Las Palomas Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Albuquerque, New Mexico.
- Location
- 8100 Palomas Avenue Ne, Albuquerque, New Mexico 87109
- CMS Provider Number
- 325036
- Inspections on file
- 37
- Latest survey
- February 9, 2026
- Citations (last 12 mo.)
- 13 (6 serious)
Citation history
Health deficiencies cited at Las Palomas Center during CMS and state inspections, most recent first.
A resident with a history of stroke, dementia with behavioral disturbance, anxiety, depression, and prior behavioral issues was on a care plan addressing risks for verbal and physical aggression and elopement, and had been placed on 1:1 supervision after earlier episodes of homicidal ideation and hospital evaluation. Despite periods of stable mood, staff documented ongoing verbal and physical aggression, culminating in the resident striking the administrator and throwing a vase at the activities director, after which 911 was called and the resident was sent to the hospital with EMS and police. The facility then discharged the resident and, according to the guardian, SSD, and hospital CM director, refused to re‑admit her when she was medically ready for discharge and showed no aggressive behavior in the hospital, leaving her to remain in the ED holding area for several days while the guardian and hospital staff arranged placement at an out‑of‑town assisted living facility, without evidence of coordinated discharge planning or an arranged receiving facility at the time of transfer.
A CNA engaged in inappropriate touching, unwanted physical contact, and use of inappropriate language with multiple residents, including those with cognitive impairment and physical disabilities. Despite reports from residents, the CNA was initially allowed to return to work with limited restrictions, leading to further incidents. The facility did not immediately remove the CNA from resident care or fully investigate the allegations, resulting in continued risk and harm to residents.
Multiple residents with varying cognitive abilities reported inappropriate physical contact, sexual abuse attempts, and grooming behaviors by a CNA. The facility's investigation relied on resident questionnaires and did not substantiate the allegations, allowing the CNA to return to work until further complaints led to his removal. The investigation process did not thoroughly address or prevent further abuse.
Two residents did not receive care according to physician orders: one did not have weekly PT/INR lab results documented or communicated as required for Warfarin management, and another was observed ambulating without prescribed continuous oxygen, resulting in low oxygen saturation. The DON confirmed incomplete documentation and lapses in following provider instructions.
Three residents requiring ADL assistance for bathing did not consistently receive scheduled showers, as confirmed by documentation, staff interviews, and resident reports. Despite care plans indicating the need for regular bathing due to limited mobility or cognitive impairment, showers were frequently missed, and documentation was incomplete or inconsistent. Staff and the DON confirmed that residents generally did not refuse showers and should have received them as scheduled.
A resident was repeatedly left soiled in common areas for extended periods, with staff aware of the situation but not providing prompt assistance until specifically asked. The resident reported inadequate incontinence care, leading to embarrassment and the need for a foley catheter to be reinserted. Interviews with staff and the resident's POA highlighted ongoing concerns about hygiene and dignity.
A resident with complex medical needs and existing heel ulcers did not receive consistent or adequate wound care due to missing provider orders, lack of documentation, and failure by nursing staff to perform or record wound care. The resident and family reported missed dressing changes, and a podiatrist later found the wound neglected, leading to urgent hospital transfer and subsequent amputation.
A resident with multiple complex medical conditions, including wounds requiring treatment, was admitted without the necessary wound care orders being reviewed or entered by the provider. Despite hospital discharge instructions for wound care, no such orders were present in the physician orders during the resident's stay. The provider was unaware of the missing orders, and the standard process for reviewing and approving admitting orders was not followed, resulting in the omission of required wound care.
A CNA engaged in inappropriate and abusive interactions with multiple residents, including unwanted touching, inappropriate language, and sexual harassment. Despite reports from residents and staff, the CNA was initially allowed to return to work without a thorough investigation or immediate removal, resulting in continued risk and distress for several residents.
Multiple residents with varying cognitive abilities reported inappropriate physical contact, sexual abuse attempts, and grooming behaviors by a CNA. The facility's investigation was limited, relying mainly on questionnaires and failing to substantiate the allegations, which resulted in the CNA returning to work and further incidents occurring before eventual termination.
Staff failed to follow physician orders for two residents: one did not have weekly PT/INR testing for Warfarin therapy documented or communicated to the provider as required, and another was observed ambulating without prescribed continuous oxygen, resulting in low oxygen saturation. The DON confirmed incomplete documentation and lapses in following orders.
Three residents requiring ADL assistance, including those with limited mobility, cognitive impairments, and paralysis, were not consistently provided scheduled showers or baths. Documentation and staff interviews confirmed that showers were missed or not offered as required, and residents or their representatives reported dissatisfaction and instances of being unkempt or soiled. The DON acknowledged the deficiency and issues with documentation.
A resident was repeatedly left visibly soiled and wet in common areas for extended periods, with staff failing to provide timely incontinence care despite being aware of the situation. The resident reported feeling neglected and embarrassed, and ultimately requested a foley catheter be reinserted due to inadequate care. Interviews with staff and the resident's POA confirmed ongoing issues with cleanliness and lack of prompt assistance.
Surveyors identified that food items such as cake, whipped topping, sugar, juice, and thickened juice were stored unlabeled and undated, eggs were left out and became warm before being returned to refrigeration, and the freezer floor was found with spilled milk and debris. The Dietary Manager confirmed these deficiencies in food storage and sanitation practices.
A resident with a history of constipation and narcotic use was administered both Sennosides-Docusate and Loperamide over an extended period, despite experiencing ongoing diarrhea. Staff and nursing documentation confirmed that both medications, which have opposing effects, were given together, leading to persistent diarrhea and resident discomfort. Nursing and clinical leadership acknowledged that this practice was contraindicated and should not have occurred.
A resident with limited mobility and a history of CVA did not receive scheduled showers or consistent bed baths, despite being care planned for ADL assistance. Documentation for two months lacked records of showers or refusals, and staff interviews revealed confusion over whether hospice or facility staff were responsible for providing showers. The DON confirmed that showers should be offered according to resident preference and schedule, regardless of hospice involvement.
Surveyors observed that documents containing PHI, including vital sign sheets, census sheets, and weight lists, were left in areas accessible to unauthorized individuals. An LPN confirmed that these documents were left exposed and should have been secured to protect residents' confidentiality.
A resident received meals that were consistently cool to the taste and touch. During a meal service observation, the Dietary Manager measured food temperatures on a test tray and found the hamburger and broccoli to be significantly below the expected serving temperature, confirming the food was not served at a safe and appetizing temperature.
A resident's medical record was found to be incomplete when an LPN failed to document the administration of Imodium A-D after giving it during the morning medication pass. The LPN stated she was busy and would document it later. The DON confirmed that medications should be documented immediately after administration.
A resident receiving hospice care did not have a coordinated plan of care available in the medical record. Although a hospice RN indicated that a binder with the plan was provided at admission, an LPN stated that all hospice documentation is kept in the EMR, where the plan could not be found. The DON confirmed the absence of the coordinated plan of care.
Several residents experienced delayed or inadequate care following changes in their condition, including a resident with respiratory illness and confusion who was not promptly sent to the ER, a resident with untreated eye irritation despite repeated family notifications, a resident whose care was delayed due to lack of timely provider communication and order entry, and a resident with a third-degree sacral burn that was not reported or treated promptly before discharge. Staff and provider interviews confirmed that these deficiencies led to worsening conditions and unnecessary discomfort.
Two residents experienced significant changes in condition—one with declining ability to self-feed and another developing a third-degree sacral burn—without timely physician notification. Staff failed to communicate these changes to the appropriate medical providers, resulting in unaddressed care needs and delayed interventions, as confirmed by interviews and record reviews.
The facility did not submit required investigation results for multiple incidents of alleged abuse, neglect, and injuries to the State Survey Agency within the mandated 5 working days. The Administrator, acting as the sole abuse coordinator, confirmed delays and missing reports for several cases, including care concerns, deep tissue injuries, altercations, and falls.
The facility did not follow physician orders for oxygen administration, failed to label and date oxygen tubing for two residents, provided oxygen to a resident without a physician order, and administered an antibiotic medication to another resident without provider authorization. These deficiencies were confirmed by staff interviews and record reviews.
The facility did not ensure that written, signed, and dated progress notes from PCPs were present in the medical records for eight residents whose care was managed by an external senior service agency. Despite frequent visits by agency providers, documentation of these visits was largely absent from the EMRs, as confirmed by the DON, resulting in incomplete records for residents with complex medical needs.
A resident with Parkinson's disease and physical debility was given Morphine Sulfate at a much higher dose than ordered due to the pharmacy supplying the wrong concentration and nursing staff failing to verify the medication against the provider's order. The error persisted for several days, resulting in the resident receiving 47 incorrect doses before it was identified after a pharmacist intervened and the resident's condition declined.
Facility staff experienced repeated delays in obtaining timely responses and medical orders from a senior service PCP, resulting in delayed care for several residents. The DON and LPNs reported that response times from the PCP were inconsistent, especially on weekends, and that necessary information such as medication changes, test results, and care plans was not consistently provided to the facility. The Medical Director and administrator were aware of these ongoing issues, which affected the facility's ability to deliver prompt and coordinated care.
Staff failed to use enhanced barrier precautions, specifically gowns, during wound care for two residents with open wounds. Despite facility policy and staff training requiring both gowns and gloves for such care, observations showed that only gloves were used, not gowns, during wound care for a resident with a Stage 3 pressure ulcer and another with arterial and diabetic wounds.
A resident who needed assistance with ADLs due to chronic heart failure was found to have a plastic bag of soiled linens left on the floor outside their doorway. Staff interviews confirmed that facility policy requires dirty linens to be placed in designated bins or the biohazard room, not left on the floor.
A resident with end stage renal disease and multiple wounds, including pressure ulcers and a burn, was discharged with significant discrepancies between the medical record and the discharge MDS. The MDS failed to accurately document the resident's wounds, receipt of scheduled pain medication, and discharge destination to an Assisted Living Facility, despite supporting evidence in the clinical record.
