Clovis Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Clovis, New Mexico.
- Location
- 1201 North Norris Street, Clovis, New Mexico 88101
- CMS Provider Number
- 325077
- Inspections on file
- 17
- Latest survey
- December 5, 2025
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Clovis Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
The facility did not update and post the required daily nurse staffing information at the beginning of the shift, leaving an outdated posting that did not reflect the current date, RN, LPN, and CNA staffing hours, or the current resident census. An observation at the main entrance showed the staffing data was from a prior day, and an interview with the Administrator confirmed that the information should be posted daily but was not, potentially affecting all residents in the facility.
Surveyors found that medication storage practices were not safely maintained, including an unlocked and unattended medication cart near a nurse’s station, a nurse’s personal drinking cup stored inside a medication cart drawer, and expired Hepatitis B vaccine syringes kept in a medication storage room refrigerator. An LPN acknowledged the cart should have been locked, and the DON confirmed the vaccines were expired and that personal items should not be stored on medication carts due to infection control concerns. These issues were identified as having the potential to affect all residents in the facility.
Surveyors found multiple food service sanitation deficiencies, including a dietary aide working in the kitchen without a required hairnet, unlabeled and undated food items such as parmesan cheese and lettuce stored in the main refrigerator, and clean dishes stored under kitchen warmers on top of dirty containers. The dietary manager and kitchen director both confirmed these observations and acknowledged that staff were not following expected practices for hair restraint, food labeling, and sanitary storage of dishes, potentially affecting all residents receiving meals from the kitchen.
Surveyors found that the facility did not fully implement its infection prevention and control program when PPE was observed hanging on several room doors, but required Enhanced Barrier Precaution (EBP) signs were missing from some of those rooms. Facility policies referenced CDC guidance, and CDC EBP materials specify that clear signage indicating the type of precautions and PPE required should be posted outside rooms where EBP is in use. In an interview, the Administrator acknowledged that signs should be in place for residents on enhanced precautions, confirming that the observed lack of EBP signage in certain rooms was inconsistent with expected practice.
Surveyors found that the facility failed to maintain a safe and functional environment for all 62 residents reviewed. Observations revealed several uncovered holes in the floor near walls, with no screens or vent covers installed, and scuffed, scratched handrails throughout the building. In an interview, the MD and the Administrator confirmed that vent covers in the hallways were missing during laminate flooring replacement and acknowledged the damaged condition of the handrails.
A resident was started on two psychotropic medications, Lorazepam and Hydroxyzine, for anxiety without documented informed consent. Record review showed active orders for both medications, but no corresponding consent forms in the medical record. The DON acknowledged that staff did not complete the required psychotropic medication consent process before initiating these drugs, despite the facility’s expectation that consent be obtained prior to starting psychotropic therapy.
Staff failed to ensure that psychotropic and related medications were supported by appropriate diagnoses in the clinical record. One resident with multiple medical conditions, including paraplegia and major depressive disorder, received melatonin for insomnia and tetrabenazine for tardive dyskinesia without documented diagnoses of either condition. Another resident with depression and insomnia was given hydroxyzine for anxiety/agitation without a diagnosis of anxiety. A third resident with respiratory failure, anxiety disorder, dissociative identity disorder, bipolar disorder, and major depressive disorder was prescribed Depakote for dementia with behavioral disturbance despite having no dementia diagnosis. The DON confirmed that these medications were ordered for conditions not documented as diagnoses and acknowledged that medications should be tied to specific, documented conditions.
Surveyors identified that staff did not consistently revise care plans to reflect current orders, devices, and goals for several residents. One resident’s psychotropic care plan omitted a newly ordered hypnotic, while another’s care plan still listed a discontinued topical pain medication. A resident with severe cognitive impairment and a history of falls had multiple documented falls without corresponding updates to fall-prevention interventions. Another resident’s care plan contained conflicting information about discharge goals, listing both no discharge plans and a goal to return home. Bed rail size documented in one resident’s care plan did not match the quarter rails observed in use, and another resident’s care plan continued to list a wander guard after the order had been discontinued. The DON confirmed that these care plans were not revised to reflect current treatments and supports.
Surveyors found that two residents were using quarter-size bed rails on both upper sides of their beds without all required documentation. One resident with cervical spine issues, osteoarthritis, reduced mobility, muscle weakness, and paraplegia had a bed rail assessment recommending rails but no MD order or informed consent in the EHR, despite reporting use of the rails for repositioning. Another resident with sciatica, muscle weakness, gait abnormalities, and lack of coordination had a bed rail assessment and an MD order for rails as an enabler for turning and repositioning, but no informed consent. The DON confirmed that both residents used the rails and that the missing physician order and consents were not in place.
Surveyors found that multiple residents were receiving medications without clear, diagnosis-based indications or complete orders. Several residents had aspirin ordered daily with indications such as “preventative” or “prophylactic,” which the DON acknowledged were not appropriate or specific indications. One resident had a probiotic ordered without a stated purpose, missing dosage, and a mismatch between the ordered form and the form to be administered. Other residents were prescribed medications such as potassium chloride, atorvastatin, Colace, cetirizine, cephalexin, furosemide, and naloxone without corresponding active diagnoses (e.g., hypokalemia, hyperlipidemia, constipation, allergies, UTI, edema, or opioid use) documented in their records, and the DON confirmed that these orders did not align with the residents’ listed diagnoses.
Surveyors determined that the facility did not properly document COVID-19 vaccination status or an offer of vaccination for two residents. Record reviews showed that both residents had been admitted and had EHRs, but there was no documentation that either had received or been offered the COVID-19 vaccine. In an interview, the DON confirmed the absence of any record indicating that these residents had received or been offered COVID-19 vaccination, despite the facility’s responsibility to educate and offer vaccination and to document vaccination status.
The facility failed to timely submit a Facility Initiated Report and required follow-up to the State Survey Agency after a resident experienced an unwitnessed fall resulting in a left hand injury with swelling, deformity, bruising, and significant pain. Internal documentation and a later complaint intake showed the fall led to a broken finger, but no immediate report was sent to the state, and the follow-up report was not completed until many weeks later. The DON acknowledged that any fall with significant injury should have been reported right away and that an in-house report to the state should have been made within two hours of the facility becoming aware of the incident.
A resident admitted with adult failure to thrive, chronic heart failure, and a need for assistance with personal care had an inaccurate MDS assessment when staff documented that the resident did not use an external catheter. During observation, surveyors saw a urine collection canister in the resident’s room, and the resident confirmed ongoing use of an external catheter since before admission. The DON later verified that the resident used an external catheter and that this was not captured in the MDS assessment.
A resident admitted with partial intestinal obstruction, HTN, colostomy status, and need for post-surgical digestive system aftercare did not have a baseline care plan created within 48 hours of admission. Review of the EHR showed no baseline care plan, and the DON confirmed during interview that this required plan had not been completed.
