Life Care Center Of Farmington
Inspection history, citations, penalties and survey trends for this long-term care facility in Farmington, New Mexico.
- Location
- 1101 West Murray Drive, Farmington, New Mexico 87401
- CMS Provider Number
- 325103
- Inspections on file
- 22
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 8 (1 serious)
Citation history
Health deficiencies cited at Life Care Center Of Farmington during CMS and state inspections, most recent first.
A resident with Parkinson’s disease had an active order for carbidopa-levodopa four times daily and a care plan instruction that the resident’s son be notified of any medication changes or behaviors. Nursing staff placed the Parkinson’s medication on hold to assess behaviors and, after the resident developed weakness and arm shaking, the physician ordered a reduced dosing schedule. The resident reported not knowing the medication had been stopped until his hands began shaking, and the son, identified as POA, stated he was not informed of the discontinuation or change despite the care plan directive. The Administrator confirmed that the son should have been notified before altering the resident’s Parkinson’s medication and that this did not occur.
Staff failed to secure medication carts and left pre-poured medications unattended in resident care areas, including narcotics, in violation of facility policy. A nurse and a certified medication aide admitted to leaving medications accessible and unsupervised, with the aide reporting this occurred regularly. The DON confirmed these actions were not permitted and that only licensed staff are responsible for medication administration.
The facility did not follow its infection prevention policy by allowing symptomatic staff, including a CNA and a housekeeper, to work while ill, which contributed to a COVID-19 outbreak affecting all residents on a unit. The outbreak resulted in widespread resident infections and required prolonged isolation precautions, as the facility failed to effectively identify and control the spread of infection.
A resident with documented mental health diagnoses, including anxiety disorder, major depressive disorder, and ADHD, was admitted without an accurate PASARR screening. The PASARR form was incomplete and did not reflect the resident's mental health conditions, despite documentation in the care plan and medication records. Staff interviews confirmed the form was not properly completed or reviewed, and that PASARR responsibilities were shared between Admissions and Social Services.
A resident with multiple mental health diagnoses did not receive the full prescribed taper of Venlafaxine during a cross-taper to another antidepressant due to pharmacy supply and insurance issues. The facility failed to ensure the medication was available and administered as ordered, resulting in the resident missing several days of therapy and experiencing increased anxiety and distress. The DON and providers confirmed lapses in communication and medication administration.
A resident with severe dementia had a religious item removed from their room by a priest without prior authorization from the resident's POA. The priest claimed to have asked the resident for permission, but the resident was not capable of providing informed consent. Facility leadership confirmed that removal of personal items without proper authorization was not permitted, and the POA was not notified before the item was taken.
A resident with multiple mental health diagnoses repeatedly requested access to her medical records, both directly and through the State Ombudsman, but did not receive the records or a written denial. Facility staff, including the DON and MRD, were unclear about what information was included in the medical record and did not process the request within the required timeframe, resulting in a failure to comply with policy and federal requirements.
A resident with depression and anxiety did not receive prescribed doses of Venlafaxine for several days, and the facility failed to promptly notify the MD about the missed medication. The lapse in communication was confirmed by both the DON and MD, and the resident experienced suicidal thoughts during the period without medication.
Surveyors found that food items in the kitchen's dry storage and refrigerator were left opened, undated, and unprotected, while the kitchen itself was unclean with food debris and stains on surfaces and equipment. Single use items were stored unprotected near sinks, and staff did not consistently wear hairnets or beard guards as required. Additionally, the ice machine was improperly drained, with the drain pipe discharging below the floor and the hand washing sink draining onto it, leading to visible contamination.
A resident with hypertension, diabetes, and dementia did not receive prescribed doses of carvedilol on multiple occasions because the medication was not available and staff had inconsistent access to the emergency medication kit. Staff interviews confirmed the medication was ordered but not delivered, and there was confusion about who could access the eKit to obtain the needed medication.
Staff did not secure the E-cart containing scissors, IV catheters, and oxygen tubing, leaving it accessible to unattended residents in the day room. The shower room was also left unlocked with shaving razors and bleach cleaner stored inside, while residents walked by unsupervised. Interviews revealed staff were unaware or did not follow protocols to lock these areas and items, as confirmed by the DON.
Nurses and CMAs did not consistently date, label, or discard opened insulin pens within the required 28-day period, resulting in multiple instances where insulin pens were either undated, unlabeled, or not discarded as per policy. Staff interviews confirmed the expectation to follow these procedures, but observations showed noncompliance, affecting three residents who had active orders for Insulin Lispro.
A resident with multiple chronic conditions was assessed using the MDS, which incorrectly listed English as the primary language despite staff and social services confirming the resident primarily spoke Navajo. Staff interviews revealed that translation was often needed, and cognitive assessments conducted in Navajo yielded higher scores than those in English, highlighting the inaccuracy in the MDS documentation.
A resident with multiple diagnoses, including diabetes, dementia, and hypertension, was ordered to receive continuous oxygen therapy, but the care plan did not address this treatment. The DON confirmed that oxygen use should have been included in the care plan.
A resident with multiple medical conditions and a physician's order for continuous oxygen therapy was observed not wearing her oxygen as prescribed, including instances where the oxygen concentrator was off or the resident was not using the device during activities. Staff and the medical director confirmed that the resident should have been on continuous oxygen per the current order.
Staff did not recognize that exit doors in the Memory Unit failed to unlock when the fire alarm was activated, and this malfunction was only discovered during a fire alarm test. The Administrator was unaware of the issue until after the test, and the deficiency was not identified through the facility's QAPI process.
A resident who required staff assistance for ADLs did not receive scheduled showers for a week, and staff failed to document the reason for the missed care or provide follow-up notes. The lapse was identified after the resident's family raised concerns, and the DON confirmed both the missed showers and lack of documentation.
A facility failed to notify a resident's POA of medication changes, including increased dosages of Buspirone and Trazodone, for a resident with Alzheimer's, anxiety, depression, and dementia. The POA was unaware of these changes until after discharge, and the facility did not document consent or notification, as confirmed by the DON and Nurse #1.
A facility failed to ensure nursing staff had the necessary competencies, resulting in severe harm to two residents. One resident suffered a fatal fall due to improper assistance during a brief change, while another experienced improper catheter management and was injured further by staff pulling on his arm to assist him in standing, despite his complaints of pain. These incidents highlight significant gaps in staff training and adherence to care plans.
A resident with multiple health issues, including muscular dystrophy and obesity, fell from her bed and later died after a CNA attempted to change her brief alone during a shift change. The CNA moved the bed away from the wall, contrary to standard practice, and asked the resident to roll onto her side. The resident fell, sustaining injuries that led to her death. Other CNAs confirmed that two-person assistance was standard for such tasks, and the Director of Nursing acknowledged the deviation from standard practice.
Two residents in a LTC facility experienced inadequate pain management and assessment. One resident, with multiple fractures, was improperly handled by staff despite visible pain, while another resident suffered severe knee pain after a shower incident and was left in distress for hours before being sent to the hospital, where bilateral femur fractures were discovered. The facility's staff failed to follow proper protocols for pain assessment and management, highlighting deficiencies in training and communication.
