Fiesta Park Wellness & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Albuquerque, New Mexico.
- Location
- 8820 Horizon Boulevard Ne, Albuquerque, New Mexico 87113
- CMS Provider Number
- 325123
- Inspections on file
- 25
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Fiesta Park Wellness & Rehabilitation during CMS and state inspections, most recent first.
The facility failed to accurately complete PASARR Level I screenings for multiple residents with documented mental health diagnoses, including major depressive disorder, depression, and anxiety disorders. Despite these diagnoses being listed on admission face sheets, staff marked on the PASARR forms that the residents did not have mood, anxiety, psychotic, or related mental health conditions. The SSD reported there was no systematic process to review incoming PASARRs for accuracy and acknowledged that her department had not been reviewing these screenings, resulting in multiple inaccurate PASARRs for residents requiring mental health-related assessment.
Staff failed to maintain a safe oxygen storage area on one unit when the oxygen storage room door lock was nonfunctional, allowing the door to be opened without an access code, and portable O2 cylinders were observed sitting on the floor instead of in the designated cylinder rack. Facility policy required oxygen cylinders to be secured in a cart or bracket and stored in clean, dry locations. The Central Supply Manager acknowledged that all oxygen equipment must be stored in proper areas for safety and that improper storage could create a hazard, and the Administrator stated the oxygen storage room was expected to remain locked at all times when not in use but was unaware the keypad lock was not working.
Facility staff failed to complete an accurate discharge MDS for a resident when the discharge destination was left blank. The resident, who had diagnoses including Guillain-Barre syndrome, epilepsy, and depression, became unable to transfer out of bed and was transported by ambulance to a hospital for evaluation after a change in condition. Documentation in the medical record, including a change in condition form and progress note, showed the resident was sent to the hospital, and the DON confirmed the resident had been scheduled for discharge that day. The MDSC, who was responsible for the assessment, acknowledged that the resident was discharged to the hospital and that the discharge MDS was inaccurate because the discharge destination was not coded.
During a flooring renovation project, several residents were removed from their rooms without prior notice and were left for extended periods in wheelchairs or crowded into another room, with one resident moved from a bariatric bed with rails to a smaller standard bed without rails. Residents reported having no access to their own bathrooms, belongings, or a place to lie down, and some observed others sleeping on couches in common areas while construction workers replaced flooring in their rooms. The Administrator acknowledged the facility-wide flooring replacement and stated no complaints had been received, without indicating that residents were given notice or options before being told to leave their rooms.
During a flooring renovation, the facility failed to follow its own safety plan and manufacturer guidance for flooring adhesive, leaving multiple uncovered buckets of industrial adhesive in resident areas and applying adhesive in an open resident room without fans, open windows, or open exit doors, resulting in strong odors throughout the hallway while residents remained in nearby rooms. A visitor reported a strong, unpleasant odor despite wearing a mask, and a resident with asthma expressed concern. Review of the adhesive’s MSDS showed the need for adequate ventilation and keeping containers closed when not in use, but facility leadership believed residents were not at risk and relied on existing mechanical ventilation. At the same time, surveyors observed extensive obstruction of multiple means of egress, including resident hallways, utility and kitchen dock corridors, and the Administration wing, where beds, carts, equipment, furniture, boxes, and other items blocked or encroached on exit paths and doors while residents in wheelchairs navigated around them. A resident reported being displaced from his room for flooring work and stated that hallway items had been present, moved, and then returned, and that the hallway had been in this condition for some time.
A resident admitted after a recent defibrillator implant did not receive an initial skin assessment upon admission. The LPN responsible did not remove the resident's clothing to check for bruising or surgical sites, citing the resident's fatigue and a busy unit. No documentation of the assessment was made, and the DON confirmed the assessment was missing from the medical record.
A resident's medical record was not updated with the correct hospital discharge orders for IV antibiotics, resulting in early discontinuation and a delay in restarting the medication. The updated orders were received and used by an LPN but were not uploaded into the EMR, leaving only outdated information available for review.
The facility failed to maintain sanitary conditions in food storage and handling, with unlabeled and undated food items in the refrigerator and freezer, improper storage of a flour scoop, and thawing of meats in stagnant water. Additionally, a dietary aide was observed not wearing a hairnet, and meat was stored on the kitchen floor. These practices could affect all 107 residents and lead to foodborne illnesses.
The facility failed to conduct a required quarterly care plan meeting for a resident and did not update care plans for two residents to reflect changes in medical management, including the use of a Libre2 glucose monitor and oxygen therapy. The omissions were confirmed by facility staff.
