Las Cruces Village Nursing & Rehabilitation Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Las Cruces, New Mexico.
- Location
- 3025 Terrace Drive, Las Cruces, New Mexico 88011
- CMS Provider Number
- 325067
- Inspections on file
- 27
- Latest survey
- September 16, 2025
- Citations (last 12 mo.)
- 43
Citation history
Health deficiencies cited at Las Cruces Village Nursing & Rehabilitation Llc during CMS and state inspections, most recent first.
Two residents' care plans were not updated to reflect their current needs for fall prevention measures, such as bed positioning and fall mats, or for incontinence management with briefs, despite these interventions being in use. One resident's care plan also incorrectly listed them as an elopement risk, even though they were fully dependent and unable to leave bed. The DON confirmed that these omissions meant staff may not have been aware of the necessary care approaches.
Staff did not conduct regular rounding on multiple residents, resulting in one resident remaining on the floor for several hours after a fall and several rooms not being checked for an extended period, contrary to the facility's standard practice of rounding every two hours.
A medication cart was found unattended with insulin pen needles and lancets left on top instead of being locked inside the cart. Both an LPN and the ADON confirmed that these items should have been secured according to facility policy.
A resident with advanced Parkinson's disease, who was nonverbal and unable to use the call light, fell out of bed and remained on the floor for over three hours without staff checking on her. Video evidence confirmed that staff failed to conduct required rounds, and the resident was not discovered until the next scheduled check.
The facility did not maintain documentation showing that allegations of neglect and misappropriation of property involving two residents were thoroughly investigated. In one instance, a resident with severe cognitive impairment was left on the floor for hours after a fall, and in another, a resident reported missing money and unauthorized bank transactions. Required interviews, video reviews, and investigation records were not documented or retained.
A resident admitted with a stage 2 pressure ulcer did not have this condition or the required wound care documented in their baseline care plan within 48 hours of admission. Despite physician orders and progress notes indicating the need for pressure ulcer care, the baseline care plan omitted these details, as confirmed by the DON and the resident's family member.
A resident admitted with a stage 2 pressure ulcer did not receive timely wound care, as staff failed to obtain wound care orders for three days and did not document or perform wound care on several days following admission. The Wound Care Nurse was not available at admission, and nursing staff did not follow expected protocols for early wound management.
The facility did not provide required written discharge or transfer notifications, discharge summaries, or bed hold notices to several residents and their representatives during hospitalizations or discharges. Written notifications lacked essential information about appeal rights and Ombudsman contacts, and copies were not sent to the Ombudsman as required. Staff interviews confirmed inconsistent practices in providing and documenting these notifications.
Four residents did not have comprehensive, person-centered care plans that addressed their individual diagnoses or personal activity preferences. Two residents' care plans omitted their preferred activities, while another lacked a plan for hypertensive urgency, and a fourth did not have care plans for adrenocortical insufficiency or required bathing assistance. These deficiencies were confirmed by staff interviews and record reviews.
Staff did not notify the provider when a resident with hypertension had blood pressure and heart rate readings outside of physician-ordered parameters, despite orders to hold medication and inform the provider in such cases. The resident continued to receive isosorbide during these episodes, and the DON confirmed that provider notification did not occur as required.
Staff failed to notify the provider when a resident repeatedly refused or was not administered prescribed medications, including antihypertensive and cholesterol-lowering drugs. The provider was also not informed when medications were held due to blood pressure readings, despite the absence of specific parameters in the orders. The DON confirmed that expected communication with the provider did not occur.
A resident with multiple health conditions experienced prolonged diarrhea, which was inadequately assessed and treated by the facility. Despite frequent loose bowel movements and the use of Linzess, a medication known to cause diarrhea, the staff failed to notify the provider or adjust treatment appropriately. The resident's hydration status was not adequately monitored, leading to severe dehydration and acute kidney injury.
A facility failed to provide adequate staffing, resulting in unmet care needs for several residents. A resident requiring a Hoyer lift was not consistently toileted as ordered, while another waited up to 45 minutes for assistance due to insufficient staff. Two residents experienced significant delays in receiving assistance, with one having to eat meals in bed and another waiting hours for transfers. Staff interviews confirmed these issues, highlighting ongoing staffing challenges.
