Colfax General Ltc
Inspection history, citations, penalties and survey trends for this long-term care facility in Springer, New Mexico.
- Location
- 615 Prospect Avenue, Springer, New Mexico 87747
- CMS Provider Number
- 32E032
- Inspections on file
- 18
- Latest survey
- April 23, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Colfax General Ltc during CMS and state inspections, most recent first.
Staff did not consistently label, date, or properly store food items in the kitchen, including leaving some items open to air in the freezer and storing soda cases on the floor. The Dietary Manager confirmed these practices, which affected all residents in the facility.
Three residents receiving oxygen therapy did not have humidifiers attached to their concentrators as ordered by physicians, and the oxygen tubing and humidifier bottles were not labeled or dated as required. Staff interviews revealed a lack of knowledge about adding humidity and proper equipment labeling, and the DON confirmed that the concentrators in use could not provide humidification as ordered.
A resident with multiple complex diagnoses experienced a decline in condition, including refusal to eat and worsening symptoms, but there was no documentation or provider notification for several days. Despite medical orders to contact the provider with any changes, staff failed to do so, and the resident was eventually sent to the ER for sepsis and UTI. Nursing staff and the DON confirmed that the provider should have been notified, but both providers reported not being informed.
A resident's call light system was found to be non-functional, failing to alert staff at the nurse's station or on the unit's marquee when activated. Both nursing and CNA staff confirmed the malfunction, and the DON was not notified as required by facility policy. Additionally, staff did not perform the required 30-minute safety rounds while the call light was out of service.
The facility failed to maintain sanitary conditions in food storage and service. Observations revealed unlabeled and undated food items in the kitchen, personal food stored in resident refrigerators, and muffins left open to air. Additionally, salad mix and tomatoes were improperly stored on a hot steam table without ice during meal service. The Dietary Manager confirmed these practices were not in line with proper food handling standards.
The facility failed to cover trash cans in the kitchen, potentially affecting all 32 residents. Observations revealed a small trash can filled with trash uncovered under the dishwashing station next to an open box of muffins, and a large trash can uncovered near the kitchen sinks and stove. The Dietary Manager confirmed the issue, acknowledging that all trash cans should have lids.
The facility did not report the results of an investigation into allegations of abuse involving two residents and an agency CNA. The Administrator was unsure if the issues reported, described as problems with the CNA's bedside manner, constituted verbal abuse. This failure to report prevents the State Agency from properly reviewing the allegations.
The facility failed to investigate and report an alleged abuse incident involving two residents and an agency CNA. Despite reports of rough handling and poor bedside manner, the facility did not document or communicate the allegations to the State Agency. Interviews revealed a lack of thorough investigation and reporting, as staff were not interviewed, and the allegations were not properly documented.
A facility failed to ensure a resident's advance directive was available in their EHR or in physical form. The resident, with a DNR status, did not have their directive uploaded or accessible, as confirmed by the Social Services Director. This was discovered during a review of the resident's physician orders and care plan, which indicated the DNR status, but the directive was missing.
Failure to Properly Store and Label Food Items in Kitchen
Penalty
Summary
Staff failed to ensure proper storage and handling of food items in the kitchen, as observed during a facility inspection. Specifically, multiple food items including pecan pies, apple pies, a sheet cake, and a box of salmon fish fillets were found in the kitchen freezer without labels or dates. Additionally, a package of pepperoni, a pack of chicken nuggets, and a box of salmon fish fillets were left open to air in the freezer. A box of eggs was sealed but not labeled or dated in the refrigerator. Furthermore, two cases of soda were stored directly on the floor in the dry storage area, with one case already opened. These findings were confirmed by the Dietary Manager during an interview, who acknowledged that all food items should be labeled, dated, and stored appropriately. All 32 residents listed on the facility's census at the time were likely to be affected by these practices, as proper food storage and handling were not consistently maintained.
