Casa De Oro Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Las Cruces, New Mexico.
- Location
- 1005 Lujan Hill Road, Las Cruces, New Mexico 88005
- CMS Provider Number
- 325047
- Inspections on file
- 31
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Casa De Oro Center during CMS and state inspections, most recent first.
Surveyors found that staff failed to follow required food service safety procedures when they did not document refrigerator and freezer temperatures for both a morning and an evening shift, and did not record dish machine temperatures or chemical sanitization concentration for a breakfast dishwashing cycle. The dietary director confirmed that staff were expected to check and document these temperatures and sanitization levels each morning, evening, and after each meal, but this was not done, potentially affecting all residents who consumed food prepared in the kitchen.
The facility failed to keep care plans current and to include required IDT members in care plan meetings. For several residents, care plan conferences were held without participation or input from the responsible CNA or the provider, as confirmed by social services staff. One resident who frequently refused showers due to feeling cold or unwell had these refusals reported and documented on shower sheets, but no corresponding interventions or documentation appeared in the care plan. Another resident with painful mycotic toenails and documented orders for nail debridement and routine foot care had visibly overgrown, thick, cracked toenails, and the care plan lacked any interventions for toenail care, despite the DON stating that resident care should be documented on the care plan.
Surveyors observed that a nurse practitioner entered multiple residents’ rooms on two units without knocking, including rooms with closed doors. In interviews, the NP admitted knowing it is polite to knock but stated he was rushed, and the Administrator confirmed the expectation that staff knock before entering rooms. This conduct showed a failure to consistently respect residents’ dignity and privacy.
Facility staff failed to follow and document multiple physician and hospice orders, resulting in care that did not meet professional standards. A resident on hemodialysis had a fluid restriction order from dialysis that was never entered into the medical record, and staff reported the resident was not on fluid restriction. A resident with uncontrolled DM had orders to monitor blood glucose and a care plan directing monitoring for signs and symptoms of hypo- and hyperglycemia, yet staff did not document routine blood sugar checks, refusals, or symptom monitoring over several months after insulin orders were partially discontinued. Another resident with painful mycotic toenails had an ordered follow-up foot care appointment that was never scheduled, leaving toenails overgrown and thick. A resident with a sacrococcygeal pressure wound had updated hospice wound care orders for daily treatment that were not entered into the medical record, the prior less-frequent order remained active, and wound care was not documented on at least one ordered day.
Surveyors found that a medication cart on the 400 hall was left unlocked and unattended near the nurse’s station, despite an LPN acknowledging it should always be locked. They also observed multiple expired respiratory medications, including a Breyna inhaler and ipratropium/albuterol inhalation solutions, stored in the treatment and medication carts for several residents. Staff interviews confirmed that nurses are expected to check for expired medications daily and each shift and to remove them from the carts, but these practices were not followed.
Two residents with documented dental infections, pain, and poor oral conditions did not receive required routine and emergency dental services. One resident had a diagnosed dental infection and gingivitis, repeated nursing documentation of cavities, gum inflammation, pain, and tooth decay, and a planned extraction that was delayed by rescheduled, canceled, and missed dental appointments, with no further documentation of follow-up or completion of treatment. Another resident reported dental pain and a missing denture, had standing orders for dental consultation and later antibiotics for dental pain, but there was no documentation of dental pain in progress notes, no provider contact for dental issues, no dental referral, and no scheduled dental appointments. The MDS did not reflect the resident’s dental problems despite a care plan noting suspected or actual dental infection, and interviews confirmed that routine dental appointments were not being done and that no dental referral existed, contrary to facility policy and the DON’s expectations.
A resident with an anxiety disorder received PRN hydroxyzine 25 mg for anxious behaviors under a physician order that lacked an end date. MAR review showed repeated administrations of the PRN psychotropic over an extended period. The UM and DON confirmed that the PRN hydroxyzine had been ordered indefinitely and that the provider had not documented a clinical rationale in the medical record for continuing the PRN psychotropic beyond 14 days, contrary to the DON’s stated expectations.
A resident was transferred to the hospital due to blood in her vomit, but staff did not complete the required written Transfer Notice or Bed Hold Notification, nor did they send a copy of the Transfer Notice to the Ombudsman. Record review confirmed the absence of these documents in the resident’s medical record, and the Social Services Director acknowledged that staff were expected to complete these notices and notify the Ombudsman whenever a resident was transferred to the hospital.
Staff failed to provide and document fingernail care for a totally dependent resident who required full assistance with ADLs. The resident’s fingernails were observed to be overgrown, yellow, thick, and cracked, and the resident reported they had not been cut in a long time. The DON and a UM confirmed the condition of the nails and acknowledged that no fingernail care was documented in the medical record, despite the resident’s complete dependence on staff for ADL care.
A resident sustained an olecranon (elbow) fracture and was evaluated in the ER, where a longarm splint was applied and follow-up with an orthopedic surgeon was ordered. Subsequent provider notes at the facility documented the same diagnosis, indicated that the fracture was to be followed by an orthopedic surgeon, directed staff to schedule the orthopedic follow-up, and referenced continuing soft casts with plans for repeat X-ray and possible cast removal. Record review showed that, despite these documented orders and plans, the resident never received the required follow-up visit with an orthopedic surgeon, resulting in a failure to provide ordered treatment and care.
A resident who was totally dependent on staff for ADLs and had documented painful mycotic toenails did not receive necessary foot and nail care. Observations showed the resident’s toenails were overgrown, yellow, thick, and cracked, and the resident stated they had not been cut in a long time. Review of the medical record revealed no documentation of toenail care despite an order to remove affected mycotic nail tissue as tolerated. The DON confirmed that the resident’s toenails and fingernails were overgrown, had not been cut, and that staff had not documented providing toenail care.
A resident with essential HTN and ESRD on dialysis was receiving multiple antihypertensives (amlodipine, clonidine, carvedilol) and midodrine. A consultant pharmacist completed a new admission review and recommended evaluating the combined use of HTN and hypotension meds and possibly holding morning antihypertensives on dialysis days. The unit manager signed the recommendation form, but the provider did not sign it, did not adjust the medication orders, and did not document any clinical rationale for not following the pharmacist’s recommendations. The DON confirmed that providers were expected to review, sign, and document rationale regarding pharmacist recommendations, which did not occur in this case.
Surveyors identified that staff failed to follow infection prevention practices for two residents. For a resident receiving wound care for a shin wound and a stage 2 pressure ulcer, staff did not wear gowns during high-contact care despite posted EBP signage and available PPE, and the resident’s body was in direct contact with a CNA’s body during repositioning. For another resident with COPD on 2 LPM oxygen via nasal cannula, staff did not follow orders to change oxygen tubing weekly and label it with the date, leaving the nasal cannula in use without any date marking and with no way to determine when it was last changed.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
Staff administered narcotic pain medications earlier than ordered, failed to notify providers when pain medications were needed more frequently, and did not consistently document medication administration or reassess pain effectiveness. These actions resulted in discrepancies in controlled drug records and MARs, with some residents receiving higher or duplicate doses and incomplete pain management documentation.
Staff failed to maintain complete and accurate controlled drug records for several residents receiving narcotic pain medications, resulting in missing documentation for periods when medications were administered. The DON confirmed that staff were expected to document each administration on both the controlled drug record and the MAR, but missing records and incomplete documentation prevented proper reconciliation and tracking of controlled substances.
Staff failed to consistently document the administration of PRN opioid pain medications on both the MAR and Controlled Drug Record for several residents, resulting in missing entries, discrepancies between physician orders and documentation, and incomplete records. These documentation lapses were confirmed by interviews with the DON and other staff, who acknowledged the missing or inconsistent records and the inability to reconcile medication administration due to missing pages.
Three residents with cognitive impairments and histories of wandering were able to leave the facility multiple times due to staff failing to recognize elopement risk, incomplete documentation, and unsecured exit doors and gates. One resident was missing for over a day and required hospitalization for emergency dialysis and dehydration. Staff interviews confirmed that exit-seeking behaviors were known but not consistently addressed with updated assessments or interventions.
Medication and treatment carts were found unlocked on a unit, with lancets left on top of the medication cart. Staff interviews confirmed that these carts should have been secured and that only authorized personnel should have access. This failure to secure medication and treatment supplies affected all residents on the unit.
Two residents exited the facility grounds and were found outside by staff, but the incident was not reported to the State Agency because the Administrator did not consider it an elopement since they remained on facility property.
A resident was discharged to a hospital after a change in condition and incidents of harm to others. The facility failed to have the physician document the inability to meet the resident's needs, attempts made to do so, and how the hospital could meet those needs. The administrator confirmed the absence of this required documentation.
The facility failed to update the care plans for three residents who required two-person assistance with a lift device, as indicated in their Lift Transfer Evaluations. The care plans did not document the need for a lift device or the necessary interventions. The DON confirmed the oversight, emphasizing that care plans should reflect residents' needs and interventions.
A facility failed to develop and implement a discharge planning process for a resident, resulting in a deficiency. The resident's individualized discharge goals and needs were not documented, and the Interdisciplinary Team was not involved. The resident's POA was not informed 30 days prior to discharge, and the Social Worker was not involved in the process. The Administrator confirmed the lack of documentation and immediate discharge without proper notice.
A facility failed to complete a discharge summary and medication list for a resident discharged to a hospital. The resident, who had harmed two other residents, was discharged immediately due to posing a danger. The Administrator confirmed the lack of documentation and informed the resident's POA of the situation.
A resident's Foley catheter tubing was observed dragging on the floor while self-propelling in a wheelchair. This was confirmed by an LPN and the DON, who acknowledged that the tubing should not be on the floor. The facility's policy requires catheter tubing to be secured and kept off the floor to prevent infections.
A facility failed to implement and document wound care orders for a resident with a stage 3 pressure ulcer. The resident's wound care order, including the use of a Wound VAC, was not entered into the physician's orders, leading to a lack of documentation and implementation. The Treatment Administration Record showed no wound care documentation for several days, and there was no communication with the wound care consultant about the Wound VAC issues. The DON confirmed the oversight, resulting in staff being unaware of the necessary interventions.
A facility failed to protect residents from abuse, resulting in incidents involving verbal and physical abuse by staff. One resident was verbally abused by a CNA, leading to falls, while another was physically and verbally abused by an RN, causing fear and distress. A third resident suffered injuries during an incident with the same RN, raising concerns about the facility's response and documentation of abuse.
A facility failed to report abuse allegations involving multiple residents in a timely manner. One resident was called lazy by a CNA, leading to a fall, while another was physically abused by an RN. Despite reports to management, these incidents were not communicated to the State Agency within the required timeframe, allowing for potential further abuse.
