Average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lovington Healthcare Llc during CMS and state inspections, most recent first.
The facility did not post up-to-date nurse staffing information at the start of the shift, as required. The posted data was from the previous day and did not include current details such as the facility name, date, staffing hours for RNs, LPNs, CNAs, or the resident census. This was confirmed by the MDS Coordinator and had the potential to affect all residents in the facility.
A medication cart near the 300 hall was found unlocked and unattended, as confirmed by a facility scheduler who stated it should always be locked when not attended. This lapse had the potential to impact all 17 residents on the 300 hall.
Surveyors observed multiple large boxes, packaging materials, and a toilet obstructing the hallway in the 300 hall, impeding resident access. A staff member confirmed that these items were blocking the path and acknowledged that hallways should remain clear for resident movement.
Staff failed to follow safe food handling practices, including improper handling of cups by touching the rim, failure to label and date a drink pitcher in the refrigerator, and not properly wearing hairnets in the kitchen. These deficiencies in food preparation and service under sanitary conditions were confirmed by supervisory staff and could affect all residents in the facility.
Surveyors found that staff did not update care plans for five residents to accurately reflect current interventions, such as the use or discontinuation of mobility bars, positioning rails, pain management, and psychotropic medications. In each case, care plans either omitted new interventions or continued to list interventions that were no longer in use, despite supporting documentation and staff confirmation that updates were needed.
Surveyors observed that mechanical lifts, a housekeeping cart, and a medication cart were left on both sides of a hallway, blocking the path for residents. A receptionist confirmed that these items were not properly stored, resulting in an obstructed hallway.
A resident with documented diagnoses of major depressive disorder, PTSD, and schizoaffective disorder was admitted, but staff incorrectly completed the PASRR assessment by indicating no mental illness. The Interim DON confirmed the error during an interview.
A resident with multiple respiratory conditions was receiving oxygen therapy without a comprehensive, person-centered care plan or a physician order. The care plan lacked details on baseline vital signs, frequency, and indication for oxygen use, and staff confirmed these omissions during interviews.
A resident with multiple respiratory diagnoses was observed receiving oxygen therapy via nasal cannula, confirmed by staff, without a corresponding physician order documented in the electronic health record.
Two residents requiring oxygen therapy were observed with undated and unbagged oxygen tubing and cannulas, with some equipment found on the floor or on wheelchairs. The MDS Coordinator confirmed that oxygen supplies were not changed weekly as ordered and were not properly stored, contrary to facility expectations.
A resident with significant mobility and communication impairments was not provided with an accessible or usable call light. The call light was found on the floor and, when in hand, the resident was unable to activate it due to physical limitations. Staff confirmed the standard call light was not appropriate for the resident's needs.
A facility failed to ensure privacy for a resident during personal care, as a nurse did not pull the privacy curtain closed while treating a Stage 3 pressure ulcer, leaving the resident exposed to his roommate. The resident's daughter noted that her father would feel embarrassed by such exposure, and the facility's Administrator confirmed that privacy curtains should be used to maintain resident privacy.
A resident with a history of stroke and muscle weakness was not repositioned according to her care plan, which required repositioning every two hours to prevent skin issues. Observations showed the resident was not moved as scheduled, and staff interviews revealed confusion about the repositioning clock and documentation responsibilities.
The facility failed to accurately document tube feeding and hydration for two residents, leading to potential confusion about the care provided. One resident with stroke and dysphagia had significant lapses in documentation of Jevity and hydration flushes, while another resident with acute respiratory failure and gastrostomy status had discrepancies in the documentation of Glucerna and water flushes. Interviews confirmed that these procedures should have been documented each time they were performed.
A resident who was admitted after brain surgery did not receive prescribed hydrocodone-acetaminophen for pain management, despite severe pain levels documented. The facility staff failed to administer the medication due to its unavailability, leading the resident and his wife to leave against medical advice. Interviews revealed that the medication was available in the facility's dispensing cabinet but was not used.
The facility failed to update staffing sheets at the beginning of each shift, resulting in outdated and unclear information being posted. This issue persisted over several days, contrary to the facility's policy. The DON and Administrator confirmed the requirement for daily updates.
