New Mexico State Veterans Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Truth Or Consequences, New Mexico.
- Location
- 992 South Broadway, Truth Or Consequences, New Mexico 87901
- CMS Provider Number
- 325092
- Inspections on file
- 25
- Latest survey
- December 27, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at New Mexico State Veterans Home during CMS and state inspections, most recent first.
The facility failed to provide adequate mental health services for two residents with mental health diagnoses, including Bipolar Disorder, Depression, and PTSD. One resident expressed feelings of depression and hopelessness without receiving psychiatric evaluation or behavioral health services. Another resident on hospice expressed a wish to die, yet there was no documentation of social services provided. The facility lacked psychiatric providers, and interventions were limited to medication and chaplain visits.
A facility failed to honor a resident's right to self-determination by not allowing him to leave independently, despite having a contract for independent travel. The resident, who was cognitively intact, expressed his desire to leave the facility on his own, particularly for church, but was repeatedly informed by staff that he could not do so without supervision due to safety concerns.
The facility failed to meet care plan requirements, including the absence of key IDT members in meetings, delayed care plan meetings, and outdated care plans. These deficiencies affected residents with conditions like edema, fall risks, and mental health issues, as their care plans lacked necessary interventions and updates.
A resident with a broken bottom front tooth did not receive timely dental services due to the facility's failure to follow standard procedures. Despite the resident's request for a dental referral upon admission, no referral order was placed in the medical record, and transportation staff were not informed. The resident was only scheduled for a routine dental appointment later in the year, highlighting a lapse in care coordination.
A facility failed to provide a resident and their representative with written notifications of hospital transfers, omitting essential information such as contact details for the Ombudsman and appeal rights. The facility did not document or send transfer notices, as confirmed by staff interviews and the Ombudsman.
A facility failed to provide a resident and their representative with a written notice of the bed hold policy during hospitalizations. The resident was transferred to the hospital twice, and the facility did not document the duration for which the bed would be held or provide the necessary notification. Interviews revealed inconsistencies in procedures, with outdated forms being used and a lack of clarity regarding bed hold days for residents with specific payment sources.
A facility failed to finalize a resident's annual MDS assessment within the required 7-day period. The assessment, with an ARD in early October, was not signed off by the MDS/RN Coordinator until late November and was only marked as export ready for transmission the following day. This delay could likely lead to staff being unaware of the resident's current status and needs.
The facility failed to ensure accurate MDS assessments for three residents, leading to potential misinterpretations of their needs. One resident was incorrectly noted as unable to communicate pain, despite being cognitively intact and able to express pain levels. Another resident's MDS inaccurately documented anticoagulant use, which was not prescribed. A third resident was also misassessed regarding communication abilities, despite being able to verbally express pain.
A long-term care facility failed to meet professional standards of quality care for four residents due to medication management issues. Two residents did not receive their prescribed medications because they were unavailable, and the facility did not notify the physician or document communication with the pharmacy. Another resident received partial doses of insulin and refused trazodone without the physician being informed. Additionally, a resident did not receive Ditropan due to unavailability, and the staff failed to contact the pharmacy or notify the physician.
A facility failed to develop an individualized discharge plan for a resident, which is crucial for a safe transition to the post-discharge setting. The resident's medical record lacked documentation of discharge goals, needs, summary, recapitulation of stay, and medications. The DON confirmed the absence of these records during an interview.
A facility failed to complete a discharge summary for a resident discharged to their home. The resident's EMR lacked a recapitulation of stay, medication list, and discharge summary. The DON confirmed that the staff did not complete the necessary documentation at the time of discharge, and there was no evidence that a discharge summary was provided to the resident.
A resident in the facility expressed a need for hearing aids and had an appointment a year ago but never received them. Despite informing staff multiple times, no action was taken to address the issue. A review of the resident's records showed no documentation of any intervention or audiologist appointment. Staff interviews confirmed the resident's need was communicated, but no appointment was scheduled.
The facility failed to inform two residents of changes to their smoking privileges, resulting in confusion and dissatisfaction. One resident, cognitively intact, was unaware of the smoking schedule and expressed frustration over not being able to keep smoking items. Another resident, with moderate cognitive impairment, was not informed of the changes in smoking rules. The smoking schedule was not posted, and staff were unaware of the correct smoking times.
The facility failed to implement proper infection control measures for residents diagnosed with COVID-19 in the D Unit. Staff wore N95 masks but did not use other PPE, and there were no precaution signs or accessible PPE outside residents' rooms. Interviews revealed inconsistencies in infection control practices, with staff unaware of which residents were under COVID-19 precautions. The facility did not follow its COVID protocols or CDC guidelines, potentially risking the spread of infection.
