Coronado Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Portales, New Mexico.
- Location
- 1604 West 18th Street, Portales, New Mexico 88130
- CMS Provider Number
- 325114
- Inspections on file
- 17
- Latest survey
- June 16, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Coronado Care Center during CMS and state inspections, most recent first.
Surveyors observed that open bags of hash browns and French fries in the facility's walk-in freezer were not labeled or dated. The DM confirmed this did not meet expectations for proper food storage, resulting in a deficiency for not maintaining sanitary conditions for food storage and service.
Staff did not update or revise care plans for several residents after changes in their care needs or interventions. This included not documenting the use of a trapeze bar for mobility, failing to update hospice care status, not removing a discontinued communication board intervention, and omitting a DNR advance directive from the care plan. These omissions were confirmed through observations, record reviews, and staff interviews.
A medication aide failed to sanitize hands, disinfect equipment, and wear gloves during medication administration, resulting in a medication error rate of 10.34%. These lapses were confirmed by both the aide and the DON, and were not in accordance with facility policy or CDC guidelines.
Surveyors observed that two residents had their call lights placed on the bed and out of reach while they were asleep in recliners. Both a hospice nurse and a CNA confirmed that the call lights should have been accessible to the residents.
Staff failed to keep hallways accessible, as medication carts and a shower chair were observed on both sides of the hallway in two separate wings, blocking the path for residents. Both a Restorative Nursing Aide and a CMA confirmed that these items were obstructing the hallway and should have been kept on one side.
A resident with a documented DNR order did not have their advance directive form, the New Mexico Orders for Scope and Treatment (MOST), available in either the EHR or in physical form for staff. The DON confirmed the absence of the MOST form despite the DNR status being noted in other records.
A resident with Alzheimer's, dementia, and other cognitive and mobility issues was placed in a recliner that prevented her from getting up without assistance. Staff confirmed the recliner was used to keep the resident, who was prone to wandering, in one place, despite the care plan not including this intervention or documenting it as medically necessary.
A resident with multiple chronic conditions and newly initiated hospice care did not have a Significant Change MDS assessment completed and transmitted within the required 14-day period after the facility identified a major change in condition. Documentation showed the assessment was started but not finished, and the MDS did not reflect the resident's hospice status.
A CMA did not sanitize vital sign equipment before use, failed to perform hand hygiene before a medication pass, and did not wear gloves when handling medication for three residents. The DON confirmed that staff are expected to follow these infection control protocols.
The facility failed to ensure that a Nurse Aide completed the required CNA state licensure exam within four months of employment. The NA was hired and working full-time but had not obtained her CNA license within the required timeframe, as confirmed by the DON.
The facility failed to store food in accordance with professional standards, with issues including a box of grape juice on the floor, unlabeled and undated items in the walk-in refrigerator, and unsealed items in the freezer. The Dietary Manager confirmed these deficiencies and stated that all kitchen staff were responsible for proper food storage.
The facility failed to ensure enough food was available to serve all residents the meal on the menu and to provide second portions when requested. Observations and interviews revealed that the facility frequently ran out of food and coffee, affecting residents' ability to receive complete meals and additional servings.
The facility failed to ensure the accuracy of the PASRR assessment for a resident diagnosed with schizophrenia. The PASRR incorrectly documented that the resident did not have a mental illness, despite having a diagnosis of schizophrenia. This discrepancy was confirmed during interviews with the Admissions Coordinator and the Social Services Director.
The facility failed to ensure residents were invited to attend care plan meetings. One resident was not woken up for her meeting despite expressing a desire to attend, and another resident reported never being invited to a care plan meeting, with no documentation found in his records.
A facility failed to assess and remove a Foley catheter for a resident with a Stage 4 pressure ulcer, despite the resident being alert, oriented, and able to use a bedside commode. The resident expressed a desire to have the catheter removed, but this request was not communicated to the medical director, and no trial voiding was attempted.
The facility failed to provide an adaptive eating device for a resident during dining observation. The resident had a physician's order to use a plate guard for meals, but the meal ticket did not direct staff to provide it. During observation, the resident ate without the plate guard until a CNA placed it on the plate later in the meal. The CNA acknowledged the oversight.
