Clayton Nursing And Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Clayton, New Mexico.
- Location
- 419 Harding Street, Clayton, New Mexico 88415
- CMS Provider Number
- 325100
- Inspections on file
- 16
- Latest survey
- February 13, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Clayton Nursing And Rehab Center during CMS and state inspections, most recent first.
Surveyors found that the vaccine refrigerator temperature logs in the medication storage room were not completed on numerous dates across both day and night shifts, with large gaps in documentation over many months. An LPN acknowledged that the vaccine fridge temperature log was not being done routinely, despite nurses being responsible for all temperature logs. The DON confirmed that refrigerator temperatures were expected to be checked once per shift and recorded on the log, but this monitoring and documentation did not consistently occur.
Surveyors found that food service sanitation practices were deficient when a plate warmer used for clean dishes contained dried food particles, dried liquid splashes, and trash, and the stove and oven used for meal preparation were visibly soiled with dried food, liquid splashes, dirt, grease, and baked-on food stains. The DM acknowledged that the condition of the plate warmer, stove, and oven was dirty and did not meet his expectations, affecting food preparation and service for all residents.
Surveyors found that the facility failed to consistently implement its infection prevention and control program. A resident on Enhanced Barrier Precautions (EBP) received direct care from two CNAs who did not don required PPE despite EBP signage on the door. In a separate incident, a resident on EBP was transferred with a mechanical lift, and after completing care and removing PPE, CNAs moved the lift directly to another room without cleaning or disinfecting it. The CNAs later acknowledged they had not followed protocol, and the DON, serving as Infection Preventionist, stated that staff are expected to perform hand hygiene, follow infection control precautions, and clean and disinfect all medical equipment after each use.
Staff administered medications to several residents in the dining area during mealtimes, requiring residents to stop eating to take medication cups and receive eye drops from an LPN. Overhead paging announcements were made in the dining area on multiple mornings to reach an LPN, and kitchen serving-area ceiling vents were observed to be covered with dust and dirt, discoloring the vents and surrounding ceiling. These actions and conditions did not support a safe, clean, comfortable, and homelike environment for residents during meals.
Surveyors found that MDS assessments were not accurately completed for three residents. One resident receiving Nitrofurantoin for UTI prophylaxis did not have antibiotic use captured on the MDS, as confirmed by the MDS coordinator. Another resident with COPD and dementia, who had an order for PRN oxygen and an oxygen concentrator at the bedside, had no oxygen use documented on the MDS, which the DON acknowledged was inaccurate. A third resident with multiple comorbidities and a documented diagnosis of ankle edema was observed with red, swollen legs and ankles, yet the MDS did not reflect ankle edema, and the DON confirmed this omission.
Surveyors found that care plans for two residents were not updated to reflect current medical needs. One resident with COPD and other chronic conditions had a physician order for PRN oxygen at 2 L/min via nasal cannula, but this oxygen use was not included in the care plan, as confirmed by the DON. Another resident with multiple neurologic and urologic diagnoses, as well as wasting disease and sarcopenia, was observed with red, swollen ankles and legs; a physician note documented ankle edema, yet the care plan did not address this condition, which the DON acknowledged was missing.
A resident admitted with COPD, Alzheimer’s disease, dementia with agitation, major depressive disorder, and essential HTN had a physician order for PRN O2 at 2 L/min via nasal cannula for respiratory distress, but this treatment was not included on the baseline care plan completed at admission. Record review showed the baseline care plan lacked any indication that the resident used O2 as needed, and the DON confirmed that the resident does utilize PRN O2 and that this omission was incorrect.
A resident with chronic respiratory failure, COPD, OSA, emphysema, and MRSA carrier status had a physician order for supplemental O₂ at 2 L/min that did not specify the frequency of administration. The resident was observed in bed using a nasal cannula connected to an O₂ concentrator, and the DON acknowledged that the order lacked required frequency details. This omission in the oxygen order was identified during survey review as a failure to provide respiratory care in accordance with professional standards.
The facility failed to meet the nutritional needs and preferences of residents by not serving the menu items as planned and not providing alternate meal options. During a dinner observation, residents were served Jell-O instead of cheesecake, and the meatloaf lacked glaze due to missing ingredients. Staff interviews revealed that the kitchen did not have the necessary supplies, and residents were not informed of the menu changes. Additionally, no alternate meals were offered, contributing to the deficiency.
The facility failed to properly label and store food items in the Dietary Department, leading to potential cross-contamination risks. Observations revealed multiple unlabeled and undated food items, including containers with unidentified substances, open bags of food, and uncovered pans. The Healthcare Group Services Operationalist confirmed that staff are expected to label and date all items, which should be covered and not open to air. This deficiency could impact all 30 residents consuming food from the kitchen.
The facility failed to notify residents of the outcomes of their grievances, as grievance forms lacked documentation of investigation steps, findings, and corrective actions. Interviews revealed that the Resident Council was not always informed about grievance findings, and the Administrator acknowledged incomplete grievance forms.