The facility failed to ensure that opened insulin flex pens and prefilled syringes were properly dated when initially opened by nursing staff. Additionally, expired supplies were not kept separate from unexpired supplies, as observed in the 100-medication cart. An LPN and the Director of Nursing confirmed these deficiencies.
The facility failed to monitor and maintain the internal temperature of food at safe levels, with pork chops served at 129°F instead of the required 135°F. This deficiency could affect all 56 residents consuming food from the kitchen.
The facility failed to maintain proper infection prevention measures during medication administration and the use of medical equipment. Staff did not sanitize their hands before or after administering medications to three residents and did not sanitize the blood pressure cuff after using it on five residents. Additionally, an oxygen cannula was found on the floor and subsequently placed into a resident's nose without being replaced or sanitized.
The facility failed to ensure kitchen equipment was in safe operating condition. One section of the steam table was non-functional, with the water in the steam well cool to the touch and no steam present. A pan of pork chops placed in the well measured 129 degrees Fahrenheit. The Dietary Director confirmed the issue.
The facility failed to ensure that a resident, their representative, and the Ombudsman received a written notice of transfer as soon as practicable. The resident had an unplanned discharge to a hospital, and the DON confirmed there was no documentation of Ombudsman notification.
The facility failed to maintain records of controlled substances on each medication cart, as staff did not sign the narcotic book to show they counted the medication blister pill cards and compared them to the residents' medication sheets. A CMA and the DON confirmed the missing signatures and the requirement for staff to sign the narcotic book at the beginning and end of each shift.
The facility failed to monitor and document side effects of medications for two residents, including anticoagulants and insulin, as confirmed by the DON. This lack of monitoring occurred in both February and March 2024, potentially leading to adverse outcomes.
The facility failed to ensure the MDS was accurate for two residents. One resident's MDS incorrectly indicated the use of an anticoagulant, while another resident's MDS did not reflect a diagnosed psychotic disorder. The MDS Coordinator confirmed these errors during interviews.
The facility failed to develop and implement a comprehensive care plan within 21 days of readmission for a resident. The care plan had all items marked as resolved or cancelled, and the MDS Coordinator was unaware of the reason, confirming that the items should still be effective.
The facility failed to update a resident's diagnosis for the use of a medication and did not follow the physician's order regarding liquid consistencies for another resident. The discrepancies were confirmed by the DON and observed during a dining room incident.
A resident reported missing top dentures and was observed with several missing teeth. Despite a care plan indicating the need for dentures and a dental note recommending a follow-up appointment, the resident did not receive the necessary dental services.
A resident with dysphagia was not provided with properly thickened liquids, leading to difficulty swallowing and coughing. The resident's medical record, care plan, and physician orders lacked necessary information, and the care plan was not coordinated with the meal ticket.
The facility failed to ensure staff offered COVID-19 vaccinations to three residents. One resident's EHR did not show the vaccine offer, and the DON could not provide declination documentation. Another resident received the first dose but not the second, and a third resident had no documentation of subsequent vaccine offers after the initial dose.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information at the beginning of each shift as required. During an observation at the main entrance, the posted nurse staffing data was found to be outdated, displaying information from the previous day rather than the current date. The required posting should have included the facility name, current date, total number and actual hours worked by registered nurses, LPNs, certified nurse aides, and the resident census for each shift. This deficiency was confirmed during an interview with the MDS Coordinator, who acknowledged that the staffing data had not been posted for the current day. The issue had the potential to affect all 58 residents in the facility, as identified by the administrator's census.
Unattended Unlocked Medication Cart
Penalty
Summary
A medication cart located near the 300 hall was observed to be unlocked and unattended during a facility observation. This incident was confirmed by the facility scheduler, who acknowledged that the medication cart should be locked at all times when not attended. The unlocked cart had the potential to affect all 17 residents residing on the 300 hall, as identified by the facility census provided by the Administrator.
Obstructed Hallway Due to Improper Storage of Boxes and Equipment
Penalty
Summary
The facility failed to ensure that the hallway in the 300 hall was accessible for residents, as observed during a random inspection. On the specified date and time, three large boxes, including one with a picture of a toilet, were found piled on top of each other along with other pieces of cardboard and packaging material protruding from the top and sides, obstructing the hallway near a resident room. Additionally, a large box with a picture of a toilet and a toilet itself were found on the floor in the hallway near other resident rooms. During an interview, a facility payroll staff member confirmed that objects were present on both sides of the hallway, blocking the path for residents, and stated that items should be kept on one side to maintain a clear passage.