A resident admitted with an MDRO infection and nutritional risk was not provided with a complete baseline care plan, as their ongoing need for supplemental O2 was omitted despite daily administration and confirmation by both the POA and DON.
A resident admitted with multiple pressure ulcers did not receive necessary wound care due to missing or improperly entered treatment orders, resulting in staff not administering or documenting required treatments. The care plan and medical records lacked documentation of the resident's wounds, and essential assessments such as the Braden scale were not completed. Communication lapses and documentation failures contributed to the lack of appropriate pressure ulcer management.
The facility did not make the most recent survey results and plans of correction available in a location easily accessible to residents, families, and visitors. Instead, the survey binder was kept in the Administrator's office and was not updated with the latest reports, leaving recent survey findings unavailable for review.
Kitchen aides were observed preparing and serving food without wearing hairnets, and hairnets were not readily available at the kitchen entrance. Staff handled plates and food items without proper hair covering, and only after being prompted did one aide put on a hairnet. The District Manager confirmed that hairnets are required for kitchen staff during food preparation and service.
A resident at risk for aspiration was observed eating meals without required staff assistance, despite care plan directives for feeding support. The LPN and CNA were unaware of the resident's need for supervision, leading to inconsistencies in care. The RD and ST confirmed the resident's need for direct assistance, highlighting a failure to adhere to the care plan.
A resident experienced significant weight loss due to the facility's failure to monitor meal intakes and administer a prescribed nutritional supplement. Despite being at nutritional risk and requiring assistance with feeding, the resident struggled to eat without staff support. The ordered supplement, Gelatein Plus, was not documented or provided, and staff were unaware of the order, leading to continued nutritional decline.
A nurse in an LTC facility removed oxycodone pills from the medication cart for personal use, affecting two residents. The nurse falsely claimed the medications were discontinued and intended for the DON. Upon confrontation, the nurse admitted to taking the medications, returning the medication cards with pills missing. Residents were assessed with no adverse effects noted.
A facility failed to maintain a working call light system for a resident, as observed during a survey. The resident, unable to use the call light, mouthed 'help' while eating breakfast. Despite attempts by a surveyor to activate the call light, no sound or light was triggered. An LPN confirmed the resident's inability to use the call light and acknowledged that a pad trigger had been considered but not yet provided.
The facility failed to enforce smoking policies and provide adequate supervision, leading to residents keeping smoking materials on their person and smoking in unauthorized areas, including rooms with oxygen therapy. This placed residents at risk of burns and severe injury. Staff were aware of these violations but did not take appropriate action, and no incident reports were generated.
The facility failed to ensure the Activities Director (AD) was a qualified professional, as required by policy. The AD lacked necessary training, and despite being signed up for training twice, did not attend. Interviews revealed the Activities Assistant (AA) received no training and provided activities without direction. The Administrator confirmed the AD's repeated avoidance of training, which was a concern.
The facility failed to ensure staff were taking and recording meal temperatures before serving, as required by policy. Temperature logs for several months showed significant gaps, and staff interviews confirmed the deficiency. Despite recent in-service training, the issue persisted, with staff acknowledging the failure to comply with temperature monitoring protocols.
The facility's QAPI program was found deficient due to the Medical Director's absence from required meetings. The Medical Director did not attend QAPI meetings, instead discussing issues separately with the Administrator. This was noted during an investigation into a resident incident involving smoking in a room. The Administrator confirmed the absence and lack of attendance documentation, highlighting a failure in the QAPI program.
The facility failed to ensure a safe and comfortable environment, with broken and missing window screens observed in multiple resident rooms and a hallway. Despite identifying the need for repairs, the facility had not approved the necessary work for several months, leading to potential risks of injury and pest infestation. Interviews confirmed awareness of the issue since early 2024, but no corrective actions had been taken.
The facility failed to administer oxygen therapy according to physician orders for eight residents, with discrepancies in documented and actual oxygen levels. Additionally, a resident received oxygen without a physician order, and oxygen concentrator filters were not maintained, leading to potential risks of hyperoxia.
The facility failed to maintain an effective pest control program, resulting in a fly infestation observed in various areas, including around residents and in the dining room. Residents and staff reported the issue, but no work orders were submitted, and missing window screens were identified as a potential cause. The Maintenance Director had not contacted the pest control company to address the problem.
A resident with severe cognitive impairment had their Foley catheter bag visible from the doorway, contrary to the facility's policy requiring privacy bags for dignity. Observations confirmed the issue, and both an LPN and the DON acknowledged it as a dignity concern.
A facility failed to ensure medications were not left at the bedside for a resident who had not been assessed to self-administer medications. A medication cup with six unidentified pills was found unattended next to a resident's bed. Interviews with an LPN and the Unit Manager confirmed that medications should not be left unattended, and no resident had been assessed for self-administration. The Administrator confirmed that nursing staff were expected to observe residents taking their medications.
A resident's code status was incorrectly documented as Full Code in the EMR, despite their preference for DNR, as indicated by hospice and facility documentation. The error was confirmed by facility staff, including an LPN and the DON, who acknowledged the discrepancy and the expectation for accurate record-keeping.
The facility failed to provide the required SNFABN and NOMNC forms to two residents who were discharged from Medicare Part A services with benefit days remaining. The facility did not have copies of the NOMNC on file, and staff interviews revealed a lack of awareness and training regarding these notices. The Administrator acknowledged the absence of policies and stated that the facility follows CMS guidance.
The facility failed to provide written transfer notices to two residents and their representatives upon emergent hospital transfers, as well as to the ombudsman. One resident, who was cognitively intact, and another with severe cognitive impairment, were both transferred without receiving the required written notification. Interviews with staff confirmed the facility's non-compliance with its policy.
Failure to Coordinate Safe Discharge and Readmission for Resident With Behavioral Needs
Penalty
Summary
The deficiency involves the facility’s failure to appropriately manage the transfer and discharge of a resident with significant neurological and psychiatric diagnoses, including cerebral infarction, unspecified cerebrovascular disease, dysphagia, severe dementia with behavioral disturbance, generalized anxiety disorder, major depressive disorder, aphasia, and cognitive communication deficits. The resident had a care plan identifying risks for verbal and physical behaviors and elopement, with interventions such as monitoring for aggressive intent, evaluating triggers, providing psych/behavioral health consultation, and using calm redirection. Nursing notes documented that the resident exhibited escalating behavioral symptoms, including verbal abuse and homicidal ideations, leading to calls to local police and transfers to the hospital for evaluation and treatment. Following an earlier hospital evaluation, the resident was returned to the facility and placed on 1:1 supervision, with documentation that psych providers agreed with this level of supervision and ordered new medications. Progress notes indicated periods where the resident’s mood was pleasant and no unwanted behaviors were observed. However, on a later date, staff documented that despite 1:1 supervision, the resident continued to have verbal and physical aggression toward staff and others, and that her care could not be safely managed at that level of care. That same morning, the resident approached the administrator, DON, and supervising staff, expressed frustration with the ongoing 1:1 supervision, and then hit the administrator and threw a vase of flowers at the activities director, prompting activation of 911 and transfer to the hospital with EMS and police. The deficiency centers on the facility’s failure to ensure a safe and coordinated discharge and appropriate readmission planning after the resident was sent to the hospital. Nursing documentation shows the resident was discharged from the facility when she left with EMS and police. The guardian reported that after this transfer, the facility would not re‑admit the resident once she was ready for discharge from the hospital, resulting in the resident remaining in the hospital emergency room holding area while the guardian and hospital case managers searched for a safe placement. The social services director stated she did not believe it was a safe discharge and that the administrator decided not to re‑admit the resident. The hospital case manager director reported that when they contacted the facility, they were told the facility had done an immediate eviction and would not allow the resident to return, and that the resident showed no aggressive behavior in the hospital and did not meet criteria for hospital admission, leading to her being held in the emergency room for several days until transfer to an out‑of‑town assisted living facility could be arranged.
Failure to Prevent and Intervene in Staff-to-Resident Abuse
Penalty
Summary
The facility failed to properly intervene and prevent a Certified Nurse's Aide (CNA) from engaging in inappropriate and abusive interactions with multiple residents over several occasions. Multiple residents reported incidents involving the CNA, including inappropriate touching during peri care, unwanted hugging, and the use of inappropriate language. One resident, who was cognitively intact and had a history of stroke and paralysis, reported that the CNA touched her anus during peri care and made her feel uncomfortable. She also described repeated unwanted physical contact and inappropriate comments from the CNA. Despite these reports, the CNA was initially allowed to return to work with the restriction of not caring for the reporting resident, rather than being fully removed from resident care pending investigation. Another resident, also cognitively intact, reported that the same CNA attempted to touch her body during the night shift and, after being rebuffed, proceeded to touch her roommate under the blanket while making inappropriate comments. The roommate, who had moderate cognitive impairment and a diagnosis of Wernicke's encephalopathy, was later found fearful, confused, and agitated, and was evaluated by a Sexual Assault Nurse Examiner. The roommate was unable to recall the events during subsequent interviews, but her husband reported a significant decline in her mental and physical condition following the incident. A third resident described the CNA making inappropriate and suggestive comments during care, which made her uncomfortable, though she did not report any physical abuse. The facility's initial response to the allegations was to conduct resident questionnaires, which did not reveal further abuse at that time. The Administrator did not substantiate the initial allegation and allowed the CNA to return to work, only restricting contact with the reporting resident. It was only after additional allegations surfaced that the CNA was removed from the facility. The facility's failure to immediately and thoroughly intervene allowed the CNA continued access to residents, resulting in further incidents of alleged abuse.
Removal Plan
- Reportable sent for the initial resident.
- Two extra reportable were sent in late after new allegations of abuse.
- CNA in question was terminated.
- Center has implemented a new abuse questionnaire that allows for a more thorough investigation.
- Whole house abuse questionnaire completed with residents.