A resident with multiple health issues, including neuromuscular dysfunction of the bladder, had a catheter leg bag improperly managed by staff, leading to potential infection risks. Despite physician orders to keep the catheter below bladder level, staff placed the leg bag on the resident while in bed, risking urine backflow. Observations and interviews confirmed this practice, highlighting a lapse in infection prevention measures.
The facility failed to ensure residents were treated with respect and dignity during dining. Observations revealed CNAs and a nurse standing while feeding residents, contrary to the facility's expectation for staff to sit during mealtime assistance. Interviews confirmed awareness of this practice by the Administrator and DON.
A resident suffered bilateral femur fractures after reportedly being dropped by a staff member during a shower. The facility failed to investigate the incident or report it to the State Agency. The DON only spoke briefly with the CNA involved and did not consult the LPN on duty. The Administrator did not consider it an injury of unknown origin, leading to no investigation or report submission.
The facility failed to report unwitnessed falls resulting in injury to the State Survey Agency for two residents. One resident experienced two falls resulting in abrasions, hematomas, lacerations, and bruising. Another resident experienced two falls resulting in abrasions and a hematoma. The facility did not submit Facility Incident Reports for these incidents, as the DON explained that they did not result in serious injury.
The facility failed to include current fall prevention strategies in the care plans of two residents. Despite being used as an intervention, placing the residents at the nurse's station for increased observation was not documented in their care plans. The DON confirmed the omission and was uncertain if it should be included.
The facility failed to ensure all medication carts were locked when not in use. An unlocked and unattended medication cart was observed on A hall, with the nearby nurses' station also vacant. An LPN confirmed the cart should have been locked, potentially affecting all 35 residents in A hall by allowing unauthorized access to medications and personal health information.
Failure to Notify Resident Representative of Parkinson’s Medication Change
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of a significant medication change as directed by the resident’s care plan. The resident, who had a diagnosis of Parkinson’s disease and an active order for carbidopa-levodopa 25/100 mg, two tablets by mouth four times daily, had a comprehensive care plan dated 02/28/24 instructing staff to notify the resident’s son of medication changes and behaviors. Nursing progress notes documented that on 11/10/2025 staff placed the resident’s carbidopa-levodopa on hold for seven days to assess for improvement in behaviors, and on 11/11/2025 the resident developed weakness and upper extremity shaking after the medication was held, leading the physician to order the medication at a reduced dose of 0.5 mg four times daily due to worsening symptoms. The record also showed that during a later meeting, the resident’s son expressed concerns that he had not been informed of the recent change to the Parkinson’s medication and the side effects that occurred after it was discontinued. In interviews, the resident stated he was unaware that the facility had stopped administering his carbidopa-levodopa until his hands began to shake aggressively, which bothered him. The resident’s son, identified as the resident’s POA, reported that the facility stopped the Parkinson’s medication, which had been given four times daily, and that he only learned of the discontinuation afterward, prompting him to contact the facility to ask why it had been stopped. He stated staff told him the medication was stopped to see if this would improve the resident’s behaviors and confirmed that the facility knew they were to notify him prior to any medication changes, but he was not contacted about the carbidopa-levodopa being stopped. The Administrator acknowledged that, because the care plan directed staff to notify the son regarding medication changes or behaviors, staff should have notified him prior to any changes and confirmed that the son was not notified before the Parkinson’s medication management was altered.
Unsecured Medication Carts and Unattended Pre-Poured Medications
Penalty
Summary
Facility staff failed to properly secure and administer medications for all 112 residents listed on the census. Observations revealed that medication carts were left unlocked and unattended in hallways, providing unsupervised access to resident medications, including narcotic controlled substances. Additionally, staff were found to have pre-poured medications into unlidded cups and left them unattended on tables in resident care areas, with no licensed nurse present to supervise. These actions were in direct violation of the facility's medication administration policy, which requires medications to be prepared for one resident at a time, not to be pre-poured, and to remain secured and attended at all times. Interviews with staff confirmed these practices. A registered nurse acknowledged responsibility for keeping the medication cart locked and recognized that leaving it unsecured allowed unauthorized access to medications. A certified medication aide admitted to pre-pouring medications for multiple residents and leaving them unattended while assisting another resident, stating that this occurred once or twice a week. The aide also confirmed that the facility's policy prohibits pre-pouring and leaving medications unattended, and that staff are required to ask another qualified staff member to monitor medications if they must step away. The Director of Nursing confirmed that the facility does not permit pre-pouring medications or leaving them unsecured and unattended. She stated that only licensed individuals are responsible for medication administration and that certified nurse aides are not permitted to supervise medications. The DON acknowledged that leaving pre-poured medications unattended is unacceptable and creates significant risk, as staff would not know whose medications they were and residents or visitors could access them.
Removal Plan
- The identified CMA will not pass medications until further determination is made.
- The DON/designee checked all other medication carts to determine if there were any other pre-poured medications. No other instances of pre-poured medications were observed.
- The DON/designee checked all other medication carts to determine if there were any issues with the Narcotic counts. No discrepancies were identified.
- The DON/designee monitored residents on identified hall who received pre-poured medications, no concerns were identified. They were monitored for potential adverse medication reactions, such as a significant change in vital signs. No concerns were identified.
- Education was provided to all nurses and CMAs on-site regarding: Medications are to only be prepared for one resident at a time, using a 3-way-check (comparing the medication to the MAR and to the prescription label).
- No pre-poured medications are allowed.
- Medications are not to be left unsecured and unattended.
- Medication carts will be locked at all times when out of site or unattended.
- Nurses and CMAs that are coming in as scheduled, will receive education prior to passing any medications.
- Additional Nurses and CMAs that are not onsite will receive education via telephone and a signed acknowledgement of education will be obtained prior to their next working shift.
- Record review of new admissions audit to ensure accurate medication reconciliation, review and continuation of medications and treatments.
- Record review of staff signature sheets for checked all other medication carts to determine if there were any issues with the Narcotic counts. No discrepancies were identified.
- Interviews with nurses regarding in-services and on pre-pouring medication and leaving medications unsecure.
- Interview with the Administrator and DON regarding plan of removal, audits, and medication reconciliation processes.
Failure to Exclude Symptomatic Staff Led to COVID-19 Outbreak
Penalty
Summary
The facility failed to implement and maintain an effective Infection Prevention and Control Program (IPCP) during a COVID-19 outbreak that affected all 58 residents on Unit A. According to the facility's IPCP policy, staff with communicable diseases were to be excluded from resident contact, and a system for staff to report illness and remain off work while symptomatic was required. However, record review and interviews revealed that symptomatic staff, including a Certified Nurse Aide and a housekeeper, continued to work while ill, which contributed to the onset and spread of the outbreak. The facility did not effectively identify and control the spread of infection, resulting in unit-wide clustered transmission and prolonged isolation precautions for residents. The Infection Preventionist confirmed that the outbreak began when symptomatic staff worked while sick, and that testing was conducted every three days until all residents tested negative. The Administrator acknowledged awareness of the outbreak and confirmed that staff and residents were repeatedly tested as new cases emerged. Despite these measures, the failure to exclude symptomatic staff from resident contact and to control the spread of infection led to many residents becoming symptomatic and required the isolation of all residents in their rooms due to ongoing transmission.
