Paloma Springs Healthcare Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in T Or C, New Mexico.
- Location
- 1400 North Silver Street, T Or C, New Mexico 87901
- CMS Provider Number
- 325062
- Inspections on file
- 20
- Latest survey
- December 5, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Paloma Springs Healthcare Llc during CMS and state inspections, most recent first.
A resident was found with unexplained injuries, including a forehead bump, facial blood, and abrasions to elbows and knees. The resident could not recall the cause of the injuries, and an LPN assessed the situation before the resident was sent to the ER and diagnosed with a contusion. The incident was not reported to the State Agency as required for injuries of unknown origin, and the administrator later acknowledged this omission.
A resident who was newly admitted to hospice care experienced a significant change in condition, but the required MDS assessment reflecting this change was not signed off by the RN within the mandated 14-day period. The delay was confirmed by both documentation and staff interview.
A quarterly MDS assessment for a resident was not completed within the required three-month timeframe, as it was finalized 14 days after the assessment reference date and lacked RN signature for completion. The MDS Coordinator confirmed the delay during an interview.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
A tray of desserts in the kitchen refrigerator was found with most items missing preparation dates, contrary to facility policy requiring all prepared foods to be labeled and dated. The Dietary Director confirmed that only some desserts were dated, believing this was sufficient.
A resident was started on fluvoxamine for PTSD without documented informed consent regarding the medication's reasons, risks, and benefits. The DON confirmed that staff did not complete the required psychotropic medication consent form prior to administration, as expected by facility policy.
A resident with a history of diarrhea and gastrointestinal conditions missed multiple doses of Questran and fiber due to medication unavailability. Staff documented the missed doses and noted waiting for pharmacy delivery, but did not notify the provider about the missed medications until after several doses had been missed. The provider was only contacted later, at which point an alternative medication was ordered. Facility staff confirmed that provider notification should have occurred at the time of each missed dose, but this did not happen.
Care plan meetings were not consistently attended by all required IDT members, and meetings were not always held within the mandated timeframe after MDS assessments. In several cases, care plans were not updated to reflect new physician orders or changes in resident conditions, such as the need for daily lotion application or interventions for ongoing diarrhea. Staff interviews confirmed that providers and CNAs typically did not participate in care plan meetings or provide input, and that care plan updates were not always made as required.
A resident with gastrointestinal conditions missed multiple doses of prescribed fiber and Questran because staff did not ensure timely procurement of the medications or consistently notify the provider about missed doses. Documentation showed repeated notes of waiting for delivery, but lacked evidence of further action to obtain the medications or communicate with the provider as required by facility policy.
The facility did not ensure that physician responses to consultant pharmacist recommendations for medication regimen reviews were properly documented, including patient-specific rationales for continuing medications and communication with outside providers. Two residents with complex psychiatric and neurological conditions continued to receive medications without required documentation or follow-up, as confirmed by the DON.
A resident's room was found with orange peels, food crumbs, and paper trash on the floor, along with a lunch tray and a full urinal left on the tray table after the meal was finished. Staff confirmed these items should have been removed and the area cleaned to maintain a comfortable and homelike environment.
Two residents did not have accurate MDS assessments: one resident's dental status as edentulous was not recorded, and another resident's ongoing antipsychotic medication use was not documented in the MDS, despite clear evidence from interviews, records, and medication administration logs.
A resident with edema was prescribed furosemide, a high-risk diuretic, but the care plan did not document the diagnosis or the medication order. The DON confirmed that the care plan lacked this information, even though high-risk medications are expected to be included.
A resident with gastrointestinal conditions missed several doses of prescribed fiber and Questran medications, as documented in the MAR. Staff indicated missed doses and referenced nurse notes, but did not document provider notification in the medical record, despite contacting the on-call provider through a facility communication app. The DON confirmed the expectation for such communication to be recorded in the resident's medical record, resulting in incomplete and inaccurate documentation.
An Activity Aide in an LTC facility exploited a resident's financial resources by using their debit card for unauthorized personal purchases, totaling nearly $3,000. The aide was identified through security footage and subsequently arrested and terminated. The facility had already revised its shopping process to prevent future incidents before the survey investigation.