A facility failed to conduct required quarterly care plan meetings for a resident, resulting in an outdated care plan. The resident, admitted earlier, had his last care plan meeting in April 2024. He reported not recalling recent meetings, and the MDSC confirmed the oversight, acknowledging the missed meetings.
The facility failed to provide prescribed Restorative Nursing Program (RNP) services to two residents, impacting their ability to perform activities of daily living (ADLs). One resident was supposed to receive RNP services for passive range of motion exercises to both arms, but these were provided only once in September and not at all in October. Another resident was to receive RNP services for upper and lower extremities, but the sole Restorative Aide was unable to deliver these services due to other duties. The Director of Nursing confirmed the lack of service delivery.
The facility did not implement enhanced barrier precautions for residents with wounds or urinary catheters, as PPE was not available outside their rooms and staff were observed providing care without PPE. This oversight was due to a lack of awareness of updated guidelines by the staff.
The facility failed to obtain current signed Influenza Vaccine Informed Consent Forms for residents who received the flu vaccine. Interviews and record reviews revealed that five residents did not have the necessary consent documentation in their medical records. The LVN stated that residents signed the ICF annually, leading to missing consents for the recent vaccinations.
A resident with decreased mobility due to a stroke was unable to reach their call light, which was placed on a chair behind their bed. This oversight left the resident anxious and unable to request assistance for basic needs. Staff interviews confirmed the call light should have been within reach.
A resident reported dissatisfaction with the food served, noting burnt macaroni salad and peach cobbler with salt instead of sugar. The Food Service Director acknowledged these issues, attributing them to new dietary staff requiring supervision. A grievance form confirmed the resident's complaints, highlighting problems with food preparation.
Failure to Routinely Monitor and Document Vaccine Refrigerator Temperatures
Penalty
Summary
Surveyors identified a deficiency related to the storage and monitoring of medications in the facility’s locked medication storage room, specifically the vaccine refrigerator. During an observation on 02/10/26 at 12:55 pm, the vaccine fridge temperature log for January 2025 through February 2026 was found to be incomplete. Numerous dates on the day shift log were left blank, including extended periods such as 01/01/25 through 01/18/25, 01/20/25 through 06/01/25, 06/03/25 through 07/23/25, 07/25/25 through 09/12/25, 09/15/25 through 09/31/25, and multiple additional gaps through 02/08/26. The night shift log also contained multiple missing entries on specific dates throughout 2025, indicating that temperatures were not consistently documented as required. In an interview on 02/10/26 at 12:56 pm, an LPN confirmed that the vaccine medication fridge temperature log was not being completed routinely and stated that nurses are responsible for completing all temperature logs. On 02/11/26 at 1:38 pm, the DON further confirmed there had been inconsistency with checking the vaccine fridge temperature log. The DON stated that the fridge temperature should be checked once per shift and documented on the appropriate log, and acknowledged that this did not occur as required.
Unsanitary Storage of Dishes and Unclean Cooking Equipment in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in food service sanitation when kitchen staff failed to properly store dishes and maintain clean cooking equipment. During a random kitchen observation, the plate warmer, which is intended to hold clean plates ready for meal service, was found to contain dried food particles, dried liquid splashes, and trash. The stove was observed with dirty, dried food particles and dried liquid splash marks on the front, and dirt and grease covering the back. The oven interior had baked-on food stains throughout. The Dietary Manager confirmed that the plate warmer, stove, and oven were dirty and did not meet his expectations. These conditions were present in an area used to prepare and serve food for all 36 residents listed on the census provided by the Administrator, indicating that food was not being prepared and served under sanitary conditions as required by professional standards.
Failure to Implement EBP PPE Use and Disinfection of Shared Equipment
Penalty
Summary
The deficiency involves the facility’s failure to implement an ongoing infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP) and proper use of personal protective equipment (PPE). On the 200 hall, a resident with an EBP sign posted on the door was observed receiving direct care from two CNAs who did not wear any PPE while in the room. One CNA was already in the room without PPE, and the second CNA entered the room, closed the door, and provided direct care without donning PPE. After approximately five minutes, both CNAs assisted the resident out of the room in a wheelchair. In a subsequent interview, one of the CNAs confirmed that both were providing direct care to the resident, acknowledged that neither wore PPE, and stated they should have done so. The deficiency also includes failure to clean and disinfect shared resident-care equipment between uses. A resident on EBP was transferred from a wheelchair to a bed using a mechanical lift, and staff providing direct care appropriately donned mask, gown, and gloves. After completing the brief change, the CNAs removed their PPE, performed hand hygiene, and immediately took the mechanical lift to another room without cleaning or sanitizing it. In an interview, both CNAs confirmed they did not follow protocol by failing to clean the mechanical lift after use and stated that all medical equipment is supposed to be wiped down with bleach after each use. The DON, who serves as the facility’s Infection Preventionist, stated that all nursing staff are to perform hand hygiene before and after patient care and follow all infection control precautions, and that all medical equipment is to be cleaned and disinfected after each use.
