Las Cruces Wellness & Rehabilitation Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Las Cruces, New Mexico.
- Location
- 175 N Roadrunner Parkway, Las Cruces, New Mexico 88011
- CMS Provider Number
- 325132
- Inspections on file
- 24
- Latest survey
- November 26, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Las Cruces Wellness & Rehabilitation Llc during CMS and state inspections, most recent first.
A treatment cart containing medical supplies and equipment was found unlocked and unattended on a unit with 16 residents. Staff, including a CNA and the Wound Care Nurse, confirmed the cart was left unsecured with the keys in it, and the DON acknowledged that the cart should be locked when staff are not present.
A resident admitted with a surgical wound and IV access, both requiring enhanced barrier precautions (EBP) per physician's orders, did not have EBP documented in the baseline care plan. The DON confirmed the omission and acknowledged that EBP should have been included in the care planning process.
Two residents who required enhanced barrier precautions for wounds and IV access did not have these interventions documented in their care plans, despite physician orders. The DON confirmed that the care plans were incomplete and should have included the necessary infection control measures.
A resident with significant fall risk factors, including cognitive impairment and mobility limitations, was left unsupervised in the restroom by a CNA who did not review the care plan or use the Kardex. The resident subsequently fell, as staff failed to implement required interventions outlined in the care plan.
A resident with severe cognitive impairment, mobility issues, and a high risk for falls was left alone in the bathroom by a CNA, who went to assist another resident. The CNA did not review the care plan and relied on shift reports, resulting in the resident being found on the floor after being left unattended. The DON confirmed that the resident should not have been left alone and that staff are expected to follow care plans.
A resident with multiple health conditions experienced a fall, but the SBAR form was left incomplete and the incident was not documented in the progress notes by the LPN on duty. The DON confirmed that required documentation was missing after the fall.
A resident with a UTI missed 10 doses of the prescribed antibiotic cefuroxime due to the facility not receiving it from the pharmacy. The MAR showed the missed doses, and there was no documentation of provider notification. The DON confirmed the oversight during an interview.
The facility did not report investigation results of suspected abuse incidents involving two residents to the State Agency within the required timeframe. One resident suffered a hip displacement requiring surgery, while another had a fall without serious injury. The Administrator could not confirm or provide proof of report submission, and the State Agency had no record of receiving the reports.
The facility failed to properly notify residents and their representatives about hospital transfers, lacking documentation and omitting required contact information for the State Long-Term Care Ombudsman. Interviews revealed that while families were notified by phone, written notices were not provided, and incorrect Ombudsman contact details were used.
The facility failed to notify residents and their representatives in writing about the bed hold policy during hospital transfers. Medical records for four residents lacked documentation on the duration of the bed hold and notification details. Interviews revealed confusion among staff regarding responsibility for bed hold notifications, with the Business Office not handling the forms as expected.
The facility failed to ensure complete care plans for three residents, leading to potential unawareness of their needs by the staff. One resident's care plan did not address the discharge plan, another's lacked documentation of a Midline catheter and care instructions, and a third's was missing interventions for cellulitis, wound care, and PICC line management. These omissions could result in inadequate care for the residents' medical conditions.
The facility failed to update care plans with current information and ensure IDT participation in meetings. A resident's fluid restriction was not documented, leading to non-compliance, and another resident's PEG tube care was inadequately specified. Additionally, a resident's care plan was not updated after ingesting cream, despite behavioral issues. The DON confirmed these oversights.
A resident with a UTI did not receive 10 out of 13 doses of the prescribed antibiotic cefuroxime due to the facility's failure to obtain the medication from the pharmacy. Despite being on order, the medication was not available in the emergency kit, medication cart, or pyxis, as confirmed by the DON. This resulted in the resident not receiving appropriate treatment for the UTI.
A facility failed to ensure timely documentation of a resident's care by the provider. The resident's medical record showed multiple late entries for progress notes, all entered on the same day, long after the visits occurred. The nurse practitioner admitted to being behind on documentation and waiting to enter notes collectively. The administrator expected timely entries but did not define 'timely'.
A facility failed to ensure a resident had a physician visit every 30 days for the first 90 days after admission. The resident's EMR lacked documentation of any physician visits, and the Administrator confirmed the absence of such records. The Administrator was also unsure of the physician's visit frequency, despite expecting visits every 30 days.
The facility failed to properly store medications for 17 residents in specific rooms, as a loose white tablet was found in the medication cart. An LPN confirmed the presence of the loose tablet and intended to remove it. The facility's policy requires proper storage to maintain medication integrity and ensure safe administration.