A facility failed to create an accurate baseline care plan within 48 hours of admission for a resident identified as a high fall risk. Despite a fall risk evaluation indicating the resident's high risk, the baseline care plan did not include this information. The ADON confirmed the omission during an interview.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the State Agency (SA) for one resident. According to the incident report, the resident was found in bed with blood on her face, bed, floor, and in the trashcan. The resident was unable to recall what had happened or whether she had fallen. Nursing staff assessed the resident, noted a bump on her forehead, blood on her face, and abrasions to both elbows and knees, but could not determine the source of the bleeding. The provider was notified, and the resident was sent to the emergency room for further evaluation, where she was diagnosed with a contusion. Despite the unclear circumstances and the resident's inability to explain the injury, the incident was not reported to the SA as required for injuries of unknown origin. The interdisciplinary team later discussed the incident and concluded that the resident had likely fallen, but the administrator acknowledged that the incident should have been reported to the SA. The failure to report the incident meant that the SA was not able to review or investigate the potential neglect.
Failure to Timely Complete Significant Change MDS Assessment After Hospice Admission
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment within the required 14-day timeframe after a major change in a resident's condition. Specifically, a resident was admitted to hospice care as ordered by the physician, indicating a significant change in health status. However, the significant change MDS assessment was not signed off by the RN until several weeks later, exceeding the 14-day requirement. This was confirmed by both record review and interview with the MDS coordinator, who acknowledged the assessment was not completed within the mandated period.
Failure to Complete Timely Quarterly MDS Assessment
Penalty
Summary
The facility failed to ensure that a quarterly Minimum Data Set (MDS) assessment was completed every three months for one of four residents reviewed for MDS assessments. Specifically, for one resident, the quarterly MDS assessment had an assessment reference date (ARD) of 11/14/25 but was not signed by the RN for completion and was completed 14 days after the ARD. During an interview, the MDS Coordinator confirmed that the assessment was not completed on time. This resulted in the resident's assessment being outdated at the time of review.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential information and proper record-keeping were not consistently followed. No additional details about specific residents, their medical history, or the exact circumstances of the deficiency are provided in the report.
Failure to Label and Date Prepared Desserts in Kitchen Refrigerator
Penalty
Summary
The facility failed to store food under sanitary conditions for all 81 residents who consumed food from the kitchen. During an observation of the kitchen's walk-in refrigerator, a tray containing 12 desserts was found, with eight of the desserts lacking a date to indicate when they were prepared. In an interview, the Dietary Director confirmed that eight out of the 12 desserts on the tray did not have dates on their lids and stated that having a few with dates on the same tray should suffice. A review of the facility's Food Labeling and Dating policy, revised on 01/25/25, revealed that all food items prepared for a meal are required to be labeled and dated.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident and/or their representative was informed in advance about the administration of a psychotropic medication, specifically fluvoxamine, including the reasons for its use, as well as its risks and benefits. Record review showed that the resident had a physician's order for fluvoxamine to be given twice daily for post-traumatic stress disorder (PTSD), but there was no documentation of consent for this medication in the medical record. During an interview, the DON confirmed that staff did not obtain the required psychotropic medication consent form prior to starting the medication, despite facility expectations that this form be completed before administration.
Failure to Notify Provider of Missed Medication Doses for Resident with Diarrhea
Penalty
Summary
The facility failed to notify the provider when a resident missed multiple doses of prescribed medications intended to manage diarrhea and promote colon health. The resident, who had a history of diarrhea, noninfective gastroenteritis and colitis, cellulitis of the abdominal wall, and acquired absence of digestive tract parts, was admitted with orders for Questran and fiber tablets. Over a period in March and April, the resident missed at least 8 doses of Questran and 12 doses of fiber, as documented in the medication administration record (MAR). Progress notes repeatedly indicated that the medications were not available and that staff were waiting for pharmacy delivery, with nurses being made aware of the situation. However, there was no documentation that the provider was notified about the missed doses of either Questran or fiber during this time. The only provider notification occurred after several missed doses, when staff contacted the on-call provider, who then ordered an alternative medication (Imodium A-D). Interviews with staff confirmed that the standard process required notifying the provider and documenting the communication whenever a resident missed any medication doses. The Director of Nursing verified that, prior to the eventual notification, staff had not contacted the provider regarding the missed doses of Questran or fiber, and that such notification should have occurred at the time of each missed dose.
