Luna Wellness Rehabilitation Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Deming, New Mexico.
- Location
- 900 West Ash Street, Deming, New Mexico 88030
- CMS Provider Number
- 325079
- Inspections on file
- 21
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Luna Wellness Rehabilitation Llc during CMS and state inspections, most recent first.
Surveyors found that admission MDS assessments were not completed within the required 14-day timeframe for two residents. Record review showed that each resident’s admission MDS was finalized several weeks after admission, and an interview with the MDS Coordinator confirmed that staff did not complete these admission assessments on time.
Surveyors found that baseline care plans, which contain essential healthcare information needed upon admission, were not completed and finalized within 48 hours for two residents. Record reviews showed that each resident’s baseline care plan was dated shortly after admission but was not signed and locked until several days later, exceeding the required timeframe. In an interview, the MDS coordinator acknowledged that these baseline care plans were not completed within 48 hours and confirmed that the facility’s expectation is for baseline care plans to be completed within the first 48 hours of admission.
The facility failed to maintain adequate staffing levels, resulting in CNAs being responsible for large numbers of residents, including several requiring two-person assistance or Hoyer lift transfers, and reporting that they must rush through showers and ADL care while call lights remain unanswered for extended periods. The scheduler and administrator acknowledged staffing challenges, high turnover, and an inability to consistently schedule the desired number of CNAs per shift, including limited coverage on night shift. A resident who requires setup assistance with eating, dressing, and toilet hygiene reported having to wait for help because staff are busy. Another resident, who needs substantial assistance with transfers, was observed with an unanswered call light and ultimately transferred himself to his wheelchair after waiting, while his nurse and CNA were occupied with wound care and no other staff were present on the unit; the resident and his sister reported frequent waits of 30 minutes or more for assistance and difficulty locating staff.
A resident with a documented coccyx pressure ulcer did not receive required Braden Scale pressure injury risk assessments for over a year. Record review showed no Braden Scale had been completed since early in the prior year, despite facility policy requiring these assessments on admission/readmission, weekly for four weeks, and then quarterly or with any change in condition. During interview, the MDS coordinator confirmed that the assessment had not been done as required.
A resident with multiple chronic conditions and a history of falls was not accurately represented in the MDS assessment, as the assessment failed to document a fall with injury and the use of side rails for bed mobility, despite physician orders and care plan documentation.
Two residents with a history of falls had new interventions, such as fall mats and increased supervision, implemented by staff, but these changes were not documented in their care plans. Staff and leadership confirmed that care plans were not updated to reflect the most current fall prevention measures, despite facility expectations to do so.
The facility did not complete or document required safety assessments for bed rail use for two residents, including after a significant change in condition for one resident and prior to bed rail placement for another. Staff interviews revealed that bed rail consents were routinely obtained on admission, but safety assessments were not consistently performed or documented, and interdisciplinary team members confirmed these lapses.
A resident with a history of sexually inappropriate behavior was inadequately monitored, leading to multiple incidents of touching other residents without consent and making inappropriate comments. Despite having a care plan addressing these behaviors, interventions were removed prematurely, and staff failed to document or implement strategies to prevent further incidents. Several residents reported feeling unsafe, and staff were not adequately informed or instructed to monitor the resident's behavior.
The facility failed to report several allegations of abuse or neglect to the State Agency within the required timeframe. Incidents included inappropriate touching and comments by a resident, which were either not reported or delayed due to the administration's perception that they did not constitute abuse.
A facility failed to thoroughly investigate and implement preventive measures following multiple allegations of abuse involving a male resident. The incidents included inappropriate touching and comments towards female residents. The facility's documentation was inconsistent, lacking comprehensive witness statements and video evidence review. Staff were not consistently instructed to monitor the resident, and there was insufficient communication and documentation regarding actions taken to ensure resident safety.
The facility failed to update care plans for two residents, leading to deficiencies in addressing inappropriate behaviors and medical needs. One resident exhibited inappropriate behaviors, such as touching others without consent, which were not reflected in the care plan. Another resident's care plan lacked documentation of a fluid restriction order crucial for managing renal failure. Staff interviews revealed a lack of awareness and documentation regarding necessary monitoring and interventions.
A resident who alleged sexual abuse by a CNA did not receive timely mental health services, causing severe psycho-social distress. The facility delayed scheduling these services until the Ombudsman intervened, despite the resident's visible distress and emotional state.
