Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Casa Real during CMS and state inspections, most recent first.
A resident with chronic respiratory failure, hypoxia, and other comorbidities was observed receiving oxygen via nasal cannula connected to a portable concentrator without any corresponding physician order specifying when oxygen should be administered. The same resident had a nebulizer with tubing and a mask in the room, and neither the oxygen tubing nor the nebulizer tubing was dated to indicate when they were placed or should be changed. A CNA confirmed the resident was on oxygen and that the undated tubing should have been dated, demonstrating a failure to follow professional standards for respiratory care and oxygen use.
Nursing staff failed to correctly implement Enhanced Barrier Precautions (EBP) during wound care for a resident with a pressure ulcer. During an observed wound treatment, an LPN performed high-contact care without a gown, there was no EBP signage, and PPE was not readily accessible. In interviews, the LPN reported being told that gowns were only required for residents on transmission-based precautions, and the Infection Preventionist confirmed she believed EBP was only needed for infected wounds, reflecting a misunderstanding of EBP requirements for residents with pressure ulcers or wounds.
A resident with sepsis, morbid obesity, an abdominal wound vac, an unstageable sacral pressure ulcer, and an actual infection with a surgical wound did not have required Enhanced Barrier Precautions (EBP) signage posted in the room, and PPE was not readily accessible. During observed wound care, an LPN performed treatment without donning a gown. In interviews, the LPN reported believing gowns were only required for residents on transmission-based precautions, and the IP stated that EBP was only needed for residents with infected wounds, demonstrating a failure to implement EBP and appropriate PPE use during high-contact wound care activities.
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 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.
A resident with an indwelling urinary catheter sat in the dining room during breakfast with the urinary drainage bag exposed under the wheelchair and without a dignity cover. A nurse confirmed that the drainage bag was visible and acknowledged that all drainage bags should be covered with a dignity cover, but this one was not, resulting in the resident’s medical device being visible to others and failing to maintain the resident’s dignity.
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.
Improper Disposal of Unused Medications: Two pills were observed in the trash bin attached to the north hall med cart inside an unlabeled medication cup. An RN confirmed the meds were in the trash, and the UM stated unused meds should have been disposed of in the drug buster; controlled meds require two licensed staff and an update to the narcotic count sheet.
Therapeutic diets were not followed for a resident with hypokalemia who was ordered a regular/liberalized pureed diet. During lunch observation, the resident’s meal ticket indicated a pureed diet, but the resident was served whole Mandarin oranges instead of a pureed dessert, and a CNA confirmed the oranges were not pureed.
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.
Unsafe Food Storage and Handling in Kitchen: Surveyors observed multiple food safety lapses, including unlabeled and undated food in the refrigerator, food left open to air, meat thawing in stagnant water, dry goods and dish soap stored on the floor, and personal food on a prep table. A cigarette and lighter were also found near the food serving line, and the DM confirmed several items were stored improperly.
The facility failed to maintain infection control for two residents. An LPN and CNA cared for a resident with COVID-19 without the expected TBP communication and PPE, and the room lacked posted precaution notice. In a separate event, an LPN checked another resident’s blood glucose, did not perform hand hygiene after glove removal, and returned the used glucometer to the med cart without disinfecting it.
Failure to Monitor Antibiotic Stewardship Program: The facility did not implement or monitor its antibiotic stewardship program to prevent unnecessary antibiotic use. The IP stated there was no system to track residents on antibiotics, was unaware of the overall number of residents who had received antibiotic therapy in the past 6 months, and did not produce the records he said were on his desk. He also confirmed the program was supposed to meet monthly, but the last meeting occurred when the previous IP was still in place, and the facility later could not produce any antibiotic stewardship records.
A facility failed to ensure that a qualified IP was designated to oversee the IPCP. During interview, the facility-designated IP stated he had not completed the required infection control class, that the prior IP left in January 2025, and that he did not finish the training needed for the role because of other non-IP job duties assigned to him.
A resident's room was not maintained in a clean, comfortable, and uncluttered condition. Surveyors observed two unused O2 concentrators stored in the room, and two respiratory spirometers were left out of sealed bags and placed on top of an opened tube of Clotrimazole Cream on a shelf next to the bed. CNA, LPN, and DON interviews confirmed these items should not have been stored that way.
A facility failed to keep several residents’ care plans current by missing required quarterly care plan meetings tied to MDS assessments. Multiple residents had long gaps between documented meetings, and staff confirmed the meetings should have occurred sooner. For one resident with Alzheimer’s disease, dementia, and epilepsy, staff observed a table placed across her wheelchair during family visits, but the care plan did not address when the table should be used or removed, and the DON acknowledged that omission.
Failure to Follow Orders for Medication, Tube Feeding, and Oxygen A resident had Clotrimazole Cream in use without a physician order, another resident’s enteral feeding spike set was not changed per the ordered schedule, and three residents did not receive oxygen as ordered. One resident was found without O2 before a fall and had an O2 sat of 78%, another had the NC wrapped around the concentrator, and a resident with COPD was found without O2, became pale and diaphoretic, had low O2 sats, and later died.
Insufficient staffing led to missed baths and showers for residents, with CNAs stating these are often the first care tasks missed each day. An LPN confirmed staffing shortages were affecting residents, causing delayed brief changes and missed baths/showers, and the DON acknowledged that brief changes should not be delayed and baths/showers should be offered as scheduled and to resident preference.
Failure to review monthly pharmacy recommendations and respond to pharmacist concerns affected two residents. One resident remained on a Lispro insulin sliding scale despite a pharmacist suggesting discontinuation, and another resident continued Cetirizine daily despite a pharmacist recommending discontinuation or PRN use. The DON stated pharmacy recommendations were expected to be reviewed by a provider within a couple of days, but several months of reviews were missing and some recommendations were not addressed for weeks.
Failure to review pharmacy recommendations and implement GDRs for multiple residents. The facility did not complete required monthly pharmacy reviews for several months, and provider review of consultant pharmacist recommendations was delayed or absent for residents receiving psychotropic and other medications, including aripiprazole, lorazepam, quetiapine, escitalopram, hydroxyzine, and trazodone. The DON stated pharmacy recommendations were expected to be reviewed by a provider within a couple of days, but several were not acknowledged.
Medication Storage and Labeling Deficiencies: Surveyors found an unlabeled, undated medication cup with 4 tablets in a med cart, insulin pens without first-use or discard dates, and an expired insulin pen in another med cart. An RN confirmed the tablets had been pre-poured from the prior day and should have been discarded, and confirmed insulin pens must be labeled when first used and discarded after 28 days; an LPN verified the expired medication.
A resident with dementia, behavioral disturbance, CKD, and other comorbidities was involved in two separate sexually inappropriate incidents with another resident. After the first incident, the facility generated a written discharge notice citing safety concerns and including appeal information, but key fields such as the discharge planning conference date were left blank and there is no clear evidence the representative actually received it. Following a second similar incident, a second discharge notice was created with an undated 30‑day notice period and no conference date, and the Social Services Director reported sending both notices with the transport driver at the time of discharge. The resident’s spouse stated she was only called and told he had to leave immediately, did not receive any written discharge notice, and was unaware of her appeal rights, demonstrating a failure to provide required written discharge notification to the resident’s representative.
A resident with severe cognitive impairment and dementia-related behavioral disturbance was placed on 1:1 after an incident in which he was found on top of another resident with his pants down. Staff documented ongoing sexual behaviors and requested medroxyprogesterone, but the resident was discharged home with hospice after a second incident before the medication could take effect. His wife said she received only a late phone call, no written notice, and no chance to appeal or prepare for his return home; the hospice nurse said there was no time to plan and no home health services were in place when he arrived home.
A resident’s discharge RTA MDS was completed but not submitted within the required 14-day timeframe after the resident discharged and did not return. The MDSC confirmed the MDS was not submitted as required, while the resident’s Entry MDS had been submitted and accepted on time.