Medication Administration and Environmental Issues in Dining and Kitchen Areas
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment when staff administered medications in the dining area during mealtimes, used an overhead paging system in the dining area, and did not maintain clean kitchen vents. During a lunch meal observation, one resident was seated and eating when an LPN approached, handed the resident a medication cup, and then administered eye drops before the resident resumed eating. Two other residents who were seated and eating at their respective tables were also approached by the same LPN, given medication cups, and stopped eating their meals to take their medications. In an interview, the LPN stated that she usually administers medications in common areas and during mealtimes because that is where all the residents are. Additional observations showed that the overhead paging system was used in the dining area on two separate mornings to call an LPN to contact another staff member. A separate observation of the kitchen serving area revealed that the ceiling vents were covered with dust and dirt, causing portions of the vents and surrounding ceiling to appear brownish-black instead of their intended white color. These conditions were identified as contributing to the failure to maintain a sanitary and homelike environment for residents who eat their meals in the dining area.
Inaccurate MDS Assessments for Antibiotic Use, Oxygen Therapy, and Edema
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for three residents, resulting in omissions of current clinical conditions and treatments. For one resident with type 2 diabetes mellitus, traumatic brain injury, quadriplegia, obstructive and reflux uropathy, and a need for assistance with personal care, the record showed a physician’s order for Nitrofurantoin 100 mg for UTI prophylaxis. However, review of this resident’s MDS dated [DATE] showed that antibiotic use was not checked, and the MDS Coordinator confirmed during interview that the resident was currently taking an antibiotic and that she failed to capture this on the assessment. Another resident with COPD, Alzheimer’s disease, dementia with agitation, major depressive disorder, and hypertension was observed with an oxygen concentrator at the bedside, and physician orders documented oxygen at 2 L/min via nasal cannula as needed for respiratory distress. The resident’s MDS dated [DATE] contained no indication of oxygen use, and the DON confirmed the resident does utilize oxygen as needed and that the MDS was not accurate. A third resident with Parkinsonism, severe dementia, obstructive and reflux uropathy, wasting disease, and sarcopenia was observed asleep in a wheelchair with red, swollen legs and ankles. A physician progress note documented a diagnosis of ankle edema, but the MDS dated [DATE] did not indicate ankle edema. The DON confirmed that this resident does have ankle edema and that the MDS assessment was not accurate.
Failure to Accurately Reflect Oxygen Use and Ankle Edema in Resident Care Plans
Penalty
Summary
Surveyors identified a failure to develop and implement accurate, comprehensive care plans for two residents. One resident with COPD, Alzheimer's disease, dementia with agitation, major depressive disorder, and essential HTN had a physician order dated 08/05/25 for oxygen at 2 L/min via nasal cannula as needed for respiratory distress. However, review of this resident's care plan dated 08/04/25 showed no indication that the resident utilized oxygen as needed. During an interview on 02/13/26 at 9:20 am, the DON confirmed that the resident does use oxygen as needed and acknowledged that the care plan does not indicate this and that it should. For another resident with diagnoses including Parkinsonism, severe dementia, obstructive and reflux uropathy, wasting disease, and sarcopenia, surveyors observed the resident asleep in a wheelchair in the dining area on 02/10/26 at 10:30 am, with legs and ankles appearing red and swollen. Record review showed a physician progress note dated 08/21/24 documenting a diagnosis of ankle edema. However, the resident's care plan revised on 07/31/25 contained no indication of ankle edema. In an interview on 02/13/26 at 9:30 am, the DON confirmed that the resident does have ankle edema and stated that the resident's care plan did not meet her expectations because it should include the ankle edema and does not.
Baseline Care Plan Omitted PRN Oxygen Order for Newly Admitted Resident
Penalty
Summary
The facility failed to create an accurate baseline care plan for a newly admitted resident by omitting an essential treatment order. Record review showed the resident was admitted with COPD, Alzheimer’s disease, dementia with agitation, major depressive disorder, and essential HTN. Physician orders dated 08/05/25 directed that the resident receive oxygen at 2 L/min via nasal cannula as needed for respiratory distress. However, review of the resident’s baseline care plan dated 08/04/25 revealed no indication that the resident utilized oxygen as needed, despite this active order. In an interview, the DON confirmed that the resident does use oxygen PRN and acknowledged that the baseline care plan did not reflect this need and that it should have been included. This discrepancy between the physician’s oxygen order and the baseline care plan content constituted the identified deficiency in accurately capturing the minimum healthcare information necessary to properly care for the resident immediately upon admission.
Incomplete Oxygen Order for Resident with Chronic Respiratory Failure
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory care in accordance with professional standards by not ensuring that a physician’s order for supplemental oxygen included the frequency of administration. A resident admitted with chronic respiratory failure with hypoxia, COPD, obstructive sleep apnea, emphysema, and MRSA carrier status had a physician order dated 09/14/25 for supplemental oxygen at 2 L/min, but the order did not specify how often or under what circumstances the oxygen should be administered. During observation on 02/10/26, the resident was seen in bed wearing a nasal cannula connected to an oxygen concentrator at the bedside. In an interview on 02/13/26, the DON confirmed that the oxygen order should indicate the frequency of administration and acknowledged that it did not, resulting in incomplete respiratory care orders for this resident. The survey findings state that this failure to specify oxygen frequency in the medical order was identified for 1 of 3 residents reviewed for respiratory care and was likely to result in residents receiving too much or not enough oxygen, which could lead to worsening of their conditions.
