Northrise Wellness & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Las Cruces, New Mexico.
- Location
- 2884 North Road Runner Parkway, Las Cruces, New Mexico 88011
- CMS Provider Number
- 325111
- Inspections on file
- 21
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Northrise Wellness & Rehabilitation during CMS and state inspections, most recent first.
A resident was admitted with an unstageable pressure ulcer documented on the Admission MDS, along with a need for pressure ulcer/injury care, but the baseline care plan created within 48 hours did not include the pressure ulcer or the need for wound care. During interview, the DON confirmed the omission and stated the expectation that nurses care plan wounds and necessary wound care within the first 48 hours of admission.
Surveyors found that two residents with documented unstageable pressure ulcers and identified needs for pressure ulcer care on their admission MDS and Care Area Assessments did not have corresponding pressure ulcer or wound care interventions included in their comprehensive care plans. One resident’s care plan lacked any pressure ulcer component despite multiple unstageable and deep tissue injuries noted on admission, and another resident’s care plan omitted pressure ulcer care until it was added at a later date. The DON acknowledged that the comprehensive care plans for these residents did not address their pressure ulcers or wound care needs, contrary to facility expectations.
Surveyors found that wound care orders for two residents’ buttock wounds were not accurately documented on the Treatment Administration Record (TAR). One resident’s ordered daily wound care was missing documentation on multiple specific days, and another resident’s ordered wound care lacked documentation over an extended period. The Wound Care Nurse reported that she completed the ordered treatments on numerous dates but did not record them on the TAR, sometimes relying on the unit nurse to document instead. This resulted in incomplete and inaccurate medical records related to wound care.
A staff member was employed as an LPN using false credentials and provided care to residents without a valid license. During her employment, she demonstrated significant skill deficiencies, including improper Foley catheter handling, medication errors, incomplete documentation, and required frequent supervision and assistance from other staff. These issues were reported by multiple staff members and confirmed through disciplinary records and interviews.
A resident was subjected to improper medication administration and incomplete care by a staff member who was later found to be working under false credentials. Staff observed and reported concerns about this individual's actions, including leaving medications at the bedside and attempting incorrect IV procedures, but the facility did not report these allegations of neglect to the State Agency as required.
The facility failed to implement a water management program to minimize the risk of Legionella and other pathogens, potentially affecting all 27 residents. Key staff, including the Director of Maintenance and the DON, were unaware of their roles in preventing pathogen growth, contributing to the deficiency.
The facility failed to designate a qualified Infection Preventionist (IP) for its Infection Prevention and Control Program (IPCP). The DON is currently performing IP duties due to the IP's leave related to nursing license issues. This deficiency could affect all 27 residents in the facility.
The facility failed to develop comprehensive care plans for three residents, omitting critical information such as severe vision impairment, activity preferences, and required assistance for ADLs. This lack of documentation could lead to staff being unaware of the residents' needs.
The facility failed to ensure proper IDT participation in care plan meetings and did not update a resident's care plan to reflect a new pressure ulcer. Meetings often lacked key team members, and a resident's care plan was not revised to include a newly developed stage I pressure ulcer, potentially affecting care quality.
The facility failed to secure treatment carts on the East Unit, leaving them unlocked and unsupervised. An IV treatment cart containing sterile needles and catheters was found open, confirmed by an RN to be against protocol. Another cart with medications and scissors was also left unlocked, as confirmed by an LPN.
A fish oil supplement, 1000 mg, was found expired in the medication cart on the East Unit, intended for residents with rheumatoid arthritis. RN #16 confirmed the expiration, and the DON stated that expired medications should not be present and should be checked each shift.
The facility failed to ensure that call light pull cords in resident rooms were accessible, with cords being too short to reach unless residents were in bed. One resident's wife noted her husband was not cognizant enough to use the cord, while another resident had a trash bag tied to the cord to extend its reach. The Maintenance Director confirmed the cords were shortened to prevent tangling, leaving no alternative for residents unable to pull the cord.
The facility failed to provide written notifications to residents and their representatives regarding transfers and discharges, affecting five residents. One resident's POA only received a verbal notice and had to independently seek appeal information. The facility did not issue written transfer notices for hospitalizations due to various medical conditions. Staff confirmed that notifications were made via phone, and the Ombudsman was not informed of discharges or transfers.
