Princeton Health & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Albuquerque, New Mexico.
- Location
- 500 Louisiana Boulevard Ne, Albuquerque, New Mexico 87108
- CMS Provider Number
- 325045
- Inspections on file
- 33
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 65 (2 serious)
Citation history
Health deficiencies cited at Princeton Health & Rehabilitation during CMS and state inspections, most recent first.
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.
The facility failed to submit the required five-day follow-up investigation results to the State Agency after a resident filed an abuse grievance. An Administrator later confirmed that the allegation and the facility’s investigation summary were not reported as required, preventing the State Agency from receiving the necessary information to review and triage the abuse allegation.
A resident reported that a nurse was rude when addressing his request for additional pain medication and that the same nurse threatened another resident. The grievance was not entered into the incident reporting system, and no investigation or report to the State Agency was completed. The nurse was never informed of the grievance, the UM did not investigate or determine an outcome, and the SSD did not follow up after handing the grievance to the UM. Leadership, including the DON and administrator, later acknowledged that the abuse allegation was neither thoroughly investigated nor reported as required.
A resident with chronic respiratory failure and hypoxia had physician orders for SpO2 monitoring every shift, but review of records over several months showed multiple entries where staff documented the resident as receiving 2–5 LPM of supplemental O2 while also indicating the resident was on room air. The Respiratory Therapist Manager and the DON both confirmed that these oxygen saturation and oxygen use entries were inaccurate and should not have been documented in this manner.
Facility leadership failed to develop and implement a comprehensive Legionella Water Management Program, as the policy lacked procedures for control measures, control limits, monitoring protocols, and intervention strategies. Key staff, including the Administrator, DON, and Maintenance Director, were unaware of these deficiencies, potentially affecting all residents.
A resident with severe dementia and behavioral issues was physically restrained by three staff members in order to administer an IM Haldol injection after refusing medication and becoming aggressive, including spitting at staff. Staff interviews and documentation confirmed the use of restraint, and leadership acknowledged that this practice was not appropriate.
A resident with severe dementia and agitation was repeatedly administered Haldol injections without a qualifying diagnosis and without documented attempts at alternative interventions. Staff did not consistently record the reasons for medication use, and interviews revealed that medication was sometimes used as a first-line response to behavioral issues, contrary to facility expectations.
A resident with severe cognitive impairment and multiple diagnoses was administered oxycodone for pain following a physician's order, but the nurse failed to document the administration on the MAR after retrieving the medication from the Ekit. The DON confirmed that such documentation is required, and the nurse admitted to forgetting to record the administration.
The facility failed to investigate and document incidents of neglect, abuse, and injury for three residents. One resident was found with a head laceration, another with severe knee pain, and a third involved in a scratching incident. Required follow-up reports were either late or not submitted, and investigations were incomplete.
A facility failed to ensure medications were not left unattended on a resident's bedside table. A resident did not take her medications because she was waiting for staff assistance, and the RN admitted to leaving the medications, which included baclofen and gabapentin, on the bedside table instead of returning them to the medication cart.
A medication cart on the 600-unit was found unattended and unlocked, contrary to the requirement for secure storage of drugs and biologicals. An RN confirmed that medication carts should always be locked when not in use, highlighting a lapse in protocol that could lead to residents accessing medications not prescribed to them.
A resident's room in the facility had uneven flooring and missing tiles, creating an unsafe environment. The resident reported the issue multiple times, but the facility had not yet repaired it. The Maintenance Director attributed the problem to condensation from the air conditioning unit, which caused the floor to become uneven.
A resident with severe medical conditions and communication difficulties expressed suicidal thoughts and requested one-on-one supervision or hospitalization. Despite this, the facility only conducted frequent checks, leading to the resident swallowing razor blades in a suicide attempt. Staff failed to provide constant supervision as per the facility's policy, resulting in a preventable incident.
The facility failed to provide a safe, clean, and comfortable environment, with cigarette butts littering the courtyard and stained floors in the 600-unit hallway. Several rooms had closet doors falling off hinges. Residents expressed dissatisfaction, with one noting dirty hands from wheelchair use and another embarrassed by filthy floors. A blind resident reported a bowel movement odor in the hallway, confirmed by observation.