A resident with adult failure to thrive, chronic heart failure, and a need for assistance with personal care was observed with a canister containing urine connected to an external catheter that she reported having used since before admission. Record review showed no care plan or interventions addressing the resident’s external catheter use. The DON confirmed the resident’s use of an external catheter and acknowledged that staff had not developed or implemented a care plan for this device, despite the expectation that all catheter use be included in the care plan.
A resident with acute respiratory failure with hypoxia, morbid obesity, and COPD, who was cognitively intact and fully dependent on staff for transfers using a mechanical lift, reported that when the facility was short staffed she was unable to get out of bed because staff were not available to perform her transfers. She stated the DON told her she would need to remain in bed or in her wheelchair until late in the evening when staff could transfer her again, and she chose to stay in bed because prolonged time in the wheelchair caused her pain. The DON later confirmed that this resident requires extra staff for all transfers due to the need for a mechanical lift.
A resident with adult failure to thrive, chronic heart failure, and a need for assistance with personal care was observed with a canister containing urine connected to an external catheter that she reported having used since before admission. Review of the medical record showed no provider order documenting the need for the catheter, its type, or care instructions, and no care plan or interventions addressing catheter use. The MDS assessment also indicated that the resident did not use an external catheter, despite the DON confirming that the resident did use one and should have an order and care plan in place.
The facility failed to maintain adequate nursing staff levels to meet resident needs, as shown by review of staffing records for two residents. On one reviewed day, the per patient day (PPD) staffing ratio was documented as 2.32 staff hours per resident, which was below the stated standard average range of 2.5 to 3.48. This reflected a failure to ensure sufficient nursing staff and a licensed nurse in charge on each shift.
A resident with severe protein-calorie malnutrition, acute and chronic respiratory failure with hypoxia, cachexia, and chronic diastolic CHF was admitted on hospice services, and a physician telephone order for hospice admission was obtained. However, staff did not enter an active hospice admission order into the resident’s medical record. Review of the orders showed no hospice admit order, and the DON confirmed the absence of this order and acknowledged it should have been entered at the time of admission, resulting in an inaccurate medical record.
The facility did not ensure that a CNA completed the required 12 hours of annual in‑service training. Review of the CNA’s personnel and training records showed the CNA had only five and a half hours of in‑service education completed within the relevant one‑year period. A payroll specialist confirmed that all CNAs are expected to meet the annual training requirement and that this CNA had not done so.
The facility failed to maintain and log medication refrigerator temperatures as required, with incomplete logs found in two medication rooms. The Infection Preventionist confirmed the logs were not maintained, and the DON was unaware of the issue, indicating a lack of process to ensure proper temperature monitoring.
The facility failed to provide written transfer notices to resident representatives and the Ombudsman for two residents transferred to the hospital. Despite the facility's policy requiring verbal and written notifications for unplanned, acute transfers, no documentation of such notices was found for the residents involved. Interviews with staff confirmed the oversight, highlighting a lapse in adherence to the facility's transfer policy.
The facility failed to provide written notification of its bed hold policy to residents or their representatives during hospital transfers, as required by federal regulations. Two residents were transferred without receiving the necessary documentation, and staff interviews confirmed a lack of awareness about this requirement. This oversight could lead to distress or confusion for residents regarding their readmission.
The facility failed to update care plans for two residents after significant clinical events. One resident's care plan was not revised after a fall with injury, and another's was not updated following a hospital stay and return with therapy orders. The facility's policy requires care plans to be revised after assessments, but this was not done, increasing the risk of inappropriate care.
The facility failed to maintain a safe smoking area for residents, allowing non-self-extinguishing trash cans to be used for cigarette waste, contrary to policy. A resident requiring supervised smoking was observed with a cigarette burn on her blanket, and staff were unaware of the proper use of safety equipment, such as a locked red ash can and available smoking aprons.
The facility failed to investigate and report allegations of neglect and abuse for three residents. Two residents reported that a CNA was rude and made them feel bad for needing assistance, but these allegations were not investigated or reported to the SSA. Another resident had injuries of unknown origin, and while an initial report was sent to the SSA, a required follow-up report was not submitted. The staff involved continued to work without any investigation, leading to Immediate Jeopardy being identified by surveyors.
The facility failed to ensure nursing staff competency, resulting in a resident being hospitalized due to medication errors by an LPN. Additionally, another LPN worked without completing necessary hiring procedures, including background checks and training, using another LPN's credentials. These actions violated facility policies and highlighted significant lapses in oversight and communication.
A resident in a long-term care facility was administered an incorrect dose of morphine, leading to significant health complications and eventual death. The error occurred when an LPN, in an emergency, borrowed morphine from another resident's supply and administered 40 mg instead of the prescribed 2 mg. The facility failed to document the administration and did not notify the hospital ER of the error.
The facility failed to properly store and dispose of narcotic medications, with unsecured narcotics found in the DON's office and inadequate disposal processes. Staff reported concerns about unsecured medications, but no action was taken. The facility's medication storage rooms were disorganized, with expired and unlabeled medications dating back to 2022, leading to Immediate Jeopardy.
A resident with multiple infections and wounds did not receive a PICC line or wound vacuum as ordered by the physician. Despite clear instructions, the facility failed to implement these critical interventions, leading to the resident's condition worsening and subsequent hospitalization. Communication breakdowns and inaction by the DON and nursing staff contributed to this deficiency.
A resident with severe cognitive impairment and multiple health issues was not protected from abuse, resulting in bruising to her neck and wrists. Despite her agitation and distress, medications for anxiety were delayed, and staff made inappropriate comments. A forensic examination suggested the bruising was consistent with strangulation, contradicting staff explanations. The facility's investigation was not provided, and involved staff continued to work post-incident.
The facility's administration, including the Administrator and DON, were frequently unavailable, leading to rescheduled resident meetings and delayed communication about staff absences. An LPN worked without completing hiring procedures, administering medications without being officially employed. The DON altered medical records and wrote unauthorized orders, with no corrective actions taken despite multiple reports. These deficiencies highlight significant mismanagement and lack of accountability within the facility.
The facility failed to report several incidents and allegations to the SSA, including a medication error, unwitnessed falls with injuries, and abuse allegations by two residents against a CNA. The DON was responsible for reporting these incidents but did not fulfill this duty, leading to a lack of timely reporting and investigation.
A resident's morphine was misappropriated by an LPN who administered it to another resident under false pretenses, with the incident falsely documented as a spill. The DON and LPN signed off on this false documentation, and the NP was misled about reporting the error. The facility's Administrator was not informed, and both the DON and LPN were placed on administrative leave.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post required nurse staffing information on a daily basis at the beginning of each shift. On 12/01/25 at 11:04 AM, an observation at the main entrance showed that the nurse staffing data displayed was dated 11/30/25 and had not been updated for the current day. The posting therefore did not reflect the current date, the total number and actual hours worked by RNs, LPNs, and CNAs directly responsible for resident care per shift, nor the current resident census for that day. During an interview at 11:10 AM on the same day, the Administrator confirmed that the nursing staff data is required to be posted daily and acknowledged that it had not been posted for the current day. This deficient practice had the potential to affect all 62 residents identified in the census provided by the Administrator on 12/01/25. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency pertained to facility-wide posting of staffing information rather than to an individual resident’s care.