A resident in a long-term care facility did not receive appropriate care due to a lack of communication and implementation of medical orders. The facility failed to inform a PA about the discontinuation of Sodium Zirconium for hyperkalemia, leading to its continued inclusion in the treatment plan. Additionally, a nephrologist's recommendation for a potassium binder was not timely implemented. The facility also did not follow orders to use a Libre2 glucose monitor, continuing with finger sticks due to staff not being notified of the new order.
A facility failed to ensure proper communication and documentation for a resident receiving dialysis. Despite a policy requiring dialysis communication forms to be completed and stored in the resident's EHR, several forms were missing. Staff interviews confirmed the importance of these forms for monitoring the resident's condition, yet they were not consistently completed, leading to a deficiency in care management.
The facility failed to maintain a medication error rate below 5%, with a 50% error rate observed. Two residents received medications significantly later than the scheduled time of 7:00 am, with administration occurring at 8:40 am and 8:55 am. The CMAs acknowledged the delay, and the ADON confirmed the requirement for timely administration within one hour of the scheduled time.
The facility failed to maintain accurate medical records for seven residents by not ensuring that pharmacist recommendations were reviewed and acknowledged by providers. The Assistant Director of Nursing claimed to have conducted telephone reviews with providers, but the documentation lacked necessary signatures and details as per the facility's policy, potentially impacting residents' medication needs.
A resident reported $150.00 missing from under her mattress, but the facility failed to document or investigate the incident. The resident informed the Administrator, who acknowledged the report but did not pursue further investigation after the resident declined to file a formal grievance or police report.
A resident with spina bifida and pressure ulcers was discharged from an LTC facility without confirmed home health services due to non-payment. The facility failed to verify acceptance of the referral by the home health agency before discharge, leaving the resident to arrange services independently. The resident expressed frustration over the lack of communication and assistance from the facility.
A resident on a Consistent Carbohydrate (CCHO) diet did not receive a side salad with dinner as specified on their meal ticket. Despite informing nursing staff, the issue persisted, and during a dinner observation, the resident was served a meal without the side salad. Both an LPN and the Dietary Manager confirmed the oversight.
A resident on blood thinners experienced a fall resulting in a head laceration, but the facility delayed sending her to the ER for several hours. Despite significant bleeding and the resident's medication increasing bleeding risk, staff confusion led to a delayed response. The resident required staples for the head injury once finally treated in the ER.
Inaccurate PASARR Screenings for Residents With Mental Health Diagnoses
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate completion of Preadmission Screening and Resident Review (PASARR) Level I screenings for multiple residents with documented mental health diagnoses. Record review showed that several residents were admitted with diagnoses such as major depressive disorder, depression, and anxiety disorders, yet their PASARR Level I forms indicated that they did not have mood, anxiety, or other qualifying mental health conditions. For example, one resident admitted with major depressive disorder had a PASARR Level I dated the same day of admission that documented no mood, panic, anxiety, personality, psychotic, depression, or substance-related disorders. Similar discrepancies were identified for additional residents. Another resident admitted with major depressive disorder had a PASARR Level I completed the day prior to admission that incorrectly indicated no mood or depression-related diagnoses. Residents with documented anxiety disorders also had PASARR Level I screenings that stated they did not have anxiety, mood, or related mental health conditions. Multiple residents with diagnoses of depression or major depressive disorder had PASARR Level I screenings completed on or near their admission dates that failed to acknowledge these conditions, instead marking that no such mental health diagnoses were present. During an interview, the Social Services Director reported that the facility did not have a systematic process in place to review incoming PASARRs as part of the admission screening process. The Social Services Director stated she had only recently been informed that reviewing resident PASARRs was the responsibility of her department and acknowledged that PASARRs were not being reviewed for accuracy. She confirmed that the PASARRs for all identified residents were inaccurate and stated that they should have reflected the residents’ documented mental health diagnoses.