The facility failed to provide QAPI training to staff, potentially affecting all 127 residents. The Administrator acknowledged the absence of this training and stated that they were in the process of implementing it. This deficiency could hinder staff's ability to identify improvement opportunities and address system gaps.
The facility failed to include performance reviews in the 12 hours of annual training for three CNAs. Record reviews showed that the training records lacked performance evaluations, despite the CNAs having worked at the facility for over a year. The Staff Development Coordinator and DON confirmed the oversight.
A facility failed to document hospice services for a resident, resulting in a lack of awareness of care provided. Despite expectations for hospice staff to provide documentation, the facility's records were outdated, with the last hospice care plan dated months prior. Interviews with staff confirmed the absence of recent documentation, hindering the ability to track the resident's care.
A facility failed to ensure proper communication and monitoring for a resident with ESRD undergoing dialysis. Despite having physician orders for dialysis, the facility did not complete post-dialysis monitoring and assessments, as evidenced by incomplete Dialysis Communication Records. The DON confirmed the oversight, acknowledging that nurses should have completed the necessary documentation.
Two residents were prescribed psychotropic medications without appropriate psychiatric diagnoses. One resident received quetiapine for depression without a psychiatric diagnosis, confirmed by the DON. Another resident was given ziprasidone for dementia with behaviors, despite unclear psychiatric notes and the Medical Director's opinion that it should not be used for dementia.
The facility failed to document medication refrigerator temperatures on the East and [NAME] Units and did not secure a treatment cart on the 500 Unit. Temperature logs showed incomplete entries, and the treatment cart was found unlocked without staff present. The DON confirmed these deficiencies, which could impact all 127 residents.
The facility failed to maintain proper food storage and temperature documentation, potentially affecting all residents consuming food prepared in the kitchen. An observation revealed a bag of hash browns with an erased date in the freezer, and the kitchen's District Manager confirmed the issue. Additionally, temperature logs for snack refrigerators on two units showed multiple dates without recorded temperatures, confirmed by CMA #8, CMA #9, and the DON.
The facility failed to provide a homelike environment, with issues such as broken blinds, scuffed walls, misaligned toilets, and vents covered with plastic. Residents reported discomfort due to these conditions, and the crash cart in the Dementia unit was found with dead bugs.
The facility failed to develop comprehensive care plans for two residents, one with a PEG tube and another with unstageable deep tissue injuries. The care plans lacked necessary interventions for these conditions, as confirmed by the DON, indicating a gap in addressing the residents' specific medical needs.
The facility failed to review and revise care plans for nine residents, leading to deficiencies in care. Required interdisciplinary team members were absent from care plan meetings, and meetings were not held within seven days of MDS assessments. Additionally, care plans were not updated with current resident information, such as medical orders and health status changes, potentially impacting the quality of care provided.
A resident with multiple health conditions, including dementia and obesity, experienced two falls in the restroom due to inadequate supervision and unclear care plan interventions. The resident required assistance for transfers but attempted to transfer independently when left alone or when staff did not respond to the call bell. The care plan lacked specific instructions for assistance levels and call light usage, contributing to the falls.
The facility failed to provide adequate staffing, resulting in unmet needs for two residents. One resident was left in bed in wet briefs due to insufficient staff, while another missed scheduled showers. Staff shortages were cited as the reason, with fewer CNAs working than required. The DON emphasized the expectation for prompt call light responses and proper documentation of missed showers.
A resident's wound care was not completed as ordered, with missing initials on the treatment administration record (TAR) and insufficient documentation in nurse progress notes. The resident's physician had ordered daily wound care, but on several occasions, the TAR was not initialed, and notes indicated delays and lack of clarification on the wound care frequency. The DON expected daily completion and documentation of wound care, with any provider contact attempts recorded.
A resident with dementia and encephalopathy developed a pressure ulcer on her right heel, but the facility failed to notify the provider or document interventions. Despite staff noting the injury, there were no wound measurements or timely wound care orders. Interviews revealed a lack of communication and documentation, contributing to inconsistent care and potential worsening of the ulcer.
A facility failed to provide prescribed medications, Lyrica and Nephro-Vite, to a resident as ordered by a physician. The medications were not documented as administered over several days, and a CMA indicated they were unavailable until after the resident was hospitalized. There was no record of communication with the pharmacy, and the DON confirmed the lack of documentation and the facility's responsibility in ensuring medication administration.
A resident's request to change their code status from DNR to full code was not updated in their medical records, care plan, or MOST form. Despite the resident's clear request during a care plan meeting, the facility did not complete the necessary documentation to reflect this change, potentially leading to their wishes not being honored in a life-threatening situation.
The facility failed to ensure that the consultant pharmacist's recommendations were reviewed and implemented by the physician for two residents. One resident had an as-needed order for lorazepam without a stop date, and the electronic medical record lacked documentation for its continued use. Another resident's medication review recommendations were not specified, and the Director of Nursing had not received the drug regimen review from the provider. This oversight could lead to unnecessary medication use.
The facility failed to accurately document the Minimum Data Set (MDS) assessments for two residents. One resident had a urinary tract infection that was not recorded in the MDS, despite being treated with antibiotics. Another resident with a PEG tube did not have her tube flushes documented in the MDS. These inaccuracies were confirmed by staff interviews.
The facility failed to manage enteral tubes for two residents properly. One resident's tube feeding was not administered according to physician orders, potentially affecting nutritional intake. Another resident with a PEG tube lacked a care plan for site maintenance, leading to inadequate care. Observations revealed the tube site was crusty and without a dressing, prompting a late order for daily care.
A resident's medical records were incomplete and inaccurate, with missing documentation for PEG tube care and unclear medication orders. The resident, with diagnoses including bipolar disorder and major depressive disorder, had a PEG tube care order that was not documented in the TAR, and there was confusion regarding the use of aripiprazole, an antipsychotic medication.
The facility failed to protect resident medical records when a computer on a medication cart was left unlocked and unattended, exposing information for all 126 residents. A CMA confirmed the oversight, admitting the computer should not have been left open.
The facility failed to ensure staff were aware of residents' code statuses and CPR procedures, leading to a delay in initiating CPR for a resident found unconscious. Interviews revealed that CNAs were uncertain about code statuses and procedures, and CPR certification tracking was not effectively managed.
Failure to Monitor Food Storage Temperatures and Dishwashing Sanitization
Penalty
Summary
Surveyors identified a deficiency related to food service safety practices involving monitoring of refrigeration, freezing, and dishwashing sanitation. Record review of the kitchen upright refrigerator temperature log for January 2026 showed that staff did not document the refrigerator temperature on the evening shift of 01/25/26 and the morning shift of 01/26/26. Similarly, review of the kitchen upright freezer temperature log for January 2026 revealed that staff did not document the freezer temperature on the evening shift of 01/25/26 and the morning shift of 01/26/26. In addition, review of the dish machine log for January 2026 showed that staff did not document dish machine temperatures or the chemical sanitization concentration for the breakfast dishwashing cycle on 01/26/26. During an interview on 01/26/26 at 1:15 PM, the dietary director stated that staff were expected to check refrigerator and freezer temperatures when they arrived in the morning and in the evening, and confirmed that these temperatures were not documented for the specified shifts. The dietary director also stated that staff were expected to check dish washer temperatures and chemical sanitization concentration after each meal and confirmed that these checks were not documented for the breakfast dishwashing cycle. These failures had the potential to affect all 134 residents who consumed food prepared in the kitchen.
Failure to Revise Care Plans and Include Required IDT Members in Care Plan Meetings
Penalty
Summary
The deficiency involves the facility’s failure to revise care plans with current information and to ensure required interdisciplinary team (IDT) members participated in care plan meetings. For one resident admitted in August 2019, care plan meeting notes from late December 2025 showed that neither the CNA responsible for the resident nor the provider attended or provided input. Another resident admitted in March 2025 had a care plan meeting in December 2025 attended by a family member, Unit Manager (UM), Social Services Director (SSD), recreation staff, dietician, and scheduler, but there was no indication that the responsible CNA or provider participated. A third resident admitted in April 2025 had a December 2025 care plan meeting attended by the UM, Social Services Assistant (SSA), recreation staff, dietician, and scheduler, again without the provider or CNA. The SSD confirmed that CNAs with responsibility for residents and providers were not invited to care plan meetings and did not attend the meetings for two of the residents. The facility also failed to update care plans with current resident conditions and interventions for two residents. One resident reported sometimes receiving only one shower a week and refusing showers when feeling cold or unwell; two CNAs confirmed that this resident had been refusing showers and that refusals were reported to the nurse and documented on a shower sheet. However, review of the resident’s care plan dated January 2026 showed no interventions or documentation of shower refusals, and the UM confirmed the resident was often non‑compliant with showering and that these refusals were not reflected in the care plan. Another resident admitted in January 2024 had overgrown, yellow, thick, and cracked toenails observed during survey, with the resident stating they had not been cut in a long time; the DON confirmed the toenails were overgrown. A progress note from October 2025 documented painful mycotic toenails and instructions for removal of affected nail tissue with follow‑up for routine foot care, yet the resident’s care plan dated January 2026 did not include interventions for toenail care, and the DON stated that resident care should be documented on the care plan.
Failure to Knock Before Entering Resident Rooms
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to dignity and respect when a nurse practitioner (NP) repeatedly entered resident rooms without knocking. On 01/27/26 at 11:57 AM on the 500 unit, the NP opened the closed doors and walked into the rooms of residents #24, #38, #44, and #111 without knocking. On the same date at 12:01 PM on the 700 unit, the NP entered the rooms of residents #141 and #142 without knocking, even though their door was open. During an interview at 11:43 AM, the NP acknowledged that it is polite to knock before entering a resident’s room and explained that he was in a hurry and rushed, which is why he did not knock. In a separate interview at 12:16 PM, the Administrator confirmed that her expectation is that staff knock before entering residents’ rooms. These observations and interviews demonstrate that the facility failed to ensure residents were treated with respect and dignity by not consistently knocking before entering their rooms, affecting six randomly observed residents.
