Grants Wellness & Rehabilitation Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Grants, New Mexico.
- Location
- 840 Lobo Canyon Road, Grants, New Mexico 87020
- CMS Provider Number
- 325058
- Inspections on file
- 17
- Latest survey
- January 22, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Grants Wellness & Rehabilitation Llc during CMS and state inspections, most recent first.
Surveyors found that multiple residents were kept in cold rooms on one unit where thermostats in individual rooms did not function and temperatures were controlled from the nurse’s station, with staff acknowledging frequent complaints about the cold and the lack of temperature logs. In addition, a resident with atopic dermatitis, type 2 DM with neuropathy, varicose veins with inflammation, and dementia was observed multiple times lying directly on a bare plastic mattress without sheets or blankets, despite CNA, RN, and DON expectations that beds be remade immediately after linens are removed and that residents not remain on uncovered mattresses.
A resident with diabetes, prior TIA and stroke, cognitive communication deficit, and depression had multiple MDS assessments in which Section C (Cognitive Patterns) was repeatedly left incomplete. Across several assessments, items determining whether BIMS should be conducted, the BIMS questions themselves, the staff assessment for mental status, and short- and long-term memory fields were left unanswered or dashed, resulting in no BIMS score while some cognitive items were still coded (e.g., memory and decision-making). The MDS Coordinator confirmed responsibility for these assessments and acknowledged that Section C was expected to be fully completed but was not.
A resident with Type 2 DM, neuropathy, paraplegia, and reduced mobility had a physician order for daily diabetic foot checks, including skin assessment, shoe inspection, and pedal pulse checks, but this care was not documented as completed over an extended period. The resident’s care plan did not include diabetic foot care despite the order. A later podiatry consult identified thickened, painful toenails, nail dystrophy, localized edema, and slightly diminished foot and ankle ROM, and the podiatrist performed nail debridement and recommended ongoing daily foot checks. The DON acknowledged that it was expected for physician orders to be followed and confirmed the ordered foot care was not provided as required.
The facility's Legionnaires Water Management Program lacked essential procedures, control limits, monitoring protocols, and intervention strategies to prevent the introduction and spread of Legionella in the water system. Leadership, including the Administrator, DON, and Infection Control Preventionist, were unaware of these deficiencies, potentially affecting all residents.
A resident with severe cognitive impairment and neurological disease was observed in the dining room with an actively bleeding hand wound, blood on his hands, face, and clothing, and was left to feed himself with bloody hands. Staff served his meal and walked away without addressing the bleeding, and the DON confirmed this was unacceptable and that the wound should have been cleaned and covered.
Two residents were administered psychotropic and related medications, including antidepressants, anticonvulsants, antianxiety, and antipsychotics, without documented informed consent forms in their medical records. The DON confirmed that such consent should have been obtained and documented to ensure residents or their guardians were aware of the reasons, risks, and benefits of each medication.
Two residents were admitted with complex medical conditions, but the facility did not complete baseline care plans within 48 hours for one, and for the other, the care plan failed to address several key diagnoses such as dementia with psychotic disturbance, infection, and blindness. The DON confirmed these omissions and delays did not meet expectations for timely and comprehensive care planning.
A resident with blindness and depression did not have a care plan addressing activities, despite documented needs and expressed interest in participating in activities like bingo if assisted. The DON confirmed the Activities Department was responsible for this care plan, but it had not been developed. The resident was observed attempting to engage in activities without support.
The facility did not ensure the safe operation of essential kitchen equipment by failing to replace a broken plastic light cover over the stove. The dietary manager noted the cover had been broken since September 2023 and had not submitted a formal repair request, relying instead on verbal requests. The cover was held together with old, dirty tape, with a piece missing.
A facility failed to accommodate a resident's needs by not ensuring the call light was within reach and lacking signage in Navajo-Dine. The resident, with a history of falls, had the call light under the bed during multiple observations. A CMA confirmed the need for the call light to be accessible. Additionally, required signage in Navajo-Dine was missing, as confirmed by Social Services.
The facility failed to provide a home-like environment for 33 residents due to mice droppings found in various areas, including dining rooms and resident rooms. Staff reported the issue to management, but the problem persisted, indicating inadequate cleaning and pest control measures.