Failure to Provide Ordered Humidification and Proper Labeling for Oxygen Therapy
Penalty
Summary
Staff failed to follow physician orders and professional standards for three residents requiring oxygen therapy. Specifically, the oxygen concentrators for these residents did not have humidifiers attached as ordered, and the oxygen tubing and humidifier bottles were not labeled or dated according to the prescribed schedule. Observations in the residents' rooms confirmed the absence of humidifiers and missing labels and dates on the equipment. Physician orders for all three residents required weekly changes of humidifiers and nasal cannulas, with proper labeling and dating, but these were not carried out as directed. Interviews with facility staff, including CNAs and an RN, revealed a lack of knowledge and understanding regarding the process for adding humidity to the concentrators and the importance of labeling and dating the equipment. The Director of Nursing confirmed that the concentrators in use were not capable of adding humidity, which was required by the physician orders. These failures resulted in the facility not meeting professional standards of quality for the affected residents.
Failure to Notify Provider of Resident's Decline in Condition
Penalty
Summary
The facility failed to notify a resident's medical provider of a decline in condition, as required. The resident, who had a history of acute kidney failure, dementia, COPD, alcoholic cirrhosis, stroke, and UTI, was admitted with multiple complex diagnoses. Progress notes indicated that the resident had refused to eat for several days, and the medical doctor had instructed staff to consider emergency evaluation and hydration if the condition did not improve within 24 hours, with explicit instructions for nurses to contact providers with any concerns or changes. However, there were no progress notes documenting the resident's health status or any evaluations from 03/13/25 through 03/15/25, despite the resident's ongoing decline. On 03/16/25, the resident was sent to the emergency room for a decline in condition, ultimately requiring air medical transport for specialty care due to sepsis and UTI. Interviews with nursing staff and the DON confirmed that the provider should have been notified of the change in condition, but both providers interviewed stated they were not informed. The lack of documentation and failure to notify the provider of the resident's worsening symptoms directly led to the deficiency.
Non-Functioning Call Light System in Resident Room
Penalty
Summary
A deficiency was identified when a resident's call light system was found to be non-functional during multiple observations. The call light, when activated, did not trigger any audible or visual alerts at the nurse's station or on the unit's electronic marquee, preventing staff from being notified of the resident's need for assistance. This malfunction was confirmed by both a registered nurse and a certified nursing assistant, who acknowledged that the call light should have been fully operational but was not. Further interviews revealed that the certified nursing assistant intended to notify maintenance of the issue, but the Director of Nursing was not made aware of the malfunction. According to facility policy, such malfunctions should be reported to the charge nurse and then to maintenance. Additionally, while the call light was out of service, staff were expected to conduct 30-minute safety rounds for the affected resident, but these rounds were not being performed. The deficiency was limited to one resident among those observed for call light functionality.
Deficiencies in Food Storage and Service Conditions
Penalty
Summary
The facility failed to maintain sanitary conditions in food storage and service, as observed during a survey. In the kitchen, several food items were not labeled or dated, including crinkle cut fries, frozen meat, biscuits, cubed meat, and chicken tenders stored in freezers. Additionally, a Styrofoam To-Go container labeled with a staff member's name was found in the kitchen refrigerator, indicating personal food storage in a resident-designated area. The Dietary Manager confirmed that all food should be labeled, dated, and that staff should not store personal food in the resident refrigerator. Further observations revealed that a box of muffins was left open to air on a kitchen table, which the Dietary Manager acknowledged should have been sealed. In the dining room, salad mix and chopped tomatoes were stored on a hot steam table without ice during meal service, resulting in the salad being served to residents at an improper temperature. The Dietary Manager confirmed that these items should have been kept on ice to maintain appropriate cold storage during meal service.
Uncovered Trash Cans in Kitchen
Penalty
Summary
The facility failed to ensure that all garbage and refuse containers in the kitchen were properly covered, which could potentially affect all 32 residents identified on the resident census list. During an observation on January 30, 2025, at 11:45 am, it was noted that a small trash can filled with trash was uncovered and stored under the dishwashing station next to an open box of muffins. Additionally, a large trash can filled with trash was uncovered next to the three-compartment kitchen sinks and stove. During an interview conducted at 11:48 am with the Dietary Manager, it was confirmed that both trash cans were uncovered in the kitchen near food preparation areas. The Dietary Manager acknowledged that all trash cans should be stored with lids.
