Los Alamos Wellness & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Alamos, New Mexico.
- Location
- 1011 Sombrillo Court, Los Alamos, New Mexico 87544
- CMS Provider Number
- 325056
- Inspections on file
- 27
- Latest survey
- March 30, 2026
- Citations (last 12 mo.)
- 8 (1 serious)
Citation history
Health deficiencies cited at Los Alamos Wellness & Rehabilitation during CMS and state inspections, most recent first.
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 with coccyx pressure injuries did not receive consistent, ordered wound care and monitoring. One resident was admitted with a stage 2 ulcer and multiple risk factors, but the care plan lacked specific pressure-relief and repositioning interventions, weekly wound assessments were missed, physician orders for collagen, calcium alginate, and Medihoney dressings were not consistently followed, and a nurse applied an unauthorized dressing intended for less frequent changes. The wound progressed from a small stage 2 lesion to a large unstageable ulcer later described in the hospital as a large stage III/IV sacral decubitus ulcer. Another resident with a history of ulcers developed coccyx redness progressing to a stage 3 ulcer; although daily collagen dressing changes were ordered, the dressing observed in place was six days old despite TAR entries indicating daily care, which the DON identified as false documentation. The NP and medical director both reported they were not notified of the lack of improvement in these wounds, and surveyors cited these failures as causing worsening of the residents’ pressure injuries and resulting in Immediate Jeopardy.
A resident with multiple comorbidities, including muscle wasting, morbid obesity, endocrine disorders, and mild cognitive impairment, developed a skin tear on the LLE after bumping it on a door. Nursing staff documented the initial wound, subsequent dressing changes, surrounding redness, and later an open lesion with 5+ pitting edema, but several weekly skin assessments lacked measurements and there were gaps in wound documentation. Despite ongoing non-healing of the wound and no improvement, there were no changes in wound care orders for an extended period, and nursing staff did not notify the provider of the lack of progress. The DON confirmed the absence of provider notification and treatment changes during this time, and the NP reported she relied on nurses for wound status and had not been informed that the wound was not improving.
A resident with a left lower leg skin tear did not receive consistent weekly wound assessments with measurements, as required, and several weeks of documentation were missing. Despite a physician order and subsequent referrals by an NP and the medical director for evaluation at a hospital wound care clinic, nursing staff did not ensure that the referral was communicated to medical records, and no appointment or visit to the wound clinic occurred. The DON later confirmed missed weekly assessments, and the medical records staff reported never receiving the referral, resulting in the resident not being seen at the wound clinic as ordered.
Surveyors observed a medication cart on the memory care unit left unlocked and unattended for over 30 minutes, with two residents in close proximity to the cart. The cart was located at the back of the unit and remained unsecured while the Housekeeping Director and a CNA, both of whom acknowledged the cart should not be left unlocked, left the area to look for a nurse. The CNA later returned and locked the cart. In an interview, the DON confirmed the cart had been unlocked and stated that medication carts are required to be locked when not in use.
Surveyors identified that two residents with coccyx pressure injuries had inaccurate and inconsistent medical record documentation. One resident’s weekly wound reports showed an ongoing coccyx pressure injury, yet a weekly skin check documented that the resident had no skin impairment despite stating the assessment was based on direct observation and staff communication. Another resident had a care plan noting a history of ulcers without updated wound interventions, and the TAR showed daily wound care documented as completed, but an observation revealed the dressing was several days old, leading the DON to confirm that multiple days of wound care entries were false documentation.
Staff did not ensure that food items in a locked unit and a resident room refrigerator were labeled, dated, or properly stored, and failed to maintain required temperature logs. Multiple containers of food and beverages were found unlabeled, undated, and in one case expired, with staff confirming these deficiencies during interviews.
Staff did not label or date food items stored in the locked unit refrigerator and freezer, and there was no documentation of daily refrigerator temperatures. Multiple food items, including punch, cheese, lettuce, sandwich meat, salsa, and bread, were found unlabeled and undated, and staff interviews confirmed the lack of proper labeling and unclear responsibility for temperature monitoring.
A clipboard containing a resident's private health information was left face up and unattended in the lobby, making sensitive clinical records visible to unauthorized individuals. This lapse was confirmed by facility staff during the survey.
A resident with dementia and a history of traumatic brain injury was physically pushed by an RN, resulting in injury, as witnessed by two staff members. Despite the incident being reported, the RN continued working in the unit, and the facility's administrator did not conduct a thorough investigation or notify the family, leaving residents at risk for further abuse.
A facility did not report an alleged abuse incident, where a nurse was witnessed yelling at and pushing a resident, to the State Agency. The Administrator, acting as Abuse Coordinator, did not document the event or initiate an investigation, as she did not believe abuse had occurred, leaving the accused nurse on the unit.
A facility did not conduct a thorough investigation after a staff member reported witnessing a nurse yelling at and pushing a resident. The Administrator reviewed video footage and obtained statements but did not remove the accused nurse from the unit, did not formally document the investigation at the time, and did not notify the resident's family, contrary to facility policy.
A resident with a history of femur fracture, cognitive deficits, and high fall risk was left unsupervised and able to ambulate without assistance, despite being care planned for wheelchair use and requiring help with transfers. Nursing staff failed to notice or intervene as the resident moved around the locked unit, and one nurse was observed inattentive and possibly asleep during the incident, resulting in a fall and ongoing risk of accidents.
