Gallup Nursing & Rehabilitation Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Gallup, New Mexico.
- Location
- 306 East Nizhoni Blvd, Gallup, New Mexico 87301
- CMS Provider Number
- 325118
- Inspections on file
- 23
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Gallup Nursing & Rehabilitation Llc during CMS and state inspections, most recent first.
Surveyors found that staff failed to follow physician-ordered parameters for blood pressure (BP) medications for two residents. For one resident, lisinopril was given despite a systolic BP below the ordered hold parameter. For another resident, carvedilol was withheld on two occasions even though the documented BP and heart rate were within the ordered range for administration, and required nursing notes explaining the omissions were not entered. The DON confirmed that vital signs should be documented in the MAR and that medications must be administered or held according to provider orders, which did not occur in these cases.
Surveyors found that a resident room had multiple strips of floor tape that were worn, curling, and leaving sticky, uneven residue near the bedside area, and that a hallway near the dining room had a hose connected to a wall-mounted water source by an ice machine that was not properly secured in its protective case, causing water to drip and form a puddle on the floor. The Maintenance Supervisor and the ADM acknowledged that floor tape should remain flat and that the hose should be secured to prevent tripping and slipping hazards for residents.
Surveyors found that multiple resident rooms and bathrooms were not maintained in safe and functional condition, including windowsills separating from walls with visible gaps, loose tiles near beds, damaged heating vents, and an electrical outlet housing separated from the wall. Walls and bathroom doors in several rooms had scuff marks, chipped or uneven paint, and visible unpainted wood putty. According to the Maintenance Supervisor, surfaces should be evenly painted, windowsills should not separate from walls, and rooms are expected to be kept in good repair so that residents feel at home.
A resident was admitted and did not have a baseline care plan developed within 48 hours as required by facility policy. Record review showed the baseline care plan was initiated more than two days after admission. In interviews, the DON and the Administrator confirmed their expectation that baseline care plans be completed within 48 hours, and acknowledged that this did not occur for this resident.
A resident with HTN and cardiac conditions had a physician order for carvedilol to be held only if SBP was below a specified threshold or HR was under 60 bpm. On two occasions, the MAR showed carvedilol doses as not administered with instructions to see a nurse or progress note, even though the recorded vital signs were within ordered parameters for administration. No corresponding nursing or progress notes were found to explain why the doses were held, while other doses with similar vital signs were documented as given. The DON confirmed that when a medication is marked as held with a direction to see a note, a note explaining the reason is expected, and acknowledged the medical record was not accurate.
A resident with dementia, bladder neck obstruction, and an indwelling Foley catheter for chronic urinary retention was observed on multiple occasions without required catheter privacy measures and with improper tubing positioning. The facility’s policy required drainage bags to be covered with a privacy bag when out of bed and catheter tubing to be secured off the floor. During meal and common-area observations, the resident’s drainage bag lacked a privacy cover and the catheter tubing was seen touching the floor. CNAs, the DON, and the Administrator all acknowledged that catheter bags should be covered and tubing should not drag on the floor, confirming that established infection control procedures were not followed.
A resident with a history of falls and multiple medical conditions experienced an unwitnessed fall resulting in a head injury. Despite facility policy, no neurological checks were documented, leading to a delay in identifying a severe brain bleed. The resident's condition worsened, resulting in hospitalization and eventual passing.
A resident experienced an unwitnessed fall resulting in a head injury, which was not reported to the SSA as required by the facility's policy. The resident was found on the floor with a cut over the right eye and later sent to the ER for a CT scan due to altered mental status. The incident was not logged in the facility's Incident Report Log, and the administrator was unaware of the event, as the responsible agency nurse was no longer employed.
The facility's binding arbitration agreement failed to include a provision for selecting a convenient venue for arbitration proceedings. This deficiency was confirmed by the facility Administrator and noted during a record review. Although the facility's Admission Guide mentioned the provision, it lacked a signed acknowledgment from residents, potentially affecting 56 of the 57 residents who signed the agreement.
A resident felt disrespected when a staff member closed his room door without proper communication, as his music was deemed too loud during a nearby meeting. The Housekeeping Manager informed the roommate instead of the resident and did not wait for a response, assuming agitation. This action violated the resident's rights to dignity and respect.