Failure to Secure Oxygen Storage Room and Properly Store Oxygen Cylinders
Penalty
Summary
Facility staff failed to maintain a safe oxygen (O2) storage environment on the 200-unit by not securing the oxygen storage room and not properly storing oxygen cylinders. Record review of the facility’s Oxygen Administration Policy dated 06/2020 showed that oxygen cylinders were required to be secured in a cylinder cart or bracket at all times and stored in clean, dry locations. On observation, the oxygen storage room keypad door lock on the 200-unit was without power, nonoperational, and its screen remained blank and did not activate when touched, allowing the door to be opened without entering an access code. Additional observation showed portable medical oxygen cylinders sitting on the floor instead of being stored in the designated oxygen cylinder rack. In interviews, the Central Supply Manager stated that all oxygen equipment, including portable oxygen tanks, must be stored in proper storage areas for safety and that improper storage could create a hazard, and the Administrator stated the oxygen storage room should remain locked at all times when not in use and acknowledged she was not aware the keypad lock was not functioning and that the door could be opened without a code. No specific residents or their medical histories were identified in the report; the deficiency pertained to the general safety of the oxygen storage area accessible to residents, staff, and the public.
Inaccurate Discharge MDS Due to Omitted Discharge Destination
Penalty
Summary
Facility staff failed to ensure an accurate Minimum Data Set (MDS) assessment for one resident when the discharge MDS did not include the resident’s discharge destination. The resident had been admitted with Guillain-Barre syndrome, epilepsy, and depression, and was later unable to transfer out of bed and was sent to the hospital via ambulance for evaluation after experiencing abdominal pain. Record review showed a Change in Condition form and progress note documenting the transfer to the hospital, and the DON stated the resident had been scheduled for discharge on the same day the resident was sent to the hospital. However, the discharge MDS for that resident, completed by the MDS Coordinator, was left with the discharge destination field blank, despite the MDSC acknowledging that the resident was discharged to the hospital and that the assessment was therefore inaccurate. This deficiency was identified through record review of the face sheet, Change in Condition form, progress note, and discharge MDS, as well as interviews with the DON and the MDSC, who confirmed that the discharge destination should have been coded and that it was her responsibility to complete accurate MDS assessments.
Failure to Provide Notice and Appropriate Accommodations During Room Renovations
Penalty
Summary
Surveyors found that during a flooring renovation on the 400 hallway, multiple resident rooms were emptied of furniture and flooring while construction workers were present, yet several residents remained on the hallway and were displaced from their rooms without prior notice. One resident reported being told by staff to leave his room so carpet could be removed and flooring installed, with no advance notice, and then having to sit in his wheelchair from 7:40 a.m. to 6:00 p.m. without access to his own bathroom, belongings, or a place to lie down. Another observation showed three residents together in a single resident room, with two in wheelchairs and one lying in a standard hospital bed without rails. A resident who normally used a bariatric bed with rails stated she was moved out of her room without notice to a smaller standard bed without rails and was not told how long she would be out of her room or how staff would assist her with restroom needs, given that her required equipment remained in her original room. Another resident stated she was removed from her room at 8:00 a.m. and not allowed to return until after 7:00 p.m., with no prior notice and no place to nap, remaining in her wheelchair all day and observing other residents sleeping on couches in common areas. A third resident reported being moved out of her room without notice for flooring replacement and not being informed when she could return or where she could use the restroom privately with her wheelchair. The Administrator stated the facility was replacing flooring throughout the building and that the 400 hallway was the last area to be completed, and reported not receiving any complaints from residents during the construction, without indicating that residents had been given notice or options before being told to leave their rooms.
Inadequate Ventilation of Flooring Adhesive Fumes and Blocked Egress During Renovation
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe and comfortable environment during a flooring renovation project, specifically related to inadequate ventilation of construction adhesive fumes and obstruction of the means of egress. The facility’s Safety Plan for the floor renovation, dated 09/16/2025, identified affected resident units and noted potential issues such as unpleasant odors from materials in use. The plan instructed staff to contain aerosol dust and debris with ventilation as needed, close doors where applicable to provide barriers, and remove patient activity and exposure in areas being worked on as allowable. Despite these written instructions, surveyors observed that these measures were not implemented as required during active construction. During observations on the 400 hallway, surveyors found multiple five-gallon buckets of industrial flooring adhesive uncovered and accessible in resident areas, including three buckets in an electrical closet with the door open, one bucket on a hallway table, and another on the floor. Adhesive was visible on the sides and bottoms of the buckets, and residents were