Failure to Maintain Secure and Proper Medication Storage
Penalty
Summary
Surveyors identified a deficiency in the facility’s safe medication storage practices involving unsecured medication carts, expired medications, and personal items stored with medications. During an observation, a medication cart located near the nurse’s station was found unlocked and unattended, and an LPN confirmed that the cart was not locked and should have been. In a subsequent medication storage observation, a nurse’s personal drinking cup was found stored in the bottom right-hand drawer of the 100-hall medication cart. The same observation of the East/West medication storage room vaccine refrigerator revealed an opened box containing five prefilled syringes of Hepatitis B vaccine with an expiration date of 05/19/25, indicating the vaccines were expired. The DON confirmed that the vaccines were expired and should be disposed of and that personal drinks or items should not be on the medication carts due to infection control concerns. These practices were noted as having the potential to affect all 62 residents in the facility, as identified by the census provided by the Administrator on 12/01/25, and were cited as failures to ensure drugs and biologicals were stored in locked compartments and maintained according to accepted professional principles.
Food Service Sanitation and Labeling Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency related to food service sanitation and safe food handling practices affecting the facility’s dietary services. During a kitchen observation, a dietary aide was seen working without a hairnet. In an interview immediately afterward, the aide reported being a new employee and stated she was unaware that a hairnet was required at all times in the kitchen. The dietary manager confirmed that the aide was not properly wearing a hairnet and stated that the expectation is for all staff to properly wear hairnets while in the kitchen or serving food. Additional observations in the kitchen revealed food storage and dish storage issues. Inspectors observed what appeared to be dry parmesan cheese and lettuce in the main refrigerator without any labels indicating contents or preparation dates. The kitchen director confirmed these items were not labeled or dated and stated that his expectation is for all items in the refrigerator to be properly labeled, dated, and stored. Inspectors also observed dishes stored under the kitchen warmers on top of other dirty containers. The kitchen director confirmed that the dishes were not stored under sanitary conditions and stated that his expectation is for all dishes and kitchen equipment to be stored under sanitary conditions.
Failure to Post Required Enhanced Barrier Precaution Signage for Rooms Using PPE
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the implementation of Enhanced Barrier Precautions (EBP). During a random observation on 12/01/25 at 10:22 a.m., PPE was observed hanging on the doors outside rooms 100, 205, 306, 307, and 311, indicating use of precautions; however, EBP signs were not posted outside rooms 205, 306, and 307. Record review of the facility’s infection control policies and procedures dated 07/15/25 showed the facility referred to CDC guidance, and review of CDC’s Enhanced Barrier Precautions in Nursing Homes (Slide 28, Communication) indicated that appropriate and legible EBP signs should be displayed outside the door of rooms where EBP is required, specifying the type of precaution and PPE to be used during high-contact resident care activities. In an interview on 12/05/25 at 11:35 a.m., the Administrator stated that signs should be in place for residents with enhanced precautions. This failure to post required EBP signage occurred in a facility housing 62 residents per the census provided by the Administrator on 12/01/25. The report does not provide specific clinical details or medical histories of individual residents affected, but it establishes that the missing EBP signs were in rooms where PPE use suggested enhanced precautions were in effect, and that the facility’s practice did not align with its referenced CDC guidelines or the Administrator’s stated expectations regarding signage for residents on enhanced precautions.
Uncovered Floor Vents and Damaged Handrails Create Unsafe Environment
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe and functional environment for all 62 residents reviewed. During an observation of the facility, surveyors noted several uncovered holes in the floor near the wall, each approximately 1.5 inches by 8 inches long, with no screens or vent covers in place. Additional observations showed that handrails throughout the facility were scuffed and scratched. In a subsequent observation and interview with the Maintenance Director and the Administrator, both confirmed that there were no vent covers in the hallways and acknowledged that the vents were missing while laminate flooring was being replaced, as well as the presence of the scuffed and scratched handrails. No specific resident medical histories or conditions were described in the report, and the deficiency was cited as affecting the environment for all 62 residents reviewed.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure a resident and/or their representative were informed in advance about prescribed medications and understood the reasons, risks, and benefits, resulting in a lack of informed consent for psychotropic medications. Record review for Resident #3 showed physician orders for Lorazepam 0.5 mg by mouth twice daily for anxiety starting 09/09/25, and Hydroxyzine HCL 25 mg by mouth twice daily for anxiety starting 10/22/25. Further review of the medical record revealed there were no consent forms for the use of either Lorazepam or Hydroxyzine. In an interview on 12/05/25 at 1:22 p.m., the DON confirmed that staff did not obtain the required psychotropic medication consent forms prior to initiating these medications for Resident #3, despite the expectation that such consent be completed before starting psychotropic drugs. If the residents or their representatives are not informed of the risks and benefits of the medication or treatment alternatives, they are not able to make informed decisions regarding residents' care.
Psychotropic and Related Medications Used Without Corresponding Diagnoses
Penalty
Summary
Facility staff failed to ensure that psychotropic and related medications were prescribed and documented as medically necessary to treat specific, diagnosed conditions for multiple residents. One resident admitted with diagnoses including gastroenteritis, hypotension, chronic pain, constipation, paraplegia, and major depressive disorder had active orders for melatonin 3 mg at bedtime for insomnia and tetrabenazine 12.5 mg three times daily for tardive dyskinesia, despite having no documented diagnoses of insomnia or tardive dyskinesia in the clinical record. Another resident admitted with depression, insomnia, cerebral infarction, and hyperlipidemia had an order for hydroxyzine 50 mg twice daily for anxiety/agitation, but there was no documented diagnosis of anxiety in the record. A third resident admitted with respiratory failure, anxiety disorder, history of ischemic attack, dissociative identity disorder, bipolar disorder, and major depressive disorder had an order for Depakote 125 mg three times daily for dementia with behavioral disturbance, although there was no diagnosis of dementia documented in the record. During interview, the DON confirmed that these residents did not have the corresponding diagnoses (insomnia, tardive dyskinesia, anxiety, or dementia) for which the medications were ordered, and acknowledged that medications should be documented to treat specific conditions as diagnosed, which was not done in these cases.