The facility failed to provide written bed hold notices to residents or their representatives when transferred to the hospital. This deficiency affected four residents who were hospitalized for various medical conditions, including altered mental status and gastrointestinal bleeding. The Director of Nursing confirmed that staff did not complete the required notices, potentially leaving residents unaware of the bed hold policy.
The facility failed to ensure accurate MDS assessments for four residents, leading to discrepancies in documenting conditions such as pressure ulcers, falls, and MASD. Interviews confirmed these inaccuracies, which could result in inadequate care planning.
The facility failed to document accurate baseline care plans within 48 hours for three residents, leading to potential risks of inadequate care. One resident's wounds and necessary interventions were omitted, another's MASD diagnosis was not documented, and a third resident's dysphagia, PEG tube, and diet orders were not included. The MDS Coordinator confirmed these omissions.
A facility failed to obtain and implement wound care orders for a resident with a Stage II pressure ulcer on the coccyx. Despite the ulcer being present upon admission, there were no wound care orders in place until several days later. Nursing staff did not consult with the facility provider to obtain necessary orders, and the Director of Nursing acknowledged the oversight, which could lead to inconsistent interventions and worsening of the ulcer.
A facility failed to ensure a resident with a condom catheter had a physician's order and a documented clinical condition justifying its use. The resident, who was continent, had a catheter without an order or clinical documentation. The DON confirmed the absence of necessary documentation, contrary to facility expectations.
A facility failed to change a resident's nasal cannula within the required 7-day period, as observed during a survey. The resident's cannula lacked a date indicating when it was last changed, despite a physician's order for continuous oxygen. The DON stated that cannulas are changed weekly, but a CNA could not confirm if the resident's cannula had been changed, potentially affecting the resident's oxygen supply.
A resident was inappropriately administered Remeron, an antidepressant, for muscle weakness, which is not a valid medical diagnosis for its use. The resident's diagnoses included cognitive communication deficit and severe dementia without behavioral disturbances, none of which justified the medication. The DON confirmed the inappropriate prescription, highlighting a failure to ensure medications were medically necessary.
The facility failed to provide appropriate treatment and care for two residents, leading to deficiencies in wound care and skin condition management. One resident did not receive documented wound care for several days after admission, and another resident developed MASD without provider notification or treatment documentation. Staff interviews confirmed lapses in assessing and documenting care, highlighting a failure in the facility's processes for managing residents' conditions.
The facility failed to report investigation results of alleged medication diversion and injuries of unknown origin to the State Agency within five days. A resident with unexplained fractures and missing narcotics from the Emergency Kit were not properly documented or reported, as confirmed by the DON.
The facility did not post daily nurse staffing data, omitting the total number and actual hours worked by RNs, LPNs, and CNAs. An observation revealed missing information at the entrance, and the DON confirmed the night shift nurse's responsibility for posting complete data.
The facility failed to develop care plans addressing the individualized discharge goals and needs for three residents reviewed for discharge planning. Record reviews and an interview with Social Services staff confirmed the absence of such documentation in the residents' care plans and charts.
Failure to Accurately Care Plan Admission Pressure Ulcer Within 48 Hours
Penalty
Summary
The facility failed to develop an accurate baseline care plan within 48 hours of admission for one resident, resulting in omission of critical wound information. Record review showed the resident was admitted on an unspecified date, and the Admission MDS documented that the resident had one unstageable pressure ulcer present on admission and required pressure ulcer/injury care. However, review of the resident’s baseline care plan, dated 02/19/26, revealed that staff did not document the presence of the pressure ulcer or the need for wound care. In an interview on 02/20/26 at 1:31 PM, the DON confirmed that the resident’s care plan did not indicate the pressure ulcer or wound care needs and stated that her expectation was for nurses to care plan wounds and necessary wound care within the first 48 hours of admission. This deficient practice could likely result in residents not receiving appropriate care and may place residents at risk of an adverse event or worsening of their condition after admission.