A resident with dysphagia required post-meal checks for pocketed food, but the facility failed to document these checks. An LPN admitted to not documenting the checks and was unsure if they were being performed. The DON confirmed the lack of documentation, despite expectations for staff to record these checks.
The facility did not create baseline care plans within 48 hours for four residents, omitting critical physician's orders and diagnoses such as antibiotics for UTIs, continuous oxygen use, rheumatoid arthritis and diabetes medications, and dementia with antipsychotic treatment. These omissions were confirmed by the DON and Social Services.
A facility failed to complete a comprehensive MDS assessment within the required 14-day period for a resident. The resident was admitted, but the MDS assessment was only completed after the deadline. The MDS Nurse confirmed the delay and acknowledged the expectation for timely completion, which could lead to unmet care needs.
A resident with behavior problems and impulsivity ingested skin cream due to the facility's failure to store creams out of reach. The resident had a history of unsafe behaviors, yet was not assessed for potential danger, leading to the incident.
A facility failed to follow proper infection control practices when a resident's nasal cannula tubing was not labeled with the date it was changed. The resident had specific physician's orders for oxygen delivery, and an LPN confirmed the oversight, citing the busy work environment as a reason for forgetting to date the tubing.
The facility failed to maintain a homelike environment for 46 residents due to several burnt-out and flickering light bulbs in the dining room. An observation revealed multiple lighting issues, and the Administrator confirmed the problem, stating that an order for replacement was in place without a specified date.
The facility failed to revise the care plan for a resident with a Stage III pressure ulcer who frequently refused repositioning and offloading. Despite staff being aware of the resident's noncompliance, this information was not documented in the care plan, leading to potential gaps in care.
Unsecured Treatment Cart Left Unattended
Penalty
Summary
A deficiency was identified when staff failed to secure a treatment cart containing medical supplies and equipment on the South Unit, where 16 residents reside. On the morning of 11/26/25, an observation revealed the treatment cart was left unlocked with the keys in it, and no staff were present in the area. This was confirmed by a CNA and the Wound Care Nurse during interviews, both acknowledging the cart was unsecured. The Director of Nursing also confirmed that the treatment cart should be locked if staff are not present.
Failure to Document Enhanced Barrier Precautions in Baseline Care Plan
Penalty
Summary
The facility failed to develop a complete baseline care plan for one of three residents sampled for enhanced barrier precautions (EBP), an infection control intervention aimed at reducing the transmission of multidrug-resistant organisms (MDROs). Record review showed that the resident was admitted with a surgical wound to the right hip and required IV access, both of which necessitated EBP as per physician's orders. However, the baseline care plan did not document the need for EBP for the surgical wound and IV access. During an interview, the Director of Nursing confirmed that the resident's baseline care plan was missing the required EBP documentation and acknowledged that the facility team should have included this information.
Failure to Include Enhanced Barrier Precautions in Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two of three residents sampled who were on enhanced barrier precautions (EBP) for infection control related to wounds and IV access. For one resident, physician's orders indicated the need for EBP due to a wound on the left leg and IV therapy, but the care plan did not document these precautions. Similarly, another resident had physician's orders for EBP for a wound on the right foot and IV access, yet the care plan lacked this information. The Director of Nursing confirmed during interviews that the care plans for both residents did not include the required EBP interventions and acknowledged that the facility team should have included these precautions in the care planning process.
Failure to Implement Fall Prevention Care Plan
Penalty
Summary
The facility failed to implement the comprehensive care plan for a resident with multiple risk factors for falls, including Alzheimer's disease, blindness in one eye, hearing loss, muscle weakness, difficulty walking, lack of coordination, and a need for assistance with personal care. The care plan identified the resident as being at risk for falls due to gait, balance, and cognitive deficits, and required staff to review past falls, determine causes, and implement interventions. Despite these documented needs and interventions, a certified nursing assistant (CNA) left the resident alone in the restroom after assisting them, instructing the resident to use the call light when finished. The CNA left to assist another resident and returned after 5-6 minutes to find the resident on the floor, indicating the resident had fallen while unsupervised. The CNA reported not reviewing the resident's care plan and relying solely on shift reports for instructions, and also stated not having access to the Kardex, which contains important patient information. The Director of Nursing (DON) confirmed that the resident should not have been left alone on the toilet and that staff have access to the care plan, which is also available in the Kardex. The failure to follow the care plan and ensure staff were aware of and implemented required interventions directly led to the resident being left unsupervised and experiencing a fall.