A resident with dementia and muscle wasting wandered into another resident's room and sustained facial injuries. The facility failed to notify the resident's POA, who is the resident's daughter, about the incident. The following day, the POA noticed the injuries and informed an LPN, who confirmed the bruising. The DON acknowledged the failure to notify the POA.
A resident with severe cognitive impairment, known to wander into other residents' rooms, was not provided with timely interventions or supervision, leading to an incident where he was found with facial injuries. Despite staff awareness of his behavior, no care plan was implemented until after the incident.
The facility failed to properly handle and store medications and supplies, including not disposing of eye drops within 30 days, mixing expired and unexpired supplies, and pre-pouring medications. Expired medications were also found stored with unexpired ones, and the DON confirmed that staff should clean out storage rooms and carts weekly.
The facility failed to maintain proper infection prevention measures in laundry handling. A housekeeper was observed sorting dirty laundry without full PPE, and a CNA improperly transported soiled linens without using a bag, allowing them to touch her scrubs. These actions could lead to the spread of infections.
The facility failed to provide a homelike environment by not repairing a damaged drawer, not preventing or removing cockroaches from a CPAP humidifier tank, and not addressing water leaks and a damaged ceiling in the therapy room. Residents reported issues, but the problems persisted, posing safety hazards.
The facility failed to meet professional standards when an LPN hid medications in food without residents' knowledge or proper consent. The care plans lacked instructions for this practice, and the DON confirmed no orders or POA permissions were documented.
The facility failed to maintain proper records of controlled substances on multiple medication carts. Staff did not sign the narcotic book to show they counted the medication blister cards and compared them to the residents' medication sheets on several occasions. Interviews with LPNs and the DON confirmed that the narcotic book should be signed at each shift change to ensure the narcotic count is correct and the keys are properly handed over.
The facility failed to ensure the comprehensive care plan was accurate for a resident using an indwelling urinary catheter. The care plan incorrectly documented the use of an intermittent catheter, despite physician orders and observations indicating the use of an indwelling catheter. Staff confirmed the discrepancy during interviews.
The facility failed to document weekly wound assessments for a resident with a stage 2 pressure ulcer. Despite physician orders for daily wound care and the wound being resolved, the EHR lacked documentation of weekly assessments, as confirmed by the DON.
A resident with Parkinson's disease, major depressive disorder, and chronic kidney disease experienced significant weight loss. Despite physician orders for weekly weights and mirtazapine to increase appetite, the facility did not implement a nutritional plan or provide nutritional shakes. The DON acknowledged the lack of action due to the resident's short stay.
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.
Failure to Submit Required Abuse Investigation Follow-Up to State Agency
Penalty
Summary
The facility failed to submit the required five-day follow-up investigation results to the State Agency for a resident who filed an abuse grievance. The resident submitted an allegation of abuse grievance on 10/31/25, which required the facility to complete and send a summary of its investigation to the State Agency. During an interview on 12/19/25 at 1:49 pm, the Administrator confirmed that the allegation of abuse grievance filed by this resident was not submitted to the State Agency, although it should have been. As a result, the State Agency did not receive the facility’s investigation summary needed to review and triage the allegation for further investigation.
Failure to Investigate and Report Abuse Allegation
Penalty
Summary
The facility failed to complete a thorough investigation and report findings within five working days for an allegation of abuse involving one resident. The resident filed a grievance stating that a nurse spoke to him rudely regarding his request for additional pain medication, telling him she could only provide Tylenol, and reported that this nurse had been rude since his admission. The resident also reported witnessing the same nurse threaten another resident. The grievance, dated 10/13/25, was not entered on the facility’s incident report list covering 10/31/25 through 12/12/25, indicating that no incident investigation or report was completed for this allegation. During subsequent interviews, the resident stated he no longer had concerns about pain medication but confirmed the nurse’s prior rude behavior made him feel bad. The nurse identified in the grievance reported she was unaware a grievance had been filed and that management had never discussed the incident with her. The DON stated she was out of town on the date of the grievance but would have expected management to investigate the allegation. The unit manager recalled the grievance but acknowledged he did not conduct an investigation and was unaware of any outcome. The social services director reported she had given the grievance to the unit manager for investigation but did not follow up. The administrator confirmed that the allegation of abuse was not thoroughly investigated or reported to the State Agency as required.