Failure to Follow and Document Physician and Hospice Orders for Fluids, Diabetes Management, Foot Care, and Wound Care
Penalty
Summary
The deficiency involves multiple failures by facility staff to follow and document physician and hospice orders, resulting in services that did not meet professional standards of quality. For one resident with end stage renal disease on hemodialysis, a Hemodialysis Communication Record dated 01/29/26 contained an order for a 1500 ml fluid restriction. This order was not entered into the resident’s medical record, and a CNA stated the resident was not on a fluid restriction. The DON confirmed that the fluid restriction order had been received on 01/29/26, was not entered into the medical record, and that the resident’s fluids were not restricted as ordered. Another resident with a diagnosis of diabetes mellitus had convalescent care orders dated 10/15/25 to check blood sugar levels before meals and at bedtime. Insulin orders for Humulin R before meals and at bedtime were discontinued on 10/17/25 after the resident refused insulin, blood sugar checks, and blood work, but the resident continued on Insulin Glargine 20 units twice daily. The care plan, revised 10/21/25, directed staff to monitor blood glucose levels as ordered and to monitor for signs and symptoms of high and low blood sugar and report abnormal findings. However, medication administration records from October 2025 through February 2026 showed no documentation of blood sugar levels or refusals, and no documentation of monitoring for symptoms of high or low blood sugar. Vital sign records showed intermittent blood sugar readings only on specific dates, and progress notes from 10/16/25 to 02/02/26 did not document monitoring for signs or symptoms of high or low blood sugars. An LPN stated there was no current order in the medical record to monitor blood sugar levels, that the monitoring order was inadvertently discontinued with the Humulin R order, and that he did not routinely monitor diabetic residents for signs and symptoms of high or low blood sugar. The DON confirmed staff did not document monitoring for signs and symptoms, and the physician and medical director both stated that blood sugar monitoring should have continued. A third resident was observed to have overgrown, yellow, thick, and cracked toenails and reported that their toenails had not been cut in a long time. The DON confirmed the toenails were overgrown and had not been cut. A progress note from a medical appointment dated 10/28/25 documented painful mycotic toenails and a follow-up appointment in two months for routine foot care, but the medical record contained no documentation that a follow-up appointment was scheduled. The DON confirmed that a two‑month follow-up for routine foot care had been ordered and that no follow-up appointment was scheduled. For another resident with a pressure wound on the sacrococcygeal area, a physician’s order dated 01/14/26 directed wound care with normal saline or wound cleanser, calcium alginate, and optifoam every Monday, Wednesday, and Friday. Hospice documentation dated 01/28/26 provided new wound care orders: discontinue the previous sacrococcygeal wound care orders, cleanse with wound cleanser, apply calcium alginate and crushed Flagyl, then cover with carboflex and optifoam, with wound care to be completed daily and as needed. These hospice wound care orders were not entered into the resident’s medical record. The January 2026 Treatment Administration Record showed no wound care documented on 01/29/26. The wound care nurse confirmed that the hospice order from 01/28/26 was not entered, that the 01/14/26 order remained in the record, and that there was no documentation that the provider was notified of the new hospice orders. The DON confirmed that hospice had provided new daily wound care orders, that there was no documentation of provider notification, that the medical record still contained the 01/14/26 order, and that the resident did not receive wound care on 01/29/26.
Unlocked Medication Cart and Expired Medications on 400 Hall
Penalty
Summary
Surveyors identified a deficiency in the facility’s medication management practices related to securing and storing drugs and biologicals for all 20 residents on the 400 hall. During an observation of the 400 hall, the medication cart near the nurse’s station was found unlocked with no staff present, and an LPN confirmed that the cart was not secured and that it should always be locked. The facility’s failure to keep the medication cart locked meant that medications were not properly secured in accordance with requirements that drugs be stored in locked compartments. Surveyors also found multiple expired medications in the treatment and medication carts on the 400 hall. For a resident admitted on 08/08/23, a Breyna inhaler (160-4.5 mcg) stored in the treatment cart was observed to be expired as of December 2025. For a resident admitted on 06/24/10, ipratropium bromide and albuterol sulfate inhalation solution (0.5 mg/3 mg per 3 ml) in the treatment cart was expired as of 06/20/25. For a resident admitted on 02/03/23, an IPAT-ALUBUT UD0 0.5-3 MG/3AMPUL-NEB medication in the medication cart was expired as of 02/25. In interviews, the LPN stated that nurses are supposed to check medications daily for expiration and remove expired or discontinued medications to the designated medication room for disposal, and the DON confirmed that expired medications should not be in the carts and that nurses should check for expired medications each shift.
Failure to Ensure Routine and Emergency Dental Services for Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents received needed routine and emergency dental services as required, including annual oral examinations and timely follow-up for identified dental problems. For one resident, admitted in early December, provider progress notes documented a dental infection on mid-January requiring an urgent dental referral, mandibular x-rays, chlorhexidine mouthwash, and multiple antibiotics. A subsequent provider note in late February documented gingivitis and continuation of chlorhexidine. Nursing notes over the following months repeatedly identified obvious cavities or broken teeth, inflamed or bleeding gums, mouth or facial pain, difficulty chewing, and rotting tooth decay. The resident complained of dental pain and was noted to be taking antibiotics prior to planned dental work, and staff documented that the resident was to have dental extractions due to poor dental health. Dental records for this resident showed a dental visit in late March, initiation of antibiotics, and a plan for dental extraction pending insurance authorization. However, subsequent dental appointments were rescheduled, canceled when the resident did not want to go, or missed as no-shows on multiple dates. After mid-June, there was no further documentation in the medical record regarding any additional dental appointments, the status of the gingivitis, or whether the planned dental extractions were ever completed. Despite ongoing documentation of dental decay and pain, the record lacked evidence of continued efforts to secure or complete the necessary dental treatment. For a second resident, admitted in late February of the prior year, the face sheet and interview revealed that the resident reported not having been to the dentist, experiencing dental pain, and having a missing denture. Physician orders from admission included a standing order to obtain dental consultation and treatment as needed for health and comfort, and a later order to schedule a dental evaluation that was subsequently discontinued without clear directions. In January of the following year, the resident was prescribed Amoxicillin-CLAV for dental pain, but progress notes contained no documentation of dental pain, no indication that the provider was contacted about dental issues, and no referral for a dental appointment. The quarterly MDS did not reflect any dental issues such as broken or loose dentures or mouth/facial pain, despite the care plan noting a suspected or actual dental infection. Interviews with the social services director and scheduler confirmed that no dental referral existed for this resident, that no routine dental appointments were being done, and that there were no past or future dental appointments scheduled, contrary to the facility’s own dental policy and the DON’s stated expectation that all residents receive annual dental exams and that staff follow dental orders.
Failure to Ensure PRN Psychotropic Medication Had Time-Limited Order and Rationale
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident did not receive a PRN psychotropic medication beyond 14 days without documented medical necessity and an end date. One resident with an anxiety disorder, admitted on 10/20/25, had a physician’s order dated 12/05/25 for hydroxyzine 25 mg by mouth every 12 hours as needed for anxious behaviors. The order did not include an end date. Medication administration records for January 2026 show that the resident received hydroxyzine multiple times throughout the month, including on at least 16 separate occasions. During interviews, the Unit Manager stated that the resident had been on PRN hydroxyzine since admission and confirmed that the provider had not documented a rationale in the medical record for the long-term PRN use without an end date. The DON also confirmed that the PRN hydroxyzine was ordered indefinitely, that there was no provider-documented rationale in the resident’s record, and that his expectation is that the provider document a clinical rationale for any PRN hydroxyzine order with an end date greater than 14 days.
Failure to Provide Required Written Transfer and Bed-Hold Notices for Hospitalized Resident
Penalty
Summary
The facility failed to provide required written transfer and bed-hold documentation for a resident who was hospitalized. Record review showed that the resident was admitted to the facility on an unspecified date and was later sent to the hospital due to blood in her vomit, as documented in a nurse’s progress note dated 11/12/25. However, review of the resident’s medical record revealed there was no documented transfer notice or bed-hold notification associated with this hospital transfer. During an interview on 01/30/26 at 8:53 AM, the Social Services Director confirmed that staff did not complete a written Transfer Notice or a written Bed Hold Notification for the resident’s transfer to the hospital, and that a written copy of the Transfer Notice was not sent to the Ombudsman. The Social Services Director also confirmed that staff were expected to complete a written Transfer Notice and Bed Hold Notification for residents transferred to the hospital and to send a copy of the written Transfer Notice to the Ombudsman, but this did not occur for this resident’s hospitalization.
Failure to Provide and Document Fingernail Care for a Dependent Resident
Penalty
Summary
Facility staff failed to provide necessary ADL assistance, specifically fingernail care, to a resident who was totally dependent on staff for ADLs. The resident’s admission record showed he had been admitted to the facility, and his annual MDS documented that he was totally dependent on staff to complete ADL care. During an observation and interview, the resident’s fingernails were noted to be overgrown, yellow, thick, and cracked, and the resident reported that his fingernails had not been cut in a long time. The DON and Unit Manager both confirmed that the resident’s fingernails were overgrown, thick, and in need of medical care, and the Unit Manager stated that the condition would require referral to an outside provider. Review of the resident’s medical record showed no documentation that fingernail care had been provided, and the DON confirmed that staff had not documented any fingernail care despite the resident’s total dependence on staff for ADLs. This failure to provide and document fingernail care for a totally dependent resident constituted a deficiency in ADL assistance that was likely to affect the dignity and health of the resident.
Failure to Ensure Orthopedic Follow-Up After Elbow Fracture
Penalty
Summary
Surveyors identified a deficiency in which a resident with an olecranon (elbow) fracture did not receive the ordered follow-up care with an orthopedic surgeon. Emergency room documentation dated 09/18/25 showed the resident was diagnosed with an olecranon fracture, placed in a longarm splint, and instructed to follow up with an orthopedic surgeon. A provider progress note dated 09/23/25 documented the same diagnosis and stated the fracture was being followed by an orthopedic surgeon, with instructions to schedule an orthopedic follow-up and to continue soft casts for at least six weeks. A subsequent provider note dated 12/03/25 again referenced the olecranon fracture as being followed by an orthopedic surgeon and indicated that an X-ray could be repeated and the soft cast removed. Record review of the resident’s medical record revealed that, despite these recommendations and documentation, the resident did not have a follow-up visit with an orthopedic surgeon as ordered by the ER and the facility provider. This failure to ensure the resident received the recommended orthopedic follow-up constituted the cited deficiency in providing appropriate treatment and care according to orders, preferences, and goals for one of six residents reviewed for accidents.
Failure to Provide Foot and Nail Care for Dependent Resident
Penalty
Summary
The facility failed to provide appropriate foot care and nail care for one resident who was totally dependent on staff for ADLs, resulting in overgrown, yellow, thick, and cracked toenails. The resident had been admitted on an unspecified date and had a documented history of painful mycotic toenails, with a progress note directing removal of all affected mycotic nail tissue to the exposed nail beds as tolerated. During observations, the resident reported that his toenails had not been cut in a long time, and surveyors noted the overgrown condition of the toenails. Review of the medical record showed no documentation that staff had provided toenail care, and the DON confirmed that the resident’s toenails were overgrown, had not been cut, and that there was no documentation of toenail care being provided. The DON further confirmed during observation that the resident’s fingernails were also overgrown and had not been cut, reinforcing that nail care had not been performed or documented. The lack of documented toenail care, despite the resident’s dependence on staff and the existing order to remove mycotic nail tissue, demonstrates that staff did not carry out or record necessary foot and nail care for this resident.
