Casa Del Sol Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Las Cruces, New Mexico.
- Location
- 2905 East Missouri Avenue, Las Cruces, New Mexico 88011
- CMS Provider Number
- 325108
- Inspections on file
- 20
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Casa Del Sol Center during CMS and state inspections, most recent first.
The facility failed to honor resident choice regarding both dining location and smoking privileges. On one occasion, all residents who typically ate breakfast in the dining room were required to eat in their rooms after staff told them there was not enough CNA coverage, even though three CNAs were on the day shift and the DON later acknowledged there was no valid reason residents could not have used the dining room. In a separate situation, a resident who had signed a smoking agreement had his smoking privileges revoked and was placed on 1:1 supervision based on a roommate’s report and staff detecting smoke odor, without staff directly observing him smoking in a prohibited area, while the resident denied smoking in the bathroom and expressed a desire to continue smoking.
Two residents with indwelling Foley catheters had care plans indicating catheter use, but no corresponding physician orders were documented in their medical records. Review of the charts showed that, despite the presence of Foley catheters noted in the care plans, the physician order sections contained no entries authorizing or detailing the catheters. In an interview, the UM confirmed that staff had not entered the Foley catheter orders into the records and acknowledged that these orders should have been documented.
A resident’s admission MDS inaccurately documented the presence of a Foley catheter, even though the resident did not have one. During observation, the resident was seen without a Foley catheter, and the UM later confirmed that the MDS entry indicating a Foley catheter was marked in error. This reflects a failure to accurately assess and document the resident’s catheter status on the MDS.
A resident was not transferred to the hospital for several hours after a provider ordered the transfer based on recent lab results. The RN on duty delayed sending the resident, citing an inability to print transfer documents, while an LPN on the same shift reported that the printer had been malfunctioning for some time and that he had not received any related education or discipline. The Unit Manager later found the resident still in the facility the next morning, confirmed the delay in carrying out the provider’s order, and identified that no disciplinary action had been documented for the involved staff.
Surveyors found that a resident with a Foley catheter, care planned for this device, did not have required enhanced barrier precaution signage or PPE (gowns and gloves) available outside the room. During observation, no sign or PPE was present, and in interview the UM confirmed their absence and acknowledged that both were expected for this resident due to the Foley catheter. This deficiency was identified for one of three residents reviewed for Foley catheter-related infection control practices.
Surveyors found that two discharged residents did not have discharge summaries in their medical records. Review of facility documentation confirmed that both residents had been discharged, but no discharge summaries were completed or filed. In an interview, the ADON acknowledged that staff should have completed these discharge summaries and that they were expected to be present in the medical record.
A medication cart was observed unlocked and unattended in a hallway, with no staff present nearby. The unit manager confirmed the cart should have been locked when not attended. This lapse had the potential to impact all residents on the affected hall.
Two residents who use mobility aids were unable to access the outdoor gazebo ramp due to a PVC shower chair being left on the ramp, obstructing passage for both a walker and a wheelchair. The maintenance director confirmed the equipment should not have been placed there and was unsure why it was left on the ramp.
Staff did not follow a physician's order to collect a urinalysis with culture and sensitivity from a resident with multiple medical conditions, including a Foley catheter. Although documentation indicated the sample was collected, there were no lab results, and the unit manager later confirmed the lab never received the sample.
The facility failed to properly store and document medications, with open medications lacking open dates and a loose tablet found in a medication cart. Additionally, temperatures for medication refrigerators were not documented for several days, risking medication efficacy.
The facility failed to provide adequate dining space, affecting 57 residents. Observations showed overcrowding with wheelchairs and walkers, hindering movement and requiring staff to stand while assisting residents. Interviews confirmed these challenges, and the DON acknowledged the need for better flow and seating arrangements during meals.
The facility failed to meet care plan requirements by not including all necessary Interdisciplinary Team members in meetings and not holding meetings within seven days of MDS completion for several residents. Additionally, care plans were not updated with current resident information, such as new diagnoses and treatments, leading to incomplete care planning.
The facility failed to ensure CNAs demonstrated competency in necessary skills to care for residents. Three CNAs did not have documented competency evaluations at hire or routinely after, potentially leading to inadequate care. Personnel files lacked evidence of evaluations, confirmed by interviews with the Nurse Practice Educator and DON.
The facility did not complete annual performance reviews for two CNAs, hired in 2018 and 2019, as confirmed by the Nurse Practice Educator. This oversight could result in undertrained staff and inadequate care.
The facility failed to provide routine dental services for two residents, resulting in one resident losing a tooth and not receiving dental care since admission. Another resident's dental care was neglected, with staff not brushing teeth regularly and no dental visits since admission. The Records Manager relied on residents or families to request dental appointments, leading to inadequate dental care management.
A CNA in an LTC facility failed to perform hand hygiene before assisting multiple residents with eating and drinking, as observed during a dining room inspection. The CNA admitted to not following proper hygiene protocols, which was confirmed by the infection control nurse. This lapse in hygiene practices could expose residents to foodborne illnesses.
A resident was not treated with respect and dignity when CNAs stood over him while assisting with meals instead of sitting at eye level, as expected. The CNAs cited a crowded dining area as the reason for standing, despite knowing the proper protocol.
A facility failed to maintain a homelike environment by not repairing a broken windowsill trim in a resident's room. The resident reported the issue had persisted for months, and an observation confirmed the damage. The Maintenance Director acknowledged the problem, noting it was caused by the resident's bed movement scraping the trim.
A facility failed to complete a comprehensive MDS assessment within the required 14 days after a resident's admission. The resident was admitted, but the assessment was delayed beyond the mandated timeframe. The MDS Coordinator confirmed the delay and acknowledged the requirement for timely completion. This could potentially result in unmet resident preferences and care needs.
A resident admitted to hospice experienced a delay in the completion of their Significant Change MDS assessment, which was not finalized within the required 14-day period. The MDS Coordinator confirmed the delay, which could impact the resident's care and services.
The facility failed to ensure accurate MDS assessments for three residents, leading to discrepancies in their medical records. One resident's MDS inaccurately documented pain medication and antiplatelet use, another resident's MDS incorrectly recorded a pneumonia diagnosis and anticoagulant use, and a third resident's discharge MDS inaccurately stated the discharge location. These inaccuracies could result in the facility not having an accurate understanding of the residents' needs.
