mobility and self-care, reported that a CNA refused to help and told her she could do some care herself, making her feel she was not trying in her recovery. Documentation and interviews confirmed that staff did not provide timely wound care or required assistance, and that these interactions caused residents to feel uncomfortable and negatively about their care.
A resident with a history of opioid dependence and polysubstance abuse was on a secure unit with a care plan that included safety risk evaluations and monitoring for signs of substance abuse. Staff later observed the resident discarding an empty Suboxone packet, even though the resident was not prescribed this medication, and the incident was reported to the on-call provider with subsequent monitoring and a room search. However, the care plan was not revised to reflect this new substance-related event, and both the DON and Administrator acknowledged that the care plan should have been updated when this new risk and behavior were identified.
Surveyors identified that a medication cart on the north hall was left unlocked and unattended outside a resident room. An LPN acknowledged that the cart was hers and that she had not locked it before leaving to answer a call light, despite facility expectations. The DON confirmed that all medication and treatment carts are required to remain locked when not in use or when staff are away from them.
Surveyors found that a document containing multiple residents’ PHI, including full names, room numbers, and code status, was left unattended and visible on a south nurse’s station counter. An RN confirmed the document was a resident list with PHI and acknowledged it had been left exposed and that such information should not be left unattended.
Surveyors found that a lunch tray return cart containing uncovered, soiled food trays and dishes was left unattended in a main hallway outside an activity room. The housekeeping/laundry manager acknowledged seeing the unattended cart, and the Dietary Manager confirmed that such carts are supposed to remain only in designated areas, such as near the nurse’s station or in the kitchen, and should be returned to the kitchen for cleaning as soon as all trays are collected. This failure was cited as likely to expose all residents to potential pathogens associated with food waste.
Two residents with scheduled showers reported that they were offered or received showers in very cold water during a prolonged period when hot water was not reliably available in care areas. One resident stated he refused cold showers and was only offered sponge baths once or twice, despite his preference to stay clean. Another resident reported receiving cold showers, including being rinsed with cold water while still soaped, and subsequently began refusing showers and bed baths due to the cold water. A CNA confirmed that water in the shower rooms was “ice cold” for several months, leading to resident complaints and refusals, while the Maintenance Director reported that a needed part to correct the hot water problem was on back order, delaying resolution and resulting in the facility not honoring residents’ bathing preferences.
Surveyors observed that unused medications were improperly discarded in a trash bin attached to a medication cart on the north hallway, rather than being disposed of in a designated drug disposal container. Two pills, a round blue tablet stamped "61" and an oblong orange tablet stamped "20," were found together in an unlabeled medication cup in the trash. An RN confirmed the medications were discarded there and acknowledged that unused medications should be placed in the drug buster container in the cart drawer. The Unit Manager also confirmed that facility practice requires all unused medications to be disposed of using the drug buster and that controlled substances must be destroyed by two licensed staff and documented on the narcotic count sheet.
The facility failed to follow documented allergy information, diet orders, and meal tickets for three residents. A resident with a documented chocolate allergy was served chocolate ice cream after requesting it, and the Nutrition Director admitted not reading the allergy notation on the meal ticket. Another resident on a pureed diet received whole mandarin oranges instead of pureed fruit, which a CNA confirmed. A third resident whose meal ticket called for a grilled Swiss sandwich received a sandwich that was not grilled, as confirmed by a CNA and a dietary manager.