Failure to Revise and Update Resident Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to timely revise and update comprehensive care plans for multiple residents as required. For one resident with anxiety, depression, chronic pain, constipation, paraplegia, and major depressive disorder, the physician ordered melatonin 3 mg at bedtime for insomnia, but the resident’s care plan, last revised on 12/01/25, did not include melatonin among the listed psychotropic medications (which did include mirtazapine, sertraline, buspirone, lorazepam, hydroxyzine, and tetrabenazine). Another resident with chronic pain syndrome, COPD, hypertension, depression, and atherosclerotic heart disease had a physician’s order for Voltaren gel discontinued on 09/19/25, yet the care plan revised on 11/25/25 still contained an intervention to apply Voltaren gel as ordered, reflecting outdated information. A third resident with a history of falling, lack of coordination, cirrhosis, muscle weakness, and periorbital cellulitis had a quarterly MDS showing severe cognitive impairment and a history of falls since admission. The care plan, initiated on 02/14/25 and revised for multiple fall dates (09/18/25, 10/5/25, 10/10/25, 10/21/25, 11/1/25, 11/6/25, 11/18/25), identified the resident as at risk for falls but did not include revised interventions to ensure safety after these fall events. Another resident with a stable lumbar burst fracture, DM2, depression, and parkinsonism had a care plan revised on 04/15/25 that simultaneously documented the resident as a long-term resident with no plans for discharge and also stated a goal to increase ADL status and return home with family, indicating that discharge goals in the care plan were not updated to reflect current status. For a resident with hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, the most recent bed rail assessment recommended quarter-size rails on both upper sides of the bed, and observation on 12/02/25 confirmed quarter-size rails in place. However, the physician order dated 09/23/24 specified half-size bed rails, and the care plan revised on 11/19/25 documented use of half-size rails, showing the care plan did not reflect the current quarter-size rails in use. Another resident with severe protein-calorie malnutrition, acute and chronic respiratory failure with hypoxia, cachexia, and chronic diastolic heart failure had a physician’s order for a wander guard discontinued on 10/07/25, but the care plan revised on 11/12/25 still listed an intervention for a wander guard in place. In an interview, the DON confirmed that the care plans for these residents were not revised to include or remove the respective medications, devices, fall interventions, discharge goals, and bed rail sizes as appropriate.
Failure to Obtain Orders and Informed Consent for Bed Rail Use
Penalty
Summary
Surveyors identified a deficiency in the facility’s process for assessing, ordering, and obtaining informed consent for bed rail use. Facility policy requires that before using bed rails, staff try alternative approaches, assess the resident for safety risk, review risks and benefits with the resident or representative, obtain informed consent, and correctly install and maintain the bed rail. For one resident with spondylolysis of the cervical spine, osteoarthritis, reduced mobility, muscle weakness, and paraplegia, the record showed a completed bed rail assessment recommending quarter-size bed rails on both upper sides of the bed. However, review of the electronic health record revealed there was no physician order for bed rails and no informed consent on file. During observation, quarter-size bed rails were present on both upper sides of this resident’s bed, and in interview the resident confirmed using the bed rails for repositioning. For another resident with sciatica on the left side, muscle weakness, abnormalities of gait and mobility, and lack of coordination, the record showed a bed rail assessment recommending quarter-size bed rails on both upper sides of the bed. The electronic health record contained a physician order for quarter-size bed rails as an enabler for turning and repositioning, but there was no informed consent documented. Observation confirmed quarter-size bed rails on both upper sides of this resident’s bed, and the resident reported using the rails for repositioning. In an interview, the DON confirmed that both residents were using quarter-size bed rails on both upper sides of their beds, that one resident did not have a physician order or informed consent, and that the other resident did not have informed consent, despite facility requirements.
Medication Regimens Lacking Diagnosis-Based Indications and Complete Orders
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents’ drug regimens were free from unnecessary drugs by not providing adequate, diagnosis-based indications for use and complete medication orders. For one resident with COPD, hypertension, and hyperlipidemia, the physician order for aspirin 81 mg daily listed the indication only as “preventative,” without specifying the clinical reason for use. The DON confirmed that “preventative” is not an appropriate indication and that the order did not meet her expectations. Another resident with gastroenteritis, colitis, hypotension, chronic pain, constipation, paraplegia, and major depressive disorder had an order for Acidophilus Probiotic that lacked a clear indication of use and did not include the dosage. The order also contained a discrepancy between the form ordered (tablet) and the form to be given (capsule). The DON confirmed that “probiotic” was not an appropriate indication, that the dosage was missing, and that the form of the medication in the order and instructions should match. For a third resident with emphysema, anemia, Bell’s palsy, and cerebral ischemic attack, there were orders for potassium chloride ER for hypokalemia, atorvastatin for hyperlipidemia, and Colace for constipation, even though the resident did not have diagnoses of hypokalemia, hyperlipidemia, or constipation. This resident also had an aspirin order with the indication “prophylactic” and a standing naloxone order despite having no current opioid medications. The DON confirmed that the indications did not relate to the resident’s diagnoses and that the naloxone order was not appropriate in the absence of opioid use. A fourth resident with depression, insomnia, cerebral infarction, and hyperlipidemia had orders for cetirizine for allergies and cephalexin for a UTI, but there were no corresponding diagnoses of allergies or UTI listed. This resident also had an aspirin order with the indication “preventative,” which the DON stated was not an appropriate indication. A fifth resident with respiratory failure, anxiety disorder, history of ischemic attack, dissociative identity disorder, bipolar disorder, and major depressive disorder had an order for furosemide for bilateral lower edema, although edema was not listed as a diagnosis, and an aspirin order with the indication “prophylactic.” The DON confirmed that this resident did not have a diagnosis of edema and that the medication indications did not relate to the resident’s diagnoses, and again stated that “prophylactic” was not an appropriate indication of use.
Failure to Document COVID-19 Vaccination Status and Offer for Two Residents
Penalty
Summary
Surveyors found that the facility failed to ensure medical records contained documentation that each resident received or was offered COVID-19 vaccination, as required by facility policy. Record review for one resident (R #4) showed an admission date but no documentation in the Electronic Health Record (EHR) that the resident had received or been offered the COVID-19 vaccine. Similarly, record review for another resident (R #5) showed an admission date but no documentation in the EHR that the resident had received or been offered the COVID-19 vaccine. During an interview on 12/05/25 at 1:22 p.m., the DON confirmed that there was no record for either resident indicating receipt of, or an offer of, the COVID-19 vaccination. The deficiency was identified during review of five residents’ records for immunizations, with two residents lacking any documentation of COVID-19 vaccination status or offer of vaccination in their EHRs, despite the facility’s responsibility to educate residents and staff on COVID-19 vaccination, offer the vaccine to eligible individuals, and properly document vaccination status.