Inaccurate Documentation of Oxygen Saturations and Oxygen Use
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records for a resident with chronic respiratory failure and hypoxia. The resident was admitted with this diagnosis and had physician orders in place from July through December for SpO2 monitoring every shift. Review of the resident’s oxygen saturation records from early September through mid-December showed multiple instances where documentation indicated the resident was receiving supplemental O2 at 2 to 5 LPM while simultaneously being documented as on room air, which indicates the resident was not actually receiving supplemental oxygen at those times. Record review identified seven such inaccurate entries in September, one in October, and two in December. During an interview, the Respiratory Therapist Manager stated that nursing staff are expected to document oxygen saturations accurately and should not document supplemental oxygen when the resident is on room air, and confirmed that the resident’s O2 saturation documentation had been inaccurate on multiple occasions. In a separate interview, the DON also confirmed that the resident’s O2 saturation documentation was not accurate and acknowledged it should have been accurate.
Inadequate Legionella Water Management Program and Lack of Staff Awareness
Penalty
Summary
The facility failed to develop and implement an adequate Legionella Water Management Program (LWMP) to minimize the risk of Legionella bacteria in the building's water system. Record review of the LWMP, last revised in August 2024, revealed that the policy lacked procedures for using control measures to prevent the introduction and spread of Legionella. Additionally, the policy did not specify control limits or parameters, nor did it include monitoring procedures such as documented testing protocols for Legionella or established control limits for the measures being monitored. There were also no established interventions for when control limits were not met or in the event of a healthcare-associated legionellosis case in the facility. During interviews with the Administrator, Regional Corporate Nurse, DON, Maintenance Director, and Environmental Services Manager, it was confirmed that facility leadership was unaware of the inadequacies in the LWMP. They stated they did not know the plan was missing essential procedures, acceptable control limits and parameters, monitoring protocols, or intervention strategies for non-compliance or legionellosis cases. This lack of awareness and incomplete policy had the potential to affect all residents in the facility.
Resident Restrained for Haldol Injection During Behavioral Episode
Penalty
Summary
Staff failed to ensure a resident was free from physical restraints when three staff members held down a resident with severe dementia and agitation in order to administer an intramuscular injection of Haldol, an antipsychotic medication. The resident, who had a history of behavioral issues including anger, resistance to care, and exit-seeking, became verbally and physically abusive after repeatedly expressing a desire to leave the facility. Despite the care plan indicating the need to anticipate and meet the resident's needs and to monitor for medication side effects, staff proceeded to restrain the resident during the administration of the medication after he refused it and became aggressive, including spitting at staff. Documentation in the nursing progress notes initially described the restraint and was later struck through after the Unit Manager advised that holding a resident down for medication was not appropriate. Interviews with staff confirmed that the resident was physically restrained during the injection, and that alternative interventions, such as redirection or bargaining, were not consistently attempted prior to the use of restraint. The Director of Nursing and Unit Manager both acknowledged that physically restraining a resident for medication administration was not acceptable practice.
Failure to Prevent Unnecessary Use of Psychotropic Medication
Penalty
Summary
Staff administered Haldol, an antipsychotic medication, to a resident with severe dementia and agitation on multiple occasions without a qualifying diagnosis and without first attempting other interventions. The resident's care plan indicated behavioral issues such as anger, resistance to care, wandering, and exit-seeking, with interventions including medication administration, monitoring for side effects, and psychiatric referral. Despite these interventions, the resident received Haldol injections repeatedly, as documented in the Medication Administration Record and nursing progress notes, often in response to agitation, verbal threats, or physical aggression. The documentation revealed that staff did not consistently record the reasons for administering Haldol, and in at least one instance, there was no nursing progress note to justify the use of the medication. Interviews with facility staff, including the Social Services Assistant and Unit Manager, indicated that the resident's behaviors were attributed to his dissatisfaction with being at the facility, and that medication should not have been the first intervention. The Unit Manager specifically stated that staff were expected to try other interventions before resorting to Haldol, and that medication should not be the initial response to behavioral issues. The Physician Assistant who ordered the Haldol stated it was intended for severe agitation and that suicidal threats alone did not warrant its use. The PA also acknowledged that staff could interpret 'extreme agitation' subjectively, potentially leading to inconsistent administration of the medication. The repeated use of Haldol without documented attempts at alternative interventions and without a clear qualifying diagnosis constituted the deficiency identified by surveyors.
