Mescalero Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Mescalero, New Mexico.
- Location
- 454 Lipan Avenue, Mescalero, New Mexico 88340
- CMS Provider Number
- 325116
- Inspections on file
- 20
- Latest survey
- December 5, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Mescalero Care Center during CMS and state inspections, most recent first.
Several residents' personal fund accounts were not accurately updated or documented for months, with outdated balances provided and no record of ongoing deposits or withdrawals. Residents reported not receiving financial statements or being informed of their account balances, and staff interviews confirmed incomplete record-keeping and lack of access to accurate account information.
A staff member who also served as a resident's POA attempted to withdraw over $7,000 from the resident's account without consent, but was stopped by facility staff. The same staff member was repeatedly observed yelling at other staff in front of residents, causing fear and distress among residents and staff. Multiple residents reported being afraid to speak out due to the staff member's connections to leadership and fear of retaliation.
An LPN was observed pre-pouring medications for multiple residents, placing pills into labeled and unlabeled cups in advance of administration. The LPN acknowledged this was done to speed up the process, despite facility policy prohibiting pre-pouring. Facility leadership confirmed that medications are to be prepared and administered immediately for each resident, and that this practice was not followed.
A resident's POA, who was also the facility's Business Office Manager, attempted to withdraw over $7,000 from the resident's account. The facility did not report this allegation of misappropriation to the State Agency within the required 24-hour period, as confirmed by record review and administrator interview.
The facility did not employ a Certified Dietary Manager or equivalent qualified staff to oversee food and nutrition services for approximately one month. Dietary staff and the administrator confirmed the absence of a dietary manager, and the dietitian was only present one day per week, affecting all residents receiving meals from the kitchen.
The facility did not maintain sanitary food storage practices or monitor refrigerator and freezer temperatures in the nourishment room. Expired food items and improperly stored sandwiches without expiration dates were found, and staff interviews revealed uncertainty and lack of oversight regarding temperature checks and food expiration monitoring.
Staff did not notify the provider when a resident with hypertension had repeated episodes of high blood pressure and low pulse outside of physician-ordered parameters, and continued to administer amlodipine without contacting the physician as required. The DON confirmed that staff failed to follow the notification protocol for abnormal vital signs.
Multiple residents were prescribed and administered psychotropic medications without appropriate psychiatric diagnoses or documented medical necessity, and staff failed to implement or document gradual dose reductions as required. In several cases, psychotropic medications were continued without patient-specific rationales, and one resident experienced excessive sedation due to the combination and frequency of prescribed medications.
The facility did not provide required written discharge or transfer notifications, discharge summaries, or bed hold notifications for three residents who were either discharged home or transferred to the hospital. Verbal education was provided in some cases, but necessary written documentation and notifications to residents, representatives, and the Ombudsman were not completed.
Surveyors identified that three residents had inaccurate MDS assessments. One resident was incorrectly documented as having received insulin instead of semaglutide, another had restorative nursing services omitted from their assessment despite receiving them, and a third was inaccurately reported as having a stage 2 pressure ulcer when only a blister and cellulitis were present. These inaccuracies were confirmed through record review and staff interviews.
The facility did not update care plans for several residents after significant changes in their care needs, such as repeated refusals of showers, new fall prevention measures, and the addition of anti-anxiety medications. Staff confirmed that care plans were not revised to include these new interventions or changes, resulting in care plans that did not reflect the most current resident information.
Staff failed to notify a physician as required when a resident's blood pressure and pulse readings met criteria for notification, and continued to administer antihypertensive medication despite these readings. Additionally, wound care was performed on both legs of another resident, although physician orders were only present for the left leg. These actions did not meet professional standards of practice.
A resident's care plan did not include her personal activity preferences, and there was no documentation that activities such as spiritual/religious services, music, or reading materials were offered over several months. The resident reported not being offered in-room activities or engagement, and the Activities Director confirmed that not all activities were documented.
The facility did not ensure that several residents received face-to-face physician visits at least every 60 days, as required. Review of medical records and staff interviews confirmed that multiple residents went extended periods without being seen by a physician, with some not having a visit for several months or longer. The DON acknowledged that the required frequency of physician visits was not maintained.
A CNA did not receive a performance review within the required 12-month period. Record review and interview with the HR Manager confirmed that the last evaluation was not completed on time.
Surveyors found that the facility did not ensure that physicians reviewed and implemented consultant pharmacist recommendations for medication regimen reviews, nor did they provide required patient-specific rationales when declining to follow these recommendations. Multiple residents with psychiatric and behavioral health diagnoses continued to receive psychotropic and anxiolytic medications without documented justification for not attempting gradual dose reductions, as confirmed by review of medical records and interviews with the DON.
Three residents did not receive required dental care, including routine assessments and follow-up for reported dental issues such as loose dentures, lost fillings, and toothache. Despite physician orders and requests from family or residents, staff did not ensure dental consults or services were provided, and documentation confirmed a lack of dental visits during their stays.
Staff failed to maintain complete and accurate medical records for two residents, including missing documentation of pain location and effectiveness of pain medication for one resident, and failure to update a diagnosis of major depressive disorder in the EMR for another, as confirmed by the DON.
The facility did not ensure that required Effective Communication training was completed by a RN, an LPN, and a CNA, as shown by missing completion dates in their training records and confirmed by the Human Resource Manager.
Several staff members, including RNs, an LPN, and a CNA, did not complete required training on resident rights, as confirmed by record review and the Human Resource Manager. This deficiency was identified during a review of staff training records.
Mandatory QAPI training was not completed by a registered nurse, an LPN, and a CNA, as confirmed by review of training transcripts and staff interviews. The Human Resource Manager verified that these staff members had not fulfilled the required training.
Two staff members did not complete required annual infection control training, as confirmed by review of training records and facility staff. This failure occurred despite the facility's policy mandating yearly infection control education for all staff.
A CNA did not complete the required 12 annual in-service training hours, with only 1 hour documented for the year, as confirmed by the HR Manager.
Two residents were administered psychotropic medications, including trazodone and hydroxyzine, without documented consent or evidence that they or their representatives were informed of the reasons, risks, and benefits of these medications. The DON confirmed that staff did not follow the required process of obtaining verbal and written consent prior to starting these medications.