A resident was sexually abused by a CNA while being assisted in the shower, causing severe emotional distress. The facility did not schedule behavioral health services for the resident until the Ombudsman intervened, despite the resident's visible distress and past trauma.
A facility failed to thoroughly investigate an abuse allegation and implement preventive measures after a resident reported that a CNA put his fingers inside her while assisting her in the shower. The investigation lacked detailed documentation and specific questioning of the CNA, and preventive actions were not promptly taken to ensure the resident's safety.
The facility failed to develop a comprehensive care plan for a resident, omitting essential details such as diagnosis, treatment/medications, and required assistance. The DON confirmed the care plan was incomplete and should have included the resident's specific needs.
Failure to Complete Timely Admission MDS Assessments
Penalty
Summary
The deficiency involves the facility’s failure to complete comprehensive Minimum Data Set (MDS) admission assessments within 14 calendar days of admission for two residents. Record review showed that one resident was admitted on an unspecified date, but the admission MDS assessment for this resident was not completed until 02/04/26. Another resident was also admitted on an unspecified date, and the admission MDS assessment for this resident was not completed until 01/28/26. During an interview on 03/12/26 at 1:55 PM, the MDS Coordinator confirmed that staff did not complete the admission MDS assessments for these two residents within the required 14-day timeframe. The report states that this deficient practice could likely result in residents’ needs not being met, and it was identified through record review of admission records and MDS assessments, as well as staff interview. No additional medical history or clinical condition details for the residents are provided in the report.
Failure to Complete Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The deficiency involves the facility’s failure to create accurate baseline care plans within 48 hours of admission for two of three residents reviewed. Record review showed that one resident was admitted on an unspecified date, but the baseline care plan, dated 01/18/26, was not signed and locked (finalized by all authors) until 01/21/26, which exceeded the 48-hour requirement. Another resident was also admitted on an unspecified date, and their baseline care plan, dated 02/26/26, was not signed and locked until 03/02/26. During an interview on 03/12/26 at 1:50 PM, the MDS coordinator confirmed that the baseline care plans for these two residents were not completed within 48 hours of admission and stated that the expectation was for baseline care plans to be completed within the first 48 hours of admission. This failure to timely finalize baseline care plans, which contain the minimum healthcare information necessary to properly care for residents upon admission, was identified by surveyors as a deficient practice that could likely result in residents not receiving appropriate care and may place them at risk of an adverse event or worsening of their condition after admission.
Insufficient Staffing Leading to Delayed Assistance With ADLs and Call Lights
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff on each shift to meet residents’ needs, resulting in delayed care and inadequate assistance with activities of daily living (ADLs). Multiple CNAs reported being assigned large caseloads, including several residents requiring two-person assistance or use of a Hoyer lift, and stated there were not enough CNAs scheduled. CNAs described having to wait for help from other units, rushing through showers and ADL care, and leaving call lights unanswered for up to 30 minutes while they were occupied with other residents. One CNA reported that showers are done on day shift because there are not enough staff on night shift to complete them. The scheduler confirmed that only two to five CNAs are scheduled per 12-hour shift depending on availability, that there is high staff turnover, and that she often cannot find staff to cover call-ins. The administrator acknowledged staffing is a challenge, that he would like more CNAs on the floor than he is able to schedule, and that night shift typically has only two CNAs. Resident-specific findings further demonstrated the impact of staffing shortages. One resident’s care plan showed a need for setup/clean-up assistance with eating and hydration, and setup assistance with upper and lower body dressing and toilet hygiene; this resident reported that sometimes there are not enough staff and that he has to wait for assistance because staff are busy. Another resident’s MDS documented substantial/maximal assistance needs for sit-to-stand and partial/moderate assistance for toilet transfer and sit-to-lying, with supervision or touching assistance needed for lying to sitting. During an observation, this resident’s call light was on while no staff were present on the unit; the CNA had gone to lunch and the LPN and assigned CNA were occupied with wound care. By the time the scheduler responded to the call light, the resident had already transferred himself to his wheelchair, stating he did it himself after waiting. The resident and his sister reported that he had needed help to get out of bed, became tired of waiting, and that he sometimes waits 30 minutes or more for assistance and that it can be hard to find staff.