A facility failed to develop a comprehensive care plan for a resident, omitting critical information about a foley catheter and high-risk medications, Eliquis and Lasix. Staff interviews confirmed these omissions, highlighting a lack of individualized planning for the resident's care needs.
A resident with end-stage renal disease did not receive their prescribed Renvela medication on multiple occasions due to delays in reordering and receiving the medication from the pharmacy. Staff interviews confirmed that the medication was not reordered in a timely manner, leading to missed doses and a failure to meet professional standards of care.
A facility failed to provide regular oral hygiene care for a resident who required assistance with activities of daily living (ADL). The resident's sister reported irregular teeth brushing, and a CNA admitted to only occasionally brushing the resident's teeth. Documentation for February 2025 lacked records of oral care, and both the Unit Manager and DON confirmed the expectation for twice-daily brushing, as per the facility's policy.
A resident admitted with pressure ulcers on the sacrum and heels did not receive timely wound care orders, with delays of two to three days in obtaining and implementing treatment. The nursing staff failed to consult the provider for necessary orders, contrary to the facility's expectations, potentially leading to inconsistent interventions and worsening of the ulcers.
A resident with chronic pain in her nose and tongue experienced a delay in receiving prescribed pain management treatment. Despite a recommendation from an ENT specialist to start amitriptyline, the facility did not administer the medication until 16 days after the appointment, resulting in continued unnecessary pain. The delay was confirmed by the unit manager and DON during an interview.
A facility failed to ensure timely documentation of a resident's care by the provider during required visits. The NP did not sign and date progress notes at the time of the visit, and there were delays in sending these notes to the facility. The wound care nurse confirmed that they did not receive the consultant's progress notes on the day of the visit, relying instead on verbal orders.
A resident admitted with multiple diagnoses, including a traumatic subdural hemorrhage and thrombocytopenia, was prescribed Eliquis, an anticoagulant. The facility failed to document the required monitoring for bleeding, as confirmed by staff interviews, leading to incomplete medical records.
The facility failed to provide behavioral health training for one CNA, which could impact care for residents with mental health needs. A review revealed that a CNA did not complete the required training, despite residents with anxiety, schizophrenia, and dementia being present. This deficiency was confirmed by the Nurse Practice Educator.
The facility did not submit the results of investigations into misappropriation of property and an abuse allegation to the State Agency within the required five-day period. In both cases, the follow-up reports were completed but not reported in a timely manner, as confirmed by the administrator.
Failure to Honor Resident Choice for Dining Location and Smoking Privileges
Penalty
Summary
The deficiency involves the facility’s failure to honor resident choice regarding dining location and smoking, as required under resident rights to self-determination. A resident reported that on a specific Saturday, residents were told they could not eat breakfast in the dining room because a CNA had called out, and all residents who normally ate in the dining room were required to eat in their rooms instead. Review of employee timecards for that date showed three CNAs were working the day shift. The DON stated the facility was supposed to have four CNAs but only had three, confirmed that residents had to eat in their rooms and not in the dining room, and acknowledged there was no reason this should have occurred and that residents should have been able to eat breakfast in the dining room. The deficiency also includes the facility’s revocation of a resident’s smoking privileges without staff directly observing a violation of the smoking policy. The resident, who had signed a Smoking Agreement and Procedures form stating that failure to comply with designated locations, times, and rules could result in termination of smoking privileges, reported that his smoking privileges were taken away and that he had been placed on 1:1 care because staff said he was smoking in the bathroom, which he denied. Progress notes documented that his roommate reported he had been smoking in the bathroom and that his smoking privileges were revoked, and later that the ombudsman was notified that the resident was non-compliant with the smoking policy based on the roommate’s report and his frequent exits from the center, and that he was on 1:1 supervision. The Administrator confirmed that smoking privileges were removed because the roommate said the resident was smoking in the bathroom, that staff never caught him but could smell him, that he liked to keep his smoking materials instead of handing them to staff, and that a new smoking agreement and procedure had been implemented after his admission.
Missing Physician Orders for Foley Catheters in Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents with indwelling Foley catheters when physician orders for the catheters were not documented in their charts. Record review showed that one resident, admitted on an unspecified date, had a care plan dated 03/03/26 indicating the presence of a Foley catheter, but the physician’s orders contained no documented order for that catheter. Another resident, also admitted on an unspecified date, had a care plan dated 02/09/26 indicating the presence of a Foley catheter, yet the physician’s orders similarly lacked any documented order for the catheter. During an interview on 03/09/26 at 2:28 p.m., the Unit Manager confirmed that staff had not entered Foley catheter orders into the medical records for these two residents and acknowledged that such orders should have been documented.
Inaccurate MDS Documentation of Foley Catheter Status
Penalty
Summary
The deficiency involves the facility’s failure to ensure an accurate MDS assessment for one resident regarding the presence of a Foley catheter. Record review of the resident’s face sheet showed an admission on an unspecified date, and the admission MDS, dated on an unspecified date, documented that the resident had a Foley catheter. However, during an observation on 03/09/26 at 2:15 p.m., the resident was observed without a Foley catheter in place. In a subsequent interview at 2:28 p.m., the Unit Manager confirmed that the resident did not have a Foley catheter and acknowledged that the MDS incorrectly indicated the presence of a Foley catheter. This inaccurate documentation on the MDS constituted a failure by staff to correctly assess and record the resident’s catheter status, resulting in an MDS that did not reflect the resident’s actual condition.
Failure to Timely Transfer Resident to Hospital After Provider Order
Penalty
Summary
The deficiency involves the facility’s failure to provide timely hospital transfer for a resident after a provider ordered the transfer based on recent lab results. Record review showed that the resident was admitted on an unspecified date and later sent to the hospital on another unspecified date. A 5‑day follow‑up report documented that at approximately 11:00 p.m. on 01/14/26, the resident’s provider ordered that the resident be sent to the hospital due to recent lab findings. However, the resident was not actually sent out until after 6:30 a.m. on 01/15/26. During this period, the RN on duty did not carry out the transfer order, stating that she did not send the resident because she was unable to print the documents needed for transfer to the hospital. Further interviews and record reviews clarified the circumstances around this delay. An LPN working the same night shift reported that the printer had not been working for a while at the beginning of the year and stated that he did not receive any education or disciplinary action related to transferring residents to the hospital. The Unit Manager confirmed that when she arrived at the facility on the morning of 01/15/26, the resident had still not been sent to the hospital despite the provider’s order from the previous night, and that the resident was then sent to the hospital at that time. The Unit Manager also stated that education and disciplinary action regarding sending residents to the hospital had been given verbally to the RN and LPN, but later confirmed, after reviewing their personnel files, that no disciplinary action had actually been documented for either staff member.