Failure to Provide Required Written Transfer, Appeal, Ombudsman, and Bed-Hold Notices During Hospitalizations
Penalty
Summary
Surveyors identified that the facility failed to provide required written transfer and bed-hold information for multiple residents who were hospitalized. For three residents who experienced transfers to the hospital after events such as falls with injury, unresponsiveness, and episodes of nausea, vomiting, and bleeding, record review showed there were no written transfer notices or written bed-hold notices in their medical records. Specifically, one resident transferred after a fall on 01/31/26 had no documented written transfer notice or bed-hold notice. Another resident transferred on 02/27/26 for nausea, vomiting, and bleeding, and later readmitted on 03/05/26, had no written transfer notification that included information on appeal rights or Ombudsman contact, and no written bed-hold notification. A third resident transferred on 01/29/26 after a fall with a forehead laceration and again on 03/17/26 for unresponsiveness, also had no documented written transfer or bed-hold notices for either hospitalization. The deficiency also included the facility’s failure to provide required content in transfer notices and to notify the State Long-Term Care Ombudsman in writing. For the residents reviewed, there was no evidence that written transfer notices were provided to the residents or their representatives in a language and manner they could understand, and the notices were missing required elements such as a statement of appeal rights, the name, mailing and email address, and phone number of the entity receiving appeals, and information on how to obtain and complete an appeal form. The notices also lacked the name, phone number, and mailing and email address of the State Long-Term Care Ombudsman, and written copies of the transfer notices were not sent to the Ombudsman. During interview, the Social Services Director confirmed that transfer and bed-hold notices were not documented for at least one resident’s hospitalization, that she does not notify the Ombudsman about transfers to the hospital, and that she only emails a monthly list of residents discharged from the facility without sending written copies of transfer or discharge notices.
Failure to Timely Retrieve Residents From ER After Discharge
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from neglect by not arranging timely transportation back to the facility after emergency room (ER) discharge. A consumer complaint alleged that residents sent to the local ER were being left there for extended periods after discharge. For one resident with an admission date of 10/13/25, records showed multiple cognitive and behavioral diagnoses, including Alzheimer’s disease, vascular dementia with agitation and other behavioral disturbances, mild cognitive impairment, cognitive communication deficit, and restlessness and agitation. A change of condition MDS documented a Brief Interview for Mental Status (BIMS) score of 1 and frequent incontinence of urine and bowel. Nursing progress notes for this resident showed that 911 was called at 3:00 AM and the resident was transferred to the ER after a fall. Hospital discharge instructions indicated the resident was discharged from the ER at approximately 5:21 AM, while the ER nurse reported discharge at about 5:30 AM. The ER nurse stated she made numerous calls to the facility but was unable to reach anyone. She reported that the resident was very disoriented and that the ER did not have enough staff to provide 1:1 supervision. The ER nurse eventually reached the Administrator, who stated staff would come to pick up the resident as soon as possible. Facility records showed the resident was not discharged from the facility on that date, and the ER nurse reported that facility staff did not pick the resident up until approximately 8:30 AM, several hours after discharge. A second resident, admitted on 11/25/25, had diagnoses including Alzheimer’s disease, dementia with behavioral disturbance, bipolar disorder with severe depression and psychotic features, depression, and anxiety disorder. The admission MDS documented a BIMS score of 2, frequent urinary incontinence, constant bowel incontinence, and a need for substantial/maximal assistance with toileting hygiene. Nursing notes showed this resident was sent to the ER for evaluation after a fall and did not return until the following morning. Hospital discharge instructions documented discharge from the ER at 10:16 PM, and the Administrator confirmed being notified of the discharge at about 10:30 PM and that the facility did not have 24-hour transportation. The Administrator acknowledged the resident was not picked up until approximately 9:00 AM the next day. The ER nurse reported making several calls to the facility that went to voicemail, eventually reaching the Administrator, who initially stated staff were on the way, then stopped answering calls. During the approximately 11-hour wait, the ER nurse stated the resident was confused, attempted to get out of bed, and became more confused as the night progressed.