Failure to Meet Nutritional Needs and Menu Adherence
Penalty
Summary
The facility failed to meet the nutritional needs and preferences of all 30 residents as listed on the facility census. During a dinner observation, it was noted that the staff did not serve the food items as listed on the menu. Specifically, residents were served Jell-O with whipped topping instead of the French orange cheesecake that was on the menu, and the meatloaf served did not have the glaze as indicated. Interviews with staff, including an LPN and the Dietary Manager, revealed that the kitchen did not have the necessary ingredients for the cheesecake or the glaze for the meatloaf due to a delay in the food order. Residents expressed their dissatisfaction with the substitutions and confirmed they were not informed of the menu changes. Additionally, the facility did not provide an alternate meal menu to the residents. The Dietary Manager admitted that no alternate meals were made or offered, citing low census and minimal alternate requests as reasons. The Registered Dietitian confirmed that the posted menu should include alternate menu choices and that the meals served should match the posted menus. The lack of alternate meal options and failure to serve the menu items as planned contributed to the deficiency in meeting the residents' nutritional needs and preferences.
Failure to Properly Label and Store Food
Penalty
Summary
The facility failed to store food in a manner that prevents cross-contamination, as observed in the Dietary Department's refrigerators and freezers. Several food items were found unlabeled and undated, including a four-quart plastic container with an unidentified substance, two five-pound bags of slightly black colored stalks, a two-inch pan of red liquid, a six-quart plastic container of unidentified food, and a tray of 6 oz. glasses of yellow liquid. Additionally, a ten-pound bag of frozen diced chicken, two one-pound bags of beef patties, two one-pound bags of boiled eggs, two ten-pound rolls of Provolone cheese, and a fifty-pound bag of bread crumbs were open to air and not dated. A four-inch soiled steel pan with a two-ounce scoop containing crusted, crumbly food was also found open to air and not labeled or dated. During an interview, the Healthcare Group Services Operationalist stated that it was expected for staff to label and date all items, and they should be covered and not open to air. These failures have the potential to result in cross-contamination, the growth of foodborne pathogens, and foodborne illness, affecting all 30 residents who consume food from the kitchen.
Failure to Notify Residents of Grievance Resolutions
Penalty
Summary
The facility failed to notify four residents of the outcomes or resolutions of their grievances, as revealed through record review and interviews. The grievance log showed that grievances filed by residents regarding issues such as clothing not being changed, snacks being thrown out, cold air from the air conditioner during meal times, a missing candy dish, and a CNA talking on the phone during a shower were marked as resolved. However, the grievance forms lacked documentation of the steps taken to investigate, summaries of findings, confirmation of the grievances, corrective actions, or the issuance date of the written decision. Interviews with the Resident Council and the Administrator further highlighted the deficiency. The Resident Council stated that they were not always informed about the facility's findings regarding their grievances. The Administrator admitted that staff did not complete the grievance forms properly, which resulted in residents not being informed of the resolutions of their grievances.
Failure to Conduct Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to revise the care plan for a resident due to the absence of quarterly care plan meetings as required. The resident was admitted to the facility on an unspecified date, and the last care plan meeting was documented on April 30, 2024. During an interview on October 28, 2024, the resident expressed that he did not recall having a care plan meeting recently. Furthermore, the Minimum Data Set Coordinator (MDSC) acknowledged on October 30, 2024, that she was responsible for scheduling and conducting these meetings and confirmed that the resident had missed his last two quarterly care plan meetings.
Failure to Provide Restorative Nursing Program Services
Penalty
Summary
The facility failed to maintain the ability of two residents to perform activities of daily living (ADLs) due to inadequate provision of Restorative Nursing Program (RNP) services. Resident #6 was admitted to the facility and had physician orders for RNP services two to three times a week for passive range of motion exercises to both arms. However, documentation revealed that these services were provided only once in September and not at all in October. Interviews with the resident, a Restorative Certified Nursing Assistant (RCNA), a Certified Nursing Assistant (CNA), a Registered Nurse (RN), and the Director of Nursing (DON) confirmed that the resident did not receive the prescribed RNP services, which were intended to give him a sense of purpose and enjoyment. Similarly, Resident #25 was admitted with physician orders for RNP services three times a week for passive range of motion exercises to the upper and lower extremities. The RCNA, who was the only Restorative Aide in the facility, stated that he was often occupied with other duties, such as working on the floor and transporting residents, which prevented him from providing the necessary RNP services to Resident #25. The DON confirmed that Resident #25 did not receive the prescribed RNP services. This lack of service delivery was attributed to the RCNA's additional responsibilities, which hindered the consistent provision of restorative therapy to the residents.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for six residents who had either an open wound or a urinary catheter, increasing the risk of spreading multidrug-resistant organisms (MDROs). Observations revealed that personal protective equipment (PPE) was not available outside the rooms of residents with urinary catheters, and there were no signs indicating the need for PPE use during direct care. Specifically, residents with indwelling or suprapubic catheters did not have accessible PPE, and staff were observed providing care without using PPE. Additionally, residents with wounds also lacked PPE stations outside their rooms, and staff were observed providing care without PPE. Interviews with the Skin Care team lead nurse and the Director of Nursing/Infection Preventionist indicated a lack of awareness and implementation of updated EBP guidelines. The facility's procedure for EBP required PPE to be accessible and located outside patient rooms, but this was not adhered to, leading to the deficiency.
