Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at New Mexico State Veterans Home during CMS and state inspections, most recent first.
Failure to Provide Behavioral Health Treatment and Psychotherapy: A resident with PTSD, depression, anxiety, and suicidal thoughts did not receive the consistent counseling/psychotherapy that was documented as needed, another resident with bipolar disorder and reported hallucinations was not reported to the PMHNP or referred for psychiatric consult, and a third resident with MDD, schizophrenia, dementia, GAD, and recurrent SI repeatedly sought psychiatric care but the record did not show follow-through with psychiatrist services or psychotherapy notes.
The facility failed to ensure psychotropic medications were medically necessary for two residents. One resident with depression, unspecified psychosis, and PTSD had orders for bupropion, duloxetine, and quetiapine, but the provider did not document a clinical rationale after the pharmacist recommended GDRs. Another resident with PTSD, vascular dementia with behavioral disturbance, anxiety, and a sleep disorder received olanzapine and trazodone; the pharmacist recommended a GDR for trazodone, but no clinical rationale was documented and staff confirmed no GDR had been attempted.
A facility failed to ensure MDS accuracy for 3 residents. One resident’s Significant Change MDS omitted a UTI diagnosis after treatment with IV antibiotics, another resident’s MDS did not include an active stage 4 sacral pressure ulcer documented by the wound care provider, and a third resident’s Quarterly MDS omitted a UTI despite provider orders and nursing notes showing treatment with oral Cipro.
Care plan meetings for multiple residents were missing required IDT participation, including the physician and CNA, and several meetings were not held within the required timeframe after MDS completion. Care plans were also not updated to reflect current resident information, including weight loss, a stage 2 pressure injury, changed activity preferences, need for one-on-one activities, and ear wax buildup with related interventions.
Pharmacist recommendations were not properly addressed for three residents. One resident had a fall and a pharmacy review flagged several meds as fall-risk contributors, but the provider disagreed without documenting a clinical rationale. A second resident with MDD, psychosis, and PTSD had GDR recommendations for bupropion, duloxetine, and quetiapine, but the provider only wrote brief comments such as stable and did not document a rationale. A third resident with PTSD, vascular dementia, anxiety, and a sleep disorder had fall-related medication review findings and later GDR recommendations for trazodone and olanzapine, but the provider again selected disagree without documenting a clinical rationale.
The facility failed to store food under sanitary conditions when staff did not label and date items in the receiving kitchen refrigerator. Surveyors found an opened container of Pace Picante sauce past its expiration date and a large sour cream container with no open date. The DS stated staff are to mark food items when opened and discard expired items, and the Dry Storage Policy requires all storage containers to be labeled and dated.
Incomplete and inaccurate resident records were found when PASRRs omitted documented mental health diagnoses, a wound-related diagnosis was not updated after a provider note identified a chronic stage 4 pressure injury, staff did not document repeated attempts or refusals when offering lotion for very dry feet, and the chart lacked documentation of provider communication about changing levofloxacin from IV to PO.
Staff failed to treat a resident with dignity when two MRS staff were observed sitting in the common area and dining room at House 2, interacting with each other but not with residents. The resident said the staff did not care about residents and did not answer when asked why they were there. The DM identified the staff as medical record staff who were not usually assigned to the unit, and the Administrator stated staff were expected to engage with residents and explain their presence if asked.
A resident had an order for Sertraline for major depressive disorder, but the medical record did not contain documented consent for the psychotropic medication. During interview, the HS confirmed the order and stated that consents should be completed for psychotropic meds, but no consent was found in the record.
A resident was transferred to the hospital for AMS, and although staff documented a written transfer notice and bed hold notice, the facility did not send a copy of the transfer notice to the Ombudsman. An RN said nursing staff complete the notice at transfer but was unsure if it is sent, and the Ombudsman stated she does not receive copies of the written transfer notices.
Late Completion of Admission MDS Assessment: The facility failed to complete a resident’s admission MDS assessment within the required 14-day timeframe after admission. Record review showed the assessment was completed after the deadline, and the MDS Coordinator confirmed the delay during interview.
A resident’s quarterly MDS assessment was not completed within the required 92-day timeframe after a Significant Change MDS. Record review showed the quarterly ARD occurred 105 days after the prior ARD, and the MDS Coordinator confirmed the assessment was not completed on time.