Resident Left Unattended in Bathroom Resulting in Fall
Penalty
Summary
A cognitively impaired resident with multiple diagnoses, including Alzheimer's disease, blindness in one eye, hearing loss, muscle weakness, difficulty walking, lack of coordination, and a need for assistance with personal care, was left unattended in the bathroom by a CNA. The resident required substantial to maximal assistance for toileting hygiene, toilet transfers, and sit-to-stand movements, as documented in the care plan and MDS assessment. The care plan specifically identified the resident as being at risk for falls due to gait, balance, and cognitive deficits, and required interventions to address these risks. Despite these documented needs, the CNA left the resident alone in the restroom to assist another resident, instructing the resident to use the call light when finished. Upon returning after 5-6 minutes, the CNA found the resident on the floor. The CNA admitted to not reviewing the care plan and not having access to the Kardex, relying instead on shift reports. The DON confirmed that the resident had a severely impaired BIMS score and that the CNA should not have left the resident unattended, as staff are expected to follow care plans, which are accessible through the Kardex.
Incomplete Medical Record Documentation Following Resident Fall
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for one resident. Specifically, the resident, who had multiple diagnoses including Alzheimer's disease, blindness in one eye, hearing loss, muscle weakness, difficulty walking, lack of coordination, and required assistance with personal care, experienced a fall. The Situation-Background-Assessment-Recommendation (SBAR) form related to the fall was not signed or completed, and there was no documentation of the fall in the resident's progress notes by the LPN who was on duty at the time. The Director of Nursing confirmed that staff did not complete the SBAR note or document a progress note after the fall.
Failure to Notify Provider of Missed Antibiotic Doses
Penalty
Summary
The facility failed to notify the provider of missed medication doses for a resident diagnosed with a urinary tract infection (UTI). The resident was prescribed cefuroxime, an antibiotic, to be taken twice daily for 10 days. However, the medication administration record (MAR) indicated that the resident missed 10 doses over several days. The nurse progress notes did not document any notification to the provider about these missed doses. During an interview, the Director of Nursing (DON) confirmed that the doses were missed because the facility did not receive the medication from the pharmacy and could not confirm that the provider was notified.
Failure to Report Investigation Results to State Agency
Penalty
Summary
The facility failed to report the results of investigations into suspected abuse incidents involving two residents to the State Agency within the required five-day period. Resident #270 experienced a fall that resulted in an emergency room visit and a diagnosis of acute displacement of the left hip, necessitating surgery. Despite this serious incident, there was no documentation indicating that a follow-up report was submitted to the State Agency. Similarly, Resident #271 sustained a fall that led to an ER visit, although no serious injury was reported. Again, there was no documentation of a follow-up report being sent to the State Agency. During an interview, the Administrator was unable to confirm or provide proof of when these reports were sent, and a review of the State Agency Reporting system showed no record of receiving the reports for either resident.
Failure to Notify Residents and Representatives of Hospital Transfers
Penalty
Summary
The facility failed to provide timely and proper notification to residents and their representatives regarding transfers to the hospital. Specifically, for four residents, the facility did not document that a copy of the transfer notice was provided to the resident representatives. Additionally, the transfer notices lacked the name, phone number, and address of the Office of the State Long-Term Care Ombudsman. Furthermore, the facility did not send a written copy of the transfer notices to the Ombudsman for three of the residents. These deficiencies were confirmed through record reviews and interviews with facility staff, including the Administrator, Social Worker, and LPN. The report highlights specific instances where the facility's staff did not adhere to the required procedures for notifying residents and their representatives about hospital transfers. For example, one resident was transferred to the hospital without a documented transfer notice, and the Administrator confirmed the absence of such documentation. Interviews with the Social Worker and LPN revealed that while they notify families by phone, they do not provide written transfer notices to the families or the Ombudsman. Additionally, the binder at the nurse's station contained incorrect contact information for the Ombudsman, listing a Volunteer Ombudsman instead of the official contact details.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notice of the bed hold policy to residents and their representatives during hospital transfers, affecting four residents. The medical records of these residents lacked documentation on the duration of the bed hold, who was notified, and whether the notification was provided to the residents or their families. This deficiency was identified through record reviews and interviews, revealing that the facility did not ensure proper communication regarding bed hold policies. Interviews with staff, including an LPN and the Business Office Manager, highlighted a lack of clarity and responsibility in handling bed hold notifications. The LPN indicated that nurses create the bed hold notice document but do not complete it, leaving it to the Business Office, which in turn does not handle the forms. The Administrator confirmed the absence of documentation for one resident's transfer, acknowledging the expectation for bed hold notifications to be signed by residents or their representatives promptly.