A resident's comprehensive MDS assessment was not completed within the required 14-day period following admission. The delay was confirmed by the MDS Coordinator during an interview and was identified through record review.
A resident who experienced a major decline and was placed on palliative care did not have a significant change MDS assessment completed within the required 14-day period. The assessment was delayed beyond the mandated timeframe, as confirmed by the MDS coordinator.
Two residents did not have their quarterly MDS assessments completed within the required three-month timeframe, as the assessments were conducted 92 days after the previous assessment reference date. This was confirmed by record review and staff interview.
The facility did not complete, submit, or finalize MDS assessments within the required timeframe for multiple residents. Review of records showed that MDS assessments were missing for several residents, and the facility received error messages from the state regarding these missing submissions. The MDS coordinator was unable to provide a reason for the delays.
A resident admitted with an order for trazodone, a high-risk antidepressant, did not have this medication included in their baseline care plan. The DON confirmed that the baseline care plan should have listed all high-risk medications, but this was not done.
Two residents did not have their personal preferences and religious practices accurately reflected in their care plans, despite this information being documented in assessments and communicated to staff. The care plans failed to include important details about activity preferences and religious restrictions, as confirmed by facility staff.
Staff did not ensure that a fall mat, as ordered by the physician, was placed next to a resident's bed when the resident was in bed. Despite the resident's history of falls and a diagnosis of dementia, observations found the fall mat folded away from the bed on multiple occasions. Interviews with a family member, an LPN, and the DON confirmed that the fall mat was required to be next to the bed, but this was not done.
A registered nurse did not receive the required annual training on abuse, neglect, and exploitation, as confirmed by a review of training records and an interview with the HR manager.
A CNA did not complete the required annual behavioral health training, as confirmed by both training records and the Human Resource Manager. This deficiency was identified during a review of staff training compliance.
The facility failed to promote resident self-determination by not accommodating the wishes of three residents to go out into the community. An anonymous complaint and interviews revealed that residents had not left the facility for non-medical reasons for over a year. The Activities Director confirmed that community outings had not resumed after the COVID-19 pandemic, despite previous outings. Residents confirmed the cessation of shopping trips, which had recently resumed.
The facility failed to provide RN services for at least 8 consecutive hours a day, 7 days a week. Staff timesheets revealed that on four specific dates, the RN either did not work or worked fewer than the required hours. The administrator confirmed these findings, which could affect all 25 residents in the facility.
The facility failed to document the temperature of the walk-in refrigerator and freezer on five specific dates, potentially affecting all 25 residents who consume food prepared in the kitchen. The Dietary Manager confirmed the missing entries and stated that temperatures should be documented three times a day.
The facility's QAPI Committee failed to establish and implement necessary policies and procedures for feedback, data collection, monitoring, and adverse event monitoring. The Administrator confirmed the absence of these policies, citing the need for updates and staff retraining.
The facility failed to maintain an infection prevention and control program by not having a water management program to minimize the risk of Legionella and other opportunistic pathogens. This deficiency was confirmed through interviews with the Maintenance Director, Administrator, and Infection Control Nurse, all of whom acknowledged the absence of such a program. This failure could potentially affect all 25 residents in the facility.
The facility failed to ensure care plan revision and meeting requirements for six residents, leading to discrepancies in care plans, unaddressed dental issues, and incomplete documentation of pressure ulcers. The DON confirmed the lack of updates and documentation during interviews.
The facility failed to ensure residents received appropriate treatment and services to maintain or prevent a decrease in range of motion (ROM) for some residents who could benefit from therapy services or a restorative nursing program (RNP). One resident had not had a therapy evaluation since admission and had no orders for therapy or restorative nursing services, despite having arthritis and expressing a desire to improve mobility. The facility did not have a process to evaluate residents for ROM needs or provide services to those who could benefit from an RNP.
The facility failed to ensure that residents had a physician visit at least every 60 days for three of the five residents reviewed. The deficiency was confirmed through record reviews and interviews with the medical records clerk and the DON, revealing lapses in the required medical assessments.
The facility failed to ensure necessary dental services for two residents. One resident had ill-fitting dentures that were not addressed despite being reported, and another resident had not seen a dentist since admission, with no appointments scheduled.
A facility failed to ensure accurate medical records when an LPN documented a resident's wound as a diabetic foot ulcer, while a wound care consultation identified it as a stage 2 pressure ulcer. The DON confirmed the documentation error.
The facility failed to provide behavioral health training for an RN, an LPN, and a CNA, despite admitting residents with significant mental health diagnoses. The Administrator and DON confirmed the lack of training, which could likely result in residents not receiving necessary services.
The facility failed to complete comprehensive MDS Assessments within 14 days for two residents. Both assessments were still in progress and not completed by the required timeframe, as confirmed by the Infection Control Nurse.
The facility failed to include necessary interventions for edema in a resident's care plan, despite physician's orders and the resident's condition. The DON confirmed the omission.
The facility failed to ensure that physician's orders were entered for a resident experiencing depression and poor appetite. Despite the provider's progress note indicating that Mirtazapine was to be ordered, no such order was found in the resident's records. Interviews confirmed a communication gap between the provider and the facility's medical records process.
The facility failed to ensure that call lights were functional and accessible in residents' bedrooms. One resident's call light cord was missing, leading to unmet needs and frustration. An LPN confirmed the absence of the call light cord and noted that the resident did not use her call light.
Failure to Accurately Manage and Communicate Resident Personal Funds
Penalty
Summary
The facility failed to properly manage, document, and communicate the personal funds of multiple residents. For several residents, including those admitted prior to and during the review period, the last documented transactions in their personal fund accounts occurred in July, despite ongoing monthly deposits and regular withdrawals for shopping and salon services. Staff did not record any deposits or withdrawals after these dates, and the quarterly financial statements provided to residents reflected outdated balances that did not account for subsequent transactions. Residents reported not being informed of their account balances and not receiving requested financial statements. Interviews with staff revealed that the Business Office Manager (BOM) was unable to determine the actual balances in residents' accounts due to a lack of access to bank statements and incomplete manual record-keeping. The BOM confirmed that the financial records had not been updated for several months and that the statements given to residents were inaccurate. Additionally, there was uncertainty regarding whether residents or their representatives had received quarterly statements as required. Multiple residents expressed distrust and discomfort regarding the handling of their funds and the lack of transparency from the BOM.