Failure to Address Consultant Pharmacist’s Medication Recommendations
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a physician reviewed and either implemented or documented a rationale for not following a consultant pharmacist’s recommendations for a resident’s medication regimen. The resident had essential hypertension and end stage renal disease requiring dialysis and was receiving multiple antihypertensive medications, including amlodipine, clonidine, and carvedilol, as well as midodrine for cramping related to dialysis. A New Admission Review form dated 11/18/25 documented that the pharmacist recommended evaluation of the concurrent use of medications for both hypertension and hypotension and suggested possibly holding the morning doses of antihypertensives on dialysis days. The form was signed by the unit manager but did not contain a provider signature. Record review showed no documentation in the resident’s medical record that the provider had reviewed the pharmacist’s recommendations or provided a clinical rationale for not following them. The resident’s orders for antihypertensives and midodrine had not been changed since the pharmacist’s recommendation. During interviews, the unit manager confirmed the pharmacist’s recommendation and acknowledged the absence of the provider’s signature and any changes to the medication orders, and stated she could not determine if the provider had reviewed the recommendation. The DON confirmed that providers were expected to review all pharmacist recommendations, sign the recommendation forms, and document a clinical rationale if they did not agree with the recommendations, which had not occurred in this case.
Failure to Follow Enhanced Barrier Precautions and Oxygen Tubing Change Protocols
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to enhanced barrier precautions (EBP) and respiratory equipment care. For one resident with wounds, federal guidance on EBP indicated that residents with wounds require targeted gown and glove use during high-contact care activities such as wound care and assisting with positioning. The resident had active wound care orders for a right shin wound and a stage 2 pressure ulcer. During an observed wound care procedure, there was a sign on the resident’s door directing staff to use EBP for high-contact care, and PPE was available in a bin next to the door. Despite this, the wound care nurse did not don a gown while performing wound care, and the CNA assisting with positioning also did not wear a gown. The CNA was observed rolling the resident onto her side so that the front of the resident’s body was against the CNA’s body. Both staff later confirmed they had not worn gowns, and the DON confirmed that all staff are expected to follow EBP for high-contact care, including wound care and assistance with wound care. A second deficiency involved failure to follow physician orders for changing and labeling oxygen tubing for a resident with COPD who was receiving oxygen at 2 LPM via nasal cannula. The physician’s orders required weekly oxygen tubing changes and labeling each component with the date and initials. During observation and interview, the resident was wearing a nasal cannula that had no date indicating when it was last changed, and the resident did not know when or how often staff changed it. The CNA confirmed that the nasal cannula lacked a date and that she could not determine when it was last changed, stating that staff are expected to write the date on the tubing when it is changed. The DON later confirmed that staff are expected to change oxygen tubing every seven days and label it with the date of change, which had not been done for this resident.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Adhere to Professional Standards in Narcotic Medication Administration and Documentation
Penalty
Summary
The facility failed to meet professional standards of practice in the administration and documentation of narcotic pain medications for four residents. Staff administered narcotic medications earlier than the prescribed intervals, with multiple instances where medications were given less than the ordered four or six hours apart. In some cases, residents received higher doses than ordered or duplicate doses within a short time frame. These actions were documented in the controlled drug records and medication administration records (MARs), showing discrepancies in timing and dosage. Additionally, staff did not consistently notify providers when residents required pain medications more frequently than ordered. There was no documentation indicating that providers were informed about the increased frequency of pain medication requests, which would have been necessary for proper pain management assessment and potential adjustment of orders. Interviews with staff and the nurse practitioner confirmed that provider notification was expected but did not occur, and that the nurse practitioner relied on MAR documentation to assess pain management needs. Documentation practices were also deficient, as staff failed to consistently record the administration of narcotic medications and the reassessment of pain effectiveness on the MARs. The lack of documentation meant that subsequent staff and providers were not fully informed about the residents' pain management and medication usage. Interviews with staff and the DON revealed a lack of clarity regarding the timing of PRN medication administration and the importance of thorough documentation, further contributing to the deficiencies identified.
Failure to Maintain Complete Controlled Drug Records for Multiple Residents
Penalty
Summary
The facility failed to maintain complete and accurate controlled drug records for several residents who were prescribed and administered controlled substances, such as hydrocodone-acetaminophen and oxycodone-acetaminophen, for pain management. For one resident, there were multiple periods where the controlled drug records were missing, despite documentation on the Medication Administration Record (MAR) indicating that the medications had been administered during those times. Specifically, there were no controlled drug records for certain periods, even though the MAR showed that doses were given, resulting in a lack of documentation to track the use of these controlled substances. Another resident's controlled drug record for oxycodone-acetaminophen was found to have missing pages, and the Director of Nursing (DON) confirmed that the facility was expected to keep all controlled drug records for narcotic medications but was unaware of the missing records until requested by surveyors. Similarly, for another resident, the controlled drug record for oxycodone was missing pages for a specified period, which was also acknowledged by the DON during an interview. In addition, for a fourth resident, staff failed to document the administration of oxycodone on the controlled drug record, even though the MAR indicated that the medication had been given on specific dates and times. The DON confirmed during interviews that staff were expected to document each administration of controlled medications on both the controlled drug record and the MAR, and that completed records should be retained and scanned into the resident's medical record. The absence of these records prevented reconciliation of the medications administered with the MARs and resulted in incomplete documentation for the acquisition, administration, and disposal of controlled substances for multiple residents.
Incomplete and Inaccurate Documentation of Narcotic Medication Administration
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for six residents who were receiving PRN opioid pain medications. Staff did not consistently document the administration of narcotic medications on both the Medication Administration Record (MAR) and the Controlled Drug Record as required. In several instances, medication administrations were recorded on the Controlled Drug Record but not on the MAR, and vice versa. Additionally, there were discrepancies between the physician’s orders and the instructions on the Controlled Drug Record, such as mismatched dosing intervals. For multiple residents, including those with intact cognitive function and ongoing pain management needs, the documentation failures included missing entries for administered doses, late documentation, and missing pages from Controlled Drug Records. In some cases, the Controlled Drug Record was incomplete or could not be reconciled due to missing documentation. Interviews with staff, including the DON and a nurse practitioner, confirmed that staff were expected to document all narcotic administrations on both the MAR and Controlled Drug Record, and that these records were used to assess pain management and medication usage. The lack of accurate and complete documentation affected the ability to track medication administration and ensure orders were followed as written. The DON and other staff acknowledged the missing or inconsistent documentation and the inability to reconcile records due to missing pages. These deficiencies were observed across all six residents reviewed for misappropriation of property, with specific examples of undocumented or mismatched medication administrations detailed for each resident.
Failure to Prevent Resident Elopement Due to Inadequate Risk Assessment and Security
Penalty
Summary
The facility failed to prevent multiple incidents of resident elopement due to inadequate recognition of elopement risk, failure to secure exit doors and gates, and insufficient supervision. Three residents with cognitive impairments and histories of wandering or elopement were able to leave the facility on several occasions. Staff did not consistently identify or document residents' elopement risk, and elopement assessments were either incomplete or not updated after incidents occurred. For example, one resident with dementia and muscle weakness had a documented history of exit-seeking behavior, but staff failed to document interventions or clinical suggestions on her elopement evaluation. Interviews with staff confirmed that this resident frequently attempted to leave and would follow others out of the facility if not closely monitored. Physical security measures were also lacking. Exit doors and exterior gates, including those in the dining room and south courtyard, were found to be either malfunctioning or left unsecured. Maintenance staff admitted that the south courtyard gate was routinely left unlocked during the day and only secured at night, and that the padlock was not always used. After one resident was found outside in the parking lot, the administrator instructed maintenance to secure the gates, but prior to this, the area was accessible and unsafe for residents. The lack of proper supervision and environmental controls led to multiple elopements. One resident with end-stage renal failure, diabetes, and cognitive impairment eloped multiple times, including an incident where she was missing for approximately 30 hours and was later hospitalized for emergency dialysis, dehydration, and sunburn. Another resident with dementia and psychiatric diagnoses left the facility with a peer, and staff failed to update elopement assessments or care plans after these events. Staff interviews revealed that there was a general awareness of residents' exit-seeking behaviors, but appropriate risk assessments, documentation, and immediate interventions were not consistently implemented.
Medication and Treatment Carts Left Unsecured
Penalty
Summary
Surveyors observed that both the medication cart and the treatment cart on the 500 unit were left unlocked, making medications and medical supplies accessible to unauthorized individuals. Specifically, lancets used for blood sugar checks were found in a tray on top of the medication cart. These observations were confirmed by interviews with a registered nurse and the unit manager, who acknowledged that the carts should have been secured and that lancets should not be stored on top of the cart. A review of facility policies revealed that only licensed nurses, pharmacy staff, and authorized medication aides are permitted access to medication carts, and that treatment carts and their keys must be secured at all times. The failure to secure these carts and properly store medical supplies affected all 37 residents on the 500 unit, as identified by the facility's census list.
Failure to Report Resident Elopement to State Agency
Penalty
Summary
The facility failed to report two incidents of elopement involving two residents to the State Agency. On the specified date, a maintenance assistant observed the two residents in the facility's south parking lot area, and one of the residents later confirmed that both had exited through the back gate and were subsequently brought back inside by staff. During an interview, the Administrator acknowledged awareness that the residents were found outside by the dumpsters but stated that the incident was not considered an elopement because the residents remained on facility grounds. As a result, the incident was not reported to the State Agency as required.
Lack of Physician Documentation in Resident Discharge
Penalty
Summary
The facility failed to ensure that the physician documented the required discharge information in the medical records of a resident who was discharged. The resident was admitted to the facility and later experienced a change in condition, prompting the provider to order a transfer to a hospital for a higher level of care. The administrator notified the resident's Power of Attorney about the immediate discharge due to the resident harming two other residents and posing an immediate danger. However, the medical records lacked documentation from the physician regarding the facility's inability to meet the resident's needs, the attempts made to meet those needs, and how the transferring facility could meet them. During an interview, the administrator confirmed the absence of this documentation, which is a required part of the discharge process.
