Manzano Del Sol By Purehealth
Inspection history, citations, penalties and survey trends for this long-term care facility in Albuquerque, New Mexico.
- Location
- 5201 Roma Avenue Ne, Albuquerque, New Mexico 87108
- CMS Provider Number
- 325074
- Inspections on file
- 21
- Latest survey
- December 12, 2025
- Citations (last 12 mo.)
- 48 (1 serious)
Citation history
Health deficiencies cited at Manzano Del Sol By Purehealth during CMS and state inspections, most recent first.
A required Five-Day Report detailing the results of an abuse investigation was not submitted to the State Survey Agency after an incident involving a resident. Although the initial incident report was sent, facility records and administrator interview confirmed the follow-up report was missing.
A resident with multiple medical conditions experienced two falls shortly after admission, resulting in a right femoral neck fracture and subsequent hospitalization. The facility did not conduct an investigation into the falls or the injury, and the DON did not submit the required Five Day Follow-Up report to the State Agency.
A facility failed to accurately complete the MDS Assessment for a resident, incorrectly documenting the absence of pressure ulcers at both admission and discharge. Despite progress notes indicating a pressure ulcer on the coccyx at admission and a stage 3 pressure ulcer at discharge, the MDS was not updated to reflect these conditions. The DON confirmed the inaccuracies in the MDS coding.
A resident with multiple health issues experienced a significant decline in nutritional intake and weight loss, which the facility staff failed to recognize as a change in condition. Despite worsening symptoms, including pocketing food and drink, elevated heart rate, and low oxygen saturation, the staff delayed sending the resident to the hospital for two days. The resident was eventually hospitalized with dehydration, urinary tract infection, and sepsis, highlighting the facility's inadequate monitoring and delayed response.
The facility failed to prevent accidents and ensure safe transfers, leading to multiple incidents where residents fell due to unlocked beds, improper use of Hoyer lifts, and lack of supervision during transfers. Staff did not adhere to care plans and proper procedures, resulting in falls and potential injuries.
The facility failed to ensure expired supplies were separated from unexpired ones and did not consistently document medication refrigerator temperatures. An expired Medstream dressing change kit was found stored with non-expired supplies, and temperature logs for the medication refrigerator were incomplete, risking the potency and effectiveness of stored medications.
A resident with multiple contractures did not receive a restorative nursing program after rehabilitation services ended. The resident's care plan aimed to improve her range of motion, but no restorative therapy was provided, leading to her being found in a fetal position and unable to get out of bed. The Director of Rehabilitation confirmed the lack of therapy and stated that the resident would benefit from a restorative program.
Failure to Submit Required Five-Day Abuse Investigation Report
Penalty
Summary
The facility failed to complete and submit a required Five-Day Report to the State Survey Agency following an allegation of resident-to-resident abuse. Record review showed that while the initial incident report was submitted to the State Survey Agency, there was no documentation indicating that the follow-up Five-Day Report, which includes the results of the facility's investigation, was ever sent. During an interview, the Administrator confirmed the absence of the Five-Day Report for the incident and stated that it was expected to be submitted within the required timeframe.
Failure to Submit Required Five Day Report After Resident Falls and Injury
Penalty
Summary
The facility failed to complete and submit a Five Day Report to the State Agency following allegations of neglect involving a resident who experienced multiple falls and sustained a right femoral neck fracture. The resident, who had diagnoses including cardiomyopathy, type 2 diabetes mellitus, unspecified dementia, hypoxemia, and atherosclerotic heart disease, was admitted and subsequently fell twice shortly after admission. The falls were documented in the Facility Reported Incident, but the times of the falls were not recorded. The resident complained of pain, which led to the diagnosis of a right femoral neck fracture, and was then discharged to the hospital. A review of the resident's electronic health record revealed no evidence that the facility conducted an investigation into the falls or the resulting fracture. During an interview, the DON stated that no investigation was completed because the resident did not return to the facility after hospitalization. The DON acknowledged awareness of the requirement to submit a Five Day Follow-Up report to the State Agency but did not do so in this case.
Inaccurate MDS Assessment for Pressure Ulcers
Penalty
Summary
The facility failed to ensure an accurate and comprehensive Minimum Data Set (MDS) Assessment for a resident, which is a federally mandated assessment instrument. Upon admission, the resident was documented as having no pressure ulcers, despite progress notes indicating the presence of a pressure ulcer on the coccyx measuring 2 cm by 1.4 cm by 0.2 cm. At discharge, the resident's MDS Assessment again inaccurately indicated no pressure ulcers, even though progress notes documented a stage 3 pressure ulcer. The Director of Nursing confirmed that the resident had a pressure ulcer at both admission and discharge, and acknowledged that the MDS was incorrectly coded.