Failure to Timely Self-Report Unwitnessed Fall With Injury to State Survey Agency
Penalty
Summary
The facility failed to timely submit a Facility Initiated Report and a five-day follow-up report to the State Survey Agency (SSA) for an unwitnessed fall with injury and subsequent left hand injury involving Resident #7. Nursing documentation dated 09/16/25 at 6:13 a.m. showed that Resident #7 reported falling into a wheelchair, with noted swelling, mild deformity, bruising, and pain rated 6/10 to the left hand. A facility complaint intake report dated 10/10/25 documented that Resident #7 had an unwitnessed fall on 09/16/25 resulting in a broken finger. Review of the SSA’s intake records showed no facility report was received on 09/16/25 for this unwitnessed fall with injury, and the SSA follow-up report indicated the facility’s follow-up was not completed until 12/04/25, 79 days after the fall. During interview, the DON stated that any fall with significant injury should have been reported right away and acknowledged that an in-house report to the state should have been made within two hours of the facility becoming aware of the unwitnessed fall on 09/16/25. This sequence of events demonstrates that staff did not report the unwitnessed fall with injury and the left hand injury for Resident #7 within the required timeframe, and the facility did not provide the mandatory self-initiated incident report or timely five-day follow-up report to the SSA as required.
Failure to Accurately Document External Catheter Use on MDS Assessment
Penalty
Summary
The facility failed to complete an accurate Minimum Data Set (MDS) assessment for one resident upon admission and subsequent assessment. The resident was admitted with diagnoses including adult failure to thrive, chronic heart failure, and a need for assistance with personal care. Review of the resident’s MDS assessment, specifically section H, showed that staff documented the resident as not using an external catheter. However, during an observation of the resident’s room, surveyors noted a canister with what appeared to be urine collecting, and the resident confirmed in an interview that the canister was connected to an external catheter that she had been using since before admission. In a later interview, the DON also confirmed that the resident utilized an external catheter and acknowledged that this device had not been included in the resident’s MDS assessment, despite it being in use.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to create a baseline care plan within 48 hours of admission for one resident, identified as R #67. Record review showed that this resident was admitted with diagnoses including partial intestinal obstruction, essential hypertension, colostomy status, and a need for surgical aftercare following digestive system surgery. Review of the resident’s electronic health record revealed that no baseline care plan was present. In an interview, the DON confirmed that the baseline care plan had not been completed and acknowledged that it should have been in place.
Failure to Care Plan for Resident’s External Catheter Use
Penalty
Summary
Surveyors identified that the facility failed to develop and implement an accurate, comprehensive care plan addressing a resident’s use of an external catheter. The resident was admitted with diagnoses including adult failure to thrive, chronic heart failure, and a need for assistance with personal care. During a random observation of the resident’s room, surveyors noted a canister containing what appeared to be urine. In a subsequent interview, the resident confirmed that the canister was connected to an external catheter that she had been using since before admission to the facility. Review of the resident’s electronic health record showed there was no care plan or interventions in place related to the resident’s external catheter use. In an interview, the DON confirmed that the resident does use an external catheter and acknowledged that the facility failed to develop and implement a care plan that included this device and the needed interventions. The DON also stated that her expectation is that every resident who uses a catheter, whether external or not, should have a care plan that includes necessary interventions.
Failure to Provide Required Transfer Assistance for Dependent Resident
Penalty
Summary
The facility failed to provide required ADL assistance with transfers for a resident who was fully dependent on staff for all transfers, toileting hygiene, and bathing. The resident had diagnoses including acute respiratory failure with hypoxia, morbid obesity, and COPD, and required the use of a mechanical lift for all transfers from bed to wheelchair. The resident’s MDS documented that she was cognitively intact with a BIMS score of 15 and dependent on staff for all transfers. Despite this documented need, the resident reported that when the facility was short staffed, she was unable to get out of bed because there were not enough staff available to perform the lift transfer. During an interview, the resident stated that on a specific date she could not get out of bed due to staffing shortages and recalled this date because she documented it on her phone. She reported that the DON told her that, due to short staffing, she would either need to remain in bed or stay in her wheelchair until late in the evening, around 9:00 pm or 10:00 pm, when staff would again be available to transfer her. The resident stated it was painful to remain in her wheelchair that long, so she stayed in bed. In a subsequent interview, the DON stated she did not remember having that conversation with the resident but confirmed that it takes extra staff to transfer this resident because she requires a mechanical lift for all transfers.
Lack of Orders and Care Planning for Resident Using External Catheter
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to provide appropriate care and clinical oversight for a resident using an external urinary catheter. The resident was admitted with diagnoses including adult failure to thrive, chronic heart failure, and a need for assistance with personal care. During an observation of the resident’s room, surveyors noted a canister containing what appeared to be urine. In an interview, the resident confirmed that the canister was connected to an external catheter that she had been using since before admission. Record review showed there was no physician order for the catheter, including no documentation of the need for the catheter, the type of catheter to be used, or instructions for its care. The resident’s electronic health record contained no care plan or interventions addressing the use of an external catheter. Additionally, the MDS assessment indicated that the resident did not use an external catheter, which conflicted with the resident’s report and the DON’s confirmation that the resident did in fact use one and should have an order and care plan in place.
Inadequate Nursing Staffing Levels Below PPD Standard
Penalty
Summary
The facility failed to maintain appropriate staffing levels to meet resident needs, as identified for one of two residents reviewed for staffing. Surveyors determined that the facility did not provide enough nursing staff every day to meet the needs of every resident and did not ensure a licensed nurse was in charge on each shift. Record review of the facility’s per patient day (PPD) staffing log showed that on 11/24/25 the staffing ratio was 2.32 staff hours per resident day, which was below the stated standard average ratio of 2.5 to 3.48. This deficiency was cross-referenced to tag F-690.
Failure to Enter Hospice Admission Order in Medical Record
Penalty
Summary
Facility staff failed to maintain an accurate and updated medical record for one resident when they did not document a hospice admission order upon the resident’s admission. The resident was admitted with diagnoses including unspecified severe protein-calorie malnutrition, acute and chronic respiratory failure with hypoxia, cachexia, and chronic diastolic (congestive) heart failure. Record review showed a physician telephone order dated 05/02/05 for the resident to be admitted to hospice, but review of the resident’s orders revealed no corresponding hospice admission order entered into the active medical record. During interview, the DON confirmed there was no active hospice admission order for the resident and stated that such an order should have been entered when the resident was admitted on hospice orders. This failure to transcribe and enter the hospice admission order into the resident’s medical record resulted in the record not reflecting the physician’s hospice admission order for the resident.
Failure to Ensure Required Annual In‑Service Training for CNA
Penalty
Summary
The facility failed to ensure a CNA received the required 12 hours of annual in‑service training. Record review of CNA #2’s personnel file showed this CNA was hired on 03/11/20. Further review of CNA #2’s in‑service training transcript dated 12/05/25 showed the CNA had completed only five and a half hours of in‑service training during the period from 12/06/24 to 12/05/25. In an interview, the Payroll Specialist stated she expects all CNAs to complete the required amount of training each year and confirmed that CNA #2 had not met this requirement. This deficiency is related to the facility’s failure to ensure CNAs receive the necessary in‑service training hours, including education in dementia care and abuse prevention, as required for maintaining skills to meet residents’ care needs.