Failure to Report Abuse Allegations
Penalty
Summary
The facility failed to report the results of an investigation regarding allegations of abuse involving two residents. During an interview, the Administrator admitted that an incident involving an agency CNA and two residents was not reported to the State Agency (SA). One resident reported issues with the CNA's bedside manner towards them and the other resident, but the facility could not define what was meant by 'bedside manner' in this context. The Administrator was unsure if this could be considered verbal abuse and acknowledged that all allegations of abuse, including verbal abuse, should be reported to the SA. The lack of reporting prevents the SA from appropriately triaging the allegation for further investigation.
Failure to Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation and report findings within five working days for an allegation of abuse involving two residents. Resident #8 reported concerns about the bedside manner of an agency CNA while assisting Resident #22. Despite multiple residents confirming the CNA's poor attitude, the facility's investigation did not document any allegations of abuse in the nursing progress notes for either resident. Resident #8, who was cognitively intact, reported that the CNA was rough with Resident #22, causing him to scream in pain. However, this was not documented or reported to the State Agency. Interviews with staff revealed a lack of communication and documentation regarding the incident. An anonymous employee and several nurses were aware of the allegations but did not ensure they were reported to the appropriate authorities. The Assistant Director of Nursing was informed but did not follow through with a complete investigation. The Social Services Director, who was part of the investigation team, was not made aware of the roughness allegation and only interviewed residents, not staff. The Administrator and the Interim Director of Nursing confirmed that the facility's investigation process was incomplete, as nursing staff were not interviewed, and the allegations were not reported to the State Agency. The failure to conduct a thorough investigation and report the findings hindered the State Agency's ability to triage the allegation for further investigation.
Failure to Maintain Resident's Advance Directive in Records
Penalty
Summary
The facility failed to ensure that a resident's current advance directive was available in their Electronic Health Record (EHR) or in physical form for staff access. The resident, identified as having a Do Not Resuscitate (DNR) status, did not have their advance directive form uploaded into the EHR or available physically, despite this being confirmed by the Social Services Director. This oversight was identified during a review of the resident's physician orders and care plan, which both indicated the resident's DNR status, yet the actual directive was missing from the records.
Latest citations in New Mexico
Surveyors found that the facility did not provide required written transfer and bed-hold notices when several residents were sent to the hospital for events such as falls with injury, unresponsiveness, and episodes of nausea, vomiting, and bleeding. Medical records lacked written transfer notices and bed-hold notifications, and the transfer information that should have been given to residents or their representatives did not include mandated details about appeal rights, how to request an appeal, or how to contact the State LTC Ombudsman. The Social Services Director reported that she does not notify the Ombudsman of hospital transfers and only sends a monthly email list of discharged residents, without written copies of transfer or discharge notices.
Two cognitively impaired residents with dementia and significant behavioral and continence needs were sent to a local ER after falls and were discharged back to the facility’s care, but the facility failed to provide timely transportation for their return. In both cases, hospital discharge times were documented, yet ER staff reported making multiple unsuccessful calls to the facility, reaching the Administrator only after repeated attempts. One resident, described as very disoriented, remained in the ER for several hours after discharge without 1:1 supervision, while the other waited approximately 11 hours, during which ER staff observed increasing confusion and attempts to get out of bed. The Administrator acknowledged awareness of the discharges, the lack of 24-hour transportation, and that the residents were not picked up until many hours after they had been discharged from the ER.