Failure to Address Resident's Decline Leads to Hospitalization
Penalty
Summary
The facility failed to provide adequate care for a resident who was admitted with multiple diagnoses, including fetal alcohol syndrome, severe intellectual disabilities, urinary tract infection, urinary retention, and dysphagia. The staff did not recognize the resident's decrease in nutritional intake and significant weight loss as a change in condition. Despite the resident's declining health, including a significant weight loss of 13 pounds in a week and a decrease in supplement intake, the staff did not take timely action to address these issues. The resident's condition worsened with symptoms such as pocketing food and drink, elevated heart rate, low oxygen saturation, and fever. Despite these alarming signs, the staff delayed sending the resident to the hospital for two days. The resident was eventually admitted to the hospital with dehydration, urinary tract infection, and sepsis. Interviews with staff and the resident's guardian revealed inconsistencies in communication regarding the resident's condition and care, contributing to the delay in appropriate medical intervention. The facility's staff, including the nurse practitioner and director of nursing, acknowledged the resident's decline but failed to act promptly. The resident's guardian and hospital staff expressed concerns about the resident's malnourishment and dehydration upon hospital admission. The facility's lack of timely response and inadequate monitoring of the resident's condition likely contributed to the resident's severe health deterioration.
Failure to Prevent Accidents and Ensure Safe Transfers
Penalty
Summary
The facility failed to prevent accidents and provide safe transfers for residents, leading to multiple incidents. One resident, admitted with multiple diagnoses including hypotension, anemia, depression, and malnutrition, fell out of bed because the bed was not locked. Staff interviews confirmed that the bed was often moved for various reasons but was not relocked, which led to the resident falling while reaching for water. The facility's care plan for this resident indicated that the bed should always be locked, but this was not adhered to, resulting in the fall and subsequent injury to the resident. Another resident, who was totally dependent on staff for assistance and required a Hoyer lift for transfers, fell when the lift tipped over during a transfer. The incident report revealed that the CNAs assisting the resident did not use the Hoyer lift correctly, causing it to tip and graze the resident's head. The DON confirmed that improper use of the Hoyer lift was the cause of the incident. Despite attending in-service training on the proper usage of Hoyer lifts, the staff failed to follow correct procedures, leading to the resident's fall. Additionally, a resident who required supervision during transfers fell while transferring from a wheelchair to a shower chair because the wheelchair brakes were not locked. The resident and a CNA were present during the incident, but the CNA did not ensure the brakes were locked, resulting in the resident sliding out of the wheelchair. The Director of Rehabilitation confirmed that the CNA should have either reminded the resident to lock the brakes or locked them herself. Another resident also experienced a fall during a transfer with a Hoyer lift, which tipped over due to incorrect use by the staff, as confirmed by the DON and the incident report.
Failure to Manage Expired Supplies and Document Refrigerator Temperatures
Penalty
Summary
The facility failed to ensure that expired supplies were not kept with unexpired supplies and that staff documented the medication refrigerator temperatures. During an observation of the 100 hall medication room, a Medstream dressing change kit was found to be expired and stored with non-expired supplies. A medication technician confirmed the supplies were expired and stated that nursing staff were expected to periodically check and remove expired or soon-to-expire supplies. This oversight could result in the use of expired supplies on residents, potentially compromising their care. Additionally, a review of the 100 hall medication room's refrigerator temperature logs revealed that staff did not document the temperatures on multiple occasions. Insulin and other medications requiring refrigeration were stored in the refrigerator, which had both an analog temperature gauge and a digital temperature sensor. The Director of Nursing confirmed that staff were required to check and document refrigerator temperatures daily to ensure they remained within the appropriate range of 36 to 46 degrees Fahrenheit. The failure to document these temperatures could affect the potency and effectiveness of the medications stored within.