- Center Nursing staff will be re-educated on the following areas by the Nurse Educator/Designee: If abuse or behavioral issues are occurring (combative/physical behavior, threatening behavior, or anything that could be harmful to oneself or any other person), the victim should be separated from the aggressor immediately.
- The aggressor should be placed on 1:1 supervision immediately and remain on this type of monitoring until they have been sent to the ER, a behavioral unit, or the provider has cleared them of all potential to harm themselves or others.
- Documentation needs to occur to reflect this monitoring and clear discontinuation of the 1:1 and reasoning by a provider.
- If a staff member is accused of abuse, they should be replaced on their shift and removed from the building until police arrive (if necessary), removed from the schedule, and not put back on the schedule until an investigation is completed and they have been cleared by the Administrator or DON to return.
- The provider, nurse manager and family have to be notified immediately.
- The eInteract change in condition assessment needs to be completed filled out with all the details of what happened.
- Monitoring and interventions need to continue to happen and be documented if the residents remain in the building, until we know they have stabilized per the provider or have left the center.
- Administrator and DON were educated on the need for individual reports for each resident regarding abuse.
- Center has implemented a new abuse questionnaire that allows for a more thorough investigation.
- When an allegation of abuse is identified, the center will report to the state agency.
Failure to Investigate and Prevent Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate multiple allegations of abuse involving four residents, all of whom were reviewed for abuse. In one case, a cognitively intact resident reported that a CNA touched her anus during pericare and made her feel uncomfortable through unwanted physical contact and inappropriate language. The incident was reported to the Social Services Director, who informed the Administrator. The CNA was initially placed on leave, and an abuse questionnaire was conducted with other residents, but the investigation concluded the allegation was unsubstantiated, and the CNA was allowed to return to work with the condition of no further contact with the reporting resident. Another resident with moderate cognitive impairment reported that the same CNA attempted to sexually abuse her and her roommate. She described the CNA entering her room at night, attempting to touch her, and then moving to her roommate, where she witnessed inappropriate contact and heard inappropriate comments. Nursing notes documented these allegations, and a police report was filed. The roommate, who also had moderate cognitive impairment and a history of adult sexual abuse, was found fearful and confused, unable to recall the events or the CNA involved. Her husband was informed of an assault but was not given details. A fourth resident, cognitively intact, reported that the CNA made inappropriate comments and attempted to groom her, though she denied any inappropriate physical contact. She did not report these incidents to staff at the time. The Administrator stated that after the initial allegation, the CNA was suspended pending investigation, but the investigation relied on resident questionnaires and was deemed unsubstantiated, allowing the CNA to return to work. Only after further allegations did the facility bar the CNA from returning. The facility's investigation process did not thoroughly address or substantiate the multiple allegations, and steps to prevent further abuse were not adequately implemented.
Removal Plan
- Facility sent in late reportable for the second and third identified residents.
- Change in Condition with provider and responsible parties notified.
- Whole house abuse questionnaire completed with residents.
- Skin check for residents involved as appropriate.
- Psychiatric service referral for residents involved as appropriate.
- CNA in question was terminated.
- Center leadership staff will be re-educated on the following areas by Market Resource Nurse.
- Investigations start with removal of staff member and protection of resident.
- Abuse questionnaires to be completed by those who have the potential to be affected by the staff member or resident.
- Individual self-reports to follow for any other residents who are identified during the questionnaires.
- Change in condition with provider and responsible party notification for those affected or impacted.
- Skin checks for residents involved as appropriate Social services to complete wellness checks and offer psychosocial support as appropriate.
- Psychiatric services referral for residents involved as appropriate.
Failure to Follow Physician Orders for Lab Monitoring and Oxygen Therapy
Penalty
Summary
The facility failed to follow provider orders and maintain professional standards of quality for two residents. For one resident on Warfarin therapy, physician orders required weekly Prothrombin Time and International Normalized Ratio (PT/INR) testing every Monday, with results to be communicated to the provider and documented in the nursing notes, including any new orders received. Record review showed that on multiple dates, there was no documentation that the INR was completed, results recorded, provider notified, or new orders obtained. The Director of Nursing confirmed that the required documentation was incomplete and that there was no record of INR results prior to a certain date. For another resident with a physician order for continuous oxygen to maintain oxygen saturation above 88%, a hospice nurse observed the resident being walked in the hallway without oxygen. Upon checking, the resident's oxygen saturation was found to be 82%. The hospice nurse immediately notified staff and ensured the resident was returned to her room and placed back on her oxygen concentrator. These findings indicate that staff did not consistently follow physician orders for both medication monitoring and oxygen therapy.
Failure to Provide Scheduled Bathing Assistance to Dependent Residents
Penalty
Summary
The facility failed to provide activities of daily living (ADL) assistance, specifically with bathing and showering, to three residents who required such care. Documentation and interviews revealed that these residents were not consistently offered or given showers according to their scheduled times, despite their care plans indicating a need for assistance due to conditions such as limited mobility, legal blindness, and cognitive impairments. For example, one resident was scheduled for showers twice weekly but received significantly fewer showers than scheduled over several months, as confirmed by both electronic records and shower sheets. Interviews with the residents and their representatives indicated that the residents did not regularly refuse showers and expressed a desire to receive them as scheduled. Staff members, including nursing assistants and nurses, confirmed that the residents generally liked to receive showers and did not often refuse them. The Director of Nursing acknowledged that showers should be offered at least twice a week and confirmed that the affected residents were not offered or given enough showers according to their schedules. Observations further supported the deficiency, with one resident appearing unkempt and having dirty nails, and another resident's representative reporting that the resident was sometimes soiled during visits. Staff interviews also revealed that missed showers were sometimes due to staffing issues, and there were inconsistencies and missing documentation regarding whether showers were offered or refused. The facility's documentation practices did not consistently reflect the care provided, contributing to the failure to meet the residents' ADL needs.
Failure to Maintain Resident Dignity During Incontinence Episodes
Penalty
Summary
Facility staff failed to ensure a resident's dignity and respect by not promptly addressing episodes of incontinence while the resident was in common areas. Multiple observations documented the resident seated in a wheelchair with visibly wet clothing and a strong odor of urine, remaining soiled for extended periods in public spaces. Staff, including a CNA and a Nurse Practice Educator, were aware of the resident's condition but did not immediately provide assistance until the resident specifically requested a brief change. The resident reported having to wear two briefs due to inadequate absorbency and stated that staff would not change her unless she asked. Interviews with the resident's POA revealed ongoing concerns about hygiene and cleanliness, with the POA noting that the resident frequently complained about not being clean and required a new outfit after being soiled during a medical appointment. Staff interviews indicated that while some CNAs monitor incontinent residents and address needs regardless of assignment, this was not consistently practiced. The resident ultimately requested the re-insertion of a foley catheter due to infrequent changes and embarrassment from being soiled in public and during medical visits. The DON stated that staff are expected to complete rounding but cannot force residents to accept care, though there was no indication in the report that the resident refused care during the observed incidents.
Failure to Provide Consistent and Adequate Wound Care
Penalty
Summary
A deficiency occurred when the facility failed to provide consistent and adequate wound care for a resident with multiple complex medical conditions, including acute osteomyelitis, cutaneous abscess, diabetes with chronic kidney disease, and end-stage renal disease. Upon admission, the resident had documented wounds, specifically bilateral heel ulcers with osteomyelitis, and was discharged from the hospital with orders for ongoing wound care and evaluation by a wound care team. However, review of the resident's records revealed a lack of timely wound care orders and documentation, with no wound care orders entered until more than two weeks after admission, despite the presence of wounds requiring attention. Nursing notes and treatment administration records showed inconsistent documentation of wound assessments and care. Several entries noted the presence of wounds but indicated that no special care was provided, and there was no evidence of wound care being performed or documented on multiple days. Interviews with staff confirmed that wound care was not provided in the absence of provider orders or documentation in the treatment administration record. The skin treatment nurse acknowledged assessing the wounds but did not ensure that appropriate orders were entered or that care was documented. The resident and his family also reported that dressing changes were not performed as needed, and requests for wound care were often delayed or unaddressed by nursing staff. The deficiency culminated when the resident was evaluated by a podiatrist, who found the left heel wound to be neglected and in need of urgent care, resulting in a recommendation for immediate hospital transfer. The hospital record later confirmed that the resident's left foot and leg were amputated below the knee. The lack of consistent wound care, failure to follow up on hospital discharge orders, and inadequate documentation and communication among staff directly contributed to the resident not receiving care that would promote wound healing.
Removal Plan
- Initiate a new admit audit to ensure all tasks and admissions items are complete and confirm any outstanding items as complete during the stand down process.
- Perform QAPI as an education piece and update to wound care order verification process.
- Educate the team on the new clinical review protocol, including reviewer of all new admit orders, LPN unit manager, unit manager, director of nursing, treatment nurse, SHTL, admissions director, and Administrator.
- Admission is to notify the IDT team that a resident is admitting with wounds.
- Unit manager and/or designee will review the orders with the provider.
- If the wound is thought to be complex or needs additional oversight, the NExcell provider will be contacted.
- Hold weekly wound care meeting by the IDT team to ensure process is followed and all orders are entered timely, appropriately, updated care plan, accurate care plan, pictures taken with the swift phone.
- Conduct whole house skin sweep audit to identify any undocumented wounds.
- Confirm all treatment orders are in place and accurate.
- Audit all care plans to ensure accuracy per wound orders.
- Re-educate direct care staff on Wound Documentation and inputting orders upon admission.
- Re-educate Center Nurses on completion of skin assessments weekly per schedule.
- Educate nurses on their responsibility with communication with management and provider for the change in condition process/documentation when a resident is having a change in condition (including new or worsening wounds).
- Educate nurses on Genesis wound processes which include the DIMES, timely and accurate identification and documentation for wounds/wound changes, change in condition process, and appropriate treatment/intervention implementation upon identification of new or worsening wounds.