Failure to Implement Enhanced Barrier Precautions for Resident With Foley Catheter
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to enhanced barrier precautions for a resident with a Foley catheter. Record review showed the resident was admitted on an unspecified date and had a Foley catheter care plan dated 03/03/26. During an observation on 03/09/26 at 2:15 p.m., surveyors noted that there was no enhanced barrier precaution sign or PPE available outside the resident’s room, despite the resident’s need for such precautions due to the Foley catheter. In a subsequent interview at 2:18 p.m., the Unit Manager confirmed that the enhanced barrier precautions sign and PPE were not in place and stated that she expected staff to have both in place for this resident because of the Foley catheter. The report further notes that this failure to follow proper infection control practices occurred for one of three residents sampled for Foley catheters and that the facility did not provide the required signage and PPE for staff and visitors to use during high-contact care under enhanced barrier precautions. The deficient practice was identified through observation, interview, and record review, and it was specifically linked to the absence of appropriate infection control measures for the resident with a Foley catheter.
Failure to Complete and Maintain Discharge Summaries for Discharged Residents
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to provide required discharge summaries for two of three sampled residents who were discharged. Record review of the admission/discharge report showed that Resident #1 was discharged on 01/07/26, but the resident’s medical record did not contain a discharge summary. Similarly, nursing progress notes for Resident #2 documented that this resident was discharged on 01/07/26, yet the resident’s medical record also lacked a discharge summary. During an interview on 01/14/26 at 10:12 a.m., the ADON confirmed that both residents did not have discharge summaries and stated that staff should have completed these summaries and that they should be present in the medical record. The deficiency centers on the inaction of facility staff in completing and placing discharge summaries into the medical records for these discharged residents, despite the facility’s expectation, as confirmed by the ADON, that such documentation be completed and maintained.
Unattended Unlocked Medication Cart Found on Resident Hall
Penalty
Summary
Surveyors observed that medications were not properly secured on the 300 hall, as a medication cart was found unlocked and unattended in the hallway. No staff were present in the area at the time of the observation. The unit manager later confirmed that the cart was indeed unlocked and acknowledged that medication carts are required to be locked when unattended. This deficiency had the potential to affect all 14 residents residing on the 300 hall, as identified on the resident census provided by the Administrator.
Obstruction of Gazebo Ramp Limits Mobility Access
Penalty
Summary
The facility failed to provide reasonable accommodation for the mobility needs of two residents who use assistive devices, such as a front wheel walker and a wheelchair, by not ensuring that the ramp to the outdoor gazebo was accessible. One resident reported being unable to use the ramp due to medical equipment, specifically a PVC shower chair, being left on the ramp, making it too narrow for her walker. Another resident, who uses a wheelchair, also stated she could not use the ramp when medical equipment was present. Observations confirmed that the PVC shower chair was repeatedly left at the top of the ramp over multiple days, obstructing access. The maintenance director acknowledged the chair should not have been placed there and was unsure why it was left on the ramp.
Failure to Complete Physician-Ordered Urinalysis
Penalty
Summary
Staff failed to follow a physician's order for a resident who was admitted with multiple diagnoses, including a fracture of the lower end of the left femur, generalized muscle weakness, pain in the left hip, and repeated falls. The physician had ordered a urinalysis with culture and sensitivity to be collected from the resident's Foley catheter, specifically instructing that the sample be collected from the tube and not the collection bag. Documentation on the treatment administration record indicated that the urine sample was collected as ordered. However, a review of the medical record revealed that there were no laboratory results for the urinalysis or culture and sensitivity. During an interview, the unit manager confirmed that there were no results on file and was unaware that the urinalysis had not been collected. Upon contacting the laboratory, it was confirmed that the urine sample was never received for processing.
Medication Storage and Documentation Deficiencies
Penalty
Summary
The facility failed to properly store medications, as observed during a survey. On the B Unit Medication Cart, lactulose solution and enulose were found open without an open date. Similarly, on the D Unit Medication Cart, a loose white round tablet with no markings was found, and lactulose solution was also open without an open date. These observations indicate a lack of adherence to proper medication labeling and storage protocols. Additionally, the facility did not document temperatures for the medication refrigerators on multiple days. The black medication refrigerator contained insulin, gabapentin, and suppositories, while the white locked medication refrigerator contained bisacodyl suppositories, morphine, and flu vaccines. The absence of temperature documentation for these refrigerators on specific dates was confirmed by CMA #8 and the DON, who acknowledged that medications could spoil if not stored within the appropriate temperature range.
Insufficient Dining Space Affects Resident Safety and Experience
Penalty
Summary
The facility failed to provide sufficient space for dining, which affected the dining experience and safety of all 57 residents. During observations on two separate occasions, the dining area was noted to be overcrowded with residents' wheelchairs and walkers, making it difficult for both residents and staff to move around. This congestion led to incidents such as a resident's wheelchair wheels getting caught on another resident's wheelchair, and staff having to stand while assisting residents with eating due to the lack of space. Interviews with CNAs confirmed the challenges faced during mealtimes, as they often had to stand to assist residents due to the crowded conditions. The DON acknowledged the issue, stating that the expectation is for residents to have an easier flow for getting in and out during meals, and that staff should be seated at eye level with residents to better assess them. The facility was in the process of addressing the space issue to improve the dining experience for residents and staff.