Failure to Protect Residents from Abuse, Exploitation, and Intimidation by Staff Member
Penalty
Summary
The facility failed to protect residents from abuse, neglect, and exploitation, as evidenced by multiple incidents involving the Business Office Manager (BOM). The BOM, who also served as a resident's Power of Attorney (POA), attempted to withdraw $7,208.42 from the resident's facility account. The attempt was prevented by staff, and the resident, who was cognitively intact and able to make financial decisions, was informed of the situation and did not consent to the withdrawal. The BOM was an employee at the time of the attempted exploitation. Additionally, the BOM was reported to have yelled at staff members on multiple occasions in areas accessible to residents, including the front lobby and common areas. These incidents were witnessed by residents and confirmed by staff and the facility administrator. The administrator provided examples of the BOM's aggressive behavior, including yelling in the presence of residents and family members, which caused visible fear among those present. The Ombudsman also reported being intimidated by the BOM during an encounter in the facility's lobby. Residents expressed fear of retaliation due to the BOM's connections to tribal leadership, with some stating they were afraid of being removed from the facility if they reported the BOM's behavior. Both residents interviewed did not report their concerns to anyone for fear of retaliation. The administrator confirmed that both staff and residents were afraid of the BOM and her family ties, contributing to an environment where residents felt unsafe and unable to report abuse or mistreatment.
Failure to Follow Professional Standards for Medication Administration
Penalty
Summary
The facility failed to meet professional standards of practice for medication administration for five out of eight residents reviewed. During an observation, an LPN was found to have prepared multiple residents' medications in advance, placing pills for different residents into separate medicine cups, some of which were labeled with residents' initials and one that was not labeled at all. The LPN admitted to preparing the medications early to expedite administration and confirmed that staff were not supposed to pre-pour medications. The medication cups contained varying numbers of pills, and the LPN identified which cup corresponded to which resident, including one cup with no identifying initials. During a joint interview, the DON and ADON confirmed that staff were expected to prepare and administer medications to each resident immediately after preparation and that pre-pouring medications was not permitted. They acknowledged that this practice could result in medications being given to the wrong residents and could lead to medication errors. The observations and interviews confirmed that the facility did not adhere to its own policies and professional standards regarding medication administration.
Failure to Timely Report Alleged Misappropriation of Resident Funds
Penalty
Summary
The facility failed to report an allegation of misappropriation of resident property to the State Agency within the required 24-hour timeframe. Specifically, a resident's Power of Attorney (POA), who was also the facility's Business Office Manager, attempted to withdraw $7,208.42 from the resident's facility account. The incident occurred on 09/17/25, but the initial report to the State Agency was not submitted until 10/10/25, well beyond the mandated reporting window. Record review confirmed the delay in reporting, and during an interview, the administrator acknowledged that the incident was not reported within 24 hours as required. The resident's POA, being an employee of the facility, was directly involved in the attempted misappropriation, and the failure to promptly report the allegation constituted a deficiency in the facility's compliance with reporting requirements.
Failure to Employ Qualified Dietary Manager
Penalty
Summary
The facility failed to employ a Certified Dietary Manager (CDM) or an individual with equivalent qualifications to oversee the food and nutrition service, as required by regulations. Interviews with dietary staff revealed that the facility had not had a dietary manager for approximately one month, and staff were unsure if a dietitian was present. The administrator confirmed that the dietitian only worked at the facility one day per week and that there had been no dietary manager since a specific date. This deficiency potentially affected all 29 residents who consumed food prepared in the facility's kitchen, as identified by the resident matrix. The absence of a qualified dietary manager or equivalent staff meant that the facility did not meet the regulatory requirements for food service management and oversight during the period in question.
Failure to Maintain Sanitary Food Storage and Temperature Monitoring
Penalty
Summary
The facility failed to store and serve food under sanitary conditions in accordance with professional standards for all 29 residents who consumed food or drinks from the nutrition refrigerator or freezer. Observations revealed that there was no temperature log for the refrigerator or freezer in the nourishment room, and staff were unsure of the location or existence of such logs. Interviews with nursing and dietary staff confirmed that kitchen staff were responsible for monitoring temperatures, stocking, and removing expired items, but had not been checking or recording temperatures for the nutrition room refrigerator and freezer. Further inspection of the nutrition refrigerator and freezer found expired food items, including a sandwich and a bag of shredded cheese, as well as several individually packaged peanut butter and jelly sandwiches without expiration dates. These sandwiches, which were labeled to be stored frozen until served, were found in the refrigerator instead of the freezer. The DON confirmed the presence of expired items, lack of expiration dates, improper storage of food items, and uncertainty regarding temperature monitoring responsibilities.
Failure to Notify Provider of Abnormal Vital Signs
Penalty
Summary
Facility staff failed to notify the physician of abnormal vital signs for a resident with a diagnosis of essential hypertension. According to physician orders, staff were required to hold amlodipine and call the physician if the resident's systolic blood pressure (SBP) was less than 100, diastolic blood pressure (DBP) was less than 50, or pulse was less than 50. Additionally, staff were to administer the medication and call the physician if SBP was greater than 180, DBP was greater than 100, or pulse was greater than 100. Despite these clear parameters, staff documented multiple instances where the resident's SBP exceeded 180 and pulse was below 50, yet still administered amlodipine and did not notify the physician as required. Review of the Medication Administration Record (MAR) for April and May 2025 showed repeated occurrences of elevated blood pressure and low pulse readings, with no corresponding documentation of physician notification. Progress notes for March and April 2025 also lacked evidence of provider notification regarding these abnormal findings. The Director of Nursing confirmed that staff did not follow the order to notify the physician when the resident's blood pressure was elevated or pulse was low.