Deficient Food Handling and Sanitation Practices in Kitchen and Dining Areas
Penalty
Summary
Staff failed to follow safe food handling practices, as evidenced by transportation personnel serving residents cups by touching the rim with bare hands. This was confirmed by the MDS Coordinator, who stated that the expectation is for staff to handle cups by the sides and avoid touching the rim. Additionally, a drink pitcher containing a brown liquid was found in the main refrigerator without a label indicating its contents or preparation date. The Dietary Aide admitted to forgetting to place the label on the pitcher before returning it to the refrigerator, despite having the label in her pocket. Further observations revealed that a dishwasher was not properly wearing a hairnet, with hair hanging out and not fully covered. This was observed on two separate occasions and confirmed by both the dishwasher and the Dietary Supervisor, who stated that all staff are expected to properly wear hairnets while in the kitchen or serving food. These practices were identified as deficiencies in food preparation and service under sanitary conditions, potentially affecting all 59 residents in the facility.
Failure to Revise Care Plans to Reflect Current Resident Needs and Interventions
Penalty
Summary
The facility failed to ensure that care plans were revised in a timely and accurate manner for five residents, as required by regulations. For one resident, although a safety device evaluation, physician order, and consent for bed mobility bars were completed, the care plan was not updated to reflect the use of these devices, despite their presence in the resident's room and the resident's stated use of them for positioning. Another resident had an order for positioning rails, and these were in use, but the care plan did not include any information about them. In both cases, the Interim Director of Nursing (IDON) confirmed that the care plans should have been revised to include these devices. A third resident's care plan continued to reference repositioning bars, even though there was no assessment, order, or consent for their use, and the bars were not present in the resident's room. The resident confirmed that she no longer used the bars and was unsure when or why they were removed. The IDON acknowledged that the care plan was not updated to remove this intervention. Similarly, another resident's care plan included interventions for pain medication administration, but there were no orders for pain medication, no administration of such medication, and pain monitoring consistently indicated no pain. The IDON stated the care plan was initially created as a preventative measure but was not revised when it became clear the intervention was unnecessary. For the fifth resident, the care plan indicated the use of a psychotropic medication, but the medication had been discontinued and there were no current orders for it. The IDON confirmed that the care plan should have been updated to reflect the discontinuation. In all cases, the lack of timely care plan revisions meant that the documented plans of care did not accurately reflect the residents' current needs and interventions in place at the time of the survey.
Obstructed Hallways Due to Equipment and Carts
Penalty
Summary
The facility failed to ensure that the hallway in the 100 hall was accessible for residents, as observed on two separate occasions. On both days, mechanical lifts were found positioned on both the right and left sides of the hallway near various resident rooms, along with a housekeeping cart and a medication cart also placed on either side of the hallway. These items were observed to be blocking the residents' path. During an interview, the receptionist confirmed that objects were present on both sides of the hallway, obstructing the clear passage that should be maintained for residents.
Inaccurate PASRR Assessment for Mental Illness Diagnoses
Penalty
Summary
The facility failed to ensure the accuracy of the Pre-Admission Screening and Resident Review (PASRR) assessment for one resident. Record review showed that the resident was admitted with diagnoses of major depressive disorder, post-traumatic stress disorder (PTSD), and schizoaffective disorder, bipolar type. However, the PASRR completed for this resident indicated that there was no diagnosis or suspicion of mental illness. During an interview, the Interim Director of Nursing confirmed that the resident did have these mental health diagnoses and acknowledged that the PASRR documentation was incorrect.
Failure to Develop Comprehensive Care Plan for Oxygen Therapy
Penalty
Summary
Staff failed to develop a comprehensive care plan for a resident who was admitted with multiple respiratory diagnoses, including Chronic Obstructive Pulmonary Disease (COPD) with acute exacerbation, pleural effusion, acute and chronic respiratory failure with hypoxia, and an anxiety disorder. The care plan in place noted the use of oxygen therapy related to COPD and respiratory therapy, and included an intervention to monitor for signs and symptoms of respiratory distress and report to the provider as needed. However, the care plan lacked person-centered interventions, did not specify baseline vital signs, and did not describe the oxygen therapy in terms of frequency or indication for use. Observation confirmed that the resident was using an oxygen concentrator with a nasal cannula in her room. Review of the electronic health record revealed there was no physician order for the use of oxygen. Staff interviews confirmed the resident was receiving oxygen therapy and that the care plan did not meet expectations for person-centered interventions related to oxygen therapy.