Failure to Maintain and Log Refrigerator Temperatures
Penalty
Summary
The facility failed to maintain medication and biological refrigerator temperatures within the required range and did not consistently log these temperatures for three refrigerators in two medication rooms. This deficiency was identified through observations, staff interviews, and record reviews. The facility's policy, IC401 Medication and Vaccine Refrigerator/Freezer Temperatures, mandates that refrigerators and freezers used for storing medications and vaccines should operate within an acceptable temperature range and be checked twice daily. However, the temperature logs for the refrigerators in the East/West Hall and North Hall medication rooms were found to be incomplete, with less than 50% and approximately 75% of the required entries recorded, respectively. During interviews, the Infection Preventionist (IP) confirmed the logs were not maintained and acknowledged that the temperature logs should be filled out every 12 hours as part of infection control. The Director of Nursing (DON) also expressed a lack of awareness regarding the incomplete logs and indicated that a process would be implemented to ensure proper maintenance of temperatures and logs. The failure to consistently monitor and document refrigerator temperatures had the potential to expose residents to unsafe or ineffective treatments.
Failure to Provide Required Transfer Notices
Penalty
Summary
The facility failed to provide written transfer notices to resident representatives and the Ombudsman for two residents reviewed for transfer requirements. This deficiency was identified during a review of the facility's policy and interviews with staff. The policy, titled OPS404 Discharge and Transfer, required that for unplanned, acute transfers to a hospital, the resident and their representative should be notified verbally followed by written notification. However, the facility did not adhere to this policy, as evidenced by the lack of documentation of written transfer notices for the residents involved. Resident R14, who had a history of chronic obstructive pulmonary disease, type two diabetes mellitus, Parkinsonism, ventricular premature depolarization, and transient cerebral ischemic attack, was transferred to the emergency room without a written notice being provided to her representative. Similarly, Resident R30, who was moderately cognitively impaired and had been diagnosed with pneumonia, acute respiratory failure with hypoxia, and sepsis, was also transferred to the hospital without a written notice. Interviews with the Social Services Director, Center Executive Director, Director of Nurses, and the Administrator confirmed the failure to provide the required transfer/discharge notices.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of its bed hold policy to residents or their representatives during transfers to the hospital, as required by federal regulations. This deficiency was identified through interviews and records review, which revealed that two residents, R14 and R30, were not given the necessary documentation prior to their hospital transfers. The facility's policy, AR 102 Bed-Holds, mandates that a written Bed Hold Policy Notice & Authorization form be provided to residents or their representatives, regardless of payer, when a resident is transferred to a hospital or on therapeutic leave. However, the facility did not adhere to this policy, as evidenced by the lack of documentation in the electronic medical records of R14 and R30. R14, who had a BIMS score indicating intact cognition, was transferred to the emergency room due to a significant change in condition, but there was no record of the bed hold policy being communicated. Similarly, R30, who was moderately cognitively impaired, was hospitalized for several days without receiving the required bed hold notice. Interviews with facility staff, including the Social Services Director and the Center Executive Director, confirmed that the facility had not been providing these notices for at least two years, and staff were unaware of the requirement. This oversight created a potential for distress or confusion for residents regarding their readmission to the facility.
Failure to Update Care Plans After Significant Clinical Events
Penalty
Summary
The facility failed to update and revise care plans for two residents, R30 and R41, following significant changes in their clinical conditions. For R41, the care plan was not updated after a fall with injury occurred. Despite the fall being documented in the Fall Investigation Report and the Minimum Data Set (MDS) indicating a fall with injury, the care plan did not reflect new interventions or goals to address the fall risk. Interviews with the Director of Nursing (DON) and the MDS Coordinator (MDSC) confirmed that the care plan should have been updated within 24 hours of the fall, but it was not. For R30, the care plan was not revised following a hospital stay and return to the facility. R30 had been diagnosed with pneumonia, acute respiratory failure, and sepsis, and upon return, had orders for physical, occupational, and speech therapy. However, these therapies and the hospitalization were not reflected in the care plan. The MDSC stated that the care plan was only updated for annual MDSs and did not attend care plan meetings, indicating a gap in the process of updating care plans after significant events. The facility's policy requires care plans to be reviewed and revised after each assessment, including comprehensive and quarterly reviews, to reflect the resident's response to care and changing needs. The failure to update the care plans for R30 and R41 after significant clinical events created an increased risk for inappropriate care and services, as the care plans did not align with the residents' current clinical conditions.
Unsafe Smoking Area and Supervision Deficiency
Penalty
Summary
The facility failed to ensure the designated resident smoking area was safe for residents, specifically for one resident who required supervised smoking due to an inability to light a cigarette. The facility's policy required ashtrays made of non-combustible materials and metal containers with self-closing covers in all designated smoking areas. However, observations revealed that the smoking area had non-self-extinguishing trash cans lined with plastic bags, which contained cigarette butts, ashes, and trash. Additionally, one of the self-closing ashtrays was missing a part of its lid, and a red self-extinguishing ash can was locked, preventing its use. The Activity Director, who was supervising the residents, was unaware of the key's location to unlock the red ash can, and the Maintenance Director confirmed the presence of cigarette waste in the non-self-extinguishing trash can. The resident involved, who was cognitively intact but required supervision for smoking, was observed with a cigarette burn on a blanket covering her. Despite the availability of smoking aprons, the resident was not required to wear one, as she was generally considered capable of holding her cigarette without incident. Interviews with staff, including the Activity Director and the Administrator, revealed a lack of awareness and communication regarding the proper disposal of cigarette waste and the use of safety equipment, such as the red ash can and smoking aprons. This oversight created a potential hazard for fire accidents in the smoking area.
Failure to Investigate and Report Abuse Allegations
Penalty
Summary
The facility failed to complete and document thorough investigations and implement corrective actions regarding allegations of neglect and abuse for three residents. Specifically, the staff did not investigate the allegations made by two residents who reported that a Certified Nurse Aide (CNA) was rude and made them feel bad for needing assistance. The allegations were not reported to the State Survey Agency (SSA), and there was no documentation of a thorough investigation. Additionally, another resident had injuries of unknown origin, and while an initial incident report was sent to the SSA, a required five-day follow-up report was not submitted. The facility's records showed that the staff involved continued to work without any investigation being conducted into the allegations. The lack of investigation and reporting led to the identification of Immediate Jeopardy by surveyors. The facility's failure to address these allegations appropriately resulted in a deficiency being cited. The staff did not follow the necessary procedures to ensure the safety and well-being of the residents, and the lack of documentation and investigation contributed to the severity of the deficiency.
Removal Plan
- A full abuse investigation will occur within the facility to ensure no other residents have witnessed abuse, or been abused.
- If any further abuse allegations are brought forward, the facility will remove any resident from the abuse situation, and proper monitoring and interventions will be initiated immediately upon notification.
- If any staff are identified in an allegation of abuse, they will be placed on administrative leave until the investigation is complete.
- The Interim Director of Nursing/designee re-educated current staff regarding abuse policy.
