Las Estancias By Pure Health
Inspection history, citations, penalties and survey trends for this long-term care facility in Albuquerque, New Mexico.
- Location
- 3620 Las Estancias Dr Sw, Albuquerque, New Mexico 87121
- CMS Provider Number
- 325126
- Inspections on file
- 23
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Las Estancias By Pure Health during CMS and state inspections, most recent first.
A resident with hyperopia had a care plan intervention requiring coordination of an eye care consultation, but staff did not schedule a vision appointment for approximately three months after the care plan update. The resident reported not seeing an eye doctor for over two years and expressed concern about not having a vision appointment. Review of the EHR showed no completed or scheduled vision visit during that period, and the Scheduler acknowledged delaying the call to arrange the appointment. The Social Services Assistant confirmed there was no in-house vision provider and that the appointment should have been scheduled sooner.
The facility's kitchen was found to have several sanitation deficiencies, including unlabeled and undated liquid pitchers in the refrigerator, and unclean counter tops, shelves, floors, and a heated plate dispenser. The Culinary Manager confirmed these conditions did not meet cleanliness expectations, potentially affecting all 115 residents.
The facility failed to develop comprehensive care plans for four residents, resulting in deficiencies related to bed rail use and antibiotic management. Residents with various medical conditions, including osteomyelitis, rheumatoid arthritis, and malignant neoplasm, had bed rails for safety and independence, but their care plans lacked documentation for this aspect of care. Additionally, a resident's antibiotic management was not documented in the care plan, leading to oversight in medication management. Observations and interviews confirmed these deficiencies, with the DON acknowledging the lack of proper care planning.
The facility failed to provide meals that were palatable, attractive, and at a safe temperature, as reported by several residents. Complaints included overcooked, flavorless, and cold food, with some residents opting for outside food. Observations confirmed the lack of visual appeal, and Resident Council minutes documented ongoing concerns. The Culinary Supervisor acknowledged the issues but made changes only upon receiving complaints.
The facility failed to change nasal cannulas for two residents within the recommended seven-day period, as observed during a survey. The nasal cannulas were not dated, and staff could not confirm when they were last changed, despite the facility's protocol to change them weekly. This oversight could lead to the cannulas becoming obstructed and unsanitary, potentially affecting the residents' oxygen therapy.
The facility failed to offer a COVID-19 vaccination to a resident, as evidenced by the absence of documentation in the resident's EHR. This was confirmed by the DON during an interview, highlighting a lapse in the facility's vaccination protocol.
The facility failed to ensure CNAs received the required 12 hours of in-service training per year. Three CNAs did not complete any training past August 2023, yet continued to work shifts. The Administrator confirmed the lack of evidence for ongoing training, indicating a deficiency in maintaining training standards.
A facility failed to ensure the accuracy of a PASRR assessment for a resident with multiple mental health diagnoses, including major depressive disorder and bipolar disorder. The PASRR inaccurately documented that the resident did not have a mental illness, which was confirmed by the President of Clinical Services, indicating a significant oversight in the assessment process.
A resident's care plan was not updated to include specific interventions for fall prevention, continuous oxygen therapy, and recent vision loss. The DON confirmed the lack of an individualized fall protocol and discrepancies in the care plan regarding oxygen therapy and ADL self-care performance deficit. These omissions could result in staff being unaware of the resident's care needs.
A resident with complex medical conditions was prescribed an antibiotic without a stop date, contrary to the facility's antibiotic stewardship policy. The DON confirmed the lack of a care plan and oversight during clinical meetings, leading to potential overuse of antibiotics.
A facility failed to offer the influenza vaccine to a resident, as revealed by a review of the resident's EHR. The DON confirmed the absence of documentation showing that the vaccine was offered, which is essential for preventing flu spread.
Failure to Timely Coordinate Vision Services per Care Plan
Penalty
Summary
The facility failed to coordinate and schedule timely vision services for one resident with a documented need for eye care. The resident’s face sheet showed admission to the facility prior to the events described, and the care plan dated 09/07/25 documented a diagnosis of hyperopia and included an intervention to arrange consultation with an eye care practitioner as required. Review of the electronic health record on 07/07/26 revealed no documentation that a vision appointment had been completed or scheduled. During an interview, the resident reported not having seen an eye doctor in over two years, stated that the facility was aware of this, and confirmed that lack of a vision appointment was one of his major concerns and that he wanted an appointment. The Scheduler, who is responsible for making resident appointments, stated that the resident had not had a vision consultation since admission and that the next appointment was scheduled for 07/01/26. She further stated that she did not call to schedule this appointment until 12/16/25, acknowledging that the appointment should have been scheduled sooner after the care plan update on 09/07/25 indicating the need for a vision appointment. The Social Services Assistant confirmed that the facility no longer had an in-house vision provider and agreed that the resident’s vision appointment should have been scheduled earlier than 12/16/25 following the care plan update.
Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which could potentially affect all 115 residents. During an observation, it was noted that two liquid pitchers in the refrigerator were not labeled or dated, which is against the facility's standards. Additionally, the kitchen's counter tops, shelves, and floors were found to have food particles, spilled liquids, trash, and dust. The heated plate dispenser, used to heat and store plates, also had food particles, spilled liquid, and dust on it. During an interview, the Culinary Manager acknowledged that these conditions did not meet his expectations for cleanliness and confirmed that all food and drink items should be labeled and dated.
Deficient Care Planning for Bed Rail Use and Antibiotic Management
Penalty
Summary
The facility failed to develop and implement accurate, person-centered comprehensive care plans for four residents, leading to deficiencies in addressing their specific needs. Resident #4 was admitted with multiple diagnoses, including acute osteomyelitis, chronic pain syndrome, and rheumatoid arthritis. Despite consenting to bed rails for safety and comfort, there was no care plan addressing their use. Observations confirmed the presence of bed rails, and interviews with the resident and the Director of Nursing (DON) revealed the absence of a care plan for this aspect of care. Similarly, Resident #72, who had diagnoses such as muscle wasting, osteoporosis, and pain in the hip and knee, also consented to bed rails for safety and independence. However, their care plan did not include any documentation regarding the use of bed rails. Observations and interviews confirmed the presence of bed rails and the resident's awareness of their use, but the DON acknowledged the lack of a care plan. Resident #109, admitted with conditions including malignant neoplasm of the tongue and cognitive communication deficit, had an antibiotic prescribed upon admission. However, the care plan did not document the antibiotic management, and there was no stop date for the medication in the electronic medical record. The DON confirmed this oversight. Lastly, Resident #164, with diagnoses such as a fracture of the sacrum and spinal stenosis, also had bed rails for safety and independence, but their care plan lacked documentation for bed rail use. Observations and interviews confirmed the presence and use of bed rails, with the DON acknowledging the deficiency in the care plan.
Deficiency in Meal Quality and Presentation
Penalty
Summary
The facility failed to ensure that meals served to residents were palatable, attractive, and at a safe and appetizing temperature. Multiple residents reported dissatisfaction with the quality of food, describing it as overcooked, lacking flavor, and often served cold. Observations during meal times confirmed that the food lacked visual appeal, with meals being served on neutral-colored dinnerware that did not enhance the presentation. Residents expressed that the food did not meet their expectations, with some opting to have food brought in from outside the facility. Interviews with residents revealed consistent complaints about the food quality, including reports of repetitive menus featuring chicken and pork, and meals that were not in line with national dietary standards. The facility's records showed ongoing concerns about food quality, as documented in Resident Council minutes, where residents repeatedly raised issues about cold and unappetizing food. The Culinary Supervisor acknowledged the lack of color and appeal in the menu offerings and indicated that changes to meals were made only when complaints were received or on an as-needed basis in the dining area.
Failure to Change Nasal Cannulas Timely
Penalty
Summary
The facility failed to adhere to professional standards of practice for respiratory care by not changing the nasal cannulas for two residents, R #46 and R #62, within the recommended seven-day period. During an observation, it was noted that R #46's nasal cannula was not dated, and staff could not confirm when it was last changed. The Assistant Director of Nursing-Facility Wide (ADON-FW) and CNA #6 both acknowledged that the nasal cannulas are typically changed weekly on Sundays, but neither could verify if R #46's cannula had been changed as required. This lack of documentation and adherence to protocol could lead to the nasal cannula becoming obstructed, non-functional, and unsanitary, potentially affecting the resident's oxygen therapy. Similarly, R #62's nasal cannula was also found without a date indicating when it was last changed. The physician's orders for both residents specified oxygen administration via nasal cannula every shift, yet the facility's failure to document and ensure timely changes of the cannulas represents a deviation from the expected standard of care. This oversight in maintaining proper respiratory care equipment could compromise the residents' health by not providing the necessary oxygen therapy effectively.