Failure to provide required ADL care affected three residents. One resident with dementia was left without toileting or brief changes for long periods, another resident who was totally dependent due to quadriplegia and TBI had repeated extended gaps without toileting and developed moisture associated skin damage, and a third resident did not receive showers as scheduled and had no documented urostomy bag changes in the TAR. Staff interviews confirmed the expected toileting, bathing, and urostomy care routines were not being met.
A resident who wore corrective lenses had a scratched pair of glasses discussed during a care conference, and the POA requested an eye doctor visit for new glasses. Facility notes referenced obtaining a consult as needed, but the SSD later stated she had not made the appointment or followed up with the POA for the provider information, despite stating that facility protocol was to follow up within the same week.
A facility failed to adequately supervise two residents in memory care to prevent repeated resident-to-resident sexual contact. One resident had dementia with severe cognitive impairment and documented inappropriate sexual behaviors, while the other had advanced dementia, wandered the unit, and was known to enter rooms and disrobe. Staff found the male resident on top of the female resident with his pants down, and later found the two residents kissing and partially undressed. Interviews showed the assigned 1:1 monitor was distracted when the resident walked away and returned to the room.
Missing dialysis communication logs for a resident receiving hemodialysis. The resident had CKD, anemia, DM2, HTN, cardiomyopathy, and a history of refusing dialysis on and off. Nursing staff stated the resident was assessed after returning from dialysis and abnormal findings were reported to the NP or on-call provider, while the DON said dialysis logs with pre-treatment info were expected three times weekly. However, multiple dialysis communication log entries were missing from the record, and the facility could not produce the missing logs when requested.
A resident developed a new coccyx pressure ulcer, but neither the provider nor the POA was notified by facility staff. The POA only became aware of the wound after the resident was hospitalized, and the NP responsible for the resident was also not informed. Multiple staff interviews confirmed that required notifications were not made when the pressure ulcer was discovered.
A resident developed a stage two pressure ulcer on the coccyx that was not consistently identified, measured, or documented by nursing staff, despite evidence of its presence and ongoing treatment. Barrier cream was applied multiple times, and CNAs noted redness in the area, but licensed staff failed to properly assess or record the wound's progression. Facility leadership and staff interviews confirmed that required wound care protocols were not followed, resulting in the ulcer being unmonitored and unmeasured.
A resident's shower and refusal records were not consistently documented according to the facility's schedule and policy. Review of the EHR showed multiple missed entries for scheduled showers, with staff confirming that documentation was incomplete and should have been maintained at all times.
A facility failed to update a resident's care plan to reflect the removal of a bathroom door alarm, the use of a fall mat, and an anti-roll back device on the resident's wheelchair. The alarm was removed by an RN who thought it was a restraint, and the care plan lacked documentation for the fall mat and anti-roll back device, which were confirmed by staff to be in use. This oversight could lead to staff being unaware of the resident's care needs.
A facility failed to obtain physician orders for a resident's safety devices, including a bathroom door alarm, fall mat, and anti-roll back device. The Maintenance Manager installed the alarm without an order, and the DON confirmed the absence of orders for these devices. A review of the resident's physician orders showed no documentation for these safety measures.
A facility failed to provide timely foot care for a diabetic resident, resulting in long toenails and delayed podiatry appointments. The resident's daughter reported the issue, and staff interviews confirmed the lack of timely care. The Director of Nursing emphasized the importance of following physician orders for diabetic foot care, but the facility did not ensure timely podiatry appointments, as documented in the resident's records.
A resident's bathroom was found in an unsanitary condition with feces on the floor, a sticky surface, and a foul odor. The handheld shower head was on the floor, and wash bins with dirty cloths were uncovered. A CNA reported ongoing issues with the resident's bathroom cleanliness, while the DON was unaware of the situation. Housekeeping staff indicated that CNAs clean body fluids before they disinfect the area.
The facility's central patio walkway was found to be unsafe due to broken and uneven concrete and brick pavers, posing a fall risk to residents, staff, and visitors. The issue was identified during a tour in October 2024 and reported to the Maintenance Manager, who acknowledged the problem and submitted a repair request, but no repair date was set.
A resident with multiple medical conditions was improperly discharged from a LTC facility to a homeless shelter without medications or care instructions. The facility failed to document the discharge process or communicate with the resident's doctor. The administrator claimed the discharge was due to inappropriate behaviors, but there was no supporting documentation. The resident was later hospitalized with pneumonia.
A facility failed to provide a written discharge notice to a resident and the Ombudsman, resulting in an unplanned and inappropriate discharge. The resident, who was cognitively intact and independent, was taken to a homeless shelter without prior notification. The facility's records lacked documentation of the discharge notice or reasons, and the Ombudsman confirmed no notice was received.
A CNA failed to report a fall involving a resident with a history of muscle weakness, hemiplegia, and dementia. The resident was found partially on the floor, and the CNA attempted to return the resident to bed without assistance. The CNA did not report the fall or the injuries to the nurse, who later observed the resident with visible injuries. The CNA admitted to not reporting the incident, leading to their termination.
A resident with multiple health issues, including cognitive and mobility impairments, was left unsupervised in the bathroom, contrary to their care plan. This led to the resident falling while attempting to call for help, resulting in abrasions. The DON confirmed the expectation that staff should not leave the resident alone, but was unsure of the duration of unsupervised time.
A resident with dementia was left covered in feces after a CNA used abusive language and abandoned their care. LPNs found the resident in a state of neglect, with feces on their body and surroundings. The CNA was not located on the unit after the incident and returned only to continue yelling profanities before leaving again. The facility's administrator confirmed the CNA's inappropriate behavior.
A resident with dementia and Parkinson's disease experienced a decline in health leading to death. A former employee, related to the resident, received unauthorized PHI via text from another former employee, including allegations of abuse by a CNA. The SSD confirmed the incident but denied sharing details, while the Administrator stressed that PHI should only be shared with listed contacts.
A facility failed to report an abuse allegation within the required timeframe. A resident with dementia and Parkinsonism was subjected to loud profane language by a CNA, who admitted to becoming angry and cursing at the resident. The Administrator was informed of the incident the same night, but the report was submitted to the State Agency the next morning, missing the two-hour reporting requirement.
A resident with dementia and hemiplegia suffered a fractured knee due to improper transfer by a CNA, who failed to use a gait belt as per facility training. The resident's feet became tangled during the transfer, causing intense pain. Despite the resident's complaints, the CNA did not report the incident or seek immediate assessment, leading to the resident's injury.
A resident admitted with multiple diagnoses, including high blood pressure, did not receive the prescribed medication losartan until four days after admission due to a failure to enter the order into the medical record. An LPN confirmed this as a medication error, highlighting a lapse in the facility's medication administration process.
The facility failed to prevent and manage pressure ulcers for two residents. One resident's left heel ulcer worsened due to inadequate monitoring and treatment, leading to an amputation. Another resident did not receive regular skin evaluations, resulting in a lack of documentation and oversight of their pressure ulcer. Staffing shortages and inconsistent wound care practices contributed to these deficiencies.
A resident at risk for dehydration due to chronic kidney disease and other conditions did not receive timely IV fluid hydration as ordered by a physician. The facility delayed the administration of IV fluids by five days due to a lack of supplies and staff awareness. Additionally, the resident's fluid intake was inconsistently documented, leading to prolonged dehydration and an untreated UTI. Interviews confirmed the resident's significant thirst and the staff's failure to monitor fluid intake properly.
A resident with a pressure ulcer was discharged without receiving necessary wound care instructions, leading to a worsening condition and subsequent hospitalization. Interviews with staff and the resident's niece confirmed the lack of discharge documentation and communication, resulting in a left below-knee amputation.