A facility failed to create a Baseline Care Plan within 48 hours for a newly admitted resident with complex medical conditions, including acute respiratory failure and post-COVID-19 condition. The plan was completed three days post-admission, as confirmed by the Administrator, which deviated from required protocols.
A resident with hepatic encephalopathy did not receive a prescribed dose of lactulose due to staff holding the medication after the resident experienced loose stools. The DON clarified that the medication was intended to manage encephalopathy, not constipation, and loose stools were a sign of the medication's effectiveness.
Failure to Follow BP Medication Parameters and Document Withheld Doses
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services met professional standards of quality by not following physician orders for blood pressure medications for two residents. For one resident, a physician’s order dated 07/16/25 directed that lisinopril be held if the systolic blood pressure was less than 110 mmHg. Review of the Medication Administration Record (MAR) from 01/01/26 to 01/21/26 showed that on 01/05/26, staff administered lisinopril despite a documented systolic blood pressure of 105 mmHg, which was below the ordered hold parameter. For the second resident, a physician’s order dated 11/20/25 specified that carvedilol for hypertension be held only if the systolic blood pressure was less than 110 mmHg or the heart rate was less than 60 beats per minute. The MAR for 01/01/26 to 01/21/26 showed that on 01/01/26, a dose of carvedilol was not administered and was marked “see progress note,” even though the recorded systolic blood pressure was 118 mmHg and heart rate was 70 beats per minute, both within parameters; the corresponding progress notes from 01/01/26 to 01/02/26 contained no documentation explaining the withheld dose. On 01/16/26, the evening dose of carvedilol was again not administered and referenced a nurse’s note, while the MAR documented a systolic blood pressure of 156 mmHg and heart rate of 60 beats per minute, which were within the ordered parameters, and nursing notes from 01/16/26 to 01/17/26 did not document a reason for withholding the medication. During an interview, the DON confirmed that vital signs are expected to be documented in the electronic MAR and that medications should be administered or held according to the provider’s parameters, and acknowledged that staff did not follow the orders in these instances.
Failure to Maintain Safe Flooring and Control Water Leakage Hazards
Penalty
Summary
Surveyors identified a deficiency in maintaining a safe environment when multiple strips of adhesive tape were observed on the bedroom floor near the bedside area in Room 41. Several of these tape strips were worn, partially detached, and curling upward at the edges, and dark adhesive residue remained where tape had deteriorated or been removed, creating uneven and sticky surface areas. These conditions were directly observed in the resident room and were acknowledged by the Maintenance Supervisor, who stated his expectation that tape applied to floors should be flat to the ground to prevent a tripping hazard. Surveyors also observed a deficiency in the hallway leading to the dining room, where a hose connected to a wall-mounted water source next to the ice machine was actively dripping water onto the floor, forming a small puddle. The hose was supposed to be secured within a clear plastic protective case, but the case did not securely hold the hose in place, allowing the dripping to occur in an area accessible to all residents. In interviews, both the Maintenance Supervisor and the Administrator stated that the hose nozzle should be secured inside the clear plastic case to prevent water from dripping onto the floor and that tape placed on the floor should remain flat with the surface to prevent residents from tripping or falling.
Failure to Maintain Safe and Functional Resident Room Environments
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain a safe, clean, and functional physical environment in multiple resident rooms and bathrooms. Observations showed that several windowsills were separating from the wall, unpainted, or had loose tiles, including in rooms near specific beds where gaps of approximately 0.5 to 1 inch were noted between the sill and the wall. In one room, the windowsill closest to a bed was unpainted and separating from the wall, while in other rooms the windowsills near beds had loose tiles or were separating from the wall. An electrical outlet housing behind a bed was also observed to be separated from the wall. Additional observations revealed scuff marks, chipped paint, and uneven paint coverage on bathroom walls and other wall surfaces in several rooms. One room’s interior bathroom door had visible, unpainted wood putty, and the bathroom door and multiple walls had uneven paint coverage, with scuffed walls behind a bed. Another room’s heating vent had three broken horizontal slats, indicating the vent was damaged and could not properly control the flow of warm air, and the same room’s bathroom walls had scuff marks and chipped paint. During an interview, the Maintenance Supervisor stated that scuff marks should be painted evenly, windowsills should be in good repair and not separating from the wall, and that it was his expectation that resident rooms be in good repair so residents feel like they are at home.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for one resident. The facility’s policy on Care Plans – Baseline, dated December 2016, required that a baseline care plan be developed within 48 hours of a resident’s admission to ensure the resident’s immediate care needs are met and maintained. Record review showed that the resident was admitted on an identified date, but the baseline care plan for this resident was not initiated until 01/12/26, which was more than 48 hours after admission. During interviews, the DON stated that it was her expectation that the resident’s baseline care plan should have been completed on 01/11/26, and the Administrator stated that it was her expectation that residents’ baseline care plans be completed within 48 hours of admission. This deficiency was identified for 1 of 1 resident reviewed for baseline care plans and was based on record review of the resident’s face sheet and baseline care plan, as well as staff interviews confirming that the facility did not meet its own policy requirement for timely completion of the baseline care plan.