Late Transmission of Quarterly MDS Assessment: The facility failed to transmit a resident’s Quarterly MDS within the required timeframe after completion. Record review showed the assessment was completed, but it was not sent to the federal agency until after the 14-day window, and the MDS Coordinator confirmed the delay.
A resident with a cough and phlegm reported that the facility MD said cough syrup would be prescribed, but he had not received it. The provider note documented Robitussin cough syrup, yet the MAR/orders did not include the medication. An RN stated the ADON accompanies the MD during resident visits and enters new orders, and confirmed the resident had no cough syrup order.
Failure to Provide Individualized Activities Based on Resident Preferences: Two residents did not receive an ongoing activities program based on their stated interests. One resident's preferences for animals and religious services were not included in the care plan or daily activity documentation, and the AD confirmed the plan was not client centered. Another resident reported being bored and lonely, had difficulty attending group activities, and his preferences for music and going outside were not reflected in the care plan or documented one-on-one activities.
Failure to provide foot care was identified for a resident with onycholysis and DM2. The resident’s toenails were observed to be long and discolored, and the resident said they needed to be cut by the podiatrist but could not recall the last time this occurred. Staff confirmed the nails were long, were unsure when podiatry last saw the resident, and noted that only the podiatrist could cut toenails for residents with DM or nail issues.
Expired Diclofenac topical gel was found in a treatment cabinet, and an LPN confirmed it was expired and had no resident name on it. The ADON stated two residents had current PRN Diclofenac orders, but staff could not determine which resident the medication belonged to. The Administrator stated nurses are expected to check medication carts and treatment cabinets for expired meds.
A resident with a Foley catheter was ordered to be on EBP, but surveyors observed that gowns were not visible in the room and the resident stated staff did not wear gowns when transferring him or showering him. Staff interviews showed confusion about when gowns and gloves were required, and an LPN later found gowns stored in the resident’s dresser drawer rather than readily available at the room entrance.
Failure to document and provide flu and pneumococcal vaccinations: one resident signed consent for the annual flu shot but did not receive it for the current flu season, and another resident had no consent form or documentation showing the resident was educated on or offered the flu or pneumococcal vaccines. An RN confirmed the missing documentation and missed vaccination.
Failure to Offer and Document COVID-19 Vaccination for Two Residents. Record review showed that two residents did not have evidence in their charts that staff offered the COVID-19 vaccine, and one resident's immunization record showed the last dose was received previously. An RN confirmed the records lacked documentation that the vaccine had been offered.
Survey results were not posted in a prominent, accessible location for residents and the public. Several residents said they did not know where the latest state survey results were, and an observation found the survey binder only in the front hall of the main building where residents do not live. The Administrator confirmed the results were only in that building and were not accessible to all residents or the public.
Failure to post daily nurse staffing information was identified when the posted PPD form in the lobby showed prior dates, predicted staffing hours, and no count of staff working. The form did not reflect the current day, and interviews confirmed it was being posted weekly instead of daily and was not updated with actual staffing numbers or census changes.
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.