Failure to Accurately Complete PASARR Screening for Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure the accuracy of the Preadmission Screening and Resident Review (PASARR) for a resident with multiple mental health diagnoses. Record reviews showed that the resident was admitted with diagnoses including anxiety disorder, major depressive disorder, and ADHD. Despite these diagnoses, the PASARR form completed for the resident was inaccurate: Section A, which identifies the type of review, was left blank, and Section C, which should list mental illness evaluation criteria, was marked 'No' and did not include the resident's mental health diagnoses. The resident's Minimum Data Set and care plan both documented the use of antidepressant medication for depression, further confirming the presence of mental health conditions that should have been reflected in the PASARR. Interviews with facility staff revealed that the Admissions Director acknowledged the PASARR was incorrect and did not align with the resident's medical orders. The Social Services Assistant stated she was familiar with the PASARR process but had not received formal training and was not involved in the completion or review of the resident's PASARR. The Administrator and Social Services Director both confirmed that PASARR responsibilities are shared between Admissions and Social Services, and both agreed that the PASARR for this resident was not completed accurately, as required.
Failure to Provide Complete Prescribed Medication Taper
Penalty
Summary
A deficiency occurred when a resident with diagnoses of anxiety disorder, major depressive disorder, and ADHD did not receive the full provider-ordered taper of Venlafaxine during a cross-taper process to another antidepressant. The facility failed to obtain and administer the complete medication regimen as ordered, resulting in an unintended interruption of therapy. Record review showed that the resident did not receive Venlafaxine for a period of several days, and this lapse was due to the pharmacy only providing the first week of the taper and failing to supply the second week because of insurance-related issues. The facility did not ensure the medication was available or administered as prescribed. Interviews with the DON confirmed that the resident went approximately one week without the prescribed medication, leading to increased anxiety and distress. The DON acknowledged that the facility is responsible for ensuring residents receive all prescribed medications regardless of insurance or pharmacy barriers. The resident's medical doctor and psychiatric provider both confirmed they were not notified in a timely manner about the missed doses, and the psychiatric provider noted the resident experienced emotional distress and physical symptoms during the period without medication.
Failure to Honor Resident Choice and Secure Authorization for Removal of Personal Religious Item
Penalty
Summary
A deficiency occurred when an outside individual, specifically a priest, entered the room of a resident with severe cognitive impairment and removed a religious item without obtaining authorization from the resident's Power of Attorney (POA). The resident, who had diagnoses including dementia, Parkinson's Disease, and a history of intracerebral hemorrhage, was assessed as having severe cognitive impairment with a Brief Interview of Mental Status (BIMS) score of 03. The priest claimed to have asked the resident for permission before removing the item, but the resident's POA stated that the resident was not capable of providing informed consent due to his dementia. The POA was not notified prior to the removal of the item, and the family believed the removal constituted theft. The incident was reported to the facility's Ombudsman, who also noted that the camera in the resident's room had been turned off for approximately eight minutes during the time of the incident. The Director of Nursing (DON) and the Administrator both confirmed that no one, regardless of their status, was permitted to remove personal items from a resident's room without proper authorization from the resident or their legal representative. The Administrator acknowledged that the situation should have been addressed through a care conference with the POA, but this did not occur.
Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to provide a resident with access to her medical records after multiple requests were made by both the resident and the New Mexico State Ombudsman acting on her behalf. The resident, who had diagnoses including anxiety disorder, major depressive disorder, and ADHD, requested her medical records in the first week of July from several staff members, including nurses, the DON, the Medical Records Director (MRD), and the Administrator (ADM). Despite these requests, the resident did not receive any part of her medical records, nor was she given a written explanation for the delay or denial. Documentation shows that the Ombudsman initially requested the records via email on July 1, with follow-up requests made in subsequent weeks. The facility's Health Information Management Manual states that requested copies should be provided within two working days, and that residents must receive a timely, written denial if access is denied. However, the records were not provided within the required timeframe, and no written denial was issued to the resident or her representative. Interviews with facility staff revealed confusion regarding what constituted the resident's medical record, particularly concerning pharmacy communications and medication information. The MRD and DON indicated that pharmacy information was not considered part of the medical record, and the ADM stated he was unaware of the initial request but expected records to be provided promptly. Despite these statements, the resident's requests remained unfulfilled, and the facility did not follow its own policy or federal requirements regarding access to medical records.
Failure to Notify MD of Missed Antidepressant Doses
Penalty
Summary
The facility failed to notify the Medical Director (MD) of missed doses of an antidepressant medication, Venlafaxine, for a resident diagnosed with anxiety disorder, major depressive disorder, and ADHD. The resident did not receive Venlafaxine for a period of seven days, as documented in the Medication Administration Record. During this time, the facility did not communicate the missed doses or the unavailability of the medication to the MD, despite the resident's ongoing mental health conditions and the prescribed medication schedule. The deficiency was confirmed through record review and interviews, which revealed that the DON acknowledged the MD was not informed of the missed doses, and the MD confirmed he was not notified until the second week of the missed medication. The resident subsequently experienced suicidal thoughts, which were documented in the provider's visit notes after the period without medication. The MD stated he would have taken steps to provide the medication sooner if he had been notified promptly.
Deficient Food Storage, Sanitation, and Staff Hygiene in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in food storage, preparation, and service areas, as evidenced by multiple observations and record reviews. In the kitchen's dry storage and refrigerator, numerous food items such as granulated garlic, fruit cups, pizza slices, bread, seasonings, cereals, and prepared foods were found opened, undated, and in some cases unsealed or exposed to air. The facility's own food safety policy required all food items to be labeled, dated, and stored in a manner that protects them from contamination, but these procedures were not followed. The Dietary Manager confirmed that all food items should be labeled, dated, and protected from air and contamination. The kitchen environment was observed to be unclean, with stains and spatters on the walls, food particles on the microwave, black debris around stove burners, white splashes on the oven, buildup on baseboards, and crumbs and splatter on food preparation surfaces. A sugar container was found with a lid that did not fit and brownish debris inside. The facility's cleaning schedule required daily cleaning of these areas, but these tasks were not completed as required. Additionally, single use items such as cloth napkins and Styrofoam plates were left exposed and unprotected near the hand washing sink, contrary to the Dietary Manager's statement that such items should be protected and stored away from potential contamination sources. Staff were also observed not adhering to personal hygiene standards, with one staff member not wearing a hairnet properly and another with facial hair not wearing a beard guard while working in the kitchen. The facility's food safety policy addressed the risk of physical contaminants such as hair but did not specifically require hairnets or beard guards. Furthermore, the ice machine was not properly drained through an air gap, with the drain pipe discharging below the floor surface and the hand washing sink draining onto the ice machine drain pipe, resulting in a black substance around the pipe. The Dietary Manager was unaware of these drainage issues, which were not addressed in the facility's policy.