Two residents who required staff assistance for ADLs and transfers reported neglectful and rude behavior by a CNA and delayed nursing response to care needs. One resident with a history of cerebral infarction and schizophrenia stated that a CNA mocked him and that his requested wound dressing change was not performed for several hours, which was later corroborated by video showing a long gap between the CNA’s visit and the nurse’s entry to the room. Another resident with a right femur fracture, type II DM, and repeated falls, who needed one-person assistance for mobility and self-care, reported that a CNA refused to help and told her she could do some care herself, making her feel she was not trying in her recovery. Documentation and interviews confirmed that staff did not provide timely wound care or required assistance, and that these interactions caused residents to feel uncomfortable and negatively about their care.
A resident with a history of opioid dependence and polysubstance abuse was on a secure unit with a care plan that included safety risk evaluations and monitoring for signs of substance abuse. Staff later observed the resident discarding an empty Suboxone packet, even though the resident was not prescribed this medication, and the incident was reported to the on-call provider with subsequent monitoring and a room search. However, the care plan was not revised to reflect this new substance-related event, and both the DON and Administrator acknowledged that the care plan should have been updated when this new risk and behavior were identified.
Surveyors identified that a medication cart on the north hall was left unlocked and unattended outside a resident room. An LPN acknowledged that the cart was hers and that she had not locked it before leaving to answer a call light, despite facility expectations. The DON confirmed that all medication and treatment carts are required to remain locked when not in use or when staff are away from them.
Surveyors found that a document containing multiple residents’ PHI, including full names, room numbers, and code status, was left unattended and visible on a south nurse’s station counter. An RN confirmed the document was a resident list with PHI and acknowledged it had been left exposed and that such information should not be left unattended.
Surveyors found that a lunch tray return cart containing uncovered, soiled food trays and dishes was left unattended in a main hallway outside an activity room. The housekeeping/laundry manager acknowledged seeing the unattended cart, and the Dietary Manager confirmed that such carts are supposed to remain only in designated areas, such as near the nurse’s station or in the kitchen, and should be returned to the kitchen for cleaning as soon as all trays are collected. This failure was cited as likely to expose all residents to potential pathogens associated with food waste.
Two residents with scheduled showers reported that they were offered or received showers in very cold water during a prolonged period when hot water was not reliably available in care areas. One resident stated he refused cold showers and was only offered sponge baths once or twice, despite his preference to stay clean. Another resident reported receiving cold showers, including being rinsed with cold water while still soaped, and subsequently began refusing showers and bed baths due to the cold water. A CNA confirmed that water in the shower rooms was “ice cold” for several months, leading to resident complaints and refusals, while the Maintenance Director reported that a needed part to correct the hot water problem was on back order, delaying resolution and resulting in the facility not honoring residents’ bathing preferences.
Surveyors observed that unused medications were improperly discarded in a trash bin attached to a medication cart on the north hallway, rather than being disposed of in a designated drug disposal container. Two pills, a round blue tablet stamped "61" and an oblong orange tablet stamped "20," were found together in an unlabeled medication cup in the trash. An RN confirmed the medications were discarded there and acknowledged that unused medications should be placed in the drug buster container in the cart drawer. The Unit Manager also confirmed that facility practice requires all unused medications to be disposed of using the drug buster and that controlled substances must be destroyed by two licensed staff and documented on the narcotic count sheet.
The facility failed to follow documented allergy information, diet orders, and meal tickets for three residents. A resident with a documented chocolate allergy was served chocolate ice cream after requesting it, and the Nutrition Director admitted not reading the allergy notation on the meal ticket. Another resident on a pureed diet received whole mandarin oranges instead of pureed fruit, which a CNA confirmed. A third resident whose meal ticket called for a grilled Swiss sandwich received a sandwich that was not grilled, as confirmed by a CNA and a dietary manager.