Failure to Provide Restorative Nursing Program
Penalty
Summary
The facility failed to ensure that a resident received appropriate treatment and services to prevent a decrease in range of motion and mobility. The resident, who had multiple contractures in the left shoulder, left lower leg, left ankle and foot, left elbow, and right foot and ankle, was not provided with a restorative nursing program after rehabilitation therapy services ended. The resident's care plan aimed to improve her range of motion and functional abilities, but no restorative therapy was provided after the cessation of rehabilitation services. During an observation, the resident was found lying in bed in a fetal position, unable to get out of bed. The Director of Rehabilitation confirmed that the resident had not received any physical, occupational, or restorative therapy since the rehabilitation services ended. The Director also stated that the resident would benefit from a restorative nursing program to prevent further worsening of her contractures and possibly improve her condition.
Latest citations in New Mexico
Surveyors found that the facility did not provide required written transfer and bed-hold notices when several residents were sent to the hospital for events such as falls with injury, unresponsiveness, and episodes of nausea, vomiting, and bleeding. Medical records lacked written transfer notices and bed-hold notifications, and the transfer information that should have been given to residents or their representatives did not include mandated details about appeal rights, how to request an appeal, or how to contact the State LTC Ombudsman. The Social Services Director reported that she does not notify the Ombudsman of hospital transfers and only sends a monthly email list of discharged residents, without written copies of transfer or discharge notices.
Two cognitively impaired residents with dementia and significant behavioral and continence needs were sent to a local ER after falls and were discharged back to the facility’s care, but the facility failed to provide timely transportation for their return. In both cases, hospital discharge times were documented, yet ER staff reported making multiple unsuccessful calls to the facility, reaching the Administrator only after repeated attempts. One resident, described as very disoriented, remained in the ER for several hours after discharge without 1:1 supervision, while the other waited approximately 11 hours, during which ER staff observed increasing confusion and attempts to get out of bed. The Administrator acknowledged awareness of the discharges, the lack of 24-hour transportation, and that the residents were not picked up until many hours after they had been discharged from the ER.
Two residents who required staff assistance for ADLs and transfers reported neglectful and rude behavior by a CNA and delayed nursing response to care needs. One resident with a history of cerebral infarction and schizophrenia stated that a CNA mocked him and that his requested wound dressing change was not performed for several hours, which was later corroborated by video showing a long gap between the CNA’s visit and the nurse’s entry to the room. Another resident with a right femur fracture, type II DM, and repeated falls, who needed one-person assistance for mobility and self-care, reported that a CNA refused to help and told her she could do some care herself, making her feel she was not trying in her recovery. Documentation and interviews confirmed that staff did not provide timely wound care or required assistance, and that these interactions caused residents to feel uncomfortable and negatively about their care.
A resident with a history of opioid dependence and polysubstance abuse was on a secure unit with a care plan that included safety risk evaluations and monitoring for signs of substance abuse. Staff later observed the resident discarding an empty Suboxone packet, even though the resident was not prescribed this medication, and the incident was reported to the on-call provider with subsequent monitoring and a room search. However, the care plan was not revised to reflect this new substance-related event, and both the DON and Administrator acknowledged that the care plan should have been updated when this new risk and behavior were identified.
Surveyors identified that a medication cart on the north hall was left unlocked and unattended outside a resident room. An LPN acknowledged that the cart was hers and that she had not locked it before leaving to answer a call light, despite facility expectations. The DON confirmed that all medication and treatment carts are required to remain locked when not in use or when staff are away from them.
Surveyors found that a document containing multiple residents’ PHI, including full names, room numbers, and code status, was left unattended and visible on a south nurse’s station counter. An RN confirmed the document was a resident list with PHI and acknowledged it had been left exposed and that such information should not be left unattended.
Surveyors found that a lunch tray return cart containing uncovered, soiled food trays and dishes was left unattended in a main hallway outside an activity room. The housekeeping/laundry manager acknowledged seeing the unattended cart, and the Dietary Manager confirmed that such carts are supposed to remain only in designated areas, such as near the nurse’s station or in the kitchen, and should be returned to the kitchen for cleaning as soon as all trays are collected. This failure was cited as likely to expose all residents to potential pathogens associated with food waste.
Two residents with scheduled showers reported that they were offered or received showers in very cold water during a prolonged period when hot water was not reliably available in care areas. One resident stated he refused cold showers and was only offered sponge baths once or twice, despite his preference to stay clean. Another resident reported receiving cold showers, including being rinsed with cold water while still soaped, and subsequently began refusing showers and bed baths due to the cold water. A CNA confirmed that water in the shower rooms was “ice cold” for several months, leading to resident complaints and refusals, while the Maintenance Director reported that a needed part to correct the hot water problem was on back order, delaying resolution and resulting in the facility not honoring residents’ bathing preferences.