Failure to Complete Required Braden Scale Assessments for Resident With Pressure Ulcer
Penalty
Summary
Surveyors identified a deficiency in pressure injury risk assessment when record review showed that a resident with a documented coccyx pressure ulcer on 03/06/26 had not received a Braden Scale assessment since 01/07/25. Review of the resident’s assessments confirmed the absence of any Braden Scale evaluations after that date, despite the presence of a pressure ulcer. In an interview on 03/12/26 at 4:39 PM, the MDS coordinator acknowledged that no Braden Scale had been completed since 01/07/25 and confirmed that such assessments were required quarterly or with any change in condition. Review of the facility’s Pressure Injury Prevention and Management Policy further showed that licensed nurses were required to conduct Braden Scale assessments on admission/readmission, weekly for four weeks, and then quarterly or whenever the resident’s condition changed, which had not been followed for this resident.
Inaccurate MDS Assessment Documentation
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one resident. Specifically, the MDS assessment did not accurately reflect the resident's history of falls and the use of side rails for bed mobility and transfers. The resident, who was admitted with multiple diagnoses including chronic peripheral insufficiency, type 2 diabetes with skin complications, unilateral osteoarthritis of the left knee, generalized muscle weakness, need for assistance with personal care, and unspecified dementia with agitation, experienced several falls as documented in the facility's incident list. Despite these incidents and physician's orders for the use of 2 1/4 side rails to assist with mobility and independence, the MDS admission assessment failed to document a fall with injury and the use of side rails. The MDS coordinator confirmed during an interview that these details should have been included in the resident's assessment, indicating a lapse in accurately capturing the resident's needs and care requirements.
Failure to Revise Care Plans with Current Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that care plans were revised to reflect current interventions for two residents with a history of falls. For one resident admitted with repeated falls, the Interdisciplinary Team (IDT) added a fall mat as an intervention after a fall, and the mat was observed in use during a site visit. However, the resident's care plan was not updated to include this intervention. Similarly, another resident with multiple falls had several interventions in place, including the use of side rails, a fall mat, and placement in a common area for closer supervision, as confirmed by staff interviews and direct observation. Despite these interventions being implemented, the care plans for both residents did not document the use of the fall mat, call light within reach, or placement in a common area as fall prevention strategies. Staff interviews, including those with a CNA, LPN, MDS coordinator, and DON, confirmed that the care plans were not revised to include these interventions, even though facility expectations required such updates when new interventions were added.
Failure to Assess Bed Rail Safety and Obtain Consent
Penalty
Summary
The facility failed to ensure that residents were properly assessed for the safety risks associated with bed rail use, specifically the risk of entrapment, for two out of three residents reviewed for accidents. For one resident, staff completed a bed rail assessment in January, but did not reassess after a significant change in condition in July, despite the resident experiencing several falls and a decline in mobility. Observations confirmed the presence of bed rails and a fall mat, and interviews with staff revealed that the resident was unaware of the risks of getting up unassisted and that bed rails were used as a fall prevention measure. However, no updated assessment was documented following the change in the resident's condition. For another resident, bed rails were in use as ordered by a physician to assist with mobility and independence, but there was no documentation of a side rail assessment in the medical record. Progress notes did not mention the use of side rails, and the care plan referenced their use without evidence of a prior safety assessment. Interviews with staff indicated that consents for bed rails were routinely obtained upon admission, but assessments for bed rail safety were not completed prior to their placement. The interdisciplinary team confirmed that residents should be assessed for bed rail safety before and after placement, especially following changes in condition, but acknowledged that these assessments and consents were not consistently documented or obtained.
Failure to Protect Residents from Inappropriate Behavior
Penalty
Summary
The facility failed to protect residents from abuse, specifically failing to prevent a resident with a history of sexually inappropriate behavior from engaging in such actions. This resident, who had diagnoses including vascular dementia and cerebral infarction, was not adequately monitored or managed, leading to multiple incidents where he touched other residents without consent, entered their personal spaces unclothed, and made inappropriate comments. Despite having a care plan that initially addressed these behaviors, the interventions were removed prematurely, and staff failed to document or implement strategies to prevent further incidents. Several residents reported feeling unsafe due to the actions of this resident. One resident, with a history of PTSD and hallucinations, reported being touched on the leg, which led to her feeling unsafe and experiencing hallucinations about the resident entering her room. Another resident, with moderate cognitive impairment, was subjected to inappropriate sexual comments, which she did not hear, but staff failed to take appropriate action to monitor the resident making these comments. Additionally, a resident with severe cognitive impairment was touched on the thigh, and although her power of attorney was informed, the facility did not take sufficient steps to prevent recurrence. The facility's staff, including CNAs and RNs, were not adequately informed or instructed to monitor the resident's behavior, leading to repeated incidents. Interviews with staff revealed a lack of awareness and documentation regarding the resident's inappropriate behaviors, and the facility's administration did not consider the incidents to be sexual in nature, despite evidence to the contrary. This lack of appropriate response and monitoring resulted in a failure to protect residents from potential harm and distress.