Lack of Signed Consent Forms for Flu Vaccinations
Penalty
Summary
The facility failed to ensure that a current Influenza Vaccine Informed Consent Form (ICF) was signed by residents prior to receiving the flu vaccine. This deficiency was identified during interviews and record reviews, which revealed that five residents who received the flu vaccine did not have a signed ICF in their medical records. The Director of Nursing confirmed that consents should be part of the medical record, but the Licensed Vocational Nurse (LVN) stated that residents only signed the ICF once, as the form indicated it was an annual requirement. This practice led to the absence of current consent forms for the residents who received the flu vaccine. The record reviews for the five residents showed that they received the flu vaccine on various dates, but their electronic medical records did not contain the necessary ICFs. The LVN mentioned that if a resident refused the vaccination, they would sign a declination form, and a new ICF would be required for future vaccinations. However, this process was not followed for the residents who received the vaccine, resulting in a lack of documentation to confirm whether the vaccine was given or refused, and whether the residents were educated about the vaccine's benefits and risks.
Failure to Ensure Resident Access to Call Light
Penalty
Summary
The facility failed to provide reasonable accommodations for a resident's needs and preferences, specifically regarding access to a call light. The resident, who had decreased mobility due to a history of a stroke, left and right-sided weakness, and impaired balance, required the call light to be within reach at all times. During an observation, the call light was found on a chair behind the resident's bed, out of reach, causing the resident to appear anxious and unable to request assistance for water and a shower. Interviews with a nurse aide and the Director of Nursing confirmed that the call light should have been placed within the resident's reach.
Food Palatability and Preparation Issues
Penalty
Summary
The facility failed to ensure that food served to residents was palatable and met their satisfaction, as evidenced by the experience of one resident. On the evening of 10/27/24, a resident reported that the macaroni salad served during dinner smelled burnt, and the peach cobbler contained salt instead of sugar. Further interviews revealed that on 10/29/24, burnt pasta was found in the refrigerator, indicating issues with food preparation. The Food Service Director acknowledged the problems, attributing them to the new dietary staff who required significant supervision. A grievance form dated 10/28/24 corroborated the resident's complaint, noting that the pasta for the minestrone soup was scorched, coleslaw was served without dressing, and the peach cobbler was improperly prepared.
Latest citations in New Mexico
Surveyors found that the facility did not provide required written transfer and bed-hold notices when several residents were sent to the hospital for events such as falls with injury, unresponsiveness, and episodes of nausea, vomiting, and bleeding. Medical records lacked written transfer notices and bed-hold notifications, and the transfer information that should have been given to residents or their representatives did not include mandated details about appeal rights, how to request an appeal, or how to contact the State LTC Ombudsman. The Social Services Director reported that she does not notify the Ombudsman of hospital transfers and only sends a monthly email list of discharged residents, without written copies of transfer or discharge notices.
Two cognitively impaired residents with dementia and significant behavioral and continence needs were sent to a local ER after falls and were discharged back to the facility’s care, but the facility failed to provide timely transportation for their return. In both cases, hospital discharge times were documented, yet ER staff reported making multiple unsuccessful calls to the facility, reaching the Administrator only after repeated attempts. One resident, described as very disoriented, remained in the ER for several hours after discharge without 1:1 supervision, while the other waited approximately 11 hours, during which ER staff observed increasing confusion and attempts to get out of bed. The Administrator acknowledged awareness of the discharges, the lack of 24-hour transportation, and that the residents were not picked up until many hours after they had been discharged from the ER.
Two residents who required staff assistance for ADLs and transfers reported neglectful and rude behavior by a CNA and delayed nursing response to care needs. One resident with a history of cerebral infarction and schizophrenia stated that a CNA mocked him and that his requested wound dressing change was not performed for several hours, which was later corroborated by video showing a long gap between the CNA’s visit and the nurse’s entry to the room. Another resident with a right femur fracture, type II DM, and repeated falls, who needed one-person assistance for mobility and self-care, reported that a CNA refused to help and told her she could do some care herself, making her feel she was not trying in her recovery. Documentation and interviews confirmed that staff did not provide timely wound care or required assistance, and that these interactions caused residents to feel uncomfortable and negatively about their care.