Failure to Ensure Medically Necessary Use and Monitoring of Psychotropic Medications
Penalty
Summary
Surveyors identified that the facility failed to ensure that residents did not receive psychotropic medications unless medically necessary. Several residents were prescribed and administered psychotropic medications without appropriate psychiatric diagnoses documented in their medical records. For example, one resident received hydroxyzine for restlessness or anxiety despite not having a diagnosis of anxiety, and another received trazodone for sleep related to congestive heart failure without a psychiatric diagnosis or a documented rationale for continued PRN use beyond 14 days. The DON confirmed that staff are expected to ensure medications are ordered to treat a diagnosed condition and that PRN psychotropic medications should not be ordered for longer than 14 days without justification. Additionally, the facility did not consistently implement or document gradual dose reductions (GDR) for residents on long-term psychotropic medications. Multiple residents with psychiatric diagnoses such as anxiety, depression, and insomnia were maintained on medications like sertraline, trazodone, escitalopram, hydroxyzine, buspirone, lorazepam, mirtazapine, and Nuplazid for extended periods. Pharmacist recommendations for GDRs were either declined or not accompanied by patient-specific rationales from the prescribing providers. The DON confirmed that GDRs were not performed and that providers did not supply adequate justification for maintaining current dosages. Furthermore, one resident exhibited signs of excessive sedation, including frequent daytime sleepiness and missed meals, after being prescribed both alprazolam and hydroxyzine on scheduled regimens. The resident's POA reported increased sleepiness and was unaware of the frequency and combination of these medications, noting that the resident previously only received alprazolam as needed. Observations confirmed the resident was often asleep during the day, and the DON acknowledged the medication regimen and its effects.
Failure to Provide Required Written Discharge, Transfer, and Bed Hold Notifications
Penalty
Summary
The facility failed to provide required written discharge or transfer notifications and documentation to residents and their representatives for three residents who were either discharged or transferred to the hospital. For one resident who was discharged home, there was no written discharge notice, discharge summary, recapitulation of stay, or medication reconciliation documented in the medical record. Although the resident and family were verbally educated about medications and upcoming appointments, the necessary written documentation and notifications were not completed, and the Ombudsman did not receive a discharge notice. For two other residents who were transferred to the hospital after falls, the facility did not provide written transfer notifications or bed hold notifications as required. Staff interviews confirmed that written notices were not being completed or sent to the Ombudsman, and the Business Office Manager did not complete a bed hold notification for one of the residents. The Director of Nursing confirmed that these required notifications and summaries were not being documented or provided.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for three residents. For one resident, the MDS inaccurately documented that the resident received an insulin injection, when in fact the resident only received a semaglutide injection and no insulin. This was confirmed by both the Medication Administration Record (MAR) and the MDS Coordinator. For another resident, the MDS assessment failed to reflect that the resident had received Restorative Nursing Program (RNP) services, including both active and passive range of motion exercises, within the seven days prior to the assessment, despite documentation showing these services were provided. The MDS Coordinator acknowledged that these services should have been included in the assessment. Additionally, a third resident's MDS assessment inaccurately indicated the presence of a stage 2 pressure ulcer, when the resident actually had an open blister and cellulitis on the lower left leg, but no pressure wounds. This discrepancy was confirmed through review of the skin assessment, physician's orders, and interview with the MDS Coordinator. In each case, the inaccurate MDS assessments were identified through record review and staff interviews, demonstrating a failure to accurately assess and document the residents' conditions and care provided.
Failure to Revise Care Plans with Updated Resident Information and Interventions
Penalty
Summary
The facility failed to ensure that care plans were revised to reflect the most current information and interventions for four residents. For one resident, documentation showed repeated refusals of showers, but the care plan was not updated to address these refusals or to specify actions staff could take to encourage bathing. Another resident experienced a fall and was subsequently placed under increased monitoring and redirection, but these interventions were not added to the care plan. In both cases, staff confirmed that the care plans were not revised as required following changes in the residents' conditions or care needs. Additionally, a resident with a history of falls and dementia had new interventions ordered, including a fall mat, bed in the lowest position, and a new medication for anxiety, but these were not incorporated into the care plan. Another resident was prescribed an additional anti-anxiety medication, but the care plan was not updated to reflect this change. Interviews with the MDS Coordinator and DON confirmed that the care plans did not include these new interventions or medications, despite expectations that care plans be revised with any changes in resident care.
Failure to Follow Physician Orders for Medication and Wound Care
Penalty
Summary
Facility staff failed to follow professional standards of practice for two residents regarding medication administration and wound care. For one resident with a diagnosis of essential hypertension, physician orders specified that staff should withhold amlodipine and notify the physician if the systolic blood pressure exceeded 180, diastolic exceeded 100, or pulse was less than 50. Despite multiple documented instances where the resident's blood pressure was above 180 and pulse was below 50, staff continued to administer the medication and did not notify the physician as required. Review of the medication administration record and progress notes confirmed that no physician notification occurred during these episodes. For another resident diagnosed with cellulitis in both legs, staff performed wound care on both legs, although physician orders were only present for wound care on the left leg. The resident confirmed that wound care was being performed on both legs, and staff interviews corroborated that wound care was provided to the right leg without a corresponding physician order. The treatment administration record only documented wound care for the left leg, and the Director of Nursing confirmed that staff were expected to obtain orders before performing wound care on the right leg, which was not done. These findings were based on record reviews, staff and resident interviews, and direct observation. The deficiencies involved failure to notify the physician as required by orders and performing wound care without appropriate physician authorization, both of which did not meet professional standards of practice.
Failure to Provide and Document Resident-Preferred Activities
Penalty
Summary
The facility failed to provide an ongoing activity program tailored to a resident's personal preferences, as identified in the resident's Annual MDS assessment. The resident's care plan did not include her stated preferences for activities such as spiritual/religious activities, music, and reading materials. Documentation for several months showed no evidence that these preferred activities were offered or provided, and there was no record of activity participation or refusals for these preferences. During interviews, the resident reported not being offered in-room activities, including those she specifically desired, such as prayer, bible study, music, games, arts/crafts, and gardening. She also stated that staff did not engage with her in conversation or watch TV with her. The Activities Director confirmed the accuracy of the resident's preferences as documented in the MDS assessment and acknowledged that not all activities provided were documented in the resident's chart.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure that residents received physician visits at least every 60 days, as required. Record reviews for four residents revealed significant lapses between physician visits, with intervals far exceeding the mandated 60-day period. For example, one resident was seen by the Medical Director on two occasions several months apart, and another had not been seen by a physician since the previous year. These findings were confirmed by the Director of Nursing (DON) during interviews, who acknowledged that the required frequency of physician visits was not met for these residents. The DON also stated that while the physician visited the facility weekly and saw new admissions, residents on skilled services, those with specific needs, and all residents annually, there was no evidence that all residents received face-to-face physician visits at least every 60 days. The lack of timely physician assessments was documented in the electronic medical records and verified through staff interviews, demonstrating a pattern of non-compliance with regulatory requirements for physician oversight.