Deficiencies in Care Plan Meetings and Updates
Penalty
Summary
The facility failed to meet care plan requirements for several residents, as evidenced by the absence of required Interdisciplinary Team (IDT) members during care plan meetings for two residents. Specifically, the care plan meetings for these residents did not include all necessary team members, such as therapy, activities, and infection prevention staff, which are crucial for comprehensive care planning. Additionally, the facility did not typically invite Certified Nursing Assistants (CNAs) or providers to these meetings, which could have contributed to incomplete care planning. Furthermore, the facility did not hold care plan meetings within the required seven days following the completion of the Minimum Data Set (MDS) assessments for multiple residents. This delay in scheduling care plan meetings was confirmed by the Social Services Worker, who admitted to being behind in scheduling these meetings. As a result, several residents did not have timely care plan meetings, which are essential for updating and addressing their current health conditions and care needs. Additionally, the facility failed to revise care plans with the most current resident information. For instance, one resident's care plan was not updated to reflect a new diagnosis and treatment for a urinary tract infection, despite having a physician's order for antibiotics. This oversight was confirmed by the MDS coordinator, highlighting a lack of communication and documentation within the facility's care planning process.
Lack of Competency Evaluations for CNAs
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) demonstrated competency in skills and techniques necessary to care for residents' needs. Specifically, three CNAs, identified as CNA #8, CNA #9, and CNA #16, did not have documented competency evaluations at the time of hire or routinely after hire. This lack of evaluation could result in CNAs working with residents without adequate knowledge, potentially leading to injury or inappropriate care. The personnel files for CNA #8, CNA #9, and CNA #16 revealed that no competency evaluations were documented to demonstrate their knowledge, ability, and skills to care for residents. Interviews with the Nurse Practice Educator and the Director of Nursing confirmed the absence of these evaluations. The Director of Nursing stated that competency evaluations should be conducted before staff begin working with residents to ensure proficiency in resident care.
Failure to Conduct Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to conduct performance reviews at least every 12 months for two certified nursing assistants (CNAs), specifically CNA #10 and CNA #16, out of a sample of three CNAs. This deficiency was identified through interviews and record reviews. CNA #10 was hired on November 14, 2018, and CNA #16 was hired on February 25, 2019. However, there were no performance evaluations found in their employee files. During an interview on March 17, 2025, the Nurse Practice Educator confirmed the absence of performance evaluations for these CNAs. This lack of evaluations could potentially lead to staff being undertrained and providing inadequate care.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to ensure that residents received necessary dental services, impacting two residents who were sampled for dental care. Resident #18 reported that a tooth had fallen out approximately a week prior and had not been seen by a dentist since admission. A review of Resident #18's records showed a physician's order for dental consultation as needed, but no dental visit had occurred since admission, as confirmed by the Medical Records staff. Similarly, Resident #23 had not received routine dental care since admission, as noted in the medical records and confirmed by the Records Manager. The resident's sister reported that staff did not regularly brush the resident's teeth, and the resident had not been to the dentist since admission. The Records Manager indicated that dental appointments were made only if the resident requested them or if the family decided care was needed, highlighting a lack of proactive dental care management for residents unable to advocate for themselves.
Failure to Maintain Hand Hygiene During Meal Assistance
Penalty
Summary
The facility failed to maintain sanitary conditions in food service by not adhering to professional standards of hand hygiene. During an observation in the dining room, it was noted that a CNA did not perform hand hygiene before assisting multiple residents with eating and drinking. This included actions such as cutting sandwiches, moving food on plates, and placing drinks closer to residents. The CNA assisted four residents without performing hand hygiene, except for two instances during the entire meal service. In an interview, the CNA admitted to not performing hand hygiene before assisting each resident, acknowledging that she was supposed to do so. The infection control nurse confirmed that staff were expected to perform hand hygiene prior to assisting residents with eating and drinking. This lack of adherence to hygiene practices could potentially expose residents to foodborne illnesses, although the report does not specify any direct consequences or illnesses resulting from this deficiency.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with respect and dignity when staff did not sit next to the resident while assisting with eating. During a lunch observation, CNA #9 stood over the resident instead of sitting beside him, and later asked CNA #16 to assist, who also stood over the resident. Both CNAs confirmed in interviews that they stood over the resident due to the crowded dining area, despite knowing the expectation to sit at eye level with the resident. The Director of Nursing stated that staff should sit down with the resident at eye level during meal assistance.
Failure to Maintain Homelike Environment Due to Broken Windowsill Trim
Penalty
Summary
The facility failed to provide a homelike environment in good condition for a resident by not repairing the trimming on the windowsill in the resident's room. During an interview, the resident pointed out that the trimming on her windowsill had been broken for months, although she could not recall the exact duration. An observation confirmed that a section of the trimming was broken off near the resident's bed. The Maintenance Director acknowledged that the windowsill trim was broken and needed replacement again, attributing the damage to the resident's bed being moved up and down, which scraped the trimming off.
Failure to Complete Timely MDS Assessment
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set (MDS) assessment within the required 14 calendar days after admission for one of the residents reviewed. Specifically, the resident was admitted on a certain date, but the Admission MDS assessment was not completed until January 21, 2025, which exceeded the 14-day requirement. During an interview, the MDS Coordinator confirmed that the assessment was not completed within the mandated timeframe and acknowledged that such assessments should be completed within 14 days of admission. This oversight could potentially result in the resident's preferences and care needs not being adequately addressed.
Delayed MDS Assessment for Hospice Admission
Penalty
Summary
The facility failed to complete and transmit a Significant Change Minimum Data Set (MDS) assessment within 14 days after determining a significant change in a resident's condition. Specifically, a resident was admitted to hospice on November 13, 2024, indicating a major change in health status. However, the MDS assessment reflecting this significant change was not completed and signed off by the Registered Nurse until December 19, 2024, exceeding the required 14-day timeframe. During an interview on March 17, 2025, the MDS Coordinator confirmed the delay in completing the Significant Change MDS assessment for the resident following their admission to hospice. This deficiency could likely result in the resident not receiving the appropriate care and services needed due to the delay in updating their care plan.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for three residents, leading to discrepancies in their medical records. For one resident, the MDS inaccurately documented that the resident did not receive scheduled pain medication, despite having an order for pregabalin to treat neuropathy. Additionally, the MDS incorrectly coded clopidogrel, an antiplatelet medication, as an anticoagulant. Another resident's MDS inaccurately recorded a diagnosis of pneumonia, which was not present in the seven days prior to the assessment reference end date, and also incorrectly documented the use of an anticoagulant, despite the resident only being prescribed an antiplatelet medication. A third resident's discharge MDS inaccurately stated that the resident was discharged to a short-term general hospital, while the discharge plan and interviews with staff confirmed that the resident was actually discharged home with their daughter. These inaccuracies in the MDS assessments could result in the facility not having an accurate understanding of the residents' needs, as confirmed by interviews with the MDS coordinator and unit manager.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop an accurate, person-centered comprehensive care plan for a resident, which could result in staff being unaware of the resident's current and actual needs. The resident was admitted with several medical conditions, including a traumatic subdural hemorrhage, acute embolism and thrombosis of the right axillary vein, thrombocytopenia, and neuromuscular dysfunction of the bladder. The resident had orders for a foley catheter change, Lasix for fluid retention, and Eliquis for cerebrovascular accident. However, the care plan did not document the presence of the foley catheter or the high-risk medications Eliquis and Lasix. Interviews with facility staff, including a registered nurse, the MDS coordinator, and the unit manager, confirmed the omissions in the care plan. The staff acknowledged that the resident's care plan should have included the foley catheter and interventions for its care, as well as the high-risk medications. The failure to include these critical elements in the care plan indicates a lack of comprehensive and individualized planning for the resident's care needs.