Failure to Revise Care Plans for Lift Device Needs
Penalty
Summary
The facility failed to revise the care plans for three residents, identified as R #8, R #9, and R #10, who were reviewed for Resident/Patient/Client Neglect. Each resident's Lift Transfer Evaluation indicated the need for at least two staff members to assist with a lift device. However, the care plans for these residents did not document the requirement for a lift device or the necessary interventions. Specifically, R #8's Lift Transfer Evaluation dated 02/02/25, R #9's dated 01/01/25, and R #10's dated 01/31/25 all revealed the need for two-person assistance with a lift device, yet their care plans dated 02/03/25, 02/04/25, and 02/03/25, respectively, lacked this information. During an interview on 02/27/25, the Director of Nursing (DON) confirmed the oversight and stated that care plans should reflect the residents' needs and interventions, including the use of lift devices and the number of staff required for safe utilization.
Failure in Discharge Planning Process
Penalty
Summary
The facility failed to develop and implement a discharge planning process for a resident, identified as R #26, which resulted in a deficiency. The facility did not create an individualized discharge plan that included the resident's goals and needs. Additionally, the Interdisciplinary Team (IDT) was not involved in the discharge planning process, and there was no documentation of the resident's Power of Attorney (POA) being involved prior to the notice of discharge. The resident was admitted to the facility on March 25, 2023, and discharged on January 25, 2025, without a documented discharge plan. Interviews with facility staff revealed further deficiencies in the discharge process. The Social Worker confirmed she was not involved in the discharge and did not complete a discharge note for the resident. The Administrator acknowledged that the resident's discharge goals or needs were not documented and that the resident was not given a 30-day notice for discharge. A discharge meeting was held on the day of discharge with the resident's POA over the phone, and the Administrator documented the immediate discharge in the progress notes.
Failure to Complete Discharge Summary and Medication List
Penalty
Summary
The facility failed to ensure that a discharge summary, including a recapitulation of the resident's course of treatment and a list of all medications, was completed for a resident at the time of discharge. The resident was admitted to the facility on an unspecified date and discharged to a local hospital on January 25, 2025. Upon review, it was found that the staff did not document the necessary discharge summary or medication list, nor did they provide the resident with a discharge summary. During an interview on February 28, 2025, the Administrator confirmed that the discharge summary was not completed at the time of the resident's discharge. Additionally, the Administrator noted that the resident's Power of Attorney was informed of the immediate discharge due to the resident harming two other residents, which posed an immediate danger. The facility decided not to accept the resident back due to this risk.
Inadequate Foley Catheter Care Observed
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with a Foley catheter. During an observation in the Activity Room, the resident's catheter tubing was seen dragging on the floor as the resident self-propelled in a wheelchair. This was confirmed by an LPN and the Director of Nursing (DON), both acknowledging that the catheter tubing should not be on the floor. The facility's policy on indwelling urinary catheters specifies that catheter tubing should be secured, keeping the drainage bag below the level of the patient's bladder and off the floor. The failure to adhere to this policy could likely result in infections for the resident.
Failure to Implement and Document Wound Care Orders
Penalty
Summary
The facility failed to ensure that wound care orders were implemented and documented for a resident with a stage 3 pressure ulcer. The resident was admitted with a pressure ulcer on the sacrum, and a wound care consultation recommended the use of a Wound VAC and specific dressings. However, the facility staff did not enter the wound care order into the physician's orders, leading to a lack of documentation and implementation of the prescribed wound care. The Treatment Administration Record for the resident showed no documentation of wound care from October 23 to October 29, 2024. Additionally, the nursing progress notes did not indicate any communication with the wound care consultant regarding the failure of the Wound VAC to stay on the resident. An LPN involved in the care could not recall specific dates or details of the wound care provided and did not document the care, as it was the responsibility of the wound care nurse. The Director of Nursing confirmed that the wound care order was not entered, which meant staff were not prompted to provide the necessary care. The lack of documentation and communication with the wound care consultant contributed to the deficiency, as staff were unaware of the resident's current condition and the required interventions for the pressure ulcer.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, resulting in multiple incidents involving three residents. One resident, identified as R #12, experienced verbal abuse from a CNA who called her lazy, leading the resident to attempt tasks independently and fall. The CNA's behavior was reported by the resident, her sister, and other staff members, but the facility's administration was not aware of the issue until after the resident's sister reported it. The facility's investigation confirmed the verbal abuse, and it was noted that the CNA had a loud and bossy demeanor that was distressing to residents. Another resident, R #117, reported being physically and verbally abused by an RN. The resident described being hit and degraded by the RN, who also dragged her off a chair in a confrontational manner. A CNA witnessed the RN's aggressive behavior and reported it to the unit manager, but the incident was not documented or addressed promptly. The resident expressed fear of the RN, indicating a significant breach in the facility's duty to provide a safe environment. The third resident, R #94, suffered physical injuries, including bruises and skin tears, during an incident with the same RN. The RN reported the resident as being combative, but the extent of the injuries and the lack of previous documentation of such behavior raised concerns. A CNA observed blood in the resident's room and on the RN, but did not report it. The facility's failure to document and investigate these incidents promptly contributed to the residents' harm and distress.
Failure to Report Abuse Allegations Timely
Penalty
Summary
The facility failed to report alleged abuse incidents involving four residents to the State Agency in a timely manner. Resident #12 reported being called lazy by CNA #16, which led to her attempting to use the restroom independently and falling. Despite multiple reports from other residents and staff about CNA #16's behavior, the facility did not report the incident to the State Agency within the required two-hour timeframe. Additionally, the facility did not submit a five-day follow-up report for Resident #16's altercation with a roommate within the mandated period. Resident #117 experienced abuse from RN #24, who was observed yelling and physically dragging the resident. Despite the incident being reported to the unit manager, it was not communicated to the State Agency within the required timeframe. Furthermore, Resident #94 sustained injuries during an encounter with RN #24, who was the only staff present during the incident. The resident was described as combative, but the extent of the injuries and the lack of previous documentation of such behavior raised concerns about the incident's handling. The facility's failure to report these incidents promptly allowed for potential further abuse, as evidenced by RN #24's subsequent involvement in another incident. The lack of timely reporting and investigation into these allegations of abuse highlights significant deficiencies in the facility's handling of abuse allegations, potentially compromising resident safety.
Facility Lacks QAPI Training for Staff
Penalty
Summary
The facility failed to provide Quality Assurance and Performance Improvement (QAPI) training to its staff, which could potentially affect all 127 residents. During an interview, the Administrator admitted that the facility did not have the QAPI training in place for staff and mentioned that they were in the process of implementing it. This lack of training could result in staff being unable to identify opportunities for improvement, address gaps in systems or processes, develop and implement an improvement or corrective plan, and continuously monitor the effectiveness of interventions.
Deficiency in CNA Annual Training
Penalty
Summary
The facility failed to include performance reviews as part of the required 12 hours of annual training for three certified nurse aides (CNAs). This deficiency was identified through interviews and record reviews, which revealed that the training records for CNAs #34, #35, and #36 did not contain performance evaluations. Despite the CNAs having worked at the facility for more than a year, their performance reviews were not utilized as part of their annual training. The Staff Development Coordinator confirmed the absence of performance evaluations in the training records, and the Director of Nursing (DON) acknowledged that while performance reviews were conducted, they were not incorporated into the annual training hours.
Failure to Document Hospice Services
Penalty
Summary
The facility failed to ensure that a resident receiving hospice services received treatment and care in accordance with professional standards of practice. The deficiency was identified when the facility did not have documentation regarding the services provided to the resident by hospice staff. The resident was admitted to the facility with an order for hospice services, which included bed baths three times a week and weekly visits from a hospice nurse. However, the facility did not have recent documentation from hospice staff, with the last recorded hospice care plan dated several months prior. Interviews with facility staff, including an LPN and the DON, revealed that hospice staff were expected to fax or drop off documentation of the care provided, which should then be scanned into the resident's chart and placed in a hospice binder at the nurses' station. Despite these expectations, the facility was unable to determine the last time hospice staff provided care to the resident or what specific services had been rendered. This lack of documentation could lead to staff being unaware of the services provided by hospice and potentially result in unmet resident needs or a worsening condition.
Failure in Dialysis Communication and Monitoring
Penalty
Summary
The facility failed to ensure proper communication and collaboration with the dialysis center for a resident with end-stage renal disease (ESRD) who required dialysis treatment. The resident had physician orders for dialysis on specific days and times, but the facility did not complete the necessary post-dialysis monitoring and assessments. The Dialysis Communication Records for multiple dates showed that while pre-dialysis information was recorded, there was no documentation of post-dialysis information, monitoring, or assessments. During an interview, the Director of Nursing (DON) confirmed that the dialysis communication sheets were incomplete for the specified dates. The DON acknowledged that a nurse should have completed these sheets when the resident left for and returned from dialysis. This lack of documentation and monitoring could result in the facility being unaware of the resident's condition and any complications that might arise during dialysis treatment.
Inappropriate Use of Psychotropic Medications Without Proper Diagnosis
Penalty
Summary
The facility failed to ensure that residents did not receive psychotropic medications unless necessary to treat a specific psychiatric diagnosis. For one resident, quetiapine, an antipsychotic medication, was prescribed for depression without a corresponding psychiatric diagnosis. The Director of Nursing (DON) confirmed that the resident did not have a psychiatric diagnosis justifying the use of the antipsychotic medication, indicating that the physician ordered it for depression. Another resident was prescribed ziprasidone, a medication typically used for schizophrenia or bipolar disorder, for dementia with behaviors. The resident's care plan indicated a risk for complications related to psychotropic drugs, and the medication was to be administered as ordered by the provider. However, the psychiatric notes were unclear about the specific reason for the medication, and the Medical Director expressed that she would not typically prescribe ziprasidone for dementia, suggesting a lack of clarity and appropriate diagnosis for the medication's use.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to properly store medications by not documenting temperatures for medication refrigerators on the East and [NAME] Units and by not securing a treatment cart on the 500 Unit. On the East Unit, the medication refrigerator temperature logs for September 2024 showed recorded temperatures on only a few days, with temperatures ranging from 41 to 45 degrees. There were several days when the temperature was not documented at all. Similarly, on the [NAME] Unit, the temperature logs from September 16 to September 30, 2024, showed consistent temperatures of 48 degrees on the days recorded, but there were missing entries for several days, and no documentation was available for the first half of the month. Interviews with CMA #8 and CMA #9 confirmed the missing temperature documentation, and the DON acknowledged the blank dates and uncertainty about whether temperatures were taken on those days. Additionally, the facility failed to secure a treatment cart on the 500 Unit. On September 27, 2024, observations revealed the treatment cart was unlocked, and staff were not present. LPN #36 confirmed the cart was unlocked and stated it did not have a key, making it impossible to lock. The DON also confirmed the treatment cart was unlocked and stated that treatment carts should be locked. These deficiencies in medication storage and security had the potential to affect all 127 residents in the facility.