The facility failed to maintain complete and accurate medical records for two residents. One resident's nursing administration record lacked documentation of water administration through a PEG tube, despite orders. Another resident's medical record did not document their death, including the time and notifications made. Staff interviews confirmed these documentation lapses.
The facility failed to ensure staff adhered to transmission-based precautions for residents diagnosed with COVID-19. Despite the requirement for all staff and visitors to wear N95 masks, multiple staff members, including an RN, LPN, and CNA, were observed not complying with this protocol. The regional nurse consultant confirmed the mask requirement, highlighting a significant lapse in infection control measures.
A resident with Alzheimer's disease was involuntarily secluded when a CNA blocked their bedroom doorway with a bed to prevent wandering into other rooms. The facility's administrator confirmed this action was against the resident's will and acknowledged it as a deficiency.
A CMA in a LTC facility misappropriated controlled narcotics by documenting the administration of medications to three residents that were not actually given. The incident was uncovered after a colleague reported a suspicious text from the CMA, who claimed it was a joke. An investigation revealed discrepancies in medication records, and interviews with the residents confirmed they did not receive the medications as documented. The CMA was the only staff member to document the administration of these medications, leading to her termination.
Failure to Update Care Plans for Fall Prevention, Incontinence, and Elopement Risk
Penalty
Summary
The facility failed to revise and update the care plans for two residents following changes in their care needs and health status. For both residents, observations revealed that their beds were in the lowest position and fall mats were in place due to their high risk for falls, and both were wearing briefs due to incontinence. However, their care plans did not document the use of bed positioning, fall mats, or the use of briefs and related interventions. Additionally, one resident's care plan continued to list them as an elopement risk, despite updated assessments showing the resident was fully dependent for activities of daily living and unable to leave the bed independently. Interviews with the DON confirmed that the care plans lacked documentation of these interventions and that the care plans should have been updated to reflect the current needs and approaches for each resident. The absence of these updates meant that staff may not have been aware of the necessary interventions for fall prevention, incontinence management, and elopement risk, as the care plans did not accurately reflect the residents' current conditions and required care strategies.
Failure to Perform Regular Rounding on Residents
Penalty
Summary
Staff failed to perform regular rounding on 11 out of 19 residents in the 400 Unit, as evidenced by record review, video surveillance, and interviews. One resident fell out of bed and remained on the floor for approximately three hours without staff checking on them. Video footage confirmed that staff did not round on several rooms between 11:00 PM and 3:23 AM, affecting multiple residents. The facility's standard practice, as stated by the Administrator, is to round on residents at least every two hours, but this was not followed during the cited period.
Unsecured Medication Cart with Insulin Needles and Lancets
Penalty
Summary
A medication cart located near the 500 and 600 unit halls was observed to be left unattended with insulin pen needles and lancets placed on top of it, rather than being secured inside the locked compartments as required. This observation was made during a survey at the nurses' station, and both an LPN and the Assistant Director of Nursing confirmed that these items were not properly secured. The facility failed to ensure that all drugs and biologicals, including injection devices and lancets, were stored in locked compartments in accordance with professional standards.
Resident Left Unattended After Fall Due to Missed Staff Rounds
Penalty
Summary
Staff failed to conduct required rounds on a resident who was dependent on staff for mobility and unable to use the call light or call out for help due to advanced Parkinson's disease and nonverbal status. Video evidence showed that the resident fell out of bed and remained on the floor for over three hours without staff checking on her. The last staff entry into the resident's room occurred late in the evening, and no one re-entered until early the next morning, at which point the resident was found on the floor. The resident's medical history included Parkinson's disease with dyskinesia, repeated falls, muscle weakness, disorientation, and dependence on a wheelchair. The resident required assistance with personal care and was unable to ambulate independently. The administrator confirmed that staff are expected to conduct rounds every two hours, especially for residents unable to seek help on their own, but this standard was not met in this case.