The facility failed to respect resident privacy and dignity by not knocking on bedroom doors before entering. A nurse entered a resident's room without knocking while the resident was asleep and later returned with a CMA, again without knocking. The nurse also entered another resident's room without knocking to perform personal care. The facility's policy requires staff to knock and announce their presence, but staff were in a hurry looking for supplies.
A facility failed to maintain infection control practices for a resident with a Foley catheter. Observations revealed that the resident's catheter bag was resting on the floor due to its attachment to the bed's bottom rail. A registered nurse confirmed that the catheter bag should not be on the floor.
Failure to Maintain Comfortable Temperatures and Provide Bed Linens
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, comfortable, and homelike environment by not maintaining appropriate room temperatures for several residents and not providing bed linens for one resident. Surveyors observed that one resident was sleeping in a room that was noticeably colder than the common area, with the room thermostat set to 59°F and a wall furnace present but not functioning when the thermostat was adjusted. Another resident reported that his room was often cold despite the thermostat being set to 78°F. A third resident, sharing the cold room, was heard moaning in discomfort; a CNA stated this resident was moaning because she was cold and did not like being cold. Staff interviews revealed that CNAs and the Maintenance Supervisor believed the room thermostats did not work and that the 300-unit was often colder than other areas. The Maintenance Supervisor confirmed that room temperatures on the 300-unit were controlled by a thermostat at the nurse’s station, that he was aware of recent complaints, and that he did not keep logs of temperature readings. The RN and DON both acknowledged ongoing complaints about cold temperatures on the 300-unit, with the RN noting the nursing station vent constantly blew cold air and that residents had recently complained about cold rooms. The deficiency also includes the facility’s failure to provide bed linens for a resident with multiple chronic conditions, including atopic dermatitis, type 2 diabetes mellitus with diabetic neuropathy, varicose veins with inflammation, and unspecified dementia. This resident was repeatedly observed lying directly on a bare mattress without linens at multiple times throughout the same day. CNA staff reported that all CNAs are responsible for making resident beds and that beds should be re-made immediately after linens are removed. The RN stated that resident beds should be made without unnecessary delay, that residents should not lie directly on the plastic mattress surface because prolonged contact could disrupt the skin, and that residents can be cold without a blanket. The DON stated it was her expectation that all residents’ beds be made immediately after linens are removed and acknowledged that residents cannot rest comfortably without linens and that delays in making beds could contribute to worsening skin issues.
Incomplete MDS Cognitive Assessments for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate and complete completion of the Minimum Data Set (MDS) cognitive assessment (Section C) for one resident. The resident was admitted with multiple diagnoses, including type 2 diabetes mellitus with diabetic autonomic neuropathy, a personal history of TIA and cerebral infarction without residual deficits, a cognitive communication deficit, and depression. These conditions were documented on the resident’s face sheet and establish that the resident had relevant cognitive and neurological history at the time the MDS assessments were due. Multiple MDS assessments for this resident, each with different assessment dates, showed repeated omissions and unanswered items in Section C (Cognitive Patterns). On one MDS, the item asking whether the Brief Interview for Mental Status (BIMS) should be conducted (C0100) was left unanswered, and all BIMS items (C0200–C0500) were unanswered, resulting in no BIMS score, while the staff assessment for mental status (C0600) was also dashed. Despite these omissions, short-term memory (C0700) and cognitive skills for daily decision making (C1000) were coded as “memory ok” and “modified independence.” On subsequent MDS assessments, C0100 was sometimes coded “yes,” but the BIMS items (C0200–C0500) were dashed, C0600 remained dashed, and short-term and long-term memory items (C0700, C0800) were also dashed, again resulting in the absence of a BIMS score. Across several MDS assessments, this pattern of incomplete coding persisted: key cognitive assessment items were either left unanswered or dashed, including the decision to conduct BIMS, the BIMS questions themselves, the staff assessment for mental status, and memory items. During an interview, the MDS Coordinator stated she was responsible for completing these MDS assessments for the resident and acknowledged that it was her expectation that the assessments, including Section C, be fully completed and not dashed or left unanswered. The documented record review and the MDS Coordinator’s statements together show that the facility did not ensure an accurate and fully completed MDS cognitive assessment for this resident.