Failure to Offer COVID-19 Vaccination to Resident
Penalty
Summary
The facility failed to offer COVID-19 vaccinations to one of the five residents reviewed for COVID-19 vaccinations. Specifically, the electronic health record (EHR) of Resident #8 did not contain any documentation indicating that the COVID-19 vaccine was offered or administered to the resident. This was confirmed during an interview with the Director of Nursing (DON), who acknowledged the absence of evidence in the EHR regarding the offer of the COVID-19 vaccination to Resident #8.
Deficiency in CNA In-Service Training Compliance
Penalty
Summary
The facility failed to ensure that Certified Nurse Aides (CNAs) received the required 12 hours of in-service training per year, as evidenced by the records of three CNAs. CNA #1, CNA #2, and CNA #3 did not complete any training past August 2023, which was confirmed by the facility's Administrator during an interview. Despite the lack of evidence of ongoing training, these CNAs continued to work shifts providing care for residents. The Administrator acknowledged that the facility does not have proof of the CNAs completing the necessary training, which is a requirement to meet the care needs of the residents. The personnel files of the CNAs showed that their Caregiver Criminal History Screenings were cleared, but their in-service training records were incomplete, indicating a deficiency in maintaining the required training standards.
Inaccurate PASRR Assessment for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure the accuracy of the Pre-Admission Screening and Resident Review (PASRR) assessment for a resident, which is crucial for determining appropriate placement and services in long-term care. The resident was admitted with multiple mental health diagnoses, including major depressive disorder, unspecified psychosis, schizoaffective disorder, anxiety disorder, delusional disorders, and bipolar disorder. However, the PASRR documentation inaccurately stated that the resident did not have a diagnosis or suspected mental illness. This discrepancy was confirmed during an interview with the President of Clinical Services, highlighting a significant oversight in the resident's assessment process.
Failure to Revise Care Plan for Resident's Needs
Penalty
Summary
The facility failed to revise the care plan for a resident, identified as R #21, to address several critical care needs. The care plan did not include specific interventions for fall prevention, despite the resident's history of falls. Additionally, the care plan was not updated to reflect the resident's current medical order for continuous oxygen therapy, as it still listed an as-needed order. Furthermore, the care plan did not address the resident's recent acute vision loss, which occurred after a dialysis session, and did not include interventions to assist with the resident's activities of daily living (ADL) self-care performance deficit related to this vision impairment. The Director of Nursing (DON) confirmed during an interview that the care plan was not accurately revised. The DON was unable to provide a facility fall protocol and acknowledged that there was no individualized fall protocol for the resident. The discrepancies between the care plan and the resident's current medical orders for oxygen therapy were also confirmed. Additionally, the care plan lacked specific interventions to address the resident's impaired visual function and ADL self-care performance deficit. These oversights in updating the care plan could lead to staff being unaware of the resident's care needs and preferences, potentially resulting in the resident not receiving the necessary care.
Failure to Monitor Antibiotic Stop Date
Penalty
Summary
The facility failed to adequately monitor and document the stop date for an antibiotic prescribed to a resident, identified as R #109, who was admitted with multiple complex medical conditions including malignant neoplasm of the tongue, dysphagia, otitis media, and cognitive communication deficit. The resident was prescribed Ofloxacin otic solution for an ear infection, but the physician's order did not include a stop date, which is a requirement according to the facility's antibiotic stewardship policy. This oversight was confirmed during an interview with the Director of Nursing (DON), who acknowledged that the care plan should have included the reason for the antibiotic, start and stop dates, and interventions to prevent infection. The deficiency was further highlighted by the lack of a care plan for the antibiotic use, as confirmed by the DON. The Medical Director's progress notes indicated uncertainty about whether the ear infection was related to the resident's cancer diagnosis, yet the antibiotic was continued without reassessment or a stop date. The DON stated that the administration team reviews all antibiotics during morning clinical meetings, but they overlooked the missing stop date in this case. This failure to adhere to the antibiotic stewardship policy could lead to potential overuse of antibiotics.
Failure to Offer Influenza Vaccine to Resident
Penalty
Summary
The facility failed to offer the influenza vaccine to one of the five residents reviewed for immunizations. Specifically, a review of the electronic health record (EHR) for a resident revealed that the staff did not offer the influenza vaccination. During an interview, the Director of Nursing (DON) confirmed that there was no evidence in the resident's EHR indicating that the influenza vaccine had been offered. This oversight means the resident was not given the opportunity to consent to or decline the vaccine, which is crucial for preventing the spread of the flu within the facility.