A medication cart was observed left unlocked and unattended on a locked unit, and a registered nurse confirmed that this was not in accordance with proper procedures for medication security.
The facility failed to maintain comfortable water temperatures in resident shower rooms, affecting all 63 residents. Despite initial complaints in October, the issue persisted into December, with water temperatures consistently below comfortable levels. Residents expressed dissatisfaction, and some refused showers due to the cold water. The Maintenance Director admitted to manually adjusting temperatures during work hours, leaving the facility without hot water in the evenings and weekends.
The facility failed to provide a nourishing bedtime snack, resulting in a 15-hour gap between dinner and breakfast for several residents. Dinner was served at 5:00 PM, and breakfast at 8:00 AM. Residents expressed a desire for bedtime snacks, which were previously provided. The Dietary Supervisor indicated that snacks were left in the nourishment room, but it was unclear if residents were informed. The RD confirmed that an evening snack should be provided.
The facility's kitchen was found to have unsanitary conditions, with unsealed and unlabeled food items and dirty equipment. Residents reported receiving food at incorrect temperatures, which was confirmed by observations showing hot foods below 120 F and cold foods above 40 F. Despite this, the Dietary Manager deemed the temperatures acceptable for serving.
The facility's call light system was not functioning properly, with audible alerts not working for several weeks. This issue, noted in Resident Council meetings, affected all residents as staff were unaware of activated call lights unless they were in the hallway. Interviews with staff confirmed the problem, and the Regional Nurse Consultant was unaware of the deficiency.
A resident experienced persistent nausea and abdominal pain, leading to an ER visit and a diagnosis of gall stones. The facility failed to notify the resident's POA, providers, and DON, preventing necessary adjustments to the care plan. Interviews confirmed the lack of communication, which hindered informed decision-making regarding the resident's treatment.
The facility failed to revise care plans for three residents, resulting in unmet care needs. One resident missed a quarterly care plan meeting due to the Social Services Director's absence. Another resident's care plan was not updated with a new gall stones diagnosis after an ER visit. A third resident's care plan lacked instructions to keep the bed elevated to prevent daytime sleeping, despite staff and family approval of this practice.
A resident experienced prolonged nausea, vomiting, and abdominal pain, but the facility failed to send her to the ER in a timely manner. Despite the resident's requests and symptoms, staff did not notify the nurse practitioner or document the administration of medications. The resident was eventually diagnosed with gallstones after being sent to the ER.
The facility failed to ensure physicians reviewed and responded to pharmacist recommendations for five residents, leading to potential medication management issues. Recommendations included addressing fall risks, adjusting doses for kidney disease, and reducing psychotropic medication doses. Despite these documented recommendations, there was no evidence of physician review or action.
A facility failed to dispose of a discontinued controlled substance, Ativan, for a resident. Despite the medication being discontinued, 73 doses were found in the locked medication cart in the Dementia Unit. An LPN confirmed the medication should have been removed immediately after discontinuation, indicating a lapse in medication management procedures.
A facility failed to ensure a resident's advance directive was accurately reflected in their EHR, leading to conflicting information. The resident's EHR indicated a DNR status, while the MOST forms showed both DNR and full code statuses. The MDSC confirmed the inconsistency and verified the resident's wish to remain a full code, CPR.
A resident with severe dementia and depression experienced a 44-day delay in receiving psychiatric services due to ineffective communication and follow-up between the facility and psychiatric providers. The delay was exacerbated by the facility's failure to provide timely access to the resident's EHR, resulting in the resident not receiving necessary behavioral health care.
A facility failed to maintain accurate medical records for a resident regarding their smoking status. Initially assessed as a safe smoker, a later assessment inaccurately stated the resident did not smoke. Interviews with the resident and an LPN confirmed the resident was a smoker, and the Regional Nurse Consultant acknowledged the inaccuracy.
A resident with chronic pain was not administered Pregabalin as prescribed due to pending pharmacy delivery, resulting in unmanaged pain and a 911 call for hospital transport. The DON confirmed the medication was missed on four occasions.
A resident's preference for regular showers was not honored, as she only received one shower out of nine scheduled opportunities. Her daughter reported that the resident rarely got showers and had greasy hair, despite not refusing them. The DON confirmed that the lack of documentation on paper shower sheets indicated showers were not given.
A resident with severe mental impairment and dependency on staff for toileting was given unnecessary medications due to inadequate monitoring. Despite experiencing diarrhea, staff continued administering constipation medications without documenting constipation. The DON acknowledged the error in medication administration.
A resident with a high fall risk was found without non-skid socks, with the call light and water out of reach, no fall mat, bed not in the lowest position, and wheelchair brakes unlocked. Staff interviews confirmed non-adherence to the care plan for fall precautions.
A resident was found with a soiled brief, disheveled hair, and dirty fingernails, indicating a failure to provide scheduled showers and personal hygiene assistance. Records showed the last documented shower was several days prior, and an LPN confirmed the lack of recent hygiene care.
Facility staff failed to follow infection prevention protocols by not using PPE when entering the room of a COVID-19 positive resident. The Administrator and Regional Administrative Officer entered the room without PPE, despite clear indications and staff confirmation that PPE was required.