Failure to Complete Timely CNA Performance Review
Penalty
Summary
The facility failed to complete a performance review at least every 12 months for one certified nurse aide (CNA). Record review showed that the CNA was hired on 07/18/11 and the last documented performance review was on 02/20/24. During an interview, the Human Resource Manager confirmed that no more recent performance evaluation had been completed for this CNA. This deficiency was identified through interview and record review, and it specifically involved the lack of timely performance evaluation for the CNA as required.
Failure to Document Rationale for Not Implementing Pharmacist Medication Recommendations
Penalty
Summary
The facility failed to ensure that the consultant pharmacist's recommendations regarding gradual dose reductions (GDR) and medication regimen reviews were properly reviewed and implemented by the attending physicians or that appropriate, patient-specific rationales were documented when recommendations were not followed. In multiple cases, the medical director or attending physician either disagreed with the pharmacist's recommendation or chose to maintain the current medication regimen, but did not provide the required rationale with patient-specific information in the residents' medical records. For several residents with psychiatric diagnoses such as anxiety disorder, depression, major depressive disorder, panic disorder, and psychotic disorder, the pharmacist made recommendations to evaluate the necessity of ongoing psychotropic and anxiolytic medications, including sertraline, trazodone, escitalopram, hydroxyzine, buspirone, lorazepam, mirtazapine, and Nuplazid. Despite these recommendations, the medical director or provider often marked disagreement or chose to maintain the current dose, but failed to elaborate with patient-specific reasons for not attempting a GDR or discontinuation, as required by federal guidelines. This pattern was observed across multiple residents, with forms signed and dated by the provider but lacking the necessary documentation of clinical justification. Interviews with the Director of Nursing (DON) confirmed that the pharmacist's recommendations were not implemented and that the required rationales for not performing GDRs were not provided in the medical records. The documentation reviewed included medication administration records, physician orders, pharmacist recommendations, and summary reports, all of which consistently showed the absence of patient-specific rationales when recommendations for dose reduction or medication discontinuation were declined by the provider.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to ensure that three out of four sampled residents received necessary dental services, including routine dental care and annual oral inspections. One resident reported needing her dentures checked due to looseness, but medical records confirmed she had not been seen by a dentist since admission. Another resident's Power of Attorney stated that a dental filling had fallen out approximately six months prior, and although the issue was reported to staff and a dental appointment was requested, there was no evidence the resident was seen by a dentist after the incident. Documentation also noted ongoing oral issues, such as red and irritated gums and a broken tooth cap, with instructions for a dental appointment, but no follow-up occurred. A third resident reported experiencing a toothache and stated he had not seen a dentist since admission. The Director of Nursing was unaware of the resident's toothache and confirmed that no monthly dental assessments were present in the record, nor had the resident received dental care during his stay. Physician orders and treatment records for all three residents included dental consults as needed, but these were not acted upon, resulting in a lack of dental services for the affected residents.
Incomplete and Inaccurate Medical Record Documentation for Two Residents
Penalty
Summary
Facility staff failed to ensure that medical records were complete and accurate for two residents. For one resident, physician orders indicated acetaminophen was to be administered as needed for pain, and the medication administration record (MAR) showed multiple instances where the medication was given along with the resident's reported pain level. However, staff did not consistently document the specific reason for administration, the location of the pain, or whether the medication was effective, except for one instance where throat pain was noted. The Director of Nursing (DON) confirmed that staff did not document the required information and acknowledged that such documentation is expected to help guide further treatment decisions. For another resident, the admission record did not list any mental health diagnoses, despite physician orders and provider progress notes indicating a diagnosis of major depressive disorder (MDD) and ongoing orders for mirtazapine to treat depression and appetite. Staff failed to update the resident's electronic medical record (EMR) to include the diagnosis of MDD, as confirmed by the DON. The expectation was that all new diagnoses should be promptly updated in the EMR, but this was not done for this resident.
Failure to Ensure Completion of Effective Communication Training for Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff completed the mandatory Effective Communication training, as evidenced by the absence of completion dates on the online training transcripts for three staff members: a registered nurse, a licensed practical nurse, and a certified nursing assistant. Record reviews confirmed that these staff members had not completed the required training. During an interview, the Human Resource Manager verified that the Effective Communication Training had not been completed for these individuals. This deficiency was identified through both documentation review and staff interview, indicating a lapse in the facility's training program for direct care staff regarding effective communication.
Failure to Provide Resident Rights Training to Staff
Penalty
Summary
The facility failed to provide resident rights training to four out of five sampled staff members, including registered nurses, a licensed practical nurse, and a certified nursing assistant. Record reviews showed that these staff members did not complete the required training on resident rights, which is intended to help staff promote and protect the rights of each resident and emphasize individual dignity and self-determination. During an interview, the Human Resource Manager confirmed that these staff members had not completed the training. No information about residents' medical history or condition at the time of the deficiency was provided in the report.
Failure to Ensure Completion of Mandatory QAPI Training by Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff completed the mandatory Quality Assurance and Performance Improvement (QAPI) training. Record reviews of employee training transcripts revealed that a registered nurse, a licensed practical nurse, and a certified nursing assistant had not completed the required QAPI training. This was confirmed during an interview with the Human Resource Manager, who acknowledged that these staff members had not fulfilled the training requirement. The deficiency was identified through a review of training records and staff interviews.
Failure to Ensure Annual Infection Control Training for Staff
Penalty
Summary
The facility failed to ensure that all required staff completed annual infection control training as part of its infection prevention and control program. Record review showed that one certified nursing assistant completed infection control training in November 2022 and one registered nurse completed the training in December 2023, but neither had completed the required training for the current year. During an interview, the Human Resource Manager confirmed that these staff members had not fulfilled the annual training requirement for 2025, despite the facility's policy that mandates yearly completion of infection control training. This lapse in training was identified through review of staff training records and confirmed by facility staff, indicating that the infection prevention and control program's standards, policies, and procedures were not fully implemented for all staff as required.