Incomplete Documentation of Held Antihypertensive Medication
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records related to medication administration for one resident prescribed carvedilol for hypertension and other cardiac conditions. The physician’s order dated 11/20/25 directed that carvedilol be held only if the resident’s systolic blood pressure was less than 110 mmHg or heart rate was less than 60 beats per minute. Review of the Medication Administration Record (MAR) for 01/01/26 showed the morning dose of carvedilol was documented as not administered with a direction to “see progress note,” while the recorded vital signs that morning were a systolic blood pressure of 118 mmHg and heart rate of 70 beats per minute, which were within the ordered parameters for administration. No corresponding progress note was found for that date explaining why the medication was withheld. Further review of the MAR from 01/01/26 to 01/21/26 showed that the evening dose of carvedilol on 01/01/26 was documented as administered, with the same vital signs recorded for that evening as in the morning (systolic blood pressure 118 mmHg and heart rate 70 beats per minute). On 01/16/26, the evening dose of carvedilol was again documented on the MAR as not administered with a notation to “see nurses note,” yet the resident’s vital signs that day showed a systolic blood pressure of 156 mmHg and heart rate of 60 beats per minute, which were within the parameters for giving the medication. No nursing note was entered on 01/16/26 or 01/17/26 to explain the reason for withholding the dose. In an interview, the DON stated that when a nurse documents a medication as held with a direction to see a note, it is expected that a corresponding note be entered, and confirmed that the resident’s medical record regarding medication administration was not accurate.
Failure to Maintain Catheter Privacy and Tubing Position per Infection Control Policy
Penalty
Summary
The deficiency involves the facility’s failure to follow its catheter care and infection prevention procedures for a resident with an indwelling Foley catheter. The facility’s Catheter Care Procedure, last revised June 2020, required that catheter drainage bags be kept below the level of the bladder, off the floor, and covered with a privacy bag when the resident is out of bed. The resident, originally admitted with dementia and bladder neck obstruction and assessed with a BIMS score indicating severe cognitive impairment, had physician orders for an indwelling Foley catheter PRN for chronic urinary retention. During a lunch observation in the dining room, the resident was seen sitting in a wheelchair with the catheter drainage bag uncovered, without the required privacy bag. In a separate observation in a common TV area, the same resident was seen in a wheelchair with the urinary catheter tubing touching the floor, contrary to the facility’s policy to keep tubing off the floor. Staff interviews confirmed that these practices did not meet facility expectations: a CNA stated that all residents should have a privacy bag covering their urinary drainage bags, another CNA reported that the previous CNA had forgotten to attach the catheter bag to the chair and acknowledged that the tubing should not be dragged on the floor, and both the DON and the Administrator confirmed that catheter tubing should not touch the ground and that a privacy bag should always be in place when residents are out of their rooms. These observations and statements demonstrate that the facility did not maintain its infection prevention and control program for this resident’s catheter care.
Failure to Conduct Neurological Checks After Resident Fall
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice following an unwitnessed fall that resulted in injury. The resident, who had a history of frequent falls and was at high risk for falls due to multiple medical conditions including Parkinson's Disease, dementia, and generalized muscle weakness, was found on the floor with a laceration over his right eye. Despite the facility's policy requiring neurological checks for 72 hours following an unwitnessed fall, no neuro evaluations were completed or documented for the resident. The resident's condition deteriorated over the following days, with vital signs indicating changes and a noted alteration in mental status. The resident was eventually sent to the emergency room for a CT scan, which revealed a large left temporal lobe bleed and other significant brain hemorrhages. The lack of timely and appropriate neurological assessments likely contributed to the delay in identifying the resident's life-threatening condition. Interviews with facility staff, including the Director of Nursing and the Assistant Director of Nursing, confirmed that the expected neurological checks were not performed. The facility's failure to adhere to its own post-fall assessment and monitoring policy resulted in the resident's hospitalization and subsequent passing, highlighting a significant deficiency in the care provided to the resident.