Deficiencies in Food Storage and Temperature Documentation
Penalty
Summary
The facility failed to maintain proper food storage and temperature documentation practices, which could potentially affect all residents consuming food prepared in the kitchen. During an observation of the kitchen's walk-in freezer, a bag of hash browns was found with an erased date that was not visible. The kitchen's District Manager confirmed that the date on the bag was erased and stated that dates should be readable on all packaged food. This oversight in food storage practices could lead to foodborne illnesses if not addressed. Additionally, the facility did not consistently document the temperatures of snack refrigerators on the East and [NAME] Unit. The temperature logs for these refrigerators showed multiple dates where temperatures were not recorded. Interviews with CMA #8, CMA #9, and the DON confirmed that staff failed to document refrigerator temperatures daily, as required. This lack of documentation could compromise the safety of food stored in these refrigerators, posing a risk to residents' health.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a comfortable and homelike environment for several residents, as evidenced by various deficiencies observed during the survey. In one instance, a resident's room had broken blinds that were stuck and could not be adjusted, which was confirmed by the Maintenance Director. Another resident's room had scuff marks on the walls, and a large area behind the bed was not painted to match the rest of the room, as confirmed by the Maintenance Director. Additionally, a resident's restroom vent was covered with plastic, aluminum foil, and duct tape, which was falling off, and the resident reported that the vent had been covered for a year due to cold temperatures. Further observations revealed that a resident's toilet was misaligned, making it difficult to use, and the bathroom window was covered with plastic. Another resident's air vent was full of lint and dust, which was falling onto the resident, as confirmed by the resident and the Maintenance Director. In another room, the vent was covered with plastic and duct tape, which was torn and tattered. Additionally, the crash cart in the Dementia unit was found to have black dead bugs on it, as confirmed by an LPN. These deficiencies indicate a failure to provide a safe, clean, and comfortable environment for the residents.
Deficiencies in Care Planning for Residents with Special Needs
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, leading to deficiencies in their care. Resident #14, who had a Percutaneous Endoscopic Gastrostomy (PEG) tube for feeding, did not have a care plan addressing the management and care of the PEG tube. Despite having a physician's order to flush the PEG tube twice daily with 60 ml of water, this critical aspect of care was omitted from the resident's care plan. This oversight was confirmed during an interview with the Director of Nursing (DON), highlighting a gap in the resident's care planning process. Similarly, Resident #123, who was admitted with two unstageable deep tissue injuries, did not have a care plan addressing the management of these pressure ulcers. The comprehensive assessment conducted upon admission identified these injuries, yet the care plan failed to include necessary interventions for their care. This omission was also confirmed by the DON, indicating a lack of comprehensive planning for the resident's specific medical needs. These deficiencies in care planning could potentially lead to inadequate care and worsening of the residents' medical conditions.
Care Plan Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised for nine residents, leading to deficiencies in the care provided. The interdisciplinary team (IDT) meetings for several residents did not include all required team members, such as direct care providers, which could result in incomplete care planning. For instance, the care plan meetings for some residents were attended by staff who were not familiar with the residents' daily care needs, and providers were not invited to these meetings unless specifically requested by the resident or their representative. Additionally, the facility did not conduct care plan meetings within the required seven days following the completion of the Minimum Data Set (MDS) assessments for some residents. This delay in care plan meetings was evident in the cases of two residents, where meetings were not held within the stipulated timeframe after their MDS assessments. This oversight could lead to care plans not reflecting the most current resident conditions and interventions. Furthermore, the facility failed to update care plans with the most current resident information. Several residents had changes in their health status or new medical orders that were not reflected in their care plans. For example, one resident's care plan did not include interventions for oxygen use, while another resident's care plan lacked documentation of treatment for constipation and diarrhea. These omissions could result in staff being unaware of necessary care interventions, potentially impacting the quality of care provided to the residents.
Failure to Prevent Falls for a Resident at Risk
Penalty
Summary
The facility failed to prevent accidents for a resident who was at risk for falls. The resident, who had multiple diagnoses including encephalopathy, type 2 diabetes mellitus, morbid obesity, and unspecified dementia with psychotic disturbance, experienced two falls in the restroom. The first fall occurred when a CNA left the resident alone in the restroom, advising her to call for assistance when finished. The resident attempted to transfer herself to her wheelchair, which moved, causing her to fall and report pain in her right mid-lower back. X-rays were ordered following this incident. The second fall happened on the same day when the resident attempted to toilet herself independently after staff did not respond to her call bell. She reported pain in both knees after this fall. The resident's quarterly MDS assessment indicated that she required supervision or touching assistance for sit-to-stand, chair/bed-to-chair, and toilet transfers. However, the care plan did not specify the level of assistance required for these activities, nor did it document the expectation for the resident to use the call light when transferring. Interviews with staff revealed that the resident was selective about which CNAs she allowed to assist her and was more likely to attempt transfers without assistance when certain CNAs were on duty. The DON confirmed that the fall prevention interventions in place prior to the falls included keeping the bed in a low position, providing verbal cues and sequencing, and encouraging the use of the call light. However, the care plan lacked specific details on the verbal cues and sequence to be used, and it was not updated to include the expectation for the resident to use the call light prior to transferring.
Staffing Shortages Lead to Unmet Resident Needs
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of residents, as evidenced by the experiences of two residents. On the morning of 09/30/24, Resident #12 was observed in bed wearing pajamas and reported that staff had not assisted her in getting up or changing her wet brief. She had pressed the call bell but was unsure how long she had been waiting. Nursing Assistant #16 responded to her call light after 24 minutes and admitted that Resident #12 was not assisted earlier due to being short-staffed, with only two CNAs working instead of the usual three. Similarly, Resident #66 did not receive scheduled showers due to staffing shortages. On 09/26/24, CNA #18 reported that the unit was short-staffed, with only two CNAs instead of the required four, resulting in missed showers for residents. Resident #66 confirmed that she was informed she would not receive a shower that day and frequently missed showers due to insufficient staffing. The Director of Nursing stated that staff are expected to respond to call lights promptly and that residents should not miss showers unless they refuse, which should be documented.
Failure to Complete and Document Wound Care as Ordered
Penalty
Summary
The facility failed to meet professional standards of care for a resident who required wound care. The resident had a physician's order dated 07/03/24 for daily wound care on the left foot, which included cleansing, applying Skin-prep, MediHoney, and calcium alginate, and covering with specific dressings. However, the treatment administration record (TAR) for July 2024 showed that staff did not initial the TAR on 07/05/24, 07/09/24, and 07/11/24 to confirm that the wound care was completed. Additionally, the nurse progress notes lacked documentation on whether the wound care was completed on these dates. The nurse progress notes revealed that on 07/09/24, an LPN noted that wound care would be completed the following day and mentioned pending clarification on the frequency of the wound care. There was no documentation of attempts to contact the provider for clarification on the wound care orders. On 07/11/24, another note indicated that wound care would be completed the next day. During an interview, the Director of Nursing (DON) stated that her expectation was for wound care to be completed daily as ordered and documented in the TAR, with any provider contact attempts noted in the progress notes.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide adequate care and treatment for a resident with a pressure ulcer on her right heel, as per professional standards. The resident, who was admitted with diagnoses including encephalopathy and unspecified dementia, had a bandage on her right heel but was unsure of the nature of the wound or the frequency of dressing changes. Staff documented bruising on the resident's right heel during skin assessments on multiple occasions but failed to provide measurements or descriptions. Additionally, there was no documentation of the provider being notified about the pressure injury or any interventions to prevent its worsening. The resident's medical records revealed that she had fallen twice, and staff noted a stage one pressure injury on her right heel, applying a foam dressing and instructing offloading while in bed. However, there were no wound measurements or notifications to the provider about the injury. The provider's progress notes did not mention the pressure injury, and there were no wound care orders for the resident's right heel until over a month after the initial documentation of bruising. Orders for heel protectors and Mepilex application were entered much later, and a referral to wound care was only made after significant delay. Interviews with staff, including a registered nurse and nurse practitioner, revealed a lack of communication and documentation regarding the resident's condition. The RN admitted to not documenting reeducation efforts or the application of Mepilex, while the NP was unaware of the pressure injury and did not recall giving orders for wound care. The DON confirmed that staff are expected to document and report any wounds or pressure injuries, but this was not done in the resident's case. The lack of timely notification and documentation likely contributed to inconsistent interventions and the potential worsening of the pressure ulcer.
Failure to Administer Prescribed Medications
Penalty
Summary
The facility failed to ensure pharmaceutical services were adequately provided for a resident, leading to a deficiency in medication administration. A review of the resident's physician orders revealed prescriptions for Lyrica and Nephro-Vite, which were not documented as administered from August 2 to August 7, 2024. During an interview, a CMA stated that the medications were unavailable until after the resident was transferred to the hospital on August 7, 2024. Additionally, there was no documentation of communication with the pharmacy regarding these medications in the resident's progress notes. The DON confirmed the lack of documentation and acknowledged the facility's responsibility to ensure the resident received the prescribed medications.
Failure to Update Resident's Code Status
Penalty
Summary
The facility failed to update the medical record for a resident regarding their advanced directive and code status. The resident, identified as R #20, had a physician's order, a Medical Orders for Scope of Treatment (MOST) form, and a care plan all indicating a do not resuscitate (DNR) status. However, during a care plan meeting, the resident requested a change in their code status from DNR to full code, which allows for cardiopulmonary resuscitation (CPR) to be performed if necessary. Despite the resident's request, the facility did not complete a new MOST form, nor did they update the resident's orders and care plan to reflect the change to full code. Interviews with the Social Services Director and Assistant confirmed that the code status was discussed during care plan meetings and that staff should have completed the necessary documentation to reflect the resident's wishes. The failure to update the resident's code status could result in their wishes not being honored in a life-threatening event.
Failure to Implement Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that the consultant pharmacist's recommendations were reviewed and implemented by the physician, or that the physician provided a rationale for not following the recommendations for two residents. For one resident, a pharmacy consultation report indicated that there was an as-needed order for lorazepam, which had been in place for more than 14 days without a stop date. The recommendation was for a clinical rationale for continuation, but the resident's electronic medical record did not provide any additional information regarding the indication for continued use or rationale on why the pharmacist's recommendation was not implemented. The Director of Nursing confirmed the lack of documentation for the continued use of lorazepam. For another resident, the pharmacist's medication review progress notes contained recommendations that were not specified in the report. The Director of Nursing stated that she did not receive the drug regimen review back from the provider for August and was still waiting for September's review. This lack of follow-up on the pharmacist's recommendations could result in residents receiving unnecessary medications, potentially leading to drug interactions or adverse side effects.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for two residents, which is a federally mandated process for clinical assessment in Medicare or Medicaid-certified nursing homes. For one resident, identified as R #12, the facility did not document a urinary tract infection (UTI) in the MDS assessment, despite the resident having been prescribed antibiotics for a suspected UTI within the past 30 days. This discrepancy was confirmed during an interview with the Director of Nursing (DON), who acknowledged that the MDS should have reflected the UTI diagnosis. Another resident, identified as R #14, had a Percutaneous Endoscopic Gastrostomy (PEG) tube for feeding, which was not documented in the Medicare 5-day MDS assessment. The resident's physician orders included instructions to flush the PEG tube twice daily with water, yet this was not captured in the MDS. This oversight was confirmed by both a registered nurse and the MDS Licensed Practical Nurse (LPN), who acknowledged that the PEG tube flushes were not recorded in the assessment. These inaccuracies in the MDS assessments could lead to an incomplete understanding of the residents' medical needs.