Failure to Administer Medication as Prescribed
Penalty
Summary
The facility failed to meet professional standards of quality by not administering medications according to physician's orders for a resident with end-stage renal disease. The resident was prescribed Renvela, a medication used to control phosphorus levels, to be taken three times a day with meals. However, the medication was not administered on multiple occasions due to it being unavailable. Specifically, the medication was not given on two consecutive days, as documented in the medication administration record and progress notes, which indicated that the facility was awaiting the medication from the pharmacy. Interviews with staff revealed that the medication was not reordered in a timely manner, as it should have been when there were nine pills left. The medication was only reordered on the day it ran out, and it was received the following day late at night. This delay in reordering and receiving the medication resulted in the resident missing several doses, which is a failure to adhere to the physician's orders and maintain the professional standards of care expected in the facility.
Failure to Provide Regular Oral Hygiene Care
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for a resident who required help with oral hygiene. The resident's sister reported that the resident did not have his teeth brushed regularly. A review of the resident's Quarterly Minimum Data Set (MDS) indicated that he was dependent on assistance for ADL care. A Certified Nursing Assistant (CNA) admitted to occasionally brushing the resident's teeth at night but not regularly, and typically only rinsing his mouth. The facility's ADL documentation for February 2025 did not record any oral care being provided. The Unit Manager confirmed that the resident's teeth should be brushed twice daily, as per the facility's oral health policy, but acknowledged the lack of documentation. The Director of Nursing (DON) also stated that the expectation was for residents' teeth to be brushed at least twice a day and documented accordingly. The facility's oral health policy mandates oral hygiene to be performed at least twice daily to maintain oral health and prevent systemic diseases.
Failure to Obtain Timely Wound Care Orders for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to ensure timely wound care orders and implementation for a resident with pressure ulcers upon admission. The resident was admitted with pressure ulcers on the sacrum and both heels, but wound care orders were not obtained or implemented for the sacrum ulcer until two days after admission and for the heel ulcers until three days after admission. This delay in obtaining and implementing wound care orders could result in the provider being unaware of the resident's current condition, leading to inconsistent interventions and worsening of the pressure ulcers. The facility's records revealed that the nursing staff did not consult with the facility provider to obtain wound care orders for the resident's pressure ulcers, which were present upon admission. The facility wound care nurse stated that it is expected for nursing staff to contact the provider to obtain wound care orders upon admission if residents are admitted with pressure ulcers. However, this protocol was not followed, resulting in a delay in the treatment of the resident's pressure ulcers.
Delay in Pain Management for Resident
Penalty
Summary
The facility failed to effectively manage pain for a resident, identified as R #13, who was experiencing chronic pain in her nose and tongue. The resident had been suffering from atypical facial pain, a condition characterized by chronic, constant pain without an apparent cause. During an appointment with an Ear, Nose, and Throat (ENT) specialist on January 29, 2025, it was recommended that the resident be started on amitriptyline, an antidepressant medication often used to treat chronic pain, with a plan to gradually increase the dosage. However, the facility did not implement this treatment plan in a timely manner. The resident's medication order for amitriptyline was not initiated until February 14, 2025, resulting in a 16-day delay from the date of the ENT appointment. This delay in administering the prescribed medication led to the resident continuing to experience unnecessary pain. The deficiency was confirmed during an interview with the unit manager and the Director of Nursing (DON), who acknowledged the delay in starting the prescribed treatment. This oversight in pain management was identified during a review of the resident's records and interviews, highlighting a lapse in the facility's adherence to the prescribed treatment plan for managing the resident's pain.
Deficiency in Timely Documentation of Provider Visits
Penalty
Summary
The facility failed to ensure that a resident's care was properly documented by the provider during required visits. Specifically, the provider did not sign and date progress notes at the time of the visit for a resident who was receiving wound care treatment. The record review revealed that the nurse practitioner (NP) responsible for the resident's care did not sign the progress notes on the day of the visit and delayed sending these notes to the facility. For instance, a note from a visit on February 6 was not signed until February 9 and was not sent to the facility until February 20. Similar delays were noted for subsequent visits, with some notes not being sent to the facility until March 14, despite visits occurring in February and early March. During an interview, the facility's wound care nurse confirmed that they did not receive the wound care consultant's progress notes on the day of the visit. Instead, the nurse relied on verbal orders provided by the consultant during rounds. This practice resulted in a lack of timely written documentation, which is essential for ensuring that the resident's needs are met and that care is appropriately coordinated. The absence of signed and dated progress notes at the time of the visit constitutes a deficiency in the facility's documentation practices.
Incomplete Medical Record Documentation for Anticoagulant Monitoring
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for a resident, which could negatively impact the care provided. The resident in question was admitted with several diagnoses, including a traumatic subdural hemorrhage, acute embolism and thrombosis of the right axillary vein, and thrombocytopenia. A physician's order was in place for the resident to receive Eliquis, an anticoagulant, to manage a cerebrovascular accident. However, the facility did not document the necessary monitoring for bleeding, which is crucial for residents on anticoagulants. Interviews with staff revealed that the facility's protocol requires monitoring for bleeding in residents taking anticoagulants, and this should be documented in the electronic medical record. Despite this requirement, there was no documentation of monitoring for bleeding for the resident from the time of admission until several weeks later. Both a registered nurse and the unit manager confirmed the lack of documentation, acknowledging that the expected monitoring had not been recorded, which constitutes a deficiency in maintaining accurate medical records.