Failure to Administer Ordered Medication Due to Unavailable Supply and Access Issues
Penalty
Summary
The facility failed to provide care that met professional standards for one resident by not obtaining and administering carvedilol as ordered by the physician. The resident, who had diagnoses including type II diabetes, dementia, and hypertension, was admitted with a physician's order for carvedilol to be given twice daily for hypertension. Record review showed that the medication was not administered on several occasions because it was not available, as documented in the Medication Administration Record and nursing progress notes. Staff interviews revealed that the carvedilol had been ordered from the pharmacy, but it was not delivered. The Certified Medication Technician reported checking on the medication status daily and attempting to access the emergency kit (eKit) for the medication, but did not have access and had to rely on nurses to obtain it. There was inconsistency among staff regarding access to the eKit, with some nurses able to access it and others losing access if they did not log in regularly. The Director of Nursing confirmed that any nurse could pull medication from the eKit, but if access was lost, another nurse should have been asked to assist.
Failure to Secure Emergency Cart and Shower Room Creates Accident Hazards
Penalty
Summary
Staff failed to ensure that the B Unit was free from accident hazards by not securing the Emergency Cart (E-cart) and the shower room. The E-cart, which contained scissors, IV catheters, and oxygen tubing, was found unlocked and accessible to residents in the day room, with several residents present and unattended by staff. The facility's E-cart policy did not address the need to lock the cart to prevent unauthorized access. Additionally, the shower room was left unlocked and unattended, with shaving razors and a bottle of Cloralen bleach cleaner stored in an unsecured vanity. Several residents were observed walking by the open shower room without staff supervision. Interviews with staff revealed a lack of awareness and adherence to safety protocols. A nurse stated she was unsure if the E-cart should be locked, while multiple CNAs acknowledged that the shower room should have been locked when not in use. The DON confirmed that both the E-cart and the shower room should be secured to prevent resident access to potentially hazardous items, and that the items found in both locations could pose risks to residents if left accessible.
Failure to Date, Label, and Discard Opened Insulin Pens as Required
Penalty
Summary
Nurses and Certified Medication Aides (CMAs) failed to properly date and discard opened insulin pens within the required 28-day period for three residents. Observations revealed that one insulin pen was opened and not dated, another was opened and dated but not discarded after 28 days, and a third was opened, undated, and unlabeled, making it impossible to identify the owner. The facility's policy and the manufacturer's instructions both require that opened multidose insulin pens be dated and discarded within 28 days, and that each pen be labeled with the resident's name upon first use. Interviews with staff, including a nurse, the Director of Nursing (DON), and the Consultant Pharmacist (CP), confirmed that the expectation is to date, label, and timely discard insulin pens. However, the observed practices did not align with these requirements, resulting in the potential for residents to receive insulin that was either expired or not properly identified. The records confirmed that the affected residents had active orders for Insulin Lispro.
Inaccurate MDS Assessment Due to Incorrect Primary Language Documentation
Penalty
Summary
Facility staff failed to complete an accurate Minimum Data Set (MDS) assessment for a resident with multiple diagnoses, including chronic respiratory failure with hypoxia, COPD, Parkinson's disease, and paroxysmal atrial fibrillation. The resident's face sheet indicated an admission date and listed these diagnoses. Multiple MDS assessments documented the resident's primary language as English. However, interviews with nursing staff, a CNA, and the Social Services Assistant revealed that the resident primarily spoke Navajo and understood Navajo better than English. Staff reported that they often needed to find a Navajo-speaking staff member to translate for the resident. Further, the Social Services Assistant, who spoke Navajo fluently, completed the resident's Brief Interview of Mental Status (BIMS) in English on one occasion, resulting in a score indicating moderate cognitive impairment. When the BIMS was later conducted in Navajo, the resident scored higher, suggesting better cognitive function when assessed in their primary language. The Social Services Director acknowledged that the discrepancy in BIMS scores was likely due to the language used during the assessment and confirmed that the MDS should have reflected Navajo as the resident's primary language.
Care Plan Not Updated for Oxygen Therapy
Penalty
Summary
The facility failed to update the care plan for a resident who was admitted with diagnoses including Type II diabetes, dementia, and hypertension. Physician orders dated 05/08/25 indicated that the resident required continuous oxygen at 2 liters per minute via nasal cannula, with instructions to maintain oxygen saturation above 90%. However, review of the resident's care plan showed that it did not address the use of oxygen therapy. During an interview, the DON confirmed that oxygen use should be included in the care plan if a resident is receiving it. This omission demonstrates that the care plan was not revised to reflect the resident's current treatment needs as required.
Failure to Ensure Continuous Oxygen Therapy as Ordered
Penalty
Summary
A resident with diagnoses including type II diabetes, dementia, and hypertension was admitted to the facility and had a physician's order for continuous oxygen at 2 liters per minute via nasal cannula, with instructions to keep oxygen saturation above 90%. Record review showed that the resident's oxygen saturation dropped to 87% on room air and was at 90% when on 2 liters of oxygen, indicating a need for consistent oxygen therapy as ordered. Despite these orders, observations revealed that the resident was not consistently receiving oxygen as prescribed. On one occasion, the resident wore the nasal cannula, but the oxygen concentrator was not turned on. At another time, the resident was seen participating in activities without wearing the oxygen. Interviews with nursing staff and the medical director confirmed that the resident should have been on continuous oxygen per the physician's order, and that the order had not been changed to allow for discontinuation or intermittent use.
Failure to Identify Exit Door Malfunction During Fire Alarm Activation
Penalty
Summary
Facility staff failed to identify and address a malfunction in the exit doors of the Memory Unit, as the doors did not unlock when the fire alarm was activated. This issue was discovered during an observation when staff tested the fire alarm and found that all three exit doors remained locked. The Administrator confirmed in an interview that he was unaware of the malfunction until the fire alarm test was conducted, and stated that his expectation was for staff to have recognized the problem prior to the test. The deficiency was not identified through the facility's Quality Assurance and Performance Improvement (QAPI) process, indicating a lapse in the facility's ability to detect and address quality deficiencies related to emergency preparedness.
Failure to Provide Timely ADL Assistance and Documentation for Showering
Penalty
Summary
Staff failed to provide timely assistance with activities of daily living (ADLs), specifically showering, for one resident who required the help of one staff member for personal care. The resident was scheduled to receive showers on Wednesday and Saturday evenings, but did not receive a shower for a seven-day period. There was no documentation in the resident's medical record or care plan explaining the missed showers, nor any follow-up notes regarding the reason for the lapse. The issue was brought to the attention of the Director of Nursing after the resident's daughter expressed concern about the lack of showers over five days, and the Director confirmed the absence of both the showers and the required documentation.