Failure to Develop Comprehensive Care Plans for Residents With Pressure Ulcers
Penalty
Summary
Surveyors identified a deficiency in the development and implementation of accurate, person-centered comprehensive care plans related to pressure ulcers for two residents. For one resident, the admission MDS dated 01/15/26 documented one unstageable pressure ulcer present on admission and two additional unstageable pressure injuries presenting as deep tissue injuries, also present on admission. The Care Area Assessment dated 01/21/26 indicated a need for pressure ulcer care. However, review of this resident’s care plan dated 01/16/26 showed that no care plan addressing pressure ulcers or the need for wound care had been developed. For the second resident, the admission MDS documented one unstageable pressure ulcer present on admission, and the Care Area Assessment dated 01/06/26 indicated a need for pressure ulcer care. The resident’s care plan, initiated on 12/28/25, did not include a care plan for pressure ulcers at that time; a pressure ulcer care plan was not added until 02/20/26. During an interview on 02/20/26 at 1:33 PM, the DON confirmed that comprehensive care plans for both residents did not include plans for their pressure ulcers and the need for wound care, despite the facility’s expectation that staff complete comprehensive care plans to include pressure ulcers and wound care needs.
Incomplete and Inaccurate Wound Care Documentation on TAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records related to wound care treatments for two residents. For one resident with a physician’s order dated 01/15/26 for daily wound care to the right buttock using normal saline, Medihoney, calcium alginate gauze, and a silicone bordered dressing, the Treatment Administration Record (TAR) for January 2026 showed no documentation that wound care was completed on 01/19/26, 01/21/26, and 01/23/26. For another resident with a physician’s order dated 01/01/26 for wound care to bilateral buttocks, including cleansing with normal saline, application of Sureprep to surrounding tissue, Medihoney to the wound bed, and coverage with a sacral silicone bandage, the January 2026 TAR contained no documentation of wound care from 01/02/26 through 01/23/26. During an interview on 02/20/26, the Wound Care Nurse stated she worked Monday through Friday and completed all wound care on those days. She reported that she did perform wound care for the first resident on 01/19/26, 01/21/26, and 01/23/26 but did not document these treatments on the TAR. She also stated she completed wound care for the second resident on 01/01/26, 01/02/26, 01/05/26 through 01/09/26, 01/12/26 through 01/16/26, and 01/19/26 through 01/23/26, but again did not document these treatments on the TAR. The Wound Care Nurse indicated that sometimes the unit nurse documented completion of wound care on the TAR, and acknowledged she should ensure that either she or the unit nurse documented the wound care as completed. The survey findings state that this failure to accurately document wound care had the potential to negatively impact the care staff provide due to inaccurate records.
Unlicensed Staff Member Provided Nursing Care and Demonstrated Incompetence
Penalty
Summary
The facility failed to ensure that nursing staff possessed the appropriate competencies and valid credentials to provide nursing services to all residents. An individual, identified as SM #1, was employed and worked as an LPN without holding a valid license, using false credentials that initially passed through the facility's background and license verification systems. During her employment, SM #1 demonstrated significant lapses in nursing skills, including improper handling of a resident's Foley catheter, which caused the resident pain, and multiple instances of incomplete documentation and medication errors. Staff interviews and disciplinary records revealed that SM #1 required extended orientation and frequent supervision due to her inability to complete competencies and perform basic nursing tasks independently. Further review showed that SM #1 was involved in several incidents, such as presenting a resident with unrecognized medications, attempting blood sugar checks on a non-diabetic resident, and being perceived as unskilled in IV administration. Other staff members reported that SM #1 often failed to perform her duties, required assistance from other nurses, and was frequently inattentive to resident care. Documentation issues, improper medication handling, and incomplete assessments were noted during her tenure. Staff expressed concerns about her proficiency and reported these issues to supervisors. The facility's investigation confirmed that SM #1 had worked for several months under false pretenses, and her lack of skills and credentials directly impacted the care provided to residents. The facility only discovered the falsification after multiple disciplinary actions and an incident involving improper Foley catheter care. SM #1 resigned when confronted with the investigation and refused to cooperate further.