Surveyors observed that unused medications were improperly discarded in a trash bin attached to a medication cart on the north hallway, rather than being disposed of in a designated drug disposal container. Two pills, a round blue tablet stamped "61" and an oblong orange tablet stamped "20," were found together in an unlabeled medication cup in the trash. An RN confirmed the medications were discarded there and acknowledged that unused medications should be placed in the drug buster container in the cart drawer. The Unit Manager also confirmed that facility practice requires all unused medications to be disposed of using the drug buster and that controlled substances must be destroyed by two licensed staff and documented on the narcotic count sheet.
The facility failed to follow documented allergy information, diet orders, and meal tickets for three residents. A resident with a documented chocolate allergy was served chocolate ice cream after requesting it, and the Nutrition Director admitted not reading the allergy notation on the meal ticket. Another resident on a pureed diet received whole mandarin oranges instead of pureed fruit, which a CNA confirmed. A third resident whose meal ticket called for a grilled Swiss sandwich received a sandwich that was not grilled, as confirmed by a CNA and a dietary manager.
Failure to Provide Required Written Transfer, Appeal, Ombudsman, and Bed-Hold Notices During Hospitalizations
Penalty
Summary
Surveyors identified that the facility failed to provide required written transfer and bed-hold information for multiple residents who were hospitalized. For three residents who experienced transfers to the hospital after events such as falls with injury, unresponsiveness, and episodes of nausea, vomiting, and bleeding, record review showed there were no written transfer notices or written bed-hold notices in their medical records. Specifically, one resident transferred after a fall on 01/31/26 had no documented written transfer notice or bed-hold notice. Another resident transferred on 02/27/26 for nausea, vomiting, and bleeding, and later readmitted on 03/05/26, had no written transfer notification that included information on appeal rights or Ombudsman contact, and no written bed-hold notification. A third resident transferred on 01/29/26 after a fall with a forehead laceration and again on 03/17/26 for unresponsiveness, also had no documented written transfer or bed-hold notices for either hospitalization. The deficiency also included the facility’s failure to provide required content in transfer notices and to notify the State Long-Term Care Ombudsman in writing. For the residents reviewed, there was no evidence that written transfer notices were provided to the residents or their representatives in a language and manner they could understand, and the notices were missing required elements such as a statement of appeal rights, the name, mailing and email address, and phone number of the entity receiving appeals, and information on how to obtain and complete an appeal form. The notices also lacked the name, phone number, and mailing and email address of the State Long-Term Care Ombudsman, and written copies of the transfer notices were not sent to the Ombudsman. During interview, the Social Services Director confirmed that transfer and bed-hold notices were not documented for at least one resident’s hospitalization, that she does not notify the Ombudsman about transfers to the hospital, and that she only emails a monthly list of residents discharged from the facility without sending written copies of transfer or discharge notices.
Failure to Timely Retrieve Residents From ER After Discharge
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from neglect by not arranging timely transportation back to the facility after emergency room (ER) discharge. A consumer complaint alleged that residents sent to the local ER were being left there for extended periods after discharge. For one resident with an admission date of 10/13/25, records showed multiple cognitive and behavioral diagnoses, including Alzheimer’s disease, vascular dementia with agitation and other behavioral disturbances, mild cognitive impairment, cognitive communication deficit, and restlessness and agitation. A change of condition MDS documented a Brief Interview for Mental Status (BIMS) score of 1 and frequent incontinence of urine and bowel. Nursing progress notes for this resident showed that 911 was called at 3:00 AM and the resident was transferred to the ER after a fall. Hospital discharge instructions indicated the resident was discharged from the ER at approximately 5:21 AM, while the ER nurse reported discharge at about 5:30 AM. The ER nurse stated she made numerous calls to the facility but was unable to reach anyone. She reported that the resident was very disoriented and that the ER did not have enough staff to provide 1:1 supervision. The ER nurse eventually reached the Administrator, who stated staff would come to pick up the resident as soon as possible. Facility records showed the resident was not discharged from the facility on that date, and the ER nurse reported that facility staff did not pick the resident up until approximately 8:30 AM, several hours after discharge. A second resident, admitted on 11/25/25, had diagnoses including Alzheimer’s disease, dementia with behavioral disturbance, bipolar disorder with severe depression and psychotic features, depression, and anxiety disorder. The admission MDS documented a BIMS score of 2, frequent urinary incontinence, constant bowel incontinence, and a need for substantial/maximal assistance with toileting hygiene. Nursing notes showed this resident was sent to the ER for evaluation after a fall and did not return until the following morning. Hospital discharge instructions documented discharge from the ER at 10:16 PM, and the Administrator confirmed being notified of the discharge at about 10:30 PM and that the facility did not have 24-hour transportation. The Administrator acknowledged the resident was not picked up until approximately 9:00 AM the next day. The ER nurse reported making several calls to the facility that went to voicemail, eventually reaching the Administrator, who initially stated staff were on the way, then stopped answering calls. During the approximately 11-hour wait, the ER nurse stated the resident was confused, attempted to get out of bed, and became more confused as the night progressed.