Failure to Report Unwitnessed Fall with Injury
Penalty
Summary
The facility failed to report an unwitnessed fall with injury for a resident to the State Survey Agency (SSA), as required by their policy. The incident involved a resident who was found on the floor in their room with a cut over the right eye. The nursing progress notes indicated that the resident was later sent to the emergency room for a CT scan due to a change in mental status. Despite these events, the facility's Incident Report Log did not contain any record of the fall being reported. The facility's policy mandates that a licensed nurse complete an incident report and perform a post-fall assessment following each resident fall. Additionally, a Neurological Flow Sheet should be completed for any unwitnessed fall or witnessed fall with a head injury. However, the administrator confirmed that the incident was not reported to her, and thus, not filed with the SSA. The nurse responsible for documenting the fall was an agency nurse who is no longer employed at the facility, which contributed to the failure in reporting the incident.
Arbitration Agreement Lacks Venue Provision
Penalty
Summary
The facility failed to ensure that their binding arbitration agreement included a provision for the selection of a convenient venue, which is necessary for arbitration proceedings. This omission could potentially deter residents from exercising their rights to seek arbitration due to the inconvenience and frustration it may cause. The deficiency was identified during a record review of the facility's Voluntary Arbitration Agreement, which was found to be undated and lacking the necessary provision. During an interview, the facility Administrator confirmed the absence of this provision in the arbitration agreement, although it was mentioned in the facility's Admission Guide. However, the Admission Guide did not include a signed acknowledgment from residents confirming receipt, understanding, and inclusion of this provision as part of the Voluntary Arbitration Agreement. This issue has the potential to affect 56 of the 57 facility residents who signed the binding arbitration agreement.
Failure to Respect Resident's Rights and Dignity
Penalty
Summary
The facility failed to uphold a resident's rights to dignity and respect when a staff member closed a resident's room door against his wishes and without proper communication. The incident involved a resident who was listening to music at a volume audible in the hallway. The Housekeeping Manager (HM) closed the door at the request of the facility Administrator due to a nearby staff meeting. The HM informed the resident's roommate instead of the resident himself and did not wait for the resident's response, assuming he was agitated. This action led the resident to feel disrespected and uncared for by the staff.
Failure to Create Timely Baseline Care Plan
Penalty
Summary
The facility failed to create a Baseline Care Plan within 48 hours of admission for one of the residents reviewed. This deficiency was identified during a record review and interview process. The resident in question, identified as R #108, was admitted with multiple complex medical conditions, including acute respiratory failure with hypoxia, type 2 diabetes mellitus with neuropathy, hyperlipidemia, obstructive sleep apnea, hypertension, atherosclerotic heart disease, congestive heart failure, pneumonia due to coronavirus disease, asthma, muscle wasting and atrophy, overactive bladder, difficulty in walking, and post-COVID-19 condition. Despite these significant health issues, the baseline care plan, which is crucial for ensuring immediate and appropriate care, was not created until more than 48 hours after the resident's admission. The delay in creating the baseline care plan was confirmed during an interview with the facility's Administrator, who acknowledged that the staff did not complete the plan within the required timeframe. The baseline care plan for the resident was only completed three days after admission, which is a clear deviation from the expected protocol. This oversight could potentially lead to a decline in the resident's condition due to the staff's lack of awareness of the necessary care requirements, as the baseline care plan is essential for guiding immediate care upon admission.
Failure to Administer Medication as Prescribed
Penalty
Summary
The facility failed to meet professional standards of practice in the administration of medication for a resident diagnosed with hepatic encephalopathy. The resident was prescribed lactulose, a medication intended to decrease ammonia levels in the blood, to be administered 45 milliliters by mouth three times a day. However, a review of the Medication Administration Record for September 2024 revealed that the midday dose of lactulose was not administered on September 3, 2024, due to a note to hold the medication. The nurse's progress note indicated that the resident had experienced three loose stools since the morning, which led to the decision to withhold the medication. During an interview, the Director of Nursing stated that the lactulose should not have been held due to loose stools, as the medication was prescribed to manage encephalopathy, not constipation, and loose stools were indicative of the medication's desired effect.
