Desert Springs Health Care Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Hobbs, New Mexico.
- Location
- 1701 N Turner Street, Hobbs, New Mexico 88240
- CMS Provider Number
- 325129
- Inspections on file
- 20
- Latest survey
- January 30, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Desert Springs Health Care Llc during CMS and state inspections, most recent first.
A resident with multiple comorbidities and generalized muscle weakness had a care plan requiring two-person assistance for ADLs, including bathing and bed mobility. During a bed bath provided by one CNA, who reported being unaware of the two-person assist requirement, the CNA remained on one side of the bed while the resident rolled toward the opposite side and fell from the bed to the floor. The resident sustained a laceration to a finger, reported pain in the arm, leg, and hip, and was later found to have a displaced distal femur fracture and a displaced fracture of the fifth finger, requiring surgical repair.
The facility failed to ensure safe and appropriate respiratory care by not maintaining clear and authorized oxygen therapy orders for three residents. One resident with COPD, DM2, and dementia had an order for 2 L O2 to keep SpO2 above 90%, but the order did not specify when O2 should be used, and the resident reported using it only when she felt she needed it. Another resident with CHF, chronic respiratory failure with hypoxia, A-fib, and other cardiac conditions had an order for 2 L O2 with titration to maintain SpO2 at 92%, but the order did not indicate whether O2 was to be continuous or PRN. A third resident with hypertension, kidney failure, DM2, cellulitis, and metabolic encephalopathy was observed on O2 via nasal cannula and concentrator without any physician order in place for supplemental O2 use, as confirmed by the DON.
Surveyors found that two residents were receiving medications without appropriate indications based on their documented diagnoses. One resident, whose conditions included heart disease, Alzheimer’s disease, DM2, and CKD, had an order for apixaban twice daily for A-fib despite having no A-fib diagnosis. Another resident, diagnosed with DM2, bipolar disorder, HTN, COPD, and RA, was ordered memantine and Aricept at bedtime for Alzheimer’s disease, although this diagnosis was not present in the record. The DON confirmed in interviews that these residents did not have the diagnoses for which the medications were ordered and stated that medications should only be ordered and administered for conditions the residents actually have.
Surveyors found that the facility did not consistently implement its infection prevention and control program when two residents who required contact or Enhanced Barrier Precautions did not have appropriate precaution signage posted or PPE readily available outside their rooms. One resident with active shingles and an order for contact precautions had no contact precaution sign or accessible PPE at the room entrance. Another resident with multiple pressure injuries and other wounds, with several wound care orders in place, lacked an EBP sign on the room door, a fact later confirmed by a CNA.
A resident with a history of traumatic SDH, anemia, urinary retention, and repeated falls, and a BIMS score indicating moderate cognitive impairment, was on a dietician-ordered regular diet with soft and bite-sized texture and thin liquids. During a meal, the resident requested a tortilla but was denied based on the diet order and subsequently refused to eat the meal. In a later interview, the resident stated understanding the choking risk yet still wished to have a tortilla. The DON confirmed the resident’s right to refuse dietary orders and that staff should have involved nursing or the dietician to allow the resident to exercise this choice, but this did not occur.
Surveyors found that the facility did not ensure that two residents' advance directives and New Mexico MOST forms matched the code status orders in the EHR. For one resident, the EHR listed Full Code while the signed advance directive and MOST form indicated DNR, which the DON confirmed was inaccurate. For another resident, the medical orders reflected DNR status while the MOST form documented a preference for Full Code with CPR. The DON acknowledged that these discrepancies did not meet expectations and that the orders should match the residents' MOST forms.
A resident with active physician orders for Zoloft for depression, Depakote and Gabapentin for dementia with behaviors and anxiety, and Aspirin and Clopidogrel for stroke prophylaxis was inaccurately coded on the MDS. In Section N – Medications, staff documented that the resident was not receiving antidepressant, anticonvulsant, or antiplatelet medications, and the MDS coordinator later confirmed that this assessment was incorrect.
A resident was admitted without a baseline care plan being developed and implemented within 48 hours, as required. Review of the EHR showed no baseline care plan, and the comprehensive care plan was not initiated until a later date. In an interview, the DON confirmed that a baseline care plan had not been completed for this resident, despite the expectation that all new admissions have such a plan in place within 48 hours.