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 Follow Wound Care Orders and Monitor Pressure Ulcers Resulting in Worsening Wounds
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary treatment and services to prevent the development and worsening of pressure ulcers for two residents with wounds. One resident was admitted with a stage 2 coccyx pressure ulcer measuring 2.3 x 4.2 cm and had multiple risk factors, including type 2 diabetes mellitus, an unstageable pressure ulcer diagnosis, muscle wasting and atrophy, and severe protein-calorie malnutrition. The admission evaluation documented a sacral pressure sore and functional limitations requiring assistance with mobility and ADLs. The care plan identified a pressure ulcer and risk for further breakdown but did not include interventions such as a pressure-relieving mattress, wheelchair cushion, or specific repositioning requirements. Weekly wound reports for this resident showed inconsistent documentation, with missing weekly assessments and progression from deep tissue injury to unstageable status, along with changes in wound size and tissue characteristics. Physician orders for this resident’s coccyx wound changed over time, including orders for collagen dressings, calcium alginate, moisture barrier cream, and later Medihoney with calcium alginate, but the Treatment Administration Records showed missed wound care on multiple ordered days. Moisture barrier cream ordered every shift was only documented twice daily. Staff interviews revealed that a previous wound treatment nurse had been providing wound care treatments without provider orders and that on one occasion a nurse applied a dressing that was not in accordance with the physician’s order, changing to a dressing intended to be changed every three days. A corrective action memo documented that during wound rounds, the dressing found on the resident was not the ordered dressing, bore the initials and date of the nurse who changed it, and the wound was observed to have worsened. The family reported that the wound, initially the size of a quarter on admission, became larger, with blue discoloration around the sore and eventually the size of a business card, and that they were told the dressing orders had been changed so it would be changed less often to reduce pain. Further documentation for this resident showed that the NP expected orders to be followed and to be notified of wound changes but confirmed she had not been informed of the worsening wound. A nursing note recorded that the resident was discharged to the hospital due to the unstageable wound, and the hospital admission assessment described a large sacral decubitus ulcer, stage III or IV, and noted worsening from the previously documented stage II, quarter-sized wound at the prior hospital discharge. For the second resident, the care plan identified a pressure ulcer or risk related to a history of ulcers but contained no updated wound or treatment interventions. Progress notes documented coccyx redness and later a stage 3 coccyx pressure ulcer measuring 1 x 1 x 0.1 cm. Provider orders directed daily dressing changes with collagen and dry dressing, but the TAR showed wound care documented on only some days, and an observation of wound care revealed a dressing dated six days earlier, indicating that daily wound care had not been performed as ordered. The DON confirmed the dressing age and stated that the TAR entries for several days represented false documentation. The medical director stated he had not been notified that the wound was not improving and that he expected nursing staff, including the wound care nurse, to keep him informed of changes so he could monitor and direct wound care. The surveyors determined that these failures—missing and inconsistent wound assessments, failure to follow physician wound care orders, provision of wound treatments without orders, lack of appropriate care plan interventions, missed treatments, and inaccurate documentation—resulted in the worsening of pressure wounds for both residents. The facility was notified of a finding of Immediate Jeopardy related to these practices.
Removal Plan
- Assess and treat Resident #4 wound; ensure wound is improving.
- Notify the physician of inaccurate documentation.
- Suspend the charge nurse alleged to have falsified documentation pending investigation.
- Complete an audit of all residents with wounds to ensure all orders are carried out correctly; verify dressings are dated correctly and ordered treatments are in place.
- Re-educate all licensed nurses on the wound care policy.
- Re-educate all licensed nurses on identification of wound progression, including proper wound assessment and monitoring techniques to recognize signs of wound decline or lack of progression.
- Re-educate all licensed nurses on correct documentation of completed wound care.
- Re-educate all licensed nurses on when and how to notify the provider regarding worsening wound status to ensure new orders are obtained as needed.
- Re-educate all licensed nurses on completing wound treatments exactly as ordered.
- Re-educate all licensed nurses on the zero-tolerance policy for falsifying documentation.
- Require nurses to complete competency related to completing wound dressings correctly.
- Complete nurse re-education and competency observation by the interim DON or designee prior to nurses completing any wound care for residents.
- Educate agency nurses prior to their shift beginning by the interim DON or designee.
- Consult with the wound provider for consenting residents.
- Conduct weekly wound audits of current residents with wounds for two weeks, including wound assessment, documentation, notifications, and treatments.
- After the initial two weeks, select 5 random residents weekly for review.