Failure to Provide Required Written Transfer, Appeal, Ombudsman, and Bed-Hold Notices During Hospitalizations
Penalty
Summary
Surveyors identified that the facility failed to provide required written transfer and bed-hold information for multiple residents who were hospitalized. For three residents who experienced transfers to the hospital after events such as falls with injury, unresponsiveness, and episodes of nausea, vomiting, and bleeding, record review showed there were no written transfer notices or written bed-hold notices in their medical records. Specifically, one resident transferred after a fall on 01/31/26 had no documented written transfer notice or bed-hold notice. Another resident transferred on 02/27/26 for nausea, vomiting, and bleeding, and later readmitted on 03/05/26, had no written transfer notification that included information on appeal rights or Ombudsman contact, and no written bed-hold notification. A third resident transferred on 01/29/26 after a fall with a forehead laceration and again on 03/17/26 for unresponsiveness, also had no documented written transfer or bed-hold notices for either hospitalization. The deficiency also included the facility’s failure to provide required content in transfer notices and to notify the State Long-Term Care Ombudsman in writing. For the residents reviewed, there was no evidence that written transfer notices were provided to the residents or their representatives in a language and manner they could understand, and the notices were missing required elements such as a statement of appeal rights, the name, mailing and email address, and phone number of the entity receiving appeals, and information on how to obtain and complete an appeal form. The notices also lacked the name, phone number, and mailing and email address of the State Long-Term Care Ombudsman, and written copies of the transfer notices were not sent to the Ombudsman. During interview, the Social Services Director confirmed that transfer and bed-hold notices were not documented for at least one resident’s hospitalization, that she does not notify the Ombudsman about transfers to the hospital, and that she only emails a monthly list of residents discharged from the facility without sending written copies of transfer or discharge notices.
Failure to Timely Retrieve Residents From ER After Discharge
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from neglect by not arranging timely transportation back to the facility after emergency room (ER) discharge. A consumer complaint alleged that residents sent to the local ER were being left there for extended periods after discharge. For one resident with an admission date of 10/13/25, records showed multiple cognitive and behavioral diagnoses, including Alzheimer’s disease, vascular dementia with agitation and other behavioral disturbances, mild cognitive impairment, cognitive communication deficit, and restlessness and agitation. A change of condition MDS documented a Brief Interview for Mental Status (BIMS) score of 1 and frequent incontinence of urine and bowel. Nursing progress notes for this resident showed that 911 was called at 3:00 AM and the resident was transferred to the ER after a fall. Hospital discharge instructions indicated the resident was discharged from the ER at approximately 5:21 AM, while the ER nurse reported discharge at about 5:30 AM. The ER nurse stated she made numerous calls to the facility but was unable to reach anyone. She reported that the resident was very disoriented and that the ER did not have enough staff to provide 1:1 supervision. The ER nurse eventually reached the Administrator, who stated staff would come to pick up the resident as soon as possible. Facility records showed the resident was not discharged from the facility on that date, and the ER nurse reported that facility staff did not pick the resident up until approximately 8:30 AM, several hours after discharge. A second resident, admitted on 11/25/25, had diagnoses including Alzheimer’s disease, dementia with behavioral disturbance, bipolar disorder with severe depression and psychotic features, depression, and anxiety disorder. The admission MDS documented a BIMS score of 2, frequent urinary incontinence, constant bowel incontinence, and a need for substantial/maximal assistance with toileting hygiene. Nursing notes showed this resident was sent to the ER for evaluation after a fall and did not return until the following morning. Hospital discharge instructions documented discharge from the ER at 10:16 PM, and the Administrator confirmed being notified of the discharge at about 10:30 PM and that the facility did not have 24-hour transportation. The Administrator acknowledged the resident was not picked up until approximately 9:00 AM the next day. The ER nurse reported making several calls to the facility that went to voicemail, eventually reaching the Administrator, who initially stated staff were on the way, then stopped answering calls. During the approximately 11-hour wait, the ER nurse stated the resident was confused, attempted to get out of bed, and became more confused as the night progressed.