Failure to Obtain Physician Order for Oxygen Therapy
Penalty
Summary
A resident with a history of chronic obstructive pulmonary disease with acute exacerbation, pleural effusion, acute and chronic respiratory failure with hypoxia, and anxiety disorder was observed using an oxygen concentrator with a nasal cannula in her room. Staff, including a Certified Medication Aid and the Interim Director of Nursing, confirmed that the resident was receiving oxygen therapy. However, a review of the resident's electronic health record revealed there was no physician order for the use of oxygen. The Interim Director of Nursing acknowledged that the resident should have had an order for oxygen use, but none was present at the time of the survey.
Failure to Maintain Infection Control for Oxygen Equipment
Penalty
Summary
The facility failed to maintain proper infection prevention and control measures for two residents who required oxygen therapy. For one resident with COPD, anxiety disorder, and anemia, observations revealed that the oxygen tubing and cannula in use were not dated, and the tubing on both the concentrator and portable oxygen were missing date and time labels. During a meal observation, this resident was seen wearing oxygen with tubing and cannula that were not dated or stored in a bag. Another resident with cerebral palsy, diabetes mellitus, seizure disorder, and acute respiratory failure with hypoxia was also found to have deficiencies in oxygen equipment management. The oxygen tubing connected to the concentrator in the resident's room was observed on the floor and, although dated, was not stored in a bag. During a meal observation, this resident was also seen wearing oxygen with tubing and cannula that were not dated or bagged. The MDS Coordinator confirmed these findings and stated that the expectation is for all tubing and cannulas to be changed weekly as ordered and kept in bags, not on the floor or on wheelchairs.
Failure to Provide Accessible Call Light for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident with a history of stroke, hemiplegia, hemiparesis, generalized muscle weakness, and speech disturbance was not provided with reasonable accommodation for their needs and preferences. The resident was totally dependent on staff for activities of daily living, including the use of the call bell for assistance. During observation, the call light was found on the floor behind the bed, out of the resident's reach, and the resident was unable to use the standard push button call light due to impaired mobility. The resident attempted multiple times to press the call light button but was unsuccessful. Interviews with staff, including Social Services and the Director of Nursing, confirmed that the push button call light was difficult for the resident to use and that a soft touch call light would be more appropriate given the resident's physical limitations. The failure to provide an accessible and usable call light for the resident resulted in the resident being unable to request assistance as needed.
Failure to Ensure Privacy During Personal Care
Penalty
Summary
The facility failed to ensure privacy during personal care for a resident, identified as R #1, who was being treated for a Stage 3 pressure ulcer on his right buttock. During a wound care observation, Registered Nurse (RN) #1 entered R #1's room, closed the door, but did not pull the privacy curtain closed, leaving R #1 exposed to his roommate who was present in the room. This oversight occurred despite the resident's care plan and the expectation set by the facility's Administrator that privacy curtains should be used to ensure resident privacy during personal care, especially when a roommate is present. R #1's daughter expressed that her father, being a proud man, would feel embarrassed by such exposure.
Failure to Reposition Resident as Per Care Plan
Penalty
Summary
The facility failed to meet professional standards of quality care for a resident by not adhering to the prescribed repositioning schedule outlined in the care plan. The resident, who was admitted with diagnoses including stroke, muscle weakness, and dysphagia, had a care plan that required repositioning every two hours to prevent skin integrity issues. Observations revealed that the resident was not repositioned according to the schedule indicated by the repositioning clock in her room. Specifically, the resident was observed lying on her back when she should have been repositioned to her left or right side as per the clock's instructions. Interviews with staff, including an LPN, CNA, and the ADON, indicated a lack of understanding and communication regarding the repositioning schedule. The LPN admitted to not knowing how to read the repositioning clock, while the CNA acknowledged that the resident had not been repositioned as required. The ADON and RNC confirmed that the staff were expected to follow the repositioning clock and document each repositioning event, although documentation was not consistently maintained. This lack of adherence to the care plan and documentation requirements led to the deficiency identified by the surveyors.