Failure to Provide Behavioral Health Training
Penalty
Summary
The facility failed to provide necessary behavioral health training for one of the three certified nursing assistants (CNA #8) sampled for training. This deficiency was identified through a review of training records and confirmed by the Nurse Practice Educator. The lack of training could potentially impact the care provided to residents with specific mental health needs. The report highlights three residents with mental health diagnoses: one with an anxiety disorder, another with schizophrenia, and a third with dementia, anxiety, and depression. Despite these residents' needs, CNA #8 did not complete the required behavioral health training, which is essential for recognizing and responding to the mental health issues these residents may present with.
Failure to Timely Report Investigation Results of Abuse and Misappropriation
Penalty
Summary
The facility failed to report the results of investigations into misappropriation of resident property and allegations of abuse to the State Agency within the required five-day timeframe. In one instance, a resident reported that $45 was missing from her purse, but the facility did not submit the follow-up report regarding this misappropriation to the State Agency until nearly a month after the initial incident was reported. Documentation confirmed that the investigation was completed, but the required notification was delayed. In a separate case, another resident reported experiencing pain after a staff member performed an improper transfer. The facility completed its investigation within the required period, but the follow-up report to the State Agency was not submitted until almost a month after the incident. In both cases, the administrator confirmed the late submission of the follow-up reports to the State Agency, failing to meet the regulatory requirement for timely reporting.
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Surveyors found that the facility did not provide required written transfer and bed-hold notices when several residents were sent to the hospital for events such as falls with injury, unresponsiveness, and episodes of nausea, vomiting, and bleeding. Medical records lacked written transfer notices and bed-hold notifications, and the transfer information that should have been given to residents or their representatives did not include mandated details about appeal rights, how to request an appeal, or how to contact the State LTC Ombudsman. The Social Services Director reported that she does not notify the Ombudsman of hospital transfers and only sends a monthly email list of discharged residents, without written copies of transfer or discharge notices.
Two cognitively impaired residents with dementia and significant behavioral and continence needs were sent to a local ER after falls and were discharged back to the facility’s care, but the facility failed to provide timely transportation for their return. In both cases, hospital discharge times were documented, yet ER staff reported making multiple unsuccessful calls to the facility, reaching the Administrator only after repeated attempts. One resident, described as very disoriented, remained in the ER for several hours after discharge without 1:1 supervision, while the other waited approximately 11 hours, during which ER staff observed increasing confusion and attempts to get out of bed. The Administrator acknowledged awareness of the discharges, the lack of 24-hour transportation, and that the residents were not picked up until many hours after they had been discharged from the ER.
Two residents who required staff assistance for ADLs and transfers reported neglectful and rude behavior by a CNA and delayed nursing response to care needs. One resident with a history of cerebral infarction and schizophrenia stated that a CNA mocked him and that his requested wound dressing change was not performed for several hours, which was later corroborated by video showing a long gap between the CNA’s visit and the nurse’s entry to the room. Another resident with a right femur fracture, type II DM, and repeated falls, who needed one-person assistance for mobility and self-care, reported that a CNA refused to help and told her she could do some care herself, making her feel she was not trying in her recovery. Documentation and interviews confirmed that staff did not provide timely wound care or required assistance, and that these interactions caused residents to feel uncomfortable and negatively about their care.
A resident with a history of opioid dependence and polysubstance abuse was on a secure unit with a care plan that included safety risk evaluations and monitoring for signs of substance abuse. Staff later observed the resident discarding an empty Suboxone packet, even though the resident was not prescribed this medication, and the incident was reported to the on-call provider with subsequent monitoring and a room search. However, the care plan was not revised to reflect this new substance-related event, and both the DON and Administrator acknowledged that the care plan should have been updated when this new risk and behavior were identified.
Surveyors identified that a medication cart on the north hall was left unlocked and unattended outside a resident room. An LPN acknowledged that the cart was hers and that she had not locked it before leaving to answer a call light, despite facility expectations. The DON confirmed that all medication and treatment carts are required to remain locked when not in use or when staff are away from them.
Surveyors found that a document containing multiple residents’ PHI, including full names, room numbers, and code status, was left unattended and visible on a south nurse’s station counter. An RN confirmed the document was a resident list with PHI and acknowledged it had been left exposed and that such information should not be left unattended.
Surveyors found that a lunch tray return cart containing uncovered, soiled food trays and dishes was left unattended in a main hallway outside an activity room. The housekeeping/laundry manager acknowledged seeing the unattended cart, and the Dietary Manager confirmed that such carts are supposed to remain only in designated areas, such as near the nurse’s station or in the kitchen, and should be returned to the kitchen for cleaning as soon as all trays are collected. This failure was cited as likely to expose all residents to potential pathogens associated with food waste.
Two residents with scheduled showers reported that they were offered or received showers in very cold water during a prolonged period when hot water was not reliably available in care areas. One resident stated he refused cold showers and was only offered sponge baths once or twice, despite his preference to stay clean. Another resident reported receiving cold showers, including being rinsed with cold water while still soaped, and subsequently began refusing showers and bed baths due to the cold water. A CNA confirmed that water in the shower rooms was “ice cold” for several months, leading to resident complaints and refusals, while the Maintenance Director reported that a needed part to correct the hot water problem was on back order, delaying resolution and resulting in the facility not honoring residents’ bathing preferences.
Surveyors observed that unused medications were improperly discarded in a trash bin attached to a medication cart on the north hallway, rather than being disposed of in a designated drug disposal container. Two pills, a round blue tablet stamped "61" and an oblong orange tablet stamped "20," were found together in an unlabeled medication cup in the trash. An RN confirmed the medications were discarded there and acknowledged that unused medications should be placed in the drug buster container in the cart drawer. The Unit Manager also confirmed that facility practice requires all unused medications to be disposed of using the drug buster and that controlled substances must be destroyed by two licensed staff and documented on the narcotic count sheet.