A resident with a history of opioid dependence and polysubstance abuse was on a secure unit with a care plan that included safety risk evaluations and monitoring for signs of substance abuse. Staff later observed the resident discarding an empty Suboxone packet, even though the resident was not prescribed this medication, and the incident was reported to the on-call provider with subsequent monitoring and a room search. However, the care plan was not revised to reflect this new substance-related event, and both the DON and Administrator acknowledged that the care plan should have been updated when this new risk and behavior were identified.
Surveyors identified that a medication cart on the north hall was left unlocked and unattended outside a resident room. An LPN acknowledged that the cart was hers and that she had not locked it before leaving to answer a call light, despite facility expectations. The DON confirmed that all medication and treatment carts are required to remain locked when not in use or when staff are away from them.
Surveyors found that a document containing multiple residents’ PHI, including full names, room numbers, and code status, was left unattended and visible on a south nurse’s station counter. An RN confirmed the document was a resident list with PHI and acknowledged it had been left exposed and that such information should not be left unattended.
Surveyors found that a lunch tray return cart containing uncovered, soiled food trays and dishes was left unattended in a main hallway outside an activity room. The housekeeping/laundry manager acknowledged seeing the unattended cart, and the Dietary Manager confirmed that such carts are supposed to remain only in designated areas, such as near the nurse’s station or in the kitchen, and should be returned to the kitchen for cleaning as soon as all trays are collected. This failure was cited as likely to expose all residents to potential pathogens associated with food waste.
Two residents with scheduled showers reported that they were offered or received showers in very cold water during a prolonged period when hot water was not reliably available in care areas. One resident stated he refused cold showers and was only offered sponge baths once or twice, despite his preference to stay clean. Another resident reported receiving cold showers, including being rinsed with cold water while still soaped, and subsequently began refusing showers and bed baths due to the cold water. A CNA confirmed that water in the shower rooms was “ice cold” for several months, leading to resident complaints and refusals, while the Maintenance Director reported that a needed part to correct the hot water problem was on back order, delaying resolution and resulting in the facility not honoring residents’ bathing preferences.
Surveyors observed that unused medications were improperly discarded in a trash bin attached to a medication cart on the north hallway, rather than being disposed of in a designated drug disposal container. Two pills, a round blue tablet stamped "61" and an oblong orange tablet stamped "20," were found together in an unlabeled medication cup in the trash. An RN confirmed the medications were discarded there and acknowledged that unused medications should be placed in the drug buster container in the cart drawer. The Unit Manager also confirmed that facility practice requires all unused medications to be disposed of using the drug buster and that controlled substances must be destroyed by two licensed staff and documented on the narcotic count sheet.
The facility failed to follow documented allergy information, diet orders, and meal tickets for three residents. A resident with a documented chocolate allergy was served chocolate ice cream after requesting it, and the Nutrition Director admitted not reading the allergy notation on the meal ticket. Another resident on a pureed diet received whole mandarin oranges instead of pureed fruit, which a CNA confirmed. A third resident whose meal ticket called for a grilled Swiss sandwich received a sandwich that was not grilled, as confirmed by a CNA and a dietary manager.
Failure to Provide Required Written Transfer, Appeal, Ombudsman, and Bed-Hold Notices During Hospitalizations
Penalty
Summary
Surveyors identified that the facility failed to provide required written transfer and bed-hold information for multiple residents who were hospitalized. For three residents who experienced transfers to the hospital after events such as falls with injury, unresponsiveness, and episodes of nausea, vomiting, and bleeding, record review showed there were no written transfer notices or written bed-hold notices in their medical records. Specifically, one resident transferred after a fall on 01/31/26 had no documented written transfer notice or bed-hold notice. Another resident transferred on 02/27/26 for nausea, vomiting, and bleeding, and later readmitted on 03/05/26, had no written transfer notification that included information on appeal rights or Ombudsman contact, and no written bed-hold notification. A third resident transferred on 01/29/26 after a fall with a forehead laceration and again on 03/17/26 for unresponsiveness, also had no documented written transfer or bed-hold notices for either hospitalization. The deficiency also included the facility’s failure to provide required content in transfer notices and to notify the State Long-Term Care Ombudsman in writing. For the residents reviewed, there was no evidence that written transfer notices were provided to the residents or their representatives in a language and manner they could understand, and the notices were missing required elements such as a statement of appeal rights, the name, mailing and email address, and phone number of the entity receiving appeals, and information on how to obtain and complete an appeal form. The notices also lacked the name, phone number, and mailing and email address of the State Long-Term Care Ombudsman, and written copies of the transfer notices were not sent to the Ombudsman. During interview, the Social Services Director confirmed that transfer and bed-hold notices were not documented for at least one resident’s hospitalization, that she does not notify the Ombudsman about transfers to the hospital, and that she only emails a monthly list of residents discharged from the facility without sending written copies of transfer or discharge notices.