Failure to Notify POA of Medication Changes
Penalty
Summary
The facility failed to notify the family member/Power of Attorney (POA) of a resident when changes in the resident's medication were made. The resident, who had been diagnosed with Alzheimer's disease, anxiety, depression, and dementia with psychotic disturbance, experienced changes in their medication regimen, including increases in dosages of Buspirone and Trazodone. However, there was no documentation in the resident's medical record indicating that the family or POA was informed of these changes, nor was there any record of verbal consent being obtained for the medication adjustments. Interviews with the family member/POA revealed dissatisfaction with the facility's communication, as they were unaware of the medication increases until after the resident's discharge. The family member/POA expressed concerns about the lack of notification and the inability to make informed decisions regarding the resident's care. The Director of Nursing confirmed that staff should have notified the family prior to any medication changes and documented the consent in the resident's medical record, which did not occur in this case. Nurse #1 acknowledged the medication increase was due to the resident's anxiety-related behaviors but admitted to not notifying the family member/POA.
Inadequate Staff Competency Leads to Resident Harm
Penalty
Summary
The facility failed to ensure that nursing staff had the necessary competencies to provide adequate care for two residents, resulting in severe consequences. One resident, who was dependent on staff for all activities of daily living due to conditions such as muscular dystrophy and obesity, suffered a fatal fall from the bed. The incident occurred when a CNA attempted to change the resident's brief alone, despite the care plan indicating the need for assistance from one or two staff members. The CNA moved the bed away from the wall and asked the resident to roll over, which led to the resident rolling off the bed and sustaining a serious head injury that resulted in death. Another resident experienced inadequate care related to catheter management and assistance with standing. The resident, who had multiple diagnoses including dementia and Parkinson's disease, was found to have his catheter leg bag positioned incorrectly while in bed, risking infection. Additionally, staff were observed pulling the resident by his right arm to assist him in standing, despite the resident's complaints of pain and visible bruising. This improper handling led to further injury, including a fractured clavicle and ribs, as confirmed by x-rays. Interviews with staff revealed a lack of specific training and awareness regarding the residents' care needs. The CNA involved in the fall with the first resident admitted to changing the resident alone due to shift change and being unaware of the proper procedures. Similarly, staff assisting the second resident were not informed of the extent of his injuries and continued to use inappropriate methods to help him stand, exacerbating his condition. These deficiencies highlight a significant gap in staff training and adherence to care plans, resulting in harm to the residents.
Removal Plan
- Resident #1 was discharged to the hospital.
- Resident #12 was reassessed by therapy to review level of assist for transfers. Staff working with Resident #2 were educated to follow the individual care plan that was updated on how to transfer safely with regards to his current fracture. Resident #2 was also reassessed regarding his catheter bag needs and the care plan was updated. Staff working with Resident #2 were educated to follow catheter needs as directed by care plan.
- An audit was completed by the DON and Infection Preventionist (IP) Nurse to ensure that all residents who require peri-care are care planned for level of assistance required with peri-care. All changes will be reflected in the Kardex for CNAs.
- An audit was completed by the DON and IP Nurse to ensure that all residents with current fractures are care planned for level of assistance required due to their injury. All changes will be reflected in the Kardex for CNAs.
- An audit was completed by the DON and IP Nurse to ensure that all residents with urinary catheter bags are care planned with catheter bag change instructions. All changes will be reflected in the Kardex for CNAs.
- Policies and procedures related to person centered care planning and resident rights were reviewed and utilized for education.
- Education of licensed nursing staff and CNAs related to providing peri-care per individual care planned needs will be completed. These staff will not be allowed to work until they have received the education which will be provided prior to the start of their shift.
- Education of licensed nursing staff and CNAs related to how to transfer a resident appropriately who have current fractures will be started. These staff will not be allowed to work until they have received their education and will receive education prior to the start of their shift.
- Education of licensed nursing staff and CNAs related to a resident's individualized catheter bag change needs will be completed to educate to follow the resident's care plans with regards to bag change needs.
- Medical Director was notified of the IJ.
- Root cause analysis completed and taken to QAPI.
- QAPI to be conducted.
Failure to Provide Adequate Supervision Leads to Resident's Fatal Fall
Penalty
Summary
The facility failed to prevent an accident involving a resident who was dependent on staff for all activities of daily living. The resident, who had muscular dystrophy, obesity, chronic pain, a cardiac pacemaker, and disc degeneration, was unable to assist in movements such as rolling or sitting up. Despite this, a CNA attempted to change the resident's brief alone during a shift change, moving the bed away from the wall and asking the resident to roll onto her side. The resident fell from the bed, sustaining injuries that led to her death at the hospital later that day. The CNA involved in the incident stated that she typically changed the resident with another person but decided to proceed alone due to the busy shift change. She moved the bed away from the wall to access both sides, which was not standard practice, and asked the resident if she could hold herself on her side. The resident agreed, but during the process, she rolled off the bed and hit her head. The CNA immediately notified the nurse, and the resident was assessed and transferred to the hospital, where she later passed away. Interviews with other CNAs revealed that it was common practice to use two people for pericare, especially for residents who were unable to assist themselves. They stated they would not move the bed away from the wall without another person present. The Director of Nursing confirmed that moving the bed away from the wall was not standard practice and should not have been done without additional assistance. This incident highlights a failure in providing adequate supervision and care, leading to a tragic outcome.
Inadequate Pain Management and Assessment in LTC Facility
Penalty
Summary
The facility failed to adequately assess and manage the pain of two residents, leading to significant deficiencies in their care. Resident #1, who had multiple diagnoses including dementia, Parkinson's disease, and a history of falls, was subjected to improper handling by staff. Despite the resident's visible signs of pain and verbal complaints, staff continued to pull on his injured right arm to assist him in getting out of bed. This occurred even after the resident's Power of Attorney had notified the facility of the issue. Subsequent medical evaluations revealed that Resident #1 had sustained multiple fractures, including a communicated fracture of the distal clavicle and several rib fractures, which were not properly addressed by the facility staff. Resident #11, who also had dementia and other significant health issues, experienced severe pain after an incident in the shower. Despite her complaints of severe knee pain and visible distress, the facility staff delayed in providing adequate medical attention. The resident was left sitting in pain for several hours before being seen by a physician and subsequently sent to the hospital. At the hospital, it was discovered that Resident #11 had bilateral femur fractures, which required surgical intervention. The delay in addressing her pain and the lack of immediate medical evaluation contributed to the severity of her condition. The report highlights a lack of proper training and communication among the facility staff regarding the handling and pain management of residents with known injuries. Both residents experienced significant pain and distress due to the staff's failure to follow appropriate protocols for assessing and managing pain, as well as a lack of timely medical intervention. These deficiencies in care reflect a broader issue of inadequate staff training and awareness in handling residents with complex medical needs.