Latest citations in New Mexico
Surveyors found that the facility did not provide required written transfer and bed-hold notices when several residents were sent to the hospital for events such as falls with injury, unresponsiveness, and episodes of nausea, vomiting, and bleeding. Medical records lacked written transfer notices and bed-hold notifications, and the transfer information that should have been given to residents or their representatives did not include mandated details about appeal rights, how to request an appeal, or how to contact the State LTC Ombudsman. The Social Services Director reported that she does not notify the Ombudsman of hospital transfers and only sends a monthly email list of discharged residents, without written copies of transfer or discharge notices.
Two cognitively impaired residents with dementia and significant behavioral and continence needs were sent to a local ER after falls and were discharged back to the facility’s care, but the facility failed to provide timely transportation for their return. In both cases, hospital discharge times were documented, yet ER staff reported making multiple unsuccessful calls to the facility, reaching the Administrator only after repeated attempts. One resident, described as very disoriented, remained in the ER for several hours after discharge without 1:1 supervision, while the other waited approximately 11 hours, during which ER staff observed increasing confusion and attempts to get out of bed. The Administrator acknowledged awareness of the discharges, the lack of 24-hour transportation, and that the residents were not picked up until many hours after they had been discharged from the ER.
Two residents who required staff assistance for ADLs and transfers reported neglectful and rude behavior by a CNA and delayed nursing response to care needs. One resident with a history of cerebral infarction and schizophrenia stated that a CNA mocked him and that his requested wound dressing change was not performed for several hours, which was later corroborated by video showing a long gap between the CNA’s visit and the nurse’s entry to the room. Another resident with a right femur fracture, type II DM, and repeated falls, who needed one-person assistance for mobility and self-care, reported that a CNA refused to help and told her she could do some care herself, making her feel she was not trying in her recovery. Documentation and interviews confirmed that staff did not provide timely wound care or required assistance, and that these interactions caused residents to feel uncomfortable and negatively about their care.
A resident with a history of opioid dependence and polysubstance abuse was on a secure unit with a care plan that included safety risk evaluations and monitoring for signs of substance abuse. Staff later observed the resident discarding an empty Suboxone packet, even though the resident was not prescribed this medication, and the incident was reported to the on-call provider with subsequent monitoring and a room search. However, the care plan was not revised to reflect this new substance-related event, and both the DON and Administrator acknowledged that the care plan should have been updated when this new risk and behavior were identified.
Surveyors identified that a medication cart on the north hall was left unlocked and unattended outside a resident room. An LPN acknowledged that the cart was hers and that she had not locked it before leaving to answer a call light, despite facility expectations. The DON confirmed that all medication and treatment carts are required to remain locked when not in use or when staff are away from them.
Surveyors found that a document containing multiple residents’ PHI, including full names, room numbers, and code status, was left unattended and visible on a south nurse’s station counter. An RN confirmed the document was a resident list with PHI and acknowledged it had been left exposed and that such information should not be left unattended.
Surveyors found that a lunch tray return cart containing uncovered, soiled food trays and dishes was left unattended in a main hallway outside an activity room. The housekeeping/laundry manager acknowledged seeing the unattended cart, and the Dietary Manager confirmed that such carts are supposed to remain only in designated areas, such as near the nurse’s station or in the kitchen, and should be returned to the kitchen for cleaning as soon as all trays are collected. This failure was cited as likely to expose all residents to potential pathogens associated with food waste.
Two residents with scheduled showers reported that they were offered or received showers in very cold water during a prolonged period when hot water was not reliably available in care areas. One resident stated he refused cold showers and was only offered sponge baths once or twice, despite his preference to stay clean. Another resident reported receiving cold showers, including being rinsed with cold water while still soaped, and subsequently began refusing showers and bed baths due to the cold water. A CNA confirmed that water in the shower rooms was “ice cold” for several months, leading to resident complaints and refusals, while the Maintenance Director reported that a needed part to correct the hot water problem was on back order, delaying resolution and resulting in the facility not honoring residents’ bathing preferences.