Failure to Report Alleged Neglect and Medication Errors
Penalty
Summary
The facility failed to report allegations of neglect involving a resident who was affected by improper medication administration and incomplete care by a staff member who was later found to be working under false credentials. Specifically, the staff member left medications at the resident's bedside, administered medications that were not recognized by the resident, and attempted to perform procedures such as IV administration incorrectly. Documentation and required assessments for the resident were also incomplete, and concerns about the staff member's competence and actions were raised by both nursing and CNA staff to supervisors. Despite these incidents and staff concerns, the facility did not report the allegations of neglect to the State Agency as required. The Director of Nursing confirmed during an interview that the allegations related to the staff member's neglectful actions were not reported. The resident involved was receiving intravenous antibiotics and had incomplete admission and discharge documentation during their stay.
Failure to Implement Water Management Program for Infection Control
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically lacking a water management program to minimize the risk of Legionella and other opportunistic pathogens in the building's water system. This deficiency could potentially affect all 27 residents living in the facility. The facility's Water Management Policy, revised in September 2024, outlined the need for a Water Management Plan overseen by a team including center leadership, infection preventionist, maintenance employees, safety officers, risk and quality management staff, and the Director of Nursing. However, interviews revealed that key personnel, including the Director of Maintenance and the Director of Nursing, were not aware of or involved in any activities or meetings related to water management and the prevention of Legionella growth. The Director of Maintenance, who has been in the position since October 2023, stated he was unaware of any responsibilities related to preventing the growth of Legionella or other waterborne pathogens, as these tasks were previously handled by an administrator who left in mid-2024. The Director of Nursing also confirmed a lack of involvement in meetings or actions regarding waterborne pathogen management. The current Administrator acknowledged that the Director of Maintenance should have a diagram of the water system and be aware of potential growth areas for pathogens, but he was not aware of the Water Management Plan team or involved in any related meetings. This lack of awareness and involvement among key staff members contributed to the facility's failure to implement an effective infection control program.
Failure to Designate a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified, trained, or certified Infection Preventionist (IP) responsible for the Infection Prevention and Control Program (IPCP). This deficiency was identified during an interview and record review. The Director of Nursing (DON) revealed that the current IP had issues with her nursing license and has been on leave since January 10, 2025, due to these issues. Consequently, the DON has been performing the IP duties and is working towards obtaining her IP certification. A review of the former IP's time sheet confirmed that she last worked at the facility on January 10, 2025. This failure could potentially affect all 27 residents in the facility, as identified by the resident matrix provided by the Administrator.
Deficient Care Planning for Residents
Penalty
Summary
The facility failed to develop accurate, person-centered comprehensive care plans for three residents, which could result in staff being unaware of the residents' current and actual needs. For one resident, the care plan did not document the severe vision impairment and how staff would assist the resident, despite the admission record and Minimum Data Set (MDS) assessment indicating a severe vision impairment. Another resident's care plan failed to include their activity preferences, which were identified as very important during the MDS assessment interview. Additionally, the care plan for a third resident did not document the resident's functional level and the assistance needed to complete Activities of Daily Living (ADLs), even though the MDS assessment detailed substantial or maximal assistance required for various ADLs. The MDS Coordinator confirmed that the care plan should have included the resident's functional abilities, highlighting a gap in documentation and care planning.
Inadequate IDT Participation and Care Plan Updates
Penalty
Summary
The facility failed to meet care plan requirements for several residents due to inadequate participation of the Interdisciplinary Team (IDT) and failure to update care plans with current resident information. For one resident, the care plan meeting was attended only by the resident and a social services worker, lacking input from other essential team members. Another resident's care plan meeting included the dietary manager, family member, nurse navigator, social services staff, rehabilitation staff, and recreation staff, but no further meetings were held to ensure ongoing interdisciplinary input. Similarly, another resident's care plan meetings were inconsistently attended by necessary team members, with some meetings missing key participants such as the CNA and providers. Additionally, the facility did not revise a resident's care plan to reflect a new medical condition. The resident developed a stage I pressure ulcer on the right heel, which was documented in the nursing progress notes but not updated in the care plan. This oversight indicates a failure to ensure that the care plan accurately reflected the resident's current health status and necessary interventions, potentially impacting the quality of care provided.