Inaccurate Documentation of Tube Feeding and Hydration
Penalty
Summary
The facility failed to ensure accurate documentation of medical records for two residents, leading to potential confusion regarding the services and treatments provided. For the first resident, who was admitted with diagnoses including stroke, muscle weakness, and dysphagia, there were significant lapses in documenting the administration of enteral feeding and hydration flushes. Despite physician orders specifying the administration of Jevity 1.5 and hydration flushes via a PEG tube, the Nurse Administration Record (NAR) showed that staff documented the administration of Jevity only three times out of 60 opportunities in April and 12 times out of 32 opportunities in May. Similarly, hydration flushes were documented only five times out of 150 opportunities in April and 25 times out of 80 opportunities in May. Interviews with nursing staff confirmed that these procedures should have been documented each time they were performed. For the second resident, who was admitted with acute respiratory failure with hypoxia, gastrostomy status, and dysphagia, there were also discrepancies in documentation. The physician orders required the administration of Glucerna 1.5 and water flushes multiple times a day. However, the Medication Administration Record (MAR) indicated that Glucerna was documented 71 times out of 80 opportunities, and water flushes were documented only 36 times out of 96 opportunities. The Regional Nurse Consultant confirmed that the staff failed to document the tube feeding and hydration as required, which could lead to confusion about the care provided to the resident.
Failure to Administer Prescribed Pain Medication
Penalty
Summary
The facility failed to effectively manage pain for a resident who was admitted from the hospital following brain surgery. The resident was prescribed hydrocodone-acetaminophen for pain management, as indicated in the hospital discharge orders and the facility's physician orders. However, the staff did not administer the prescribed pain medication, resulting in the resident experiencing severe pain, as documented in the pain evaluation form. The resident's pain level was recorded as 9 out of 10, indicating very severe pain, yet the Treatment Administration Record showed that the medication was not given. The resident and his wife expressed their dissatisfaction with the lack of pain management, leading them to leave the facility against medical advice. Interviews with the Licensed Vocational Nurse and the Regional Nurse Consultant revealed that the facility did not have the hydrocodone readily available, although it was present in the facility's medication dispensing cabinet. The staff's failure to administer the prescribed pain medication as ordered contributed to the resident's prolonged pain and subsequent decision to leave the facility.
Failure to Update Staffing Sheets Timely
Penalty
Summary
The facility failed to update the staffing sheets at the beginning of each shift or in a timely manner to reflect the staff working that day. On multiple occasions, the posted staffing sheets were not updated to show the current staff, including the evening shift. Specifically, on 03/25/24, the staffing sheet was not in a clear and readable format and was not updated for the evening shift. This issue persisted on 03/26/24 and 03/27/24, where the sheets were not updated to reflect the current date. The facility's policy requires the posting of staffing information daily at the beginning of each shift, but this was not adhered to. During an interview, the DON and the Administrator confirmed that the staffing sheets should be completed and posted daily at the beginning of each shift.
Failure to Properly Date Insulin Pens and Separate Expired Supplies
Penalty
Summary
The facility failed to ensure that opened insulin flex pens and prefilled syringes were properly dated when initially opened by nursing staff. During an observation of medication cart 100, it was found that a Basagler flex pen and an Ozempic prefilled syringe did not have open dates written on them. Both medications were in use, and this was confirmed by an LPN and the Director of Nursing, who acknowledged that staff should have written the dates on all insulin pens. Additionally, the facility did not ensure that expired supplies were kept separate from unexpired supplies. An observation of the 100-medication cart revealed two open bottles of Assure Dose glucose control tests that did not have open dates written on them. These tests expire within 90 days of opening. An LPN confirmed that staff should have dated the two open bottles of Assure Dose with an open date.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to store and serve food under sanitary conditions in accordance with professional standards of food service safety. Specifically, staff did not monitor the internal temperature of food to ensure it was safe for consumption. During an observation of the lunch meal trays, the dietary aide recorded the temperature of the pork chops at 129 degrees Fahrenheit, which is below the FDA Food Code requirement of 135 degrees Fahrenheit for hot foods. The Dietary Director confirmed that the food temperatures were not at an acceptable level. This deficiency could potentially affect all 56 residents who consume food prepared in the facility's kitchen.