Surveyors observed that unused medications were improperly discarded in a trash bin attached to a medication cart on the north hallway, rather than being disposed of in a designated drug disposal container. Two pills, a round blue tablet stamped "61" and an oblong orange tablet stamped "20," were found together in an unlabeled medication cup in the trash. An RN confirmed the medications were discarded there and acknowledged that unused medications should be placed in the drug buster container in the cart drawer. The Unit Manager also confirmed that facility practice requires all unused medications to be disposed of using the drug buster and that controlled substances must be destroyed by two licensed staff and documented on the narcotic count sheet.
The facility failed to follow documented allergy information, diet orders, and meal tickets for three residents. A resident with a documented chocolate allergy was served chocolate ice cream after requesting it, and the Nutrition Director admitted not reading the allergy notation on the meal ticket. Another resident on a pureed diet received whole mandarin oranges instead of pureed fruit, which a CNA confirmed. A third resident whose meal ticket called for a grilled Swiss sandwich received a sandwich that was not grilled, as confirmed by a CNA and a dietary manager.
Failure to Provide Required Written Transfer, Appeal, Ombudsman, and Bed-Hold Notices During Hospitalizations
Penalty
Summary
Surveyors identified that the facility failed to provide required written transfer and bed-hold information for multiple residents who were hospitalized. For three residents who experienced transfers to the hospital after events such as falls with injury, unresponsiveness, and episodes of nausea, vomiting, and bleeding, record review showed there were no written transfer notices or written bed-hold notices in their medical records. Specifically, one resident transferred after a fall on 01/31/26 had no documented written transfer notice or bed-hold notice. Another resident transferred on 02/27/26 for nausea, vomiting, and bleeding, and later readmitted on 03/05/26, had no written transfer notification that included information on appeal rights or Ombudsman contact, and no written bed-hold notification. A third resident transferred on 01/29/26 after a fall with a forehead laceration and again on 03/17/26 for unresponsiveness, also had no documented written transfer or bed-hold notices for either hospitalization. The deficiency also included the facility’s failure to provide required content in transfer notices and to notify the State Long-Term Care Ombudsman in writing. For the residents reviewed, there was no evidence that written transfer notices were provided to the residents or their representatives in a language and manner they could understand, and the notices were missing required elements such as a statement of appeal rights, the name, mailing and email address, and phone number of the entity receiving appeals, and information on how to obtain and complete an appeal form. The notices also lacked the name, phone number, and mailing and email address of the State Long-Term Care Ombudsman, and written copies of the transfer notices were not sent to the Ombudsman. During interview, the Social Services Director confirmed that transfer and bed-hold notices were not documented for at least one resident’s hospitalization, that she does not notify the Ombudsman about transfers to the hospital, and that she only emails a monthly list of residents discharged from the facility without sending written copies of transfer or discharge notices.
Failure to Timely Retrieve Residents From ER After Discharge
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from neglect by not arranging timely transportation back to the facility after emergency room (ER) discharge. A consumer complaint alleged that residents sent to the local ER were being left there for extended periods after discharge. For one resident with an admission date of 10/13/25, records showed multiple cognitive and behavioral diagnoses, including Alzheimer’s disease, vascular dementia with agitation and other behavioral disturbances, mild cognitive impairment, cognitive communication deficit, and restlessness and agitation. A change of condition MDS documented a Brief Interview for Mental Status (BIMS) score of 1 and frequent incontinence of urine and bowel. Nursing progress notes for this resident showed that 911 was called at 3:00 AM and the resident was transferred to the ER after a fall. Hospital discharge instructions indicated the resident was discharged from the ER at approximately 5:21 AM, while the ER nurse reported discharge at about 5:30 AM. The ER nurse stated she made numerous calls to the facility but was unable to reach anyone. She reported that the resident was very disoriented and that the ER did not have enough staff to provide 1:1 supervision. The ER nurse eventually reached the Administrator, who stated staff would come to pick up the resident as soon as possible. Facility records showed the resident was not discharged from the facility on that date, and the ER nurse reported that facility staff did not pick the resident up until approximately 8:30 AM, several hours after discharge. A second resident, admitted on 11/25/25, had diagnoses including Alzheimer’s disease, dementia with behavioral disturbance, bipolar disorder with severe depression and psychotic features, depression, and anxiety disorder. The admission MDS documented a BIMS score of 2, frequent urinary incontinence, constant bowel incontinence, and a need for substantial/maximal assistance with toileting hygiene. Nursing notes showed this resident was sent to the ER for evaluation after a fall and did not return until the following morning. Hospital discharge instructions documented discharge from the ER at 10:16 PM, and the Administrator confirmed being notified of the discharge at about 10:30 PM and that the facility did not have 24-hour transportation. The Administrator acknowledged the resident was not picked up until approximately 9:00 AM the next day. The ER nurse reported making several calls to the facility that went to voicemail, eventually reaching the Administrator, who initially stated staff were on the way, then stopped answering calls. During the approximately 11-hour wait, the ER nurse stated the resident was confused, attempted to get out of bed, and became more confused as the night progressed.