Failure to Timely Retrieve Residents From ER After Discharge
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from neglect by not arranging timely transportation back to the facility after emergency room (ER) discharge. A consumer complaint alleged that residents sent to the local ER were being left there for extended periods after discharge. For one resident with an admission date of 10/13/25, records showed multiple cognitive and behavioral diagnoses, including Alzheimer’s disease, vascular dementia with agitation and other behavioral disturbances, mild cognitive impairment, cognitive communication deficit, and restlessness and agitation. A change of condition MDS documented a Brief Interview for Mental Status (BIMS) score of 1 and frequent incontinence of urine and bowel. Nursing progress notes for this resident showed that 911 was called at 3:00 AM and the resident was transferred to the ER after a fall. Hospital discharge instructions indicated the resident was discharged from the ER at approximately 5:21 AM, while the ER nurse reported discharge at about 5:30 AM. The ER nurse stated she made numerous calls to the facility but was unable to reach anyone. She reported that the resident was very disoriented and that the ER did not have enough staff to provide 1:1 supervision. The ER nurse eventually reached the Administrator, who stated staff would come to pick up the resident as soon as possible. Facility records showed the resident was not discharged from the facility on that date, and the ER nurse reported that facility staff did not pick the resident up until approximately 8:30 AM, several hours after discharge. A second resident, admitted on 11/25/25, had diagnoses including Alzheimer’s disease, dementia with behavioral disturbance, bipolar disorder with severe depression and psychotic features, depression, and anxiety disorder. The admission MDS documented a BIMS score of 2, frequent urinary incontinence, constant bowel incontinence, and a need for substantial/maximal assistance with toileting hygiene. Nursing notes showed this resident was sent to the ER for evaluation after a fall and did not return until the following morning. Hospital discharge instructions documented discharge from the ER at 10:16 PM, and the Administrator confirmed being notified of the discharge at about 10:30 PM and that the facility did not have 24-hour transportation. The Administrator acknowledged the resident was not picked up until approximately 9:00 AM the next day. The ER nurse reported making several calls to the facility that went to voicemail, eventually reaching the Administrator, who initially stated staff were on the way, then stopped answering calls. During the approximately 11-hour wait, the ER nurse stated the resident was confused, attempted to get out of bed, and became more confused as the night progressed.
Failure to Timely Provide Wound Care and Required Assistance, Resulting in Resident Neglect
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from neglect when staff did not respond appropriately to requests for care and assistance. One resident with a history of cerebral infarction due to embolism and schizophrenia, admitted on 01/30/26 and requiring staff assistance for ADLs and mechanical lift transfers, reported that a CNA was rude and mocking and that his wound dressing was not changed for several hours after he requested it. The Kardex showed he needed staff help for toileting, bathing, hygiene, bed mobility, dressing, and transfers. Nursing progress notes documented a change in condition on 03/02/26 after the resident stated the CNA was rude and would not assist as requested. The Administrator later confirmed, via video review, that the CNA entered the resident’s room at 2:30 am, the resident requested a dressing change, and no nurse entered the room until 5:00 am, despite the nurse’s statement that she went in “right away.” The DON also confirmed that the resident’s grievance described the wound dressing not being changed until hours after the request. Another resident, admitted with a right femur fracture, type II diabetes, and repeated falls, required one-person assistance for dressing, hygiene, bathing, bed mobility, and transfers, and could toilet herself with assistance for transfers. Nursing progress notes documented an alleged abuse incident on 03/02/26 in which this resident stated a CNA was rude, refused to help her, and told her she could perform some care tasks herself without staff assistance. An abuse questionnaire completed the same day showed the resident answered “Yes” to having interactions that made her feel uncomfortable or negative, and she reported that the CNA made her feel as though she was not trying with her own recovery. The Administrator and DON acknowledged that staff are expected to help residents as required and that staff interactions must be encouraging rather than making residents feel bad about needing assistance.
Failure to Revise Care Plan After Substance-Related Incident
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s care plan after a significant substance-related incident. The resident was originally admitted with a diagnosis of opioid dependence and resided on a secure unit related to polysubstance abuse disorder. The existing care plan, dated 01/21/26, identified the resident as residing on a secure unit due to polysubstance abuse disorder with interventions to perform safety risk evaluations on admission, as needed, and upon changes in condition. The care plan also identified the resident as at risk for substance use disorder with interventions to monitor for signs or symptoms of substance abuse. On 02/01/26, nursing notes documented that staff observed the resident discarding an empty Suboxone packet in the trash, even though the resident was not prescribed Suboxone and denied taking any. Staff notified the on-call provider, who ordered monitoring for adverse reactions, and nursing staff and security conducted a room search that revealed no additional contraband. Despite this incident, the resident’s care plan was not updated to address the new substance-related event. During interviews, the DON acknowledged awareness of the incident and confirmed the care plan was not revised, and the Administrator stated her expectation that nursing would update the care plan when a new risk or behavior was identified and confirmed she would have expected the care plan to be updated for this resident.
Unattended, Unlocked Medication Cart on North Hall
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were properly stored and secured in accordance with professional standards and facility expectations. On 03/24/26 at 9:06 a.m., surveyors observed a medication cart on the north hall left unlocked and unattended outside a resident room. At 9:08 a.m., the LPN responsible for the cart confirmed during interview that the cart was hers, that it was unlocked and unattended, and acknowledged she should have locked it before responding to a call light. Later that day at 3:37 p.m., the DON stated in an interview that medication and treatment carts are expected to be locked at all times when nurses are away from them, confirming that the observed practice did not meet facility expectations. This deficient practice was cited as likely to allow unauthorized personnel access to medications, which could result in injury or overdosing.