moving throughout the unit around these open containers. In resident room 427, flooring adhesive had been applied to the floor with the door left open while a construction worker, who was wearing a face mask, installed flooring. There was a strong adhesive odor throughout the 400 hallway, with no fans present, windows in room 427 closed, and the exit door at the end of the hallway also closed. Residents were present in nearby rooms 423, 424, 425, and 426 with their doors open. A visitor reported smelling a strong, unpleasant adhesive odor through a face mask and suggested that closing resident room doors would help protect them from the odor. Another resident with asthma stated she could not smell the odor due to difficulty smelling but was concerned about it. Record review of the flooring adhesive’s Material Safety Data Sheet showed instructions that, if inhaled, individuals should be moved to fresh air, and that adequate ventilation and respiratory protection were recommended when using the product. The MSDS also directed that accidental releases be managed by ventilating the area and that containers be kept closed when not in use. Despite this, the Administrator stated she did not believe residents were at risk from inhalation of the adhesive vapors and reported no complaints during the renovation. The Plant Operations Manager stated that the hallway’s mechanical ventilation was considered sufficient and that exit doors on certain units should be opened if residents were uncomfortable, but these doors were not open at the time of observation. The deficiency also includes extensive obstruction of the means of egress throughout the facility during the renovation. NFPA 101, Life Safety Code, requires that means of egress be continuously maintained free of obstructions or impediments. On observation, the 400 hallway, where residents were living during renovation, had its egress path blocked by two trash cans, four beds, an armchair, three tables, a chair, three 4-gallon buckets, an industrial tile cutter, and piled boxes of wood flooring strips, while residents in wheelchairs navigated around these items. Additional egress routes were blocked in multiple areas: the Utility hallway by boxes containing wheelchairs and other items; the kitchen dock hallway by a tall food tray cart, cleaning supplies, and boxes, with double exit doors further blocked by a wood pallet and a cardboard box; and the Administration wing by numerous items including vacuums, furniture, housekeeping and floor machines, a hoyer lift, medical equipment, and stacked boxes, with an emergency exit door blocked by an oxygen cylinder, printers, and boxes. Other hallways outside resident rooms had egress paths blocked or encroached upon by unused utility carts, treatment carts, a mattress, a wheelchair, a medication cart, and service carts. A resident reported being told to leave his room for most of a day so flooring could be replaced and stated that the hallway items were present when he left his room, were moved out, and then brought back, and that the hallway had been like that for a while. The Administrator acknowledged that the Maintenance Department was responsible for maintaining the facility according to the Life Safety Code, and the Plant Operations Manager stated that means of egress should be maintained throughout the remodeling period and that staff should remove items stored within the egress paths.
Failure to Complete Initial Skin Assessment on Admission
Penalty
Summary
The facility failed to complete an initial skin assessment for one of three residents reviewed for skin assessments during the admission process. Record review showed that the resident was admitted following a recent procedure to implant a defibrillator and was later discharged against medical advice due to concerns of physical abuse, presenting with bruising, swollen genitals, penile bleeding, and various other bruises. Upon review of the resident's medical chart, no initial skin assessment was found, and the Director of Nursing confirmed that the assessment should have been completed by the admitting nurse but was not present in the records. During interviews, the LPN responsible for the admission stated that he did not perform the skin assessment because the resident was fatigued, the unit was busy, and he was occupied with paperwork and the family. The LPN admitted to not removing the resident's clothing to check for bruising or surgical sites and only noted excoriation at the tip of the penis after the resident tugged on his Foley catheter. The LPN did not document any initial assessments, nor did he inform anyone that the skin check was not completed, resulting in the lack of a trigger for follow-up by other staff.
Failure to Update and Upload Hospital Discharge Orders in EMR
Penalty
Summary
The facility failed to ensure that a resident's medical record was updated with necessary and accurate hospital discharge orders. Upon admission, the resident had been receiving intravenous (IV) antibiotics for a severe infection, with hospital discharge orders specifying that the antibiotics should continue for four weeks post-discharge. However, the facility discontinued the antibiotics earlier than ordered and did not restart them until ten days later, after the nurse practitioner identified the error and re-ordered the medication. Interviews revealed that the admitting LPN received incomplete discharge orders and had to request updated orders, which were subsequently emailed to him. Although these updated orders were used for the resident's admission and reviewed with the nurse practitioner, they were not uploaded into the electronic medical record (EMR). The EMR only contained the original, outdated discharge orders, and the updated orders were not available for review by the state agency. The Director of Nursing confirmed that the updated orders should have been uploaded but were not.