Failure to Notify Provider of Non-Healing Leg Wound
Penalty
Summary
The deficiency involves the facility’s failure to notify the provider in a timely manner of changes in a resident’s skin condition, specifically a non-healing wound on the left lower leg. The resident was admitted to the facility and later discharged to the emergency room, with medical diagnoses including muscle wasting and atrophy at multiple sites, morbid obesity due to excess calories, a developmental disorder of scholastic skills, an adrenal gland disorder, hypopituitarism, and mild cognitive impairment. On one date, nursing documentation showed the resident reported bumping the lower left leg on a door, resulting in a skin tear measuring 3.2 cm by 2.6 cm; the RN cleaned the area with normal saline, applied steri-strips, and covered it with an Optifoam adhesive dressing. Subsequent nursing notes documented dressing changes and surrounding skin redness but did not document provider notification regarding wound progress. The care plan initiated for the resident on a specified date and revised later identified a non-healing skin tear with a goal for the wound to be healed by a target date, and interventions focused on nutrition, hydration, and safe transfers. Weekly skin checks documented the initial identification of the left lower leg skin tear and later described an open lesion with 5+ pitting edema, but several weekly assessments lacked wound measurements. The wound report similarly showed multiple gaps where no weekly skin assessment documentation was found. When documented, wound measurements indicated that the wound persisted and changed in size over time, but there were periods without recorded assessments. Physician orders reflected several changes in wound care treatments over time, including cleansing with normal saline or wound cleanser and use of Optifoam, NAD, xeroform, Santyl, collagen, ABD pads, and Kerlix, with some orders discontinued and new ones started. However, there were no changes in treatment orders between two specific dates despite the wound not improving. In an interview, the DON stated that all changes in wound status should be immediately reported to the provider and confirmed that the resident’s leg wound was not improving, that there were no treatment changes during the identified period, and that the treatment nurse and provider had no communication about the wound in that timeframe. The NP stated that the resident would not allow her to look at the leg and that she relied on nursing staff to report skin condition changes; she reported she was not informed that the wound was not improving.
Failure to Complete Weekly Wound Assessments and Implement Wound Clinic Referral Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders and required monitoring for a resident with a left lower leg wound. Record review of the wound report from early June through early September showed multiple gaps where no weekly skin assessment documentation, including wound description and measurements, was completed. Specifically, no weekly skin assessment was found for several date ranges, and the Director of Nursing later confirmed that four weekly skin assessments were missed. When assessments were documented, the wound was identified as a skin tear on the left lower leg front with specific length, width, and depth measurements, but these were not recorded consistently on a weekly basis as expected. The facility also failed to follow physician orders to refer the resident to a hospital wound care clinic for the front left lower extremity wound. A physician order dated late July directed a one-time referral to the wound care clinic, and subsequent progress notes documented that a nurse practitioner and the medical director each made referrals to the same wound clinic in August. However, the medical records/scheduler staff member reported never receiving any referral for this resident and confirmed that the resident was not seen at the wound care clinic. The DON stated that nurses are expected to provide copies of referrals and appointments to medical records, and the medical records staff explained that she processes referrals within hours once she receives the necessary documents. Progress notes from July through October did not show that any wound clinic appointment was made or attended, indicating that the referral orders were not carried out.
Unlocked Medication Cart on Memory Care Unit
Penalty
Summary
Surveyors identified a deficiency related to improper storage and security of medications when a medication cart on the memory care unit was observed unlocked and unattended for an extended period. On 11/18/25 at 2:00 p.m., during a random observation and interview on the memory care unit, the medication cart was found unlocked in the back of the unit with one resident standing next to it and another resident walking back and forth nearby. The cart remained unlocked from 2:00 p.m. to 2:33 p.m. The Housekeeping Director, when asked if the medication cart should be left unlocked, stated it should not and then left to look for the DON, leaving the cart still unlocked. A CNA, when asked if the medication cart should be unlocked, also stated it should not be and likewise walked away to look for the nurse, leaving the cart unsecured until she returned a few minutes later and locked it. At 2:32 p.m., during an interview, the DON confirmed that the medication cart was unlocked and stated that medication carts should be locked when not in use. The report notes that this failure to ensure medications were stored properly and that medication carts were locked and secured when not in use was a deficient practice that could result in resident injury through dosing with improperly stored medications, access to medications not prescribed for them, and possible overdose.
Inaccurate Wound Documentation and Skin Assessments for Residents With Pressure Injuries
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate medical records and skin assessments for two residents with pressure injuries. One resident was admitted with a stage 2 pressure ulcer to the coccyx, measuring 2.3 x 4.2 cm. The facility’s weekly wound report for this resident later documented a coccyx deep tissue pressure injury and then an unstageable coccyx wound with changing measurements and wound characteristics over several weeks. However, during the weekly skin check dated 09/29/25, staff documented "No" to the question of whether the resident had any skin impairment, despite the ongoing documentation of a coccyx pressure injury in the wound tracking system. The weekly skin check also stated that the assessment was completed using direct observation and communication with the resident and staff, creating a direct inconsistency between the skin check and the wound documentation. For the second resident, the face sheet showed an admission date of 01/29/24, and the care plan initiated on 10/29/24 identified a history of ulcers and risk for pressure ulcer development, but there were no further updates to the care plan related to wounds or treatment interventions as of 11/18/25. The Treatment Administration Record (TAR) contained an order for daily wound care to a stage 2 pressure injury to the coccyx, including cleansing, application of a collagen sheet, and dressing changes. The TAR showed wound care as completed on multiple dates between 11/05/25 and 11/19/25. However, during an observation of wound care on 11/18/25, the DON noted that the date on the resident’s dressing was 11/12/25, indicating the dressing was six days old and that wound care had not been provided since 11/12/25. The DON stated that the documented wound care on the TAR from 11/13/25 through 11/17/25 would therefore be false documentation by the RN.