Failure to Provide Appropriate Behavioral Health Services
Penalty
Summary
The facility failed to ensure residents with diagnosed mental health disorders, psychosocial distress, and suicidal ideation received appropriate behavioral health treatment and services for three residents reviewed for behavioral-emotional health. The deficiencies involved failure to provide or obtain psychotherapy/counseling for one resident with PTSD, major depressive disorder, anxiety, and suicidal thoughts; failure to notify the PMHNP of another resident’s hallucinations; and failure to follow through with psychiatric referral/consultation for a third resident with multiple psychiatric diagnoses and repeated suicidal ideation. One resident was admitted with PTSD, major depressive disorder, and anxiety disorder. The record showed a psychotropic evaluation listing music and psychotherapy as non-pharmacologic care, and the care plan noted the resident had PTSD and had the potential to plan on ending his life because of pain and did not want to continue. Progress notes documented that the resident said he was struggling with pain and did not want to carry on, and staff wrote they would schedule a psych appointment so he could talk about depression and suicidal thoughts. During interview, the resident stated he was very depressed, did not want to go on, had accepted counseling, but no one ever showed up for the counseling sessions. He stated the Chaplain visited occasionally but was not qualified or useful for the help he needed, and he needed a psychiatric therapist trained in PTSD. The Chaplain stated he provided spiritual and emotional assistance, but did not have formal mental health training or formal training for treating PTSD. The NP stated she provided counseling only if the resident complained of issues, did not have consistent counseling sessions with the resident, and the record did not contain documentation that she provided counseling. Another resident was admitted with bipolar disorder. A progress note documented the resident reported moles in his room and under his covers, and CNA interview confirmed the resident had been seeing moles for a couple of months and that the nurse was told. The CNA stated housekeeping would go into the room, shake the sheets, and tell the resident the moles were gone. The NP stated she was not aware the resident saw moles and would have discussed medication changes with the provider if she had known. The record did not contain other psychotropic evaluations after an earlier evaluation, did not document hallucinations or delusions on the MDS, did not include hallucinations on the care plan, and did not contain referrals for a psychiatric consult. The third resident had diagnoses including major depressive disorder, paranoid schizophrenia, unspecified dementia, generalized anxiety disorder, and suicidal ideation. The record contained repeated crisis hotline calls, statements that the resident was depressed, wanted to die, or had been looking for an alternative to suicide, and multiple requests to see a psychiatrist or be transferred for psychiatric care. The resident also reported that the facility’s mental health treatment was not working and that he wanted to see an actual psychiatrist. Social services notes documented that the resident appeared to be hallucinating about God, was lonely, isolated, and not receiving the psychiatric care he needed. The provider notes showed plans to evaluate him by psychiatry or place referrals, but the medical record did not document that he was seen by a psychiatrist or that psychotherapy notes were present. The PMHNP stated she saw the resident only when issues arose or when nurses raised concerns, and the facility leadership confirmed the facility did not have a psychiatrist and that the resident wanted to see one.
Unnecessary Psychotropic Medications and Missing GDR Documentation
Penalty
Summary
The facility failed to ensure that psychotropic medications were medically necessary for two residents reviewed for unnecessary medications. For one resident, the record showed diagnoses of major depressive disorder, unspecified psychosis not due to a substance or known physiological condition, and PTSD, with orders for bupropion 300 mg daily, duloxetine 60 mg twice daily, and quetiapine 100 mg at bedtime related to unspecified psychosis. The pharmacist recommended gradual dose reductions for all three medications during the medication regimen review, but the provider selected disagreement and documented only brief statements such as "stable" and "resident is very depressed and unspecified psychosis," without a clinical rationale for not completing the GDRs. For the second resident, the record showed diagnoses of PTSD, vascular dementia with other behavioral disturbance, anxiety disorder, and sleep disorder. The resident had orders for olanzapine 2.5 mg in the morning and 5 mg at bedtime for dementia with other behavioral disturbance, along with trazodone 50 mg at bedtime for sleep. The EMR included black box warnings for the olanzapine orders stating increased mortality in elderly patients with dementia-related psychosis. During the medication regimen review, the pharmacist recommended a GDR for trazodone 50 mg, but the provider disagreed and did not document a clinical rationale for why a GDR should not be attempted. During interview, the House Supervisor confirmed the provider was expected to review and sign pharmacist recommendations and to document a clear clinical rationale when not following them. The Registered Nurse Associate Manager also confirmed the resident receiving olanzapine did not have a diagnosis with symptoms of psychosis, that trazodone had been continued since its start, that no GDR had been attempted for trazodone, and that no clinical rationale was documented in the medical record for not implementing a GDR.
MDS assessments omitted active diagnoses
Penalty
Summary
The facility failed to ensure the MDS was accurate for 3 of 6 residents reviewed for accurate MDS assessments. For one resident, the record showed an admission followed by a transfer to the hospital for altered mental status, and later a return to the facility with a diagnosis of UTI and an order for IV ertapenem; however, the Significant Change MDS did not document the UTI diagnosis in the last 30 days. During interview, the RN and MDS Coordinator confirmed the resident had been treated with antibiotics for a UTI after returning to the facility and that the UTI diagnosis was omitted from the MDS. For another resident, the wound care consultation documented a chronic stage 4 sacral pressure injury with known osteomyelitis and assessed the resident as having a stage 4 pressure ulcer, but the Significant Change MDS did not include the stage 4 pressure ulcer as an active diagnosis. The MDS Coordinator confirmed the wound care doctor documented the stage 4 pressure ulcer and that it should have been included on the MDS. For the third resident, provider and nursing notes documented a UTI treated with ciprofloxacin, including an order for oral ciprofloxacin and multiple nursing notes stating the resident continued antibiotics for UTI, but the Quarterly MDS did not document a UTI diagnosis in the last 30 days. The MDS Coordinator confirmed the resident was treated with antibiotics for a UTI and that the diagnosis was not included on the Quarterly MDS.