The facility failed to follow documented allergy information, diet orders, and meal tickets for three residents. A resident with a documented chocolate allergy was served chocolate ice cream after requesting it, and the Nutrition Director admitted not reading the allergy notation on the meal ticket. Another resident on a pureed diet received whole mandarin oranges instead of pureed fruit, which a CNA confirmed. A third resident whose meal ticket called for a grilled Swiss sandwich received a sandwich that was not grilled, as confirmed by a CNA and a dietary manager.
Failure to Provide Required Written Transfer, Appeal, Ombudsman, and Bed-Hold Notices During Hospitalizations
Penalty
Summary
Surveyors identified that the facility failed to provide required written transfer and bed-hold information for multiple residents who were hospitalized. For three residents who experienced transfers to the hospital after events such as falls with injury, unresponsiveness, and episodes of nausea, vomiting, and bleeding, record review showed there were no written transfer notices or written bed-hold notices in their medical records. Specifically, one resident transferred after a fall on 01/31/26 had no documented written transfer notice or bed-hold notice. Another resident transferred on 02/27/26 for nausea, vomiting, and bleeding, and later readmitted on 03/05/26, had no written transfer notification that included information on appeal rights or Ombudsman contact, and no written bed-hold notification. A third resident transferred on 01/29/26 after a fall with a forehead laceration and again on 03/17/26 for unresponsiveness, also had no documented written transfer or bed-hold notices for either hospitalization. The deficiency also included the facility’s failure to provide required content in transfer notices and to notify the State Long-Term Care Ombudsman in writing. For the residents reviewed, there was no evidence that written transfer notices were provided to the residents or their representatives in a language and manner they could understand, and the notices were missing required elements such as a statement of appeal rights, the name, mailing and email address, and phone number of the entity receiving appeals, and information on how to obtain and complete an appeal form. The notices also lacked the name, phone number, and mailing and email address of the State Long-Term Care Ombudsman, and written copies of the transfer notices were not sent to the Ombudsman. During interview, the Social Services Director confirmed that transfer and bed-hold notices were not documented for at least one resident’s hospitalization, that she does not notify the Ombudsman about transfers to the hospital, and that she only emails a monthly list of residents discharged from the facility without sending written copies of transfer or discharge notices.
Failure to Timely Retrieve Residents From ER After Discharge
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from neglect by not arranging timely transportation back to the facility after emergency room (ER) discharge. A consumer complaint alleged that residents sent to the local ER were being left there for extended periods after discharge. For one resident with an admission date of 10/13/25, records showed multiple cognitive and behavioral diagnoses, including Alzheimer’s disease, vascular dementia with agitation and other behavioral disturbances, mild cognitive impairment, cognitive communication deficit, and restlessness and agitation. A change of condition MDS documented a Brief Interview for Mental Status (BIMS) score of 1 and frequent incontinence of urine and bowel. Nursing progress notes for this resident showed that 911 was called at 3:00 AM and the resident was transferred to the ER after a fall. Hospital discharge instructions indicated the resident was discharged from the ER at approximately 5:21 AM, while the ER nurse reported discharge at about 5:30 AM. The ER nurse stated she made numerous calls to the facility but was unable to reach anyone. She reported that the resident was very disoriented and that the ER did not have enough staff to provide 1:1 supervision. The ER nurse eventually reached the Administrator, who stated staff would come to pick up the resident as soon as possible. Facility records showed the resident was not discharged from the facility on that date, and the ER nurse reported that facility staff did not pick the resident up until approximately 8:30 AM, several hours after discharge. A second resident, admitted on 11/25/25, had diagnoses including Alzheimer’s disease, dementia with behavioral disturbance, bipolar disorder with severe depression and psychotic features, depression, and anxiety disorder. The admission MDS documented a BIMS score of 2, frequent urinary incontinence, constant bowel incontinence, and a need for substantial/maximal assistance with toileting hygiene. Nursing notes showed this resident was sent to the ER for evaluation after a fall and did not return until the following morning. Hospital discharge instructions documented discharge from the ER at 10:16 PM, and the Administrator confirmed being notified of the discharge at about 10:30 PM and that the facility did not have 24-hour transportation. The Administrator acknowledged the resident was not picked up until approximately 9:00 AM the next day. The ER nurse reported making several calls to the facility that went to voicemail, eventually reaching the Administrator, who initially stated staff were on the way, then stopped answering calls. During the approximately 11-hour wait, the ER nurse stated the resident was confused, attempted to get out of bed, and became more confused as the night progressed.
Failure to Timely Provide Wound Care and Required Assistance, Resulting in Resident Neglect
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from neglect when staff did not respond appropriately to requests for care and assistance. One resident with a history of cerebral infarction due to embolism and schizophrenia, admitted on 01/30/26 and requiring staff assistance for ADLs and mechanical lift transfers, reported that a CNA was rude and mocking and that his wound dressing was not changed for several hours after he requested it. The Kardex showed he needed staff help for toileting, bathing, hygiene, bed mobility, dressing, and transfers. Nursing progress notes documented a change in condition on 03/02/26 after the resident stated the CNA was rude and would not assist as requested. The Administrator later confirmed, via video review, that the CNA entered the resident’s room at 2:30 am, the resident requested a dressing change, and no nurse entered the room until 5:00 am, despite the nurse’s statement that she went in “right away.” The DON also confirmed that the resident’s grievance described the wound dressing not being changed until hours after the request. Another resident, admitted with a right femur fracture, type II diabetes, and repeated falls, required one-person assistance for dressing, hygiene, bathing, bed mobility, and transfers, and could toilet herself with assistance for transfers. Nursing progress notes documented an alleged abuse incident on 03/02/26 in which this resident stated a CNA was rude, refused to help her, and told her she could perform some care tasks herself without staff assistance. An abuse questionnaire completed the same day showed the resident answered “Yes” to having interactions that made her feel uncomfortable or negative, and she reported that the CNA made her feel as though she was not trying with her own recovery. The Administrator and DON acknowledged that staff are expected to help residents as required and that staff interactions must be encouraging rather than making residents feel bad about needing assistance.