Unattended PHI Document Left Exposed at Nurse’s Station
Penalty
Summary
Surveyors identified a deficiency in the facility’s protection of residents’ personal health information (PHI) when a document containing multiple residents’ full names, assigned room numbers, and code status was left unattended and exposed on the south nurse’s station counter. On 03/16/26 at 9:04 a.m., an observation revealed a piece of paper on a clipboard with complete resident information placed on top of the south nurse’s counter in public view. At 9:06 a.m., during an interview, RN #2 confirmed that the list contained residents’ names, room numbers, and code status, acknowledged that it had been left exposed and unattended, and stated that PHI should not be left unattended. No additional clinical details or medical histories of the residents listed on the document were provided in the report.
Unattended Soiled Lunch Cart Left Uncovered in Hallway
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the handling of soiled food service equipment. On 03/24/26 at 12:58 pm, a lunch tray return cart containing soiled food trays and dishes that were uncovered was observed sitting unattended in the main hallway outside the activity room. At 1:06 pm, the housekeeping/laundry manager confirmed she saw the return cart left unattended in that location. At 1:08 pm, the Dietary Manager stated that lunch return carts should only be left in designated areas such as by the nurse’s station or inside the kitchen, and that the cart should be returned to the kitchen for cleaning as soon as all trays have been picked up, which did not occur in this instance. This deficient practice was noted as likely to expose all residents to potential pathogens associated with food waste.
Failure to Honor Resident Bathing Preferences During Prolonged Hot Water Issues
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ bathing preferences when hot water was not reliably available in resident care areas. Record review showed that one resident was scheduled to receive three showers per week on specific days, and another resident was scheduled for two showers per week. One resident reported that staff attempted to have him shower in cold water, which he refused, and that sponge baths were only offered once or twice during the period when the hot water was not working. He stated that he liked to be clean and did not feel like himself when he was dirty. A CNA reported that there was no hot water in resident care areas from the middle of December until early March, and that large barrels of warm water were brought to shower rooms to offer sponge baths, which this resident refused. Another resident, also on a scheduled twice-weekly shower regimen, stated that she received cold showers and began refusing showers because of how cold the water was. She described the water running cold unpredictably, including an instance when the water was initially warm but turned cold while she was still soaped, requiring rinsing with cold water, which she described as horrible. A social services note documented that this resident’s daughter reported the resident had been declining showers and bed baths offered because the water was too cold. A CNA corroborated that the water was “ice cold” and that residents began complaining and refusing showers around mid-December. The Maintenance Director stated that it took a while for hot water to reach the shower room and that a needed part to fix the cold-water problem was on back order, contributing to the prolonged period of inadequate hot water and resulting in residents not having their bathing preferences honored.
Improper Disposal of Unused Medications on Medication Cart
Penalty
Summary
Surveyors identified a deficiency related to accident hazards and inadequate supervision when unused medications were improperly discarded on the north hallway. During observation of the north hall nurses’ station, two medications were found in the trash bin attached to the medication cart, placed together inside an unlabeled medication cup. The pills were described as a round blue pill stamped with “61” and an oblong orange pill stamped with “20.” In an interview immediately following the observation, an RN confirmed that these medications were in the trash bin and stated that unused medications should instead be disposed of in the drug buster, a sealed container for drug disposal located in the bottom drawer of the cart. In a subsequent interview, the Unit Manager confirmed that all unused medications are to be disposed of using the drug buster and acknowledged that this did not occur, further stating that if the medications are controlled substances such as narcotics, two licensed personnel are required to dispose of them together and document the disposal on the narcotic count sheet. This deficient practice was noted as likely to affect any resident who might acquire and ingest the discarded medications, potentially causing medication side effects.
Failure to Follow Allergy, Diet, and Meal Ticket Requirements
Penalty
Summary
The facility failed to provide meals consistent with residents’ documented allergies, diet orders, and meal tickets for three residents. One resident, admitted with a documented allergy to chocolate, had a face sheet and lunch ticket indicating they were not to receive chocolate. During a lunch observation, this resident was served and was eating chocolate ice cream. An LPN confirmed the resident’s chocolate allergy and that the resident should not be eating chocolate. The Nutrition Director acknowledged that the meal ticket stated the resident should not have chocolate but reported serving chocolate ice cream after the resident requested it, stating he had not read that the resident was allergic to chocolate. Another resident, admitted with hypokalemia and ordered a regular/liberalized pureed diet per the MDS, had a lunch ticket indicating a pureed diet but was observed receiving whole mandarin oranges instead of pureed fruit. A CNA confirmed that the dessert was not pureed. A third resident’s meal ticket specified a grilled Swiss sandwich, but observation of the tray showed the sandwich was not grilled. During interviews, a CNA and a dietary manager confirmed that the sandwich was not grilled as ordered on the meal ticket.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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