Unlocked Treatment Carts Pose Safety Risk
Penalty
Summary
The facility failed to ensure the safety of residents on the East Unit by not securing treatment carts when not supervised by staff. During an observation, an IV treatment cart was found unlocked and open, containing sterile needles and intravenous catheters, with no staff present. This was confirmed by an RN who acknowledged that the cart should be locked when not in sight or control. Additionally, another treatment cart was observed unlocked and open, containing medications such as diclofenac, bacitracin, nystatin, mupirocin, silvasorb, and scissors, again with no staff present. An LPN confirmed that this cart was also supposed to be locked.
Expired Medication Found in Medication Cart
Penalty
Summary
The facility failed to properly store medications, as observed on the East Unit's medication cart, where a fish oil supplement, 1000 mg, was found to be expired since December 2024. This medication was intended to help reduce pain, improve morning stiffness, and relieve joint tenderness in people with rheumatoid arthritis. During an interview, RN #16 confirmed the expiration of the fish oil supplement and acknowledged that it should not have been present in the medication cart. Additionally, the Director of Nursing (DON) confirmed that expired medications should not be in the medication carts and that nurses are responsible for checking for expired medications during each shift.
Inadequate Call Light System in Resident Rooms
Penalty
Summary
The facility failed to ensure that the call light pull cords in residents' rooms were adequately equipped to allow residents to call for help. This deficiency was observed in the rooms of three residents, where the pull cords were not reachable unless the residents were in bed. One resident's wife reported that her husband was not cognizant enough to pull the cord, leaving him without an option to call for help. Another resident had a trash bag tied to the end of the call light cord, which was too short for him to reach, and he was unsure why the bag was there, except possibly to make the cord longer. A third resident was observed to be unable to reach the call light from his bed, and the Maintenance Director confirmed that the pull cords could not be reached if residents were not in bed. The Maintenance Director explained that the cords were shortened to prevent tangling, and there was no alternative method for residents who were not cognizant enough to pull the cord. The director also confirmed that the facility did not have a way to modify the pull cords for such residents, and some cords had bags tied to them to make them easier to grip. This practice could likely result in residents being unable to call for assistance when needed.
Failure to Provide Written Transfer and Discharge Notices
Penalty
Summary
The facility failed to provide timely written notifications to residents and their representatives regarding transfers and discharges, as well as information on appeal rights and contact details for the Ombudsman. Specifically, five residents were affected by this deficiency. For one resident, the Power of Attorney (POA) only received a verbal notice of discharge and was not informed in writing about the discharge plan, appeal rights, or Ombudsman contact information. The POA had to independently seek out information to appeal the discharge, as the facility did not provide the necessary details. Additionally, the facility did not issue written transfer notices for residents who were sent to the hospital. In several cases, residents were transferred due to medical conditions such as altered mental status, gastrointestinal bleeding, low blood pressure, and elevated white blood cell count. The records for these transfers lacked documentation of written notices, and the facility's staff confirmed that they did not provide such notices to residents or their representatives. Interviews with facility staff, including a Registered Nurse and the Director of Nursing, revealed that the facility's practice was to notify families of hospital transfers via phone, without providing written documentation. Furthermore, the Social Services department did not notify the Ombudsman of resident discharges or transfers, which is a required procedure. This lack of proper notification could lead to residents and their representatives being uninformed about their rights and the reasons for transfers or discharges.