Failure to Timely Provide Wound Care and Required Assistance, Resulting in Resident Neglect
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from neglect when staff did not respond appropriately to requests for care and assistance. One resident with a history of cerebral infarction due to embolism and schizophrenia, admitted on 01/30/26 and requiring staff assistance for ADLs and mechanical lift transfers, reported that a CNA was rude and mocking and that his wound dressing was not changed for several hours after he requested it. The Kardex showed he needed staff help for toileting, bathing, hygiene, bed mobility, dressing, and transfers. Nursing progress notes documented a change in condition on 03/02/26 after the resident stated the CNA was rude and would not assist as requested. The Administrator later confirmed, via video review, that the CNA entered the resident’s room at 2:30 am, the resident requested a dressing change, and no nurse entered the room until 5:00 am, despite the nurse’s statement that she went in “right away.” The DON also confirmed that the resident’s grievance described the wound dressing not being changed until hours after the request. Another resident, admitted with a right femur fracture, type II diabetes, and repeated falls, required one-person assistance for dressing, hygiene, bathing, bed mobility, and transfers, and could toilet herself with assistance for transfers. Nursing progress notes documented an alleged abuse incident on 03/02/26 in which this resident stated a CNA was rude, refused to help her, and told her she could perform some care tasks herself without staff assistance. An abuse questionnaire completed the same day showed the resident answered “Yes” to having interactions that made her feel uncomfortable or negative, and she reported that the CNA made her feel as though she was not trying with her own recovery. The Administrator and DON acknowledged that staff are expected to help residents as required and that staff interactions must be encouraging rather than making residents feel bad about needing assistance.
Failure to Revise Care Plan After Substance-Related Incident
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s care plan after a significant substance-related incident. The resident was originally admitted with a diagnosis of opioid dependence and resided on a secure unit related to polysubstance abuse disorder. The existing care plan, dated 01/21/26, identified the resident as residing on a secure unit due to polysubstance abuse disorder with interventions to perform safety risk evaluations on admission, as needed, and upon changes in condition. The care plan also identified the resident as at risk for substance use disorder with interventions to monitor for signs or symptoms of substance abuse. On 02/01/26, nursing notes documented that staff observed the resident discarding an empty Suboxone packet in the trash, even though the resident was not prescribed Suboxone and denied taking any. Staff notified the on-call provider, who ordered monitoring for adverse reactions, and nursing staff and security conducted a room search that revealed no additional contraband. Despite this incident, the resident’s care plan was not updated to address the new substance-related event. During interviews, the DON acknowledged awareness of the incident and confirmed the care plan was not revised, and the Administrator stated her expectation that nursing would update the care plan when a new risk or behavior was identified and confirmed she would have expected the care plan to be updated for this resident.
Unattended, Unlocked Medication Cart on North Hall
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were properly stored and secured in accordance with professional standards and facility expectations. On 03/24/26 at 9:06 a.m., surveyors observed a medication cart on the north hall left unlocked and unattended outside a resident room. At 9:08 a.m., the LPN responsible for the cart confirmed during interview that the cart was hers, that it was unlocked and unattended, and acknowledged she should have locked it before responding to a call light. Later that day at 3:37 p.m., the DON stated in an interview that medication and treatment carts are expected to be locked at all times when nurses are away from them, confirming that the observed practice did not meet facility expectations. This deficient practice was cited as likely to allow unauthorized personnel access to medications, which could result in injury or overdosing.
Unattended PHI Document Left Exposed at Nurse’s Station
Penalty
Summary
Surveyors identified a deficiency in the facility’s protection of residents’ personal health information (PHI) when a document containing multiple residents’ full names, assigned room numbers, and code status was left unattended and exposed on the south nurse’s station counter. On 03/16/26 at 9:04 a.m., an observation revealed a piece of paper on a clipboard with complete resident information placed on top of the south nurse’s counter in public view. At 9:06 a.m., during an interview, RN #2 confirmed that the list contained residents’ names, room numbers, and code status, acknowledged that it had been left exposed and unattended, and stated that PHI should not be left unattended. No additional clinical details or medical histories of the residents listed on the document were provided in the report.