Deficient Management of Enteral Tubes for Two Residents
Penalty
Summary
The facility failed to properly manage enteral tubes for two residents, leading to deficiencies in their care. Resident #13 had specific physician orders for tube feeding to run from 3:00 PM to 11:00 AM at 75 ml per hour. However, observations on two separate days revealed that the tube feeding machine was off, and no feeding supplies were present in the room. An LPN confirmed that the feeding was stopped earlier than ordered, which was not in compliance with the physician's instructions. The Director of Nursing acknowledged that not following the prescribed feeding schedule could result in the resident not meeting nutritional requirements and potential weight loss. Resident #14, who had a PEG tube, did not have a care plan in place for the tube's maintenance. During an interview, it was noted that the resident's PEG tube site appeared crusty, and there was no dressing in place. A nurse practitioner provided an order for daily PEG tube site care only after this observation. The Director of Nursing confirmed that there were no prior orders for the care of the PEG tube site, indicating a lapse in ensuring proper care and maintenance of the resident's medical needs.
Incomplete and Inaccurate Medical Records for a Resident
Penalty
Summary
The facility failed to ensure complete and accurate medical records for a resident, identified as R #40, which could potentially impact the care provided. The resident was admitted with diagnoses including protein-calorie malnutrition, bipolar disorder, and major depressive disorder. A review of the resident's physician's orders revealed a directive for PEG tube care, which was not documented in the treatment administration record (TAR) for August and September 2024. This omission meant that staff did not document the completion of PEG tube care, indicating a lapse in maintaining accurate medical records. Additionally, there was confusion regarding the resident's medication orders. The physician's progress notes from June 2024 indicated a continuation of aripiprazole for bipolar disorder, yet the order from July 2024 listed the medication for major depressive disorder. The Director of Nursing (DON) confirmed that the documentation for the use of the antipsychotic medication was unclear, and the order was entered incorrectly, leading to further inaccuracies in the resident's medical records.
Failure to Safeguard Resident Medical Records
Penalty
Summary
The facility failed to safeguard resident medical record information for all 126 residents, as observed during a survey. On the morning of June 17, 2024, a computer on the medication cart in the 500 Unit, specifically in rooms [ROOM NUMBER] and 507, was found open with the screen unlocked and unattended by staff. This allowed resident information to be visible and accessible. During an interview later that evening, CMA #11 confirmed that the computer was left open with resident information visible, acknowledging that it should not have been left unlocked. CMA #11 explained that he had stepped away briefly to attend to another matter.
Deficiency in CPR Protocols and Code Status Awareness
Penalty
Summary
The facility failed to ensure a functional system was in place for initiating or not initiating CPR during emergencies for all 73 residents who were Full Code. This deficiency was highlighted by an incident involving a resident who was found unconscious in their bedroom. The staff began CPR four minutes after the LPN was notified, and suctioning was initiated six minutes after CPR started. The resident's code status was Full Code, but the CNA who responded did not know this at the time of the incident, despite being CPR certified. Interviews with various CNAs revealed a lack of awareness regarding residents' code statuses and uncertainty about the procedures to follow in emergencies. The facility's CPR policy requires licensed nursing staff to maintain current CPR certification and to perform CPR unless there is a written order not to resuscitate. However, the report indicates that the tracking of CPR certifications was not effectively managed, as the payroll department did not track certifications for any staff until recently. The DON expected CNAs to know where to find residents' code statuses and to initiate CPR if certified, but interviews showed that staff were not consistently aware of this information. This lack of clarity and preparedness could lead to delays in providing necessary life-saving measures.
Latest citations in New Mexico
Surveyors found that the facility did not provide required written transfer and bed-hold notices when several residents were sent to the hospital for events such as falls with injury, unresponsiveness, and episodes of nausea, vomiting, and bleeding. Medical records lacked written transfer notices and bed-hold notifications, and the transfer information that should have been given to residents or their representatives did not include mandated details about appeal rights, how to request an appeal, or how to contact the State LTC Ombudsman. The Social Services Director reported that she does not notify the Ombudsman of hospital transfers and only sends a monthly email list of discharged residents, without written copies of transfer or discharge notices.
Two cognitively impaired residents with dementia and significant behavioral and continence needs were sent to a local ER after falls and were discharged back to the facility’s care, but the facility failed to provide timely transportation for their return. In both cases, hospital discharge times were documented, yet ER staff reported making multiple unsuccessful calls to the facility, reaching the Administrator only after repeated attempts. One resident, described as very disoriented, remained in the ER for several hours after discharge without 1:1 supervision, while the other waited approximately 11 hours, during which ER staff observed increasing confusion and attempts to get out of bed. The Administrator acknowledged awareness of the discharges, the lack of 24-hour transportation, and that the residents were not picked up until many hours after they had been discharged from the ER.
Two residents who required staff assistance for ADLs and transfers reported neglectful and rude behavior by a CNA and delayed nursing response to care needs. One resident with a history of cerebral infarction and schizophrenia stated that a CNA mocked him and that his requested wound dressing change was not performed for several hours, which was later corroborated by video showing a long gap between the CNA’s visit and the nurse’s entry to the room. Another resident with a right femur fracture, type II DM, and repeated falls, who needed one-person assistance for mobility and self-care, reported that a CNA refused to help and told her she could do some care herself, making her feel she was not trying in her recovery. Documentation and interviews confirmed that staff did not provide timely wound care or required assistance, and that these interactions caused residents to feel uncomfortable and negatively about their care.
A resident with a history of opioid dependence and polysubstance abuse was on a secure unit with a care plan that included safety risk evaluations and monitoring for signs of substance abuse. Staff later observed the resident discarding an empty Suboxone packet, even though the resident was not prescribed this medication, and the incident was reported to the on-call provider with subsequent monitoring and a room search. However, the care plan was not revised to reflect this new substance-related event, and both the DON and Administrator acknowledged that the care plan should have been updated when this new risk and behavior were identified.
Surveyors identified that a medication cart on the north hall was left unlocked and unattended outside a resident room. An LPN acknowledged that the cart was hers and that she had not locked it before leaving to answer a call light, despite facility expectations. The DON confirmed that all medication and treatment carts are required to remain locked when not in use or when staff are away from them.
Surveyors found that a document containing multiple residents’ PHI, including full names, room numbers, and code status, was left unattended and visible on a south nurse’s station counter. An RN confirmed the document was a resident list with PHI and acknowledged it had been left exposed and that such information should not be left unattended.
Surveyors found that a lunch tray return cart containing uncovered, soiled food trays and dishes was left unattended in a main hallway outside an activity room. The housekeeping/laundry manager acknowledged seeing the unattended cart, and the Dietary Manager confirmed that such carts are supposed to remain only in designated areas, such as near the nurse’s station or in the kitchen, and should be returned to the kitchen for cleaning as soon as all trays are collected. This failure was cited as likely to expose all residents to potential pathogens associated with food waste.
Two residents with scheduled showers reported that they were offered or received showers in very cold water during a prolonged period when hot water was not reliably available in care areas. One resident stated he refused cold showers and was only offered sponge baths once or twice, despite his preference to stay clean. Another resident reported receiving cold showers, including being rinsed with cold water while still soaped, and subsequently began refusing showers and bed baths due to the cold water. A CNA confirmed that water in the shower rooms was “ice cold” for several months, leading to resident complaints and refusals, while the Maintenance Director reported that a needed part to correct the hot water problem was on back order, delaying resolution and resulting in the facility not honoring residents’ bathing preferences.
Surveyors observed that unused medications were improperly discarded in a trash bin attached to a medication cart on the north hallway, rather than being disposed of in a designated drug disposal container. Two pills, a round blue tablet stamped "61" and an oblong orange tablet stamped "20," were found together in an unlabeled medication cup in the trash. An RN confirmed the medications were discarded there and acknowledged that unused medications should be placed in the drug buster container in the cart drawer. The Unit Manager also confirmed that facility practice requires all unused medications to be disposed of using the drug buster and that controlled substances must be destroyed by two licensed staff and documented on the narcotic count sheet.
The facility failed to follow documented allergy information, diet orders, and meal tickets for three residents. A resident with a documented chocolate allergy was served chocolate ice cream after requesting it, and the Nutrition Director admitted not reading the allergy notation on the meal ticket. Another resident on a pureed diet received whole mandarin oranges instead of pureed fruit, which a CNA confirmed. A third resident whose meal ticket called for a grilled Swiss sandwich received a sandwich that was not grilled, as confirmed by a CNA and a dietary manager.
Failure to Provide Required Written Transfer, Appeal, Ombudsman, and Bed-Hold Notices During Hospitalizations
Penalty
Summary
Surveyors identified that the facility failed to provide required written transfer and bed-hold information for multiple residents who were hospitalized. For three residents who experienced transfers to the hospital after events such as falls with injury, unresponsiveness, and episodes of nausea, vomiting, and bleeding, record review showed there were no written transfer notices or written bed-hold notices in their medical records. Specifically, one resident transferred after a fall on 01/31/26 had no documented written transfer notice or bed-hold notice. Another resident transferred on 02/27/26 for nausea, vomiting, and bleeding, and later readmitted on 03/05/26, had no written transfer notification that included information on appeal rights or Ombudsman contact, and no written bed-hold notification. A third resident transferred on 01/29/26 after a fall with a forehead laceration and again on 03/17/26 for unresponsiveness, also had no documented written transfer or bed-hold notices for either hospitalization. The deficiency also included the facility’s failure to provide required content in transfer notices and to notify the State Long-Term Care Ombudsman in writing. For the residents reviewed, there was no evidence that written transfer notices were provided to the residents or their representatives in a language and manner they could understand, and the notices were missing required elements such as a statement of appeal rights, the name, mailing and email address, and phone number of the entity receiving appeals, and information on how to obtain and complete an appeal form. The notices also lacked the name, phone number, and mailing and email address of the State Long-Term Care Ombudsman, and written copies of the transfer notices were not sent to the Ombudsman. During interview, the Social Services Director confirmed that transfer and bed-hold notices were not documented for at least one resident’s hospitalization, that she does not notify the Ombudsman about transfers to the hospital, and that she only emails a monthly list of residents discharged from the facility without sending written copies of transfer or discharge notices.