- Educate CNA's on the change in condition process for CNA's (including skin changes) and stop and watch.
- Ensure 100% of available staff have been educated on these processes. Any staff member that has not been scheduled, on leave of absence (FMLA), vacation, or PRN staff will be educated prior to returning to their next shift.
- Director of Nursing/Designee will audit education sign-off sheets to ensure that all nursing staff receive the education mentioned above.
- Director of Nursing/Designee will conduct 5 random audits of Residents that have wounds for skin assessment, order accuracy and for wound care process abidance. This will be audited weekly for 12 weeks.
- DON/designee and the Administrator/designee will bring the results of the audits to the QAPI committee for tracking, trending and further recommendations to ensure compliance with the plan. The audits will be brought to the QAPI committee for 3 months.
- Administrator will oversee the QAPI committee.
Failure to Enter and Review Wound Care Orders Upon Admission
Penalty
Summary
The facility failed to ensure that a physician or provider reviewed and entered all necessary orders for a resident upon admission, specifically omitting wound care orders for a resident with multiple complex medical conditions. The resident was admitted with diagnoses including acute osteomyelitis of the left ankle and foot, cutaneous abscess of the left foot, diabetes with chronic kidney disease, and end stage renal disease. Hospital discharge orders included instructions for wound care and evaluation by a wound care team, but these were not entered into the facility's physician orders upon admission. A review of the resident's physician orders revealed that there were no orders to monitor or provide wound care for any existing wounds from the day of admission until the resident was discharged. During interviews, the physician assistant recalled the resident and his wounds but was unaware that no wound care orders had been entered during the resident's stay. The physician assistant stated that it was standard for facility nurses to contact her to review and approve admitting orders, but she could not recall being contacted about this admission or reviewing the orders for this resident. The deficiency was identified when it was found that the resident did not have wound care orders in place during their stay, despite having wounds that required treatment. The lack of review and entry of necessary orders by the provider resulted in the resident not having documented wound care provided as directed by the hospital discharge instructions.
Removal Plan
- Initiate a new admit audit to ensure all tasks and admissions items are complete and confirmed during the stand down process.
- Update the wound care order verification process.
- Educate the team on the new clinical review protocol, including notification of the IDT team when a resident is admitted with wounds.
- Unit manager or designee to review orders with the provider for new admissions with wounds.
- Contact NExcell provider if an admitting wound is considered complex or needs additional oversight.
- Hold wound care meetings by the IDT team to ensure process is followed and all orders are entered appropriately, care plans are updated and accurate, and wound pictures are taken.
- Conduct whole house skin sweep audits to identify any undocumented wounds.
- Confirm all treatment orders are in place and accurate.
- Audit all care plans to ensure accuracy per wound orders.
- Re-educate direct care staff on wound documentation and inputting orders upon admission.
- Re-educate Center Nurses on completion of skin assessments.
- Educate nurses on responsibility for communication with management and provider for change in condition process/documentation, including new or worsening wounds.
- Educate nurses on Genesis wound processes, including DIMES, identification and documentation for wounds/wound changes, change in condition process, and appropriate treatment/intervention implementation.
- Educate CNAs on the change in condition process for CNAs (including skin changes) and stop and watch.
- Ensure 100% of available staff have been educated on these processes, with any unscheduled staff to be educated prior to their next shift.
- Director of Nursing/Designee to audit education sign-off sheets to ensure all nursing staff receive the required education.
- Director of Nursing/Designee to conduct random audits of residents with wounds for skin assessment, order accuracy, and wound care process abidance.
- Bring audit results to the QAPI committee for tracking, trending, and further recommendations.
- Administrator to oversee the QAPI committee.
Failure to Prevent and Respond to Staff Abuse Allegations
Penalty
Summary
The facility failed to protect residents from abuse by not properly intervening and preventing a Certified Nurse's Aide (CNA) from engaging in inappropriate and abusive interactions with multiple residents over several occasions. One resident, who was cognitively intact and had a history of stroke and paralysis, reported that the CNA touched her anus during peri care and made her feel uncomfortable. She also described the CNA attempting to hug her and using inappropriate language. The incident was reported to the Social Services Director, who informed the Administrator and the facility's Abuse Officer. Despite the report, the CNA was allowed to return to work the same day with the only restriction being no further contact with the reporting resident. Another resident, also cognitively intact and with multiple medical diagnoses, reported that the same CNA attempted to sexually abuse her during the night shift. She described kicking the CNA away and verbally confronting him, after which the CNA moved to her roommate and was observed placing his hand under the roommate's blanket and making inappropriate comments. The roommate, who had moderate cognitive impairment and a history of Wernicke's encephalopathy, was later found on the floor, confused and fearful, and was evaluated by a Sexual Assault Nurse Examiner. The roommate's husband reported that his wife was emotionally distressed and experienced a decline in her condition following the incident. A third resident reported that the CNA made inappropriate comments to her during personal care, which she found unsettling and suggestive of grooming behavior, though she denied any physical abuse. She did not report these incidents initially due to the CNA's night shift schedule and limited contact. The facility Administrator, upon being informed of the initial allegation, conducted an investigation but did not substantiate the abuse and allowed the CNA to return to work. It was only after additional allegations surfaced that the CNA was removed from the facility. The facility's initial response did not include immediate removal of the accused staff member or comprehensive investigation, resulting in continued risk to other residents.
Removal Plan
- Reportable sent for the initial resident.
- Two extra reportable were sent in after new allegations of abuse.
- CNA in question was terminated.
- Center has implemented a new abuse questionnaire that allows for a more thorough investigation.
- Whole house abuse questionnaire completed with residents.
- Center Nursing staff will be re-educated on the following areas by the Nurse Educator/Designee: If abuse or behavioral issues are occurring (combative/physical behavior, threatening behavior, or anything that could be harmful to oneself or any other person), the victim should be separated from the aggressor immediately.
- The aggressor should be placed on 1:1 supervision immediately and remain on this type of monitoring until they have been sent to the ER, a behavioral unit, or the provider has cleared them of all potential to harm themselves or others.
- Documentation needs to occur to reflect this monitoring and clear discontinuation of the 1:1 and reasoning by a provider.
- If a staff member is accused of abuse, they should be replaced on their shift and removed from the building until police arrive (if necessary), removed from the schedule, and not put back on the schedule until an investigation is completed and they have been cleared by the Administrator or DON to return.
- The provider, nurse manager and family have to be notified immediately.
- The eInteract change in condition assessment needs to be completed filled out with all the details of what happened.
- Monitoring and interventions need to continue to happen and be documented if the residents remain in the building, until we know they have stabilized per the provider or have left the center.
- Administrator and DON were educated on the need for individual reports for each resident regarding abuse.
- Center has implemented a new abuse questionnaire that allows for a more thorough investigation.
- When an allegation of abuse is identified, the center will report to the state agency.
Failure to Investigate and Prevent Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate multiple allegations of abuse and did not take adequate steps to prevent further abuse involving four residents. One resident, who was cognitively intact and had a history of stroke and paralysis, reported that a CNA touched her anus during pericare and later attempted to hug her and used inappropriate language. The incident was reported, and the CNA was initially placed on leave, but the investigation relied primarily on abuse questionnaires with other residents and did not substantiate the allegation, allowing the CNA to return to work with the condition of no further contact with the reporting resident. Another resident, with moderate cognitive impairment and a history of heart failure, reported that the same CNA attempted to sexually abuse her and her roommate. She described the CNA entering her room at night, attempting to touch her, and then moving to her roommate, where inappropriate physical contact and comments were observed. The roommate, who also had moderate cognitive impairment and a diagnosis of Wernicke's encephalopathy, was found fearful and confused, and a SANE nurse was called to evaluate her for sexual assault. The roommate's husband was informed of an assault but not given details, and he noted his wife's increasing confusion. A fourth resident, cognitively intact, reported that the CNA made inappropriate comments and attempted to groom her, though she denied any physical abuse and had not reported these incidents previously. The facility's investigation into these allegations was limited, with the administrator and social services director disagreeing on whether the abuse occurred. The administrator did not substantiate the allegations and allowed the CNA to return to work until further allegations led to the CNA's termination. Documentation and interviews revealed that the facility did not conduct a thorough investigation or implement sufficient measures to prevent further abuse after the initial reports.
Removal Plan
- Facility sent in late reportable for the second and third identified residents.
- Change in Condition with provider and responsible parties notified.
- Whole house abuse questionnaire completed with residents.
- Skin check for residents involved as appropriate.
- Psychiatric service referral for residents involved as appropriate.
- CNA in question was terminated.
- Center leadership staff will be re-educated on the following areas by Market Resource Nurse.
- Investigations start with removal of staff member and protection of resident.
- Abuse questionnaires to be completed by those who have the potential to be affected by the staff member or resident.
- Individual self-reports to follow for any other residents who are identified during the questionnaires.
- Change in condition with provider and responsible party notification for those affected or impacted.
- Skin checks for residents involved as appropriate.
- Social services to complete wellness checks and offer psychosocial support as appropriate.
- Psychiatric services referral for residents involved as appropriate.
Failure to Follow Physician Orders for Anticoagulation Monitoring and Oxygen Therapy
Penalty
Summary
The facility failed to follow provider orders and maintain professional standards of quality for two residents. For one resident on Warfarin therapy, physician orders required weekly Prothrombin Time and International Normalized Ratio (PT/INR) testing every Monday, with results to be communicated to the provider and documented in the nursing notes, including any new orders received. Record review showed that on multiple specified dates, there was no documentation that the INR was completed, results recorded, provider notified, or new orders obtained. The Director of Nursing confirmed that the required documentation was incomplete and that there was no record of INR results prior to a certain date. For another resident with a physician order for continuous oxygen to maintain oxygen saturation above 88%, a hospice nurse observed the resident being walked in the hallway without oxygen. Upon checking, the resident's oxygen saturation was found to be 82%. The hospice nurse immediately notified staff and ensured the resident was returned to her room and placed back on her oxygen concentrator. These findings indicate that staff did not consistently follow physician orders for both medication monitoring and oxygen therapy.