Deficient Care Plan Development, IDT Participation, and Timely Revisions
Penalty
Summary
The facility failed to ensure that care plan meetings were conducted with the required interdisciplinary team (IDT) members for several residents. In multiple instances, care plan meetings were held with only select staff present, such as the Social Services Director, RN, or Activity Director, while other required contributors like the MDS Coordinator, Nurse Aide, Food Service Staff, and Physician were marked as not applicable or did not participate. Interviews with staff confirmed that providers and CNAs typically do not attend or provide input for care plan meetings, and that input from all required disciplines was not routinely sought. Additionally, the facility did not consistently hold care plan meetings within the required 7-day timeframe following the completion of the Minimum Data Set (MDS) assessments. For some residents, there was no documentation of a care plan meeting occurring within seven days after the MDS was completed, and in one case, the care plan meeting was held before the MDS assessment was finalized. Staff interviews confirmed these timing discrepancies and the lack of adherence to required scheduling protocols. The care plans were also not revised to reflect the most current resident information and physician orders. For example, one resident had a new order for daily application of lotion to the extremities, but this intervention was not added to the care plan. Another resident with a history of diarrhea and multiple related physician orders did not have these diagnoses or interventions reflected in the care plan. The DON confirmed that these updates should have been made to ensure the care plans were accurate and current.
Failure to Administer Medications as Ordered Due to Inadequate Medication Procurement and Notification
Penalty
Summary
The facility failed to meet professional standards of quality by not administering medications as ordered by the physician for one resident. The resident, who had diagnoses including diarrhea, noninfective gastroenteritis and colitis, cellulitis of the abdominal wall, and acquired absence of parts of the digestive tract, had physician orders for fiber tablets and Questran to manage their gastrointestinal conditions. Despite these orders, the medication administration records showed multiple instances where both fiber and Questran were not administered as prescribed over several weeks. Documentation in the medication administration record and progress notes indicated that staff repeatedly noted the medications were not available and were waiting for delivery from the pharmacy or local store. However, there was no documentation that staff took further steps to obtain the medications in a timely manner, such as contacting the pharmacy, notifying the staff member responsible for purchasing over-the-counter medications, or escalating the issue to ensure the resident received the ordered therapy. Additionally, staff did not consistently notify the provider about the missed doses, as required by facility policy, with only one documented instance of provider notification after several missed doses had already occurred. Interviews with nursing staff and the DON confirmed that the expected procedures for medication shortages were not followed. Staff were expected to notify the provider and document communication for each missed dose, as well as to contact the pharmacy or arrange for over-the-counter medication purchases. The facility's own policy required these actions, but records and interviews showed that these steps were not consistently taken, resulting in the resident missing multiple doses of prescribed medications.
Failure to Document Physician Response to Pharmacy Medication Review Recommendations
Penalty
Summary
The facility failed to ensure that consultant pharmacist recommendations regarding medication regimen reviews were properly reviewed and implemented by the physician, or that the physician provided documentation with a patient-specific rationale for not following the recommendations. For two residents, the pharmacist had recommended gradual dose reductions (GDR) for medications including Doxepin, Prazosin, and Bupropion for one resident, and hydroxyzine and haloperidol for another. In these cases, the physician either did not provide a rationale for continuing the medications or failed to document that the recommendations were sent to outside providers for review. One resident had multiple psychiatric and sleep-related diagnoses and was receiving several medications for these conditions. The pharmacy made repeated recommendations for GDR, but the physician did not provide patient-specific reasons for continuing the medications, and there was no documentation that recommendations were communicated to the outside provider responsible for some of the prescriptions. The Director of Nursing (DON) confirmed that no rationale or follow-up was documented for these recommendations. Another resident with severe dementia, anxiety, and auditory hallucinations was prescribed hydroxyzine and PRN haloperidol. The pharmacy recommended a GDR for hydroxyzine and discontinuation or documentation for continued PRN use of haloperidol. The physician's responses were incomplete, lacking patient-specific rationale and anticipated duration of use for the PRN medication, and the haloperidol order did not have an end date. The DON confirmed the absence of required documentation in the medical record.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
Staff failed to maintain a safe, clean, and homelike environment for one resident, as evidenced by the presence of orange peels, food crumbs, and paper trash on the floor of the resident's room. Additionally, a lunch tray from an earlier meal remained on the resident's tray table well after the meal was finished, and a full urinal was left on the same tray table. These conditions were confirmed by both a CNA and the facility Administrator during interviews, who acknowledged that the room should have been cleaned, the tray removed after the meal, and the urinal emptied and taken off the tray table. The observations and interviews directly document the failure to provide a comfortable and homelike environment as required, with specific details about the uncleanliness and improper handling of personal care items in the resident's room.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two residents. For one resident, interviews and record reviews revealed that she was edentulous and required dentures, but her Admission MDS did not reflect her lack of natural teeth. The MDS Coordinator was unaware of the resident's dental status at the time of assessment and confirmed that the information was not accurately entered. For another resident, physician's orders and medication administration records showed that the resident was receiving daily haloperidol, an antipsychotic medication, over several months. However, the Quarterly MDS inaccurately documented that the resident had not received any antipsychotic medications. The MDS Coordinator confirmed the resident was receiving haloperidol and acknowledged the omission on the MDS assessment.