A resident was receiving supplemental O2 via nasal cannula and had a floor mat placed beside the bed, but the facility failed to develop and implement a comprehensive care plan addressing these interventions. Record review showed an active O2 order without corresponding care plan interventions, and there was no order for the floor mat. Observations confirmed the resident’s use of O2 and the floor mat, and both the ADON and DON acknowledged that these should have been included in the care plan but were not.
A resident with COPD, DM2, and dementia had a physician order for oxygen at 2 L via nasal cannula to maintain oxygen saturation above 90%. The care plan documented continuous oxygen use at 2 L, but observations showed the resident was not on oxygen and reported using it only when needed. The DON confirmed the resident used oxygen on an as-needed basis and that the care plan had not been revised to reflect this current oxygen intervention, resulting in an inaccurate care plan.
A resident with multiple chronic conditions, including CKD, dementia, Alzheimer’s disease, muscle weakness, and a history of falls, was found during wound care to have an overgrown great toenail curving toward the adjacent toe. An LPN reported that podiatry provides quarterly nail care and that CNAs, nurses, or providers are expected to trim nails between podiatry visits, with the resident’s next podiatry appointment not yet due. The DON stated that staff are responsible for ensuring nails do not become overgrown and acknowledged that the resident’s toenail condition did not meet her expectations.
A resident with DM2, depression, anxiety, and dementia was receiving Risperidone, but the consent form on file listed schizophrenia as the indication while the current MD order listed dementia without behavioral disturbance. A pharmacist’s review noted that consent for Risperidone related to dementia with behavior disturbance could not be found and requested an update to the record. The MDS regional coordinator later confirmed that the consent did not match the current physician order, demonstrating the facility’s failure to maintain an accurate and updated medical record for this medication.
The facility failed to assess the risk of entrapment for residents using bed rails, affecting five residents. Although risks and benefits were reviewed, necessary bedrail assessments were not completed, and alternatives to bed rails were not considered. The DON acknowledged the oversight, stating that consent forms were completed but was unaware of the need for separate assessments.
The facility did not post daily nurse staffing data as required. Observations on November 16, 2024, revealed no current staffing information at the main nurses' station, and outdated information in the 100 hall, last updated on September 26, 2024. Interviews with an LVN and an RN confirmed the absence and outdated status of the postings.
A resident at risk for falls fell during a bed bath due to improperly locked bed wheels. The staff member was unfamiliar with the bed equipment, leading to the bed moving and the resident falling, resulting in injuries requiring hospital treatment.
Failure to Follow Two-Person Assist Care Plan During Bed Bath Resulting in Fall and Fractures
Penalty
Summary
The facility failed to ensure a resident’s environment was free from accident hazards and that adequate supervision and assistance were provided during personal care, resulting in a fall with injury. The resident was admitted with multiple diagnoses including chronic systolic heart failure, major depressive disorder, morbid obesity, type 2 diabetes mellitus, and generalized muscle weakness. Her care plan, revised on 06/03/25, specified that she required two-person assistance for bathing/showering, bed mobility, dressing, toilet use, and transfers with a Hoyer lift. On 12/27/25, progress notes documented that the resident was in her room with her husband and requested a bed bath. During this bed bath, she fell from her bed, sustained a laceration to her left pinky finger, and complained of pain to her left arm, leg, and hip. Interview with CNA #2 revealed that he responded to the resident’s request for a bed bath and provided care while positioned on one side of the bed. During the bath, the resident rolled toward the opposite side of the bed, and CNA #2 was unable to prevent her from rolling out of the bed, resulting in her fall to the floor. CNA #2 stated he assisted the resident without a second staff member because he was unaware that she required two-person assistance as outlined in her care plan. The DON stated that residents who require two-person assistance are expected to receive help from two staff members and that CNA #2 should have been informed of this requirement during shift report. Hospital records later documented that the resident was admitted with a displaced oblique fracture of the distal femur and a displaced fracture of the middle phalanx of the fifth finger and underwent surgery to repair these fractures.