Failure to Maintain Proper Infection Control with Catheter Use
Penalty
Summary
The facility failed to maintain proper infection prevention measures for a resident with a leg catheter bag. The resident, who was admitted with multiple diagnoses including dementia, difficulty walking, communication deficit, intracerebral hemorrhage, type II diabetes, Parkinson's disease, and neuromuscular dysfunction of the bladder, had physician orders to change the catheter bag as needed for infection, obstruction, or when the closed system is compromised. The catheter was to be kept below the level of the bladder. However, observations and interviews revealed that staff did not adhere to these orders. A video review and interviews with staff and the resident's Power of Attorney indicated that the catheter leg bag was placed on the resident while he lay in bed, which could cause urine to back up into the bladder. The Power of Attorney reported seeing recordings of staff putting the leg bag on the resident early in the morning, and the resident remained in bed for hours with the leg bag at the same height as the catheter. This practice was confirmed by a CNA and the Director of Nursing, who acknowledged that failing to change the catheter leg bag when the resident was in bed could lead to a urinary tract infection.
Failure to Ensure Dignified Dining Experience
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity during dining, as observed in three instances. During lunch, a CNA was seen standing and feeding two residents simultaneously, moving back and forth between them. Another CNA was also observed standing while feeding a resident. Additionally, a nurse stood while feeding a resident who was seated in a reclining chair, explaining that she did so to monitor other residents. Interviews with the Administrator and DON revealed that they were aware of the staff's practice of standing while feeding residents, although their expectation was for staff to sit when assisting residents with eating.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for a resident, which was not reported to the State Agency. The incident involved a resident who was reportedly dropped by a staff member during a shower, resulting in bilateral femur fractures. The resident's daughter was informed by the facility staff that her mother was fine, but later received a call from the hospital indicating the need for surgery due to the fractures. The resident subsequently suffered a stroke and passed away. The Director of Nursing (DON) admitted to not conducting an official investigation into the incident and only had a brief conversation with the Certified Nursing Assistant (CNA) involved, who claimed nothing unusual occurred. The DON did not speak with the Licensed Practical Nurse (LPN) on duty at the time. The facility's Administrator also confirmed that no investigation or five-day report was submitted, as he did not consider it an injury of unknown origin. This lack of action and reporting could potentially lead to residents going without necessary treatment and being exposed to further injuries.
Failure to Report Unwitnessed Falls Resulting in Injury
Penalty
Summary
The facility failed to report unwitnessed falls resulting in injury to the State Survey Agency for two residents. Resident #10 experienced two unwitnessed falls, one resulting in an abrasion on the right knee and a hematoma on the face, and another resulting in lacerations on the forehead and nose, as well as bruising and swelling on the left hand, wrist, and forearm. Resident #7 experienced two unwitnessed falls, one resulting in an abrasion on the left knee and another resulting in a hematoma on the right elbow and a laceration on the back of the head. The facility did not submit Facility Incident Reports for these incidents, as the Director of Nursing explained that they did not result in serious injury, such as a fracture or hospital admittance.
Failure to Include Fall Prevention Strategies in Care Plans
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans that included current fall prevention strategies for two residents. For Resident #7, the care plan did not list placing the resident at the nurse's station for increased observation, despite this being a documented intervention used when the resident struggled to fall back to sleep. Similarly, for Resident #10, the care plan did not include the intervention of placing the resident at the nurse's station for increased observation, even though the resident was observed at the nurse's station and had a history of impulsive behavior leading to frequent falls. The Director of Nursing confirmed that this intervention was used for both residents but was not included in their care plans, and was uncertain if it should be included.
Unlocked Medication Cart
Penalty
Summary
The facility failed to ensure all medication carts were locked when not in use. This deficiency was observed on A hall, where the medication cart was found unlocked and accessible at 3:52 pm. The cart remained unattended for five minutes, and the nearby nurses' station was also vacant during this time. During an interview, an LPN confirmed that the medication cart was hers and acknowledged that it should have been locked. This failure potentially affects all 35 residents in A hall by allowing unauthorized access to medications and personal health information.
Latest citations in New Mexico
Surveyors found that the facility did not provide required written transfer and bed-hold notices when several residents were sent to the hospital for events such as falls with injury, unresponsiveness, and episodes of nausea, vomiting, and bleeding. Medical records lacked written transfer notices and bed-hold notifications, and the transfer information that should have been given to residents or their representatives did not include mandated details about appeal rights, how to request an appeal, or how to contact the State LTC Ombudsman. The Social Services Director reported that she does not notify the Ombudsman of hospital transfers and only sends a monthly email list of discharged residents, without written copies of transfer or discharge notices.
Two cognitively impaired residents with dementia and significant behavioral and continence needs were sent to a local ER after falls and were discharged back to the facility’s care, but the facility failed to provide timely transportation for their return. In both cases, hospital discharge times were documented, yet ER staff reported making multiple unsuccessful calls to the facility, reaching the Administrator only after repeated attempts. One resident, described as very disoriented, remained in the ER for several hours after discharge without 1:1 supervision, while the other waited approximately 11 hours, during which ER staff observed increasing confusion and attempts to get out of bed. The Administrator acknowledged awareness of the discharges, the lack of 24-hour transportation, and that the residents were not picked up until many hours after they had been discharged from the ER.
Two residents who required staff assistance for ADLs and transfers reported neglectful and rude behavior by a CNA and delayed nursing response to care needs. One resident with a history of cerebral infarction and schizophrenia stated that a CNA mocked him and that his requested wound dressing change was not performed for several hours, which was later corroborated by video showing a long gap between the CNA’s visit and the nurse’s entry to the room. Another resident with a right femur fracture, type II DM, and repeated falls, who needed one-person assistance for mobility and self-care, reported that a CNA refused to help and told her she could do some care herself, making her feel she was not trying in her recovery. Documentation and interviews confirmed that staff did not provide timely wound care or required assistance, and that these interactions caused residents to feel uncomfortable and negatively about their care.
A resident with a history of opioid dependence and polysubstance abuse was on a secure unit with a care plan that included safety risk evaluations and monitoring for signs of substance abuse. Staff later observed the resident discarding an empty Suboxone packet, even though the resident was not prescribed this medication, and the incident was reported to the on-call provider with subsequent monitoring and a room search. However, the care plan was not revised to reflect this new substance-related event, and both the DON and Administrator acknowledged that the care plan should have been updated when this new risk and behavior were identified.
Surveyors identified that a medication cart on the north hall was left unlocked and unattended outside a resident room. An LPN acknowledged that the cart was hers and that she had not locked it before leaving to answer a call light, despite facility expectations. The DON confirmed that all medication and treatment carts are required to remain locked when not in use or when staff are away from them.
Surveyors found that a document containing multiple residents’ PHI, including full names, room numbers, and code status, was left unattended and visible on a south nurse’s station counter. An RN confirmed the document was a resident list with PHI and acknowledged it had been left exposed and that such information should not be left unattended.
Surveyors found that a lunch tray return cart containing uncovered, soiled food trays and dishes was left unattended in a main hallway outside an activity room. The housekeeping/laundry manager acknowledged seeing the unattended cart, and the Dietary Manager confirmed that such carts are supposed to remain only in designated areas, such as near the nurse’s station or in the kitchen, and should be returned to the kitchen for cleaning as soon as all trays are collected. This failure was cited as likely to expose all residents to potential pathogens associated with food waste.