Failure to Provide Bed Hold Notices
Penalty
Summary
The facility failed to provide written notices of the bed hold policy to residents or their representatives when residents were transferred to the hospital. This deficiency was identified for four residents who were reviewed for hospitalization. Specifically, the medical records of these residents did not contain any documentation of a written bed hold notice, which is required to inform residents or their representatives of how long their bed would be held during their absence. The deficiency was confirmed during an interview with the Director of Nursing (DON), who acknowledged that the staff did not complete the bed hold notices prior to sending the residents to the hospital. The residents involved were sent to the hospital for various medical reasons, including altered mental status, gastrointestinal bleeding, abdominal pain, low blood pressure, elevated white blood cell count, and uncontrolled pain. The absence of written notices could result in residents or their representatives being unaware of the bed hold policy upon their return from the hospital.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for four residents, which could result in an inaccurate understanding of their needs. Resident #4 was admitted with a Stage II pressure ulcer on the coccyx, but the admission MDS incorrectly documented no unhealed pressure ulcers. Similarly, Resident #7 experienced a fall after admission, yet the MDS inaccurately recorded no falls since admission. Resident #11 was admitted with multiple wounds, including a pressure wound on the left heel and other ulcerations, but the MDS failed to document these conditions. Lastly, Resident #184 had Moisture Associated Skin Damage (MASD) due to incontinence, which was not recorded in the Medicare 5-Day MDS Assessment. Interviews with the Director of Nursing and the MDS Coordinator confirmed the discrepancies in the MDS assessments for these residents. The inaccuracies in the MDS documentation were identified through record reviews and staff interviews, highlighting a pattern of oversight in accurately capturing the residents' medical conditions and care needs upon admission. These deficiencies in documentation could potentially lead to inadequate care planning and interventions for the affected residents.
Failure to Document Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to create accurate baseline care plans within 48 hours of admission for three residents, leading to potential risks of inadequate care. Resident #11 was admitted with multiple wounds, including cellulitis, sepsis, and MRSA infections, but the baseline care plan did not document these wounds or any interventions for their treatment. The MDS Coordinator confirmed that the baseline care plan should have included these details. Resident #184 was admitted with Moisture Associated Skin Damage (MASD) due to incontinence, but the baseline care plan did not document this condition or any interventions. The MDS Coordinator acknowledged that the baseline care plan was not completed within the required 48-hour timeframe and failed to include the MASD diagnosis, which was noted in the resident's progress notes. Resident #185 had several diagnoses, including severe protein-calorie malnutrition, dysphagia, and a PEG tube for enteral feeding. However, the baseline care plan did not document the dysphagia diagnosis, the presence of the PEG tube, or the specific diet and feeding orders. The MDS Coordinator confirmed these omissions, indicating that the baseline care plan should have included all relevant medical information and interventions.
Failure to Obtain and Implement Wound Care Orders
Penalty
Summary
The facility failed to ensure that wound care orders were obtained and implemented for a resident with a pressure ulcer. Upon admission, the resident had a Stage II pressure ulcer on the coccyx, as noted in the wound care consultation. Despite this, the facility did not have wound care orders in place for the resident's pressure ulcer from the time of admission until several days later. The Treatment Administration Record for December 2024 and January 2025 showed a lack of orders for the treatment of the pressure ulcer until January 11, 2025. Additionally, the facility's nursing progress notes indicated that staff did not consult with the facility provider to obtain necessary wound care orders for the resident's pressure ulcer, which was present upon admission. The Director of Nursing acknowledged that nursing staff failed to identify wounds upon admission and did not obtain orders for the pressure ulcer, which was against the facility's expectations. This deficiency could lead to inconsistent interventions and worsening of the pressure ulcer.
Lack of Physician Order and Clinical Justification for Condom Catheter Use
Penalty
Summary
The facility failed to ensure that a resident with a condom catheter had a physician's order and a documented clinical condition justifying its use. During an interview, the resident stated that he had a catheter to streamline the process of elimination, despite being continent of bowel and bladder. An observation confirmed the presence of a catheter, but a review of the resident's physician orders and medical record revealed no order or documented clinical condition necessitating the use of a condom catheter. The Director of Nursing confirmed the absence of an order or clinical documentation, acknowledging that the facility's expectation is for all residents to have orders and clinical reasons for catheter use.
Failure to Change Nasal Cannula as Scheduled
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident by not changing the nasal cannula within the required 7-day period. During an observation, it was noted that the resident's nasal cannula was not dated, indicating when it had last been changed. The resident had a physician's order for continuous oxygen at 2 liters via nasal cannula. The Director of Nursing (DON) stated that nasal cannulas are typically changed weekly on Sundays, and a piece of tape with the date is used to document the change. However, a Certified Nursing Assistant (CNA) confirmed that the resident's cannula did not have a date, and she could not verify if it had been changed as per the schedule. This oversight could lead to the nasal cannula becoming obstructed, non-functional, and unsanitary, potentially affecting the resident's oxygen supply.