Incomplete Care Plans for Residents
Penalty
Summary
The facility failed to ensure complete care plans for three residents, leading to potential unawareness of their needs by the staff. For Resident #106, the care plan did not address the discharge plan or any referrals to the local contact agency, as confirmed by Social Services. Resident #108's care plan lacked documentation of a Midline catheter and instructions for its care, despite physician's orders for its maintenance. The MDS Nurse confirmed these omissions, highlighting the need for resident-specific care plans. Resident #265's care plan was incomplete, missing documentation of interventions for cellulitis, two wounds on the right leg, and the presence of a PICC line. The MDS Nurse confirmed these deficiencies, noting that the care plan only included medication orders for pain and lacked specific instructions for observing and managing cellulitis. These omissions could result in inadequate care for the residents' medical conditions.
Care Plan Deficiencies in LTC Facility
Penalty
Summary
The facility failed to revise care plans with the most current resident information and did not ensure the participation of the required Interdisciplinary Team (IDT) members in care plan meetings for several residents. For one resident, there was no documentation of a care plan meeting, and the social services staff confirmed that no meeting had occurred. Another resident's family member was not invited to care plan meetings and was unaware of their ability to attend, with the care plan not being completed with IDT members due to the facility's short-term nature. In another case, a resident receiving dialysis had a fluid restriction order that was not documented in the care plan. The resident exceeded fluid intake limits multiple times, and the Certified Nursing Assistants (CNAs) were not informed of the fluid restrictions, leading to a lack of adherence to the prescribed care. The Director of Nursing (DON) confirmed that the fluid restriction was not care planned, acknowledging it was overlooked. Additionally, a resident with a PEG tube had a care plan that did not specify the required care for the tube, despite having physician orders for its maintenance. Another resident with behavioral issues ingested cream, but the care plan was not updated to reflect this incident or the necessary interventions to prevent recurrence. The DON confirmed the care plan should have been revised to include these details.
Failure to Administer Prescribed Antibiotic for UTI
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of urinary tract infection (UTI) received appropriate treatment. The resident, who was discharged to the facility from the hospital with a UTI, was prescribed cefuroxime, an antibiotic, to be taken twice daily for 10 days. However, the medication administration record (MAR) indicated that the resident missed 10 out of 13 doses of the prescribed antibiotic over several days. The deficiency occurred because the facility did not receive the medication from the pharmacy, as confirmed by the Director of Nursing (DON). Progress notes repeatedly documented that the cefuroxime was on order but not available in the emergency kit, medication cart, or pyxis. This lack of medication availability led to the resident not receiving the necessary treatment for the UTI, potentially putting the resident at risk for worsening infection.
Failure to Timely Document Provider Progress Notes
Penalty
Summary
The facility failed to ensure that a resident's care was reviewed and documented by the provider at each required visit. Specifically, the facility did not have written, signed, and dated progress notes from the provider for a resident at the time of each visit. The resident's electronic medical record showed multiple instances where progress notes were entered as late entries, all on the same date, well after the actual visits occurred. These late entries spanned several dates over a period of months, indicating a significant delay in documentation. Interviews with the nurse practitioner revealed that he was behind on entering progress notes into the medical records and had entered several late entries for the resident on a single day. He admitted to waiting to collect a series of notes before entering them into the system. The facility administrator confirmed that her expectation was for providers to enter their notes in a timely manner, although she did not specify what constituted 'timely'. This lack of timely documentation could result in the resident's needs not being met due to facility staff being unaware of the resident's current status.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure that a resident had a physician visit at least every 30 days for the first 90 days after admission. A review of the electronic medical record (EMR) for the resident revealed no documentation indicating that the resident was seen by a physician. During an interview, the Administrator confirmed the absence of physician documentation in the resident's medical record and was unable to determine if the resident had been seen by a physician. Additionally, the Administrator was unsure of the frequency with which the resident's physician visits the facility, although her expectation was for physicians to see their residents at least once every 30 days for the first 90 days.
Improper Medication Storage in Facility
Penalty
Summary
The facility failed to properly store medications for all 17 residents in rooms 135-151, as identified by the Resident Matrix. During an observation of the medication cart assigned to these rooms, a loose white oval tablet was found between the medication cards in the second drawer of the cart. This was confirmed by an LPN, who acknowledged the presence of the loose tablet and stated they would remove it. The facility's Storage of Medication Policy, dated September 2018, requires that medications and biologicals be stored properly to maintain their integrity and support safe, effective drug administration. The policy also specifies that medication storage should be clean, well-lit, organized, and free of clutter.