Failure to Timely Provide Wound Care and Required Assistance, Resulting in Resident Neglect
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from neglect when staff did not respond appropriately to requests for care and assistance. One resident with a history of cerebral infarction due to embolism and schizophrenia, admitted on 01/30/26 and requiring staff assistance for ADLs and mechanical lift transfers, reported that a CNA was rude and mocking and that his wound dressing was not changed for several hours after he requested it. The Kardex showed he needed staff help for toileting, bathing, hygiene, bed mobility, dressing, and transfers. Nursing progress notes documented a change in condition on 03/02/26 after the resident stated the CNA was rude and would not assist as requested. The Administrator later confirmed, via video review, that the CNA entered the resident’s room at 2:30 am, the resident requested a dressing change, and no nurse entered the room until 5:00 am, despite the nurse’s statement that she went in “right away.” The DON also confirmed that the resident’s grievance described the wound dressing not being changed until hours after the request. Another resident, admitted with a right femur fracture, type II diabetes, and repeated falls, required one-person assistance for dressing, hygiene, bathing, bed mobility, and transfers, and could toilet herself with assistance for transfers. Nursing progress notes documented an alleged abuse incident on 03/02/26 in which this resident stated a CNA was rude, refused to help her, and told her she could perform some care tasks herself without staff assistance. An abuse questionnaire completed the same day showed the resident answered “Yes” to having interactions that made her feel uncomfortable or negative, and she reported that the CNA made her feel as though she was not trying with her own recovery. The Administrator and DON acknowledged that staff are expected to help residents as required and that staff interactions must be encouraging rather than making residents feel bad about needing assistance.
Failure to Revise Care Plan After Substance-Related Incident
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s care plan after a significant substance-related incident. The resident was originally admitted with a diagnosis of opioid dependence and resided on a secure unit related to polysubstance abuse disorder. The existing care plan, dated 01/21/26, identified the resident as residing on a secure unit due to polysubstance abuse disorder with interventions to perform safety risk evaluations on admission, as needed, and upon changes in condition. The care plan also identified the resident as at risk for substance use disorder with interventions to monitor for signs or symptoms of substance abuse. On 02/01/26, nursing notes documented that staff observed the resident discarding an empty Suboxone packet in the trash, even though the resident was not prescribed Suboxone and denied taking any. Staff notified the on-call provider, who ordered monitoring for adverse reactions, and nursing staff and security conducted a room search that revealed no additional contraband. Despite this incident, the resident’s care plan was not updated to address the new substance-related event. During interviews, the DON acknowledged awareness of the incident and confirmed the care plan was not revised, and the Administrator stated her expectation that nursing would update the care plan when a new risk or behavior was identified and confirmed she would have expected the care plan to be updated for this resident.
Unattended, Unlocked Medication Cart on North Hall
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were properly stored and secured in accordance with professional standards and facility expectations. On 03/24/26 at 9:06 a.m., surveyors observed a medication cart on the north hall left unlocked and unattended outside a resident room. At 9:08 a.m., the LPN responsible for the cart confirmed during interview that the cart was hers, that it was unlocked and unattended, and acknowledged she should have locked it before responding to a call light. Later that day at 3:37 p.m., the DON stated in an interview that medication and treatment carts are expected to be locked at all times when nurses are away from them, confirming that the observed practice did not meet facility expectations. This deficient practice was cited as likely to allow unauthorized personnel access to medications, which could result in injury or overdosing.
Unattended PHI Document Left Exposed at Nurse’s Station
Penalty
Summary
Surveyors identified a deficiency in the facility’s protection of residents’ personal health information (PHI) when a document containing multiple residents’ full names, assigned room numbers, and code status was left unattended and exposed on the south nurse’s station counter. On 03/16/26 at 9:04 a.m., an observation revealed a piece of paper on a clipboard with complete resident information placed on top of the south nurse’s counter in public view. At 9:06 a.m., during an interview, RN #2 confirmed that the list contained residents’ names, room numbers, and code status, acknowledged that it had been left exposed and unattended, and stated that PHI should not be left unattended. No additional clinical details or medical histories of the residents listed on the document were provided in the report.