Failure to Label and Date Food Items in Freezer
Penalty
Summary
During an observation of the facility's walk-in freezer, surveyors found two bags of what appeared to be hash browns and two bags of what appeared to be French fries that were open and undated. The Dietary Manager confirmed during an interview that these items were not labeled or dated, which did not meet his expectations for food storage. The report notes that this practice failed to ensure food items were stored and served under sanitary conditions, as required by professional standards. The deficiency was identified as potentially affecting 76 residents listed on the facility's census at the time of the survey.
Failure to Update and Revise Care Plans Following Changes in Resident Needs
Penalty
Summary
The facility failed to ensure that care plans were updated and revised for five residents following changes in their care needs or interventions. For one resident with multiple diagnoses including multiple sclerosis and muscle weakness, a trapeze bar was observed in use for mobility and repositioning, but this intervention was not reflected in the care plan. The Director of Nursing confirmed that the care plan had not been revised to include this equipment. Two residents receiving or previously receiving hospice care did not have their care plans updated accordingly. One resident's care plan contained outdated hospice interventions from over a year prior, despite the resident no longer being on hospice. Another resident, currently on hospice as indicated by the Minimum Data Set, had no mention of hospice care in the comprehensive care plan. The Assistant Director of Nursing confirmed these omissions and stated that care plans should be revised to reflect hospice status when relevant. Additional deficiencies included a resident with a cognitive communication deficit whose care plan listed the use of a communication board with word cards, although this intervention was no longer in use and not available in the resident's room. Staff interviews confirmed the communication board was ineffective and had been discontinued, but the care plan was not updated. Another resident with a DNR advance directive had this order documented in the medical record and on the MOST form, but the care plan did not reflect the DNR status. The Director of Nursing confirmed the care plan was not revised after the DNR order was established.
Medication Error Rate Exceeds Acceptable Threshold Due to Lapses in Hand Hygiene and Equipment Disinfection
Penalty
Summary
Staff failed to maintain a medication error rate below 5%, with 3 medication errors observed out of 29 opportunities, resulting in a 10.34% error rate. During medication administration, a Certified Medication Aide (CMA) did not clean the blood pressure cuff and vital sign equipment before taking a resident's vitals, did not sanitize her hands before beginning a medication pass for another resident, and failed to don gloves before opening a capsule for a third resident. These actions were directly observed during the survey. The CMA confirmed during interview that she should have sanitized her hands before the medication pass, cleaned the vital sign equipment before and between each resident, and worn gloves before handling medications. The Director of Nursing also confirmed that staff are expected to follow these procedures. Review of facility policy and CDC guidelines further supported the requirement for hand hygiene and equipment disinfection before and after resident contact and medication administration.
Call Lights Not Accessible to Residents in Rooms
Penalty
Summary
The facility failed to ensure that call lights were within reach of residents in their rooms for two out of four residents reviewed for call light accessibility. In one instance, a resident was observed asleep in a recliner while the call light was placed on top of the bed, out of her reach. This was confirmed by a hospice nurse who stated that the call light should have been accessible. In another case, a different resident was also found asleep in a recliner with the call light similarly placed on the bed and not within reach, which was confirmed by a certified nurse assistant. These observations were made during surveyor rounds and were corroborated by staff interviews.
Hallway Accessibility Obstructed by Equipment
Penalty
Summary
Facility staff failed to ensure that hallways were accessible for residents, as observed on two separate occasions. On the [NAME] Wing, a medication cart was found on the right side of the hallway near one room, and a shower chair was on the left side near another room, resulting in objects on both sides of the hallway. During an interview, the Restorative Nursing Aide confirmed that these items were blocking the residents' path and stated that all items should be kept on one side to maintain a clear passage. Similarly, in the South Wing, two medication carts were observed on opposite sides of the hallway near different rooms, again obstructing the path. The Certified Medication Aide interviewed at that time also confirmed the presence of objects on both sides of the hallway and acknowledged that items should be kept on one side.
Advance Directive Not Available in EHR or Physical Form
Penalty
Summary
The facility failed to ensure that a resident's current advance directive, specifically the New Mexico Orders for Scope and Treatment (MOST), was available in the resident's Electronic Health Record (EHR) or in physical form for staff access. Record reviews showed that the resident was admitted to the facility and had a documented Do Not Resuscitate (DNR) order in both the physician orders and care plan. However, the actual advance directive form was not present in the EHR or available physically. During an interview, the Director of Nursing confirmed that the MOST form was missing from both the EHR and physical records, despite the resident's DNR status being documented elsewhere.