CNA Did Not Receive Required Annual In-Service Training
Penalty
Summary
The facility failed to ensure that a certified nursing assistant (CNA) received the required minimum of 12 in-service training hours within a year of their hire date. Record review showed that the CNA, hired on 07/18/11, had only completed 1 in-service training hour during the review period. This was confirmed by the Human Resource Manager during an interview, who acknowledged that the CNA did not meet the annual in-service training requirement. The report specifically notes the lack of adequate training hours for this CNA, with no mention of other staff or residents directly affected in the findings.
Failure to Obtain and Document Medication Consent for Psychotropic Drugs
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were informed in advance about the medications they were receiving, including the reasons, risks, and benefits associated with those medications. For one resident with a physician's order for trazodone to address sleep issues related to systolic heart failure, staff did not document obtaining consent for the medication. The Director of Nursing (DON) confirmed that the required psychotropic medication consent form was not completed prior to the resident starting the medication, as expected by facility policy. Similarly, another resident had physician's orders for hydroxyzine for anxiety and trazodone for insomnia, but staff did not document consent for either medication. The DON confirmed that staff failed to obtain the necessary consent forms for both medications. The DON also stated that nurses are expected to obtain verbal consent before administering the first dose and then follow up with a written consent signed by the resident's power of attorney, but this process was not followed in these cases.
Failure to Complete Admission MDS Assessment Within Required Timeframe
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set (MDS) assessment within 14 calendar days after admission for one resident. Record review showed that the resident was admitted on a specific date, but the Admission MDS assessment was not accepted until a much later date, exceeding the required 14-day timeframe. During an interview, the MDS Coordinator confirmed that the assessment was not completed within the mandated period and acknowledged that Admission MDS assessments should be completed within 14 days of admission. This lapse in timely assessment was identified through record review and staff interview, and it specifically affected one of nine residents reviewed for MDS compliance.
Failure to Timely Complete Significant Change MDS Assessment After Resident Placed on Palliative Care
Penalty
Summary
A significant change in condition assessment was not completed within the required timeframe for a resident who experienced a major decline and was placed on palliative care. The resident was admitted and subsequently had physician orders initiated for palliative care due to declining health and failure to thrive. Nursing progress notes confirmed the resident's placement on palliative care, indicating a significant change in condition. However, the Minimum Data Set (MDS) assessment reflecting this significant change was not completed and signed off by the RN until 15 days after the determination of the change, and was not accepted until even later. The MDS coordinator confirmed that the assessment was not completed within the mandated 14-day period following the determination of the significant change.
Failure to Complete Timely Quarterly MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were completed every three months for two of nine residents reviewed. Specifically, quarterly MDS assessments for these residents were not completed within the required timeframe, as they were conducted 92 days after the previous assessment reference date. This was confirmed through record review and an interview with the MDS Coordinator, who acknowledged that the quarterly MDS assessments for the affected residents were not completed on time.
Failure to Timely Complete and Submit MDS Assessments
Penalty
Summary
The facility failed to complete, submit, and finalize Minimum Data Set (MDS) assessments within the required timeframe for nine residents. Record reviews showed that for each of these residents, the MDS 3.0 Missing OBRA Assessment Report indicated that the assessments were not received by the state, despite having established target dates. The residents involved had documented admission records, but their corresponding MDS assessments were not transmitted as required. During interviews, the facility's MDS coordinator was unable to explain the reason for the delayed submissions and indicated a need to consult with the facility's MDS consultant. Additionally, the State Agency MDS Coordinator confirmed that the assessments had not been received and that the facility had been sent error messages related to these missing assessments.
Baseline Care Plan Omission for High-Risk Medication
Penalty
Summary
The facility failed to create an accurate baseline care plan for a resident who was admitted with an order for trazodone, an antidepressant medication classified as high-risk. Upon review of the resident's admission record and hospital medication list, it was found that the resident had an order for trazodone to be administered as needed for sleep. The physician's order confirmed the medication and its purpose related to the resident's systolic (congestive) heart failure. However, the baseline care plan developed for the resident did not include the order for trazodone. During an interview, the Director of Nursing confirmed that the resident had an order for this high-risk medication and acknowledged that the baseline care plan should have included all high-risk medications, but it did not in this case.
Failure to Develop Person-Centered Comprehensive Care Plans
Penalty
Summary
The facility failed to develop accurate, person-centered comprehensive care plans for two residents, as required. For one resident, the Annual MDS Assessment documented personal preferences for activities, but these preferences were not included in the resident's care plan. The Activities Director confirmed that the care plan did not reflect the resident's stated preferences from the MDS Assessment. For another resident, documentation showed that the resident is a Jehovah's Witness and values religious practices, as indicated in both the Activities Initial Review and the MDS Assessment. However, the care plan did not include information about the resident's religion, specific beliefs, or which activities the resident could or could not participate in. The MDS Coordinator confirmed that this information was communicated by the resident and documented elsewhere, but was not incorporated into the comprehensive care plan.
Failure to Place Fall Mat as Ordered for Resident with Fall History
Penalty
Summary
Staff failed to ensure that a fall mat, as ordered by the physician, was in place next to a resident's bed when the resident was in bed. The resident had a documented history of falls and a diagnosis of dementia, and after a previous fall, the care plan included placing a fall mat and keeping the bed in the lowest position when the resident was in bed. Despite these orders, observations on two separate occasions found the fall mat folded up next to the bathroom rather than positioned next to the bed while the resident was in bed with the bed in the lowest position and the head elevated. Interviews with the resident's family member, an LPN, and the DON confirmed that the fall mat was supposed to be next to the bed whenever the resident was in bed, in accordance with the physician's order and the resident's fall history. The staff's failure to follow these orders and ensure the fall mat was properly placed constituted a deficiency in providing adequate supervision and accident prevention for the resident.