Failure to Document Administration of Pain Medication
Penalty
Summary
A resident with multiple complex medical conditions, including anoxic brain damage, chronic respiratory failure, COPD, Alzheimer's disease, dementia, and bipolar disorder, was admitted to the facility and was under hospice care. The resident was found to have a contusion on the left foot and reported significant pain, which was assessed by a hospice nurse practitioner who ordered an x-ray and subsequently, after the resident's pain was rated at 7 out of 10, a hospice physician ordered oxycodone 5 mg every six hours as needed for pain greater than five. On the day the pain medication was ordered and administered, the nurse retrieved oxycodone from the Ekit and gave it to the resident. However, there was no documentation on the resident's medication administration record (MAR) to indicate that the oxycodone had been administered. During interviews, the DON confirmed that staff are required to document all medications pulled from the Ekit on the MAR, and the nurse involved acknowledged that she administered the medication but forgot to document it.
Failure to Investigate and Report Allegations of Neglect and Abuse
Penalty
Summary
The facility failed to complete and document thorough investigations, implement preventive measures, and take corrective actions regarding allegations of neglect, abuse, and injury of unknown origin for three residents. For one resident, staff found him on the floor with a bleeding laceration on his head, but the facility did not submit a required five-day follow-up report to the State Agency (SA) within the designated period. Additionally, the facility's incident records showed no investigation into the abuse allegations for this resident. Another resident was found on the floor in the hallway, complaining of severe knee pain, but the facility submitted the five-day follow-up report three days late and failed to provide an addendum addressing preventive measures. A third resident was involved in an incident where they scratched another resident, but the facility did not conduct a thorough investigation or submit the required follow-up report. The facility administrator confirmed these deficiencies during an interview.
Medication Mismanagement: Pills Left Unattended
Penalty
Summary
The facility failed to ensure that medications were not left unattended on a resident's bedside table, which is a breach of professional standards of quality. During an observation, a small cup containing two pills was found on the bedside table of a resident's room. The resident explained that she did not take the medications when the nurse brought them because she was waiting for staff assistance to change her brief. The Registered Nurse (RN) involved admitted to leaving the medications on the bedside table, acknowledging that she should have returned them to the medication cart and disposed of them if necessary. The medications involved were baclofen, prescribed for spasticity, and gabapentin, prescribed for chronic pain, as per the resident's physician orders.
Unattended and Unlocked Medication Cart
Penalty
Summary
The facility failed to ensure that medication carts were locked when unattended, which is a violation of the requirement to store drugs and biologicals securely. During an observation on the 600-unit, a medication cart was found unattended and unlocked. This was confirmed by an interview with a Registered Nurse (RN), who acknowledged that medication carts should be locked and secured at all times when not in use. This oversight could potentially lead to residents ingesting medications not intended for them.
Uneven Flooring and Missing Tiles in Resident's Room
Penalty
Summary
The facility failed to provide a safe and functional environment for a resident due to uneven flooring and missing tiles in the resident's room and bathroom. During an observation, it was noted that the floor was uneven, and multiple tiles were missing near the window, with an unoccupied bed placed over the affected area. Additionally, a floor tile was missing near the toilet in the resident's bathroom. The resident expressed dissatisfaction, stating that the floors were in poor condition and that he had reported the issue to the facility staff multiple times. The Maintenance Director explained that the air conditioning unit had caused condensation during the warmer months, leading to the floor becoming uneven. Despite being aware of the issue, the facility had not yet repaired the flooring, opting instead to place a bed over the affected area while waiting for repairs.