A facility failed to develop an accurate baseline care plan within 48 hours of admission for a resident, which is essential for immediate care. The resident had specific physician's orders for a bland diet, fluid restrictions, and Jevity 1.2 via a peg tube, along with water flushes before and after medication. However, these interventions were not included in the baseline care plan, an omission confirmed by the DON.
The facility failed to complete a comprehensive MDS within 14 days for a resident admitted on [DATE]. The assessment was still in progress and not completed by 05/08/24, as confirmed by an LPN.
A facility failed to complete a baseline care plan within 48 hours of admission for a resident, omitting critical medications such as Seroquel, Sertraline, and Xanax. This was confirmed by an LPN during an interview.
A resident with Parkinson's disease did not receive their prescribed Sinemet medication on time due to an emergency situation that delayed the morning dose. This led to the omission of the 12:00 PM dose, contrary to the physician's orders and the resident's care plan.
Inadequate Mental Health Services for Residents
Penalty
Summary
The facility failed to provide adequate mental health services for two residents, R #62 and R #70, who were reviewed for mental health. R #62, who was admitted with diagnoses including Bipolar Disorder, Depression, Dementia, and PTSD, reported not receiving any behavioral health services since admission. Despite expressing feelings of depression and hopelessness, there was no documentation of a psychiatric consultation or evaluation by a psychiatric professional. The care plan for R #62 lacked interventions for his mental health diagnoses beyond medication administration and monitoring for side effects. R #62's medical records did not include orders for behavior monitoring or the effectiveness of prescribed medication for his mental health conditions. Interviews with staff revealed that the facility did not have a psychiatric provider or counselor, and interventions were limited to medication and occasional visits from a chaplain. The Director of Nursing confirmed the absence of a psychiatric referral and evaluation, and the care plan did not address all of R #62's mental health diagnoses. Similarly, R #70, who was admitted to hospice, expressed a wish to die and showed increased emotional distress. Despite these signs, there was no documentation of social services being provided, and the facility relied on hospice's assessment of the emotional state as part of the disease process. The facility's chaplain, who lacked a social work degree, was the primary source of emotional support, and the Director of Nursing acknowledged the lack of mental health care for R #70.
Failure to Honor Resident's Right to Self-Determination
Penalty
Summary
The facility failed to promote resident self-determination for one resident who was not allowed to leave the facility independently, despite having a contract that permitted independent travel. The resident, who was cognitively intact with a BIMS score of 15, expressed a desire to leave the facility on his own, particularly to attend church on Sundays. Despite his insistence and the existence of an Independent Travel Contract approved by the Interdisciplinary Care Team, the facility staff repeatedly informed him that he could not leave without staff supervision due to safety concerns. The resident's progress notes indicate multiple instances where he was reminded of the facility's policy requiring staff accompaniment when leaving the campus. The resident consistently asserted his right to leave independently, referencing his travel contract. Social services and nursing staff documented their attempts to communicate the facility's policy and safety concerns to the resident, as well as efforts to involve the resident's family in addressing the issue. However, the resident maintained his stance, leading to a deficiency in honoring his right to self-determination.
Deficiencies in Care Plan Development and Revision
Penalty
Summary
The facility failed to ensure that care plan requirements were met for several residents, leading to deficiencies in the care provided. For multiple residents, the required Interdisciplinary Team (IDT) members did not participate in care plan meetings. This included the absence of key personnel such as the Director of Nursing (DON) or Assistant Director of Nursing (ADON), and the physician or medical director was not invited to these meetings. This lack of comprehensive team involvement could result in incomplete care plans that do not fully address the residents' needs. Additionally, the facility did not hold a care plan meeting within the required seven days of completing the admission Minimum Data Set (MDS) assessment for one resident. This delay in care planning could lead to a lack of timely interventions and adjustments to the resident's care, potentially impacting their health and well-being. The facility also failed to revise care plans with the most current resident information for several residents. For instance, one resident's care plan did not reflect their edema condition or the interventions in place to manage it, such as the use of compression stockings and medication. Another resident's care plan did not document actual falls or the necessary interventions to prevent future falls. Furthermore, a resident with mental health diagnoses did not have a care plan that included all relevant diagnoses or non-pharmacological interventions, such as involving the Chaplain or social worker when showing signs of depression.
Failure to Schedule Dental Services for Resident with Broken Tooth
Penalty
Summary
The facility failed to ensure that a resident, identified as R #62, received necessary dental services for a broken tooth. Upon admission, R #62 informed the staff about a broken bottom front tooth and expressed a desire to see a dentist. Despite this, no action was taken to schedule a dental appointment. A review of R #62's nursing progress notes from March 2024 indicated that the resident reported the cracked tooth and requested a dental referral, but no referral order was placed in the medical record. Interviews with staff, including an LPN and the Director of Nursing (DON), confirmed that the standard procedure was not followed. The LPN acknowledged that a referral order should have been entered into the resident's medical record, and transportation should have been notified to schedule the appointment. However, the transportation staff was unaware of the issue and had only scheduled R #62 for a routine annual dental appointment later in December 2024. The DON confirmed that the staff failed to enter the necessary referral order for the resident to see a dentist.