Failure to Timely Provide Wound Care and Required Assistance, Resulting in Resident Neglect
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from neglect when staff did not respond appropriately to requests for care and assistance. One resident with a history of cerebral infarction due to embolism and schizophrenia, admitted on 01/30/26 and requiring staff assistance for ADLs and mechanical lift transfers, reported that a CNA was rude and mocking and that his wound dressing was not changed for several hours after he requested it. The Kardex showed he needed staff help for toileting, bathing, hygiene, bed mobility, dressing, and transfers. Nursing progress notes documented a change in condition on 03/02/26 after the resident stated the CNA was rude and would not assist as requested. The Administrator later confirmed, via video review, that the CNA entered the resident’s room at 2:30 am, the resident requested a dressing change, and no nurse entered the room until 5:00 am, despite the nurse’s statement that she went in “right away.” The DON also confirmed that the resident’s grievance described the wound dressing not being changed until hours after the request. Another resident, admitted with a right femur fracture, type II diabetes, and repeated falls, required one-person assistance for dressing, hygiene, bathing, bed mobility, and transfers, and could toilet herself with assistance for transfers. Nursing progress notes documented an alleged abuse incident on 03/02/26 in which this resident stated a CNA was rude, refused to help her, and told her she could perform some care tasks herself without staff assistance. An abuse questionnaire completed the same day showed the resident answered “Yes” to having interactions that made her feel uncomfortable or negative, and she reported that the CNA made her feel as though she was not trying with her own recovery. The Administrator and DON acknowledged that staff are expected to help residents as required and that staff interactions must be encouraging rather than making residents feel bad about needing assistance.
Failure to Revise Care Plan After Substance-Related Incident
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s care plan after a significant substance-related incident. The resident was originally admitted with a diagnosis of opioid dependence and resided on a secure unit related to polysubstance abuse disorder. The existing care plan, dated 01/21/26, identified the resident as residing on a secure unit due to polysubstance abuse disorder with interventions to perform safety risk evaluations on admission, as needed, and upon changes in condition. The care plan also identified the resident as at risk for substance use disorder with interventions to monitor for signs or symptoms of substance abuse. On 02/01/26, nursing notes documented that staff observed the resident discarding an empty Suboxone packet in the trash, even though the resident was not prescribed Suboxone and denied taking any. Staff notified the on-call provider, who ordered monitoring for adverse reactions, and nursing staff and security conducted a room search that revealed no additional contraband. Despite this incident, the resident’s care plan was not updated to address the new substance-related event. During interviews, the DON acknowledged awareness of the incident and confirmed the care plan was not revised, and the Administrator stated her expectation that nursing would update the care plan when a new risk or behavior was identified and confirmed she would have expected the care plan to be updated for this resident.
Unattended, Unlocked Medication Cart on North Hall
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were properly stored and secured in accordance with professional standards and facility expectations. On 03/24/26 at 9:06 a.m., surveyors observed a medication cart on the north hall left unlocked and unattended outside a resident room. At 9:08 a.m., the LPN responsible for the cart confirmed during interview that the cart was hers, that it was unlocked and unattended, and acknowledged she should have locked it before responding to a call light. Later that day at 3:37 p.m., the DON stated in an interview that medication and treatment carts are expected to be locked at all times when nurses are away from them, confirming that the observed practice did not meet facility expectations. This deficient practice was cited as likely to allow unauthorized personnel access to medications, which could result in injury or overdosing.
Unattended PHI Document Left Exposed at Nurse’s Station
Penalty
Summary
Surveyors identified a deficiency in the facility’s protection of residents’ personal health information (PHI) when a document containing multiple residents’ full names, assigned room numbers, and code status was left unattended and exposed on the south nurse’s station counter. On 03/16/26 at 9:04 a.m., an observation revealed a piece of paper on a clipboard with complete resident information placed on top of the south nurse’s counter in public view. At 9:06 a.m., during an interview, RN #2 confirmed that the list contained residents’ names, room numbers, and code status, acknowledged that it had been left exposed and unattended, and stated that PHI should not be left unattended. No additional clinical details or medical histories of the residents listed on the document were provided in the report.