Failure to Provide Adequate Supervision for Suicidal Resident
Penalty
Summary
The facility failed to protect a resident from abuse and neglect by not providing adequate supervision after the resident expressed suicidal thoughts. The resident, who had a history of severe medical conditions including anoxic brain damage, acute respiratory failure, and depression, communicated her distress and desire to die to a Social Services Assistant (SSA). Despite this, the facility did not implement a one-on-one supervision or send the resident to the hospital as requested, which was a critical oversight given her mental state. The resident's care plan noted her communication difficulties due to a brain injury and tracheostomy, and she was known to express frustration with her condition. On the day of the incident, the resident told the SSA that she wanted to die and requested either one-on-one supervision or to be sent to the hospital. The SSA reported this to the nurse and the Director of Nursing (DON), but the facility only decided to conduct frequent checks instead of providing constant supervision. This lack of immediate and appropriate response led to the resident swallowing razor blades in a suicide attempt. Interviews with staff revealed that the resident was left unsupervised at the nurses' station, allowing her to return to her room and harm herself. The nurse on duty did not follow up on the resident's whereabouts after she left the nurses' station, and the DON was informed of the resident's suicidal ideation but did not ensure that a staff member remained with the resident as per the facility's Suicide Threats Policy. This series of inactions and miscommunications resulted in a serious incident that could have been prevented with proper adherence to the facility's policies.
Removal Plan
- The facility will identify any residents who have expressed a suicidal comment.
- Social Services will interview any residents identified to evaluate the mental condition of the resident in reference to any suicidal thoughts. The facility will immediately implement any measures per the facility's Suicide Threats Policy which are required to be initiated.
- Education of staff, which includes Administration, Direct Care Staff on the facility. Policy and procedures for suicide threats voiced by a resident.
- Staff will report any resident threats of suicide immediately to the Nurse Supervisor, Charge Nurse, DON/designee, and Physician.
- A staff member will remain with the resident until appropriate direction is provided by the physician.
- Any resident who expresses a suicide threat will be transferred to the hospital for evaluation.
- A psychiatric consultation will be initiated.
- Facility will initiate a facility wide sweep of all residents to determine if any residents exhibit suicide ideation. The facility will follow the following procedures: a. A standard format of questions will be utilized. b. The format will include the resident's name, person who is conducting the interview, and date of interview.
- Any residents identified at Risk for Suicide Ideation during facility-wide screening, Suicide Threat Policy will be initiated.
Facility Fails to Maintain Clean and Comfortable Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents, particularly in the courtyard and the 600-unit hallway. Observations revealed that the courtyard smoking area and grass edge were littered with cigarette butts, and the floors in the 600-unit hallway were visibly stained and unkempt. Additionally, several resident rooms had closet doors falling off their hinges. Interviews with residents highlighted their dissatisfaction with the cleanliness of the facility. One resident, who used a wheelchair, reported that his hands became dirty from propelling himself down the hallway, while another resident expressed embarrassment over the filthy floors when having visitors. A third resident, who is blind, noted that the hallways smelled of bowel movement, which was particularly distressing due to his heightened sense of smell. An observation confirmed the presence of the odor in the hallway.
Failure to Notify POA of Resident Injury
Penalty
Summary
The facility failed to notify the Power of Attorney (POA) for a resident who wandered into another resident's room and sustained an injury. The resident, who has dementia with behavioral disturbances and muscle wasting, was found by a Certified Nursing Aide (CNA) with a scratch on the right side of his face and red lips. The incident occurred on July 5, 2024, but there was no documentation indicating that the resident's POA, who is the resident's daughter, was informed of the incident. The following day, the POA noticed the resident appeared injured and informed a Licensed Practical Nurse (LPN). Upon examination, the LPN observed bruising on the resident's face, with red, purple, and black circles around the eyes. The resident was unable to explain what happened. The Director of Nursing (DON) confirmed that the facility did not notify the POA about the incident, acknowledging that they should have done so.