- The education includes the policy, with emphasis on separating the victim from the aggressor immediately and placing the aggressor on 1:1 supervision.
- Documentation needs to occur to reflect monitoring and clear discontinuation of the 1:1, and reasoning by a provider.
- If a staff member is accused of abuse, they should be replaced on their shift and removed from the building until police arrive (if necessary), removed from the schedule, and not put back on the schedule until an investigation is completed, and they have been cleared by the Administrator or DON to return.
- The provider, nurse manager, and family have to be notified immediately.
- The eInteract change in condition assessment needs to be completed filled out with all the details of what happened.
- Monitoring and interventions need to continue to happen and be documented if the resident remains in the building, until we know they have stabilized per the provider, or have left the center.
- The Interim Director of Nursing/designee will begin education and continue until all staff have been educated prior to their next shift.
- Any licensed staff member on leave of absence (FMLA), vacation, or PRN staff will be re-educated prior to returning to duty.
- New hires/agency staff are educated on the abuse policy and process during orientation.
Deficiencies in Nursing Staff Competency and Hiring Practices
Penalty
Summary
The facility failed to ensure that nursing staff demonstrated appropriate competency and skills, leading to several deficiencies. An LPN, who also served as a Unit Manager, failed to administer accurate medication dosages to a resident, resulting in the resident being admitted to the hospital for difficulty breathing and altered mental status. Additionally, the LPN did not follow the facility's process for receiving emergency medications and inaccurately documented on the medication administration record to intentionally deceive. The facility's policies required staff to utilize the Automated Medication Dispensing Systems and report medication errors, but these protocols were not followed. Furthermore, another LPN began working without completing an application, having a background clearance, or demonstrating competency prior to providing care to residents. This LPN worked for three shifts without the necessary background checks, TB testing, or training. The Payroll/Scheduler discovered that this LPN was not a hired employee and had used another LPN's credentials to log into the electronic medication record system. The Administrator and Corporate Human Resources were notified but initially instructed to expedite the hiring process instead of addressing the unauthorized work. The facility's hiring policy required offers of employment to be contingent upon successful completion of hiring requirements, including background checks and health screenings. However, these procedures were not followed, as evidenced by the lack of documentation for the LPN's background clearance and training prior to working. The Administrator was unaware of the unauthorized work until informed by the Payroll/Scheduler, highlighting a breakdown in communication and oversight within the facility's management.
Removal Plan
- A full audit of all current staff working in the center will occur to ensure the proper hiring process was completed, including screening and training, with emphasis on: background checks, finger prints, Electronic Health Record (EHR) access.
- Anyone identified as not meeting these requirements will be removed from the schedule until requirements are met.
- A full audit of current direct care staff will occur to ensure all direct care staff have their own EHR access.
- Market Human Resources/designee will re-educate current management staff on hiring process, including required screening and training prior to beginning work within the center.
- Nurse manager/designee will provide education to all staff that they are never to use another staff member's sign-in for any application. If they are unable to use their own sign-in, they will contact IT and/or management until their access issues have been resolved.
- Education will continue until all identified staff have been educated prior to their next shift. Any management staff member on leave of any type, or PRN (as needed) staff will be re-educated prior to returning to duty. New hires will be educated on this process upon hire.
- The Administrator/designee will review new hires daily to ensure the process for new hires is being followed.
- The Director of Nursing/designee will begin education. 100% of currently scheduled staff will have been educated on this information. Any staff member that is not on the current schedule, is on leave of any type, or PRN staff will be educated prior to returning to their next shift. New hires/agency staff will be educated during orientation.
Medication Error Leads to Resident Harm
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when nursing staff administered the wrong dose of medication. A resident, who was initially admitted and later discharged, experienced an altered mental status, tachycardia, low blood pressure, and hypoxia. The resident was found in a distressed state by a CNA and was taken to the nursing station for vital sign assessment. The resident's condition required immediate medical intervention, including the administration of morphine as ordered by a nurse practitioner. The error occurred when an LPN, in an emergency situation, borrowed morphine from another resident's supply and administered it to the affected resident. The LPN was unsure of the correct dosage and administered 40 milligrams instead of the prescribed 2 milligrams. This mistake was compounded by the fact that the LPN did not use the specific syringe designed for the morphine prescription, leading to the overdose. The resident became less responsive after receiving the incorrect dose, prompting staff to call EMS for hospital transfer. The facility's records did not document the administration of morphine to the resident, and there was no evidence that the hospital ER was notified of the medication error. The resident was admitted to the hospital with several health issues, including sepsis, pneumonia, and acute renal failure, and later passed away. The facility's failure to properly administer medication and document the incident resulted in significant harm to the resident.
Removal Plan
- An audit will be completed of every resident with a narcotic order, to ensure that all narcotics ordered are on the medication carts. If medications are missing, then the medication availability process will be followed and pulled from the Omnicell/Ekit.
- All nursing staff will be re-educated on the six rights of medication administration with an emphasis on right patient/resident and right dosage.
- Nurse manager/designee will provide education to all nursing staff on medication availability process.
- A unit manager will begin education and continue until all licensed nursing staff have been educated prior to their next shift. New hires/agency staff will be educated during orientation.
- A unit manager will begin education. 100% of currently scheduled staff will be educated on this information. Any staff member that is not on the current schedule will be educated prior to returning to their next shift. New hires/agency staff will be educated during orientation.
- The Director of Nursing/designee will begin education. 100% of currently scheduled staff will have been educated on this information. Any staff member that is not on the current schedule will be educated prior to returning to their next shift. New hires/agency staff will be educated during orientation.
Improper Storage and Disposal of Narcotic Medications
Penalty
Summary
The facility failed to ensure proper storage and disposal of narcotic medications, which were found unsecured in the Director of Nursing's (DON) office. Observations revealed that the office was unlocked and accessible to residents, staff, and visitors, with various prescription bottles, including narcotics like morphine and fentanyl, left on the desk and in an open box on the floor. These medications were undated and not labeled with the residents' names, violating the facility's policy that requires controlled substances to be stored under double lock and accessible only to licensed nursing staff. Interviews with staff members, including the DON, revealed a lack of adherence to the facility's medication management policies. The DON admitted to not logging narcotics due to being busy and confirmed that medications should not be left unsecured in her office. Other staff members reported observing narcotics in the DON's unlocked desk drawers and expressed concerns to the administration and corporate human resources, but no action was taken. Additionally, the facility's process for disposing of unused and expired medications was inadequate, with the DON stating that medications were held for months before destruction, contrary to the policy requiring immediate logging and secure storage. Further investigation uncovered that the Infection Control Storage room contained unlabeled boxes and bins of medications, some dating back to 2022, without any destruction logs. The facility's medication reconciliation logs lacked documentation for these medications, and the Administrator was unaware of their presence. Interviews with other staff members corroborated the DON's failure to follow proper procedures, with reports of narcotics being hidden during inspections and a lack of organization in medication storage rooms. These deficiencies led to the identification of Immediate Jeopardy, highlighting significant risks to resident safety due to improper medication management.