Failure to Label, Date, and Monitor Food Storage in Resident Refrigerators
Penalty
Summary
Surveyors observed that staff failed to ensure all food items stored in the locked unit and a specific resident room refrigerator were properly labeled and dated. During the initial walkthrough, multiple containers of punch/juice, nutritional supplements, and salsa were found unlabeled and undated in the locked unit refrigerator. Additionally, an uncovered container of punch/juice was found to be expired and improperly stored. Packaged frozen food items in the freezer were also found without labels or dates. Further investigation revealed that the refrigerator temperature log for the resident room was not available for review. Interviews with a CNA and the Housekeeping Supervisor confirmed that the food items belonged to residents and should have been labeled and dated, but were not. The Housekeeping Supervisor also verified the absence of a required temperature log for the refrigerator.
Failure to Label, Date, and Monitor Food Storage in Locked Unit Refrigerator
Penalty
Summary
Staff failed to ensure that all food items stored in the locked unit refrigerator were labeled and dated, as observed during a walkthrough when multiple items such as containers of punch/juice, cheese, lettuce, turkey sandwich meat, salsa, and bread were found unlabeled and undated. Additionally, packaged frozen food items in the freezer were also unlabeled and undated, and one uncovered container of punch/juice was dated but not covered. There was no refrigerator temperature log available for review, and staff interviews confirmed that the responsibility for maintaining the temperature log was unclear, with nursing staff indicating it was the kitchen staff's duty. These actions and inactions resulted in food not being stored and served under sanitary conditions for all 20 residents in the locked unit.
Failure to Safeguard Resident PHI in Public Area
Penalty
Summary
A deficiency occurred when the Admissions Coordinator left a clipboard containing a resident's private health information (PHI) face up and unattended in the facility lobby, making the information visible to unauthorized residents, visitors, and staff. This incident was observed during a random check, and the Human Resources Director confirmed that the PHI was left exposed and should not have been accessible in this manner. The event involved the failure to safeguard clinical record information for one resident, as the PHI was not properly secured and was left in a public area where it could be viewed by individuals without authorization.
Failure to Protect Resident from Abuse and Inadequate Investigation
Penalty
Summary
The facility failed to protect a resident from abuse when a Registered Nurse (RN) was witnessed by two staff members yelling at and physically pushing a resident, resulting in the resident falling and sustaining a cut on the nose and a swollen lip. The incident occurred in the memory care unit and was observed by a Laundry Aide and a Certified Nursing Assistant, both of whom reported the event to the Administrator and provided written statements. The resident involved had a history of traumatic brain injury, unspecified dementia, psychotic disorder with delusions, and mild neurocognitive disorder with behavioral disturbance. Despite the incident being reported, the RN accused of abuse was not removed from the unit and continued to work with residents. The Administrator interviewed the involved staff and the resident, but did not notify the family or conduct a thorough investigation beyond these interviews. The Administrator also could not locate any handwritten notes from the incident and relied on recollection for documentation. The failure to remove the accused staff member from resident care and the lack of a comprehensive investigation left residents at continued risk for abuse. The incident was not promptly or thoroughly addressed, and the facility did not take adequate steps to ensure the safety of the residents following the reported abuse.
Failure to Report Alleged Abuse Incident to State Agency
Penalty
Summary
The facility failed to provide an incident report to the State Survey Agency regarding an alleged abuse incident involving a resident. On 12/30/24, a Certified Nurse Aide and another staff member witnessed a Registered Nurse yelling at and pushing a resident. This incident was reported to the Administrator, who serves as the Abuse Coordinator. However, the incident was not documented in the facility's incident log, and no investigation was observed by the reporter. The Administrator confirmed during an interview that she did not believe abuse had occurred and therefore did not report the incident to the State Agency, resulting in the alleged abuser remaining on the unit and the incident not being formally investigated or reported.
Failure to Thoroughly Investigate Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident and a Registered Nurse (RN). According to the report, a Certified Nurse Aide and another staff member witnessed the RN yelling at and pushing the resident. The incident was reported to the Administrator, who is also the Abuse Coordinator. The Administrator reviewed video footage and obtained written statements from involved staff but did not remove the accused RN from the unit or conduct a comprehensive investigation beyond these steps. The Administrator did not formally document the investigation process at the time of the incident and did not notify the resident's family of the allegation. The facility's Abuse Prevention and Prohibition Program requires prompt and thorough investigations of abuse allegations, protection of residents during investigations, and reassignment or suspension of accused staff until the investigation is complete. However, the Administrator did not follow these procedures, as the accused RN continued working in the unit and the investigation was limited to a video review and informal statements. The lack of a formal written report and failure to notify the family were also noted as deficiencies.