Sanitary Lapses in Food Storage and Handling
Penalty
Summary
The facility failed to maintain sanitary conditions in food storage and handling, as observed during a survey. In the kitchen, several food items, including diced potatoes, salad mix, diced ham, ground pork, and chicken breast, were found unlabeled and undated in the refrigerator and freezer. Additionally, a flour scoop was improperly stored on top of a flour bag in the dry storage area. The Dietary Manager acknowledged these issues, confirming that all food items should be labeled and dated, and that flour scoops should be stored in a sanitary manner. Further observations revealed additional sanitary lapses, including six packs of meat stored on the kitchen floor, a dietary aide not wearing a hairnet, and packages of bologna and turkey being thawed in stagnant water instead of under running water. The Dietary Manager confirmed these findings, stating that food should not be stored on the floor, staff should wear hairnets, and frozen meats should be thawed safely. These practices potentially affect all 107 residents and could lead to foodborne illnesses if not addressed.
Failure to Update Care Plans and Conduct Required Meetings
Penalty
Summary
The facility failed to conduct a quarterly care plan meeting for a resident as required by their admission and Minimum Data Set (MDS) assessment. Despite the resident's expressed desire to participate in such meetings, neither the resident nor their emergency contact had been involved in a care plan meeting. The Social Services Assistant confirmed that the meeting should have occurred in December 2024 but did not, and there was no documentation of a care plan meeting in the resident's electronic health record. Additionally, the facility did not update the care plans for two residents to reflect changes in their medical management. One resident's care plan was not updated to include the use of a Libre2 glucose monitor for diabetic management, despite physician orders and the resident's preference to avoid finger sticks. Another resident's care plan lacked documentation of oxygen use, which was ordered to maintain oxygen saturation levels. The Assistant Director of Nursing acknowledged that these updates should have been made to the care plans but were not.
Failure to Communicate Medication Changes and Implement Diabetic Management Orders
Penalty
Summary
The facility failed to provide quality care that meets professional standards for a resident by not effectively communicating with healthcare providers and not implementing necessary medication recommendations. The resident, who was admitted to the facility, had an order for Sodium Zirconium to manage hyperkalemia, which was discontinued without proper communication to the Physician Assistant (PA). The PA continued to include Sodium Zirconium in the resident's treatment plan, unaware of its discontinuation. Additionally, the resident's nephrologist recommended starting a potassium binder medication, but this was not implemented in a timely manner, leading to a delay in the resident receiving necessary medication. Furthermore, the facility did not follow physician orders regarding the use of a Libre2 glucose monitor for diabetic management. Despite the resident's preference and a physician order to use the Libre2 device, nursing staff continued to use the finger stick method for blood glucose monitoring. This was due to a lack of awareness among the nursing staff about the new order, as it was not entered correctly to notify them. The Assistant Director of Nursing confirmed that the order should have been visible to the nursing staff, and the PA had educated the staff on using the Libre2 device when the order was placed.
Failure in Dialysis Communication and Documentation
Penalty
Summary
The facility failed to ensure proper communication and collaboration with the dialysis center for a resident requiring dialysis services. The facility's policy mandates that nursing staff use dialysis communication records to convey information to the dialysis provider and maintain these records in the resident's Electronic Health Record (EHR). However, a review of the resident's EHR revealed missing dialysis communication forms for several dates, indicating a lapse in documentation and communication. Interviews with facility staff, including Licensed Practical Nurses and the Assistant Director of Nursing, confirmed that the dialysis communication forms are essential for monitoring the resident's condition and any changes during or after dialysis treatment. Despite the facility's policy and staff acknowledgment of the importance of these forms, the forms were not consistently completed and documented, leading to a deficiency in the resident's care management.
Medication Administration Errors Exceed 5% Threshold
Penalty
Summary
The facility failed to ensure that medications were administered with an error rate less than 5%, resulting in a medication error rate of 50%. During observations, medications were administered to two residents, with 13 medication errors observed out of 26 medications administered. Specifically, one resident received aspirin, furosemide, gabapentin, and sertraline at 8:40 am, although these medications were scheduled for 7:00 am. Another resident received gabapentin, losartan, flomax, senna, duloxetine, fluticasone spray, magnesium, miralax, and a lidocaine patch at 8:55 am, also scheduled for 7:00 am. The Certified Medication Aides (CMAs) involved acknowledged the late administration of medications. The Assistant Director of Nursing (ADON) confirmed that medications scheduled for 7:00 am should be administered within one hour before to one hour after the scheduled time, meaning they should have been given by 8:00 am. The failure to administer medications within the prescribed time frame led to the observed medication errors.