Removal Plan
- The current care plan was revised to observe/monitor behaviors of touching. Resident #24 was immediately placed on 15-minute observations. Then, every shift thereafter, when behavior resolves 15-minute safety check will resolve.
- Safety Surveys were conducted to ask all residents and nursing staff employees if they felt unsafe around Resident #24.
- Education has been provided to staff: To increase staff awareness of when an event occurs related to inappropriate sexual comments and/or behavior; the staff will communicate during daily huddles. Additional education provided include: Abuse and Neglect; 15-minute Safety Checks during a new event; then every shift for residents identified to have a pattern of inappropriate behaviors until resolved. Know your Resident - which includes the process for reviewing the pattern of current and past behaviors, and interventions in the Care Plan with all staff and new employees. Shift huddle handoff will include not only medical report but also behavior changes and or concerns.
- On-Going Monitoring: New events will require 15-minute checks for inappropriate behaviors. After 15 minutes checks have concluded, checks will be every shift for those residents that have a pattern of inappropriate behavior or show signs of behavioral escalation.
- CNA's making the 15-minute observation checks will immediately report to the charge nurse any changes in behavior or inappropriate sexual remarks or actions. For residents that have a history of behavioral issues, after the 15 minute checks have expired, the behavioral monitoring will occur every shift. Any changes and or escalation in behavioral will be reported.
- Attempts are made to provide education on care plan and current interventions to Resident #24. However, due to BIMS score of 3.0, the resident does not comprehend the education.
- The Charge nurse is to verify every shift with the CNA assigned of the 15-minute observations. Then every shift thereafter.
- All resident care plans have been updated to address observation and monitoring of the encouraging all residents on the reporting of any unwanted pilfering/physical contact, including verbalizations that maybe offensive from any other resident.
- If an event occurs going forward that involves inappropriate sexual comments and/or gestures, the resident will immediately be placed on 15-minute observation checks and the observation checks are documented for the established timeframe. The care plan will be updated to reflect the interventions put in place.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to report multiple allegations of abuse or neglect to the State Agency within the required two-hour timeframe. This deficiency involved six residents who were either directly involved in or witnessed incidents of inappropriate behavior by another resident. For instance, a CNA witnessed a resident attempting to take another resident to his room while touching her thigh, but this incident was not reported promptly. Similarly, another resident reported feeling unsafe after being touched by a male resident, yet the facility delayed reporting this incident as well. The facility's administration did not consider some of these incidents as abuse, which contributed to the failure to report them. For example, an incident where a resident asked another if she liked sex was not reported because the administration believed the comment was not heard. Additionally, incidents where a resident entered another's room without pants and touched her leg, and another where a resident felt unsafe due to a male resident's actions, were not reported because the administration did not perceive them as abuse. These actions and inactions led to the deficiency in timely reporting of abuse or neglect allegations.
Inadequate Investigation and Prevention of Abuse Allegations
Penalty
Summary
The facility failed to conduct a thorough investigation and implement preventive measures following allegations of abuse involving multiple residents. The incidents involved a male resident, identified as R #24, who was reported to have inappropriate interactions with several female residents. These interactions included touching a resident's thigh, making inappropriate comments, and entering a resident's room without clothing. Despite these reports, the facility's documentation was inconsistent and lacked comprehensive witness statements, video evidence review, and clear preventive actions. In one instance, a resident's Power of Attorney was informed of an incident where another resident touched her thigh, but the facility handled the situation internally without clear communication of the actions taken. The facility's investigation reports were inconsistent, with discrepancies in incident dates and lack of detailed documentation regarding the review of video footage and witness statements. Additionally, the facility concluded that some incidents did not occur or were unsubstantiated without sufficient evidence to support these conclusions. The facility's response to these incidents was inadequate, as there were no specific interventions in place to address the behaviors of the resident involved in the allegations. Staff were not consistently instructed to monitor the resident, and there was a lack of clear communication and documentation regarding the actions taken to ensure the safety of the residents involved. This failure to properly investigate and implement preventive measures put residents at risk of continued abuse.