Latest citations in New Mexico
Surveyors found that the facility did not provide required written transfer and bed-hold notices when several residents were sent to the hospital for events such as falls with injury, unresponsiveness, and episodes of nausea, vomiting, and bleeding. Medical records lacked written transfer notices and bed-hold notifications, and the transfer information that should have been given to residents or their representatives did not include mandated details about appeal rights, how to request an appeal, or how to contact the State LTC Ombudsman. The Social Services Director reported that she does not notify the Ombudsman of hospital transfers and only sends a monthly email list of discharged residents, without written copies of transfer or discharge notices.
Two cognitively impaired residents with dementia and significant behavioral and continence needs were sent to a local ER after falls and were discharged back to the facility’s care, but the facility failed to provide timely transportation for their return. In both cases, hospital discharge times were documented, yet ER staff reported making multiple unsuccessful calls to the facility, reaching the Administrator only after repeated attempts. One resident, described as very disoriented, remained in the ER for several hours after discharge without 1:1 supervision, while the other waited approximately 11 hours, during which ER staff observed increasing confusion and attempts to get out of bed. The Administrator acknowledged awareness of the discharges, the lack of 24-hour transportation, and that the residents were not picked up until many hours after they had been discharged from the ER.
Two residents who required staff assistance for ADLs and transfers reported neglectful and rude behavior by a CNA and delayed nursing response to care needs. One resident with a history of cerebral infarction and schizophrenia stated that a CNA mocked him and that his requested wound dressing change was not performed for several hours, which was later corroborated by video showing a long gap between the CNA’s visit and the nurse’s entry to the room. Another resident with a right femur fracture, type II DM, and repeated falls, who needed one-person assistance for mobility and self-care, reported that a CNA refused to help and told her she could do some care herself, making her feel she was not trying in her recovery. Documentation and interviews confirmed that staff did not provide timely wound care or required assistance, and that these interactions caused residents to feel uncomfortable and negatively about their care.
A resident with a history of opioid dependence and polysubstance abuse was on a secure unit with a care plan that included safety risk evaluations and monitoring for signs of substance abuse. Staff later observed the resident discarding an empty Suboxone packet, even though the resident was not prescribed this medication, and the incident was reported to the on-call provider with subsequent monitoring and a room search. However, the care plan was not revised to reflect this new substance-related event, and both the DON and Administrator acknowledged that the care plan should have been updated when this new risk and behavior were identified.
Surveyors identified that a medication cart on the north hall was left unlocked and unattended outside a resident room. An LPN acknowledged that the cart was hers and that she had not locked it before leaving to answer a call light, despite facility expectations. The DON confirmed that all medication and treatment carts are required to remain locked when not in use or when staff are away from them.
Surveyors found that a document containing multiple residents’ PHI, including full names, room numbers, and code status, was left unattended and visible on a south nurse’s station counter. An RN confirmed the document was a resident list with PHI and acknowledged it had been left exposed and that such information should not be left unattended.
Surveyors found that a lunch tray return cart containing uncovered, soiled food trays and dishes was left unattended in a main hallway outside an activity room. The housekeeping/laundry manager acknowledged seeing the unattended cart, and the Dietary Manager confirmed that such carts are supposed to remain only in designated areas, such as near the nurse’s station or in the kitchen, and should be returned to the kitchen for cleaning as soon as all trays are collected. This failure was cited as likely to expose all residents to potential pathogens associated with food waste.
Two residents with scheduled showers reported that they were offered or received showers in very cold water during a prolonged period when hot water was not reliably available in care areas. One resident stated he refused cold showers and was only offered sponge baths once or twice, despite his preference to stay clean. Another resident reported receiving cold showers, including being rinsed with cold water while still soaped, and subsequently began refusing showers and bed baths due to the cold water. A CNA confirmed that water in the shower rooms was “ice cold” for several months, leading to resident complaints and refusals, while the Maintenance Director reported that a needed part to correct the hot water problem was on back order, delaying resolution and resulting in the facility not honoring residents’ bathing preferences.