Resident Restrained in Recliner Without Medical Necessity
Penalty
Summary
A resident with diagnoses including Alzheimer's, dementia, depression, cognitive communication deficit, unsteadiness on feet, and a psychotic disorder with hallucinations was observed in situations that led to the use of a physical restraint. The resident's care plan included interventions such as providing diversions, structured activities, education, close supervision, and regular rounds to address her risk of elopement and wandering. However, during observation, the resident was seen attempting to leave the dining room in her wheelchair and later attempting to get out of a recliner with the footrest extended. A Certified Nursing Assistant (CNA) stated that the recliner was used to keep the resident, who was identified as a wanderer, safely in one place. The CNA confirmed that the resident could not get out of the recliner without assistance. This use of the recliner as a restraint was not documented as a medical necessity and was not part of the resident's care plan interventions, resulting in the resident not being free from physical restraints.
Failure to Complete and Transmit Significant Change MDS Assessment Timely
Penalty
Summary
The facility failed to complete and transmit a Significant Change Minimum Data Set (MDS) assessment within 14 days after determining a significant change in a resident's condition. Specifically, a resident with diagnoses including chronic obstructive pulmonary disease, major depressive disorder, cerebral aneurysm, and chronic heart failure was admitted to the facility and later started on hospice care. The resident's clinical census and physician order indicated that hospice services began, but the MDS assessment did not reflect this change, and the Significant Change MDS was started but not completed within the required timeframe. During interviews, the resident confirmed being on hospice, while the MDS Coordinator acknowledged that the Significant Change MDS assessment was not completed as expected. The record review showed discrepancies between the resident's current care status and the documentation in the MDS, indicating that the facility did not follow the mandated timeline for updating and transmitting the assessment after a major change in the resident's health status.
Failure to Maintain Infection Prevention and Control Practices
Penalty
Summary
Certified Medication Aide (CMA) #1 failed to follow proper infection prevention and control practices for three residents. Specifically, the CMA did not clean the blood pressure cuff and vital sign equipment before taking vital signs for one resident, did not sanitize her hands before beginning a medication pass for another resident, and did not don gloves before opening a medication capsule for a third resident. During interviews, the CMA acknowledged these lapses, and the Director of Nursing confirmed that staff are expected to perform hand hygiene before and after each medication pass and to sanitize equipment and don gloves as required.
Failure to Ensure Nurse Aide Competency
Penalty
Summary
The facility failed to provide documentation confirming that a Nurse Aide (NA) employed by the facility had completed a Nurse Aide Training and Competency Evaluation Program (NATCEP) or a Competency Evaluation Program (CEP) within four months of being employed. The NA was hired on 12/01/23 and was working full-time as of 05/17/24. Although the NA completed the CNA training, she did not complete the CNA state licensure exam within the required timeframe. This deficiency was confirmed during an interview with the Director of Nursing (DON), who acknowledged that the NA did not obtain her CNA license within four months of her hire date.
Food Storage Deficiencies
Penalty
Summary
The facility failed to ensure food was stored in accordance with professional standards of food service safety. In the dry storage area, a 10-pound box of grape juice was observed stored on the bare floor. The Dietary Manager (DM) confirmed that items should not be on the floor and should be stored on shelves, and that all kitchen staff were responsible for ensuring this standard was met. In the walk-in refrigerator, several food items were found not labeled or dated, including a small pan of orange fluff salad, a single tomato wrapped in saran wrap, a 2-quart plastic container of apple sauce, a case of sour cream packets, an open pack of flour tortillas, two packs of corn tortillas, and two 2-quart pitchers of juice. The DM confirmed that all items should be labeled and dated, and that all kitchen staff were responsible for this task. In the facility freezer, a box of beef patties, a box of cookie dough, and a box of Salisbury steak patties were found open to air and not sealed. The DM confirmed that these items should be sealed to avoid freezer burn and that staff were expected to close the boxes after removing food items.