Failure to Include High-Risk Medication and Diagnosis in Care Plan
Penalty
Summary
The facility failed to develop an accurate, person-centered comprehensive care plan for one resident with a diagnosis of edema. Record review showed that the resident was admitted with edema and had a physician's order for furosemide, a high-risk diuretic medication, to be administered daily. The resident's Minimum Data Set Assessment also indicated the use of a high-risk diuretic. However, the care plan, as revised, did not document the resident's diagnosis of edema or the order for furosemide. During an interview, the Director of Nursing confirmed that the care plan did not include the resident's use of furosemide, despite facility expectations that high-risk medications be included in care plans.
Incomplete Documentation of Missed Medication Doses and Provider Notification
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for a resident with multiple gastrointestinal diagnoses, including diarrhea, noninfective gastroenteritis and colitis, cellulitis of the abdominal wall, and acquired absence of digestive tract parts. Record review showed that the resident had physician orders for fiber tablets and Questran to manage their conditions, but the medication administration record (MAR) documented multiple missed doses of both medications over March and April. Staff used codes indicating missed doses and referenced progress or nurse notes, but there was no documentation in the medical record that the provider was notified about the missed doses. During an interview, the DON confirmed that the resident missed several doses of Questran and fiber, and that staff had contacted the on-call provider through a facility communication application regarding the unavailability of Questran. However, this communication was not documented in the resident's medical record, contrary to facility expectations. The lack of documentation regarding provider notification and missed medication doses resulted in incomplete and inaccurate medical records for the resident.
Unauthorized Use of Resident's Debit Card by Activity Aide
Penalty
Summary
The facility failed to prevent staff exploitation of a resident's financial resources, leading to unauthorized use of a resident's debit card by an Activity Aide (AA). The incident involved the misuse of a resident's bank debit card by AA #1, who made unauthorized withdrawals and purchases totaling nearly $3,000. The resident's Power of Attorney (POA) discovered the missing funds and reported suspicious charges, prompting a police investigation. The investigation revealed that AA #1 used the resident's debit card for personal expenses, including gas, groceries, baby clothes, and alcohol. The facility's records showed that AA #1 had been destroying documents and receipts, further complicating the situation. The police used security footage to identify AA #1 as the individual responsible for the unauthorized transactions, leading to her arrest and termination from the facility. The deficiency was identified as past noncompliance, as the facility had already implemented corrective measures before the survey investigation. These measures included revising the shopping process to ensure only the Activity Director could handle residents' financial transactions, and conducting audits to verify the return of cards, change, and receipts to residents.
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 one of the two residents reviewed. The record review revealed that the resident was admitted to the facility on an unspecified date, and a fall risk evaluation conducted on April 26, 2024, indicated that the resident was at high risk for falls. However, the baseline care plan, dated April 29, 2024, did not include this critical information about the resident's high fall risk. During an interview on July 23, 2024, the Assistant Director of Nursing confirmed that the baseline care plan did not reflect the resident's high fall risk, which is a necessary component for ensuring appropriate care immediately upon admission.