Failure to Follow Professional Standards for Respiratory Care and Oxygen Use
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory care in accordance with professional standards for one resident with significant respiratory and cardiac conditions. The resident was admitted with systemic lupus erythematosus, morbid obesity, chronic respiratory failure with hypoxia, cor pulmonale, and hypertension. Record review showed a physician order for Ipratropium-Albuterol solution, 3 ml to inhale orally three times a day for seven days for persistent congestion, but there was no physician order for supplemental oxygen specifying when oxygen should be administered. During observation, the resident was seen wearing a nasal cannula connected to a portable oxygen concentrator, and the nasal cannula tubing was not dated. A nebulizer machine was also observed on the resident’s dresser with tubing and a mask, and this tubing was likewise not dated. In an interview, a CNA confirmed that the resident was on oxygen and acknowledged that neither the concentrator tubing nor the nebulizer tubing was dated, and that they should have been dated. These findings demonstrate that oxygen was being used without corresponding medical orders and that oxygen and nebulizer tubing were not changed or tracked in accordance with professional standards.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Nursing staff were not competent in implementing Enhanced Barrier Precautions (EBP) for a resident with a pressure ulcer, resulting in improper use of personal protective equipment (PPE) during wound care. During an observation of wound care for Resident #1, there was no signage posted indicating that EBP was required, and PPE was not readily accessible for activities of daily living, wound care, or other high-contact resident care activities. Licensed Practical Nurse (LPN) #1 was observed performing wound care for Resident #1 without donning a gown before providing this high-contact treatment. In an interview following the observation, LPN #1 stated she was unaware that gowns were required for all wound care and reported that the Infection Preventionist (IP) had instructed staff that gowns were only needed for residents on transmission-based precautions. In a separate interview, the IP stated that EBP was not needed for all residents with a pressure ulcer or wound and was only required for residents with an infected wound. This demonstrated a lack of understanding by the IP regarding EBP requirements for PPE use, which contributed to the nursing staff’s failure to follow appropriate infection control practices for residents with pressure ulcers or wounds.
Failure to Implement Enhanced Barrier Precautions and PPE for Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain an infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP) and appropriate use of personal protective equipment (PPE) for a resident with significant wounds and infection. The resident was admitted with diagnoses including sepsis, morbid obesity, and a cutaneous abscess of the abdominal wall, and had physician orders for wound care to an unstageable sacral pressure ulcer and for monitoring a wound vac to the abdomen. The resident’s care plan documented risk for skin breakdown, nutritional risk related to multiple diagnoses and wound healing needs, and an actual infection with a surgical wound. During observation of the resident’s room, surveyors noted there was no EBP signage posted and PPE was not readily accessible. Further observation showed that during wound care provided in the resident’s room, an LPN performed the treatment without donning a gown. In interview, the LPN stated she was unaware that gowns were required for all wound care and reported that the Infection Preventionist (IP) had instructed staff that gowns were only needed for residents on transmission-based precautions. In a separate interview, the IP stated that EBP was not needed for all residents with pressure ulcers or wounds, but only for residents with infected wounds. These actions and statements demonstrate that required EBP signage was not posted, PPE was not made readily available, and staff did not implement EBP during high-contact wound care activities 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 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 Maintain Dignity by Leaving Urinary Drainage Bag Uncovered in Dining Area
Penalty
Summary
The facility failed to maintain a resident’s dignity by not ensuring a privacy cover was used on the resident’s urinary drainage bag while the resident was in a public area. During a breakfast observation on 03/24/26 at 9:09 a.m. in the locked unit dining room, Resident #11 was seen sitting in a wheelchair with the urinary drainage bag exposed under the wheelchair and without a dignity cover. Record review showed that the resident had a physician’s order for an indwelling catheter, initiated on 02/01/26, to continuously drain urine from the bladder. In an interview at 9:11 a.m., Registered Nurse #3 confirmed that the resident’s drainage bag was exposed without a dignity cover and stated that all drainage bags should be covered with a dignity cover, acknowledging that this one did not have a cover. This deficiency is likely to result in the resident's medical device being visible to other residents and staff, thereby failing to maintain the resident's dignity.
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.
Improper Disposal of Unused Medications
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when unused medications were found in the trash bin attached to the north hallway medication cart. During observation, two medications were seen inside an unlabeled medication cup in the trash bin: a round blue pill stamped with 61 and an oblong orange pill stamped with 20. RN #1 confirmed the medications were in the trash bin and stated unused medications should be disposed of in the drug buster located in the bottom drawer. The Unit Manager also stated that all unused medications are to be disposed of using the drug buster and that this did not happen; he further stated that controlled medications such as narcotics require two licensed personnel to dispose of them together and to update the narcotic count sheet.
Therapeutic Diet Not Followed for a Resident
Penalty
Summary
Therapeutic diets were not provided as prescribed for R #12. R #12 was admitted with a diagnosis of hypokalemia and the MDS indicated a regular/liberalized pureed diet. During lunch observation on 3/26/26 at 11:42 a.m., R #12's lunch ticket showed a pureed diet, but the resident was served whole Mandarin oranges instead of a pureed dessert. CNA #2 confirmed that the Mandarin oranges were whole and not pureed.
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.
Unsafe Food Storage and Handling in Kitchen
Penalty
Summary
Food was not stored and served under sanitary conditions when kitchen staff failed to keep food items labeled, dated, and properly covered in the kitchen refrigerators and food preparation areas. During observation on 09/22/25, surveyors found one sheet pan of food in the kitchen refrigerator that was not labeled or dated, one pack of yellow American sliced cheese open to air, and a tobacco cigarette and cigarette lighter in the kitchen near the food serving line. The Dietary Manager stated that food items should be stored appropriately, labeled, and dated, and that the cigarette and lighter should not have been in the kitchen. On 09/23/25, surveyors observed 4 tubes of hamburger meat sitting in a sink with stagnant water while defrosting, which the Dietary Manager confirmed. They also observed a 32 oz bottle of vanilla and a 16 oz container of garlic powder sitting on the bare floor in the dry storage room, a container of chili beans on the preparation table with no label or date that the Dietary Aide identified as personal food, and a package of cheese, a block of butter, and an egg sandwich left open to air on the grill, with 2 loaves of bread open to air on the steam table. In addition, a 5 gallon bucket of dish soap was observed sitting on the bare floor in the dish room, which the Dietary Manager confirmed should not have been there.
Infection Control Failures With COVID-19 Precautions and Glucometer Handling
Penalty
Summary
The facility failed to maintain a safe, controlled environment for two residents reviewed, including a resident with COVID-19 and another resident who received blood glucose monitoring. For the resident with COVID-19, an LPN entered the room wearing only a disposable mask after the resident told her he had COVID-19 and needed her to keep her distance. The resident stated he had COVID as of the prior day and had started medications for it that day. Record review listed COVID-19 as a diagnosis, and the Infection Preventionist stated that once a provider places an order for PAXLOVID, Transmission-Based Precautions should be added and the associated education and protocol provided. The Infection Preventionist also confirmed that facility policy required an order for TBP and that TBP included wearing an N95. For the same resident, a CNA provided perineal care while wearing only a disposable mask, and the CNA stated it was her first day back, that no one had told her about the precaution, and that she did not see Transmission-Based Precautions posted outside the room. The CNA stated she should have worn an N95 for this type of infection. In a separate observation, the LPN checked another resident’s blood glucose, did not perform hand hygiene after removing gloves, and placed the used glucometer back into the top drawer of the medication cart. The LPN stated she failed to wash her hands and disinfect the glucometer, and confirmed that facility policy required hand hygiene between patient care and disinfection of the glucometer after use with the facility-approved disinfectant.