Care Plan Meetings Missing Required IDT Input and Timely Revisions
Penalty
Summary
The facility failed to ensure care plan meetings were prepared, reviewed, and revised by the interdisciplinary team for multiple residents. For several residents, the care plan meeting notes showed that the physician and CNA were not included in the meetings, and staff did not document any input from those required members. This was identified for residents including R #2, R #4, R #5, R #11, R #18, R #28, R #29, and R #92. In interviews, the SSW, RN Associate Manager, and MDS Coordinator confirmed that the physician and CNA did not attend certain care plan meetings and that no input from them was documented. The facility also failed to hold some care plan meetings within 7 days of completion of the MDS assessment. R #4’s annual MDS was completed on 02/18/26, but the care plan meeting occurred on 02/26/26 and was documented as not within 7 days. R #28’s admission MDS was completed on 02/25/26, but the care plan meeting was held on 03/10/26, and staff confirmed it was not within 7 days. R #29’s quarterly MDS was completed on 02/25/26, but the care plan meeting was held on 03/05/26, which was also outside the 7-day timeframe. Staff confirmed these timing issues during interview. The facility also failed to revise care plans using the most current resident information for several residents. R #1’s care plan was not updated after a 6.5% significant weight loss, a new stage 2 pressure ulcer to the sacrum, discharge from the Restorative Nursing Program, or updated activity preferences from the Significant Change MDS. R #2’s care plan revision did not include current activity preferences such as being around animals and participating in religious services. R #5’s care plan did not reflect his stated need for one-on-one activities, his preferences, or his reports of boredom and loneliness. R #124’s care plan did not document wax buildup in the ear or the related interventions. Staff and the Activities Director confirmed several of these omissions during interview.
Pharmacist Recommendations Not Documented With Clinical Rationale
Penalty
Summary
The facility failed to ensure that consultant pharmacist recommendations were reviewed and either implemented by the physician or accompanied by a documented clinical rationale for not following the recommendations in a timely manner for 3 of 5 residents reviewed for unnecessary medications. The deficiency involved residents with medication regimen review findings related to falls and gradual dose reduction (GDR) recommendations, but the provider did not document reasons for disagreeing with the pharmacist’s recommendations in the medical record. For one resident, the record showed admission orders for gabapentin, risperidone, venlafaxine, carvedilol, losartan potassium-HCTZ, and melatonin. A pharmacy review noted the resident had a recent fall and identified those medications as potentially contributing to falls. The pharmacist recommended that the medications be reviewed for changes, but the provider selected disagree and did not document a clinical rationale for not changing the medications. The medical record also did not contain a clinical rationale for why the medications should not be changed. For another resident with diagnoses including major depressive disorder, unspecified psychosis, and PTSD, physician orders included bupropion, duloxetine, and quetiapine. In the medication regimen review, the pharmacist recommended GDRs for all three medications. The provider selected disagree and entered brief comments such as stable and resident is very depressed and unspecified psychosis, but did not document a clinical rationale for why the GDRs should not be completed. The medical record likewise did not contain a clinical rationale for the decisions. For a third resident with PTSD, vascular dementia with behavioral disturbance, anxiety disorder, and a sleep disorder, physician orders included oxycodone, olanzapine, trazodone, and amlodipine. A pharmacy review noted a recent fall and identified these medications as potentially contributing to falls, recommending review for changes. Later medication regimen reviews recommended GDRs for trazodone and olanzapine. In each instance, the provider selected disagree but did not document a clinical rationale for not changing the medications or for not completing the GDRs. Interviews with nursing management confirmed the provider did not document the required rationale and that staff were unsure of the process for ensuring those rationales were documented.