Failure to Implement Interventions for Wandering Resident
Penalty
Summary
The facility failed to prevent an accident involving a resident with severe cognitive impairment, who was known to wander into other residents' rooms. This resident, admitted with diagnoses including benign intracranial hypertension and dementia with behavioral disturbances, had a Brief Interview of Mental Status (BIMS) score indicating severe cognitive impairment. Despite being aware of the resident's tendency to wander, the facility did not implement any interventions to monitor or manage his movements until after an incident occurred. On multiple occasions, the resident was found in other residents' rooms, including an incident where he was found with scratches and redness on his face after being pushed out of another resident's room. Staff interviews revealed that the resident's wandering behavior was known since his admission, yet no care plan or interventions were put in place to address this behavior until several days after the incident. This lack of timely intervention and supervision potentially put the resident and others at risk for harm.
Improper Handling and Storage of Medications and Supplies
Penalty
Summary
The facility failed to ensure proper handling and storage of medications and supplies, leading to several deficiencies. Eye drops were not disposed of within 30 days of opening, as observed in the 300 and 200 unit medication carts. Expired supplies, such as safety syringes and shielded IV straight catheter hubs, were found mixed with unexpired supplies in the 300 and 400 unit medication storage rooms. Additionally, medications were not kept in their original packages, with pre-poured medications found in unmarked cups and a loose green capsule observed in the 400 north side medication cart. The DON confirmed that nursing staff should not pre-pour medications and should keep their carts clean of loose medications. Expired medications were also found stored with unexpired medications. Six enoxaparin syringes with an expiration date of 10/2023 were found in the 500 unit medication storage room, and a bottle of tubersol with an open date of 03/20/24 was found in the 400 medication storage room. The tubersol was house stock and should have been discarded after 30 days. The DON stated that staff were supposed to clean out medication storage rooms and carts weekly to check for expired items, but this was not effectively carried out, leading to the deficiencies observed.
Infection Control Deficiencies in Laundry Handling
Penalty
Summary
The facility failed to maintain proper infection prevention measures in two key areas: the transport of soiled laundry and the use of personal protective equipment (PPE) by staff. During an observation, a housekeeper was seen sorting dirty laundry while only wearing gloves, without the required gown, face mask, and eye protection. The housekeeper acknowledged knowing where the PPE items were kept but admitted to not wearing them consistently due to difficulty breathing. The Vice President of Clinical Services confirmed that the housekeeper should have been wearing full PPE while handling soiled laundry to protect against potential contaminants. In another instance, a certified nursing assistant (CNA) was observed handling soiled linens improperly. The CNA placed soiled linens on a chair without a covering and then transported them without using a bag, allowing the linens to touch her scrubs. The CNA explained that this practice was due to a lack of available bags. The Director of Nursing confirmed that staff should place soiled linens in a plastic bag immediately upon removal from the resident's bed and should never allow the linens to touch their clothing. These actions and inactions by the staff could lead to the spread of infections within the facility.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to provide a homelike environment for two residents by not repairing a damaged drawer, not preventing or removing cockroaches from a CPAP humidifier tank, and not addressing water leaks and a damaged ceiling in the therapy room. One resident's closet drawer was missing the face and handle, making it inoperable, and despite informing multiple staff members, the issue was not fixed. The maintenance director was unaware of the problem due to not receiving a work order from the staff. Another resident reported seeing roaches in her room, including inside her CPAP machine, which led to the replacement of the CPAP. The resident felt grossed out by the roaches, and the nurse unit manager suggested the roaches might be due to food stored in the resident's room. The respiratory therapist confirmed the presence of roaches in the CPAP machine and documented the incident. The therapy room had significant water leaks, with large trash bins and wet towels placed to catch the leaking water. The ceiling had missing tiles and exposed pipes, and the leaks had been ongoing for months. Staff members, including the physical therapist and restorative aide, expressed concerns about the safety hazards posed by the leaks, such as wet floors and falling ceiling tiles. Despite attempts to repair the leaks, the problem persisted, affecting the therapy room and the front desk reception area.