Failure to Monitor Antibiotic Stewardship Program
Penalty
Summary
The facility failed to ensure its antibiotic stewardship program was implemented and monitored to prevent unnecessary antibiotic use. During an interview, the Infection Preventionist stated there was no system in place to track residents on antibiotics and was unaware of the overall number of residents who had received antibiotic therapy in the past 6 months. He also stated that he had the records on his desk but did not produce any records and pointed to a stack of papers instead. In a separate interview, the Infection Preventionist stated the antibiotic stewardship program was expected to meet monthly, but the last meeting had been held in January 2025 when the previous Infection Preventionist was still in place. The facility later failed to produce any records related to the antibiotic stewardship program.
Unqualified Infection Preventionist Assigned to IPCP
Penalty
Summary
The facility failed to ensure that a qualified individual was designated as the Infection Preventionist responsible for the Infection Prevention and Control Program. During an interview on 09/26/25 at 1:30 PM, the Infection Preventionist stated that he had not finished the Infection Control class offered earlier in the year, even though he was the facility-designated Infection Preventionist. He also stated that the previous Infection Control Preventionist left in January 2025 and that he was required to attend and complete infection control training before being assigned to the role, but he did not do so because he had other non-IP related jobs assigned to him.
Unstored Medical Items and Clutter in Resident Room
Penalty
Summary
The facility failed to maintain R #9's room in a clean, comfortable, and uncluttered condition. On 09/23/2025, surveyors observed two unused O2 concentrators stored in the corner of R #9's room. On 09/29/2025, the same two O2 concentrators were still in the corner of the room, indicating they had remained there since the earlier observation. During the 09/29/2025 observation, surveyors also found two respiratory spirometers not stored in sealed bags and placed on top of an opened tube of Clotrimazole Cream 1% on a shelf next to R #9's bed. CNA #2 confirmed the unused O2 concentrators were in the room and stated they should not have been there. LPN #1 confirmed the spirometers were not stored in bags and were on top of the opened cream, and stated those items should not have been left open on the shelf. The DON also stated the unused O2 concentrators should not have been stored in R #9's room, the spirometers should have been stored in sealed bags, and the Clotrimazole Cream should not have been left open on the shelf.
Care plans not kept current and wheelchair table use not addressed
Penalty
Summary
The facility failed to keep care plans current for multiple residents by not holding required quarterly care plan meetings in line with their admission dates and MDS assessments. For R #7, the record showed quarterly MDS assessments were completed on 12/21/24, 03/20/25, and 06/19/25, but the care plan meeting progress notes showed a meeting on 03/06/25 and then not again until 08/28/25. R #7's sister stated she was contacted in May to schedule a June care plan meeting, but no meeting occurred, and the SSD confirmed the meeting should have been held between 03/06/25 and 08/28/25 but was not. For R #8, quarterly MDS assessments were completed on 03/04/25, 06/03/25, and 09/02/25, but the care plan meeting record showed a meeting on 12/05/24 and then not again until 08/28/25; the resident stated he had not had a care plan meeting for a long time and wanted to be involved in his care, and the SSSD confirmed the meeting should have occurred sooner. For R #11, the record showed quarterly MDS assessments on 04/04/25 and 07/05/25, with care plan meetings documented on 10/10/24 and 01/23/25, and the SSD confirmed no meeting had occurred since 01/23/25 even though one should have. For R #60, quarterly MDS assessments were completed on 04/01/25 and 07/02/25, but the last documented care plan meeting was 12/19/24; the SSD stated the last meeting actually occurred on 03/24/25 but was not documented, and confirmed two care plan meetings should have occurred since then but did not. For R #37, who had Alzheimer’s disease, dementia without behavioral disturbance, and epilepsy, staff observed a table across the arms of her wheelchair during a family visit, appearing to secure her in the wheelchair, and later observed her without the table. The care plan dated 09/25/25 did not include use of the table when family was present or removal of the table when family was not present, and the DON acknowledged the care plan lacked any plan for family to attach or remove the table or for staff to remove it if family left it attached.
Failure to Follow Orders for Medication, Tube Feeding, and Oxygen
Penalty
Summary
The facility failed to obtain a physician order for a resident’s use of Clotrimazole Cream 1%. Record review showed no order for the cream, yet during observation a tube of Clotrimazole Cream 1% was found opened on a shelf next to the resident’s bed. The resident stated that staff put the cream on him sometimes. An LPN stated she did not know the resident was using the cream and confirmed the medication should have had a physician order and should not have been left open on the resident’s shelf. The DON also stated there were no orders present for the cream. The facility failed to follow the physician’s order for enteral feeding maintenance for a resident receiving tube feeding. During observation, the resident was asleep with tube feeding running, and the feeding bag label was dated with a time of 0200 at 9:25 am. The physician’s order required the feeding spike set to be changed as needed with each new bottle and every night shift for maintenance of the enteral feeding system. An RN confirmed the date written on the tube feeding spike set and stated that, per the order, it should have been replaced every 24 hours during night shift and should have been changed before her shift started. The facility also failed to follow physician orders for oxygen use for three residents. One resident with severe cognitive impairment and diagnoses including atrial fibrillation, diabetes, and respiratory failure was ordered continuous oxygen at 1 LPM via nasal cannula, but was observed without oxygen while seated in a wheelchair and later fell face down in front of the wheelchair with an oxygen saturation of 78% before oxygen was applied. Another resident was ordered oxygen at 2 LPM via nasal cannula, but was observed with the oxygen concentrator at bedside and the nasal cannula wrapped around it; the resident stated therapy had told him he did not need oxygen. A third resident with COPD and other diagnoses was ordered continuous oxygen and supplemental oxygen at 3 LPM via nasal cannula every day and night shift, but was found sitting in the dining room without oxygen, pale and diaphoretic, with later documentation showing oxygen saturations in the low 80s and worsening shortness of breath before the resident died later that day.
Insufficient Staffing Led to Missed Baths and Delayed Care
Penalty
Summary
The facility failed to provide sufficient nursing staff every day to meet resident needs and to have a licensed nurse in charge on each shift when staff did not offer baths or showers to residents as scheduled. During interviews, a CNA stated that due to staffing shortages, resident baths and showers are the first things missed each day and that residents complain about missed showers. Another CNA confirmed that residents miss baths and showers because of insufficient staffing. An LPN stated there is a shortage of staffing, residents are affected by it, resident brief changes are delayed, and baths/showers are missed due to low staffing. The DON confirmed that resident brief changes should not be delayed and that residents should be offered baths/showers as scheduled and to their preference.
Failure to Review Monthly Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that a licensed pharmacist completed monthly drug regimen reviews for residents and that pharmacist recommendations were reviewed and responded to by a facility provider in a timely manner. Record review showed no pharmacist recommendations were available for any resident for October 2024, November 2024, and June 2025. In addition, pharmacist recommendations dated 05/19/25 through 05/21/25 for all residents were not reviewed by the facility provider until 06/12/25, and recommendations dated 08/18/25 were not reviewed until 09/05/25. For R #4, physician orders dated 09/12/24 showed Lispro insulin 100 units/mL was ordered as a sliding scale. A pharmacist recommendation dated 12/30/24 stated the sliding scale should be considered for discontinuation and finger stick blood glucose checks limited to as needed due to the 2024 Standards of Care Diabetes Care in Older Adults, but the recommendation was not responded to by a facility provider and the MAR from 01/01/25 through 09/30/25 showed the sliding scale order remained unchanged each month. For R #7, physician orders dated 11/16/24 showed Cetirizine 5 mg daily for rhinitis, and a 12/30/24 pharmacist recommendation stated the medication should be considered for discontinuation or changed to as needed; the MAR showed Cetirizine 5 mg was administered daily through 06/19/25, was discontinued on 06/15/25, restarted on 06/20/25, and discontinued again on 07/25/25. The DON stated on 09/29/25 that pharmacy recommendations were expected to be reviewed and responded to by a provider within a couple of days, and confirmed the recommendations for R #4 and R #7 should have been acknowledged and implemented.