Inappropriate Use of Psychotropic Medication for a Resident
Penalty
Summary
The facility failed to ensure that a resident did not receive psychotropic medication without a medical necessity. Specifically, a resident was administered Remeron, an antidepressant, for muscle weakness, which is not an appropriate medical diagnosis for the use of this medication. The resident's admission record indicated diagnoses of cognitive communication deficit, other symbolic dysfunctions, and severe dementia without behavioral, psychotic, mood, or anxiety disturbances, none of which justify the use of Remeron. The physician's order dated January 11, 2025, prescribed Remeron 15 mg at bedtime for muscle weakness, and the Medication Administration Record confirmed that the resident received this medication every evening starting from that date. During an interview, the Director of Nursing confirmed the order for Remeron for muscle weakness and acknowledged that the resident did not have a medical diagnosis appropriate for the use of this medication. This oversight could lead to the resident receiving unnecessary medication, increasing the risk of adverse side effects.
Deficiencies in Wound Care and Skin Condition Management
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards for two residents, leading to deficiencies in wound care and skin condition management. For one resident, the facility did not implement convalescent care orders for multiple wounds upon admission. The resident had several wounds, including ulcerations and a surgical wound, which required specific wound care treatments. However, the staff did not document any wound care orders or treatments between the resident's admission and several days later, nor did they assess the resident's skin upon admission. This lack of documentation and care could have led to the staff and physician being unaware of changes in the resident's condition. Another resident developed Moisture Associated Skin Damage (MASD) due to incontinence, but the facility failed to notify the provider or document any treatment for this condition. The resident's progress notes consistently recorded the presence of MASD over several days, yet there was no documentation of provider notification or treatment orders in the medical record. Interviews with staff confirmed that the nurse should have assessed the resident's skin, contacted the provider for orders, and documented any communication and treatment. The deficiencies highlight a failure in the facility's processes for implementing care orders and managing changes in residents' conditions. The lack of documentation and communication with providers regarding wound care and skin conditions could lead to worsening of residents' health. The facility's staff did not follow established protocols for assessing and documenting care, which are critical for ensuring residents receive appropriate treatment.
Failure to Timely Report Investigation Results
Penalty
Summary
The facility failed to report the results of investigations regarding alleged medication diversion and injuries of unknown origin to the State Agency within the required five-day period. This deficiency was identified through record reviews and interviews. In one case, a resident was sent to the emergency room due to a nosebleed and was found to have rib fractures and a compression fracture of the Thoracic 10 vertebrae. Despite efforts to determine the cause, no explanation was found, and the facility did not document that a follow-up report was submitted to the State Agency within the required timeframe. In another incident, the facility reported missing narcotics, with the initial incident occurring on a specified date. The medication count on the Emergency Kit was found to be inaccurate, and new interventions were developed to secure the kit. However, the facility again failed to document that a follow-up report was submitted to the State Agency within five days of the incident. The Director of Nursing confirmed the lack of documentation for both incidents during an interview.
Failure to Post Daily Nurse Staffing Data
Penalty
Summary
The facility failed to post daily nurse staffing data that included the total number and actual hours worked by registered nurses, licensed practical nurses, and certified nurse aides responsible for resident care per shift. During an observation on January 30, 2025, it was noted that the nurse staffing data posted at the front entrance did not include the required information for the day. In an interview, the Director of Nursing (DON) confirmed that the night shift nurse is responsible for posting this data, which should include the total number of staff scheduled for each shift and the number of hours each nursing staff member is scheduled to work.
Failure to Develop Individualized Discharge Plans
Penalty
Summary
The facility failed to develop care plans addressing the individualized discharge goals and needs for three residents (R #11, R #12, and R #13) reviewed for discharge planning. Record reviews revealed that the care plans for these residents, dated 01/19/24, 03/06/24, and 04/01/24 respectively, did not include documentation of their discharge goals and needs. During an interview on 05/01/24, the Social Services (SS) staff confirmed the absence of such documentation in the residents' care plans and charts.
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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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