Surveyors observed that unused medications were improperly discarded in a trash bin attached to a medication cart on the north hallway, rather than being disposed of in a designated drug disposal container. Two pills, a round blue tablet stamped "61" and an oblong orange tablet stamped "20," were found together in an unlabeled medication cup in the trash. An RN confirmed the medications were discarded there and acknowledged that unused medications should be placed in the drug buster container in the cart drawer. The Unit Manager also confirmed that facility practice requires all unused medications to be disposed of using the drug buster and that controlled substances must be destroyed by two licensed staff and documented on the narcotic count sheet.
The facility failed to follow documented allergy information, diet orders, and meal tickets for three residents. A resident with a documented chocolate allergy was served chocolate ice cream after requesting it, and the Nutrition Director admitted not reading the allergy notation on the meal ticket. Another resident on a pureed diet received whole mandarin oranges instead of pureed fruit, which a CNA confirmed. A third resident whose meal ticket called for a grilled Swiss sandwich received a sandwich that was not grilled, as confirmed by a CNA and a dietary manager.
Failure to Provide Required Written Transfer, Appeal, Ombudsman, and Bed-Hold Notices During Hospitalizations
Penalty
Summary
Surveyors identified that the facility failed to provide required written transfer and bed-hold information for multiple residents who were hospitalized. For three residents who experienced transfers to the hospital after events such as falls with injury, unresponsiveness, and episodes of nausea, vomiting, and bleeding, record review showed there were no written transfer notices or written bed-hold notices in their medical records. Specifically, one resident transferred after a fall on 01/31/26 had no documented written transfer notice or bed-hold notice. Another resident transferred on 02/27/26 for nausea, vomiting, and bleeding, and later readmitted on 03/05/26, had no written transfer notification that included information on appeal rights or Ombudsman contact, and no written bed-hold notification. A third resident transferred on 01/29/26 after a fall with a forehead laceration and again on 03/17/26 for unresponsiveness, also had no documented written transfer or bed-hold notices for either hospitalization. The deficiency also included the facility’s failure to provide required content in transfer notices and to notify the State Long-Term Care Ombudsman in writing. For the residents reviewed, there was no evidence that written transfer notices were provided to the residents or their representatives in a language and manner they could understand, and the notices were missing required elements such as a statement of appeal rights, the name, mailing and email address, and phone number of the entity receiving appeals, and information on how to obtain and complete an appeal form. The notices also lacked the name, phone number, and mailing and email address of the State Long-Term Care Ombudsman, and written copies of the transfer notices were not sent to the Ombudsman. During interview, the Social Services Director confirmed that transfer and bed-hold notices were not documented for at least one resident’s hospitalization, that she does not notify the Ombudsman about transfers to the hospital, and that she only emails a monthly list of residents discharged from the facility without sending written copies of transfer or discharge notices.
Failure to Timely Retrieve Residents From ER After Discharge
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from neglect by not arranging timely transportation back to the facility after emergency room (ER) discharge. A consumer complaint alleged that residents sent to the local ER were being left there for extended periods after discharge. For one resident with an admission date of 10/13/25, records showed multiple cognitive and behavioral diagnoses, including Alzheimer’s disease, vascular dementia with agitation and other behavioral disturbances, mild cognitive impairment, cognitive communication deficit, and restlessness and agitation. A change of condition MDS documented a Brief Interview for Mental Status (BIMS) score of 1 and frequent incontinence of urine and bowel. Nursing progress notes for this resident showed that 911 was called at 3:00 AM and the resident was transferred to the ER after a fall. Hospital discharge instructions indicated the resident was discharged from the ER at approximately 5:21 AM, while the ER nurse reported discharge at about 5:30 AM. The ER nurse stated she made numerous calls to the facility but was unable to reach anyone. She reported that the resident was very disoriented and that the ER did not have enough staff to provide 1:1 supervision. The ER nurse eventually reached the Administrator, who stated staff would come to pick up the resident as soon as possible. Facility records showed the resident was not discharged from the facility on that date, and the ER nurse reported that facility staff did not pick the resident up until approximately 8:30 AM, several hours after discharge. A second resident, admitted on 11/25/25, had diagnoses including Alzheimer’s disease, dementia with behavioral disturbance, bipolar disorder with severe depression and psychotic features, depression, and anxiety disorder. The admission MDS documented a BIMS score of 2, frequent urinary incontinence, constant bowel incontinence, and a need for substantial/maximal assistance with toileting hygiene. Nursing notes showed this resident was sent to the ER for evaluation after a fall and did not return until the following morning. Hospital discharge instructions documented discharge from the ER at 10:16 PM, and the Administrator confirmed being notified of the discharge at about 10:30 PM and that the facility did not have 24-hour transportation. The Administrator acknowledged the resident was not picked up until approximately 9:00 AM the next day. The ER nurse reported making several calls to the facility that went to voicemail, eventually reaching the Administrator, who initially stated staff were on the way, then stopped answering calls. During the approximately 11-hour wait, the ER nurse stated the resident was confused, attempted to get out of bed, and became more confused as the night progressed.