Unattended Soiled Lunch Cart Left Uncovered in Hallway
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the handling of soiled food service equipment. On 03/24/26 at 12:58 pm, a lunch tray return cart containing soiled food trays and dishes that were uncovered was observed sitting unattended in the main hallway outside the activity room. At 1:06 pm, the housekeeping/laundry manager confirmed she saw the return cart left unattended in that location. At 1:08 pm, the Dietary Manager stated that lunch return carts should only be left in designated areas such as by the nurse’s station or inside the kitchen, and that the cart should be returned to the kitchen for cleaning as soon as all trays have been picked up, which did not occur in this instance. This deficient practice was noted as likely to expose all residents to potential pathogens associated with food waste.
Failure to Honor Resident Bathing Preferences During Prolonged Hot Water Issues
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ bathing preferences when hot water was not reliably available in resident care areas. Record review showed that one resident was scheduled to receive three showers per week on specific days, and another resident was scheduled for two showers per week. One resident reported that staff attempted to have him shower in cold water, which he refused, and that sponge baths were only offered once or twice during the period when the hot water was not working. He stated that he liked to be clean and did not feel like himself when he was dirty. A CNA reported that there was no hot water in resident care areas from the middle of December until early March, and that large barrels of warm water were brought to shower rooms to offer sponge baths, which this resident refused. Another resident, also on a scheduled twice-weekly shower regimen, stated that she received cold showers and began refusing showers because of how cold the water was. She described the water running cold unpredictably, including an instance when the water was initially warm but turned cold while she was still soaped, requiring rinsing with cold water, which she described as horrible. A social services note documented that this resident’s daughter reported the resident had been declining showers and bed baths offered because the water was too cold. A CNA corroborated that the water was “ice cold” and that residents began complaining and refusing showers around mid-December. The Maintenance Director stated that it took a while for hot water to reach the shower room and that a needed part to fix the cold-water problem was on back order, contributing to the prolonged period of inadequate hot water and resulting in residents not having their bathing preferences honored.
Improper Disposal of Unused Medications on Medication Cart
Penalty
Summary
Surveyors identified a deficiency related to accident hazards and inadequate supervision when unused medications were improperly discarded on the north hallway. During observation of the north hall nurses’ station, two medications were found in the trash bin attached to the medication cart, placed together inside an unlabeled medication cup. The pills were described as a round blue pill stamped with “61” and an oblong orange pill stamped with “20.” In an interview immediately following the observation, an RN confirmed that these medications were in the trash bin and stated that unused medications should instead be disposed of in the drug buster, a sealed container for drug disposal located in the bottom drawer of the cart. In a subsequent interview, the Unit Manager confirmed that all unused medications are to be disposed of using the drug buster and acknowledged that this did not occur, further stating that if the medications are controlled substances such as narcotics, two licensed personnel are required to dispose of them together and document the disposal on the narcotic count sheet. This deficient practice was noted as likely to affect any resident who might acquire and ingest the discarded medications, potentially causing medication side effects.
Failure to Follow Allergy, Diet, and Meal Ticket Requirements
Penalty
Summary
The facility failed to provide meals consistent with residents’ documented allergies, diet orders, and meal tickets for three residents. One resident, admitted with a documented allergy to chocolate, had a face sheet and lunch ticket indicating they were not to receive chocolate. During a lunch observation, this resident was served and was eating chocolate ice cream. An LPN confirmed the resident’s chocolate allergy and that the resident should not be eating chocolate. The Nutrition Director acknowledged that the meal ticket stated the resident should not have chocolate but reported serving chocolate ice cream after the resident requested it, stating he had not read that the resident was allergic to chocolate. Another resident, admitted with hypokalemia and ordered a regular/liberalized pureed diet per the MDS, had a lunch ticket indicating a pureed diet but was observed receiving whole mandarin oranges instead of pureed fruit. A CNA confirmed that the dessert was not pureed. A third resident’s meal ticket specified a grilled Swiss sandwich, but observation of the tray showed the sandwich was not grilled. During interviews, a CNA and a dietary manager confirmed that the sandwich was not grilled as ordered on the meal ticket.
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