Failure to Review Pharmacy Recommendations and Implement GDRs
Penalty
Summary
The facility failed to complete required pharmacy reviews of resident medications for 5 of 8 residents reviewed, including residents 4, 7, 39, 63, and 105. The record review showed that pharmacy recommendations were missing for all residents in the facility for October 2024, November 2024, and June 2025, and that pharmacist recommendations dated 05/19/25 through 05/21/25 were not reviewed by a facility provider until 06/12/25. Recommendations dated 08/18/25 were not reviewed by a facility provider until 09/05/25. Resident 4 was receiving aripiprazole 2 mg twice daily for major depression, and a pharmacist recommendation dated 07/24/25 stated the medication required an indication for use and to consider a GDR. That recommendation was not acknowledged by a facility provider. Resident 7 had pharmacist recommendations on 02/21/25 and 04/17/25 stating PRN psychotropic orders needed a 14-day stop date and that lorazepam needed physician re-evaluation; the first was not acknowledged, and the second was not signed and acknowledged until 20 days later. Resident 39 had pharmacist recommendations stating hydroxyzine should be evaluated for continued use and that quetiapine and escitalopram should be evaluated for current dose and possible GDR; neither recommendation was acknowledged by a facility provider. Resident 63 had a pharmacist recommendation to evaluate quetiapine and escitalopram doses and consider a GDR, and it was not acknowledged. Resident 105 had a pharmacist recommendation to attempt a dose reduction of trazodone used for insomnia, and it was not acknowledged by a facility provider. The DON stated pharmacy recommendations were expected to be reviewed each month by a facility provider within a couple of days, and confirmed the recommendations for residents 4, 7, 39, 63, and 105 should have been acknowledged and implemented.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly store medications in the medication carts by leaving expired medications in the carts, pre-pouring medications, and failing to label insulin pens with the date of first use and discard date. During observation of the south unit medication cart, surveyors found an unlabeled, undated medication cup containing 4 white tablets, an insulin pen for Resident #71 with no date of first use and no discard date after 28 days, and an insulin pen for Resident #123 with no date of first use and no discard date after 28 days. RN #3 stated that the tablets in the medication cup were from the previous day and were meant to be discarded, confirmed that medications should not be pre-poured, and confirmed that insulin pens must be labeled when first used and discarded after 28 days. During observation of the north unit medication cart, surveyors found an insulin pen for Resident #74 with an expiration date of 06/24/25, and LPN #1 verified that the medication was expired.
Failure to Provide Proper Written Discharge Notice to Resident’s Representative
Penalty
Summary
The deficiency involves the facility’s failure to provide proper written notice of discharge to a resident’s representative. The resident in question was admitted with multiple diagnoses including dementia with behavioral disturbance, paroxysmal atrial fibrillation, restlessness and agitation, chronic kidney disease, history of pulmonary embolism, and was receiving palliative care. Following a reported incident on 06/22/25 in which the resident was found on top of another resident with his pants down, attempting to pull down the other resident’s pants and touching her private area, the facility documented a Notice of Intent to Discharge. This notice stated that discharge would be effective 30 days from 06/22/25 due to safety concerns related to the resident’s clinical or behavioral status, and it included appeal contact information. However, the discharge planning conference date was left blank, and the method of delivery was noted only as “verbal and hand deliver,” without clear evidence that the representative actually received the written notice at that time. A second incident was documented on 06/30/25, when a hospice RN reportedly found the same resident in bed with the same female resident, kissing her and attempting to put his hands down her pants, with his pants partially down. Following this, a second Notice of Intent to Discharge was created, again citing safety of individuals in the facility as the reason for discharge. This second notice identified a 30‑day notice period but left the effective date blank and again omitted a specific date for the discharge planning conference. The letter was signed by the Social Services Director and included appeal contact information, with a handwritten note indicating the wife lived two hours away, did not drive, and that the notice was “also hand delivered.” In interview, the resident’s wife stated that she was never told about a planned discharge in advance and that she was only called late in the afternoon and told to come pick him up, which she could not do. She reported that the facility told her they could no longer keep him and that they would send him home, and she confirmed she did not receive a written discharge notice and was unaware she could contest the discharge. She described concerns about her ability to care for him at home and indicated she would have preferred that he remain in the facility. In a separate interview, the Social Services Director stated that the first notice was given to the wife after the first incident and that, after the second incident, the Administrator directed an immediate discharge. The SSD reported that both written notices were sent with the driver to give to the wife when the resident was dropped off, but this conflicts with the wife’s statement that she did not receive written notice, demonstrating the facility’s failure to ensure written discharge notice was provided to the resident’s representative.
Unsafe Immediate Discharge After Repeated Resident-to-Resident Sexual Incidents
Penalty
Summary
The facility failed to ensure that one resident was appropriately discharged after repeated incidents involving another resident in the memory care unit. The resident had diagnoses including dementia with behavioral disturbance, restlessness and agitation, chronic kidney disease, atrial fibrillation, a history of pulmonary embolism, and was receiving palliative care. His discharge MDS showed a BIMS score of 1, indicating severe cognitive impairment. After the first incident, the resident was placed on 1:1 monitoring and the care plan noted inappropriate touching, but it did not identify other sexual behaviors or a discharge plan. Record review showed that on the first incident, staff found the resident on top of a female resident with his pants down and attempting sexual contact. He was separated and placed on 1:1 monitoring. Nursing notes documented ongoing behavioral concerns over the following days, including agitation, anxiety, unwanted behaviors, touching himself in the presence of staff, and continued inappropriate sexual behaviors. The facility also requested medroxyprogesterone to reduce sexual behaviors, and the medication order was dated shortly before the resident was discharged. The DON stated the medication typically required weeks to show positive changes, but the resident was discharged after only a short period on the medication. The resident was later found again with the same female resident in his room, and the facility issued an immediate discharge to home with hospice services. The wife stated she was called late in the day and told to pick him up, but she was not given written discharge notice and was not prepared to bring him home. She stated she did not know she could contest the discharge and would have preferred that he remain at the facility. The hospice nurse stated the discharge was inappropriate because there was no time to plan for it and no home health services were in place when the resident arrived home. The Administrator and SSD gave conflicting accounts about the resident’s behavior, the location of the incidents, and the discharge planning process, and the record did not provide additional evidence supporting the immediate discharge.
Late Submission of Discharge MDS
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment for one resident, R #5, was submitted for finalization within 14 days. Record review showed R #5 was admitted to the facility and later discharged on 07/10/25. The EHR MDS Assessments page showed a 06/27/25 Entry MDS that was submitted within 14 days and accepted, but the 07/10/25 Discharge Return Anticipated MDS was completed and not submitted within the required 14-day timeframe, and R #5 did not return to the facility. During an interview on 09/29/25 at 3:48 pm, the MDS Coordinator confirmed that R #5's discharge MDS was not submitted and should have been submitted within 14 days.
Failure to Provide Required ADL, Toileting, Bathing, and Urostomy Care
Penalty
Summary
Failure to provide daily care needs occurred for three residents who required assistance with ADLs, toileting, bathing, and urostomy care. One resident with dementia and behavioral disturbances required help with bathing, grooming, personal hygiene, dressing, eating, locomotion, and toileting, but the ADL tracking form showed multiple days when the resident was not toileted or changed for approximately 8 to 12 hours. An LPN stated the resident was incontinent and should be checked at least every two hours for toileting and changing. A second resident who was totally dependent for ADLs due to quadriplegia, traumatic brain injury, contractures, muscle spasticity, and being bed bound had multiple extended periods without toileting, including gaps of approximately 9 to 22 hours, and a skin assessment showed moisture associated skin damage to the front right thigh. Staff interviews confirmed the resident should be assisted with transfers and checked for toileting and changing at least every two hours. A third resident was supposed to be offered a bath or shower every day and as needed, but documentation showed only 6 baths/showers out of 31 opportunities in one month and 7 out of 25 opportunities in the next; the resident also had a urostomy bag order to be changed as needed, yet no assistance with urostomy changes was documented in the TAR. The resident stated staff did not help with the urostomy bag or showers because they said they were short staffed, and the DON confirmed the expectations for brief checks, showers, and urostomy documentation were not met.