Failure to Provide Scheduled Bathing and Showering Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs), specifically bathing and showering, for three residents who required such care. Documentation and interviews revealed that these residents were not consistently offered or given showers according to their scheduled times, despite their care plans indicating a need for assistance due to conditions such as limited mobility, legal blindness, and cognitive impairments. For example, one resident was scheduled for showers twice weekly but received significantly fewer showers than scheduled over several months, as confirmed by both electronic records and shower sheets. This resident was observed to be unkempt and reported not receiving showers as scheduled. Another resident, who required ADL assistance due to cognitive impairments, was also not provided showers according to the facility's schedule. Documentation showed discrepancies between the number of showers scheduled and those actually given, with the resident expressing frustration about not receiving at least two showers per week. Staff interviews confirmed that this resident did not typically refuse showers, and the DON acknowledged that the resident was not offered enough showers. A third resident, dependent on staff for multiple ADLs due to paralysis and limited mobility, similarly did not receive showers as scheduled. Documentation indicated that the resident was given fewer showers than scheduled, and the resident's representative reported that the resident frequently complained about not being bathed enough and was sometimes found soiled. Staff interviews and record reviews confirmed issues with both the provision and documentation of showers, with the DON unable to explain missing documentation or blank entries.
Failure to Maintain Resident Dignity During Incontinence Episodes
Penalty
Summary
Facility staff failed to ensure a resident's dignity and respect by not promptly addressing episodes of incontinence while the resident was in common areas. Multiple observations documented the resident seated in a wheelchair, visibly wet from the lower shirt to the knees, and remaining soiled for at least 15 minutes in a public area. The resident reported having to wear two briefs due to inadequate absorbency and stated that staff would not change her unless she specifically requested it. Staff interviews confirmed awareness of the resident's condition, with one CNA acknowledging the resident was wet and another stating that any certified staff should assist with changing a soiled resident, regardless of assignment. Additional observations noted a strong odor of urine and the resident remaining wet after moving between common areas, with staff present but not intervening until the resident directly requested assistance. The resident's Power of Attorney expressed concerns about the bathing schedule and the resident's ongoing complaints about not being clean. The resident had a history of incontinence, previously managed with a foley catheter, which had been removed three months prior. After continued issues with incontinence care, the resident requested the catheter be reinserted, citing embarrassment and discomfort from being soiled, including during a medical appointment. The Director of Nursing stated that staff are expected to complete rounds but cannot force residents to accept care, noting that some residents refuse assistance. However, the report documents that the resident was not offered timely care and was left soiled in public areas, impacting her dignity.
Deficient Food Storage and Sanitation Practices Identified
Penalty
Summary
Surveyors observed multiple failures in food storage and handling within the facility's kitchen. Specifically, several food items, including large trays of cake, bags of whipped topping, a container of sugar, a pitcher of juice, and a tray of thickened juice, were found unlabeled and undated in the refrigerator and on shelves. Additionally, a tray of eggs was left out under a food warmer and was not kept on ice or refrigerated, and when touched, the eggs were warm before being returned to the refrigerator. The kitchen freezer floor was also found to have spilled milk and debris, including paper and plastic wrappers. These findings were confirmed by the Dietary Manager during an interview.
Failure to Withhold Contraindicated Medications During Diarrhea Episodes
Penalty
Summary
A resident with a history of iliac artery aneurysm and left-sided hemiplegia was admitted to the facility and prescribed multiple medications, including Sennosides-Docusate for constipation and Loperamide for diarrhea. The resident was also receiving morphine for pain management. Despite the presence of ongoing diarrhea, both Sennosides-Docusate and Loperamide were administered concurrently over an extended period, as documented in the Medication Administration Record and confirmed by staff interviews. This practice is contraindicated, as the medications have opposing effects and should not be given together. Nursing notes and interviews revealed that the resident experienced frequent, loose, and watery stools for at least two weeks, with multiple episodes of diarrhea documented. The resident reported feeling unclean, having a persistent foul odor, and being left in soiled briefs for extended periods due to staff unavailability. The resident also expressed a preference for showers over bed baths, which was not accommodated. Certified Nurse Aides and LPNs confirmed the resident's ongoing diarrhea and the continued administration of both medications, with some staff acknowledging that the medications should not have been given together. The facility's Nurse Practitioner and Director of Nursing both stated that standard practice would be to hold or discontinue Sennosides-Docusate if a resident developed diarrhea and to administer Loperamide as needed. However, the review of records and staff interviews confirmed that this protocol was not followed, resulting in the resident receiving both medications simultaneously and experiencing ongoing diarrhea and discomfort.
Failure to Provide Scheduled Showers and ADL Assistance
Penalty
Summary
A deficiency occurred when a resident who required assistance with activities of daily living (ADLs), including bathing and showering, did not receive showers as scheduled or requested. The resident, who had a history of cerebrovascular accident (CVA) resulting in limited mobility and required two staff members for transfers, reported not receiving showers and only receiving inconsistent bed baths. The resident stated he had not received a bed bath in about two weeks and expressed distress over his hygiene. Review of the care plan confirmed the need for ADL assistance, and the shower schedule indicated the resident was to receive showers twice weekly. However, documentation for April and May showed no record of showers or refusals, and only four bed baths were documented in May, with no shower sheets available for April. Interviews with staff revealed confusion regarding responsibility for providing showers, with a CNA stating hospice was responsible and an LPN confirming multiple calls to hospice without response. The LPN also stated that facility CNAs would provide bed baths when hospice did not come, but confirmed the resident had not received a shower. The Director of Nursing acknowledged that residents should receive showers according to their preferences and schedule, regardless of hospice involvement. This lack of coordination and documentation led to the resident not receiving the necessary ADL care for bathing and showering.
Failure to Safeguard Residents' Private Health Information
Penalty
Summary
During routine observations on Unit 1 and Unit 2, surveyors found that the facility failed to safeguard residents' clinical record information. On multiple occasions, documents containing private health information (PHI), such as a vital sign sheet, a daily resident census sheet, and a weight list, were left in areas accessible to unauthorized individuals. Specifically, the vital sign sheet and census sheet were left face-up on the nurses' station counters, making residents' names, room numbers, and vital signs visible to anyone approaching the area. Additionally, a weight list with all residents' weights was found hanging outside a resident's room, facing outward and visible to passersby. Interviews with LPNs on both units confirmed that these documents were left inappropriately exposed and acknowledged that they should have been placed face-down or not left in public view. The observations and staff interviews indicate that the facility did not adequately protect residents' PHI during the survey period, resulting in unauthorized access to confidential information.
Failure to Serve Food at Safe and Appetizing Temperature
Penalty
Summary
The facility failed to serve food at a safe and appetizing temperature for one resident reviewed for food preference. During the midday meal service, meal trays were delivered to the unit and distributed to residents, with the last tray reserved for temperature testing. The Dietary Manager measured the temperature of the hamburger and broccoli on the test tray and found them to be 96.8°F and 94.7°F, respectively, which he acknowledged were too cool, as the expected temperature should be about 130°F. The Dietary Manager was unable to measure the temperature of the tater tots. Additionally, the resident interviewed reported that her meals most days arrived cool to the taste and touch.
Failure to Accurately Document Medication Administration
Penalty
Summary
The facility failed to ensure that medical records were updated and accurate for one resident. Review of the resident's face sheet confirmed admission to the facility, and a provider order indicated that Imodium A-D was to be administered as needed for diarrhea. On review of the medication administration record (MAR), it was found that no Imodium A-D had been documented as given by midday, despite an LPN stating during interview that she had administered the medication during the morning medication pass. The LPN acknowledged that she had not documented the administration due to being very busy and intended to document it later. The Director of Nursing confirmed that all medications should be documented immediately after administration, and that there should be no delay between giving and documenting medications.
Lack of Coordinated Hospice Plan of Care in Resident Record
Penalty
Summary
The facility failed to ensure a coordinated plan of care was available for a resident receiving hospice services. Record review showed that the resident was on hospice care according to the admission Minimum Data Set. During interviews, a hospice RN stated that a hospice binder containing the coordinated plan of care and admitting documentation was brought at admission, while an LPN reported that hospice documentation is kept in the Electronic Medical Record (EMR) and that the facility does not have hospice binders. However, review of the resident's EMR revealed that the coordinated plan of care was not present. The Director of Nursing confirmed that there was no coordinated plan of care available for review.
Delayed and Inadequate Response to Changes in Condition and Wound Care
Penalty
Summary
The facility failed to provide appropriate treatment and care for four residents experiencing changes in condition, resulting in delayed or inadequate medical intervention. In one case, a resident with a history of respiratory illness, confusion, and declining physical status was not promptly sent to the emergency room despite ongoing symptoms such as cough, lethargy, and low blood pressure. Multiple staff interviews confirmed that the resident's condition worsened over several days, and both nursing staff and the physician assistant acknowledged that the resident should have been transferred to the hospital sooner. The resident was eventually diagnosed with pneumonia, UTI, kidney inflammation, and sepsis after being sent to the ER. Another resident experienced red, irritated eyes over the holiday period, with family members repeatedly notifying staff of the issue. Despite these notifications, there was no documented response or intervention until several days later, when the provider finally assessed the resident and prescribed medication for allergic conjunctivitis. The delay in addressing the change in condition was confirmed by both family interviews and facility staff, who acknowledged that the concern was not escalated to nursing or the provider in a timely manner. A third resident with multiple diagnoses, including stroke and acute kidney failure, had care delays due to lack of timely communication and order entry from an external primary care provider. The resident experienced confusion, falls, and behavioral changes, with delays in both antibiotic and psychiatric medication orders. Additionally, a fourth resident developed a third-degree burn on the sacrum that was not promptly reported to the physician, and wound care was delayed. Documentation and interviews revealed that the wound worsened, and the resident was discharged to an assisted living facility while still in pain and with an unhealed wound. The physician assistant and medical director both confirmed that the wound should have been reported and treated earlier, and that the resident should not have been discharged in that condition.