Failure to Provide Transfer Notifications and Appeal Rights
Penalty
Summary
The facility failed to provide timely written notification to a resident and their representative regarding transfers to the hospital. The resident, who had trouble breathing and experienced a fall, was transferred to the hospital on two occasions. However, the facility did not provide the resident or their representative with written transfer notices, nor did they include necessary information such as the contact details for the Office of the State Long-Term Care Ombudsman or the resident's appeal rights. Additionally, the facility did not send a copy of the transfer notices to the Ombudsman. Interviews with staff, including an LPN and the DON, revealed that the facility did not have a process in place to complete or provide transfer notifications before or after hospital transfers. The staff did not document the required information in the resident's medical record or provide the resident with a transfer assessment. The Ombudsman confirmed that no transfer notices were received from the facility, indicating a systemic issue in the facility's notification process.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide a written notice of the bed hold policy to a resident and their representative during instances of hospitalization. The resident, identified as R #12, was transferred to the hospital on two occasions, once for abnormal laboratory results and another time after hitting his head during a fall. In both instances, the facility did not document the duration for which the bed would be held, nor did they provide the resident or his representative with the necessary written notification of the bed hold policy. The forms used by the facility lacked spaces to document the number of days the bed would be held, and there was no evidence that the resident or his representative received the notification. Interviews with staff, including an LPN and the Director of Nursing (DON), revealed inconsistencies in the facility's procedures. The LPN stated that nurses were responsible for completing a Bed-Hold Authorization & Agreement form and discussing the policy with alert residents. However, the DON confirmed that the Bed-Hold Authorization & Agreement form was outdated and should not have been used. Additionally, the facility's bed hold policy did not specify that residents with certain payment sources, such as the Veterans Administration, had an unlimited number of bed hold days. This information was not included in the notifications provided to the resident, leading to a lack of clarity and proper documentation regarding the bed hold policy for R #12.
Delayed Finalization of MDS Assessment
Penalty
Summary
The facility failed to ensure the timely finalization of the annual Minimum Data Set (MDS) assessment for one resident, which was not transmitted and accepted within the required 7-day period. Specifically, the resident's annual MDS assessment had an Assessment Reference Date (ARD) of October 10, 2024, but the MDS/RN Coordinator did not sign off on the assessment until November 20, 2024. Furthermore, the assessment was only marked as export ready for electronic transmission on November 21, 2024. This delay in finalizing the MDS assessment could likely lead to staff being unaware of the resident's current status and needs.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for three residents, which could result in an inaccurate understanding of their needs. For one resident, the MDS assessment indicated that a pain assessment interview was not conducted because the resident was rarely or never understood, despite the resident having a Brief Interview for Mental Status (BIMS) score indicating cognitive intactness and the ability to communicate pain levels verbally. This discrepancy was confirmed by an LPN who stated that the resident had no issues with communication. Another resident's quarterly MDS assessment inaccurately documented the use of an anticoagulant, which was not supported by the physician's orders. The Director of Nursing confirmed that the resident did not take anticoagulant medication. Additionally, a third resident's admission MDS assessment also failed to conduct a pain assessment interview due to the assumption of communication difficulties, despite the resident having a moderate cognitive impairment and being able to verbally communicate pain levels, as confirmed by an LPN.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to meet professional standards of quality care for four residents due to several medication-related issues. For two residents, the facility did not notify the physician when medications were unavailable. Resident #18 did not receive amitriptyline for neuropathy on multiple occasions in August 2024 because the medication was not available, and there was no documentation of the pharmacy being contacted or the physician being notified. Similarly, Resident #48 did not receive metolazone for edema on several days in November 2024, and again, there was no documentation of communication with the pharmacy or physician. Additionally, the facility failed to administer medications according to physician's orders for two residents. Resident #51 received only partial doses of insulin glargine on multiple occasions in October and November 2024, and there was no documentation of the physician being informed of these partial doses. Furthermore, Resident #51 refused trazodone on numerous occasions in November 2024, but the staff did not notify the physician of these refusals. Lastly, Resident #87 did not receive Ditropan for bladder control on several days in November 2024 due to the medication being unavailable. The staff documented the unavailability but did not contact the pharmacy or notify the physician. The Director of Nursing confirmed that staff should have contacted the pharmacy and documented their communication in the resident's progress notes.