Failure to Provide Ordered Diabetic Foot Care
Penalty
Summary
The deficiency involves the facility’s failure to provide physician-ordered diabetic foot care for one resident with multiple high-risk conditions. The resident was admitted with Type 2 diabetes mellitus with diabetic autonomic neuropathy, paraplegia, cognitive communication deficit, reduced mobility, and unsteadiness on feet. Review of the resident’s care plan dated 08/05/25 showed that diabetic foot care was not included. A physician order dated 09/11/25 directed daily diabetic foot care and checks, including observation of the feet, toes, ankles, and soles for alterations in skin integrity, color, temperature, and cleanliness, inspection of shoes for proper fit and excessive wear, and checking pedal pulses every night shift. Review of the Treatment Administration Record from 09/11/25 through 01/14/26 revealed that the ordered diabetic foot care was not completed by nursing staff for the entire period reviewed. A podiatry consultation on 01/14/26 documented diagnoses of Type 2 diabetes mellitus with hyperglycemia, onychogryphosis, nail dystrophy, pain in both toes, localized edema, and slightly diminished range of motion in the foot and ankle joints without pain. The podiatrist performed debridement and trimming of thickened, painful toenails and recommended daily foot checks, supportive shoes, and moisturizing lotions with precautions. During an interview on 01/22/26, the DON stated it was her expectation that physician orders, including diabetic foot care, be followed and confirmed that the ordered foot care for this resident was not followed as prescribed.
Inadequate Legionella Water Management Program
Penalty
Summary
The facility failed to develop and implement an adequate Legionnaires Water Management Program (LWMP) as part of its infection prevention and control program. Record review showed that the LWMP, last revised in June 2020, lacked essential procedures for using control measures to prevent the introduction and spread of Legionella in the building's water system. The policy did not specify control limits or parameters, did not include monitoring procedures or documented environmental testing protocols for Legionella, and did not establish acceptable control limits for the measures being monitored. Additionally, there were no established interventions for when control limits were not met or in the event of a healthcare-associated legionellosis case in the facility. During an interview with facility leadership, including the Administrator, DON, Corporate Nurse, Corporate Maintenance Director, and the Infection Control Preventionist, it was revealed that they were unaware of the inadequacies in the LWMP. They did not know that the plan lacked procedures for control measures, acceptable control limits and parameters, monitoring procedures, testing protocols, or established interventions for non-compliance or cases of legionellosis. These failures had the potential to affect all residents in the facility.
Failure to Provide Dignified Care for Resident with Active Bleeding Wound
Penalty
Summary
A resident with a history of cognitive communication deficit and degenerative disease of the nervous system, and who was assessed as having severe cognitive impairment, was observed sitting in the dining room during lunch with an actively bleeding wound on his right hand. The resident had blood on both hands, his face, and clothing, and was seen feeding himself with his bloody hands, including picking butter out of single-serve butter cups. Staff served the resident his meal tray and then walked away without addressing the bleeding wound or cleaning the resident. The Director of Nursing confirmed that the resident had an open, actively bleeding wound and blood on his hands and clothing, and acknowledged that it was not acceptable for the resident to be in the dining room in that condition. The DON stated that the wound should have been cleansed and covered, and that staff should have attended to the resident's wound before serving his meal. The failure to provide care with dignity and respect was directly observed and verified during the survey.
Failure to Obtain and Document Informed Consent for Psychotropic and Related Medications
Penalty
Summary
The facility failed to ensure that residents or their guardians were fully informed about the medications they were receiving, including the reasons for use, risks, and benefits. For two of three residents reviewed for unnecessary medications, there was no documentation in the electronic medical record of signed consent forms for prescribed medications such as antidepressants, anticonvulsants, antianxiety, and antipsychotic drugs. Specifically, one resident was prescribed Escitalopram, Depakote, Quetiapine, and Hydroxyzine for conditions including depression, anxiety related to traumatic brain injury, and agitation, but no consent forms were found in the record for any of these medications. Similarly, another resident was prescribed Citalopram and Hydroxyzine for depression and anxiety related to dementia, but again, no signed consent forms were present in the medical record. During interviews, the DON confirmed that there should have been signed consent forms for these medications. The lack of documented consent indicates that residents or their responsible parties were not adequately informed about the medications being administered.