Care Plan Deficiencies for Resident Behaviors and Medical Needs
Penalty
Summary
The facility failed to revise the care plans for two residents, leading to deficiencies in addressing inappropriate behaviors and medical needs. Resident #24 exhibited behaviors such as touching other residents without consent and entering their rooms, which were not updated in the care plan. Despite multiple incidents reported by staff and residents, including inappropriate touching and entering rooms without consent, the care plan lacked interventions to address these behaviors. Staff were not consistently instructed to monitor Resident #24 for these behaviors, and the care plan did not reflect the need for such monitoring. Resident #31's care plan was also deficient as it did not include a physician's order for fluid restriction, which was crucial for managing their renal failure. The care plan documented the need for monitoring fluid intake and output due to hemodialysis but omitted the specific fluid restriction order. This oversight could lead to inadequate management of the resident's condition, as the care plan did not provide complete guidance for staff on fluid management. Interviews with staff, including LPNs, CNAs, and the DON, revealed a lack of awareness and documentation regarding the necessary monitoring and interventions for these residents. The facility's interim DON acknowledged the staffing limitations that affected the ability to provide one-to-one monitoring for Resident #24. The absence of documented interventions and monitoring instructions in the care plans contributed to the deficiencies identified during the survey.
Failure to Provide Mental Health Services After Alleged Sexual Abuse
Penalty
Summary
The facility failed to provide necessary mental health services for a resident who alleged sexual abuse by a staff member. The resident, who was admitted for therapy due to a right hip fracture, reported that a CNA sexually abused her during a shower. The incident was reported to the facility management, and the administrator initiated an investigation and reported it to the appropriate agencies. However, the facility did not schedule or consider behavioral health services for the resident until the Ombudsman brought it up during a meeting on a later date. The resident expressed severe psycho-social distress and depression due to the incident and her past trauma from an abusive relationship. Despite the resident's visible distress and emotional state, the facility delayed scheduling mental health services, which were only arranged after the Ombudsman's intervention. The facility's policy on abuse prevention includes follow-up counseling for residents in need, but this was not initiated promptly for the resident in question.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse, resulting in severe psycho-social distress. The resident, who was admitted for therapy due to a right hip fracture, alleged that a CNA sexually abused her while assisting her in the shower. The incident was reported to the facility management, and the Administrator initiated an investigation and reported it to the appropriate agencies. However, the facility did not schedule or consider behavioral health services for the resident until the Ombudsman brought it up, despite the resident's visible distress and emotional trauma from the incident and her past abusive relationship. The resident expressed that the incident brought up past trauma and caused significant emotional distress. She reported the abuse to the facility management a week after it occurred, stating she was in shock and did not know what to say. The facility held a care conference with the resident and scheduled a mental health appointment, but this was only done after the Ombudsman intervened. The resident was visibly distressed during interviews and observations, crying and showing signs of emotional trauma when discussing the incident and her past abusive relationship.
Failure to Investigate Allegation of Abuse and Implement Preventive Measures
Penalty
Summary
The facility failed to conduct a thorough investigation and implement preventive measures following an allegation of abuse by a resident. The resident, who was admitted for therapy due to a right hip fracture, alleged that a CNA put his fingers inside her while assisting her in the shower. The incident was reported to have occurred one or two weeks prior to the report date. The facility's investigation did not include specific questions to the CNA about the incident, nor did it document any preventive or corrective actions taken to ensure the resident's safety. The facility's complaint investigation file lacked detailed documentation of the events surrounding the alleged abuse. Witness statements from staff members only referred to the moments when the resident reported the allegation, without any information about the time of the alleged incident. Additionally, the facility did not document any other witness statements or specific questions about the care provided by the CNA in question. The resident safe surveys conducted did not include questions related to sexual abuse or the CNA's bathing technique. During interviews, the resident expressed difficulty in reporting the incident due to past experiences of abuse and depression. The facility's administrator confirmed that the CNA was placed on administrative leave but was not specifically questioned about the resident's allegation. The facility's policy on abuse reporting and prevention was not fully adhered to, as the investigation did not gather comprehensive information from all relevant parties, and preventive measures were not promptly implemented to protect the resident from further harm.
Incomplete Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for one of the two residents sampled for abuse. The resident was admitted on an unspecified date, and the admission Minimum Data Set (MDS) was completed on 02/05/24. However, the care plan dated 02/01/24 only included the resident's wish to return home, preferences for activities, and advanced directives for emergencies. It did not include essential details such as diagnosis, treatment/medications, and the assistance needed and provided by the facility. During an interview on 03/07/24, the Director of Nursing (DON) confirmed that the care plan was incomplete and acknowledged that it should have included the resident's specific needs of care.
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.
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