Failure to Develop Individualized Discharge Plan
Penalty
Summary
The facility failed to develop an individualized discharge plan for a resident, which is necessary to ensure a safe transition from the facility to the resident's post-discharge setting. The resident was discharged on 09/27/24, but a review of the medical record revealed that the staff did not document a discharge plan, including the resident's discharge goals and needs. Additionally, the discharge summary, recapitulation of stay, and medications were not recorded in the resident's medical record. During an interview on 11/21/24, the Director of Nursing (DON) confirmed that the discharge goals or needs were not documented in the resident's charts.
Failure to Complete Discharge Summary
Penalty
Summary
The facility failed to ensure the completion of a discharge summary for a resident who was discharged to their home. The resident's Electronic Medical Record (EMR) lacked a recapitulation of the resident's stay, a medication list, and a discharge summary. During an interview, the Director of Nursing (DON) confirmed that the staff did not complete the discharge summary at the time of the resident's discharge. The DON also acknowledged that the staff should have completed and signed the resident's recapitulation of stay on the same day as the discharge. There was no documentation indicating that a discharge summary was provided to the resident.
Failure to Provide Hearing Aids to Resident
Penalty
Summary
The facility failed to ensure that a resident received proper treatment to maintain hearing, which could compromise their quality of life. The resident expressed a need for hearing aids and mentioned having an appointment a year ago but never received the aids or any follow-up information. Despite informing staff multiple times about the need for hearing aids, no action was taken to address the issue. A review of the resident's progress notes and medical records revealed no documentation of any intervention by staff to obtain hearing aids or refer the resident for an audiologist appointment. Interviews with staff, including a CNA and the Director of Nursing (DON), confirmed that the resident's need for hearing aids was communicated, but no appointment was scheduled. The DON stated that the protocol involved staff informing transportation to schedule appointments, but this was not done for the resident in question.
Failure to Inform Residents of Smoking Policy Changes
Penalty
Summary
The facility failed to ensure that residents were adequately informed of changes to their rights regarding smoking privileges. Two residents, one with a cognitive impairment and another cognitively intact, were not made aware of the smoking schedule or the locations where they could smoke. The facility's smoking policy, which states that smoking is a privilege and not a right, was not effectively communicated to these residents. One resident expressed frustration over not being able to keep their smoking items and not being informed of the smoking schedule, while the other resident was unaware of the changes in smoking rules and did not have a copy of the smoking schedule. The facility's documentation revealed inconsistencies, such as a signed smoking policy in one resident's medical record but not in the other's. Additionally, the smoking schedule was not posted in the housing units, and staff members, including a CNA, were unaware of the correct smoking times. The Director of Nursing confirmed that the smoking policy had changed earlier in the year, but the communication of these changes to residents was inadequate, leading to confusion and dissatisfaction among the residents.
Inadequate Infection Control Measures for COVID-19 in D Unit
Penalty
Summary
The facility failed to maintain proper infection prevention measures for residents diagnosed with COVID-19, particularly in the D Unit. Observations revealed that staff wore N95 masks but did not utilize other necessary personal protective equipment (PPE) such as gowns, gloves, or face shields. Additionally, there were no transmission-based precaution signs on residents' doors, and PPE was not readily accessible outside of residents' rooms but was instead located in a secured staff area away from resident care areas. Residents in common areas were not wearing masks, and staff did not enforce mask-wearing among residents. Interviews with various staff members, including a CNA, the Director of Nursing (DON), and the Infection Control Coordinator, highlighted inconsistencies and gaps in the facility's infection control practices. The DON and QAPI nurse were responsible for infection prevention and control, yet they did not ensure that proper precautions were in place, such as placing signs or PPE outside the rooms of residents diagnosed with COVID-19. The Infection Control Coordinator was unaware of which residents were recently cleared from COVID-19 precautions, indicating a lack of communication and tracking within the facility. The facility's COVID protocols and CDC guidelines were not adequately followed. The protocols required that residents with COVID-19 be quarantined and that staff wear appropriate PPE, including gowns and gloves, when interacting with infected residents. However, these measures were not implemented, and staff were not adequately informed or trained on the necessary precautions. The failure to adhere to these protocols and guidelines likely contributed to the potential spread of infection within the facility, affecting all residents on the D Unit.
Failure to Develop Accurate Baseline Care Plan
Penalty
Summary
The facility failed to create an accurate baseline care plan within 48 hours of admission for a resident, identified as R #8, which is necessary to properly care for them immediately upon their admission. The record review revealed that R #8 was admitted to the facility on an unspecified date and had specific physician's orders dated 09/06/24 and 09/07/24, which included a bland diet, no food by mouth, fluid restrictions, and Jevity 1.2 at 65 ml per hour via a peg tube, along with a requirement to flush 30 ml of water before and after medication administration. However, the baseline care plan dated 09/07/24 did not include interventions for the peg tube, such as the water flush and Jevity feeding. This oversight was confirmed during an interview with the Director of Nursing (DON) on 09/11/24, who acknowledged the omission in the baseline care plan.