Failure to Document Thorough Investigations of Alleged Neglect and Misappropriation
Penalty
Summary
The facility failed to provide evidence that allegations of neglect and misappropriation of property were thoroughly investigated for two residents. In the first case, a resident with severe cognitive impairment (BIMS score of 0) was reported to have fallen out of bed and remained on the floor for approximately three hours without staff rounding. The facility's incident report did not include documentation of interviews with all staff present during the incident, communication with the resident's family, or findings from a review of facility video footage. The Administrator confirmed that there was no documentation of these investigative steps, despite having viewed the video. In the second case, a resident with intact cognitive function (BIMS score of 15) reported unauthorized transactions on his bank statement and missing cash from his wallet. The grievance report was incomplete, lacking follow-up documentation. The Administrator stated that an investigation was conducted but could not provide evidence that the allegation of misappropriation of property was thoroughly investigated. The corporate nurse confirmed that administrators are expected to document all interviews and retain all investigation-related documents, which was not done in these cases.
Failure to Include Pressure Ulcer and Wound Care in Baseline Care Plan
Penalty
Summary
The facility failed to develop an accurate baseline care plan within 48 hours of admission for one of three residents reviewed. Specifically, a resident was admitted with a documented stage 2 pressure ulcer on the sacrum, as noted in physician orders and progress notes. The physician orders included specific wound care instructions, and the admission MDS indicated the presence of a pressure ulcer and the need for pressure ulcer care. However, the baseline care plan created for the resident did not document the existence of the pressure ulcer or the need for wound care. During interviews, the resident's family member reported that there was no plan of care in place, and the DON confirmed that the baseline care plan did not include the pressure ulcer or wound care needs. The deficiency was identified through record review and interviews, which showed that the required information for immediate care was not included in the baseline care plan as expected.
Failure to Provide Timely Wound Care for Pressure Ulcer on Admission
Penalty
Summary
A deficiency occurred when staff failed to provide timely and appropriate wound care for a resident admitted with a stage 2 pressure ulcer. Upon admission, the resident had an existing wound, but staff did not obtain wound care orders until three days later. Documentation shows that wound care was not performed or recorded on the day of admission and for several subsequent days. The Treatment Administration Record for the relevant period lacked entries indicating that wound care was provided, and there were no progress notes explaining the omission. Interviews with facility staff revealed that the Wound Care Nurse was not present at the time of admission and only assessed the resident's wound several days later. The Director of Nursing confirmed that the expectation is for nurses to obtain care orders and provide wound care within the first 48 hours of admission. However, this protocol was not followed, resulting in a lack of consistent wound management for the resident during the initial days of their stay.
Failure to Provide Required Written Discharge, Transfer, and Bed Hold Notifications
Penalty
Summary
The facility failed to provide the required written discharge or transfer information to residents and their representatives for multiple residents who were hospitalized or discharged. Specifically, there was no written notification of discharge or transfer provided in a language and manner understandable to the resident or their representative, and in some cases, no documentation of the discharge or transfer was present in the medical record. For one resident, there was no discharge summary that included a recapitulation of the stay, final clinical status, or medication reconciliation. Additionally, written notices did not include required information about appeal rights or contact information for the State Long-Term Care Ombudsman. For several residents who were transferred to the hospital, the facility did not provide written transfer notifications or bed hold notifications at the time of transfer or as soon as practicable. In some cases, the bed hold notification was completed but did not indicate who was notified, and there was no evidence that a written copy was given to the resident or their representative. Staff interviews confirmed that written notifications were not consistently provided, and that the process for notifying residents, representatives, and the Ombudsman was not followed as required. The facility also failed to send copies of the written discharge or transfer notices to the Ombudsman, instead only sending a list of residents who transferred or were discharged. Staff responsible for these notifications, including the Social Services Director and Business Office Manager, confirmed that written notifications were not always provided or documented, and that family members were sometimes only notified by phone or required to pick up written notices in person. These deficiencies were identified through record review and staff and resident interviews.
Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement accurate, person-centered comprehensive care plans for four residents. For two residents with dementia and other behavioral or mood disorders, the care plans did not include their personal preferences for activities, such as pet visits, group activities, going outdoors, and religious services, as identified in their MDS Annual Assessments. The Activity Director confirmed that these preferences, although assessed, were not incorporated into the residents' care plans. Additionally, one resident with a primary diagnosis of hypertensive urgency did not have a care plan addressing this condition, and another resident with adrenocortical insufficiency lacked a care plan for this diagnosis as well as for the level of assistance required for showering or bathing, as indicated in the MDS assessment. The corporate nurse confirmed the absence of these care plans. These omissions were identified through record reviews and staff interviews.