Failure to Develop and Implement Timely and Comprehensive Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement adequate baseline care plans within 48 hours of admission for two out of three residents reviewed. For one resident with multiple complex diagnoses, including urinary tract infection, diabetes, depression, blindness, and traumatic brain injury, the baseline care plan was not completed until four days after admission, exceeding the required 48-hour timeframe. This delay was confirmed by record review and interview with the Director of Nursing, who acknowledged the care plan should have been completed within the specified period. For another resident with a history of cerebrovascular disease, Klebsiella pneumoniae infection, anemia, diabetes, hyperlipidemia, dementia with psychotic disturbance, blindness, hypertension, chronic kidney disease, and urinary tract infection, the baseline care plan developed did not address several critical conditions, including dementia with psychotic disturbance, Klebsiella pneumoniae, blindness, and sequelae of cerebrovascular disease. The Director of Nursing confirmed that these conditions should have been included in the baseline care plan and that it is her expectation for care plans to be both timely and comprehensive.
Incomplete Care Plan for Resident with Blindness and Depression
Penalty
Summary
The facility failed to ensure a comprehensive care plan was complete for one resident with diagnoses of blindness and depression. Record review showed that, despite the resident's admission and documented needs, there was no care plan addressing activities for this individual. Interviews revealed that the resident listens to music and TV for entertainment, would participate in bingo if assisted, and walks in the hallway to stay occupied. The DON confirmed that the Activities Department is responsible for creating such care plans and was unsure why one had not been developed. Observations showed the resident attempting to engage in activities, such as entering a bingo game but leaving after not receiving assistance.
Failure to Maintain Safe Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential equipment in safe operating condition by not replacing a broken plastic light cover located directly over the cooking area of the stove. During an initial tour of the kitchen, it was observed that the light in the stove hood had a broken plastic cover, with tape holding part of it together, and a piece of the cover was completely missing. The tape was hanging loosely and appeared old and dirty. In an interview, the dietary manager revealed that the light cover had been broken since he started working at the facility in September 2023. He admitted that he had not submitted a formal work order to repair or replace the light cover, although he had verbally requested the repair. The dietary manager was uncertain about if or when the light cover would be repaired, confirming the presence of loose and dirty tape holding the cover together.
Failure to Accommodate Resident Needs and Preferences
Penalty
Summary
The facility failed to provide reasonable accommodations for a resident's needs, specifically regarding the accessibility of the call light and the availability of signage in the resident's preferred language, Navajo-Dine. Observations revealed that the resident's call light was consistently out of reach, being found under the bed on multiple occasions. This was confirmed by a Certified Medical Assistant who acknowledged the resident's need for assistance and the importance of having the call light within reach due to the resident's history of falls. Additionally, the care plan indicated that signage should be available in both English and Navajo-Dine, but observations showed a lack of such signage in the designated area, which was confirmed by Social Services.
Facility Fails to Maintain a Home-like Environment Due to Mice Infestation
Penalty
Summary
The facility failed to maintain a comfortable and home-like environment for all 33 residents, as evidenced by the presence of mice droppings in multiple areas of the facility. Observations conducted on various dates revealed mice droppings in the main conference room, main dining area, secondary dining area, and several resident rooms in the 400 hall. These findings indicate a lack of adequate cleaning and pest control measures, which are essential for ensuring a safe and comfortable living environment for the residents. Interviews with staff members, including a Certified Medical Assistant and a housekeeper, confirmed the presence of mice and their droppings throughout the facility. The staff reported that they had informed management about the issue, and the housekeeper mentioned that she attempts to clean the droppings daily. Despite these efforts, the problem persisted, suggesting that the facility's current cleaning and maintenance practices were insufficient to address the infestation effectively.
Failure to Respect Resident Privacy and Dignity
Penalty
Summary
The facility failed to uphold the residents' rights to dignity and privacy by not knocking on their bedroom doors before entering. This deficiency was observed in the interactions involving two residents. During an observation, a Registered Nurse (RN) entered a resident's room without knocking while the resident was asleep. The RN also entered multiple empty rooms without knocking and later returned to the same resident's room with a Certified Medical Assistant (CMA), again without knocking. In another instance, the RN entered a different resident's room without knocking to perform personal care. An interview with the CMA revealed that the facility's policy requires staff to knock and announce their presence before entering a resident's room, but the staff were in a hurry looking for supplies for another resident.
Infection Control Deficiency in Catheter Care
Penalty
Summary
The facility failed to maintain proper infection control practices for a resident who was reviewed for catheter care. During observations on two consecutive days, it was noted that the resident's urine catheter bag was improperly positioned, resting on the floor due to its attachment to the bottom rail of the bed, which was in the lowest position. This improper positioning of the catheter bag was confirmed by a registered nurse, who acknowledged that the catheter bag should not be resting on the floor.
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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