Unattended Soiled Lunch Cart Left Uncovered in Hallway
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the handling of soiled food service equipment. On 03/24/26 at 12:58 pm, a lunch tray return cart containing soiled food trays and dishes that were uncovered was observed sitting unattended in the main hallway outside the activity room. At 1:06 pm, the housekeeping/laundry manager confirmed she saw the return cart left unattended in that location. At 1:08 pm, the Dietary Manager stated that lunch return carts should only be left in designated areas such as by the nurse’s station or inside the kitchen, and that the cart should be returned to the kitchen for cleaning as soon as all trays have been picked up, which did not occur in this instance. This deficient practice was noted as likely to expose all residents to potential pathogens associated with food waste.
Failure to Honor Resident Bathing Preferences During Prolonged Hot Water Issues
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ bathing preferences when hot water was not reliably available in resident care areas. Record review showed that one resident was scheduled to receive three showers per week on specific days, and another resident was scheduled for two showers per week. One resident reported that staff attempted to have him shower in cold water, which he refused, and that sponge baths were only offered once or twice during the period when the hot water was not working. He stated that he liked to be clean and did not feel like himself when he was dirty. A CNA reported that there was no hot water in resident care areas from the middle of December until early March, and that large barrels of warm water were brought to shower rooms to offer sponge baths, which this resident refused. Another resident, also on a scheduled twice-weekly shower regimen, stated that she received cold showers and began refusing showers because of how cold the water was. She described the water running cold unpredictably, including an instance when the water was initially warm but turned cold while she was still soaped, requiring rinsing with cold water, which she described as horrible. A social services note documented that this resident’s daughter reported the resident had been declining showers and bed baths offered because the water was too cold. A CNA corroborated that the water was “ice cold” and that residents began complaining and refusing showers around mid-December. The Maintenance Director stated that it took a while for hot water to reach the shower room and that a needed part to fix the cold-water problem was on back order, contributing to the prolonged period of inadequate hot water and resulting in residents not having their bathing preferences honored.
Improper Disposal of Unused Medications on Medication Cart
Penalty
Summary
Surveyors identified a deficiency related to accident hazards and inadequate supervision when unused medications were improperly discarded on the north hallway. During observation of the north hall nurses’ station, two medications were found in the trash bin attached to the medication cart, placed together inside an unlabeled medication cup. The pills were described as a round blue pill stamped with “61” and an oblong orange pill stamped with “20.” In an interview immediately following the observation, an RN confirmed that these medications were in the trash bin and stated that unused medications should instead be disposed of in the drug buster, a sealed container for drug disposal located in the bottom drawer of the cart. In a subsequent interview, the Unit Manager confirmed that all unused medications are to be disposed of using the drug buster and acknowledged that this did not occur, further stating that if the medications are controlled substances such as narcotics, two licensed personnel are required to dispose of them together and document the disposal on the narcotic count sheet. This deficient practice was noted as likely to affect any resident who might acquire and ingest the discarded medications, potentially causing medication side effects.
Failure to Follow Allergy, Diet, and Meal Ticket Requirements
Penalty
Summary
The facility failed to provide meals consistent with residents’ documented allergies, diet orders, and meal tickets for three residents. One resident, admitted with a documented allergy to chocolate, had a face sheet and lunch ticket indicating they were not to receive chocolate. During a lunch observation, this resident was served and was eating chocolate ice cream. An LPN confirmed the resident’s chocolate allergy and that the resident should not be eating chocolate. The Nutrition Director acknowledged that the meal ticket stated the resident should not have chocolate but reported serving chocolate ice cream after the resident requested it, stating he had not read that the resident was allergic to chocolate. Another resident, admitted with hypokalemia and ordered a regular/liberalized pureed diet per the MDS, had a lunch ticket indicating a pureed diet but was observed receiving whole mandarin oranges instead of pureed fruit. A CNA confirmed that the dessert was not pureed. A third resident’s meal ticket specified a grilled Swiss sandwich, but observation of the tray showed the sandwich was not grilled. During interviews, a CNA and a dietary manager confirmed that the sandwich was not grilled as ordered on the meal ticket.
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