Failure to Provide Annual Abuse, Neglect, and Exploitation Training to RN
Penalty
Summary
The facility failed to provide required annual training on abuse, neglect, and exploitation to one registered nurse. Review of the nurse's training transcript showed that the last completion date for this training was 12/31/23, indicating that the training had not been completed within the required timeframe. During an interview, the Human Resource Manager confirmed that the nurse had not completed the necessary training since 2023 and acknowledged that the training is required to be completed annually.
Failure to Provide Required Behavioral Health Training to Staff
Penalty
Summary
The facility failed to provide required behavioral health training to one certified nursing assistant (CNA) out of five staff members reviewed for training compliance. Record review showed that the CNA did not complete the behavioral health training as required. During an interview, the Human Resource Manager confirmed that the CNA had not completed the annual behavioral health training for the current year, despite the requirement for annual completion.
Failure to Promote Resident Self-Determination
Penalty
Summary
The facility failed to promote resident self-determination by not accommodating the wishes of three residents to go out into the community. This deficiency was identified through an anonymous complaint and interviews with the residents and the Activities Director. The complaint revealed that residents had not left the facility for non-medical reasons for over a year and expressed a desire to go shopping. The Activities Director confirmed that the facility had not resumed regular community outings after the COVID-19 pandemic, despite previously taking residents shopping and to the casino. Interviews with the residents confirmed that the facility had stopped taking them shopping for several years, but shopping trips had recently resumed. The deficiency was cited as past noncompliance, as the facility had already taken steps to address the issue before the survey investigation. The residents confirmed that they had participated in shopping trips in the current year, although one resident had not felt up to going but was offered the opportunity.
Failure to Provide RN Services for Required Hours
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. This deficiency was identified through a review of staff timesheets from 04/22/24 through 05/21/24, which revealed that the facility did not have an RN present for the required hours on four specific dates. On 04/26/24, the RN worked for 5 hours and 45 minutes; on 05/04/24, no RN hours were worked; on 05/10/24, the RN worked for 7 hours and 36 minutes; and on 05/13/24, the RN worked for 7 hours and 18 minutes. The administrator confirmed these findings during an interview on 05/22/24 at 3:18 PM. This deficiency could affect all 25 residents in the facility, as identified on the facility census list provided by the Director of Nursing on 05/19/24.
Failure to Document Refrigerator and Freezer Temperatures
Penalty
Summary
The facility failed to document the temperature of the walk-in refrigerator and walk-in freezer, which could potentially affect all 25 residents who consume food prepared in the kitchen. Record reviews revealed that temperatures were not documented on five specific dates for both the refrigerator and freezer. During an interview, the Dietary Manager (DM) confirmed the missing entries and acknowledged that temperatures should be documented three times a day. The DM also stated that kitchen staff are trained to check and document temperatures daily, and her expectation is that staff accurately record the temperatures as observed.
QAPI Committee Lacks Policies and Procedures
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) Committee failed to establish and implement policies and procedures for feedback, data collection systems, monitoring, and adverse event monitoring. This deficiency was identified through a record review of the QAPI Committee binder, which revealed the absence of any policies and procedures. During an interview, the Administrator confirmed the lack of QAPI policies and procedures, stating that the facility was in the process of updating them due to the ineffectiveness of previous policies and the need to retrain new staff on the updated procedures.
Failure to Implement Water Management Program for Infection Control
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, specifically by not having a water management program to minimize the risk of Legionella and other opportunistic pathogens in the building's water system. This deficiency was identified through record review and interviews with the Maintenance Director, Administrator, and Infection Control Nurse, all of whom confirmed the absence of such a program. The Maintenance Director was unaware of any water management program, did not have a map of the water system, and did not know where Legionella or other waterborne pathogens could grow. The Administrator and Infection Control Nurse also confirmed the lack of a water management program and any actions to minimize the risk of these pathogens. This failure could potentially affect all 25 residents living in the facility, as identified by the Resident Matrix provided by the Administrator. The absence of a water management program to control Legionella and other opportunistic pathogens poses a significant risk to the health and safety of the residents, as these bacteria can cause serious illnesses, particularly in individuals with compromised health. The findings highlight a critical gap in the facility's infection control measures, which are essential for preventing the spread of communicable diseases and infections.
Care Plan Revision and Meeting Deficiencies
Penalty
Summary
The facility failed to ensure care plan revision and care plan meeting requirements for six residents. For one resident, the care plan was not updated to reflect the current treatment for a diabetic ulcer on the left heel, including the presence of a skin graft and the involvement of an outside wound care provider. Another resident's care plan did not reflect their actual functional abilities as documented in their MDS assessment, leading to discrepancies in the level of assistance required for activities of daily living (ADLs). Additionally, two residents had issues with their dentures that were not documented in their care plans, despite staff being aware of the problems and the residents expressing concerns about their dental care and the fit of their dentures. The facility also failed to document a pressure ulcer in another resident's care plan, even though the ulcer was acquired in the facility and had been treated over a period of time. The care plan did not include any information about the pressure ulcer, its treatment, or its healing status. Furthermore, the facility did not hold a care plan meeting within seven days after the completion of the MDS assessment for one resident, and the interdisciplinary team (IDT) participation in the care plan meeting was incomplete. The care plan meeting did not include input from the resident's provider or CNAs, and the nurses, although invited, did not usually attend. These deficiencies could result in care plans not being updated with the most current resident conditions and appropriate interventions, staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions. The Director of Nursing (DON) confirmed the lack of updates and documentation in the care plans during interviews, highlighting the facility's failure to maintain accurate and current care plans for its residents.