Failure to Complete MDS Assessment Within 14 Days of Admission
Penalty
Summary
The facility failed to ensure a comprehensive Minimum Data Set (MDS) was completed within 14 calendar days after admission for one of the residents reviewed. Specifically, the resident was admitted on [DATE], but the Admission MDS assessment was still in progress and not completed by 05/08/24. This was confirmed during an interview with an LPN on 05/08/24 at 4:05 PM, who acknowledged that the assessment had not been completed within the required timeframe.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to complete a baseline care plan within 48 hours of admission for a resident, which is necessary to provide effective and person-centered care. The resident was admitted to the facility and had physician's orders for Seroquel, Sertraline, and Xanax. However, the baseline care plan created on the same day of admission did not include these medications. This omission was confirmed during an interview with an LPN, who acknowledged that the medications were ordered upon admission but were not included in the baseline care plan as required.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to ensure medications were administered as ordered by the physician for a resident diagnosed with Parkinson's disease. The resident was prescribed Sinemet 25-100 mg to be taken four times a day at specific times. However, on one occasion, the medication was not administered at the scheduled 12:00 PM time due to the morning dose being given late at 11:20 AM. This delay was caused by an emergency situation where the nurse had to send another resident to the hospital, resulting in the inability to administer the subsequent dose on time. The resident's care plan specifically indicated the need to administer medications as ordered and to monitor and document the effectiveness and side effects. Despite this, the Medication Administration Record (MAR) showed a missed dose, and the nurse's note confirmed the delay and subsequent omission of the 12:00 PM dose. This failure to administer the medication as scheduled could potentially impact the therapeutic effects of the treatment for the resident's Parkinson's disease.
Latest citations in New Mexico
Surveyors found that the facility did not provide required written transfer and bed-hold notices when several residents were sent to the hospital for events such as falls with injury, unresponsiveness, and episodes of nausea, vomiting, and bleeding. Medical records lacked written transfer notices and bed-hold notifications, and the transfer information that should have been given to residents or their representatives did not include mandated details about appeal rights, how to request an appeal, or how to contact the State LTC Ombudsman. The Social Services Director reported that she does not notify the Ombudsman of hospital transfers and only sends a monthly email list of discharged residents, without written copies of transfer or discharge notices.
Two cognitively impaired residents with dementia and significant behavioral and continence needs were sent to a local ER after falls and were discharged back to the facility’s care, but the facility failed to provide timely transportation for their return. In both cases, hospital discharge times were documented, yet ER staff reported making multiple unsuccessful calls to the facility, reaching the Administrator only after repeated attempts. One resident, described as very disoriented, remained in the ER for several hours after discharge without 1:1 supervision, while the other waited approximately 11 hours, during which ER staff observed increasing confusion and attempts to get out of bed. The Administrator acknowledged awareness of the discharges, the lack of 24-hour transportation, and that the residents were not picked up until many hours after they had been discharged from the ER.
Two residents who required staff assistance for ADLs and transfers reported neglectful and rude behavior by a CNA and delayed nursing response to care needs. One resident with a history of cerebral infarction and schizophrenia stated that a CNA mocked him and that his requested wound dressing change was not performed for several hours, which was later corroborated by video showing a long gap between the CNA’s visit and the nurse’s entry to the room. Another resident with a right femur fracture, type II DM, and repeated falls, who needed one-person assistance for mobility and self-care, reported that a CNA refused to help and told her she could do some care herself, making her feel she was not trying in her recovery. Documentation and interviews confirmed that staff did not provide timely wound care or required assistance, and that these interactions caused residents to feel uncomfortable and negatively about their care.
A resident with a history of opioid dependence and polysubstance abuse was on a secure unit with a care plan that included safety risk evaluations and monitoring for signs of substance abuse. Staff later observed the resident discarding an empty Suboxone packet, even though the resident was not prescribed this medication, and the incident was reported to the on-call provider with subsequent monitoring and a room search. However, the care plan was not revised to reflect this new substance-related event, and both the DON and Administrator acknowledged that the care plan should have been updated when this new risk and behavior were identified.
Surveyors identified that a medication cart on the north hall was left unlocked and unattended outside a resident room. An LPN acknowledged that the cart was hers and that she had not locked it before leaving to answer a call light, despite facility expectations. The DON confirmed that all medication and treatment carts are required to remain locked when not in use or when staff are away from them.
Surveyors found that a document containing multiple residents’ PHI, including full names, room numbers, and code status, was left unattended and visible on a south nurse’s station counter. An RN confirmed the document was a resident list with PHI and acknowledged it had been left exposed and that such information should not be left unattended.