Failure to Timely Provide Wound Care and Required Assistance, Resulting in Resident Neglect
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from neglect when staff did not respond appropriately to requests for care and assistance. One resident with a history of cerebral infarction due to embolism and schizophrenia, admitted on 01/30/26 and requiring staff assistance for ADLs and mechanical lift transfers, reported that a CNA was rude and mocking and that his wound dressing was not changed for several hours after he requested it. The Kardex showed he needed staff help for toileting, bathing, hygiene, bed mobility, dressing, and transfers. Nursing progress notes documented a change in condition on 03/02/26 after the resident stated the CNA was rude and would not assist as requested. The Administrator later confirmed, via video review, that the CNA entered the resident’s room at 2:30 am, the resident requested a dressing change, and no nurse entered the room until 5:00 am, despite the nurse’s statement that she went in “right away.” The DON also confirmed that the resident’s grievance described the wound dressing not being changed until hours after the request. Another resident, admitted with a right femur fracture, type II diabetes, and repeated falls, required one-person assistance for dressing, hygiene, bathing, bed mobility, and transfers, and could toilet herself with assistance for transfers. Nursing progress notes documented an alleged abuse incident on 03/02/26 in which this resident stated a CNA was rude, refused to help her, and told her she could perform some care tasks herself without staff assistance. An abuse questionnaire completed the same day showed the resident answered “Yes” to having interactions that made her feel uncomfortable or negative, and she reported that the CNA made her feel as though she was not trying with her own recovery. The Administrator and DON acknowledged that staff are expected to help residents as required and that staff interactions must be encouraging rather than making residents feel bad about needing assistance.
Failure to Revise Care Plan After Substance-Related Incident
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s care plan after a significant substance-related incident. The resident was originally admitted with a diagnosis of opioid dependence and resided on a secure unit related to polysubstance abuse disorder. The existing care plan, dated 01/21/26, identified the resident as residing on a secure unit due to polysubstance abuse disorder with interventions to perform safety risk evaluations on admission, as needed, and upon changes in condition. The care plan also identified the resident as at risk for substance use disorder with interventions to monitor for signs or symptoms of substance abuse. On 02/01/26, nursing notes documented that staff observed the resident discarding an empty Suboxone packet in the trash, even though the resident was not prescribed Suboxone and denied taking any. Staff notified the on-call provider, who ordered monitoring for adverse reactions, and nursing staff and security conducted a room search that revealed no additional contraband. Despite this incident, the resident’s care plan was not updated to address the new substance-related event. During interviews, the DON acknowledged awareness of the incident and confirmed the care plan was not revised, and the Administrator stated her expectation that nursing would update the care plan when a new risk or behavior was identified and confirmed she would have expected the care plan to be updated for this resident.
Unattended, Unlocked Medication Cart on North Hall
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were properly stored and secured in accordance with professional standards and facility expectations. On 03/24/26 at 9:06 a.m., surveyors observed a medication cart on the north hall left unlocked and unattended outside a resident room. At 9:08 a.m., the LPN responsible for the cart confirmed during interview that the cart was hers, that it was unlocked and unattended, and acknowledged she should have locked it before responding to a call light. Later that day at 3:37 p.m., the DON stated in an interview that medication and treatment carts are expected to be locked at all times when nurses are away from them, confirming that the observed practice did not meet facility expectations. This deficient practice was cited as likely to allow unauthorized personnel access to medications, which could result in injury or overdosing.
Unattended PHI Document Left Exposed at Nurse’s Station
Penalty
Summary
Surveyors identified a deficiency in the facility’s protection of residents’ personal health information (PHI) when a document containing multiple residents’ full names, assigned room numbers, and code status was left unattended and exposed on the south nurse’s station counter. On 03/16/26 at 9:04 a.m., an observation revealed a piece of paper on a clipboard with complete resident information placed on top of the south nurse’s counter in public view. At 9:06 a.m., during an interview, RN #2 confirmed that the list contained residents’ names, room numbers, and code status, acknowledged that it had been left exposed and unattended, and stated that PHI should not be left unattended. No additional clinical details or medical histories of the residents listed on the document were provided in the report.