Failure to Follow Up on Vision Services
Penalty
Summary
The facility failed to follow up on a family concern regarding a resident’s vision services. Record review showed the resident wore corrective lenses. During a care conference, the resident’s POA told facility staff that there was a scratch on the resident’s glasses and requested that the resident be taken to an eye doctor for new glasses. The care conference notes documented obtaining a consult as needed/indicated and treatment. The Social Services Director later stated that the family had discussed replacing the glasses because the scratch was affecting the resident’s vision, that the POA was going to provide the provider’s name, and that she would make the appointment, but she had not done so and had not followed up with the POA to obtain the provider information. She also stated that facility protocol was to follow up at least the same week.
Failure to Supervise Residents During Repeated Sexual Contact Incidents
Penalty
Summary
The facility failed to provide adequate supervision to prevent resident-to-resident sexual contact involving two residents in the memory care unit. One resident had dementia with behavioral disturbance, severe cognitive impairment on MDS, and was documented as having inappropriate sexual behaviors, including being found on top of another resident with his pants down and attempting to initiate sexual contact. The other resident had advanced dementia, wandered the unit, was independent with ambulation, and was documented as having poor impulse control and disrobing behaviors. The record shows multiple incidents in which the two residents were found together in intimate contact. On one occasion, staff found the male resident on top of the female resident with his pants down and attempting to pull down her pants and grab her private parts. Another incident documented the male resident with his pants partially down and both residents kissing on his bed. The female resident was also described as wandering into rooms and lying in other residents’ beds, while the male resident was placed on 1:1 monitoring after the first incident. The facility’s own documentation and interviews showed that supervision was not maintained consistently. The Administrator stated the assigned 1:1 monitor was distracted and helping another resident when the male resident walked away and returned to his room, where he was again found with the same female resident. The Administrator later clarified that after a Depo shot the male resident was monitored for 24 hours and then downgraded from 1:1 to line-of-sight monitoring, but no order change was provided. Staff interviews also confirmed the female resident’s advanced dementia and wandering behavior, and the Social Services Director stated the second incident occurred while the male resident was still on 1:1 monitoring.
Missing Dialysis Communication Logs
Penalty
Summary
The facility failed to provide dialysis services consistent with professional standards for a resident with chronic kidney disease stage 4/5 who was receiving hemodialysis on a Monday, Wednesday, Friday schedule with early morning transport to an outside dialysis center. The resident’s record showed multiple diagnoses including cardiomyopathy, chronic buttock ulcer, hyperlipidemia, hypertension, type 2 diabetes, anemia, mood disorder, and kidney disease. The care plan documented a history of refusing dialysis and later noted that the resident agreed to start dialysis and continued to refuse on and off. Record review of the resident’s EMR did not locate consistent documentation of communications between the facility and the dialysis provider. The filed dialysis communication log from 06/01/25 through 09/23/25 was missing multiple entries, including dates in June, July, August, and September. The record also showed that the resident returned from dialysis with a communication form that was supposed to be scanned into the EMR, but the surveyor could not find consistent evidence that these communications were maintained. During interviews, the RN stated the resident returned from dialysis around 11:00 a.m., was assessed on arrival, and any abnormal findings were to be reported to the NP or on-call provider. The DON stated residents going to dialysis were sent with a communication log containing pre-treatment information such as weight, vital signs, and a to-go meal if applicable, and that the nurses were expected to file the log for scanning into medical records. The DON also stated that medical records expected these communication logs three times weekly, but the facility had inconsistent medical records personnel and could not produce the missing dialysis communication logs when requested.
Failure to Notify Provider and POA of New Pressure Ulcer
Penalty
Summary
The facility failed to notify the appropriate medical provider and the resident's Power of Attorney (POA) when a new coccyx pressure ulcer was identified in a resident. The pressure ulcer was discovered on the resident's coccyx, but the POA was not informed by the facility and only learned of the condition from the hospital over a month later. Interviews with facility staff, including the Skin Health Lead and the Unit Manager, revealed that neither the provider nor the POA was notified as required when the new pressure ulcer was identified. Further interviews confirmed that the Nurse Practitioner responsible for the resident was also not informed of the new pressure ulcer and was unaware of its existence. The Director of Nursing acknowledged that both the provider and the POA should have been notified immediately upon discovery of the pressure ulcer, but this did not occur. The lack of timely notification was confirmed by multiple staff members and the POA, indicating a breakdown in communication regarding a significant change in the resident's condition.
Failure to Identify, Document, and Monitor Pressure Ulcer
Penalty
Summary
Facility staff failed to provide necessary treatment and services to prevent the development and worsening of a pressure ulcer for one resident. The resident was admitted and later discharged to the hospital, where a stage two pressure ulcer on the coccyx was identified. Facility records showed that the coccyx pressure ulcer was not consistently identified, measured, or documented by nursing staff, despite evidence from wound care supply orders, skin evaluations, and shower sheets indicating the presence of skin damage in the coccyx area. The only documentation of the coccyx pressure ulcer occurred on one occasion, and no measurements were ever recorded to monitor changes in the wound. Nursing staff applied barrier cream to the resident's coccyx pressure ulcer on multiple occasions, as indicated by the Medication Administration Record, but failed to document the presence or progression of the wound. Certified Nursing Assistants also noted redness in the coccyx area on several shower sheets, but this information was not followed up with proper wound assessment or documentation by licensed nursing staff. Interviews with facility staff, including the Skin Health Lead, Unit Manager, and Director of Nursing, confirmed that the expected protocols for wound identification, measurement, and documentation were not followed for this resident. The resident's family was not informed about the presence of the coccyx pressure ulcer, and facility leadership initially denied its existence prior to the resident's hospital transfer. However, interviews with nursing staff confirmed that the wound was present and being treated, albeit without proper documentation or monitoring. The lack of consistent assessment and documentation led to the pressure ulcer being unmonitored and unmeasured, contrary to facility policy and standard care expectations.
Incomplete Shower Documentation for a Resident
Penalty
Summary
The facility failed to ensure that shower documentation was complete and accurate for one resident. Record reviews showed that the resident was scheduled to receive a bath or shower every Monday, Wednesday, and Friday, but there were multiple instances where showers were neither documented as given nor as refused. Specifically, in January, only seven out of twenty-one scheduled showers were documented with no refusals noted; in February, five out of twenty-three were documented with five refusals; and in March, nine out of thirty-one were documented with two refusals. There was no documentation available for the remaining opportunities, and refusals were not consistently recorded in the electronic health record (EHR). Interviews with facility staff, including a CNA, an RN, and the DON, confirmed that showers and refusals should be documented on the resident's shower sheet and in the EHR. Staff acknowledged that the documentation was incomplete and that the required records were not maintained as per facility policy and professional standards. The lack of complete and accurate documentation was confirmed by all interviewed staff members.
Failure to Update Resident Care Plan with Critical Interventions
Penalty
Summary
The facility failed to update a resident's care plan to reflect changes in their care needs and interventions. Specifically, the care plan did not accurately reflect the removal of a bathroom door alarm, the use of a fall mat, and the use of an anti-roll back device on the resident's wheelchair. The bathroom door alarm, initially installed to alert staff when the resident entered the bathroom, was removed by a registered nurse who mistakenly believed it was a restraint. The removal was not documented in the care plan, and there was no order for its placement or removal. Additionally, the care plan lacked documentation for the use of a fall mat, which was intended to prevent injury during a seizure, and an anti-roll back device on the resident's wheelchair, which was meant to prevent falls when the resident attempted to stand up. Interviews with facility staff, including CNAs, the Maintenance Manager, the Director of Nursing, and the Director of Rehab, revealed a lack of awareness and communication regarding these interventions. The staff confirmed the presence and purpose of the fall mat and anti-roll back device, but these were not reflected in the care plan or supported by physician orders. The failure to update the care plan with these critical interventions could lead to staff being unaware of the resident's care needs and preferences, potentially resulting in inadequate care for the resident.