Failure to Provide ROM Services and RNP
Penalty
Summary
The facility failed to ensure residents received appropriate treatment and services to maintain or prevent a decrease in range of motion (ROM) for some of the 25 residents who could benefit from therapy services or a restorative nursing program (RNP). The facility did not have a process to evaluate residents for ROM needs or provide services to residents who could benefit from an RNP. The Director of Rehabilitative Services (DOR) confirmed that rehabilitative services staff do not evaluate every resident for ROM needs and therapy evaluations are only completed for residents with an order. Additionally, the facility does not have an RNP, and therapy does not recommend RNP for residents who do not qualify for therapy services or when they discharge from therapy. Several residents in the facility could benefit from an RNP, but no specific residents were identified by the DOR. One resident, identified as R #156, was observed laying in bed with the head of the bed flat and with bent fingers on his left hand. The resident had been unable to sit up for nine years, had arthritis in his hands, wrists, elbows, and fingers, and expressed a desire to bend his hips to sit in a chair. R #156 had not had a physical or occupational therapy evaluation since admission and had no orders for therapy or restorative nursing services. The care plan for R #156 did not include interventions for increasing mobility or preventing a decrease in ROM. Interviews with the DOR, CNA #21, and the DON confirmed that R #156 had not been evaluated for therapy, CNAs were not trained or expected to complete ROM exercises, and the facility did not have an RNP.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure that residents had a physician visit at least every 60 days for three of the five residents reviewed. Specifically, Resident #52 was admitted to the facility and had their last physician visit on 12/17/23. Resident #53 was admitted and had their last physician visit on 11/11/23. Resident #54 was admitted and had their last physician visit on 12/17/23. These findings were confirmed by the medical records clerk and the Director of Nursing (DON) during interviews on 05/22/24. The lack of timely physician visits was verified through the review of the residents' Electronic Medical Records (EMR). Additionally, Resident #202 was admitted on 11/13/18 and had their last physician visit on 01/13/24, with no follow-up progress notes available despite requests for all physician progress notes by the DON. The deficiency was identified through record reviews and interviews, which revealed that the facility did not comply with the requirement for residents to have a physician visit at least every 60 days. The medical records clerk and the DON confirmed the dates of the last physician visits for the residents in question, indicating a lapse in the required medical assessments. This failure to ensure timely physician visits could potentially delay care and treatment for the residents' medical conditions, as noted in the report.
Failure to Provide Necessary Dental Services
Penalty
Summary
The facility failed to ensure residents obtained necessary dental services, resulting in deficiencies for two residents. Resident #102 had dentures that did not fit properly, causing them to float and move in his mouth. Despite CNA #11 reporting the issue to the nurse multiple times, no action was taken to address the problem. The Director of Nursing (DON) confirmed the issue but admitted that Resident #102 had not been to a dentist, which was necessary to resolve the problem with the dentures. Resident #202 also did not receive appropriate dental care. The resident's family member reported that Resident #202 had not been taken to the dentist for an unspecified period. A review of the medical record confirmed that Resident #202 had not seen a dentist since admission, and no dental appointments were scheduled. LPN #32 corroborated that there were no dental appointments for Resident #202, indicating a lack of routine dental care for the resident.
Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure medical records were complete and accurate for one of the four residents reviewed for documentation accuracy. Specifically, a Licensed Practical Nurse (LPN) documented a wound on a resident's left outer heel as a diabetic foot ulcer, while a wound care consultation note later identified the wound as a stage 2 pressure ulcer. The Director of Nursing (DON) confirmed the discrepancy, acknowledging that the LPN had documented the wound incorrectly. This inaccuracy in medical records has the potential to negatively impact the care provided to the resident.
Failure to Provide Behavioral Health Training for Staff
Penalty
Summary
The facility failed to provide behavioral health training for three staff members, including an RN, an LPN, and a CNA, out of four staff sampled for training. This deficiency was identified through record reviews and interviews. The records revealed that residents with significant mental health diagnoses, such as unspecified mood disorder, schizoaffective disorder, bipolar type, and anxiety disorder, were admitted to the facility. However, the staff members in question did not complete the necessary training to address these behavioral health needs. The Administrator and the Director of Nursing (DON) confirmed that these staff members had not received additional training despite their roles involving direct interaction with all residents, including those with mental health diagnoses. The hire dates for the staff members ranged from 2006 to 2023, indicating that the lack of training was not a recent oversight but a persistent issue. The facility's failure to ensure that these staff members were adequately trained in behavioral health could likely result in residents not receiving the necessary services to maintain their well-being.
Failure to Complete MDS Assessments Within 14 Days
Penalty
Summary
The facility failed to ensure a comprehensive Minimum Data Set (MDS) Assessment was completed within 14 calendar days after admission for two residents. Resident #151 was admitted on [DATE], and their Admission MDS assessment was still in progress and not completed by 05/22/24. Similarly, Resident #156 was admitted on [DATE], and their Admission MDS assessment was also still in progress and not completed by 05/22/24. The Infection Control Nurse confirmed that both assessments were not completed within the required timeframe, which could likely result in residents' preferences and care needs not being met.
Failure to Develop Comprehensive Care Plan for Edema
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was admitted with a condition of edema. Despite having physician's orders to apply and remove TED hose daily and monitor for edema every shift, these interventions were not included in the resident's care plan. The resident confirmed during an interview that she experiences leg swelling and wears stockings daily to manage it. The Director of Nursing (DON) acknowledged that the care plan did not include the necessary treatment and monitoring for edema as ordered by the physician.
Failure to Enter Physician's Orders for Behavioral Health Treatment
Penalty
Summary
The facility failed to ensure that physician's orders were entered for a resident reviewed for behavioral health. The resident's Power of Attorney (POA) reported that the resident had been experiencing depression and had not been eating or drinking well. The POA had spoken with the facility doctor, who indicated that a medication would be ordered to help with the resident's depression and appetite. However, a review of the resident's medical record revealed no orders or progress notes from the provider's visit on the specified date. Interviews with the LPN and Medical Records Clerk confirmed that there were no progress notes or physician's orders in the resident's electronic medical record or in the binder at the nurse's station. The provider's progress note indicated that Mirtazapine was to be ordered, but no such order was found in the resident's records. Further interviews confirmed that the provider is expected to deliver or fax progress notes to medical records after each visit, and the medical records clerk is responsible for giving these notes to the nurses to review and enter any orders. The facility acknowledged the communication gap and indicated that they are working on developing a better way of communicating with the provider. The failure to enter the physician's order for Mirtazapine could likely result in the resident not receiving the appropriate medication or treatment, potentially leading to a worsening of the resident's condition.
Call Light System Deficiency
Penalty
Summary
The facility failed to ensure that call lights were functional and accessible in residents' bedrooms, specifically for one resident out of three randomly sampled. During an observation, it was noted that the call light cord was missing in the bedroom of one resident. The resident confirmed in an interview that she did not have a call light cord and expressed frustration that aides did not respond to her needs. An LPN also confirmed the absence of the call light cord and mentioned that the resident did not use her call light.
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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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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