Failure to Notify Physician of Resident Decline and Wound Development
Penalty
Summary
The facility failed to notify the physician regarding significant changes in the condition of two residents. One resident, who had a history of dementia and impaired swallowing, experienced a decline in her ability to feed herself, as evidenced by consistently low meal intake percentages and observations of her struggling to eat without assistance. Despite documentation in her care plan indicating the need for meal assistance and supervision, staff interviews revealed inconsistent understanding and communication about her needs. The resident's Power of Attorney reported multiple instances where meal trays were left untouched, and staff interviews confirmed that she was often only provided set-up assistance rather than direct feeding help. Neither the registered dietitian nor the physician's assistant was made aware of the resident's feeding difficulties or low intake, and there was no documentation of physician notification regarding her decline in self-feeding ability. Another resident developed a third-degree burn on the sacrum, which was acquired in-house and documented by the facility's Skin Health Team Lead. The wound was described as hot to the touch, with moderate exudate and significant pain reported by the resident. Despite the severity of the wound, there was no documentation that the resident's physician was notified at the time of discovery or as the wound worsened. Progress notes and wound evaluations over several days failed to mention physician notification, and interviews with the physician assistant and medical director confirmed that they were not informed of the wound. The wound care nurse attempted to contact the resident's doctor but did not follow up to ensure successful communication and did not notify the facility's nurse practitioner or medical director. Family interviews further revealed a lack of communication regarding the resident's wound and its deterioration. The resident's daughter was not informed of the wound upon admission and only learned of its worsening condition through direct observation and communication with the wound nurse. The daughter described a rapid decline in her mother's condition, including increased pain, confusion, and eventual hospitalization for septic shock following discharge from the facility. Staff interviews confirmed that there was an expectation for nursing staff to notify providers of significant changes, but this did not occur in these cases, resulting in a failure to ensure timely medical intervention.
Failure to Timely Submit Abuse and Incident Investigation Reports
Penalty
Summary
The facility failed to ensure that the results of all investigations into allegations of abuse, neglect, exploitation, misappropriation, and injuries of unknown source were submitted to the State Survey Agency within the required 5 working days. A review of records and interviews revealed that the Administrator, who serves as the abuse coordinator and is solely responsible for reporting, did not submit timely follow-up investigation reports for multiple incidents. The State Survey Agency notified the facility that 26 self-reported incidents were still pending 5-day follow-up investigations, despite attempts to contact the Administrator. Specific cases included incidents involving care concerns, deep tissue injury, resident altercations, allegations of staff misconduct, and falls, with several reports being submitted weeks or months after the incident, and at least one case with no evidence of submission at all. The Administrator confirmed these delays during interviews and record reviews, acknowledging that the required reports were not submitted within the mandated timeframe.
Failure to Follow Physician Orders and Documentation Standards for Oxygen and Medication Administration
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for four residents. For one resident, oxygen was administered at 2.5 liters per minute (LPM) via nasal cannula, contrary to the physician's order for 5 LPM, and the oxygen tubing was not labeled or dated as required. Certified Nursing Assistants (CNAs) were unaware of the correct oxygen flow rate, and both CNAs and a Licensed Practical Nurse (LPN) confirmed the discrepancies. Another resident's oxygen tubing was also found unlabeled and undated, despite physician orders specifying weekly labeling and dating. A third resident was provided oxygen at 2 LPM daily without any physician order present in the record, which was confirmed by the Director of Nursing (DON). For a fourth resident, staff entered and administered an antibiotic medication under a Nurse Practitioner's (NP) name without an actual order or permission from the NP. The medication was requested by the family and was a prior home medication, but there was no documentation to support its use at the time, and it was later placed on hold pending further review. The DON stated that staff should not enter medication orders without provider authorization and that this action violated nursing licensure standards.
Lack of Physician Progress Notes Following Resident Visits
Penalty
Summary
The facility failed to ensure that residents had written, signed, and dated progress notes from their primary care physicians (PCPs) after each required visit. This deficiency was identified for eight residents whose care was managed by a senior service agency, rather than by providers directly connected to the facility. Record reviews for these residents revealed that, over the past six months, there were no progress notes submitted by the PCPs or their agency for any visits, despite the residents having multiple complex medical diagnoses such as acute and chronic respiratory failure, chronic kidney disease, dementia, fractures, heart failure, and psychiatric conditions. The face sheets for each of the eight residents indicated that their PCPs were affiliated with an external senior service agency. According to the Director of Nursing (DON), these PCPs and other providers from the agency would conduct in-person visits at the facility and sometimes transport residents to the agency's clinic for appointments. The DON estimated that each resident was seen by a PCP weekly. However, upon review of the electronic medical records (EMRs), it was confirmed that there were very few, if any, progress notes documenting these visits. Interviews with the DON further clarified that the senior service agency seldom provided the required written, signed, and dated progress notes for the visits conducted, either at the facility or at the agency's clinic. This resulted in incomplete resident records, as there was a lack of documentation and review of the care provided by the PCPs for these residents.
Failure to Verify and Administer Correct Morphine Dose
Penalty
Summary
A medication error occurred when a resident with Parkinson's disease and age-related physical debility was administered Morphine Sulfate at an incorrect concentration. The provider had ordered Morphine Sulfate 20 mg/5 ml to be given at various intervals for pain management, but the pharmacy supplied Morphine Sulfate 20 mg/1 ml instead. Facility staff failed to verify that the medication received matched the provider's order, resulting in the administration of a higher dose than intended. Over several days, a total of 47 doses of the incorrect medication were given before the error was discovered. The error was identified after the resident exhibited declining health, including shallow breathing, low oxygen saturation, and decreased responsiveness. A pharmacist contacted the facility to clarify the order, leading to the discovery that the wrong concentration had been administered. Nursing documentation confirmed that the medication and dose were not properly checked by staff at the time of receipt or during administration, which directly contributed to the prolonged medication error.
Delayed Physician Response and Communication Deficiency
Penalty
Summary
Facility administration failed to ensure a system for receiving timely responses from primary care providers (PCPs) for all residents reviewed for physician communications. Record review showed that multiple residents were under the care of a senior service provider, and staff reported repeated delays in obtaining orders and medical directives from these PCPs. The DON confirmed that there were instances where staff had to escalate issues to her, and she personally contacted the PCP to obtain necessary orders. There were also delays in receiving medication changes and new medication orders, resulting in delayed care for residents. Additionally, the senior service PCPs did not consistently provide results of visits, diagnostic tests, or medical plans to the facility. Interviews with LPNs revealed that while the PCP typically responded within 20-30 minutes on weekdays, response times on weekends could extend to 12-24 hours, and there were occasions where responses took 2-3 hours. The facility Medical Director acknowledged ongoing issues with slow responses from the senior service PCPs and stated that this had been discussed with the facility administrator. The administrator confirmed awareness of the delays and acknowledged that care for some residents had been delayed due to the PCP's lack of timely response and failure to provide necessary information about resident care.
Failure to Use Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) during wound care for two residents with open wounds. According to the Centers for Medicare and Medicaid Services (CMS) guidelines, EBP requires the use of gowns and gloves during high-contact care activities for residents with wounds, regardless of known infection or colonization with multidrug-resistant organisms (MDROs). Observations revealed that the Skin Health Team Lead (SHTL) performed wound care on a resident with a Stage 3 pressure ulcer on the right heel and another resident with an arterial wound at a left ankle amputation site and a diabetic wound on the right toe. In both cases, the SHTL used hand sanitizer and donned gloves but did not wear a gown as required by EBP protocols. Record reviews confirmed the presence of open wounds and active treatment orders for both residents. During interviews, the Infection Control Coordinator stated that the facility's policy required staff to use gowns and gloves for residents with open wounds and that staff had been trained on EBP procedures. Despite this, direct observations showed that the required gown was not used during wound care for these residents, constituting a failure to follow established infection prevention and control protocols.
Soiled Linens Left on Floor Compromises Cleanliness Standards
Penalty
Summary
Facility staff failed to maintain a clean and homelike environment for a resident who required assistance with activities of daily living due to chronic disease related to congestive heart failure. During an observation, a plastic bag filled with soiled linen was found left on the floor in front of the resident's doorway. Interviews with a CNA and the DON confirmed that facility policy requires soiled linens to be placed in designated bins or the biohazard room, and not left on the floor in resident rooms.
Inaccurate Discharge MDS Documentation for Resident with Multiple Wounds
Penalty
Summary
The facility failed to ensure the accuracy of the discharge Minimum Data Set (MDS) for one resident. Upon review, discrepancies were found between the resident's medical records and the information documented in the discharge MDS. The resident, who had a history of end stage renal disease, dependence on dialysis, and depression, was admitted with multiple skin issues, including two Stage 1 pressure ulcers, one Stage 4 pressure ulcer, and a skin tear. Wound evaluations during the resident's stay identified additional and more severe wounds, such as unstageable pressure ulcers on both heels, a Stage 4 pressure ulcer on the right medial ankle, a Stage 1 pressure ulcer on the rear left ankle, and a third-degree burn to the sacrum. These findings were not consistently or accurately reflected in the discharge MDS. Further review of the resident's medication administration records showed that a scheduled lidocaine patch was applied and removed as ordered for pain management, but the discharge MDS did not document that the resident received this scheduled pain medication. Additionally, the discharge MDS failed to accurately record the resident's discharge destination, omitting that the resident was discharged to an Assisted Living Facility with family support. The MDS Coordinator stated that she relied on the accuracy of the medical records and would question staff if discrepancies were noted, but the inaccuracies in the MDS persisted, resulting in an incomplete and inaccurate assessment at discharge.