Failure to Maintain Clear and Authorized Oxygen Therapy Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory care in accordance with professional standards by not having clear or complete oxygen orders for multiple residents. One resident with COPD, DM2, and dementia had a physician order for oxygen at 2 L via nasal cannula to keep oxygen saturation above 90%, but the order did not specify when the oxygen should be used. During observation, this resident was not wearing oxygen and the concentrator was off; the resident stated she only wears oxygen when she needs it. The DON confirmed that the resident only wears oxygen as needed and that the order did not specify when oxygen should be worn, acknowledging that it should. Another resident with CHF, chronic respiratory failure with hypoxia, major depressive disorder, A-fib, sleep apnea, and atherosclerotic heart disease had an order for 2 L of oxygen via nasal cannula with titration to maintain oxygen saturation at 92%, but the order did not indicate whether oxygen was to be administered continuously or PRN. The DON confirmed this lack of specificity and stated the order should indicate when to administer oxygen. A third resident with hypertension, kidney failure, DM2, cellulitis of the right lower limb, and metabolic encephalopathy was observed lying in bed wearing a nasal cannula connected to an oxygen concentrator. The ADON confirmed the resident was on oxygen, and the DON later confirmed that this resident did not have a medical order for oxygen use, despite using supplemental oxygen.
Medications Administered Without Corresponding Diagnoses
Penalty
Summary
The facility failed to ensure residents’ drug regimens were free from unnecessary medications by not confirming that ordered drugs had appropriate indications based on current diagnoses. For one resident, admitted with diagnoses including atherosclerotic heart disease, Alzheimer’s disease, atherosclerosis of coronary artery bypass grafts, type 2 diabetes mellitus, and chronic kidney disease, the medical record contained an order for apixaban 2.5 mg orally twice daily for atrial fibrillation. Record review and interview with the DON confirmed that this resident did not have a diagnosis of atrial fibrillation, and the DON acknowledged that this did not meet her expectations because medications should be ordered and administered only for diagnoses the resident has. For another resident, admitted with diagnoses including type 2 diabetes mellitus, bipolar disorder, essential hypertension, COPD, and rheumatoid arthritis, the current medical orders included memantine 10 mg (two tablets at bedtime) and Aricept 10 mg (one tablet at bedtime), both ordered for Alzheimer’s disease. Record review and the DON’s interview confirmed that this resident did not have a diagnosis of Alzheimer’s disease, despite receiving two medications specifically ordered for that condition. The DON stated that medications should only be ordered and administered for diagnoses the resident has, confirming that these orders did not align with the resident’s documented conditions.
Failure to Post Precaution Signage and Provide PPE for Residents Requiring Enhanced Barrier and Contact Precautions
Penalty
Summary
The facility failed to implement an ongoing infection prevention and control program by not ensuring that required Enhanced Barrier Precautions (EBP) and contact precautions were visibly posted and supported with readily available PPE for certain residents. One resident with focal traumatic brain injury, zoster (shingles), and an elevated white blood cell count had a physician order dated 01/13/26 for contact precautions due to an active shingles infection described as highly transmissible and acquired by physical contact. On 01/28/26 at 1:49 pm, observation of this resident’s room showed there was no sign on the door indicating contact precautions and no PPE readily accessible outside the room, despite the active order. Another resident with multiple diagnoses including hypertension, kidney failure, type 2 diabetes mellitus, cellulitis of the right lower limb, and metabolic encephalopathy had multiple wound care orders dated 01/23/26 for unstageable pressure injuries and other wounds to the left hip, right and left ischium, both heels, sacrum, and right big toe. During a random observation of this resident’s room on 01/28/25 at 1:29 pm, there was no EBP sign posted. In a subsequent interview on 01/30/26 at 11:28 am, a CNA confirmed that this resident did not have an EBP sign posted, demonstrating that the facility did not consistently implement its infection prevention and control measures for residents requiring enhanced precautions.
Failure to Honor Resident Choice Regarding Dietary Orders
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to make choices about significant aspects of their life, specifically the right to refuse dietician orders. The resident was admitted with diagnoses including traumatic subdural hemorrhage, anemia, urinary retention, and repeated falls. A quarterly MDS showed a BIMS score of 12, indicating moderate cognitive impairment. Dietician orders dated 01/09/26 specified a regular diet with soft and bite-sized texture and thin liquid consistency. During a dining room observation on 01/28/26 at 12:52 pm, the resident requested a tortilla and was told he could not have one due to his diet order, after which he pushed his plate away and did not eat his meal. Later that afternoon, during an interview, the resident stated he really wanted to eat a tortilla, reported he had been told he could not have one because he might choke, and stated he understood the risks and still wanted a tortilla. In a subsequent interview on 01/30/26 at 4:26 pm, the DON confirmed the resident was on a soft, bite-sized diet and acknowledged that the resident had the right to refuse his dietary orders. The DON stated that staff should have communicated with the nurse or dietician to provide the resident the opportunity to refuse his dietary orders so he could have a tortilla, confirming that this process did not occur at the time of the incident.