Unattended Soiled Lunch Cart Left Uncovered in Hallway
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the handling of soiled food service equipment. On 03/24/26 at 12:58 pm, a lunch tray return cart containing soiled food trays and dishes that were uncovered was observed sitting unattended in the main hallway outside the activity room. At 1:06 pm, the housekeeping/laundry manager confirmed she saw the return cart left unattended in that location. At 1:08 pm, the Dietary Manager stated that lunch return carts should only be left in designated areas such as by the nurse’s station or inside the kitchen, and that the cart should be returned to the kitchen for cleaning as soon as all trays have been picked up, which did not occur in this instance. This deficient practice was noted as likely to expose all residents to potential pathogens associated with food waste.
Failure to Honor Resident Bathing Preferences During Prolonged Hot Water Issues
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ bathing preferences when hot water was not reliably available in resident care areas. Record review showed that one resident was scheduled to receive three showers per week on specific days, and another resident was scheduled for two showers per week. One resident reported that staff attempted to have him shower in cold water, which he refused, and that sponge baths were only offered once or twice during the period when the hot water was not working. He stated that he liked to be clean and did not feel like himself when he was dirty. A CNA reported that there was no hot water in resident care areas from the middle of December until early March, and that large barrels of warm water were brought to shower rooms to offer sponge baths, which this resident refused. Another resident, also on a scheduled twice-weekly shower regimen, stated that she received cold showers and began refusing showers because of how cold the water was. She described the water running cold unpredictably, including an instance when the water was initially warm but turned cold while she was still soaped, requiring rinsing with cold water, which she described as horrible. A social services note documented that this resident’s daughter reported the resident had been declining showers and bed baths offered because the water was too cold. A CNA corroborated that the water was “ice cold” and that residents began complaining and refusing showers around mid-December. The Maintenance Director stated that it took a while for hot water to reach the shower room and that a needed part to fix the cold-water problem was on back order, contributing to the prolonged period of inadequate hot water and resulting in residents not having their bathing preferences honored.
Improper Disposal of Unused Medications on Medication Cart
Penalty
Summary
Surveyors identified a deficiency related to accident hazards and inadequate supervision when unused medications were improperly discarded on the north hallway. During observation of the north hall nurses’ station, two medications were found in the trash bin attached to the medication cart, placed together inside an unlabeled medication cup. The pills were described as a round blue pill stamped with “61” and an oblong orange pill stamped with “20.” In an interview immediately following the observation, an RN confirmed that these medications were in the trash bin and stated that unused medications should instead be disposed of in the drug buster, a sealed container for drug disposal located in the bottom drawer of the cart. In a subsequent interview, the Unit Manager confirmed that all unused medications are to be disposed of using the drug buster and acknowledged that this did not occur, further stating that if the medications are controlled substances such as narcotics, two licensed personnel are required to dispose of them together and document the disposal on the narcotic count sheet. This deficient practice was noted as likely to affect any resident who might acquire and ingest the discarded medications, potentially causing medication side effects.
Failure to Follow Allergy, Diet, and Meal Ticket Requirements
Penalty
Summary
The facility failed to provide meals consistent with residents’ documented allergies, diet orders, and meal tickets for three residents. One resident, admitted with a documented allergy to chocolate, had a face sheet and lunch ticket indicating they were not to receive chocolate. During a lunch observation, this resident was served and was eating chocolate ice cream. An LPN confirmed the resident’s chocolate allergy and that the resident should not be eating chocolate. The Nutrition Director acknowledged that the meal ticket stated the resident should not have chocolate but reported serving chocolate ice cream after the resident requested it, stating he had not read that the resident was allergic to chocolate. Another resident, admitted with hypokalemia and ordered a regular/liberalized pureed diet per the MDS, had a lunch ticket indicating a pureed diet but was observed receiving whole mandarin oranges instead of pureed fruit. A CNA confirmed that the dessert was not pureed. A third resident’s meal ticket specified a grilled Swiss sandwich, but observation of the tray showed the sandwich was not grilled. During interviews, a CNA and a dietary manager confirmed that the sandwich was not grilled as ordered on the meal ticket.
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.
Trusted by long-term care providers and associations.