Latest citations in New Mexico
Surveyors found that the facility did not provide required written transfer and bed-hold notices when several residents were sent to the hospital for events such as falls with injury, unresponsiveness, and episodes of nausea, vomiting, and bleeding. Medical records lacked written transfer notices and bed-hold notifications, and the transfer information that should have been given to residents or their representatives did not include mandated details about appeal rights, how to request an appeal, or how to contact the State LTC Ombudsman. The Social Services Director reported that she does not notify the Ombudsman of hospital transfers and only sends a monthly email list of discharged residents, without written copies of transfer or discharge notices.
Two cognitively impaired residents with dementia and significant behavioral and continence needs were sent to a local ER after falls and were discharged back to the facility’s care, but the facility failed to provide timely transportation for their return. In both cases, hospital discharge times were documented, yet ER staff reported making multiple unsuccessful calls to the facility, reaching the Administrator only after repeated attempts. One resident, described as very disoriented, remained in the ER for several hours after discharge without 1:1 supervision, while the other waited approximately 11 hours, during which ER staff observed increasing confusion and attempts to get out of bed. The Administrator acknowledged awareness of the discharges, the lack of 24-hour transportation, and that the residents were not picked up until many hours after they had been discharged from the ER.
Two residents who required staff assistance for ADLs and transfers reported neglectful and rude behavior by a CNA and delayed nursing response to care needs. One resident with a history of cerebral infarction and schizophrenia stated that a CNA mocked him and that his requested wound dressing change was not performed for several hours, which was later corroborated by video showing a long gap between the CNA’s visit and the nurse’s entry to the room. Another resident with a right femur fracture, type II DM, and repeated falls, who needed one-person assistance for mobility and self-care, reported that a CNA refused to help and told her she could do some care herself, making her feel she was not trying in her recovery. Documentation and interviews confirmed that staff did not provide timely wound care or required assistance, and that these interactions caused residents to feel uncomfortable and negatively about their care.
A resident with a history of opioid dependence and polysubstance abuse was on a secure unit with a care plan that included safety risk evaluations and monitoring for signs of substance abuse. Staff later observed the resident discarding an empty Suboxone packet, even though the resident was not prescribed this medication, and the incident was reported to the on-call provider with subsequent monitoring and a room search. However, the care plan was not revised to reflect this new substance-related event, and both the DON and Administrator acknowledged that the care plan should have been updated when this new risk and behavior were identified.
Surveyors identified that a medication cart on the north hall was left unlocked and unattended outside a resident room. An LPN acknowledged that the cart was hers and that she had not locked it before leaving to answer a call light, despite facility expectations. The DON confirmed that all medication and treatment carts are required to remain locked when not in use or when staff are away from them.
Surveyors found that a document containing multiple residents’ PHI, including full names, room numbers, and code status, was left unattended and visible on a south nurse’s station counter. An RN confirmed the document was a resident list with PHI and acknowledged it had been left exposed and that such information should not be left unattended.
Surveyors found that a lunch tray return cart containing uncovered, soiled food trays and dishes was left unattended in a main hallway outside an activity room. The housekeeping/laundry manager acknowledged seeing the unattended cart, and the Dietary Manager confirmed that such carts are supposed to remain only in designated areas, such as near the nurse’s station or in the kitchen, and should be returned to the kitchen for cleaning as soon as all trays are collected. This failure was cited as likely to expose all residents to potential pathogens associated with food waste.
Two residents with scheduled showers reported that they were offered or received showers in very cold water during a prolonged period when hot water was not reliably available in care areas. One resident stated he refused cold showers and was only offered sponge baths once or twice, despite his preference to stay clean. Another resident reported receiving cold showers, including being rinsed with cold water while still soaped, and subsequently began refusing showers and bed baths due to the cold water. A CNA confirmed that water in the shower rooms was “ice cold” for several months, leading to resident complaints and refusals, while the Maintenance Director reported that a needed part to correct the hot water problem was on back order, delaying resolution and resulting in the facility not honoring residents’ bathing preferences.
Surveyors observed that unused medications were improperly discarded in a trash bin attached to a medication cart on the north hallway, rather than being disposed of in a designated drug disposal container. Two pills, a round blue tablet stamped "61" and an oblong orange tablet stamped "20," were found together in an unlabeled medication cup in the trash. An RN confirmed the medications were discarded there and acknowledged that unused medications should be placed in the drug buster container in the cart drawer. The Unit Manager also confirmed that facility practice requires all unused medications to be disposed of using the drug buster and that controlled substances must be destroyed by two licensed staff and documented on the narcotic count sheet.