Failure to Supervise High Fall Risk Resident and Prevent Accident Hazards
Penalty
Summary
The facility failed to ensure an environment free from accident hazards and did not provide adequate supervision for a resident identified as a high fall risk who required ambulatory assistance devices. The resident, admitted with a right femur fracture and cognitive communication deficits, was documented as chair-bound, unable to stand, and dependent on a wheelchair. Despite these needs, the resident experienced a fall while transferring from bed to chair. Subsequent observations and video footage revealed that the resident was able to ambulate unassisted in the locked unit while the assigned nurse was inattentive and did not intervene or redirect the resident, even as the resident moved out of camera range and attempted to use her wheelchair independently. Further review showed that the nurse was observed sitting on a couch with her hand over her face and did not notice the resident's movements or provide necessary supervision. Staff interviews confirmed concerns about the nurse's lack of attentiveness, with one staff member reporting the nurse appeared to be asleep while the resident was standing unsupported against a wall. The resident's care plan identified her as high risk for falls due to generalized weakness, yet the required supervision and assistance were not provided, resulting in the resident being left unsupervised and at risk for further accidents.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
Surveyors observed that a medication cart on the locked unit was left unlocked and unattended by staff during the initial walkthrough. This was directly confirmed during an interview with a registered nurse, who acknowledged that the medication cart should not be left in such a state. The report documents that the facility failed to ensure that medication carts were locked when unattended, as required by professional standards for the storage of drugs and biologicals.
Facility Fails to Maintain Comfortable Shower Water Temperatures
Penalty
Summary
The facility failed to maintain a comfortable water temperature in the resident shower rooms, affecting all 63 residents. The issue was first reported in the resident council minutes on 10/15/24, where a resident complained about cold showers. Despite this, the problem persisted, as evidenced by multiple observations and interviews conducted on 12/04/24 and 12/05/24. During these observations, the Maintenance Director measured water temperatures in various shower rooms, finding them to be consistently below comfortable levels, ranging from 90.0 to 96.6 degrees Fahrenheit. The Maintenance Director acknowledged the water was cold and stated that the facility had been experiencing issues with the hot water heater since September 2024. Interviews with residents and staff further highlighted the impact of the deficient water temperatures. Residents expressed dissatisfaction, with some refusing showers due to the cold water, while others reported not having showers for days. Staff, including a CNA, confirmed the ongoing issue, noting that they had to let the water run for extended periods without success in reaching a warm temperature. The Maintenance Director admitted to manually adjusting the water temperature during his working hours, but this left the facility without hot water in the evenings and weekends. The Administrator acknowledged the problem, citing a broken hot water heater as the cause of the temperature control issues.
Failure to Provide Nourishing Bedtime Snacks
Penalty
Summary
The facility failed to provide a nourishing bedtime snack to residents, resulting in more than 14 hours between the evening meal and breakfast for eight residents reviewed for snacks. Dinner was served at 5:00 PM, and breakfast at 8:00 AM, creating a 15-hour gap between meals. During an interview with the Resident Council, residents expressed that they were not provided with a bedtime snack and that they would like to have snacks at bedtime as they used to receive them before. The Dietary Supervisor mentioned that snacks were left in the nourishment room for residents who asked, but it was unclear if nursing staff informed residents about the availability of snacks. The Registered Dietitian confirmed that an evening snack should be provided by dietary staff.
Sanitation and Food Temperature Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen and food storage areas, as observed on multiple occasions. Food items were found unsealed, unlabeled, and undated, including packages of mashed potatoes, carrots, shredded cheese, green beans, ice cream cups, and bins of flour and sugar. The kitchen itself was not clean, with dried food on the stove, soiled steam table water wells, and a dirty plate warmer. Additionally, a trash can was left uncovered when not in use. These conditions were confirmed by the Dietary Manager, who acknowledged that the kitchen should be cleaner and that food items should be properly labeled and sealed. Residents reported that their food was often not served at the correct temperature, with several stating that their meals were cold upon arrival. Observations confirmed that food temperatures were not maintained within safe ranges, with hot foods like fried eggs and oatmeal measuring below the recommended 120 F, and cold foods like fruit cups above the recommended 40 F. Despite these findings, the Dietary Manager stated that the temperatures were acceptable and intended to serve the food to residents. This practice of serving food at improper temperatures could potentially lead to foodborne illnesses among the residents.
Deficient Call Light System in Facility
Penalty
Summary
The facility failed to maintain a functioning call light system, which is essential for residents to request assistance. Observations and interviews revealed that the call light system's audible alerts were not operational for several weeks, affecting the ability of staff to respond promptly to residents' needs. The issue was first noted in Resident Council meeting minutes from October and November, where residents expressed concerns about delayed call light response times. Despite these concerns, the problem persisted, as evidenced by multiple observations where call lights in various rooms were activated but did not alert staff at the nurses' station. Interviews with staff, including a CNA, an LPN, and the MDS Coordinator, confirmed that the audible alerts were not functioning, and staff were unaware of activated call lights unless they were physically in the hallway to see the lights above the room doors. The Regional Nurse Consultant acknowledged that the call lights should be fully functional, including the audible alerts, but was unaware of the ongoing issue. This deficiency likely affected all 63 residents in the facility, as they were unable to reliably communicate their needs to the staff.
Failure to Notify POA and Providers of Resident's Condition
Penalty
Summary
The facility failed to notify the resident's Power of Attorney (POA), facility providers, and the Director of Nursing (DON) when a resident experienced nausea and abdominal pain over several days. The resident, identified as R #12, reported nausea to the nursing staff, who administered Pepto-Bismol and later Zofran, but the symptoms persisted. Despite the resident's refusal of pain and blood pressure medications due to nausea, and a call from the resident's daughter/POA expressing concern over the resident's lack of food intake, the facility did not notify the necessary parties. The resident eventually insisted on being sent to the emergency room, where she was diagnosed with gall stones. Interviews with staff and the resident's POA revealed that the facility did not inform the POA, Nurse Practitioner, Registered Dietitian, or DON about the resident's ongoing symptoms or the subsequent diagnosis. The lack of communication prevented these parties from making informed decisions regarding the resident's care and potential changes to her treatment plan or diet. The Regional Nurse Consultant confirmed that the staff should have notified the facility providers and DON of the resident's condition and diagnosis to potentially adjust the care plan.