Mismatch Between Advance Directives, MOST Forms, and EHR Code Status Orders
Penalty
Summary
Surveyors identified that the facility failed to ensure residents' current advance directives and New Mexico Orders for Scope of Treatment (MOST) forms matched the code status orders in the electronic health record (EHR) for two residents. For one resident, the face sheet showed admission on a specified date, and the physician orders in the EHR documented the resident as Full Code for advance directive code status. However, the resident's current advance directive and MOST form, signed on a later date, indicated the resident had chosen Do Not Resuscitate (DNR). During an interview, the DON confirmed that this resident's code status should be DNR and not Full Code, acknowledging the inaccuracy and that staff had not updated the resident's code status in the EHR. For another resident, the admission record showed admission on a specified date, and the current medical orders included an order, dated on a specific day, to not attempt resuscitation due to DNR status. In contrast, the resident's MOST form, dated on another specific day, documented that the resident chose to be Full Code and wanted CPR performed if needed. In an interview, the DON stated that this discrepancy did not meet her expectations because the resident's medical order should match the MOST form, but it did not. The report states that this deficient practice is likely to result in confusion, delay, and residents not having their wishes honored if a life-threatening event occurred.
Inaccurate MDS Medication Coding for Psychotropic and Antiplatelet Drugs
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for one resident when required medication use was not correctly documented. Record review showed that this resident had multiple active physician orders, including Zoloft 100 mg daily for depression, Depakote Sprinkles 125 mg two capsules twice daily for dementia with behaviors, Gabapentin 300 mg twice daily for anxiety, Aspirin 81 mg daily for prophylactic measures related to a history of stroke, and Clopidogrel 75 mg daily for prophylactic measures related to a history of stroke. These orders established that the resident was receiving antidepressant, anticonvulsant, and antiplatelet medications during the assessment period. Despite these active medication orders, the resident’s MDS, in Section N – Medications, indicated that the resident did not take antidepressant, anticonvulsant, or antiplatelet medications. During an interview, the MDS coordinator confirmed that the assessment for this resident was inaccurate and acknowledged that it should have reflected the use of antidepressant, anticonvulsant, and antiplatelet medications but did not.
Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
Surveyors identified a deficiency in which the facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident. Record review showed that this resident was admitted on an identified date, but there was no evidence of a baseline care plan in the Electronic Health Record. Further review revealed that the resident’s comprehensive care plan was not developed and implemented until a later date, well beyond the required 48-hour timeframe for a baseline care plan. During an interview, the DON confirmed that the facility did not develop and implement a baseline care plan for this resident and stated that her expectation is that every resident has a baseline care plan in place within 48 hours of admission. The report notes that if the facility fails to develop and implement a baseline care plan, residents might not receive the care and services they need.
Failure to Care Plan for Oxygen Use and Floor Mat
Penalty
Summary
The facility failed to develop and implement an accurate, comprehensive care plan for a resident when staff did not include interventions for the use of supplemental oxygen and a floor mat. The resident was admitted on an identified date, and review of the care plan dated shortly after admission showed no care plan addressing the resident’s use of supplemental oxygen or the presence of a floor mat. Medical orders showed that the resident had an order, dated several days after admission, for supplemental oxygen via nasal cannula, but there was no corresponding care plan with interventions for this treatment. Surveyor observations and staff interviews confirmed the omission. During a random observation of the resident’s room, the resident was seen lying in bed wearing a nasal cannula connected to an oxygen concentrator, and a floor mat was present on the floor next to the right side of the bed. The ADON confirmed that the resident was using oxygen and had a floor mat in place. The DON also confirmed the resident’s use of oxygen and a floor mat and acknowledged that both should have been included in a care plan with interventions prior to their use, but were not.
Failure to Revise Care Plan to Reflect PRN Oxygen Use
Penalty
Summary
The deficiency involves the facility’s failure to revise and maintain an accurate care plan regarding a resident’s oxygen use. The resident was admitted with COPD, type 2 diabetes mellitus, and dementia. A physician’s order dated 08/14/25 directed oxygen via nasal cannula at 2 L to maintain oxygen saturation above 90%. The resident’s care plan, revised on 12/31/25, documented that the resident used oxygen via nasal cannula at 2 L continuously. However, this care plan was not updated to reflect the resident’s actual pattern of oxygen use. During an observation on 01/28/26, the resident was seen in her room with an oxygen concentrator next to the bed, but she was not wearing the nasal cannula and the machine was turned off. The resident stated she only wears her oxygen when she needs it. In a subsequent interview on 01/30/26, the DON confirmed that the resident only uses oxygen as needed and acknowledged that the care plan was not accurate and should have been revised. This failure to revise the care plan to reflect current oxygen interventions constituted the cited deficiency.