Facility Fails to Provide Adequate Food and Second Portions
Penalty
Summary
The facility failed to ensure that there was enough food to serve all residents the meal on the menu and to provide second portions when requested. During a dining observation, it was noted that some residents were served meals without vegetables because the facility ran out of vegetables. Interviews with staff and residents confirmed that the facility frequently ran out of food and coffee, with residents reporting that this occurred at least twice a week. One resident mentioned that the facility often did not provide coffee with meals, especially in the morning and evening, because only one pot of coffee was made to avoid waste. Another resident stated that the facility ran out of food often, affecting their ability to receive a complete meal as per the menu. Additionally, the facility failed to serve second portions of meals when requested by residents. Multiple residents reported that they seldom received second servings because the kitchen did not have enough food. During a dining observation, residents asked for a second helping of egg salad but were told that there were no second portions available because the kitchen had run out. Staff interviews confirmed that the kitchen often ran out of food, leaving residents unable to get additional servings. This deficiency affected the nutritional needs and preferences of the residents, as they were often left hungry and unable to receive the full meal as planned.
Inaccurate PASRR Assessment for Resident with Schizophrenia
Penalty
Summary
The facility failed to ensure the accuracy of the Pre-Admission Screening and Resident Review (PASRR) assessment for a resident diagnosed with schizophrenia. The resident's most recent PASRR, dated 12/27/21, incorrectly documented that the resident did not have a mental illness, despite having a diagnosis of schizophrenia. This discrepancy was confirmed during interviews with the Admissions Coordinator and the Social Services Director, who acknowledged that the PASRR should have included the schizophrenia diagnosis. The PASRR was initially completed by the discharging hospital, but facility staff did not review it for accuracy prior to the resident's admission.
Failure to Involve Residents in Care Plan Meetings
Penalty
Summary
The facility failed to ensure residents were invited to attend care plan meetings, as evidenced by the cases of two residents. Resident #23 was admitted to the facility and expressed a desire to be involved in her care plan meetings. However, she did not attend her last care plan meeting because she was napping, and the nursing staff decided not to wake her. The Social Services Director (SSD) acknowledged that the meeting should have been rescheduled to accommodate Resident #23's participation. This indicates a failure to respect the resident's expressed wishes and to involve her in her care planning process. Resident #30, who was also admitted to the facility, reported that he had never been invited to a care plan meeting. A review of his Electronic Health Record confirmed the absence of documentation indicating that a care plan meeting had been held for him. The SSD admitted that there was no Care Plan Conference form for Resident #30 in his records, which should have been maintained. This lack of documentation and failure to invite the resident to participate in care planning highlights a significant oversight in the facility's care planning process.
Failure to Assess and Remove Foley Catheter
Penalty
Summary
The facility failed to ensure a resident admitted with an indwelling Foley catheter was assessed for its removal. The resident, who was admitted with a Stage 4 pressure ulcer, had a Foley catheter in place to prevent the wound from getting infected or soiled. Despite the resident being alert, oriented, and able to use a bedside commode, the catheter was not removed, and no trial voiding was attempted. The resident expressed a desire to have the catheter removed, but this request was not communicated to the medical director by the staff. Interviews with the LPN, DON, and NP revealed that there was no clear diagnosis related to the Foley catheter use, and no attempts were made to discontinue the catheter since the resident's admission. The medical director stated that if a resident is cognitively aware and able to use a bedside commode, the expectation would be to attempt to discontinue the catheter as soon as possible. However, the staff did not inform the medical director of the resident's wish to have the catheter removed. The wound care nurse confirmed that the resident's wound remained stable and that the resident did not experience pain during dressing changes or when using the bedside commode, indicating that the resident could sustain transfers and bedside toileting without pain. This lack of action likely contributed to the resident not regaining bladder control and potentially developing bladder incontinence or a bladder infection.
Failure to Provide Adaptive Eating Device
Penalty
Summary
The facility failed to provide an adaptive eating device for a resident during dining observation. The resident had a physician's order dated 05/13/24 to use a plate guard for meals to improve self-feeding skills. However, the resident's meal ticket did not direct staff to provide the adaptive feeding equipment. During a dining observation on 05/13/24, the resident ate her meal without the plate guard until a CNA placed it on the plate later in the meal. The CNA acknowledged that the resident had an order for the plate guard and should have been served with it initially.
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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