Care Plan Revision Deficiencies for Three Residents
Penalty
Summary
The facility failed to ensure that care plans were revised for three residents, leading to deficiencies in addressing their care needs. For one resident, a quarterly care plan meeting was not conducted as required, with the last meeting having occurred several months prior. The Social Services Director was unavailable due to jury duty, and the care plan team did not hold the meeting in her absence. This resulted in the resident not having a care plan meeting for an extended period, as confirmed by both the resident and the Social Services Director. Another resident's care plan was not updated to reflect a new diagnosis of gall stones after returning from the emergency room. The Regional Nurse Consultant acknowledged that the care plan should have been updated to include this diagnosis. Additionally, a third resident's care plan did not include instructions to keep the bed in a high position to prevent sleeping during the day, despite this being a practice observed by staff and approved by the resident's son. The Minimum Data Set Coordinator confirmed that the care plan should have included this detail, but it was not documented.
Failure to Monitor and Intervene for Resident's Prolonged Illness
Penalty
Summary
The facility failed to monitor and provide appropriate interventions for a resident experiencing prolonged nausea, vomiting, and abdominal pain. Despite the resident's repeated complaints and requests to be sent to the emergency room (ER), the staff did not take timely action. The resident was eventually sent to the ER after several days of symptoms, where she was diagnosed with gallstones. The facility's records showed that the resident did not have active orders for the medications administered, and there was no documentation in the Medication Administration Record (MAR) for the medications given. Interviews with staff and the resident's Power of Attorney (POA) revealed that the facility did not notify the nurse practitioner of the resident's condition or the subsequent diagnosis of gallstones. The staff also failed to document progress notes for one of the days the resident was ill. The lack of communication and documentation contributed to the delay in providing the necessary medical intervention for the resident's condition.
Physician Inaction on Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that physicians reviewed and responded to the pharmacist's monthly drug regimen recommendations for five residents. The pharmacist had identified several issues, including fall risks associated with certain medications, potential kidney damage due to inappropriate dosing, and the need for gradual dose reductions of psychotropic medications. Despite these recommendations being documented, there was no evidence that the physicians reviewed or considered them, as none of the recommendations were signed or acknowledged. For instance, one resident had multiple falls, and the pharmacist recommended reviewing medications like gabapentin and quetiapine, which increase fall risk. Another resident with kidney disease was prescribed medications at doses that could exacerbate their condition, yet the recommendations to adjust these doses were not addressed. Additionally, recommendations for gradual dose reductions of medications like amitriptyline and carbamazepine were ignored, leaving residents potentially overmedicated. The lack of physician response to these recommendations indicates a significant oversight in the medication management process at the facility.
Failure to Dispose of Discontinued Controlled Substance
Penalty
Summary
The facility failed to properly dispose of a controlled substance, Ativan, that was discontinued for a resident. The resident had multiple prescriptions for Ativan, with the most recent being discontinued on November 6, 2024. Despite the discontinuation, three bubble pack cards containing a total of 73 doses of Ativan were found in the locked, controlled substance drawer of the medication cart in the Dementia Unit. These cards were labeled as prescribed for the resident, indicating that the medication was not removed from the cart as required after being discontinued. During an observation on December 3, 2024, an LPN confirmed that the Ativan was discontinued and acknowledged that the medication should have been removed from the cart immediately following the discontinuation. The presence of the discontinued medication in the cart suggests a lapse in the facility's medication management and disposal procedures, which could lead to mishandling or theft of the controlled substance.
Inconsistent Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that a resident's current advance directive was accurately reflected in their Electronic Health Record (EHR). The resident, identified as R #11, had conflicting information regarding their advance directive status. The face sheet in the EHR indicated that the resident was listed as Do Not Attempt Resuscitation (DNR), while the Medical Orders For Scope of Treatment (MOST) forms showed discrepancies. One form indicated a DNR status, while another form indicated a full code status, which involves attempting cardiopulmonary resuscitation (CPR). During an interview, the Minimum Data Set Coordinator (MDSC) confirmed that the resident's advance directives did not match the EHR and acknowledged the presence of both DNR and full code directives in the resident code status book at the nurses' station. The MDSC verified with the resident that they wished to remain a full code, CPR. This inconsistency in documentation is likely to cause confusion and delay potentially life-saving procedures.