Failure to Timely Provide Wound Care and Required Assistance, Resulting in Resident Neglect
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from neglect when staff did not respond appropriately to requests for care and assistance. One resident with a history of cerebral infarction due to embolism and schizophrenia, admitted on 01/30/26 and requiring staff assistance for ADLs and mechanical lift transfers, reported that a CNA was rude and mocking and that his wound dressing was not changed for several hours after he requested it. The Kardex showed he needed staff help for toileting, bathing, hygiene, bed mobility, dressing, and transfers. Nursing progress notes documented a change in condition on 03/02/26 after the resident stated the CNA was rude and would not assist as requested. The Administrator later confirmed, via video review, that the CNA entered the resident’s room at 2:30 am, the resident requested a dressing change, and no nurse entered the room until 5:00 am, despite the nurse’s statement that she went in “right away.” The DON also confirmed that the resident’s grievance described the wound dressing not being changed until hours after the request. Another resident, admitted with a right femur fracture, type II diabetes, and repeated falls, required one-person assistance for dressing, hygiene, bathing, bed mobility, and transfers, and could toilet herself with assistance for transfers. Nursing progress notes documented an alleged abuse incident on 03/02/26 in which this resident stated a CNA was rude, refused to help her, and told her she could perform some care tasks herself without staff assistance. An abuse questionnaire completed the same day showed the resident answered “Yes” to having interactions that made her feel uncomfortable or negative, and she reported that the CNA made her feel as though she was not trying with her own recovery. The Administrator and DON acknowledged that staff are expected to help residents as required and that staff interactions must be encouraging rather than making residents feel bad about needing assistance.
Failure to Revise Care Plan After Substance-Related Incident
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s care plan after a significant substance-related incident. The resident was originally admitted with a diagnosis of opioid dependence and resided on a secure unit related to polysubstance abuse disorder. The existing care plan, dated 01/21/26, identified the resident as residing on a secure unit due to polysubstance abuse disorder with interventions to perform safety risk evaluations on admission, as needed, and upon changes in condition. The care plan also identified the resident as at risk for substance use disorder with interventions to monitor for signs or symptoms of substance abuse. On 02/01/26, nursing notes documented that staff observed the resident discarding an empty Suboxone packet in the trash, even though the resident was not prescribed Suboxone and denied taking any. Staff notified the on-call provider, who ordered monitoring for adverse reactions, and nursing staff and security conducted a room search that revealed no additional contraband. Despite this incident, the resident’s care plan was not updated to address the new substance-related event. During interviews, the DON acknowledged awareness of the incident and confirmed the care plan was not revised, and the Administrator stated her expectation that nursing would update the care plan when a new risk or behavior was identified and confirmed she would have expected the care plan to be updated for this resident.
Unattended, Unlocked Medication Cart on North Hall
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were properly stored and secured in accordance with professional standards and facility expectations. On 03/24/26 at 9:06 a.m., surveyors observed a medication cart on the north hall left unlocked and unattended outside a resident room. At 9:08 a.m., the LPN responsible for the cart confirmed during interview that the cart was hers, that it was unlocked and unattended, and acknowledged she should have locked it before responding to a call light. Later that day at 3:37 p.m., the DON stated in an interview that medication and treatment carts are expected to be locked at all times when nurses are away from them, confirming that the observed practice did not meet facility expectations. This deficient practice was cited as likely to allow unauthorized personnel access to medications, which could result in injury or overdosing.
Unattended PHI Document Left Exposed at Nurse’s Station
Penalty
Summary
Surveyors identified a deficiency in the facility’s protection of residents’ personal health information (PHI) when a document containing multiple residents’ full names, assigned room numbers, and code status was left unattended and exposed on the south nurse’s station counter. On 03/16/26 at 9:04 a.m., an observation revealed a piece of paper on a clipboard with complete resident information placed on top of the south nurse’s counter in public view. At 9:06 a.m., during an interview, RN #2 confirmed that the list contained residents’ names, room numbers, and code status, acknowledged that it had been left exposed and unattended, and stated that PHI should not be left unattended. No additional clinical details or medical histories of the residents listed on the document were provided in the report.