Improper Food Labeling and Dating in Receiving Kitchen Refrigerator
Penalty
Summary
The facility failed to store food under sanitary conditions for all 127 residents who eat food from the kitchen when staff did not label and date food items in the receiving kitchen refrigerator. During an observation of the receiving kitchen refrigerator, surveyors found a large container of Pace Picante sauce that had been opened and dated 03/12/26 with an expiration date of 03/31/26, and a large sour cream container that had no date when it was opened. During interview, the Dietary Supervisor stated staff are to mark food items when they are opened and should throw out expired food items. Record review of the facility's Dry Storage Policy, dated 12/18/15, stated that food is to be labeled and dated on all storage containers.
Incomplete and inaccurate resident medical record documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for multiple residents when documentation did not match resident diagnoses, treatments, or staff actions. For two residents, the PASRR did not include all documented mental health diagnoses: one resident’s record showed PTSD, major depressive disorder, and anxiety disorder, but the PASRR did not list those diagnoses, and another resident’s record showed PTSD and anxiety disorder, but the PASRR did not include them. During interview, the admission coordinator confirmed the diagnoses should have been included on the PASRRs. For another resident, the wound care consultation note documented a chronic stage 4 sacral pressure injury with known osteomyelitis, but the face sheet did not include the diagnosis of chronic stage 4 pressure ulcer. The MDS Coordinator confirmed the wound care doctor documented the stage 4 pressure ulcer and that staff did not update the diagnosis list. For a different resident with very dry and flaky feet, staff documented dry skin on the feet and lower legs and noted use of cream on the legs, but staff also stated they offered lotion to the resident’s feet and the resident refused; however, they did not document those attempts or refusals. For another resident, physician orders included levofloxacin IV for sepsis and levofloxacin oral for UTI, but nursing progress notes from the relevant period did not document any communication with the provider about changing the antibiotic from IV to oral route, and there were no provider progress notes in the record for that period. An RN confirmed that nothing was documented regarding the change in levofloxacin in the resident’s medical record.
Staff Failed to Interact Respectfully With Residents on Unit
Penalty
Summary
The facility failed to ensure a resident was treated with respect and dignity when staff in House 2 did not interact with residents or explain why they were on the unit. During an interview, the resident stated that staff sitting in the common area did not care about the residents, described them as "two guard dogs just sitting around in the house," and said they were only present when surveyors were there; the resident also stated that when he asked what they were doing, they did not respond. During observation of House 2 at lunch, two staff were seen sitting at the dining table eating lunch and interacting with each other but not with residents. The DM identified the two staff as medical record staff and stated they are not usually at the house. One of the medical record staff stated she was there because she was told to be there and that she goes where she is told to go. The Administrator stated she had directed staff to start going to the different units to get to know residents and expected them to be engaged with residents and to answer if asked why they were at the unit.
Missing Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident and/or the resident’s representative were informed in advance of the medications received and understood the reasons, risks, and benefits of the medication. Record review for Resident #2 showed a physician’s order dated 04/06/26 for Sertraline 50 mg by mouth once daily for major depressive disorder. Review of the medical record showed staff did not document consent for Sertraline. During an interview on 04/21/26 at 1:22 PM, the House Supervisor confirmed that Resident #2 had an order for Sertraline to treat depressive disorder and stated that consents should be completed for psychotropic medications, but no consent for Sertraline was present in the resident’s record.
Failure to Send Transfer Notice to Ombudsman
Penalty
Summary
The facility failed to provide the required transfer information for one resident when staff did not send a copy of the written transfer notice to the Ombudsman after the resident was transferred to the hospital for altered mental status. Record review showed the resident was admitted to the facility on an unspecified date, was transferred to the hospital on 02/25/26 due to altered mental status, and that staff documented a written transfer notice and bed hold notice for the transfer. During interview, an RN stated that nursing staff complete the transfer notice at the time of transfer but was unsure whether the notice is sent to the Ombudsman. The Ombudsman later stated that the facility does not send her a copy of the written transfer notices.
Late Completion of Admission MDS Assessment
Penalty
Summary
The facility failed to ensure a comprehensive MDS assessment was completed within 14 calendar days after admission for one resident, R #132. Record review showed R #132 was admitted to the facility on an unspecified date, but staff did not complete the admission MDS assessment until 04/13/26. During an interview on 04/21/26 at 4:27 PM, the MDS Coordinator confirmed that the admission MDS assessment was not completed within 14 days of the resident’s admission to the facility.