Failure to Maintain Appropriate Toenail Care Between Podiatry Visits
Penalty
Summary
The facility failed to provide adequate foot care for one resident when staff allowed a toenail to become overgrown between podiatry visits. The resident, who had multiple diagnoses including metabolic encephalopathy, chronic kidney disease, generalized muscle weakness, dementia, Alzheimer’s disease, and a history of repeated falls, was observed during wound care to the right ankle, at which time an LPN removed the resident’s sock and revealed an overgrown right great toenail that was curving slightly toward the second toe. Record review showed the resident had been admitted with these conditions, and interview with the LPN confirmed that quarterly podiatry appointments are made for nail care and that CNAs, nurses, or providers are expected to trim nails between podiatry visits; the LPN also confirmed the resident’s next podiatry appointment was scheduled for a later date. In a separate interview, the DON stated that CNAs, nurses, or providers should ensure nails do not become overgrown and acknowledged that the condition of this resident’s toenail did not meet her expectations.
Inaccurate Antipsychotic Consent Documentation
Penalty
Summary
The facility failed to maintain an accurate and updated medical record for one resident when the documented consent for an antipsychotic medication did not match the current physician order. The resident was admitted with diagnoses including Type 2 DM, major depressive disorder, anxiety, and dementia. A pharmacist’s Medication Regimen Review dated 11/26/25 noted that a consent could not be found for the resident’s Risperidone for the diagnosis of dementia with behavior disturbance and requested that the record be updated once consent was obtained. Review of the current consent for Risperidone, dated 08/26/24, showed it was completed for the diagnosis of schizophrenia. Further record review showed that the physician’s order dated 10/20/25 listed the indication for Risperidone as dementia, unspecified severity, without other behavioral disturbance, which did not match the diagnosis documented on the existing consent form. During an interview on 01/30/25, the MDS regional coordinator confirmed that the consent did not match the physician’s orders and acknowledged that the consent should be updated to reflect the current order. This discrepancy demonstrated that the facility did not ensure the resident’s medical record, specifically the consent for Risperidone, was accurate and consistent with the physician’s current orders.
Failure to Assess Bed Rail Entrapment Risk
Penalty
Summary
The facility failed to ensure that staff assessed residents who utilized bed rails for the risk of entrapment. This deficiency affected five residents who used bed rails, as staff did not complete the necessary bedrail assessments. Although the risks and benefits of bed rails were reviewed with the residents, the assessments to evaluate the risk of entrapment were not conducted. Additionally, staff did not attempt to use appropriate alternatives to bed rails or determine if these alternatives met the residents' needs, as no bedrail assessments were completed. During an interview, the Director of Nursing (DON) acknowledged that staff did not complete bedrail assessments. The DON mentioned that consent forms for the use of bedrails were completed, but she was unaware that a separate bedrail assessment was required. This oversight could potentially lead to residents experiencing injury by becoming trapped between the mattress and the bedrail.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing data, which is a requirement. On November 16, 2024, at 1:15 pm, it was observed that there was no nurse staffing information posted for the day at the main nurses' station. Additionally, the staffing information available at the nurses' station in the 100 hall was outdated, with the last update being on September 26, 2024. During an interview, an LVN confirmed that the nurse staffing information was not posted as required at the main hall nurses' station. Furthermore, an RN corroborated that the staffing information in the 100 hall was outdated, confirming the date discrepancy.
Failure to Lock Bed Wheels Leads to Resident Fall
Penalty
Summary
The facility failed to prevent an accident involving a resident who was at risk for falls due to weakness and a history of falls. The incident occurred when the resident was receiving a bed bath, and the bed was not fully locked. Specifically, the wheels at the top of the bed were not locked, which allowed the bed to move when the resident braced herself against the wall. This movement caused the resident to fall to the ground, resulting in injuries that required hospital treatment. The staff member providing the bed bath was not familiar with the proper use of the bed and its brakes, contributing to the incident. The resident required maximal assistance for movements such as rolling and sitting up, indicating a high level of dependency on staff for safe transfers. The failure to ensure the bed was fully locked and the staff's unfamiliarity with the equipment were key factors leading to the resident's fall and subsequent injuries.
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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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