Unattended Soiled Lunch Cart Left Uncovered in Hallway
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the handling of soiled food service equipment. On 03/24/26 at 12:58 pm, a lunch tray return cart containing soiled food trays and dishes that were uncovered was observed sitting unattended in the main hallway outside the activity room. At 1:06 pm, the housekeeping/laundry manager confirmed she saw the return cart left unattended in that location. At 1:08 pm, the Dietary Manager stated that lunch return carts should only be left in designated areas such as by the nurse’s station or inside the kitchen, and that the cart should be returned to the kitchen for cleaning as soon as all trays have been picked up, which did not occur in this instance. This deficient practice was noted as likely to expose all residents to potential pathogens associated with food waste.
Failure to Honor Resident Bathing Preferences During Prolonged Hot Water Issues
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ bathing preferences when hot water was not reliably available in resident care areas. Record review showed that one resident was scheduled to receive three showers per week on specific days, and another resident was scheduled for two showers per week. One resident reported that staff attempted to have him shower in cold water, which he refused, and that sponge baths were only offered once or twice during the period when the hot water was not working. He stated that he liked to be clean and did not feel like himself when he was dirty. A CNA reported that there was no hot water in resident care areas from the middle of December until early March, and that large barrels of warm water were brought to shower rooms to offer sponge baths, which this resident refused. Another resident, also on a scheduled twice-weekly shower regimen, stated that she received cold showers and began refusing showers because of how cold the water was. She described the water running cold unpredictably, including an instance when the water was initially warm but turned cold while she was still soaped, requiring rinsing with cold water, which she described as horrible. A social services note documented that this resident’s daughter reported the resident had been declining showers and bed baths offered because the water was too cold. A CNA corroborated that the water was “ice cold” and that residents began complaining and refusing showers around mid-December. The Maintenance Director stated that it took a while for hot water to reach the shower room and that a needed part to fix the cold-water problem was on back order, contributing to the prolonged period of inadequate hot water and resulting in residents not having their bathing preferences honored.
Improper Disposal of Unused Medications on Medication Cart
Penalty
Summary
Surveyors identified a deficiency related to accident hazards and inadequate supervision when unused medications were improperly discarded on the north hallway. During observation of the north hall nurses’ station, two medications were found in the trash bin attached to the medication cart, placed together inside an unlabeled medication cup. The pills were described as a round blue pill stamped with “61” and an oblong orange pill stamped with “20.” In an interview immediately following the observation, an RN confirmed that these medications were in the trash bin and stated that unused medications should instead be disposed of in the drug buster, a sealed container for drug disposal located in the bottom drawer of the cart. In a subsequent interview, the Unit Manager confirmed that all unused medications are to be disposed of using the drug buster and acknowledged that this did not occur, further stating that if the medications are controlled substances such as narcotics, two licensed personnel are required to dispose of them together and document the disposal on the narcotic count sheet. This deficient practice was noted as likely to affect any resident who might acquire and ingest the discarded medications, potentially causing medication side effects.
Failure to Follow Allergy, Diet, and Meal Ticket Requirements
Penalty
Summary
The facility failed to provide meals consistent with residents’ documented allergies, diet orders, and meal tickets for three residents. One resident, admitted with a documented allergy to chocolate, had a face sheet and lunch ticket indicating they were not to receive chocolate. During a lunch observation, this resident was served and was eating chocolate ice cream. An LPN confirmed the resident’s chocolate allergy and that the resident should not be eating chocolate. The Nutrition Director acknowledged that the meal ticket stated the resident should not have chocolate but reported serving chocolate ice cream after the resident requested it, stating he had not read that the resident was allergic to chocolate. Another resident, admitted with hypokalemia and ordered a regular/liberalized pureed diet per the MDS, had a lunch ticket indicating a pureed diet but was observed receiving whole mandarin oranges instead of pureed fruit. A CNA confirmed that the dessert was not pureed. A third resident’s meal ticket specified a grilled Swiss sandwich, but observation of the tray showed the sandwich was not grilled. During interviews, a CNA and a dietary manager confirmed that the sandwich was not grilled as ordered on the meal ticket.
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