Infection Control Deficiencies in Hand Hygiene and Equipment Sanitization
Penalty
Summary
The facility failed to maintain proper infection prevention measures during medication administration and the use of medical equipment. Specifically, staff did not sanitize their hands before or after administering medications to three residents. Additionally, staff did not sanitize the blood pressure cuff after using it on five residents. These actions were observed during medication administration rounds, where Licensed Practical Nurses (LPNs) were seen preparing and administering medications without following hand hygiene protocols and using the same blood pressure cuff on multiple residents without sanitizing it in between uses. The facility's Medication Administration policy and CDC guidelines were not adhered to, as confirmed by the Assistant Director of Nursing (ADON) during an interview. Furthermore, an oxygen cannula was found on the floor and subsequently placed into a resident's nose without being replaced or sanitized. This incident was observed when a Certified Nursing Assistant (CNA) picked up the cannula from the floor, placed it on another resident's bed, and then inserted it into the resident's nose. The LPN confirmed that the staff should have replaced the cannula with a new one after it had been on the floor and another person's bed. These deficiencies highlight significant lapses in infection control practices within the facility.
Non-Functional Kitchen Equipment
Penalty
Summary
The facility failed to ensure kitchen equipment was in safe operating condition. During an observation on 03/26/24 at 12:15 PM, one section of the steam table was found to be non-functional. The steam table light was off, the well dial was set to high, but the water in the steam well was cool to the touch, and there was no steam present. A pan of pork chops placed in the well measured 129 degrees Fahrenheit. On 03/25/24 at 1:30 PM, the Dietary Director confirmed the problems with the steam table.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to ensure that residents, resident representatives, and the Ombudsman received a written notice of transfer as soon as practicable. This deficiency was identified for one resident who was admitted to a hospital. The administration progress note and the Discharge Minimum Data Set (MDS) indicated that the resident had an unplanned discharge to a short-term general hospital. During an interview, the Director of Nursing (DON) confirmed that there was no documentation showing that the Ombudsman was notified of the resident's transfer from the facility.
Failure to Maintain Records of Controlled Substances
Penalty
Summary
The facility failed to maintain records of controlled substances on each medication cart, as observed on multiple occasions. Specifically, staff did not sign the narcotic book to show they counted the medication blister pill cards and compared them to the residents' medication sheets for numerous dates between 3/11/24 to 03/19/24. This was observed on the 200 medication cart on 03/24/24 at 4:05 pm. During an interview on 03/25/24 at 4:06 pm, a Certified Medication Aide (CMA) confirmed that there were missing signatures from the narcotic book. The CMA stated that they counted the narcotics at the beginning and end of each shift but failed to document this in the narcotic book. The Director of Nursing (DON) also confirmed during an interview on 03/25/24 at 4:45 pm that the nursing staff should sign the narcotic book when they come onto and go off each shift to ensure the narcotic count is correct before the oncoming shift nurse takes the keys for the narcotic box from the off-going shift nurse.
Failure to Monitor Medication Side Effects
Penalty
Summary
The facility failed to ensure they monitored for side effects of medication for two residents, leading to a deficiency in medication management. Resident #56 had a physician's order for clopidogrel bisulfate and enoxaparin sodium, but staff did not document monitoring for the anticoagulant in February and March 2024. Similarly, Resident #111 had physician's orders for enoxaparin sodium and insulin lispro, but staff failed to document monitoring for the anticoagulant and blood sugar levels in both February and March 2024. During an interview, the Director of Nursing confirmed that staff should monitor and document residents on insulin and anticoagulants. However, the DON acknowledged that staff did not document monitoring for Resident #111's anticoagulants, hyperglycemia, and hypoglycemia, nor did they monitor Resident #56 for the anticoagulant. This lack of documentation and monitoring could lead to adverse outcomes for the residents involved.