The facility failed to follow documented allergy information, diet orders, and meal tickets for three residents. A resident with a documented chocolate allergy was served chocolate ice cream after requesting it, and the Nutrition Director admitted not reading the allergy notation on the meal ticket. Another resident on a pureed diet received whole mandarin oranges instead of pureed fruit, which a CNA confirmed. A third resident whose meal ticket called for a grilled Swiss sandwich received a sandwich that was not grilled, as confirmed by a CNA and a dietary manager.
Failure to Provide Required Written Transfer, Appeal, Ombudsman, and Bed-Hold Notices During Hospitalizations
Penalty
Summary
Surveyors identified that the facility failed to provide required written transfer and bed-hold information for multiple residents who were hospitalized. For three residents who experienced transfers to the hospital after events such as falls with injury, unresponsiveness, and episodes of nausea, vomiting, and bleeding, record review showed there were no written transfer notices or written bed-hold notices in their medical records. Specifically, one resident transferred after a fall on 01/31/26 had no documented written transfer notice or bed-hold notice. Another resident transferred on 02/27/26 for nausea, vomiting, and bleeding, and later readmitted on 03/05/26, had no written transfer notification that included information on appeal rights or Ombudsman contact, and no written bed-hold notification. A third resident transferred on 01/29/26 after a fall with a forehead laceration and again on 03/17/26 for unresponsiveness, also had no documented written transfer or bed-hold notices for either hospitalization. The deficiency also included the facility’s failure to provide required content in transfer notices and to notify the State Long-Term Care Ombudsman in writing. For the residents reviewed, there was no evidence that written transfer notices were provided to the residents or their representatives in a language and manner they could understand, and the notices were missing required elements such as a statement of appeal rights, the name, mailing and email address, and phone number of the entity receiving appeals, and information on how to obtain and complete an appeal form. The notices also lacked the name, phone number, and mailing and email address of the State Long-Term Care Ombudsman, and written copies of the transfer notices were not sent to the Ombudsman. During interview, the Social Services Director confirmed that transfer and bed-hold notices were not documented for at least one resident’s hospitalization, that she does not notify the Ombudsman about transfers to the hospital, and that she only emails a monthly list of residents discharged from the facility without sending written copies of transfer or discharge notices.
Failure to Timely Retrieve Residents From ER After Discharge
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from neglect by not arranging timely transportation back to the facility after emergency room (ER) discharge. A consumer complaint alleged that residents sent to the local ER were being left there for extended periods after discharge. For one resident with an admission date of 10/13/25, records showed multiple cognitive and behavioral diagnoses, including Alzheimer’s disease, vascular dementia with agitation and other behavioral disturbances, mild cognitive impairment, cognitive communication deficit, and restlessness and agitation. A change of condition MDS documented a Brief Interview for Mental Status (BIMS) score of 1 and frequent incontinence of urine and bowel. Nursing progress notes for this resident showed that 911 was called at 3:00 AM and the resident was transferred to the ER after a fall. Hospital discharge instructions indicated the resident was discharged from the ER at approximately 5:21 AM, while the ER nurse reported discharge at about 5:30 AM. The ER nurse stated she made numerous calls to the facility but was unable to reach anyone. She reported that the resident was very disoriented and that the ER did not have enough staff to provide 1:1 supervision. The ER nurse eventually reached the Administrator, who stated staff would come to pick up the resident as soon as possible. Facility records showed the resident was not discharged from the facility on that date, and the ER nurse reported that facility staff did not pick the resident up until approximately 8:30 AM, several hours after discharge. A second resident, admitted on 11/25/25, had diagnoses including Alzheimer’s disease, dementia with behavioral disturbance, bipolar disorder with severe depression and psychotic features, depression, and anxiety disorder. The admission MDS documented a BIMS score of 2, frequent urinary incontinence, constant bowel incontinence, and a need for substantial/maximal assistance with toileting hygiene. Nursing notes showed this resident was sent to the ER for evaluation after a fall and did not return until the following morning. Hospital discharge instructions documented discharge from the ER at 10:16 PM, and the Administrator confirmed being notified of the discharge at about 10:30 PM and that the facility did not have 24-hour transportation. The Administrator acknowledged the resident was not picked up until approximately 9:00 AM the next day. The ER nurse reported making several calls to the facility that went to voicemail, eventually reaching the Administrator, who initially stated staff were on the way, then stopped answering calls. During the approximately 11-hour wait, the ER nurse stated the resident was confused, attempted to get out of bed, and became more confused as the night progressed.