Failure to Notify Provider of Abnormal Vital Signs as Ordered
Penalty
Summary
Facility staff failed to notify the provider of abnormal vital signs for a resident with a diagnosis of essential hypertension. Physician orders specified that isosorbide should be held and the medical doctor notified if the resident's systolic blood pressure was less than 100 or greater than 150, or if the pulse was less than 50. Despite this, staff documented several instances where the resident's blood pressure exceeded 150 and the pulse dropped below 50, but there was no evidence that the provider was notified as required by the order. Review of the medication administration record showed that the resident continued to receive isosorbide daily during periods when vital signs were outside the specified parameters. The Director of Nursing confirmed that staff did not contact the physician or provider to report the elevated blood pressure and low heart rate, contrary to the physician's instructions. The expectation was for staff to notify the provider as directed in the order, but this did not occur.
Failure to Notify Provider of Medication Refusals and Held Doses
Penalty
Summary
The facility failed to meet professional standards of practice for medication management for one of three residents reviewed. Specifically, staff did not notify the physician or provider when a resident repeatedly refused prescribed medications, including atorvastatin and carvedilol, or when medications were held due to blood pressure readings. Documentation showed that the resident refused atorvastatin on multiple occasions across two months and that carvedilol was either refused or held several times, sometimes due to blood pressure readings. However, there were no documented notifications to the physician or provider regarding these refusals or the holding of medications. Additionally, the order for carvedilol did not include parameters for when the medication should be held based on blood pressure readings, yet staff held the medication for various blood pressure values without provider guidance. The Director of Nursing confirmed that staff did not contact the physician or provider about the resident's medication refusals or about concerns regarding blood pressure readings, despite the expectation that such communication should occur. The resident involved had diagnoses including cerebrovascular disease, essential hypertension, and hyperlipidemia.
Failure to Adequately Assess and Treat Prolonged Diarrhea
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, specifically in the assessment and treatment of prolonged diarrhea. The resident, who was admitted with multiple diagnoses including metabolic encephalopathy, type 2 diabetes mellitus, unspecified dementia, delirium, dysphagia, and gastrostomy status, experienced persistent diarrhea. Despite documentation of frequent loose bowel movements, the facility did not adequately assess the cause or provide appropriate treatment. The resident's medical records revealed that they were receiving Linzess, a medication known to cause diarrhea, without a corresponding diagnosis of irritable bowel syndrome or chronic constipation. Additionally, the resident was prescribed Imodium A-D to treat diarrhea, which is contradictory to the effects of Linzess. The nursing staff failed to document notifying the provider about the resident's ongoing diarrhea after the initial report on November 19, 2024, and did not question the concurrent use of Linzess and Imodium A-D. Furthermore, the facility did not take timely action to assess the resident's hydration status, despite signs of dehydration indicated by elevated sodium and chloride levels in lab results. The resident's hydration was solely dependent on PEG tube administration, and the staff did not request additional fluids to compensate for the fluid loss due to diarrhea. This oversight contributed to the resident's severe dehydration and acute kidney injury, as diagnosed during a hospital visit following a fall.
Staffing Shortages Lead to Unmet Resident Care Needs
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of several residents, leading to unmet care requirements. Resident #1, who requires assistance with a Hoyer lift and two staff members for toileting, was not consistently assisted as per physician's orders. Documentation revealed missed toileting sessions, and staff interviews confirmed the inability to ensure the resident was toileted three times daily due to staffing shortages. Resident #3 reported waiting up to 45 minutes for assistance in or out of bed, as the facility lacked enough staff to meet the needs of residents requiring two-person assistance with Hoyer lifts. On one occasion, only one CNA was available for the entire housing unit, which included several residents needing significant assistance. This shortage led to delays and unmet care needs, as confirmed by staff interviews. Resident #4 and Resident #5 also experienced significant delays in receiving assistance due to staffing shortages. Resident #4, who requires a sit-to-stand device, had to eat meals in bed instead of the dining room, which she preferred for social interaction. Resident #5, who also requires a Hoyer lift, reported waiting over an hour for assistance and sometimes up to three hours to be transferred to bed after lunch. Staff interviews corroborated these accounts, highlighting the facility's ongoing staffing challenges.