Unattended Soiled Lunch Cart Left Uncovered in Hallway
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the handling of soiled food service equipment. On 03/24/26 at 12:58 pm, a lunch tray return cart containing soiled food trays and dishes that were uncovered was observed sitting unattended in the main hallway outside the activity room. At 1:06 pm, the housekeeping/laundry manager confirmed she saw the return cart left unattended in that location. At 1:08 pm, the Dietary Manager stated that lunch return carts should only be left in designated areas such as by the nurse’s station or inside the kitchen, and that the cart should be returned to the kitchen for cleaning as soon as all trays have been picked up, which did not occur in this instance. This deficient practice was noted as likely to expose all residents to potential pathogens associated with food waste.
Failure to Honor Resident Bathing Preferences During Prolonged Hot Water Issues
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ bathing preferences when hot water was not reliably available in resident care areas. Record review showed that one resident was scheduled to receive three showers per week on specific days, and another resident was scheduled for two showers per week. One resident reported that staff attempted to have him shower in cold water, which he refused, and that sponge baths were only offered once or twice during the period when the hot water was not working. He stated that he liked to be clean and did not feel like himself when he was dirty. A CNA reported that there was no hot water in resident care areas from the middle of December until early March, and that large barrels of warm water were brought to shower rooms to offer sponge baths, which this resident refused. Another resident, also on a scheduled twice-weekly shower regimen, stated that she received cold showers and began refusing showers because of how cold the water was. She described the water running cold unpredictably, including an instance when the water was initially warm but turned cold while she was still soaped, requiring rinsing with cold water, which she described as horrible. A social services note documented that this resident’s daughter reported the resident had been declining showers and bed baths offered because the water was too cold. A CNA corroborated that the water was “ice cold” and that residents began complaining and refusing showers around mid-December. The Maintenance Director stated that it took a while for hot water to reach the shower room and that a needed part to fix the cold-water problem was on back order, contributing to the prolonged period of inadequate hot water and resulting in residents not having their bathing preferences honored.
Improper Disposal of Unused Medications on Medication Cart
Penalty
Summary
Surveyors identified a deficiency related to accident hazards and inadequate supervision when unused medications were improperly discarded on the north hallway. During observation of the north hall nurses’ station, two medications were found in the trash bin attached to the medication cart, placed together inside an unlabeled medication cup. The pills were described as a round blue pill stamped with “61” and an oblong orange pill stamped with “20.” In an interview immediately following the observation, an RN confirmed that these medications were in the trash bin and stated that unused medications should instead be disposed of in the drug buster, a sealed container for drug disposal located in the bottom drawer of the cart. In a subsequent interview, the Unit Manager confirmed that all unused medications are to be disposed of using the drug buster and acknowledged that this did not occur, further stating that if the medications are controlled substances such as narcotics, two licensed personnel are required to dispose of them together and document the disposal on the narcotic count sheet. This deficient practice was noted as likely to affect any resident who might acquire and ingest the discarded medications, potentially causing medication side effects.
Failure to Follow Allergy, Diet, and Meal Ticket Requirements
Penalty
Summary
The facility failed to provide meals consistent with residents’ documented allergies, diet orders, and meal tickets for three residents. One resident, admitted with a documented allergy to chocolate, had a face sheet and lunch ticket indicating they were not to receive chocolate. During a lunch observation, this resident was served and was eating chocolate ice cream. An LPN confirmed the resident’s chocolate allergy and that the resident should not be eating chocolate. The Nutrition Director acknowledged that the meal ticket stated the resident should not have chocolate but reported serving chocolate ice cream after the resident requested it, stating he had not read that the resident was allergic to chocolate. Another resident, admitted with hypokalemia and ordered a regular/liberalized pureed diet per the MDS, had a lunch ticket indicating a pureed diet but was observed receiving whole mandarin oranges instead of pureed fruit. A CNA confirmed that the dessert was not pureed. A third resident’s meal ticket specified a grilled Swiss sandwich, but observation of the tray showed the sandwich was not grilled. During interviews, a CNA and a dietary manager confirmed that the sandwich was not grilled as ordered on the meal ticket.
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