Failure to Timely Provide Wound Care and Required Assistance, Resulting in Resident Neglect
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from neglect when staff did not respond appropriately to requests for care and assistance. One resident with a history of cerebral infarction due to embolism and schizophrenia, admitted on 01/30/26 and requiring staff assistance for ADLs and mechanical lift transfers, reported that a CNA was rude and mocking and that his wound dressing was not changed for several hours after he requested it. The Kardex showed he needed staff help for toileting, bathing, hygiene, bed mobility, dressing, and transfers. Nursing progress notes documented a change in condition on 03/02/26 after the resident stated the CNA was rude and would not assist as requested. The Administrator later confirmed, via video review, that the CNA entered the resident’s room at 2:30 am, the resident requested a dressing change, and no nurse entered the room until 5:00 am, despite the nurse’s statement that she went in “right away.” The DON also confirmed that the resident’s grievance described the wound dressing not being changed until hours after the request. Another resident, admitted with a right femur fracture, type II diabetes, and repeated falls, required one-person assistance for dressing, hygiene, bathing, bed mobility, and transfers, and could toilet herself with assistance for transfers. Nursing progress notes documented an alleged abuse incident on 03/02/26 in which this resident stated a CNA was rude, refused to help her, and told her she could perform some care tasks herself without staff assistance. An abuse questionnaire completed the same day showed the resident answered “Yes” to having interactions that made her feel uncomfortable or negative, and she reported that the CNA made her feel as though she was not trying with her own recovery. The Administrator and DON acknowledged that staff are expected to help residents as required and that staff interactions must be encouraging rather than making residents feel bad about needing assistance.
Failure to Revise Care Plan After Substance-Related Incident
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s care plan after a significant substance-related incident. The resident was originally admitted with a diagnosis of opioid dependence and resided on a secure unit related to polysubstance abuse disorder. The existing care plan, dated 01/21/26, identified the resident as residing on a secure unit due to polysubstance abuse disorder with interventions to perform safety risk evaluations on admission, as needed, and upon changes in condition. The care plan also identified the resident as at risk for substance use disorder with interventions to monitor for signs or symptoms of substance abuse. On 02/01/26, nursing notes documented that staff observed the resident discarding an empty Suboxone packet in the trash, even though the resident was not prescribed Suboxone and denied taking any. Staff notified the on-call provider, who ordered monitoring for adverse reactions, and nursing staff and security conducted a room search that revealed no additional contraband. Despite this incident, the resident’s care plan was not updated to address the new substance-related event. During interviews, the DON acknowledged awareness of the incident and confirmed the care plan was not revised, and the Administrator stated her expectation that nursing would update the care plan when a new risk or behavior was identified and confirmed she would have expected the care plan to be updated for this resident.
Unattended, Unlocked Medication Cart on North Hall
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were properly stored and secured in accordance with professional standards and facility expectations. On 03/24/26 at 9:06 a.m., surveyors observed a medication cart on the north hall left unlocked and unattended outside a resident room. At 9:08 a.m., the LPN responsible for the cart confirmed during interview that the cart was hers, that it was unlocked and unattended, and acknowledged she should have locked it before responding to a call light. Later that day at 3:37 p.m., the DON stated in an interview that medication and treatment carts are expected to be locked at all times when nurses are away from them, confirming that the observed practice did not meet facility expectations. This deficient practice was cited as likely to allow unauthorized personnel access to medications, which could result in injury or overdosing.
Unattended PHI Document Left Exposed at Nurse’s Station
Penalty
Summary
Surveyors identified a deficiency in the facility’s protection of residents’ personal health information (PHI) when a document containing multiple residents’ full names, assigned room numbers, and code status was left unattended and exposed on the south nurse’s station counter. On 03/16/26 at 9:04 a.m., an observation revealed a piece of paper on a clipboard with complete resident information placed on top of the south nurse’s counter in public view. At 9:06 a.m., during an interview, RN #2 confirmed that the list contained residents’ names, room numbers, and code status, acknowledged that it had been left exposed and unattended, and stated that PHI should not be left unattended. No additional clinical details or medical histories of the residents listed on the document were provided in the report.