Failure to Include Oxygen Therapy in Baseline Care Plan
Penalty
Summary
The facility failed to develop an accurate baseline care plan within 48 hours of admission for a resident who was admitted with a history of infection related to multidrug-resistant organisms (MDRO) and was at nutritional risk due to inadequate oral intake. Although the baseline care plan addressed the infection and nutritional risk, it did not include the resident's need for supplemental oxygen (O2), despite documentation showing the resident received O2 at 2 LPM daily during their stay. Interviews with the resident's Power of Attorney and the Director of Nursing confirmed that the resident was on O2 upon admission and throughout their stay, and that this need was not included in the baseline care plan as required.
Failure to Provide and Document Pressure Ulcer Care
Penalty
Summary
A resident with end stage renal disease, dependence on dialysis, and depression was admitted to the facility with multiple pressure ulcers, including two Stage 1 ulcers and one Stage 4 ulcer, as well as a skin tear. Upon admission and throughout the resident's stay, staff failed to complete a Braden assessment to determine the risk of further pressure ulcer development. The care plan did not document the resident's existing pressure ulcers, and physician orders for wound care were either missing or not properly entered into the Medication Administration Record (MAR) or Treatment Administration Record (TAR). Wound evaluations documented the presence and progression of the resident's pressure ulcers, but there was no evidence that wound care treatments were administered as ordered. The Skin Health Team Lead (SHTL) entered treatment orders into the electronic record, but due to a selection error in the software, these orders did not transfer to the MAR/TAR, resulting in nursing staff not providing or documenting the required wound care. The SHTL and facility leadership confirmed that nurses relied on the TAR to provide treatments, and since the orders were not present, treatments were not completed or recorded. Additionally, there was a lack of documentation regarding physician notification of new or worsening wounds, and progress notes from both nursing and medical staff failed to address the resident's pressure ulcers or their treatments. Weekly skin checks and other care plan interventions were not consistently documented, and the resident's wounds were not properly tracked or managed. These failures led to a lack of necessary treatment and services to promote healing and prevent the development of new pressure ulcers.
Survey Results Not Accessible to Residents and Visitors
Penalty
Summary
The facility failed to make the most recent survey results and any associated plan of corrections readily accessible to residents, family members, legal representatives, and visitors. During an observation of the facility lobby and an interview with the Administrator, it was found that the survey report binder was not present in a public area but instead kept in the Administrator's office for updating purposes. The binder available was labeled for surveys from 2021-2023 and did not include reports from 2024 or 2025. Record review confirmed that seven survey investigations had been conducted between 2024 and January 2025, but these were not available for review by residents or visitors.
Failure to Ensure Kitchen Staff Wore Hairnets During Meal Service
Penalty
Summary
During lunch meal service, multiple kitchen aides were observed preparing and serving food without wearing hairnets, as required to prevent cross contamination. Specifically, staff were seen in the kitchen and at the kitchen entrance without hairnets, and there were no hairnets available near the entrance. The Dietary Manager had to retrieve a hairnet from the back of the kitchen when requested by the surveyor. Three kitchen aides were observed handling plates, placing food items and lids, and assembling meal trays without hairnets. Later, one kitchen aide was seen wearing a hairnet after the initial observation. The District Manager confirmed in an interview that kitchen staff are expected to wear hairnets during food preparation and service. This deficiency was identified as potentially affecting all residents in the facility, as all were served food prepared under these conditions.
Failure to Provide Required Meal Assistance and Supervision
Penalty
Summary
The facility failed to provide the necessary assistance for a resident during meal times, which could likely result in the resident being at risk for aspiration and choking. During an observation, the resident was seen eating breakfast in bed without staff present, despite the care plan indicating a need for feeding assistance and monitoring for aspiration. The Licensed Practical Nurse (LPN) stated that the resident could feed himself and did not require supervision, contradicting the care plan and nutritional assessment that highlighted the resident's need for assistance due to a high aspiration risk. Further interviews and record reviews revealed inconsistencies in the care provided to the resident. The Registered Dietician (RD) and Speech Therapist (ST) both confirmed that the resident required direct assistance during meals, with the ST specifying one-on-one feeding due to the resident's inability to feed himself and aspiration risk. Despite these directives, the resident was observed eating lunch alone, and a gelatin supplement was missing from his meal tray. A Certified Nursing Assistant (CNA) later checked on the resident after he coughed while drinking, indicating a lack of consistent supervision and adherence to the care plan requirements.
Failure to Monitor Nutritional Status and Administer Supplements
Penalty
Summary
The facility failed to ensure a resident maintained acceptable nutritional status by not monitoring meal intakes and not providing the ordered nutritional supplement. Observations revealed that the resident struggled to eat breakfast in bed without staff assistance, despite needing thickened liquids and being dependent on staff for feeding. The care plan indicated the resident was at nutritional risk and required monitoring of meal intake and assistance with feeding, but these interventions were not followed. The resident experienced significant weight loss over several months, and there was no documentation of meal intake percentages, which the Registered Dietician relied on for assessing the resident's nutritional status. Additionally, the resident had an order for Gelatein Plus, a high-protein supplement, to be given twice daily, but this was not documented in the Medication Administration Record or Treatment Administration Record. Interviews with staff, including the LPN and CNA, confirmed that the supplement was not provided, and there was a lack of awareness about the order. The Dietary Manager stated that the supplement was available in Central Supply, but it was not being administered to the resident. This lack of coordination and communication among staff contributed to the resident's continued weight loss and nutritional risk.
Nurse Misappropriates Resident Medications for Personal Use
Penalty
Summary
The facility failed to protect residents from the misappropriation of their medications when a nurse removed oxycodone pills from the medication cart for personal use. This incident involved two residents whose narcotic pain medications were taken by a nurse under the pretense of delivering them to the Director of Nursing (DON). The nurse claimed the medications were discontinued and intended for the DON, but later admitted to taking them for personal use. The nurse was confronted and confessed to taking the medications, returning the medication cards with 13 oxycodone pills missing. The residents involved were assessed, and it was confirmed that there were no adverse reactions or unrelieved pain as a result of the missing medications. One resident confirmed receiving effective pain medication, while the other did not show any visible signs of distress or pain during observation. The facility conducted an investigation and confirmed that no other medications were missing from the medication carts.
Non-Functional Call Light System
Penalty
Summary
The facility failed to ensure that the call light system was in working order for a resident during a random observation. During the observation, the resident was seen sitting upright in bed and mouthing the word 'help' while eating breakfast. The surveyor attempted to use the call light pinned to the side of the resident's bed, but there was no audible sound or light outside the resident's room. An interview with an LPN revealed that the resident was unable to use the call light, and although there was consideration to provide the resident with a pad to trigger the call light, it had not been implemented. The LPN was unaware that the call light for the resident was not functional.
Failure to Enforce Smoking Policies and Supervision
Penalty
Summary
The facility failed to implement adequate safety measures to prevent accidents related to smoking among residents. The facility's policies and procedures regarding the storage of smoking materials were not enforced, and residents were not properly assessed for safe smoking practices. The designated smoking area was not adequately supervised, leading to residents keeping smoking materials on their person and smoking in unauthorized areas, including their rooms. This lack of supervision and enforcement of smoking policies placed residents at risk of burns and severe injury. One resident, who was cognitively intact but had a history of unsafe smoking practices, was found smoking in her room despite being on continuous oxygen therapy. The resident's smoking materials were not stored at the nurse's station as required, and she was able to keep cigarettes and a lighter in her room. Staff interviews revealed that residents, including this one, often kept their smoking materials on their person, and the facility's policy of storing these materials at the nurse's station was not followed. The Director of Nursing (DON) and other staff members were aware of these violations but did not take appropriate action to address them. Other residents were also found to be non-compliant with the smoking policy, keeping their smoking materials with them and smoking in unauthorized areas. Staff interviews indicated a lack of awareness and enforcement of the facility's smoking policies. The DON and Administrator were not informed of incidents involving residents smoking in their rooms or keeping smoking materials, and no incident reports were generated for these violations. This systemic failure to enforce smoking policies and supervise residents adequately led to a significant risk of accidents and injuries.
Removal Plan
- Resident #78's smoking assessment was updated to ensure accuracy and has been identified as a supervised smoker. Her care plan was updated to reflect this.
- Resident #78's room and person were observed for smoking material and none was found, as she was compliant in providing her smoking material to the staff when asked.
- Resident #78 was re-educated on the smoking policy and agreed to follow the policy. Family was notified of the policy as well.
- Resident #78 was given a behavioral contract. If she does not adhere to the policy, she will be given a 30-day discharge notice.
- All residents who smoke were assessed by licensed nursing staff with no injury identified related to smoking.
- The Administrator/designee began individual meetings with smokers for the identified residents who smoke at the center to review the smoking policy/process, and/or initiate behavioral contract.
- The Administrator/designee compiled a list of residents who smoke at the center to be placed at the nurses station and will be updated as needed.
- A whole house sweep of resident smoking materials was completed by the Administrator/designee to ensure no items are observed in the resident rooms or observed on the resident and will be obtained if found, or a behavioral contract will be initiated if they do not agree to give up items.
Unqualified Activities Director in LTC Facility
Penalty
Summary
The facility failed to ensure that the Activities Director (AD) was a qualified professional, as required by their policy. The policy mandates that the recreation program in skilled nursing facilities must be directed by a qualified therapeutic recreation specialist or an activities professional with specific qualifications. However, a review of the AD's personnel file revealed that she lacked the necessary specialized training or equivalent qualifications for the role. This deficiency was identified during a personnel file review, interviews, and a facility policy review. Interviews with the Senior Activity Director (SAD) and the Activities Assistant (AA) highlighted further issues. The SAD, who did not work full-time at the facility, mentioned that the AD had been signed up for the required training twice but failed to attend both times, citing last-minute reasons. The AA, who had been working for three months, stated that she had not received any training and was providing activities without direction from the AD. The facility's Administrator confirmed that the AD had been with the facility for over a year and had repeatedly avoided attending the scheduled and paid-for training, which had been a concern.