Failure to Administer Medications Per Guidelines
Penalty
Summary
The facility failed to meet professional standards of quality for two residents when staff did not administer medications per recommended guidelines. On 04/21/24, during an observation of the 500 south medication cart, an LPN was found storing medications in the cart's top drawer, with the intent to hide these medications in food without the residents' knowledge. The care plans for both residents did not contain instructions for such administration, and there was no documentation of consent from the residents or their responsible parties for this practice. The LPN confirmed that the medications were hidden in food because it was the only way to get the residents to take them. Further interviews revealed that the Director of Nursing (DON) was aware that there were no orders for administering medications without the residents' knowledge. The DON also confirmed that the residents' records did not contain documentation showing that the Power of Attorney (POA) had given permission for staff to hide the medications in food. This lack of proper documentation and consent indicates a failure to adhere to professional standards and physician orders, potentially compromising the therapeutic outcomes for the residents involved.
Failure to Maintain Records of Controlled Substances
Penalty
Summary
The facility failed to maintain proper records of controlled substances on the 400 north, 500 south, and 600 front medication carts. According to the facility's policy, nursing staff must count controlled medications at the end of each shift, with both the outgoing and incoming nurses making the count together and documenting any discrepancies. However, observations revealed that staff did not sign the narcotic book to show they counted the medication blister cards and compared them to the residents' medication sheets on multiple occasions. Specifically, the 500 south medication cart was not signed for three shifts on 04/12/24 and 04/13/24, the 600 hall front medication cart was not signed on 04/20/24, and the 400 north medication cart was not signed for two shifts on 04/05/24 and 04/12/24. Interviews with several LPNs and the Director of Nursing confirmed that the narcotic book should be signed by both the outgoing and incoming nurses at each shift change to ensure the narcotic count is correct and that the keys are properly handed over. The failure to follow this procedure could likely lead to the diversion of controlled substances. The Director of Nursing acknowledged the importance of this practice and confirmed that the nurses should have signed the narcotic sheets as required by the facility's policy.
Inaccurate Care Plan for Catheter Use
Penalty
Summary
The facility failed to ensure the comprehensive care plan was accurate for one resident reviewed for care plan accuracy. During an observation, the resident was noted to be wearing a catheter bag for an indwelling urinary catheter. However, the resident's care plan inaccurately documented the use of an intermittent catheter. The resident's current physician order summary indicated a monthly change for the indwelling catheter, but the care plan, revised earlier, incorrectly stated the use of an intermittent catheter. Interviews with the Nurse Unit Manager and the Director of Nursing confirmed the discrepancy, acknowledging that the care plan should have accurately reflected the use of an indwelling catheter.
Failure to Document Weekly Wound Assessments
Penalty
Summary
The facility failed to document weekly wound assessments for a resident with a stage 2 pressure ulcer. The resident, who was admitted with diagnoses including metabolic encephalopathy, cerebral infarction, and type 2 diabetes mellitus, had physician orders for daily wound care. However, the Electronic Health Record (EHR) lacked documentation of weekly wound assessments, which should include wound measurements, appearance, and reaction to treatment. During an interview, the Director of Nursing (DON) confirmed that staff monitored and treated the resident's wound, which was resolved by the time of the interview. Despite this, the DON acknowledged that staff did not document the required weekly wound assessments. This failure to document could likely result in the resident's wound progression not being evaluated on a weekly basis.
Failure to Address Resident's Weight Loss
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident with significant weight loss. The resident, who had diagnoses including Parkinson's disease, major depressive disorder, and chronic kidney disease, experienced a 7% weight loss in less than one month. Despite physician orders for weekly weights and the administration of mirtazapine to increase appetite, the facility did not implement a nutritional plan or provide nutritional shakes or fortified nutrition shakes. The resident's weight records showed fluctuations and a significant drop, but no follow-up orders for monthly weights were documented. During an interview, the Director of Nursing (DON) acknowledged that the resident was started on mirtazapine for loss of appetite but stated that no further actions were taken due to the resident's short stay in the facility. The lack of a comprehensive plan to address the resident's weight loss and the absence of nutritional interventions contributed to the deficiency identified by the surveyors.
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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.
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