Failure to Timely Retrieve Residents From ER After Discharge
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from neglect by not arranging timely transportation back to the facility after emergency room (ER) discharge. A consumer complaint alleged that residents sent to the local ER were being left there for extended periods after discharge. For one resident with an admission date of 10/13/25, records showed multiple cognitive and behavioral diagnoses, including Alzheimer’s disease, vascular dementia with agitation and other behavioral disturbances, mild cognitive impairment, cognitive communication deficit, and restlessness and agitation. A change of condition MDS documented a Brief Interview for Mental Status (BIMS) score of 1 and frequent incontinence of urine and bowel. Nursing progress notes for this resident showed that 911 was called at 3:00 AM and the resident was transferred to the ER after a fall. Hospital discharge instructions indicated the resident was discharged from the ER at approximately 5:21 AM, while the ER nurse reported discharge at about 5:30 AM. The ER nurse stated she made numerous calls to the facility but was unable to reach anyone. She reported that the resident was very disoriented and that the ER did not have enough staff to provide 1:1 supervision. The ER nurse eventually reached the Administrator, who stated staff would come to pick up the resident as soon as possible. Facility records showed the resident was not discharged from the facility on that date, and the ER nurse reported that facility staff did not pick the resident up until approximately 8:30 AM, several hours after discharge. A second resident, admitted on 11/25/25, had diagnoses including Alzheimer’s disease, dementia with behavioral disturbance, bipolar disorder with severe depression and psychotic features, depression, and anxiety disorder. The admission MDS documented a BIMS score of 2, frequent urinary incontinence, constant bowel incontinence, and a need for substantial/maximal assistance with toileting hygiene. Nursing notes showed this resident was sent to the ER for evaluation after a fall and did not return until the following morning. Hospital discharge instructions documented discharge from the ER at 10:16 PM, and the Administrator confirmed being notified of the discharge at about 10:30 PM and that the facility did not have 24-hour transportation. The Administrator acknowledged the resident was not picked up until approximately 9:00 AM the next day. The ER nurse reported making several calls to the facility that went to voicemail, eventually reaching the Administrator, who initially stated staff were on the way, then stopped answering calls. During the approximately 11-hour wait, the ER nurse stated the resident was confused, attempted to get out of bed, and became more confused as the night progressed.
Failure to Timely Provide Wound Care and Required Assistance, Resulting in Resident Neglect
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from neglect when staff did not respond appropriately to requests for care and assistance. One resident with a history of cerebral infarction due to embolism and schizophrenia, admitted on 01/30/26 and requiring staff assistance for ADLs and mechanical lift transfers, reported that a CNA was rude and mocking and that his wound dressing was not changed for several hours after he requested it. The Kardex showed he needed staff help for toileting, bathing, hygiene, bed mobility, dressing, and transfers. Nursing progress notes documented a change in condition on 03/02/26 after the resident stated the CNA was rude and would not assist as requested. The Administrator later confirmed, via video review, that the CNA entered the resident’s room at 2:30 am, the resident requested a dressing change, and no nurse entered the room until 5:00 am, despite the nurse’s statement that she went in “right away.” The DON also confirmed that the resident’s grievance described the wound dressing not being changed until hours after the request. Another resident, admitted with a right femur fracture, type II diabetes, and repeated falls, required one-person assistance for dressing, hygiene, bathing, bed mobility, and transfers, and could toilet herself with assistance for transfers. Nursing progress notes documented an alleged abuse incident on 03/02/26 in which this resident stated a CNA was rude, refused to help her, and told her she could perform some care tasks herself without staff assistance. An abuse questionnaire completed the same day showed the resident answered “Yes” to having interactions that made her feel uncomfortable or negative, and she reported that the CNA made her feel as though she was not trying with her own recovery. The Administrator and DON acknowledged that staff are expected to help residents as required and that staff interactions must be encouraging rather than making residents feel bad about needing assistance.
Failure to Revise Care Plan After Substance-Related Incident
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s care plan after a significant substance-related incident. The resident was originally admitted with a diagnosis of opioid dependence and resided on a secure unit related to polysubstance abuse disorder. The existing care plan, dated 01/21/26, identified the resident as residing on a secure unit due to polysubstance abuse disorder with interventions to perform safety risk evaluations on admission, as needed, and upon changes in condition. The care plan also identified the resident as at risk for substance use disorder with interventions to monitor for signs or symptoms of substance abuse. On 02/01/26, nursing notes documented that staff observed the resident discarding an empty Suboxone packet in the trash, even though the resident was not prescribed Suboxone and denied taking any. Staff notified the on-call provider, who ordered monitoring for adverse reactions, and nursing staff and security conducted a room search that revealed no additional contraband. Despite this incident, the resident’s care plan was not updated to address the new substance-related event. During interviews, the DON acknowledged awareness of the incident and confirmed the care plan was not revised, and the Administrator stated her expectation that nursing would update the care plan when a new risk or behavior was identified and confirmed she would have expected the care plan to be updated for this resident.
Unattended, Unlocked Medication Cart on North Hall
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were properly stored and secured in accordance with professional standards and facility expectations. On 03/24/26 at 9:06 a.m., surveyors observed a medication cart on the north hall left unlocked and unattended outside a resident room. At 9:08 a.m., the LPN responsible for the cart confirmed during interview that the cart was hers, that it was unlocked and unattended, and acknowledged she should have locked it before responding to a call light. Later that day at 3:37 p.m., the DON stated in an interview that medication and treatment carts are expected to be locked at all times when nurses are away from them, confirming that the observed practice did not meet facility expectations. This deficient practice was cited as likely to allow unauthorized personnel access to medications, which could result in injury or overdosing.
Unattended PHI Document Left Exposed at Nurse’s Station
Penalty
Summary
Surveyors identified a deficiency in the facility’s protection of residents’ personal health information (PHI) when a document containing multiple residents’ full names, assigned room numbers, and code status was left unattended and exposed on the south nurse’s station counter. On 03/16/26 at 9:04 a.m., an observation revealed a piece of paper on a clipboard with complete resident information placed on top of the south nurse’s counter in public view. At 9:06 a.m., during an interview, RN #2 confirmed that the list contained residents’ names, room numbers, and code status, acknowledged that it had been left exposed and unattended, and stated that PHI should not be left unattended. No additional clinical details or medical histories of the residents listed on the document were provided in the report.
Unattended Soiled Lunch Cart Left Uncovered in Hallway
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the handling of soiled food service equipment. On 03/24/26 at 12:58 pm, a lunch tray return cart containing soiled food trays and dishes that were uncovered was observed sitting unattended in the main hallway outside the activity room. At 1:06 pm, the housekeeping/laundry manager confirmed she saw the return cart left unattended in that location. At 1:08 pm, the Dietary Manager stated that lunch return carts should only be left in designated areas such as by the nurse’s station or inside the kitchen, and that the cart should be returned to the kitchen for cleaning as soon as all trays have been picked up, which did not occur in this instance. This deficient practice was noted as likely to expose all residents to potential pathogens associated with food waste.
Failure to Honor Resident Bathing Preferences During Prolonged Hot Water Issues
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ bathing preferences when hot water was not reliably available in resident care areas. Record review showed that one resident was scheduled to receive three showers per week on specific days, and another resident was scheduled for two showers per week. One resident reported that staff attempted to have him shower in cold water, which he refused, and that sponge baths were only offered once or twice during the period when the hot water was not working. He stated that he liked to be clean and did not feel like himself when he was dirty. A CNA reported that there was no hot water in resident care areas from the middle of December until early March, and that large barrels of warm water were brought to shower rooms to offer sponge baths, which this resident refused. Another resident, also on a scheduled twice-weekly shower regimen, stated that she received cold showers and began refusing showers because of how cold the water was. She described the water running cold unpredictably, including an instance when the water was initially warm but turned cold while she was still soaped, requiring rinsing with cold water, which she described as horrible. A social services note documented that this resident’s daughter reported the resident had been declining showers and bed baths offered because the water was too cold. A CNA corroborated that the water was “ice cold” and that residents began complaining and refusing showers around mid-December. The Maintenance Director stated that it took a while for hot water to reach the shower room and that a needed part to fix the cold-water problem was on back order, contributing to the prolonged period of inadequate hot water and resulting in residents not having their bathing preferences honored.
Improper Disposal of Unused Medications on Medication Cart
Penalty
Summary
Surveyors identified a deficiency related to accident hazards and inadequate supervision when unused medications were improperly discarded on the north hallway. During observation of the north hall nurses’ station, two medications were found in the trash bin attached to the medication cart, placed together inside an unlabeled medication cup. The pills were described as a round blue pill stamped with “61” and an oblong orange pill stamped with “20.” In an interview immediately following the observation, an RN confirmed that these medications were in the trash bin and stated that unused medications should instead be disposed of in the drug buster, a sealed container for drug disposal located in the bottom drawer of the cart. In a subsequent interview, the Unit Manager confirmed that all unused medications are to be disposed of using the drug buster and acknowledged that this did not occur, further stating that if the medications are controlled substances such as narcotics, two licensed personnel are required to dispose of them together and document the disposal on the narcotic count sheet. This deficient practice was noted as likely to affect any resident who might acquire and ingest the discarded medications, potentially causing medication side effects.
Failure to Follow Allergy, Diet, and Meal Ticket Requirements
Penalty
Summary
The facility failed to provide meals consistent with residents’ documented allergies, diet orders, and meal tickets for three residents. One resident, admitted with a documented allergy to chocolate, had a face sheet and lunch ticket indicating they were not to receive chocolate. During a lunch observation, this resident was served and was eating chocolate ice cream. An LPN confirmed the resident’s chocolate allergy and that the resident should not be eating chocolate. The Nutrition Director acknowledged that the meal ticket stated the resident should not have chocolate but reported serving chocolate ice cream after the resident requested it, stating he had not read that the resident was allergic to chocolate. Another resident, admitted with hypokalemia and ordered a regular/liberalized pureed diet per the MDS, had a lunch ticket indicating a pureed diet but was observed receiving whole mandarin oranges instead of pureed fruit. A CNA confirmed that the dessert was not pureed. A third resident’s meal ticket specified a grilled Swiss sandwich, but observation of the tray showed the sandwich was not grilled. During interviews, a CNA and a dietary manager confirmed that the sandwich was not grilled as ordered on the meal ticket.
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