Failure to Monitor and Record Meal Temperatures
Penalty
Summary
The facility failed to ensure that staff were taking and recording meal temperatures to confirm they were served at safe temperatures before each meal was served. This deficiency was identified through observation, record review, interviews, and policy review. The facility's policy required that all foods be held at appropriate temperatures, greater than 135 degrees Fahrenheit for hot holding and less than 41 degrees Fahrenheit for cold holding, with temperatures recorded at the time of service. However, the review of food temperature logs revealed significant gaps in documentation for the months of April, May, June, and July 2024, indicating a failure to consistently monitor and record meal temperatures. Interviews with staff, including a cook and the Dietary Manager (DM), confirmed that meal temperatures were not consistently taken or recorded. The cook admitted to not taking temperatures due to being busy, despite being aware of the requirement and having participated in a recent in-service training on the importance of completing temperature logs. The DM acknowledged awareness of the issue and stated that even after the in-service training, staff were still not completing the logs. The District Dietary Manager also expressed the expectation that staff should complete temperature logs and that no food should be served before temperatures are taken and documented.
Medical Director's Absence from QAPI Meetings
Penalty
Summary
The facility failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) program by not having the Medical Director attend the required meetings. According to the facility's policy, the QAPI group should include the Medical Director, among other key personnel. However, during an interview, the Medical Director admitted to not attending the QAPI meetings and instead discussed issues with the Administrator separately. The Administrator confirmed that the Medical Director did not attend the meetings and that there was no signature page to document attendance. This deficiency was highlighted during an investigation into an incident where a resident lit a cigarette in her room, which was noted in a progress note from October 2023. The Medical Director did not recall the incident and was unsure if it was discussed in a QAPI meeting. The Administrator mentioned that the meetings were divided into various categories such as business, clinical, safety, and people, and that the Medical Director was provided with information on infections, wounds, antibiotics, and antipsychotics, to which she gave feedback. However, the lack of direct participation in QAPI meetings by the Medical Director was identified as a failure in the facility's QAPI program, potentially affecting all residents.
Facility Fails to Maintain Safe Environment Due to Unrepaired Windows
Penalty
Summary
The facility failed to maintain a safe and comfortable environment for its residents, as evidenced by broken and shattered windows, as well as windows without screens, observed in a main hallway and 18 resident rooms. This deficiency was identified through observations, maintenance audits, and interviews. The facility's Preventative Maintenance Policy requires a program for scheduling maintenance on equipment and the physical plant, but this was not effectively implemented. An email exchange revealed that the facility had conducted inspections and identified the need for repairs, including 28 screens, 18 handles, seven sashes, six crank mechanisms, and repairs for broken glass. However, these repairs had not been approved by the corporate office, leaving the facility in a state of disrepair. Interviews with the Maintenance Director (MD) and the Administrator confirmed that the facility had been aware of the issues since February 2024, but no action had been taken to address them. The MD expressed frustration over the lack of approval for repair quotes, which had been pending for approximately six months. The Administrator acknowledged the problem and indicated it was on his list of issues to address. The lack of action resulted in a potential risk of injury from broken glass and pest infestation due to missing window screens, as evidenced by a recent fly problem in the facility.
Oxygen Therapy Administration Deficiencies
Penalty
Summary
The facility failed to ensure that eight residents received oxygen therapy according to physician orders, leading to potential risks of hyperoxia. Observations revealed discrepancies between the documented oxygen levels and the actual settings on the oxygen cannisters. For instance, a resident with a physician order for 2 liters per minute (lpm) was observed receiving 4 lpm, while another resident with an order for 5 lpm was receiving 8 lpm. These discrepancies were confirmed by a Licensed Practical Nurse (LPN) who admitted to not verifying the oxygen settings before documenting them. Additionally, the facility did not have a physician order in place for a resident who was receiving oxygen therapy. This lack of documentation raised concerns about how staff were monitoring and managing the resident's oxygen use. The Director of Nursing (DON) acknowledged that it was the responsibility of the nursing staff to understand and follow physician orders, and that documentation should not occur without verification of the orders. The facility also failed to maintain the cleanliness of oxygen concentrator filters for two residents. Observations showed a significant buildup of dust and lint on the filters, indicating that they had not been cleaned as per the physician's orders. The DON was unaware of the condition of the filters and stated that the Certified Nursing Assistants (CNAs) were responsible for changing them. This oversight in maintenance could potentially impact the effectiveness of the oxygen therapy provided to the residents.
Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of flies in multiple areas of the building. During the survey, flies were observed around residents, their food, and in common areas such as the dining room. Specific observations included flies buzzing around two residents while they were eating, with one resident expressing frustration over the persistent fly problem. In the dining room, flies were seen landing on residents, their food, and utensils, causing residents to swat them away. Staff members also acknowledged the fly issue, noting that it had been particularly bad recently. The facility did not provide a pest control policy when requested by the survey team. Interviews with staff revealed that no work orders had been submitted to address the fly problem, despite complaints from residents. The Maintenance Director was aware of the issue and attributed it to missing window screens, which allowed flies to enter the building. Although the pest control company visited monthly, no specific action had been taken to address the recent fly infestation. The Administrator expected the pest control measures to be effective, but the current situation indicated otherwise.
Failure to Maintain Resident Dignity with Visible Catheter Bag
Penalty
Summary
The facility failed to ensure that a resident was cared for in a dignified manner by allowing the resident's Foley catheter bag to be visible from the doorway of the room. This was observed during two separate occasions, where the catheter bag containing dark-colored urine was hanging on the bed and visible from the hallway. The facility's policy, revised on 07/01/19, clearly states that urinary catheter bags should be covered to maintain the dignity of the residents. The resident involved, identified as having severe cognitive impairment with a BIMS score of three out of 15, was readmitted to the facility on an unspecified date. During interviews, both an LPN and the DON confirmed that the catheter bag should have been placed in a privacy bag to prevent it from being seen by anyone passing by the resident's room. The LPN acknowledged that the visibility of the catheter bag was indeed a dignity issue, aligning with the facility's policy on providing considerate and respectful treatment to residents.
Medication Mismanagement: Unattended Pills at Bedside
Penalty
Summary
The facility failed to ensure that medications were not left at the bedside for a resident who had not been assessed to self-administer medications. This deficiency was observed in one of two residents who were not evaluated for self-administration capabilities out of a sample of 46 residents. The facility's policy requires that residents who wish to self-administer medications be evaluated for their capability, and if deemed appropriate, a physician or advanced practice provider order is necessary. Additionally, self-administration must be care planned, and medications should be stored securely. However, there was no evidence in the resident's electronic medical record indicating an assessment for self-administration had been completed. During an observation, a medication cup with six unidentified pills was found on the table next to the resident's bed while the resident was dozing off. No nursing staff was present in the room at that time. Interviews with the LPN and Unit Manager confirmed that medications should not be left unattended at a resident's bedside, and no resident in the facility had been assessed to self-administer their medications. The Administrator also confirmed that the expectation was for nursing staff to observe residents taking their medications and not leave them unattended.
Incorrect Code Status in EMR for Resident
Penalty
Summary
The facility failed to ensure the correct code status was maintained in the electronic medical record (EMR) for a resident, identified as R209, who was reviewed for Advance Directives/Code Status. The physician's orders in the EMR incorrectly indicated the resident's code status as Full Code, despite the resident's preference for Do Not Resuscitate (DNR) in the event of being found not breathing or without a pulse. This discrepancy was identified during a review of the resident's records, which included two New Mexico Orders For Scope of Treatment (MOST) forms, one completed by the hospice team indicating DNR and another by the facility team indicating Full Code. Both forms were signed by the resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13 out of 15. The error in the code status was confirmed during interviews with facility staff, including a Licensed Practical Nurse (LPN) and the Director of Nursing (DON). The DON acknowledged that the resident's code status had been incorrectly entered as Full Code from a specific period, despite the resident's wishes and other documentation indicating DNR. The Administrator also confirmed the expectation that each resident's code status should be accurately reflected in their records. This failure created the potential for unwanted Cardiopulmonary Resuscitation (CPR) to be performed on the resident.
Failure to Provide Required Medicare Notices
Penalty
Summary
The facility failed to provide written documentation of the Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNFABN) and the Notice of Medicare Non-coverage (NOMNC) for two residents, R40 and R86, out of a sample of 46 residents. This deficiency was identified through a review of records, interviews, and facility policy review. Both residents were discharged from Medicare Part A services with benefit days remaining and chose to remain in the facility. However, the facility did not provide the required SNFABN forms to these residents, as indicated by the documentation, which stated that the facility was not doing them. Although the NOMNC was acknowledged by the beneficiaries or their representatives, there were no copies on file. Interviews with facility staff revealed a lack of awareness and training regarding these notices. The Social Service Assistant, who had been at the facility for three and a half months, was unaware of the notices and had not been trained on how to issue them. The Administrator confirmed that the SNF ABNs had not been done and acknowledged the absence of policies, stating that the facility follows CMS guidance. This lack of documentation and communication potentially left the residents unable to make informed decisions about their care and unaware of additional costs for services not covered by Medicare.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide timely written notification of transfer to the hospital for two residents, R19 and R81, as well as their representatives and the ombudsman. According to the facility's policy, written notice should be given to the resident and their representative prior to an unplanned acute transfer, followed by verbal notification. However, in the case of R19, who was cognitively intact with a BIMS score of 15, there was no evidence of written transfer notice provided when the resident was sent to the hospital due to a drop in blood pressure and low oxygen saturation. R19 confirmed during an interview that no written notice was received. Similarly, R81, who had severe cognitive impairment with a BIMS score of 3, was transferred to the hospital after a change in vital signs without any written notice provided to the resident or their representative. A family member of R81 confirmed that no written notice was received. Interviews with facility staff, including an LPN and the Administrator, revealed that the facility had not been providing written notifications to residents, their representatives, or the ombudsman as required by their policy.
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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