Incomplete Medical Records and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure complete and accurate medical records for two residents, which could potentially impact the care provided. For one resident, the nursing administration record did not document the administration of 135 mL of water through a PEG tube on multiple occasions, despite physician orders. Interviews with staff revealed that feeding pumps were programmed to administer feedings and water flushes automatically, but documentation was still required. The Director of Nursing confirmed that staff did not document several water boluses as expected. For another resident, the facility's medical record lacked documentation regarding the resident's death. Although the hospice nurse's progress note indicated the resident had passed and notifications were made, the facility's records did not reflect this information. The Assistant Director of Nursing confirmed the absence of documentation about the resident's death, including the time of death and notifications made to the family and provider.
Failure to Adhere to COVID-19 Transmission-Based Precautions
Penalty
Summary
The facility failed to maintain proper infection prevention measures by not ensuring that staff adhered to transmission-based precautions for residents diagnosed with COVID-19. During an interview, the front desk staff confirmed that the facility had residents diagnosed with COVID-19 and that all staff and visitors were required to wear N95 masks. However, observations revealed multiple instances of non-compliance. An RN in the Alzheimer unit was observed not wearing an N95 mask while at the nurse's station. Similarly, an LPN in the East unit was seen wearing a surgical mask that did not cover her nose and stated she was not informed about the mask requirements. Further observations showed that a CNA in the hallway near the nurse's station was wearing a surgical mask, and the wound care nurse had to remind her of the N95 mask requirement. Additionally, an LPN in the [NAME] unit was observed sitting at the nurse's station without a mask. The regional nurse consultant confirmed that all facility staff were required to wear N95 masks in nursing units and patient care areas when there was a resident diagnosed with COVID-19. These lapses in following the infection control program could potentially lead to the spread of infections among the 67 residents in the facility.
Involuntary Seclusion of Resident Due to Wandering
Penalty
Summary
The facility failed to protect a resident from involuntary seclusion, which is defined as the separation of a resident from other residents or confinement to their room against their will. This incident involved a resident diagnosed with Alzheimer's disease, insomnia, and hypertension. On a specific date, the resident's bedroom doorway was blocked by the bed while the resident was inside, preventing them from moving freely throughout the unit. This action was taken by a CNA during the day shift because the resident was wandering around the unit and entering other residents' rooms. The incident was confirmed by the facility's administrator, who acknowledged that the staff should not confine residents to their rooms against their will. The nurse assigned to the resident on the day of the incident was informed by the DON about the blocked doorway, but by the time she checked, the doorway was no longer obstructed. The administrator confirmed that the resident was involuntarily secluded by the facility staff, which constitutes a deficiency in the care provided to the resident.
Misappropriation of Residents' Medications by CMA
Penalty
Summary
The facility failed to prevent the misappropriation of residents' medications, specifically controlled narcotics, by a Certified Medication Aide (CMA). The incident involved three residents who were documented as having received medications that they did not actually receive. CMA #8 documented that a resident received a PRN oxycodone, another received a PRN hydrocodone, and a third received two alprazolam tablets, when in fact, these medications were not administered as recorded. The discrepancies were discovered during an investigation initiated after CMA #9 reported a text from CMA #8, in which she asked for residents' medications for personal use, claiming it was a joke. The investigation revealed that CMA #8 was the only staff member to document the administration of the controlled narcotics to the three residents on the specified date. Interviews with the residents confirmed that they did not recall receiving the medications as documented. One resident, who was moderately impaired, did not remember receiving Percocet for a headache, while another, who was cognitively intact, stated she did not request or take hydrocodone, preferring Tylenol instead. The third resident, also cognitively intact, confirmed receiving only one alprazolam tablet instead of two. The facility's investigation and police report corroborated these findings, leading to the termination of CMA #8.
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.
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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