Failure to Revise Care Plan After Substance-Related Incident
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s care plan after a significant substance-related incident. The resident was originally admitted with a diagnosis of opioid dependence and resided on a secure unit related to polysubstance abuse disorder. The existing care plan, dated 01/21/26, identified the resident as residing on a secure unit due to polysubstance abuse disorder with interventions to perform safety risk evaluations on admission, as needed, and upon changes in condition. The care plan also identified the resident as at risk for substance use disorder with interventions to monitor for signs or symptoms of substance abuse. On 02/01/26, nursing notes documented that staff observed the resident discarding an empty Suboxone packet in the trash, even though the resident was not prescribed Suboxone and denied taking any. Staff notified the on-call provider, who ordered monitoring for adverse reactions, and nursing staff and security conducted a room search that revealed no additional contraband. Despite this incident, the resident’s care plan was not updated to address the new substance-related event. During interviews, the DON acknowledged awareness of the incident and confirmed the care plan was not revised, and the Administrator stated her expectation that nursing would update the care plan when a new risk or behavior was identified and confirmed she would have expected the care plan to be updated for this resident.
Unattended, Unlocked Medication Cart on North Hall
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were properly stored and secured in accordance with professional standards and facility expectations. On 03/24/26 at 9:06 a.m., surveyors observed a medication cart on the north hall left unlocked and unattended outside a resident room. At 9:08 a.m., the LPN responsible for the cart confirmed during interview that the cart was hers, that it was unlocked and unattended, and acknowledged she should have locked it before responding to a call light. Later that day at 3:37 p.m., the DON stated in an interview that medication and treatment carts are expected to be locked at all times when nurses are away from them, confirming that the observed practice did not meet facility expectations. This deficient practice was cited as likely to allow unauthorized personnel access to medications, which could result in injury or overdosing.
Unattended PHI Document Left Exposed at Nurse’s Station
Penalty
Summary
Surveyors identified a deficiency in the facility’s protection of residents’ personal health information (PHI) when a document containing multiple residents’ full names, assigned room numbers, and code status was left unattended and exposed on the south nurse’s station counter. On 03/16/26 at 9:04 a.m., an observation revealed a piece of paper on a clipboard with complete resident information placed on top of the south nurse’s counter in public view. At 9:06 a.m., during an interview, RN #2 confirmed that the list contained residents’ names, room numbers, and code status, acknowledged that it had been left exposed and unattended, and stated that PHI should not be left unattended. No additional clinical details or medical histories of the residents listed on the document were provided in the report.
Unattended Soiled Lunch Cart Left Uncovered in Hallway
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the handling of soiled food service equipment. On 03/24/26 at 12:58 pm, a lunch tray return cart containing soiled food trays and dishes that were uncovered was observed sitting unattended in the main hallway outside the activity room. At 1:06 pm, the housekeeping/laundry manager confirmed she saw the return cart left unattended in that location. At 1:08 pm, the Dietary Manager stated that lunch return carts should only be left in designated areas such as by the nurse’s station or inside the kitchen, and that the cart should be returned to the kitchen for cleaning as soon as all trays have been picked up, which did not occur in this instance. This deficient practice was noted as likely to expose all residents to potential pathogens associated with food waste.
Failure to Honor Resident Bathing Preferences During Prolonged Hot Water Issues
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ bathing preferences when hot water was not reliably available in resident care areas. Record review showed that one resident was scheduled to receive three showers per week on specific days, and another resident was scheduled for two showers per week. One resident reported that staff attempted to have him shower in cold water, which he refused, and that sponge baths were only offered once or twice during the period when the hot water was not working. He stated that he liked to be clean and did not feel like himself when he was dirty. A CNA reported that there was no hot water in resident care areas from the middle of December until early March, and that large barrels of warm water were brought to shower rooms to offer sponge baths, which this resident refused. Another resident, also on a scheduled twice-weekly shower regimen, stated that she received cold showers and began refusing showers because of how cold the water was. She described the water running cold unpredictably, including an instance when the water was initially warm but turned cold while she was still soaped, requiring rinsing with cold water, which she described as horrible. A social services note documented that this resident’s daughter reported the resident had been declining showers and bed baths offered because the water was too cold. A CNA corroborated that the water was “ice cold” and that residents began complaining and refusing showers around mid-December. The Maintenance Director stated that it took a while for hot water to reach the shower room and that a needed part to fix the cold-water problem was on back order, contributing to the prolonged period of inadequate hot water and resulting in residents not having their bathing preferences honored.
Improper Disposal of Unused Medications on Medication Cart
Penalty
Summary
Surveyors identified a deficiency related to accident hazards and inadequate supervision when unused medications were improperly discarded on the north hallway. During observation of the north hall nurses’ station, two medications were found in the trash bin attached to the medication cart, placed together inside an unlabeled medication cup. The pills were described as a round blue pill stamped with “61” and an oblong orange pill stamped with “20.” In an interview immediately following the observation, an RN confirmed that these medications were in the trash bin and stated that unused medications should instead be disposed of in the drug buster, a sealed container for drug disposal located in the bottom drawer of the cart. In a subsequent interview, the Unit Manager confirmed that all unused medications are to be disposed of using the drug buster and acknowledged that this did not occur, further stating that if the medications are controlled substances such as narcotics, two licensed personnel are required to dispose of them together and document the disposal on the narcotic count sheet. This deficient practice was noted as likely to affect any resident who might acquire and ingest the discarded medications, potentially causing medication side effects.
Failure to Follow Allergy, Diet, and Meal Ticket Requirements
Penalty
Summary
The facility failed to provide meals consistent with residents’ documented allergies, diet orders, and meal tickets for three residents. One resident, admitted with a documented allergy to chocolate, had a face sheet and lunch ticket indicating they were not to receive chocolate. During a lunch observation, this resident was served and was eating chocolate ice cream. An LPN confirmed the resident’s chocolate allergy and that the resident should not be eating chocolate. The Nutrition Director acknowledged that the meal ticket stated the resident should not have chocolate but reported serving chocolate ice cream after the resident requested it, stating he had not read that the resident was allergic to chocolate. Another resident, admitted with hypokalemia and ordered a regular/liberalized pureed diet per the MDS, had a lunch ticket indicating a pureed diet but was observed receiving whole mandarin oranges instead of pureed fruit. A CNA confirmed that the dessert was not pureed. A third resident’s meal ticket specified a grilled Swiss sandwich, but observation of the tray showed the sandwich was not grilled. During interviews, a CNA and a dietary manager confirmed that the sandwich was not grilled as ordered on the meal ticket.
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