Two residents with scheduled showers reported that they were offered or received showers in very cold water during a prolonged period when hot water was not reliably available in care areas. One resident stated he refused cold showers and was only offered sponge baths once or twice, despite his preference to stay clean. Another resident reported receiving cold showers, including being rinsed with cold water while still soaped, and subsequently began refusing showers and bed baths due to the cold water. A CNA confirmed that water in the shower rooms was “ice cold” for several months, leading to resident complaints and refusals, while the Maintenance Director reported that a needed part to correct the hot water problem was on back order, delaying resolution and resulting in the facility not honoring residents’ bathing preferences.
Surveyors observed that unused medications were improperly discarded in a trash bin attached to a medication cart on the north hallway, rather than being disposed of in a designated drug disposal container. Two pills, a round blue tablet stamped "61" and an oblong orange tablet stamped "20," were found together in an unlabeled medication cup in the trash. An RN confirmed the medications were discarded there and acknowledged that unused medications should be placed in the drug buster container in the cart drawer. The Unit Manager also confirmed that facility practice requires all unused medications to be disposed of using the drug buster and that controlled substances must be destroyed by two licensed staff and documented on the narcotic count sheet.
The facility failed to follow documented allergy information, diet orders, and meal tickets for three residents. A resident with a documented chocolate allergy was served chocolate ice cream after requesting it, and the Nutrition Director admitted not reading the allergy notation on the meal ticket. Another resident on a pureed diet received whole mandarin oranges instead of pureed fruit, which a CNA confirmed. A third resident whose meal ticket called for a grilled Swiss sandwich received a sandwich that was not grilled, as confirmed by a CNA and a dietary manager.
Failure to Provide Required Written Transfer, Appeal, Ombudsman, and Bed-Hold Notices During Hospitalizations
Penalty
Summary
Surveyors identified that the facility failed to provide required written transfer and bed-hold information for multiple residents who were hospitalized. For three residents who experienced transfers to the hospital after events such as falls with injury, unresponsiveness, and episodes of nausea, vomiting, and bleeding, record review showed there were no written transfer notices or written bed-hold notices in their medical records. Specifically, one resident transferred after a fall on 01/31/26 had no documented written transfer notice or bed-hold notice. Another resident transferred on 02/27/26 for nausea, vomiting, and bleeding, and later readmitted on 03/05/26, had no written transfer notification that included information on appeal rights or Ombudsman contact, and no written bed-hold notification. A third resident transferred on 01/29/26 after a fall with a forehead laceration and again on 03/17/26 for unresponsiveness, also had no documented written transfer or bed-hold notices for either hospitalization. The deficiency also included the facility’s failure to provide required content in transfer notices and to notify the State Long-Term Care Ombudsman in writing. For the residents reviewed, there was no evidence that written transfer notices were provided to the residents or their representatives in a language and manner they could understand, and the notices were missing required elements such as a statement of appeal rights, the name, mailing and email address, and phone number of the entity receiving appeals, and information on how to obtain and complete an appeal form. The notices also lacked the name, phone number, and mailing and email address of the State Long-Term Care Ombudsman, and written copies of the transfer notices were not sent to the Ombudsman. During interview, the Social Services Director confirmed that transfer and bed-hold notices were not documented for at least one resident’s hospitalization, that she does not notify the Ombudsman about transfers to the hospital, and that she only emails a monthly list of residents discharged from the facility without sending written copies of transfer or discharge notices.
Failure to Timely Retrieve Residents From ER After Discharge
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from neglect by not arranging timely transportation back to the facility after emergency room (ER) discharge. A consumer complaint alleged that residents sent to the local ER were being left there for extended periods after discharge. For one resident with an admission date of 10/13/25, records showed multiple cognitive and behavioral diagnoses, including Alzheimer’s disease, vascular dementia with agitation and other behavioral disturbances, mild cognitive impairment, cognitive communication deficit, and restlessness and agitation. A change of condition MDS documented a Brief Interview for Mental Status (BIMS) score of 1 and frequent incontinence of urine and bowel. Nursing progress notes for this resident showed that 911 was called at 3:00 AM and the resident was transferred to the ER after a fall. Hospital discharge instructions indicated the resident was discharged from the ER at approximately 5:21 AM, while the ER nurse reported discharge at about 5:30 AM. The ER nurse stated she made numerous calls to the facility but was unable to reach anyone. She reported that the resident was very disoriented and that the ER did not have enough staff to provide 1:1 supervision. The ER nurse eventually reached the Administrator, who stated staff would come to pick up the resident as soon as possible. Facility records showed the resident was not discharged from the facility on that date, and the ER nurse reported that facility staff did not pick the resident up until approximately 8:30 AM, several hours after discharge. A second resident, admitted on 11/25/25, had diagnoses including Alzheimer’s disease, dementia with behavioral disturbance, bipolar disorder with severe depression and psychotic features, depression, and anxiety disorder. The admission MDS documented a BIMS score of 2, frequent urinary incontinence, constant bowel incontinence, and a need for substantial/maximal assistance with toileting hygiene. Nursing notes showed this resident was sent to the ER for evaluation after a fall and did not return until the following morning. Hospital discharge instructions documented discharge from the ER at 10:16 PM, and the Administrator confirmed being notified of the discharge at about 10:30 PM and that the facility did not have 24-hour transportation. The Administrator acknowledged the resident was not picked up until approximately 9:00 AM the next day. The ER nurse reported making several calls to the facility that went to voicemail, eventually reaching the Administrator, who initially stated staff were on the way, then stopped answering calls. During the approximately 11-hour wait, the ER nurse stated the resident was confused, attempted to get out of bed, and became more confused as the night progressed.
Failure to Timely Provide Wound Care and Required Assistance, Resulting in Resident Neglect
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from neglect when staff did not respond appropriately to requests for care and assistance. One resident with a history of cerebral infarction due to embolism and schizophrenia, admitted on 01/30/26 and requiring staff assistance for ADLs and mechanical lift transfers, reported that a CNA was rude and mocking and that his wound dressing was not changed for several hours after he requested it. The Kardex showed he needed staff help for toileting, bathing, hygiene, bed mobility, dressing, and transfers. Nursing progress notes documented a change in condition on 03/02/26 after the resident stated the CNA was rude and would not assist as requested. The Administrator later confirmed, via video review, that the CNA entered the resident’s room at 2:30 am, the resident requested a dressing change, and no nurse entered the room until 5:00 am, despite the nurse’s statement that she went in “right away.” The DON also confirmed that the resident’s grievance described the wound dressing not being changed until hours after the request. Another resident, admitted with a right femur fracture, type II diabetes, and repeated falls, required one-person assistance for dressing, hygiene, bathing, bed mobility, and transfers, and could toilet herself with assistance for transfers. Nursing progress notes documented an alleged abuse incident on 03/02/26 in which this resident stated a CNA was rude, refused to help her, and told her she could perform some care tasks herself without staff assistance. An abuse questionnaire completed the same day showed the resident answered “Yes” to having interactions that made her feel uncomfortable or negative, and she reported that the CNA made her feel as though she was not trying with her own recovery. The Administrator and DON acknowledged that staff are expected to help residents as required and that staff interactions must be encouraging rather than making residents feel bad about needing assistance.