Surveyors found that a lunch tray return cart containing uncovered, soiled food trays and dishes was left unattended in a main hallway outside an activity room. The housekeeping/laundry manager acknowledged seeing the unattended cart, and the Dietary Manager confirmed that such carts are supposed to remain only in designated areas, such as near the nurse’s station or in the kitchen, and should be returned to the kitchen for cleaning as soon as all trays are collected. This failure was cited as likely to expose all residents to potential pathogens associated with food waste.
Two residents with scheduled showers reported that they were offered or received showers in very cold water during a prolonged period when hot water was not reliably available in care areas. One resident stated he refused cold showers and was only offered sponge baths once or twice, despite his preference to stay clean. Another resident reported receiving cold showers, including being rinsed with cold water while still soaped, and subsequently began refusing showers and bed baths due to the cold water. A CNA confirmed that water in the shower rooms was “ice cold” for several months, leading to resident complaints and refusals, while the Maintenance Director reported that a needed part to correct the hot water problem was on back order, delaying resolution and resulting in the facility not honoring residents’ bathing preferences.
Surveyors observed that unused medications were improperly discarded in a trash bin attached to a medication cart on the north hallway, rather than being disposed of in a designated drug disposal container. Two pills, a round blue tablet stamped "61" and an oblong orange tablet stamped "20," were found together in an unlabeled medication cup in the trash. An RN confirmed the medications were discarded there and acknowledged that unused medications should be placed in the drug buster container in the cart drawer. The Unit Manager also confirmed that facility practice requires all unused medications to be disposed of using the drug buster and that controlled substances must be destroyed by two licensed staff and documented on the narcotic count sheet.
The facility failed to follow documented allergy information, diet orders, and meal tickets for three residents. A resident with a documented chocolate allergy was served chocolate ice cream after requesting it, and the Nutrition Director admitted not reading the allergy notation on the meal ticket. Another resident on a pureed diet received whole mandarin oranges instead of pureed fruit, which a CNA confirmed. A third resident whose meal ticket called for a grilled Swiss sandwich received a sandwich that was not grilled, as confirmed by a CNA and a dietary manager.
Failure to Provide Required Written Transfer, Appeal, Ombudsman, and Bed-Hold Notices During Hospitalizations
Penalty
Summary
Surveyors identified that the facility failed to provide required written transfer and bed-hold information for multiple residents who were hospitalized. For three residents who experienced transfers to the hospital after events such as falls with injury, unresponsiveness, and episodes of nausea, vomiting, and bleeding, record review showed there were no written transfer notices or written bed-hold notices in their medical records. Specifically, one resident transferred after a fall on 01/31/26 had no documented written transfer notice or bed-hold notice. Another resident transferred on 02/27/26 for nausea, vomiting, and bleeding, and later readmitted on 03/05/26, had no written transfer notification that included information on appeal rights or Ombudsman contact, and no written bed-hold notification. A third resident transferred on 01/29/26 after a fall with a forehead laceration and again on 03/17/26 for unresponsiveness, also had no documented written transfer or bed-hold notices for either hospitalization. The deficiency also included the facility’s failure to provide required content in transfer notices and to notify the State Long-Term Care Ombudsman in writing. For the residents reviewed, there was no evidence that written transfer notices were provided to the residents or their representatives in a language and manner they could understand, and the notices were missing required elements such as a statement of appeal rights, the name, mailing and email address, and phone number of the entity receiving appeals, and information on how to obtain and complete an appeal form. The notices also lacked the name, phone number, and mailing and email address of the State Long-Term Care Ombudsman, and written copies of the transfer notices were not sent to the Ombudsman. During interview, the Social Services Director confirmed that transfer and bed-hold notices were not documented for at least one resident’s hospitalization, that she does not notify the Ombudsman about transfers to the hospital, and that she only emails a monthly list of residents discharged from the facility without sending written copies of transfer or discharge notices.