Failure to Obtain Physician Orders for Safety Devices
Penalty
Summary
The facility failed to meet professional standards of quality for a resident by not obtaining physician orders for specific safety measures. The Maintenance Manager installed an alarm on the resident's bathroom door without a physician's order, and the Director of Nursing confirmed that there were no orders for the door alarm, fall mat, or anti-roll back device. A review of the resident's physician orders revealed no active or discontinued orders for these safety devices, indicating a lack of proper documentation and authorization for their use.
Failure to Provide Timely Diabetic Foot Care
Penalty
Summary
The facility failed to provide adequate foot care for a resident with diabetes, as evidenced by the resident's long toenails and the lack of timely podiatry appointments. The resident's daughter reported that her father's toenails were very long and required trimming, and she had requested a podiatry appointment in early December 2024, which had not been scheduled. Interviews with facility staff revealed that the resident was last seen by a podiatric technician on January 16, 2025, for nail care, but there was no documentation available for previous podiatry appointments. Certified Nurse Aides (CNAs) noted the resident's long toenails during showers and documented the need for podiatry care on shower sheets. The Director of Nursing acknowledged the importance of nail care for diabetic residents and stated that physician orders should be followed, and podiatry appointments scheduled timely. Record reviews showed that the resident had physician orders for daily diabetic foot care, including inspection of feet and shoes, and checking pedal pulses. Despite these orders, the facility did not ensure timely podiatry appointments, leading to the resident's long toenails and potential risk for discomfort or infection.
Infection Control Deficiency in Resident's Bathroom
Penalty
Summary
The facility failed to maintain proper infection control practices for a resident, as observed during a survey. The resident's bathroom was found to be in an unsanitary condition, with feces on the floor, a sticky floor surface, and urine present in the toilet. Additionally, the handheld shower head was improperly placed on the bare floor, and wash bins containing dirty washcloths were left uncovered under the bathroom sink. The room and bathroom also emitted a foul odor, indicating a lack of cleanliness and sanitation. Interviews with facility staff revealed further issues contributing to the deficiency. A Certified Nurse Aide (CNA) reported that the resident's bathroom frequently had a foul smell and feces on the floor and walls, due to the resident's habit of taking showers with a brief on and flushing briefs and paper towels down the toilet, causing drain backups. The Director of Nursing (DON) was unaware of the bathroom's condition but confirmed that the observed state was unacceptable. The Housekeeping Director and Housekeeping Account Manager stated that CNAs are responsible for cleaning body fluids, while housekeeping disinfects the areas afterward. Following the observation, the Housekeeping Director instructed an increase in the cleaning frequency of the resident's bathroom.
Unsafe Patio Walkway Poses Fall Risk
Penalty
Summary
The facility failed to maintain a safe and level central patio walkway, which affected all residents using the patio for smoking and other activities. During an observation on January 21, 2025, it was noted that the paved concrete and brick pavers were broken and uneven, with some areas having a 1/2 inch hole and others showing a change in elevation. This condition poses a potential fall risk to residents, staff, and visitors. The Business Office Manager (BOM) reported that during a walking tour with an insurance company observer in October 2024, the patio's condition was identified as a fall risk. The BOM communicated this concern to the Maintenance Manager (MM) immediately after the tour. The MM acknowledged awareness of the issue and stated that a request for repair funds had been submitted, but no repair date was set.
Improper Discharge of Resident to Homeless Shelter
Penalty
Summary
The facility failed to ensure proper documentation and procedures were followed in the discharge of a resident, leading to an unsafe and unplanned discharge. The resident, who had been admitted with multiple medical conditions including epilepsy, dysphagia, and a recent myocardial infarction, was transferred to a local homeless shelter without medications or care instructions. The facility did not document the reason for the discharge, the location of the discharge, or any efforts made to meet the resident's needs prior to discharge. Interviews with the New Mexico Council on Aging Case Manager and Housing Specialist, as well as the Homeless Shelter Case Manager, revealed that the resident was left at the shelter without any prior notice or medical documentation. The resident stayed at the shelter for 14 days before being taken to the hospital with pneumonia. The facility's records did not contain any discharge or transfer orders, nor did they document any discharge planning or communication with the resident's doctor. The facility administrator claimed the discharge was at the resident's request due to inappropriate behaviors, but there was no documentation to support this claim. The administrator admitted to driving the resident to the shelter personally and acknowledged that no medical records or medications were provided to the shelter. The facility's Ombudsman and the Homeless Shelter Case Manager both expressed concerns about the appropriateness and planning of the discharge.
Failure to Provide Discharge Notice and Documentation
Penalty
Summary
The facility failed to provide a written notice of discharge to a resident, as well as to the resident's representative and the Ombudsman, which is a requirement for ensuring residents can advocate for their rights. The resident, who was cognitively intact and independent in daily activities, was discharged without any documented order or plan. The facility's records did not contain any documentation of a discharge notice or the reasons for the discharge. The resident was taken to a local homeless shelter without prior notification to the Ombudsman or the resident's representative. The resident stayed at the shelter for 14 nights before being admitted to a hospital for pneumonia. The Ombudsman confirmed that she did not receive any notice of the discharge, and the facility administrator admitted to not providing any notice or documentation regarding the discharge. This lack of communication and documentation led to an unplanned and inappropriate discharge.
CNA Fails to Report Resident Fall and Injuries
Penalty
Summary
A Certified Nurse Aide (CNA) failed to report a fall with injury involving a resident, which was a deficiency identified during a survey. The resident, who had a history of muscle weakness, dysphasia, right-sided hemiplegia following a stroke, hypotension, and unspecified dementia, was at risk for falls due to impaired mobility and poor safety awareness. On the morning of the incident, the CNA found the resident partially on the floor and attempted to return the resident to bed without assistance. The CNA did not report the fall or the injuries sustained by the resident to the nurse on duty. The nurse later observed the resident with visible injuries, including bright red blood from the right upper forearm/elbow area and a swollen contusion on the right upper forehead/temple area. Upon questioning, the CNA admitted to not reporting the fall or the injuries to the nurse, despite being trained to do so. The facility's administrator confirmed the CNA's failure to report the incident, which led to the CNA's termination. The nurse assessed the resident, treated the wounds, and arranged for the resident to be sent out by ambulance.
Inadequate Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to ensure that a resident was free from accidents due to inadequate supervision while using the toilet. The resident, who was admitted with multiple diagnoses including non-traumatic interceder hemorrhage, cerebral edema, cognitive communication deficit, lack of coordination, muscle weakness, and difficulty in walking, required assistance with personal care and was at risk for falls. The care plan specified that staff should offer toileting assistance every two hours and not leave the resident alone in the bathroom. However, the resident was found on the bathroom floor with abrasions after attempting to reach the call string for help, indicating that the staff left the resident unsupervised. During an interview, the Director of Nursing (DON) acknowledged that it was expected that staff should not leave the resident alone in the bathroom, but was unsure of the duration the resident was left unattended. The resident reported being left alone for a long time and attempted to get off the toilet, which led to the fall. This incident highlights a failure to adhere to the care plan, which increased the risk of injury to the resident.
Resident Neglected and Abused by CNA
Penalty
Summary
The facility failed to protect a resident from abuse and neglect when a staff member used loud, foul, abusive language and abandoned the resident instead of providing care. The resident, who had multiple diagnoses including dementia, altered mental status, and hallucinations, was left covered in feces. The incident occurred when a CNA was asked to assist the resident to bed. Instead, the CNA was heard yelling profanities and subsequently left the unit, leaving the resident in a state of neglect. LPNs on duty discovered the resident alone and covered in feces, with some of it dried and on the resident's face, hands, mouth, legs, and body, as well as on the bed, floor, and walls. The CNA responsible for the resident's care was not found on the unit after the incident and returned only to continue yelling profanities before leaving again. The facility's administrator was informed of the incident and confirmed the CNA's inappropriate behavior and abandonment of the resident. Attempts to contact the CNA were unsuccessful.