Incomplete Documentation of Dysphagia Care
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for one of the residents reviewed for documentation accuracy. The resident in question had a diagnosis of dysphagia, which required their mouth to be checked for pocketed food and debris after meals. However, it was found that the nurses, who were responsible for performing these checks, did not document when they checked the resident for pocketing after meals. During interviews, an LPN admitted to not documenting these checks and expressed uncertainty about how to verify if the checks were being performed. The Director of Nursing confirmed that staff did not document these checks, despite the expectation that they should be doing so.
Failure to Create Timely Baseline Care Plans
Penalty
Summary
The facility failed to create a baseline care plan within 48 hours of admission for four residents, which accurately reflected their current medical conditions and physician's orders. For one resident, the baseline care plan did not include the physician's orders for an antibiotic and continuous use of oxygen, despite the resident having a diagnosis of a urinary tract infection and requiring oxygen therapy. Another resident's care plan was incomplete and lacked the physician's orders for an antibiotic treatment for a urinary tract infection. Additionally, the baseline care plan for a third resident did not document the physician's orders for medications used to treat rheumatoid arthritis and diabetes. A fourth resident's care plan was not completed within the required timeframe and failed to include the diagnosis of dementia and the physician's orders for an antipsychotic medication. These deficiencies were confirmed through interviews with the Director of Nursing and Social Services, indicating a lack of proper documentation and planning for the residents' immediate healthcare needs upon admission.
Failure to Complete Timely MDS Assessment
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set (MDS) assessment within the federally mandated 14-day period following a resident's admission. Specifically, the deficiency involved one resident, identified as R #266, whose admission MDS assessment was not completed within the required timeframe. The resident was admitted on an unspecified date, and the MDS assessment was only completed on July 1, 2024, exceeding the 14-day requirement. During an interview, the MDS Nurse confirmed that the assessment was not completed on time and acknowledged the expectation for such assessments to be completed within 14 days of admission. This oversight could potentially result in the resident's preferences and care needs not being adequately addressed.
Failure to Secure Skin Creams Leads to Resident Ingestion
Penalty
Summary
The facility failed to ensure that skin creams were stored out of reach of a resident, leading to an incident where the resident ingested a cream. The resident, who had a history of behavior problems and impulsivity, was found with white cream on her teeth and tongue, prompting a hospital visit. Upon investigation, it was discovered that two tubes of barrier cream and an empty jar of zinc cream were in the resident's bedside drawer, indicating that the creams were accessible to her. The resident's care plan noted her impulsivity and poor safety awareness, yet she was not assessed for potential danger despite previous incidents of removing her midline catheter and tampering with electrical outlets. The Director of Nursing confirmed that the resident's impulsivity and lack of safety awareness should have prompted an assessment for potential danger, which was not conducted. This oversight contributed to the resident's access to and ingestion of the creams.
Infection Control Deficiency: Undated Nasal Cannula Tubing
Penalty
Summary
The facility failed to adhere to proper infection control practices for a resident identified during a random observation. Specifically, the nasal cannula tubing used for delivering oxygen to the resident was not labeled with the date it was changed. This oversight was observed during a room inspection, where it was noted that the tubing lacked a date to indicate when it had been replaced. The resident had physician's orders for oxygen titration and a specific oxygen flow rate via nasal cannula. During an interview, an LPN confirmed that the nasal cannula tubing was not dated and mentioned that the tubing is typically changed on Sundays. However, due to the busy nature of their work, staff sometimes forget to check if the tubing is dated, leading to this deficiency.
Failure to Maintain Homelike Environment Due to Lighting Issues
Penalty
Summary
The facility failed to provide a homelike environment for all 46 residents, as evidenced by the condition of the dining room lighting. During an observation on June 25, 2024, it was noted that several light bulbs in the dining room were either burnt out or flickering. Specifically, the first ceiling circular hanging light had three bulbs burnt out and one flickering, the second ceiling circular light had four bulbs burnt out, the bistro light near the hallway had one bulb burnt out, and the middle circular hanging light had one bulb burnt out. An interview with the Administrator on June 27, 2024, confirmed the issue, and she stated that there was an order for the bulbs to be replaced, although no specific date was provided for this action.
Failure to Revise Care Plan for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to revise the care plan for a resident (R #11) who had a Stage III pressure ulcer upon admission. Despite the resident's frequent refusals to be repositioned and noncompliance with offloading, these refusals were not documented in the care plan. Interviews with the Wound Care Nurse and a CNA confirmed that the resident often refused repositioning and preferred to remain on her back, but this information was not included in the care plan. Additionally, the care plan did not provide guidance on what staff should do when the resident refused offloading and repositioning. The Director of Nursing confirmed that the resident's refusals and noncompliance were not care planned, acknowledging that these should have been documented. This oversight could lead to staff being unaware of the resident's care preferences and needs, potentially impacting the quality of care provided.
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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