Failure to Revise Care Plan After Substance-Related Incident
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s care plan after a significant substance-related incident. The resident was originally admitted with a diagnosis of opioid dependence and resided on a secure unit related to polysubstance abuse disorder. The existing care plan, dated 01/21/26, identified the resident as residing on a secure unit due to polysubstance abuse disorder with interventions to perform safety risk evaluations on admission, as needed, and upon changes in condition. The care plan also identified the resident as at risk for substance use disorder with interventions to monitor for signs or symptoms of substance abuse. On 02/01/26, nursing notes documented that staff observed the resident discarding an empty Suboxone packet in the trash, even though the resident was not prescribed Suboxone and denied taking any. Staff notified the on-call provider, who ordered monitoring for adverse reactions, and nursing staff and security conducted a room search that revealed no additional contraband. Despite this incident, the resident’s care plan was not updated to address the new substance-related event. During interviews, the DON acknowledged awareness of the incident and confirmed the care plan was not revised, and the Administrator stated her expectation that nursing would update the care plan when a new risk or behavior was identified and confirmed she would have expected the care plan to be updated for this resident.
Unattended, Unlocked Medication Cart on North Hall
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were properly stored and secured in accordance with professional standards and facility expectations. On 03/24/26 at 9:06 a.m., surveyors observed a medication cart on the north hall left unlocked and unattended outside a resident room. At 9:08 a.m., the LPN responsible for the cart confirmed during interview that the cart was hers, that it was unlocked and unattended, and acknowledged she should have locked it before responding to a call light. Later that day at 3:37 p.m., the DON stated in an interview that medication and treatment carts are expected to be locked at all times when nurses are away from them, confirming that the observed practice did not meet facility expectations. This deficient practice was cited as likely to allow unauthorized personnel access to medications, which could result in injury or overdosing.
Unattended PHI Document Left Exposed at Nurse’s Station
Penalty
Summary
Surveyors identified a deficiency in the facility’s protection of residents’ personal health information (PHI) when a document containing multiple residents’ full names, assigned room numbers, and code status was left unattended and exposed on the south nurse’s station counter. On 03/16/26 at 9:04 a.m., an observation revealed a piece of paper on a clipboard with complete resident information placed on top of the south nurse’s counter in public view. At 9:06 a.m., during an interview, RN #2 confirmed that the list contained residents’ names, room numbers, and code status, acknowledged that it had been left exposed and unattended, and stated that PHI should not be left unattended. No additional clinical details or medical histories of the residents listed on the document were provided in the report.
Unattended Soiled Lunch Cart Left Uncovered in Hallway
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the handling of soiled food service equipment. On 03/24/26 at 12:58 pm, a lunch tray return cart containing soiled food trays and dishes that were uncovered was observed sitting unattended in the main hallway outside the activity room. At 1:06 pm, the housekeeping/laundry manager confirmed she saw the return cart left unattended in that location. At 1:08 pm, the Dietary Manager stated that lunch return carts should only be left in designated areas such as by the nurse’s station or inside the kitchen, and that the cart should be returned to the kitchen for cleaning as soon as all trays have been picked up, which did not occur in this instance. This deficient practice was noted as likely to expose all residents to potential pathogens associated with food waste.
Failure to Honor Resident Bathing Preferences During Prolonged Hot Water Issues
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ bathing preferences when hot water was not reliably available in resident care areas. Record review showed that one resident was scheduled to receive three showers per week on specific days, and another resident was scheduled for two showers per week. One resident reported that staff attempted to have him shower in cold water, which he refused, and that sponge baths were only offered once or twice during the period when the hot water was not working. He stated that he liked to be clean and did not feel like himself when he was dirty. A CNA reported that there was no hot water in resident care areas from the middle of December until early March, and that large barrels of warm water were brought to shower rooms to offer sponge baths, which this resident refused. Another resident, also on a scheduled twice-weekly shower regimen, stated that she received cold showers and began refusing showers because of how cold the water was. She described the water running cold unpredictably, including an instance when the water was initially warm but turned cold while she was still soaped, requiring rinsing with cold water, which she described as horrible. A social services note documented that this resident’s daughter reported the resident had been declining showers and bed baths offered because the water was too cold. A CNA corroborated that the water was “ice cold” and that residents began complaining and refusing showers around mid-December. The Maintenance Director stated that it took a while for hot water to reach the shower room and that a needed part to fix the cold-water problem was on back order, contributing to the prolonged period of inadequate hot water and resulting in residents not having their bathing preferences honored.
Improper Disposal of Unused Medications on Medication Cart
Penalty
Summary
Surveyors identified a deficiency related to accident hazards and inadequate supervision when unused medications were improperly discarded on the north hallway. During observation of the north hall nurses’ station, two medications were found in the trash bin attached to the medication cart, placed together inside an unlabeled medication cup. The pills were described as a round blue pill stamped with “61” and an oblong orange pill stamped with “20.” In an interview immediately following the observation, an RN confirmed that these medications were in the trash bin and stated that unused medications should instead be disposed of in the drug buster, a sealed container for drug disposal located in the bottom drawer of the cart. In a subsequent interview, the Unit Manager confirmed that all unused medications are to be disposed of using the drug buster and acknowledged that this did not occur, further stating that if the medications are controlled substances such as narcotics, two licensed personnel are required to dispose of them together and document the disposal on the narcotic count sheet. This deficient practice was noted as likely to affect any resident who might acquire and ingest the discarded medications, potentially causing medication side effects.
Failure to Follow Allergy, Diet, and Meal Ticket Requirements
Penalty
Summary
The facility failed to provide meals consistent with residents’ documented allergies, diet orders, and meal tickets for three residents. One resident, admitted with a documented allergy to chocolate, had a face sheet and lunch ticket indicating they were not to receive chocolate. During a lunch observation, this resident was served and was eating chocolate ice cream. An LPN confirmed the resident’s chocolate allergy and that the resident should not be eating chocolate. The Nutrition Director acknowledged that the meal ticket stated the resident should not have chocolate but reported serving chocolate ice cream after the resident requested it, stating he had not read that the resident was allergic to chocolate. Another resident, admitted with hypokalemia and ordered a regular/liberalized pureed diet per the MDS, had a lunch ticket indicating a pureed diet but was observed receiving whole mandarin oranges instead of pureed fruit. A CNA confirmed that the dessert was not pureed. A third resident’s meal ticket specified a grilled Swiss sandwich, but observation of the tray showed the sandwich was not grilled. During interviews, a CNA and a dietary manager confirmed that the sandwich was not grilled as ordered on the meal ticket.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