Failure to Timely Retrieve Residents From ER After Discharge
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from neglect by not arranging timely transportation back to the facility after emergency room (ER) discharge. A consumer complaint alleged that residents sent to the local ER were being left there for extended periods after discharge. For one resident with an admission date of 10/13/25, records showed multiple cognitive and behavioral diagnoses, including Alzheimer’s disease, vascular dementia with agitation and other behavioral disturbances, mild cognitive impairment, cognitive communication deficit, and restlessness and agitation. A change of condition MDS documented a Brief Interview for Mental Status (BIMS) score of 1 and frequent incontinence of urine and bowel. Nursing progress notes for this resident showed that 911 was called at 3:00 AM and the resident was transferred to the ER after a fall. Hospital discharge instructions indicated the resident was discharged from the ER at approximately 5:21 AM, while the ER nurse reported discharge at about 5:30 AM. The ER nurse stated she made numerous calls to the facility but was unable to reach anyone. She reported that the resident was very disoriented and that the ER did not have enough staff to provide 1:1 supervision. The ER nurse eventually reached the Administrator, who stated staff would come to pick up the resident as soon as possible. Facility records showed the resident was not discharged from the facility on that date, and the ER nurse reported that facility staff did not pick the resident up until approximately 8:30 AM, several hours after discharge. A second resident, admitted on 11/25/25, had diagnoses including Alzheimer’s disease, dementia with behavioral disturbance, bipolar disorder with severe depression and psychotic features, depression, and anxiety disorder. The admission MDS documented a BIMS score of 2, frequent urinary incontinence, constant bowel incontinence, and a need for substantial/maximal assistance with toileting hygiene. Nursing notes showed this resident was sent to the ER for evaluation after a fall and did not return until the following morning. Hospital discharge instructions documented discharge from the ER at 10:16 PM, and the Administrator confirmed being notified of the discharge at about 10:30 PM and that the facility did not have 24-hour transportation. The Administrator acknowledged the resident was not picked up until approximately 9:00 AM the next day. The ER nurse reported making several calls to the facility that went to voicemail, eventually reaching the Administrator, who initially stated staff were on the way, then stopped answering calls. During the approximately 11-hour wait, the ER nurse stated the resident was confused, attempted to get out of bed, and became more confused as the night progressed.
Failure to Timely Provide Wound Care and Required Assistance, Resulting in Resident Neglect
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from neglect when staff did not respond appropriately to requests for care and assistance. One resident with a history of cerebral infarction due to embolism and schizophrenia, admitted on 01/30/26 and requiring staff assistance for ADLs and mechanical lift transfers, reported that a CNA was rude and mocking and that his wound dressing was not changed for several hours after he requested it. The Kardex showed he needed staff help for toileting, bathing, hygiene, bed mobility, dressing, and transfers. Nursing progress notes documented a change in condition on 03/02/26 after the resident stated the CNA was rude and would not assist as requested. The Administrator later confirmed, via video review, that the CNA entered the resident’s room at 2:30 am, the resident requested a dressing change, and no nurse entered the room until 5:00 am, despite the nurse’s statement that she went in “right away.” The DON also confirmed that the resident’s grievance described the wound dressing not being changed until hours after the request. Another resident, admitted with a right femur fracture, type II diabetes, and repeated falls, required one-person assistance for dressing, hygiene, bathing, bed mobility, and transfers, and could toilet herself with assistance for transfers. Nursing progress notes documented an alleged abuse incident on 03/02/26 in which this resident stated a CNA was rude, refused to help her, and told her she could perform some care tasks herself without staff assistance. An abuse questionnaire completed the same day showed the resident answered “Yes” to having interactions that made her feel uncomfortable or negative, and she reported that the CNA made her feel as though she was not trying with her own recovery. The Administrator and DON acknowledged that staff are expected to help residents as required and that staff interactions must be encouraging rather than making residents feel bad about needing assistance.
Failure to Revise Care Plan After Substance-Related Incident
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s care plan after a significant substance-related incident. The resident was originally admitted with a diagnosis of opioid dependence and resided on a secure unit related to polysubstance abuse disorder. The existing care plan, dated 01/21/26, identified the resident as residing on a secure unit due to polysubstance abuse disorder with interventions to perform safety risk evaluations on admission, as needed, and upon changes in condition. The care plan also identified the resident as at risk for substance use disorder with interventions to monitor for signs or symptoms of substance abuse. On 02/01/26, nursing notes documented that staff observed the resident discarding an empty Suboxone packet in the trash, even though the resident was not prescribed Suboxone and denied taking any. Staff notified the on-call provider, who ordered monitoring for adverse reactions, and nursing staff and security conducted a room search that revealed no additional contraband. Despite this incident, the resident’s care plan was not updated to address the new substance-related event. During interviews, the DON acknowledged awareness of the incident and confirmed the care plan was not revised, and the Administrator stated her expectation that nursing would update the care plan when a new risk or behavior was identified and confirmed she would have expected the care plan to be updated for this resident.
Unattended, Unlocked Medication Cart on North Hall
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were properly stored and secured in accordance with professional standards and facility expectations. On 03/24/26 at 9:06 a.m., surveyors observed a medication cart on the north hall left unlocked and unattended outside a resident room. At 9:08 a.m., the LPN responsible for the cart confirmed during interview that the cart was hers, that it was unlocked and unattended, and acknowledged she should have locked it before responding to a call light. Later that day at 3:37 p.m., the DON stated in an interview that medication and treatment carts are expected to be locked at all times when nurses are away from them, confirming that the observed practice did not meet facility expectations. This deficient practice was cited as likely to allow unauthorized personnel access to medications, which could result in injury or overdosing.