Quarterly MDS Assessment Not Completed Within Required Timeframe
Penalty
Summary
The facility failed to ensure that an MDS assessment was completed every three months for 1 resident, R #10, when a quarterly MDS assessment was not completed within 92 days of the previous assessment reference date. Record review showed R #10 had a Significant Change MDS assessment with an ARD of 12/08/25, followed by a Quarterly MDS assessment with an ARD of 03/23/26, which was 105 days after the prior ARD. During an interview on 04/21/26 at 4:36 PM, the MDS Coordinator confirmed that staff did not complete R #10's MDS assessments within 92 days of the Significant Change MDS.
Late Transmission of Quarterly MDS Assessment
Penalty
Summary
The facility failed to complete and transmit a Quarterly MDS assessment within 14 days of completion for one resident, R #10. Record review showed the Quarterly MDS was completed on 03/31/26, but the facility did not transmit it to the federal agency until 04/15/26. During an interview on 04/21/26 at 4:36 PM, the MDS Coordinator confirmed that staff did not transmit R #10's Quarterly assessment within the required 14-day timeframe.
Failure to Implement Physician Order for Cough Syrup
Penalty
Summary
The facility failed to meet professional standards of practice for one resident when staff did not implement a physician-ordered cough syrup after a provider visit. The resident stated he had a cough with a lot of phlegm for several weeks and reported that the facility doctor had told him he would prescribe cough syrup, but he had not received any yet. The provider visit note documented that the resident had a cough with phlegm and that Robitussin cough syrup would be prescribed. However, the physician's orders did not include any cough syrup order, and the nursing progress note only stated that the doctor saw the resident and that new orders were noted. During interview, an RN stated the ADON goes with the facility doctor when he sees residents and enters any new orders, and confirmed that the resident did not have an order for cough syrup.
Failure to Provide Individualized Activities Based on Resident Preferences
Penalty
Summary
The facility failed to provide an ongoing activities program designed to meet the interests of two residents by not documenting or offering meaningful individualized activities based on their stated preferences. For one resident, the record showed preferences for being around animals and participating in religious services, but these preferences were not included in the care plan revision and were not documented in the daily participation records for February or March 2026. During interview, the Activities Director stated that activity assessments and care plans should be based on each resident and confirmed that this resident's care plan was not client centered to include personal preferences; she also stated that because of the resident's lack of participation, one-to-one activity should be provided in the activity program. For the second resident, the record and interview showed that he had difficulty attending group activities, spent a lot of time in bed, and reported being bored and lonely. His Significant Change MDS identified preferences that were very important to listen to music and go outside for fresh air when the weather was good, but his care plan did not include those preferences and the medical record did not document one-to-one activities or activities that met his interests. The resident stated that staff did not provide one-on-one activities, and the Activities Director confirmed that she did not see any one-on-one activities offered to him and did not know whether he enjoyed watching movies or conversing as activities.
Failure to Provide Foot Care for Resident With Diabetes and Nail Issues
Penalty
Summary
Provide appropriate foot care was not provided for one resident with onycholysis and type 2 diabetes mellitus with unspecified complications. During observation, the resident’s toenails appeared long and discolored, and the resident confirmed that the toenails were very long and wanted them cut. The resident stated that the toenails needed to be cut by the podiatrist and was unable to remember the last time the toenails had been cut. Record review showed that staff documented the resident was scheduled to see the podiatrist on 01/05/26 but was in the hospital and would be rescheduled. Another note dated 09/25/25 stated the resident was last seen by the podiatrist on 01/24/25 and a request would be made for the resident to see the podiatrist. During interview, an RN confirmed the toenails were long and was unsure how frequently the podiatrist visited the facility or when the resident’s toenails were last cut. The Registered Nurse Associate Manager later confirmed that only the podiatrist was able to cut toenails for residents with diabetes mellitus or nail issues and was unable to determine when the resident was last seen by the podiatrist.