Unattended Soiled Lunch Cart Left Uncovered in Hallway
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the handling of soiled food service equipment. On 03/24/26 at 12:58 pm, a lunch tray return cart containing soiled food trays and dishes that were uncovered was observed sitting unattended in the main hallway outside the activity room. At 1:06 pm, the housekeeping/laundry manager confirmed she saw the return cart left unattended in that location. At 1:08 pm, the Dietary Manager stated that lunch return carts should only be left in designated areas such as by the nurse’s station or inside the kitchen, and that the cart should be returned to the kitchen for cleaning as soon as all trays have been picked up, which did not occur in this instance. This deficient practice was noted as likely to expose all residents to potential pathogens associated with food waste.
Failure to Honor Resident Bathing Preferences During Prolonged Hot Water Issues
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ bathing preferences when hot water was not reliably available in resident care areas. Record review showed that one resident was scheduled to receive three showers per week on specific days, and another resident was scheduled for two showers per week. One resident reported that staff attempted to have him shower in cold water, which he refused, and that sponge baths were only offered once or twice during the period when the hot water was not working. He stated that he liked to be clean and did not feel like himself when he was dirty. A CNA reported that there was no hot water in resident care areas from the middle of December until early March, and that large barrels of warm water were brought to shower rooms to offer sponge baths, which this resident refused. Another resident, also on a scheduled twice-weekly shower regimen, stated that she received cold showers and began refusing showers because of how cold the water was. She described the water running cold unpredictably, including an instance when the water was initially warm but turned cold while she was still soaped, requiring rinsing with cold water, which she described as horrible. A social services note documented that this resident’s daughter reported the resident had been declining showers and bed baths offered because the water was too cold. A CNA corroborated that the water was “ice cold” and that residents began complaining and refusing showers around mid-December. The Maintenance Director stated that it took a while for hot water to reach the shower room and that a needed part to fix the cold-water problem was on back order, contributing to the prolonged period of inadequate hot water and resulting in residents not having their bathing preferences honored.
Improper Disposal of Unused Medications on Medication Cart
Penalty
Summary
Surveyors identified a deficiency related to accident hazards and inadequate supervision when unused medications were improperly discarded on the north hallway. During observation of the north hall nurses’ station, two medications were found in the trash bin attached to the medication cart, placed together inside an unlabeled medication cup. The pills were described as a round blue pill stamped with “61” and an oblong orange pill stamped with “20.” In an interview immediately following the observation, an RN confirmed that these medications were in the trash bin and stated that unused medications should instead be disposed of in the drug buster, a sealed container for drug disposal located in the bottom drawer of the cart. In a subsequent interview, the Unit Manager confirmed that all unused medications are to be disposed of using the drug buster and acknowledged that this did not occur, further stating that if the medications are controlled substances such as narcotics, two licensed personnel are required to dispose of them together and document the disposal on the narcotic count sheet. This deficient practice was noted as likely to affect any resident who might acquire and ingest the discarded medications, potentially causing medication side effects.
Failure to Follow Allergy, Diet, and Meal Ticket Requirements
Penalty
Summary
The facility failed to provide meals consistent with residents’ documented allergies, diet orders, and meal tickets for three residents. One resident, admitted with a documented allergy to chocolate, had a face sheet and lunch ticket indicating they were not to receive chocolate. During a lunch observation, this resident was served and was eating chocolate ice cream. An LPN confirmed the resident’s chocolate allergy and that the resident should not be eating chocolate. The Nutrition Director acknowledged that the meal ticket stated the resident should not have chocolate but reported serving chocolate ice cream after the resident requested it, stating he had not read that the resident was allergic to chocolate. Another resident, admitted with hypokalemia and ordered a regular/liberalized pureed diet per the MDS, had a lunch ticket indicating a pureed diet but was observed receiving whole mandarin oranges instead of pureed fruit. A CNA confirmed that the dessert was not pureed. A third resident’s meal ticket specified a grilled Swiss sandwich, but observation of the tray showed the sandwich was not grilled. During interviews, a CNA and a dietary manager confirmed that the sandwich was not grilled as ordered on the meal ticket.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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