Unauthorized Disclosure of Resident's PHI
Penalty
Summary
The facility failed to safeguard clinical record information, resulting in the disclosure of private health information (PHI) to unauthorized persons. This incident involved a resident who was admitted with multiple diagnoses, including dementia and Parkinson's disease. The resident experienced a decline in health that led to his death. A former employee of the facility, who was also the resident's daughter-in-law, received a text message from another former employee. The message contained sensitive information about the resident's condition prior to his death, including allegations of possible abuse by a Certified Nurses Aide (CNA) and conjecture about the cause of death. The daughter-in-law contacted the Social Services Director (SSD) to confirm the information, who acknowledged the incident and mentioned that the CNA was suspended. The facility Administrator was aware of the family's concerns about neglect but was unsure how the daughter-in-law was contacted. The Administrator emphasized that resident health care information should only be shared with listed contacts. The SSD confirmed speaking with the daughter-in-law but denied providing details about the incident, although she was aware of it from a staff meeting.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of staff-to-resident abuse within the required two-hour timeframe to the State Agency. The incident involved a resident with dementia and Parkinsonism, who was subjected to loud profane language by a CNA. The CNA became angry and frustrated, cursing loudly at the resident before leaving the area and clocking out. The facility's Administrator was informed of the incident between 9:00 pm and 10:00 pm on the day it occurred, but the initial incident report was not submitted to the State Agency until the following morning at 10:34 am, exceeding the mandated reporting window.
Improper Transfer Leads to Resident's Knee Fracture
Penalty
Summary
The facility staff failed to prevent an accident involving a resident who required extensive assistance for activities of daily living due to conditions such as dementia, diabetes, and hemiplegia following a cerebral infarction. The resident, who was cognitively intact, experienced a fractured knee after being improperly transferred by a Certified Nurses Aide (CNA) from a wheelchair to a bed. The resident's care plan specified the need for staff to stand on the weaker left side during assistance, but this was not adhered to during the transfer. The incident occurred when the resident requested a brief change from CNA #1, who expressed frustration due to workload. During the transfer, the CNA lifted the resident without using a gait belt, contrary to the facility's training protocols. The resident's feet became tangled, resulting in intense pain and a subsequent fracture. Despite the resident's complaints of pain, the CNA continued with the brief change and did not report the incident to a nurse or seek immediate assessment. Interviews with other staff members confirmed that the facility's training required the use of a gait belt and proper support of the resident's body to prevent such accidents. The administrator's investigation revealed that CNA #1 admitted to not using the proper technique, leading to the resident's injury. The incident highlights a failure in adhering to established transfer protocols, resulting in harm to the resident.
Medication Administration Error for Resident
Penalty
Summary
The facility failed to meet professional standards of quality by not administering medications in accordance with the physician's orders for a resident. The resident was admitted to the facility with multiple diagnoses, including seizures, mood disorder, dysphagia, and a history of transient ischemic attack. The hospital transfer orders indicated that the resident had a past medical history of second-degree atrioventricular block and high blood pressure, with a specific medication order to begin losartan, 50 mg by mouth daily, upon admission. However, upon review of the resident's Medication Administration Record (MAR), it was found that the staff did not administer losartan until four days after the resident's admission. The Licensed Practical Nurse (LPN) confirmed that the order was not entered into the medical record upon admission, resulting in the resident not receiving the medication as prescribed. This oversight was identified as a medication error, indicating a failure in the facility's medication administration process.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development and worsening of pressure wounds for two residents. For one resident, the facility did not timely identify a new wound, monitor changes, provide daily treatments as ordered, or notify the physician of the wound's worsening condition. This resident was admitted with a risk for pressure ulcers and later developed an unstageable pressure ulcer on the left heel, which was not properly documented or treated, leading to a below-the-knee amputation. The facility's wound care nurse (WCN) acknowledged that the resident's left heel pressure ulcer deteriorated over time, and there was a lack of consistent weekly skin evaluations. The WCN was also required to work the floor due to staffing shortages, which contributed to the oversight. The resident's medical records did not reflect any updates or changes to the wound care orders, and the wound care was not consistently provided as per the physician's orders. For the second resident, the facility failed to complete and document weekly skin evaluations. The resident had an unstageable pressure ulcer on the right heel, and there was a significant gap between skin evaluations conducted by the WCN. The facility's failure to conduct regular skin assessments and document the condition of the resident's wounds contributed to the deficiency.
Removal Plan
- The nursing team initiated a whole house resident skin sweep to identify all current wounds in the facility and assess for correct identification and treatment. Any identified concerns, including refusals of wound care/assessment and worsening wounds, will include change in condition documentation and notification to the provider and family. Any new orders will be followed.
- Nurses will be educated on completion of skin assessments on admission and weekly per schedule.
- Nurses will be educated on their responsibility with communication with management and the change in condition process/documentation when a resident is having a change in condition (including new or worsening wounds).
- Nurses will be educated on wound processes which include the DIMES (Debridement/devitalized tissue, Infection or inflammation, Moisture balance, wound Edge preparation and wound depth), timely and accurate identification and documentation for wounds/wound changes, change in condition process, and appropriate treatment/intervention implementation upon identification of new or worsening wounds.
- CNAs will be educated on how to minimize pressure, friction and shearing, change in condition process for CNA's (including skin changes) and stop and watch.
Failure to Provide Adequate Hydration and Timely IV Fluids
Penalty
Summary
The facility failed to ensure adequate hydration for a resident, identified as R #34, who was at risk for dehydration due to chronic kidney disease, hypertension, cognitive impairment, and poly-pharmacy. The resident was dependent on staff for fluid intake and had a physician's order for IV fluid hydration due to hypercalcemia, a suspected UTI, and dehydration. However, the facility did not provide the ordered IV fluids in a timely manner, with a delay of five days from the physician's order. This delay was attributed to the unavailability of IV supplies and the nursing staff's lack of awareness of where to find them. Additionally, the facility did not adequately document and monitor the resident's fluid intake. Records showed inconsistent documentation of the resident's urinary output and fluid intake, with several instances where no fluid intake was recorded. Interviews with staff and the resident's husband confirmed that the resident experienced significant thirst and that staff failed to document fluid intake consistently. The Director of Nursing acknowledged that the nursing staff did not follow the expected procedures for administering IV fluids and tracking fluid intake, contributing to the resident's prolonged dehydration and untreated UTI.
Failure to Provide Discharge Instructions for Wound Care
Penalty
Summary
The facility failed to provide a discharge summary and post-discharge plan of care for a resident with a pressure wound. The resident, who had a left heel pressure ulcer, was discharged to live with her niece without receiving wound care instructions. The facility's records show that the wound care nurse documented the ulcer's measurements, but there was no documentation of wound care instructions being given to the resident prior to discharge. This lack of communication and documentation likely contributed to the worsening of the resident's condition. Upon discharge, the resident's condition deteriorated, leading to an emergency room visit where the ulcer was found to be non-healing with signs of infection. The resident subsequently underwent a left below-knee amputation. Interviews with the resident, her niece, the social services director, the wound care nurse, and the director of nursing confirmed that the necessary discharge instructions and care plans were not provided, highlighting a significant lapse in the facility's discharge procedures.
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What surveyors actually found near you
We read the 11 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Santa Fe
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Santa Fe Care Center | 0.2 mi | ★★★★★ | 4 | 0 |
| Los Alamos Wellness & Rehabilitation | 24.4 mi | ★★★★★ | 7 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.