Unattended PHI Document Left Exposed at Nurse’s Station
Penalty
Summary
Surveyors identified a deficiency in the facility’s protection of residents’ personal health information (PHI) when a document containing multiple residents’ full names, assigned room numbers, and code status was left unattended and exposed on the south nurse’s station counter. On 03/16/26 at 9:04 a.m., an observation revealed a piece of paper on a clipboard with complete resident information placed on top of the south nurse’s counter in public view. At 9:06 a.m., during an interview, RN #2 confirmed that the list contained residents’ names, room numbers, and code status, acknowledged that it had been left exposed and unattended, and stated that PHI should not be left unattended. No additional clinical details or medical histories of the residents listed on the document were provided in the report.
Unattended Soiled Lunch Cart Left Uncovered in Hallway
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the handling of soiled food service equipment. On 03/24/26 at 12:58 pm, a lunch tray return cart containing soiled food trays and dishes that were uncovered was observed sitting unattended in the main hallway outside the activity room. At 1:06 pm, the housekeeping/laundry manager confirmed she saw the return cart left unattended in that location. At 1:08 pm, the Dietary Manager stated that lunch return carts should only be left in designated areas such as by the nurse’s station or inside the kitchen, and that the cart should be returned to the kitchen for cleaning as soon as all trays have been picked up, which did not occur in this instance. This deficient practice was noted as likely to expose all residents to potential pathogens associated with food waste.
Failure to Honor Resident Bathing Preferences During Prolonged Hot Water Issues
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ bathing preferences when hot water was not reliably available in resident care areas. Record review showed that one resident was scheduled to receive three showers per week on specific days, and another resident was scheduled for two showers per week. One resident reported that staff attempted to have him shower in cold water, which he refused, and that sponge baths were only offered once or twice during the period when the hot water was not working. He stated that he liked to be clean and did not feel like himself when he was dirty. A CNA reported that there was no hot water in resident care areas from the middle of December until early March, and that large barrels of warm water were brought to shower rooms to offer sponge baths, which this resident refused. Another resident, also on a scheduled twice-weekly shower regimen, stated that she received cold showers and began refusing showers because of how cold the water was. She described the water running cold unpredictably, including an instance when the water was initially warm but turned cold while she was still soaped, requiring rinsing with cold water, which she described as horrible. A social services note documented that this resident’s daughter reported the resident had been declining showers and bed baths offered because the water was too cold. A CNA corroborated that the water was “ice cold” and that residents began complaining and refusing showers around mid-December. The Maintenance Director stated that it took a while for hot water to reach the shower room and that a needed part to fix the cold-water problem was on back order, contributing to the prolonged period of inadequate hot water and resulting in residents not having their bathing preferences honored.
Improper Disposal of Unused Medications on Medication Cart
Penalty
Summary
Surveyors identified a deficiency related to accident hazards and inadequate supervision when unused medications were improperly discarded on the north hallway. During observation of the north hall nurses’ station, two medications were found in the trash bin attached to the medication cart, placed together inside an unlabeled medication cup. The pills were described as a round blue pill stamped with “61” and an oblong orange pill stamped with “20.” In an interview immediately following the observation, an RN confirmed that these medications were in the trash bin and stated that unused medications should instead be disposed of in the drug buster, a sealed container for drug disposal located in the bottom drawer of the cart. In a subsequent interview, the Unit Manager confirmed that all unused medications are to be disposed of using the drug buster and acknowledged that this did not occur, further stating that if the medications are controlled substances such as narcotics, two licensed personnel are required to dispose of them together and document the disposal on the narcotic count sheet. This deficient practice was noted as likely to affect any resident who might acquire and ingest the discarded medications, potentially causing medication side effects.
Failure to Follow Allergy, Diet, and Meal Ticket Requirements
Penalty
Summary
The facility failed to provide meals consistent with residents’ documented allergies, diet orders, and meal tickets for three residents. One resident, admitted with a documented allergy to chocolate, had a face sheet and lunch ticket indicating they were not to receive chocolate. During a lunch observation, this resident was served and was eating chocolate ice cream. An LPN confirmed the resident’s chocolate allergy and that the resident should not be eating chocolate. The Nutrition Director acknowledged that the meal ticket stated the resident should not have chocolate but reported serving chocolate ice cream after the resident requested it, stating he had not read that the resident was allergic to chocolate. Another resident, admitted with hypokalemia and ordered a regular/liberalized pureed diet per the MDS, had a lunch ticket indicating a pureed diet but was observed receiving whole mandarin oranges instead of pureed fruit. A CNA confirmed that the dessert was not pureed. A third resident’s meal ticket specified a grilled Swiss sandwich, but observation of the tray showed the sandwich was not grilled. During interviews, a CNA and a dietary manager confirmed that the sandwich was not grilled as ordered on the meal ticket.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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