Delay in Psychiatric Services for Resident
Penalty
Summary
The facility failed to ensure that a resident received necessary behavioral health care and services, specifically in the area of psychiatric care. The resident, who was admitted with severe dementia with agitation, depression, and dementia with behavioral disturbance, was referred to a psychiatric provider on 10/23/24. However, there was a significant delay in the resident receiving psychiatric services, as the initial evaluation by a psychiatric provider did not occur until 12/06/24, 44 days after the referral. This delay was due to ineffective communication and follow-up between the facility and the psychiatric provider. The Social Services Director acknowledged that the referral was made and expected the resident to be seen within a week, but the facility did not follow up on the referral. Additionally, the psychiatric services owner reported that the delay was partly due to the facility not providing access to the resident's Electronic Health Record (EHR). The Regional Nurse Consultant confirmed that the resident should have been seen sooner and that the psychiatric provider should have had timely access to the EHR. These lapses in communication and coordination resulted in the resident not receiving timely psychiatric care.
Inaccurate Smoking Assessment in Resident's Medical Record
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, specifically regarding their smoking assessment. The resident was admitted to the facility and initially assessed as a safe smoker requiring minimal supervision. However, a subsequent assessment inaccurately documented that the resident did not smoke. Despite this, the resident's care plan, last reviewed in December, indicated that the resident was a safe smoker who could smoke independently. Interviews with the resident and a Licensed Practical Nurse confirmed that the resident was indeed a smoker. The Regional Nurse Consultant acknowledged that the most recent smoking assessment was inaccurate and should have reflected the resident's smoking status.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, specifically regarding medication administration. The resident, who was admitted with multiple diagnoses including low back pain, chronic pain syndrome, and intervertebral disc degeneration, had a provider order for Pregabalin to be administered three times daily for pain management. However, the medication was not administered on four scheduled occasions due to pending delivery from the pharmacy. The resident's daily care notes indicated that the medication was not available for administration on multiple occasions, leading to unmanaged pain. This resulted in the resident calling 911 for pain relief and being transported to the hospital. The Director of Nursing confirmed that the medication was not administered as required by the provider's orders, acknowledging the lapse in medication administration for the resident.
Failure to Honor Resident's Shower Preferences
Penalty
Summary
The facility failed to ensure that a resident was bathed according to her preferences, which is a violation of her right to self-determination and choice. The resident's daughter reported that her mother rarely received showers and often had greasy hair, despite being able to make choices about her care and not refusing showers when offered. The resident was scheduled to have showers on Wednesdays and Saturdays, but a review of the shower sheets and documentation survey reports from March 20 to April 17 revealed that she only received one shower out of nine opportunities. The Director of Nursing confirmed that staff were supposed to document showers on paper shower sheets, and the absence of such documentation indicated that the resident did not receive a shower.
Failure to Monitor Medication Side Effects
Penalty
Summary
The facility failed to adequately monitor a resident for side effects of medications, leading to the administration of unnecessary drugs. The resident, who was admitted for skilled services with a primary diagnosis of metabolic encephalopathy and had a severe impairment in mental status, was dependent on staff for toileting and transfers. The resident's medication orders included senna and bisacodyl for constipation and loperamide for diarrhea. Despite the resident experiencing multiple instances of diarrhea, staff continued to administer senna and bisacodyl daily without documenting any instances of constipation. Interviews with the resident's daughter and a CNA revealed that the resident had ongoing diarrhea, which was reported to the nursing staff. The Director of Nursing acknowledged that the staff should not have administered stool softeners on days when the resident had diarrhea and had been given loperamide. This oversight in monitoring and medication administration resulted in the resident receiving unnecessary medications, potentially leading to adverse outcomes.
Failure to Implement Fall Precautions
Penalty
Summary
The facility failed to meet professional standards of quality for a resident when staff did not implement the resident's care plan for fall precautions. The resident, who was admitted with diagnoses including senile degeneration of the brain, muscle weakness, muscle wasting, Type II diabetes, hypertension, and respiratory failure, had a history of falls. The care plan included specific fall prevention measures such as using a fall mat, locking wheelchair brakes, ensuring the resident wore non-skid socks, and positioning the bed in the lowest position. However, during an observation, the resident was found without non-skid socks, the call light was out of reach, the water was out of reach, there was no fall mat, the bed was not in the lowest position, and the wheelchair brakes were not locked. Interviews with staff revealed a lack of adherence to the care plan. An LPN confirmed the resident was not wearing non-skid socks and that the wheelchair brakes were not locked. The Director of Nursing stated that fall prevention measures should be implemented at all times if they are part of a resident's care plan. The failure to follow the care plan for fall precautions was evident and contributed to the deficiency noted in the report.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for a resident, specifically in the areas of bathing and personal hygiene. On 03/18/24, the resident was observed lying in bed with a soiled brief, disheveled hair, and long fingernails with heavy debris. The resident's shower schedule indicated showers were to be given on Saturdays and Wednesdays, but records showed the last documented shower was on 03/13/24. Interviews with an LPN confirmed the resident's unclean condition and the lack of documentation for showers since the specified date.
Failure to Follow Infection Prevention Protocols
Penalty
Summary
The facility staff failed to follow proper infection prevention protocols when they did not ensure staff utilized personal protective equipment (PPE) upon entering the room of a resident confirmed positive for COVID-19. During an observation, the Administrator and the Regional Administrative Officer entered the resident's room without donning PPE, despite the presence of a PPE container indicating the need for such precautions. Interviews with RN #1 and the Director of Nursing confirmed that PPE should have been worn before entering the room. The Administrator acknowledged the oversight, stating they were unaware of the precautionary status until after exiting the room.
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.