Expired and Unlabeled Medication Found in Treatment Cabinet
Penalty
Summary
The facility failed to properly store medications for 2 residents sampled for medication storage when staff did not ensure medications in the treatment cabinet were not expired. During an observation of House #1's treatment cabinet, one Diclofenac sodium topical gel 1% was found expired in February 2026. An LPN confirmed that nurses are expected to check daily for expired medications and follow the facility process for expired medications, and also stated she did not know which resident the Diclofenac sodium topical gel belonged to because there was no resident name on the medication. The Administrator stated nurses are expected to do weekly and daily cleaning of medication carts and treatment cabinets/carts for expired medications. The ADON stated that R #46 and R #85 had current orders for Diclofenac PRN, but she was not sure why the medication did not have a resident name on the box and did not know which resident it belonged to.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an infection prevention and control program when staff did not follow enhanced barrier precautions for a resident with a Foley catheter. Record review showed the resident had an order dated 02/27/26 for EBP related to the Foley catheter, and surveyors observed an EBP sign on the bathroom door, gloves hanging near the door, and a Foley catheter bag hanging on the bed frame. During the observation, the resident stated staff did not wear gowns when transferring him to his wheelchair or when showering him. Interviews showed inconsistent understanding of the EBP requirements. A CNA stated there should be a box with gowns and gloves in the resident’s room if the resident was on EBP, but she was unsure whether the resident was on EBP. An LPN confirmed the resident was on EBP because of the Foley catheter and stated staff were expected to wear gowns and gloves when working with the catheter, but also stated staff did not need to wear gowns when transferring residents on EBP, only when touching the wound or catheter. She later found gowns in the resident’s top dresser drawer after searching the room. The Registered Nurse Associate Manager confirmed there should be an EBP sign and a bin with PPE near the entrance of rooms for residents on EBP, but stated staff were expected to wear gowns and gloves only when they had direct contact with wounds or catheters.
Failure to Document and Provide Flu and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure residents were educated on and offered influenza and pneumococcal immunizations, and failed to ensure that residents who completed and signed consent forms received the vaccinations. Record review showed that one resident signed an immunization consent form accepting the annual influenza vaccine, but the immunization record showed the resident’s last influenza vaccine was received on 10/15/22 and there was no documentation that the 2025-2026 flu season vaccine was given. Record review for another resident showed no immunization consent form on file and no documentation that the resident was offered the influenza or pneumococcal vaccines. During interview, the RN confirmed that the first resident completed consent but did not receive the influenza vaccine for the 2025-2026 flu season, and that the second resident’s medical record did not contain information regarding influenza or pneumococcal vaccines and did not document that the resident was educated and offered those vaccines.
Failure to Document and Offer COVID-19 Vaccination
Penalty
Summary
The facility failed to offer COVID-19 vaccination to 2 of 5 residents reviewed for COVID-19 vaccinations. Record review showed that Resident #2's immunization report documented the last COVID-19 vaccination received was on 01/20/22, but the medical record did not contain any COVID-19 vaccine forms showing that staff offered or administered the vaccine. Resident #132's medical record also did not contain any immunization consent forms, and staff did not document that the resident was offered the COVID-19 vaccine. During interview, RN #1 confirmed that neither resident's medical record contained evidence that they had been offered the COVID-19 vaccine.
Survey Results Not Posted in Accessible Location
Penalty
Summary
The facility failed to post the most recent state survey results in a prominent and accessible location for residents and the public. During a Resident Council meeting, several residents stated they did not know where the latest state survey results were located. An observation later showed a binder with the survey results in the front hall of the main building, which is the portion of the campus where offices are located but residents do not reside. The Administrator confirmed that the survey results were only located in the main building and that not all residents go there, meaning the results were not accessible to all residents or the public.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to publicly post nurse staffing data on a daily basis for all 128 residents in the census. During an observation of the lobby area of the annex, the Daily Per Patient Day (PPD) form was displayed on the counter and was dated 04/13/26 to 04/19/26. The form included nursing hours and CNA hours per shift, but it did not include the number of staff working and did not include staffing information for the current date of 04/21/26. During interviews, the Senior Manager of Administration stated the posted PPD form did not include the current date and reflected predicted staffing hours rather than actual hours worked, and that it was supposed to be posted weekly on Monday mornings. The Nursing Administration Administrative Assistant confirmed the form was supposed to be posted weekly, did not include the current date, showed predicted staff hours for upcoming shifts, and was not updated and reposted with actual hours worked each shift or changes to the census. The Administrator later confirmed staff were expected to post the Daily PPD form daily, not weekly, and to document actual staffing numbers rather than predicted staffing hours.
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.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 4 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Truth Or Consequences
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Paloma Springs Healthcare Llc | 1.4 mi | ★★★★★ | 4 | 0 |
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