Failure to Maintain Accurate Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records in accordance with accepted professional standards for seven residents. The deficiency was identified through a review of monthly pharmacist recommendations for medications prescribed to these residents. The recommendations included suggestions for dose reductions, medication discontinuations, and the need for specific medication end dates. However, the documentation lacked signatures from the attending physicians or providers, indicating that the recommendations were not reviewed or acknowledged by them. The Assistant Director of Nursing (ADON2) was responsible for reviewing the pharmacist recommendations and claimed to have contacted the appropriate providers to discuss the recommendations. ADON2 considered these discussions as telephone reviews and orders, which she believed she was authorized to execute as a Registered Nurse. Despite this, the documentation did not reflect that these were telephone orders, nor did it include the necessary details such as the prescriber's signature, which is required by the facility's policy on telephone orders for medications. The facility's policy, dated June 2020, outlines the procedure for receiving telephone orders, which includes documenting the order details and obtaining the prescriber's countersignature within a reasonable timeframe. The failure to adhere to this policy resulted in incomplete documentation, as there was no indication that the providers had been contacted or that the orders had been read back to them for confirmation. This lack of proper documentation could adversely impact the residents' medication needs by not having accurate information available.
Failure to Investigate Missing Money
Penalty
Summary
The facility failed to investigate an allegation of missing money for a resident, which is a deficiency likely to result in resident financial hardship. The resident reported having $150.00 in a green baggie under her mattress, which went missing sometime in December 2024. Although she did not file a formal grievance, she verbally informed the Administrator about the missing money. The facility's records from August 2024 through January 2025 showed no documentation of this incident. The Administrator acknowledged being aware of the missing money and stated that the resident refused to file a police report or formal grievance. Despite searching for the money, it was not found, and no further investigation was conducted.
Failure to Ensure Safe Discharge for Resident
Penalty
Summary
The facility failed to ensure a safe discharge for a resident, identified as R #81, by not confirming that necessary home health services were arranged and accepted before her discharge. R #81, who had multiple diagnoses including spina bifida with hydrocephalus and pressure ulcers, was discharged due to non-payment. Despite being informed of her discharge, R #81 was not provided with confirmation of home health services, which were crucial for her ongoing care needs, particularly for managing her pressure ulcers. The facility's records indicated that a referral was made to a home health agency, HH #1, on the day of discharge, but there was no confirmation of acceptance from the agency before R #81 left the facility. Interviews revealed that HH #1 did not accept the referral due to insurance issues and passed it to another agency, HH #2, which had not received any referral. The Social Services Director assumed the referral was accepted without verification, leading to R #81 being discharged without confirmed home health support. R #81 expressed frustration over the lack of communication and assistance from the facility regarding her discharge plan. She was left to arrange for her own home health services after being discharged, as she had not been contacted by any agency to discuss her care needs. This oversight in discharge planning resulted in R #81 not receiving the necessary services immediately upon returning home, leaving her to navigate the process unassisted.
Failure to Serve Meal as Per Resident's Dietary Needs
Penalty
Summary
The facility failed to meet the nutritional needs and preferences of a resident on a Consistent Carbohydrate (CCHO) diet, as evidenced by the staff's failure to serve the food items listed on the resident's meal ticket. The resident was supposed to receive a side salad with dinner, as indicated on the meal ticket dated 01/07/25. However, during an interview, the resident reported that the kitchen staff did not consistently follow the meal instructions, and despite informing the nursing staff, the issue persisted. During a dinner observation, the resident was served a meal without the side salad. Both a Licensed Practical Nurse and the Dietary Manager confirmed that the resident did not receive the side salad and acknowledged that it should have been provided as per the meal ticket.
Delayed Emergency Response for Resident on Blood Thinners
Penalty
Summary
The facility failed to provide appropriate interventions for a resident who experienced a fall resulting in a head laceration while on blood thinners. The resident, who was taking Apixaban, a blood thinner, fell and hit her head on a bedside table, causing a laceration and significant bleeding. Despite the severity of the injury and the resident's medication, which increased the risk of bleeding, the facility delayed sending the resident to the emergency room for several hours. The incident occurred at approximately 6:00 am, but the resident was not transported to the hospital until around 9:48 am, after EMS was contacted at 7:26 am. Interviews with staff revealed confusion and a lack of urgency in handling the situation. LPNs involved in the incident could not recall whether they called 911 or scheduled an EMS transport, which contributed to the delay. The Nurse Practitioner and Assistant Director of Nursing acknowledged that the resident should have been sent to the ER immediately due to the head injury and blood thinner use. The delay in treatment could have exacerbated the resident's condition, as the head laceration required staples to repair once the resident was finally seen in the ER.
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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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