Removal Plan
- A full audit of current medications for destruction was performed to ensure all medication was accounted for, logged, secured, and locked in a medication storage area or lock box until pick-up was completed or pharmacy destruction was initiated.
- All nursing staff was re-educated on Medication Storage Policy.
- The Director of Nursing/designee began education. 100% of currently scheduled staff have been educated on this information (Medication Storage). Any staff member that is not on the current schedule will be educated prior to returning to their next shift.
- New hires/agency staff will be educated during orientation.
Failure to Implement Physician's Orders for PICC Line and Wound Vacuum
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. Specifically, the facility did not follow through with physician's orders to place a peripherally inserted central catheter (PICC) line for intravenous antibiotic treatment and to order and apply a wound vacuum for a resident with multiple wounds and infections. The resident had been admitted with acute osteomyelitis, cellulitis, and acute kidney failure, and required specific medical interventions to manage these conditions. Despite receiving orders from the wound care clinic and the physician for a PICC line and wound vacuum, the facility did not implement these orders. The Director of Nursing (DON) was informed of the need for a PICC line, but the local hospital could not perform the procedure due to the resident's inability to stay still. The facility was supposed to manage the insertion of the PICC line and administer intravenous antibiotics, but these actions were not completed. Additionally, the wound vacuum was not ordered or applied as instructed, and the resident continued to receive only oral antibiotics. Interviews with staff revealed communication breakdowns and a lack of follow-through on the part of the DON and other nursing staff. The resident's condition worsened, leading to hospitalization due to the progression of infections and the lack of appropriate treatment. The wound care physician confirmed that the failure to start the PICC line and IV antibiotics likely contributed to the deterioration of the resident's wounds and overall condition.
Failure to Protect Resident from Abuse Resulting in Bruising
Penalty
Summary
The facility failed to protect a resident, identified as R #4, from abuse, resulting in bruising to her neck and wrists. R #4 was admitted to the facility with multiple diagnoses, including reduced mobility, acute respiratory failure, and severe cognitive impairment. During her stay, R #4 exhibited behaviors directed towards others and self-inflicted behaviors. On a particular night, R #4 became very agitated, and her family member was informed by the facility that it was not necessary to visit despite the resident's distress. The following day, bruising was observed on R #4 by her hospice nurse, leading to a forensic examination and police investigation. Interviews with staff and hospice personnel revealed that R #4 was extremely agitated, throwing things and pulling at her gown and oxygen tubing. LPN #4 and LPN #5 attempted to calm her, with LPN #4 making inappropriate comments about wishing the resident would die. The hospice nurse and a Sexual Assault Nurse Examiner (SANE) noted bruising consistent with strangulation, which contradicted the staff's explanation that the resident had caused the bruising herself. The facility's Director of Nursing (DON) was not forthcoming with information about the night shift nurses, and the facility's investigation into the incident was not provided despite repeated requests. The facility's records indicated that medications for anxiety and agitation were not administered to R #4 until after midnight, despite her distress earlier in the evening. The staffing schedule showed that the involved staff members continued to work following the incident, with LPN #5 eventually being terminated and LPN #4 suspended. The lack of timely medication administration and the inappropriate handling of the resident's agitation contributed to the failure to protect R #4 from abuse.
Administrative Failures and Unauthorized Practices in LTC Facility
Penalty
Summary
The facility's administration, including the Administrator and the Director of Nursing (DON), failed to effectively manage the facility, leading to several deficiencies. Key administrative staff were frequently unavailable, leaving the facility without leadership or direction. This absence resulted in the rescheduling of resident meetings and a lack of timely communication regarding staff absences, which hindered the ability to find appropriate coverage. Interviews with various staff members, including the Payroll/Scheduler and Social Worker, revealed that the Administrator and DON were often unreachable, and their absence was a common occurrence. This lack of presence and communication led to frustration among staff and impacted the care provided to residents. The facility also allowed an LPN to work without completing necessary hiring procedures, such as an application, background clearance, and competency demonstration. This LPN administered medications to residents over a weekend, despite not being officially employed by the facility. The Administrator was unaware of this situation until informed by the Payroll/Scheduler, highlighting a significant lapse in oversight and communication within the facility's management. Additionally, there were discrepancies in medication administration records, with documentation falsely indicating that another LPN administered medications during the same period. Furthermore, the DON was reported to have altered medical records and written orders without practitioner consent, which is outside the scope of her practice. This included modifying or deleting documentation and writing orders that were not authorized by the providers. These actions were reported by multiple staff members and a Nurse Practitioner, who expressed concerns about the DON's practices. Despite these reports, no corrective actions were taken by the facility's administration, further exacerbating the issues of mismanagement and lack of accountability.
Failure to Report Incidents and Allegations
Penalty
Summary
The facility failed to provide Facility Initiated Reports (FIRs) to the State Survey Agency (SSA) for several incidents involving residents. These incidents included a medication error where a nurse administered 40 mg of morphine intended for one resident to another, and the error was not reported to the SSA. Additionally, there was an injury of unknown origin for a resident that was reported two days late, and multiple unwitnessed falls with injuries for two residents that were not reported in a timely manner. The Director of Nursing (DON) was responsible for reporting these incidents but failed to do so. The report also highlights allegations of abuse by two residents against a Certified Nurse Aide (CNA), which were not investigated or reported to the SSA. The abuse allegations were documented in an Abuse Questionnaire form, but the facility did not take further action to investigate or report these claims. The Administrator assumed that the DON had completed the necessary reports, but there was no documentation to support this. Furthermore, the facility's records revealed that another resident experienced an unwitnessed fall resulting in a bump on the forehead and required a CT scan. This incident was reported to the SSA, unlike the others. The lack of timely reporting and investigation of these incidents and allegations indicates a failure in the facility's processes for ensuring resident safety and compliance with reporting requirements.
Misappropriation of Resident's Medication
Penalty
Summary
The facility failed to prevent the misappropriation of a resident's medication, specifically morphine, which was intended for one resident but was administered to another. The incident involved a Licensed Practical Nurse (LPN) who accessed the medication cart of a Registered Nurse (RN) under the pretense of an emergency situation, claiming a verbal order from a Nurse Practitioner (NP) to administer morphine to a different resident. The RN witnessed the LPN taking morphine from the original resident's supply and administering it to another resident, while falsely documenting the medication as spilled on the narcotic tracking sheet. The Director of Nursing (DON) and the LPN signed off on the false documentation, and the NP was informed of the misappropriation but was misled to believe that a report would be filed with the State Agency for a medication error, which was not done. The facility's Administrator was unaware of the incident until later, indicating a failure in communication and reporting within the facility. Both the DON and the LPN were placed on administrative leave following the incident, and they were unavailable for interviews.
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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