Inaccurate MDS Documentation for Two Residents
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurate for two residents. For the first resident, the quarterly MDS indicated the resident was taking an anticoagulant, but the Electronic Health Record (EHR) showed no physician's order for such medication since the resident's admission. The MDS Coordinator confirmed this was an error during an interview, acknowledging that the resident had not been prescribed an anticoagulant. For the second resident, the psychiatric physician notes indicated a diagnosis of schizoaffective disorder, and the care plan noted the use of psychotropic medication. However, the quarterly MDS did not reflect the resident's psychotic disorder. The MDS Coordinator stated she was unaware of the diagnosis and would typically consult with the physician to correct any inaccuracies. This oversight resulted in the MDS not accurately representing the resident's psychiatric condition.
Failure to Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to ensure a comprehensive care plan was developed and implemented within 21 days of readmission for a resident. Record review revealed that the care plan, dated 03/22/24, had all items marked as resolved or cancelled. During an interview on 03/29/24, the MDS Coordinator stated she did not know why the staff marked all items in the care plan as resolved or cancelled, and confirmed that all items should still be effective as they were still pertinent to the resident.
Failure to Update Diagnosis and Follow Liquid Consistency Orders
Penalty
Summary
The facility failed to provide services that meet professional standards when staff did not update the diagnosis for the use of a medication ordered for a resident and did not follow the physician's order regarding liquid consistencies for another resident. Specifically, a resident was admitted with a diagnosis of anxiety and had an order for alprazolam to be administered via PEG tube for insomnia and anxiety. However, the face sheet was not updated to include the diagnosis of insomnia, despite the medication being administered daily for both conditions. This discrepancy was confirmed during an interview with the Director of Nursing (DON) and the Minimum Data Set (MDS) Coordinator. Additionally, another resident had a diet order for mechanical soft texture and mildly thick consistency liquids. Despite this, the Administrator served the resident two cups of cranberry juice that were thin liquids, contrary to the physician's order. The DON confirmed that staff should have served thickened liquids and should have notified the physician for approval of any dietary changes, which was not done on that day.
Failure to Provide Necessary Dental Services
Penalty
Summary
The facility failed to ensure a resident received necessary dental services. During an interview, the resident stated her top dentures were missing and she had informed the facility's administrator, although she could not recall when. An observation confirmed the resident had several missing teeth and was not wearing dentures. The resident's care plan indicated she had upper and lower dentures and was at risk for difficulty chewing, malnutrition, and dehydration. A dental note from a few months prior indicated a follow-up appointment was needed for upper dentures, but the Social Services Director confirmed that the resident had not attended this follow-up appointment.
Failure to Provide Properly Thickened Liquids for Resident with Dysphagia
Penalty
Summary
The facility failed to ensure that a resident with dysphagia received food and drink prepared in a form designed to meet their individual needs. The resident had a diagnosis of dysphagia and required extremely thick, pudding-like drink consistency. However, during multiple observations, the resident was given drinks that were not properly thickened, leading to difficulty swallowing and coughing. The Occupational Therapy Director and Minimum Data Set Director had to intervene by adding thickener to the resident's drink after noticing the inconsistency. The resident's medical record, care plan, and physician orders did not include the necessary information regarding the required thickened liquids. The care plan and orders were not coordinated with the meal ticket, resulting in the resident receiving inappropriate drink consistency. This lack of coordination and documentation led to the resident experiencing difficulty swallowing and potential choking hazards during mealtimes.
Failure to Ensure COVID-19 Vaccination Offer and Documentation
Penalty
Summary
The facility failed to ensure staff offered COVID-19 vaccinations to three out of five residents reviewed for COVID-19 vaccines. For one resident, the Electronic Health Record (EHR) did not show that the staff offered the COVID-19 vaccination, and the Director of Nursing (DON) could not provide documentation of the resident's declination, despite the resident stating she did not decline the vaccine. Another resident received the first dose of the COVID-19 vaccine, but the EHR did not indicate that the second dose was administered, which the DON and Infection Preventionist (IP) confirmed. A third resident received a COVID-19 vaccine but there was no documentation to show that staff offered subsequent doses after the initial vaccination.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Lovington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| White Sands Healthcare | 16.3 mi | ★★★★★ | 14 | 2 |
| Desert Springs Health Care Llc | 20.3 mi | ★★★★★ | 12 | 0 |
| Shinnery Oaks Community | 31.9 mi | ★★★★★ | 2 | 0 |
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